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McKenna DP, McMonagle MP. Plain film of the abdomen remains a low sensitivity test in A&E. Ir J Med Sci 2024; 193:341-343. [PMID: 37340226 PMCID: PMC10808235 DOI: 10.1007/s11845-023-03427-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND Plain film abdomens (PFA) are frequently used in the emergency department to help guide the management of patients presenting with abdominal symptoms. A plain film abdomen contributes minimally to clinical scenarios due to low sensitivity and specificity. Is a PFA useful in the emergency setting or does it serve to further complicate decision making? AIM We hypothesise that PFAs in the emergency department are over utilised to falsely reassure clinicians and patients alike. METHODS A search of the National Integrated Medical Imaging System (NIMIS) database in an Irish tertiary referral hospital was conducted. All plain film abdominal radiographs requested by the emergency department between 01/01/2022 and 31/08/2022 were identified. Requests where there was suspicion of foreign body were excluded. A retrospective search of the NIMIS database identified subjects who underwent subsequent imaging. RESULTS A total of 619 abdominal films were deemed suitable for inclusion. These comprised of 338 male and 282 female subjects. Subjects had an average age of 64 years. Fifty-seven per cent of PFAs detected no abnormality. Forty-two per cent of subjects had subsequent imaging. The plain film findings correlated with further imaging in only 15% of cases. One case of ruptured aortic aneurysm and 11 perforations were detected on computerised tomography, none of these cases were evident on abdominal X-ray. CONCLUSION Plain film abdomen requests are over utilised in the emergency department. PFAs are not sensitive for detecting acute pathology and should not be used to decide if a patient requires further imaging or a full clinical assessment.
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Affiliation(s)
- Daniel P McKenna
- Department of Surgery, University Hospital Waterford, Dunmore Road, Waterford, X91 ER8E, UK.
| | - Morgan P McMonagle
- Department of Surgery, University Hospital Waterford, Dunmore Road, Waterford, X91 ER8E, UK
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McMonagle MP, Sarani B, Jenoff J, Schwab CW. Vascular damage control at the thoracic outlet. Ann R Coll Surg Engl 2021; 103:e244-e248. [PMID: 34464576 DOI: 10.1308/rcsann.2020.7100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is challenging due to the anatomical location at the thoracic outlet. Historically, vessel ligation has been used to control bleeding, but this is often performed late, when metabolic exhaustion is established, and is associated with upper-limb ischaemia and limb loss. Rapid proximal control through the chest with temporary intravascular shunting is the damage control technique of choice to temporise blood loss and restore perfusion until the patient is physiologically optimised for a delayed definitive vascular repair. We describe a case of vascular damage control in a patient after gunshot wound.
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Affiliation(s)
| | - B Sarani
- George Washington University Hospital, Washington, DC, USA
| | - J Jenoff
- Jefferson University Hospital, Philadelphia, PA, USA
| | - C W Schwab
- Penn-Presby Trauma Center, Philadelphia, PA, USA
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McMonagle MP, Kilduff CL, Reilly P, Sims C. The 'Philadelphia Technique' for abdominal closure. Ann R Coll Surg Engl 2020; 102:638-640. [PMID: 32538125 DOI: 10.1308/rcsann.2020.0142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | | | - P Reilly
- Penn Presbyterian Medical Center, Philadelphia, US
| | - C Sims
- Penn Presbyterian Medical Center, Philadelphia, US
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Handelman GS, Rogers AC, Babiker Z, Lee MJ, McMonagle MP. Media messaging in diagnosis of acute CXR pathology: an interobserver study among residents. Intern Emerg Med 2018; 13:1257-1263. [PMID: 29705886 DOI: 10.1007/s11739-018-1859-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 04/21/2018] [Indexed: 11/30/2022]
Abstract
The objectives of the study were to determine whether diagnostic accuracy and reliability by on-call teams is affected by communicating chest radiograph (CXR) images via instant messaging on smartphones in comparison to viewing on a workstation. 12 residents viewed 100 CXR images each with a 24% positive rate for significant or acute findings sent to their phones via a popular instant messaging application and reported their findings if any. After an interval of 42 days they viewed the original DICOM images on personal computers and again reported their findings. There were no statistically significant differences in accuracy, agreement, sensitivity, specificity, positive predictive value or negative predictive value between desktop workstation viewed images and images sent via the mobile application. Media messaging is a useful adjunct for quick second opinions on radiological images, without significant decay in diagnostic accuracy. If technical, ethical and legal issues are addressed, it could be incorporated into practice as a useful adjunct.
