Evisceration after abdominal stab wounds: is laparotomy required?

OBJECTIVES

To determine the incidence of intra-abdominal injury requiring laparotomy after an abdominal stab wound with evisceration. To identify clinical signs that increase the likelihood of an intra-abdominal injury in the presence of such a wound.

METHODS

Information was collected prospectively over an 8-year period on all patients who presented to our urban level I trauma center with an abdominal stab wound and evisceration. This information included which organ eviscerated, presence of other indications for laparotomy, organs injured, and postoperative complications. All comparisons used the Fisher's exact chi2.

RESULTS

A total of 81 patients were admitted with evisceration after an abdominal stab wound. Sixty-one patients (75%) had eviscerated omentum, 18 patients (22%) had eviscerated small bowel, and 2 patients (2%) had eviscerated colon. Sixty-two patients (76%) had evisceration as the sole indication for laparotomy, the remaining 19 patients (24%) had another indication such as hypotension or peritonitis. Overall, 63 patients (78%) had an intra-abdominal injury that required repair. This was true regardless of organ eviscerated (omentum = 77% vs. viscus = 80%, not significant) or clinical presentation (no other indication = 76% vs. another indication = 84%, not significant).

CONCLUSION

The majority of patients who present with an evisceration after a stab wound to the abdomen require a laparotomy. This is true regardless of what has eviscerated or the presence of other clinical indications to operate. Evisceration should continue to prompt operative intervention.

Interaction of factor XII and high molecular weight kininogen with cytokeratin 1 and gC1qR of vascular endothelial cells and with aggregated Abeta protein of Alzheimer's disease

High molecular weight kininogen (HK) attaches to endothelial cells at separate sites on the heavy and light chains by a process which requires 15-50 microM zinc. Previously identified binding proteins include gClqR, cytokeratin 1, and the urokinase plasminogen activator receptor (U-par), however, their relative contribution to binding are not yet clarified. We have purified the binding proteins by affinity chromatography, in the presence of zinc ion, and identified cytokeratin 1 and gC1qR by amino acid sequencing of an internal peptide and by immunoblot as heavy chain and light chain binding proteins, respectively. Antibody to cytokeratin 1 inhibited HK binding to endothelial cells by 30%, antibody to gClqR inhibited HK binding to endothelial cells by 72%, and a mixture of both inhibited binding by 86%. The binding and activation of the proteins of the kinin-forming cascade along the cell surface is zinc-dependent. Similarly, proteins of the plasma kinin-forming cascade can be activated by binding to aggregated A(beta) protein of Alzheimer's disease. Activation of the cascade using purified proteins or upon addition of Abeta to plasma requires aggregation of A(beta) and the reactions are zinc-dependent. In plasma, HK is cleaved and bradykinin is liberated. The data demonstrate that aggregated A(beta) can bind and activate proenzymes of the plasma kinin-forming cascade to release bradykinin and these reactions are dependent on zinc ion.

Cytokeratin 1 and gC1qR mediate high molecular weight kininogen binding to endothelial cells

High molecular weight kininogen (HK) attaches to endothelial cells by separate sites on the heavy and light chains and requires 15-50 microM zinc. Previously identified binding proteins include gC1qR, cytokeratin 1, and the urokinase plasminogen activator receptor; however, their relative contributions to binding are not yet clarified. We have prepared affinity columns to which were coupled either cleaved HK or peptide LDCNAEVYVVPWEKKIYPTVNCQPLGM derived from heavy-chain domain 3. Endothelial cell membranes were solubilized and chromatographed in the presence or absence of zinc ion, the bound proteins were eluted, and active fractions were identified by dot blot using biotinylated HK, SDS/PAGE, and Western blot analysis. The peptide containing column eluate revealed but one band at 68 kDa if zinc ion was present which was identified as cytokeratin 1 by amino acid sequencing of an internal peptide. The HK affinity column revealed bands at 68 kDa (cytokeratin 1), 33 kDa (gC1qR), and 66 kDa (unidentified). HK or domain 3-derived peptide bound to the 68 kDa band; prekallikrein and Factor XII did not. HK or Factor XII bound to the 33-kDa band if zinc was present while no binding to the 66 kDa band was observed. Antibody to cytokeratin 1 inhibited HK binding to endothelial cells by 30%, antibody to gC1qR inhibited HK binding to endothelial cells by 72%, and a mixture of both inhibited binding by 86%. Our data suggest HK binding by interaction of the heavy-chain domain 3 with cytokeratin 1 and the light chain with gC1qR.

