Pediatric falls: is height a predictor of injury and outcome?

Falls account for a significant proportion of pediatric injuries and deaths. A retrospective review of pediatric patients (age 0-14 years) was performed to determine whether patterns of injuries and outcomes could be predicted on the basis of the height of the fall. In addition we evaluated the triage criterion "fall greater than 15 feet" for transport of patients to a trauma center. Patients were stratified by the height of the fall: greater than or less than 15 feet. The end points for analysis were the associated injuries and survival. Patients who fell less than 15 feet had a higher incidence of intracranial injuries (and fewer extremity fractures than patients who fell more than 15 feet). Skull fractures were the most frequent injury and were associated with an increase in intracranial injuries in both subgroups. In conclusion low-level falls are associated with significant intracranial injuries. The evaluation of patients sustaining low-level falls should not be limited on the basis of the height of the fall. Using falls of greater than 15 feet as a triage criterion for transport to a trauma center needs to be prospectively evaluated to ensure that critically injured patients are triaged appropriately.

Fetal Death after Trauma in Pregnancy

Trauma in pregnancy places the mother and fetus at risk. The objective of this study is to identify risk factors independently associated with acute termination of pregnancy and/or fetal mortality after trauma. The medical and trauma registry records of 80 injured pregnant patients were reviewed. Data were collected and then analyzed by univariate and multivariate analysis. Three patients died (3.7%), 23 had the pregnancy acutely terminated (30%), and 14 suffered fetal death (17.5%). The only independent risk factors for fetal mortality were an Injury Severity Score (ISS) ≥9 and a nonviable pregnancy (<23 weeks). The combination of both risk factors increased the likelihood of fetal mortality by fivefold over that of patients without either risk factor. Maternal hemodynamic parameters did not predict fetal loss. Two patients lost their fetuses despite insignificant trauma (ISS = 1) and normal hemodynamic parameters, whereas eight delivered normal babies despite major trauma (ISS ≥ 16). Hemodynamic stability on admission does not predict fetal mortality. Although the presence of moderate to severe injuries (ISS ≥ 9) increases the likelihood of fetal mortality, this complication may occur even with insignificant trauma. Close maternal and fetal monitoring is justified, regardless of maternal hemodynamic presentation or severity of injury.

Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally-inserted central catheters

BACKGROUND AND AIMS

Total parenteral nutrition (TPN) is typically delivered through catheters inserted into the superior vena cava (SVC) via a subclavian or internal jugular vein approach. A peripherally-inserted central venous catheter (PICC), utilizing a cephalic or basilic venous approach, may provide a safe alternative to the standard catheter approach and, because non-physician providers can insert the PICC, may introduce a potential cost-savings to health care institutions. We sought to determine if PICC lines are safer and more cost-effective than the standard central venous catheter approach for hospitalized patients who require TPN.

METHODS

One hundred and two hospitalized patients (age range, 18-88 years) who required TPN were prospectively randomized to receive therapy via a centrally-inserted subclavian catheter (n=51) or a peripherally-inserted PICC line (n=51). The primary end-point was the development of a complication requiring catheter removal. Other end-points included catheter infection and thrombophlebitis. Cost associated with insertion and maintenance of each catheter was also studied.

RESULTS

Complication-free delivery rate (without the need to remove or replace the catheter) was 67% for subclavian catheters and 46% for PICC lines (P<0.05). The overall infection rate was 4.9 per 1000 catheter days and was similar for each catheter type (P=0.68). PICC lines were associated with higher rates of clinically-evident thrombophlebitis (P<0.01), difficult insertion attempts (P<0.05), and malposition on insertion (P<0.05). No catheter complications resulted in significant long-term morbity or mortality. No significant difference was noted between the two catheter types in terms of aborted insertion attempts (P=0.18), dislodgement (P=0.12), or line occlusion (P=0.25). After standardizing costs for each hospital, the direct institutional costs for insertion and maintenance of PICC lines (US$22.32+/-2.74 per day) was greater than that for subclavian lines (US$16.20+/-2.96 per day;P<0.05).

