It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study.

INTRODUCTION: Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS. METHODS: Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared. RESULTS: All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171-10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109-4.888, P = 0.027). CONCLUSION: After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.

Sarcopenia is associated with mortality in non-critical elderly patients visiting the emergency department.

Introduction: Geriatric syndrome (GS) increases risk of disability and mortality in older adults. Sarcopenia is a predominant illness of GS and accelerate its progression. This study aimed to investigate associations between mortality, emergency department (ED) re-visits and GS-related illnesses among older adults who visited the ED. Method: This retrospective observational study enrolled elderly patients who visited the ED in our hospital between January 2018 and October 2020. Patients were evaluated for potential sarcopenia, which was defined by both low handgrip strength and calf circumference. Follow-up was at least 6 months. Data of age, gender, mortality, ED re-visits, and GS-related illnesses were collected and analyzed for associations. Results: A total of 273 older adults aged 74 years or older were included, of whom 194 were diagnosed with possible sarcopenia. Older adults with possible sarcopenia also had significantly lower body mass index (BMI); a higher proportion needed assistance with daily activities; more had malnutrition, frailty, and history of falls (all p < 0.001) and acute decline in activities of daily living (p = 0.027). Multivariate analysis showed that possible sarcopenia [adjusted hazard ratio, aHR): 9.89, 95% confidence interval (CI): 1.17-83.81, p = 0.036], living in residential institutions (aHR: 2.85, 95% CI: 1.08-7.50, p = 0.034), and frailty (aHR: 7.30, 95% CI: 1.20-44.62, p = 0.031) were associated with mortality. Aged over 85 years (adjusted odds ratio: 2.44, 95% CI: 1.25-4.80, p = 0.02) was associated with ED re-visits. Conclusion: Sarcopenia is associated with mortality among older adults who visit ED. Initial screening for sarcopenia and relevant risk factors among older adults in the ED may help with early intervention for those at high-risk and may improve their prognosis.

Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure.

BACKGROUND: Severe blunt chest injury sometimes induces acute respiratory failure (ARF), requiring ventilator use. We aimed to evaluate the effect of performing rib fixation with the addition of video-assisted thoracoscopic surgery (VATS) on patients with ARF caused by blunt thoracic injury with ventilator dependence. METHODS: This observational study prospectively enrolled patients with multiple bicortical rib fractures with hemothorax caused by severe blunt chest trauma. All patients received positive pressure mechanical ventilation within 24 h after trauma because of ARF. Some patients who received rib fixation with VATS were enrolled as group 1, and the others who received only VATS were designated as group 2. The length of ventilator use was the primary clinical outcome. Rates of pneumonia and length of hospital stay constituted secondary outcomes. RESULTS: A total of 61 patients were included in this study. The basic demographic characteristics between the two groups exhibited no statistical differences. All patients received operations within 6 days after trauma. The length of ventilator use was shorter in group 1 (3.19 ± 3.37 days vs. 8.05 ± 8.23, P = 0.002). The rate of pneumonia was higher in group 2 (38.1% vs. 75.0%, P = 0.005). The length of hospital stay was much shorter in group 1 (17.76 ± 8.38 days vs. 24.13 ± 9.80, P = 0.011). CONCLUSION: Rib fixation combined with VATS could shorten the length of ventilator use and reduce the pneumonia rate in patients with severe chest blunt injury with ARF. Therefore, this operation could shorten the overall length of hospital stay.

The advantages of adding rib fixations during VATS for retained hemothorax in serious blunt chest trauma - A prospective cohort study.

