James A. Vosswinkel

Altered protein metabolism following coronary artery bypass graft (CABG) surgery

The aim of the present study was to investigate the acute effect of CABG (coronary artery bypass graft) surgery on the rates of synthesis of muscle protein, the positive acute-phase protein fibrinogen and the negative acute-phase protein albumin. Synthesis rates of muscle protein, fibrinogen and albumin were measured simultaneously before and 4 h after the end of surgery from the incorporation of L-[(2)H(5)]phenylalanine (given at 43 mg/kg of body weight) in 12 patients undergoing CABG surgery. Surgery was performed either with the use of extracorporeal circulation with cardiopulmonary bypass (on-pump; n=5) or with the beating heart procedure without cardiopulmonary bypass (off-pump; n=7). Post-surgical muscle protein fractional synthesis rates were decreased by 36+/-6.5% compared with pre-surgical values (1.59+/-0.10 compared with 0.97+/-0.08%/day respectively; P<0.001). In contrast, the synthesis rates of both fibrinogen (36+/-4 compared with 100+/-11 mg.day(-1).kg(-1) of body weight; P<0.0001) and albumin (123+/-12 compared with 178+/-19 mg.day(-1).kg(-1) of body weight; P<0.001) were both significantly increased after surgery. No significant differences were found between surgery performed with or without cardiopulmonary bypass. In conclusion, the results demonstrate that CABG surgery has a profound effect on protein metabolism, with a differential response of protein synthesis in muscle and liver.

Torsion of the gallbladder: laparoscopic identification and treatment.

Torsion of the gallbladder is an unusual cause of necrosis of the gallbladder. Since its first description a century ago, its diagnosis prior to operative exploration has been extremely elusive. The diagnostic value of current radiological imaging is limited. In the present report, we describe a case of torsion of the gallbladder in which laparoscopy was used successfully to identify and treat this condition without the usual requirement of open exploration. Additionally, the etiology, incidence, clinical presentation, radiologic studies, and treatment of the condition are reviewed.

Functional assessment of disease-free saphenous vein grafts at redo coronary artery bypass grafting

BACKGROUND Reoperations for coronary artery bypass grafting are on the rise. The general rule of replacing all saphenous vein grafts (SVGs) older than 5 years of age at the time of reoperation has recently been challenged on clinical grounds. This study provides functional data of endothelial behavior in long-term vein grafts. METHODS Previously placed SVGs were removed at the time of redo operations. Nitric oxide (NO) measurements in real time were carried out before and after stimulation with morphine. The measurements were compared to the angiographic appearance of the grafts obtained prior to operation. Grafts were categorized into 3 groups: disease-free, moderately diseased, and severely diseased. RESULTS Sixteen grafts were analyzed. Five were angiographically disease-free, 4 had moderate, and 7 severe disease. In the disease-free group, peak NO production after 10(-6) mol/L morphine stimulation was 35 mol/L, equivalent to the production of native saphenous vein. The severely diseased group did not demonstrate an increase in NO production, and the moderately diseased group produced a small rise in production. CONCLUSIONS Measurement of NO release of old SVGs, when angiographically pristine, equals that of native saphenous vein. These findings support the recent clinical observations that long-term angiographically disease-free vein grafts are biologically privileged.

Critical analysis of injuries sustained in the TWA flight 800 midair disaster.

BACKGROUND Previous reports of commercial airline disasters have reviewed incidents occurring at takeoff and landing. The purpose of the present study, which represents the first analysis of aviation injuries incurred during a midflight incident, was to examine the injuries sustained by the victims of the TWA Flight 800 disaster and to determine any correlation of injuries with structural damage and seat location. METHODS Complete autopsy records, toxicology screening, and forensic analysis were reviewed. Injuries were assessed by anatomic region and severity by using the Abbreviated Injury Scale. The National Transportation Safety Board report of the investigation was applied to correlate individual injuries with seat location and structural damage. A comparison was performed against injury data from takeoff and landing incidents. RESULTS All 230 passengers of TWA Flight 800 were recovered as fatalities. Head, thoracic, and abdominal injuries were multiple and severe, contributing to the mortality of the occupants. Analysis revealed that the severity of injury and anatomic injury pattern did not generally correlate with seating position or structural damage. A comparison of these injuries with those of takeoff and landing crashes showed differences in injury pattern and severity. CONCLUSION Passengers of Flight 800 sustained instantaneous fatal blunt force injury. Analysis of the data revealed no global correlation between seat position and pattern of injury. In contrast to injuries incurred during crashes at takeoff and landing, these midflight injuries were too extreme to warrant a reappraisal of current passenger protective safety measures or standards.

Outcomes following prolonged mechanical ventilation: analysis of a countywide trauma registry.