CONCLUSION

PICC catheters have higher thrombophlebitis rates and are more difficult to insert into certain patients when compared to the standard subclavian approach for central venous access in hospitalized patients who require TPN. Because of this, PICCs may be less cost-effective than currently believed because of the difficulty in inserting and maintaining the catheter.

Prevention of venous thromboembolism after injury: an evidence-based report--part I: analysis of risk factors and evaluation of the role of vena caval filters

BACKGROUND

Trauma surgeons use a variety of methods to prevent venous thromboembolism (VT). The rationale for their use frequently is based on conclusions from research on nontrauma populations. Existing recommendations are based on expert opinion and consensus statements rather than systematic analysis of the existing literature and synthesis of available data. The objective is to produce an evidence-based report on the methods of prevention of VT after injury.

METHODS

A panel of 17 national authorities from the academic, private, and managed care sectors helped design and review the project. We searched three electronic databases (MEDLINE, EM-BASE, and Cochrane Controlled Trial Register) to identify articles relevant to four key questions: methods of prophylaxis, methods of screening, risk factors for VT, and the role of vena caval filters. The initial 4,093 titles yielded 73 articles for meta-analysis. A random-effects model was used for all pooled results. Study quality was evaluated by previously published quality scores. In this article (part I), we report on the question ranked by the experts as the most important, i.e., Which is the best method to prevent VT?, and also on the incidence of deep venous thrombosis and pulmonary embolism in trauma patients.

RESULTS

The incidence of deep venous thrombosis and pulmonary embolism reported in different studies varies widely. The pooled rates are 11.8% for deep venous thrombosis and 1.5% for pulmonary embolism. Only a few randomized controlled trials have evaluated the methods of VT prophylaxis among trauma patients, and combining their data is difficult because of different designs and preventive methods used. The quality of most studies is low. Meta-analysis shows no evidence that low-dose heparin, mechanical prophylaxis, or low-molecular-weight heparin are more effective than no prophylaxis or each other. However, the 95% confidence intervals of many of the comparisons are wide; therefore, a clinically important difference may exist.

CONCLUSION

The trauma literature on VT prophylaxis provides inconsistent data. There is no evidence that any existing method of VT prophylaxis is clearly superior to the other methods or even to no prophylaxis. Our results cast serious doubt on the existing policies on VT prophylaxis, and we call for a large, high-quality, multicenter trial that can provide definitive answers.

Sugar control of the plant cell cycle: differential regulation of Arabidopsis D-type cyclin gene expression

In most plants, sucrose is the major transported carbon source. Carbon source availability in the form of sucrose is likely to be a major determinant of cell division, and mechanisms must exist for sensing sugar levels and mediating appropriate control of the cell cycle. We show that sugar availability plays a major role during the G(1) phase by controlling the expression of CycD cyclins in Arabidopsis. CycD2 mRNA levels increase within 30 min of the addition of sucrose; CycD3 is induced after 4 h. This corresponds to induction of CycD2 expression early in G(1) and CycD3 expression in late G(1) near the S-phase boundary. CycD2 and CycD3 induction is independent both of progression to a specific point in the cell cycle and of protein synthesis. Protein kinase activity of CycD2- and CycD3-containing cyclin-dependent kinases is consistent with the observed regulation of their mRNA levels. CycD2 and CycD3 therefore act as direct mediators of the presence of sugar in cell cycle commitment. CycD3, but not CycD2, expression responds to hormones, for which we show that the presence of sugars is required. Finally, protein phosphatases are shown to be involved in regulating CycD2 and CycD3 induction. We propose that control of CycD2 and CycD3 by sucrose forms part of cell cycle control in response to cellular carbohydrate status.

