Non-traumatic Cases Research Articles

A nontraumatic myositis ossificans case of the forearm: Case report and literature review.

Myositis ossificans (MO) is a rare, benign ossifying lesion characterized by focal formation of heterotopic bone and cartilage in extraskeletal soft-tissue that most commonly occurs in young adults. In most cases, no causative factor can be identified. The diagnosis of MO is usually based on the patient's history of trauma, clinical signs, on imaging appearance and histological examination. We present a non-traumatic MO case of the forearm in a 40-year-old man with weakness in left finger motion, a decrease in prehension for more than three weeks, without any weight loss, malaise, anorexia or fever. The clinical symptoms and radiological findings can be easily confused with malignant lesions. Treatment is usually conservative but, due to the limited strength and range of motion of the left hand, the tumor was extirpated and the diagnosis of MO was made by biopsy. The patient had no neurological deficits after surgical treatment and was discharged on the fifth day after the surgery in good condition with the recommendation to begin a rehabilitation program.

Abstract P443: Identification of Traumatic and Non-Traumatic Intracranial Bleeding Subtypes in Patients With Non-Valvular Atrial Fibrillation Receiving Oral Anticoagulant Therapy Using Primary Care Data From the United Kingdom

Introduction: Classification of intracranial bleeding (ICB) by trauma status is important in research relating to anticoagulant therapy. We evaluated trauma status of ICB subtypes - intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and subdural hematoma (SDH) - in a large population of patients with non-valvular atrial fibrillation (NVAF) receiving oral anticoagulant (OAC) therapy. Methods: Using the IQVIA Medical Research Data UK primary care database, we followed 45,164 patients with NVAF newly prescribed OAC therapy to identify incident ICB cases, and categorized them as ICH, SAH or SDH based on the coded description. We identified cases with a code suggesting the event was traumatic (e.g. head injury) or non-traumatic within 90 days either side of the ICB event, and manually reviewed the patient records for cases without such a code to identify other entries indicating trauma in the time period. ICH and SAH cases without a trauma/non-trauma code were classed as non-traumatic and SDH cases without a trauma/non-trauma code were classed as traumatic. Results: A total of 286 ICB cases were identified: 45.5% ICH, 41.9% SDH, 12.6% SAH. Classification of cases is shown in the Table. Most traumatic cases were SDH (77.3%, 85/110); most non-traumatic cases were ICH (66.5%, 117/176). Classification by the presence of a trauma/non-trauma code was 82.5% for SDH, 33.3% for SAH and 10.8% for ICH. Classification of all but one non-traumatic ICH case and all non-traumatic SAH cases were by the absence of a trauma/non-trauma code. For SDH, 75.3% of traumatic SDH cases were based on a trauma code, and 100% of non-traumatic SDH cases were based on a non-trauma code. Conclusion: Among patients with NVAF receiving OAC therapy, the majority of incident ICB cases were non-traumatic. Classification of SDH was predominantly made from trauma/non-trauma codes; cases of ICH and SAH were mostly based on the absence of trauma/non-trauma codes using non-trauma as the default category.

Relationship of Lipid Profile with Wagner Severity Level in Diabetic Feet at General Hospital Dr. M. Djamil Padang

A B S T R A C TIntroduction Diabetic foot is an erosion or injury to the epidermis or the distal soleof the foot and the base of the foot in people with diabetes mellitus (DM). Diabeticfoot is a major cause of limb amputation in non-traumatic cases. Per year, as manyas 2-3% of people with diabetes experience complications of diabetic foot. Theprevalence of DM sufferers with diabetic foot is 20-40% in developing countries. InIndonesia, the prevalence of DM sufferers with diabetic foot is around 15% with 32%mortality rate. One factor plays an important role in predisposing the occurrence ofdiabetic foot is the lipid profile. The aim of this study was to determine the correlationbetween lipid profile and Wagner Severity Level on diabetic foot patients at Dr. M.Djamil Central Public Hospital, Padang in the period of July 2020 to December 2020.Method: This research is an observational analytic study with cross sectionalanalytic design. The research sample of 47 cases was taken by non-probabilitysampling with the consecutive sampling method. This research is an observationalanalytic study with cross sectional analytic design. The research sample of 47 caseswas taken by non-probability sampling with the consecutive sampling method.Result: There were 47 cases that met the inclusion criteria where the 51-60 yearsage group (55.3%) was the largest group in cases of diabetic foot. Of these groups, itwas dominated by female patients, namely 31 patients (66.0%). Meanwhile, the BodyMass Index (BMI) was dominated by the group with BMI <25 kg/m2 with a total of26 patients (55.3%). Diabetic foot patient at Dr. M Djamil Central Public HospitalPadang who underwent amputation was 25 patients (53.2%) where most of them,namely 40 patients (85.1%) had suffered from Diabetes Mellitus for> 5-10 years. Thefindings obtained based on the Wagner Severity Level were that the Wagner grade 3-5 (heavy) group consisted of 24 people (51.1%) and Wagner 1-2 (mild) as many as 23people (48.9%). The results of the bivariate test between lipid profile levels withWagner Severity Level in diabetic foot patients showed a significant correlation asindicated by a p value <0.05. Conclusion: Wagner Severity Level which is gettinghigher in diabetic foot patients shows low HDL levels, high LDL levels and high levelsof triglycerides in blood plasma.

