Epidemiology and Outcomes of ARDS After Pediatric Trauma

BACKGROUND

Results of recent studies suggest that the incidence and mortality of ARDS may be higher than previously thought in pediatric trauma patients. We conducted a systematic review of the literature on incidence, risk factors, prognostic factors, and outcomes of ARDS after pediatric trauma in the ICU.

METHODS

Medical literature databases were searched up to April 2020. Guidelines for reporting systematic reviews and meta-analyses were followed. Articles that reported quantitative data with regard to the incidence, risk factors, prognostic factors, mortality, or other outcomes for ARDS in subjects with pediatric trauma admitted to the ICU were included. Two authors independently screened and assessed eligibility of all identified studies, collected data, and assessed the methodological quality of selected studies. Data extraction was performed by using a standardized data extraction sheet. Quality assessment was performed by using the Newcastle-Ottawa scale for cohort studies. A meta-analysis was not performed because the studies used overlapping cohorts or different ARDS criteria.

RESULTS

Nine studies were included. The incidence was reported in 4 studies, risk factors in 1, mortality in 7, and other outcomes in 2. The largest cohort included 148,749 subjects from a national trauma database. The ARDS incidence was 1.8%-7.6% when using adult ARDS criteria, with 1.8% in the largest cohort, and 4.2% when using pediatric ARDS criteria. Mortality was 7.6%-22.9% when using adult ARDS criteria and 11.1%-34.0% when using the pediatric ARDS criteria. Identified risk factors included mechanism of injury, higher injury severity scores, abnormal breathing frequencies, and lower Glasgow coma scale scores at hospital presentation. ARDS was associated with a longer duration of mechanical ventilation, longer ICU and hospital length of stay, and a higher likelihood of requiring post-discharge care.

CONCLUSIONS

The ARDS incidence of 4.2% in the subjects with pediatric trauma in the ICU was comparable with 3.2% in the general pediatric ICU population; however, mortality associated with trauma-associated ARDS was higher and more commonly due to multi-system organ failure rather than hypoxemia.

Traumatic Sternal Fractures can be Safely Treated Conservatively - A 13-Year Retrospective Cohort Study

Background

Traumatic sternal fractures are rare injuries with little evidence supporting the best treatment strategy. This study assessed treatment outcomes from our level-I trauma centre.

Methods

A retrospective cohort study was conducted, including all sternal fracture patients admitted to our level-I trauma centre between 2007 and 2019. Patients with sternal fractures due to cardiopulmonary resuscitation, patients <16 years, patients who died during initial hospital stay, and patients lost to follow-up were excluded from analysis.

Results

In 13 years, 355 patients with traumatic sternal fractures were admitted, corresponding to 2% of all trauma patients. 262 patients were included in analysis. Mean age was 52 years and 71% of patients were male. Mean ISS was 19 (range 4-66). The majority of sternal fractures was located in the sternal body. Six patients (2%) underwent primary sternal fixation. Treatment failure occurred in three patients (1%) and was significantly higher in the surgical treatment group (p=0.001). There was no difference in treatment failure between patients with and without concomitant spinal fractures.

Conclusions

Conservative treatment is safe and effective for traumatic sternal fractures. Surgical treatment should be reserved for rare cases, such as imminent respiratory failure or debilitating symptomatic non-union.

Analysis of human neutrophil phenotypes as biomarker to monitor exercise-induced immune changes

The amplitude of the innate immune response reflects the degree of physiological stress imposed by exercise load. An optimal balance of exercise intensity and duration is essential for a balanced immune system and reduces the risk of dysfunction of the immune system. Therefore, it is hypothesized that neutrophils, as key players in the innate immune system, can be used as biomarker in detecting overtraining. The aim was to monitor the state of the innate immune system by phenotyping neutrophils during consecutive bouts of prolonged exercise. Study subjects were recruited from a cohort of walkers participating in a walking event on 3 consecutive days. Participants with immune deficiencies were excluded. Questionnaires to determine the physiological status of the participants were completed. Analysis of neutrophil receptor expression was done by a point-of-care fully automated flow cytometer. A total of 45 participants were recruited, of whom 39 participants were included for data analysis. Study participants had a median age of 64 (58-70) years. The absolute numbers CD16^dim /CD62L^bright and CD16^bright /CD62L^dim neutrophils were increased after the first 2 days of exercise followed by an adaptation/normalization after the third day. Participants with activated neutrophils (high CD11b expression) had an impaired physical feeling indicated by the participant on a lower visual analog scale compared to participants who did not have activated neutrophils (P = 0.017, P = 0.022). Consecutive days of prolonged exercise results in an initial systemic innate immune response, followed by normalization/adaptation. Increased neutrophil activation was associated with impaired physical feeling measured by a validated VAS score indicated by the participant. Fully automated point-of-care flow cytometry analysis of neutrophil phenotypes in a field laboratory might be a useful tool to monitor relevant differences in the systemic innate immune response in response to exercise.

