Management and outcomes of firearm-related vascular injuries

BACKGROUND

Violence due to firearms is a major global public health issue and vascular injuries from firearms are particularly lethal. The aim of this study was to analyse population-based epidemiology of firearm-related vascular injuries.

METHODS

This was a retrospective nationwide epidemiological study including all patients with firearm injuries from the national Swedish Trauma Registry (SweTrau) from January 1, 2011 to December 31, 2019. There were 71,879 trauma patients registered during the study period, of which 1010 patients were identified with firearm injuries (1.4%), and 162 (16.0%) patients with at least one firearm-related vascular injury.

RESULTS

There were 162 patients admitted with 238 firearm-related vascular injuries, 96.9% men (n = 157), median age 26.0 years [IQR 22-33]. There was an increase in vascular firearm injuries over time (P < 0.005). The most common anatomical vascular injury location was lower extremity (41.7%) followed by abdomen (18.9%) and chest (18.9%). The dominating vascular injuries were common femoral artery (17.6%, 42/238), superficial femoral artery (7.1%, 17/238), and iliac artery (7.1%, 17/238). Systolic blood pressure (SBP) < 90 mmHg or no palpable radial pulse in the emergency department was seen in 37.7% (58/154) of patients. The most common vascular injuries in this cohort with hemodynamic instability were thoracic aorta 16.5% (16/97), femoral artery 10.3% (10/97), inferior vena cava 7.2% (7/97), lung vessels 6.2% (6/97) and iliac vessels 5.2% (5/97). There were 156 registered vascular surgery procedures including vascular suturing (22%, 34/156) and bypass/interposition graft (21%, 32/156). Endovascular stent was placed in five patients (3.2%). The 30-day and 90-day mortality was 29.9% (50/162) and 33.3% (54/162), respectively. Most deaths (79.6%; 43/54) were within 24-h of injury. In the multivariate regression analysis, vascular injury to chest (P < 0.001) or abdomen (P = 0.002) and injury specifically to thoracic aorta (P < 0.001) or femoral artery (P = 0.022) were associated with 24-h mortality.

CONCLUSIONS

Firearm-related vascular injuries caused significant morbidity and mortality. The lower extremity was the most common injury location but vascular injuries to chest and abdomen were most lethal. Improved early hemorrhage control strategies seem critical for better outcome.

Thoracoabdominal gastrectomy and distal 2/3 esophageal resection with wide lymph node dissection for type II and III adenocarcinoma at the gastro-esophageal junction

BACKGROUND

For locally advanced Siewert type II and III tumors we have performed total gastrectomy including resection of the distal 2/3 of the esophagus, through separate abdominal and right chest incisions (THX-ABD). The procedure involves wide lymphadenectomy in the abdomen/chest and a Roux-en-Y jejunostomy to the level of the azygos vein or above. The aim of the study was to investigate short- and long-term results for this rarely used procedure.

METHODS

Retrospective study of 83 radio-chemotherapy naïve patients with adenocarcinoma at the gastro-esophageal junction (Siewert type II n = 65 and type III n = 18) operated upon 1986-2011.

RESULTS

2/83 (2.4%) patients died in hospital. 70/83 (84%) patients had R0-resections. 82/83 (99%) patients had free longitudinal resection margins. Overall 5-year survival was 22/83 (27%).

CONCLUSION

THX-ABD can be performed with high rates of R0 resections and with low in-hospital mortality. Long-term survival rate was not better compared with less extensive surgical procedures.

Validation of the paracetamol absorption test for measuring gastric tube emptying in esophagectomized patients versus gold standard scintigraphy

OBJECTIVE

Scintigraphy is the gold standard for objective measurement of delayed gastric tube emptying after esophagectomy. The aim of this pilot study is to validate, by reference to scintigraphy, the paracetamol absorption test for measuring gastric tube emptying in esophagectomized patients.

MATERIAL AND METHODS

The paracetamol absorption test and scintigraphy were performed simultaneously in 13 patients who had undergone an esophagectomy with gastric tube reconstruction. Emptying was calculated for both methods and compared. Post-esophagectomy symptoms and quality of life (QoL) were assessed by European Organization on Research and Treatment of Cancer questionnaires.

RESULTS

Mean time to 50% emptying was 17 min measured with the paracetamol absorption test and 23 min with scintigraphy. For time to 25% emptying, Bland-Altman calculation gave a bias of 1.6 min and 95% limits of agreement (LoA) of -6.3 to 9.5 min. For time to 50% emptying, there was one outlier resulting in a bias of -6.33 min and 95% LoA of -36.4 to 23.8 min. For time to 75% emptying, bias was -11.6 min and 95% LoA of -38.5 to 15.4 min. Post-esophagectomy symptoms were similar to those reported previously, and QoL was comparable to the general Swedish population.

