Outcomes of non-operative management of penetrating abdominal trauma

BACKGROUND

Selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is routinely practised in our trauma centre. This study aims to report the outcomes of patients who have failed SNOM.

METHODS

Patients presenting with PAT from 1 May 2015 - 31 January 2018 were reviewed. They were categorised into immediate laparotomy and delayed operative management (DOM) groups. Outcomes compared were postoperative complications, length of hospital stay and mortality.

RESULTS

A total of 944 patients with PAT were reviewed. After excluding 100 patients undergoing damage control surgery, 402 (47.6%) and 542 (52.4%) were managed non-operatively and operatively, respectively. In the SNOM cohort, 359 (89.3%) were managed successfully without laparotomy. Thirty-seven (86.0%) patients in the DOM group had a therapeutic laparotomy, and six (14.0%) had an unnecessary laparotomy. Nine (20.9%) patients in the DOM group developed complications. The DOM group had lesser complications. However, the two groups had no difference in hospital length of stay (LOS). There was no mortality in the non-operative management (NOM) group.

CONCLUSION

In this study, we demonstrated no mortality and less morbidity in the DOM group when appropriately selected compared to the immediate laparotomy group. This supports the selective NOM approach for PAT in high volume trauma centres.

The impact of thromboelastography on patients with penetrating abdominal trauma requiring intensive care

BACKGROUND

Trauma-induced coagulopathy (TIC) is a complex multifaceted process which contributes to higher mortality rates in severely injured trauma patients. Thromboelastography (TEG) is effective in detecting TIC which assists in instituting goal-directed therapy as part of damage control resuscitation.

METHODS

This retrospective study included all adult patients over a 36-month period with penetrating abdominal trauma who required a laparotomy, blood products and admission for critical care. Analysis included demographics, admission data, 24-hour interventions, TEG parameters and 30-day outcomes.

RESULTS

Eighty-four patients with a median age of 28 years were included. The majority (93%; 78/84) suffered from a gunshot injury, with 75% (63/84) receiving a damage control laparotomy. Forty-eight patients (57%) had a TEG. Injury severity score and total fluid and blood product administered in the first 24 hours were all significantly higher in patients who had a TEG (p < 0.05). TEG profiles were: 42% (20/48) normal, 42% (20/48) hypocoagulable, 12% (6/48) hypercoagulable and 4% (2/48) mixed parameters. Fibrinolysis profiles were: 48% (23/48) normal, 44% (21/48) fibrinolysis shutdown and 8% (4/48) hyperfibrinolysis. Mortality rate was 5% (4/84) at 24 hours and 26% (22/84) at 30 days, with no difference between the two groups. High-grade complication rates, days on a ventilator and intensive care unit length of stay were all significantly higher in patients who did not have a TEG.

CONCLUSION

TIC is common in severely injured penetrating trauma patients. The usage of a thromboelastogram did not impact on 24-hour or 30-day mortality but did result in a decreased intensive care stay and a decreased high-grade complication rate.

Spectrum of coagulation profiles in severely injured patients - a subgroup analysis from the fluids in resuscitation of severe trauma trial

BACKGROUND

Trauma-induced coagulopathy (TIC) is a major contributing factor to worsening bleeding in trauma patients. The objective of this study is to describe the spectrum of coagulation profiles amongst severely injured patients.

METHODS

This is a retrospective study of all patients with complete baseline TEG coagulation parameters collected prior to randomisation in the FIRST (fluids in resuscitation of severe trauma) trial between January 2007 and December 2009. Parameters recorded for this study included patient demographics, mechanism of injury, admission vital signs, lactate, base excess, coagulation studies prothrombin time (PT), international normalised ratio (INR), thromboelastography (TEG) parameters, volume, and type of fluids administered, volume of blood products administered, length of intensive care unit (ICU) stay and major outcomes.

RESULTS

A total of 87 patients were included in this study, with a median injury severity score (ISS) of 20 and 57.5 had a penetrating injury mechanism. Coagulopathy was highly prevalent in this cohort, of which a majority (69%) was diagnosed with hypercoagulopathy and 24% had a hypocoagulopathy status on admission. There was no difference in age, gender and amount of pre-hospital fluids administered across the three groups. The median volume of blood products was higher in the hypocoagulopathy group, although not statistically significant. Overall, the 30-day mortality rate was 13%, with case fatalities occurring in only coagulopathic patients: hypercoagulopathy (15%) and hypocoagulopathy (10%).

CONCLUSION

TIC is not an infrequent diagnosis in severely injured patients resulting in increased morbidity and mortality. Determining the coagulation profile using TEG at presentation in this group of patients may inform appropriate management guidelines in order to improve outcome.