A cohort study to evaluate infection prevention protocol in pediatric trauma patients with blunt splenic injury in a Dutch level 1 trauma center

PURPOSE

Asplenic patients are at increased risk for the development of overwhelming postsplenectomy infection (OPSI) syndrome. It is believed that adequate immunization, antimicrobial prophylaxis, as well as appropriate education concerning risks on severe infection lead to the decreased incidence of OPSI. The aim of this study was to analyze the methods used to prevent OPSI in trauma patients splenectomized before the age of 18.

PATIENTS AND METHODS

A retrospective, single-center study of all pediatric patients sustaining blunt splenic injury (BSI) managed at our level 1 trauma center from January 1979 to March 2012 was performed. A questionnaire was sent to all the included patients to determine the level of knowledge concerning infection risks, the use of antibiotics, and compliance to vaccination recommendations. Furthermore, we investigated whether the implementation of guidelines in 2003 and 2011 resulted in higher vaccination rates.

RESULTS

We included 116 children with BSI. A total of 93 completed interviews were eligible for analysis, resulting in a total response rate of 80% and 1,116 patient years. Twenty-seven patients were splenectomized, and 66 patients were treated by a spleen preserving therapy (including embolization). Only two out of 27 splenectomized patients were adequately vaccinated, five patients without a spleen used prophylactic antibiotics, and about half of the asplenic patients had adequate knowledge of the risk that asplenia entails. A total of 22/27 splenectomized patients were neither adequately vaccinated nor received prophylactic antibiotics. There was no OPSI seen in our study population during the 1,116 follow-up years.

CONCLUSION

The vaccination status, the level of knowledge concerning prevention of an OPSI, and the use of prophylactic antibiotics are suboptimal in pediatric patients treated for BSI. Therefore, we created a new follow-up treatment guideline to have adequate preventive coverage to current standards for these patients.

Impaired bone healing in multitrauma patients is associated with altered leukocyte kinetics after major trauma

Animal studies have shown that the systemic inflammatory response to major injury impairs bone regeneration. It remains unclear whether the systemic immune response contributes to impairment of fracture healing in multitrauma patients. It is well known that systemic inflammatory changes after major trauma affect leukocyte kinetics. We therefore retrospectively compared the cellular composition of peripheral blood during the first 2 weeks after injury between multitrauma patients with normal (n=48) and impaired (n=32) fracture healing of the tibia. The peripheral blood-count curves of leukocytes, neutrophils, monocytes, and thrombocytes differed significantly between patients with normal and impaired fracture healing during the first 2 weeks after trauma (P-values were 0.0122, 0.0083, 0.0204, and <0.0001, respectively). Mean myeloid cell counts were above reference values during the second week after injury. Our data indicate that leukocyte kinetics differ significantly between patients with normal and impaired fracture healing during the first 2 weeks after major injury. This finding suggests that the systemic immune response to major trauma can disturb tissue regeneration.

Pressure ulcers in trauma patients with suspected spine injury: a prospective cohort study with emphasis on device-related pressure ulcers

Of all patients in a hospital environment, trauma patients may be particularly at risk for developing (device-related) pressure ulcers (PUs), because of their traumatic injuries, immobility, and exposure to immobilizing and medical devices. Studies on device-related PUs are scarce. With this study, the incidence and characteristics of PUs and the proportion of PUs that are related to devices in adult trauma patients with suspected spinal injury were described. From January-December 2013, 254 trauma patients were visited every 2 days for skin assessment. The overall incidence of PUs was 28·3% (n = 72/254 patients). The incidence of device-related PUs was 20·1% (n = 51), and 13% (n = 33) developed solely device-related PUs. We observed 145 PUs in total of which 60·7% were related to devices (88/145). Device-related PUs were detected 16 different locations on the front and back of the body. These results show that the incidence of PUs and the proportion of device-related PUs is very high in trauma patients.