CONCLUSIONS

There was reasonably close correlation between the paracetamol absorption test and scintigraphy for time to 25% and 50% emptying, except for one outlier. For time to 75% emptying the methods were in less accordance. The results indicate that the paracetamol absorption test may be a useful screening tool for identifying delayed gastric tube emptying in this patient group.

Two different surgical approaches in the treatment of adenocarcinoma at the gastroesophageal junction

BACKGROUND

Adenocarcinoma at the gastroesophageal junction may be regarded as of esophageal or of gastric origin, and tumor removal may follow the principles of esophagectomy or extended gastrectomy. We determined the impact of this strategy on our patients with tumors at this site.

METHODS

Baseline patient and tumor characteristics were collected, and tumors were categorized according to Siewert's classification (I, II, or III) of gastroesophageal junction tumors. Totally, 133 patients were operated on between 1990 and 2001. Ninety-six patients with type I (n = 67), II (n = 26), and III (n = 3) tumors underwent esophagectomy and gastric tube reconstruction, and 37 patients with type I (n = 5), II (n = 26), and III (n = 6) tumors underwent extended gastrectomy and long Roux-en-Y reconstructions.

RESULTS

After adjusting for the independently significant impact factors-tumor stage, tumor dissection (R0-R2), and length of tumor free resection margins-we did not find any specific survival benefit associated with either of the two evaluated surgical approaches for tumor resection and reconstruction. The EORTC quality of life forms revealed good results as indicated by the functional scales and the symptom scales.

CONCLUSIONS

Provided that adequate tumor dissection is performed, patients with adenocarcinoma at the gastroesophageal junction can be resected and reconstructed using the principles for esophagectomy or extended gastrectomy.

Oxytocin is expressed throughout the human gastrointestinal tract

BACKGROUND/AIM

Several studies have described that oxytocin exerts stimulatory or inhibitory effects on gut functions. Recently, mRNA for oxytocin and its receptor was found throughout the entire human gastrointestinal (GI) tract. The aim of this study was to examine the cellular localization and distribution of the corresponding proteins.

MATERIAL AND METHODS

Full-thickness biopsies from 24 patients, covering the entire GI tract, were collected during operations at the Department of Surgery in Malmö and Lund. The biopsies were taken from non_affected margins. The biopsies were fixed by immersion, rinsed in buffered sucrose, and kept frozen at 70 degrees C. Indirect immunofluorescence with primary antibodies to oxytocin and its receptor was used.

RESULTS

Oxytocin was expressed in nerve cell bodies and nerve fibres in the myenteric and submucous ganglia all along the GI tract. Immunoreactive nerve cell bodies in myenteric ganglia predominated in the proximal (antrum and duodenum) and distal gut, while those in the submucous ganglia were more numerous in the ileum and colon. The oxytocin receptor was not detectable by two different antibodies in any tissue in the GI tract.

CONCLUSION

Oxytocin is expressed in the myenteric and submucous ganglia and nerve fibres along the entire human GI tract. The role for oxytocin in the physiology and pathophysiology of the bowel remains to be settled.

Circulating cat allergen and immune complexes in cat-allergic children

BACKGROUND

The first encounters with allergens seem to influence the development of allergy. Food antigens have been detected in sera as free antigens and in complexes with IgG but less is known about the presence of inhalant allergens.

OBJECTIVE

To investigate the presence of the major cat allergen Fel d 1, either as free allergen and/or in complexes with IgG and IgE antibodies in sera from atopic children.

METHODS

Serum samples from 33 cat allergic asthmatic children, 7-17 years old, and 15 non-allergic controls were investigated for the presence of Fel d 1 by ELISA (detection limit 0. 13 microg/L). To detect immune complexes (IC), the IgG fraction from Fel d 1 positive sera was purified by affinity chromatography. Purified and non-absorbed material was then analysed for allergen content and specific IgG antibody levels. Immune complexes with Fel d 1 IgE were detected by coupling anti-Fel d 1 MoAb to paramagnetic particles.

RESULTS

Fel d 1 was detected (0.15-1.8 microg/L) in 23 of the 33 patients (70%) but not from any of the controls. Eighteen samples contained IgE-Fel d 1 IC and two of four tested samples contained Fel d 1 in the IgG fraction. Electrophoresis and Western blotting of IgG purified material using anti-Fel d 1 MoAb corroborated the presence of IgG-Fel d 1 IC.

CONCLUSION

Free-circulating inhalant allergen and IC with allergens may contribute to maintaining immune responsiveness and sensitivity.