The differential expression of toll like receptors and RIG-1 in the placenta of neonates with in utero infections

Novel biomarkers of in utero infections are needed to help guide early therapy. The toll like receptors (TLRs) and retinoic acid-inducible gene 1 (RIG-1) are proteins involved in the initial reaction of the innate immune system to infectious diseases. This study tested the hypothesis that a panel of TLRs and RIG-1 in the placenta could serve as an early biomarker of in utero infections. The TLRs and RIG-1 expression as determined by immunohistochemistry was scored in 10 control placentas (normal delivery or neonatal damage from known non-infectious cause), 8 placentas from documented in utero bacterial infection, and 7 placentas from documented in utero viral infections blinded to the clinical information. The non-infected placentas showed the following profile: no expression (TLR1, TLR3, TLR4, TLR7, TLR8), moderate expression (TLR2), and strong expression (RIG-1). The bacterial and viral infection cases shared the following profile: no to mild expression (TLR 2, TLR7, and RIG1), moderate expression (TLR4), and strong expression (TLR1, TLR3, and TLR8). The histologic findings in the chorionic villi were equivalent in the infected cases and controls, underscoring the need for molecular testing by the surgical pathologist when in utero infection is suspected. The results suggest that a panel of TLRs/RIG-1 analyses can allow the pathologist and/or clinician to diagnose in utero infections soon after birth. Also, treatments to antagonize the effects of TLR1, 3, and 8 may help abrogate in utero neonatal damage.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND

Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL.

METHODS

All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded.

RESULTS

Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%.

CONCLUSION

DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

Damage control laparotomy outcomes in a major urban trauma centre

BACKGROUND: Damage control laparotomy (DCL) is associated with high mortality. The purpose of this study was to review the outcomes of DCL. METHODS: All patients undergoing DCL for penetrating trauma from May 2015 to July 2017 were reviewed. Data retrieved were demographics, mechanism of injury, vitals, and biochemical parameters. Injury severity was described by the revised trauma score (RTS), penetrating abdominal trauma index (PATI), injury severity score (ISS) and trauma and injury severity score (TRISS). Indications for DCL, length of ICU stay, number of procedures and primary abdominal closure rates, complications and mortality were recorded. RESULTS: Fifty-one patients underwent DCL and 47 patients sustained gunshot injuries. Indications for laparotomy were haemodynamic instability (n = 27) and peritonism in stable patients (n = 22). The medians for the different severity scores were RTS 7.36, ISS 20, and PATI 30. The organs most commonly injured, in decreasing frequency, were small bowel (33), large bowel (25), abdominal vasculature (22), liver (18), stomach (14), kidney (10), diaphragm (10), spleen (9) and pancreas (8). DCL procedures performed were abdominal packing (36), temporary bowel ligation (30), vascular (5) and ureteric (1) shunting. The median number of laparotomies performed per patient was three, with a primary fascial closure rate of 69%. The mortality rate was 29%. CONCLUSION: DCL in our centre is associated with a 29% mortality rate. Severe acidosis, massive blood transfusion in first 24 hours and median PATI score more than 47 are independent risk factors associated with increased mortality.

A contemporary prospective review of 205 consecutive patients with penetrating colon injuries

BACKGROUND

Management of colon injuries has significantly evolved in the recent decades resulting in considerably decreased morbidity and mortality. We set out to investigate penetrating colon injuries in a high-volume urban academic trauma center in South Africa.

METHODS

All patients with penetrating colon injuries admitted between 1/2015 and 1/2018 were prospectively enrolled. Data collection included demographics, injury profile and outcomes. Primary outcome was in-hospital mortality. Secondary outcome was morbidity.

RESULTS

Two-hundred and five patients were included in the analysis. Stab and gunshot wounds constituted 18% and 82% of the cases, respectively. Mean age was 28.9 (10.2) years and 96.1% were male. Median injury severity score (ISS) and penetrating abdominal trauma index (PATI) were 16 (9-25) and 19 (10-26), respectively. A total of 47.8% of the patients had a complication per Clavien-Dindo classification. Colon leak rate was 2.4%. Wound and abdominal organ/space infection rate was 15.1 and 6.3%, respectively. Overall in-hospital mortality was 9.3%. Risk factors for mortality were higher ISS and PATI, shock on admission, need for blood transfusion, intra-abdominal vascular injury, damage control surgery, and extra-abdominal severe injuries.

CONCLUSIONS

Contemporary overall complication rate remains high in penetrating colon injuries, however, anastomotic leak rate is decreasing. Colon injury associated mortality is related to overall injury burden and hemorrhage rather than to colon injuries.

New biomarkers of human papillomavirus infection in epidermodysplasia verruciformis

The cause of epidermodysplasia verruciformis is infection by human papillomavirus, usually types 5 or 8, and it exhibits a high potential for malignant transformation. The diagnostic histologic features of epidermodysplasia verruciformis are not always present and can be mimicked by non-viral diseases. The purpose of this study was to interrogate such lesions for new potential biomarkers to aid in the diagnostic accuracy. HPV DNA was high copy and localized to the upper half of the lesion in cells with cytologic features that included perinuclear halos, blue-grey cytoplasm, and hyper/parakeratosis. Serial section analyses demonstrated that there was increased expression of importin-β, exportin-5, Mcl1, p16, Ki67 and PDL1 in 13/13 epidermodysplasia verruciformis lesions. Each of these proteins localized primarily to the less differentiated cells in the parabasal aspect of the lesion. Only Ki67 and exportin-5 were expressed in the normal epithelia, though much less so, in 13/13 aged matched controls. It is concluded that the host response to HPV 5/8 infection in epidermodysplasia verruciformis includes the up regulation of several proteins including p16, Ki67, importin-β, exportin-5, Mcl1, and PDL1. Thus, these proteins may serve as new biomarkers of this disease that can aid in cases that are equivocal for epidermodysplasia verruciformis on histologic examination.