Distribution and treatment of clavicular fractures in monotrauma and polytrauma patients

Background

Although extensive research for the optimal treatment of clavicle fractures has been performed, comparative studies between monotrauma and polytrauma patients are lacking.

Objective

To compare fracture distribution and treatment in monotrauma and polytrauma patients with a clavicle fracture.

Methods

Single center retrospective cohort study. Fractures were classified by the Robinson classification. Monotrauma patients sustained only a clavicle fracture or a clavicle fracture plus a minor abrasion, hematoma, or superficial skin lesion leading to an Injury Severity Score (ISS) of 4 or 5 respectively. Polytrauma patients had an ISS ≥16 as a result of injury in 2 or more Abbreviated Injury Scale (AIS) regions.

Results

154 monotrauma and 155 polytrauma patients with a clavicle fracture were identified. Monotrauma patients had a higher incidence of Type IIB fractures (displaced midshaft) compared to polytrauma patients (P = 0.002). No difference was observed regarding Type I (medial) and Type III (lateral) fractures. In monotrauma patients, Type IIB fractures were treated operatively more frequently (P = 0.004). The initial treatment for Type I and Type III fractures did not differ between monotrauma and polytrauma patients.

Conclusions

Monotrauma patients had a higher incidence of displaced midshaft clavicle fractures compared to polytrauma patients, and monotrauma patients with displaced midshaft clavicle fractures were treated operatively more frequently. No differences were found in the distribution and treatment of medial and lateral clavicle fractures.

Demographics of the injury pattern in severely injured patients with an associated clavicle fracture: a retrospective observational cohort study

Background

Despite an increasing interest in the treatment of clavicle fractures, this is still a not yet defined area in severely injured patients as most studies exclude these patients. Analyzing fracture type and evaluate accompanying injuries can provide valuable information in an early stage of trauma care.

Objective

To identify prevalence, fracture type and accompanying injuries of clavicle fractures in the severely injured patient.

Methods

We included all severely injured patients (ISS ≥ 16) with a clavicle fracture from January 2007 - December 2011. We prospectively collected data about demographics, injuries, trauma mechanism and mortality. Fractures were classified using the Robinson classification.

Results

A total of 1534 patients had an ISS ≥16, of which 164 (10.7%) patients had a clavicle fracture. Traffic related accidents were the main cause of injury (65%). Most fractures were midshaft fractures (66.5%) of which 56% were displaced. Seven patients were treated operatively. There was no significant difference in ISS between the three fracture types. 83% of the patients sustained additional injury to the head and neck; the most prevalent injuries were skull or skull base fractures (41.5%) and maxillofacial fractures (29%). Furthermore 77% of the patients had additional thoracic injury; the most prevalent injuries were rib fractures (59%) and a pneumothorax (38%). The mortality rate was 21.4%.

Conclusion

A clavicle fracture was present in more than 10% of the severely injured patients. Displaced midshaft clavicle fractures were the most common type of fracture. Additional injuries to the head and neck region occurred in 83% of the patients and thoracic injuries occurred in 77% of the patients.

Acute-phase concentrations of soluble fibrinogen inhibit neutrophil adhesion under flow conditions in vitro through interactions with ICAM-1 and MAC-1 (CD11b/CD18)

BACKGROUND

Immobilized fibrinogen and fibrin facilitate leukocyte adhesion, as they are potent ligands for leukocyte MAC-1 (CD11b/CD18). However, fibrinogen in its soluble form also binds to MAC-1, albeit with low affinity. The level of soluble fibrinogen is increased during chronic and acute inflammation, but the function of this increase is unknown.

OBJECTIVES

To study the effect of soluble fibrinogen in concentrations found in severe acute inflammation on leukocyte adhesion.

METHODS

Isolated leukocytes and soluble fibrinogen were studied in various in vitro settings under static and under flow conditions.

RESULTS

Soluble fibrinogen functioned as a natural antagonist of neutrophil functions that are dependent on MAC-1, such as the respiratory burst induced by unopsonized zymosan and adhesion to ICAM-1 and heparin. In addition, soluble fibrinogen inhibited lymphocyte function-associated antigen 1-dependent lymphocyte binding to ICAM-1 through a direct interaction with ICAM-1. Soluble fibrinogen reduced MAC-1-dependent binding of interleukin-8-activated neutrophils to ICAM-1-expressing cells under flow conditions. Importantly soluble fibrinogen in acute-phase concentrations (4-10 mg mL(-1) ) dose-dependently reduced neutrophil firm adhesion to tumor necrosis factor-α-activated endothelium to 40% under flow conditions.

