Never to be missed again - an analysis of 55 consecutive cases of traumatic diaphragmatic hernia.

BACKGROUND: This report reviews our clinical experience with 55 cases of traumatic diaphragmatic hernia at a Brazilian university hospital. Traumatic diaphragmatic hernia is an uncommon injury and presents diagnostic and therapeutic challenges. Occasionally, it is missed in trauma patients and is usually associated with significant morbidity and mortality. This analysis aimed to improve the diagnostic outcomes of trauma patient care. METHODS: Retrospective design analysis of database records of trauma patients at HC-Unicamp were performed to investigate incidence, trauma mechanism, diagnosis, herniated organs, associated injuries, trauma score, morbidity and mortality. RESULTS: Fifty-five patients were analysed. Blunt trauma was two-fold more frequent than penetrating trauma and was associated with high-grade injury; motor vehicle collision was the most common mechanism. Left-sided hernia was four-fold more frequent than that on the right side, although critical injuries were more frequently associated with the right side. The stomach was the most herniated organ in both trauma mechanisms. Preoperative diagnosis was mostly performed using chest radiography (55%). Postoperative diagnosis was mostly performed via laparotomy rather than laparoscopy. Associated injuries were observed in 43 patients (78%) and the mortality rate was 20% for both the sides. CONCLUSION: Isolated injuries are rare, and the presence of associated injuries increases morbidity and mortality. Chest radiography in the trauma bay is useful as an initial examination, although it is not suitable for use as a definitive method. Despite the use of laparoscopy in a few cases, laparotomy is the most common approach.

Prevalence of cocaine and derivatives in blood and urine samples of trauma patients and correlation with injury severity: a prospective observational study.

PURPOSE: The abuse of cocaine and its derivatives presents a likely risk factor for injury. Trauma incurred by cocaine and derivative abusers may be more severe than that incurred by non-users. OBJECTIVES: To ascertain the presence of cocaine and its derivatives in trauma patients and to correlate RTS (Revised Trauma Score) and ISS (Injury Severity Score) with the presence of cocaine and its derivatives in blood and urine samples. METHODS: All trauma victims treated in an emergency unit between November 11, 2012 and September 15, 2013 were included in the study. Blood and urine samples were collected on admission to hospital. RTS and ISS scores were then compared with the presence or absence of cocaine and its derivatives in the samples. The associations between RTS < 7.84 and ISS > 16 and the independent variables were evaluated by the gross odds ratio values, determined by univariate logistic regression. Multivariate analysis was performed using multivariate logistic regression. RESULTS: Of 453 patients (83.7% male) included in the study, 28.6% presented ISS > 16 and 33.6% presented RTS < 7.84. A total of 435 samples were collected, and 86 (19.8%) provided positive samples for cocaine, 48 (11%) for crack and 69 (15.9%) for cocaethylene. Compared to other patients, drug users showed a greater probability of RTS < 7.84 (2.18 times greater) and a greater probability of ISS > 16 (1.76 times greater). CONCLUSION: For the trauma patients included in our study, the use of cocaine and its derivatives was shown to be associated with more severe traumas, as demonstrated by their RTS and ISS scores.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland.

BACKGROUND: Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery. METHODS: The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future. RESULTS: Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems. CONCLUSIONS: The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Management of severe thoracic impalement trauma against two-wheeled horse carriage: a case report and literature review.

Thoracic injuries in general are of great importance due to their high incidence and high mortality. Thoracic impalement injuries are rare but severe due to the combination of cause, effect and result. This study's primary objective is to report the case of a young man who was impaled by a two-wheeled horse carriage shaft while crashing his motorcycle in a rural zone. An EMT-B ferry was called at the crash scene and a conscious patient was found, sustaining a severe impalement injury to the left hemithorax, suspended over the floor by the axial skeleton with the carriage shaft coming across his left chest. As a secondary objective, a literature review of thoracic impalement injuries is performed. Cases of thoracic impalement injury require unique and individualized care based on injury severity and affected organs. Reported protocols for managing impalement injuries are entirely anecdotal, with no uniformity on impaled patient's approach and management. In penetrating trauma, it is essential not to remove the impaled object, so that possible vascular lesions remain buffered by the object, avoiding major bleeding and exsanguination haemorrhage. Severed impaled thoracic patients should be transferred to a specialist centre for trauma care, as these lesions typically require complex multidisciplinary treatment. High-energy thoracic impalement injuries are rare and hold a high mortality rate, due to the complexity of trauma and associated injuries such as thoracic wall and lung lesions. Modern medicine still seems limited in cases of such seriousness, not always with satisfactory results.

Penetrating bladder trauma: a high risk factor for associated rectal injury.

