Surgical Outcomes of Epidural Hematoma in Trauma Patients with Absent Pupillary Reactions: A National Trauma Data Analysis.

BACKGROUND: Absent pupillary reaction occasionally heralds a poor prognosis following severe head injury. The purpose of the study was to evaluate the outcome of all patients who underwent acute evacuation of epidural hematoma (EDH) despite absent bilateral pupillary reaction. METHODS: The Trauma Quality Improvement Program (TQIP) database for the calendar years 2017 and 2018 was accessed for the study. Adult patients ≥18 years of age who sustained severe traumatic brain injury (TBI) with the diagnosis of EDH and underwent evacuation of the hematoma were included in the study. The patients' characteristics, injury severity score (ISS), Glasgow Coma Scale (GCS) score, midline shift, and comorbidities were compared between patients who had absence of both pupillary reaction (ABPR) and those who presented with presence of both pupillary reaction (PBPR). The primary outcome of the study was in-hospital mortality. Propensity score matching analyses were performed for the study. RESULTS: No significant differences were found between the ABPR and PBPR groups regarding the median age (37 years [interquartile range (IQR): 26-53] vs. 40 years [IQR: 28-55]), gender (males; 81.9 vs. 79.5%), median ISS (29 [25.5-34] vs. 27 [25-33]), GCS score (3 [3-4] vs. 3 [3-3], presence of significant midline shift (75.9 vs. 79.5%), and comorbidities. The patients who presented with ABPR had a significantly higher mortality (34.9 vs. 10.8%; p = 0.002). A higher number of patients were discharged to skilled nursing and rehabilitation facilities (16.7 vs. 10.8% and 46.3 vs. 41.9%, respectively; p = 0.045). CONCLUSION: Approximately 65% of severe TBI patients survived after the evacuation of the EDH despite the absence of pupillary reaction.

Comparison of Intravascular Uptake and Technical Ease Between Anteroposterior and Oblique Views During Lumbar Medial Branch Block.

BACKGROUND: Inadvertent intravascular injection of local anesthetics can lead to false-negative results following lumbar medial branch block (MBB) performed to diagnose facet joint origin pain. A previous study demonstrated that the type of approach method could affect the incidence of intravascular injections and technical ease of the procedure. OBJECTIVES: The primary objective of our study was to compare the incidence of inadvertent intravascular injection and technical ease of the MBB between anteroposterior (AP) and oblique (OB) views. STUDY DESIGN: Prospective randomized trial. SETTING: An interventional pain management practice in South Korea. METHODS: The incidence of intravascular uptake of contrast medium was compared using AP and OB fluoroscopic views during lumbar MBB. Injection time, radiation dose, and patient discomfort during lumbar MBB were also compared. Risk factors associated with a longer procedure time and a higher radiation dose were analyzed. RESULTS: The incidence of intravascular injection was 22.5% (23/102) in the AP group and 17.6% (18/102) in the OB group (P = 0.382). A significantly longer injection time and a higher dose of radiation were required to complete 3 levels of MBB in the OB group than in the AP group (45.9 seconds vs 61.9 seconds, P = 0.001; 27.4 centigray [cGy]/cm2 vs 42.2 cGy/cm2, I = 0.004). The OB approach and left side injection were the risk factors associated with a longer total procedure time (odds ratio [OR] = 6.64, 95% CI, 1.99-22.17, P = 0.002; OR = 0.20, 95% CI, 0.06-0.67, P = 0.009, OB and AP, respectively). LIMITATIONS: The physician performing the MBB could recognize the AP or OB fluoroscopic view during procedure. CONCLUSION: The overall incidence rate of intravascular injection during lumbar MBB showed nearly 20% in both approach methods groups. The OB approach and left side MBBs were associated with a longer total procedure time and a higher radiation dose.

Pulmonary Complications and Sepsis Following Severe Acute Subdural Hematoma in Patients Who Underwent Craniotomy versus Craniectomy: A Propensity Score Matched Analysis.

BACKGROUND: The purpose of the study was to evaluate the impact of craniotomy (CO) and decompressive craniectomy (DC) for evacuation of acute subdural hematoma (SDH) on pulmonary complications and sepsis. METHODS: Study data were obtained from the National Trauma Data Bank (2007-2010). Only patients who met all of the following criteria were included in this analysis: sustained blunt injuries, presented with severe traumatic brain injury, sustained an associated SDH, presented with an initial Glasgow Coma Scale (GCS) score ≤ 8 and an Abbreviated Injury Scale score of head ≥ 3, and underwent a CO or DC within 4 hours of hospital arrival. Patient characteristics and outcomes were compared between CO and DC, the two procedural groups. The data were first compared between the two unmatched groups; then propensity score matching and a matched pairs analysis were performed. RESULTS: From the total population of 2,370 patients, 1,852 (78%) of them underwent CO, and the remaining 518 (22%) underwent DC. Some differences were found between the CO and DC groups regarding age (mean [standard deviation (SD)]: 47.9 years [22.8] versus 39.6 years [20.1]; p < 0.001), sex (male: 70.1% versus 74.7%; p = 0.05), race (white: 77.4% versus 73.4%; p = 0.06), the injury mechanism (fall: 50.7% versus 33.2%; p < 0.001), Injury Severity Score (mean [SD]: 28.0 [9.3] versus 30.5 [10.0]; p < 0.001), and GCS score (median [interquartile range] 3 [3-5] versus 3 [3-4])). After the propensity score matching, no significant differences were found between the groups on the variables just listed (all p > 0.05). No significant differences were seen between the CO and DC groups in the incidences of these conditions: acute respiratory distress syndrome (ARDS) (12.0% versus 8.1%; p = 0.20), pneumonia (34.9% versus 37.6%; p = 0.60), pulmonary embolism (PE) (3.5% versus 1.6%; p = 0.30), and systemic sepsis (6.2% versus 8.1%; p = 0.5). CONCLUSION: Although most of the patients underwent CO for acute SDH, no significant differences were observed in the incidence of ARDS, pneumonia, PE, or systemic sepsis when compared with patients who underwent DC.

