Selective conservatism in the management of thoracic trauma remains appropriate in the 21st century

Introduction

Selective conservatism for thoracic trauma is well established but the emergence of new technologies may cause management strategies to continue to evolve.

Methods

A retrospective study was conducted on thoracic trauma patients managed in a single institution in South Africa over a 4-year period to determine the appropriateness of our current policy of selective conservatism.

Results

A total of 1,239 patients were included in the study; 112 required an emergency thoracotomy, 125 were admitted for observation and 1,002 required a tube thoracostomy (TT). Ninety-one per cent of the patients were male and the median age was 24 years. Seventy-five per cent of the cases were penetrating trauma and the remaining were blunt trauma. The indications for TT were pneumothorax (PTX) (n=382, 38%), haemothorax (HTX) (n=300, 30%) and haemopneumothorax (HPTX) (n=320, 32%).A total of 13% (127/1,002) of all chest x-rays (CXR) following tube removal demonstrated residual pathologies that precluded immediate discharge: 32 (8%) in Group A (PTX), 44 (15%) in Group B (HTX) and 51 (16%) in Group C (HPTX). All 32 patients in Group A were simply observed and did not require further intervention. In Group B, 17 patients required repeat TTs and 27 required video assisted thoracoscopic surgery (VATS) for clearance of residual HTX. Twenty-nine patients in Group C required repeat TTs and twenty-two required VATS.

Conclusions

The vast majority of patients with thoracic trauma can be managed conservatively with TT alone. Residual pathology appeared to be lowest in patients with a PTX, which seldom requires treatment, while only a minority of patients required repeat TTs or VATS for a retained HTX. Selective conservatism is still appropriate in the current era in a developing world setting.     

Computed tomography-guided percutaneous core needle biopsy in pancreatic tumor diagnosis

AIM: To evaluate the techniques, results, and complications related to computed tomography(CT)-guided percutaneous core needle biopsies of solid pancreatic lesions.METHODS: CT-guided percutaneous biopsies of solid pancreatic lesions performed at a cancer reference center between January 2012 and September 2013 were retrospectively analyzed. Biopsy material was collected with a 16-20 G Tru-Core needle(10-15 cm; Angiotech, Vancouver, CA) using a coaxial system and automatic biopsy gun. When direct access to the lesion was not possible, indirect(transgastric or transhepatic) access or hydrodissection and/or pneumodissection maneuvers were used. Characteristics of the patients, lesions, procedures, and histologic results were recorded using a standardized form. RESULTS: A total of 103 procedures included in the study were performed on patients with a mean age of 64.8 year(range: 39-94 year). The mean size of the pancreatic lesions was 45.5 mm(range: 15-195 mm). Most(75/103, 72.8%) procedures were performed via direct access, though hydrodissection and/or pneumodissection were used in 22.2%(23/103) of cases and indirect transhepatic or transgastric access was used in 4.8%(5/103) of cases. Histologic analysis was performed on all biopsies, and diagnoses were conclusive in 98.1%(101/103) of cases, confirming3.9%(4/103) of tumors were benign and 94.2%(97/103) were malignant; results were atypical in 1.9%(2/103) of cases, requiring a repeat biopsy to diagnose a neuroendocrine tumor, and surgical resection to confirm a primary adenocarcinoma. Only mild/moderate complications were observed in 9/103 patients(8.7%),and they were more commonly associated with biopsies of lesions located in the head/uncinate process(n =8), than of those located in the body/tail(n = 1) of the pancreas, but this difference was not significant.CONCLUSION: CT-guided biopsy of a pancreatic lesion is a safe procedure with a high success rate, and is an excellent option for minimally invasive diagnosis.     

Gingival granulomatosis with polyangiitis (Wegener's granulomatosis) as a primary manifestation of the disease

Granulomatosis with polyangiitis (GPA) is a potentially lethal disease characterized by systemic necrotizing vasculitis, which affects small‐ and medium‐sized blood vessels and is often associated with serum cytoplasmic antineutrophil cytoplasmic antibody. The upper and lower respiratory tract and kidney are the most involved sites, but oral lesions can be identified in 6–13% of the cases, whereas in only 2% of the cases, oral manifestations represent the first signal of the disease usually as gingival swellings or unspecific ulcerations. Without treatment, the mainstay of which is the combination of immunosuppressants and systemic corticosteroids, GPA may run a fatal course. In this report we describe an original case of GPA affecting a 75‐year‐old female patient referred to our service due to a gingival swelling with 3‐month duration. Although the patient was correctly diagnosed and promptly treated, she died 3 months after the initial diagnosis.     

Bone marrow origin of a B-cell lymphoma

To search for precursors of the neoplastic B cells in a patient with a nodular lymphoma, we produced a monoclonal antibody to a variable region idiotope on the lymphoma IgM heavy chain. Clonal ancestors of the lymphoma cells were identified by this marker among bone marrow pre- B cells (5% to 26%). A second antiidiotype (anti-Id) antibody specific for the complete lymphoma IgM kappa recognized 10% of B cells in bone marrow and blood and greater than 95% of B cells in lymphomatous lymph nodes, including one obtained after tumor conversion to a diffuse large cell lymphoma. Immunoglobulin gene analysis surprisingly revealed expansion of multiple clones of early B lineage cells in bone marrow, including members of the neoplastic clone. The data suggest that this lymphoma arose through a progression of transformational events beginning in bone marrow: first, creation of an oligoclonal pre- neoplastic pool of pre-B cells, subsequent conversion of a single subclone into low grade neoplastic B cells that homed to the lymph node follicles, and later progression to a more invasive form of the B-cell lymphoma.     