Demographics and mechanisms were analyzed in prospectively maintained level one trauma center database 1990-2012. Among 2,693 trauma laparotomies, 113 (4.1%) presented bladder lesions; 51.3% with penetrating injuries (n = 58); 41.3% (n = 24) with rectal injuries, males corresponding to 95.8%, mean age 29.8 years; 79.1% with gunshot wounds and 20.9% with impalement; 91.6% arriving the emergence room awake (Glasgow 14-15), hemodynamically stable (average systolic blood pressure 119.5 mmHg); 95.8% with macroscopic hematuria; and 100% with penetrating stigmata. Physical exam was not sensitive for rectal injuries, showing only 25% positivity in patients. While 60% of intraperitoneal bladder injuries were surgically repaired, extraperitoneal ones were mainly repaired using Foley catheter alone (87.6%). Rectal injuries, intraperitoneal in 66.6% of the cases and AAST-OIS grade II in 45.8%, were treated with primary suture plus protective colostomy; 8.3% were sigmoid injuries, and 70.8% of all injuries had a minimum stool spillage. Mean injury severity score was 19; mean length of stay 10 days; 20% of complications with no death. Concomitant rectal injuries were not a determinant prognosis factor. Penetrating bladder injuries are highly associated with rectal injuries (41.3%). Heme-negative rectal examination should not preclude proctoscopy and eventually rectal surgical exploration (only 25% sensitivity).

Disminución de las transfusiones alogénicas por la generalización del uso de recuperadores de sangre postoperatorios en cirugía de prótesis de rodilla / Decrease in allogenic transfusions due to the spread of use of postoperative retransfusion systems in knee replacement surgery

Objetivos. Los equipos medicoquirúrgicos disponen de múltiples herramientas para reducir la necesidad de transfusión alogénica perioperatoria. En nuestro centro se ha generalizado el uso de recuperadores de sangre filtrada en el postoperatorio de la cirugía de prótesis total de rodilla desde 2006. El objetivo de este estudio fue evaluar si el uso de recuperadores de sangre filtrada disminuyó la tasa de transfusiones en nuestra práctica clínica habitual. Material y métodos. Estudio de cohortes retrospectivo: grupo 2004, pacientes intervenidos de prótesis total de rodilla durante 2004, antes del uso de recuperadores de sangre filtrada; y grupo 2008, pacientes intervenidos de prótesis total de rodilla durante 2008, usando recuperadores. Se registraron sexo, niveles de hemoglobina preoperatorio y al cuarto día, masa total eritrocitaria perdida, reinfusión de sangre recuperada y transfusión de banco durante la estancia hospitalaria. Resultados. Ambos grupos fueron homogéneos en cuanto a sexo, hemoglobinas en el preoperatorio y el cuarto día, y masa total eritrocitaria perdida. La proporción de pacientes transfundidos fue significativamente menor en el grupo 2008 frente al grupo 2004 (20,18 vs. 42,19%), con un riesgo relativo de ser transfundido de 0,47 y NNT de 4,54; p = 0,0017. Conclusiones. En nuestro centro el uso de recuperadores disminuyó la proporción de pacientes transfundidos durante el ingreso para cirugía de prótesis total de rodilla, aunque este resultado no puede generalizarse debido a la ausencia de un criterio definido para indicar las transfusiones(AU)

Objectives. Surgical teams have several tools in order to reduce the need for postoperative allogenic transfusion. Postoperative autotransfusion of unwashed shed blood has become common practice for total knee replacement surgery since 2006 in our hospital. This study was designed to evaluate if this practice has reduced allogenic blood transfusions. Material and methods. A retrospective study comparing two cohorts, group 2004 with patients operated on for total knee replacement during the year 2004, before the use of the retransfusion system, and group 2008, patients operated on in the year 2008, with regular use of the retransfusion system. Gender, preoperative and postoperative haemoglobin levels, total amount of calculated erythrocytes lost, reinfusion of shed blood and allogenic blood transfusion during hospital stay were recorded. Results. Both groups were similar as regards gender, preoperative and postoperative hemoglobin levels, and total amount of erythrocytes lost. The proportion of transfused patients was significantly lower in group 2008 versus group 2004 (20.18% versus 42.19%), with a relative risk of being transfused of 0.47 and a NNT of 4.54. P = .0017. Conclusions. In our hospital the use of postoperative retransfusion systems has reduced the proportion of transfused patients during hospitalization for total knee replacement surgery, although this result cannot be generalized due to the lack of a fixed transfusion trigger(AU)

[Decrease in allogenic transfusions due to the spread of use of postoperative retransfusion systems in knee replacement surgery]. / Disminución de las transfusiones alogénicas por la generalización del uso de recuperadores de sangre postoperatorios en cirugía de prótesis de rodilla.

