Clinical uses of the medicinal leech: a practical review.

The medicinal leech, Hirudo medicinalis, is an excellent example of the use of invertebrates in the treatment of human disease. Utilized for various medical indications since the ancient times, the medicinal leech is currently being used in a narrow range of well-defined and scientifically-grounded clinical applications. Hirudotherapy is most commonly used in the setting of venous congestion associated with soft tissue replantations and free flap-based reconstructive surgery. This is a comprehensive review of current clinical applications of hirudotherapy, featuring a comprehensive search of all major medical search engines (i.e. PubMed, Google Scholar, ScientificCommons) and other cross-referenced sources. The authors focus on indications, contraindications, practical application/handling of the leech, and therapy-related complications.

Tertiary survey of the trauma patient in the intensive care unit.

The issues surrounding the arrival of trauma patients to the ICU have been defined. By necessity, many of these topics are dealt with elsewhere in greater detail. The basic framework within which this phase of care could be optimized has been provided. Pitfalls related to patients' mode of arrival to the ICU affect subsequent management and should direct specific clinical activity. The tertiary survey is a complete summation and cataloguing of a patient's injuries. The need for ongoing resuscitation determines how much attention can be paid to the tertiary survey. Clinical suspicion based on mechanism and pattern of injury and thorough, repeated, complete physical examination are the essential elements of the tertiary survey. The survey is affected by factors that alter patients' mental status because examination is most reliable in patients who can localize pain. Medications, intoxication, and head injuries are common factors that interfere with the reliability of the tertiary survey for variable periods. Radiographic assessment is used to identify injuries suspected on the basis of mechanism of injury, injury pattern, and findings on physical examination. Some studies may be done portably; others require transport within the hospital. The intensivist must prioritize these ongoing diagnostic studies based on patient stability and the need for ongoing resuscitation.

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.

Time and motion: a study of trauma surgeons' work at the bedside during the first 24 hours of blunt trauma care.

BACKGROUND: The current literature defines the costs of trauma care in terms of hospital costs and charges. We sought to define the qualitative and quantitative labor costs of trauma care by measuring the various components of bedside care provided by surgeons at a community hospital. METHODS: We conducted a prospective time-and-motion study during the initial 24 hours of blunt trauma patients' stay in the hospital at a Level II trauma center. The services provided by two surgeons and one nurse practitioner were examined. All patients were resuscitated and seen initially by one of the physicians. Ten service elements (SEs) were defined, and total time (TT) spent was the sum of time spent on all service elements for that patient. We defined labor cost as TT. Data on Injury Severity Score (ISS), alcohol intoxication, length of stay, operative procedures, and injury mechanism were also collected. Data are in minutes as means +/- SEM. Analysis of linear correlation was by Pearson correlation coefficient, and intergroup comparison of means was by two-tailed t test. RESULTS: Fifty-eight patients were studied. Mean ISS and length of stay were 11.8 +/- 3 and 4.6 +/- 3 days, respectively. A mean of seven SEs were provided per patient, and the number of SEs provided correlated directly with ISS (r = 0.75, p < 0.01). The mean TT spent was 171 +/- 9 minutes, and it correlated directly with ISS (r = 0.64, p < 0.01). For patients undergoing operative procedures by the trauma surgeon, the procedures consumed the greatest portion of TT: 73 +/- 6 minutes (24%). For patients not undergoing operative procedures, resuscitation and time spent in the radiology department consumed the majority of TT: 30 minutes for each SE (40% of TT). Serum ethanol was greater than 0.10 in 33 of 58 patients (57%), and these patients required significantly more TT (135 vs. 193 minutes; p < 0.05) than nonintoxicated patients. CONCLUSION: A significant labor cost (TT) was required for the care of blunt trauma patients, and the majority of that cost was not spent in the operating room but involved the performance of cognitive services. Significant correlation existed between ISS and labor cost. The presence of ethanol intoxication significantly increased this commitment. These data might be of use in creating provider reimbursement schemes for trauma care. This methodology may have applications in the design of hospital systems for trauma care.

Gunshot wounds below the popliteal fossa: a contemporary review.

The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.

Determining anatomic injury with computed tomography in selected torso gunshot wounds.

BACKGROUND: Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs. METHODS: Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management. RESULTS: Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases. CONCLUSION: CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.

Who pays for failed organ procurement and what is the cost of altruism?