BACKGROUND: Serious blunt chest trauma usually induces hemothorax, pneumothorax, and rib fracture. Early video-assisted thoracoscopic surgery (VATS) to evacuate retained hemothorax is one commonly used treatment. In this study, a new strategy was implemented to combine VATS with fractured rib fixation simultaneously. METHODS: This prospective observational study was performed from January 2013 to April 2018. All patients were aged 18 years or older and had blunt chest trauma with displaced fractures in more than three ribs. No patients had acute respiratory failure within 24 h after trauma. Patients with retained hemothorax who received VATS constituted the study cohort. Subsequently, patients who received rib fixation during VATS procedures were compared with those who did not. Clinical outcomes such as dose of analgesics, and length of hospital stay were recorded. RESULTS: During the study period, 128 patients were enrolled. Available demographic characteristics of the 2 groups were compared, and no statistical differences were observed. The rates of shorter temporary ventilator dependence after operations were lower in the rib fixation group (0% vs. 24.7%, P = 0.017). Persistent air leakage more than 5 days after operations were also lower in the rib fixation group (0% vs. 10.4%, P = 0.001). The length of stay in overall hospital stay were longer for patients who received VATS without rib fixation (9.29 ±â€¯2.51 days vs. 12.39 ±â€¯4.65, P = 0.001). Furthermore, the rib fixation group were administered much lower doses of opiates during their hospital stays (52.45 ±â€¯15.67 mg vs. 77.24 ±â€¯50.42 mg, P = 0.001). CONCLUSION: Adding rib fixation during VATS in the management of retained hemothorax can contribute to shorten whole treatment courses. Rib fixation can also reduce pain, thus reducing dependence on analgesics.

Early Management of Retained Hemothorax in Blunt Head and Chest Trauma.

BACKGROUND: Major blunt chest injury usually leads to the development of retained hemothorax and pneumothorax, and needs further intervention. However, since blunt chest injury may be combined with blunt head injury that typically requires patient observation for 3-4 days, other critical surgical interventions may be delayed. The purpose of this study is to analyze the outcomes of head injury patients who received early, versus delayed thoracic surgeries. MATERIALS AND METHODS: From May 2005 to February 2012, 61 patients with major blunt injuries to the chest and head were prospectively enrolled. These patients had an intracranial hemorrhage without indications of craniotomy. All the patients received video-assisted thoracoscopic surgery (VATS) due to retained hemothorax or pneumothorax. Patients were divided into two groups according to the time from trauma to operation, this being within 4 days for Group 1 and more than 4 days for Group 2. The clinical outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, infection rates, and the time period of ventilator use and chest tube intubation. RESULT: All demographics, including age, gender, and trauma severity between the two groups showed no statistical differences. The average time from trauma to operation was 5.8 days. The ventilator usage period, the hospital and ICU length of stay were longer in Group 2 (6.77 vs. 18.55, p = 0.016; 20.63 vs. 35.13, p = 0.003; 8.97 vs. 17.65, p = 0.035). The rates of positive microbial cultures in pleural effusion collected during VATS were higher in Group 2 (6.7 vs. 29.0%, p = 0.043). The Glasgow Coma Scale score for all patients improved when patients were discharged (11.74 vs. 14.10, p < 0.05). DISCUSSION: In this study, early VATS could be performed safely in brain hemorrhage patients without indication of surgical decompression. The clinical outcomes were much better in patients receiving early intervention within 4 days after trauma.

Application of time series analysis in modelling and forecasting emergency department visits in a medical centre in Southern Taiwan.

OBJECTIVE: Emergency department (ED) overcrowding is acknowledged as an increasingly important issue worldwide. Hospital managers are increasingly paying attention to ED crowding in order to provide higher quality medical services to patients. One of the crucial elements for a good management strategy is demand forecasting. Our study sought to construct an adequate model and to forecast monthly ED visits. METHODS: We retrospectively gathered monthly ED visits from January 2009 to December 2016 to carry out a time series autoregressive integrated moving average (ARIMA) analysis. Initial development of the model was based on past ED visits from 2009 to 2016. A best-fit model was further employed to forecast the monthly data of ED visits for the next year (2016). Finally, we evaluated the predicted accuracy of the identified model with the mean absolute percentage error (MAPE). The software packages SAS/ETS V.9.4 and Office Excel 2016 were used for all statistical analyses. RESULTS: A series of statistical tests showed that six models, including ARIMA (0, 0, 1), ARIMA (1, 0, 0), ARIMA (1, 0, 1), ARIMA (2, 0, 1), ARIMA (3, 0, 1) and ARIMA (5, 0, 1), were candidate models. The model that gave the minimum Akaike information criterion and Schwartz Bayesian criterion and followed the assumptions of residual independence was selected as the adequate model. Finally, a suitable ARIMA (0, 0, 1) structure, yielding a MAPE of 8.91%, was identified and obtained as Visitt=7111.161+(at+0.37462 at-1). CONCLUSION: The ARIMA (0, 0, 1) model can be considered adequate for predicting future ED visits, and its forecast results can be used to aid decision-making processes.

The surgical stabilization of multiple rib fractures using titanium elastic nail in blunt chest trauma with acute respiratory failure.

