Antibiotic Treatment Has No Influence on Anal Fistula Formation and Recurrent Perianal Abscess After Incision and Drainage of Cryptogenic Perianal Abscess: A Randomized Single-Blind Prospective Study

BACKGROUND

Anal fistula commonly appears after incision and drainage of perianal abscess. Theoretically, fistula develops as a consequence of infection process. Antibiotic treatment was suggested to decrease the possibility of fistula development.

OBJECTIVE

We hypothesized that antibiotic treatment has no influence on development of anal fistula after surgical treatment of perianal abscess.

DESIGN

A single blind randomized prospective study.

SETTING AND PATIENTS

Patients with primary cryptogenic abscess were eligible to participate. Patients were divided in two groups. Patients in Group I received amoxicillin 875mg/clavulanic acid 125mg during 7 days after surgery and Group II patients received no antibiotics. Study database included demographics, clinical and laboratory data.

MAIN OUTCOME MEASURES

Patients were examined in our outpatient clinic 2 weeks, four months and 1 year after surgery and telephone questionnaire performed 6 month after surgery. Primary Outcome was formation of anal fistula. Secondary Outcome was recurrent perianal abscess.

RESULTS

Overall 98 patients completed the study. Groups were not different on inclusion. Anal fistula was diagnosed in 16 (16.3%) patients in Group I (treatment group) and 10 (10.2%) patients in the Group II (control group) (p = 0.67). Nine patients (9.2%) developed recurrent perianal abscess, 4 in the treatment group, and 5 in the control group (p = 0.73).

LIMITATIONS

Relatively small number of patients treated in single Medical Center.

CONCLUSION

Antibiotic therapy has no influence on anal fistula or recurrent perianal abscess formation after incision and drainage of perianal abscess. See Video Abstract.

Release Our Hostages Now!

It has been the policy of Rambam Maimonides Medical Journal to limit the number of editorials published. However, silence and standing on the sidelines is not an option in light of the atrocities and inhumanity we witnessed on October 7. The savagery of the Hamas massacre was executed indiscriminately upon children, women, older people (some of whom are Holocaust survivors), infants, and even medical professionals caring for the casualties. Currently, there are about 230 women, men, children, and babies being held hostage by Hamas; among them are cancer patients and others with serious disorders, doctors, and other medical professionals. We cannot rest and must address the plight of our hostages who are being held by terrorists motivated by hatred and showing no respect for life, whether that of their enemies, their own people, or even themselves. ...

Inappropriate Journal Authorship, Disputes, Plagiarism, and Mistrust in the Institution: Different Beasts ... Same Problem

We would like to thank Professor Marshall Lichtman for his letter, his interesting proposal, and using this venue to promote discussion of the topic. Professor Lichtman proposed a numerical calculation for authorship based on the authors’ perceptions of their relative contribution to a scientific publication, an idea also suggested by Jozsef Kovacs. The only limitation imposed by this system is that the total of all authors’ fractional contributions to any one publication equals no more than one. Lichtman’s interesting proposal serves as a disincentive to offer gift authorship to colleagues whose contributions were minimal, if they contributed at all.

Transanal endoscopic microsurgery technique: an acceptable approach for retrorectal tumors

INTRODUCTION

Retrorectal lesions (RRLs) are rare lesions that originate from the tissue present in the retrorectal space. The gold standard of care is complete resection regardless of pathology. The traditional approaches (anterior, posterior, and combined) are relatively well described. Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique offered as an alternative approach for RRLs.

AIM

To evaluate the outcomes of patients diagnosed with RRL and treated by the TEM approach, especially postoperative complications, and the recurrence rate.

METHODS

Patients with RRLs treated with the TEM technique in one medical center between 2000 and 2020 were identified. Their postoperative outcomes were compared with historical controls.

RESULTS

Thirty-nine patients diagnosed with RRL were operated on using the TEM platform. Thirty-seven RRLs were benign, and two were malignant. Their median size (IQR) was 20 mm (15, 32.5). The median distance (IQR) from the anal verge was 50 mm (50, 72.5). The median operative time (IQR) was 48.5 min (41.75, 60). All, except one lesion, were completely resected. The median length of stay (IQR) was one day (1, 1 day). Postoperative complications were diagnosed in three patients, two of which resolved following a second operation.

CONCLUSIONS

The implementation of TEM for the resection of RRLs demonstrated excellent overall results with acceptable complication and recurrence rate and represented a viable alternative surgical approach.

Authorship Disputes in Scholarly Biomedical Publications and Trust in the Research Institution

INTRODUCTION

When authorship disputes arise in academic publishing, research institutions may be asked to investigate the circumstances. We evaluated the association between the prevalence of misattributed authorship and trust in the institution involved.

METHODS

We measured trust using a newly validated Opinion on the Institution's Research and Publication Values (OIRPV) scale (range 1-4). Mayer and Davies' Organizational Trust for Management Instrument served as control. Association between publication misconduct, gender, institution type, policies, and OIRPV-derived Trust Scores were evaluated.

RESULTS

A total of 197 responses were analyzed. Increased reporting of authorship misconduct, such as gift authorship, author displacement within the authors' order on the byline, and ghost authorship, were associated with low Trust Scores (P<0.001). Respondents from institutions whose administration had made known (declared or published) their policy on authorship in academic publications awarded the highest Trust Scores (median 3.06, interquartile range 2.25 to 3.56). Only 17.8% favored their administration as the best authority to investigate authorship dispute honestly. Of those who did not list the administration as their preferred option for resolving disputes, 58.6% (95/162) provided a Trust Score <2.5, which conveys mistrust in the institution.

CONCLUSIONS

Increased reporting of publication misconducts such as gift authorship, author displacement within the order of the authors' byline, and ghost authorship was associated with lower Trust Scores in the research institutions. Institutions that made their policies known were awarded the highest Trust Scores. Our results question whether the research institutions' administrations are the appropriate authority for clarifying author disputes in all cases.

