Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma.

BACKGROUND: The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults. METHODS: Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively. RESULTS: Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05). CONCLUSION: Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.     

Multicenter clinical trial of recombinant human insulin-like growth factor I in patients with acute renal failure.

BACKGROUND: Patients with acute renal failure (ARF) have high morbidity and mortality rates, particularly if they have serious comorbid conditions. Several studies indicate that in rats with ARF caused by ischemia or certain nephrotoxins, insulin-like growth factor-I (IGF-I) enhances the recovery of renal function and suppresses protein catabolism. METHODS: Our objective was to determine whether injections of recombinant human IGF-I (rhIGF-I) would enhance the recovery of renal function and is safe in patients with ARF. The study was designed as a randomized, double-blind, placebo-controlled trial in intensive care units in 20 teaching hospitals. Seventy-two patients with ARF were randomized to receive rhIGF-I (35 patients) or placebo (37 patients). The most common causes of ARF in the rhIGF-I and placebo groups were, respectively, sepsis (37 and 35% of patients) and hypotension or hemodynamic shock (42 and 27% of patients). At baseline, the mean (+/- SD) APACHE II scores in the rhIGF-I and placebo-treated groups were 24 +/- 5 and 25 +/- 8, respectively. In the rhIGF-I and placebo groups, the mean (median) urine volume and urinary iothalamate clearances (glomerular filtration rate) were 1116 +/- 1037 (887) and 1402 +/- 1183 (1430) ml/24 hr and 6.4 +/- 5.9 (4.3) and 8.7 +/- 7.2 (4.4) ml/min and did not differ between the two groups. Patients were injected subcutaneously every 12 hours with rhIGF-I, 100 microgram/kg desirable body weight, or placebo for up to 14 days. Injections were started within six days of the onset of ARF. The primary end-point was a change in glomerular filtration rate from baseline. Other end points included changes from baseline in urine volume, creatinine clearance and serum urea, creatinine, albumin and transferrin, frequency of hemodialysis or ultrafiltration, and mortality rate. RESULTS: During the treatment period, which averaged 10.7 +/- 4.1 and 10.6 +/- 4.5 days in the rhIGF-I and placebo groups, there were no differences in the changes from baseline values of the glomerular filtration rate, creatinine clearance, daily urine volume, or serum urea nitrogen, creatinine, albumin or transferrin. In patients who did not receive renal replacement therapy, there was also no significant difference in serum creatinine and urea between the two groups. Twenty patients in the rhIGF-I group and 17 placebo-treated patients underwent dialysis or ultrafiltration. Twelve rhIGF-I-treated patients and 12 placebo-treated patients died during the 28 days after the onset of treatment. CONCLUSIONS: rhIGF-I does not accelerate the recovery of renal function in ARF patients with substantial comorbidity.     

The combined insulin and sulfonylurea therapy in diabetes of elderly people

The usefulness and safety of the combined insulin-sulfonylurea (gliclazide) therapy were investigated in 70 elderly diabetic patients poorly controlled by insulin alone. More than half (45 diabetics, 64% of total) ameliorated significantly their metabolic control after six months of the combined treatment: not only the glycemic profile and glycated hemoglobin Alc were significantly decreased, but the daily insulin dose was reduced by approx. 35% (p < 0.01). These positive results in terms of improved glycemic control as well as reduction of daily insulin needs were still present after a mean period of follow-up of 5 years. The good percentage of positive results, the small incidence of hypoglycemic episodes and the consistent reduction of peripheral hyperinsulinism make this intervention (insulin-gliclazide) a safe strategy that can be adopted in a population of elderly diabetics, poorly controlled on insulin alone.     