CONCLUSIONS

We propose a model in which the increased circulating concentrations of soluble fibrinogen found during the acute-phase response can act as a natural antagonist of leukocyte recruitment, and therefore might contribute to the resolution of inflammation.

Use of a web portal for support and research after a disaster: opportunities and lessons learned

Background

In this report we describe the development and use of a web portal in the aftermath of the 2004 tsunami. This large scale disaster confronted many displaced people with death, despair and need for information and support. Awareness and insight in the emotional impact of disasters can provide opportunities for surveillance and early treatment. Moreover, online support systems can contribute to community building, empowerment of victims and resilience.

Objective

We evaluate the development and use of a multilingual web portal that combined a platform for information, emotional support, self assessment and referral with research opportunities. The rapid development, use, advantages, difficulties and learning points are discussed.

Methods

A multidisciplinary working group from the University Medical Centre Utrecht, the Major Incident Hospital and the Central Military Hospital developed a web portal for tsunami victims. The webportal combined: (1) a forum aimed at community building, (2) self assessment tools that in the same time function as a reseach survey, (3) e-consultation, and (4) an information portal.

Results

Within 3 weeks after the tsunami, the working group launched an open, online service (www.TISEI.org. Tsunami Intrenational Survey on Emotional Impact) to foster community) support in the aftermath of the disaster. It combined four functionalities that were earlier previously only used separately. The portal had over 36.800 unique visitors in the first two years. At least 31% (144/464) percent of the Dutch surviving victims could be reached for a survey through the site. The TISEI-environment was available in 15 languages and visitors came from all over the world. Ninety-five percent of all visitors came from Europe or the United States. Subsequent to immediate disaster support, the web portal also served as a memorial archive for anniversary meetings and follow-up incentives. Difficulties we experienced were lack of funding, time pressure, victim-anonymisation, international collaboration and long term maintenance.

Conclusions

A multilingual website with combined modalities for emotional care and research after a natural disaster proved feasible. Web based services like www.TISEI.org in the aftermath of mass disasters can help community building and deliver low level, patient centred and easily accessible information and care. A multilingual website with combined modalities for emotional care and research after a natural disaster proved feasible. Growing Internet penetration world wide and especially the rapid expansion and influence of online communities enables delivery of care and perform research with the internetInternet as a platform. The unpredictable nature of disaster does put time pressure on the development of online solutions and influenced the yield of our site. This highlights the necessity of developing methods and (inter) national collaborations in advance, secure funding, and learn from earlier initiatives.

Intramedullary nailing of the femur and the systemic activation of monocytes and neutrophils

Background

Trauma such as found patients with femur fractures, induces a systemic inflammatory response, which ranges from mild SIRS to ARDS. Neutrophils (i.e. PMN) play an important role in the pathogenesis of this inflammatory condition. Additional activation of PMNs during intramedullary nailing (IMN) is thought to act as a second immunological hit. Damage control orthopedics has been developed to limit this putative exacerbation of the inflammatory response. The hypothesis is tested that IMN exacerbates systemic inflammation, thereby increasing the risk for ARDS.

Methods

Thirty-eight trauma patients who required IMN for femur fracture were included. The development of SIRS and ARDS was recorded. Blood samples were taken prior and 18 hours after IMN. Inflammatory response was analyzed by changes in plasma IL-6 levels, monocyte (HLA-DR) and PMN phenotype (MAC-1 and responsiveness for the innate immune stimulus fMLP in the context of active FcγRII).

Results

Plasma IL-6 was significantly enhanced in severely injured patients compared to patients with isolated femur fractures and matched controls (P = 0.005; P = 0.018). This enhanced inflammatory tone was associated with a lower percentage HLA-DR positive monocytes (P = 0.002). The systemic PMN compartment was activated, characterized by an increased MAC-1 expression and a significantly decreased sensitivity for the innate stimulus fMLP Interestingly the PMN compartment was not affected by IMN.

Conclusions

Multitrauma patients were characterized by a marked activation of the systemic inflammatory response, associated with a systemic activation of the monocyte and PMN compartments. IMN particularly affected the monocyte arm of the systemic innate immune system.

Validation of the Thorax Trauma Severity Score for mortality and its value for the development of acute respiratory distress syndrome

BACKGROUND

The aim of the present study was to evaluate and to validate the Thorax Trauma Severity Score (TTSS) for mortality.