Platelet glycoprotein Ib: a zinc-dependent binding protein for the heavy chain of high-molecular-weight kininogen

Domains 3 and 5 of high-molecular-weight kininogen (HK) have been shown to bind to platelets in a zinc-dependent reaction. However, the platelet-binding proteins responsible for this interaction have not been identified. We have focused on the platelet-binding site for the heavy chain (domain 3), which we approached using a domain 3-derived peptide ligand and isolated binding proteins by affinity chromatography. The domain 3-derived peptide, thrombin, HK, factor XII, as well as antibody to glycocalicin (the N-terminal portion of the alpha chain of GPIb) recognized a protein at 74 kD. We also isolated the thrombin receptor (PAR 1) at 45 kD, however, none of the above-mentioned ligands bound to this protein. Isolation of platelet membrane proteins using a monoclonal anti-glycocalicin antibody column revealed the same HK binding protein at 74 kD, which was reactive with anti-GPIb and represents a GPIb fragment. By photoaffinity labeling, HK interacted with membrane GPIb, which was then isolated in native form (135 kD) along with gC1qR, a ligand for the HK light chain. Finally, (125)I-HK binding to platelets was significantly inhibited by the anti-GPIb antibody. These results suggest that the GPIb alpha chain, a known thrombin binding protein, is also one of the zinc-dependent platelet membrane binding sites for HK domain 3.

Zinc-dependent activation of the plasma kinin-forming cascade by aggregated beta amyloid protein

Beta Amyloid proteins (Abeta) of 38, 40, and 42 amino acids long were assessed for their ability to activate the plasma kinin-forming cascade in vitro. Incubation with a mixture of Factor XII (Hageman Factor), prekallikrein, and high-molecular-weight kininogen (HK) led to conversion of prekallikrein to kallikrein that was dependent on zinc ion. No activation occurred if Factor XII was omitted. There was rapid generation of bradykinin equal to the molar HK input indicating complete cleavage. Incubation of aggregated Abeta with diluted human plasma also led to prekallikrein activation and HK cleavage. Activation of the cascade by Abeta (1-38) was dependent upon its preincubation time in buffer, suggesting that aggregation of Abeta is required, and studies with Abeta (1-40) revealed time-dependent aggregation by microscopy and augmented zinc-dependent binding of both Factor XII and HK to aggregated Abeta. These data demonstrate that aggregated Abeta can bind and activate proenzymes of the plasma kinin-forming cascade in a zinc-dependent reaction to release bradykinin and is of sufficient potency to do so at physiologic concentrations of each protein and in the presence of naturally occurring protease inhibitors.

The value of somatostatin-receptor scintigraphy in newly diagnosed endocrine gastroenteropancreatic tumors

BACKGROUND

Conventional imaging techniques do not routinely detect endocrine gastroenteropancreatic tumors preoperatively. The purpose of this study was to determine whether the new technique of somatostatin-receptor scintigraphy would improve the detection rate of these tumors before initial treatment.

STUDY DESIGN

In a prospective study, 55 patients with a recent diagnosis of endocrine gastroenteropancreatic tumors (22 intestinal carcinoids, 17 gastrinomas, 10 nonfunctioning pancreatic tumors, and 6 insulinomas), were examined with somatostatin-receptor scintigraphy, computed tomography, and ultrasonography. Results of the three imaging modalities were compared with findings at surgical exploration.

