Neuromas as the cause of pain in the residual limbs of amputees. An ultrasound study.

AIM: To explore the morphology of neuromas and to determine the differences, if any, between asymptomatic and symptomatic neuromas using ultrasound. MATERIALS AND METHODS: Eighty patients with symptomatic neuromas were included in this retrospective review. High-resolution ultrasound examination was performed. Transducer pressure allowed real-time analysis of both symptomatic and asymptomatic neuromas. Quantifiable assessment of pain by the patient assigned a pain score of 0, 1, 2, or 3, to each neuroma. RESULTS: One hundred and fifty-nine neuromas were identified in total. Fifty-three neuromas were asymptomatic (pain score=0), very severe pain was recorded in 54 (pain score=3), 16 neuromas were mildly painful (pain score=1) and 36 were moderately painful (pain score=2). The average number of neuromas per patient was 1.98, and the average number of symptomatic neuromas per patient was 1.3. There was no correlation between pain score and patient age, neuroma volume, amputation type, and time since amputation. CONCLUSIONS: High-resolution ultrasound can distinguish between asymptomatic and symptomatic neuromas. Patient age, time since amputation, the type of amputation, and the neuroma volume were not related to the presence of pain.

Sonographic appearances of medial retinacular complex injury in transient patellar dislocation.

AIM: To describe the sonographic appearances of the medial retinacular (MPFR) complex of the knee in patients with acute and recurrent patellar dislocation. MATERIALS AND METHODS: Thirty patients were scanned within 2-4 weeks of an acute episode of lateral patellar dislocation. Eleven gave a history of recurrent patellar dislocation. Ten patients had examination under anaesthesia with arthroscopy and repair of the injury. The sonographic and operative results were compared. RESULTS: The normal sonographic appearance of the MPFR is described. Of the 10 patients who underwent examination under anaesthesia, four patients had complete avulsion of the MPFR from the patella, two patients had avulsion of the MPFR from the adductor tubercle and four patients had avulsion of the MPFR from both the patella and adductor tubercle. There was complete correlation between the sonographic and operative findings for injuries of the MPFR. Other findings included partial retinacular tears, injury to the medial collateral ligament, haematoma within vastus medialis obliquus (VMO) and bony avulsions from the patella and adductor tubercle CONCLUSION: Sonography gives reliable information regarding the site of the injury and its extent thus helping to decide whether conservative or operative treatment is the most appropriate approach to management of the injury.

Breast infection due to dirofilariasis.

We describe a case of dirofilariasis of the breast in a woman presenting with a breast lump. The mammogram and ultrasound appearances are described with histopathological correlation. The suspicion of a parasitic infection was raised by the presence of rod-like structures within a hypoechoic nodule on sonography, appearances that have not been previously described. The case illustrates an unusual diagnostic problem since it presented in a non-endemic area.

Computed tomography in the evaluation of penetrating neck trauma: a preliminary study.

HYPOTHESIS: Penetrating neck trauma has traditionally been evaluated by surgical exploration and/or invasive diagnostic studies. We hypothesized that computed tomography (CT), used as an early diagnostic tool to accurately determine trajectory, would direct or eliminate further studies or procedures in stable patients with penetrating neck trauma. DESIGN: Retrospective case series. SETTING: Academic, urban, level I trauma center. PATIENTS: Hemodynamically stable patients without hard signs of vascular injury or aerodigestive violation who had sustained penetrating trauma to the neck. INTERVENTIONS: Patients underwent a spiral CT as an initial diagnostic study after initial evaluation in the trauma bay. Further invasive studies were directed by CT findings. MAIN OUTCOME MEASURES: Number of invasive studies performed. RESULTS: Twenty-three patients were identified during the 30-month period. Nineteen patients sustained gunshot wounds; 3, shotgun wounds; and 1, a stab wound. One patient died of a cranial gunshot wound. Three isolated zone I, 1 isolated zone II, 9 isolated zone III, and 10 multiple neck zone trajectories were evaluated. Thirteen patients were identified by CT to have trajectories remote from vital structures and required no further evaluation. Ten patients underwent angiography. Only 2 underwent bronchoscopy and esophagoscopy. Four patients were discharged from the emergency department; 7 other patients were discharged within 24 hours. No adverse patient events occurred before, during, or after CT scan. CONCLUSIONS: Computed tomography in stable selected patients with penetrating neck trauma appears safe. Invasive studies can often be eliminated from the diagnostic algorithm when CT demonstrates trajectories remote from vital structures. As a result, efficient evaluation and early discharge from the trauma bay or emergency department can be realized. Further prospective study of CT scan after penetrating neck trauma is needed.