Prevention of venous thromboembolism after injury: an evidence-based report--part II: analysis of risk factors and evaluation of the role of vena caval filters

OBJECTIVE

In part II, we describe the results of the literature search and data analysis concerning risk factors for venous thromboembolism and the role of vena caval filters (VCF) in preventing pulmonary embolism.

METHODS

The methodology used in part I was used in part II.

RESULTS

Spinal fractures and spinal-cord injuries increase the risk for development of deep venous thrombosis (DVT) by twofold and threefold, respectively. Patients with DVT were an average of 9 years older than patients without DVT. No specific age cut-off point for increased risk could be established because data could not be combined across studies. Patients with prophylactically inserted VCF had a lower incidence of pulmonary embolism (0.2%) compared with concurrently managed patients without VCF (1.5%) or historical controls without VCF (5.8%). These results are reported on uncontrolled studies with observational design.

CONCLUSION

Spinal injuries, spinal cord injuries, and age are risk factors for development of DVT. Prophylactic placement of VCF in selected trauma patients may decrease the incidence of pulmonary embolism. Future research with well-designed studies is required to provide definitive answers.

Serologic testing for celiac disease in the United States: results of a multilaboratory comparison study

The aim of this study was to compare the efficiencies of six reference laboratories for serologic testing for celiac disease. Serum from 20 patients with untreated celiac disease and from 20 controls was thawed, divided, and distributed to each participating laboratory, which performed endomysial antibody tests. Five laboratories also performed antigliadin antibody tests. Sensitivity for endomysial antibody immunoglobulin A (IgA) varied from 57 to 90%. In all laboratories, the specificity for celiac disease was 100%. The sensitivity and specificity for both IgA and IgG antigliadin antibody varied significantly. When results from all three tests were combined in each laboratory, sensitivity was 90 to 100%. The specificity for endomysial antibody was 100% in the laboratories. Sensitivity was less than reported previously. Standardization of these tests is needed in the United States.

Triggering the cell cycle in plants

In essence, the mitotic cell cycle in eukaryotes involves the duplication and separation of chromosomes, coupled to the process of dividing one cell into two. Cytokinesis is therefore the culmination of a series of events that were triggered during G1 phase, and brings the daughter cells back to the starting position in G1 for another possible round of division. In all eukaryotes, progression through the cell cycle is controlled by cyclin-dependent kinases that bind to positive regulators called cyclins. This review explores some of the pathways that trigger the plant cell cycle, with emphasis on the G1 phase. Examples include signalling pathways involving glutathione and cellular redox potential, the possible existence of a G1 DNA-damage checkpoint, and the plant hormones auxin and cytokinin. Progress in understanding the link between cell proliferation, cell differentiation and the cell-cycle machinery in a developmental context is discussed.

Iatrogenic esophagitis

A variety of medications have been reported to cause esophageal injury. Nearly 1000 cases have probably been described in the past 30 years, and this is a vast under-representation. Pill-induced esophageal injury is also associated with many underlying esophageal diseases. This review addresses the etiology, diagnosis, and clinical features of pill-induced esophageal injury as well as the specific medications that have been reported to cause it. Ways to prevent esophageal injury, including better instructions to patients who are prescribed such medications, are also discussed.

Cyclin D control of growth rate in plants

The mechanisms by which plants modulate their growth rate in response to environmental and developmental conditions are unknown, but are presumed to involve specialized regions called meristems where cell division is concentrated. The possible role of cell division in influencing meristem activity and overall plant growth rate is controversial, with a prevailing view that cell division is secondary to higher order meristem controls. Here we show that a reduction in the length of the cell-cycle G1 phase and faster cell cycling occur when the rate of cell division in transgenic tobacco plants is increased by the plant D-type cyclin CycD2 (ref. 8). The plants have normal cell and meristem sizes, but elevated overall growth rates, an increased rate of leaf initiation and accelerated development in all stages from seedling to maturity. We conclude that cell division is a principal determinant of meristem activity and overall growth rate, and propose that modulation of plant growth rate is achieved through regulation of G1.

