John E. Mazuski

Outcome After Colectomy for Clostridium Difficile Colitis

PURPOSEClostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C.difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis.METHODSA population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher’s exact tests. Statistical significance was designated as P < 0.05.RESULTSSixty-seven patients (mean age, 69 (range, 40–86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure, <90 mmHg). Forty-three of 67 patients (64 percent) presented with an acute surgical abdomen. Mean white blood cell count was 27.2; mean percent bands was 12. Twelve of 67 patients (18 percent) had a negative C. difficile colitis stool assay. Abdominal computed tomography correctly diagnosed 45 of 46 patients (98 percent) who were imaged. Twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2–297) days.CONCLUSIONSPatients with fulminant C. difficile colitis often present with an unexplained abdominal illness with a marked leukocytosis that rapidly progresses to shock and peritonitis. Although frequently developed during a hospitalization and often after a surgical procedure, it may develop outside of a hospital setting. Diarrhea may be absent and stool cytology may be negative for C. difficile toxin. Perforation and infarction are frequently found at surgery. In those patients who survive, a prolonged hospitalization is common. Mortality from fulminant C. difficile colitis remains high despite surgical intervention.

Outcome and utility of scoring systems in the management of the mangled extremity

BACKGROUND The role of scoring systems as predictors of amputation and functional outcome in severe blunt extremity trauma was examined. METHODS All severe extremity injuries treated over a 10-year period were scored retrospectively using four scoring systems: Mangled Extremity Syndrome Index (MESI), Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), and Limb Salvage Index (LSI). RESULTS Twenty-three upper (UE) and 51 lower extremity (LE) injuries were evaluated. Sensitivity and specificity, respectively, were MESI 100% and 50%, MESS 79% and 83%, PSI 96% and 50%, and LSI 83% and 83%. For each system, there were no differences between patients with good and poor functional outcomes. CONCLUSION All of the scoring systems were able to identify the majority of patients who required amputation. However, prediction in individual patients was problematic. None of the scoring systems were able to predict functional outcome.

The unreliability of CT scans and initial chest radiographs in evaluating blunt trauma induced diaphragmatic rupture

OBJECTIVE There is no gold standard for early and reliable diagnosis of traumatic diaphragmatic rupture (TDR). The purpose of this study is to correlate CT scans, chest radiographs, and intubation on the ability to diagnosis traumatic diaphragmatic rupture. MATERIALS AND METHODS Twenty patients with blunt trauma induced diaphragmatic rupture were identified from a five year review of a Level 1 Trauma Registry. RESULTS Ten of the 20 (50%) patients had TDR on initial chest X-ray, all on the left side. Twelve patients had both chest X-rays and a chest and abdominal CT scan; however, only five (42%) of the CT scans were diagnostic. Of the 12 patients initially intubated, TDR was diagnosed in only four (33%) patients on initial chest X-ray and in one (14%) of seven patients having chest and abdominal CT scans and being intubated. CONCLUSION The early diagnosis of blunt traumatic diaphragmatic rupture, especially in intubated patients, continues to be a diagnostic dilemma. There is a significantly better possibility of identifying left over right-sided TDR (P < or = 0.05). Diagnosing TDR is also facilitated by extubation. If the suspicion exists, a post extubation chest radiograph should be performed to evaluate for TDR.

Computed tomography in the diagnosis of blunt thoracic injury

BACKGROUND Computed tomography (CT) is an important diagnostic modality in the evaluation of blunt head and abdominal injuries, but it has not been routinely used to evaluate blunt chest trauma. METHODS One hundred seventy stable patients with blunt thoracic trauma were evaluated with chest x-ray (CXR), and subsequently by CT. RESULTS Of a total of 131 fractures, 53% were identified on initial CXR, 39% on CT, and 26% were not seen on either study. Twenty-one pneumothoraces were seen on CT but not on CXR. Chest tubes were placed in 8 patients and 12 patients were observed without incident. One hemothorax identified by CT scan alone required treatment. Four of 6 diaphragmatic injuries were seen on CT and 2 on CXR. Parenchymal abnormalities were apparent in 189 lung fields on CT and in 66 lung fields on CXR. Most represented atelectasis and did not require treatment. Altogether, CT scanning resulted in changes in management for 11 patients (6%). CONCLUSIONS Although CXR is less sensitive in detecting parenchymal and pleural injuries than CT, the majority of the injuries identified by CT alone are minor and require no treatment. CXR remains the primary modality for diagnostic evaluation of blunt thoracic trauma.