Evolution in damage control for exsanguinating penetrating abdominal injury.

OBJECTIVE: Damage control (DC) has proven valuable in exsanguinated patients. The purpose of this study was to quantify and qualify the impact of current damage control principles applied in a penetrating abdominal injury (PAI) population. METHODS: Over a 3-year period (June 1997-May 2000), of 271 laparotomies for PAI, 24 patients underwent DC (8.9%). Demographics, injury grade, resuscitative and operative parameters, acid-base status, coagulation profiles, fluid/transfusion requirements, definitive repairs, abdominal closure, complications, and outcomes were reviewed. Data were compared with our DC experience a decade earlier. Fisher's exact test was used for comparisons. RESULTS: Overall survival improved for equivalent Injury Severity Score, Revised Trauma Score, TRISS, admission systolic blood pressure, operating room systolic blood pressure, and Penetrating Abdominal Trauma Index score. Solids (1.2 vs. 1.3), hollow organ (1.5 vs. 1.7), and major vascular injuries (0.5 vs. 0.8) per patient remain unchanged. Currently, there was less hypothermia with equivalent operating room times. In intensive care unit survivors, acid-base status was similar but coagulopathy and hypothermia were less severe. Definitive colon management has shifted from ostomies to anastomoses. Eventual fascial closure occurred in 14 of 19 (74%) compared with 12 of 14 (86%) in the historical group. There were three gastrointestinal fistulae (one pancreatic), one anastomotic leak, and three intra-abdominal abscesses. CONCLUSION: Continued application of DC principles has led to improved survival with PAI. Better control of temperature, experience with the open abdomen, and intensive care unit care may be causative.

The mesenteric hemodynamic response to circulatory shock: an overview.

The mesenteric hemodynamic response to circulatory shock is characteristic and profound; this vasoconstrictive response disproportionately affects both the mesenteric organs and the organism as a whole. Vasoconstriction of post-capillary mesenteric venules and veins, mediated largely by the alpha-adrenergic receptors of the sympathetic nervous system, can effect an "autotransfusion" of up to 30% of the total circulating blood volume, supporting cardiac filling pressures ("preload"), and thereby sustaining cardiac output at virtually no cost in nutrient flow to the mesenteric organs. Under conditions of decreased cardiac output caused by cardiogenic or hypovolemic shock, selective vasoconstriction of the afferent mesenteric arterioles serves to sustain total systemic vascular resistance ("afterload"), thereby maintaining systemic arterial pressure and sustaining the perfusion of non-mesenteric organs at the expense of mesenteric organ perfusion (Cannon's "flight or fight" response). This markedly disproportionate response of the mesenteric resistance vessels is largely independent of the sympathetic nervous system and variably related to vasopressin, but mediated primarily by the renin-angiotensin axis. The extreme of this response can lead to gastric stress erosions, nonocclusive mesenteric ischemia, ischemic colitis, ischemic hepatitis, ischemic cholecystitis, and/or ischemic pancreatitis. Septic shock can produce decreased or increased mesenteric perfusion, but is characterized by an increased oxygen consumption that exceeds the capacity of mesenteric oxygen delivery, resulting in net ischemia and consequent tissue injury. Mesenteric organ injury from ischemia/reperfusion due to any form of shock can lead to a triggering of systemic inflammatory response syndrome, and ultimately to multiple organ dysfunction syndrome. The mesenteric vasculature is therefore a major target and a primary determinant of the systemic response to circulatory shock.

