[Trauma Analysis in Patients Examined by Whole-Body CT]

PURPOSE OF THE STUDY The purpose of this study was to assess the available information on patients with a whole-body CT and to ascertain whether the number of examinations could be reduced. MATERIAL AND METHODS This retrospective study included all patients who underwent a whole-body CT in the University Hospital Olomouc during a period of one year. Epidemiologic data of patients and information about the trauma and injuries suffered were collected. The injuries were assessed using the Abbreviated Injury Scale and the Injury Severity Score and classified as high- and low-energy injuries. These two groups were subsequently compared. RESULTS A total of 338 patients were examined, of whom 75% were male and the median age of all patients was 48 years. The most frequent causes of trauma were road accidents in 53% and falls from height in 25%. Ninety-one percent of examined patients were admitted to hospital, 42% underwent a surgery and 3% died. The average ISS was 10.7 and the severity of injury increased with age (p = 0.01). The patients after an attempted suicide and those after motorbike and bike accidents had the highest ISS observed. A higher ISS was detected more often in high-energy traumas than in low-energy traumas (p = 0.002). A completely negative polytrauma CT scan finding was observed in 5 patients with low-energy trauma and in 9 patients with high-energy trauma. CONCLUSIONS High-energy injuries were shown to be associated with higher severity as well as more negative CT scans than lowenergy ones. Bearing in mind that a whole-body CT scan is an extensive examination in which relatively high doses of radiation are used, it should always be considered whether a selective CT of fewer body parts would not be sufficient for the diagnosis. Key words: abbreviated injury scale, injury severity score, multiple trauma.

Early complications in surgery of umbilical and epigastric hernias

INTRODUCTION

Repairs of umbilical and epigastric hernias are common surgical procedures; the choice of the surgical method generally depends on the size of the hernial sac and fascial defect.

METHODS

Data of patients operated on for umbilical or epigastric hernias in our hospital during two years were assessed retrospectively. The study group included 264 patients; 212 had an umbilical hernia and 52 had an epigastric hernia. We assessed epidemiologic and clinical parameters and their correlation with the occurrence of early postoperative complications. We also looked for the recurrence rate, although during only a short follow-up period.

RESULTS

In the case of umbilical hernias, early complications occurred in 6.7% (11/165) after surgery with a simple suture and in 4.3% (2/47) with mesh repair, and the recurrence rates were 3% (5/165) and 21.3% (10/47), respectively. The risk of early complications was significantly higher in larger hernias. The recurrence rate increased with older age, an increased size of the hernial sac and fascial defect, and in patients with type 2 diabetes. In epigastric hernias, early complications occurred in 5.3% (1/19) after surgery with a simple suture and in 6.1% (2/33) with mesh repair. Recurrences only occurred in operations with mesh repair, in 9% (3/33). The risk of early complications was significantly higher in type 2 diabetes patients.

CONCLUSION

Early complications were slightly more frequent in epigastric hernia repairs with mesh implantation, but this was not the case of umbilical hernias. We recommend mesh implantation in larger and borderline sized hernias to reduce the risk of recurrence.

Individualized dosing of vancomycin in geriatric patients

AIMS

Pharmacotherapy in geriatric patients is challenging due to frequent multimorbidity, polypharmacy, increased risk of adverse drug effects, and altered pharmacokinetics and pharmacodynamics associated with aging. Therapeutic drug monitoring (TDM) is a dosing individualisation strategy that helps to minimise toxicity whilst maximising the efficacy of the agent. Routine TDM of vancomycin is recommended in clinical practice in order to optimise drug exposure. Guidelines by Rybak et al. from 2009 on vancomycin TDM promote monitoring of trough concentrations only, with higher target ranges for dosage adjustment. The aim of the study was to evaluate the practice of vancomycin TDM in geriatric (aged 65 ys) and non-geriatric patients, compare two methods of dosing adjustment (trough-based vs. AUC-based approach), and finally determine covariates enabling to choose an appropriate initial vancomycin maintenance dosing regimen in geriatric patients.   Methods: A retrospective analysis of all vancomycin plasma concentrations determined during a five year period in patients treated with IV vancomycin in the University Hospital Olomouc was performed. Haemodialysis patients were excluded. Each trough value was compared with the guidelines by Rybak et al. and subsequently, pharmacokinetic modelling was performed to assess individual AUC24 values.

RESULTS

A total of 1,458 vancomycin concentrations were included, which represented 799 individual monitoring events in 380 patients. Vancomycin was most commonly prescribed for sepsis (41.6% of all patients). Pathogens with MIC > 1 mg/L were responsible for 16.7% of all infections. Initial dosing led to optimum vancomycin exposure in 37.8% of patients. Vancomycin dosage based on the guidelines by Rybak et al. from 2009 would agree with the AUC-based dosing adjustments in 65% of all monitoring events. Approximately 19.1% of trough concentrations were below the minimum target suggested by the guidelines despite the fact that their corresponding AUC24/MIC ratios were high enough ( 400), and in further 6.1% of monitoring events, the trough-only approach would fail to accurately identify supratherapeutic concentrations. Initial dosing of 1 g twice daily was prescribed to 62.9% of patients, although it would be considered as optimal only in 32.1% of all patients. For 48 % of patients in the non-geriatric cohort, higher dosing (3 to 4 g daily) would be necessary to achieve optimum vancomycin exposure, whereas for 56% of geriatric patients, lower dosage regimens (up to 1.5 g daily) would be considered optimal. The estimated glomerular filtration rate was the most significant covariate in the pharmacokinetic model enabling the construction of a dosing nomogram.

CONCLUSION

AUC-based vancomycin monitoring is superior to trough-based approach as the latter can lead to unnecessarily aggressive dosing in over a quarter of patients. A simple nomogram using the estimated glomerular filtration rate may increase the percentage of patients receiving an optimal initial vancomycin dose.