The Defeat Depression Campaign

The Royal College of Psychiatrists launched a five year campaign in 1992 to better inform health practitioners and the public about depression. A questionnaire survey of Sheffield general practitoners (GPs) to assess the impact of the Defeat Depression Campaign on their knowledge and clinical management of depression was carried out in May 1994, half way through the campaign. Overall, 75% of GPs who responded indicated that the Defeat Depression Campaign had had little or no impact on their clinical practice. It would appear that at its mid-point the Defeat Depression Campaign failed to achieve its main goals in relation to educating GPs about depression and its management.

A review of training in neuropsychiatry

The boundary between neurology and psychiatry has never been sharply defined. It remains the case that a number of conditions (e.g. epilepsy, head-injury sequelae, dementia, and conversion hysteria) are seen by both neurologists and psychiatrists (Reynolds & Trimble, 1989). Few neurologists would dispute that there may be a marked psychiatric element to the presentation of multiple sclerosis, and it has long been noticed that even unmedicated chronic schizophrenic patients sometimes exhibit abnormalities of movement and so-called “soft” neurological signs such as dysgraphia and clumsiness (Lishman, 1988). These and other conditions may all on occasion present to the neuropsychiatrist.

An urban trauma centre experience with abdominal vena cava injuries

BACKGROUND

The aim of the study was to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies which affect the outcome.

METHOD

A retrospective review was conducted of AVC injuries in patients attending the trauma centre at Groote Schuur Hospital, Cape Town, from January 2003 to December 2011. Demographic data, mechanism and agent of injury, level of injury, physiological parameters, associated injuries, trauma scores, management strategy, morbidity and mortality, and length of hospital stay were taken from the trauma centre's operative databank at Groote Schuur Hospital.

RESULTS

Thirty-fi ve patients with AVC injuries were identifi ed. There were 33 penetrating injuries (94%). Gunshot wounds accounted for 28 of them (85%). There were 19 (54%) infrarenal, 9 (26%) juxtarenal, 3 (7%) suprarenal and 4 (11%) retrohepatic AVC injuries. Most patients were treated with ligation (66%). There were 17 (49%) deaths. There were signifi cant differences in the preoperative systolic blood pressure (p = 0.044), number of red cell units transfused (p = 0.001), serum lactate (p = 0.007), arterial pH (p = 0.002) and preoperative temperature (p = 0.000) between the survivors and non-survivors. There was also a signifi cant difference in ligation versus repair between the two groups (p = ≤ 0.000). There was no difference in the injury severity, level of injury and the number of associated injuries between survivors and non-survivors.

CONCLUSION

AVC injuries are associated with high mortality. Patients presenting with clinical and physiological evidence of shock and who require "damage control" surgery are more likely to suffer a worse outcome, particularly when multiple physiological deragements are present. Patients who died often have severe associated injuries.

A practical guide to expedition medical planning

Expedition medical planning is integral in ensuring participant safety and maximising the likelihood of achieving the expedition aims. The task of producing a medical plan will often fall to a medical officer of limited experience. The aim of this article is to provide a concise, practical guide to aid junior medical officers (MOs) in forming a robust and pragmatic medical plan.

The Skeleton Coast Diet Plan: body mass and body fat changes on an arduous expedition

OBJECTIVES

No one has ever walked the 500 Km Skeleton Coast of Namibia totally unsupported. Fourteen explorers overcame this by carrying, along with all their other equipment, hand-held pumps to desalinate sea water on a daily basis to produce sufficient potable water. This paper highlights the changes in body mass, waist circumference and body fat in the group on this unique 20 day expedition.

METHODS

Eight males (mean (SD)) 42.3 (9.7) years, height 1.741 (0.043) m, weight 78.7 (8.6) kg, body mass index (BMI) 24.8 (2.0) kg/m(2)) and six females (mean (SD) 40.0 (5.3) years, height 1.628 (0.043) m, weight 63.2 (5.5) kg, BMI 23.8 (1.8) kg/m(2)) undertook the expedition. Average pack weight at the start of the expedition for the men was 32.5 kg, and 26.5 kg for the women. On most days, the team walked for 8 - 10 hours on varying terrain then pumped water for a further 4 hours. Measurements taken included height, body mass, waist circumference and skin-fold thickness at four regions of the body, and were taken before, during and at the end of the expedition. The approximate daily calorific intake for each team member was 2400 - 3000 kcal.