Uncertainty in incident rates for trucks carrying dangerous goods.

This paper addresses the uncertainty associated with release and fire incident rates for trucks in transit carrying dangerous goods. The research extends the treatment of uncertainty beyond sensitivity analysis, low-best-high estimates and confidence intervals, and represents the uncertainty through probability density functions. The analysis uses Monte Carlo simulations to propagate the uncertainty in the input variables through to the resulting release and fire incident rates. The paper illustrates how we can combine information on accident and non-accident releases and fires to generate probability density functions for the total expected releases and fires per billion vehicle kilometres for trucks carrying dangerous goods.

Surgical airway management in the intensive care unit.

Despite having been a known surgical procedure for over 5000 years, the specifics of how, when, and why to perform a surgical airway are still debated. With new procedures, equipment, and techniques, operative airway management is becoming more complex. New methods of surgical airway management have to be evaluated against the gold standard, which will always be the open tracheostomy performed in the operating room. Unlike Dr. Jackson in 1909, surgeons today have to evaluate these new procedures not only by their efficacy but also by their cost effectiveness.

The traveling intensive care unit patient. Road trips.

Transport of critically ill or injured patients in the hospital is a necessary part of ICU care. Although the overall severity of misadventures occurring during patient transfer is minimal, potential complications risk patient deterioration in settings that may not be equipped to handle cardiovascular, respiratory, or neurologic emergencies safely. The critical care team should provide the same level of monitoring and care to the transported patient outside the ICU as he or she receives the unit. Each hospital should have a system that meets acceptable standards for safe transfer of the ICU patient, which minimizes risk and maximizes diagnostic and treatment yield.

Issues in potential organ donor management.

The shortage of organ donors has become a serious problem in modern medicine. Room for improvement exists in our ability to convert potential donors to actual donors based on the available numbers and a significant amount of recent research. A significant percentage of the potential donors represent head-injured patients, so a significant amount of responsibility falls on surgeons to optimize the opportunity for donation. There are clear steps along the pathway from potential to actual donor where physicians can have a significant effect on the rate of successful donation: 1. Identify all potential donors and institute a review system to verify that all potential donors are being identified in your area. 2. Establish an acceptable method to rapidly and accurately determine brain death in potential donors using the local available services. 3. Approach all potential donor families for consent, decouple death notification and consent request, use a member of the hospital team and an OPO representative to approach the family, and make the request in a private setting. 4. Use an aggressive, proactive approach to the medical management of the potential donor using the techniques described to limit the number of medical failures and maximize the number of organs donated per donor. Institute a review process to evaluate any medical failures that occur. Given the difference between the numbers of potential versus actual donors, the authors' significant contact with potential donors, and the clear opportunities for improvement in their approach, the surgical community must address these issues surrounding the optimal management of potential donors and their families.

Anger management group treatment for cocaine dependence: preliminary outcomes.

Cocaine abusers who fail to manage anger appropriately may have greater difficulty achieving and maintaining abstinence. We conducted a pilot study to examine an anger management group treatment in a sample of 59 men and 32 women with a diagnosis of cocaine dependence. Participants attended a 12-week anger management group treatment and background substance abuse treatment. Levels of anger, negative affect, and anger control were measured at baseline, weekly during treatment, and at 3-month posttreatment follow-up. Levels of anger decreased and anger control increased between baseline and the end of treatment. End-of-treatment changes were maintained at follow-up. These findings were not moderated by gender, age, or psychiatric medication use. In the absence of a randomized control group, we cannot make conclusive statements regarding the effectiveness of the anger management group treatment. However, these preliminary findings demonstrate the need for a randomized clinical trial to test the efficacy of the anger management group treatment.

Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation.

