Plain film of the abdomen remains a low sensitivity test in A&E.

BACKGROUND: Plain film abdomens (PFA) are frequently used in the emergency department to help guide the management of patients presenting with abdominal symptoms. A plain film abdomen contributes minimally to clinical scenarios due to low sensitivity and specificity. Is a PFA useful in the emergency setting or does it serve to further complicate decision making? AIM: We hypothesise that PFAs in the emergency department are over utilised to falsely reassure clinicians and patients alike. METHODS: A search of the National Integrated Medical Imaging System (NIMIS) database in an Irish tertiary referral hospital was conducted. All plain film abdominal radiographs requested by the emergency department between 01/01/2022 and 31/08/2022 were identified. Requests where there was suspicion of foreign body were excluded. A retrospective search of the NIMIS database identified subjects who underwent subsequent imaging. RESULTS: A total of 619 abdominal films were deemed suitable for inclusion. These comprised of 338 male and 282 female subjects. Subjects had an average age of 64 years. Fifty-seven per cent of PFAs detected no abnormality. Forty-two per cent of subjects had subsequent imaging. The plain film findings correlated with further imaging in only 15% of cases. One case of ruptured aortic aneurysm and 11 perforations were detected on computerised tomography, none of these cases were evident on abdominal X-ray. CONCLUSION: Plain film abdomen requests are over utilised in the emergency department. PFAs are not sensitive for detecting acute pathology and should not be used to decide if a patient requires further imaging or a full clinical assessment.

Media messaging in diagnosis of acute CXR pathology: an interobserver study among residents.

The objectives of the study were to determine whether diagnostic accuracy and reliability by on-call teams is affected by communicating chest radiograph (CXR) images via instant messaging on smartphones in comparison to viewing on a workstation. 12 residents viewed 100 CXR images each with a 24% positive rate for significant or acute findings sent to their phones via a popular instant messaging application and reported their findings if any. After an interval of 42 days they viewed the original DICOM images on personal computers and again reported their findings. There were no statistically significant differences in accuracy, agreement, sensitivity, specificity, positive predictive value or negative predictive value between desktop workstation viewed images and images sent via the mobile application. Media messaging is a useful adjunct for quick second opinions on radiological images, without significant decay in diagnostic accuracy. If technical, ethical and legal issues are addressed, it could be incorporated into practice as a useful adjunct.

The Twin Evils of Concomitant Rare Pathology with Variant Anatomy: Superior Mesenteric Artery Aneurysm and a Replaced Right Hepatic Artery.

Aneurysmal degeneration of the superior mesenteric artery (SMA) is a rare clinical finding, estimated to affect <1% of the general population in postmortem studies. Due to the rare prevalence of aneurysms affecting the SMA, there are no clear or definitive published consensus guidelines for its management at presentation, with both surgical and endovascular options described. An aberrant or replaced right hepatic artery (RRHA) is thought to affect 10-15% of the population. The prevalence of both conditions presenting concomitantly is unknown, but undoubtedly even rarer. We describe the successful management of a symptomatic SMA aneurysm with an RRHA emerging from the aneurysmal sac presenting to our vascular unit. This was repaired via an open surgical approach with SMA aneurysmectomy and interposition grafting using reversed vein with preservation of RHA liver perfusion via a novel reconstruction option. This case highlights the challenge that visceral aneurysms pose, especially when simple or orthodox reconstruction options are limited due to rare or unusual anatomy.

Mycotic Aneurysm of the Extracranial Internal Carotid Artery, Resect and Ligate or Reconstruct?

Mycotic aneurysmal disease of the extracranial carotid arteries (ECA) is a rare entity associated with a high morbidity, including rupture, hemorrhage, airway obstruction, and stroke. Surgical management is challenging due to difficult dissection through infected or inflamed tissue. This report highlights a case of ECA-aneurysm infection presenting with stroke and an occluded internal carotid artery, likely due to microbial arteritis on a background of osteomyelitis. Operative intervention was performed to definitively treat the infection and prevent the potential associated complications. In this case, the incident vessel was 100% occluded at presentation, allowing vessel ligation and resection without carotid complex reconstruction.

