The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis.

Trauma pancreaticoduodenectomy (TP) remains a challenging operation with morbidity and mortality rates as high as 80% and 50%. Many trauma surgeons consider it surgical dogma to avoid performing a TP during the index operation for patients with severe pancreatic or duodenal injuries. However, there is no modern analysis evaluating this belief. Therefore, we hypothesized no difference in risk of mortality between patients with severe pancreatic or duodenal injury undergoing a TP for penetrating trauma to propensity-matched controls undergoing laparotomy without TP. The Trauma Quality Improvement Program (2010-2016) was queried for adults with severe penetrating pancreatic or duodenal injuries undergoing laparotomy. A 1:2 propensity-matching including demographics/comorbidities, injury severity score, vitals on admission, Glasgow Coma Scale and concomitant injuries for laparotomy with or without TP was performed. Risk of mortality was reported using a univariable logistic regression model. Of 2182 patients with severe pancreatic or duodenal injuries undergoing laparotomy, 54 (2.5%) underwent TP and 2128 (97.5%) underwent laparotomy without TP. There were no differences in propensity-matching characteristics. Patients undergoing TP had a similar mortality rate (20.0% vs. 28.7%, p = 0.302) but a longer length of stay (LOS) (27.5 vs. 16.5 days, p = 0.017). The TP group had a similar associated risk of mortality (OR = 0.62, p = 0.302) but higher risk of major complications (OR 3.44, CI 1.35-17.47, p = 0.015). In appropriately selected penetrating trauma patients with severe pancreatic/duodenal injuries, TP is associated with a similar risk of mortality compared to laparotomy without TP. However, TP patients did have an increased associated risk of major complications and longer LOS.

Age- and gender-associated changes in the concentrations of serum TGF-1ß, DHEA-S and IGF-1 in healthy captive baboons (Papio hamadryas anubis).

Age-related changes in the concentration of factors like TGF-1ß, DHEA-S and IGF-1 may increase the risk of disease and illnesses in advanced life. A better understanding of these changes would aid in the development of more appropriate treatments and/or preventative care for many conditions associated with age. Due to their similar immune system and vulnerability to pathogens, baboons are an ideal model for humans. However, little research has been done examining the general effects of age in baboons. Therefore, we wanted to further examine the effects of aging in baboons by determining the age-dependent changes in serum TGF-1ß, DHEA-S and IGF-1 concentrations. Blood samples were collected during routine health checks in 113-118 captive baboons. In addition, longitudinal samples from 23 to 27 adult individuals were collected an average of 10.7years apart. Both age and gender influenced the concentrations of serum TGF-1ß and IGF-1. When both genders were analyzed together, TGF-1ß increased 16.1% as adults, compared to younger and older animals, but male and female baboons showed a slightly different temporal pattern of change. IGF-1 decreased with increasing age and males had a 30% greater concentration of IGF-1 than did females. While there was no effect of gender among our population, serum DHEA-S was negatively correlated with age, decreasing by 51.6% in the oldest animals. There were no effects of age or gender on serum IGFBP-3. In longitudinal samples collected from the same individuals, the concentrations of TGF-1ß, DHEA-S and IGF-1 were reduced with age. The results presented herein provide additional knowledge of the aging process in baboons and further validate the use of this species as an appropriate model for aging in humans.

Impact of thrombocytopenia on survival of baboons with genetically modified pig liver transplants: clinical relevance.

