Traumatic Injury of the Superior Mesenteric Vein: Ligate,Repair or Shunt?

Abstract We report a case of SMV injury in a critically ill patient. The patient was a 19-year-old woman involved in a motor vehicle collision. Her injuries included grade II splenic and renal lacerations, devascularized and lacerated right and transverse colon, a transected transverse mesocolon, a massive shear injury of her abdominal wall, and two partial SMV transections. At initial damage control laparotomy, the SMV was ligated, the devascularized bowel resected and a temporary abdominal closure applied. At re-operation, a mesocaval shunt using saphenous vein was employed. The shunt failed and the patient required a saphenous vein jump graft. Although visceral vascular injuries are rare, ligation of the SMV in a damage control situation is acceptable. This case study is the first to discuss appropriate treatment when interruption to a patient's collateral visceral venous drainage limits the surgeon’s ability to ligate. In these situations, bypass shunts may be successful.     

Safety and reliability of external fixation for basicervical and intertrochanteric fractures in high-risk elderly patients

Forty elderly patients with basicervical and pertrochanteric fractures were managed with uniplanar AO external fixator under regional anaesthetic block of the femoral nerve and lateral cutaneous nerve of the thigh from April 2003 to March 2006. The mean age of the patients was 67.9 ± 5.5 years. External fixator application was performed under radiological control after closed reduction had been obtained. Comorbid factors, duration of surgery, duration of hospitalisation, complications, walking ability, time to union and mortality rate were recorded. Patients were followed up for a mean period of 12 ± 4.5 months. Superficial pin tract infection occurred in 13 patients, healing in varus >10° and with shortening >2 cm occurred in six patients, and one patient suffered a spontaneous ipsilateral femoral neck fracture after removal of the fixator. The mean time for union was 10.4 ± 1.2 weeks. Rapid union rate and minor complications obtained in the present study are comparable to those obtained with standard internal fixation techniques. Minimal intraoperative blood loss, short operative time and early patient mobilisation are advantages signifying uniplanar external fixator application under regional anaesthetic block to be a viable option in treatment of basicervical and pertrochanteric fractures in high-risk elderly patients.     

Endobronchial ultrasound: new insight for the diagnosis of sarcoidosis.

A diagnosis of sarcoidosis should be substantiated by pathological means in order to thoroughly exclude other diseases. The role of real-time endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in the diagnosis of sarcoidosis has not been reported. The purpose of the present study is to evaluate the diagnostic yield of EBUS-TBNA in demonstrating the pathological features of sarcoidosis. In total, 65 patients with suspected sarcoidosis, with enlarged hilar or mediastinal lymph nodes on computed tomography, were included in the study. Patients with a suspected or known malignancy or previously established diagnosis of sarcoidosis were excluded. Convex probe endobronchial ultrasonography integrated with a separate working channel was used for EBUS-TBNA. Surgical methods were performed in those in whom no granulomas were detected by EBUS-TBNA. Patients were followed up clinically. EBUS-TBNA was performed on a total of 77 lymph node stations in 65 patients. A final diagnosis of sarcoidosis was made for 61 (93.8%) of the patients. The remaining four patients were diagnosed as having Wegener's granulomatosis (n=1) or indefinite (n=3). In patients with a final diagnosis of sarcoidosis, EBUS-TBNA demonstrated noncaseating epithelioid cell granulomas in 56 (91.8%) of the patients. No complications were reported. Endobronchial ultrasound-guided transbronchial needle aspiration proved to be a safe procedure with a high yield for the diagnoses of sarcoidosis.     

Embolisierende Thrombose bei Fehlbildung der V. cava inferior

Persistent left-sided inferior vena cava (VCI) is a rare venous anomaly, its prevalence being estimated at 0.2-0.5%. Thrombotic occlusion of a VCI has been reported in only a few of these cases. We report the case of a 24-year old woman who suffered an acute thrombosis in a left-sided VCI and recurrent pulmonary embolism. After thrombectomy the course was uneventful. The diagnostic approach and the treatment strategy are discussed with reference to the literature.     

Prevalence of Artemisia species pollinosis in western Poland: impact of climate change on aerobiological trends, 1995-2004.

BACKGROUND: Artemisia species pollen represents a major cause of allergy in Central Europe. Variations in the pollen season, the influence of climate variables and the prevalence of pollinosis to it were analyzed in Poznan, in western Poland between 1995 and 2004. METHODS: A Hirst volumetric spore trap was used for atmospheric sampling. Pollination date trend analysis and Spearman correlation tests were performed. Skin prick tests (SPT) and allergen specific immunoglobulin (lg)E antibody measurements were performed in 676 and 524 patients, respectively. RESULTS: The Artemisia species pollen season grew longer due to a clear advance in the starting day and only a slightly earlier end point; the peak day also came slightly earlier. Rainfall in the first fortnight of July highly influenced pollen season severity. Temperature was directly correlated with daily Artemisia species pollen levels; relative humidity was inversely correlated. Twelve percent of patients had a positive SPT reaction to Artemisia species. Their symptoms were rhinitis and conjunctivitis (15%), atopic dermatitis (15%), chronic urticaria (14.3%), bronchial asthma (2.4%), and facial and disseminated dermatitis (1.3%). Elevated specific IgE concentrations were detected in the sera of 10.1% of patients. CONCLUSIONS: Artemisia species pollen is an important cause of pollinosis in western Poland. Pollen season intensity is highly influenced by rainfall in the previous weeks. Trends towards earlier season starts and longer duration, possibly caused by climate change, may have an impact on the allergic population.     

