Glen Schlaphoff

Institutional practice guidelines on management of pelvic fracture-related hemodynamic instability : Do they make a difference?

BACKGROUND The management of patients with hemodynamic instability related to pelvic fracture is a major challenge, with high morbidity and mortality. Evidence-based institutional practice guidelines (PG) were developed as a strategy to optimize the care of these patients. The aims of this study were to evaluate the adherence to the new PG and compare the outcomes before and after their implementation. METHODS Major blunt trauma patients (Injury Severity Score [ISS] > 15) with hemodynamic instability (initial base deficit > 6 mEq/L or received > 6 units of packed red blood cells [PRBCs] during the first 12 hours) related to pelvic fracture were investigated. Patients presenting with ongoing bleeding from other regions or with severe head injury (Glasgow Coma Scale score < 9) were excluded. The pre-PG group (n = 17) were patients managed during the 18 months ending on December 31, 2001. The post-PG group (n = 14) consisted of patients managed during the subsequent 18 months. Demographics, ISS, shock severity, resuscitation, and outcome data were prospectively collected. The adherence to the key steps of PG was evaluated retrospectively in the pre-PG and prospectively in the post-PG group, including abdominal clearance (AC) with diagnostic peritoneal aspiration/lavage or ultrasound (<15 minutes), noninvasive pelvic binding (PB) (<15 minutes), pelvic angiography (PA) (<90 minutes after admission), and minimally invasive orthopedic fixation (MIOF) (<24 hours). Data are presented as mean +/- SEM or percentages. RESULTS The pre-PG and post-PG groups were similar regarding age (40 +/- 4 years vs. 42 +/- 6 years), gender (both 71% male), ISS (39 +/- 3 vs. 37 +/- 4), admission base deficit (9 +/- 1 vs. 10 +/- 1) admission systolic blood pressure (116 +/- 7 vs. 112 +/- 6 mm Hg), Glasgow Coma Scale score (12 +/- 1 vs. 12 +/- 1), and PRBC transfusion in the first 12 hours (9 +/- 2 U vs. 9 +/- 2 U). The adherence to the guidelines in the post-PG period was as follows: AC, 100%; PB, 86% (p < 0.05 based on t test or chi test); PA, 93% (p < 0.05 based on t test or chi test); and MIOF, 86%. In the pre-PG period, adherence to the guidelines was as follows: AC, 65%; PB, 0%; PA, 30%; and MIOF 52%. In the post-PG period, the 24-hour PRBC transfusion decreased from 16 +/- 2 U to 11 +/- 1 U and the mortality decreased from 35% to 7% (p < 0.05 based on t test or chi test for both). CONCLUSION The adherence to the PG as a reflection of optimal management was significantly improved. PG focusing particular on timely hemorrhage control reduced the 24-hour transfusion requirements and the mortality rate in the post-PG group.

Hemodynamically Unstable Pelvic Fractures: Recent Care and New Guidelines

Consistent care of hemodynamically unstable pelvic fracture patients is a major management issue. It was uncertain whether the introduction of newly developed clinical practice guidelines would require much change in current delivery of care at our institution. Assessment of recent care was undertaken and compared with the newly developed evidence-based best practice guidelines. A multidisciplinary project team developed clinical practice guidelines for determination of early optimum management of hemodynamically unstable patients with pelvic fractures. The guidelines recommend a definitive management plan to arrest hemorrhage within 30 minutes. Intra-abdominal hemorrhage should be assessed with diagnostic peritoneal aspiration (DPA) and/or focused assessment with sonography for trauma (FAST). Early noninvasive stabilization of the pelvis followed by angiography within 90 minutes are recommended if intra-abdominal hemorrhage is not found. Recent care was assessed in a historical cohort of patients, identified in a prospectively maintained trauma registry, between June 1999 and December 2001. Investigations, interventions, and times were then compared with the new guidelines. The delivery of care to 30 patients (mortality 37%, mean ISS 37.8 ± 20.9) was studied. Compared with the new guidelines, the abdominal assessment rate with DPA and/or FAST was 53% and early (< 90 minutes) angiography rate was 38%. A form of pelvic external stabilization was applied in 27% of cases. Noninvasive pelvic stabilization was not performed at all. The recent care of hemodynamically unstable pelvic fracture patients was not in line with newly developed guidelines. There is an opportunity to markedly improve the rates of initial assessment of the abdomen, pelvic stabilization, and early angiography.