Right ventricular end-diastolic volume as a measure of preload

Right ventricular (RV) end-diastolic volume index (RVEDVI) measured by a modified thermodilution pulmonary artery catheter has been proposed as an improved measure of cardiac preload, compared with pulmonary capillary wedge pressure (PCWP). This study compared the correlation of RVEDVI and PCWP with cardiac index (CI) to determine which parameter better reflected ventricular preload. Modified thermodilution catheters were placed in 38 critically ill patients. Hemodynamic parameters were recorded in these patients at 2- to 4-hour intervals for 1 to 7 days. Complete data sets (1,008) were obtained. Regression analysis was performed comparing PCWP, RVEDVI, RV ejection fraction (RVEF) to CI in the entire group and in individual patients. Because mathematical coupling may exist between RVEDVI and CI, the correlation between these variables was corrected for mathematical coupling using the method described by Stratton. Simple regression analysis of data from all patients, uncorrected for mathematical coupling, yielded a significant correlation between CI and RVEDVI (r = 0.60, p < 0.0001), RVEF (r = 0.37, p < 0.0001), and PCWP (r = 0.01, p < 0.001). Correction for mathematical coupling between RVEDVI and CI resulted in a minor changes of the correlation coefficient to 0.56. In individual patients, a significant, uncorrected correlation (p < 0.05) was found between RVEDVI and CI in 27 of the 38 patients, whereas 11 patients had a significant correlation between PCWP and CI. RVEDVI correlated more closely with CI than did PCWP, even after correlation for mathematical coupling. In both the group as a whole and in individual patients, RVEDVI was a better indicator of cardiac preload.

Management of selected rectal injuries by primary repair

BACKGROUND Diversion of the fecal stream with or without primary repair has been the mainstay of therapy for rectal injuries. Because primary repair has replaced colostomy as the treatment of choice for most colon injuries, we reviewed our experience with primary repair of rectal injuries in order to determine if primary repair without diversion is a feasible option in selected patients. MATERIALS AND METHODS All traumatic rectal injuries over the past 48 months were reviewed for mechanism of injury, diagnosis, treatment, and outcome. RESULTS Thirty consecutive patients with extraperitoneal rectal injuries were identified. Six of the 30 patients underwent primary repair without diversion. Five were repaired transanally, and 1 was repaired at celiotomy. There was no morbidity related to the rectal repair in patients who underwent primary repair without diversion, and there were no deaths. CONCLUSIONS Based on a small number of patients, these data suggest that primary repair of rectal injuries in selected patients may be feasible. Further prospective investigation is needed to determine which patients may be successfully treated in this fashion.

Evaluation of the thoracic and lumbar spine after blunt trauma

BACKGROUND Routine performance of thoraco-lumbar (TL) spinal radiology in patients with blunt trauma is controversial. PATIENTS AND METHODS To establish indications for radiologic screening of the TL spine, a retrospective review of 344 patients who had radiologic evaluation of the spine was performed. RESULTS Forty-seven patients had abnormalities detected on radiologic evaluation. One hundred eighty-six patients had at least one clinical finding suggestive of injury. Thirty-two had abnormal radiographs. Thirteen of these abnormalities represented old or minor fractures and were not treated. Nineteen patients had injuries requiring treatment. Two patients were treated with activity restriction, 12 with a back brace, 4 with operative fixation, and 1 patient died prior to operation. Of the 129 patients who were awake, alert, and without clinical evidence of injury, 10 had abnormal radiologic studies. Three patients had old fractures, 4 had transverse process fractures, and 3 had spondylolisthesis. None of these patients required treatment. Twenty-nine patients had equivocal clinical examinations primarily due to altered levels of consciousness. Five patients had abnormal radiologic studies, 3 of whom required treatment. Three factors associated with the occurrence of TL spine injury were identified: an Injury Severity Score > or = 15, a positive clinical examination, and a fall of > or = 10 feet. CONCLUSIONS These data suggest that patients who are awake, alert, and with no clinical evidence of injury do not require radiologic study of the TL spine. Patients with equivocal or positive clinical findings or with altered levels of consciousness should have complete TL spine evaluation.