RESULTS

Significant decreases in mean body mass (p < 0.001, d=0.50) and mean BMI (p < 0.001, d = 0.67) were observed after the 20 day trek compared to baseline values. Mean waist circumference decreased during the expedition (p < 0.001, d = 0.67). There were significant reductions in all measures of skinfold thicknesses and overall percentage body fat at Day 13 (p < 0.001, d = 1.19) and Day 21 (p < 0.001, d = 1.98) in comparison to baseline values

CONCLUSIONS

All participants lost significant amounts of both body mass and body fat, with body fat reducing by over 30%.

Surgical management and outcome of civilian gunshot injuries to the pancreas

BACKGROUND

Pancreatic injuries are uncommon but result in substantial morbidity and mortality. This study evaluated the factors associated with morbidity and mortality in civilian patients with pancreatic gunshot wounds.

METHODS

This was a single-institution, retrospective review of patients with gunshot wounds of the pancreas treated from 1976 to 2009 in Cape Town, South Africa. Univariable and multivariable analyses were performed.

RESULTS

A total of 219 patients (205 male, median age 27 years) had pancreatic American Association for the Surgery of Trauma grade I-II (111 patients) and grade III-V (108) gunshot injuries to the pancreatic head (72), neck (8), body (75) and tail (64). The patients underwent 239 laparotomies, including drainage of the pancreas (169), distal pancreatectomy (59) and pancreaticoduodenectomy (11). Some 218 patients had 642 associated intra-abdominal and 91 vascular injuries. Forty-three (19.6 per cent) required an initial damage control procedure. A total of 150 patients (68.5 per cent) had 407 postoperative complications (median 4, range 1-7). The 46 patients (21.0 per cent) who died had a median of 3 (range 1-7) complications. Median (range) intensive care unit and total hospital stay were 5 (1-153) and 11 (1-255) days respectively. Multivariable analyses identified age, high-grade pancreatic injury, associated vascular injuries and need for repeat laparotomy as predictors of morbidity. Age, shock on admission, need for damage control surgery, high-grade pancreatic injuries and associated vascular injuries were significant factors associated with mortality.

CONCLUSION

Morbidity and mortality rates were high after gunshot injuries to the pancreas. Initial shock and severe injury combined with need for damage control surgery were associated with the highest risk of death.

Practical matters for the control of contamination in a nuclear medicine department

A practicable and safe methodology is required for the control of contamination arising due to work in nuclear medicine departments, taking account of the range of radionuclides used for diagnostic and therapeutic procedures. A method for categorising radionuclides is proposed, based on their contamination derived limits. The categories utilised are: low energy gamma, imaging gamma, high energy gamma with beta, low energy beta, high energy beta and (51)Cr. A framework for the preparation of a risk assessment for the control of contamination in a nuclear medicine department is presented. This includes assessment of the procedures performed, occupancies and workflows for the department and a review of control measures. A risk assessment should also include a contamination monitoring programme and a practicable approach is presented.

A three-dimensional finite element model of maximal grip loading in the human wrist

The aim of this work was to create an anatomically accurate three-dimensional finite element model of the wrist, applying subject-specific loading and quantifying the internal load transfer through the joint during maximal grip. For three subjects, representing the anatomical variation at the wrist, loading on each digit was measured during a maximal grip strength test with simultaneous motion capture. The internal metacarpophalangeal joint load was calculated using a biomechanical model. High-resolution magnetic resonance scans were acquired to quantify bone geometry. Finite element analysis was performed, with ligaments and tendons added, to calculate the internal load distribution. It was found that for the maximal grip the thumb carried the highest load, an average of 72.2 +/- 20.1 N in the neutral position. Results from the finite element model suggested that the highest regions of stress were located at the radial aspect of the carpus. Most of the load was transmitted through the radius, 87.5 per cent, as opposed to 12.5 per cent through the ulna with the wrist in a neutral position. A fully three-dimensional finite element analysis of the wrist using subject-specific anatomy and loading conditions was performed. The study emphasizes the importance of modelling a large ensemble of subjects in order to capture the spectrum of the load transfer through the wrist due to anatomical variation.

Does the Level of Axillary Node Clearance Influence Adjuvant Treatment in Patients with Breast Cancer?

Background: The SIGN (Scottish Intercollegiate Guidelines Network) guidelines on axillary surgery do not advise as to whether level 1/2 or level 3 clearances should be performed when axillary clearance is required. Although there is a theoretical risk of increased morbidity, in experienced hands a level 3 clearance reduces the chance of residual tumour and allows for full staging.Materials and Methods: 124 consecutive axillary clearances (level 1, 2 and 3) were performed by a single operator. Level 1 and 2 nodes were removed as a single specimen, with level 3 nodes removed separately. Patient case notes, operation notes and pathology reports were used in the collection of data and all data were recorded in an Excel databaseResults: Of the 124 axillary clearances performed, 64 (52%) had level 1/2 lymph nodes positive for carcinoma. Of these 64 patients, 14 (11%) also had positive level 3 nodes. One patient (1%) had negative level 1/2 nodes but positive level 3 nodes. The Nottingham Prognostic Index (NPI) value increased in two patients when the level 3 nodes were included (6.6 to 7.6 and 4.3 to 5.3).Discussion: While it is generally accepted that axillary radiotherapy deals with residual level 3 nodal involvement, basic surgical oncologic principles would suggest that removal of as much tumour as possible should be performed. The patient with positive level 3 nodes but negative level 1/2 nodes would have been under-treated, with viable tumour remaining. Furthermore, the under-estimate of the NPI when level 3 nodes are not included could lead to sub-optimal adjuvant therapy being offered. The performance of a level 3 clearance can preclude the need for axillary radiotherapy, thereby reducing morbidity.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3114.

