Frontiers of Medicine

ISSN 2095-0217

ISSN 2095-0225(Online)

CN 11-5983/R

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REVIEW
Emergency strategies and trends in the management of liver trauma
Hongchi Jiang, Jizhou Wang
Front Med. 2012, 6 (3): 225-233.  
https://doi.org/10.1007/s11684-012-0186-6

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The liver is the most frequently injured organ during abdominal trauma. The management of hepatic trauma has undergone a paradigm shift over the past several decades, with mandatory operation giving way to nonoperative treatment. Better understanding of the mechanisms and grade of liver injury aids in the initial assessment and establishment of a management strategy. Hemodynamically unstable patients should undergo focused abdominal sonography for trauma, whereas stable patients may undergo computed tomography, the standard examination protocol. The grade of liver injury alone does not accurately predict the need for operation, and nonoperative management is rapidly becoming popular for high-grade injuries. Hemodynamic instability with positive focused abdominal sonography for trauma and peritonitis is an indicator of the need for emergent operative intervention. The damage control concept is appropriate for the treatment of major liver injuries and is associated with significant survival advantages compared with traditional prolonged surgical techniques. Although surgical intervention for hepatic trauma is not as common now as it was in the past, current trauma surgeons should be familiar with the emergency surgical skills necessary to manage complex hepatic injuries, such as packing, Pringle maneuver, selective vessel ligation, resectional debridement, and parenchymal sutures. The present review presents emergency strategies and trends in the management of liver trauma.

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Orthopedic management in the polytrauma patient
Jason J. Halvorson, Holly T-P. Pilson, Eben A. Carroll, Zhongyu John Li
Front Med. 2012, 6 (3): 234-242.  
https://doi.org/10.1007/s11684-012-0218-2

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The past century has seen many changes in the management of the polytraumatized orthopedic patient. Early recommendations for non-operative treatment have evolved into early total care (ETC) and damage control orthopedic (DCO) treatment principles. These principles force the treating orthopaedist to take into account multiple patient parameters including hypothermia, coagulopathy and volume status before deciding upon the operative plan. This requires a multidisciplinary approach involving critical care physicians, anesthesiologists and others.

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Diagnostic criteria of latent autoimmune diabetes in adults (LADA): a review and reflection
Yu Liao, Yufei Xiang, Zhiguang Zhou
Front Med. 2012, 6 (3): 243-247.  
https://doi.org/10.1007/s11684-012-0201-y

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Diabetes has become a major public health problem in China nowadays. There are almost 97 million diabetic patients nationwide. Latent autoimmune diabetes in adults (LADA) is a subtype of autoimmune diabetes. Although it has been reported for about 20 years, the diagnostic criteria of this disease remain controversial. The discussion mainly focused on serum autoantibodies, period of insulin need and age of diagnosis. Besides, β cell function, metabolic parameters, genetic factors and cell immunity may also contribute to the formulation of the criteria. Here, we aim to review and discuss the diagnostic criteria of latent autoimmune diabetes in adults.

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AML1-ETO driven acute leukemia: insights into pathogenesis and potential therapeutic approaches
Megan A. Hatlen, Lan Wang, Stephen D. Nimer
Front Med. 2012, 6 (3): 248-262.  
https://doi.org/10.1007/s11684-012-0206-6

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The AML1-ETO fusion transcription factor is generated by the t(8;21) translocation, which is present in approximately 4%–12% of adult and 12%–30% of pediatric acute myeloid leukemia (AML) patients. Both human and mouse models of AML have demonstrated that AML1-ETO is insufficient for leukemogenesis in the absence of secondary events. In this review, we discuss the pathogenetic insights that have been gained from identifying the various events that can cooperate with AML1-ETO to induce AML in vivo. We also discuss potential therapeutic strategies for t(8;21) positive AML that involve targeting the fusion protein itself, the proteins that bind to it, or the genes that it regulates. Recently published studies suggest that a targeted therapy for t(8;21) positive AML is feasible and may be coming sometime soon.