铀矿接尘人员矽肺发生的特点

目的 了解铀矿接尘人员矽肺发生的规律与特点。方法 利用单因素分析法对核工业矿山与地质系统间、纯铀矿与混铀矿接尘人员间,矽肺患者的发病工龄、发病年龄、病程及死亡年龄进行分析。结果 随着时间的推移,铀矿接尘人员的发病工龄、发病年龄、病程及死亡年龄均延长。地质系统的矽肺Ⅰ期患者的发病工龄、发病年龄分别为(10.15±5.95)年、(40.60±9.86)岁,短于矿山系统的患者[(14.23±8.12)年、(41.38±10.98)岁];地质系统的矽肺Ⅰ期患者的病程(P50)及死亡年龄分别为14.29年及(53.69±10.04)岁,长于矿山系统的患者[12.52年及(51.45±10.85)岁]。纯铀矿的矽肺Ⅰ期患者的发病工龄为(11.78±8.06)年,发病年龄为(38.04±9.89)岁,短于混铀矿的患者[(12.74±6.29)年、(41.40±10.67)岁];纯铀矿的矽肺Ⅰ期患者的病程(P50)为14.59年,死亡年龄为(53.93±10.60)岁,均长于混铀矿的患者[13.20年、(51.82±10.20)岁]。结论地质系统与矿山系统、纯铀矿及混铀矿接尘者矽肺发生情况的差别可能与所接触粉尘的理化性质及各自的工作环境有关。     

Blood pressure support in extremely premature infants is affected by different courses of antenatal steroids

Objective:  To examine the effects of partial, single and multiple courses of antenatal corticosteroids (ANS) on the need for blood pressure support in extremely premature infants.
Methods:  Extremely premature infants with gestational age of 24 to 28 weeks were included in this study during a 5-year period. The main outcome measure of the study was the amount of blood pressure support during the first 3 days of life.
Results:  The study infants (n = 163) were divided into: infants not exposed (ANS; n = 27) and exposed to ANS (ANS; n = 136). Blood pressure support was significantly lower in ANS compared with No ANS (65% vs 96%; p = 0.003) and in single course (SANS; n = 73) and ≥2 courses (MANS; n = 34) compared with partial course of ANS (PANS; n = 29) (62%, 56% vs 86%; p = 0.03). The number of infants who received volume support and the amount of volume support were significantly lower in ANS compared with that in No ANS (p < 0.001) and in SANS and MANS compared with that in PANS (p < 0.02).
Conclusion:  Exposure to multiple courses of ANS was as beneficial as single course of ANS in decreasing the need for blood pressure support in extremely premature infants.     

Leukocyte-technetium-99m uptake in Crohn''s disease:Does it show subclinical disease?

AIM:To evaluate inflammatory activity in patients with Crohn‘s disease (CD) using technetium-99m-hexamethylpropyleneamine oxime (99mTc-HMPAO) granulocyte scintigraphy.METHODS: Twenty patients (7 male and 13 female) with CD and five healthy volunteers were selected for 99mTc-HMPAO granulocyte scintigraphy. The Crohn‘s Disease Activity Index (CDAI), blood tests and C-reactive protein (CRP) of each patient were performed 7 d before the scintigraphic images. The leukocytes were labeled according to the Internat...     

NMDA receptor genotypes associated with the vulnerability to develop dyskinesia

Dyskinesias are involuntary muscle movements that occur spontaneously in Huntington''s disease (HD) and after long-term treatments for Parkinson''s disease (levodopa-induced dyskinesia; LID) or for schizophrenia (tardive dyskinesia, TD). Previous studies suggested that dyskinesias in these three conditions originate from different neuronal pathways that converge on overstimulation of the motor cortex. We hypothesized that the same variants of the N-methyl--aspartate receptor gene that were previously associated with the age of dyskinesia onset in HD were also associated with the vulnerability for TD and not LID. Genotyping patients with LID and TD revealed, however, that these two variants were dose-dependently associated with susceptibility to LID, but not TD. This suggested that LID, TD and HD might arise from the same neuronal pathways, but TD results from a different mechanism.     

Effect of the vertebral syndrome in cervical osteochondrosis on the course of I-IIA stage hypertension and cerebral electrical activity and hemodynamics

Examination included two groups of patients with I-IIA stage essential hypertension combined with cervical osteochondrosis: with and without the vertebral syndrome. It revealed significant polymorphism of clinical symptoms, more severe course of vascular pathology, disorders of cerebral hemodynamics with decreased pulse blood filling, increased tone of arterioles, venules and veins, signs of disturbances of venous outflow and features of bioelectric brain activity indicating dysfunction of the middle structures in patients with the vertebral syndrome of cervical osteochondrosis. Since the pathogenic significance of cervical osteochondrosis is mostly realized in the presence of the vertebral syndrome, therapeutic policy should involve both antihypertensive agents and measures that control vertebrogenic pathology as well as medicamentous correction of hemodynamic cerebral disturbances.