Nonoperative management of splenic injuries: have we gone too far?

HYPOTHESIS

Patients with severe blunt injuries to the spleen have a high likelihood of failing nonoperative management of splenic injuries (NOMSI).

DESIGN

Review of medical records, helical computed tomographic imaging data, and trauma registry data.

SETTING

Academic level I trauma center at a large county hospital.

PATIENTS

A total of 105 patients with blunt trauma to the spleen, admitted between January 1995 and December 1998, who survived more than 48 hours and had complete records. Of these patients, 53 (56%) were selected for NOMSI. The splenic injury was graded by the Organ Injury Scale of the American Association for the Surgery of Trauma (grades I to V, with grade V being the worst possible injury).

MAIN OUTCOME MEASURES

Failure of NOMSI, defined as the need for operation to the spleen after a period of nonoperative management.

RESULTS

Compared with patients who had successful NOMSI, the 29 patients (52%) in whom NOMSI failed were older and more severely injured. They also required extra-abdominal operations more frequently, underwent transfusion with more units of blood while being managed nonoperatively, and had higher grades of splenic injury. Splenic injury grade III or higher and transfusion of more than 1 U of blood were identified as independent risk factors for failure of NOMSI. The existence of both risk factors predicted failure in 97% of cases. The grading by computed tomography correlated well with the actual injury to the spleen as seen at operation.

CONCLUSIONS

In patients with high-grade splenic injuries who require a transfusion of more than 1 U of blood, NOMSI is very likely to fail. Decreasing the threshold for operation or intensifying the monitoring is highly recommended for such patients.

Computer-assisted visualizations of neural networks: expanding the field of view using seamless confocal montaging

Microscopic analysis of anatomic relationships within the neural networks of adult and developing tissues often requires sampling large spatial regions of neuronal architecture. To accomplish this, there are two common imaging approaches: (1) image the entire area at once with low spatial resolution; or (2) image small sections at higher magnification/resolution and then join the sections back together by mosaic reconstruction (photomontaging). Low magnification imaging is relatively rapid to perform, resulting in a visualization that encompasses a large field of view with an extended depth of field. However, for fluorescence microscopy, low magnification visualizations are often plagued by poor spatial resolution. High magnification imaging possesses superior spatial resolution, but it produces an image with limited depth of field. When creating a larger field of view, the final image is also fragmented at the boundaries where multiple images are stitched together. Using confocal microscopy as well as features of common image processing programs, we outline a new method to transform individual, spatially contiguous z-series into a montage with a seamless field of view and an extended depth of field. In addition, we show that the manual alignment of images our method requires does not introduce significant errors into the final image. We illustrate our method for visualizing neural networks using tissues from the adult gastropod mollusc, Tritonia diomedea, and the developing zebrafish, Danio rerio.

Effects of a program of intervention on parental distress following infant death

A longitudinal study of 144 parents (65 fathers, 79 mothers) was conducted to evaluate the effectiveness of a program of intervention in relieving the psychological distress of parents affected by infant death. Participants were assessed in terms of their psychiatric disturbance, depression, anxiety, physical symptoms, dyadic adjustment, and coping strategies. The experimental group (n = 84) was offered an intervention program comprising the use of specially designed resources and contact with a trained grief worker. A control group (n = 60) was given routine community care. Parental reactions were assessed at four to six weeks postloss (prior to the implementation of the intervention program), at six months postloss, and at 15 months postloss. A series of multivariate analyses of variance revealed that the intervention was effective in reducing the distress of parents, particularly those assessed prior to the intervention as being at high-risk of developing mourning difficulties. Effects of the intervention were noted in terms of parents' overall psychiatric disturbance, marital quality, and paternal coping strategies.