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Mechanisms and impacts of chromosomal translocations in cancers
Jing H. Wang
Front Med. 2012, 6 (3): 263-274.  
https://doi.org/10.1007/s11684-012-0215-5

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Chromosomal aberrations have been associated with cancer development since their discovery more than a hundred years ago. Chromosomal translocations, a type of particular structural changes involving heterologous chromosomes, have made a critical impact on diagnosis, prognosis and treatment of cancers. For example, the discovery of translocation between chromosomes 9 and 22 and the subsequent success of targeting the fusion product BCR-ABL transformed the therapy for chronic myelogenous leukemia. In the past few decades, tremendous progress has been achieved towards elucidating the mechanism causing chromosomal translocations. This review focuses on the basic mechanisms underlying the generation of chromosomal translocations. In particular, the contribution of frequency of DNA double strand breaks and spatial proximity of translocating loci is discussed.

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Dual faces of SH2-containing protein-tyrosine phosphatase Shp2/PTPN11 in tumorigenesis
Shuangwei Li, Diane DiFang Hsu, Hongyang Wang, Gen-Sheng Feng
Front Med. 2012, 6 (3): 275-279.  
https://doi.org/10.1007/s11684-012-0216-4

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PTPN11, which encodes tyrosine phosphatase Shp2, is a critical gene mediating cellular responses to hormones and cytokines. Against original prediction as tumor suppressor for tyrosine phosphatases, PTPN11 was first identified as a proto-oncogene because activating mutations of this gene are associated with leukemogenesis. However, most recent experimental data suggest PTPN11/Shp2 acting as a tumor suppressor in hepatocarcinogenesis. This review focuses on the tumor-promoting or suppressing roles of the gene PTPN11/Shp2 in different cell types.

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Gastrointestinal damage caused by swallowing multiple magnets
Shiqi Liu, Jianhui Li, Yi Lv
Front Med. 2012, 6 (3): 280-287.  
https://doi.org/10.1007/s11684-012-0207-5

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Swallowing multiple magnets is not uncommon worldwide and it frequently leads to serious consequences. However, most patients fail to receive timely and correct diagnosis and treatment. A literature search was performed to establish an algorithm for these accidents by the authors to identify relevant articles published from June 1987 to October 2010 in Google, Medline, ISI Web of Knowledge Ovid, CNKI, Korea Med and library document delivery, using search terms “magnet ingestion, ” “fistula, ” and “perforation. ” A total of 149 patients with ingestion of magnetic foreign bodies from 20 countries and areas were identified. 22 of them were companioned with neurological and psychiatric disorders. Swallowing magnets occurred throughout childhood and adolescent, mostly ranging 2 to 4 years in age. Various gastrointestinal damages such as necrosis and intestinal perforation or fistula were encountered. Damage from swallowing multiple magnets carries a significant risk of morbidity and even mortality throughout childhood to adolescent worldwide. Older children and adults with neurological and psychiatric problems may be at high risk for such accidents. Early intervention is crucial.

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RESEARCH ARTICLE
Estimation of the minimum effective dose of tramadol for postoperative analgesia in infants using the continual reassessment method
Yue’e Dai, Dongxu Lei, Zhenghua Huang, Yan Yin, G. Allen Finley, Yunxia Zuo
Front Med. 2012, 6 (3): 288-295.  
https://doi.org/10.1007/s11684-012-0208-4

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Tramadol is a potent analgesic. However, the analgesia efficacy of tramadol, particularly its minimum effective dose (MED), is not clear. The aim of this study is to find MED of tramadol for postoperative analgesia in infants. The continual reassessment method (CRM) was performed to find MED. Infants undergoing surgeries were included in the 3 phases of this series. In each phase, 24 participants were allocated a different tramadol dose. Pain intensity was measured by face, legs, activity, cry, consolability (FLACC) measurement at 3-hour intervals. Tramadol was considered ineffective if the FLACC score was higher than 4 in 10 at anytime. In phase 1, seven dose levels were used within the range 0.1–0.4 mg?kg-1·h-1. Phase 1 was insufficient to identify the MED, and we increased the dose to 0.4–0.8 mg?kg-1·h-1 in phase 2. Phase 2 was insufficient to identify the MED. In phase 3, local anesthetic wound infiltration was introduced, and the tramadol dose levels tested were the same as in phase 1. The successful analgesia probability of tramadol 0.4 mg?kg-1?h-1 was 82.1% (95% CI, 0.742–0.925) in phase 1. In phase 2, it was 84.7% (95% CI, 0.789–0.991) with the dose 0.8 mg?kg-1?h-1. Phase 1 and phase 2 were insufficient to identify the MED. In phase 3, the successful analgesia probability for dose 0.35 mg?kg-1?h-1 was 96.7% (95% CI, 0.853–0.997).We have demonstrated that tramadol provides insufficient analgesia for surgeries considered to cause moderate-to-severe postoperative pain in infants if used as the sole analgesic, and that local anesthetic wound infiltration enhances the efficacy of tramadol.