Using the diamond intermediate anastomosis in composite sequential bypass grafting for critical limb ischemia.

Composite sequential bypass grafting is an effective alternative in the treatment of peripheral vascular disease when autologous vein is limited. We describe a modified technique for composite sequential bypass grafting anastomosis using a combination of synthetic graft with native vein connected via a common intermediate anastomotic junction, which also benefits from having additional outflow at the native, noncontiguous arteriotomy in a diamond configuration. This technique was piloted on six patients to treat critical limb ischemia when no other revascularization options were deemed suitable. Limb salvage with resolution of symptoms was achieved in all six patients at the 6-month follow-up. The diamond anastomosis is a promising method to maximize limb salvage using a unique composite sequential bypass configuration when native vein is limited.

Mineralocorticoid deficiency in hemorrhagic shock.

BACKGROUND: In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI). MATERIALS AND METHODS: Thirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP <90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ≤2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD. RESULTS: At ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ≤60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7-22] versus 5 [2-7], P = 0.015) and had increased crystalloid requirements (18L [14-23] versus 9L [6-10], P < 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria. CONCLUSIONS: MD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.

Reducing time to urgent surgery by transporting resources to the trauma patient.

BACKGROUND: Time to definitive trauma care directly influences patient survival. Patient transport (retrieval) services are essential for the transportation of remotely located trauma patients to a major trauma centre. Trauma surgical expertise can potentially be combined with the usual retrieval response (surgically supported response) and delivered to the patient before patient transportation. We identified the frequency and circumstances of such surgically supported retrievals. METHODS: Retrospective review of trauma patients transported by the NRMA CareFlight, New South Wales Medical Retrieval Service, Australia, from 1999 to 2003, identifying patients who had a surgically supported retrieval response and an urgent surgical procedure carried out before patient transportation to an major trauma centre. RESULTS: Seven hundred and forty-nine trauma interhospital patient transfers were identified of which 511 (68%) were categorized as urgent and 64% of which were rural based. Three (0.4%) patients had a surgically supported retrieval response and had an urgent surgical procedure carried out before patient transportation. All patients benefited from that early surgical intervention. CONCLUSION: A surgically supported retrieval response allows for the more timely delivery of urgent surgical care. Patients can potentially benefit from such a response. There are, however, important operational considerations in providing a surgically supported retrieval response.

Alpha glutathione S-transferase: a potential marker of ischemia-reperfusion injury of the intestine after cardiac surgery?

BACKGROUND: The aim of the study was to assess the utility of alpha glutathione S-transferase (alphaGST) as a potential marker of intestinal ischemia-reperfusion injury in children after cardiac surgery. METHODS: Twenty-six patients undergoing cardiac surgery were enrolled in this longitudinal experimental study. Blood samples were drawn for analysis at specified time points during surgery and analyzed for alphaGST levels. Clinical indices of splanchnic morbidity were assessed up to discharge from hospital. Results were analyzed using Mann-Whitney tests and linear mixed effects models. RESULTS: Two groups were identified. Group 1 (n = 16) showed no intestinal morbidity and group 2 (n = 10) had signs of intestinal morbidity. Statistical differences were shown between the 2 groups with respect to time with aortic cross-clamp (ACC) in situ, time on cardiac bypass, duration of operation, time to enteral feeding and full feeding, time on mechanical ventilation, and time in the intensive care unit postoperatively. The serum concentration of alphaGST was significantly higher for group 2 and this rise was greatest after removal of the ACC. CONCLUSIONS: AlphaGST showed significant elevation in patients with prolonged bypass times and ACC times. These patients also displayed signs of intestinal morbidity, suggesting that this marker may be useful in screening patients at risk for intestinal pathology. This rise in alphaGST was associated with a prolonged ischemia time, and was greatest after the cross-clamp was released, suggesting that it is a postischemic reperfusion phenomenon leading to its elevation. A low alphaGST level appears to exclude significant intestinal ischemia.