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Affiliation(s)
- Guy S Handelman
- Department of Radiology, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK
| | - Ailin C Rogers
- Department of Surgery, Beaumont Hospital, Dublin, Ireland
| | - Zafir Babiker
- Department of Radiology, University Hospital Waterford, Waterford, Ireland
| | - Michael J Lee
- Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - Morgan P McMonagle
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
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Ahmed O, Rogers AC, Balfe P, Waldron BM, Pretorius F, McMonagle MP. Clinical utility of abdominal and pelvic ultrasound in the evaluation of right iliac fossa pain in females. Ir J Med Sci 2017; 186:775-779. [PMID: 28130666 DOI: 10.1007/s11845-017-1557-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 01/11/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Ultrasound (US) is often the imaging modality of choice in women with acute right iliac fossa (RIF) pain, identifying the appendix in up to 99% of patients. The literature, however, lacks clear guidelines on how ultrasonography should be performed to maximise sensitivity and specificity in such patients. Many centres perform untargeted abdomino-pelvic scans, including organs such as the liver and spleen, which unlikely contribute to the presenting complaint. AIMS We aimed to evaluate the clinical utility of unfocussed abdominal and pelvic US in women of reproductive age with acute RIF pain. METHODS This multicentre study describes 501 women between the ages of 12 and 50, over a 3-year period from three institutions, presenting acutely with RIF pain and investigated with US abdomen and pelvis. RESULTS 5.9% of cases confirmed appendicitis sonographically. A normal appendix was visualised in 0.2%. Over 10% identified gynaecological pathology, 41% relating to the right ovary. 10.4% incidental extra-pelvic findings were unrelated to the acute clinical presentation. 0.8% of patients had extra-pelvic findings meriting further clinical assessment. CONCLUSION The results herein reflect findings from high volume emergency surgical departments, demonstrating that unfocussed abdominal and pelvic ultrasounds are not an appropriate use of resources in reproductive women with RIF pain. Clinically relevant extra-pelvic US findings account for less than 1%, rarely contributing to the acute presentation. The appendix was only visualised in 6% of patients, suggesting that a focussed appendiceal and pelvic US would better assist diagnosis with a higher yield and increased sensitivity and specificity.
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Affiliation(s)
- O Ahmed
- Department of General Surgery, University Hospital Kerry, Tralee, County Kerry, Republic of Ireland.
| | - A C Rogers
- Department of General Surgery, University Hospital Kerry, Tralee, County Kerry, Republic of Ireland.,Department of General Surgery, University Hospital Waterford, Waterford, Republic of Ireland.,Department of General Surgery, St Luke's Hospital Kilkenny, Kilkenny, Republic of Ireland
| | - P Balfe
- Department of General Surgery, St Luke's Hospital Kilkenny, Kilkenny, Republic of Ireland
| | - B M Waldron
- Department of General Surgery, University Hospital Kerry, Tralee, County Kerry, Republic of Ireland
| | - F Pretorius
- Department of General Surgery, St Luke's Hospital Kilkenny, Kilkenny, Republic of Ireland
| | - M P McMonagle
- Department of General Surgery, University Hospital Waterford, Waterford, Republic of Ireland
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Rogers AC, Turley LP, Cross KS, McMonagle MP. Meta-analysis of the use of surgical sealants for suture-hole bleeding in arterial anastomoses. Br J Surg 2016; 103:1758-1767. [PMID: 27714778 DOI: 10.1002/bjs.10308] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/07/2016] [Accepted: 07/21/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Suture-hole bleeding in arterial anastomoses prolongs operating time and increases blood loss, particularly with the use of prosthetic grafts. Surgical sealants (such as fibrin) may be used as haemostatic adjuncts in vascular surgery. This is a systematic review and meta-analysis of published studies that investigated the utility of surgical sealants in arterial-to-prosthetic graft anastomoses. METHODS A systematic review was undertaken of papers published until January 2015 on Embase, MEDLINE, PubMed, PubMed Central and Cochrane databases that analysed the use of surgical sealants as haemostatic adjuncts after arterial anastomoses. RCTs were included, with study endpoints of time to haemostasis or haemostasis at 5 min. Secondary outcomes included treatment failure, mean difference in estimated blood loss and duration of surgery. Sensitivity and subgroup analyses were performed, as well as funnel plot analysis for publication bias. RESULTS A total of 2513 citations were reviewed; 19 RCTs comprising 1560 patients were ultimately included in the analysis. The majority of studies compared fibrin sealant with control haemostatic measures. Pooled analysis suggested that surgical sealants reduced the time to haemostasis (mean difference 243·26 (95 per cent c.i. 183·99 to 302·53) s; P < 0·001), improved haemostasis at 5 min (odds ratio 4·50, 95 per cent c.i. 2·59 to 7·81; P < 0·001), and were associated with less treatment failure, blood loss and shorter duration of surgery. CONCLUSION Surgical sealants appear to reduce suture-hole bleeding significantly in vascular prosthetic graft anastomoses compared with standard haemostatic measures.
