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1.  Diagnostic implications of computed tomography pulmonary angiography in patients with pulmonary embolism 
Annals of Thoracic Medicine  2016;11(4):269-276.
INTRODUCTION:
Pulmonary embolism (PE) is a serious cardiovascular and pulmonary complication worldwide. We aimed to assess the implications of different computed tomography pulmonary angiography (CTPA) parameters in patients with acute PE.
METHODS:
A retrospective observational study to include patients presented with clinical suspicious of PE who underwent CTPA was conducted. Patients' demographics, clinical presentation, risk factors, laboratory investigations, management, and outcome were analyzed. Computed tomography findings included clot burden (Qanadli score [QS]) and right ventricular dysfunction (RVD) parameters.
RESULTS:
A total of 45 patients with radiologically confirmed diagnosis of PE were included in the study; of these patients, 8 (17.8%) died during the hospital course. Patients who died were 13 years older than those who survived, and the mortality rate was significantly higher in patients with cancer. The two groups were comparable for cardiovascular parameters. The mean clot burden (QS) was 19.5 ± 11.3 points and 53% of patients had QS >18 points. Obesity (52.4% vs. 12.5%; P = 0.01), hypertension (54.4% vs. 23.8%; P = 0.03), and median D-dimer levels (7.8 vs. 3.4; P = 0.03) were significantly higher in patients with QS >18. Among right ventricular (RV) dysfunction parameters, only higher RV/left ventricular (LV) ratio (P = 0.001) and bowing of interventricular septum (P = 0.001) were associated with higher QS. A significant positive correlation was found between RV short axis (r = 0.499, P = 0.001), RV/LV ratio (r = 0.592, P = 0.001), and pulmonary artery (PA) diameter (r = 0.301, P = 0.04) with the PA clot burden. Receiver operating characteristic curve for clot burden showed a cutoff value of 17.5 points to accurately predict RV dysfunction.
CONCLUSIONS:
Clot burden >18 is associated with RV dysfunction in patients with acute PE. Echocardiography and RVD parameters showed no correlation with in-hospital deaths. CTPA has clinicoradiological implications for risk stratification in PE patients. As the sample size is small, our findings warrant further larger prospective studies.
doi:10.4103/1817-1737.191868
PMCID: PMC5070436  PMID: 27803753
Computed tomography angiogram; pulmonary embolism; right ventricular dysfunction; thromboembolism
2.  The “Triple-Q Algorithm:” A practical approach to the identification of liver topography 
The descriptive identification and interpretation of liver pathology continue to raise debate, especially for trainees and junior physicians. There is wide diversity in the description of liver segmentation with sometimes contradictory terminology between French and American literature. Attempts were made to create a unified nomenclature that simplifies the problem. We propose a simple approach to describe the location of liver pathology in different settings by referring to an algorithm based on three questions. Explanations to answer these questions and correctly describe the location of liver pathology are herein described. In conclusion, we think that the adoption of such an algorithm called arbitrary “the Triple-Q Algorithm” will facilitate the understanding of liver topography for the young physicians, as well as it will allow for the accurate description and localization of the pathological lesions in the liver. This could be achieved after testing and validating this algorism in prospective studies. This could have academic and clinical implications in the medical education and the patient care.
doi:10.4103/2229-516X.192588
PMCID: PMC5108097  PMID: 27857888
Hepatic topography; liver segmentation; nomenclature of liver anatomy
3.  Pattern and predictors of mortality in necrotizing fasciitis patients in a single tertiary hospital 
Background
Necrotizing fasciitis (NF) is a fatal aggressive infectious disease. We aimed to assess the major contributing factors of mortality in NF patients.
Methods
A retrospective study was conducted at a single surgical intensive care unit between 2000 and 2013. Patients were categorized into 2 groups based on their in-hospital outcome (survivors versus non-survivors).
Results
During a14-year period, 331 NF patients were admitted with a mean age of 50.8 ± 15.4 years and 74 % of them were males Non-survivors (26 %) were 14.5 years older (p = 0.001) and had lower frequency of pain (p = 0.01) and fever (p = 0.001) than survivors (74 %) at hospital presentation. Diabetes mellitus, hypertension, and coronary artery disease were more prevalent among non-survivors (p = 0.001). The 2 groups were comparable for the site of infection; except for sacral region that was more involved in non-survivors (p = 0.005). On admission, non-survivors had lower hemoglobin levels (p = 0.001), platelet count (p = 0.02), blood glucose levels (p = 0.07) and had higher serum creatinine (p = 0.001). Non-survivors had greater median LRINEC (Laboratory Risk Indicator for NECrotizing fasciitis score) and Sequential Organ Failure Assessment (SOFA) scores (p = 0.001). Polybacterial and monobacterial gram negative infections were more evident in non-survivors group. Monobacterial pseudomonas (p = 0.01) and proteus infections (p = 0.005) were reported more among non-survivors. The overall mortality was 26 % and the major causes of death were bacteremia, septic shock and multiorgan failure. Multivariate analysis showed that age and SOFA score were independent predictors of mortality in the entire study population.
Conclusion
The mortality rate is quite high as one quarter of NF patients died during hospitalization. The present study highlights the clinical and laboratory characteristics and predictors of mortality in NF patients.
doi:10.1186/s13017-016-0097-y
PMCID: PMC4977757  PMID: 27508002
Necrotizing fasciitis; Predisposing factors; Presentation; Management; Mortality
4.  Occupational injuries: Global and local perspectives  
Nepal Journal of Epidemiology  2016;6(2):560-562.
doi:10.3126/nje.v6i2.15161
PMCID: PMC5073172  PMID: 27774343
5.  Patterns and management of degloving injuries: a single national level 1 trauma center experience 
Background
Degloving soft tissue injuries (DSTIs) are serious surgical conditions. We aimed to evaluate the pattern, management and outcome of DSTIs in a single institute.
