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Shock is defined as a change of circulation which results in hypoxia at the tissue level. Lactate and base deficit (BD) are associated with a high risk of multiple organ dysfunction in trauma patients. In this study we evaluated the influence of early recognition of shock in trauma patients.In a retrospective study, relevant data were collected from the Radboud University Nijmegen Medical Centre (RUNMC) database between January 2009 and December 2010. Vital parameters were taken at the accident scene, and patients were divided into four shock classes. Arterial blood gas analysis was performed on arrival in the emergency department. Statistical analysis was performed with SPSS version 17.0. Statistical significance was assumed at p ≤ 0.05.A total of 255 patients were included. Patients who suffered from prehospital shock, and those who were intubated prior to hospital admittance showed a bad outcome, presenting with a more severe metabolic acidosis, higher ISS and higher mortality. There was a significant difference for bicarbonate and BD between shockclass I + II and shockclass III + IV, respectively 22.7 vs. 19.7 and -3.4 vs. -6.9. Intubated patients had a decreased bicarbonate and BD compared to not intubated patients, respectively 21.81 vs. 23.24 and -5.08 vs. -2.38. Mortality and ISS were higher in patients in shock class III and IV. Significant differences in serum lactate levels were not found.Prehospital shock influences patient outcome; outcome of patients is related to initial shock classification. Further validation of our shock classification, however, is necessary.

Contains fulltext : 50465.pdf (Publisher’s version ) (Closed access) BACKGROUND: Fatigue is one of the most frequently reported symptoms after Mild Traumatic Brain Injury (MTBI). To date, systematic and comparative studies on fatigue after MTBI are scarce, and knowledge on causal mechanisms is lacking. OBJECTIVES: To determine the severity of fatigue six months after MTBI and its relation to outcome. Furthermore, to test whether injury indices, such as Glasgow Coma Scale scores, are related to higher levels of fatigue. METHODS: Postal questionnaires were sent to a consecutive group of patients with an MTBI and a minor-injury control group, aged 18-60, six months after injury. Fatigue severity was measured with the Checklist Individual Strength. Postconcussional symptoms and limitations in daily functioning were assessed using the Rivermead Post Concussion Questionnaire and the SF-36. RESULTS: A total of 299 out of 618 eligible (response rate 52%) MTBI patients and 287 out of 482 eligible (response rate 60%) minor-injury patients returned the questionnaire. Ninety-five MTBI patients (32%) and 35 control patients (12%) were severely fatigued. Severe fatigue was highly associated with the experience of other symptoms, limitations in physical and social functioning, and fatigue related problems like reduced activity. Of various trauma severity indices, nausea and headache experienced on the ED were significantly related to higher levels of fatigue at six months. CONCLUSIONS: In conclusion, one third of a large sample of MTBI patients experiences severe fatigue six months after injury, and this experience is associated with limitations in daily functioning. Our finding that acute symptoms and mechanism of injury rather than injury severity indices appear to be related to higher levels of fatigue warrants further investigation.

Item does not contain fulltext OBJECTIVES: Intramedullary nailing has been accepted as the treatment of choice for femoral shaft fractures. The aim of our study was to determine the incidence and implications of rotational malalignment after intramedullary nailing using computed tomography measurements. DESIGN: Cohort study. SETTING: Patients who postoperatively visited the orthopaedic outpatient and radiology clinics. PATIENTS: Seventy-six patients, 59 men and 17 women, with a mean age of 28.4 years (15-88). INTERVENTION: Patients treated on a fracture table with an antegrade reamed AO nail (n = 46) or Grosse Kempf nail (n = 30) for a unilateral femoral shaft fracture between 1988 and 1998 were included in the study. MAIN OUTCOME MEASUREMENTS: Patients filled out a questionnaire concerning pain, daily activities, and sport. Oxford, Western Ontario and McMaster University osteoarthritis index, and Harris Hip and Knee Society scores were obtained. Physical exams and computed tomography measurements were established. RESULTS: Twenty-one patients (28%) were found to have a rotational malalignment of 15degrees or more. There was no significant difference in rotational deformity with either the AO or Grosse Kempf nail. The incidence of malrotation was independent of the fracture level. Patients with a torsional deformity had difficulties with more demanding activities like running, sports, and climbing stairs. Patients with an external rotational malalignment (n = 12) have more functional problems than patients with an internal rotational malalignment (n = 9). Clinically determined rotation differences are not accurate (+/-20degrees) compared with the established computed tomography measurements. CONCLUSIONS: Rotational malalignment after intramedullary nailing for femoral fractures is found in 28% of the patients in this study. These patients have difficulties with more demanding activities, especially when they have an external torsional deformity.

