The contribution of the Israeli trauma system to the survival of road traffic casualties

BACKGROUND

According to the World Health Organization, over one million people die annually from traffic crashes, in which over half are pedestrians, bicycle riders and two-wheel motor vehicles. In Israel, during the last decade, mortality from traffic crashes has decreased from 636 in 1998 to 288 in 2011. Professionals attribute the decrease in mortality to enforcement, improved infrastructure and roads and behavioral changes among road users, while no credit is given to the trauma system. Trauma systems which care for severe and critical casualties improve the injury outcomes and reduce mortality among road casualties.

GOALS

1) To evaluate the contribution of the Israeli Health System, especially the trauma system, on the reduction in mortality among traffic casualties. 2) To evaluate the chance of survival among hospitalized traffic casualties, according to age, gender, injury severity and type of road user.

METHODS

A retrospective study based on the National Trauma Registry, 1998-2011, including hospitalization data from eight hospitals.

OUTCOMES

During the study period, the Trauma Registry included 262,947 hospitalized trauma patients, of which 25.3% were due to a road accident. During the study period, a 25% reduction in traffic related mortality was reported, from 3.6% in 1998 to 2.7% in 2011. Among severe and critical (ISS 16+) casualties the reduction in mortality rates was even more significant, 41%; from 18.6% in 1998 to 11.0% in 2011. Among severe and critical pedestrian injuries, a 44% decrease was reported (from 29.1% in 1998 to 16.2% in 2011) and a 65% reduction among bicycle injuries. During the study period, the risk of mortality decreased by over 50% from 1998 to 2011 (OR 0.44 95% 0.33-0.59. In addition, a simulation was conducted to determine the impact of the trauma system on mortality of hospitalized road casualties. Presuming that the mortality rate remained constant at 18.6% and without any improvement in the trauma system, in 2011 there would have been 182 in-hospital deaths compared to the actual 108 traffic related deaths. A 41% difference was noted between the actual number of deaths and the expected number.

CONCLUSIONS

This study clearly shows that without any improvement in the health system, specifically the trauma system, the number of traffic deaths would be considerably greater. Although the health system has a significant contribution on reducing mortality, it does not receive the appropriate acknowledgment or resources for its proportion in the fight against traffic accidents.

Prevention of perioperative venous thromboembolism and coronary events: differential responsiveness to an intervention program to improve guidelines adherence

INTRODUCTION

Prevention of venous thromboembolism and coronary events (with beta-blockers) during and after surgery is at the top of a list of safety practices for hospitalized patients, recommended by the Agency for Health Care Research and Quality (AHRQ). We wished to determine and improve adherence to clinical guidelines for these topics in our institution. PATIENTS, MATERIAL, AND METHODS: A prospective survey was conducted over several weeks on operated patients in a 1200-beds medical center (a teaching, community and referral hospital in Jerusalem, Israel). Eligibility for and actual administration of prophylactic treatment with anticoagulant and beta-blockers were determined. Following an intervention program, which included staff meetings, development of local protocols, and academic detailing by a nurse, the survey was repeated.

RESULTS

In general, adherence to recommended anticoagulation prophylaxis was low, found in only 29% [95% confidence interval (CI) = 23-36] of eligible patients. After the intervention, adequate anticoagulation increased to 50% (95% CI = 40-59) of eligible patients (P < 0.001). Initiation of beta-blockers in preventing perioperative cardiac events was very low (0%, 95% CI = 0-5%) and did not increase after intervention.

CONCLUSIONS

Adherence to guidelines for prevention of surgical complications was found to be low in our institution. A multifaceted intervention significantly increased use of prophylaxis for venous thromboembolism but not for coronary events. This differential response suggests that the success of a quality improvement project strongly depends on topic content and its phase of acceptance.

Mast cells and eosinophils have a potential profibrogenic role in Crohn disease

BACKGROUND

Mast cells and eosinophils have an important role in allergic inflammation and probably also in chronic inflammatory diseases resulting in fibrosis, such as Crohn disease where fibrosis is present as strictures. The involvement of mast cells and eosinophils in Crohn disease fibrosis was investigated.

METHODS

Biopsies from diseased foci were stained for mast cells, eosinophils, anti-collagen type IV and VIII, laminin and alpha-smooth muscle actin (alpha-SMA) (IHC). Fibroblasts outgrown from the biopsies and a normal fetal intestinal fibroblast line were cultured in the presence of the human mast cell line HMC-1, or of human peripheral blood eosinophil (MACS, purity > 98%) sonicates, or of selected mediators. Fibroblast proliferation (3H-thymidine), collagen synthesis ([3H]-proline) and collagen gel contraction were evaluated.

RESULTS

Mast cells were present in all the biopsies and only faintly positive for extra cellular matrix (ECM) products. Pronounced eosinophilia was detected in only two cases. Mast cell sonicates increased both Crohn disease (alpha-SMA positive) and control fibroblast proliferation, decreased collagen production and increased collagen gel contraction. Eosinophil sonicates increased fibroblast proliferation, gel contraction and collagen production. TNF-alpha decreased collagen production. Histamine, tryptase and chymase had no influence.