Methods
A retrospective analysis was performed for patients admitted with DSTIs from 2011to 2013. Presentation, management and outcomes were analyzed according to the type of DSTI.
Results
Of 178 DSTI patients, 91 % were males with a mean age of 30.5 ± 12.8. Three-quarter of cases was due to traffic–related injuries. Eighty percent of open DSTI cases were identified. Primary debridement and closure (62.9 %) was the frequent intervention used. Intermediate closed drainage under ultrasound guidance was performed in 7 patients; however, recurrence occurred in 4 patients who underwent closed serial drainage for recollection and ended with a proper debridement with or without vacuum assisted closure (VAC). Closed DSTIs were mainly seen in the lower extremity and back region and initially treated with conservative management as compared to open DSTIs. Infection and skin necrosis were reported in 9 cases only. Open DSTIs were more likely involving head and neck region and being treated by primary debridement/suturing and serial debridement/washout with or without VAC. All-cause DSTI mortality was 9 % that was higher in the closed DSTIs (19.4 vs 6.3 %; p = 0.01).
Conclusion
The incidence of DSTIs is 4 % among trauma admissions over 3 years, with a greater predilection to males and young population. DSTIs are mostly underestimated particularly in the closed type that are usually missed at the initial presentation and associated with poor outcomes. Treatment guidelines are not well established and therefore further studies are warranted.
doi:10.1186/s13017-016-0093-2
PMCID: PMC4962500  PMID: 27468300
Degloving; Soft tissue injury; Debridement; Management; Trauma
6.  Presentation, Management, and Outcome of Thyroglossal Duct Cysts in Adult and Pediatric Populations: A 14-Year Single Center Experience 
Oman Medical Journal  2016;31(4):276-283.
Objectives
A thyroglossal duct cyst (TDC) is a frequent congenital midline anomaly of the neck that usually manifests during the first decade of life. We aimed to describe the presentation, management, and outcome of TDC in pediatric and adult cases.
Methods
A retrospective observational analysis was conducted for all patients diagnosed and treated for TDC between 2000 and 2014 in a single center in Qatar. Data included patients’ demographics, presentations, preoperative investigations, anesthesia type, histopathological findings, surgical management, recurrences, and complications.
Results
We identified 102 patients, of which 57% were males. The mean age of patients was 20.2±15.6 years. A bimodal distribution of TDC has been observed, which peaked between the ages of 6–13 years and at ≥19 years. The preoperative evaluation mainly includes ultrasonography (66%), thyroid function test (44%), and fine-needle aspiration cytology (10%). The median size of the cyst was 25 (2–60) mm. Patients mainly presented with an asymptomatic midline neck mass at or below the hyoid bone (82%), followed by fistula (9%), infection (2%), and dysphagia (2%). Eighty-nine cases were identified preoperatively as TDC. The histopathological findings confirmed TDC with hyoid bone in 61 cases, and TDC alone in 38 cases. Eighty patients underwent the Sistrunk procedure while excision of TDC alone was observed in 18 cases. Five cases of recurrent disease were also treated. Adults had a greater median cyst size (30 (9–60) vs. 22 (2–55) mm; p = 0.005) and required prolonged operation time (69 (1–169) vs. 32.5 (1–140) mins; 
p = 0.004) compared to the pediatric group.
Conclusion
The occurrence of TDC shows a bimodal age distribution. Preoperative evaluation and time for surgery vary whereas clinical presentations, surgical management, and postoperative outcomes are comparable among adult and pediatric groups. Ultrasonography is the preferred diagnostic modality, and the Sistrunk procedure remains the primary choice of treatment.
doi:10.5001/omj.2016.54
PMCID: PMC4927737  PMID: 27403240
Thyroglossal Duct Cyst; Pediatrics; Adults; Sistrunk, Neck
7.  Intravascular extra-digital glomus tumor of the forearm 
Journal of Surgical Case Reports  2016;2016(7):rjw124.
Intravascular glomus tumor in the forearm is very rare and usually presents with persistent pain and focal tenderness. The diagnosis of this condition can be easily missed or delayed. There is no successful treatment so far other than surgical excision in most of cases. We presented a 45-year-old female presented with intravascular glomus tumor in her left forearm. The swelling was excised and the post-operative course was uneventful. Intravascular glomus tumor of the forearm is extremely rare and the persistent pain and tenderness are very suspicious. Diagnostic imaging may not be indicated in every case.
doi:10.1093/jscr/rjw124
PMCID: PMC4946538  PMID: 27421300
8.  Early and late intramedullary nailing of femur fracture: A single center experience 
Background:
Femur fracture (FF) is a common injury, and intramedullary nailing (IMN) is the standard surgical fixation. However, the time of intervention remains controversial. We aimed to describe the reamed IMN (rIMN) timing and hospital outcomes in trauma patients presenting with FF.
Materials and Methods:
A retrospective analysis was conducted for all patients admitted with FF and they underwent fixation at level 1 trauma unit between January 2010 and January 2012. Patients were divided into Group I with early rIMN (<12 h) and Group II with late rIMN (≥12 h). Patients’ demographics, clinical presentations, mechanism of injury, pulmonary complications, organ failure, length of stay, and mortality were described.
