Close Follow-up Observation Research Articles

Peripheral Monocyte Percentage as a Potential Indicator of Prognosis in Patients with Chronic Subdural Hematoma Receiving Conservative Therapy

Studies have confirmed active and abnormal inflammation in the hematoma cavity of chronic subdural hematoma (CSDH). However, a relationship between the peripheral blood status and the prognosis of CSDH patients has not been demonstrated. We retrospectively analyzed 245 CSDH patients who received conservative therapy (67 under close follow-up observation, 103 treated with atorvastatin, and 75 treated with atorvastatin combined with dexamethasone) from 2014 to 2021 to evaluate the role of major inflammation-associated cells in the prognostic assessment of patients. Univariate and multivariate analyses were performed to assess the potential factors that could indicate the prognosis among the 103 patients who underwent observation only or atorvastatin therapy. Changes in peripheral blood inflammation-associated cells at different time points were compared between patients with good and poor outcomes. Furthermore, the changes in inflammatory cells in 75 patients who received atorvastatin combined with dexamethasone were analyzed. The monocyte percentage was the only independent influencing factor in subsequent follow-up assessments. Patients with good outcomes had obviously lower circulating monocyte percentages in their peripheral blood counts throughout the treatment period. The monocyte percentage was also significantly decreased in the patients who responded well to atorvastatin combined with dexamethasone. The peripheral monocyte percentage was significantly higher in patients who transitioned to surgery because of a poor response to pharmacotherapy. The peripheral monocyte percentage may be a convenient and effective indicator for predicting the outcome of CSDH for patients receiving conservative treatment. A higher percentage of monocytes could be a risk factor for a poor response.

Kimura's disease successively affecting multiple body parts: a case-based literature review

BackgroundKimura’s disease is a rare, benign, chronic inflammatory disease that presents as painless, solid masses mainly affecting the deep subcutaneous areas of the head and neck, especially the salivary glands, parotid glands and nearby lymph nodes. It is characterized by elevated peripheral blood eosinophil and Immunoglobulin E (IgE) levels.Case presentationA 31-year-old Asian male presented with an orbital space-occupying lesion lasting for 1.5 years. Ten years prior, surgical excision of bilateral fossa cubitalis and groin masses was performed, and the pathological examination showed "lymphoproliferative disease". One year later, masses reappeared near the surgical sites; they grew slowly and shrank after glucocorticoid treatment. At this point, admission examinations showed in the peripheral blood an eosinophil proportion of 13.4%, a total IgE level of 26,900.00 IU/mL, prurigo present on the whole body, and multiple palpable masses near the bilateral fossa cubitalis and groin. The left eyeball was exophthalmic. The left elbow mass was excised, and the pathological examination confirmed Kimura’s disease. Oral glucocorticoid therapy is taken and tapering regularly. The eosinophil count returned to normal, the IgE level gradually decreased, the orbital space-occupying lesion and elbow and groin masses shrank significantly, and the whole-body skin prurigo disappeared. Currently, the patient has been in a stable condition for eighteen months.ConclusionOur case provides a novel insight that Kimura’s disease should be involved in the differential diagnosis of inflammatory lesion mass of orbit and also supports systemic regular glucocorticoid as a valuable therapy of such condition, but close follow-up and long-term observation are crucial.

Clinical features and risk factors of Raynaud\u2019s phenomenon in primary Sj\xf6gren\u2019s syndrome