Role of cytokines and platelet-activating factor in inflammatory bowel disease

BACKGROUND: Platelet-activating factor (PAF) and cytokines, such as interleukins, tumor necrosis factor, and others, are thought to play a role in the inflammatory process involving gastrointestinal disorders such as Crohns disease, ulcerative colitis, ischemic colitis, or antibiotic-associated colitis. PURPOSE: This study was undertaken to review the latest literature on the role of PAF and cytokines in the genesis of inflammatory bowel disease and implications for therapy and management. RESULTS: PAF is an endogenous phospholipid involved in hypersensitivity and inflammatory reactions such as platelet and neutrophil aggregation, vasodilation, increased vascular permeability, and leukocyte adhesion, which have been associated with inflammatory processes. Cytokines are peptides that regulate and coordinate inflammatory and immunologic responses. Increased production of cytokines has been reported during Crohns disease and ulcerative colitis and is correlated with disease activity. CONCLUSIONS: Because PAF and cytokines may have an important role in the pathogenesis of inflammatory bowel disease, their inhibition by specific antagonists, mediators, or other agents such as steroids may have a potential therapeutic benefit in treatment and management of these inflammatory diseases in the near future.

Contribution of cyclooxygenase-1 and cyclooxygenase-2 to prostanoid formation by human enterocytes stimulated by calcium ionophore and inflammatory agents.

The stimulation of intestinal epithelial cell cyclooxygenase (COX) enzymes with inflammatory agents and the inhibition of COX-1 and COX-2 enzymes has the potential to increase understanding of the role of these enzymes in intestinal inflammation. The aim of this study was to determine the contributions of COX-1 and -2 to the production of specific prostanoids by unstimulated and stimulated intestinal epithelial cells. Cultured enterocytes were stimulated with lipopolysaccharide (LPS), interleukin-1 (IL-1)beta (IL-1 beta), and calcium ionophore (Ca Ion), with and without COX inhibitors. Valerylsalicylic acid (VSA) was employed as the COX-1 inhibitor, and SC-58125 and NS398 were used as the COX-2 inhibitors. Prostanoids were quantitated by Elisa assay. Western immunoblotting demonstrated the presence of constitutive COX-1 and inducible COX-2 enzyme. Unstimulated prostanoid formation was not decreased by the COX-1 inhibitor. All of the stimulants evaluated increased prostaglandin E2 (PGE2) production. Only Ca Ion stimulated prostaglandin D2 (PGD2) production while IL-1 beta, and Ca Ion, but not LPS, increased prostaglandin F2 alpha (PGF2 alpha) formation. Ca Ion-stimulated prostanoid formation was uniformly inhibited by COX-2, but not COX-1, inhibitors. IL-1 beta-stimulated PGE2 and PGE2 alpha formation was significantly decreased by both COX-1 and COX-2 inhibitors. VSA, in a dose-dependent manner, significantly decreased IL-1 beta-stimulated PGE2 and PGF2 alpha production. Unstimulated prostanoid formation was not dependent on constitutive COX-1 activity. The stimulation of intestinal epithelial cells by Ca Ion seemed to uniformly produce prostanoids through COX-2 activity. There was no uniform COX-1 or COX-2 pathway for PGE and PGF2 alpha formation stimulated by the inflammatory agents, suggesting that employing either a COX-1 or COX-2 inhibitor therapeutically will have varying effects on intestinal epithelial cells dependent on the prostanoid species and the inflammatory stimulus involved.

Traumatic train injuries

Train accidents involving motor vehicles and pedestrians can be devastating. Approximately 1,234 fatalities were recorded in the United States in 1989. The literature from the United States is sparse, prompting a 7-year review of 23 consecutive train accident victims. Twenty (87%) were male, with an average age of 30.6 years. Sixteen (70%) were intoxicated at the time of the accident, and the average Injury Severity Score was 21.4. There was a total of eight traumatic amputations occurring in the 11 (48%) patients involved as pedestrians. Two of these were railroad workers, and nine were trespassers. Fourteen (61%) accidents occurred between the hours of 2300 and 0700. Three (14%) patients died. Although alcohol use occurred in 16 (70%), there was no significance between alcohol use and amputation. Thus, non-railroad employed pedestrians, because of a lack of protection, are more prone to traumatic amputations, primarily of the lower extremities, than those involved in motor vehicle accidents.