Renal injury mechanisms of motor vehicle collisions: analysis of the crash injury research and engineering network data set.

PURPOSE: Injury prevention requires efficient diagnosis and management, and knowledge of collision kinematics may allow first responders to triage victims earlier based on crash scene assessment. We identified possible collision patterns and vehicle interior components that may have a role in kidney injury following motor vehicle collision. MATERIALS AND METHODS: A total of 115 cases (131 renal injuries) were identified in the multicenter Crash Injury Research and Engineering Network database. For each case a crash investigation was performed, identifying vehicle kinematic characteristics, vehicle damage profile and an assessment of the interior compartment to determine points of occupant contact and restraint system use. A multidisciplinary team reviewed each case to establish a probable mechanism for all injuries sustained. Review of the medical record was performed to identify subject demographics and injury characteristics. Cases were analyzed based on frontal vs side impact. RESULTS: Of the subjects 52% were male. Mean age was 36.1 years and median injury severity score was 33. Overall injuries were low grade in 72.5% of patients, 30% were unrestrained and 47.6% of collisions were side impact. No difference was observed between frontal and lateral collisions with respect to renal injury severity. For frontal impact the seat belt was the source in 26 of 29 renal injuries (90%) and 12 of 15 unrestrained cases (80%) were due to direct impact with the steering column. Of 131 side impact injuries 62 were attributable to impact with lateral compartment elements. Side impact injuries were associated with lateral door panel impact (41 of 61) with the armrest accounting for 22. The mean lateral compartment intrusion was 29.6 cm. No grade V injuries occurred when vehicle intrusion was less than 30 cm. The mean change in velocity for frontal and lateral collisions was 24.0 and 31.5 mph, respectively (p <0.05). In frontal collisions the change in velocity for kidney injuries sourced to the steering wheel vs seat belt injuries was statistically greater (41.5 vs 28.4 mph, p = 0.05). CONCLUSIONS: Renal injury in frontal and side impact collisions appears to occur after direct impact from objects in the vehicle compartment. For frontal crashes occupant acceleration into the seat belt or steering wheel seems to result in renal injuries. Side impact injuries occur when the vehicle side panel intrudes into the compartment, striking the occupant. Further collision evaluation in larger data sets is required to substantiate our findings.

Monckeberg's calciphylaxis with necrosis of the glans penis: a case presentation.

Monckeberg's calcific sclerosis of the media of the small-sized and medium-sized arteries is a well described and potentially life-threatening condition seen almost exclusively in patients with end-stage renal disease (ESRD) and with hyperparathyroidism. Penile gangrene resulting from this entity is associated with a mortality as high as 64%. A 65-year-old man with ESRD on dialysis for 6 years was referred to Harborview Medical Center with severe penile pain and partial necrosis of his glans penis, which progressed despite medical management. The patient had previously undergone amputations on all four extremities. After intraoperative biopsies of the proximal corpora cavernosa and spongiosum demonstrated viable tissue, he underwent partial penectomy. Pathologic evaluation revealed calciphylaxis within the media of the penile vessels. Two months later the patient had persistent wound-healing issues with intractable pain and thus underwent a complete penectomy with ultimate resolution of his severe pain.

Emphysematous pyelonephritis: a case report and review of the literature.

We present a case of fulminant emphysematous pyelonephritis in a 44-year-old diabetic woman culminating in emergent nephrectomy. Current management strategies and their outcomes are reviewed.

American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy, dialysis, and death in patients with blunt injury and nephrectomy for penetrating injuries.

BACKGROUND: Despite broad clinical use of the American Association of the Surgery of Trauma (AAST) injury scale for kidney, it has only been found to predict the need for renal surgery in single institution series. We sought to validate this scheme for morbidity and mortality in a national cohort of patients with renal injury. METHODS: A retrospective cohort design was used to determine the association between increasing AAST scores and nephrectomy, dialysis, and mortality. The cohort included all patients with a renal injury in the National Trauma Data Bank (NTDB) from 1994 and 2003. Univariate and multivariate prediction models were used for analysis of data. RESULTS: At the time of review, a total of 742,774 patient records were registered in the NTDB. Renal injury occurred in 8465 patients (1.2%). Increasing injury grade was associated with a greater nephrectomy (RR 12-127), dialysis (RR 1.3-4.7), and mortality (RR 1.3-1.9) rate for blunt kidney injury. For penetrating injury, nephrectomy was the only outcome that was associated with higher grades of renal injury with a RR of 7.7 to 31 for grades III to V injuries. CONCLUSION: The AAST injury scale for kidney predicts for morbidity in blunt and penetrating renal injury and for mortality in blunt injury. Thus, we continue to support its use as a clinical and research tool.

Randomized prospective blinded study validating acquistion of ureteroscopy skills using computer based virtual reality endourological simulator.

PURPOSE: Surgical simulation has emerged in the last decade as a potential tool for aiding acquisition of technical skills, including anesthesia protocols, trauma management, cardiac catheterization and laparoscopy. We evaluate and validate the use of a computer based ureteroscopy simulator (URO Mentor, Simbionix Ltd., Lod, Israel) in the acquisition of basic ureteroscopic skills. MATERIALS AND METHODS: We assessed 20 novice trainees for the ability to perform basic ureteroscopic tasks on a computer based ureteroscopy simulator. Participants were randomized to receive individualized mentored instruction or no additional training, and subsequently underwent post-testing. Pre-training and post-training improvement in performance was assessed by objective simulator based measurements. Subjective overall performance was rated using a validated endourological global rating scale by an observer blinded to subject training status. RESULTS: Demographics and pre-test scores were similar between groups. Post-testing revealed a significant effect of training on objective and subjective measurements. Spearman rank correlation demonstrated a significant association between objective simulator based measurements and the endourological global rating scale. CONCLUSIONS: Use of a computer based ureteroscopy simulator resulted in rapid acquisition of ureteroscopic skills in trainees with no prior surgical training. Results of this study demonstrate the use of a virtual reality ureteroscopy simulator in endourological training. Correlation of simulator based measurements with a previously validated endourological global rating scale provides initial validation of the ureteroscopy simulator for the assessment of ureteroscopic skills.