METHODS

By database analysis 712 patients with an injury to the chest admitted to the Universal Medical Center Utrecht between 2000 and 2004 were studied. All patients with a score of ≥1 on the AISthorax were included in the study. The patients' file was evaluated for: TTSS, intensive care unit stay, days on ventilation, thorax trauma-related complications (eg, acute respiratory distress syndrome [ARDS]), total hospital stay, and mortality.

RESULTS

Of the 516 patients included in the study, 140 (27%) developed thorax-related complications. The overall in-hospital mortality rate was 10%. The receiver operating characteristic curve for predicting mortality demonstrated an adequate discrimination by a value of 0.844. The TTSS was statistically significant higher in patients who died of thorax-related complications than in patients who died because of nonthorax-related complications and survivors (P < 0.001, confidence interval [CI] 95%). In patients who developed ARDS the TTSS was significant higher (P = 0.005, CI 95%).

CONCLUSION

This study supports the use of the TTSS for predicting mortality in thoracic injury patients. Furthermore, the TTSS appears capable of predicting ARDS.

A systematic review of randomized controlled trials exploring the effect of immunomodulative interventions on infection, organ failure, and mortality in trauma patients

Introduction

Following trauma, patients may suffer an overwhelming pro-inflammatory response and immune paralysis resulting in infection and multiple organ failure (MOF). Various potentially immunomodulative interventions have been tested. The objective of this study is to systematically review the randomized controlled trials (RCTs) that investigate the effect of potentially immunomodulative interventions in comparison to a placebo or standard therapy on infection, MOF, and mortality in trauma patients.

Methods

A computerized search of MEDLINE, the Cochrane CENTRAL Register of Controlled Trials, and EMBASE yielded 502 studies, of which 18 unique RCTs were deemed relevant for this study. The methodological quality of these RCTs was assessed using a critical appraisal checklist for therapy articles from the Centre for Evidence Based Medicine. The effects of the test interventions on infection, MOF, and mortality rates and inflammatory parameters relative to the controls were recorded.

Results

In most studies, the inflammatory parameters differed significantly between the test and control groups. However, significant changes in infection, MOF, and mortality rates were only measured in studies testing immunoglobulin, IFN-γ, and glucan.

Conclusions

Based on level 1b and 2b studies, administration of immunoglobulin, IFN-γ, or glucan have shown the most promising results to improve the outcome of trauma patients.

[Endovascular treatment of 4 patients with a traumatic rupture of the thoracic aorta]

OBJECTIVE

To present our initial results with the endovascular treatment of traumatic rupture of the thoracic aorta.

DESIGN

Retrospective.

METHOD

Between April and October, 2002, 4 men between the ages of 22 and 46 were treated endovascularly for a traumatic rupture of the thoracic aorta. The diagnosis 'rupture of the thoracic aorta' was made on the basis of CT-angiography in all cases. In the first case, a thoracic Gore TAG-endoprosthesis (Gore & Associates; Den Bosch) was used, and in 3 cases a Talent-endoprosthesis (Medtronic AVG; Heerlen).

RESULTS

There was an average of 2.5 days (limits: 0-5 days) between admission and the placement of the endoprosthesis. There was one intra-operative complication in the form of a dissection of the right femoral artery when the endoprosthesis was inserted. In 3 cases, the left subclavian artery was occluded by the prosthesis. This had no negative consequences for the patients during the follow-up period (limits: 4-12 months). The CT-angiogram taken 3 months after the operation consistently showed a good position of the endoprosthesis with no signs of leakage.

CONCLUSION

For a limited follow-up period, the endovascular treatment of a traumatic rupture of the thoracic aorta has been shown to be safe and effective. The long term results must be awaited.

[Multitrauma patients: principles of 'damage control surgery']

The principles of damage control surgery were applied in the cases of three severely injured multitrauma patients, men aged 47 and 33 years who had a motorcycle accident and a 66-year-old man who had a car crash. Victims of major trauma suffer from a worsening physiologic derangement manifested by the triad of acidosis, hypothermia and coagulopathy. This often leads to a vicious cycle that heralds imminent death or organ failure. Damage control surgery involves three distinct stages. The first consists of rapid temporary measures to control bleeding and contamination, followed by rapid closure of the abdomen. The second involves aggressive correction of the lethal triad in the intensive care unit. The third is the planned re-operation for the definitive repair of the injuries. As shown in these three patients, the appropriate use of this strategy can lead to a decrease in the morbidity and mortality in complex trauma patients.