Objective: To study the ability of glial (glial fibrillary acidic protein [GFAP] and S100b) and neuronal (neuron specific enolase [NSE]) protein levels in peripheral blood to predict outcome after severe traumatic brain injury.Methods: Eighty-five patients with severe traumatic brain injury (admission Glasgow Coma Score [GCS] ≤ 8) were included. Blood samples taken at the time of hospital admission were analyzed for S100b, GFAP, and NSE. Data collected included demographic and clinical variables. Outcome was assessed using the Glasgow Outcome Scale (GOS) at 6 months post injury.Results: The median serum levels of S100b, GFAP, and NSE were raised 18.3 fold (S100b), 4.6 fold (GFAP), and twofold (NSE) compared to normal reference values. S100b, GFAP, and NSE serum levels correlated significantly with the injury severity score and CT findings but not with age, sex, or GCS. S100b, GFAP, and NSE levels were significantly higher in patients who died or had a poor outcome 6 months post injury than in those who were alive or had good outcome. S100b level >1.13 μg/L was the strongest predictor of death with 100% discrimination, but GFAP (>1.5 μg/L) and NSE (>21.7 μg/L) levels also strongly predicted death (adjusted odds ratios 5.82 [for GFAP] and 3.91 [for NSE]). S100b, GFAP, and NSE all strongly predicted poor outcome (adjusted odds ratios 5.12 [S100b], 8.82 [GFAP], and 3.95 [NSE]).Conclusions: These results suggest that determination of serum levels of glial and neuronal proteins may add to the clinical assessment of the primary damage and prediction of outcome after severe traumatic brain injury.

We describe a patient who was admitted to our hospital with an enlarged left lobe of the thyroid gland. Since fine-needle aspiration showed atypical follicular cells, a surgical exploration followed. Owing to extensive tumor infiltration into the surrounding tissues curative surgery was not possible, and only an incisional biopsy was taken. Histological examination of this biopsy revealed a mixed tumor composed of epithelial and myoepithelial cells. A primary thyroid tumor, metastasis of a salivary gland, and a skin appendage tumor could be excluded based on clinical examination, conventional histology, and immunohistochemistry. A tumor of the left breast treated 12 years earlier had originally been classified as an intraductal/intracystic carcinoma with focal invasion, but was re-examined. Using immunohistochemistry, the breast tumor was reclassified as a malignant adenomyoepithelioma. The current tumor was apparently a metastasis from this primary breast tumor. An updated review of the literature is given, including current knowledge on histological and immunohistochemical features of adenomyoepithelioma of the breast, with special attention to the reported pathological characteristics of recurrent and malignant tumors. Based on the reported pathological characteristics of recurrent and metastatic tumors we offer a diagnostic tool for identifying potentially malignant and recurrent tumors.

Bilateral carotid artery dissection is a rare and unusual complication of blunt cervicofacial trauma. The diagnosis of a carotid injury is rarely suspected in trauma patients with neurological deficits. Neurological symptoms may develop in a delayed fashion. Angiography should be considered in trauma patients with hemiplegia and a normal mental status and in patients with blunt cervical trauma with an abnormal neurological examination. Initial heparinisation can prevent arterial thrombosis and neurological deterioration.