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Early and marked up-regulation of TNF-α in acute respiratory distress syndrome after cardiopulmonary bypass
Tao Li, Nanfu Luo, Lei Du, Jin Liu, Lina Gong, Jing Zhou
Front Med. 2012, 6 (3): 296-301.  
https://doi.org/10.1007/s11684-012-0219-1

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Despite the technique of cardiopulmonary bypass (CPB) improved the development of modern cardiac surgery, many factors during CPB have been reported to induce acute respiratory distress syndrome (ARDS). The present study was to investigate which pro-inflammatory factors involved in the early phase of ARDS. Ten patients underwent valve replacement surgery with or without ARDS were enrolled for analysis of pulmonary function and inflammatory factors release including white blood cell (WBC), neutrophils, CD11b, CD18, interleukin (IL)-8 and tumor necrosis factor-α (TNF-α). The results demonstrated that the ratio of arterial oxygen tension/fraction of inspire oxygen (PaO2/FiO2) was greatly reduced in ARDS patients, but only the release of TNF-α was significantly increased, which was reversely correlated to the values of PaO2/FiO2. Also, the count of neutrophils adhesive to pulmonary endothelial cells was significantly increased in ARDS patients. Therefore, we concluded that TNF-α was quickly up-regulated and involved in the pathogenesis of CPB-induced ARDS via guiding primed neutrophils to pulmonary interstitium.

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EMLA? Cream coated on endotracheal tube with or without epidural lidocaine reduces isoflurane requirement during general anesthesia
Hai Yu, Qinjun Chu, Jin Liu, Li Chen, Ying Wang, Yunxia Zuo
Front Med. 2012, 6 (3): 302-306.  
https://doi.org/10.1007/s11684-012-0194-6

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This study was designed to evaluate the effect of tracheal topical anesthesia using EMLA? Cream (EC) coated on the endotracheal tube (ETT) with or without epidural anesthesia (EA) on isoflurane requirement during general anesthesia (GA) and investigate whether EC coated on the ETT with EA was associated with the additive effect compared with the effect when each anesthetic was administered independently. The prospective randomized, double-blinded, and controlled study included 60 ASA I–II patients scheduled for upper abdominal surgery requiring GA. Patients were randomly assigned to one of the following groups: group 1 received GA, group 2 received EC+ GA, group 3 received GA+ EA, and group 4 received EC+ GA+ EA. Isoflurane was administered at the required concentrations to maintain the mean arterial pressure at a level not exceeding 20% of preoperative values. The percentage mean expired concentration (%MEC) was used in calculating the isoflurane requirement. Emergence agitation, postoperative sore throat, and hoarseness were recorded. Groups 2, 3, and 4 exhibited a significant reduction on isoflurane requirement compared with group 1 (P<0.05). The isoflurane requirement evaluated by %MEC decreased by 12%, 38%, and 50% in groups 2, 3, and 4, respectively. The incidence of emergence agitation was significantly lower in groups 2 and 4 than those in groups 1 and 3 (P<0.05). Tracheal topical anesthesia using EC coated on ETT with or without EA reduced the isoflurane requirement during GA, indicating that EC combined with EA exhibited an additive effect on the requirement of general anesthetic.