Esophageal lichen planus: the Mayo Clinic experience

Lichen planus (LP) is an inflammatory papulosquamous disease which may affect the squamous epithelium of the esophagus. We reviewed six patients with esophageal lichen planus (ELP) seen at Mayo Clinic Rochester between 1984 and 1998. The presenting symptoms were dysphagia (in all six patients) and odynophagia (two patients). Cervical esophageal strictures were seen in four patients; average number of esophageal dilatations required was 15 (range, 10-18). Esophageal biopsies demonstrated the classical histologic findings of ELP in two patients, and a lymphocytic infiltrate in the other four. Concomitant lichen planus (LP) was seen at other sites in five patients: all five had oral LP preceeded by ELP symptoms in all five; three had genital LP preceeded by ELP symptoms in all three; two had dermal LP, preceeded by ELP symptoms in one. Proton pump inhibitors were tried unsuccessfully in all patients. Four patients were started on systemic steroid medication; three had resolution of symptoms within 1 month.

Controlled induction of GUS marked clonal sectors in Arabidopsis

Stably transformed Arabidopsis lines in which GUS marked cell clones are readily produced in response to heat-shock have been established and characterized. Control of GUS activation is achieved by heat-shock-induced FLP recombinase activity which "switches on" expression of a GUS marker gene previously held transcriptionally silent. To obtain efficient GUS sectoring, single insert Arabidopsis lines carrying FLP recombinase under the control of a heat-shock-inducible promoter and an FLP-activatable GUS construct were generated. Analysis of GUS sectoring in lines hemizygous and homozygous for both inserts was conducted after various regimes of heat-shock were given at various developmental stages. It is shown that GUS sectoring events can be efficiently induced in most vegetative, aerial and sexual structures in Arabidopsis. Furthermore, the frequency of sectoring events, sector size and, to some extent, the tissues in which sectors are generated can be readily controlled by choice of the conditions and timing of heat-shock used.

Control of plant growth and development through manipulation of cell-cycle genes

The plant embryo is a relatively simple structure consisting of a primordial shoot and root, whose development is frozen in the form of a seed. Most development of the mature plant takes place post-embryonically, and is the consequence of cell division and organogenesis in small regions known as meristems, which originate in the embryonic shoot and root apices. Significant recent progress has been made in understanding the mechanisms that control the plant cell cycle at a molecular level, and the first attempts have been made to control plant growth through modulation of cell-cycle genes. These results suggest that there is significant potential to control plant growth and architecture through manipulation of cell division rates. However, a full realisation of the promise of such strategies will probably require a much greater understanding of cell division control and how its upstream regulation is co-ordinated by spatial relationships between cells and by environmental signals.

The expression of D-cyclin genes defines distinct developmental zones in snapdragon apical meristems and is locally regulated by the Cycloidea gene

Three D-cyclin genes are expressed in the apical meristems of snapdragon (Antirrhinum majus). The cyclin D1 and D3b genes are expressed throughout meristems, whereas cyclin D3a is restricted to the peripheral region of the meristem, especially the organ primordia. During floral development, cyclin D3b expression is: (a) locally modulated in the cells immediately surrounding the base of organ primordia, defining a zone between lateral organs that may act as a developmental boundary; (b) locally modulated in the ventral petals during petal folding; and (c) is specifically repressed in the dorsal stamen by the cycloidea gene. Expression of both cyclin D3 genes is reduced prior to the cessation of cell cycle activity, as judged by histone H4 expression. Expression of all three D-cyclin genes is modulated by factors that regulate plant growth, particularly sucrose and cytokinin. These observations may provide a molecular basis for understanding the local regulation of cell proliferation during plant growth and development.

Celiac disease and recurrent pancreatitis

BACKGROUND

Celiac disease is associated with pancreatico-biliary disease. Postulated mechanisms include reduced gallbladder emptying due to impaired cholecystokinin release and pancreatitis due to malnutrition. We hypothesize that celiac disease may also be associated with pancreatico-biliary abnormalities due to duodenal inflammation and papillary stenosis.