Results:
A total of 307 eligible patients with FF were identified (156 patients in Group I and 151 patients in Group II). Patients in Group II were older (36 ± 18 vs. 29 ± 9; P = 0.001) and had higher rate of polytrauma (35% vs. 18%, P = 0.001), head injury (5% vs. 12%, P = 0.68) and bilateral FF (10.7% vs. 5.1%; P = 0.07) in comparison to Group I. Group II had longer stay in Intensive Care Unit (7 [1–56] vs. 2 [1–17] days; P = 0.009) and hospital (13 [2–236] vs. 9 [1–367]; P = 0.001). There were no significant differences in outcomes between the two groups in terms of sepsis, renal failure, fat embolism, adult respiratory distress syndrome and death.
Conclusions:
Based on this analysis, we believe that early rIMN is safe in appropriately selected cases. In patients with traumatic FFs, early rIMN is associated with low hospital complications and shorter hospital stay. The rate of pulmonary complications is almost the same in the early and late group. Further prospective randomized studies with large sample size would be ideal using the information garnered from the present study.
doi:10.4103/2229-5151.190649
PMCID: PMC5051057  PMID: 27722116
Femur; fracture; intramedullary nailing; outcomes; reamed; timing; trauma
9.  London Trauma Conference 2015 
Avery, Pascale | Salm, Leopold | Bird, Flora | Hutchinson, Anja | Matthies, Ashley | Hudson, Anthony | Jarman, Heather | Nilsson, Maria Bergman | Konig, Tom | Tai, Nigel | Fevang, Espen | Hognestad, Børge | Abrahamsen, Håkon B. | Cheetham, Olivia V. | Thomas, Matthew J. C. | Rooney, Kieron D. | Murray, Josephine | Tunnicliff, Malcolm | Collinson, Joseph W. | Brown, Thomas | Pritchett, Christopher | Pritchett, Christopher S. A. | Jadav, Mark | Meredith, Gareth | Plumb, Jamie | Harris, Steve | Langford, Roger | Hunter, J. G. | Sage, A. | Madden, R. | Flamank, O. | Broadbent, B. | Marsh, S. | Lewis, H. | Daniels, E. | Roberts, N. | Hunter, J. G. | Sage, A. | Madden, R. | Flamank, O. | Broadbent, B. | Marsh, S. | Lewis, H. | Daniels, E. | Lin, N. | Roberts, N. | Bulford, Samuel | Houghton-Budd, Silas | Pearson, Sam | Clear-Hill, Megan | Menzies, David J. | Leonard, James P. | Keogh, Conor | Quinn, Ray | Hinds, John D. | Roberts, N. | Ashton-Cleary, D. | Jadav, M. | Mahmood, Ismail | El-Menyar, Ayman | Younis, Basil | Khalid, Ahmed | Nabir, Syed | Ahmed, Mohamed Nadeem | Al-Yahri, Omer | Al-Thani, Hassan | Young, Katie | Hendrickson, Susan A. | Phillips, Georgina | Gardiner, Matthew D. | Hettiaratchy, Shehan | Crossland, Alexandra Alice | Hudson, Anthony | Brassington, Nicholas C. | Hudson, Anthony | McWhirter, Emily | Reid, Bjørn O. | Rehn, Marius | Uleberg, Oddvar | Krüger, Andreas J. | Jennings, Cara | Kapadia, Yasmin | Bew, Duncan | Townsend, Jenny | Hurst, Tom P. | Foster, Elizabeth A. | Brown, Thomas B. | Collinson, Joseph | Pritchett, Christopher | Slade, Toby | Tønsager, Kristin | Rehn, Marius | G.Ringdal, Kjetil | J.Krüger, Andreas | Hesselfeldt, Rasmus | Wulffeld, Sandra | Sonne, Asger | Rasmussen, Lars S. | Steinmetz, Jacob | Renninson, Thomas J. | Thomson, Nadine | Pynn, Harvey | Hooper, Timothy J. | Hudson, Anthony | Dawson, Jacinta | Matthies, Ashley | Friberg, Morten Langfeldt | Rognås, Leif | Wills, Jessica F. G. | Hudson, Anthony | Turner, Conor D. A. | Rehn, Marius | Nunn, James | Erdogan, Mete | Green, Robert S. | Minor, Samuel | Erdogan, Mete | Hartlen, Kathy | Green, Robert S. | Bird, Ruth | Grupping, Rachael L. | Stacey, Amelia M. | Rehn, Marius | Lockey, David J. | Abiks, S. | Cutler, L. | Monaghan, K. | Al-Rais, A. | Hymers, C. | Bloomer, R. | Kapadia, Y. | Seidenfaden, Sophie-Charlott | Riddervold, Ingunn S. | Kirkegaard, Hans | Juul, Niels | Bøtker, Morten T. | Gao, Alice | Perkins, Zane | Grier, Gareth | Tzannes, Alex | Hudson-Peacock, Nathan J. | Otto, Quentin | Phillipson, Laurie | Thomas, Rik | Heyworth, Ainsley | Otto, Quentin | Hudson-Peacock, Nathan J. | Phillipson, Laurie | Heyworth, Ainsley | Ley, Erica | Banner, Daniel | Heyworth, Ainsley | Ley, Erica | Benson, Madeleine | Hudson-Peacock, Nathan | Stone, Tony | Ley, Erica | Rousson, Louise | Heyworth, Ainsley | Lineham, Beth A. | Lee, Matthew J. | Gough, Martin | Seligman, William H. | Thould, Hannah E. | Dinsmore, Andrew | Tan, Charlotte | Thompson, Julian | Eynon, C. Andy | Lockey, David J. | Wahlin, Rebecka M. Rubenson | Lindström, Veronica | Ponzer, Sari | Vicente, Veronica | Eligio, Pamela | Hudson, Anthony | Young, Robert | Amiras, Dimitri | Sinha, Ian
Table of contents
I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015
Pascale Avery, Leopold Salm, Flora Bird
A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol
Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman
A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study
Maria Bergman Nilsson, Tom Konig, Nigel Tai
A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study
Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen
A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia
Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney
A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?