Low profile REBOA device for increasing systolic blood pressure in hemodynamic instability: single-center 4-year experience of use of ER-REBOA

BackgroundHemodynamic instability due to torso hemorrhage can be managed with the assistance of resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a report of a single-center experience using the ER-REBOA™ catheter for traumatic and non-traumatic cases as an adjunct to hemorrhage control and as part of the EndoVascular resuscitation and Trauma Management (EVTM) concept. The objective of this report is to describe the clinical usage, technical success, results, complications and outcomes of the ER-REBOA™ catheter at Örebro University hospital, a middle-sized university hospital in Europe.MethodsData concerning patients receiving the ER-REBOA™ catheter for any type of hemorrhagic shock and hemodynamic instability at Örebro University hospital in Sweden were collected prospectively from October 2015 to May 2020.ResultsA total of 24 patients received the ER-REBOA™ catheter (with the intention to use) for traumatic and non-traumatic hemodynamic control; it was used in 22 patients. REBOA was performed or supervised by vascular surgeons using 7–8 Fr sheaths with an anatomic landmark or ultrasound guidance. Systolic blood pressure (SBP) increased significantly from 50 mmHg (0–63) to 95 mmHg (70–121) post REBOA. In this cohort, distal embolization and balloon rupture due to atherosclerosis were reported in one patient and two patients developed renal failure. There were no cases of balloon migration. Overall 30-day survival was 59%, with 45% for trauma patients and 73% for non-traumatic patients. Responders to REBOA had a significantly lower rate of mortality at both 24 h and 30 days.ConclusionsOur clinical data and experience show that the ER-REBOA™ catheter can be used for control of hemodynamic instability and to significantly increase SBP in both traumatic and non-traumatic cases, with relatively few complications. Responders to REBOA have a significantly lower rate of mortality.

Factors determining outcome of post-angiogram-negative subarachnoid hemorrhage.

Aim:To determine the risk factors affecting outcome at the end of 90 days of post-angiogram-negative subarachnoid hemorrhage (SAH).Methods:Non-traumatic SAH cases were reviewed from the case records of patients who had reported to the Department of Neurology of a tertiary care hospital and 50 angio-negative SAH cases were included after excluding all the cases with known cause of hemorrhage after doing computed tomography angiography (CTA)/digital subtraction angiography (DSA). The presence of hypertension, diabetes mellitus, coronary artery disease (CAD), history of alcohol and smoking, and various scales like Hunt and Hess Scale (HHS), World Federation of Neurological Surgeons (WFNS), and Fisher scale had been recorded at admission. The outcome was assessed at 90 days post-SAH using the Modified Rankin Scale (mRS).Statistical analyses:The association between the outcome and the factors was assessed using the Pearson Chi-Square test and the risk factors/predictors of outcome were assessed using logistic regression.Results:The following variables were important risk factors for predicting poor outcome of angio-negative SAH (mRS 3 to 6): hypertension (P = 0.011), diabetes mellitus (P = 0.032), being an alcoholic (P = 0.019), HHS grade 4 to 5 (P < 0.01), and WFNS grade 4 to 5 (P < 0.01). On multivariate regression analysis, hypertension (P = 0.032) was an independent predictor of unfavorable outcome.Conclusions:At time of admission, presence of hypertension, diabetes mellitus, history of alcohol consumption, and poor grades of HHS and WFNS scale are predictors of poor outcome of angio-negative SAH.