Evidence for insulin resistance in black women from South Africa

OBJECTIVE: The rate of glucose disposal was determined in 10 black and 10 white obese nondiabetic urban women from South Africa to assess insulin resistance.DESIGN AND METHODS: Euglycemic hyperinsulinemic clamp and body composition analysis.RESULTS: Age, body mass index (BMI), anthropometric measurements and body composition were similar in both groups of women. A five-level computed tomography (CT) scan showed a similar mean subcutaneous fat mass in both groups of women (black obese women 555±9.0 vs white obese women 532±6.0 cm2), but less visceral fat in black obese women (90±3.0 vs 121±3.1 cm2; P<0.05). Black obese women had higher fasting free fatty acid (997±69 vs 678±93 μmol/l; P<0.05) and lactate concentrations (1462±94 vs 1038±39 μmol/l; P<0.05), but lower fasting insulin levels (87±12 vs 155±9 pmol/l; P<0.001). Black obese women also had a more favorable HDL: total cholesterol ratio (30.5% vs 23.0%; P<0.04). The mean glucose disposal rate (M) and disposal expressed as glucose sensitivity index (M/I) were reduced in the black obese women vs white obese women (M: 7.1±0.8 vs 13.7±1.0 mmol/kg·min−1×100; P<0.01, and M/I: 0.12±0.01 vs 0.24±0.02 mmol/kg·min−1/pmol/l×1000; P<0.01). Only black obese women showed a significant decrease in C-peptide levels during the clamp (2.9±0.22 vs 1.2±0.12 nmol/l; P<0.001). During the euglycemic period, the black obese women had higher lactate levels at all time points, but only the white obese women had increased lactate levels (918±66 to 1300±53 μmol/l; P<0.05).CONCLUSION: Black obese women demonstrate a higher degree of insulin resistance, despite less visceral fat and a higher HDL: total-cholesterol ratio. In addition, endogenous β-cell secretory function in black obese women appears to be more sensitive to the suppressive effect of exogenous insulin administration. The significant increase in lactate levels in white obese women confirms that they are more insulin sensitive.

Free fatty acids and insulin levels—relationship to leptin levels and body composition in various patient groups from South Africa

OBJECTIVE: To investigate the relationship between leptin concentrations, various metabolic indices and body composition in six different groups.DESIGN AND MEASUREMENTS: Anthropometric measurements, fasting plasma glucose, serum insulin, C-peptide, FFA and leptin levels were performed. In the obese and diabetic subjects, body composition was analysed with bio-impedance equipment and as a 5 level CT scan.SUBJECTS: Five lipoatrophic diabetes mellitus (LDM) patients, five normal subjects (N), nine white and nine black obese women (WW, BW), and nine white and nine black diabetic women (DWW, DBW) were investigated after an overnight fast.RESULTS: In both ethnic groups there was a positive correlation between leptin and BMI (black group: r=0.8; P<0.0001, white group: r=0.7, P<0.002) and leptin and SC fat mass (black group: r=0.6; P<0.005, white group: r=0.6; P<0.004).CONCLUSIONS: Across the groups, there were positive linear correlations between leptin concentrations, BMI, SC fat mass and FFA levels. Leptin and FFA concentrations are higher and insulin levels lower in both groups of black women compared to the two groups of white women, despite a similar BMI and body fat mass. In the DBW the large increase in visceral fat mass may be indicative of a more complex relationship between compensatory insulin resistance, elevated FFA levels and leptin secretion.

Reversible cerebral vasoconstriction syndrome following indomethacin.

Background Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by severe thunderclap headaches and transient segmental cerebral arterial vasoconstriction. Precipitating factors, including the postpartum state and exposure to vasoactive substances are identified in approximately 50% of cases. Non-steroidal anti-inflammatory drugs have rarely been associated with RCVS. Case description We report a case of a 51-year-old female with RCVS after administration of indomethacin given to relieve pain caused by renal colic. Cerebral imaging showed non-aneurysmal cortical subarachnoid hemorrhage, and formal angiography demonstrated widespread multifocal segmental narrowing of medium-sized cerebral arteries. These changes resolved on repeat angiography at 3 weeks. Discussion Indomethacin is a commonly used drug for treatment of certain primary headache disorders. To date, its mechanism of action remains unclear. A well described side effect of indomethacin is headache, which may be secondary to its vasoconstrictive effects. In our case, we postulate indomethacin, either alone or in combination with emotional stress from pain, triggered or exacerbated an underlying predisposition to RCVS.