[Luxatio cordis in blunt-trauma thoraco-abdominal injuries]

A 56-year old woman was admitted to the emergency ward after suffering a blunt thoraco-abdominal high-velocity trauma as she hit the wheel when her car drove into a tree. A laparotomy was performed because of haemodynamic instability and radiographic suspicion of a diaphragmatic rupture. Besides haemorrhage from liver and spleen injuries, an abdominal herniation of the heart through a ruptured pericardium and diaphragm was found. Haemostasis of liver, splenectomy and suturing of defects in pericardium and diaphragm resulted in a haemodynamically stable situation. A high index of suspicion of rupture of pericardium and diaphragm with luxation of the heart in the trauma patient is important to reduce morbidity and mortality due to delay of surgical intervention.

[Registration of postoperative complications to improve the results of surgery]

OBJECTIVE

To analyse the consequences of postoperative complications in 1418 surgical patients.

DESIGN

Prospective descriptive study.

SETTING

St. Elisabeth Hospital in Tilburg, The Netherlands.

METHOD

In the period 1986-1992 all postoperative complications and their consequences occurring during or after the clinical treatment of surgical patients were registered.

RESULTS

In 5% of the 28,485 surgical procedures (= 1418 patients) postoperative complications were found. To treat these complications, 577 patients had to be reoperated on, 233 patients several times, and generally because of postoperative infections. Readmission after discharge was necessary in 310 patients for treatment of their complications. Mean hospital stay for all patients was 10 days, as against 21 days in patients with postoperative complications. On the basis of the figures recorded, quality enhancing measures were taken, e.g. regarding antibiotic prophylaxis and wound treatment.

CONCLUSION

The consequences of postoperative complications are considerable. With respect to quality control in health care it is important to develop national registration and documentation of surgical complications.

Internal fixation of open unstable pelvic fractures

From 1980 through 1990 14 patients with severely complicated unstable fractures of the pelvis were treated. There were 13 men and one women (mean age, 28 years). Eight fractures also involved the acetabulum. The injuries were accompanied by anorectal (nine), urogenital (eight), vascular (three), and nerve (three) injuries. After resuscitation, fractures were stabilized immediately, preferably using internal fixation, notwithstanding fecal contamination in certain cases. Anorectal ruptures were treated with lavage of the distal colon and a divergent stoma. The urogenital lesions also were treated primarily. Two patients died early after treatment of accompanying injuries. Infectious complications were seen seven times. In one patient internal fixation broke down. All fractures healed with good functional results. At last follow-up examination all patients were continent for feces. It is concluded that early internal stabilization of these complex injuries achieves a low mortality rate and good functional results. Immediate repair of urogenital and sphincter lesions, with concomitant divergent stoma and lavage of the distal colon, gives good results notwithstanding the risk of infectious complications.

Fracture-dislocations of the tarsometatarsal joint, a combined anatomical and computed tomographic study

Based on anatomical and computed tomographic data as well as experience with the treatment of 30 patients with fracture-dislocation of the tarsometatarsal (Lisfranc) joint, a pathophysiological model is described in which the shape of the foot and ligamentous configuration in combination with applied forces are of pivotal importance. CT imaging helps to elucidate the extent of the lesions, easily overlooked in straight radiographs. In the transverse plane we discern three grades of dislocation. Grade 1, virtually no displacement; grade 2, dislocation of half of the shaft; grade 3, total displacement. Treatment is generally dictated by the severity of the lesion and ranges from plaster application to open reduction and internal fixation. Quality of reduction is easily visualized with CT imaging.

Angiosarcoma of the irradiated breast: a new problem after breast conserving therapy?

Post-irradiation angiosarcoma of the breast is an uncommon neoplasm. The first patient with this disease after breast conserving therapy was reported in 1987 and only a few more patients can be traced in the literature since that time. Two more cases are presented in this paper: both women in the seventh decade of life. The tumour became apparent five and seven years after the primary treatment of breast cancer. The possible influence of irradiation and lymphoedema in inducing this malignancy is discussed.