Fresh Frozen Plasma Increases Hemorrhage in Blunt Traumatic Brain Injury and Uncontrolled Hemorrhagic Shock

BACKGROUND

Blunt traumatic brain injury (bTBI) and uncontrolled hemorrhagic shock (UCHS) are common causes of mortality in polytrauma. We studied the influence of fresh frozen plasma (FFP) resuscitation in a rat model with both bTBI and UCHS before achieving hemorrhage control.

METHODS

The bTBI was induced by an external weight drop (200 g) onto the bare skull of anesthetized male Lewis (Lew/SdNHsd) rats; UCHS was induced by resection of two-thirds of the rats' tails. Fifteen minutes following trauma, bTBI+UCHS rats underwent resuscitation with FFP or lactated Ringer's solution (LR). Eight groups were evaluated: (1) Sham; (2) bTBI; (3) UCHS; (4) UCHS+FFP; (5) UCHS+LR; (6) bTBI+UCHS; (7) bTBI+UCHS+FFP; and (8) bTBI+UCHS+LR. Bleeding volume, hematocrit, lactate, mean arterial pressure (MAP), heart rate, and mortality were measured.

RESULTS

The study included 97 rats that survived the immediate trauma. Mean blood loss up to the start of resuscitation was similar among UCHS only and bTBI+UCHS rats (P=0.361). Following resuscitation, bleeding was more extensive in bTBI+UCHS+FFP rats (5.2 mL, 95% confidence interval [CI] 3.7, 6.6) than in bTBI+UCHS+LR rats (2.5 mL, 95% CI 1.2, 3.8) and bTBI+UCHS rats (1.9 mL, 95% CI 0, 3.9) (P=0.005). Overall mortality increased if bleeding was above 4.5 mL (92.3% versus 8%; P<0.001). Mortality was 83.3% (10/12) in bTBI+UCHS+FFP rats, 41.7% (5/12) in bTBI+UCHS+LR rats, and 64.3% (9/14) in bTBI+UCHS rats.

CONCLUSION

The bTBI did not exacerbate bleeding in rats undergoing UCHS. Compared to LR, FFP resuscitation was associated with a significantly increased blood loss in bTBI+UCHS rats.

Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections

BACKGROUND

Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections.

OBJECTIVES

The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction.

METHODS

The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy.

RESULTS

A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA.

CONCLUSIONS

CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).

Misdiagnosis of Acute Appendicitis in the Emergency Department: Prevalence, Associated Factors, and Outcomes According to the Patients' Disposition

Background: Although abdominal pain is one of the most common complaints of patients presenting to the emergency department (ED), and acute appendicitis is a leading surgical differential diagnosis of patients presenting with abdominal pain, the diagnosis of acute appendicitis remains challenging. We examined the missed diagnosis rate of acute appendicitis in one ED and evaluated the association between disposition (discharge home or hospitalization in the wrong department) and complicated appendicitis. Methods: We retrospectively evaluated the medical records of patients with acute appendicitis and periappendicular abscess from January 1, 2013, to December 31, 2016. Results: The diagnosis of acute appendicitis was missed in 7.1% of patients (90/1,268) at their first ED encounter: 44 were discharged, and 47 were hospitalized with a wrong diagnosis (1 female patient was both discharged and then hospitalized with an incorrect diagnosis). Compared to the patients who were correctly diagnosed, patients with a missed diagnosis were older (median age 29 years vs 23 years, P=0.022), their time between ED first encounter and surgery was longer (median 29.5 hours vs 9.3 hours, P<0.001), and their rate of complicated appendicitis was higher (54.4% vs 27.5%, P<0.001). Missed females were more commonly hospitalized (26/39), while missed males were more commonly discharged from the ED (31/52) (P=0.019). No differences in the time between the first ED encounter and surgery (29.6 hours vs 29.6 hours, P=0.29) and the rate of complicated appendicitis (63.8% vs 43.2%, P=0.06) were noted between hospitalized patients with a wrong diagnosis and those discharged from the ED. Of the 25 patients with periappendicular abscesses, only 3 could be related to missed diagnoses during their first encounter in the ED. Conclusion: We found that 7.1% of patients were missed during their first encounter in the ED. Hospitalization in departments other than general surgery was not protective against delay in surgery or the development of complicated appendicitis. Periappendicular abscess was attributable to late referral rather than a missed diagnosis in most patients.

Education, training and technological innovation, key components of the ESTES-NIGHTINGALE project cooperation for Mass Casualty Incident preparedness in Europe

Disasters induced by extreme weather events and terrorism-related activities, causing mass casualty incidents (MCIs) in Europe, are expected to increase in the upcoming years. This challenging scenario demands a high level of readiness and coordinated multi-disciplinary response to reduce morbidity and mortality. The European Society of Trauma and Emergency Surgery (ESTES) is one of the 23 partners of the European-funded project Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE), whose primary objective is to promote the exchange in experiences and define the best practices among first responders. Additionally, the project promotes multi-disciplinary and multi-institutional efforts to achieve technological innovation that will enhance preparedness in MCI management. This manuscript aims to describe the challenges of MCI triage, the education and training programs for MCI response in Europe, and the technological innovation that may aid optimal response. These three elements were discussed by ESTES Disaster and Military Surgery Section members during the German Society for Trauma Surgery session at the ECTES 2022 in Oslo "TDSC^® and beyond: ideas and concepts for education and training in Terror Preparedness", additionally the manuscript describes the first steps of the cooperation between ESTES and the rest of the NIGHTINGALE consortium.

Violence against women in Israel: injury mechanisms and clinical outcomes following hospitalization

PURPOSE

The objective of this study was to evaluate the relative contributions of different mechanisms of assault to injury and mortality in women in Israel.

METHODS

We identified females hospitalized between 2011 and 2020 following an assault, secondary to blunt, stabbing, or shooting mechanisms of injury, in the Israeli Program for Registration of Trauma Patients (National Trauma Registry). To avoid bias due to temporary hospitalizations for non-medical reasons, we included patients with injuries graded as Abbreviated Injury Scale ≥ 2.

