James C. Doherty

Comparison of nonoperative management with renorrhaphy and nephrectomy in penetrating renal injuries.

BACKGROUND We reviewed our experience with penetrating renal injuries to compare nonoperative management of penetrating renal injuries with renorrhaphy and nephrectomy in light of concerns for unnecessary explorations and increased nephrectomy rates. METHODS In this retrospective study, we reviewed the records of 98 penetrating renal injuries from 2003 to 2008. Renal injuries were classified according to the American Association for the Surgery of Trauma and analyzed based on nephrectomy, renorrhaphy, and nonoperative management. Patient characteristics and outcomes measured were compared between management types. Continuous variables were summarized by means and compared using t test. Categorical variables were compared using χ² test. RESULTS Nonoperative management was performed in 40% of renal injuries, followed by renorrhaphy (38%) and nephrectomy (22%). Of renal gunshot wounds (n = 79), 26%, 42%, and 32% required nephrectomy, renorrhaphy, and were managed nonoperatively, respectively. No renal stab wound (n = 16) resulted in a nephrectomy and 81% were managed conservatively. Renal injuries managed nonoperatively had a lower incidence of transfusion (34 vs. 95%, p < 0.001), shorter mean intensive care unit (ICU) (3.0 vs. 9.0 days, p = 0.028) and mean hospital length of stay (7.9 vs. 18.1 days, p = 0.006), and lower mortality rate (0 vs. 20%, p = 0.005) compared with nephrectomy but similar to renorrhaphy (transfusion: 34 vs. 36%, p = 0.864; mean ICU: 3.0 vs. 2.8 days, p = 0.931; mean hospital length of stay: 7.9 vs. 11.2 days, p = 0.197; mortality: 0 vs. 6%, p = 0.141). The complication rate of nonoperative management was favorable compared with operative management. CONCLUSIONS Selective nonoperative management of penetrating renal injuries resulted in a lower mortality rate, lower incidence of blood transfusion, and shorter mean ICU and hospital stay compared with patients managed by nephrectomy but similar to renorrhaphy. Complication rates were low and similar to operative management.

Elevated immunoreactive endothelin-1 levels in newborn rabbit lungs after meconium aspiration

Objective Our prime objective was to study the production of big endothelin-1 (Big ET-1) and its conversion to ET-1 in the lungs of newborn rabbits exposed to meconium. Our second objective was to study the effect of captopril on endothelin expression. Design Prospective, comparative study. Setting Research laboratory of the Michael Reese Hospital and the University of Illinois, Chicago. Subjects Two-wk-old rabbit pups. Interventions Rabbit pups were instilled with meconium or saline into the lungs. Another group, pretreated with captopril, was also instilled with either meconium or saline. Measurements and Main Results After meconium or saline instillation, lung lavage was performed. Big ET-1 and ET-1 were measured in lung lavage fluid by using a commercially available enzyme-linked immunosorbent assay kits in all groups. Also, lungs were studied by histochemistry analysis for a morphologic evaluation of meconium-induced damage. In the lavage fluid of saline-instilled pups, ET-1 remained low and no increase in Big ET-1 levels was observed. In meconium-instilled animals, bioactive ET-1 levels were significantly higher, with a peak at 8 hrs after instillation. The conversion ratio of Big ET-1 to ET-1 in the meconium group increased from 2.19 at the initial period to 7.19 at 8 hrs after meconium instillation. Conclusions Our conclusion is that aspiration of meconium causes lung injury in the newborn and that this injury is associated with a significant increase in ET peptide production in the lungs. We also showed that ET production is inhibited by pretreatment of rabbits with captopril before meconium-induced injury. ET-1 and its conversion from ET-1 in response to meconium may play important roles in increasing pulmonary vascular resistance and lung cell death, even in the absence of hypoxia. In general, we conclude, that ET-1 levels are significantly elevated in meconium-instilled rabbits compared with saline-instilled ones, and both can be significantly inhibited by pretreatment with captopril. Whether ET-1 contributes directly to the pathophysiology of or is simply a marker of meconium aspiration syndrome remains speculative.

Use of animal models to test novel therapies in sepsis.

We read with interest the recent article by Strand et al. (1) demonstrating improved survival with N G -monomethyl-L-arginine (L-NMMA) in a porcine model of sepsis. We applaud the authors for utilizing a model of such obvious sophistication and complexity. As was pointed out at the annual meetings of both the Society of Critical Care Medicine and the American Thoracic Society, the recent clinical failure of several novel strategies in sepsis may, in part, be attributed to the failure of preclinical animal models to adequately simulate clinical sepsis. The model employed by the authors is a resuscitated fecal peritonitis model. This model offers several important advantages, including a controlled polymicrobial bacterial inoculum, aggressive resuscitation of intravascular volume, and large animal size with measurement of hemodynamic variables similar to that used in patients. All of these items have been cited previously as important features of a clinically relevant model of sepsis (2-4).

A Traumatic Direct Inguinal Hernia from Pelvic Ring Disruption

Introduction Pelvic fractures usually involve a high-energy traumatic mechanism and account for approximately 3% of all blunt traumatic skeletal injuries. Additional musculoskeletal injuries are found in over 80% of unstable pelvic fractures. Traumatic abdominal wall hernias (TAWHs) are a rare entity, and traumatic inguinal hernias (TIHs) associated with open-book pelvic fractures have not been described previously. Case Presentation We present the case of a 45-year-old male motorcyclist involved in a collision resulting in a traumatic direct inguinal hernia due to abdominal wall disruption from an open-book pelvic fracture. He underwent a combined operation with an open reduction and internal fixation (ORIF) of his pelvic fracture and an abdominal wall reconstruction with a modified Stoppa technique utilizing mesh for his hernia. Discussion This is a unique presentation of a TIH due to an open-book pelvic fracture after blunt abdominal trauma. The formation of TAWH is typically from a combination of local tangential shearing forces and a sudden rise in intraabdominal pressures damaging the muscle, fascia, and peritoneum while the skin remains intact. In patients without hollow viscous injuries and gross contamination, these hernias can be repaired safely with mesh in the acute setting simultaneously with pelvic reduction.