Abdominal gunshot wounds: possibilities for selective conservative management

Two men aged 45 and 26 years, respectively, presented with abdominal gunshot wounds and were treated successfully using a nonsurgical approach. Normally, abdominal gunshot wounds are treated surgically in the Netherlands. This policy produces negative laparotomy findings in 22-41% of procedures. With an increasing number of gunshot wound patients presenting to emergency departments, a better understanding of abdominal gunshot wounds is needed. Immediate laparotomy is indicated for patients with haemodynamic instability, signs of peritonitis or massive intra-abdominal fluid visible with focused abdominal ultrasonography for trauma. However in selected cases and with the use of strict diagnostic and follow-up procedures, it is possible to treat these patients with a nonsurgical approach. Physical examination, adequate CT investigation and possibly additional radiological evaluation play a pivotal role in this approach. Therefore, assessment by a multidisciplinary trauma team is crucial at the time of presentation and during further treatment for abdominal gunshot wounds. Ned Tijdschr Geneeskd.     

High- versus low-dose oxytocin for augmentation or induction of labor

OBJECTIVE: To compare the use of high- and low-dose oxytocin for augmentation or induction of labor. DATA SOURCES: Clinical trials were accessed through MEDLINE (1966-November 2003). Published literature relevant to the use of oxytocin for augmentation or induction of labor was evaluated. STUDY SELECTION AND DATA EXTRACTION: Articles identified from the data sources were evaluated and included if they were clinical trials comparing high-versus low-dose oxytocin for augmentation or induction of labor. DATA SYNTHESIS: Oxytocin is a treatment of choice for augmentation and induction of labor; however, no consensus exists regarding optimal dosing. Relevant studies comparing high-dose (2-6 mU/min) and low-dose (1-2 mU/min) therapy for labor augmentation and induction were evaluated. CONCLUSIONS: High-dose oxytocin decreases the time from admission to vaginal delivery, but does not appear to decrease the incidence of cesarean sections when compared with low-dose therapy.     

Diagnostic accuracy and reproducibility in the interpretation of Ottawa ankle and foot rules by specialized emergency nurses

OBJECTIVES: The ED is often confronted with long waiting periods. Because of the progressive shortage in general practitioners, further growth is expected in the number of patients visiting the ED without consulting a general practitioner first. These patients mainly present with minor injuries suitable for a standardized diagnostic protocol. The question was raised whether these injuries can be treated by trained ED nurses (specialized emergency nurses [SENs]). The aim of this study was to evaluate the diagnostic accuracy and reproducibility of SENs in assessing ankle sprains by applying the Ottawa Ankle Rules (OAR) and Ottawa Foot Rules (OFR). METHODS: In a prospective study, all ankle sprains presented in the ED from April to July 2004 were assessed by both a SEN and a junior doctor (house officer [HO]) randomized for first observer. Before the study, SENs were trained in applying OAR and OFR. In all patients, radiography was performed (gold standard). The diagnostic accuracy for the application of OAR and OFR was calculated for both groups and was compared using z statistics. Furthermore, from the paired results, reproducibility was calculated using kappa statistics. RESULTS: In total, 106 injuries were assessed in pairs, of which 14 were ultimately found to concern acute fractures (prevalence, 13%). The sensitivity for the SEN group was 0.93 (95% confidence interval [CI], 0.64-1.00) compared with 0.93 (95% CI, 0.64-1.00) for the HO group (no significance [ns]). The specificity of the nurses was 0.49 (95% CI, 0.38-0.60) compared with 0.39 (95% CI, 0.29-0.50) for the doctors (ns). The positive predictive value for the SEN group was 0.22 (95% CI, 0.13-0.35) compared with 0.19 (95% CI, 0.11-0.31) for the HO group (ns). The negative predictive value for the nurses was 0.98 (95% CI, 0.87-1.00) compared with 0.97 (95% CI, 0.84-1.00) for the doctors (ns). The interobserver agreement for the OAR and OFR subsets was kappa = 0.38 for the lateral malleolus; kappa = 0.30, medial malleolus; kappa = 0.50, navicular; kappa = 0.45, metatarsal V base; and kappa = 0.43, weight-bearing. The overall interobserver agreement for the OAR was kappa = 0.41 and kappa = 0.77 for the OFR. CONCLUSION: Specialized emergency nurses are able to assess ankle and foot injuries in an accurate manner with regard to the detection of acute fractures after a short, inexpensive course.     

Microstructure and biomechanical characteristics of bone substitutes for trauma and orthopaedic surgery

Background  

Many (artificial) bone substitute materials are currently available for use in orthopaedic trauma surgery. Objective data on their biological and biomechanical characteristics, which determine their clinical application, is mostly lacking. The aim of this study was to investigate structural and in vitro mechanical properties of nine bone substitute cements registered for use in orthopaedic trauma surgery in the Netherlands.