Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm

LEVEL OF EVIDENCE

Literature synthesis and expert opinion, Level V.

Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19

Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm

ABSTRACT

This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians.

LEVEL OF EVIDENCE

Consensus algorithm from the Western Trauma Association, Level V.

Association Between American Board of Surgery Initial Certification and Risk of Receiving Severe Disciplinary Actions Against Medical Licenses

Importance

Board certification is used as a marker of surgeon quality and professionalism. Although some research has linked certification in surgery to outcomes, more research is needed.

Objective

To measure associations between surgeons obtaining American Board of Surgery (ABS) certification and examination performance with receiving future severe disciplinary actions against their medical licenses.

Design, Setting, and Participants

Retrospective analysis of severe license action rates for surgeons who attempted ABS certification based on certification status and examination performance. Surgeons who attempted to become certified were classified as certified or failing to obtain certification. Additionally, groups were further categorized based on whether the surgeon had to repeat examinations and whether they ultimately passed. The study included surgeons who initially attempted certification between 1976 and 2017 (n = 44 290). Severe license actions from 1976 to 2018 were obtained from the Federation of State Medical Boards, and certification data were obtained from the ABS database. Data were analyzed between 1978 and 2008.

Main Outcomes and Measures

Severe license action rates were analyzed across certified surgeons and those failing to obtain certification, as well as across examination performance groups.

Results

The final dataset included 36 197 men (81.7%) and 8093 women (18.3%). The incidence of severe license actions was significantly greater for surgeons who attempted and failed to obtain certification (incidence rate per 1000 person-years = 2.49; 95% CI, 2.13-2.85) than surgeons who were certified (incidence rate per 1000 person years = 0.77; 95% CI, 0.71-0.83). Adjusting for sex and international medical graduate status, the risk of receiving a severe license action across time was also significantly greater for surgeons who failed to obtain certification. Surgeons who progressed further in the certification examination sequence and had fewer repeated examinations had a lower incidence and less risk over time of receiving severe license actions.

Conclusions and Relevance

Obtaining board certification was associated with a lower rate of receiving severe license actions from a state medical board. Passing examinations in the certification examination process on the first attempt was also associated with lower severe license action rates. This study provides supporting evidence that board certification is 1 marker of surgeon quality and professionalism.

Clinical course of severe colitis: a comparison between Crohn’s Disease and ulcerative colitis

Few data are available about the clinical course of severe colonic Crohn’s disease (CD). The aim of this study is to describe the clinical course of severe Crohn’s colitis in a patient cohort with isolated colonic or ileocolonic CD, and to compare it with the clinical course of patients with severe ulcerative colitis (UC). Thirty-four patients with severe Crohn’s colitis were prospectively identified in our cohort of 593 consecutive hospitalized patients through evaluation of the Crohn’s Disease Activity Index score and the Harvey-Bradshaw Index. One hundred sixty-nine patients with severe ulcerative colitis were prospectively identified in our cohort of 449 consecutive hospitalized patients through evaluation of the Lichtiger score and the Truelove-Witts score. We evaluated the following data/aspects: response to steroids, response to biologics, colectomy rate in acute, colectomy rate during follow-up, megacolon and cytomegalovirus infection rate. We did not find significant differences in the response to steroids and to biologics, in the percentage of cytomegalovirus infection and of megacolon, while the rate of colectomy in acute turned out to be greater in patients with severe Crohn’s colitis compared to patients with severe UC, and this difference appeared to be the limit of statistical significance (Chi-squared 3.31, p = 0.069, OR 0.39); the difference between the colectomy rates at the end of the follow-up was also not significant. In the whole population, by univariate analysis, according to the linear regression model, a young age at diagnosis is associated with a higher overall colectomy rate (p = 0.024) and a higher elective colectomy rate (p = 0.022), but not with a higher acute colectomy rate, and an elevated ESR is correlated with a higher overall colectomy rate (p = 0.014) and a higher acute colectomy rate (p = 0.032), but not with a higher elective colectomy rate. This correlation was significant on multivariate analysis. The overall rate of colectomy in the cohort of patients with severe Crohn’s colitis was greater than that of the cohort of patients with severe UC, but this figure is not supported by a different clinical response to steroid therapy or rescue therapy with biologics. The clinical course of severe Crohn’s colitis requires to be clarified by prospective studies that include a larger number of patients in this subgroup of disease.

