Impairment of aortal tone by no flow-reflow conditions and its partial amelioration by mannitol

BACKGROUND

Although postischemic cardiac or pulmonary dysfunction can relate to the impact of remotely generated oxygen stress mediators on the heart, their direct effect on the vascular bed remains unresolved. Thus, we tested these remote effects in an ex-vivo double organ model.

METHODS

After stabilization With Krebs-Henseleit solution, isolated rat livers were either perfused or made ischemic for 2 hours. Aortic rings were stabilized, immersed in postischemic liver perfusates and their functions were tested. Some organs originated from donors fed with tungstate, whereas others had mannitol (0.25 g/kg) in the buffer.

RESULTS

Incubation of aortic rings with postischemic hepatic effluent resulted in protracted contraction. Spasm was slightly lesser when the livers were pretreated with tungstate or exposed to mannitol, but worse in pretreated rings. The return to basal tone was abrupt in all ischemia-reperfusion aortae. The response of the rings to phenylephrine under the influence of the ischemia-reperfusion hepatic effluent was deficient. Mannitol prevented most abnormal responses.

CONCLUSIONS

Aortal tone impairment can occur by direct influence of the ischemia-reperfusion liver. It cannot be attributed entirely to xanthine oxidase, but also to other hepatic-released factors.

Appendicitis in the elderly: what has changed?

BACKGROUND

The course and outcome of appendicitis in the elderly differs from that of the general population. The rates of perforated appendices, error in diagnosis, postoperative complications and mortality may be related to the time lapse between onset of symptoms and admission, and hence delay in surgery.

OBJECTIVES

To evaluate if these factors have improved in recent years.

METHODS

A retrospective study was carried out of all 61 patients over age 60 who underwent appendectomies in a major metropolitan hospital during 1988-98.

RESULTS

We found that most patients had appendectomies within the first 24 hours of admission and within 3 days of symptoms. Rate of perforation was 43%, error 5.6%, morbidity 41%, and mortality 3.2%.

CONCLUSIONS

The high rate of appendix perforation in the elderly is not due to delay. The literature reveals little improvement in the statistics of the disease over the last five decades, despite advances in imaging and surgical technique. This may be explained by the increasing inclusion of octogenarian patients.

Problematic intubation in soldiers: are there predisposing factors?

Attempts by a combat medical officer to secure the airway of a multiple-injury patient in the field may frequently end in failure. The recurrence of such failures, despite Advanced Trauma Life Support training, is perplexing; therefore, we studied the prevalence of clinical criteria that could predispose active soldiers to difficult intubation. Such known anatomical features and the Mallampati classification were assessed by experts in 250 soldiers at a military outpatient clinic of the Israel Defense Forces. It was found that most soldiers had normal airways. Limitations of head and neck movement, or in opening the mouth, were not observed. Other risk factors were noted in only a small percentage of the study population. Mallampati classes I and II were noted in 40% and 31%, respectively. No statistically significant differences between young (18-21 years) and older (40-44 years) soldiers were found. It was concluded that difficult intubations among soldiers are unlikely to be associated with anatomical causes. Complicated scenarios and deficient skills of the physicians are the most important factors that contribute to in-field failures to secure airway control. Several recommendations to remedy this situation are offered.

Factors contributing to physicians' success in the advanced trauma life support program in Israel

BACKGROUND

Since its introduction in Israel, more than 4,000 physicians from various specialties and diverse medical backgrounds have participated in the Advanced Trauma Life Support course.

OBJECTIVES

To analyze the factors that influence the success of physicians in the ATLS written tests.

METHODS

A retrospective study was conducted of 4,475 physicians participating in the Israeli ATLS training program between 1990 and 1996. Several variables in the records of these physicians were related to their success or failure in the final written examination of the course.

RESULTS

Age, the region of medical schooling, and the medical specialty were found to significantly influence the successful completion of the ATLS course.

CONCLUSIONS

Physicians younger than 45 years of age or with a surgical specialty are more likely to graduate the ATLS course. The success rate could be improved if the program's text and questionnaires were translated into Hebrew.