Adenomyosis following endometrial resection-a retrospective study

The aim of this study was to evaluate the presence of adenomyosis in women following endometrial resection who subsequently undergo hysterectomy. Out of 227 women who underwent endometrial resection 9.3% (21) subsequently had a hysterectomy. Of these, 28.5% were shown to have adenomyosis on histological examination compared with a case control group incidence of 7.5%.

Training of staff for the delivery of PET/CT services in the UK

Evidence for the cost effectiveness of PET/CT imaging is now driving the widespread introduction of PET/CT services throughout the UK. The provision of PET/CT facilities will require a workforce of medical, scientific, technical and engineering staff who are adequately trained and fit for purpose. Suitably trained staff in this speciality are scarce. The development and accreditation of training courses and other educational resources for training programmes in all disciplines will therefore be required at a national and regional level. The implementation of PET/CT training can be achieved more cost-effectively by developing multi-professional learning resources whenever possible. It is intended that the recommendations would be implemented by close co-operation of both public and private healthcare providers together with educational establishments.

Long-term continuous positive airway pressure (CPAP) outcomes from a sleep service using limited sleep studies and daycase CPAP titration in the management of obstructive sleep apnoea/hypopnoea syndrome

BACKGROUND

Detailed polysomnography (PSG) and overnight continuous positive airway pressure (CPAP) titration as the basis for investigation and treatment of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) incurs high costs from inpatient stays and technician attendance, even when split night studies are employed. Responding to rapidly increasing demand, from 1996 the sleep service at Glasgow Royal Infirmary adopted limited sleep studies and daycase CPAP titration as first line management. Here we describe the outcomes of this service between 1996 and 1999.

METHODS

Data were collected from prospective records made at follow up by sleep technicians and by casenote review.

RESULTS

Results were available for 158 subjects (97.5%) of 162 commenced on CPAP during this period. One hundred and forty-eight (91%) were diagnosed by limited sleep studies and 80 (50%) were diagnosed at home. The median follow up was 23 months (interquartile range (IQR), 13-35). Median use of CPAP in those continuing therapy was 5.3 hours/night (IQR, 3.1 to 6.5) and 77% were still using CPAP at three years. Only initial low CPAP compliance (< 2 hours/night) significantly predicted early CPAP cessation. In those still on CPAP in 1999, the mean drop in Epworth Sleepiness Scale score was 4.6 points (95% confidence intervals, 3.2 to 6.0).

CONCLUSION

These data from the CPAP population at Glasgow Royal Infirmary provide information on longterm outcomes using a diagnostic protocol based on limited sleep studies and daycase CPAP titration.

Detection of HIV-1 provirus and RNA by in situ amplification

The detection of the HIV-1 provirus that can integrate into a host cell nucleus and remain latent for years is problematic. The threshold of in situ hybridization, which is about 10 copies per cell, is too high to detect one integrated copy of the provirus. Although polymerase chain reaction (PCR) can detect 1 provirus per 100,000 cells, it cannot determine the specific cellular localization of the virus. These problems can be resolved with PCR in situ hybridization. Adapting this method to RNA detection (reverse transcriptase [RT] in situ PCR) allows one to determine whether viral infection is latent or productive as well as to detect the host response in the form of cytokine mRNA expression. These methodologies have demonstrated that (1) there is massive infection of CD4 cells by HIV-1 prior to AIDS-defining symptomatology, (2) progression of AIDS is marked by the progressive destruction of CD4 cells, as evidenced by an increased ratio of productively to latently infected cells, (3) the primary target of the virus in the uterine cervix, lung, central nervous system, and skeletal muscle is the macrophage and its derivatives, and (4) AIDS-related diseases such as AIDS dementia are marked by both many viral-infected cells and upregulation of a wide variety of cytokines, primarily in the neighboring noninfected cells. This chapter will describe the methodologies for detecting HIV-1 DNA and RNA in paraffin-embedded tissue sections as well as the colabeling experiments needed to define the host response to the viral invasion.

Transdiaphragmatic pleural lavage in penetrating thoracoabdominal trauma

BACKGROUND

The purpose of this study was to determine the incidence of thoracic sepsis following a systematic thoracic cavity washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma.

METHODS

Prospectively collected data on all patients presenting with penetrating thoracoabdominal trauma between July 1999 and July 2002 were analysed. Patients with peritoneal biliary-gastroenteric (BGE) contamination and a diaphragmatic laceration were managed by laparotomy and transdiaphragmatic thoracic lavage.