Long-term outcomes following vehicle trauma related acute kidney injury requiring renal replacement therapy: a nationwide population study

Acute kidney injury (AKI) is a frequent complication of traumatic injury; however, long-term outcomes such as mortality and end-stage kidney disease (ESKD) have been rarely reported in this important patient population. We compared the long-term outcome of vehicle-traumatic and non-traumatic AKI requiring renal replacement therapy (AKI-RRT). This nationwide cohort study used data from the Taiwan National Health Insurance Research Database. Vehicle-trauma patients who were suffered from vehicle accidents developing AKI-RRT during hospitalization were identified, and matching non-traumatic AKI-RRT patients were identified between 2000 and 2010. The incidences of ESKD, 30-day, and long-term mortality were evaluated, and clinical and demographic associations with these outcomes were identified using Cox proportional hazards regression models. 546 vehicle-traumatic AKI-RRT patients, median age 47.6 years (interquartile range: 29.0–64.3) and 76.4% male, were identified. Compared to non-traumatic AKI-RRT, vehicle-traumatic AKI-RRT patients had longer length of stay in hospital [median (IQR):15 (5–34) days vs. 6 (3–11) days; p < 0.001). After propensity matching with non-traumatic AKI-RRT cases with similar demographic and clinical characteristics. Vehicle-traumatic AKI-RRT patients had lower rates of long-term mortality (adjusted hazard ratio (HR), 0.473; 95% CI, 0.392–0.571; p < 0.001), but similar rates of ESKD (HR, 1.166; 95% CI, 0.829–1.638; p = 0.377) and short-term risk of death (HR, 1.134; 95% CI, 0.894–1.438; p = 0.301) as non-traumatic AKI-RRT patients. In competing risk models that focused on ESKD, vehicle-traumatic AKI-RRT patients were associated with lower ESKD rates (HR, 0.552; 95% CI, 0.325–0.937; p = 0.028) than non-traumatic AKI-RRT patients. Despite severe injuries, vehicle-traumatic AKI-RRT patients had better long-term survival than non-traumatic AKI-RRT patients, but a similar risk of ESKD. Our results provide a better understanding of long-term outcomes after vehicle-traumatic AKI-RRT.

Tranexamic Acid Use in Foot and Ankle Surgery.

Background:There is a potential role for tranexamic acid (TXA) use in foot and ankle procedures; however, the benefits of this intervention have not been fully elucidated. The purpose of this study was to explore the safety, outcomes, and medical complication profile of the use of intravenous TXA in patients undergoing foot and ankle surgery.Methods:A prospective study with retrospective review of 241 patients undergoing elective and traumatic foot and ankle procedures was performed. One gram of intravenous (IV) TXA was administered prior to incision. Patients were followed and evaluated for medical comorbidities, intraoperative blood loss, wound complication, superficial and deep infections, hematoma formation, medical complications, 30-day hospital readmission rate, and return visits to the emergency department or urgent care setting prior to first postoperative visit. Descriptive statistics were used for subgroup analysis. Mean postoperative follow-up was 4.5 months.Results:Estimated blood loss in all cases was less than 20 mL. There was 1 case of superficial cellulitis (1/241, 0.4%), 1 deep infection after Achilles tendon repair (1/241, 0.4%), 4 cases of delayed wound healing (4/241, 1.6%), 1 instance of deep vein thrombosis (1/241, 0.4%), and 2 cases of postoperative pulmonary embolism (2/241, 0.8%). There were no instances of postoperative hematoma formation. There were no additional recorded thromboembolic events. There were no adverse drug reactions. There were no 30-day hospital readmissions or return visits to the emergency department or urgent care setting before the first postoperative visit. In a subgroup analysis, there was no significant difference in wound complications or infections between nondiabetics and diabetics (P > .05) and traumatic and nontraumatic cases (P > .05).Conclusions:The use of IV TXA in foot and ankle surgeries was associated with low risk of wound complications, infections, hematoma formation, thromboembolic events, and overall complication rates with minimal side effect profile. Perioperative tranexamic acid use may prove to be beneficial in foot and ankle surgery patients but especially in higher-risk patients such as those with diabetes, trauma, and those that are immunocompromised.Level of Evidence:Level IV, case series.