OBJECTIVES: Surgical teams have several tools in order to reduce the need for postoperative allogenic transfusion. Postoperative autotransfusion of unwashed shed blood has become common practice for total knee replacement surgery since 2006 in our hospital. This study was designed to evaluate if this practice has reduced allogenic blood transfusions. MATERIAL AND METHODS: A retrospective study comparing two cohorts, group 2004 with patients operated on for total knee replacement during the year 2004, before the use of the retransfusion system, and group 2008, patients operated on in the year 2008, with regular use of the retransfusion system. Gender, preoperative and postoperative haemoglobin levels, total amount of calculated erythrocytes lost, reinfusion of shed blood and allogenic blood transfusion during hospital stay were recorded. RESULTS: Both groups were similar as regards gender, preoperative and postoperative hemoglobin levels, and total amount of erythrocytes lost. The proportion of transfused patients was significantly lower in group 2008 versus group 2004 (20.18% versus 42.19%), with a relative risk of being transfused of 0.47 and a NNT of 4.54. P=.0017. CONCLUSIONS: In our hospital the use of postoperative retransfusion systems has reduced the proportion of transfused patients during hospitalization for total knee replacement surgery, although this result cannot be generalized due to the lack of a fixed transfusion trigger.

Extended scaling in the magnetic critical phenomenology of the σ-phase Fe0.53-Cr0.47 and Fe0.52-V0.48 alloys.

The magnetization of the sigma-phase Fe(0.53)Cr(0.47) and Fe(0.52)V(0.48) alloys was studied as a function of temperature and field. The experiments show that both materials behave magnetically as re-entrant spin glass systems. Field versus temperature diagrams were obtained where the locations of the paramagnetic phase, the intermediate ferromagnetic-like phase and the spin glass fundamental state were displayed. These diagrams are in qualitative agreement with the predictions of the mean field theory for the interplay between the ferromagnetic and spin glass orderings. The critical phenomenology near the para-ferromagnetic transition could be investigated. It was found that the paramagnetic susceptibility is quite well described by the extended scaling scheme, where the reduced temperature is written as τ = (T - T(c))/T. The value obtained for the susceptibility critical exponent γ is intermediate between the prediction of the 3D Heisenberg universality class and the large values observed in spin glasses, as previously found in other re-entrant systems. The data do not confirm the validity of the extended scaling in the ferromagnetic-like phase. Using either the conventional or extended scaling protocols, the exponents ß and δ were found to have values close to those reported for spin glass transitions. Despite the relevance of disorder and the anomalous values determined for ß, γ and δ, the Widom scaling relation holds as an equality.

WT1 mutations may be a cause of severe renal failure due to nephroblastomatosis in Wilms' tumor patients.

Wilms' tumor suppressor gene (WT1) encodes a transcription factor required for normal development of the genitourinary system. Germline WT1 mutations have been described in a wide spectrum of pathological conditions, including kidney diseases, genital abnormalities and Wilms' tumor. Here we report a 4-year-old male patient who presented with bilateral cryptorchidism, Wilms' tumor, nephroblastomatosis and renal failure without nephrotic proteinuria. Sequence analysis of the WT1 gene demonstrated a constitutional heterozygous nonsense mutation in exon 7, which leads to a truncation of the WT1 protein at the zinc-finger 1. In the DNA of the tumor, we observed the same mutation in homo/hemizygosity. Given the requirement of WT1 for normal development, the WT1 mutation is likely to be responsible for the nephroblastomatosis and, in consequence, for the severe renal failure observed in our patient. This finding extends the spectrum of kidney diseases related to WT1 mutations and points to the need to screen for this gene in children with genitourinary abnormalities and Wilms' tumor because of the associated risk of nephroblastomatosis and renal failure in those carrying WT1 mutations.

Endoscopic recanalization following accidental ligation of the common hepatic duct. A new technique.

Bile duct injury is a known complication of cholecystectomy. While minor injuries can be treated endoscopically, successful endoscopic management of complete ligation of the common hepatic duct (CHD) has not been described. Our aim was to report a novel technique for endoscopic recanalization of accidently ligated CHD. We demonstrated a 75 year old woman presented with a small bile leak and complete ligation of the CHD after open cholecystectomy subjected to successful biliary endoscopic recanalization. Cholangiogram demonstrated resolution of the bile leak and minimal residual narrowing of the CHD. Endoscopic intervention following biliary needle puncture access may avoid surgery in patients with CHD ligation or complex stenosis.

A 20-year experience with portal and superior mesenteric venous injuries: has anything changed?