Focal active colitis as a predictor of inflammatory bowel disease: results from a single-center experience

The term focal active colitis (FAC) is conventionally used to describe the presence of isolated cryptitis, characterized by an inflammatory infiltrate consisting of intraepithelial neutrophils and/or neutrophils invading the lumen of the criptae, with no other microscopic alteration of the colonic mucosa and, in particular, without the presence of signs of chronic inflammation. To date, only four studies, including one conducted in a pediatric population, have been performed to evaluate the clinical significance of this disease. The aim of this retrospective study on prospectively-collected data is to evaluate the clinical implications of the focal active colitis, since there still remains a marked uncertainty regarding this topic and about how often such a diagnosis will presage a diagnosis of inflammatory bowel disease (IBD). Clinical, endoscopic, and pathological data were retrospectively reviewed from 30 patients with focal active colitis, who had no other diagnostic findings on colorectal biopsy and no history of chronic inflammatory bowel disease. The histological findings were correlated with clinical diagnoses. Thirty patients (11 males, 19 females; age 24-80 years, median 56 years) (0.5%) out of 5,600 undergoing colonoscopy between January 2012 and December 2016 presented a definitive diagnosis of FAC. Follow-up ranged from 6 to 60 months (median 24 months). At endoscopy, 19 patients (63%) had mild and non-specific changes, such as mild mucosal erythema, while 11 (37%) had normal findings. Eight patients were documented as having irritable bowel syndrome, while nine cases could be attributed to the effects of drugs, five presented FAC as incidental finding, one a diagnosis of infectious colitis, and seven a diagnosis of IBD (4 with Crohn’s disease). FAC was confirmed to be a more significant predictor of IBD than the previous literature would indicate, even if larger prospective studies, targeted to study this relationship, are needed to understand more clearly its clinical significance.

Age: is it all in the head? Factors influencing mortality in elderly patients with head injuries

BACKGROUND

Elderly patients, an increasing segment of the population, who sustain traumatic brain injury (TBI) are known to have worse outcomes, including higher mortality. This objective of this study was to examine the Crash Injury Research Engineering Network and to determine at what age motor vehicle crash fatalities from head injuries increased.

METHODS

The Crash Injury Research Engineering Network database was queried from 1996 to 2009. Study inclusion criteria were adult vehicle occupants with TBI, with an Abbreviated Injury Scale score ≥2. The age at which mortality increased was calculated. Patients younger and older than this cutoff age were compared to determine differences in crash characteristics. The determined cutoff age was compared with one found in a larger, population-based database.

RESULTS

There were 915 patients who met the study criteria. An increase in mortality was seen at age 60 years despite no difference in Injury Severity Score and a decrease in crash severity. Patients ≤60 years were more likely to have alcohol involved, to be in a rollover crash, and had higher crash speeds. Comparing the element of the crash attributed to the head injury, the patients >60 years were more likely to have struck the airbag, door, and seat. An analysis of the larger database revealed an increase in mortality at age 70 years.

CONCLUSIONS

There was a higher mortality secondary to head injuries in those older than 60 years involved in motor vehicle crashes. Improved safety measures in vehicle design may decrease the number of head injuries seen in the older population.

[Acute neoplastic colic obstructions: therapy and postoperative complications. Our experience]

Authors report their experience about neoplastic large bowel obstructions and present two cases of anastomotic leakage resolution by means of transtomy wash-out. They observe that the most important problem in this surgery is anastomotic leakage which, if small, can be solved in a non operative way. According with literature, they also point out anastomotic leakage is commonly due to the impossibility of a correct preparation of colon to operation in emergency. They conclude it is possible, in case of little leakages, to perform trans-stomy wash out which permits a good toilette and sterilization of the colon.

Teaching breaking bad news using mixed reality simulation

BACKGROUND

Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress.

METHODS

Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training.

RESULTS

Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum.

CONCLUSION

This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education.

[Our experience in inguinal hernia recurrences treatment]

Reporting their personal experience, the authors focus on characteristics and causes of recurrence, either after traditional surgery or with tension-free technique. They describe difficulties and advantages in open interventions and laparoscopic ones. Facing a relapse it's convenient to assume an "eclectic" behaviour, thinking both of general and specific single patient anatomo-pathologic features.

Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center

Marking the fifth year after the attack on the Pentagon, staff at the burn center in Washington, DC, memorialize in a contemplative frame of mind. These reflections are drawn from members of the extended burn team and render an interwoven sketch in prose that previously has not been heard.

Estimated Height, Weight, and Body Mass Index: Implications for Research and Patient Safety

BACKGROUND

Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of self-reported height and weight and HCP estimations of height, weight, and body mass index (BMI) classification when compared with measured height, weight, and calculated BMI.

STUDY DESIGN

Attending physicians, residents, and nurses provided height and weight estimates along with BMI categorizations for 110 trauma patients at a large, teaching hospital with a Level I trauma center. Patients provided reports of their heights and weights. Measured heights and weights were obtained with appropriate calibrated devices, and BMIs were calculated. Estimates and categorizations were then compared with measured and calculated values.

RESULTS

HCPs were 41% and 53% accurate in estimating height and weight, respectively. Self-reports had higher accuracy (69% and 92%, respectively) but still resulted in a BMI misclassification of 32%. Twenty-two percent of patient self-reports were unobtainable. When HCPs attempted to categorize a patient into a BMI group, the accuracy was 56%. Functioning, calibrated instruments for measuring height and weight were frequently unavailable in relevant hospital locations.

CONCLUSIONS

This study demonstrated that HCPs' estimates of height, weight, and BMI category are highly inaccurate. Patient self-reports are better, but are unavailable at times. Objective measurements with calibrated instruments are necessary for accuracy in research studies and for patient safety in clinical practice. Efforts to ensure the availability of calibrated instruments may be necessary in the hospital setting.

[Etiopathogenic hypothesis on carcinoma of the gallbladder: our study]

The authors are interested in determining causes of gallbladder cancer (GBC). By this intention, they theorize a correlation between genetic modifications (which are responsible of malignant transformation of biliary epithelium) and some intestinal infections. From 1999 to 2004 they observed 15 GBC and all 15 gallbladder have been analyzed histologically and from microbiological aspect; by these means from 1999 till 2004 they have studied also 30 persons with colelithiasis. The authors noticed that bile of both groups contained, in three cases in the first and in 8 cases in the second, a germ named Escherichia Coli which normally lives in intestine, while in 10 operated gallbladders of the first group and 12 of the second there was a positive for k-ras. They are studying to confirm their theories.

[Treatment of skin neoplasms with polidocanol infiltrations. Our experience]

The authors try to explain the importance of day surgery today. They report their 5 years experience in treatment of face and neck skin neoplasms by injections of a sclerosant product as hydropolyethoxydodecan, in case of a difficult good esthetic result with surgery or other therapies because of patients general conditions, such as diabetic ones, or because of their viral nature. Then they affirm to have treated 350 benign and malign tumors with this method. All subjects presented a complete resolution of disease in few weeks and none between them controlled has actually complications or recruitment of neoplasm. They conclude by saying that this result is probably due to local ischemic reaction caused by the substance used.

[Acute pancreatitis: our experience in the light of natural history]

The Authors enumerate main steps of acute pancreatitis natural history. Then they discuss their last five years case-report. After having stated that clinical presentation depends on anatomo-pathological conditions, they consider aetiological causes and morphopathogenetic moments involved in the onset and development of this disease. They conclude stating how only proper diagnosis and treatment can prevent its potential evolution in multiorgan failure.

[Ileum-colon junction benign obstructions]

The Authors discuss on anatomical and functional characteristics of ileum-colon junction, physiological narrowing in alimentary tract and often involved in benign obstruction. They report their series and analyze all inflammatory or not inflammatory diseases potentially involved, by describing them shortly and giving some information about their clinical features and imaging. The treatment of this obstruction will be done as soon as possible, before wall lesions force to make a larger resection.