The evaluation of calcium as a prognostic factor in non-traumatic cardiopulmonary arrests

Aim: Cardiopulmonary arrests (CPA) should be rapidly responded to in emergency departments (ED). Arrests associated with coronary cardiac diseases are held responsible for about 90% of sudden mortality over the age of 18 years. In our study, the effect of calcium on prognosis was investigated in patients who were admitted to our emergency department with non-traumatic CPA and underwent cardiopulmonary resuscitation (CPR). Methods: The data of 132 non-traumatic CPA patients who were admitted to the emergency room between 1 January 2017 and 31 December 2019 were examined from the hospital registry for this cohort study. The demographic features (age, gender, mortality, and the presence of diseases in their medical history) were noted. Blood was collected from patients at the time of admission to the ED. Adjusted serum Ca+2, potassium (K+) and sodium (Na+) electrolyte levels were evaluated among patients who were either admitted to the intensive care unit or died. Results: Fifty-eight (43.93%) patients died in the emergency department, and 74 (56.07%) were admitted to intensive care units. There were no comorbid diseases in 50.76%. Coronary artery disease, respiratory diseases and others were found in 23.46%, 6.06% and 19.7% of the patients, respectively. In the patient group declared “exitus” in the intensive care unit after CPR, serum adjusted calcium levels were significantly higher compared to the surviving patient group (P=0.041) Conclusion: It was noted that adjusted Ca+2 concentration can be a beneficial parameter in determining the prognosis in non-traumatic arrest cases.

Relationship Between Institutional Volume of Out-of-Hospital Cardiac Arrest Cases and 1-Month Neurologic Outcomes: A Post Hoc Analysis of a Prospective Observational Study.

The influence of institutional volume of out-of-hospital cardiac arrest (OHCA) cases on outcomes remains unclear. This study evaluated the relationship between institutional volume of adult, nontraumatic OHCA cases and 1-month favorable neurologic outcomes. This study retrospectively analyzed data between January 2012 and March 2013 from a prospective observational study in the Kanto area of Japan. We analyzed adult patients with nontraumatic OHCA who underwent cardiopulmonary resuscitation by emergency medical service personnel and in whom spontaneous circulation was restored. Based on the institutional volume of OHCA cases, we divided institutions into low-, middle-, or high-volume groups. The primary and secondary outcomes were 1-month favorable neurologic outcomes and 1-month survival, respectively. A multivariate logistic regression analysis adjusted for propensity score and in-hospital variables was performed. Of 2699 eligible patients, 889, 898, and 912 patients were transported to low-volume (40 institutions), middle-volume (14 institutions), and high-volume (9 institutions) centers, respectively. Using low-volume centers as the reference, transport to a middle- or high-volume center was not significantly associated with a favorable 1-month neurologic outcome (adjusted odds ratio [OR] 1.21 [95% confidence interval {CI} 0.84-1.75] and adjusted OR 0.77 [95% CI 0.53-1.12], respectively) or 1-month survival (adjusted OR 1.10 [95% CI 0.82-1.47] and adjusted OR 0.76 [95% CI 0.56-1.02], respectively). Institutional volume was not significantly associated with favorable 1-month neurologic outcomes or 1-month survival in OHCA. Further investigation is needed to determine the association between hospital characteristics and outcomes in patients with OHCA.

Emergency general surgery in Italy during the COVID-19 outbreak: first survey from the real life

BackgroundCOVID-19 pandemic has rapidly spread in Italy in late February 2020. Almost all surgical services have been reorganized, with the aim of maintaining an adequate therapeutic path, especially for surgical emergencies. The knowledge of how surgeons dealing with emergency surgery have reacted to the epidemic in the real life can be useful while drafting clinical recommendations.MethodsSurgeons from multiple Italian regions were invited answering to an online survey in order to make a snapshot of their current behaviors towards COVID-19-positive patients bearing urgent surgical diseases. Questions about institutional rules and personal approach for patient treatment and to limit epidemic spread were included in a 37-item questionnaire.ResultsSeventy-one questionnaires from institutions dealing with emergency surgery were accepted. Participating surgeons were equally subdivided from a geographical point of view, with a large proportion of public (97.2%) and non-academical (91.5%) centers. In 80.3% of cases, the hospitals treated COVID-19 patients; in 69.1% of centers, a change in work plan was necessary, and 33.8% of teams had almost a surgeon infected or in preventive quarantine. The vast majority of surgeons operated only on urgent cases (73.9%), but the number of interventions significantly dropped. Up to 40% of non-traumatic abdominal emergency cases had an unusual delayed treatment. The laparoscopic approach was used in 69.6% of interventions on COVID-19 patients. Strategies to protect health care workers against COVID-19 infection and to identify asymptomatic infected surgeons were suboptimal with respect to the WHO recommendations in 70.4% and 90.2% of centers, respectively. Advanced personal protective equipment for operating room workers was adopted for all surgeries in only 12.7% of centers.DiscussionThis survey confirms that the COVID-19 outbreak is dramatically changing the practice of emergency surgery centers in Italy. Despite the reduction in number, urgent cases were on average more challenging owing to diagnostic delay. Recommendations from the International Scientific Societies are frequently not complied concerning the use of laparoscopic approach, the availability of personal protective equipment in the operating rooms, and the testing of both asymptomatic physicians and patients scheduled for surgery. A further evaluation of the short-term results of these attitudes is warranted to modulate international recommendations.