METHODS

Over a 48-month period, 169 patients referred for possible sphincter of Oddi dysfunction who underwent pancreatico-biliary manometry were tested for gliadin and endomysial antibodies. Duodenal and papillary biopsies were preformed in those patients who were positive.

RESULTS

Celiac disease was diagnosed in 12 (7.1%; 3 men, 9 women). The mean age was 61 years as compared with 37 years for those patients without celiac disease. All of the celiac patients had been referred for recurrent abdominal pain and/or idiopathic pancreatitis. Ten had idiopathic recurrent pancreatitis with elevated amylase and lipase levels. Two of these patients also had mildly elevated liver function tests associated with the abdominal pain. Only 3 of 12 patients had a prior diagnosis of celiac disease. These 12 patients had manometric evidence of stenosis and histologic evidence of periampullary inflammation as well as histologic changes consistent with celiac disease. In 10 of 12 patients sphincterotomy or extension of a prior papillotomy was performed. Two patients were treated with a gluten-free diet alone.

CONCLUSIONS

We describe 12 patients with papillary stenosis and celiac disease. In 9 cases the celiac disease was a new diagnosis. Celiac disease should be considered in the etiology of papillary stenosis or idiopathic recurrent pancreatitis.

The plant cell cycle

Molecular controls of the plant cell cycle must integrate environmental signals within developmental contexts. Recent advances highlight the fundamental conservation of underlying cell cycle mechanisms between animals and plants, overlaid by a rich molecular and regulatory diversity that is specific to plant systems. Here we review plant cell cycle regulators and their control.

Duration of antibiotic prophylaxis in high-risk patients with penetrating abdominal trauma: a prospective randomized trial

To evaluate the effect of varying durations of antibiotic prophylaxis in trauma patients with multiple risk factors for postoperative septic complications, a prospective randomized trial was undertaken at an urban level I trauma center. The inclusion criteria were full-thickness colon injury and one of the following: (1) Penetrating Abdominal Trauma Index > 25, (2) transfusion of 6 units or more of packed red blood cells, or (3) more than 4 hours from injury to operation. Patients were randomly assigned to a short course (24 hours) or a long course (5 days) of antibiotic therapy. All patients received 2 g cefoxitin en route to the operating room and 2 g intravenously piggyback every 6 hours for a total of 1 day vs. 5 days. Sixty-three patients were equally divided into short-course (n = 31) and long-course (n = 32) therapy. This was a high-risk patient population, as assessed by the mean Penetrating Abdominal Trauma Index (33), number of patients with multiple blood transfusions (51 of 63; 81%), number of patients with an Injury Severity Score greater than 15 (37 of 63; 59%), number of patients with destructive colon wounds requiring resection (27 of 63; 43%), and number of patients requiring postoperative critical care (37 of 63; 59%). Differences in intra-abdominal (1-day, 19%; 5-days, 38%) and extra-abdominal (1-day, 45%; 5-days, 25%) infection rates did not achieve statistical significance. There continues to be no evidence that extending antibiotic prophylaxis beyond 24 hours is of benefit, even among the highest risk patients with penetrating abdominal trauma. A large, multi-institutional trial will be necessary to condemn this common practice with statistical validity.

Angiographic embolization for arrest of bleeding after penetrating trauma to the abdomen

BACKGROUND

Angiographic embolization is an effective technique to control bleeding after blunt trauma to the liver or pelvis. Its role in penetrating trauma to the abdomen has not been studied.

METHODS

From January 1992 to May 1998, 40 patients underwent angiography for bleeding resulting from intra-abdominal penetrating injuries (33 gunshot wounds, 7 stab wounds). Angiographic embolization of intraperitoneal or retroperitoneal vessels was performed by standard angiographic techniques with gelatin sponge and/or coils. Data were extracted from medical records, radiology data bank, trauma registry, and morbidity/mortality records, and compared by Student's t test and chi-square test. The main outcome measures were failure of angiographic embolization to control bleeding and complications of angiographic embolization.