The 2003 Carl A Moyer Award: real-time metabolic monitors, ischemia-reperfusion, titration endpoints, and ultraprecise burn resuscitation

Real-time metabolic monitoring of varied vascular beds provides the raw data necessary to conduct ultraprecise burn shock resuscitation based on second-by-second assessment of regional tissue perfusion. It also illustrates shortcomings of current clinical practices. Arterial base deficit was continuously monitored during 11 clinical resuscitations of patients suffering burn shock using a Paratrend monitor. Separately, in a 30% TBSA rat burn model (N = 70), three Paratrend monitors simultaneously recorded arterial blood gas and tissue pCO2 of the burn wound and colonic mucosa during resuscitation at 0, 2, 4, 6, and 8 ml/kg/%TBSA. Paratrend data were analyzed in conjunction with previously reported laser Doppler images of actual burn wound capillary perfusion. With current clinical therapy, continuous monitoring of arterial base deficit revealed repetitive cycles of resolution/worsening/resolution during burn shock resuscitation. In the rat model, tissue pCO2 in both burn wounds and splanchnic circulation differed depending on the rate of fluid resuscitation (P <.01 between sham and 0 ml/kg/%TBSA and between 2 ml/kg/%TBSA and 4 ml/kg/%TBSA). Burn wound pCO2 values correlated well with laser Doppler determination of actual capillary perfusion (rho = -.48, P <.01). The following conclusions were reached: 1). Gratuitous and repetitive ischemia-reperfusion-ischemia cycles plague current clinical therapy as demonstrated by numerous "false starts" in the resolution of arterial base deficit; 2). in a rat model, real-time monitoring of burn wound and splanchnic pCO2 demonstrate a dose-response relationship with rate of fluid administration; and 3). burn wound and splanchnic pCO2 are highly correlated with direct measurement of burn wound capillary perfusion by laser Doppler imager. Either technique can serve as a resuscitation endpoint for real-time feedback-controlled ultraprecise resuscitation.

[Diagnosis and treatment of Crohn's disease]

The Authors state their ideas and report their experience about diagnosis and treatment of Crohn's disease. After having treated risk and etiological factors, they discuss typical anatomo-pathological lesions. Then they explain clinical diagnostic and surgical choices extensively: they prefer laparotomic approach. The Author's conclude that timely diagnosis spare heavy complications.

Thoracic compartment syndrome secondary to a thoracic procedure: a case report

Prolonged open sternotomy is a well-known phenomenon in the pediatric and adult cardiac surgery literature. It is usually an adjuvant in the treatment of a severely compromised heart. We present a case of thoracic compartment syndrome that developed postoperatively from a noncardiac thoracic procedure. Management, diagnosis, and literature review are presented.

[GIST of the jejuno-ileal tract]

Jejunum-ileum stromal tumors give diagnostic and therapeutical problems, especially with regard to histopathological identification and biological behavior. These tumors are very rare in all case report. After gastric stromal tumors these ones are the most frequent of all alimentary tract. They are often incidentally found; because of their potential transformation, they have to be treated by respecting oncologic eradication standards and observing prognostic criteria based on a correct histopathological evaluation (neoplasm localization and dimension, its structure, presence of cytological atypisms, mitotic index, ploidia, surgical resection). Then there has to be a good follow-up program.

[Mechanical intestinal occlusion due to phytobezoars]

The Authors reporting two cases with ileus by phytobezoar in distal jejunum and ileum, respectively, and discuss the pathophysiologic mechanism responsible for the formation of bezoars. They expose the etiological and clinical factors of this uncommon cause of small bowel obstruction and also discuss the surgical technique that consists in the removal of the phytobezoar through enterotomy.

[Treatment of substernal goiter. Our experience]

The Authors, after having reviewed substernal goitre natural history, report their five-year experience with this disease, underlining clinical features, therapeutic management, positive results. They examine the several proposed classifications and stress haemodynamic and respiratory complications. At last they shortly discuss about diagnostics and, mainly, about correct therapeutic approach which has two aims to resolve the symptomatology and to prevent relapses.

[Idiopathic gynecomastia: our experience]

The Authors reporting their experience, discuss some concepts about physiologic evolution of male and female breast. They distinguish between real and false gynaecomastia; stressing the causes of abnormal development of male breast and morphopathological characteristics of gynaecomastia. Careful diagnostic protocol is necessary for a therapeutic approach based on traditional surgery or liposuction: it depends on prevalence of glandular or adipose breast's tissue.

[A rare salivary gland neoplasm: cystadenolymphoma]

The authors, after having examined three recent cases, explain some basic concepts about diagnostics and therapy in cystadenolymphoma of salivary glands. As a matter of fact this neoplasia, in spite of its low frequency, is very important because of its still controversial etiopathology and recent tendency in increasing its incidence in females. Today the diagnostic protocol, undertaken after clinical examination, which is necessary, consists of ultrasonography or computerized tomography. But only postoperative histological examination gives a sure diagnosis and can point out main histomorphological characteristics of tumour. Therapeutic approach can be limited to conservative treatment, which is able to respect the parotid gland, its vascularization and innervation.