RESULTS

None of the insulinomas were localized by somatostatin-receptor scintigraphy, but 4 of 6 insulinomas were detected by computed tomography and ultrasonography. Of 17 gastrinomas, 9 were detected by somatostatin-receptor scintigraphy; computed tomography and ultrasonography localized only 7. Metastases from the gastrinoma were localized by somatostatin-receptor scintigraphy in all cases; computed tomography and ultrasonography detected metastases in only 6 of 9 patients. Nonfunctioning tumors could be localized by somatostatin-receptor scintigraphy, computed tomography, and ultrasonography in 4, 7, and 8 of 10 cases, respectively. Detection rate for corresponding metastases was the same for all three imaging techniques. Primary carcinoids were identified by somatostatin-receptor scintigraphy, ultrasonography, and computed tomography in 7, 8, and 11 of 22 cases, respectively. Extra-abdominal metastases were detected by somatostatin-receptor scintigraphy in only 7 of 19 patients.

CONCLUSIONS

In patients with insulinomas, somatostatin-receptor scintigraphy is not indicated because none of the six tumors was imaged. This holds true for nonfunctional pancreatic endocrine tumors and their metastases because no advantage for somatostatin-receptor scintigraphy was found over computed tomography and ultrasonography. In contrast, somatostatin-receptor scintigraphy is superior to computed tomography and ultrasonography for determining the extent of the disease in patients with gastrinomas or carcinoids. The problem of detecting primary tumors in these patients is not solved by somatostatin-receptor scintigraphy.

Balloons, beds, and breakdown. Effects of low-air loss therapy on the development of pressure ulcers in cardiovascular surgical patients with intra-aortic balloon pump support

There is limited research related to pressure ulcers in the ICU patient population and even less has focused on patients who have undergone cardiovascular surgery and IABP support. The objective of this article was to determine the incidence of pressure ulcers in the postoperative CVS patient with IABP support and to determine if LAL therapy was more effective in the prevention of pressure ulcers in this patient population. In a quasiexperimental design, a convenience sample of 36 adults was used. Patients who were placed on IABP support the day of surgery were enrolled into the study within 24 hours of admission to the cardiovascular recovery room. Data collection was daily for 4 days and continued if the patient developed a pressure ulcer. Final measurements were obtained on the day of hospital discharge. Instruments used were demographic data form, APACHE II, Patient Identification for Rotation Therapy, and the Braden Scale. The most common surgical patient in this pilot underwent aortocoronary bypass with IABP support. Pressure ulcers developed in 9 of 36 (25%) patients for a total of 17 ulcers. Patients who developed pressure ulcers were generally older, had a history of cerebrovascular disease, renal insufficiency, a higher APACHE II score, and Braden score of 9 on POD 1. In addition, these patients generally had a lower hemoglobin level, higher serum creatinine level, and an altered level of consciousness on POD 1. The results suggest that LAL therapy does make a difference in the prevention of pressure ulcers in the aortocoronary bypass patient with IABP support.

Identification of the zinc-dependent endothelial cell binding protein for high molecular weight kininogen and factor XII: identity with the receptor that binds to the globular "heads" of C1q (gC1q-R)