A lack of deceased human donor livers leads to a significant mortality in patients with acute-on-chronic or acute (fulminant) liver failure or with primary nonfunction of an allograft. Genetically engineered pigs could provide livers that might bridge the patient to allotransplantation. Orthotopic liver transplantation in baboons using livers from alpha1,3-galactosyltransferase gene-knockout (GTKO) pigs (n = 2) or from GTKO pigs transgenic for CD46 (n = 8) were carried out with a clinically acceptable immunosuppressive regimen. Six of 10 baboons survived for 4-7 days. In all cases, liver function was adequate, as evidenced by tests of detoxification, protein synthesis, complement activity and coagulation parameters. The major problem that prevented more prolonged survival beyond 7 days was a profound thrombocytopenia that developed within 1 h after reperfusion, ultimately resulting in spontaneous hemorrhage at various sites. We postulate that this is associated with the expression of tissue factor on platelets after contact with pig endothelium, resulting in platelet and platelet-peripheral blood mononuclear cell(s) aggregation and deposition of aggregates in the liver graft, though we were unable to confirm this conclusively. If this problem can be resolved, we would anticipate that a pig liver could provide a period during which a patient in liver failure could be successfully bridged to allotransplantation.

A symptomatic coracoclavicular joint.

Bilateral coracoclavicular joints were found in a 44-year-old male patient following a fall. He had an Indonesian mother and a Dutch father. Prior to the injury he was asymptomatic and had full range of movement in both shoulders but the trauma resulted in pain and limitation of movement in the left shoulder which required resection of the anomalous joint, after which full pain-free movement was restored.

[Physical diagnosis--digital rectal examination]. / Fysische diagnostiek--rectaal toucher.

For a wide range of complaints, there is an indication for digital rectal examination. The position patients should adopt depends on their physical condition and the indication concerned. The reach of the palpating index finger is fairly short. The severity of micturition complaints has little or no relation to the size of the prostate. The sensitivity of digital rectal examination for detecting prostate carcinoma ranges from about 50 to 80%. Therefore, a prostate carcinoma cannot be excluded on the basis of digital rectal examination. The positive predictive value of digital rectal examination for detecting prostate carcinoma increases as the serum PSA level increases. Digital rectal examination can make an important contribution to the diagnosis of anorectal disorders, including rectal carcinoma. In total, 5-10% of consultations with general practitioners are related to anorectal or urogenital complaints and 50% of the elderly have micturition problems; therefore digital rectal examination is one of the physician's basic skills.

Recurrent, multiple, calcified soft tissue metastases from osteogenic sarcoma without pulmonary involvement.

Osteosarcoma (osteogenic sarcoma) metastasizes primarily to the lung. With the introduction of neoadjuvant chemotherapy as part of the treatment, the overall and disease-free survival rates have dramatically improved. In this case report, a young man with multiple soft tissue and bone metastases, including a rare large bone-forming retroperitoneal metastasis, is described. Despite the extensive extrapulmonary metastases, the patient did not develop pulmonary metastases in the 4 years following initial presentation of the primary tumour.

The vanishing heart--deterioration on chest radiography with clinical improvement during prone position ventilation.

Prone position ventilation is used in the treatment of ARDS. Its beneficial effects are due to increased ventilation of the dorsal lung areas. Consequently, the now dependent parts of the lungs collapse, resulting in decreased sharpness of the cardiac silhouette. The latter may be misinterpreted as a worsening of the cardiopulmonary condition while, in fact, gas exchange and ventilation may be markedly improved. These features are illustrated in the case presented.

[Giant urinoma of the thigh]. / Reuzenurinoom van het bovenbeen.

A man aged 70 during a hospital stay over a period of a few weeks developed increasing pain and swelling of the left thigh. Despite extensive diagnostic imaging and surgical drainage, initially no diagnosis could be established. After more than 3 months the tumour proved to be caused by leakage of urine from the pelvis to the soft tissues of the leg. Unfamiliarity of the clinicians with such an extension of an urinoma contributed to the considerable diagnostic delay. Introduction of a bladder catheter stopped the flow of urine to the leg and reduced the leg circumference.

Noninvasive metabolic assessment of human donor livers: prognostic value of 31P-magnetic resonance spectroscopy for early graft function.