CONCLUSIONS

These in vitro data show that mast cells and eosinophils could be involved in modulating Crohn disease fibrosis by directly influencing intestinal fibroblast properties.

Mast cells involvement in the inflammation and fibrosis development of the TNBS-induced rat model of colitis

BACKGROUND

Mast cells have been implicated in chronic inflammatory conditions resulting in fibrosis, such as Crohn disease. However, a link between inflammation, fibrosis and mast cells has not been demonstrated in human or animal intestinal diseases. This work was undertaken to analyze whether mast cells play a role in inflammation and fibrosis in the TNBS-induced rat colitis.

METHODS

Rats were rectally instilled 2,4,6,-trinitrobenzene sulfonic acid in ethanol, and immediately or 4 days later injected daily i.p. with nedocromil sodium, a mast cell stabilizer, compound 48/80, a mast cell activator, or saline. Rats were sacrificed 5 days post-TNBS, or on day 21. Intestinal inflammation and fibrosis were assessed by gross and histopathological evaluation. Colonic mast cell numbers (toluidine blue) and collagen (type I mRNA expression) were evaluated. Mast cell sonicate was added to rat colon fibroblasts. Fibroblast proliferation (3H-thymidine), collagen synthesis (3H-proline) and contractile activity (tridimensional collagen lattice contraction) were then assessed.

RESULTS

Nedocromil reduced inflammation and fibrosis possibly by decreasing mast cell numbers and activation and consequent collagen production. Compound 48/80 slightly enhanced the severity of the disease by activating mast cells. Mast cells increased fibroblast proliferation, collagen production and contractile activity.

CONCLUSIONS

Mast cells are involved in the gastrointestinal tract inflammation and fibrosis of the TNBS-colitis rats.

High rate of candidemia in patients sustaining injuries in a bomb blast at a marketplace: a possible environmental source

In this study, a cluster of candidemia among patients sustaining injuries in a bomb blast at a marketplace was investigated by means of a multivariate analysis, a case-control study, and quantitative air sampling. Candidemia occurred in 7 (30%) of 21 patients (58% of those admitted to the intensive care unit [ICU]) between 4 and 16 days (mean, 12 days) after the injury and was the single most frequent cause of bloodstream infections. Inhalation injury was the strongest predictor for candidemia by multivariate analysis. Candidemia among the case patients occurred at a significantly higher rate than among comparable trauma patients injured in different urban settings, including a pedestrian mall (2 of 29; P=. 02), and among contemporary ICU control patients (1 of 40; P=.001). Air sampling revealed exclusive detection of Candida species and increased mold concentration in the market in comparison with the mall environment. These findings suggest a role for an exogenous, environmental source in the development of candidemia in some trauma patients.

Factors contributing to physicians' success in the advanced trauma life support program in Israel

BACKGROUND

Since its introduction in Israel, more than 4,000 physicians from various specialties and diverse medical backgrounds have participated in the Advanced Trauma Life Support course.

OBJECTIVES

To analyze the factors that influence the success of physicians in the ATLS written tests.

METHODS

A retrospective study was conducted of 4,475 physicians participating in the Israeli ATLS training program between 1990 and 1996. Several variables in the records of these physicians were related to their success or failure in the final written examination of the course.

RESULTS

Age, the region of medical schooling, and the medical specialty were found to significantly influence the successful completion of the ATLS course.

CONCLUSIONS

Physicians younger than 45 years of age or with a surgical specialty are more likely to graduate the ATLS course. The success rate could be improved if the program's text and questionnaires were translated into Hebrew.

Advanced trauma life support versus Combat Trauma Life Support courses: a comparison of cognitive knowledge decline

This prospective study was conducted to compare cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) and Combat Trauma Life Support (CTLS) courses in Israel. The investigation was based on multiple-choice questions that tested the results of 211 ATLS and CTLS course graduates and was performed 3 to 66 months after completion of the courses. These results were then compared with the examination outcomes immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the two courses. No significant difference was found in the rate of decline in knowledge gained from the two courses after a given period. Priority for refresher courses should be set regardless of type of course previously attended by physicians.

Results of reconstruction in major pelvic and extremity venous injuries

PURPOSE

Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied.

METHODS

We retrospectively reviewed 46 patients with 47 venous injuries.

RESULTS

Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations (P <.02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 +/- 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions.

CONCLUSION

Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low.

Placement of a peritoneal dialysis catheter with routine omentectomy--does it prevent obstruction of the catheter?

OBJECTIVE

To find out if routine omentectomy reduced the incidence of obstruction and other complications of catheters inserted for continuous ambulatory peritoneal dialysis (CAPD).

DESIGN

Retrospective study.

SETTING

Teaching hospital, Israel.

SUBJECTS

60 patients with end stage renal failure who needed catheters for CAPD.

INTERVENTION

Routine omentectomy during insertion of the catheter, usually under local anaesthesia.