Role of IS6110 uniplex PCR in the diagnosis of tuberculous meningitis: experience at a tertiary neurocentre.

SETTING: Tuberculous meningitis (TBM) is the commonest form of neurotuberculosis in the Indian subcontinent. Rapid laboratory confirmation of TBM is important for the institution of early treatment and to avoid associated morbidity and mortality. The polymerase chain reaction (PCR) is the most widely applied alternative rapid diagnostic technique for TBM. OBJECTIVE: To evaluate the efficacy of an in-house developed IS6110 uniplex PCR (uPCR) in the diagnosis of TBM. DESIGN: A prospective, blinded study was conducted in a large sample base of 677 cerebrospinal fluid samples from 677 patients with clinically suspected TBM. RESULTS: All culture-positive samples (n = 136) were positive (100%) by the PCR assay. The assay was found to be positive in 70% (n = 541) of the samples with a clinical diagnosis of TBM. The assay had an observed sensitivity of 76.37% (negative predictive value 59.90%) and a specificity of 89.18% (positive predictive value 94.69%). A diagnostic accuracy of 80% (kappa 0.57) was seen in patients with a clinical diagnosis of TBM. Statistical significance was observed, as patients with a clinical diagnosis of TBM were found to be 9.38 times more likely to be PCR-positive (OR 9.38, chi2 = 149.94, P < 0.001). CONCLUSION: The performance of the in-house IS6110 uPCR assay merits its use as a sensitive and specific tool for the rapid diagnosis of TBM.     

Biocidal effect of bleach on Mycobacterium tuberculosis: a safety measure.

BACKGROUND: Although treatment of sputum using bleach has shown increased sensitivity in smear microscopy, the safety aspect of sodium hypochlorite (NaOCl) has not been addressed. OBJECTIVE: To determine the biocidal effect of NaOCl on Mycobacterium tuberculosis when used as a safety measure in direct sputum smear microscopy for the diagnosis of tuberculosis (TB). METHOD: A total of 156 smear- and culture-positive pooled sputum specimens were assessed for the viability of M. tuberculosis after treatment with NaOCl. Each specimen was divided into 11 equal portions. One portion was directly cultured. Each of five portions was treated with 3.5% NaOCl and the other five with 5% NaOCl. Specimens were then cultured at intervals of 15 min and 1, 3, 15 and 24 h. RESULTS: A total of 18 (11.5%) specimens showed growth after treatment with NaOCl. Of these, 5 (3.2%) showed growth upon treatment with 3.5% NaOCl at 15 min and 15 and 24 h. Ten (6.4%) showed growth after treatment with 5% NaOCl between 15 min and 3 h, but none showed growth after 15 h. Three (1.9%) specimens showed growth in both concentrations. CONCLUSION: Our preliminary findings show that exposure of sputum to 5% NaOCl for at least 15 h may be a safety procedure in smear microscopy for the diagnosis of TB. However, further studies are warranted.     

Pathways from first health care seeking to diagnosis: obstacles to tuberculosis care in rural China.

OBJECTIVE: To examine health care seeking pathways for patients with tuberculosis (TB) and barriers related to these pathways in counties under the National TB Control Programme in rural China. METHODS: A cross-sectional study was conducted in two counties of east China in 2004-2005. A total of 557 TB patients were recruited and interviewed by physicians at the time of TB diagnosis. RESULTS: Of 557 participants, 13.3% had presented to a specialised county TB dispensary (CTD) directly after onset of symptoms, 31.4% had first sought care at a village health station and 51.2% had visited a township or county hospital first. The proportion of referral by a first health care provider to a CTD was highest in county level hospitals (73.5%) and lowest in village health stations (21.7%). The most prompt pathway from first health care seeking to TB diagnosis was to visit a CTD directly, with a median provider's delay of only one day. There was an increase in provider's delay when more health facilities were involved. CONCLUSION: To improve direct referral from general health care providers, especially village health care workers, to TB specialists would significantly shorten the delays in TB diagnosis in rural China.     

Living donor liver transplantation.

Initially living donor liver transplantation (LDLT) was almost exclusively performed in infants and children. Adult LDLT programmes were initiated several years later. In the west this programme was introduced in view of a critical shortage of deceased donors and a constant increase in waiting list mortality. At present, this procedure is accepted as a therapeutic option for patients with end-stage liver disease to make up for the shortage of donor organs from dead patients. In Asia, however, LDLT has become the predominant means of liver transplantation as donor organs from the diseased cannot be used for religious and ethical reasons. Although there have been significant improvements in surgical techniques and consequently in recipient outcome over recent years, the LDLT procedure is still associated with donor morbidity and even mortality. The overall reported donor mortality was 0.2% and donor morbidity ranged between 0% and 100%. Biliary complications and infections were the most commonly reported donor complications. Therefore, a thorough medical as well as psychological evaluation of the donor and recipient are necessary prior to this procedure. To date, LDLT comprises less than 5% of adult liver transplantations in Europe and in the United States. Recipient and graft survival are almost identical to those seen with liver transplantations from deceased donors (DD). Biliary and vascular complications are more often seen in the LDLT setting. So far, no studies have focussed on the impact of LDLT on waiting list mortality. There is international consensus that this procedure should be restricted to centres with large experience in deceased donor liver transplantations as well as in hepatobiliary surgery. Ethical issues, optimal utility and application of adult LDLT and optimal recipient and donor characteristics have yet to be defined.