Orthopedic practices and orthopedic education amidst COVID-19 pandemic – Changing trends and way ahead

The COVID-19 pandemic has affected people from different walks of life. With limited availability of personal protective equipment and testing facilities, the medical fraternity is at high risk of infection. The orthopedicians were also affected. The management protocols of trauma and nontraumatic cases and the orthopedics teaching have undergone a paradigm shift. The management has changed from aggressive surgery to conservative management. The number of patients suffering from physical trauma has come down significantly. The elective cases are postponed. Newer ways of consultation like teleconsultations have begun. Due to the closure of public transport services, follow-up of patients is also not proper. With the judicious use of resources and proper testing of patients, we can overcome this pandemic.

Time Is Money: Can Punctuality Decrease Operating Room Cost?

Inefficient operating room (OR) use wastes resources. Studies have suggested "first case on-time starts" (FCOTS) reduce OR "idle time," yet no direct association between FCOTS and markers of OR efficiency, like "last case on-time end" (LCOTE) or overtime costs, have been reported. We performed this study to evaluate factors associated with FCOTS, LCOTE, and OR overtime costs. In April 2017, our medical center launched an FCOTS improvement initiative. Prospectively collected data concerning cases performed in the 6-month pre- (October 2016 to March 2017) and post-intervention (October 2017 to March 2018) periods were retrospectively analyzed. Elective, nontraumatic cases performed by orthopaedics, gynecology, urology, minimally invasive surgery, or colorectal surgery were eligible. Univariate and multivariable analyses were used to evaluate 3 outcomes of interest: the association between FCOTS and LCOTE (primary), the change in FCOTS rates after intervention implementation (secondary), and estimated overtime cost savings associated with FCOTS (secondary). We analyzed 12,073 cases (6,095 pre- vs 5,978 post-intervention) performed over 2,631 OR days (1,401 pre vs 1,230 post). The FCOTS rate increased after intervention (76.1% vs 86.6%, p <0.001), with post-intervention cases twice as likely to start on time (adjusted odds ratio [aOR] 2.07; 95% CI 1.73 to 2.46, p < 0.001). Additionally, starting on time was associated with a higher likelihood of LCOTE (aOR 1.76; 95% CI 1.38 to 2.24, p < 0.001) and 21.8 fewer overtime minutes (95% CI 13.7 to 29.8, p < 0.001) per OR day. Post-intervention estimated savings of $87,954 in direct OR costs over 6 months were associated with the FCOTS initiative. The FCOTS initiative was associated with higher frequency of FCOTS, which was independently associated with LCOTE. This achieved an estimated 6-month cost savings of more than $80,000 in direct OR expenditures.

Electrodiagnostic Findings in 441 Patients with Ulnar Neuropathy - a Retrospective Study.

PurposeUlnar neuropathy (UN) is the second most common focal neuropathy in the upper extremities. Electrodiagnostic studies (EDx), including nerve conduction study (NCS) and electromyography (EMG), are reliable tools for the diagnosis of ulnar neuropathy. We aimed to retrospectively analyze the medical records of patients diagnosed with ulnar neuropathy in a seven-year period and report our findings.Patients and methodsIn this retrospective study, documents of the patients whose ulnar nerve injury was confirmed through electrodiagnostic study in two departments of Physical Medicine and Rehabilitation were collected and demographic data, subjective complaints of the patient, the cause, and electrodiagnostic findings were extracted from each patient’s file. The following points were specifically evaluated in the electrodiagnostic records; type of injury, location, accompanying injuries, sensory nerve action potentials (SNAP) of the fifth finger, SNAP of dorsal ulnar cutaneous nerve (DUCN), compound muscle action potential (CMAP) of abductor digiti minimi (ADM) muscle, nerve conduction velocity (NCV) across elbow, patterns of muscle involvement, and the severity of insult.ResultsOut of 441 records, 305 (69.2%) were male and 68.1% were non-traumatic. Based on our clinical criteria, the intensity of the injury was mild in most cases. The elbow and forearm were the most involved regions in non-traumatic and traumatic cases respectively. Across elbow nerve conduction velocity showed decreased velocity in 71% of records. In non-traumatic cases, the most affected muscle was ADM (97%) and then FDI (85%).ConclusionIn focal entrapments such as ulnar neuropathy, electrodiagnostic findings are very helpful in assessing location, severity, and type of injury. If a consensus is achieved for the diagnosis of UN, even retrospective studies can become valuable sources for studying UN.