Background and purpose : Preoperative irradiation with direct postoperative chemotherapy could benefit patients undergoing surgery for colorectal cancer. This study was designed to examine, in an experimental model, if such treatment is feasible without detrimental effects on early anastomotic healing. Material and methods : A colonic segment was irradiated (25 Gy) in 3 groups ( n = 10 each) of male Wistar rats. After 5 days, a colonic resection was performed with anastomotic construction; only the distal limb consisted of irradiated bowel. Postoperatively, animals received daily intraperitoneal 5-fluorouracil (5-FU, group I/CH: 17.5 mg/kg; group I/CL: 12.5 mg/kg) or saline (group I). Three additional groups were treated similarly, but with sham-irradiation: CH, CL, and C, respectively. All rats were killed 7 days postoperatively. Parameters measured were: weight, serum albumin and protein, and anastomotic bursting pressure, breaking strength and hydroxyproline content. Results : Body weight was diminished significantly in rats receiving chemotherapy. Serum albumin and protein was significantly lower in irradiated groups. At sacrifice, 40% of I/CH rats had functional rectal stenosis. The average bursting pressure ( P = 0.0005) and the average breaking strength ( P = 0.012) were only reduced significantly in the CH group. The anastomotic hydroxyproline content was significantly higher in the I/CH and I/CL groups vs. the control group. Conclusion : High-dose direct postoperative 5-FU leads to reduced anastomotic strength. Although the combination of preoperative irradiation (25 Gy) and direct postoperative high-dose 5-FU does not reduce early anastomotic strength, some stenosis may occur. The combination of preoperative irradiation and low-dose 5-FU has no such effect.

A randomized two period crossover trial was performed at the Accident and Emergency (A & E) department of the University Hospital in Nijmegen (The Netherlands). We assessed what the impact was of (mandatory) consultation of a protocol for the management of isolated traumas on treatment decisions of residents. All eight surgical residents who regularly worked in the A & E department participated in the trial. All patients who entered the A & E department between October 13, 1992 and June 9, 1993, of age 16 years or older with an isolated fracture without concomitant lesions were admitted to the study. During the experimental periods, the management protocol was available on computer (using ProtoVIEW) and during the control periods on paper. Main measurements were treatment adjustments made by residents (after consulting different information sources), and their opinion about ProtoVIEW as an information source assessed by means of a questionnaire. When protocol consultation was mandatory, residents changed their treatments almost four times more often towards the protocol than during the control periods (P = 0.01 Chi-square test). Most residents found ProtoVIEW easy to use, liked it as a useful training source while half of them said they would use the system in daily clinical practice. We conclude that mandatory protocol consultation using ProtoVIEW influenced protocol adherence positively.

Objective. In prehospital emergency medicine, rapid transport to a hospital is often required. Transport can be done by ambulance or HEMS (Helicopter Emergency Medical Service). Factors influencing transport time are mostly unknown. This study aims to identify these factors and optimize prehospital transport times. Methods. This is a retrospective study with HEMS data from 2010-2011. Trauma mechanism, patient characteristics, and weather conditions were collected from each transport. Distance to the hospital, predicted transport time, and the actual transport time were calculated. Each factor was analysed to determine influence on transport time. Results. We analysed 732 cases (612 by ambulance and 120 by helicopter) and found no association between mechanism of trauma, age, time of day, or weather conditions on transport time. However, transport by HEMS helicopter was nearly always faster, even at short distances. The average transport time of ambulance transport was 79% (95% CI 77.1–80.3) of target time, while in helicopter transport this was 39% (95% CI 37.4–42.9). Conclusion. This study shows the advantage of the HEMS helicopter in rapid transport from the scene to the hospital. Transport by helicopter was twice as fast as ground transport, independent of trauma mechanism, distance to hospital, or weather conditions.