High molecular weight kininogen (HK) and factor XII are known to bind to human umbilical vein endothelial cells (HUVEC) in a zinc-dependent and saturable manner indicating that HUVEC express specific binding site(s) for those proteins. However, identification and immunochemical characterization of the putative receptor site(s) has not been previously accomplished. In this report, we have identified a cell surface glycoprotein that is a likely candidate for the HK binding site on HUVECs. When solubilized HUVEC membranes were subjected to an HK-affinity column in the presence or absence of 50 microM ZnCl2 and the bound membrane proteins eluted, a single major protein peak was obtained only in the presence of zinc. SDS/PAGE analysis and silver staining of the protein peak revealed this protein to be 33 kDa and partial sequence analysis matched the NH2 terminus of gC1q-R, a membrane glycoprotein that binds to the globular "heads" of C1q. Two other minor proteins of approximately 70 kDa and 45 kDa were also obtained. Upon analysis by Western blotting, the 33-kDa band was found to react with several monoclonal antibodies (mAbs) recognizing different epitopes on gC1q-R. Ligand and dot blot analyses revealed zinc-dependent binding of biotinylated HK as well as biotinylated factor XII to the isolated 33-kDa HUVEC molecule as well as recombinant gC1q-R. In addition, binding of 125I-HK to HUVEC cells was inhibited by selected monoclonal anti-gC1q-R antibodies. C1q, however, did not inhibit 125I-HK binding to HUVEC nor did those monoclonals known to inhibit C1q binding to gC1q-R. Taken together, the data suggest that HK (and factor XII) bind to HUVECs via a 33-kDa cell surface glycoprotein that appears to be identical to gC1q-R but interact with a site on gC1q-R distinct from that which binds C1q.

Sensory quality ratings, consumption pattern and preference for some selected meat types in Nigeria

Sensory quality attributes, consumption pattern and preference for some selected Nigerian meat types (beef, goat meat, mutton, grasscutter (Thryonomys swinderianus raptorum), African giant rat (Cricetomys gambianus--water house) were investigated. Sensory quality scores were carried out using a panel of thirty carefully screened consumers, based on a 9-point hedonic scale: While consumer consumption pattern and preference were assessed through a field survey of 120 randomly selected respondents using a well structured questionnaire. It was found that beef was the most consumed meat followed by goat meat, then mutton, grasscutter and lastly African giant rat. Consumption of grasscutter was constrained by availability and cost. Goat meat was the most preferred, followed by beef, grasscutter, mutton and African giant rat. In laboratory sensory rating of the meat types, grasscutter had the greatest acceptability followed by goat meat, mutton, African giant rat and lastly beef. The result showed that grasscutter was the most acceptable because of its good meat colour, flavour tenderness and juiciness. It is recommended that more research effort be placed on domestication, breeding and management of grasscutter and African giant rat so as to remove the availability and high cost constraints militating against the utilization of these mammals.

Hepatic perfusion scintigraphy. Relationship of liver perfusion and ascites in patients with liver cirrhosis

Radionuclide studies were performed on 38 patients with biopsy proven liver cirrhosis in an attempt to evaluate the interrelationship between liver perfusion and ascites in cirrhotic patients. Quantitative hepatic scintigraphy was used to evaluate the relative contribution of hepatic arterial and portal venous blood flow to the hepatic circulation. Using a gamma camera and on-line computer system, a bolus of 370 MBq Tc-99m pertechnetate was injected intravenously. Time activity curves of the abdominal aorta and right lobe of the liver were obtained using a region of interest analysis where arterial and portal components were calculated. Ascites was determined by clinical examination and by ultrasonography. Of 38 patients, 10 patients (26.3%) showed normal liver perfusion (group A), 22 patients (58%) showed reduced portal venous perfusion (group B), and 6 patients (15.7%) showed pure arterial hepatic perfusion (group C). The incidence, as well as the advancement, of ascites were significant (P < 0.05) and were most frequent in group C, frequent in group B, and less frequent in group A. The results of this study suggest that the development of ascites in patients with liver cirrhosis is closely correlated with the reduction in portal blood perfusion.