RESULTS

Females accounted for 8.1% (926/11,486) of assault patients in the study population. Compared to males, females were older (40.7 vs. 31.0 years; p < 0.001), more commonly injured by the blunt trauma mechanism (72.1 vs. 48.6%; p < 0.001), and more commonly injured at a place of residence (50.9 vs. 8.2%; p < 0.001). There were no differences in the number of body areas injured, severe Injury Severity Score, and median hospitalization. Males were operated more commonly (44.6 vs. 40.0%; p = 0.008). Mortality in females and males was similar (2.8 vs. 2.3%; p = 0.43). Secondary analysis revealed that blunt injuries were responsible for 61.2% of the severe cases (ISS ≥ 16), 61.4% of the operations, 54.9% of the Intensive Care Unit (ICU) admissions, and 53.8% of the mortality observed in females. When compared to males injured by blunt trauma, females injured by this mechanism were older (43.0 ± 24.7 vs. 32.8 ± 16.1 years; p < 0.001) and had higher mortality (2.1 vs. 0.9%; p = 0.007).

CONCLUSIONS

Assault by mechanisms other than stabbing and shooting should be recognized as a source of severe morbidity and mortality in females.

Clinical Presentation of Acute Cholecystitis during the COVID-19 Outbreak

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on healthcare systems worldwide. The fear of seeking medical attention to avoid the possibility of being infected may have altered the course of some diseases.

OBJECTIVES

To describe our experience with the management of patients with acute cholecystitis during the pandemic at our medical center.

METHODS

We compared patients treated for acute cholecystitis between 1 March and 31 August 2020 (Group I) to patients admitted with the same diagnosis during the same months in 2019 (Group II). We evaluated demographics, presenting symptoms, laboratory and imaging findings at presentation, the disease's clinical course, management, and outcome.

RESULTS

Group I consisted of 101 patients and group II included 94 patients. No differences were noted for age (66 years, IQR 48-78 vs. 66 years, IQR 47-76; P = 0.50) and sex (57.4% vs. 51.1% females; P = 0.39) between the two groups. The delay between symptom onset and hospital admission was longer for Group I patients (3 days, IQR 2-7 vs. 2 days, IQR 1-3; P = 0.002). Moderate to severe disease was more commonly encountered in Group I (59.4% vs. 37.2%, P = 0.003). Group I patients more often failed conservative management (36% vs. 6%, P = 0.001) and had a higher conversion rate to open surgery (15.4% vs. 0%, P = 0.025).

CONCLUSIONS

Patients presenting with acute cholecystitis during the COVID-19 pandemic more often presented late to the emergency department and more showed adverse outcomes.

The efficiency of MarginProbe in detecting positive resection margins in epithelial breast cancer following breast conserving surgery

INTRODUCTION

Up to 30% of patients undergoing lumpectomy for breast cancer are in need for re-excision due to either close or involved margins. We evaluated the yield of Margin Probe© (MP; Dilon Technologies, USA) in a cohort of patients undergoing lumpectomy for both palpable and non-palpable tumors.

METHODS

Following lumpectomy, margins were evaluated with MP and readings were compared to the lumpectomies' pathological evaluation irrespective of whether additional margins were removed during surgery. Involved margins or the presence of DCIS within 1 mm of the resection margins were considered as positive margins.

RESULTS

48 patients with 51 tumors underwent lumpectomy. Thirteen of the 51 lumpectomies had pathological close or involved margins. MP identified 3 out of the 13 positive margins. False-positive readings were recorded in 97 out of 287 margins. The sensitivity, specificity, positive predictive value and negative predictive value were 23.1% (95%CI 5.0% 53.8%), 66.4% (95%CI 60.7%-71.9%), 3% (95%CI 0.6%-8.5%), and 95.1% (95%CI 91.1%-97.6%) respectively.

CONCLUSIONS

MP cancer detection rate is relatively low while high false-positive rate leads to unnecessary shavings in almost all patients. Evaluation of MP performance should be based on comparing MP read to pathology report.

In-vitro model for bacterial growth inhibition of compartmentalized infection treated by an ultra-high concentration of antibiotics

BACKGROUND

Pseudomonas aeruginosa (P. aeruginosa), Escherichia coli (E. coli), and Staphylococcus aureus (S. aureus) are common pathogens encountered in infected cardiovascular-implantable electronic device (CIED). Continuous, in-situ targeted, ultra-high concentration antibiotic (CITA) treatment is a novel antibiotic treatment approach for localized infections. CITA provides sufficient local antibiotic concentrations to heavily infected cavities while avoiding systemic toxicity.

AIM

In-vitro confirmation of the efficacy of the CITA treatment approach in simulated compartmentalized infections.

MATERIALS AND METHODS

A rapid automated bacterial culture analyzing system) Uro4 HB&L™ (was applied to compare the efficacy of selected antibiotics at a standard minimal inhibitory concentration (1MIC), 4MIC, and CITA at 103MIC, for growth inhibition of high bacterial loads (106 colony-forming-units/ml) of ATCC strains of P. aeruginosa, E. coli, and S. aureus.

RESULTS

The addition of gentamicin and amikacin at 1MIC concentrations only temporarily inhibited the exponential growth of E. coli and P. aeruginosa. 4MIC level extended the delay of exponential bacterial growth. Increasing concentrations of vancomycin similarly temporarily delayed S. aureus growth. All tested antibiotics at CITA of 103MIC totally inhibited the exponential growth of the tested bacteria through 72 hours of exposure. (P<0.001).

CONCLUSION

In this in-vitro model, CITA at 103MIC effectively inhibited exponential bacterial growth of high loads of P. aeruginosa, E. coli, and S. aureus. This model offers preliminary laboratory support for the benefit of the in-situ antibiotic treatment, providing ultra-high concentrations directly at the compartmentalized infection site, not achievable by the conventional intravenous and oral routes.