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Perioperative management for parturients with pulmonary hypertension: experience with 30 consecutive cases
Lulu Ma, Wei Liu, Yuguang Huang
Front Med. 2012, 6 (3): 307-310.  
https://doi.org/10.1007/s11684-012-0209-3

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Pregnancy with pulmonary hypertension is considered to be associated with increased maternal and neonatal mortality. We retrospectively reviewed all parturients with pulmonary hypertension who registered at our hospital between 1999 and December 2008. We collected information about patient characteristics, including maternal age, gravida and para, pulmonary hypertension category, New York Heart Association (NYHA) functional class, pulmonary artery pressure, mode of delivery and type of anesthesia, use of anticoagulation and advanced therapy (nitric oxide, prostacyclin analogus, bosentan or sildenafil). The overall maternal mortality was 16.7% in puerperium, and there were four fetal/neonatal deaths (13%). Logistic regression could not identify any factors, including modes of anesthesia, mode of delivery, and categories and severity of pulmonary hypertension, that were significant predictors of mortality. Maternal mortality in parturients with pulmonary hypertension is high and women with pulmonary hypertension who become pregnant warrant a multidisciplinary approach.

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Comparative cost analysis of three different anesthesia methods in gynecological laparoscopic surgery
Xiaohui Chi, Yeling Chen, Mingfeng Liao, Fei Cao, Yuke Tian, Xueren Wang
Front Med. 2012, 6 (3): 311-316.  
https://doi.org/10.1007/s11684-012-0205-7

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In the current study, we assessed and evaluated the costs and benefits of three popular methods of general anesthesia practiced in our department for gynecological laparoscopic surgery in recent years. Sixty adult female patients who underwent elective gynecological laparoscopic surgery under general anesthesia were randomly divided into three groups: group V, group I and group C. In group V, anesthesia was induced intravenously with midazolam, remifentanil, propofol and vecuronium, and maintained with continuous infusion of propofol and remifentanil. In group I, anesthesia was intravenously induced with midazolam, fentanyl, propofol and vecuronium, and maintained with inhaled isoflurane and intravenous bonus of fentanyl. In group C, anesthesia was induced as in group I, but maintained with isoflurane inhalation combined with propofol-remifentanil infusion. All patients received vecuronium for muscle relaxation. Perioperative incidences of complications and total anesthesia costs for patients in all groups were recorded. In addition, postoperative satisfaction of the patients was also noted, and similar outcomes of the satisfaction were reported in all 60 patients. Although there was no statistical significance among groups, the incidence of postoperative nausea and vomiting were higher in group C, and the rates of shivering and the needs for analgesics were higher in group V. Anesthesia costs in group I were the lowest. Therefore, it is concluded that the costs of anesthesia induced with midazolam, fentanyl, propofol, vecuronium, and maintained with isoflurane, fentanyl and vecuronium are cheapest, and there is no significant difference in patients’ satisfaction and safety among the three above-mentioned methods of anesthesia in our department.

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Potential indicators predict progress after surgical resection of gastrointestinal stromal tumors
Qinggang Hu, Shanglong Liu, Jianwei Jiang, Chen Zhang, Xiaowei Liu, Qichang Zheng
Front Med. 2012, 6 (3): 317-321.  
https://doi.org/10.1007/s11684-012-0203-9

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In order to find out the potential indicators predicting prognosis of malignant gastrointestinal stromal tumors (GISTs) after surgical resection, we collected clinical records of 80 patients with malignant GISTs. Tumor location, size, mitotic index, necrosis were compared with the prognosis of malignant GISTs by Kaplan-Meier method and log-rank test. After a median follow-up of 844 days (52–2 145), we found that as National Institutes of Health suggested, tumors with intermediate risk had more favorable prognosis than that with high risk. Their 3-year survival rate were 65.3% and 41.3%, respectively (P<0.001). Moreover, tumor size and mitotic index were associated with free survival. The 3-year survival rate for patients with tumor size≤10 cm and>10 cm were 62.3% and 41.8%, respectively (P = 0.002), Tumors with mitotic index≤5/50 HPF had a higher 3-year survival rate than tumors with mitotic index>5/50 HPF (67.1% versus 40.7%, P = 0.005). The presence of necrosis was directly related to the malignant behavior. The 3-year survival rate for presence and absence necrosis were 50.8% and 64.8% (P = 0.008). From the present study, we can conclude that besides tumors size and mitotic index, tumor location and necrosis also influence on the long-term survival of patient with malignant GISTs after surgical resection.