Josephine Murray, Malcolm Tunnicliff
A6 Curriculum mapping in ED point of care simulation
Joseph W Collinson, Thomas Brown, Christopher Pritchett
A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall
Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford
A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital
JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts
A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation
JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts
A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training
Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill
A11 Impact brain apnoea – nine cases
David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds
A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit
N Roberts, D Ashton-Cleary, M Jadav
A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma
Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani
A15 Plastics operative workload in major trauma centres: a national prospective survey
Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy
A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?
Alexandra Alice Crossland, Anthony Hudson
A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period
Nicholas C Brassington, Anthony Hudson, Emily McWhirter
A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services
Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger
A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London
Cara Jennings, Yasmin Kapadia, Duncan Bew
A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment
Jenny Townsend, Tom P Hurst, Elizabeth A Foster
A21 Live patients in trauma simulation – more than just simulation on a shoestring?
Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade
A22 Collecting core data in pre-hospital critical care using a consensus based template
Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger
A23 Prehospital interventions before and after implementation of a physician staffed helicopter
Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz
A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review
Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper
A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED
Anthony Hudson, Jacinta Dawson, Ashley Matthies
A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams
Morten Langfeldt Friberg, Leif Rognås
A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies
Jessica FG Wills, Anthony Hudson
A28 Pre-hospital management of mass casualty civilian shootings
Conor DA Turner, Marius Rehn
A30 The prevalence of alcohol-related trauma recidivism: a systematic review
James Nunn, Mete Erdogan, Robert S. Green
A31 Development of a hospital-wide program for simulation-based training in trauma care and management
Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green
A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood
Ruth Bird, Rachael L. Grupping
A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review
Amelia M. Stacey, Marius Rehn, David J. Lockey
A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?
S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia
A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)
Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker
A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre
Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes
A37 Does taking a third crew member affect the on-scene time of HEMS jobs?
Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth
A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?
Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley
A39 Code red: shock index as a prehospital indicator of massive haemorrhage
Daniel Banner, Ainsley Heyworth, Erica Ley
A40 Air ambulance tasking: how accurate are our current methods?
Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth
A41 Modern trauma burden in a district general hospital
Beth A Lineham, Matthew J Lee, Martin Gough
A42 Establishing a legal service for major trauma patients in two UK major trauma centres
William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey
A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma
Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente
A44 An audit of pre-hospital blood pressure management resulting from head injury
Pamela Eligio, Anthony Hudson
A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management
Robert Young, Dimitri Amiras, Ian Sinha
doi:10.1186/s13049-016-0248-x
PMCID: PMC4928155  PMID: 27357386
10.  The Challenging Buried Bumper Syndrome after Percutaneous Endoscopic Gastrostomy 
Case Reports in Gastroenterology  2016;10(2):224-232.
Buried bumper syndrome (BBS) is a rare complication developed after percutaneous endoscopic gastrostomy (PEG). We report a case of a 38-year-old male patient who sustained severe traumatic brain injury that was complicated with early BBS after PEG tube insertion. On admission, bedside PEG was performed, and 7 days later the patient developed signs of sepsis with rapid progression to septic shock and acute kidney injury. Abdominal CT scan revealed no collection or leakage of the contrast, but showed malpositioning of the tube bumper at the edge of the stomach and not inside of it. Diagnostic endoscopy revealed that the bumper was hidden in the posterolateral part of the stomach wall forming a tract inside of it, which confirmed the diagnosis of BBS. The patient underwent laparotomy with a repair of the stomach wall perforation, and the early postoperative course was uneventful. Acute BBS is a rare complication of PEG tube insertion which could be manifested with severe complications such as pressure necrosis, peritonitis and septic shock. Early identification is the mainstay to prevent such complications. Treatment selection is primarily guided by the presenting complications, ranging from simple endoscopic replacement to surgical laparotomy.
doi:10.1159/000446018
PMCID: PMC4939666  PMID: 27462190
Buried bumper syndrome; Percutaneous endoscopic gastrostomy tube; Complication; Treatment; Trauma
11.  Adrenal extramedullary hematopoiesis associated with beta-thalassemia trait in an adult woman: a case report and review of literature 
Highlights
•Adrenal myelolipoma with extramedullary hematopoiesis (EMH) is a rare condition.•EMH could be presented with several clinical hematological disorders.•Surgical management becomes inevitable in certain adrenal EMH cases especially in the presence of large adrenal mass.
Introduction
Adrenal myelolipoma with extramedullary hematopoiesis (EMH) is a rare condition.
Case presentation
We report a case of 48-year-old woman suffering from recurrent right hypochondrial pain for two years. Laboratory work-up revealed chronic microcytic iron deficiency anemia with beta thalassemia trait, right adrenal myelolipoma with histopathological evidence of hematopoietic cells (EMH). The patient underwent open resection of the adrenal gland and the post-operative course was uneventful.