BACKGROUND: The purpose of this study was to investigate whether phosphorus-31 magnetic resonance spectroscopy (31P-MRS) of the isolated donor liver can serve as a viability indicator with prognostic value for transplantation outcome. METHODS: Forty human donor livers preserved with University of Wisconsin solution were studied shortly before transplantation. The respective spectral peak areas of the isolated donor liver were correlated with the amount of hepatocellular graft damage and liver metabolic function shortly after implantation. RESULTS: The individual phosphomonoesters, inorganic phosphate, phosphodiesters, and nicotine adenine dinucleotide peaks were not prognostic for postoperative hepatocellular damage or liver metabolic capacity. The presence of adenosine triphosphate, however, predicts a significantly better metabolic capacity to eliminate bilirubin, to synthesize fibrinogen and antithrombin III, and to maintain a better prothrombin time after transplantation. Furthermore, this study is probably the first 31P-MRS demonstration in the human liver of phosphocreatine. CONCLUSIONS: In the clinical setting described, metabolic assessment using 31P-MRS did not result in a reliable noninvasive test to predict primary graft dysfunction. Study of the role of phosphocreatine in liver metabolism during cold storage is needed.

The miniscule benefit of serial carcinoembryonic antigen monitoring after effective curative treatment for primary colorectal cancer.

BACKGROUND: Serial carcinoembryonic antigen (CEA) levels have been recommended to detect asymptomatic recurrent colorectal cancer and to facilitate curative additional therapy. This study was designed to investigate the outcome of additional treatment for recurrent cancer in patients undergoing primary colorectal cancer treatment in a specialty center and subsequent relapsing with an elevation in serum CEA. STUDY DESIGN: Patients treated for their primary cancers at our institution whose followup included CEA monitoring and whose cancers subsequently recurred, were analyzed from a prospective database of almost 1,900 patients. CEA levels of > or = 5 ng/mL were considered elevated for purposes of treatment results. One hundred sixty-three patients were suitable for analysis. Median followup before and after recurrence was 14 months and 16 months, respectively. RESULTS: Fifty patients were able to undergo complete resection of their recurrence, and 26 of these patients are without evidence of recurrence at last followup. Two-thirds of recurrences were associated with an elevation of CEA; this elevation at recurrence was associated with decreased survival (p < 0.05, Kaplan Meier). Of the 109 patients with an elevation of CEA at recurrence, complete re-resection was accomplished in 26 patients. Of these, half remain cancer free. Of those with a normal CEA at recurrence, complete re-resection was feasible in 24 patients. CONCLUSIONS: Only 17% of patients with recurrent colorectal cancer undergoing potentially curative reresection have an elevated CEA. If we use the denominator of our patient population using an estimated relapse rate of 25-50%, the overall likelihood of CEA-directed curative re-resection confirms early estimates of less than a 5% survival advantage.

Erythropoietin potentiates thrombus development in a canine arterio-venous shunt model.

Erythropoietin (EPO) has been previously shown to affect platelet as well as red cell production. In addition, recent studies demonstrated that platelets from EPO-treated dogs are hyperreactive towards thrombin when compared to age-matched, control platelets. This report extends these observations by quantitating the thrombogenic potential of EPO in dogs. Dogs with arterio-venous (A-V) shunts received 100 U EPO/kg/day for 6 days, and thrombogenicity was serially monitored by insertion of a thrombotic surface into the A-V shunt. The resulting experimental thrombi were analyzed for platelet and erythrocyte content after formalin-fixation and chymotrypsin digestion, a technique which allows non-isotopic quantitation of cellular components. By day 5 of EPO-administration all animals demonstrated a significant increase in platelet and red cell content of the experimental thrombi; the average increase in platelet number was 2.94 +/- 0.12 fold (mean +/- 1 SE; n = 3; p = 0.006) above baseline while that for red cells was 2.46 +/- 0.18 fold above baseline (p = 0.023). After cessation of EPO, thrombogenicity returned to normal. During EPO-treatment, the percentage of thiazole orange-positive (TO+) platelets increased significantly to 17.2 +/- 1.6% (mean +/- 1 SE; n = 3) on day 5 compared to a pre-treatment level of 8.5 +/- 0.9% (p = 0.029). Although the percentage of TO+ erythrocytes also increased during the short course of EPO administration, the change was not significant. Despite the increases in TO+ cells, total platelet and erythrocyte counts did not change significantly within the time frame of these experiments. Fibrin/fibrinogen content of the experimental thrombi was unaltered with EPO-treatment. These data demonstrate that human EPO is pro-thrombotic in dogs and, in conjunction with earlier studies, suggest that hyperreactive platelets may be responsible for the potentiated thrombogenicity.