[Surgical treatment of toxic megacolon]

From 1978 to 1989, 11 patients suffering from toxic megacolon were treated. In eight patients it was based on ulcerative colitis, while Crohns' disease, infectious colitis and pseudomembranous colitis were seen once each. Patients were initially treated with intravenous fluids and corticosteroids. They were closely followed both clinically and radiologically. The plain abdominal X-ray was of great help. Conservative regimen was successful in 3 patients, the remaining had to be operated on in due course. Three patients proved to have a perforation of the bowel at the time of operation. The initial operations performed were one proctocolectomy, four times a subtotal colectomy, twice a partial colectomy and in one instance a diverting colostomy. Two patients had to undergo an additional colon resection. Postoperative complications consisted mainly of intra-abdominal abscesses. Two of the operated patients died. Follow-up is between 2 and 9 years. None of the patients had a recurrence of the toxic megacolon. Four patients had a recurrence of their underlying disease, which however could be resolved in most cases by medical means. In one patient total colectomy is being considered.

Bilateral primary breast carcinoma in a man

The case history is presented of a 56-year-old man, who had a second primary carcinoma in the contralateral breast after 13 years. Both times, he underwent a modified radical mastectomy. The axillary lymph nodes were free from tumour. The incidence in men is about 1 per cent being bilateral in 14 out of 1,000 of these cases. The therapy for men is the same as for women. Because of the smaller breast volume, tumours in men are earlier discovered and show infiltration. If metastases cannot be detected, the first choice of treatment is surgical. Radiotherapy is indicated in case surgical intervention has not been radical.

Traumatic posterior luxation of the hip

The long-term outcome of treatment of posterior hip dislocations was studied in 60 patients. Thirty-two patients had concomitant fractures of the acetabular rim and seven had also femoral head fractures. Treatment consisted of immediate reduction, followed by gentle traction during one week and progressive weight-bearing over six weeks. Thirteen patients needed internal fixation of the acetabular fracture. Fourty-six patients could be followed for a median of 6.5 years. Fifteen patients, all with associated fractures, had late complications: peri-articular ossifications (5), avascular necrosis of the femoral head (1), mild osteo-arthrosis (5) and pain of unknown origin (4). No complications were noted in patients with simple posterior dislocation of the hip. Simple traumatic posterior hip dislocation has an excellent prognosis. Poor results only occur in case of associated fractures.

[The pneumoportogram, a rare finding in septicemia due to an intra-abdominal abscess]

A man aged 73 is described with radiologically revealed air in the portal vein, a peumoportogram, on the basis of intra-abdominal sepsis. Characteristic of this finding are the air shadows extending far into the periphery of the liver in contrast to an air cholangiogram. It is an ominous sign, mostly secondary to severe intra-abdominal pathology such as ischaemic bowel necrosis, peritonitis or abscesses. Treatment should be aimed at these causes. Prognosis depends on the underlying pathology.

[Fournier's gangrene]

Two patients with a necrotizing soft tissue infection of the scrotum and perineum are described. The etiology was found to be a gram negative synergistic gangrene. Patients were managed with extensive necrotectomy with a planned second look operation and supportive antibiotics (aminoglycosides, amoxicillin, metronidazole). Despite this aggressive approach one of the patients died of ongoing necrosis. The therapeutic management for necrotizing soft tissue infection comprises early surgical intervention with supportive antibiotic treatment. Nevertheless the disease is associated with a high mortality rate.

Cecal carcinoma: a different colon malignancy?

Cecal carcinoma has been associated with a poorer prognosis than other colon carcinomas because of the presumed longstanding obscure symptoms. In a combined study of three Dutch hospitals, a total of 166 patients with cecal carcinoma were evaluated after right hemicolectomy. Special emphasis was placed on clinical symptoms related to advanced tumor growth, e.g., pain, anemia, and palpable mass. These factors and clinicopathological staging were evaluated with aid of the Cox regression model. Ninety percent of the resected specimens contained a Dukes' B or C carcinoma. Only 5% were found to have widespread metastatic disease. Overall 5 year survival rate was found to be 0.57. No statistically significant relation to pain or palpable mass was found. Anemia, however, was related to a better survival, especially in patients with a Dukes' B carcinoma. Clinicopathological staging according to Dukes' is closely related to survival. It is concluded that carcinoma of the cecum behaves similarly to other colon malignancies.

Treatment of complete rectal prolapse with foreign material

The results of treatment of complete rectal prolapse with Teflon mesh repair are described in 64 patients. Adequate fixation by posterior rectopexy was reached in all patients. In 23 per cent of the patients postoperative constipation was noticed that could adequately be managed with laxatives in most instances. After a mean follow-up of 30 months, none of the patients had complete recurrences. Four patients had new complaints of prolapse. These complaints were two times based on haemorrhoids, two other patients had a small mucosal prolapse. Modified Teflon mesh repair is recommended as a safe method to manage rectal prolapse with a high rate of success.