Conclusions
EMH could be presented with several clinical hematological disorders. Surgical management becomes inevitable in certain adrenal EMH cases especially in the presence of a large adrenal mass.
doi:10.1016/j.ijscr.2016.05.024
PMCID: PMC4885136  PMID: 27232291
Extra medullary hematopoiesis; Adrenal; Incidentiloma; Thalassemia; Case report
12.  Spontaneous Acute Mesenteroaxial Gastric Volvulus Diagnosed by Computed Tomography Scan in a Young Man 
Patient: Male, 23
Final Diagnosis: Acute spontaneous gastric volvulus
Symptoms: —
Medication: —
Clinical Procedure: Laparotomy
Specialty: Gastroenterology and Hepatology
Objective:
Rare disease
Background:
Acute gastric volvulus is a surgical emergency that requires early recognition and treatment. Acute idiopathic mesenteroaxial gastric volvulus is a rare sub-type and there are few cases reported in children and there are even fewer reports in adults.
Case Report:
We report a rare case of a 23-year-old man who presented with a 1-day history of vomiting, epigastric pain, distention, and constipation. The diagnosis for mesenteroaxial type gastric volvulus was confirmed by abdominal radiography and computed tomography. The patient was successfully treated by laparotomy with resection of the ischemic stomach wall and anastomosis.
Acute spontaneous mesenteroaxial gastric volvulus is rare in adults and early diagnosis is challenging due to non-specific symptoms. A missed or delayed diagnosis may result in serious complications due to gastric obstruction.
Conclusions:
A patient presenting with severe epigastric pain and clinical evidence of gastric outlet obstruction should be considered as a surgical emergency to rule out gastric volvulus. High index of suspicion, early diagnosis and prompt surgical management are important for favorable outcome in patients with acute spontaneous gastric volvulus.
doi:10.12659/AJCR.896888
PMCID: PMC4913727  PMID: 27112797
Gastric Outlet Obstruction; Laparotomy; Stomach Volvulus
13.  Portomesenteric Vein Thrombosis After Laparoscopic Sleeve Gastrectomy: 3 Case Reports and a Literature Review 
Case series
Patient: Male, 27 • Female, 46 • Male, 46
Final Diagnosis: —
Symptoms: Vague abdominal pain • severe nausea • vomiting • fever and diffuse abdominal tendernes
Medication: —
Clinical Procedure: —
Specialty: —
Objective:
Rare co-existance of disease or pathology
Background:
Porto-mesenteric venous thrombosis (PMVT) is an infrequent but severe surgical complication developing in patients who underwent laparoscopic bariatric surgery (sleeve gastrectomy). Herein, we describe the clinical presentation, management, and outcome of 3 rare cases of PMVT after laparoscopic sleeve gastrectomy (LSG), successfully treated at our center.
Case Report:
All patients developed PMVT post-LSG and presented with diffused abdominal pain, nausea, and vomiting. Computed tomography (CT) of the abdomen confirmed the diagnosis of portal vein thrombosis. Two patients were treated conservatively with anticoagulation and thrombolytic therapy and the third patient required operative intervention with bowel resection.
Conclusions:
PMVT is a rare presentation after LSG, which requires early diagnosis and management. Conservative management through anticoagulants and thrombolytic therapy is quite effective and, if indicated, should always be considered as the primary treatment option.
doi:10.12659/AJCR.896892
PMCID: PMC4831301  PMID: 27068354
Bariatric Surgery; Gastric Bypass; Mesenteric Veins
14.  Base deficit and serum lactate concentration in patients with post traumatic convulsion 
Asian Journal of Neurosurgery  2016;11(2):146-150.
Introduction:
Traumatic brain injury is a major cause of morbidity and mortality worldwide, and has been reported to be one of the risk factors for epileptic seizures. Abnormal blood lactate (LAC) and base deficit (BD) reflects hypoperfusion and could be used as metabolic markers to predict the outcome. The aim of this study is to assess the prognostic value of BD and LAC levels for post traumatic convulsion (PTC) in head injury patients.
Materials and Methods:
All head injury patients with PTC were studied for the demographics profile, mechanism of injury, initial vital signs, and injury severity score (ISS), respiratory rates, CT scan findings, and other laboratory investigations. The data were obtained from the trauma registry and medical records. Statistical analysis was done using SPSS software.
Results:
Amongst 3082 trauma patients, 1584 were admitted to the hospital. Of them, 401 patients had head injury. PTC was observed in 5.4% (22/401) patients. Out of the 22 head injury patients, 10 were presented with the head injury alone, whereas 12 patients had other associated injuries. The average age of the patients was 25 years, comprising predominantly of male patients (77%). Neither glasgow coma scale nor ISS had correlation with BD or LAC in the study groups. The mean level of BD and LAC was not statistically different in PTC group compared to controls. However, BD was significantly higher in patients with associated injuries than the isolated head injury group. Furthermore, there was no significant correlation amongst the two groups as far as LAC levels are concerned.
Conclusion:
Base deficit but not lactic acid concentration was significantly higher in head injury patients with associated injuries. Early resuscitation by pre-hospital personnel and in the trauma room might have impact in minimizing the effect of post traumatic convulsion on BD and LAC.
doi:10.4103/1793-5482.145117
PMCID: PMC4802936  PMID: 27057221
Base deficit; convulsion; head injury; lactic acid; trauma
15.  Traumatic injuries in patients with diabetes mellitus 
Diabetes mellitus (DM) is associated with increased in-hospital morbidity and mortality in patients sustained traumatic injuries. Identification of risk factors of traumatic injuries that lead to hospital admissions and death in DM patients is crucial to set effective preventive strategies. We aimed to conduct a traditional narrative literature review to describe the role of hypoglycemia as a risk factor of driving and fall-related traumatic injuries. DM poses significant burden as a risk factor and predictor of worse outcomes in traumatic injuries. Although there is no consensus on the impact and clear hazards of hyperglycemia in comparison to the hypoglycemia, both extremes of DM need to be carefully addressed and taken into consideration for proper management. Moreover, physicians, patients, and concerned authorities should be aware of all these potential hazards to share and establish the right management plans.
doi:10.4103/0974-2700.179461
PMCID: PMC4843569  PMID: 27162438
Diabetes; fall; hyperglycemia; hypoglycemia; traffic injury; trauma
16.  Clinical Presentation and Time-Based Mortality in Patients With Chest Injuries Associated With Road Traffic Accidents 
Archives of Trauma Research  2016;5(1):e31888.