Laparoscopic surgery in pregnancy: long-term follow-up

OBJECTIVE

To describe the long-term consequences of laparoscopic surgery during pregnancy.

SUMMARY BACKGROUND DATA

Laparoscopic surgery is well established in the surgical community. Laparoscopic surgery in the pregnant patient is not yet broadly accepted; concern has been for fetal wastage, effects of carbon dioxide (CO(2)) on the developing fetus, and long-term sequelae during childhood development.

METHODS

This report documents 11 laparoscopic cases in pregnancy with follow-up of 1 to 8 years. The patients were in their 16th to 28th week of pregnancy. Two patients had chronic cholecystitis and biliary colic resulting in weight loss and multiple admissions. Three patients had acute cholecystitis, and three patients had acute appendicitis. Two patients underwent exploration for a diagnosis of acute abdomen, and both were found to have small bowel obstruction. All patients had general anesthesia and underwent an open Hasson trocar procedure with end-tidal CO(2) monitoring, sequential compression devices, and partial left decubitus positioning. Insufflation pressure was maintained at 10 mm Hg. The operative time ranged from 25 to 90 minutes.

RESULTS

Successful laparoscopic surgery was performed in 10 cases, with one conversion to an open procedure. Intraoperative and postoperative fetal monitoring was performed for at least 24 hours. No fetal distress or demise occurred, nor were any tocolytics used. The resultant children were then monitored, and no evidence of developmental or physical abnormalities was detected during the study period.

CONCLUSION

Laparoscopic surgery is now proving to be as safe as open surgery in pregnancy. This article reports long-term follow-up with no deleterious effects to either mothers or children.

[Anastomotic dehiscence in colorectal surgery]

Anastomotic leakage represents the most dangerous complication in digestive surgery and, particularly, in colorectal one. Indeed a careful evaluation and modification of all possible risk factors and a correct procedure aren't often enough to overcome a potential postoperative leakage or at least material filtration. The Authors review their series to analyse the role of all possible general and local risk factors and to verify what conditions can suggest an two or three stages operation.

[Intrahepatic biliary lithiasis: experience in 20 years]

In confirming that intrahepatic gallstones don't represent a frequent disease in western countries, Authors specify how this incidence is going to grow up slowly, but in a progressive way. In reporting their experience since 1980 to nowadays they point out how different diagnostic procedures and therapy way of acting were in the first and in the second deca. After having explained actual therapeutic direction that is described in literature, they finish by stating how this is often conditioned by complex anatomicopathological picture and by seriousness of hepatic damage that often comes with intrahepatic lithiasis.

[Color-Doppler sonographic mapping for the choice of treatment in variceal disease]

The Authors, after having reported Huch's classification concerning both large and small saphenas varixes, make a short historical excursus about the most significant operative methods. Then they start explaining how a correct therapeutic approach can't be done without a careful hemodynamic study. After having given data about their case-report, they conclude affirming how today the duplex-scanner permits to obtain an excellent radicality also with not very invasive techniques.

Microvascular assessment of burn depth conversion during varying resuscitation conditions

Conversion of partial- to full-thickness injuries, even after the burning has stopped, remains a significant clinical problem. We developed a rat model with a wide range of burn depths to study this phenomenon by microvascular assessment. Fifty-four male Sprague-Dawley rats weighing 460 g on average were studied. Real-time tissue monitoring of pH, paCO2, and paO2 was achieved by placement of a continuous blood gas monitor transducer in the aorta. Ten, 2-cm x 2-cm burns were created on each animal with milled aluminum templates (100 degrees C) with varying contact times. Conversion of burn depth in these wounds was documented by serial laser Doppler imager scanning over a 5-hour period. Animals received Ringer's lactate resuscitation at 0, 2, 4, 6, and 8 ml/kg/%burn. Serial laser Doppler scanning directly demonstrated progressive loss of perfusion to partial-thickness burns dependent upon the amount of fluid resuscitation. Conversion of partial- to full-thickness burns in this rat model (documented by laser Doppler microvascular assessment) was dependent upon how the animals were resuscitated.