Additive effects of thermal injury and infection on the small bowel

Thermal injury is associated with functional alterations of multiple organ systems, including the gastrointestinal tract. To study the effects of ongoing infection after thermal injury on bowel mass, composition, and blood flow, male Wistar rats were randomized to receive either 30% scald burn, 30% scald burn with Pseudomonas aeruginosa wound inoculation, sham burn, or sham burn with pair feeding to burned and infected animals. On days 3 and 7 after injury, intestinal blood flow was measured with 51Cr-labeled microspheres, and intestinal mass and composition were analyzed. Burned and infected animals demonstrated a chronic loss of small bowel mass not seen in burned animals without infection by day 7 after injury. Compositional alterations of the small bowels of burned and infected animals included protein wasting similar to but occurring earlier than that seen with anorexia alone and significantly decreased deoxyribonucleic acid and ribonucleic acid content, whereas tissue water content remained unchanged. These chronic intestinal alterations in the burned and infected group could not be explained by ongoing ischemia because intestinal blood flow in these animals was not significantly altered at either time point, implying mediation by other pathophysiologic mechanisms.     

Pancreatic trauma: Diagnostic and therapeutic strategies

Opinion statement The management of pancreatic trauma provides trauma surgeons with diagnostic and therapeutic challenges. The two most important facts that must be established are the location of the injury in relation to the superior mesenteric artery and vein and the status of the main pancreatic duct. If a pancreatic injury is discovered at the time of exploration and no main ductal injury is found, debridement and wide drainage are adequate therapy regardless of the location of the injury. If the status of the duct cannot be confidently determined and the injury lies to the left of the vessels, a single attempt at cholecystocholangiography should be performed. If this is unsuccessful, distal pancreatectomy with splenectomy with no further attempts at ductal imaging are our treatments of choice. Splenic salvage may be considered in the pediatric population. If the injury lies to the right of the vessels and the status of the duct is not able to be diagnosed with thorough exploration, we recommend endoscopic retrograde cholangiopancreatography (ERCP), either intraoperatively or on an urgent basis postoperatively, with wide closed suction drainage prior to closure of the abdomen. If the ERCP shows intact pancreatic and common bile ducts, expectant management is warranted. If the duct is injured, the patient is returned to the operating room for debridement of the injury, oversewing of the proximal pancreatic duct, and a distal pancreaticojejunostomy. Use of ERCP to stent this injury type has been reported but has yet to be rigorously studied. If the ampulla is destroyed or the pancreatic head is devascularized, pancreaticoduodenectomy is required either at the original surgery or after patient stabilization if damage control laparotomy is necessary. If a stable trauma patient has findings on a computed tomography suggestive of an isolated pancreatic injury, we still recommend laparotomy using the previously mentioned algorithm. All patients with pancreatic injury should have feeding access placed intraoperatively beyond the ligament of Treitz, with our choice being a nasal-jejunal feeding tube. Postoperative pancreatic fistulae should be managed with adequate closed suction drainage, octreotide, and observation for a period of at least 4 to 8 weeks prior to contemplation of surgical intervention.     

A case of recurrent aspiration pneumonia by achalasia]

A 56-year-old woman came to our hospital with the symptoms of anorexia, body weight loss and sustained cough. Chest radiography showed diffuse, rounded, high-attenuation areas in both lung fields. The diagnosis was difficult, but, because of the symptoms and chest radiograph, we suspected miliary tuberculosis. Finally, we diagnosed her illness as achalasia with aspiration pneumonia, because we found a dilated esophagus and diffuse, rounded, high attenuation areas in chest CT scan films. Neither Mycobacterium tuberculosis nor tuberculous granulation was present in transbronchial lung biopsy specimens. Only inflammation was found in those slides. The gastrofiberscope was useful for searching for tumors, but not for diagnosing achalasia. Consequently, we identified the achalasia from the radiographic findings with the use of barium, but the patient's symptoms might not have led to that diagnosis because she was younger than the age range in which aspiration pneumonia usually occurs. The achalasia was treated with surgery rather than balloon dilation, since that was the patient's choice. Three months after surgery, her lungs had improved and body weight had increased by about 10 kg.