ObjectiveThe aim at the current study was to investigate the clinical characteristics and risk factors of Raynaud’s phenomenon (RP) in patients with primary Sjögren’s syndrome (pSS).MethodsRetrospective analysis of the medical records of 333 new-onset pSS patients was performed. Demographic, clinical, and serological data were compared between individuals with and without RP. Logistic regression analysis was used to identify risk factors.ResultsRP was present in 11.41% of the pSS patients. pSS-RP patients were younger (49.74±14.56 years vs. 54.46±13.20 years, p=0.04) and exhibited higher disease activity (11 [5.75–15] vs. 7 [4–12], p=0.03) than those without. The prevalence of lung involvement was significantly higher in pSS patients with RP (60.53% vs. 17.29%; p<0.001). A significantly higher proportion of patients with pSS-RP tested positive about antinuclear (ANA), anti-RNP, and anti-centromere antibodies (ACA) compared to those without (p=0.003, <0.001, and 0.01, respectively). Multivariate analysis identified lung involvement (odds ratio [OR]=8.81, 95% confidence interval [CI] 2.02–38.47; p=0.04), anti-RNP positive status (OR=79.41, 95% CI 12.57–501.78; p<0.0001), as well as ACA (OR=13.17, 95% CI 2.60–66.72; p=0.002) as prognostic factors for pSS-RP.ConclusionThe presence of RP defined a subset of pSS with a unique phenotype, manifesting as increased lung involvement and a higher frequency of anti-RNP antibodies and ACA, as well as greater disease activity. These results suggest that RP has clinical and prognostic value of pSS patients. Further prospective studies with a larger number of subjects are warranted to confirm our findings and assess the prognostic and treatment implications of RP in pSS patients.Key Points• Raynaud’s phenomenon (RP) was present in 38 (11.41%) of 333 patients with primary Sjögren’s syndrome (pSS), with patients with RP exhibiting a younger age and higher disease activity.• The presence of RP indicates a subset of pSS with a unique phenotype, with manifestations including increased lung involvement and a higher frequency of anti-RNP antibodies and anti-centromere antibodies.• Patients with pSS and RP need close follow-up and long-term observation (including assessment of microangiopathy), with specific attention paid to the possible development of clinical features of systemic sclerosis.

Epidemiological and clinical characteristics of 2019 novel coronavirus disease (COVID-19) in Jilin, China: A descriptive study.

Coronavirus diseases 2019 (COVID-19) has become a global pandemic. To add to the scarce information on this disease, here, we investigated the epidemiological and clinical characteristics of 93 hospitalized patients with COVID-19 in Jilin, China from January 22 to March 15, 2020.We retrospectively investigated the demographic information, recent exposure history, clinical symptoms or signs, comorbidity, chest computed tomographic (CT) scan or X-ray results, laboratory test results, diagnostic classification, treatment, length of hospitalization, complications, and outcomes.Of the 93 patients, 54 were male and 39 female. More than half of these patients had a history of exposure to infected patients. The mean incubation period was 10.4 days in 87 patients, where the data was available. The 5 most common symptoms of illness onset were fever, cough, expectoration, fatigue, and dyspnea. One patient was asymptomatic. The imaging results were abnormal in majority of the patients. Almost one-third of the patients had lymphopenia. All patients received antiviral therapy, 84 patients were treated with antibiotics and 54 received different doses of the hormone for methylprednisolone. In addition, 72 patients used traditional Chinese medicine. Oxygen therapy, high nasal flow oxygen, non-invasive ventilator, invasive ventilator and extracorporeal membrane oxygenation (ECMO) were used symptomatically in different patients. Except 1 patient who died during treatment, all others were discharged.The average incubation time is prolonged in the present analysis, as compared to that in other reports. A few patients symptoms improved but CT exacerbated. Therefore, we suggest that close follow-up observation is still required after discharge.

Tu1522 CLINICAL IMPLICATIONS AND RISK FACTORS FOR HIGH-GRADE DYSPLASIA OR CARCINOMA IN BIOPSY-PROVEN GASTRIC REGENERATIVE ATYPIA