Some factors influencing the outcome of stoma surgery

In a retrospective study, the procedure and follow-up of 266 patients with 345 stomas on the small and large bowel were reviewed to reveal possible etiologic factors for stomal complications. The overall complication rate for creating a stoma was 36 percent. No differences in overall complication rate were encountered when comparing acute and elective management; however, high output stomas and necrosis were encountered more often in the acutely managed group. Preoperative contamination was followed more often by stomal retraction. Septic events, however, occurred less frequently than in the noncontaminated procedures. Adequate supply with antibiotics might account for the lack of difference in these complications between the two groups. Antibiotics might not have prevented low-grade infections giving rise to retractive reaction. The influence of body weight was evaluated by the Quetelait index. It was demonstrated that moderate obesity had no significant influence on the outcome of the procedure. Adipose patients had a statistically significant larger number of necroses. This may be due to the relatively short and fatty mesenterium causing a compromised circulation. The outcome of stoma surgery was greatly influenced by bowel quality. Crohn's disease and bowel ischemia were encountered in 50 percent of stoma complications. In ischemic disease, significantly more necrosis was found. Retraction of the stoma occurred more often in Crohn's disease. Chronic ulcerative colitis did not have a higher complication rate.

Differences in the fiber composition of the pyramidal tract in two- and 14-month-old rats

The present study is aimed at an electron-microscopic morphometrical analysis of the pyramidal tract of 14-month-old rats at the level of the pyramis medullae and the second cervical segment, and a comparison with data obtained for rats of two months of age. Between 2 and 14 months of age there is, at the level of the pyramis medullae of the left pyramidal tract, a statistically significant increase of the number of myelinated fibers, from 91,000 to 118,000, whereas the total number of unmyelinated fibers decreases from 133,000 to 101,000. On the right side at the same level there is no statistically significant change in the number of myelinated fibers, whereas there is a significant decrease of unmyelinated fibers at this side, from 148,000 to 89,000. At the second cervical level, a statistically significant increase in the number of myelinated fibers has been noted at both sides (from 43,000 to 60,000) between 2 and 14 months, whereas the mean total number of unmyelinated fibers at this level decreases somewhat (from 35,000 to 28,000), but is not statistically significant. Several processes which might be involved in the age-related changes observed are discussed, including the possibility of a shift from unmyelinated fibers to myelinated ones, withdrawal of corticobulbar fibers and ongoing outgrowth of myelinated corticofugal fibers after two months of age, and a summarizing scheme is presented. We conclude that the pyramidal tract of the rat changes in composition after the age of two months and that continuing outgrowth of myelinated corticospinal fibers is an important aspect of this continuing development.

A detailed morphometrical analysis of the pyramidal tract of the rat

The present study is aimed at a quantitative analysis and comparison of the fibers of the pyramidal tract of the rat at two levels: the pyramis medullae and the second cervical segment. For this purpose both levels of the pyramidal tracts of 5 rats have been studied morphometrically at the ultrastructural level. Fiber numbers as well as fiber diameter distributions are presented for both myelinated and unmyelinated axons. At the level of the pyramis medullae the number of unmyelinated fibers (140,000 +/- 7000) exceeds the number of myelinated axons (103,000 +/- 6000). In contrast at the level of the second cervical segment the numbers of fibers of the axon populations studied are not significantly different, viz. 43,000 +/- 2000 myelinated and 35,000 +/- 8000 unmyelinated fibers. However, these numbers mean a significant decrease of myelinated axons (48%) compared with the pyramis medullae level and an even much larger decrease (75%) in the numbers of unmyelinated fibers. Diameter distributions, obtained from the minimal fiber diameter, show a similar, monomodal shape for all axon and myelin profiles. For unmyelinated axons the minimal diameter ranges from 0.05 to 1.21 micron with a mean of 0.18 +/- 0.03 micron. For myelinated axons a mean minimal diameter of 0.72 +/- 0.12 micron has been found (range 0.13-4.92 micron), whereas their diameter measured with myelin sheath measure 1.08 +/- 0.13 micron (range 0.25-6.03 micron). The average thickness of the myelin sheath is 0.2 micron and is strongly correlated to axon diameter. Furthermore, g-ratio has been computed at a mean of 0.65 and is fairly constant throughout the diameter spectrum. Several possibilities concerning the functional and anatomical qualities of the numerically important unmyelinated axon population in the pyramidal tract of the rat are discussed.