Spontaneous dissection of branch renal artery- is conservative management safe and effective?

PURPOSE: We analyzed the long-term results of conservative management for spontaneous branch renal artery dissection. MATERIALS AND METHODS: In the last 6 years 8 patients were treated for acute spontaneous branch renal artery dissection at our department. The diagnosis was established by angiography, which showed primary branch artery dissection in all cases. All patients were treated with antihypertensive and platelet anti-aggregate therapy. None of them underwent surgery. After treatment patients were evaluated for blood pressure and renal function and by abdominal computerized tomography angiography with 3-dimensional reconstruction. RESULTS: Median followup was 72.3 months. In 6 patients blood pressure was controlled with a single antihypertensive agent. In another patient 3 antihypertensive agents were required. The remaining patient continued to have labile hypertension because of poor compliance with treatment. Renal function was normal in 7 patients. Control computerized tomography angiography showed proximal arterial remodeling in 6 patients and persistent occlusion of primary branches in 2. CONCLUSIONS: In our experience conservative management of spontaneous branch renal artery dissection is safe and effective. Surgical treatment should be proposed at the acute stage only in patients with malignant hypertension or renal failure and at the chronic stage in those with refractory renovascular hypertension.     

Solitary enchondromas: is radiographic follow-up sufficient in patients with asymptomatic lesions?

Enchondromas are benign cartilaginous tumours and rarely transform into chondrosarcomas. Curettage is usually performed, and a low rate of complications is assumed. We analysed retrospectively data from 73 patients with enchondromas treated by curettage with respect to symptoms, therapy, complications and recurrences. All patients were treated by curettage of the tumour, in most cases followed by cancellous bone grafting. Twenty-three percent of the patients presented a complication. There were two recurrences but no malignant transformations in the follow-up period. During the same time period 29 patients with chondrosarcomas were treated, including two secondary chondrosarcomas. One had a recurrence of a benign enchondroma of the metacarpal and developed a pulmonary metastasis from a chondrosarcoma. The other was a patient with Ollier's disease who had a secondary chondrosarcoma of the radius. Malignant transformation of a solitary enchondroma to a chondrosarcoma is rare. On the other hand the complication rate of enchondroma curettage is considerable. Regular radiological follow-up of asymptomatic enchondromas may therefore be the better option.     

Chylothorax complicating thoracic surgery: conservative or early surgical management?

Postoperative chylothorax is a rare complication in thoracic surgery. There is considerable controversy concerning the management of chylothorax with some physicians favoring conservative treatment while others favor a surgical one. Considering the current surgical experience with VATS and by reviewing the problems and outcome of conservative management, the guidelines regarding timing of surgery in patients with chylous leak need to be revised.     

Marathon pancreatitis: is the etiology repetitive trauma?

Abdominal pain frequently occurs after long-distance running. The cause of the pain may be due to dehydration, diaphragmatic ischemia, muscular spasm, or myonecrosis. However, data regarding the frequency of these purported causes are currently lacking. Pancreatitis can also occur after long-distance running, but few cases have been reported, and the etiology is controversial. We report a case of pancreatitis in a thin, muscular marathon runner. We suggest the etiology in this case may be traumatic as the pancreas may have suffered repetitive injury against the posterior abdominal wall and spine.     

Barrier precautions in trauma: is knowledge enough?

OBJECTIVES: The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates. METHODS: A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned. RESULTS: Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02). CONCLUSION: The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.     

Thoracolumbar immobilization for trauma patients with torso gunshot wounds: is it necessary?

BACKGROUND: Previous studies have suggested that patients transported by emergency medical services (EMS) following major trauma had a longer injury-to-treatment interval and a higher mortality rate than their non-EMS-transported counterparts. HYPOTHESIS: There is little actual benefit of thoracolumbar immobilization for patients with torso gunshot wounds (GSW). DESIGN: Retrospective analysis of prospectively gathered data from the Maryland Institute for Emergency Medical Service Systems State Trauma Registry from July 1, 1995, through June 30, 1998. SETTINGS: All designated trauma centers in Maryland. PATIENTS: All patients with torso GSW. MAIN OUTCOME MEASURES: (1) A patient was considered to have benefited from immobilization if he or she had less than complete neurologic deficits in the presence of an unstable vertebral column, as shown by the need for operative stabilization of the vertebral column; (2) mortality. RESULTS: There were 1000 patients with torso GSW. Among them, 141 patients (14.1%) had vertebral column and/or spinal cord injuries. Two patients (0.2%) (95% confidence interval, -0.077% to 0.48%) required operative vertebral column stabilization, while 6 others required other spinal operations for decompression and/or foreign body removal. The presence of vertebral column injury was actually associated with lower mortality (7.1% vs 14.8%, P<.02). CONCLUSIONS: This study suggests that thoracolumbar immobilization is almost never beneficial in patients with torso GSW, and that a higher mortality rate existed among those GSW patients without vertebral column injury vs those with such injuries. The role of formal thoracolumbar immobilization for patients with torso GSW should be reexamined.     