Tissue biopsies are routinely performed during gastroscopy, however, the clinical implications and therapeutic strategies of lesions identified as regenerative atypia (RA) remain unclear. This study analyzed the clinical implications and risk factors for high-grade adenoma or carcinoma in patients with biopsy proven gastric RA. Between January, 2015, and December, 2016, 296 patients were diagnosed as RA after initial forceps biopsy performed during gastroscopy at Jeju National University Hospital. We retrospectively reviewed medical records, pathologic reports, and endoscopic findings. The detection rate of RA was 1.46% (296/20,271) among patients who underwent gastroscopy. Of 96 RA lesions that met eligibly criteria, 23 (24.0%) were neoplasia according to the final diagnosis; 14 (14.6%) were high-grade dysplasia or carcinoma, and 9 (9.4%) were low-grade dysplasia. Surface nodularity, surface redness, corporal lesions, and intestinal metaplasia were identified as risk factors in the univariate analysis. Multivariate analysis adjusted for age and sex showed that only surface nodularity among endoscopic findings was a statistically significant independent risk factor for highgrade dysplasia or carcinoma (p = 0.01; odds ratio, 6.4; 95% confidence interval, 1.5-26.4). Most patients initially diagnosed as RA were finally diagnosed with benign lesions such as gastritis and low-grade dysplasia. However, RA has potential that can be changed and upgraded to high-grade adenoma or carcinoma in the final diagnosis. Close follow-up observation is needed in the presence of risk factors such as surface nodularity.Table 2Risk factors for gastric high-grade dysplasia or carcinoma in cases of regenerative atypia identified by univariate and multivariate analyses.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Overexpression of Ubiquitous Mitochondrial Creatine Kinase Denotes a Worse Prognosis for Gastric Cancer Patients

Background: Ubiquitous mitochondrial creatine kinase (uMtCK) transfers high-energy phosphates from mitochondrially generated ATP to creatine to generate phosphocreatine. uMtCK overexpression has been reported in several malignant tumours, however, the clinical significance of uMtCK in gastric cancer (GC) has not been comprehensively studied. Methods: We first examined uMtCK expression in GC by qPCR and western blot. Then the clinicopathological significance of aberrant uMtCK expression was determined by immunohistochemical staining in a GC tissue microarray. Kaplan-Meier analysis was used for survival analysis. By virus transfection, we analyzed the biological function of uMtCK in GC cell in vivo and in vitro. Findings: uMtCK expression was substantially elevated in GC, significantly associated with a poor prognosis in GC patients. In univariate and multivariate analyses, uMtCK emerged as an independent prognostic factor for both disease-free survival and overall survival. In vitro, uMtCK overexpression increased GC cell proliferation, induced cell cycle transition, promoted cell migration and invasion. In vivo, uMtCK overexpression stimulated the formation of subcutaneous xenografts and tumour metastasis in nude mice. Moreover, we also revealed that high uMtCK expression promoted tumour chemoresistance to 5-fluorouracil chemotherapy. In the end, we verified that uMtCK activated the transforming growth factor-β signalling pathway, which was followed by increased levels of pSmad2 and pSmad3. Interpretation: uMtCK enhanced GC cell malignance via activating the transforming growth factor-β pathway, providing a novel independent prognostic biomarker for GC. Funding Statement: National Natural Science Foundation of China (81802420,81803073), Young Scientists of The Second Hospital of Shandong University (2018YT30). Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This research was approved by the Ethics Committee of Shanghai General Hospital. Written informed consent was obtained from all subjects, and they were subjected to close clinical follow-up observation.

Efficacy and tolerability of interferon-free antiviral therapy in kidney transplant recipients with chronic hepatitis C