Value of somatostatin receptor scintigraphy for preoperative localization of carcinoids

Most carcinoid primary tumors are small and do not cause symptoms until complications (e.g. intestinal obstruction) or symptoms and signs of the carcinoid syndrome occur. Therefore in most cases an assessment of the primary tumor and its metastases must be performed. To determine the value of somatostatin receptor scintigraphy (SRS) for localizing carcinoid tumors, we compared the results of SRS with those obtained with computed tomography (CT) and ultrasonography (US) in 22 patients who had not undergone surgery for removal of the primary tumor. We could not find an advantage of SRS over CT and US for detecting the primary lesions. Tumors > 2 cm in diameter were regularly detected using all methods. SRS was not superior to CT or US for the detection of liver metastases. SRS showed the liver metastases in 16 of 18 patients, whereas CT and US detected liver metastases in all patients. For localization of extrahepatic abdominal and extraabdominal metastases (lymph nodes, bone), whole-body SRS showed an advantage over CT and US. We conclude that SRS is not superior to CT or US for localization of primary carcinoid tumors or liver metastases, although it did prove successful for visualizing extrahepatic and extraabdominal tumor spread. Additionally, SRS is useful for identifying receptor-positive metastases that may be treated by somatostatin analogs. Thus SRS should be performed in patients with a known carcinoid tumor, except those with an appendiceal carcinoid measuring < 1 cm in diameter.

Aspiration of free blood from the peritoneal cavity does not mandate immediate laparotomy

The objective was to establish the relationship between the aspiration of free blood (+ASP) versus diagnostic peritoneal lavage (DPL), abdominal injury severity, hemodynamic instability, and the need for immediate operative intervention. We prospectively compared the significance of +ASP to +DPL in our level I trauma center. Consecutive patients received sequential needle tap, catheter aspiration (ASP), and DPL. If gross blood was withdrawn during the tap or ASP, it was returned to the peritoneal cavity before completing the DPL. The DPL was considered positive if there were > 100,000 RBCs for blunt injuries or anterior abdominal stab wounds, or > 10,000 RBCs for other penetrating injuries. During a 12-month period, 566 patients fulfilled the study criteria; they were 50 per cent blunt and 50 per cent penetrating trauma. There were 70 patients with both +ASP/+DPL, 30 with -ASP/+DPL and 4 with +ASP but -DPL. Exploratory laparotomy was performed on these 104 patients (18.4%), 22 of which were considered nontherapeutic. The ATI was statistically higher in the +ASP patients (14.9 +/- 12.9 versus 8.5 +/- 8.2, P < 0.05) but was not clinically different. Overall injury severity and hemodynamic stability were not different in the two groups. The sensitivity of DPL at detecting intra-abdominal injury was higher than the ASP group (98% versus 72%), but the specificities were equal (98%). Because +ASP patients are not more critically injured or unstable than +DPL patients, and because DPL is more accurate in detecting the need for operative intervention, aspiration should be abandoned as part of the DPL procedure in patients with abdominal trauma.

[Iodine-induced hyperthyroidism in metastatic thyroid carcinoma]

A 75-year-old man with nodular goitre (for the preceding 2 years treated with 75 micrograms/dl L-thyroxine) complained of pain over the left hip: on auscultation an arterial flow murmur was audible over the hip. The radiograph demonstrated extensive osteolysis in the flat part of the ilium. Search for the primary tumour, including two pelvic angiographs, was unsuccessful. Examination of a biopsy from the right ilium revealed a metastasis from a highly differentiated follicular thyroid carcinoma, which could not be demonstrated scintigraphically because of a reduced 99mTc-pertechnetate and 123I-iodine uptake, the result of the L-thyroxine administration. A thyrotoxic crisis occurred 2 days after the second angiography (free thyroxine 3.17 ng/dl, triiodothyronine 219 ng/dl, thyroglobulin > 250 ng/ml). Treatment with thiamazole (40 mg/d) and perchlorate (1 g/d) reduced the concentration of peripheral thyroid hormone, but the patient's general condition improved only slowly. As a result, radioiodine treatment could not be started until 9 months later. He died a further 9 months later from septicaemia originating from the metastasis.

