Safety of selective nonoperative management for blunt splenic trauma: the impact of concomitant injuries

Background

Nonoperative management for blunt splenic injury is the preferred treatment. To improve the outcome of selective nonoperative therapy, the current challenge is to identify factors that predict failure. Little is known about the impact of concomitant injury on outcome. Our study has two goals. First, to determine whether concomitant injury affects the safety of selective nonoperative treatment. Secondly we aimed to identify factors that can predict failure.

Methods

From our prospective trauma registry we selected all nonoperatively treated adult patients with blunt splenic trauma admitted between 01.01.2000 and 12.21.2013. All concurrent injuries with an AIS?≥?2 were scored. We grouped and compared patients sustaining solitary splenic injuries and patients with concomitant injuries. To identify specific factors that predict failure we used a multivariable regression analysis.

Results

A total of 79 patients were included. Failure of nonoperative therapy (n =?11) and complications only occurred in patients sustaining concomitant injury. Furthermore, ICU-stay as well as hospitalization time were significantly prolonged in the presence of associated injury (4 versus 13?days,p <?0.05). Mortality was not seen. Multivariable analysis revealed the presence of a femur fracture and higher age as predictors of failure.

Conclusions

Nonoperative management for hemodynamically normal patients with blunt splenic injury is feasible and safe, even in the presence of concurrent (non-hollow organ) injuries or a contrast blush on CT. However, associated injuries are related to prolonged intensive care unit- and hospital stay, complications, and failure of nonoperative management. Specifically, higher age and the presence of a femur fracture are predictors of failure.

     

Efficacy and tolerability of peginterferon alfa‐2a or alfa‐2b plus ribavirin in the daily routine treatment of patients with chronic hepatitis C in Germany: The PRACTICE Study

Summary. In randomized clinical trials, treatment with peginterferon plus ribavirin (RBV) results in a sustained virological response (SVR) in around half of hepatitis C virus genotype 1‐infected and 80% of genotype 2/3‐infected individuals. This study aimed to evaluate efficacy and tolerability of peginterferon alfa‐2a plus RBV compared with peginterferon alfa‐2b plus RBV for the treatment of chronic hepatitis C in routine clinical practice. The intent‐to‐treat cohort consisted of 3414 patients treated with either peginterferon alfa‐2a plus RBV (Group A) or peginterferon alfa‐2b plus RBV (Group B) in 23 centres participating in the large, multicentre, observational PRACTICE study. Collected data included baseline characteristics, treatment regimen, RBV dose and outcome. Rates of early virological response, end of treatment response and SVR were 76.6%, 75.7% and 52.9% in Group A, and 70.2%, 65.6% and 50.5% in Group B, respectively. In patients matched by baseline parameters, 59.9% of patients in Group A and 55.9% in Group B achieved an SVR (P ≤ 0.051). In genotype 1‐infected patients matched by baseline parameters and cumulative RBV dose, SVR rates were 49.6% and 43.7% for Group A and Group B, respectively (P ≤ 0.047); when matched by baseline parameters and RBV starting dose, SVR rates were 49.9% and 44.6%, respectively (P = 0.068). Overall, 21.8% of group A and 29.6% of group B patients discontinued treatment (P ≤ 0.0001). The efficacy and tolerability of peginterferon plus RBV in this large cohort of patients treated in routine daily practice was similar to that in randomized clinical trials. In matched pairs analyses, more patients achieved an SVR with peginterferon alfa‐2a compared with peginterferon alfa‐2b.     

Behaviour after cerebral lesions in children and adults. 1962

It is generally believed that brain injuries vary in their effects according to the age at which they are sustained, but the nature and extent of these differences remain elusive. A full enquiry requires, ideally, the study of strictly comparable lesions in the young and the old, the opportunity for follow-up examinations extending over decades in both groups and, lastly, the availability of behavioural tasks for which normal attainment is known, and which are equally applicable to the brain-injured child and the brain-injured adult.
The investigations of behavioural changes after brain injury in children and adults, reported here, are far from fulfilling all these requirements. In particular, these studies are obviously deficient with regard to our first postulate, that of comparable lesions. Identical lesions in children and adults are so rare that one is often forced to turn to animal experiments as a supplementary source of information. Admittedly, animal experiments introduce phylogenetic differences in addition to the ontogenetic ones; yet available animal studies can help to indicate some of the directions in which the answers to the ontogenetic question may be sought. Accordingly, we begin this account with a brief consideration of animal experiments, before presenting some of the results obtained in our laboratory in students of brain-injured about and children.     