RESULTS

A total of 217 patients had penetrating thoracoabdominal injuries, of whom 110 had BGE contamination of the peritoneal cavity with spillage into the pleural cavity. The mean Injury Severity Score was 38.1. Gunshot and stab wounds occurred in 79 (71.8 per cent) and 31 (28.2 per cent) respectively. Contamination was from the stomach (55.4 per cent), large bowel (37.3 per cent), small bowel (29.1 per cent), gallbladder and bile ducts (9.1 per cent) and pancreas (6.4 per cent). Thoracic complications occurred in six patients (5.5 per cent): empyema in two, Escherichia coli-related pneumonia in three and pleuritis in one. There were no deaths.

CONCLUSION

A thoracic washout through the injured diaphragm in patients with penetrating thoracoabdominal trauma and BGE contamination was associated with a low rate of intrathoracic septic complications.

Report on a new type of trauma full-body digital X-ray machine

The purpose of this study was to evaluate the diagnostic equivalence, radiation dose, clinical usefulness and radiographic aspects of a low-dose, full-body digital X-ray machine in a busy trauma unit. A digital trauma X-ray machine known as "LODOX" was compared with conventional radiography between June 1999 and November 2001 in the Groote Schuur Hospital Trauma Unit, Cape Town. Digital images of a variety of body regions commonly imaged in trauma were compared for diagnostic image quality in a number of categories with equivalent conventional radiographs. A seven-point equivalence scoring system ranging from much inferior (-3) through equivalent (0) to much superior (+3) was used in each category. Radiation dose was recorded and compared with that in conventional measurements. Turnaround times of patients undergoing digital and conventional X-rays were evaluated. Clinical and radiographic issues were assessed by staff feedback. The digital images when compared with conventional film had an overall mean equivalence score of -0.429, with a standard deviation (SD) of 0.77. The best digital performance was in the mediastinum (mean 0.346, SD 0.49) and the weakest was for bony detail (mean -0.654, SD 0.81). Relative digital radiation dose compared to conventional varied from 72% (chest) to 2% (pelvis), with a simple average of 6%. Radiographic points included full-body imaging capability and differing positioning, penetration, workflow and practicality considerations. The digital images required overall patient times of 5-6 min, compared with 8-48 min for conventional X-rays. New installations are under way, and computed tomography and angiography applications are being explored. FDA approval is awaited. Projected cost is similar to that of flat-panel digital units. This digital unit was felt to be diagnostically substantially equivalent to conventional radiographs, with low-dose full-body imaging, improved workflow, digital technology and long-term cost benefits as potentially favourable contributions to trauma imaging.

Human peripheral blood Valpha24+ Vbeta11+ NKT cells expand following administration of alpha-galactosylceramide-pulsed dendritic cells

BACKGROUND AND OBJECTIVES

We have undertaken the first clinical trial involving the administration of alpha-GalactosylCeramine (alpha-GalCer)-pulsed dendritic cells (DCs) to human subjects, to determine safety, optimal dose, optimal administration route and immunological effects.

MATERIALS AND METHODS

Subjects (n = 4) with metastatic malignancy received two infusions of alpha-GalCer-pulsed DCs intravenously, and two infusions intradermally. The percentages of Valpha24 Vbeta11 NKT cells in peripheral blood (PB) were determined by three-colour flow cytometry and the PB NKT cell numbers were calculated using the total number of PB lymphocytes/ml determined by automated full-blood counts.

RESULTS

No serious treatment related adverse events were observed during the study period. Administration of alpha-GalCer-pulsed DCs in vivo can significantly (P < 0.03) increase PB Valpha24+ Vbeta11+ NKT cell numbers above pretreatment baseline levels after the transient fall in the NKT numbers within 48 h.

CONCLUSIONS

Administration of alpha-GalCer-pulsed DCs is well tolerated, modulates PB Valpha24+ Vbeta11+ NKT cells and may have a role in the therapy of malignancies sensitive to activities of Valpha24+ Vbeta11+ NKT cells, or for autoimmune diseases.

An analysis of 32 surgically managed penetrating carotid artery injuries

A review of the surgical management of penetrating carotid artery injuries in the Trauma Unit at Groote Schuur Hospital, Cape Town, is presented.

MATERIALS AND METHODS

a retrospective analysis of all surgically treated penetrating carotid artery injuries over a 3-year period was performed. The policy is to repair all injuries to the common and internal carotid arteries. Ligation is reserved for patients with prolonged coma; ischaemic infarcts or cerebral oedema on computerised axial tomography of the brain; technically inaccessible high internal carotid artery injuries, and those with occluded arteries with no distal patency detected during surgery or with angiography.

RESULTS

thirty-two patients with penetrating carotid artery injuries were reviewed. Eleven patients underwent emergency exploration. Twenty-one patients had angiography prior to exploration. Injuries in the emergency group were all repaired, with improvement in level of consciousness; also, two patients had preoperative neurological deficits that improved. Three of the 21 patients in the urgent group underwent ligation of the common carotid artery: one comatose patient with a hemiparesis died following ligation; the other two had improvement in their level of consciousness, one of whom showed improvement of his hemiparesis. The remaining injuries to the common and internal carotid arteries were repaired with improvement in level of consciousness and neurological deficit when present.