RESULTS

Angiography was performed during a course of nonoperative management in 6 patients (group A), because of failure to control bleeding surgically in 23 (group B), and because of late vascular complications after an initially successful operation in 11 more (group C). In 32 patients, angiography revealed active bleeding; 29 (91 %) underwent successful angiographic embolization. Of the remaining 3 patients, 2 were successfully managed surgically (1 each from groups A and B) and 1 died despite multiple surgical maneuvers (group B). One patient who developed postoperatively a large, bleeding superior mesenteric artery pseudoaneurysm, suffered extensive bowel necrosis after angiographic embolization. No other significant complication was related to angiographic embolization.

CONCLUSIONS

Angiographic embolization after penetrating injuries to the abdomen is safe and effective for a small number of selected patients. It is a valuable tool for bleeding control when surgery has failed. It may be ideal for control of late vascular complications when reoperation is not desirable. It may prove to be a useful adjunct in the nonoperative treatment of selected injuries.

Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study

OBJECTIVE

To evaluate the role of routine helical computed tomographic (CT) scan of the entire cervical spine in high-risk patients with multiple injuries.

METHODS

Prospective study of patients with severe blunt multiple injuries, requiring intensive care unit admission and CT scan of another body area besides the cervical spine. All patients were evaluated by means of standard cervical spine radiography. A complete cervical spine CT scan was performed during the same trip to the scanner in which other body areas were evaluated. The plain films and the CT scans were read by a radiologist in a blinded manner.

RESULTS

Fifty-eight patients fulfilled the criteria for inclusion in the study. The mean Glasgow Coma Scale score was 8.9 and the mean Injury Severity Score was 24.1. Twenty patients (34.4%) had cervical spine injuries (12 stable and 8 unstable injuries). Plain radiography missed eight injuries (including three unstable) and its sensitivity was 60%, specificity 100%, positive predictive value 100%, and negative predictive value 85.1%. The helical CT scan missed two spinal injuries (both stable) and its sensitivity was 90%, specificity was 100%, positive predictive value = 100%, negative predictive value = 95%.

CONCLUSION

There is a high incidence of cervical spine injuries in the severe, blunt, multiple-injury, unevaluable patients requiring intensive care unit admission. Plain radiography alone is not reliable in diagnosing many cervical spine injuries. Complete cervical spiral computed tomography is superior to plain radiography. It is suggested that in this selected group of patients, both plain radiography and spiral computed tomography should be performed.

Complex Repair for the Management of Duodenal Injuries

The management of duodenal injuries is a subject of ongoing debate. In this study we attempt to describe duodenum-related morbidity (DRM) after primary repair or complex repair (CR) and to identify risk factors for development of complications. The medical records of 145 consecutive patients admitted to Los Angeles County+University of Southern California Medical Center with duodenal injuries between January 1991 and December 1997 were reviewed. Fifty-four (37%) died within 24 hours of admission because of associated injuries. The remaining 91 were subjected to univariate and multivariate analysis. Of them, 66 (72.5%) developed complications and 3 (3%) died. CR was used in 32 (35%) patients and with increasing frequency as the grade of duodenal injury increased. DRM rate was overall low (9%) and not different between low-grade and high-grade duodenal injuries. This occurred despite a significant increase in Injury Severity Score and abdominal Abbreviated Injury Score in patients with more severe duodenal injuries. Patients with overall complications had higher Injury Severity Scores, higher abdominal Abbreviated Injury Scores, and more severe duodenal injuries. We conclude that duodenal injuries are frequently associated with other highly lethal injuries. Liberal use of CR in patients with more severe duodenal injuries prevents DRM.