The development of direct-acting antiviral agents (DAAs) is a major step forward in the treatment of hepatitis C (HCV). The aims of the study were to evaluate the efficacy and tolerability of DAAs in kidney transplant (KT) recipients. Hepa-C is a Spanish registry of patients treated with DAAs in which clinical, virological and analytical data were prospectively included. We report on the data from 103 KT recipients who received DAAs. The most commonly used DAAs combinations were sofosbuvir/ledipasvir (n=59, 57%) and sofosbuvir+daclatasvir (n=18, 17%). Ribavirin was used in 41% of patients. Sustained viral response after 12weeks (SVR12) rate was 98%. Grade 2 or 3 anemia appeared in 14 (33%) of patients receiving ribavirin and in 9 (15%) without (p=0.03). There were three episodes of acute humoral graft rejection. No patient discontinued therapy due to adverse events. Importantly, 57 (55%) patients required immunosuppression dose adjustment. Overall, there were no statistically significant differences in the mean level of serum creatinine, eGFR and proteinuria before and after treatment. Nonetheless, seventeen (16%) patients experienced renal dysfunction (increase in serum creatinine >25%) during antiviral therapy, of whom 65% were cirrhotic in comparison with only 29% cirrhotic patients who did not develop significant renal dysfunction (p=0.004). Antiviral therapy with DAAs was highly efficacious and safe in KT recipients. Nevertheless, a non-negligible number of patients, most of them cirrhotic, developed mild allograft dysfunction and a significant proportion of patients required immunosuppression dose adjustment, warranting a close follow-up during therapy. Infection by hepatitis C virus is often found in kidney transplant patients and its presence increases mortality and graft failure. We investigated the efficacy and safety of the new direct-acting hepatitis C antivirals in this population, in which previous information is scarce. Our data shows that, as occurs in the non-transplant setting, new anti-HCV antivirals are highly efficacious kidney transplant patients. Overall, this therapy is also quite safe, although worsening of renal function is observed in 16% of patients warranting a close follow-up observation of graft function during antiviral therapy.

Hapşırma Sonrası Spontan Subkutanöz Orbital Amfizem

Mersin University Faculty of Medicine, Department of Emergency Medicine, MERSIN Mersin Toros State Hospital, Department of Emergency Medicine, MERSIN Yuzuncu Yil University Faculty Of Medicine, Department of Plastic And Reconstructive Surgery, VAN Cukurova Medical Journal 2015;40(1):193-194. A previously healthy 55-year-old man presented to the emergency department with a sudden onset of mild pain in the right eye and swelling after an episode of sneezing. He denied diplopia or any other visual changes after the swelling took place, but had difficulty opening his eyes from ptosis and swelling of the upper eyelid. There was no history of sinusitis, facial trauma or previous surgery. Furthermore, he did not have any symptoms related to dental or upper respiratory tract infections, insect bites, or open wounds. Vital signs of the patient were normal. On physical examination, there was mild ecchymosis, periorbital swelling, ptosis associated with crepitus on palpation in the around of the right eye (mostly in the right upper eyelid) without localized heat or tenderness (Figure. 1). An ophthalmologist as urgently consulted after reviewing physical examination findings. On ophthalmologic examination, the visual acuity, pupillary light reactions, extraocular movements, and the funduscopic examination were normal. Other systems examinations were also normal. CT revealed subcutaneous air right superior orbit without fracture in the orbit (Figure. 2). The patient was managed conservatively with non-steroidal antiinflammatory drug, and advised avoidance of nose blowing, sneezing or perform activities that might elevate sinus pressures. He was discharged for the outpatient treatment and followed-up during two weeks. Two week later, on follow-up, the subcutaneous emphysema gradually resolved without any complications. Orbital emphysema is an uncommon condition in the absence of facial trauma, previous surgery, insect bites, open wounds or sinusitis. In rare instances, it is observed after spontaneous, atraumatic causes such as nose blowing, sneezing or during air travel. These conditions (such as sneezing) may lead to a sudden increase in intranasal pressure, causing the defect in the lamina papyracea and subsequently allowing air to enter the surrounding orbital tissue (orbital emphysema). In most patients, orbital emphysema usually resolves in a week or 2, without adverse sequelae. Patients should be counseled to avoid activities that raise intranasal pressure such as nose blowing, sneezing, diving in pools, and flying on airplanes. All patients should have close follow-up and careful observation with pyhicians. In conclusion, orbital emphysema may occur spontaneously after unexpected events such as sneezing in the absence of trauma. The aim of this presentation is to bring awareness to physicians of this uncommon condition, and a relatively simple Editore Mektup / Letter to the Editor

Developing a follow-up strategy for patients with PSA ranging from 4 to 10 ng/ml via a new model to reduce unnecessary prostate biopsies.