Contains fulltext : 87546.pdf (Publisher’s version ) (Closed access) BACKGROUND: In renal hyperparathyroidism, it remains unclear whether intraoperative parathyroid hormone (PTH) measurements can predict postoperative outcome and guide the extent of surgical exploration. METHODS: In 42 parathyroidectomies for renal hyperparathyroidism, we analyzed the predictive value of the Miami Criterion of 50% intraoperative PTH decrease. We used receiver operating characteristic (ROC) curves to find the criterion with the best diagnostic performance. We also investigated whether the whole PTH assay improved accuracy. RESULTS: Twenty-six operations (62%) resulted in normal postoperative PTH. With the Miami Criterion, cure was predicted with a sensitivity of 95% and specificity of only 8%. Specificity could be improved to 50% using a 70% PTH decrease as cut-off level. The whole PTH assay did not improve accuracy. CONCLUSION: Prediction of cure after parathyroidectomy for renal hyperparathyroidism might be improved with a criterion of 70% PTH decrease 10 minutes after excision of all parathyroid glands. Prospective analysis needs to validate this new criterion. 01 oktober 2010

We report a lethal case of fat embolism syndrome in a nine-year-old child after a direct blunt trauma leading to a pelvic fracture. On the second day, signs of bowel perforation and septic shock led to an acute aggravation of the pulmonary symptoms, cardiac arrest and death. Fat embolism is seldom thought to occur in pediatric trauma patients; however, this case illustrates it can lead to disastrous sequela. Since there is no specific treatment for it, prevention by early fracture stabilization is the only option.

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Purpose: to determine whether intraoperative radiotherapy causes long-term negative effects on the healing of colonic anastomoses in the rat. Methods and Materials: 175 rats were divided into seven equal groups. One group served as sham-irradiated control group. In the others, following a colonic resection, 1 or 2 cm of the distal bowel limb was irradiated with a single dose of 10, 15, or 20 Gy (groups 10/1, 15/1, 20/1, 10/2, 15/2, and 20/2, respectively). Subsequently, an anastomosis was constructed. The animals were killed after 6 ( n = 10 in each group) or 12 ( n = 15) months. The abdomen was inspected for abnormalities and the colonic diameter was measured. The anastomotic segment was analyzed biochemically (hydroxyproline) and histologically. Results: During the experimental period, 1 rat (group 15/1) died because of anastomotic leakage and 3 others died from unknown causes. There was no difference in colonic diameter between groups. Altogether 17 rats developed an adenocarcinoma in the irradiated area: 11 of these had received a dose of 20 Gy. Histological observation indicated that fibrosis was present only in a limited number of animals, mostly after irradiation with a dose of 15 or 20 Gy. All anastomoses were functional and showed normal histology. The hydroxyproline content of the anastomotic segment was increased—with respect to the control group—only in the 20/2 group after 6 months. After 12 months, the hydroxyproline concentration in the (irradiated) segment distal to the anastomosis proper was higher in the 10/1 and 15/1 groups than in the control group. Otherwise, there were no differences between groups. Conclusion: Intraoperative irradiation with a single dose of 10–20 Gy, delivered to the distal limb used for anastomotic construction, does not appear to constitute a threat to anastomotic integrity. Dose-related changes included formation of adenocarcinomas and fibrosis, but function and histology of the anastomosis proper remained unaffected.

Objective: To determine if a combination of preoperative irradiation and local hyperthermia of a colonic segment is detrimental to subsequent early anastomotic healing. Design: A prospective randomized experimental trial. Setting: An animal research laboratory. Interventions: Eighty male Wistar rats were randomly divided into 4 groups. In each animal, a segment of the colon was treated successively by (sham) irradiation and (sham) hyperthermia. After 5 days, a colonic resection was performed and an anastomosis was constructed; the distal limb consisted of (sham) irradiated, (sham) hyperthermia—treated bowel. The rats were killed 3 or 7 days after surgery. Main Outcome Measures: Body weight, serum albumin and protein levels, anastomotic bursting pressure, breaking strength, and hydroxyproline content. Results: All animals tolerated (sham) treatment well. Weight was diminished, though not notably, in treated animals vs the control group. After combined preoperative irradiation and hyperthermia, the frequency of local anastomotic complications increased: 4 of 20 animals had a covered perforation when they were killed. In this group, the bursting pressure was lower 3 days after the operation (P=.008). The breaking strength was also lower but not notably. The serum albumin level was significantly lower in this group vs the control group (P=.006); the serum protein level was not decreased. After 7 days, no differences existed between the groups. The hydroxyproline content of the anastomotic tissue was notably higher in rats treated with radiation plus hyperthermia vs control rats (in both the 3- and 7-day groups). The anastomotic hydroxyproline concentration did not differ between the groups. Conclusions: The combination of preoperative irradiation and hyperthermia results in increased local anastomotic complications. Anastomotic strength is at risk in the first days after the anastomotic reconstruction. Preoperative irradiation or hyperthermia alone does not lead to impaired anastomotic healing in the early phase. Arch Surg. 1996;131:1037-1042.

The in-hospital management of polytrauma patients can be divided into four periods [1]. In the acute period problems of the ABC (airway, breathing, circulation) are addressed. When vital functions have been stabilized, the primary period starts, with time for further diagnostic procedures and for a second series of operations, addressing injuries that may become life-threatening in the near future, or which may lead to severe disability if not treated early. The secondary period begins after 48–72 h, when the patient has been optimally stabilized. During the secondary period, operative reconstruction may be performed of major closed joint injuries (e.g., acetabular fractures) and closed fractures of the forearm. The tertiary period follows after 6–7 days and is determined by two events, septic complications and rehabilitation of the patient. Optimal rehabilitation can start after only operative stabilization of all major fractures, or consolidation of such fractures if treated conservatively.

Hyperthermia is a promising method for increasing the efficacy of radiation therapy of colorectal cancer. To study the histological aspects of healing of an anastomosis in the colon, after combined preoperative (sham) irradiation and (sham) hyperthermia treatment, 48 male Wistar rats were divided randomly into four groups. In each animal, a segment of the colon was treated successively by (sham) irradiation (single dose of 25 Gy X rays) and/or (sham) hyperthermia (44 degrees C, 30 min). After 5 days, a resection of the colon was performed by construction of an anastomosis: The distal limb consisted of (sham-) irradiated and/or (sham-) hyperthermia-treated bowel. Rats were killed 3 or 7 days after the surgical procedure. Evaluation of healing of the anastomosis was made by: (1) histological analysis of sections stained with hematoxylin and eosin, (2) semiquantitative measurement of collagen in the area of the anastomosis and (3) semiquantitative analysis of the number of macrophages by immunocytochemistry. Healing of the anastomoses in animals receiving irradiation or hyperthermia alone and in control animals was relatively uneventful. There were no differences between groups in formation of collagen or infiltration by macrophages in the area of the anastomosis. Animals treated with both radiation and hyperthermia showed marked necrosis, infiltration by polymorphonuclear leukocytes and rupture of the anastomosis. It is concluded that preoperative irradiation with a single dose of 25 Gy in combination with local hyperthermia at 44 degrees C for 30 min leads to disturbed repair of anastomoses.

Contains fulltext : 98469.pdf (Publisher’s version ) (Closed access) This study aimed to evaluate the intra- and interobserver agreement for both fracture classification according to Schatzker and treatment plan of tibial plateau fractures using plain radiographs alone and with computed tomography (CT) scans. The study was carried out prospectively to assess the impact of an advanced radiographic study on the agreement of treatment plan and fracture classification of tibial plateau fractures. Eight experienced observers (six surgeons and two radiologists) classified 15 tibial plateau fractures with plain radiographs and CT scans and set up a treatment plan. Agreement was measured using kappa coefficients. Using plain radiographs alone, the mean interobserver kappa coefficient for classification was 0.47, which decreased to 0.46 after addition of CT scans. Using plain films alone for formulating a treatment plan, the mean interobserver kappa coefficient was 0.40, which decreased to 0.30 after addition of CT scans. The mean intraobserver kappa coefficient for fracture classification using plain radiographs was 0.60, which decreased to 0.57 with addition of CT scans. The mean intraobserver kappa coefficient for treatment plan based on plain radiographs alone was 0.53, which decreased to 0.45 after addition of CT scans. In contrast with other recent publications, there is no increase in inter- and intra-agreement of a CT scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. Routine CT scanning of the knee for tibial plateau fractures is not supported by this study.