Long-term outcomes of vertebroplasty for osteoporotic compression fractures.

Introduction: This study aimed to determine outcomes of percutaneous vertebroplasty for osteoporotic vertebral compression fractures (VCFs).

ORIGINAL ARTICLE: Long-term outcomes of vertebroplasty for osteoporotic compression fractures

Introduction: This study aimed to determine outcomes of percutaneous vertebroplasty for osteoporotic vertebral compression fractures (VCFs).

Vascular coil erosion into hepaticojejunostomy following hepatic arterial embolisation

BackgroundRight hepatic arterial injury (RHAI) is the most common vascular injury sustained during laparoscopic cholecystectomy, occurring in up to 7% of cholecystectomies. RHAI is also the most common vascular injury associated with a bile duct injury (BDI) and is reported to occur in up to 41 – 61% of cases when routine angiography is employed following a BDI.We present an unusual case of erosion of vascular coils from a previously embolised right hepatic artery into bilio-enteric anastomoses causing biliary obstruction. This is on a background of biliary reconstruction following a major BDI.Case presentationA 37-year old man underwent a bile duct reconstruction following a major BDI (Strasberg-Bismuth E4 injury) sustained at laparoscopic cholecystectomy. He had two separate bilio-enteric anastomoses of the right and left hepatic ducts and had a modified Terblanche Roux-en-Y access limb formed.Approximately three weeks later he was admitted for significant gastrointestinal bleeding and was hypotensive and anaemic. Selective computed tomography angiography revealed a 2 x 2 centimetre right hepatic artery pseudoaneurysm, which was urgently embolised with radiological coils.Two months later he developed intermittent fevers, rigors, jaundice, and right upper quadrant pain with evidence of intrahepatic biliary dilatation on magnetic resonance cholangiopancreatography. The degree of intrahepatic biliary dilatation progressively increased on subsequent imaging over several months, suggesting stricturing of the bilio-enteric anastomoses. Several attempts to traverse these strictures with a percutaneous transhepatic approach had failed. Then, approximately ten months after the initial BDI repair, choledochoscopy through the Terblanche access limb revealed multiple radiological coils within the bilio-enteric anastomoses, which had eroded from the previously embolised right hepatic artery. A laparotomy was performed to remove the coils, take down the existing obstructed bilio-enteric anastomoses and revise this. Following this the patient recovered uneventfully.ConclusionObstructive jaundice and cholangitis secondary to erosion of angiographically placed embolisation coils is a rarely described complication. In view of the relative frequency of arterial injury and complications following major bile duct injury, we suggest that these patients be formally assessed for associated arterial injury following a major BDI.

Effective notification of important non‐urgent radiology results: A qualitative study of challenges and potential solutions

We report on the implementation of a Radiology Notification System (RNS), set up by the medical imaging department of a major Sydney teaching hospital in March 2010. This study aimed to investigate the views of the medical imaging department staff about: (i) the results follow‐up problem encountered by the medical imaging department prior to the implementation of the RNS; (ii) what changes occurred following implementation of the RNS; and (iii) suggestions for improving the RNS.

Endovascular treatment of an acute left middle cerebral artery >6 h post stroke in a patient presenting with dysphasia and dense right hemiplegia

This paper describes the case of a 32‐year‐old man presenting with dense right hemiplegia and global aphasia caused by an acute left middle cerebral artery infarct that underwent successful endovascular therapy after being determined ineligible for intravenous tissue plasminogen activator. Clot traversion and balloon disruption followed by intra‐arterial Alteplase resulted in successful re‐canalization of his middle cerebral artery at 7 h 30 min. At 3 months post stroke, the patient had moderately severe expressive dysphasia but was mobilizing independently with normal right upper and lower limb strength. In conclusion, the 3 month outcome suggests that the therapeutic time window for endovascular therapy might exceed 6 h post stroke.