Minimizing treatment complexity of combat-related soft tissue injuries using a dedicated tension relief system and negative pressure therapy augmented by high-dose in situ antibiotic therapy and oxygen delivery: a retrospective study

BACKGROUND

Following combat-related, extensive soft tissue injury from gunshot wounds or blasts, prolonged duration from injury to full wound closure is associated with infection, increased morbidity and mortality, failure to mobilize, poor functional outcome and increased cost. The purpose of this study was to evaluate a novel treatment enabling early primary closure of combat wounds.

METHODS

This was a retrospective study of 10 soldiers and civilians with extensive combat-related soft tissue limb injuries (5 gunshot wounds, 5 blasts) treated using the TopClosure^® Tension Relief System (TRS) with simultaneous administration of regulated oxygen-enriched and irrigation negative pressure-assisted wound therapy (ROINPT) via the Vcare α^® device.

RESULTS

Nine patients were treated during the acute phase of injury and one was treated following removal of a flap due to deep infection 20 years after injury and flap reconstruction. Two patients had upper limb injury and the rest lower limb injury. With the aid of the TRS and/or ROINPT, immediate primary closure during reconstruction was achieved in 6 patients and delayed primary closure in three. Only one patient required a skin graft to close a small area of the wound after most of the wound had been closed by delayed primary closure. Wound closure was achieved within 0-37 days (median: 12.5 days, interquartile range: 2.75-19.75) from injury.

CONCLUSIONS

The TRS is a novel device for effective, early skin stretching and secure wound closure through the application of stress relaxation and mechanical creep, achieving primary closure of large defects using a simplified surgical technique and reducing the need for closure using skin grafts and flaps and the use of tissue expanders. Delivering supplemental oxygen to the wound by ROINPT reverses the reduced oxygen levels inherent in conventional negative pressure-assisted wound therapy, mitigating anaerobic contamination and reducing infection. Irrigation may accelerate the evacuation of infectious material from the wound and provide a novel method for antibiotic administration. The combination of TRS and ROINPT devices allow for early primary closure with improved functionality of combat-related limb injuries.

Retrospective Evaluation of Factors Affecting Lymph Node Retrieval Following Gastrectomies with Oncologic Intent

BACKGROUND

Adequate lymphadenectomy is an important factor affecting survival in gastric cancer patients. Retrieval and examination of at least 15 lymph nodes is recommended in order to properly stage gastric malignancies. The objectives of this study were to evaluate the proportion of patients undergoing inadequate lymphadenectomies and possible risk factors for inadequate surgery.

METHODS

This was a retrospective study that included patients, 18 years and older, who underwent gastrectomies with oncologic intent in the Hillel Yaffe Medical Center. We analyzed the association of demographic, clinical, and pathological variables with adequate number of lymph nodes.

RESULTS

The retrieval of less than 15 lymph nodes was reported in 51% (53/104) patients undergoing gastrectomies with oncologic intent. The extent of surgery was the only variable associated with inadequate lymphadenectomy on univariate analysis: subtotal/proximal versus total gastrectomy (P=0.047). Differences observed for previous surgery (P=0.193), T stage (P=0.053), N stage (P=0.051), and lymphovascular invasion (P=0.14) did not reach significance. Subtotal/proximal gastrectomy resulted in inadequate resection of lymph nodes in 56% of the patients, while this occurred in only 30% of the patients undergoing total gastrectomy (relative risk 1.865; 95% CI 0.93, 3.741). Logistic regression confirmed that only subtotal/proximal versus total gastrectomy was associated with inadequate number of lymph nodes resected (P=0.043).

DISCUSSION AND CONCLUSION

In this study we analyzed the association of patient, tumor, and surgery-related factors on adequate lymphadenectomy in patients undergoing gastrectomies for possible gastric cancer. Larger extent of the surgery (total, rather than subtotal/proximal gastrectomy) was revealed to be the only indicator positively associated with adequate lymphadenectomy.

Early postoperative dressing removal in hand surgery: Novel concepts for individualized surgical dressing management

Postoperative dressing protocols after clean surgery without implant vary widely. The purpose of this study was to elucidate whether early postoperative dressing removal is a valid option, as compared to untouched dressing or twice-weekly dressing change approach. A prospective randomized study was conducted on patients who underwent carpal tunnel release (CTR) or trigger finger release (TFR) between January and November 2020. Patients were randomly distributed into 3 groups: surgical dressing untouched until first follow up (SDU); surgical dressing changed twice a week in a health maintenance organization (HMO); and surgical dressing removed at first postoperative day (SDR). Data collected included patient characteristics, pre-and post-operative functional (QuickDASH) and autonomy (Instrumental Activities of Daily Living performance (IADL)) scores, Vancouver scar scale (VSS) and potential complications. Eighty-four patients were included: 28 (33.3%), 29 (34.5%) and 27 (32.1%) in the SDU, HMO and SDR groups, respectively. Deterioration in mean IADL score at 2-week follow-up was statistically significant in the HMO group (mean delta 3.35, p = 0.008). Quick DASH score improved significantly between preoperative and 2-week follow-up values only in the SDU group (mean delta 9.12, p = 0.012). Other parameters, including wound complications, did not differ significantly between groups. Early removal of postoperative dressing and immediate wound exposure was a safe option after CTR and TFR. An untouched bulky dressing correlated with early functional improvement. Finally, iterative dressing change in HMO showed no benefit and led to significant deterioration in early postoperative autonomy. IRB APPROVAL: 0548-18-TLV. LEVEL OF EVIDENCE: I.

Failure of observation and need for delayed tube thoracostomy in 197 unselected patients with occult pneumothorax: a retrospective study

INTRODUCTION

Occult pneumothorax (OPTX) is defined as air in the pleural space that was not suspected on plain chest X-ray but detected on CT. Controversy exists in the management of OPTX, especially in patients who require positive pressure ventilation (PPV). In this study, we investigated the need for tube thoracostomy (TT) in blunt trauma patients with OPTX.