OBJECTIVES: To identify predictive factors causing mortality in patients with injuries to the portal (PV) and superior mesenteric veins (SMV). DESIGN: Retrospective analysis of prospectively collected data. MATERIALS AND METHODS: Adults admitted with blunt or penetrating PV and SMV injuries at an academic level I trauma center during a 20-year period. RESULTS: Of 26,387 major trauma victims admitted from 1987 through 2006, 26 sustained PV or SMV injuries (PV=15, SMV=11). Mechanism of injury was penetrating in 19 (73%) and 20 were in shock. Active hemorrhage occurred in 21. Most patients had associated injuries (2.9+/-1.8/patient). Mean Injury Severity Score (ISS) was 27.8+/-16.8. All PV injuries underwent suture repair and 27% of SMV injuries were ligated. Overall mortality was 46% (PV=47%, SMV=45%). Stab wounds had a lower mortality (31%) compared to gunshot wounds (67%) and blunt injuries (57%). Nonsurvivors had a higher ISS (35.8 vs. 20.9; p=0.02), more associated injuries (3.7 vs. 2.2; p=0.02), were older, and had active hemorrhage. Active hemorrhage (p=0.04) was independently related to death while shock on admission (odds ratio=6.1, p=0.61) trended toward higher mortality. CONCLUSION: Despite improvements in trauma care, mortality of PV and SMV injuries remains high. Shock, active hemorrhage, and associated injuries were predictive of increased mortality.

Rituximab en nefritis lúpica con síndrome antifosfolípido / Antiphospholipid syndrome and lupus nephritis treated with rituximab

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DMSA study performed during febrile urinary tract infection: a predictor of patient outcome?

Technetium-99m dimercaptosuccinic acid (DMSA) study has been advocated as a method for the assessment of renal sequelae after acute febrile urinary tract infection (UTI). However, it is not known whether DMSA scintigraphy performed during acute UTI has any prognostic value for outcome assessment. The objective of this study was to evaluate the usefulness of DMSA scintigraphy performed during UTI as a predictor of patient outcome, to identify children at risk of events [vesico-ureteral reflux (VUR) or recurrent UTI] that may lead to the development of progressive renal damage. One hundred and fifty-two children (including 78 girls) with a mean age of 20 months (range 1 month to 12 years) with first febrile UTI were evaluated by DMSA scintigraphy during acute UTI. After acute UTI, children were explored by voiding cysto-urethrography. Children who presented an abnormal DMSA study, or a normal DMSA study but VUR or recurrent UTI, underwent a DMSA control study 6 months after UTI. Children with VUR were followed up by direct radionuclide cystography. DMSA scintigraphy performed during acute UTI was normal in 112 children (74%). In 95 of these children, follow-up DMSA scintigraphy was not performed owing to a good clinical outcome. In the remaining 17 children, follow-up scintigraphy was normal. Forty children (26%) presented abnormal DMSA study during acute UTI. Twenty-five of them presented a normal follow-up DMSA, and 15 presented cortical lesions. Children with abnormal DMSA had a higher frequency of VUR than children with normal DMSA (48% vs 12%). It is concluded that children with normal DMSA during acute UTI have a low risk of renal damage. Children with normal follow-up DMSA and low-grade VUR have more frequent spontaneous resolution of VUR.

[Analysis of 942 episodes of bacteremia in a cardiology institution. Experience with the Bact-Alert system]. / Análisis de 942 episodios de bacteriemia en una institución cardiológica. Experiencia con el sistema Bact-Alert.

In Instituto de Cardiología y Cirugía Cardiovascular, Fundación Favaloro, between January 1996 and October 1999, 10,793 blood cultures and 942 episodes of bacteremia, corresponding to 1883 positive blood cultures, were studied by means of the Bact-Alert System (Organon Teknika), 94% being monomicrobial episodes. Gram positive bacteria were isolated in 45%, Gram negative in 52% and fungi in 3% of episodes. Associated foci of infection were: catheters 36.5%, mediastinitis 9%, pneumonia 6%, endocarditis 6%, abdominal 6%, urinary tract infections 9%, prosthesis 2.6%, empyema 0.2%, arthritis 0.1%, skin and soft tissue 2.5%, diarrhea 0.1%, aortic aneurysm 0.2%, meningitis 0.2%, pericarditis 0.3%, endarteritis 0.1%, infusion fluids 0.2% and unknown 21%. Median time (in hours) for positivization of blood cultures according to different foci were: catheters 16.4, mediastinitis 19.2, pneumonia 14.2, endocarditis 14.5, abdominal infections 11.8, urinary tract infections 13.0 and unknown origin 19.0. As for contaminating microorganisms, the value was 30.5. Seventy two percent of blood cultures became positive within 24 h, and 87% within 48 h; only 1% became positive between 5th and 7th day. There were no important differences in time to detect positive cultures according to different foci. It was not useful to incubate blood cultures more than five days, except for special circumstances, because it does not improve recovery of clinically significant microorganisms.