Background:
Blunt chest trauma (BCT) poses significant morbidity and mortality worldwide.
Objectives:
We investigated the clinical presentation and outcome of BCT related to road traffic accidents (RTA).
Patients and Methods:
A retrospective observational analysis for patients who sustained BCT secondary to RTA in terms of motor vehicle crash (MVC) and pedestrian-motor vehicle accidents (PMVA) who were admitted to the trauma center at Hamad general hospital, Doha, Qatar, between 2008 and 2011.
Results:
Of 5118 traumatic injury cases, 1004 (20%) were found to have BCT secondary to RTA (77% MVC and 23% PMVA). The majority were males (92%), and expatriates (72%). Among MVCs, 84% reported they did not use protective devices. There was a correlation between chest abbreviated injury score (AIS) and injury severity scoring (ISS) (r = 0.35, r2 = 0.12, P < 0.001). Regardless of mechanism of injury (MOI), multivariate analysis showed that the head injury associated with chest AIS and ISS was a predictor of mortality in BCT. Overall mortality was 15%, and the highest rate was observed within the first 24 hours post-trauma.
Conclusions:
Blunt chest trauma from RTA represents one-fifth of the total trauma admissions in Qatar, with a high overall mortality. Pedestrians are likely to have more severe injuries and higher fatality rates than MVC victims. Specific injury prevention programs focusing on road safety should be implemented to minimize the incidence of such preventable injuries.
doi:10.5812/atr.31888
PMCID: PMC4853503  PMID: 27148499
Chest Trauma; Road Traffic Accidents; Injury; Pedestrians; Motor Vehicle Crashes
17.  Primary Breast Lymphoma in a Woman: A Case Report and Review of the Literature 
Patient: Female, 43
Final Diagnosis: Primary breast lymphoma
Symptoms: —
Medication: —
Clinical Procedure: CT scan • PET • chemotherapy • radiotherapy
Specialty: Oncology
Objective:
Rare disease
Background:
Primary breast lymphoma (PBL) is an unusual clinical entity accounting for 0.4–0.5% of all breast neoplasms. The usual presentation includes a painless palpable mass similar to that of breast carcinoma. Diffuse large B-cell lymphoma (DLBCL) is the most common identifiable type of PBL based on the histopathological examination.
Case Report:
We report an unusual case of a 43-year-old Indonesian woman who presented with a 7-month history of a painless mass in the left breast. A core needle biopsy revealed diffuse infiltration of large atypical lymphoid cells. The immunohistochemical biomarkers confirmed the diagnosis of a DLBCL. A bone scan showed no evidence of bone metastasis. It was treated non-surgically, based on the decision of the breast multidisciplinary team (MDT). The patient was treated with 4 cycles of combination chemotherapy with R-CODOX/IVAC. A follow-up PET scan revealed non-significant mild F-18 fluorodeoxyglucose (FDG) uptake at the periphery of the residual left breast mass, indicating a radiologically favorable response.
Conclusions:
Early and accurate diagnosis of PBL is crucial for selecting the appropriate MDT treatment strategies to avert potentially harmful surgical interventions.
doi:10.12659/AJCR.896264
PMCID: PMC4763798  PMID: 26893404
Breast Neoplasms; Fluorodeoxyglucose F18; Lymphoma, B-Cell
18.  Troponin T in Patients with Traumatic Chest Injuries with and without Cardiac Involvement: Insights from an Observational Study 
Background:
Serum troponin T (TnT) is a common marker of myocardial injury. However, its implication in the absence of clinical evidence of cardiac reason is not well established.
Aims:
The aim of this study was to identify the implications of positive TnT in traumatic chest injury (TCI) patients regardless of the cardiac involvement.
Materials and Methods:
We conducted a retrospective analysis of all TCI patients admitted to level 1 trauma center between 2008 and 2011. Patients who underwent TnT testing were divided into two groups: Group 1 (positive TnT) and Group 2 (negative TnT). The two groups were analyzed and compared, and multivariate regression analyses were performed to identify predictors of TnT positivity and mortality.
Results:
Out of 993 blunt TCI patients, 19.3% had positive TnT (Group 1). On comparison to Group 2, patients in Group 1 were 5 years younger and more likely to have head, cardiac, hepatic, splenic, and pelvic injuries, in addition to lung contusion. Positive TnT was associated with higher Injury Severity Score (ISS) (P = 0.001), higher chest Abbreviated Injury Score (AIS) (P = 0.001), and longer hospital stay (P = 0.03). In addition, Group 1 patients were more likely to undergo chest tube insertion, exploratory laparotomy, mechanical ventilation, and tracheostomy. Twenty patients had cardiac involvement, and of them 14 had positive TnT. Among 973 patients who showed no evidence of cardiac involvement, 178 had positive TnT (18.3%). There were 104 deaths (60% in Group 1). On multivariate regression analysis, the predictors of hospital mortality were positive TnT, head injury, and high ISS, whereas, the predictors of TnT positivity were cardiac, hepatic, and pelvic injuries; higher ISS; and age.