MATERIALS AND METHODS

This is a retrospective study of blunt trauma patients of all ages with evidence of OPTX, treated in the Shamir Medical Center Trauma Unit between 2008 and 2017. Two groups were defined. Group I consisted of patients requiring PPV. Group II included patients who did not require PPV. We identified the indication for TT insertion (hemothorax, significant pneumothorax, and enlarging pneumothorax). Necessity for delayed TT insertion due to enlarging pneumothorax was analyzed.

RESULTS

Overall 512 patients with traumatic pneumothorax were admitted. 197 (38.5%) had OPTX. Motor vehicle accidents and falls from height accounted for most of the injuries, 47.2 and 42.6%, respectively. Fifty-seven patients required PPV. TT was required in 31 (15.7%) patients. No differences were found between the overall rate of TT insertion between the groups (15.7 vs. 21.1%; p = 0.2) and for delayed insertion of a TT due to an enlarging pneumothorax (25.0 vs. 42.1%; p = 0.45).

CONCLUSION

TT is not indicated in every patient with OPTX even in case of mechanical ventilation.

The 4-hour target in the emergency department, in-hospital mortality, and length of hospitalization: A single center-retrospective study

BACKGROUND

The four-hour (4 h') rule in the emergency department (ED) is a performance-based measure introduced with the objective to improve the quality of care. We evaluated the association between time in the ED with in-hospital mortality and hospital length of stay (LOS).

METHODS

This was a retrospective study performed in one public hospital with over 100,000 ED referrals per year. Hospitalizations from the ED during 2017 were analyzed. We defined time in the ED as either: until a decision was made (DED); or total time in the ED (TED). In-hospital mortality and LOS were evaluated for patients with DED or TED within and beyond 4 h'.

RESULTS

Compared to patients with TED or DED within 4 h', in-hospital mortality did not increase in patients with TED beyond 4 h' (2.8% vs. 3.1%, non-significant), or DED beyond 4 h' (2.1% vs. 3.2%, p < 0.001). LOS did increase in patients with either DED or TED beyond 4 h' (p < 0.001). In-hospital mortality increased with increasing DED-TED intervals for patients hospitalized in the internal medicine departments: 3.7% (0-1 h'), 5.1% (1-2 h'), 5.7% (2-3 h'), and 7.1% (>3 h') (p < 0.001).

CONCLUSIONS

In-hospital mortality was not associated with time in the ED beyond 4 h'. LOS, however, was increased in this group of patients. Decreased LOS observed in patients with time in the ED within 4 h', does not support patients' risk as a contributing factor leading to higher trends in mortality observed in this patient group. In-hospital mortality was associated with an increase in DED-TED intervals in patients hospitalized in the internal medicine departments.

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

BACKGROUND

Self-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered.

METHODS

All patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II).

RESULTS

Group I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p<0.001), had more females (28.7% vs 4.9%, p <0.001), had longer length of hospitalization (median: 3 days vs. 2 days; p<0.001), underwent surgery more frequently (55.4% vs. 37.4%; p<0.001), and had higher mortality (2.9% vs. 0.7%; p=0.003). Possible covariates for mortality were examined and following logistic regression, self-inflicted injury remained associated with higher death rates compared to assault (OR 4.027, CI95% 1.380, 11.749; p=0.011).

CONCLUSION

In this study, patients with isolated self-inflicted abdominal injuries had higher mortality and more frequently underwent abdominal surgery.

Simplified management of a giant forehead congenital nevus allows for early reconstruction

We report simplified surgical management of giant congenital forehead nevus that customarily requires the use of tissue expander for complete excision. Commencing treatment at the age of 3 months, the TopClosure tension relief system (TRS) was applied as an external tissue expander allowing preoperative skin stretching by mechanical creep. This was followed by partial excision of the nevus. Intraoperative stress-relaxation allowed further expansion of the skin. Postoperative wound closure was secured with the aid of the TRS. Repeated, six simple staged excisions of the forehead lesion and a minor skin graft to the eyelid part, allowed for delayed primary closure of the entire lesion by the age of 2. This simple alternative approach, which allows the early start and early conclusion of the reconstructive process, should be considered as the primary option in the treatment of these patients.

Evaluation of length and complexity of written consent forms in English and Hebrew for participation in clinical trials authorized in one medical institution in Israel: A descriptive study

Informed consent forms (ICFs) in clinical trials are the only objective testimony whether the information provided to participants is comprehensive and presented in an accessible language. We evaluated the length of Hebrew ICFs and their English translations and evaluated the readability of the latter. In fifteen clinical trials (5 with pharmacogentic sub-study), the median number (IQR) of pages and words were: English clinical ICFs - 16 pages (13,18) and 7360 words (6959,8289); Hebrew clinical ICFs - 12 pages (10,14), 5807 words (5258,6403); English pharmacogenetics ICFs - 7 pages (4,11), 2930 words (2234,5100); Hebrew pharmacogenetics ICFs - 5 pages (4,8.5), 2273 words (1663,3889); the two English ICFs combined - 23 pages (18;29.5), 10,820 words (9515,15,600); and the two Hebrew ICFs combined - 19 pages (16,23), 8258 words (7340,10,515). Differences between the Hebrew clinical trial ICFs and their English translations were significant (p < 0.001). Median (IQR) Flesch Reading Ease scores for the clinical and the pharmacogenetics ICFs were 48.4 (42.7, 49.9) and 42.2 (41.7,42.65), respectively. Thirteen studies were multinational. Twelve were conducted simultaneously in the United States, where an assessment of readability scores is customary. In conclusion, the consent forms evaluated in this study were long, and readability scores were low.

Relaxation systems of the skin for the closure of large mammary defects

In mammary tumors that are large relative to breast-size, complex reconstructive methods are required. We describe an alternative system of closure. In circumstances such as this, primary closure of this skin defect may be enabled by stress relaxation of the skin and the use of a tension-relief system. Tension-relief systems secures immediate primary closure of large skin defects in patients with large for breast-size tumors by placing the tension away from the skin edges. This enables early skin closure and rapid mobilization with good functionality. Optimal healing facilitates postoperative radiotherapy on time without reconstruction failure.