BACKGROUND: Blunt chest injuries are usually combined with multiple rib fractures and severe lung contusions. This can occasionally induce acute respiratory failure and prolong ventilations. In order to reduce the periods of ventilator dependency, we propose a less invasive method of fixing multiple rib fractures. METHODS: Since October 2009, we have developed a new method to fix fractured ribs caused by blunt trauma. Rib fixations were performed using 2.0- or 2.5-mm intramedullary titanium elastic nails (TEN), with the help of video-assisted thoracoscopic surgery (VATS) and minimal thoracic incisions. All the patients' demographics and postoperative data were collected. RESULTS: From January 2010 to December 2012, a total of 65 patients presenting with multiple rib fractures resulting in acute respiratory failure were included in the study. Twelve patients received the new surgical fixation. Rib fixations were performed at an average of 4 days after trauma. Patients were successfully weaned off ventilators after an average of 3 days. The average length of stay in the hospital and the intensive care unit (ICU) was shorter for the patients with fixation than for nonsurgical patients. All twelve patients returned to normal daily activities and work. CONCLUSIONS: In the reconstruction of an injured chest wall, the VATS with TENs fixation in multiple rib fractures is feasible. This method is also effective in decreasing the length of the surgical wound. Because the structure of the chest cage is protected, the period of mechanical ventilation is shortened and the length of stay in the hospital and the ICU can be reduced.

Blunt abdominal injury with rupture of giant hepatic cavernous hemangioma and laceration of the spleen.

A 41-year-old woman with blunt abdominal trauma due to a motor vehicle accident presented to our emergency department. The patient had a history of a giant hepatic cavernous hemangioma. Emergency exploratory laparotomy was performed for suspected intra-abdominal bleeding with abdominal compartment syndrome, and more than 4 liters of blood and blood clots were removed. An active bleeding laceration (5 cm) of a hepatic cavernous hemangioma was detected in segment III of the liver. The bleeding was controlled by sutures, Teflon patches and tamponade. The abdomen was closed temporarily using the vacuum-assisted method. Because of the presence of persistent fresh blood through abdominal drainage at a rate of >1 L/h, splenectomy was performed to control the bleeding again by sutures and Teflon patches. Finally, the abdomen was closed using a biologic mesh. The patient was discharged home 30 days after trauma. Bleeding of trauma-caused hepatic hemangioma is rare, but splenic injury due to blunt abdominal trauma is common. An in-depth investigation is necessary to avoid second intervention.

The role of repairing lung lacerations during video-assisted thoracoscopic surgery evacuations for retained haemothorax caused by blunt chest trauma.

OBJECTIVES: Retained haemothorax and pneumothorax are the most common complications after blunt chest traumas. Lung lacerations derived from fractures of the ribs are usually found in these patients. Video-assisted thoracoscopic surgery (VATS) is usually used as a routine procedure in the treatment of retained pleural collections. The objective of this study was to find out if there is any advantage in adding the procedure for repairing lacerated lungs during VATS. METHODS: Patients who were brought to our hospital with blunt chest trauma were enrolled into this prospective cohort study from January 2004 to December 2011. All enrolled patients had rib fractures with type III lung lacerations diagnosed by CT scans. They sustained retained pleural collections and surgical drainage was indicated. On one group, only evacuation procedure by VATS was performed. On the other group, not only evacuations but also repair of lung injuries were performed. Patients with penetrating injury or blunt injury with massive bleeding, that required emergency thoracotomy, were excluded from the study, in addition to those with cardiovascular or oesophageal injuries. RESULTS: During the study period, 88 patients who underwent thoracoscopy were enrolled. Among them, 43 patients undergoing the simple thoracoscopic evacuation method were stratified into Group 1. The remaining 45 patients who underwent thoracoscopic evacuation combined with resection of lung lacerations were stratified into Group 2. The rates of post-traumatic infection were higher in Group 1. The durations of chest-tube drainage and ventilator usage were shorter in Group 2, as were the lengths of patient intensive care unit stay and hospital stay. CONCLUSIONS: When compared with simple thoracoscopic evacuation methods, repair and resection of the injured lungs combined may result in better clinical outcomes in patients who sustained blunt chest injuries.

M-3M3FBS-induced Ca² ⁺ movement and apoptosis in HA59T human hepatoma cells.