OBJECTIVE: Unplanned endotracheal extubation (UEE) is a common complication in medical intensive care units but very little data about UEE in surgical populations are available. Our hypothesis is that the surgical intensive care unit (SICU) population requires reintubation less frequently compared with the medical intensive care unit population. We prospectively gathered data on patients in a SICU in an attempt to identify the incidence of UEE and to study the need for reintubation after UEE. METHODS: During an 18-month period, we prospectively identified SICU patients from a quality improvement database who required ventilatory support. All patients who self-extubated were included in the study. RESULTS: Fifty-eight of 1,178 intubated patients experienced unplanned extubation 61 times during the 18-month period. A total of 22 patients (36%) required reintubation, whereas 39 patients (64%) did not. Thirty-three patients self-extubated while being actively weaned from ventilatory support. Of these, only 5 patients (15%) required reintubation and 28 patients (85%) did not (p < 0.01). CONCLUSION: A total of 85% of patients who self-extubate during the weaning process did not require reintubation in our study. Those who have an FiO2 >50%, a lower PaO2/FiO2 ratio, had UEE occur by accident, or were not being weaned when UEE occurred required reintubation more frequently. These data suggest that some of our SICU patients are intubated longer than necessary, which may translate into more ventilator related complications, longer ICU stays and increased cost.

Mesenteric vasoconstriction in response to hemorrhagic shock.

Previous studies indicate that cardiogenic shock (tamponade) in swine produces selective mesenteric ischemia due to disproportionate mesenteric vasospasm mediated primarily by the renin-angiotensin axis. Here, we characterized the systemic and mesenteric hemodynamic responses to hypovolemic shock to better understand the neurohumoral mechanisms controlling this response. Varying degrees of hypovolemic shock were produced by graded levels of hemorrhage, from 12.5 to 50% of the calculated blood volume. Systemic and mesenteric pressures and blood flows were measured, and corresponding vascular resistances were calculated. The hemodynamic responses of the mesenteric vascular bed were compared with those of the systemic (nonmesenteric) vasculature. These experiments were then repeated after confirmed blockade either of the alpha-adrenergic nervous system (phenoxybenzamine), of vasopressin (Manning compound), or of the renin-angiotensin axis (enalapril). Graded levels of hemorrhage produced corresponding graded, reproducible, steady-state levels of systemic hypotension, hypoperfusion, and peripheral vasoconstriction, i.e., hemorrhagic shock. This was associated with disproportionate degrees of mesenteric ischemia due to disproportionate mesenteric vasoconstriction. The selective component of this mesenteric vasoconstrictive response was not attenuated by a-adrenergic blockade nor by vasopressin blockade but was blocked by ablation of the renin-angiotensin axis with enalapril. Like cardiogenic shock, hemorrhagic shock generates selective mesenteric ischemia by producing a disproportionate mesenteric vasospasm that is mediated primarily by the renin-angiotensin axis.

Contingency contracting with monetary reinforcers for abstinence from multiple drugs in a methadone program.

Positive monetary contingencies for treating opioid dependence complicated by other drug use were examined. Participants (N = 102) entered 6-month methadone transition treatment (MTT) and were randomized into experimental conditions: 51 entered MTT with contingency contracts using monetary reinforcers and targeting abstinence from illicit drug and alcohol use, and 51 entered MTT without contingency contracts targeting abstinence. Outcomes were evaluated by random urinalysis and breath analysis. After 4 months of treatment, individuals in the contingency condition had longer periods of continuous abstinence (p<.005) and more drug-free tests overall (p<.04). Effects were limited, however, to the contracting period. The authors conclude that contingency contracting using monetary reinforcers may be a useful adjunct for achieving abstinence from multiple drugs of abuse during MTT.

National survey of the incidence of cervical spine injury and approach to cervical spine clearance in U.S. trauma centers.