Pain is a Limiting Factor in Patients Suitable for Transilluminated Powered Phlebectomy

OBJECTIVES

To analyze, perioperatively and in follow-up, transilluminated powered phlebectomy (TIPP), a surgical technique for the treatment of varicose veins.

METHOD

Retrospective study in one medical institution of patients undergoing TIPP between July 2015 and December 2017. Data analyzed included demographic data, surgery, and results. Postoperatively, pain was evaluated by a 10-point visual analogue scale. The Venous Clinical Severity Score (VCSS) was assessed 5-8 weeks following surgery.

RESULTS

Sixty-six patients with extensive varicosities who underwent TIPP were included. Postoperative pain scores were higher in patients undergoing bilateral compared to unilateral TIPP (visual analogue score 7 versus 5; P=0.031). Following surgery, the VCSS improved in 81.8% (54/66) of the patients. However, 39.7% (25/63; data missing in 3 patients) reported that they would not be willing to undergo a similar procedure in the future. Pain was the most common reason for dissatisfaction.

CONCLUSIONS

Transilluminated powered phlebectomy was associated with considerable pain and discomfort in many patients included in this study. For this reason, it should be reserved for a select group of patients in whom other treatment options are limited; TIPP could be considered in the following cases: patients with a large number of varicosities, reoperations, after extensive thrombophlebitis, obesity, or following bariatric surgery.

[CORRELATION BETWEEN MRI AND ARTHROSCOPIC FINDINGS IN THE DIAGNOSIS OF KNEE PATHOLOGY IN YOUNG AND ADULT PATIENTS]

BACKGROUND

MRI is increasingly used as a diagnostic tool for sports injuries involving the knees before referral to arthroscopy.

OBJECTIVES

Since degenerative changes increase with age, we aimed to evaluate whether age affects the accuracy of MRI.

METHODS

This is a retrospective study of patients with knee injury whose evaluation included both MRI and arthroscopy. Two age groups were defined: young adults (18-39 years) and adults (40 years and above).

RESULTS

Of 966 patients undergoing knee arthroscopy, 132 had preoperative MRI: 48.5% young adults and 51.5% adults. Arthroscopy identified a meniscus tear in 85% and a ligament tear in 21%. Seventeen percent had combined tears and no injury was identified in 4%. The sensitivity and specificity of MRI for ligament tears was 59%, 95%, and for meniscus tears was 91%, and 40%. The sensitivity for bucket handle tears was 86%. The sensitivity of MRI for combined injury was low, 41%. In 8% of patients no pathology was identified by MRI, which was confirmed by arthroscopy in only 4%. One patient with normal MRI had a bucket handle menisceal tear and one other patient had a tear of the anterior cruciate ligament. MRI in adults and young adults revealed that sensitivities for the different types of lesions were similar for both age groups.

CONCLUSIONS

Although degenerative changes increase with age, our hypothesis that MRI will be less sensitive in adults was proven wrong. In the presence of appropriate signs and symptoms, older age should not be considered a factor affecting decisions concerning preoperative imaging workup.

Splenectomy for breast carcinoma diffusely metastatic to the spleen presenting as severe transfusion-dependent anaemia and thrombocytopaenia

We report a 48-year-old woman with metastatic infiltrating lobular carcinoma of the breast. Though her metastatic disease remained stable, she was repeatedly admitted for symptomatic anaemia and treated by red blood cell and platelet transfusions with increasing frequency as time elapsed. Abdominal examination and ultrasound revealed splenomegaly (27 cm span). A bone marrow biopsy showed fibrosis and foci of metastatic carcinoma. Splenectomy ameliorated her transfusion-dependent anaemia and thrombocytopaenia. Histopathology revealed multiple foci of metastatic carcinoma and scattered foci of extramedullary haematopoiesis. Differential diagnosis of anaemia and thrombocytopaenia in patients with cancer include bone morrow involvement by cancer cells, iron-deficiency anaemia, microangiopathies and chemotherapy suppression of haematopoiesis. Splenic involvement with cancer is common in patients with multivisceral disease. Many may regard transfusion-dependent severe anaemia and thrombocytopaenia as an end-stage disease in these patients. Nevertheless, palliative splenectomy should be considered in patients with possible hypersplenism who will otherwise survive for a relatively prolonged period of time.

Hemodynamic consequences of extremity injuries following a terrorist bombing attack: retrospective cohort study

BACKGROUND

Extremities are commonly injured following bomb explosions. The main objective of this study was to evaluate the prevalence of hemorrhagic shock (HS) in victims of explosion suffering from extremity injuries.

METHODS

Retrospective study based on a cohort of patient records maintained in one hospital's mass casualty registry.

RESULTS

Sixty-six victims of explosion who were hospitalized with extremity injuries were identified and evaluated. Sixteen (24.2%) of these were hemodynamically unstable during the first 24 h of treatment. HS could be attributed to associated injuries in seven of the patients. In the other nine patients, extremity injury was the only injury that could explain HS in seven patients and the extremity injury was a major contributor to HS together with another associated injury in two patients. In those 9 patients, in whom the extremity injury was the sole or major contributor to HS, a median of 10 (range 2-22) pRBC was transfused during the first 24 h of treatment. Six of the nine patients were in need of massive transfusion. Fractures in both upper and lower extremities, Gustilo IIIb-c open fractures and AIS 3-4 were found to be risk factors for HS.

CONCLUSIONS

Ample consideration should be given to patients with extremity injuries due to explosions, as these may be immediately life threatening. Tourniquet use should be encouraged in the pre-hospital setting. Before undertaking surgery, emergent HS should be considered in these patients and prevented by appropriate resuscitation.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Planned Re-Laparotomy in a Non-Trauma Setting: A Single Center Experience

BACKGROUND

Damage control laparotomy (DCL) is the widely accepted procedure of choice in management of severely injured trauma patient. It has been implemented in non-trauma-related surgical pathology in the last decade.

