Determinants of survival after inferior vena cava trauma.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.     

Effet antihypertenseur des feuilles d’Inula viscosa

Inula viscosa (Asteraceae) is amedicinal plant widely used by Mediterranean population in folk medicine to treat different diseases. The antihypertensive effect of the aqueous extract obtained from Inula viscosa leaves was studied in hypertensive rats. Systolic blood pressure was measured using the indirect tail-cuff plethysmographic method (TCP). Three groups of rats were used: control group received water; L-NAME treated group received NG-nitro-L-arginine methylester (30 mg/kg per day) and group received simultaneously L-NAME (30 mg/kg per day) and aqueous extract of Inula viscose (250 mg/kg per day). After four weeks of treatment, the group receiving the L-NAME alone have developed an arterial hypertension (systolic blood pressure (SBP) = 164 ± 3 mmHg), whereas the group receiving the L-NAME and the aqueous extract of Inula viscosa have developed a SBP of 145 ± 2 mmHg. These results showed that the studied extract prevented significantly the development of hypertension induced by L-NAME. Moreover, the study of the cardiac effect of the Inula viscosa aqueous extract on the model of isolated and perfused rat heart, according to the method of Langendorff, showed a dose-dependent negative inotropic effect, which may contribute to antihypertensive effect.     

Unexplained gastrointestinal symptoms and joint hypermobility: is connective tissue the missing link?

Background Unexplained gastrointestinal (GI) symptoms and joint hypermobility (JHM) are common in the general population, the latter described as benign joint hypermobility syndrome (BJHS) when associated with musculo‐skeletal symptoms. Despite overlapping clinical features, the prevalence of JHM or BJHS in patients with functional gastrointestinal disorders has not been examined. Methods The incidence of JHM was evaluated in 129 new unselected tertiary referrals (97 female, age range 16–78 years) to a neurogastroenterology clinic using a validated 5‐point questionnaire. A rheumatologist further evaluated 25 patients with JHM to determine the presence of BJHS. Groups with or without JHM were compared for presentation, symptoms and outcomes of relevant functional GI tests. Key Results Sixty‐three (49%) patients had evidence of generalized JHM. An unknown aetiology for GI symptoms was significantly more frequent in patients with JHM than in those without (P < 0.0001). The rheumatologist confirmed the clinical impression of JHM in 23 of 25 patients, 17 (68%) of whom were diagnosed with BJHS. Patients with co‐existent BJHS and GI symptoms experienced abdominal pain (81%), bloating (57%), nausea (57%), reflux symptoms (48%), vomiting (43%), constipation (38%) and diarrhoea (14%). Twelve of 17 patients presenting with upper GI symptoms had delayed gastric emptying. One case is described in detail. Conclusions & Inferences In a preliminary retrospective study, we have found a high incidence of JHM in patients referred to tertiary neurogastroenterology care with unexplained GI symptoms and in a proportion of these a diagnosis of BJHS is made. Symptoms and functional tests suggest GI dysmotility in a number of these patients. The possibility that a proportion of patients with unexplained GI symptoms and JHM may share a common pathophysiological disorder of connective tissue warrants further investigation.     

The Association between risk factors and low back pain among commercial vehicle drivers in peninsular Malaysia: a preliminary result

To determine the risk factors associated with complain of low back pain. A cross sectional study was done from June 2004 until August 2005. Seven hundred and sixty commercial vehicle drivers from 11 bus companies in central, northern and eastern regions in Malaysia participated in this study. Modified Nordic questionnaire was used to determine the prevalence of low back pain; Maestro human vibration meter was used to measure the personal R.M.S values of lateral, anterior-posterior and vertical axes. Modified Owas was used to assess the awkward posture of the driver torso namely, bending forward movement, leaning, sitting straight and twisting. Profile of Mood States (POMS) was used to evaluate the mood states of bus drivers with complain of low back pain. A high prevalence of low back pain (60.4%) among Malaysian commercial vehicle drivers was found. Logistic regression analysis controlling for age, income, education level and non occupational activities revealed that the following factors were related to low back pain: Tension-anxiety [1.080, 95% CI 1.041-1.121], depression dejection [1.047, 95% CI 1.023-1.072], anger-hostility [1.053, 95% CI 1.027-1.081], fatigue [1.132, 95% CI 1.089-1.177] and confusion [1.114, 95% CI 1.061-1.169] of POMS, length of employment [1.001, 95% CI 1.0-1.003], steering wheel adjustment [1.521, 95% CI 1.101-2.101], perception of exposing to vibration [1.943, 95% CI 1.389-2.719]. In conclusion, combinations of risks lead to high increase of low back pain complain among Malaysian bus drivers.     

Mortality following combined fractures of the hip and proximal humerus

BACKGROUND Hip fractures and proximal humerus fractures are known to be associated with increased mortality, but the impact on mortality of combining these two common injuries is not well known.AIM To compare mortality, inpatient stay and discharge destination for patients with combined hip and proximal humerus fractures with those sustaining isolated hip fractures.METHODS Using the United Kingdom national hip fracture database, we identified all hip fracture patients over the age of 60 admitted to a single trauma unit from 2010-2016. Patients sustaining a proximal humerus fracture in addition to their hip fracture were identified using hospital coding data. We calculated the 30-d and one-year mortality for both the hip fracture cohort and the combined hip and proximal humerus fracture cohort. Other variables recorded included age, gender and whether the proximal humerus was treated with or without an operation.RESULTS We identified 4131 patients with hip fractures within the study period and out of those 40 had sustained both a hip and a proximal humerus fracture. Mean age in the hip fracture cohort was 80.9 years and in the combined fracture group 80.3 years. Out of the 40 patients in the combined group four were treated operatively. The 30-d mortality for our hip fracture cohort was 7.2% compared to the mortality of our combined cohort of 12.5%(P = 0.163). The one-year mortality for our hip fracture cohort was 26.4% compared to 40% for the combined fracture cohort(P = 0.038). We also found patients with combined injuries were less likely to return to their own home.CONCLUSION The 30-d and one-year mortality is higher for those patients who have sustained a combined hip and proximal humerus fracture when compared to those with a hip fracture alone.     

Immature ovaries and polycystic kidneys in the congenital polycystic kidney mouse may be due to abnormal sex steroid metabolism

Ke 6 is a 17beta-hydroxysteroid dehydrogenase (17betaHSD) that is expressed in the kidneys and gonads. The expression of this gene is markedly reduced in three murine models of recessive polycystic kidney disease, a developmental disorder, where some nephrons within the affected kidneys develop into huge fluid-filled cysts while the non-cystic nephrons atrophies by apoptosis. Here, we show that in the cpk/cpk mouse, which have polycystic kidneys, the female reproductive organs also fail to mature properly and remain arrested at an early stage of development. Direct measurement of 17betaHSD activity showed a severe reduction in estrogen and androgen metabolism within gonadal and non-gonadal tissues of the cpk/cpk mouse. Using immunofluorescent staining we localized the expression of the Ke 6 protein within the female mouse reproductive organs. Our findings suggest that estrogen/androgen metabolism may play an important role in the development of the urogenital systems.     

Asia-Pacific consensus on the management of gastroesophageal reflux disease: update

Background and Aims: Since the publication of the Asia‐Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed. Methods: A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Results: GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On‐demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non‐GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials. Conclusions: Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy.