Spontaneous tension pneumothorax as a complication of Coronavirus disease 2019: Case report and literature review

Primary spontaneous tension pneumothorax (STP) is a rare and life‐threatening condition. We report a case of COVID‐19‐pneumonia patient who developed STP as a complication. He had a prolonged hospital stay and was ultimately discharged asymptomatic. A systematic literature search was performed to review studies (N=12) reporting STP in the setting of COVID‐19.

Self-Extubation in Patients with Traumatic Head Injury: Determinants, Complications, and Outcomes

Background

Self-extubation is a common clinical problem associated with mechanical ventilation in trauma patients worldwide.

Objectives

This study aimed to evaluate the predisposing factors, complications, and outcomes of self-extubation in patients with head injury.

Methods

This was a retrospective cohort study.

Settings

The study was conducted in a trauma intensive care unit (TICU).

Patients

All intubated patients with head injury admitted to TICU between 2013 and 2015 were included in the study.

Interventions

Planned compared to selfextubation during weaning from sedation.

Measurements

Risk, predictors, and outcomes of self-extubation were measured.

Main Results

A total of 321 patients with head injury required mechanical ventilation, of which 39 (12%) had self-extubation and 12 (30.7%) had reintubation. The median Glasgow Coma Scale, head abbreviated injury score, and injury severity score were 9, 3, and 27, respectively. The incidence of self-extubation was 0.92/100 ventilated days. Self-extubated patients were more likely to be older, develop agitation (P = 0.001), and require restraints (P = 0.001) than those who had planned extubation. Furthermore, self-extubation was associated with more use of propofol (P = 0.002) and tramadol (P = 0.001). Patients with self-extubation had higher Ramsay sedation score (P = 0.01), had prolonged hospital length of stay (P = 0.03), and were more likely to develop sepsis (P = 0.003) when compared to the planned extubation group. The overall in-hospital mortality was significantly higher in the planned extubation group (P = 0.001). Age-adjusted predictors of self-extubation were sedation use (adjusted odds ratio [aOR]: 0.06; P = 0.001), restraint use (aOR: 10.4; P = 0.001), and tramadol use (aOR: 7.21; P = 0.01).

Conclusions

More than one-tenth of patients with traumatic head injury develop self-extubation; this group of patients is more likely to have prescribed tramadol, develop agitation, and have longer hospital length of stay and less sedation use. Further prospective studies are needed to assess the predictors of self-extubation in TICU.

The Role of Transcranial Doppler in Traumatic Brain Injury: A Systemic Review and Meta-Analysis

To evaluate whether transcranial Doppler (TCD) monitoring plays a role as a prognostic indicator, by being both a diagnostic as well as a monitoring tool for increased intracranial pressure and cerebral vasospasm (VSP), in traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to the present. Randomized control trials, case–control studies, and prospective cohort studies on TCD in TBI (>18 years old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and Extended GCOS and mortality. Data were extracted to Review Manager Software. Twenty-five articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI with abnormal TCD (mean flow velocity [MFV] >120 cm/sec or MFV <35 cm/sec and Pulsatility Index >1.2) have a >3-fold higher likelihood of having poor clinical outcome in comparison to patients with TBI and normal TCD monitoring (odds ratio [OR]: 3.87; 95% confidence interval [CI]: 2.97–5.04; P < 0.00001). Subgroup analysis revealed that abnormal TCD has a 9-fold higher likelihood of mortality (OR: 9.96; 95% CI: 4.41–22.47; P < 0.00001). Further, subgroup analysis based on TCD findings revealed that the presence of hypoperfusion on TCD (middle cerebral artery [MCA] <35 cm/s) is associated with a three-fold higher likelihood of having poor functional outcome (OR: 3.72; 95% CI: 1.97–7.0; P < 0.0001). The presence of VSP (MCA >120 cm/s) is associated with three-fold higher likelihood of poor functional outcome (OR: 3.64; 95% CI: 1.55–8.52; P = 0.003). TCD is an evolving diagnostic tool that might play a role in determining the prognosis of patients with TBI. Further prospective study is needed to prove the role of TCD in TBI.

Results of the Collis-Nissen gastroplasty in patients with Barrett's esophagus

BACKGROUND

Barrett's esophagus (BE) is an advanced stage of gastroesophageal reflux disease. Medical treatment and standard antireflux operations show a high failure rate. An elongated gastroplasty, wrapped by a total fundoplication should provide a tension-free repair with adequate protection against reflux. The aim of this study is to review the operative effects of a Collis-Nissen gastroplasty to treat reflux in Barrett's esophagus.

METHODS

From January 1989 to December 1997, 45 patients with BE (38 men, 7 women) aged 53.5 years, underwent a Collis-Nissen gastroplasty. Mean follow-up is 35.9 months (range, 6 to 110 months). Pre- and postoperative evaluations included symptom assessment, esophagogram, endoscopy, manometry, 24-hour pH study, and esophageal emptying scintigrams.

RESULTS

There were no operative deaths. All reflux symptoms were controlled. Acid reflux was significantly reduced (percent time exposure decreased from 10% to 1%) and lower esophageal sphincter (LES) pressure were restored to normal (LES gradient increased from 4 mm Hg to 11 mm Hg). LES incomplete relaxation was noted in 50% of patients postoperatively. Endoscopically, mucosal damage from reflux healed but the columnar mucosa with intestinal metaplasia persisted.

CONCLUSIONS

The Collis-Nissen gastroplasty, in patients with BE, controls reflux disease, its symptoms, and the mucosal damage associated with this condition. It restores the LES gradient but increases the resistance to bolus transit. There is no regression of the abnormal mucosa despite reflux control.

Successful repair of aortoesophageal fistula secondary to traumatic pseudoaneurysm

There have previously been only rare reported survivors of an aortoesophageal fistula resulting from a traumatic pseudoaneurysm. We report a case of a young man with a dramatic presentation who was successfully managed by immediate operative repair. A prosthetic graft was sewn within the sac of the aneurysm, with the aneurysm wall being used to protect the graft, and the esophagus was resected. Staged reconstruction of the esophagus was subsequently performed successfully. The patient is now alive and well 2 1/2 years later.

Bronchial carcinoid--twenty years' experience defines a selective surgical approach

BACKGROUND

The purpose of this study was to look at the clinical behavior of bronchial carcinoids and clarify a surgical approach.

METHODS

Eighty-four patients resected for bronchial carcinoids were retrospectively reviewed for clinicopathologic variables, surgical management, and outcome. Tumors were considered "typical" or "atypical" based on histologic features. "Conservative" surgery signified lung parenchyma-sparing procedures. Survival analysis was performed using standard statistical methods.

RESULTS

Most patients presented with an abnormal routine chest x-ray. One patient had the carcinoid syndrome. Computed tomography scan reliably predicted lymph node status and bronchoscopic biopsy diagnosed carcinoids with 70% success. Fifteen "conservative" procedures were performed. Fifteen percent of patients had atypical carcinoids, 12% presented with lymph node metastases, and 6 patients had tumorlets associated with the primary tumor. Overall survival rates were 93% and 82% at 5 and 10 years, respectively. Significantly decreased disease-free survival was found with atypical histology (p < 0.0001) and the presence of tumorlets (p = 0.02); lymph node involvement strongly tended toward poorer outcome.

CONCLUSIONS

Bronchial carcinoids have a definite malignant potential predicted by atypical histology, presence of tumorlets, and lymph node involvement. These features can be identified with routine bronchoscopic biopsy, computed tomography scanning, and intraoperative assessment including frozen section. In the select group of patients without negative features, strong consideration should be given to performing a conservative resection.