MAIN OUTCOME MEASURES

Short and long term morbidity, and mortality.

RESULTS

No patient died as a result of the procedure. The catheter obstructed in only one patient (2%) during a mean follow-up period of 28 months (range 2-108), and 90% of the catheters survived one year.

CONCLUSIONS

Routine omentectomy during insertion of a catheter for CAPD under local anaesthesia is safe and the incidence of obstruction is low. Prospective randomised studies are needed before it can be recommended as the procedure of choice.

Emergency preparedness and response in Israel during the Gulf War

We examined the effect of the emergency response on medical and public health problems during the 1991 Gulf War in Israel. On the first day of the conflict, the number of deaths from suffocation, asphyxiation, aspiration, myocardial infarction, cardiac arrest, and cerebrovascular accident increased abruptly, as did the number of sudden deaths associated with the use of tight-fitting masks with filters in sealed rooms. Much of the excess risk for death from cardiorespiratory complications during the first alert may have been a consequence of its duration (140 minutes). Mass evacuation and concrete buildings are believed to have kept the death toll from trauma down, and mask use may have protected against facial and upper-airway injuries. Falls and hip fractures, airway irritation from exposure to bleach, carbon monoxide intoxication from open kerosene heaters in sealed rooms, and self-injection with atropine syringes were also noted. A measles epidemic and increased death rates from automobile crashes were other preventable causes of death. Protection against biological warfare was limited to surveillance of trends for pneumonia and gastroenteritis. Emergency planners failed to anticipate the need for better mask fit, hands-on training in the use of masks, and special guidelines for older persons to prevent deaths from suffocation and other cardiovascular-respiratory problems in the first minutes of use. If masks are to be distributed as a protection against chemical warfare, a simpler model including the use of shrouds for whole-body skin protection might help avoid cardiorespiratory complications. Public health problems not adequately dealt with in the predisaster period are apt to emerge with greater severity during a crisis.

Tension pneumoperitoneum after blast injury: dramatic improvement in ventilatory and hemodynamic parameters after surgical decompression

Tension pneumoperitoneum is a known although rare complication of barotrauma, which can accompany blast injury. We report two patients who suffered from severe pulmonary blast injury, accompanied by tension pneumoperitoneum, and who were severely hypoxemic, hypercarbic, and in shock. After surgical decompression of their pneumoperitoneum, respiratory and hemodynamic functions improved dramatically. Several mechanisms to explain this improvement are suggested. In such cases the release of the tension pneumoperitoneum is mandatory, and laparotomy with delayed closure can be contemplated.

[Israel's ATLS program: summary and outlook]

In recent years a vigorous effort has been made to improve quality of primary trauma care in Israel. Advanced trauma life support courses (ATLS) were given to physicians throughout the country, regardless of their specialties. In 7 years 4229 physicians participated in 202 courses with an average success rate of 76%. In the future, issues such as mandatory vs. voluntary training, language barriers, and continuous decline of knowledge should be addressed if momentum is to be maintained.

Cognitive knowledge decline after Advanced Trauma Life Support courses

OBJECTIVE

To assess the cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) program in Israel, to compare the rate of decline between surgeons and nonsurgeons, and to recommend appropriate timing for refresher courses.

METHODS

A prospective study based on multiple-choice question test results of 220 ATLS course graduates was conducted 3 to 60 months after course completion. These results were then compared with the examination results immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the study groups.

RESULTS

A significant decline of cognitive knowledge over time among ATLS graduates was demonstrated. This decline was significantly greater in the nonsurgical group. A critical point of 20% cognitive knowledge loss among 50% of the examined physicians was observed around the 180th week after completion of the course.

CONCLUSION

Physicians taking the ATLS course lose a significant part of their acquired cognitive knowledge after 3.5 years. Surgeons retain their cognitive knowledge for longer periods of time. Based on the study results, the optimal timing for a refresher course is between 3 and 4 years after the initial ATLS course.

[ATLS course for surgery residents--should it be mandatory?]

Senior surgeons were asked about mandatory participation of general surgery residents in the advanced trauma life support (ATLS) course. Although trauma care in Israel is given by surgical residents, in the opinion of their senior mentors the course should continue to be mandatory for them.

Emergency preparedness and response in Israel during the Gulf War

We examined the effect of the emergency response on medical and public health problems during the 1991 Gulf War in Israel. On the first day of the conflict, the number of deaths from suffocation, asphyxiation, aspiration, myocardial infarction, cardiac arrest, and cerebrovascular accident increased abruptly, as did the number of sudden deaths associated with the use of tight-fitting masks with filters in sealed rooms. Much of the excess risk for death from cardiorespiratory complications during the first alert may have been a consequence of its duration (140 minutes). Mass evacuation and concrete buildings are believed to have kept the death toll from trauma down, and mask use may have protected against facial and upper-airway injuries. Falls and hip fractures, airway irritation from exposure to bleach, carbon monoxide intoxication from open kerosene heaters in sealed rooms, and self-injection with atropine syringes were also noted. A measles epidemic and increased death rates from automobile crashes were other preventable causes of death. Protection against biological warfare was limited to surveillance of trends for pneumonia and gastroenteritis. Emergency planners failed to anticipate the need for better mask fit, hands-on training in the use of masks, and special guidelines for older persons to prevent deaths from suffocation and other cardiovascular-respiratory problems in the first minutes of use. If masks are to be distributed as a protection against chemical warfare, a simpler model including the use of shrouds for whole-body skin protection might help avoid cardiorespiratory complications. Public health problems not adequately dealt with in the predisaster period are apt to emerge with greater severity during a crisis.