Multiple organ dysfunction after remote circulatory arrest: common pathway of radical oxygen species?

OBJECTIVES

Cardiovascular, respiratory, and vascular dysfunction can follow trauma-induced no-flow-reflow states: hemorrhage, blunt trauma, or neurogenic shock. Liver ischemia-reperfusion (IR) induces remote lung damage by means of xanthine oxidase (XO) pro-oxidant activity. This damage was not proven in the heart, neither was the independent role of radical oxygen species (ROS) established in such cases. We investigated whether multiple organ dysfunction after a trauma-like IR is XO and ROS related and whether clinically used ROS scavengers could be beneficial.

METHODS

A controlled, randomized trial in which isolated rat livers, hearts, lungs, and aortic rings were perfused with Krebs-Henseleit solutions. After stabilization, livers were either perfused or made ischemic (2 hours). Then, pairs of liver plus heart, lung, or ring were reperfused in series (15 minutes), and then the second organ circulated alone for 45 minutes. Remote organ protection against the pro-oxidant hepatic-induced toxicity was evaluated by using allopurinol (1 mmol/L, heart), mannitol (0.25 g/kg, lung), or methylene blue (40 mg/kg, ring).

RESULTS

IR liver effluents typically contained high lactate dehydrogenase, XO, and uric acid concentrations compared with control organs. IR was associated with doubled lung peak inspiratory pressure and reduced static compliance. Myocardial velocity of contraction and relaxation decreased by one third of baseline, and rings contracted abnormally and responded inadequately to phenylephrine. Wet-weight to dry-weight ratios in the remote organs increased as well. Most remote reperfusion injuries were attenuated by the drugs.

CONCLUSION

Liver no-flow-reflow directly induces myocardial, pulmonary, and vascular dysfunction. These are likely mediated by XO and ROS. The tested drugs protected against these pro-oxidants, even in the presence of circulating XO.

Medics in the Israel Defense Forces and their experience in trauma care during peacetime

BACKGROUND

In the military environment it is the medics who usually provide the initial care of mass casualties in the field.

OBJECTIVES

To determine the number of incidents of trauma encountered by medics in the Israel Defense Forces during peacetime, and to ascertain the role of these medics in providing primary trauma care to the victims.

METHODS

A retrospective questionnaire, reviewing the activities of medics in treating injured trauma victims, was distributed to medics who were in service for at least 2 years after their professional training.

RESULTS

Of the 128 responding medics, 87 (68%) had actively participated in the treatment of trauma victims under various circumstances. The average number of trauma events was 1.2 events over a period of 2 years per combat medic, and 0.7 for medics stationed in rear units. Their activities included insertion of numerous intravenous fluid lines (57% of medics), assistance in intubations (37%), tube thoracostomies (23%), insertions of central catheters (14%) or orogastric tubes (28%), and manual ventilations (41%).

CONCLUSION

Since it is difficult to increase the level of practical experience in dealing with trauma within the military framework, new techniques should be applied to improve the trauma training.

Comparative study of splenic wound healing in young and adult rats

BACKGROUND

Nonoperative management (NOM) of splenic injuries is a common practice in stable trauma patients. Nevertheless, age-related differences in the success rate of NOM have prompted inclusion of age among the criteria of patient selection. Elucidation of the cellular mechanism of splenic wound healing in the young versus that of adults may explain why age can be related to the success of NOM in splenic injuries.

METHODS

A laceration was made in the splenic antihilar surface of 40 young and 40 adult male rats. Postoperatively, at specified intervals extending until day 21, spleens were removed, fixed, and examined by routine histopathology. In addition, sections were stained histochemically for collagen fibers and immunohistochemically for myofibroblast histomorphometry.

RESULTS

The intense local hemorrhage was resorbed within 48 hours in the young rats, and within 7 days in the adults. Disappearance of germinal centers and other splenic alterations started on the first day in both groups, but regeneration of splenic parenchyma was accomplished after 14 days in the young, whereas in the adults, on day 21 it was still incomplete. Maximal myofibroblast accumulation at the laceration site was seen after two days in the young, whereas in adults only on day 4 (p < 0.0001). Collagen scars were not present in either group. Thickening of the damaged capsule, composed of collagen fibers with yellowish-green polarization colors, was observed only in adult rats.