CONCLUSION

operative repair offers the best chance of recovery.

Gene expression analysis in human monocytes, monocyte-derived dendritic cells, and alpha-galactosylceramide-pulsed monocyte-derived dendritic cells

In vitro proliferation and functional activation of V alpha 24NKT cells following stimulation with alpha-galactosylceramide (alpha-GalCer)-pulsed dendritic cells (DCs) have been observed. Because little is known about the molecular events on DCs following interaction with alpha-GalCer, we performed gene expression profiling of 2400 genes in monocytes and monocyte-derived immature DCs pulsed with alpha-GalCer (alpha-GalCer-imDCs). Overall, the expression levels of 48 genes were up-regulated and 28 were down-regulated in alpha-GalCer-imDCs. Semiquantitative RT-PCR analysis on monocytes, imDCs, alpha-GalCer-imDCs, and mature DCs confirmed the up- and down-regulation of the mRNA expression levels of 28 selected genes. Notably, we identified the specific up-regulation of mRNA expression levels of ribonuclease A and collapsin response mediator protein upon the stimulation of imDC with alpha-GalCer, suggesting a novel immunomodulating effect of alpha-GalCer on imDCs. In this study, we used imDCs prepared by culturing of monocytes with GM-CSF and IL-4 for 5 days and mDCs prepared by further culturing of imDCs with TNF alpha for two extra days.

A new approach to extraperitoneal rectal injuries: laparoscopy and diverting loop sigmoid colostomy

BACKGROUND

Current management of extraperitoneal rectal injuries involves a laparotomy and diversion of the fecal stream. In this study, we review our experience with laparoscopy and diverting loop sigmoid colostomy without laparotomy in the management of these injuries.

METHODS

All patients admitted to the trauma unit at Groote Schuur Hospital between January 1995 and May 2000 with a rectal injury were evaluated. The presence of a rectal injury was confirmed by rectal examination and proctosigmoidoscopy. Intraperitoneal injuries were excluded by laparoscopy. Only patients who did not have intraperitoneal injuries were included in the study. The patients were then managed with a diverting loop sigmoid colostomy created through an abdominal wall trephine without laparotomy.

RESULTS

Ten patients were included in the study. In eight patients, laparoscopy excluded intraperitoneal injuries. All 10 patients had a diverting loop sigmoid colostomy fashioned. There were no complications related to either the rectal injury or colostomy. Nine stomas have since been closed.

CONCLUSION

In patients with isolated extraperitoneal rectal injuries, laparoscopic exclusion of intraperitoneal injuries, followed by a diverting loop sigmoid colostomy, is a feasible option.

In vitro anti-tumour activity of alpha-galactosylceramide-stimulated human invariant Valpha24+NKT cells against melanoma

alpha-galactosylceramide (KRN 7000, alpha-GalCer) has shown potent in vivo anti-tumour activity in mice, including against melanoma and the highly specific effect of inducing proliferation and activation of human Valpha24+NKT-cells. We hypothesized that human Valpha24+NKT-cells activated by alpha-GalCer might exhibit anti-tumour activity against human melanoma. To investigate this, Valpha24+NKT-cells were generated from the peripheral blood of patients with melanoma after stimulation with alpha-GalCer pulsed monocyte-derived dendritic cells (Mo-DCs). Valpha24+NKT-cells did not exhibit cytolytic activity against the primary autologous or allogeneic melanoma cell lines tested. However, proliferation of the melanoma cell lines was markedly suppressed by co-culture with activated Valpha24+NKT-cells (mean +/- SD inhibition of proliferation 63.9 +/- 1.3%). Culture supernatants of activated Valpha24+NKT-cell cultures stimulated with alpha-GalCer pulsed Mo-DCs exhibited similar antiproliferative activities against melanoma cells, indicating that the majority of the inhibitory effects were due to soluble mediators rather than direct cell-to-cell interactions. This effect was predominantly due to release of IFN-gamma, and to a lesser extent IL-12. Other cytokines, including IL-4 and IL-10, were released but these cytokines had less antiproliferative effects. These in vitro results show that Valpha24+NKT-cells stimulated by alpha-GalCer-pulsed Mo-DCs have anti-tumour activities against human melanoma through antiproliferative effects exerted by soluble mediators rather than cytolytic effects as observed against some other tumours. Induction of local cytokine release by activated Valpha24+NKT-cells may contribute to clinical anti-tumour effects of alpha-GalCer.

Inflammatory pseudotumour in the submandibular region

We present a rare case of inflammatory pseudotumour in the submandibular region. A review of the literature revealed that this is only the second case of inflammatory pseudotumour in the submandibular region to be reported. Clinical presentation and management of this condition are discussed.