Our objective was to define medical complications and financial charges generated during the care of potential solid organ donors who fail to donate after consent has been obtained. A retrospective review of financial and medical records of potential organ donors was done at an urban level 1 trauma center. Total hospital stay (T1+T2) for the group was broken down into the interval between admission and diagnosis of lethality (T1) and between diagnosis of lethality and death (T2). Medical complications occurring during the hospital stay and charges generated during each time interval were abstracted. After consent was obtained, 19 of 53 (36%) potential donors failed to donate: 9 of 19 (47%) expired prior to legal determination of brain death; 10 patients failed to progress to brain death and were made DNR. Of these, 9 died within 24 hr, 1 survived 16 days; 6 of the 10 patients did not meet brain death criteria, and 4 were rejected by the OPO for reasons of infectious risks. There were 3.1+/-1.3 medical complications per patient. T1 was less than 4 hr in 16/19 (84%) potential donors and constituted a small percentage of the mean total hospital stay (37+/-10 hr). Charges generated during T1+T2 (33,997+/-25,843) and specifically during T2 (17,385+/-9453) were considerable. These charges were passed on to patients' families or third party payers though care was directed solely at organ procurement after diagnosis of lethality. We conclude that multiple medical complications are encountered in the care of potential organ donors; total hospital stays are short but expensive; more than 50% of charges generated during the total hospital stay arise from care provided after determination of lethality; and the goodwill of families to consent to organ donations of their loved ones appears to carry potential for significant financial burden.

The decreased adhesion of Y79 retinoblastoma cells to extracellular matrix proteins is due to a deficit of integrin receptors.

PURPOSE: This study was designed to determine whether the Y79 retinoblastoma cell line, a prototype for retinoblastoma cells, exhibits differential adhesive properties toward extracellular matrix (ECM)/basement membrane (BM) proteins compared to normal human retinal (NHR) cells. A second goal was to determine whether differences in adhesion are related to differences in the expression of integrin subunits. METHODS: Y79 cells and NHR cells were tested for their ability to adhere and spread in microtiter wells adsorbed with the ECM/BM proteins laminin, fibronectin, and type IV collagen, as well as fragments of these proteins. The presence of cell surface integrins was determined by flow cytometry, using monoclonal antibodies (mAbs) against integrin subunits. For inhibition assays, cells were preincubated with mAbs against integrin subunits before the adhesion assays. RESULTS: NHR cells adhered to and spread on laminin, fibronectin, and type IV collagen, whereas Y79 cells only adhered moderately to fibronectin. NHR cells expressed high levels of beta 1, alpha 1, alpha 2, alpha 3, alpha 4, alpha 5, alpha 6, and alpha v integrin subunits, and they used these integrin subunits to adhere to all three ECM proteins. In contrast, Y79 cells expressed high levels of only the alpha 4 and beta 1 integrin subunits, used to adhere to fibronectin. CONCLUSIONS: Y79 cells have decreased adhesive capabilities toward ECM/BM proteins, compared to NHR cells. These differences can be attributed, in part, to their significantly lower levels of alpha 1, alpha 2, alpha 3, and alpha 5 integrin subunits, which serve as receptors for type IV collagen, laminin, and fibronectin.

Peripherally inserted central venous catheters. Low-risk alternatives for ongoing venous access.

We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center. Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate). Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use. The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days). A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266). In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21%. Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%). One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use. This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population. At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.

Avalanche trauma.

Medical aspects of avalanche accidents have apparently not been studied in the American literature. Records from the Utah Avalanche Forecasting Center (UAFC) for the period 1982-1987 were reviewed and compared with similar data from Europe and Canada. One hundred forty-five avalanches involving 188 individuals were reported to the UAFC. Ninety-one (48%) people were caught, of whom 21 required medical attention. Twelve of the 91 died (13%) and nine were injured (10%). Eleven of 12 nonsurvivors and four of nine survivors were completely buried. Evidence of major blunt trauma was present in nine of ten nonsurvivors and all nine survivors. Asphyxia and blunt trauma were the most common causes of death; hypothermia appeared to have played only a minor role. These findings were similar to results obtained in Europe and Canada.

Effect of delayed operation for bleeding esophageal varices on Child's class and indices of liver function.

The charts of 38 patients managed with a period of intensive medical treatment (mean 7 days) prior to portosystemic shunting were examined. We found that the operative delay did not improve the Child's class or the indices of liver function. The operative mortality rates in these patients were 0 in Child's A patients, 13 percent in Child's B patients, and 50 percent in Child's C patients. Based on these findings, we began to operate on patients with bleeding esophageal varices as soon as they stabilized. The charts of 10 consecutive Child's C patients operated on without a period of intensive medical management (mean 3 days) were reviewed and compared with the charts of 8 Child's C patients with delayed operation. The two groups of patients were similar. We recommend that patients who need a shunt should be operated on as soon as possible after bleeding has ceased.