The accumulated experience of the Israeli Advanced Trauma Life Support program

BACKGROUND

Between January 1990 and May 1995 one faculty in Israel taught Advanced Trauma Life Support (ATLS) courses to 3,700 physicians. Two types of courses were given to three subpopulations. We studied the influence of demographic variables on students' achievements in the course and compared students' achievements as a function of their course type.

STUDY DESIGN

This study was conducted as a concurrent longitudinal study.

RESULTS

Achievements of 3,700 students were analyzed. The precourse grade, type of course, and their interaction were found to have a significant effect on the postcourse grades. Physicians practicing surgical subspecialties, in general, did better, as did students educated in English-speaking countries. Students who took part in the Combat Trauma Life Support (CTLS) course, which included the entire ATLS course and additional lectures and exercises, also ended with better scores.

CONCLUSIONS

Physician's country of origin and clinical subspecialty have a significant effect on the cognitive achievement in the ATLS course provided in Israel. An expanded ATLS course (CTLS), to include additional military trauma topics as well as additional skill station training, can improve the results of the postcourse grades.

Combat trauma life support training versus the original advanced trauma life support course: the impact of enhanced curriculum on final student scores

BACKGROUND

Within a military framework, the trauma course student, a young medical officer, is trained to become a trauma team leader and the first provider of medical aid. By adding battlefield medicine-related subjects to the basic Advanced Trauma Life Support (ATLS) course, as well as exercises tailored to the distinctive demands of military medicine, we could develop a special teaching unit: Combat Trauma Life Support (CTLS). The curriculum is basically the complete unchanged ATLS course of the American College of Surgeons enriched with lectures and practicums to fill the gap between the essentially civilian emergency department character of the ATLS course and the military tasks of the medical officer.

PURPOSE OF STUDY

To compare the cognitive knowledge achievements of trauma course participants in the Israel Defence Force Medical Corps and to delineate the impact of the course type on students' written test results.

DESIGN

A retrospective comparison analysis of pre- and post-course written test scores of 2,614 physicians who had participated in the ATLS and CTLS courses in the Israel Defence Force School of Military Medicine between 1990 and 1993.

RESULTS

The analysis indicated that students who undertook the CTLS course achieved statistically better results in written tests (87.9 +/- 8.7 vs. 79.6 +/- 11.4, R2 = 0.33).

CONCLUSIONS

We conclude that the CTLS comprehensive curriculum provides an improved training basis for the complex task of army battlefield trauma care support.

[ATLS course in emergency medicine for physicians?]

Implementation of Advanced Trauma Life Support (ATLS) skills among practicing physicians and its perceived utility in their civilian practices, as well as in their potential army combat assignments, was evaluated. 177 physicians in various subspecialties, who were graduates of ATLS training courses, answered a specially designed telephone questionnaire. An unexpectedly high percentage of physicians (47%) had used their ATLS training when called to treat trauma victims. 67% of physicians stressed the contribution of the ATLS course to enhancing their skills. We believe that a properly designed ATLS course for general practitioners would be very beneficial for trauma victims.

The impact of advanced trauma life support course on graduates with a non-surgical medical background

The aim of this study was to assess advanced trauma life support (ATLS) and combat trauma life support (CTLS) skills implementation among general practising physicians, its perceived utility in their routine daily practice as well as in their potential army combat assignments. One hundred and ten physicians, graduates of ATLS and CTLS courses, from the subspecialties of geriatrics, psychiatry and family medicine, were surveyed by telephone, to answer a specially designed questionnaire. The response rate was 82%. Professional distribution was: 6.6% geriatrics; 46.7% family physicians; and 46.7% psychaitrists. The number of trauma events treated by these physicians in their post-course practise was: geriatrics-three; family physicians-30; psychiatrists-18. We believe that a properly designed ATLS course, executed and applied to general practitioners, can be highly beneficial to trauma victims.