Abstract 126: ’Tick Tock’ it’s Time to Shock; Increased Shock Latency is Associated With Intra-Arrest Transport and Reduced Survival From Out-Of-Hospital Cardiac Arrest

Introduction: Timely defibrillation of shockable rhythms during out of hospital cardiac arrest (OHCA) is an important link in the chain of survival. In 2011 the Salt Lake City Fire Department (SLCFD) adopted ECG filtering technology to allow rhythm interpretation during CPR and a protocol to defibrillate shockable rhythms immediately upon identification. Hypothesis: We hypothesized that, under the new protocol, time from observing VF to defibrillation would, on average, be less than the 2 minutes expected by guidelines. We also hypothesized that increased shock latency would be associated with intra-arrest transport and decreased survival. Methods: Prospectively collected and abstracted defibrillator data from non-traumatic cardiac arrest cases treated by ALS providers from SLCFD between Dec 2011 and June 2019 were analyzed along with Utstein variables and outcomes. Using the defibrillator manufacturer’s review software, the timing of observed rhythm changes and defibrillation events was manually abstracted based on post-incident physician interpretation. Generalized linear and Poisson mixed models were used for analysis. Results: A total of 696 cardiac arrests with 965 shocks delivered to shockable rhythms were analyzed after excluding pediatric cases, non-ALS cases, and cases in which the defibrillator file was lost or corrupted. Median time to defibrillation was 67 sec (IQR 30-143 sec) with mixed-effects grand mean of 106 sec (95% CI 96-117 sec). Delayed defibrillation (&gt; 2 min) occurred in 293/965 (30%) of shocks. Transport of patients in arrest was associated with an increase in shock latency of 42 sec (95% CI 21-63 sec) compared to patients treated on scene. Among patients with an initial shockable rhythm, time from VF appearance to defibrillation was, on average, 40 sec (95% CI 15-66 sec) shorter among survivors than non-survivors. Conclusions: Use of an aggressive defibrillation protocol enabled by ECG filtering software resulted in a median time to defibrillation of under 2 minutes. Increasing shock latency was associated with intra-arrest transport providing a causal hypothesis for the poor outcomes observed in this population. We observed a negative association between survival and average time to defibrillation of shockable rhythms.

Neuropathic Arthropathy of the Shoulder: A Systematic Review of Classifications and Treatments.

Neuropathic arthropathy of the shoulder is a chronic progressive process characterized by joint destruction in the presence of a neurosensory deficit. Causes include syringomyelia, syphilis, diabetes, chronic alcoholism, and leprosy, with syringomyelia accounting for the vast majority of upper-extremity Charcot joints. Early presentation of this rare condition includes nonspecific symptoms such as swelling, erythema, sensory symptoms, and decreased functionality, making diagnosis challenging. We systematically reviewed 32 case reports published between 1924 and 2016. A total of 59 shoulders from 56 patients are included in this analysis. Variables include patient demographic characteristics, presentation, etiology, diagnostic techniques, treatment, outcome, and follow-up of Charcot shoulder. We compiled a total of 25 right shoulders (42%), 24 left shoulders (41%), and 10 shoulders (17%) with unspecified laterality. The mean patient age (and standard deviation) was 49 ± 11 years, and the median age was 47 years. There was a higher prevalence in men (37 shoulders [63%]) compared with women (22 shoulders [37%]). Presenting symptoms included reduced range of motion (53 shoulders [90%]), paresthesia or hypoesthesia (45 [76%]), swelling (44 [75%]), weakness (40 [68%]), pain (31 [53%]), and reduction in deep tendon reflexes (22 [37%]). Shoulder radiographs were made in all cases. The presence of a syrinx was detected in 45 shoulders (76%) with magnetic resonance imaging, myelography, or clinical diagnosis. Sixteen shoulders (27%) reported exposure to trauma, with a 69% decrease in time from presentation to diagnosis compared with non-traumatic cases. Treatment was categorized as solely nonoperative management (14 [24%]), operative management (13 [22%]), combined therapy (20 [34%]), and no treatment listed (10 [17%]). Two surgical cases (3%) were excluded from our treatment group analysis as they were treated for unrelated or misdiagnosed conditions. Our study increases awareness and understanding of this complex, progressive disease to reduce delay and misdiagnosis and to contribute to the standard-of-care recommendations. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Follow-Up of Cerebral Amyloid Angiopathy-Associated Intracranial Hemorrhage Reveals a High Prevalence of Atrial Fibrillation

