Cofactors of alcohol-related trauma at a rural trauma center.

To analyze the cofactors of alcohol-related trauma at a rural, Level II trauma center, 127 admitted trauma patients were interviewed about psychological problems, social factors, and medical histories. Patients were divided into two groups, blood alcohol content (BAC) positive and BAC negative, for analysis. Seventy-one patients (56%) were BAC negative; 56 (44%) were BAC positive. Forty-three of the 82 males (52%) had positive BAC tests, compared with 13 of the 45 females (29%) (P = .01). Fifty-one of the 56 BAC-positive patients (91%) were aged 21 to 50 years, compared with 29 of the 71 BAC-negative patients (41%) (P = .0001). Ten of the 12 patients (83%) who were recently unemployed were BAC positive, compared with 46 of the 115 patients (40%) who were not recently unemployed (P = .004). Eleven of the 12 patients (92%) with positive drug screens were BAC positive, compared with 45 of the 115 patients (39%) with negative drug screens (P = .0005). These results show that there are important cofactors of alcohol-related trauma in rural areas.

HIV infection among rural trauma patients: a blind serosurvey and literature review.

Human immunodeficiency virus (HIV) seroprevalence rates among rural trauma patients range between 0.15 and 1.32 per cent. A random sample of trauma patients treated at our rural trauma center between September 1994 and November 1995 was enrolled into a blind HIV serosurvey. Five hundred sixty-six of 1315 trauma patients (43%) were tested. Two of the 566 patients (0.35%) were HIV positive. A review of aggregate data for HIV infection among rural trauma patients in the United States show that 28 of the 4639 patients (0.60%) are HIV positive. We conclude that there was a low HIV incidence among our trauma patients from September 1994 to November 1995, and the cost-effectiveness of HIV testing for rural trauma patients is questionable with incidences between 0.5 and 1.0 per cent.

Experimental thoracoabdominal airgun wounds in a porcine model.

UNLABELLED: The Consumer Product Safety Commission estimates that there are 31,000 airgun injuries annually, 19,000 of which occur in children under 14 years of age. Case reports in the literature include 235 serious and nine lethal pediatric injuries. No experimental model of thoracoabdominal airgun pellet perforation exists. A 60-pound newly killed pig was selected as a model for pediatric airgun injuries. Two commonly available .177-caliber airguns were fired from point blank, 2.5 feet, and 5 feet. A chronograph was used to measure impact velocities for pellets fired at the already-killed pig. Autopsy study of organ wounding was completed. Perforation velocities with point-tip pellets were 407 ft/sec for the thoracic wall and 399 ft/sec for the abdomen. Of the 18 pellets shot at the chest, eight passed through the chest wall, causing 15 organ injuries. Eleven of the 18 pellets perforated the abdominal wall, producing 49 organ injuries. CONCLUSION: Airguns create serious intracavitary organ injuries in a porcine model. Moreover, ballistic research is possible in unusual surroundings, such as a packing plant.

Physician understanding of the National Practitioner Data Bank.

National Practitioner Data Bank (NPDB) reports are part of the process for acquiring staff privileges, professional credentials, and licenses throughout a physician's entire career. We surveyed our hospital's 66 residents to assess their understanding of NPDB. Only 9 residents had heard about NPDB. A follow-up survey of the 10 medical schools in Pennsylvania and Maryland showed just 4 schools covered NPDB in their curricula. Finally, we did a third survey--of 1,410 Pennsylvania Medical Society members. Eighty-one percent did not know that denial of initial license application was not a reportable offense; 69% did not know that voluntary entrance into alcohol/drug rehabilitation was not reportable; and 75% did not know that denial of expanded privileges because of level of clinical competence was reportable. Only 13% knew how to obtain their files. Our surveys suggest physicians have a poor understanding of NPDB even though these reports could have career-jeopardizing implications, especially if the Clinton administration expands access to NPDB.

Transperitoneal absorption of thermocautery-induced carbon monoxide formation during laparoscopic cholecystectomy.

Carbon dioxide pneumoperitoneum (PP) during laparoscopic cholecystectomy (LC) causes hypercapnia and acidemia. Thermocautery carbon monoxide formation during LC was studied in 15 patients. CO samples were read by electrochemical sensor as parts per million (ppm) and obtained intraperitoneally at PP, gallbladder takedown (GBTD), and exhalation. In blood, CO was measured by spectrophotometry as percentage of carboxyhemoglobin (HbCO) during anesthesia induction, at end of PP, at GBTD, and in the recovery room. Heart rate, mean arterial pressure, oxygen saturation, and end-tidal CO2 were followed prospectively. Data were analyzed by analysis of variance and Student's t test. In 35 min, thermocautery increased intraperitoneal CO from 4.7 +/- 3.8 ppm at baseline to 326 +/- 360 ppm at GBTD (p < 0.004). HbCO increased from PP to GBTD (0.7 +/- 0.6 vs. 1.2 +/- 0.7%; p < 0.01). Thermocautery produces high levels of CO intraperitoneally, which are absorbed into the circulation. Exposure time is short, which may explain the lack of hemodynamic and oxygenation changes.

Use of skin staplers in experimental gastrointestinal injuries.