OBJECTIVES

To evaluate our experience with planned re-laparotomy (PRL) in non-trauma patients and compare it to other reports.

METHODS

Charts of all patients admitted to Assaf Harofeh Medical Center who underwent PRL for non-trauma-related abdominal pathology during a 6 year period were reviewed. Data regarding demographics, vital signs, laboratory tests, indications for surgery, length of hospital stay, and mortality were obtained from medical charts. Indications for surgery, risk factors, and mortality were analyzed.

RESULTS

The study was comprised of 181 patients. Primary abdominal sepsis (50), postoperative sepsis (49), mesenteric event (32), and intestinal obstruction (28) were the most common indications for PRL. Mortality rate was 48.6%. Factors correlating with increased mortality were advanced age, hypotension, hypothermia, metabolic acidosis, and renal failure. Bowel resection was performed on 122 patients (67%) and primary intestinal anastomosis constructed in 46.7%. Mortality rate was lower in patients who underwent PRL with primary anastomosis compared to patients with postponed bowel anastomosis (33.3% vs. 55.4%, P = 0.018).

CONCLUSIONS

PRL in abdominal emergencies carries a high mortality rate. Primary anastomosis may be considered in non-trauma-related PRL.

Drug Induced Myopia Associated with Treatment for Gynecological Problems

We present three cases of women who developed acute transient myopia caused by drugs for gynecological problems. One patient was treated with disothiazide for premenstrual edema. The second had acute cystitis and was treated by sulphonamide and the third developed myopia coincident with metronidazole treatment for trichomonas vaginalis. We followed these patients by A scan ultrasonographic ocular measurements, documenting reduction of the anterior chamber depth combined with lens thickening. The ocular and myopic changes cleared up completely on discontinuation of the causative agent. The possible mechanism is thought to be an allergic reaction to the drug.

MicroRNA regulation of progesterone receptor in breast cancer

Hormone receptor status is of significant value when deciding on anti-estrogenic adjuvant therapy for breast cancer tumors. However, while estrogen receptor (ER) regulation was intensively studied, the regulation of progesterone receptor (PR) levels has not been extensively investigated. MicroRNAs (miRNAs, miRs) are post-transcriptional negative regulators of gene expression involved in diverse cellular processes. The aim of this study was to identify miRNAs that regulate PR in breast cancer.We mapped potential miRNA binding sites for miR-181a, miR-23a and miR-26b on PR mRNA and demonstrated a direct regulation of PR by these three miRNAs by in-vitro Luciferase binding assays. Over-expression of each miRNA in MCF-7 cells resulted in a reduction in the expression levels of PR mRNA. Then, expression levels of these miRNAs were measured in Formalin-Fixed, Paraffin-Embedded (FFPE) samples of 29 ER-positive breast cancer tumors and adjacent normal breast tissues. A significant reciprocal correlation between PR mRNA and the miRNA levels were identified suggesting a role for miR-181a, miR-23a and miR-26b in PR regulation in breast cancer. Moreover, the average expression fold-changes of the three miRNAs between cancerous and normal tissues displayed an opposite trend when analyzing according to Immuno-histochemistry(IHC) status. Furthermore, miR-181a and miR-26b were found to be over-expressed in most tumor tissues supporting their role in ER-positive breast cancer development. We conclude that miR-181a, miR-23a and miR-26b act as negative regulators of PR expression in ER-positive breast cancer. The diagnostic and prognostic potential of these miRNAs in breast cancer should be further evaluated.

Treatment Options in Gastrointestinal Cutaneous Fistulas

Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.

[PARATHYROID AUTOTRANSPLANTATION IN ADULTS AND CHILDREN]

The indications and methods of parathyroid autotransplantation in children and adults are reviewed, with special emphasis on the methods of immediate transplantation and delayed autotransplantation after cryopreservation. Parathyroid autotransplantation is performed during surgery when all four parathyroid glands have been intentionally resected in parathyroid hyperplasia, or when all four glands were inadvertently damaged during total thyroidectomy, or recurrent neck surgery. When parathyroid damage is suspected during thyroid or extensive neck surgery, cryopreservation of a parathyroid gland is performed. If future signs and symptoms of hypoparathyroidism develop with low blood calcium and PTH levels, then the cryopreserved gland is transplanted into the arm muscles. The maximum effective time that the parathyroid can be cryopreserved is two years. The major postoperative causes of permanent hypoparathyroidism, where parathyroid autotransplantation is indicated are: primary and secondary parathyroid hyperplasia, extensive or repeated neck surgeries which include thyroid surgery and large goiter or retrosternal goiter, particularly in children. The success rate of autotransplantation in preventing postoperative hypoparathyroidism reported in the literature is highly variable, and is dependent on timing, disease, and duration of tissue storage. Although preservation of parathyroid glands in situ at surgery is desirable, parathyroid autotransplantation during thyroidectomy virtually eliminates postoperative hypoparathyroidism. Parathyroid autotransplantation must be performed in dedicated endocrine surgical centers that have had extensive experience in performing this procedure in both children and adults.

Blunt traumatic diaphragmatic injury: A diagnostic enigma with potential surgical pitfalls

BACKGROUND

Blunt traumatic diaphragmatic injury (BTDI) is an uncommon injury and one which is difficult to diagnose. The objective of this study was to identify features associated with this injury.

METHODS

This was a retrospective study based on records of 354307 blunt trauma victims treated between 1998 and 2013 collected by the Israeli National Trauma Registry.

RESULTS

BTDI was reported in 231 (0.065%) patients. Motor vehicle accidents were responsible for 84.4% of the injuries: 97 (42.0%) were reported as drivers; 54 (23.4%) were passengers; 34 (14.7%) were pedestrians hit by cars; and 10 (4.3%) were on motorcycles. There were more males than females (2.5:1) compared with blunt trauma patients without BTDI (p<.001). Patients with BTDI were significantly younger than blunt trauma patients without BTDI (p<.001). ISS was 9-14 in 5.2%, 16-24 in 16.9%, 25-75 in 77.9%. Urgent surgery was performed in 62% of the patients and 79.7% had surgery within 24h of admission. Mortality was 26.8%. Over 40% of patients with BTDI had associated rib, pelvic and/or extremity injuries. Over 30% had associated spleen, liver and/or lung injuries. Nevertheless, less than 1% of patients with skeletal injuries and less than 2.5% with solid organ injuries overall had associated BTDI. Despite hollow viscus injury being less prevalent, up to 6% of patients with this injury had associated BTDI.