Atraumatic splenic rupture in young adult following cocaine use.

INTRODUCTION: Splenic rupture most commonly results from a traumatic mechanism. Spontaneous splenic ruptures are a rare occurrence. This is an interesting and rare case of atraumatic splenic rupture (ASR) presented after sniffing cocaine. PRESENTATION OF CASE: The patient presented with abdominal pain and tenderness with low hemoglobin on admission. The computed tomography (CT) scan of the abdomen showed possible spleen rupture with hemoperitoneum. An emergent laparotomy and total splenectomy was performed. The pathology confirmed splenomegaly and a large area of adhesion. Adjacent to the adhesion, a focal disruption of splenic parenchyma was found. DISCUSSION: ASR has been reported in the literature due to infection, inflammation, mechanical and use of certain drugs. Few cases of ASR have been described due to cocaine use. Splenomegaly is one of the risk factors of ASR. The most probable mechanism of ASR in cocaine use is sudden vasoconstriction, ischemia and infarction of the parenchyma of the spleen, which can result in vascular rupture. Our case of ASR echoes the above process. CONCLUSION: Total splenectomy resulted in a good outcome. The patient was discharged home without any services.

Polymorphisms in PDE4D are associated with a risk of COPD in non-emphysematous Koreans.

Despite extensive effort, only a few chronic obstructive pulmonary disease (COPD)-associated genes have been suggested, indicating that there must be additional risk-associated loci. Here we aimed to identify additional COPD-associated SNPs and to explore the potential relationship between COPD subgroups and the SNPs in the Korean population. We performed a genome-wide association study (GWAS) with 990 Korean individuals; 102 COPD cases and 544 controls for GWAS using Affymetrix SNP array 5.0, and 173 COPD cases and 171 controls for replication. After validating the candidate single nucleotide polymorphisms (SNP), we performed subgroup analysis by disease phenotype. Through GWAS, we identified a novel SNP in the phosphodiesterase-4D (PDE4D) gene [rs16878037 (C>T), p = 1.66 ◊ 10(-6)] that was significantly associated with COPD. This signal in PDE4D was successfully replicated in the independent set (p = 0.041). When we combined the discovery and replication data, the association signal became more significant (p = 5.69 ◊ 10(-7)). In the COPD subgroup analysis, the T allele of rs16878037 was significantly more frequent in COPD patients without severe diffusion capacity impairment (mild mixed and obstruction-dominant group) than in patients with severe impairment (severe mixed and emphysema-dominant groups). This result supports that PDE4D polymorphisms might be involved in the susceptibility to COPD especially in non-emphysematous individuals and that they could also affect the responsiveness of the PDE4 inhibitor treatment.

Role of alkyl group in the aromatic extraction using pyridinium-based ionic liquids.

The performance of N-alkylpyridinium-based ionic liquids with a SCN anion (PyILs) was evaluated for the selective extraction of aromatics from aliphatic hydrocarbons. The aromatic extraction ability of PyILs was greatly enhanced by the presence of a methyl group on the pyridinium ring at the 3- or 4-position, whereas the solubility of the aromatics in the PyILs decreased with increasing the number of methyl groups on the benzene ring. The FT-IR studies revealed that the solubility of an aromatic compound in a PyIL is closely correlated with the degree of aromatic C-H bending frequency shift observed during the dissolution of the aromatic compound in the PyIL: the larger the shift, the higher the solubility. The computational calculations on the dispersion interactions between aromatics and PyILs demonstrated that the anion-aromatic interaction is much more important than the cation-aromatic interaction in determining the aromatic solubility in PyILs, and such anion-aromatic interaction can be enhanced by introducing a methyl group at the carbon atom of the pyridinium ring.

Carboxylate-assisted formation of alkylcarbonate species from CO(2) and tetramethylammonium salts with a ß-amino acid anion.

Tetramethylammonium-based molten salts bearing a ß-amino acid anion (TMAAs) are synthesized through Michael addition reactions of amines with methyl acrylate followed by hydrolysis and subsequent neutralization by using aqueous tetramethylammonium hydroxide. The CO(2) capture performances of the TMAAs are evaluated and are shown to interact with CO(2) in a 1:1 mode in both water and alcohol. FTIR and (13)C NMR spectroscopic studies on the interactions of TMAAs with CO(2) indicate that the type of CO(2) adduct varies with the solvent used. When water is used as the solvent, a bicarbonate species is produced, whereas hydroxyethylcarbonate and methylcarbonate species are generated in ethylene glycol and methanol, respectively. Computational calculations show that the carboxylate groups of TMAAs contribute towards the formation and stabilization of 1:1 CO(2) adducts through hydrogen bonding interactions with the hydrogen atoms of the amino groups.