[Antibiotic and immunostimulating prophylaxis in colorectal surgery]

The Authors, after considering post-operatory sepsis as cause of failures and as an important economic damage, make among them a distinction according to the arising area and to the seriousness of their manifestations. They, later, describe corrective and prophylactic measures which in colo-rectal surgery ase campulsory assumptions for sepsis prevention. After relating their experience, Authors reaffirm short-term protocol validity and point out validity of alternation of large spectrum molecules in order to avoid possible arising of bacterial resistances.

[Reflections on mesenteric infarct]

The authors relate their statistic about mesenteric infarction in the last five years and they get out the starting point in order to check the characteristics of a disease, which is today distinguished by an infaust prognosis. After few mentions about etiopathology and pathologic anatomy they keep their attention on clinic manifestations of disease and on diagnostic research. After dealing with medical and surgical therapy they declare how more refined diagnostic technique could help early diagnosis and consequently decrease morbidity and morbidity, which are completely unacceptable.

[Miles operation in rectal carcinoma: history and current status]

The Authors confirm how the advent of mechanical suture has directed the management of rectal carcinoma to an increasingly conservative attitude. In reporting their experience--which consists of about twenty years (222 patients) they specify how not only an increased incidence of recurrence has not appeared, but they have also observed a reduction of theirs (-5.2%). They then attempt to outline basic moments which have characterized the history of rectal carcinoma surgery and they state how today, 80 years since it was conceived, Miles' intervention maintains its validity, even if with more restrictive indications.

[A peculiar anomaly of the main biliary duct: choledochal cystic dilatation]

The Authors report a case of choledochal cystic dilatation and examine this particular anomaly of the main biliary duct analysing the complex classification. After a brief review of the embryology of the hepato-pancreatic ring, etiopathogenetic theories, clinic characteristics, as well as diagnostic and therapeutic possibilities for this affection are taken into account. It is concluded that the best therapeutic choice should be always based on an accurate evaluation of the anatomo-pathological conditions in each single case.

Violence against surgical residents

Violence against hospital personnel is underreported (less than one in five assaults), and accurate statistics as to the rate of violence against hospital personnel are thus difficult to establish. In the psychiatric discipline, an abundance of information has been published regarding violence in the health care setting, but few studies have examined violence outside psychiatric hospitals or by patients not diagnosed with psychiatric ailments. Using a survey that elicits information about workplace violence, we sought to gauge the prevalence of violent acts affecting general hospital workers who treat victims of violence on a daily basis. The survey was completed by a cohort of surgical staff nationwide (475 responses from 57 residency programs). Two hundred and eighty residents reported having witnessed one or more physical attacks, and 179 reported having been attacked. Violent acts were more likely to be committed in a public hospital than a private institution (P = 0.05). As shown in previous research, most attacks occurred in the emergency room (P = 0.01); the wards and parking lot were next in frequency. Women residents were more likely than men to call hospital security to intervene in a potentially violent situation (P = 0.04), and junior residents (postgraduate years 1-4) were more likely to be attacked than senior residents (> or = 5 years) (P = 0.04). The attacker was most likely to be a young black male between ages 19 and 30 (P = 0.01). We found no statistical relationship between the attacker and the victim regarding sex or race. Of the 475 respondents, 470 reported that they carry a gun themselves or know someone in the hospital environment who carries a gun.

[Spontaneous retroperitoneal hematoma from ileopsoas muscle bleeding. A case report]

The Authors report a case of spontaneous retroperitoneal hematoma due to iliopsoas muscle bleeding. The different causes responsible of such hematomas are taken into account as well as clinical, therapeutical and pathophysiologic aspects connected with the spontaneous bleeding of the iliopsoas muscle. As in the case observed, the Authors suggest that often a careful wait-and-see approach represents the most appropriate therapeutical choice.

Prospective assessment of the value of computed tomography for trauma

The use of computed tomography (CT) has helped revolutionize the process and accuracy of diagnosis of the trauma patient. We have noted a striking increase in the use of CT scanning early in the management of trauma patients at our trauma center and sought to assess our experience.