ObjectiveThe aim of this study was to develop a follow-up strategy based on the new model to reduce unnecessary prostate biopsies in patients with prostate specific antigen (PSA) ranging from 4 to 10 ng/ml.MethodsA total of 436 patients with PSA ranging from 4 to 10 ng/ml who had undergone transrectal ultrasound (TRUS)-guided prostate biopsy were evaluated during the first stage. Age, PSA, free PSA (fPSA), digital rectal examination (DRE) findings, ultrasonic hypoechoic mass, ultrasonic microcalcifications, prostate volume (PV) and PSA density (PSAD) were considered as predictive factors. A multiple logistic regression analysis involving a backward elimination selection procedure was applied to select independent predictors. After a comprehensive analysis of all results, we developed a new model to assess the risk of prostate cancer and an effective follow-up strategy.ResultsAge, PSA, PV, fPSA, rate of abnormal DRE findings and rate of hypoechoic masses detected by TRUS were included in our model. A significantly greater area under the receiver-operating characteristic curve was obtained in our model when compared with using PSA alone (0.782 vs. 0.566). Patients were grouped according to the value of prostate cancer risk (PCaR). In the second stage of our study, patients with PCaR>0.52 were recommended to undergo biopsies immediately while the rest of the patients continued close follow-up observation. Compared with the first stage, the detection rate of PCa in the second stage was significantly increased (33.0% vs 21.1%, p = 0.012). There was no significant difference between the two stages in distribution of the Gleason score (p = 0.808).ConclusionsWe developed a follow-up strategy based on the new model, which reduced unnecessary prostate biopsies without delaying patients’ diagnoses and treatments.

Diagnosis and treatment of three cases of adrenocortical oncocytoma and a literature review

To investigate the diagnosis and surgical treatment of adrenocortical oncocytoma. The clinical data from three cases of adrenocortical oncocytomas (ACOs) were retrospectively analyzed and discussed in light of the relevant literature. In these three cases, one presented with virilization, while the other two cases had no typical clinical features. The tumor was completely encapsulated and was non-invasive. Microscopically, the tumor cells showed neither mitosis nor necrosis, with abundant eosinophilic cytoplasm. No recurrence or metastasis was discovered after close follow-up observation for 12-24 months. Adrenocortical ACOs are rather rare, and most of them are benign. It was hard to make a confirmed diagnosis of ACOs before surgery. Resection of tumor is the best choice, and close follow-up observation is essential.

Postoperative complications in patients with cochlear implants and impacts of nursing intervention

Conclusion: This study shows that cochlear implantation is relatively safe surgery with few major complications and within acceptable limits. However, close follow-up observation and effective medical and nursing intervention could alleviate further complications and thus become key elements for promoting recovery of patients undergoing such surgery. Objectives: Cochlear implantation has become an effective method for curing patients disabled by profound hearing loss in China. However, full exploration of the associated complications remains to be completed. The objective of this study was thus to analyse the postoperative complications in patients with cochlear implants (CIs) in order to design improved measures for clinical and nursing interventions. Methods: A retrospective study of 262 patients receiving CIs at the Department of Otorhinolaryngology/Head and Neck Surgery, Chinese People's Liberation Army General Hospital, Beijing, China from March 1997 to December 2006 was conducted. Results: Among 262 patients, 4 cases (1.5%) had 1 or more major complications requiring substantial medical or nursing interventions, including 1 case of cerebrospinal fluid (CSF) otorrhoea accompanied by meningitis, 2 cases of facial nerve paresis and 1 case of perforation of tympanic membrane. Forty cases (15.3%) had some form of minor complication that settled spontaneously or easily with conventional treatments and nursing, of which dizziness and vomiting was the most frequent (4.2%), followed by CSF gusher without otorrhoea and/or induced meningitis (2.7%), tinnitus (1.9%) and facial nerve partially exposed without paralysis (1.5%). Eleven cases (4.2%) had some symptoms associated with installation of the cochlear device. Except for one patient who had no response after implantation because his auditory nerves were underdeveloped, all the patients who received appropriate treatment and nursing intervention had a favourable prognosis.