[Somatostatin receptor scintigraphy in preoperative diagnosis of the site of endocrine gastrointestinal tumors]

To determine the value of somatostatin-receptor scintigraphy in the localization of various endocrine gastrointestinal tumors, we compared the results obtained with this new technique with the results obtained with computed tomography and sonography. We could not find an overall advantage of somatostatin-receptor scintigraphy as compared to computed tomography or sonography in the localization of intestinal carcinoids (n = 13), gastrinomas (n = 12), functionally non-active endocrine pancreatic tumors (n = 8) and various other endocrine pancreatic tumors (n = 4). In 2 patients with endocrine pancreatic tumors however, the tumors were localized preoperatively only by somatostatin-receptor scintigraphy. Somatostatin-receptor scintigraphy may occasionally be helpful in the localization of gastrointestinal endocrine tumors if these tumors are not localized by conventional imaging studies. Somatostatin-receptor scintigraphy does not solve the problem to localize small endocrine tumors.

[Scintigraphy of parathyroid adenomas with 99mTc-sestamibi in an endemic goiter area]

Recently 99mTc-Sestamibi (MIBI) has been introduced into parathyroid imaging. The purpose of this study was to evaluate the MIBI scan in an endemic goiter area. 25 patients with primary and 9 with secondary hyperparathyroidism (HPT) underwent a MIBI scan one day prior to surgical exploration of the neck. Cervicothoracic planar scintigraphy was performed 5, 15 and 120 min after i.v. injection of 444 MBq of 99mTc-Sestamibi. The MIBI scan correctly detected 20 of 25 adenomas in 25 patients with pHPT. In only 6 of 9 patients with parathyroid hyperplasia a focal uptake was found. The cause of one false-positive result in the control group was an increased MIBI uptake by a follicular adenoma of the thyroid. Parathyroid scintigraphy using 99mTc-Sestamibi as a single radiopharmaceutical is as sensitive in detecting and localizing parathyroid adenomas as the Tl/Tc-scintigraphy. Due to a high prevalence of thyroid adenomas in an endemic goiter area a higher rate of falsely positive results may be expected.

Szintigraphische Darstellung von Adenomen der Nebenschilddrüse mit 99mTc-Sestamibi in einem Strumaendemiegebiet

Als nuklearmedizinische Standardmethode zur Darstellung von Adenomen der Nebenschilddrüsen gilt die Tl/Tc-Subtraktionsszintigraphie. Ziel dieser Untersuchung war es zu untersuchen, ob sich 99mTc-Sestamibi, das sich als Ersatz für 201TI in der Myokardszintigraphie bewährt hat, auch in einem Strumaendemiegebiet zur Nebenschilddrüsenszintigraphie eignet. Wir untersuchten 25 Patienten mit klinisch und biochemisch gesichertem primären und 9 mit sekundärem Hyperparathyreoidismus (HPT) am Tage vor der Operation. 5 Patienten, bei denen der zunächst vermutete HPT ausgeschlossen werden konnte, dienten als Kontrollgruppe. Planare Aufnahmen der Halsregion und des Mediastinums wurden 5, 15 und 120 min nach der i.v. Injektion von 444 MBq 99mTc-Sestamibi durchgeführt. Im Mibi-Szintigramm wurden 20 der 25 Adenome richtig lokalisiert, während sich nur bei 6 der 9 Patienten mit sekundärem HPT eine lokale Anreicherung fand. Die Ursache eines falsch-positiven Befundes war ein follikuläres Adenom der Schilddrüse. Die Nebenschilddrüsenszintigraphie mit 99mTc-Sestamibi als einziges Radiopharmakon hat mit 80% die gleiche Sensitivität im Adenomnachweis wie die Tl/Tc-Subtraktionsszintigraphie. Da im Strumaendemiegebiet die Prävalenz von Schilddrüsenadenomen hoch ist, muß mit einer höheren Rate falsch-positiver Befunde auch dieser Methode gerechnet werden.