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Affiliation(s)
- A C Rogers
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
| | - L P Turley
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
| | - K S Cross
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
| | - M P McMonagle
- Department of Vascular Surgery, University Hospital Waterford, Waterford, Ireland
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Rogers AC, Bourke M, Galbraith AS, Ryan AG, Cross KSC, McMonagle MP. Mycotic Aneurysm of the Extracranial Internal Carotid Artery, Resect and Ligate or Reconstruct? Ann Vasc Surg 2016; 35:203.e5-203.e10. [DOI: 10.1016/j.avsg.2016.01.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 01/04/2016] [Accepted: 01/07/2016] [Indexed: 11/28/2022]
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Rogers AC, Reddy PW, Cross KS, McMonagle MP. Using the diamond intermediate anastomosis in composite sequential bypass grafting for critical limb ischemia. J Vasc Surg 2016; 63:1116-20. [DOI: 10.1016/j.jvs.2015.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 12/19/2015] [Indexed: 10/22/2022]
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Tolstoy NS, Aized M, McMonagle MP, Holena DN, Pascual JL, Sonnad SS, Sims CA. Mineralocorticoid deficiency in hemorrhagic shock. J Surg Res 2012; 180:232-7. [PMID: 22683082 DOI: 10.1016/j.jss.2012.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 04/10/2012] [Accepted: 05/04/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the critically ill, mineralocorticoid deficiency (MD) is associated with greater disease severity, the development of acute renal insufficiency, and increased mortality. We hypothesized that severely injured trauma patients presenting with hemorrhagic shock would demonstrate a high degree of MD. We also hypothesized that MD in these patients would be associated with increased length of stay, hypotension, fluid requirements, and acute kidney injury (AKI). MATERIALS AND METHODS Thirty-two trauma patients in hemorrhagic shock on admission to the trauma bay (SBP <90 mm Hg × 2) were enrolled. Blood samples were obtained on ICU admission and 8, 16, 24, and 48 hours later. Plasma aldosterone (PA) and renin (PR) were assayed by radioimmunoassay. MD was defined as a ratio of PA/PR ≤2. Demographic data, injury severity score, ICU and hospital length of stay, fluid requirements, mean arterial pressure, serum sodium, hypotension, and risk for AKI were compared for patients with and without MD. RESULTS At ICU admission, 48% of patients met criteria for MD. Patients with MD were significantly more likely to experience hypotension (MAP ≤60 mm Hg) during the study period. MD patients required significantly more units of blood in 48 h than non-MD patients (13 [7-22] versus 5 [2-7], P = 0.015) and had increased crystalloid requirements (18L [14-23] versus 9L [6-10], P < 0.001). MD patients were at higher risk for AKI according to RIFLE and AKIN criteria. CONCLUSIONS MD is a common entity in trauma patients presenting in hemorrhagic shock. Patients with MD required a more aggressive resuscitative effort, were more likely to experience hypotension, and had a higher risk of AKI than non-MD patients. Future studies are needed to fully understand the impact of MD following trauma and the potential role for hormonal replacement therapy.