Conclusions:
Positive TnT in blunt TCI patients is a common challenge, particularly in polytrauma cases. Patients with positive TnT tend to have the worst outcome even in the absence of clinical evidence of acute cardiac involvement. Positive TnT is also a reflection of the severity of chest or extrathoracic injuries; however, further prospective studies are warranted.
doi:10.4103/1947-2714.175188
PMCID: PMC4784179  PMID: 27011943
Blunt trauma; cardiac; chest injury; mortality; troponin
19.  Occupational injuries in workers from different ethnicities 
Objectives:
Occupational injuries remain an important unresolved issue in many of the developing and developed countries. We aimed to outline the causes, characteristics, measures and impact of occupational injuries among different ethnicities.
Materials and Methods:
We reviewed the literatures using PUBMED, MEDLINE, Google Scholar and EMBASE search engine using words: “Occupational injuries” and “workplace” between 1984 and 2014.
Results:
Incidence of fatal occupational injuries decreased over time in many countries. However, it increased in the migrant, foreign born and ethnic minority workers in certain high risk industries. Disproportionate representations of those groups in different industries resulted in wide range of fatality rates.
Conclusions:
Overrepresentation of migrant workers, foreign born and ethnic minorities in high risk and unskilled occupations warrants effective safety training programs and enforcement of laws to assure safe workplaces. The burden of occupational injuries at the individual and community levels urges the development and implementation of effective preventive programs.
doi:10.4103/2229-5151.177365
PMCID: PMC4795358  PMID: 27051619
Injury prevention; occupational injuries; workplace
20.  Spontaneous Atraumatic Urinary Bladder Rupture Secondary to Alcohol Intoxication: A Case Report and Review of Literature 
Patient: Male, 45
Final Diagnosis: Atraumatic urinary bladder rupture
Symptoms: Drowsiness • diffuse abdominal pain • vomiting
Medication: None
Clinical Procedure: CT cystogram • exploratory laparotomy • urinary bladder repair
Specialty: Urology
Objective:
Unusual clinical course
Background:
Spontaneous rupture of the urinary bladder (SRUB) secondary to alcohol intoxication is an uncommon presentation with high morbidity and mortality. Herein, we reported a rare case of spontaneous atraumatic rupture of the urinary bladder due to alcohol intoxication.
Case Reports:
A 45-year-old Sri Lankan man presented with drowsiness, diffuse abdominal pain, vomiting with odor of alcohol, and urinary retention 24 hours prior to the index admission. CT cystogram confirmed the urinary bladder rupture at the dome, which was repaired through exploratory laparotomy.
Conclusions:
An SRUB patient with alcohol abuse often presents with non-specific symptoms due to absence of a traumatic event, which results in missed or delayed-diagnosis. Early diagnosis and management of SRUB is crucial for uneventful recovery.
doi:10.12659/AJCR.894992
PMCID: PMC4634162  PMID: 26522816
Alcoholism; Rupture; Urinary Bladder
21.  Frequency, causes and pattern of abdominal trauma: A 4-year descriptive analysis 
Background:
The incidence of abdominal trauma is still underreported from the Arab Middle-East. We aimed to evaluate the incidence, causes, clinical presentation, and outcome of the abdominal trauma patients in a newly established trauma center.
Materials and Methods:
A retrospective analysis was conducted at the only level I trauma center in Qatar for the patients admitted with abdominal trauma (2008-2011). Patients demographics, mechanism of injury, pattern of organ injuries, associated extra-abdominal injuries, Injury Severity Score (ISS), Abbreviated Injury Scale, complications, length of Intensive Care Unit, and hospital stay, and mortality were reviewed.
Results:
A total of 6888 trauma patients were admitted to the hospital, of which 1036 (15%) had abdominal trauma. The mean age was 30.6 ± 13 years and the majority was males (93%). Road traffic accidents (61%) were the most frequent mechanism of injury followed by fall from height (25%) and fall of heavy object (7%). The mean ISS was 17.9 ± 10. Liver (36%), spleen (32%) and kidney (18%) were most common injured organs. The common associated extra-abdominal injuries included chest (35%), musculoskeletal (32%), and head injury (24%). Wound infection (3.8%), pneumonia (3%), and urinary tract infection (1.4%) were the frequently observed complications. The overall mortality was 8.3% and late mortality was observed in 2.3% cases mainly due to severe head injury and sepsis. The predictors of mortality were head injury, ISS, need for blood transfusion, and serum lactate.
Conclusion:
Abdominal trauma is a frequent diagnosis in multiple trauma and the presence of extra-abdominal injuries and sepsis has a significant impact on the outcome.
doi:10.4103/0974-2700.166590
PMCID: PMC4626935  PMID: 26604524
Abdominal trauma; mortality; Qatar; sepsis
22.  Acute Cholecystitis Complicated with Portal Vein Thrombosis: A Case Report and Literature Review 
Patient: Male, 31
Final Diagnosis: Acute cholecystitis complicated with portal vein thrombosis
Symptoms: Abdominal discomfort • fever • vomiting
Medication: —
Clinical Procedure: Abdominal ultrasound and MRI
Specialty: Gastroenterology and Hepatology
Objective:
Rare co-existance of disease or pathology
Background:
Portal vein thrombosis (PVT) is an infrequent clinical condition usually associated with multiple etiological factors and diseases. In some cases, PVT remains undiagnosed and is incidentally detected during routine examination for a known etiology.
Case Report:
Here, we present a rare case of portal vein thrombosis associated with acute cholecystitis in a 31-year-old man.