Noninvasive assessment of liver steatosis, fibrosis and inflammation in chronic hepatitis C virus infection.

BACKGROUND: Duplex-Doppler ultrasound is a noninvasive method for the assessment of hepatic hemodynamics beyond conventional gray-scale imaging. The clinical value of the method for the grading and staging of chronic hepatitis C virus (HCV) infection and the prediction of hepatic steatosis still has to be determined. This study aimed to compare Duplex-Doppler and ultrasound with the histologic staging and the estimation of hepatic steatosis in chronic HCV infection. PATIENTS AND METHODS: One hundred and nineteen consecutive patients with chronic HCV infection underwent both liver biopsy and ultrasound with Duplex-Doppler. Maximum portal venous blood flow velocity, portal venous flow undulation, hepatic venous flow pattern and spleen size were assessed and compared with histologic findings. Histologic grading and staging was performed according to the modified HAI and hepatic steatosis was estimated. RESULTS: Doppler ultrasound was unable to discriminate between different degrees of fibrosis. Sensitivity/specificity of portal venous flow and undulations for the diagnosis of hepatic cirrhosis was 74.5%/53% and 76.5%/100%. The PPV and NPV of reduced undulations was 100% and 96.2%. Mono- or biphasic hepatic venous flow indicated advanced hepatic steatosis (sensitivity 88.2%, specificity 74.5%, PPV 36.6%, NPV 97.5%). Spleen size was significantly enlarged both in patients with cirrhosis and steatosis. CONCLUSIONS: Although Duplex-Doppler of the portal and hepatic veins is not a substitute for histologic grading and staging, portal vein undulations can predict liver cirrhosis with considerable accuracy. Moreover, triphasic patterns of hepatic venous flow virtually exclude significant fatty liver disease. Additional studies should perform intraindividual follow-up investigations to further define the role of Duplex-Doppler ultrasound in chronic HCV infection.     

Die Cholera in der Schweiz

Ohne ZusammenfassungMit 5 Textabbildungen.     

Identification and cloning of a complementary DNA encoding a vicilin-like proprotein, Jug r 2, from English walnut kernel (Juglans regia), a major food allergen

Background: Walnuts and other tree nuts are important food-allergen sources that have the potential to be associated with life-threatening, IgE-mediated systemic reactions in some individuals. Objective: The purpose of this study was to characterize a complementary (c)DNA clone encoding one of the walnut food allergens. Methods: A cDNA expression library prepared from walnut somatic embryo was screened for IgE reactivity with patient serum. A reactive clone of 2060 bp, which encoded a protein of 593 amino acids in length, was subcloned by excision into the pGEX expression vector. IgE-binding inhibition experiments were performed.Results: A recombinant fusion protein was induced and shown to bind serum IgE from 9 of 15 patients tested, thus identifying a major allergen. This clone, named Jug r 2, exhibited significant homology with genes encoding the vicilin group of seed proteins. An IgE-binding inhibition experiment suggested that the encoded protein undergoes posttranslational modification into at least one major polypeptide (47 kd) and possibly several others, which is similar to the vicilin-like proteins characterized in cocoa bean (Theobroma cacao) and cottonseed (Gossypium hirsutum ). N-terminal sequencing of the 47-kd band, Jug r 2, identified it as a mature protein obtained from the precursor. A second IgE-binding inhibition experiment showed that there is minimal or no cross-reactivity between Jug r 2 and pea vicilin, peanut proteins, or cacao proteins. Conclusion: Jug r 2 is the third vicilin food allergen identified in addition to vicilins from soy and peanut. The availability of recombinant food allergens should help advance studies on the immunopathogenesis and possible treatment of IgE-mediated food hypersensitivity. (J Allergy Clin Immunol 1999;1311-20.)