Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with "normal" chest radiograph?

BACKGROUND: A major cause of morbidity and mortality after blunt chest trauma remains undetected injuries. This study evaluates the role of routine computed tomographic (CT) scan. METHODS: We studied 93 consecutive patients from January 1999 to July 2000: 73 (76.3%) after motor vehicle crash with crash speed > 10 mph, and 22 (23.7%) after fall from height > 5 ft. Simultaneous with initial clinical evaluation, anteroposterior chest radiograph and helical chest CT scan were obtained for all patients. RESULTS: Sixty-eight patients (73.1%) showed at least one pathologic sign on chest radiograph, and 25 patients (26.9%) had normal chest radiograph. In 13 (52.0%) of these 25 patients, the CT scan showed multiple injuries; among these were two aortic lacerations, three pleural effusions, and one pericardial effusion. CONCLUSION: Over 50% of patients with normal initial chest radiograph showed multiple injuries on the CT scan, among which were also two (8%) potentially fatal aortic lesions. We therefore recommend primary routine chest CT scan in all patients with major chest trauma.

[2-year evaluation of a cooperation model between a surgical university clinic and a general hospital]. / 2-Jahresbilanz eines Kooperationsmodells zwischen einer Chirurgischen Universitätsklinik und einem Spital der Grundversorgung.

INTRODUCTION: On 1 January 1998 a cooperation between an university hospital and a peripheral general hospital was initiated with the aim of reducing waiting lists and health care costs. Surgical patients initially referred to the Department of Visceral and Transplantation Surgery of the University of Bern (Inselspital) were evaluated and selected in the outpatient clinic for an operation in the peripheral hospital Grosshöchstetten. The operation and postoperative care in Grosshöchstetten was performed by a team from the university department according to the standard concept also utilized at the university hospital. RESULTS: The 574 patients referred to the university and operated on in Grosshöchstetten during a 2-year period had a morbidity rate of 3.5%, a reoperation rate of 1.0% and a mortality rate of 0.15%. The mean hospital stay was 6.3 days. The quality evaluation performed by questionnaires to patients and physicians showed an overall satisfaction rate of 95%. The cooperation resulted in reduction of the overall costs in both hospitals, and the patients' involved health insurances profited from substantially lower costs per case. CONCLUSIONS: Health care costs in both hospitals as well as the waiting list at the university hospital were markedly reduced during this 2-years trial, with an overall satisfaction rate of 95%. This form of cooperation of an university with a peripheral hospital represents a new and valuable model for effective reduction of health care costs.

Efficacy and safety of weight-adapted nadroparin calcium vs. heparin sodium in prevention of clinically evident thromboembolic complications in 1,190 general surgical patients.

AIMS: In a prospective, randomized, single, general surgery center trial, comparison of the safety and efficacy of two low molecular weight heparin (LMWH; anti-Xa heparin sodium and weight-adapted nadroparin calcium) regimens was made. PATIENTS AND METHODS: Eleven hundred and ninety patients undergoing various elective and emergency operations were randomized to receive daily either a fixed dose of 3,000 IU anti-Xa heparin sodium or a variable body weight-dependent dose of nadroparin calcium (weight <50 kg, 2,050 IU anti-Xa (WHO); 51-80 kg, 3,075 UI; 81-100 kg, 4,100 UI, and >100 kg, 6,150 UI) once until discharge. The first injection was administered 2.5-6 h before elective and emergency operations, respectively. Patients with clinical suspicion of deep venous thrombosis (DVT) underwent phlebography. Patients with signs of pulmonary embolism (PE) were further investigated by a ventilation-perfusion scan. RESULTS: Statistically, there were no significant differences in the incidence of clinically evident DVT, PE or LMWH-related complications between both prophylactic regimens. Only 4 of the total of 15 hemorrhagic complications (4 wound hematomas in the nadroparin calcium group) were not classified as clearly surgically related, Two DVTs were confirmed by phlebography (both in the nadroparin calcium group). PE was confirmed by ventilation-perfusion scans (1 fatal, 1 on autopsy) in 1 patient with heparin sodium and in 6 patients with nadroparin calcium. CONCLUSIONS: Both regimens were equally safe and the risk of clinically evident DVT and PE was similar.

Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease.