The effect of 2,4,6-trimethyl-N-(meta-3-trifluoromethyl-phenyl)-benzenesulfonamide (m-3M3FBS), a presumed phospholipase C activator, on cytosolic free Ca² ⁺ concentrations ([Ca² ⁺ ]i ) in HA59T human hepatoma cells is unclear. This study explored whether m-3M3FBS elevated basal [Ca² ⁺ ]i levels in suspended cells by using fura-2 as a Ca² ⁺ -sensitive fluorescent dye. M-3M3FBS at concentrations of 10- 50 µM increased [Ca² ⁺ ]i in a concentration-dependent fashion. The Ca² ⁺ signal was reduced partly by removing extracellular Ca² ⁺ . M-3M3FBS-induced Ca² ⁺ influx was inhibited by nifedipine, econazole, SK&F96365, aristolochic acid, and GF109203X. In Ca² ⁺ -free medium, 50 µM m-3M3FBS pretreatment inhibited the [Ca² ⁺ ]i rise induced by the endoplasmic reticulum Ca² ⁺ pump inhibitor thapsigargin. Conversely, pretreatment with thapsigargin partly reduced m-3M3FBS-induced [Ca² ⁺ ]i rise. Inhibition of inositol 1,4,5-trisphosphate formation with U73122 did not alter m-3M3FBS-induced [Ca² ⁺ ]i rise. At concentrations between 10 and 40 µM m-3M3FBS killed cells in a concentration-dependent manner. The cytotoxic effect of m-3M3FBS was not reversed by prechelating cytosolic Ca² ⁺ with 1,2-bis(2- aminophenoxy)ethane-N,N,N',N'-tetraacetic acid (BAPTA). Annexin V/propidium iodide staining data suggest that m-3M3FBS induced apoptosis in a concentration-dependent manner. M-3M3FBS also increased levels of reactive oxygen species. Together, in human hepatoma cells, m-3M3FBS induced a [Ca² ⁺ ]i rise by inducing phospholipase C-independent Ca² ⁺ release from the endoplasmic reticulum and Ca² ⁺ entry via protein kinase C-sensitive store-operated Ca² ⁺ channels. M-3M3FBS induced cell death that might involve apoptosis via mitochondrial pathways.

Effect of thymol on Ca2+ homeostasis and viability in human glioblastoma cells.

The effect of the natural essential oil thymol on cytosolic Ca(2+) concentrations ([Ca(2+)](i)) and viability in human glioblastoma cells was examined. The Ca(2+)-sensitive fluorescent dye fura-2 was applied to measure [Ca(2+)](i). Thymol at concentrations of 400-1000 µM induced a [Ca(2+)](i) rise in a concentration-dependent fashion. The response was decreased partially by removal of extracellular Ca(2+). Thymol-induced Ca(2+) signal was not altered by nifedipine, econazole, SK&F96365, and protein kinase C activator phorbol myristate acetate (PMA), but was inhibited by the protein kinase C inhibitor GF109203X. When extracellular Ca(2+) was removed, incubation with the endoplasmic reticulum Ca(2+) pump inhibitor thapsigargin or 2,5-di-tert-butylhydroquinone (BHQ) abolished thymol-induced [Ca(2+)](i) rise. Incubation with thymol also abolished thapsigargin or BHQ-induced [Ca(2+)](i) rise. Inhibition of phospholipase C with U73122 abolished thymol-induced [Ca(2+)](i) rise. At concentrations of 200-800 µM, thymol killed cells in a concentration-dependent manner. This cytotoxic effect was not changed by chelating cytosolic Ca(2+) with 1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid/acetoxy methyl (BAPTA/AM). Annexin V/propidium iodide staining data suggest that thymol (200, 400 and 600 µM) induced apoptosis in a concentration-dependent manner. Collectively, in human glioblastoma cells, thymol induced a [Ca(2+)](i) rise by inducing phospholipase C- and protein kinase C-dependent Ca(2+) release from the endoplasmic reticulum and Ca(2+) entry via non store-operated Ca(2+) channels. Thymol induced cell death that may involve apoptosis.

Roles of the genetic variation of alcohol-metabolizing enzymes on biomarkers in trauma patients with excessive alcohol intake at emergency department.