Goal: Cerebral amyloid angiopathy (CAA) is the second-most common cause of nontraumatic intracerebral hemorrhages (ICH), surpassed only by uncontrolled hypertension. We characterized the percentage, risk factors, and comorbidities of patients suffering from CAA-related ICH in relation to long-term outcomes. Material and Methods: We performed retrospective analyses and clinical follow-ups of individuals suffering from ICH who were directly admitted to neurosurgery between 2002 and 2016. Findings: Seventy-four of 174 (42%) spontaneous nontraumatic lobar ICH cases leastwise satisfied the modified Boston criteria definition for at least “possible CAA.” Females suffered a higher risk of CAA-caused ICH (42 of 74, 56.8%, P= .035). Atrial fibrillation as a major comorbidity was observed in 19 patients (25.7%). Recovery (decrease of modified Rankin scale [mRS]) was highest during hospitalization in the acute clinic. One-year mortality was as follows: 14 of 25 patients (56%) with probable CAA without supporting pathology, 6 of 18, and 8 of 31 patients with supporting pathology and possible CAA, respectively. Only 10 of 74 (13.6%) had favorable long-term outcomes (mRS ≤2). Increasing numbers of lobar hemorrhages, low initial Glasgow Coma Scale, and subarachnoid hemorrhage were significantly associated with poor survivability, whereas statins, antithrombotic agents, an intraventricular hemorrhage, and midline shift played seemingly minor roles. Conclusions: Symptomatic ICH is a serious stage in CAA progression with high mortality. The high incidence of concurrent atrial fibrillation in these patients may support data on more widespread vascular pathology in CAA.

Evaluation of interleukin-6 (IL-6) estimation in autopsied chest traumatic cases: Prospective study

Objectives: To find out if interleukin 6 (IL-6) can be considered as a traumatic death marker or not (traumatic or non-traumatic). Background: Trauma is considered as one of public health problems worldwide causing high morbidity and mortality in developed and developing areas in the worlds. A chest trauma is any state of physical force causing injury to the chest including the ribs, heart and lungs. Cytokines are regarded as important mediators in the pathological process of inflammation. In addition, chest trauma or trauma in general has no biological marker. Role of cytokines and its relation with trauma and injuries have not been researched satisfactorily. Subject, material and methods: one hundred cadavers with chest trauma sent to Zeinhom governmental mortuary as well as non-traumatic dead cases died in Menoufia university hospital and blood samples tested for interleukin 6 level by interleukin – 6 ELIZA (enzyme linked immune-sorbent assay) kits, cases divided into group I (control healthy cases), group II (that divided into two subgroups; subgroup II a include non-traumatic dead cases except cases died from myocardial infarction (MI), subgroup II b includes non-traumatic cases died MI) and group III (traumatic chest injuries deaths). Results: There is a highly significant difference between non-traumatic dead cases (not including MI cases) II a subgroup and traumatic dead cases III (P value < 0.001). As regarding to the mean of interleukin level it is higher in group III (58.3±20.6), it is above 3.5 folds as its value in non-traumatic dead cases (not including MI cases) II a subgroup (15.7±2.78). There is a highly significant difference between non-traumatic MI dead cases II b subgroup and traumatic dead cases III. As regarding to the mean of interleukin level, it is higher in group (58.3±20.6), it is above 3.5 folds as its value in non-traumatic MI dead cases-b subgroup (15.3±2.61). Conclusion: it is revealed that definitely IL6 is closely associated and increased with traumatic injury and can be considered as a trauma biomarker.

Fat Embolism, Fat Embolism Syndrome and the Autopsy.