In-house trauma attendings: is there a difference?

INTRODUCTION: Outcomes of patients who met trauma activation criteria were examined before and after implementation of in-house attending call. MATERIALS AND METHODS: Outcomes for the out-of-house period (OH) (February 1, 2001 to October 31, 2002) were compared with the in-house period (IH) (November 1, 2002 to June 30, 2004). Measures included overall mortality, length of stay (LOS) in the hospital, intensive care unit (ICU) and emergency department, and preventable deaths. RESULTS: A total of 2,019 trauma activations were studied (1,036 OH, 983 IH). The groups were equivalent on admission. There was no difference in hospital LOS, ICU LOS, ventilator days, or overall mortality. Preventable deaths occurred in 8.1% of the OH group and in 1.0% of the IH group (P < .02). CONCLUSIONS: Aggregate statistics and the use of surrogate markers to determine outcomes may not accurately portray the impact of attending surgeons on the quality of care. Implementation of in-house call resulted in a decreased incidence of preventable deaths.     

The management of renal artery atherosclerosis for renal salvage: does stenting help?

OBJECTIVE: The use of endovascular techniques to treat renal artery stenosis (RAS) has increased in recent years but remains controversial. The purpose of this study was to review the outcomes and durability of percutaneous transluminal angioplasty and stenting (PTA/S) for patients with RAS and decreasing renal function. METHODS: Between 1999 and 2004, 125 consecutive patients underwent angiography and intervention for renal salvage and formed the basis of this study. Inclusion criteria for this study included serum creatinine greater than 1.5 mg/dL, ischemic nephropathy, and high-grade RAS perfusing a single functioning kidney. Patients undergoing PTA/S for renovascular hypertension or fibromuscular dysplasia or in conjunction with endovascular stent grafting for aneurysm repair were excluded. The original angiographic imaging was evaluated for lesion grade and parenchymal kidney size. All medical records and noninvasive testing were reviewed. Preoperative and postoperative patient data were standardized and analyzed by using chi(2) tests for nominal values and t tests for continuous variables. The Modification of Diet in Renal Disease equation was used to estimate glomerular filtration rate (GFR), and univariate analysis was performed. RESULTS: Preoperative variables included the presence of coronary artery disease (93%), diabetes (44%), tobacco use (48%), and hypercholesterolemia (70%). RAS was suspected on the basis of preoperative duplex imaging or magnetic resonance angiography. Aortography and PTA/S were performed in 125 patients (mean age, 71 years; 59% male) with a mean baseline creatinine level of 2.2 mg/dL. There were two mortalities (1.6%) in the 30-day postoperative period, but there was no case of acute renal loss. Blood pressure decreased after PTA/S (151/79 mm Hg before vs 139/72 mm Hg after 1 month; P < .03). For all patients, the estimated GFR went from 33 +/- 12 mL . min(-1) . 1.73 m(-2) (mean +/- SD) to 37 +/- 19 mL . min(-1) . 1.73 m(-2) at 6 months (P = .10). Sixty-seven percent of treated patients had improvement (>10% increase in GFR) or stabilization of renal function. A rapid decline in GFR before intervention was correlated with improvement after PTA/S. Responders after PTA/S had a 27% decrease in GFR before intervention (44 +/- 13 mL . min(-1) . 1.73 m(-2) to 32 +/- 13 mL . min(-1) . 1.73 m(-2); P < .001) with a negative to positive slope change in GFR values. Ten patients underwent reintervention for in-stent restenosis. Cases without improvement in GFR after PTA/S were associated with eventual dialysis need (P = .01; mean follow-up, 19 months). Survival at 3 years was 76%, and dialysis-free survival was 63% as estimated by Kaplan-Meier analyses. CONCLUSIONS: Renal artery stenoses causing renal dysfunction can be safely treated via endovascular means. Rapidly decreasing renal function is associated with the response to renal artery angioplasty/stenting and helps identify patients for renal salvage.     

Levofloxacin-induced delirium: is it a dangerous drug in patients with renal dysfunction?

The central nervous system (CNS) toxicity of fluoroquinolones is well known but usually occurs benign. In the literature, there are a few number of severe CNS toxicity cases related to fluoroquinolones. Levofloxacin is a third-generation fluorinated quinolone antibiotic, is the active levo stereoisomer of ofloxacin, and has one of the most favorable adverse reaction profiles. We describe a case of delirium associated with levofloxacin in a 55-year-old man who was hospitalized in our medical clinic for pneumonia.