Conclusions:
Conservative treatment may be a feasible and safe approach for the management of PVT with acute cholecystitis, if treated at an early stage. Moreover, initial diagnosis based on radiological evaluation is possible only if the surgeons are familiar with this unusual condition. Therefore, a high index of suspicion is required for early diagnosis and management of patients with acute cholecystitis-associated PVT.
doi:10.12659/AJCR.894846
PMCID: PMC4578645  PMID: 26378714
Cholecystitis, Acute; Diagnosis; Portal Vein
23.  Clinical presentations and outcomes of necrotizing fasciitis in males and females over a 13-year period 
Annals of Medicine and Surgery  2015;4(4):355-360.
Background
Necrotizing fasciitis (NF) is a rapidly progressive infection of fascia and subcutaneous tissue resulting in serious outcomes. We aimed to evaluate the clinical presentations, hospital course and outcomes of NF based on patient gender.
Patients and methods
All patients admitted with NF were enrolled in the study over a 13-year period in the main tertiary hospital in Qatar. Clinical presentations, co-morbidities, severity and outcomes were analyzed and compared in male and female patients.
Results
A total of 331 NF patients were identified with a mean age of 51 ± 15 years and male to female ratio of 3:1. However, Arab Qatari females were more frequently affected by NF in comparison to their male counterparts and south Asian females (p < 0.001), respectively. Female patients were older and had significantly higher incidence of abdominal and groin NF (p < 0.004). There were 13 cases with recurrent NF; 85% of them were males. Male NF patients had significantly higher rate of organ failure (p = 0.02), but there was no significant difference in the hospital length of stay as well as mortality in both genders. Overall, there were 85 (25.7%) deaths (23 females and 62 males).
Conclusion
Necrotizing fasciitis remains a life threatening entity. Although, NF is more common in males, Qatari females are more likely to develop NF than males. NF of abdominal wall and groin is significantly higher in females. Development of organ failure is more common in males with NF. NF remains a challenging clinical problem in Qatar with a mortality rate ranging from 25 to 27% for both genders.
Highlights
•Majority of Necrotizing Fasciitis (NF) patients are males (74%).•NF of abdomen and groin is significantly higher in females.•Male patients are more severely ill with significantly more organ dysfunction.•Hospital stay and mortality of NF in both genders are comparable.•NF remains a challenging clinical problem in Qatar with a mortality rate ranging from 25 to 27% for both genders.
doi:10.1016/j.amsu.2015.09.005
PMCID: PMC4602355  PMID: 26568823
Necrotizing fasciitis; Clinical presentation; Gender; Outcome; Qatar
24.  Trauma resuscitation requiring massive transfusion: a descriptive analysis of the role of ratio and time 
Objective
We aimed to evaluate whether early administration of high plasma to red blood cells ratios influences outcomes in injured patients who received massive transfusion protocol (MTP).
Methods
A retrospective analysis was conducted at the only level 1 national trauma center in Qatar for all adult patients(≥18 years old) who received MTP (≥10 units) of packed red blood cell (PRBC) during the initial 24 h post traumatic injury. Data were analyzed with respect to FFB:PRBC ratio [(high ≥ 1:1.5) (HMTP) vs. (low < 1:1.5) (LMTP)] given at the first 4 h post-injury and also between (>4 and 24 h). Mortality, multiorgan failure (MOF) and infectious complications were studied as well.
Results
During the study period, a total of 4864 trauma patients were admitted to the hospital, 1.6 % (n = 77) of them met the inclusion criteria. Both groups were comparable with respect to initial pH, international normalized ratio, injury severity score, revised trauma score and development of infectious complications. However, HMTP was associated with lower crude mortality (41.9 vs. 78.3 %, p = 0.001) and lower rate of MOF (48.4 vs. 87.0 %, p = 0.001). The number of deaths was 3 times higher in LMTP in comparison to HMTP within the first 30 days (36 vs. 13 cases). The majority of deaths occurred within the first 24 h (80.5 % in LMTP and 69 % in HMTP) and particularly within the first 6 h (55 vs. 46 %).
Conclusions
Aggressive attainment of high FFP/PRBC ratios as early as 4 h post-injury can substantially improve outcomes in trauma patients.
doi:10.1186/s13017-015-0028-3
PMCID: PMC4536606  PMID: 26279672
Trauma; Transfusion ratio; Massive transfusion protocol; Outcome
25.  Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature 
Highlights
•A case with delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision.•In addition to a high grade injury; centrally located liver injury is a significant risk factor for major bile duct injury.•For such patients, early MRCP and ERCP may be warranted to rule out a significant bile leak.•Patients with high grade liver injury are at risk of serious complications.•There is a need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries.
Introduction
Delayed bile leak following blunt liver trauma is not common.
Presentation of case
We presented a case report and literature review of delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision; he was a restrained driver who hit a fixed object. Physical examination was unremarkable except for revelaed tachycardia, right upper quadrant abdominal tenderness, and open left knee fracture. A diagnosis of grade IV multiple liver lacerations with large hemo-peritoneum was made and urgent exploratory laparotomy was performed. The patient developed a biloma collection post- operatively. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stenting. His recovery was uneventful, and he was discharged home after 1 month.
Discussion
This is a rare case with no intra or extra hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A review of the literature to highlight the incidence of delayed bile leak revealed only few reported cases.
Conclusion
Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible.
doi:10.1016/j.ijscr.2015.08.002
PMCID: PMC4573864  PMID: 26279258
Liver; Blunt trauma; ERCP; MRCP; Bile leak; Biloma

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