BACKGROUND: In acute gallstone pancreatitis, the ideal point in time for laparoscopic cholecystectomy with special reference to the severity of the disease has been prospectively analyzed. METHODS: A total of 77 patients with biliary acute pancreatitis were admitted between November 1993 and July 1998 (37 men and 40 women; mean age, 63 years; median Apache II score, 13.3) and staged by contrast-enhanced computed tomography findings as having edematous or necrotizing disease. RESULTS: In 48 patients, laparoscopic cholecystectomy was found to be possible: 35 patients (73%) with mild and 13 patients (27%) with severe acute pancreatitis. The overall success rate was 79% (38 of 48 patients), with 85% (30 of 35 patients) and 62% (8 of 13 patients) having mild and severe disease, respectively. Median duration of time between onset of symptoms and surgery was 10 days (range, 4-19 days) in edematous and 14 days (range, 7-29 days) in necrotizing pancreatitis (p = 0.0353). Operating time (median, 80 min) and hospital stay (median, 5 days) were almost the same in both groups. Total morbidity was 8%, with no mortality. CONCLUSIONS: Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for biliary acute pancreatitis. In mild disease, this is performed safely within 7 days, whereas in severe disease, especially in extended pancreatic necrosis, at least 3 weeks should elapse because of an increased infection risk.

The role of laparoscopy in symptomatic Meckel's diverticulum.

We report two cases of symptomatic Meckel's diverticulum in adults with recurrent abdominal pain and episodes of minor lower gastrointestinal bleeding. In case 1, the diagnosis was suggested by (99m)Tc pertechnetate scan and confirmed by laparoscopy; whereas in case 2, only diagnostic laparoscopy was performed because of suspected appendicitis. A segmental small bowel resection with attached diverticulum was performed extracorporeally after exteriorization through the umbilical port site in both cases.

Pituitary adenylate cyclase-activating polypeptide modulates gastric enterochromaffin-like cell proliferation in rats.

BACKGROUND & AIMS: Gastric carcinoids (types I and II) involve the transformation of naive enterochromaffin-like (ECL) cells to the neoplastic state and are associated primarily with hypergastrinemia. In this study, we evaluated the effects of two related neuropeptides, pituitary adenylate cyclase-activating polypeptide (PACAP) and vasoactive intestinal polypeptide (VIP), on ECL cell proliferation and characterized the receptor subtype(s) and signal transduction pathways that mediate this effect. METHODS: Purified rat ECL cells were analyzed in culture for DNA synthesis as measured by 24-hour 5-bromo-2-deoxyuridine (BrdU) uptake. Reverse-transcription polymerase chain reaction (RT-PCR) with gene-specific oligonucleotide primers was performed to characterize the PACAP/VIP receptor subtype(s). RESULTS: PACAP/VIP neuropeptide-stimulated BrdU uptake was significantly greater (3.4-3.8-fold greater than control) than that at the maximal dose of gastrin (2.2-fold greater than control). PACAP-stimulated ECL cell proliferation (EC50, approximately 3 x 10(-)14 mol/L) was approximately 100-fold more potent than VIP (EC50, approximately 3x 10(-)12 mol/L). The stimulated BrdU uptake by both PACAP and VIP was competitively inhibited by PACAP-receptor antagonist (IC50, 10(-)9 mol/L, 3 x 10(-)9 mol/L, respectively) and VIP-receptor antagonist (IC50, 3 x 10(-)7 mol/L, 5 x 10(-)7 mol/L, respectively). RT-PCR identified the presence of the PACAP-specific but not PACAP/VIP receptor subtypes. The PACAP-stimulated BrdU uptake was inhibited (70%-80%) by inhibitors of adenosine 3',5'-cyclic monophosphate, phosphatidylinositol 3 kinase, and protein tyrosine kinase as well as mitogen-activated protein kinase. CONCLUSIONS: PACAP/VIP-related peptides are more potent modulators of ECL cell proliferation than gastrin, and their effect is mediated by a PACAP-specific receptor whose activation is transduced by multiple intracellular messenger systems.

A polyamine pathway-mediated mitogenic mechanism in enterochromaffin-like cells of Mastomys.

We have previously demonstrated that in Mastomys species proliferation of gastric enterochromaffin-like (ECL) cells is predominantly regulated by gastrin and by transforming growth factor-alpha (TGF-alpha) in the naive and neoplastic state, respectively. In this study we examined whether these intracellular mitogenic responses are mediated by polyamines and ornithine decarboxylase (ODC), the rate-limiting enzyme for polyamine biosynthesis. An ECL cell preparation of high purity was used to measure the effect of the polyamine derivatives putrescine, spermidine, and spermine on DNA synthesis by bromodeoxyuridine uptake. Both putrescine and spermidine augmented gastrin-stimulated, but not basal, DNA synthesis in naive cells. This proliferative response correlated with an increase in ODC activity that was partially inhibited (20%) by difluoromethylornithine (DFMO), an inhibitor of ODC (IC50, 30 pM). In contrast, all polyamines increased both basal and TGF-alpha-stimulated DNA synthesis as well as ODC activity in tumor ECL cells. DFMO completely inhibited the proliferative response of TGF-alpha (IC50, 3 pM). Thus polyamine biosynthesis is involved in proliferation of ECL cells and in particular the mitogenesis of tumor cells, suggesting a role for this pathway in the regulation of ECL cell transformation.