Fracture of the occipital condyles and associated craniocervical ligament injury: incidence, CT imaging and implications

Thin section contiguous axial computer tomography (CT) was used to demonstrate fractures of the occipital condyle and craniocervical ligament injury. During a 12-month period, 55 consecutive patients who had sustained high energy blunt trauma to the head or upper cervical region were examined (38 male and 17 female, age range 3-80 years, median 24 years). If occipital condyle fracture was suspected clinically, CT was performed from C2 to the foramen magnum with two dimensional sagittal, coronal, and curvilinear reconstructions and employing bone and soft tissue windows. Occipital condyle fractures were classified according to Anderson and Montesano types 1, 2 or 3. Injury to the internal craniocervical ligaments was described. Nine of 55 patients had occipital condyle fractures (16.4%). Injury of the alar ligaments was demonstrated in four and tectorial membrane injury in two patients. Three of the nine patients had associated fractures of cervical vertebrae. Five of nine patients had a normal Glasgow coma scale on admission (55%) and in two patients the occupital condyle fracture was the only significant injury. Plain cervical radiographs were non-diagnostic. Two patients had significant pain and limited motion of the craniocervicum several months following injury. In conclusion, CT should be performed where there is a high clinical suspicion of occipital condyle fracture, that is based mainly on the mechanism of injury.

Conservative treatment of a traumatic tear of the left hepatic duct: case report

Injury to the extra-hepatic biliary system in blunt abdominal trauma is rare and difficult to diagnose. In adults, all reported cases were treated surgically. We report a case of a traumatic tear of the left hepatic duct that was treated successfully by endoscopic retrograde cholangiopancreatography and stenting.

Stab wounds associated with terrorist activities in Israel

OBJECTIVE

To describe injuries resulting from terrorist-associated knife stabbings.

DESIGN

Retrospective case series.

SETTING

Israel (population 5.5 million).

SUBJECTS

Israeli victims (N=154) of knife stabbings on nationalistic basis (the intifada) between July 1987 and April 1994.

RESULTS

A total of 125 men and 29 women sustained stab wounds associated with terrorist activities. The median age was 28 years (range, 12-92 years), and 99 victims were aged 18 to 35 years. Seventy percent (108 patients) of the stabbing events occurred between 7 AM and 11 AM. The 154 victims sustained a total of 327 stab wounds, the median number of injuries was 2 per person (range, 1-28), and 68 individuals (44%) sustained more than 1 stab wound. The chest was the most commonly involved site (146 wounds), with the right posterior chest stabbed in 71 patients. The knife penetrated the heart in 20 patients and penetrated the peritoneal cavity in 29 patients. Overall, 29 patients (19%) had superficial injuries, 86 (56%) had internal organ injuries that mandated operative interventions, and 39 died (overall mortality, 25.3%).

CONCLUSIONS

Unlike other civilian stabbings, wounds resulting from terrorist-associated stabbings represent severe and highly lethal injuries.

Blunt injury of the small intestine and mesentery--the trauma surgeon's Achilles heel?

Eighteen patients with small intestine or mesenteric injury following blunt abdominal trauma were operated over a 34-month period. Early diagnosis and surgery, less than 6 hours after admission, was achieved in 10 patients (56%), seven of whom had haemorrhagic shock and had positive diagnostic peritoneal lavage or ultrasonography on admission. Three haemodynamically stable patients had a diagnostic abdominal computed tomography. Diagnosis was delayed in eight patients (44%) resulting in a gap between admission and surgery that varied from 20 hours to 46 days. The delay was related to lack of suspicion of injuries in haemodynamically stable patients despite a seat-belt sign, or false negative abdominal computed tomography. Diagnosis was delayed in six of seven patients (86%) where the only injury on admission was an isolated intestinal or mesenteric injury. In 11 patients there were associated abdominal or other system injuries. Late diagnosis was associated with an increased morbidity and longer hospital stay, relating to intestinal and mesenteric injury. In conclusion, a seat belt sign is highly suspicious of intestinal or mesenteric injury. Computed tomography was unreliable in diagnosing blunt intestinal and mesenteric injuries, and if equivocal, should be followed by diagnostic peritoneal lavage if nonoperative management is selected. Delayed diagnosis is often related to isolation of intestinal and mesenteric injury and results in increased morbidity and hospital stay. Every attempt should be made to reach a diagnosis within six hours of admission to the trauma unit. A management algorithm is proposed.

Hepatitis C virus viremia in SCID-->BNX mouse chimera

Chimpanzees are currently the only nonhuman animal model for reproducible propagation of hepatitis C virus (HCV). A chimeric mouse model was used for the induction of hepatitis C viremia, using BNX (beige/nude/X-linked immunodeficient) mice preconditioned by total body irradiation and reconstituted with SCID mouse bone marrow cells. HCV-infected liver fragments from patients with HCV RNA-positive sera were transplanted under the kidney capsule of the chimeric mice. HCV-specific RNA sequences were detected by reverse transcriptase nested polymerase chain reaction (RT-PCR) in serum of approximately 50% of grafted animals. In addition, normal liver specimens were incubated with HCV serum and transplanted into chimeric mice, leading to viremia in approximately 25% of animals. Sequential histologic evaluation of the liver implants, from day 2 to week 14 after transplantation, revealed loss of lobular architecture within the implants. However, viremia persisted for 10-50 days after transplantation. These results offer a new HCV model.

p53 expression in patients with cirrhosis with and without hepatocellular carcinoma

BACKGROUND

Mutated p53 acts as a dominant oncogene, whereas the wild type (wt) p53 gene product suppresses cell growth. Abnormalities in the p53 gene are reported in more than 50% of malignant tumors. Recently, an allelic loss of chromosome 17p, where the p53 gene is located, was found to be more frequent in hepatocellular carcinoma (HCC) cell lines and human tumors. In addition, in half of the cases of HCC from endemic areas for hepatitis B virus and aflatoxin, a hot spot point mutation at codon 249 was detected, as previously reported. Missense mutations in p53, mdm-2 complex formation, and other unknown mechanisms may lead to stabilization of the gene product, thus rendering it detectable by immunohistochemistry.