BACKGROUND: The overall incidence of cervical spine injury (CSI) has been estimated from small studies; the incidence of specific injury types is less well established. The approach to screening for CSI has not been well studied; variation may exist based on Trauma Center (TC) level and type (academic vs. nonacademic). We attempted to define the incidence of different types of CSI and determine whether a national standard for cervical spine clearance (CSC) could be identified. We hypothesized a significant variation in incidence of CSI and approach to CSC based on TC level and type. METHODS: In a survey of 615 TC, institutions were asked to describe themselves as academic/nonacademic and provide a Level I-IV. Questions concerned demographics, Injury Severity Score, incidence of CSI, clinical resources, and approach to CSC. Methods of CSC included protocols, use of flexion-extension films, computed tomography, magnetic resonance imaging, and cervical collars. Clinical scenarios examined indications and technique for CSC. RESULTS: A total of 637 surveys were sent to 615 TC (25 follow-ups), and 165 TC (25%) responded. A total of 156 TC provided data for type: academic 44 (28%), nonacademic 112 (72%). A total of 142 TC provided data for level: 49 (34%) Level I, 75 (53%), Level II, 18 (13%), Level III. A total of 111,219 patients were entered into the trauma registries of these TC. The overall incidence of all types of CSI was 4.3%, CSI without spinal cord injury was 3.0%, spinal cord injury without fracture was 0.70%, and delayed diagnosis of all types of CSI was 0.01%. There was no difference in the incidence of CSI overall or by subtype based on TC level or type. Injury Severity Score correlated with incidence of CSI without cord injury (r = 0.387, p < 0.01). Regarding approach to CSC, differences existed by TC level and type for responsibility for CSC and protocols for CSC (p < 0.05). Level II TC felt early flexion-extension views were potentially harmful (60%); Level I TC did not (39%) (p < 0.05). Regarding indications for CSC, there was agreement on 10 of 11 clinical scenarios. For three of five clinical scenarios examining radiographic approach to CSC there was a broad distribution of approaches to patients with normal radiographs and cervical pain, altered mental status, coma. CONCLUSION: Incidence of CSI is uniform by TC level and type. Incidence of spinal cord injury without fracture is low: 0.7%. Reported rate of missed CSI is very low: 0.01%. There is good agreement (>78%) among TC on indications for CSC but less agreement on radiographic approach to CSC.

Improving the approach to organ donation: a review.

Organ transplantation continues to be hindered by a limited supply of organs. A significant percentage of potential organ donors are lost to either medical failure or inability to obtain consent for donation. In a surgical intensive care unit (ICU) we have refocused our efforts toward aggressive resuscitation, directed by control of coagulopathy, invasive monitoring, and dedicated ICU management while implementing a rapid brain death determination protocol. Over a 6-year period the length of stay until the legal determination of brain death is made has been significantly shortened (12.0 vs. 3.4 hours; p < 0.05), as have associated charges despite this more aggressive approach. As a result, we have eliminated medical failures prior to donation (13% vs. 0%) and increased consent rates (44% vs. 71%; p < 0.05). These efforts have significantly improved the number of organs harvested per eligible donor (1.8 vs. 3.4; p < 0.05). In addition, the number of organs per actual donor has increased and is now markedly greater than the U.S. national average (4.7 vs. 3.7). We believe the approach presented, if widely applied, could potentially improve the current organ supply shortage.

Effects of an organized critical care service on outcomes and resource utilization: a cohort study.

OBJECTIVE: To determine whether the presence of an on-site, organized, supervised critical service improves care and decreases resource utilization. DESIGN: The study compared two patient cohorts admitted to a surgical intensive care unit during the same period of time. The study cohort was cared for by an on-site critical care team supervised by an intensivist. The control cohort was cared for by a team with patient care responsibilities in multiple sites supervised by a general surgeon. The main outcome measures were duration of stay, resource utilization, and complication rate. SETTING: Study patients were general surgical patients in an academic medical center. RESULTS: Despite having higher Acute Physiology and Chronic Health Evaluation II scores, patients cared for by the critical care service spent less time in the surgical intensive care unit, used fewer resources, had fewer complications and had lower total hospital charges. The difference between the two cohorts was most evident in patients with the worst APACHE II score. CONCLUSIONS: Critical care interventions are expensive and have a narrow safety margin. It is essential to develop structured and validated approaches to study the delivery of this resource. In this study, the critical care service model performed favorably both in terms of quality and cost.