Comparison of vocal tract formants in singing and nonperiodic phonation.

The skilled use of nonperiodic phonation techniques in combination with spectrum analysis has been proposed here as a practical method for locating formant frequencies in the singing voice. The study addresses the question of the degree of similarity between sung phonations and their nonperiodic imitations, with respect to both frequency of the first two formants as well as posture of the vocal tract. Using magnetic resonance imaging (MRI), linear predictive coding (LPC), and spectrum analysis, two types of nonperiodic phonation (ingressive and vocal fry) are compared with singing phonations to determine the degree of similarity/difference in acoustic and spatial dimensions of the vocal tract when these phonation types are used to approximate the postures of singing. In comparing phonation types, the close similarity in acoustic data in combination with the relative dissimilarity in spatial data indicates that the accurate imitations are not primarily the result of imitating the singing postures, but have instead an aural basis.

Changes in 31P-relaxation times during organ preservation: observations on cold stored human donor livers.

During cold preservation for transplantation the tissue hydration state changes. It is not known whether such changes lead to altered relaxation times of 31P nuclei with potential consequences for the quantification of tissue metabolites. Therefore, 31P spectroscopic and proton T1 relaxometric measurements were performed on 42 isolated human donor livers shortly before implantation. The results demonstrate that 31P T1 relaxation times change during preservation for clinical transplantation, thus quantification of tissue metabolites in cold stored donor livers may be in part dependent on the tissue hydration state. Furthermore, it appeared that changes in tissue hydration state especially affect the physico-chemical characteristics of the intracellular fluid compartment. This study indicates that reliable spectroscopic quantification of tissue metabolites, particularly during sequential spectroscopic measurements in cold stored donor organs is best warranted under fully relaxed conditions.

Complete bipartition of the atlas in the Klippel-Feil syndrome. A radiologically illustrated case report.

A patient with the Klippel-Feil syndrome is described who presented with pain in the neck after a trauma. No fractures were found. Instead, a midline cleft in both the anterior and posterior atlantic arches was found which represents an extremely rare congenital anomaly.

Erythropoietin administration increases production and reactivity of platelets in dogs.

Administration of erythropoietin (EPO) to adult dogs resulted in a dramatic increase in the number of thiazole orange-positive (TO+) platelets, also referred to as reticulated platelets. Pre-treatment level of TO+ platelets was 6.2 +/- 0.5% (mean +/- 1 SE: n = 5); following day 5 of treatment with 500 U EPO/kg/day, the percentage of TO+ platelets peaked at 16.8 +/- 2.3% (n = 5; p <0.02). After cessation of the hormone, the number of TO+ platelets fell rapidly to below starting levels. Unexpectedly, there was a significant decline in total platelet count during EPO administration despite an increased level of TO+ platelets. To assess platelet reactivity, total platelets and TO+ platelets from EPO-treated dogs were analyzed for thrombin-responsiveness as quantitated by P-selectin expression on the cell surface; reactivity was expressed as a thrombin EC50, the thrombin concentration required to activate 50% of platelets. Both total and TO+ platelets were hyperreactive during EPO treatment when compared either to pre-treatment values or to control animals. Thrombin EC50 values for total and TO+ platelets on day 5 fell to 66.5 +/- 5.4% (mean +/- 1 SE; n = 5; p <0.02) and 62.2 +/- 8.7% (n = 5; p <0.025), respectively, of pre-treatment levels. These data indicate that EPO not only promotes the synthesis of increased numbers of TO+ platelets in the dog but that these newly produced platelets are hyperreactive when compared to TO+ platelets from control animals.

Relative reactivity of platelets from thrombopoietin- and interleukin-6-treated dogs.