METHODS

To assess the relationship between p53 status at a premalignant stage and in HCC, the authors studied the immunohistologic expression of p53 in HCC and in the adjacent nontumorous resected liver tissue, using monoclonal antibody to wt and mutated p53.

RESULTS

Twelve of the 14 patients with liver tumors had HCC. Of the 12 patients with HCC and underlying cirrhosis, 8 (67%) had increased p53 expression in HCC cells. Eight of the 12 patients with p53-positive HCC cells had p53 overexpression in the nontumorous hepatocytes within regenerative nodules adjacent to HCC tissue. Three of 21 cirrhotic livers without a detectable tumor had increased p53 expression in the regenerative nodules. None of the 12 patients with chronic active hepatitis without cirrhosis or the 13 with a normal liver histology had increased p53 expression.

CONCLUSION

p53 overexpression in some cirrhotic livers and in nontumorous livers of patients with HCC may indicate a normal p53 gene response to cellular stress or, alternatively, to an abnormally or mutated p53 gene, and could occur before the development of HCC.

Pancreaticojejunostomy versus controlled pancreaticocutaneous fistula in pancreaticoduodenectomy for periampullary carcinoma

BACKGROUND

Anastomotic leak of the pancreaticojejunostomy is a major cause of morbidity and mortality following pancreaticoduodenectomy. Reports have described a large variety of techniques for performing this anastomosis and managing the pancreatic stump. In an attempt to obviate the pancreaticojejunostomy, we prospectively studied the technique of ligating the pancreatic duct and using external drains to create a temporary controlled pancreaticocutaneous fistula.

PATIENTS AND METHODS

Thirty-five consecutive patients who were to undergo pancreaticoduodenectomy for periampullary carcinoma were prospectively randomized to one of two groups: pancreaticojejunostomy (PJ) (n = 18) or controlled pancreaticocutaneous fistula (CPF) (n = 17). The groups were well matched for age, sex, coexisting medical illnesses, type of tumor, and preoperative condition. Except for the management of the pancreatic remnant, all patients in both groups underwent an identical procedure. Major morbidity, length of hospitalization, duration of the controlled pancreatic fistula, and mortality were analyzed over a mean follow-up interval of 26 months (range 5 months to 7.5 years).

RESULTS

The CPF group experienced lower overall operative morbidity rates than the PJ group (24% versus 56%, P < 0.01). Two patients (11%) in the PJ group and none in the CPF group died (P = NS). Half the morbidity in the PJ group and both mortalities were related to anastomotic leak. The CPF and PJ groups left the hospital after mean stays of 26.4 and 42.2 days respectively (< 0.01).

CONCLUSIONS

Compared to pancreaticojejunal anastomosis, creation of a temporary controlled pancreaticocutaneous fistula in patients who undergo pancreaticoduodenectomy for periampullary malignancy has no appreciable risk. It is associated with reduced morbidity and shorter length of hospitalization.

p53 expression in patients with cirrhosis with and without hepatocellular carcinoma

BACKGROUND

Mutated p53 acts as a dominant oncogene, whereas the wild type (wt) p53 gene product suppresses cell growth. Abnormalities in the p53 gene are reported in more than 50% of malignant tumors. Recently, an allelic loss of chromosome 17p, where the p53 gene is located, was found to be more frequent in hepatocellular carcinoma (HCC) cell lines and human tumors. In addition, in half of the cases of HCC from endemic areas for hepatitis B virus and aflatoxin, a hot spot point mutation at codon 249 was detected, as previously reported. Missense mutations in p53, mdm-2 complex formation, and other unknown mechanisms may lead to stabilization of the gene product, thus rendering it detectable by immunohistochemistry.

METHODS

To assess the relationship between p53 status at a premalignant stage and in HCC, the authors studied the immunohistologic expression of p53 in HCC and in the adjacent nontumorous resected liver tissue, using monoclonal antibody to wt and mutated p53.

RESULTS

Twelve of the 14 patients with liver tumors had HCC. Of the 12 patients with HCC and underlying cirrhosis, 8 (67%) had increased p53 expression in HCC cells. Eight of the 12 patients with p53-positive HCC cells had p53 overexpression in the nontumorous hepatocytes within regenerative nodules adjacent to HCC tissue. Three of 21 cirrhotic livers without a detectable tumor had increased p53 expression in the regenerative nodules. None of the 12 patients with chronic active hepatitis without cirrhosis or the 13 with a normal liver histology had increased p53 expression.

