Antegrade internal ureteral stenting: a technical refinement

A pliable, easy to place, double pigtail, internal ureteral stent made of elastomeric polyurethane is described. The tapered distal pigtail end minimizes bladder irritation and the combination of a pusher and absorbable suture enables optimal placement of the proximal pigtail end in the renal pelvis. Ten stents used in eight patients remained functional without bladder irritation for a mean period of 8 months (range, 2-14 months).     

Comparison of isotonic and hypertonic fluids in resuscitation from hypovolemic shock

Hypertonic electrolyte solutions provide effective fluids for resuscitation of burn patients and concurrent replacement of hemorrhage. Infusion of mannitol has also been advocated as a means of increasing cardiac output in acutely ill patients. Pigs which were bled to one-third of their blood volume were used in this random study of resuscitation with Ringer's lactate solution (RL), hypertonic saline solution (HSL) and RL with mannitol added (HMR) to give the same osmolality as HSL. Smaller volumes of the hyposmolar solution than of RL restored blood pressure and cardiac output. RL and HSL restored and maintained cardiac output more effectively than HMR. At 24 hours, HSL maintained blood pressure most effectively.     

Alagille's syndrome associated with cystic renal disease

Although renal abnormalities have been described in children with Alagille's syndrome, cystic kidney disease has not often been documented, and then usually only at necropsy. Three children with Alagille's syndrome are described, in two of whom a unilateral multicystic dysplastic kidney was detected by prenatal ultrasound; in the other, a solitary cortical cyst was found later in childhood. All have normal renal function, growth, and liver synthetic function but continue to have clinical and biochemical signs of cholestasis. These cases show that unilateral cystic kidney disease with or without renal dysplasia may be associated with Alagille's syndrome, that the clinical course is not necessarily unfavourable, and that Alagille's syndrome should be included in the differential diagnosis of cystic kidney disorders associated with cholestatic liver disease. Patients with Alagille's syndrome should be evaluated by renal ultrasound.     

A needs assessment for regionalization of trauma care in a rural state

Systems of trauma care in urban areas have a demonstrated survival benefit. Little is known of the benefit of trauma system organization in rural areas. We hypothesized that examination of all trauma deaths during a 1-year period would provide opportunities to improve care in our rural state. We used a medical examiner database of trauma deaths occurring during a 1-year period. Five board-certified surgeons analyzed deaths as preventable (P), potentially preventable (PP), and non-preventable (NP) using modified Delphi technique. There were 223 trauma deaths during a 1-year period. Most (63%) died at the scene prior to any medical intervention. Adjudication of the deaths demonstrated 5 P (2%; 95% CI 1-5%), 36 PP (16%; 95% CI 12-27%), and 179 NP (81%; 95% CI 76-86%). Agreement among trauma surgeons was only moderate with a k of 0.46. Suicide accounted for a significant number of the overall trauma deaths at 32 per cent. Rural trauma system design should focus on discovery, as that is where the majority of deaths occur. Suicide is a significant problem in this rural state that should be aggressively targeted with prevention programs.     

Delirium Tremens

The varied clinical manifestations and management of 14 male patients with delirium tremens (DT) have been studied. Eight patients were initially hospitalised for diseases unrelated to ethanol abuse i.e. 2 each for gun shot wound, myocardial infarction and stroke, and one each for pneumonia and gastroenteritis. One patient was going through withdrawal because of prodrome of viral hepatitis before he was hospitalised for uncontrolled agitation and delirium. Two known cases of mild essential hypertension on dietary therapy reported for agitation, abnormal behaviour, a single episode of tonic clonic seizure and hypertensive encephalopathy as they could not/did not get alcohol for 3 days. Three patients presented denovo with DT without concomitant illness. The other features besides delirium and hallucinations were tremulousness in 10, tachycardia in 12, fever in 3, diaphoresis in 2 and tonic clonic seizures in 4 patients. The symptoms fluctuated markedly at short intervals and 2 patients did not have any features of sympathetic overactivity. Altered hepatic biochemical parameters and ketonuria with normal blood sugar were noted in 4 and one patients respectively. Other biochemical parameters including serum electrolytes were normal. CT scan brain done for 5 patients revealed subdural haematoma in one. Cerebro spinal fluid (CSF) and EEG findings were noncontributory. All made good recovery with heavy doses of intravenous vitamin B complex, glucose and oral benzodiazepine. Short course of haloperidol was used in 2 patients. Two patients developed pancreatitis during follow up. All patients made complete recovery, and 8 patients have been followed for 8 to 12 months without relapse. The reason for hospitalisation in such cases is often unrelated to alcohol abuse; hence a detailed history of alcoholism is mandatory to identify those at risk as well as for prompt treatment and decreasing the mortality.Key Words: Alcohol withdrawal, Concomitant illnesses, Delirium, Precipitating events     

Improving the Glasgow Coma Scale score: motor score alone is a better predictor

BACKGROUND: The Glasgow Coma Scale (GCS) has served as an assessment tool in head trauma and as a measure of physiologic derangement in outcome models (e.g., TRISS and Acute Physiology and Chronic Health Evaluation), but it has not been rigorously examined as a predictor of outcome. METHODS: Using a large trauma data set (National Trauma Data Bank, N = 204,181), we compared the predictive power (pseudo R2, receiver operating characteristic [ROC]) and calibration of the GCS to its components. RESULTS: The GCS is actually a collection of 120 different combinations of its 3 predictors grouped into 12 different scores by simple addition (motor [m] + verbal [v] + eye [e] = GCS score). Problematically, different combinations summing to a single GCS score may actually have very different mortalities. For example, the GCS score of 4 can represent any of three mve combinations: 2/1/1 (survival = 0.52), 1/2/1 (survival = 0.73), or 1/1/2 (survival = 0.81). In addition, the relationship between GCS score and survival is not linear, and furthermore, a logistic model based on GCS score is poorly calibrated even after fractional polynomial transformation. The m component of the GCS, by contrast, is not only linearly related to survival, but preserves almost all the predictive power of the GCS (ROC(GCS) = 0.89, ROC(m) = 0.87; pseudo R2(GCS) = 0.42, pseudo R2(m) = 0.40) and has a better calibrated logistic model. CONCLUSION: Because the motor component of the GCS contains virtually all the information of the GCS itself, can be measured in intubated patients, and is much better behaved statistically than the GCS, we believe that the motor component of the GCS should replace the GCS in outcome prediction models. Because the m component is nonlinear in the log odds of survival, however, it should be mathematically transformed before its inclusion in broader outcome prediction models.