Spontaneous Closure of Ventricular Septal Defect Complicated with Acute Myocardial Infarction

A 79-year-old man was followed in our hospital for 4 years following primary percutaneous coronary intervention at another hospital to deploy two stents at the left anterior descending coronary artery for acute myocardial infarction (AMI). At the first visit in our hospital, echocardiography revealed a small ventricular septal defect (VSD, 0.8 to 1.0 cm) in the apicoseptal wall with an aneurysm that was probably the result of the AMI. There was no hemodynamic decompensation, and because the patient refused surgical correction we instead placed him under close follow-up observation in the outpatient clinic. A second follow-up echocardiography 6 months later still revealed a VSD. However, after 3 years the VSD murmur was no longer audible and follow-up echocardiography showed the defect to be nearly closed.

Partial tarsal arthrodesis for rheumatoid feet

Partial intertarsal joint arthrodesis was performed on 12 feet of 11 patients as a surgical treatment for planovalgus deformity of the foot and lesions of the intertarsal joints caused by rheumatoid arthritis. Single arthrodesis was performed on the talocalcaneal joint in eight feet, two of which underwent simultaneous total ankle arthroplasty, and on the talonavicular joint in two feet. Double arthrodesis was done on the talocalcaneal and talonavicular joints in one foot and on the talonavicular and calcaneocuboid joints in one foot. Screws or staples were used for fixation. Patients were followed for 2 years to 8 years 7 months (average 4 years 3 months). Osseous fusion was achieved in all feet, and satisfactory pain relief was obtained in all cases except one. We performed this surgery in patients who were relatively active, and the results indicated that arthrodesis of a small number of joints that caused pain and deformity was effective in reducing pain and correcting the deformity. We concluded that partial tarsal arthrodesis should be performed on a limited number of joints during the early stages of planovalgus deformity of the foot because more joints are found to be fixed during the advanced stages. However, progression of the osteoarthritis was found in the neighboring joints. Close follow-up observation is needed.

Partial tarsal arthrodesis for rheumatoid feet

Partial intertarsal joint arthrodesis was performed on 12 feet of 11 patients as a surgical treatment for planovalgus deformity of the foot and lesions of the intertarsal joints caused by rheumatoid arthritis. Single arthrodesis was performed on the talocalcaneal joint in eight feet, two of which underwent simultaneous total ankle arthroplasty, and on the talonavicular joint in two feet. Double arthrodesis was done on the talocalcaneal and talonavicular joints in one foot and on the talonavicular and calcaneocuboid joints in one foot. Screws or staples were used for fixation. Patients were followed for 2 years to 8 years 7 months (average 4 years 3 months). Osseous fusion was achieved in all feet, and satisfactory pain relief was obtained in all cases except one. We performed this surgery in patients who were relatively active, and the results indicated that arthrodesis of a small number of joints that caused pain and deformity was effective in reducing pain and correcting the deformity. We concluded that partial tarsal arthrodesis should be performed on a limited number of joints during the early stages of planovalgus deformity of the foot because more joints are found to be fixed during the advanced stages. However, progression of the osteoarthritis was found in the neighboring joints. Close follow-up observation is needed.

Management of branch duct-type intraductal papillary mucinous tumor of the pancreas based on magnetic resonance imaging.