CONCLUSION

Splenic wounds heal by regeneration and not by collagen scarring. In the young, myofibroblasts accumulate in the site of injury faster than in adults. These cells may enhance contraction and increase the rate of wound healing until parenchymatic regeneration is completed. Our results may indirectly explain the higher success rate of NOM of splenic injury in young patients.

Kerosene-induced severe acute respiratory failure in near drowning: reports on four cases and review of the literature

OBJECTIVE

The purpose of this study is to present an unusual respiratory and cardiovascular course after intoxication and near drowning in a river contaminated with kerosene.

DESIGN

Case reports and review of the literature.

SETTING

Intensive care unit of a university-affiliated hospital.

PATIENTS

Four patients after near drowning.

INTERVENTION

Supportive only.

RESULTS

The four patients developed acute respiratory failure. Cardiomyopathy was present in three patients and a persistent hypokalemia in two patients. The onset of the symptoms was delayed, which led to underestimation of the severity of their illness. Two of the four patients died. The diagnosis of hydrocarbon intoxication was based on bronchoalveolar lavage results, neutrophilic alveolitis with the presence of lipid-laden macrophages, and evidence of lipoid pneumonia from the autopsy performed on one victim. One patient who clinically deteriorated and another who developed a severe restrictive pulmonary disorder were treated with corticosteroids, which were effective only in the latter patient.

CONCLUSIONS

Acute kerosene intoxication in a near-drowning event often results in severe respiratory and cardiac failure, with a high fatality rate. Treatment with corticosteroids may lead to a rapid improvement in lung function.

Advanced trauma life support (ATLS) courses: should training be refocused towards rural physicians?

Recently there has been an increase in the number of courses designed to improve the theoretical knowledge and practical skills of health workers for immediate emergency management under life-threatening conditions. However, the numbers of applicants for these courses far exceed the available places. Priorities should be reviewed to solve the current shortfall. The purpose of this study was to compare the improvement in basic knowledge associated with the advanced trauma life support (ATLS) programme for paediatricians practising in a metropolitan area, with those practising in rural hospitals. This should facilitate proper use of the limited existing resources for training of physicians. A retrospective, comparative analysis of the impact of the ATLS courses for pediatricians was assessed by analysing scores of multiple choice tests before and after the programme. The study group comprised all Israeli paediatricians (n = 72) who completed the course during 1996. Performance was compared between paediatricians working in major, level I (n = 39) and rural, level II trauma centres (n = 33). After the course, all paediatricians improved their scores; those in level I trauma centres improved their mean precourse scores from 72 +/- 13.6 to 85 +/- 5.4, while those working in level II trauma centres improved from 67 +/- 12.4 to 85 +/- 5.0. The impact of the course was reflected in the net and proportional gains. Both were higher for paediatricians working in level II trauma centres, compared with those working in metropolitan trauma centres. Furthermore, the net gain was significantly higher (p < 0.05). Efforts should be made to increase the participation of paediatricians practising in rural level II trauma centres in trauma care courses. Further research should address the applicability of these results for recruiting primary care physicians to the ATLS courses.

[Absorbable mesh wrapping of injured kidney: a renal salvage technique]

Blunt trauma to the kidney is a rare cause of hospitalization, found in only 3% of patients hospitalized for trauma. Surgery is seldom required, but if necessary there are a variety of surgical techniques to preserve renal function. Organ-wrapping with absorbable mesh is a procedure previously described, but renal-wrapping has not gained the same acceptance as splenic or hepatic wrapping. We describe a 30-year-old man with grade III blunt renal trauma, in whom this technique was applied. He was discharged after 10 days without complications.