BACKGROUND The care of mechanically ventilated patients at high-volume centers in select nontrauma populations has variable effects on outcomes. We evaluated outcomes for trauma patients requiring prolonged mechanical ventilation (PMV). We further hypothesized that the higher mechanical ventilator volume trauma center would have better outcomes. METHODS A retrospective review of a county’s trauma registry was performed for trauma patients who were at least 18 years old admitted from 2006 to 2010. Eleven hospitals serve this suburban county, with a population of approximately 1.5 million people. The state has designated them as nontrauma centers (n = 6), area trauma centers (ATCs, n = 4), or regional trauma center (RTC, n = 1), where the last one provides the highest echelon of care. Patients requiring mechanical ventilation for at least 96 hours following injury were evaluated. RESULTS A total of 3,382 trauma patients were admitted to the RTC, and 5,870 were admitted to the other 10 hospitals in the county. Seven hundred seventy-one received mechanical ventilation at the RTC, and 687 at the other 10 hospitals combined. Of these patients, 407 at the RTC and 308 at the remaining facilities (291 at ATCs and 17 at nontrauma centers) required PMV. Median (interquartile range [IQR]) Injury Severity Score (ISS) at the RTC was higher (29 [21–41] vs. 22 [16–29] p < 0.001) than that at ATCs. Hospital length of stay (in days) was comparable between the RTC and ATCs (28 [18–45] vs. 26 [16–44.7]). With regard to complications, rates of renal failure, sepsis, and myocardial infarction were similar. The RTC had higher pneumonia rates (59% vs. 45.4%, p < 0.001) and venous thromboembolic disease rates (20.4% vs. 10.4%, p < 0.001) than did ATCs. In-hospital mortality was 17% at the RTC and 34.4% at ATCs (p < 0.001). CONCLUSION A mortality benefit but higher VTE and pneumonia rate for PMV patients at the RTC was noted. Collaborative practice initiatives are warranted to reduce morbidity and mortality across the region. LEVEL OF EVIDENCE Epidemiologic study, level IV.

Phytobezoar as a Cause of Intestinal Obstruction

IntroductionA small bowel phytobezoar is a rare cause of intestinal obstruction, whose most common cause is adhesion.Case ReportThis is a case report in which the etiology of small bowel obstruction was identified due to intussusception via computed tomography scan, and upon exploration, was found to be due to a small bowel phytobezoar.

Splenic Vein Turndown Repair in Superior Mesenteric Vein Trauma: A Reasonable Alternative

Objective: To determine previous experience and results of autologous splenic vein graft repairs in traumatic superior mesenteric vein (SMV) avulsions. Design of Study: Systemic review was conducted for SMV trauma and methods of repair between 1897 and 2010. Articles were further analyzed for use of the splenic vein as an alternative conduit and were included in this study. Results: Of the 56 articles identified during our search, 4 included use of the splenic vein as an autologous vein graft. A total of 5 cases using the splenic vein turndown repair were identified in addition to our case. Of the 6 patients, 4 survived. Only one other case exists regarding the successful use of the splenic vein turndown technique in blunt abdominal trauma. Conclusion: There is little information regarding the feasibility and success of this technique in traumatic SMV disruption. Future studies are required to assess its role in abdominal vascular trauma.

Spinal Fractures in Older Adult Patients Admitted After Low-Level Falls: 10-Year Incidence and Outcomes.

To evaluate the incidence of spinal fractures and their outcomes in the elderly who fall from low‐levels in a suburban county.

Unplanned intensive care unit admission following trauma

BACKGROUND The prevalence and outcomes of trauma patients requiring an unplanned return to the intensive care unit (ICU) and those initially admitted to a step-down unit or floor and subsequently upgraded to the ICU, collectively termed unplanned ICU (UP-ICU) admission, are largely unknown. METHODS A retrospective review of the trauma registry of a suburban regional trauma center was conducted for adult patients who were admitted between 2007 and 2013, focusing on patients requiring ICU admission. Prehospital or emergency department intubations and patients undergoing surgery immediately after emergency room evaluation were excluded. RESULTS Of 5411 admissions, there were 212 UP-ICU admissions, 541 planned ICU (PL-ICU) admissions, and 4658 that were never admitted to the ICU (NO-ICU). Of the 212 UP-ICU admits, 19.8% were unplanned readmissions to the ICU. Injury Severity Score was significantly different between PL-ICU (16), UP-ICU (13), and NO-ICU (9) admits. UP-ICU patients had significantly more often major (Abbreviated Injury Score ≥ 3) head/neck injury (46.7%) and abdominal injury (9.0%) than the NO-ICU group (22.5%, 3.4%), but significantly less often head/neck (59.5%) and abdominal injuries (17.9%) than PL-ICU patients. Major chest injury in the UP-ICU group (27.8%) occurred at a statistically comparable rate to PL-ICU group (31.6%) but more often than the NO-ICU group (14.7%). UP-ICU patients also significantly more often underwent major neurosurgical (10.4% vs 0.7%), thoracic (0.9% vs 0.1%), and abdominal surgery (8.5% vs 0.4%) than NO-ICU patients. Meanwhile, the PL-ICU group had statistically comparable rates of neurosurgical (6.8%) and thoracic surgical (0.9%) procedures but lower major abdominal surgery rate (2.0%) than the UP-ICU group. UP-ICU admission occurred at a median of 2 days following admission. UP-ICU median hospital LOS (15 days), need for mechanical ventilation (50.9%), and in-hospital mortality (18.4%) were significantly higher than those in the PL-ICU (9 days, 13.9%, 5.4%) and NO-ICU (5 days, 0%, 0.5%) groups. CONCLUSIONS UP-ICU admission, although infrequent, was associated with significantly greater hospital length of stay, rate of major abdominal surgery, need for mechanical ventilation, and mortality rates than PL-ICU and NO-ICU admission groups.

Clopidogrel-Associated Thrombotic Thrombocytopenic Purpura following Endovascular Treatment of Spontaneous Carotid Artery Dissection.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening multisystem disease secondary to platelet aggregation. We present a patient who developed profound thrombocytopenia and anemia 8 days following initiation of therapy with clopidogrel after stent placement for carotid artery dissection. She did not have a disintegrin and metalloproteinase with thrombospondin domain 13 (ADAMTS 13) deficiency. Management included steroids and therapeutic plasma exchange. Clopidogrel has rarely been associated with TTP. Unlike other causes of acquired TTP, the diagnosis of early clopidogrel-associated TTP is largely clinical given the infrequent reduction in ADAMTS 13 activity.