Previous reports have shown that interleukin-6 (IL-6) enhances the responsiveness of platelets to thrombin stimulation and has modest thrombocytopoietic effects in vivo. Thrombopoietin (TPO; mpl ligand) has been shown to have dramatic thrombocytopoietic effect in vivo, but little is known of its capacity to alter platelet function. In this study, a direct comparison of the effects of IL-6 and TPO on platelet function in dogs has been performed, with modest doses of TPO (1 microgram/kg/d) chosen to match or moderately exceed the platelet counts achieved with IL-6 (40 micrograms/kg/d) for 10 days. Platelet responsiveness to thrombin stimulation was assessed in TPO-treated, IL-6-treated, and control dogs by flow cytometric measurement of P-selectin expression. On day 5, the dose of thrombin promoting half maximal stimulation (EC50) of platelets was not significantly changed in TPO-treated dogs, whereas in IL-6-treated dogs the EC50 decreased to 73.1% +/- 6.1% (mean +/- 1 SD; n = 5) of control values (P < 0.01). These experiments were performed on both gel-filtered platelets and washed whole blood, indicating that the observed changes in EC50 were caused by cytokine-mediated alteration of platelets rather than plasma components. Because it has been shown that thiazole orange specifically labels a subpopulation of dog platelets that is less than 24 hours old, the thrombin responsiveness of these young, newly synthesized platelets was determined. The EC50 of thiazole orange-positive platelets from IL-6-treated dogs decreased dramatically by day 5 to 46.5% +/- 13.1% (n = 4) of control values (P < 0.001), whereas TPO-treated dogs did not significantly change. When TPO was directly incubated with platelets ex vivo, no effects on either thrombin-mediated P-selectin expression or adenosine diphosphate-induced fibrinogen binding were observed. These data show that IL-6 alters platelet function, as measured by reactivity to thrombin, whereas TPO does not. This divergence in function is observed even though TPO is equally, or more, effective at promoting platelet production under these experimental conditions.

Non-isotopic method for quantitation of platelets and erythrocytes in experimental thrombi.

Experimental animal models of thrombosis have been established in several species to examine factors responsible for thrombotic disorders in man. One technical facet of all thrombosis models is the need to quantitate cell deposition on thrombogenic surfaces, and this is routinely accomplished with radioisotopic labeling of specific components. Data reported here demonstrate that formalin-fixed thrombi can be hydrolyzed with chymotrypsin allowing recovery and quantitation of platelets and erythrocytes incorporated within the clot. Recovery of platelets from in vitro generated, model thrombi averaged 99 +/- 10% (mean +/- 1 SD; n = 7; range 88-116%) of calculated content; recovery of erythrocytes was 94.1 +/- 1.1% (n = 6) as measured by recovery of cellular hemoglobin after chymotrypsin hydrolysis of clots. Chymotrypsin was also shown to release platelets and erythrocytes from string-bound thrombi generated in vivo with an arterio-venous shunt model in beagle dogs. Platelet recovery from these string clots after chymotrypsin hydrolysis was independently verified with a quantitative Western blot assay of platelet antigens. These data demonstrate that experimental thrombi can be hydrolyzed with chymotrypsin, thereby not only eliminating the need for radioisotopes, but also permitting flow cytometric analysis of cells comprising the thrombus.

Quantitation of platelet life span in splenectomized dogs.

Platelet life spans in dogs were measured pre- and post- splenectomy utilizing in vitro whole blood biotinylation. Four splenectomized dogs were found to have significantly lengthened platelet life spans, 193 +/- 7 hours (mean +/- 1 SD;n=4) postsurgery vs. control life spans of 131 +/- 15 hours (n=6; p< 0.01) when analyzed with the multiple-hit model. Additionally, platelets from normal dogs transfused into splenectomized dogs were found to have convex survival curves with extended life spans approximating that of the splenectomized dog. These data indicate that the spleen is a significant determinant of platelet life span in dogs, with survivals increasing approximately 47% upon splenectomy.