Fat embolism is common following trauma and is a common autopsy finding in these cases. It may also be seen in non-traumatic cases and is seen in children as well as adults. In comparison fat embolism syndrome (FES) only occurs in a small number of trauma and non-trauma cases. Clinical diagnosis is based on characteristic clinical and laboratory findings. Fat embolism exerts its effect by mechanical blockage of vessels and/or by biochemical means including breakdown of fat to free fatty acids causing an inflammatory response. Fat embolism can be identified at autopsy on microscopy of the lungs using fat stains conducted on frozen tissue, including on formalin fixed but not processed tissue. With FES fat emboli can be seen in other organs including the brain, kidney and myocardium. Fat can also be identified with post-fixation staining, typically with osmium tetroxide. Scoring systems have been developed to try and determine the severity of fat embolism in lung tissue. Fat embolism is also common following resuscitation. When no resuscitation has taken place, the presence of fat on lung histology has been used as proof of vitality. Diagnosis of fat embolism syndrome at autopsy requires analysis of the history, clinical and laboratory findings along with autopsy investigations to determine its relevance, but is an important diagnosis to make which is not always identified clinically. This paper reviews the history, clinical and laboratory findings and diagnosis of fat embolism and fat embolism syndrome at autopsy.

Histopathological evaluation of autopsy cases with isolated pulmonary fat embolism (IPFE): is cardiopulmonary resuscitation a main cause of death in IPFE?

Background: Fat embolism (FE) may develop following many traumatic and atraumatic clinical conditions; however, fewer data exist regarding the occurrence of isolated pulmonary FE (IPFE). Cardiopulmonary resuscitation (CPR) is an emergency procedure for maintaining blood circulation and oxygenation during cardiac arrest. In this study, we aimed to evaluate the association of CPR with IPFE in autopsy cases.Methods: A total 402 cases among 4,118 autopsies were diagnosed with IPFE, and the medical background of these cases was retrospectively evaluated. Diagnosis of FE and FE grading were performed with histopathological examinations of postmortem tissue samples, and injury-severity scores of traumatic cases were assessed. Data of traumatic and atraumatic cases were statistically compared.Results: Of the IPFE cases, 298 (741%) were male and 104 (25.9%) female, with overall mean age 53.7 (2–99) years. Causes of death of studied subjects were traumatic for 302 (75.1%) and atraumatic reasons for 100 (24.9%) cases. CPR was performed for 277 cases of which 177 (63.9%) were traumatic and 100 (36.1%) were non-traumatic. In comparison to traumatic cases, significantly higher CPR frequency was determined in atraumatic IPFE (P=0.001). High grade FE in the traumatic cases, and mild-moderate grade of FE in the nontraumatic cases were found statistically significant (P=0.001).Conclusion: This study indicates that CPR may be one of the leading factors in the development of IPFE in atraumatic conditions, and this procedure was related to mild–moderate IPFE manifestations. Regardless of whether conditions were traumatic or atraumatic, in patients who survive following CPR for manifest ventilation/perfusion problems, it should be remembered that IPFE may have developed due to CPR.

Diagnostic validity of PULP (peptic ulcer perforation) score in predicting mortality in patient with operated perforated peptic ulcer in Sanglah Hospital- Denpasar

Background: Perforated peptic ulcer (PPU) is one of the most common non-traumatic emergency cases in the emergency unit, and have a high mortality rate, more than 70% in the elderly. Accurate and early identification of high-risk surgical patients with PPU is important for triage and risk stratification. The objective of this study was to evaluate the mortality in patients with operated PPU.Methods: Between January 2015 to December 2016, 50 consecutive patients with PPU who performed laparotomy were studied retrospectively. This study was a diagnostic test to evaluate the validity of PULP (Peptic Ulcer Perforation) score to predict mortality in patient with operated PPU and determine the best cut-off point. Presentation ≥ or &lt; 24 hours, age of 65 years old, the presence of preoperative shock, ASA score, the presence of AIDS or active malignancy, liver failure, concomitant use of steroids and serum creatinine &gt; 14.7 g/dL were evaluated in PULP score.Results: The cut-off point for PULP the score in the present study is &gt; 7, based on the optimal cut-off value, patients could be divided into low-risk patients (a score of &lt; 7 points), and high-risk patients (a score of &gt; 7 points). PULP score had 91.7% sensitivity, 65.4% specificity, and 78% accuracy in this study. Positive predictive value and negative predictive the values were 71% and 89.9%.Conclusion: The PULP score is sensitive to predict the mortality risk in patients operated for perforated peptic ulcer and can assist in risk stratification and triage.