Talat Chughtai

Surgically Important Bowel and/or Mesenteric Injury in Blunt Trauma: Accuracy of Multidetector CT for Evaluation

PURPOSE To determine the accuracy of multidetector computed tomography (CT) in the detection of surgically important blunt bowel and/or mesenteric injury, to identify and describe the most reliable CT features of bowel and/or mesenteric injury, and to evaluate the performance of readers with different levels of expertise. MATERIALS AND METHODS Institutional review board approval was obtained for this retrospective case-control study of 96 subjects with laparotomy-confirmed findings: 54 consecutive patients with bowel and/or mesenteric injury (surgically important and unimportant) (32 male patients, 22 female patients; mean age, 40.4 years +/- 17.6 [standard deviation]; range, 16-86 years) and 42 matched patients without bowel and/or mesenteric injury (22 male patients, 20 female patients; mean age, 36.8 years +/- 20.1; range, 14-84 years) who underwent four-detector CT prior to surgery. A second-year radiology resident, an abdominal imaging fellow, and a staff abdominal radiologist, blinded to patient outcome, independently reviewed CT studies and recorded the probability of bowel and/or mesenteric injury on a five-point scale. Sensitivity and specificity were calculated for each reviewer, and areas under the receiver operating characteristic curve (AUCs) were compared. RESULTS Thirty-eight (40%) of 96 patients had surgically important bowel and/or mesenteric injury, and 58 (60%) of 96 patients had either no or surgically unimportant bowel and/or mesenteric injury. Sensitivities of the three reviewers in the diagnosis of surgically important bowel and/or mesenteric injury ranged from 87% (33 of 38) to 95% (36 of 38); specificities ranged from 48% (28 of 58) to 84% (49 of 58). The only significantly better AUC belonged to the staff radiologist for surgically important mesenteric injury (P = .01). Bowel wall defect, extraluminal contrast material, thick large bowel, mesenteric vessel beading, abrupt termination of mesenteric vessels, and mesenteric vessel extravasation showed the best positive likelihood ratios for surgically important bowel and/or mesenteric injury; absence of peritoneal fluid showed the best negative likelihood ratio. CONCLUSION Multidetector CT findings accurately reveal surgically important bowel and/or mesenteric injury and have a high negative predictive value.

A Descriptive Study of Bicycle Helmet Use in Montreal, 2011

ObjectiveThe purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming.MethodsUsing a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1–3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated.ResultsA total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47–52 vs. 44%, 95% CI 42–45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52).ConclusionsAlthough above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.RésuméObjectifDécrire le port du casque de cycliste chez les cyclistes montréalais en vue d’instaurer des programmes de prévention des blessures.MéthodeÀ la faveur d’une étude transversale, nous avons observé les cyclistes sur des périodes de 60 minutes à 22 endroits sur l’île de Montréal. Il y a eu de 1 à 3 périodes d’observation à chaque endroit. Les observations ont eu lieu entre le 16 août et le 31 octobre 2011. Nous avons utilisé des méthodes statistiques types et calculé les rapports de cotes ajustés et non ajustés et les intervalles de confiance de 95 %.RésultatsNous avons observé 4 789 cyclistes en tout. La proportion observée de cyclistes portant le casque était de 46 % globalement (IC de 95 %: 44-47). Cette proportion était plus élevée chez les femmes (50 %, IC de 95 %: 47–52) que chez les hommes (44 %, IC de 95 %: 42–45). Les jeunes étaient proportionnellement les plus nombreux à porter un casque (73 %, IC de 95 %: 64-81), tandis que les jeunes adultes étaient proportionnellement les moins nombreux à le faire (34 %, IC de 95 %: 30-37). Le port du casque observé chez les cyclistes membres de minorités visibles était de 29 % (IC de 95 %: 25-34), contre 47 % chez les cyclistes blancs (IC de 95 %: 46-49). Les utilisateurs du BIXI (vélo en libre-service) ont été observés en train de porter un casque 12 % du temps (IC de 95 %: 10-15), contre 51 % du temps chez les cyclistes ayant leur propre vélo (IC de 95 %: 49-52).ConclusionsBien qu’il soit supérieur à la moyenne nationale, le port du casque de cycliste à Montréal est encore très faible, car la majorité des cyclistes n’en porte pas. Les programmes de prévention des blessures pourraient cibler tous les cyclistes, mais il serait justifié d’accorder une attention particulière à certains groupes: les jeunes hommes, les minorités visibles, les utilisateurs du BIXI et les cyclistes dans les zones touristiques. Par ailleurs, une collaboration avec le système de vélos en libre-service BIXI Montréalmc en vue d’assurer la disponibilité de casques de cyclistes pour les usagers du BIXI pourrait être fructueuse.

Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma.

BACKGROUND Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention. METHODS This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE. RESULTS Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%). CONCLUSION Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Successful repair of aortoesophageal fistula secondary to traumatic pseudoaneurysm

There have previously been only rare reported survivors of an aortoesophageal fistula resulting from a traumatic pseudoaneurysm. We report a case of a young man with a dramatic presentation who was successfully managed by immediate operative repair. A prosthetic graft was sewn within the sac of the aneurysm, with the aneurysm wall being used to protect the graft, and the esophagus was resected. Staged reconstruction of the esophagus was subsequently performed successfully. The patient is now alive and well 2 1/2 years later.

Pancreaticoatmospheric fistula following severe acute necrotising pancreatitis

Severe acute necrotising pancreatitis is associated with numerous local and systemic complications. Abdominal compartment syndrome requiring urgent decompressive laparotomy is a potential complication of this disease process and is associated with increased morbidity and mortality. We describe the case of a pancreaticoatmospheric fistula following decompressive laparotomy in a patient with severe acute necrotising pancreatitis. While this fistula was managed successfully using the current standard of care for pancreatic fistulas, the wound care for in this patient with drainage of the fistula through an open abdomen, is a significant challenge.