BACKGROUND: Alcohol abuse has been implicated as an important factor for accidents. We evaluated the roles of different genetic combinations of the ADH2 and ALDH2 genotypes on biomarkers in trauma patients with excessive alcohol intake at our emergency department. METHODS: Blood samples were obtained from 80 patients and 88 age-matched controls. The biomarkers, including AST, ALT, GGT, and MDA, were assayed. The polymerase chain reaction-restriction fragment length polymorphism method was used to determine the genetic polymorphisms of ADH2 and ALDH2. RESULTS: There were significant differences in the levels of AST, ALT, GGT, MDA, and AST/ALT ratios between the 2 groups. In addition, MDA values and AST/ALT ratios were significantly higher in the patients with normal activity of ADH2 than the patients with low activity of ADH2. Meanwhile, regarding ALDH2 genotypes, there were significantly higher ratios of AST/ALT in the patients with low activity of ALDH2. The highest AST/ALT ratios and MDA values were in the patients with ADH2 (*2/*2) and ALDH2 (*1/*2 and *2/*2). CONCLUSIONS: In conclusion, our results indicated that alcohol-induced liver damage or oxidative stress might be influenced by the genetic variation of ADH2 or ALDH2. Therefore, the combinations of different ADH2 and ALDH2 genotypes may be influential markers for susceptibility to alcohol-induced liver damage.

Distribution of alcohol-metabolizing enzyme genotypes in trauma patients with excessive alcohol consumption in the emergency department.

OBJECTIVES: The objective of this study was to investigate the distribution of genetic polymorphisms of alcohol-metabolizing enzymes in trauma patients with excessive alcohol consumption in the emergency department (ED). DESIGN AND METHODS: A total of 100 trauma patients and age-matched control subjects composed of 98 participants were enrolled in this study. The activities of liver enzymes and genotypes of alcohol-metabolizing enzymes, including ADH2, ALDH2, and CYP2E1, were analyzed with the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis. RESULTS: There was a significant difference in the allele frequencies of ALDH2 between the two groups. For the genotypes, there were significant differences in the genotype frequencies of ADH2 and ALDH2. There was also a significantly lower frequency in patients with the ALDH2*2 phenotype than those of the controls. For the activities of liver enzymes, there were significant differences between the two groups. For ADH2 and ALDH2, there were significantly higher ORs (odds ratios) in trauma patients with normal activity than those with weak or intermediate activity but there were no significant difference in CYP2E1 genotype between two groups. To investigate the interaction of alcohol-metabolizing enzyme genotypes, we have estimated the odds ratios in two alcohol-metabolizing pathways. The ORs of the combined genotypes of ADH2 (*1/*1+*1/*2) and ALDH2 (*1/*1) and the combined genotypes of either CYP2E1 (*c1/*c1) or CYP2E1 (*c1/*c2+*c2/*c2) and ALDH2 (*1/*1) were significantly higher than that of the reference group in the major and the minor pathway, respectively. CONCLUSIONS: Genetic variation of alcohol-metabolizing enzymes, especially ALDH2, may play an important role on the occasions of alcohol problems in the emergency department.

CT voiding urethrography and virtual urethroscopy: preliminary study with 16-MDCT.

OBJECTIVE: The purpose of this study was to demonstrate CT voiding urethrography and CT virtual urethroscopy. Fourteen CT voiding urethrography examinations on 13 men (mean age, 30 years) were prospectively performed with 16-MDCT. The clinical diagnoses of those patients included urethral injury, urethral stricture, and hypospadia. The CT voiding urethrogram was obtained with transverse CT of the voiding, contrast-filled urethra and display of 2D multiplanar and 3D virtual images. CONCLUSION: The full urethral structure was clearly shown by CT voiding urethrography and virtual urethroscopy in all patients. The results of CT voiding urethrography and conventional methods correlated closely with the urethral diseases being imaged.

Urethral diverticulum: diagnosis with virtual CT urethroscopy.

OBJECTIVE: A 26-year-old woman presented with urinary frequency. Findings were negative on voiding cystourethrography. Cystourethroscopy failed to reveal a urethral diverticulum. A new method of virtual CT urethroscopy was performed using a 16-MDCT scanner. The orifice of the diverticulum was identified clearly on 3D virtual urethroscopy. Intraoperatively, the diverticulum was identified, with the orifice location compatible with that seen on virtual urethroscopy. CONCLUSION: Virtual CT urethroscopy provides more information than conventional urethral examinations and is less invasive than conventional urethroscopy.