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Abstract
BACKGROUND Time to definitive trauma care directly influences patient survival. Patient transport (retrieval) services are essential for the transportation of remotely located trauma patients to a major trauma centre. Trauma surgical expertise can potentially be combined with the usual retrieval response (surgically supported response) and delivered to the patient before patient transportation. We identified the frequency and circumstances of such surgically supported retrievals. METHODS Retrospective review of trauma patients transported by the NRMA CareFlight, New South Wales Medical Retrieval Service, Australia, from 1999 to 2003, identifying patients who had a surgically supported retrieval response and an urgent surgical procedure carried out before patient transportation to an major trauma centre. RESULTS Seven hundred and forty-nine trauma interhospital patient transfers were identified of which 511 (68%) were categorized as urgent and 64% of which were rural based. Three (0.4%) patients had a surgically supported retrieval response and had an urgent surgical procedure carried out before patient transportation. All patients benefited from that early surgical intervention. CONCLUSION A surgically supported retrieval response allows for the more timely delivery of urgent surgical care. Patients can potentially benefit from such a response. There are, however, important operational considerations in providing a surgically supported retrieval response.
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Affiliation(s)
- Morgan P McMonagle
- NRMA CareFlight, NSW Medical Retrieval Service, Sydney, New South Wales, Australia
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Affiliation(s)
- Morgan P McMonagle
- Department of Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland [corrected]
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12
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McMonagle MP, Halpenny M, McCarthy A, Mortell A, Manning F, Kilty C, Mannion D, Wood AE, Corbally MT. Alpha glutathione S-transferase: a potential marker of ischemia-reperfusion injury of the intestine after cardiac surgery? J Pediatr Surg 2006; 41:1526-31. [PMID: 16952586 DOI: 10.1016/j.jpedsurg.2006.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of the study was to assess the utility of alpha glutathione S-transferase (alphaGST) as a potential marker of intestinal ischemia-reperfusion injury in children after cardiac surgery. METHODS Twenty-six patients undergoing cardiac surgery were enrolled in this longitudinal experimental study. Blood samples were drawn for analysis at specified time points during surgery and analyzed for alphaGST levels. Clinical indices of splanchnic morbidity were assessed up to discharge from hospital. Results were analyzed using Mann-Whitney tests and linear mixed effects models. RESULTS Two groups were identified. Group 1 (n = 16) showed no intestinal morbidity and group 2 (n = 10) had signs of intestinal morbidity. Statistical differences were shown between the 2 groups with respect to time with aortic cross-clamp (ACC) in situ, time on cardiac bypass, duration of operation, time to enteral feeding and full feeding, time on mechanical ventilation, and time in the intensive care unit postoperatively. The serum concentration of alphaGST was significantly higher for group 2 and this rise was greatest after removal of the ACC. CONCLUSIONS AlphaGST showed significant elevation in patients with prolonged bypass times and ACC times. These patients also displayed signs of intestinal morbidity, suggesting that this marker may be useful in screening patients at risk for intestinal pathology. This rise in alphaGST was associated with a prolonged ischemia time, and was greatest after the cross-clamp was released, suggesting that it is a postischemic reperfusion phenomenon leading to its elevation. A low alphaGST level appears to exclude significant intestinal ischemia.
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Affiliation(s)
- Morgan P McMonagle
- Department of Paediatric Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland.
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McMonagle MP, Wongpanit C, Hawthorne W, Vicaretti M, Fletcher J. The potential role of PI-88 (sulfonated mono-phosphorylated mannose oligosaccharide) in the modification of intimal hyperplasia after carotid artery patch grafting. Vascul Pharmacol 2006. [DOI: 10.1016/j.vph.2006.08.332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McMonagle MP. Images in clinical medicine. The importance of early cervical-spine radiography. N Engl J Med 2006; 354:e4. [PMID: 16436760 DOI: 10.1056/nejmicm040733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Affiliation(s)
- M P McMonagle
- Department of Trauma-Surgery, Westmead Hospital, Westmead, Sydney, Australia.
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Affiliation(s)
- M P McMonagle
- Department of Trauma-Surgery, Westmead Hospital, Sydney, Australia.
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