Telenzepine-sensitive muscarinic receptors on rat pancreatic acinar cells.

To identify the muscarinic subtype present on the rat pancreatic acinar cell, we examined the effects of different muscarinic receptor antagonists on amylase secretion and proteolytic zymogen processing in isolated rat pancreatic acini. Maximal zymogen processing required a concentration of carbachol 10- to 100-fold greater (10(-3) M) than that required for maximal amylase secretion (10(-5) M). Although both secretion and conversion were inhibited by the M3 antagonist 4-diphenylacetoxy-N-methyl-piperidine (4-DAMP) (50% inhibition approximately 6 x 10(-7) M and 1 x 10(-8) M, respectively), the most potent inhibitor was the M1 antagonist telenzepine (50% inhibition approximately 5 x 10(-10) M and 1 x 10(-11) M, respectively). Pirenzepine, another M1 antagonist, and the M2 antagonist methoctramine did not reduce amylase secretion or zymogen processing in concentrations up to 1 x 10(-5) M. Analysis of acinar cell muscarinic receptor by PCR revealed expression of both m1 and m3 subtypes. The pancreatic acinar cell has a distinct pattern of muscarinic antagonist sensitivity (telenzepine >> 4-DAMP > pirenzepine) with respect to both amylase secretion and zymogen conversion.

Human pancreas-specific protein. A diagnostic and prognostic marker in acute pancreatitis and pancreas transplantation.

CONCLUSION: Human pancreas-specific protein (hPASP) is a very sensitive reflector of the extent of pancreatic necrosis on the cellular level, and is of both diagnostic and prognostic value in acute pancreatitis. Furthermore, it allows the estimation of the severity of graft pancreatitis soon after simultaneous renal and pancreatic transplantation. BACKGROUND: Diagnosis of acute pancreatitis (AP) has been improved in the past 15 yr as new methods for the determination of specific pancreatic enzymes have been developed. However, these enzymes have no prognostic implications. In this prospective study, we evaluated the role of human pancreas-specific protein (hPASP) in comparison with pancreatic amylase and C-reactive protein (CRP) in acute pancreatitis and pancreas transplantation. PATIENTS AND METHODS: The study included 40 patients (22 female, 18 male; mean age 51 yr, range 22-88 yr) with AP and 7 patients (2 female, 5 male; mean age 37 yr, range 25-49 yr) with type I diabetes and renal insufficiency who underwent simultaneous kidney and pancreas transplantation. By means of contrast-enhanced computed tomography (CT) and/or intraoperative findings, patients were judged to have edematous-interstitial (AIP, n = 20, mean age 55.2 yr, range 24-88 yr) or necrotizing pancreatitis (NP, n = 20, mean age 46.3 yr, range 22-81 yr). Serum hPASP concentration was measured daily by a commercial radioimmunoassay technique. In 25 healthy subjects and in several control groups (35 patients with chronic pancreatitis, 20 patients with pancreatic carcinoma and 80 patients with different gastrointestinal diseases) a single blood specimen was taken at hospital admission for the determination of the normal range of hPASP and for specificity analysis. RESULTS: The upper normal value for hPASP in healthy subjects was found to be 52 ng/mL. Serum hPASP was elevated in all patients suffering from AP, with a median of 343 ng/mL (lower-upper quartile: 192-478 ng/mL) at hospital admission. In the daily serum monitoring with respect to the onset of symptoms, significantly higher hPASP levels were found in NP compared with AIP after day 2 (p < 0.001). In patients with NP, peak values of hPASP correlated significantly with the extent of pancreatic necroses measured by contrast-enhanced CT-scanning, whereas CRP did not. Six patients of the transplantation group had the same serum hPASP course as AIP, with almost normal values on the third postoperative day. One patient had elevated levels throughout the observation period. This patient suffered from necrotizing graft pancreatitis, confirmed by relaparotomy, and died because of subsequent septic complications.