METHODS

All trauma patients admitted to our trauma center from February 1991 to February 1992 who received any CT scan within the first 12 hours after arrival were enrolled in the study. A positive (+) CT scan was defined as a scan that demonstrated a significant finding consistent with the injury and a negative (-) CT scan was one in which there were either no abnormalities or only incidental findings unrelated to the injury. Each patient was followed daily by one of the authors (A.G.R.). Patient records were reviewed and treating surgeons were interviewed to determine whether the CT scan improved the process of therapy. Morbidity incident to the performance of the CT scans was assessed.

RESULTS

1609 trauma patients underwent 2047 CT scans (1.3 CT scans per patient). Sixteen percent (n = 260) had scans of more than one part of the body. Thirty-eight percent (n = 770) of scans were positive but 29% (n = 225) of these were not helpful to the patient care process. Overall, 29% of scans, either because they were positive or negative, assisted in the clinical care of the patient. Six percent (n = 45) of CT scans were falsely positive. Sixty-five percent of scans were true negatives. Two patients died in the CT suite, 6 died shortly after completion of the scan, and 12 required emergency trips to the operating room from the CT suite.

CONCLUSIONS

A large number of CT scans are being performed in our trauma patient population. Less than 30% contributed to patient management. Because of morbidity and cost, strict surgeon and radiologist oversight of CT for trauma is essential.

[Evaluation of the use of calcitonin in rheumatoid arthritis by bone densitometry and the study of of phospho-calcium metabolism]

Forty-eight patients were subdivided into three groups according to the stage of their rheumatoid arthritis and to whether or not they received glucocorticoids; they were compared to healthy volunteers of similar sex, age, and body weight. Before calcitonin treatment, bone mineral content (BMC) of RA patients was significantly lowered, especially in patients with 3rd and 4th Steinbroker degree and in those taking glucocorticoids. Synthetic eel calcitonin was administered in three 60-day cycles separated by 40-day intervals with daily dosage 40 U.M.R.C. (1 vial). This treatment did not result in a increase of BMC compared to baseline. A further decrease of BMC observed at the end of treatment was not statistically significant. No appreciable variation was found in parameters of phospho-calcic metabolism.

[ Tissue and blood CEA levels in stomach cancer]

The assays of serum CEA is a useful prognostic marker in patients with stomach cancer. In this study pre-operative serum CEA and tissue CEA in tumour or biopsy were assayed in a group of patients with gastric carcinoma in order to assess their prognostic roles. Based on an analysis of the results the authors affirm that high serum CEA levels in patients with advanced stages of stomach cancer indicate a fatal prognosis, and likewise the finding of tissue CEA in loco-regional lymph nodes at the same concentration as that in the primary tumour is also the sign of a severe prognosis.

[Our experience with early gastric cancer]

Authors assert that, in Early gastric cancer diagnosis, anatomicomedical characteristics expressed on the basis of canons formulated by Endoscopy Japanese Society and by Lauren's unexipered classification are of particular interest. After having referred on characteristics observed on a group of patients, in the light of data given from medical Literature, they try to extrapolate aetiopathogenetic factors. These, together with anatomicopathological characteristics of the lesion, are the premises for a wise radical therapeutic choice.

[Anatomo-clinical considerations on early gastric cancer]

After having asserted the still rising interest for an as early as possible diagnosis of gastric cancer, authors refer on a group of patients who are carriers of Early gastric cancer. After having touched upon localization and histological characteristics of neoplasms, linger on the rules that leaded their therapeutic choice and they report the results of a follow-up dragged ten years long. They terminate affirming only a timeliness diagnosis can consent a really decisive therapeutic approach.

[Tumor markers in colorectal cancer]

Over the past ten years numerous studies have been carried out to identify tumour markers able to diagnose cancer of the digestive tract. The paper reports the combined use of some markers (CEA, TPA, GICA, CA 125) in patients with carcinoma of the colon-rectum. The Authors conclude that although these markers are of little use, especially in association, in the early diagnosis of disease, it is very important to utilise these markers to monitor patients following surgical, chemotherapeutic or radiotherapeutic treatment.

[Clinical considerations on spontaneous pneumothorax]

The authors, after confirming the social interest of spontaneous pneumothorax, report the results of their experience taking hint from it for some clinical considerations. They mention different therapies suggested for the treatment of this disease; particularly they dwell upon aspiration techniques considered today the treatment of choice in most cases. They conclude affirming that this technique improves results, diminishes risks and complications, and considerably reduces hospitalization.