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Obesity and overweight prevalence and its association with undiagnosed hypertension in Shanghai population, China: a cross-sectional population-based survey
Xinjian Li, Jiying Xu, Haihong Yao, Yanfei Guo, Minna Chen, Wei Lu
Front Med. 2012, 6 (3): 322-328.  
https://doi.org/10.1007/s11684-012-0204-8

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The aim of this study was to determine the prevalence of overweight and obese subjects in the Shanghai population of China and its association with undiagnosed hypertension, by taking age, gender and place of residence (urban or suburban) into account. A cross-sectional population-based survey was conducted in 2007. The sample included 13 359 participants aged 15–69 years. Weight, height, and blood pressure were recorded, and information about gender, age and place of residence was obtained. Overweight and obesity prevalence were calculated by the body mass index (BMI) definition recommended by Working Group on Obesity in China (normal weight, 18.5–23.9 kg/m2; overweight, 24–27.9 kg/m2; obesity,≥28 kg/m2). Undiagnosed hypertension was defined by China criteria in accord with that of WHO-ISH (subjects with systolic pressure≥140 mmHg, and/or diastolic pressure≥90 mmHg). Multiple logistic regression analyses were used to assess the association of overweight or obesity with undiagnosed hypertension by adjusting for age, gender and place of residence. The overall overweight, obesity, and undiagnosed hypertension prevalence were 27.6% (95% CI: 26.8–28.4), 6.6% (95% CI: 6.2–7.0), and 15.5% (95% CI: 14.9–16.1), respectively. Compared to normal weight subjects, the odds ratios (OR) for subjects who were overweight and had hypertension was 2.33 (95% CI: 2.10–2.59); that for obesity and hypertension was 4.27 (95% CI: 3.66–4.99). These data suggest that overweight and obesity prevalence and their association with undiagnosed hypertension are high in our study population.

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CASE REPORT
The second short-term warm ischemia after vascular anastomosis did not affect early renal function recovery in renal transplantation: a case report
Tao Qiu, Jiangqiao Zhou, Xiuheng Liu, Minghuan Ge, Zhiyuan Chen
Front Med. 2012, 6 (3): 329-331.  
https://doi.org/10.1007/s11684-012-0211-9

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Ischemic postconditioning was defined as rapid intermittent interruptions of blood ?ow in the early phase of reperfusion, which has been found to be protective against renal ischemia-reperfusion injury (IRI) in animal models but not in clinical trials. We describe a case that the allograft renal vein was twisted because of the surgeon’s mistake, which caused the warm ischemia of allograft after reperfusion. The allograft restored blood flow without second reperfusion and cold preservation after 9 min of warm ischemia. The patient was followed up for 3 months and the allograft worked well without complications.

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COMMENTARY
Emergent limited perioperative transesophageal echocardiography: should new guidelines exist for limited echocardiography training for anesthesiologists?
Yong G. Peng, Gregory M. Janelle
Front Med. 2012, 6 (3): 332-337.  
https://doi.org/10.1007/s11684-012-0212-8

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Bedside limited echocardiography, or focused cardiac ultrasound, continues to gain popularity in many emergency rooms, intensive care units, and operating rooms as a rapid method of assessing unstable patients. Effective monitoring of cardiovascular function in conditions like cardiac arrest or near-arrest is the crucial step to guide successful resuscitative efforts. Transesophageal echocardiography (TEE) has emerged as one of the preferred cardiac diagnostic and monitoring modalities in the intraoperative setting due to the fact that it is less invasive than many other monitors, is immediately accessible, and allows for continuous real-time monitoring of cardiac function. However, the minimum training requirements needed for the anesthesia provider to obtain the competency, knowledge, and skills for basic certification in perioperative TEE far exceed those developed for other medical specialties. We believe there is an urgent need to develop (1) practical guidelines for emergent perioperative TEE use for anesthesiologists and (2) a requisite educational curriculum to teach the basic skills necessary to aid in the diagnosis and treatment of cardiac arrest or near-arrest scenarios. The measures elucidated in this report summarize the efforts of the Department of Anesthesiology at the University of Florida in establishing the necessary steps to make this process not only practical, but accessible to all trainees. We hope that these collective efforts will provide more trainees the confidence in utilizing TEE to aid in establishing a diagnosis in critical situations.

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16 articles