[Retroperitoneal sarcoma. Treatment of 51 patients]

Soft tissue sarcomas are exceedingly rare, making up less than 1% of all solid malignancies. In the retroperitoneum, they tend to be large when diagnosed and are a therapeutic challenge to the surgical oncologist. Our experience with 51 patients with retroperitoneal sarcomas operated on during the past 4 years is presented. 37 were primary and 26 presented as recurrent tumors. The group included many different histological subtypes, the majority being high grade tumors. Complete resection was achieved in 84%, necessitating extensive surgery, but was not possible in 8 patients (16%) who underwent partial resection or biopsy only. There was 1 perioperative fatality (2%). 18 (35%) suffered complications, all of which were reversible. The estimated 5-year survival in the complete resection group is 40%, while none of those who underwent partial resection survived more than 2 years. There was significantly better survival in patients with primary, low grade sarcomas which were smaller than 8 cm, compared to those with high-grade, recurrent sarcomas larger than 8 cm. Local recurrence developed in 8 patients of the complete resection group (18%), 2 months to 3 years after surgery. These data show that despite the concept of retroperitoneal sarcomas as being aggressive, invasive tumors with a poor prognosis, the prognosis is not unusually bad. With proper surgical technique, resectability may be high, with improved overall survival.

[The "wandering spleen" syndrome]

We describe a 26-year-old woman with thrombocytopenia discovered during gestation. On admission for evaluation of abdominal pain, torsion of an ectopic spleen was found. The spleen was removed and the thrombocytopenia resolved.

Primary trauma care experience of army reserve combat medics: is a new approach needed?

Combat medics play a significant role in any fighting unit. In recent years, during times of peace and low-intensity military conflicts, as well as in operations other than war, reserve combat medics have been challenged to treat major casualties in the field. Although this work requires important manual skills, the medics perform basic treatment maneuvers that are not necessarily for saving of lives. A sample survey of reserve combat medics revealed that most (70%) were engaged in medical care for trauma victims during their regular and reserve service. Many (32.5%) were involved in incidents with multiple casualties. These incidents included seriously injured victims, with 39.2% of the medics being involved with air evacuation and 44.4% with fatalities. Not all medics are exposed to major trauma, but for those who are, the numbers of patients per medic is not large. Therefore, the need to educate the medics in cognitive, and more importantly, in manual skills, is obvious. Suggestions for the means to do so are provided.

Morgagni hernia: unique presentations in elderly patients

We present case reports of 2 patients who were admitted to our ward for complications of Morgagni hernias. Both patients were elderly. Morgagni hernia is a rare condition. Its unique and late presentation are presented and discussed.

Model of implantation of tumor cells simulating recurrence in colonic anastomosis in mice

PURPOSE

Local recurrence after colorectal cancer surgery is usually perianastomotic. An experiment was designed to investigate whether free intraluminal cells can penetrate through a colonic anastomosis and thereby cause local recurrence.

METHODS

BALB/c and C57/BL mice underwent ascending colotomy followed by watertight anastomosis. Thereafter, CT-26 murine colon carcinoma cells were injected into the cecal lumen 2 cm proximal to the anastomosis of syngeneic BALB/c mice, whereas B-16 murine melanoma cells were injected in the same fashion into C57/BL mice. Control animals without anastomosis received similar injections. Animals were killed 24 hours, 72 hours, and 30 days after surgery and were checked for tumorigenesis.

RESULTS

Results of peritoneal fluid cytology were negative after 24 hours, whereas after 72 hours cancer cells were identified in the peritoneal fluid of 80 percent of mice with colotomy and anastomosis compared with 20 percent of control mice. Thirty days after surgery, 11.1 percent of the control BALB/c mice developed pericecal tumor growth, similar to the overall rate of murine melanoma in C57/BL. In mice with anastomoses, perianastomotic tumor growth was observed in 47.5 percent of BALB/c mice (P < 0.001) and was correlated with the number of injected cells. Tumor growth reached approximately 75 percent tumor take with high cell densities, whereas in C57/BL mice no difference was found between the experimental and control groups.

CONCLUSIONS

The findings suggest that free intraluminal cancer cells of colonic origin may penetrate through watertight anastomoses and implant on the anastomotic or peritoneal surface and initiate tumor growth. This anastomotic penetration is cell-mass dependent. The reported experimental model is simple, reproducible, and advantageous for studies of colonic anastomosis.