We assessed the usefulness of magnetic resonance imaging (MRI) in identifying nonmalignant intraductal papillary mucinous tumors (IPMTs) of the pancreas. Thirty-three patients with branch duct-type IPMT diagnosed by endoscopic retrograde cholangiopancreatography were prospectively examined with magnetic resonance cholangiopancreatography followed by dynamic gadolinium-enhanced MRI examinations, and patients with no findings suggestive of malignancy, including a solid mass, mural nodules, a main pancreatic duct wider than 5 mm in diameter, and stenosis of the main pancreatic duct, were prospectively followed up with sequential MRI examinations once or twice a year. Twenty-six (79%) patients showed no findings suggestive of malignancy in the initial MRI examination. The diameter (mean +/- standard error) of the main pancreatic duct was 3.9 +/- 0.7 mm and that of the ectatic branch pancreatic duct was 36.0 +/- 9.1 mm. Twenty-three patients were prospectively followed for more than 36 months and 22 of them showed no findings suggestive of malignancy during follow-up periods ranging from 39 to 77 months (mean = 55 months). MRI was useful to identify nonmalignant IPMTs of the branch duct type, and close follow-up observation with serial MRI examinations may be appropriate in the management of such patients.

The effect of polytrauma in persons with traumatic spine injury. A prospective database of spine fractures.

A mixed cross-sectional survey and cohort study using a prospectively gathered database of persons with traumatic spine injury. To identify demographic and injury mechanism factors that predict greater injury severity, and to determine the effect of injury severity on outcomes in traumatic spine fracture. Traumatic spine fracture outcome studies have focused on defining type and level of vertebral fracture without considering the severity of associated injuries. In the trauma population, greater injury severity has been shown to be related to worse outcome. No studies have been reported on the effect of injury severity on outcome in the traumatic spine fracture population. Prospectively collected data on 830 persons with traumatic spine injury who were admitted to a trauma hospital were reviewed. Patient demographics; injury mechanism; hospital events; and disability, employment, and pain status at discharge, 1 year, and 2 years after injury were recorded. Associations between these factors and trauma severity (Injury Severity Score) were explored using Pearson's correlation and analysis of variance. Trauma was more severe in patients who had been married previously, who were involved in a motor vehicle accident, were ejected from the vehicle, had loss of consciousness, had higher-level and multiple complicated vertebral fractures, or had neurologic deficit. Those more severely injured had longer lengths of stay, more surgery, more complications, higher mortality, more disability, and less return to work. Persons with traumatic spine injury and polytrauma have poorer short- and long-term outcomes. This high-risk group may require aggressive interventions, more hospital resources, and close follow-up observation after discharge from hospital to optimize outcome.

Can Doppler Pressure Measurement Replace “Exclusion” Arteriography in the Diagnosis of Occult Extremity Arterial Trauma?

Although highly accurate, contrast arteriography is a costly, invasive, and time-consuming method to rule out occult arterial damage in injured extremities. Accordingly the authors assessed the sensitivity and specificity of Doppler-derived arterial pressure measurements in trauma victims undergoing evaluation for possible extremity arterial damage. Arterial pressure index (API) was calculated (Doppler arterial pressure distal to injury/Doppler arterial pressure in uninvolved arm), but not used in clinical decision making in 100 consecutive injured limbs in 93 trauma victims. All patients then underwent contrast arteriography. Twenty limbs had an API less than 0.90 and an abnormal arteriogram, whereas 75 had both a normal API and a normal contrast study. One limb had a significant angiographic abnormality with an API greater than 0.90; two others had API less than 0.90 but normal arteriograms. Two limbs with a normal API had false-positive arteriograms. When compared with arteriography, an API less than 0.90 had a sensitivity of 87% and a specificity of 97% for arterial disruption in this series. Sensitivity and specificity rose to 95% and 97% when API was compared with clinical outcome. In the absence of obvious signs of arterial injury, API may be a reasonable substitute for screening arteriography in the traumatized extremity, particularly if close follow-up observation can be assured.

Management of increased lead absorption and lead poisoning in children.

THE primary aim of treatment for plumbism in children is the prevention of injury to the nervous system. In the long run, societal steps to minimize adventitious lead absorption will be needed to obtain this goal. In practice today, therapeutic intervention at the subclinical stage of lead poisoning and close follow-up observation during the preschool years can do much to prevent the severe forms of residual nervous-system injury. At least 25 per cent of young children with acute lead encephalopathy or recurrent but less severe clinical bouts of plumbism sustain permanent injury to the nervous system.1 2 3 Current chelation therapy started . . .