CONCLUSION

p53 overexpression in some cirrhotic livers and in nontumorous livers of patients with HCC may indicate a normal p53 gene response to cellular stress or, alternatively, to an abnormally or mutated p53 gene, and could occur before the development of HCC.

Diagnosis of traumatic rupture of the thoracic aorta using dynamic rapid sequence axial computerized tomography

The use of intravenous contrast enhanced rapid sequence (dynamic) computerized tomography (CT) of the chest led to the successful diagnosis and treatment of traumatic rupture of the thoracic aorta in three patients. Early diagnosis of this often fatal injury may result in a favorable outcome; and in the hemodynamically stable patient with multisystem injury a well-performed CT may preclude the use of more invasive techniques. When aortic disruption is suspected, dynamic rapid sequence axial CT of the chest may not only exclude but also confirm the diagnosis, in addition to accurately detecting other major intrathoracic injuries.

Malignant neuroepithelioma of the colon

A rare case of malignant peripheral neuroepithelioma originating from the right colon is presented. The patient underwent right hemicolectomy followed by combination chemotherapy and there has been no evidence of tumour recurrence or metastases during three years of follow up. Emphasis is given to the extremely unusual location of this tumour and the favorable clinical outcome.

[Kidney transplantation from living, related donors]

Kidney transplantation is the best treatment for selected end-stage renal patients. The shortage of cadaveric organs for transplantation has led to the development of a protocol for kidney transplantation from living, related donors. In the past 20 years, 58 living, related kidney transplantations were done in our department. Mean patient age was 30 +/- 10 (SD) years and mean donor age was 36 +/- 10. There were 34 transplantations between brothers or sisters, 15 from parent to child, 4 between cousins, 4 between spouses and 1 from son to father. Mean follow-up time was 4 years. 1 and 5 years after transplantation, patient survival rates were 85% and 80%, respectively, graft survival rates were 85% and 75%. The introduction of cyclosporin-A as an immunosuppressive agent in 1985 led to improvement in graft survival rates: from 77% and 51% after 1 and 5 years, respectively, to 88% and 84%. No correlation between HLA match or patient's age and graft survival rates was found. We conclude that living, related donor transplantation is effective for suitable cases of end-stage renal disease. It should be recommended to patients who have a healthy, interested family member.

Torture rhabdomyorhexis--a pseudo-crush syndrome

Two patients who were systematically tortured and deprived of any oral intake presented with acute renal failure several days later. Unlike the classical crush syndrome, we describe a clinical entity wherein repeated direct muscle injury from blunt trauma, in addition to forced dehydration, led to myoglobinuria and renal failure. The literature is reviewed, and biochemical indices predicting severity of injury, pathophysiology, and management protocol are described. This pseudo-crush syndrome caused by rhabdomyorhexis in addition to rhabdomyolysis is an unusual entity, in part related to extreme sociopolitical factors.

Hepatitis B virus infection associated with hematopoietic tumors

Hepatitis B virus (HBV) infection and replication have been linked to the development of hepatocellular carcinoma. Bone marrow-derived cells, as well as mesenchymal and epithelial cells, were recently shown to support HBV replication. We hypothesize that the mechanism that links HBV infection and liver tumors might also promote tumor development in tissues permissive for HBV replication. Between 1980 and 1993 we retrospectively identified 22 patients who were hepatitis B surface antigen (HBsAg) carriers and had extra-hepatic malignancies. These patients had 25 tumors, of which 22 were bone marrow derived. HBsAg was detected by immunohistochemistry in bone marrow cells of leukemia patient and of 3 of 10 lymphoma patients. In addition, in 4 of 10 patients with lymphoma, including 2 patients in which HBsAg stained bone marrow cells, HBsAg was also detected in the endothelial cells of blood vessels of the tumor tissue. These results suggest that the identification of an HBV gene product in endothelial cells might point to a role of HBV infection in the development of certain hematopoietic tumors, possibly through activation of cytokines or growth factors, which may eventually lead to bone marrow cell proliferation.

[Pulmonary embolism despite inferior vena cava filter]

The Greenfield filter is an effective and safe means of preventing postoperative pulmonary embolism in high-risk patients. However, it does not give absolute protection. We report a 69-year-old man who presented with deep vein thrombosis. Medical work-up revealed pancreatic tumor (Trousseau's sign). The Greenfield filter was placed in the inferior vena cava before operation. 11 days after total pancreatectomy clinical signs of pulmonary embolism appeared and the diagnosis was confirmed by ventilation-perfusion scan; anticoagulant therapy was instituted. The incidence of pulmonary embolism following interruption of the inferior vena cava by introducing the Greenfield filter is low (2.2%). Nevertheless, the diagnosis of pulmonary embolism should be considered in any patient with appropriate clinical signs, regardless of whether a filter was inserted.