CONCLUSIONS

BTDI is infrequent following blunt trauma. Hollow viscus injuries were more predictive of BTDI than skeletal or solid organ injuries.

Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention

IMPORTANCE

Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion.

OBJECTIVE

To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015.

MAIN OUTCOMES AND MEASURES

Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score.

RESULTS

Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P < .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P < .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores.

CONCLUSIONS AND RELEVANCE

Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.

Concomitant hollow viscus injuries in patients with blunt hepatic and splenic injuries: an analysis of a National Trauma Registry database

INTRODUCTION

Non-operative management has become the standard approach for treating stable patients sustaining blunt hepatic or splenic injuries in the absence of other indications for laparotomy. The liberal use of computed tomography (CT) has reduced the rate of unnecessary immediate laparotomies; however, due to its limited sensitivity in the diagnosis of hollow viscus injuries (HVI), this may be at the expense of a rise in the incidence of missed HVI. The aim of this study was to assess the incidence of concomitant HVI in blunt trauma patients diagnosed with hepatic and/or splenic injuries, and to evaluate whether a correlation exists between this incidence and the severity of hepatic or splenic injuries.

METHODS

A retrospective cohort study involving blunt trauma patients with splenic and/or liver injuries, between the years 1998 and 2012 registered in the Israel National Trauma Registry. The association between the presence and severity of splenic and/or liver injuries and the incidence of HVI was examined.

RESULTS

Of the 57,130 trauma victims identified as suffering from blunt torso injuries, 2335 (4%) sustained hepatic injuries without splenic injuries (H group), 3127 (5.4%) had splenic injuries without hepatic injuries (S group), and 564 (1%) suffered from both hepatic and splenic injuries (H+S group). Overall, 957 patients sustained 1063 HVI. The incidence of HVI among blunt torso trauma victims who sustained neither splenic nor hepatic injuries was 1.5% which is significantly lower than in the S (3.1%), H (3.1%), and H+S (6.7%) groups. In the S group, there was a clear correlation between the severity of the splenic injury and the incidence of HVI. This correlation was not found in the H group.

CONCLUSIONS

The presence of blunt splenic and/or hepatic injuries predicts a higher incidence of HVI, especially if combined. While in blunt splenic injury patients there is a clear correlation between the incidence of HVI and the severity of splenic injury, such a correlation does not exist in patients with blunt hepatic injury.

Pitfalls to avoid in the medical management of mass casualty incidents following terrorist bombings: the hospital perspective

BACKGROUND

The unique patterns of injury following explosions together with the involvement of numerous physicians, most of whom are not experienced in trauma, may create problems in the medical management of mass casualty incidents.

METHODS

Four hundred patient files admitted in 19 mass casualty events following bombing incidents were reviewed and possible areas which could impact survival were defined.

RESULTS

Forty-nine (9.3 %) patients had an Injury Severity Score ≥16. Of 205 patients in whom triage decisions were available, 5 of 25 severely injured patients were undertriaged by the triage officers at the door of the hospital. Following primary evaluation inside the emergency department critical injuries in two patients were missed due to distracting, less serious injuries. Of 68 (16.1 %) patients who were operated, 28 were in need of either immediate, urgent or high-priority operations. Except for neurosurgical cases which needed to be transferred to other hospitals, there was no delay in surgery. One patient underwent negative laparotomy. There were 15 in-hospital deaths, 6 of which were deemed as either anticipated or unanticipated mortality with possibility for improvement.

CONCLUSION

Medical management should be evaluated following MCIs as this may illustrate possible problems which many need to be addressed in contingency planning.

Abdominal blast injuries: different patterns, severity, management, and prognosis according to the main mechanism of injury

PURPOSE

To review the frequency, different patterns, anatomic severity, management, and prognosis of abdominal injuries in survivors of explosions, according to the main mechanism of injury.

METHODS

A MEDLINE search was conducted from January 1982 to August 2013, including the following MeSH terms: blast injuries, abdominal injuries. EMBASE was also searched, with the same entries. Abdominal blast injuries (ABIs) have been defined as injuries resulting not only from the effects of the overpressure on abdominal organs, but also from the multimechanistic effects and projectile fragments resulting from the blast. Special emphasis was placed on the detailed assessment of ABIs in patients admitted to GMUGH (Gregorio Marañón University General Hospital) after the Madrid 2004 terrorist bombings, and in patients admitted to HYMC (Hillel Yaffe Medical Centre) in Hadera (Israel) following several bombing episodes. The anatomic severity of injuries was assessed by the abdominal component of the AIS, and the overall anatomic severity of casualties was assessed by means of the NISS.

RESULTS

Abdominal injuries are not common in survivors of terrorist explosions, although they are a frequent finding in those immediately killed. Primary and tertiary blast injuries have predominated in survivors from explosions in enclosed spaces reported outside of Israel. In contrast, secondary blast injuries causing fragmentation wounds were predominant in suicide bombings in open and/or semi-confined spaces, mainly in Israel, and also in military conflicts. Multiple perforations of the ileum seem to be the most common primary blast injury to the bowel, but delayed bowel perforations are rare. Secondary blast injuries carry the highest anatomic severity and mortality rate. Most of the deaths assessed occurred early, with hemorrhagic shock from penetrating fragments as the main contributing factor. The negative laparotomy rate has been very variable, with higher rates reported, in general, from civilian hospitals attending a large number of casualties.

CONCLUSIONS

The pattern, severity, management, and prognosis of ABI vary considerably, in accordance with the main mechanism of injury.