TRAIL expression by activated human CD4(+)V alpha 24NKT cells induces in vitro and in vivo apoptosis of human acute myeloid leukemia cells

Human Valpha24NKT cells are activated by alpha-galactosylceramide (alpha-GalCer)-pulsed dendritic cells in a CD1d-dependent and a T-cell receptor-mediated manner. Here, we demonstrate that CD4(+)V alpha 24NKT cells derived from a patient with acute myeloid leukemia (AML) M4 are phenotypically similar to those of healthy donors and, in common with those derived from healthy donors, express tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) when the cells are activated by alpha-GalCer-pulsed dendritic cells but not prior to activation. We also show that myeloid leukemia cells from patients with AML M4, but not from patients with AML M0 or M1, undergo apoptosis following culture with TRAIL-expressing autologous or allogeneic healthy donor V alpha 24NKT cells. Apoptosis of AML M4 leukemia cells from patient peripheral blood was almost completely blocked by a neutralizing monoclonal antibody against TRAIL, indicating that TRAIL on V alpha 24NKT cells is essential for the induction of apoptosis in AML M4 leukemia cells. A nonobese diabetic-severe combined immunodeficient human leukemia (AML M4) model showed that human activated CD4(+)V alpha 24NKT cells induced apoptosis of human leukemia cells in vivo. This is the first evidence that activated V alpha 24NKT cells express TRAIL and that TRAIL causes apoptosis of monocytic leukemia cells from patients with AML M4 in vitro and in vivo. Adoptive immune therapy with activated V alpha 24NKT cells, or other strategies to increase activated V alpha 24NKT cells in vivo, may be of benefit to patients with AML M4. (Blood. 2001;97:2067-2074)

Analysis of human V alpha 24+ CD4+ NKT cells activated by alpha-glycosylceramide-pulsed monocyte-derived dendritic cells

Human V alpha 24+ NKT cells with an invariant TCR (V alpha 24-J alpha Q) have been shown to be specifically activated by synthetic glycolipids such as alpha-galactosylceramide and alpha-glucosylceramide in a CD1d-restricted and V alpha 24 TCR-mediated manner. We recently characterized V alpha 24+ CD4- CD8- double negative (DN) NKT cells using alpha-galactosylceramide-pulsed monocyte-derived dendritic cells. Here, we compare V alpha 24+ CD4+ NKT cells with human V alpha 24+ DN NKT cells from the same donor using alpha-galactosylceramide-pulsed monocyte-derived dendritic cells. Human V alpha 24+ CD4+ NKT cells were phenotypically and functionally similar to the human V alpha 24+ DN NKT cells characterized previously. Both of them use V alpha 24-J alpha Q-V beta 11 TCR and express CD161 (NKR-P1A), but not the other NK receptors tested so far. They also produce cytokines such as IL-4 and IFN-gamma, and, in regard to IL-4 production, V alpha 24+ CD4+ NKT cells produce more IL-4 than V alpha 24+ DN NKT cells. The cells exhibit marked cytotoxic activity against the U937 tumor cell line, but not against the NK target cell line, K562. Although at least some of the factors responsible for the stimulation of V alpha 24+ NKT cells have been clarified, little is known regarding the killing phase of these cells. Here we show that the cytotoxic activity of V alpha 24+ NKT cells against U937 cells is mediated mainly through the perforin pathway and that ICAM-1/LFA-1 as well as CD44/hyaluronic acid interactions are important for the effector phase of V alpha 24+ NKT cell-mediated cytotoxicity against U937 cells.

Dendritic cells are targets for human invariant Valpha24+ natural killer T-cell cytotoxic activity: an important immune regulatory function

OBJECTIVE

Human invariant Valpha24+ natural killer T (NKT) cells, a subpopulation of NK cell-receptor (NKR-P1A)-expressing T cells with an invariant Valpha24JalphaQ T-cell receptor (TCR), are stimulated by the glycolipid a-galactosylceramide (KRN7000), in a CD1d-dependent, TCR-mediated fashion. Little is known about invariant Valpha24+ NKT cell function or mechanisms of effector activity. Evidence suggests this cell population protects against autoimmunity and has antitumor effects against leukemia and solid tumors.

MATERIALS AND METHODS

We compared the phenotype and function of invariant Valpha24+ NKT cells, from patients with chronic myeloid leukemia (CML) and normal donors, generated by stimulation of peripheral blood mononuclear cells with alpha-galactosylceramide pulsed monocyte-derived dendritic cells. The CD4(-)CD8(-) (double negative) population was studied further.

RESULTS

Activated human invariant Valpha24+ NKT cells were cytotoxic against autologous and allogeneic peripheral blood dendritic cells and monocyte-derived dendritic cells but not against autologous or allogeneic T-cell PHA blasts, B-cell lymphoblastoid cell lines, monocytes, or leukemic cells from patients with CML. The findings are consistent with previous observations showing the importance of CD1d in target cell recognition. None of the Valpha24+ NKT cell lines expressed the NK markers CD16, CD56, CD94, or killer inhibitory receptors, but all expressed NKR-P1A. There was no difference in phenotype, function, or ease of generation of invariant Valpha24+ NKT cells between normal donors and patients with CML.

CONCLUSION

Based on our results and the previous evidence linking reduced Valpha24+ NKT cells to autoimmunity, we propose that double-negative Valpha24+ NKT cells have important immune regulatory functions, including contribution to the prevention of excessive antigen stimulation by virtue of cytotoxic activity against antigen presenting cells, particularly in dendritic cells.