Elective laparoscopic appendectomy in patients with familial Mediterranean fever

Familial Mediterranean fever (FMF) also known as hereditary polyserositis, is an inherited disorder commonly found in Armenians, Turks, Arabs, Balkans, and Jews originating from North African countries. The diagnosis of FMF is based on clinical findings and family history, as no specific diagnostic test is yet available. One of its main clinical features is recurrent acute episodes of peritonitis. During such an episode, physical examination and laboratory findings may be similar to those for acute appendicitis. Therefore up to two-thirds of FMF patients undergo emergency appendectomy, with the appendix being normal in most cases. As laparoscopic appendectomy has proved to be safe and advantageous, and to prevent misdiagnosis and unnecessary emergency surgery, we performed elective laparoscopic appendectomy in 13 FMF patients ranging in age from 8 to 32 years. They had been suffering from the disease for 1 to 12 years (mean 3.8) and had had an average of 3.5 yearly episodes of FMF peritonitis. All procedures were concluded by laparoscopy without conversion to open surgery. The average postoperative hospital stay was 3.07 days. The only complication was superficial wound infection in one patient (7.6%), and the mean time to regain full normal activity was 8.5 days. We conclude that elective laparoscopic appendectomy in FMF patients is safe. It helps to exclude appendicitis as a cause for peritonitis in these patients and may prevent unnecessary emergency surgery.

Subtotal colectomy with primary ileocolonic anastomosis for obstructing carcinoma of the left colon: valid option for elderly high risk patients

During a period of 4 years, 20 patients with obstructing carcinoma of the left colon were treated by subtotal colectomy with primary ileocolonic anastomosis. Thirteen patients (65%) were 65 years of age or older. All patients presented to the emergency room with large bowel obstruction. Twelve patients (age > 65) suffered other systemic diseases (chronic obstructive pulmonary disease, ischemic heart disease, morbid obesity), placing them in a high risk category. The mortality rate was 5% (1/20), 7.6% if only high risk patients are considered. The one-stage procedure in the treatment of obstructing carcinoma of the left colon offers the patient a number of advantages over stage intervention elimination of colostomy, namely removal of occult lesions in the resected colon, shorter hospitalization and low morbidity and mortality. We found this procedure to be a valid option also in the elderly (> 65) high risk patient. Metastatic disease in our view is not a contraindication, since the elimination of colostomy will improve the quality of life of these patients.

Case report: the management of penetrating cardiac trauma with major coronary artery injury--is cardiopulmonary bypass essential?

Major coronary artery injury in penetrating cardiac trauma is relatively uncommon and is associated with a poor prognosis. However, for a variety of reasons, the outcome for such patients has been improving during the last two decades. The main factor responsible for this change is, according to some authors, the use of emergency cardiopulmonary bypass (CPB). We present a case of complete transection of the LAD coronary artery managed by primary ligation of the vessel, but because of progressive signs of extensive myocardial infarction, the patient underwent emergency CPB and an aortocoronary bypass graft. The patient experienced a good cardiac recovery but died 5 days later of irreversible anoxic brain damage. In reviewing the literature concerning the absolute need for emergency CPB in the management of penetrating coronary artery injury (PCAI), we found that the overall outcome for patients treated with emergency CPB was not significantly better than for those treated with ligation alone. We believe that CPB is not always essential in the management of PCAI and should be instituted only when the injury to a main coronary artery is very proximal, whenever associated intracardiac injuries exist, or when the patient develops extensive myocardial infarction or uncontrolled arrhythmias following ligation of the injured coronary vessel.

A novel approach to military combat trauma education

A heterogeneous group of 77 physicians on compulsory or reserve military service were exposed to a 5-day course in trauma management, specifically designed for military medical personnel. Cognitive knowledge of trauma care delivery of the medical officers was assessed by means of multiple-choice written tests, which were held before and upon completion of the course. The significantly improved (p less than 0.0001) scores of the post-course test demonstrate the value of a condensed trauma educational program. Analysis of the background variants (i.e., medical education, military, and residency training, and time since graduation) revealed that the relatively short but intensive course sufficed to surmount the difficulties inherent in instructing a student body composed of individuals with dissimilar professional experience. We advocate the institution of a compact course in trauma treatment, with the specific aim of enhancing the medical officer's knowledge in this critical field of medical care.

[Penetrating neck injuries]

The frequency of penetrating neck injuries has increased in recent years. In 16 patients with such injuries treated during the past 2 years, neck exploration was performed immediately. In 4 there was destruction of the throat or trachea, in 3 a tear in the esophagus, in 1 a tear in the hypopharynx and in 1 a tear in the submandibular region penetrating the floor of the mouth. In 8 there was no damage to the neck organs. Of the 16, 1 died on the operating table from hemorrhage from multiple tears of the hypopharynx, the esophagus and the thyroid gland. 2 different approaches are used in dealing with penetrating neck injuries: immediate exploration, or the use of imaging methods to diagnose the degree of damage, followed by close supervision. In the light of our experience we advocate immediate neck exploration.