Undocumented reports exist concerning use of skin staplers to close small perforations of the gut. This study examined use of this device in experimental gastrointestinal injuries in dogs. In 18 anesthetized mongrel dogs, matching uniform perforations were made with a sterile leather punch; one perforation of each pair was closed with 3-0 silk and the other with a skin stapler. A total of 80 stomach, 238 small intestine, and 140 colon perforations were created. Hole sizes progressed from 1.9 to 5.0 mm. Unrepaired intestinal wounds leaked and were lethal. No leaks were identified in wounds closed with either sutures or staples provided that closure was complete. Speed of staple closure was faster than that of suture closure (1.2 vs. 16.0 seconds), but ease of closure was similar. It is concluded that skin staplers are safe for repair of small wounds, created under ideal conditions, in canine gastrointestinal tracts. Similar injuries in traumatized humans deserve study, but existing skin staplers may be ineffective for human intestine since gut wall thickness in humans is less than that in dogs.

Metabolic and thermoregulatory responses to burn wound colonization.

This study was designed to determine whether there is a relationship between bacterial colonization of the burn wound and resting oxygen consumption (VO2) and colonic temperature (Tc) in burned rats. Resting VO2, Tc, and blood, spleen, and wound cultures were monitored for 2 weeks after 30% total body surface full-thickness burns. The wounds of 53 animals were seeded with 10(8) nonvirulent P. aeruginosa (NVP) at the time of injury, while the wounds of 33 rats were allowed to colonize spontaneously. The seeded wounds contained 10(6) colony forming units/gm (CFU/gm) by the fourth postburn day (PBD), while the unseeded wounds did not reach this level of colonization until after the first week postinjury. Wound seeding accelerated the metabolic and thermoregulatory responses to injury. Average VO2 and Tc of the seeded group were above the unseeded group on PBD's 3-4 and 7-8, but there were no significant differences between groups on PBD's 14-15. Although the unseeded animals were hypermetabolic during the first week, they remained afebrile. There was a significant correlation between wound bacterial counts and the increase in resting VO2 of 44 nonbacteremic animals, but variations in the data suggest that factors other than number of viable wound bacteria affect this relationship. Changes in Tc were unrelated to wound bacterial count but were correlated with changes in VO2. Taken together, the data suggest that bacteria in the burn wound contribute to the rise in energy expenditure following thermal injury.

Quantitation of rate of wound closure and the prediction of death following major burns.

Data were obtained from 100 consecutive patients requiring hospitalization for 2 weeks or more for treatment of major burns. Age, total percentage burn, mechanism of injury, presence or absence of inhalation injury, and outcome were recorded. Serial weekly burn wound maps were used to calculate the wound closure index (WCI), previously defined as the slope of a straight line fitted to percentage burn as a function of time by linear regression analysis. Logistic regression analysis was used to construct an equation incorporating age, percentage burn and WCI. Addition of the WCI significantly improved the discriminant ability of the logistic regression model. The composite index correctly predicted survival in 97 percent of patients. Rapid wound closure, as measured by the WCI, correlated with survival.

Obstruction of defunctionalized loop ten years after jejunoileal bypass for morbid obesity.

We have reported a case of obstruction due to volvulus of the ileosigmoid anastomosis ten years after jejunoileal bypass. Revision of the ileosigmoid anastomosis with drainage of the defunctionalized limb into the cecum relieved the obstruction.

The significance of clostridial isolates in intra-abdominal sepsis.

In order to evaluate the significance of clostridial species in intra-abdominal infections, the bacteriology records of three hospitals were reviewed during a period of five years. Included in this report were 41 patients from whom clostridial species were recovered from specimens of free peritoneal fluid, abscess cavities or bile. Seven patients died for a mortality rate of 17.1 per cent. Most patients had polymicrobial infections of which clostridial organisms were one of the several anaerobes isolated. Clostridium perfringens was the single most frequently noted species, identified in 23 of the patients, but it was not associated with a different mortality rate than was observed for the other clostridial species. Clostridial bacteremia was uncommon and demonstrated in only one patient. The mean age of the patients was 56.4 years; 56.2 for males and 56.8 for females. Neither age nor sex of the patient influenced the likelihood of survival. The source of the clostridial isolates--bile, abscess cavity or free peritoneal fluid--had no effect upon the outcome. Several underlying conditions were responsible for the intraperitoneal clostridial organisms identified in this series. Only mesenteric infarction proved significantly predictive of a fatal result. Antibiotic coverage specifically directed against clostridia did not influence survival.

Wound Closure Index: a guide to prognosis in burned patients.

Speed of closure of the burn wound has been shown to influence survival in several large series, yet is difficult to quantitate. A computerized wound mapping system is described which records and computes the extent of the burn wound and its rate of closure. The program stores, displays, and modifies a series of Lund and Browder charts for each patient. The percentage of the wound which is open is computed. Linear regression analysis is used to compute a Wound Closure Index (WCI). The hospital courses of 40 consecutive patients treated for major burns were analyzed using this system. Patients with less than 20% BSA burned, or with burns requiring less than 2 weeks' hospitalization, were excluded from the study. There were 31 survivors and nine who died. Mean WCI for survivors was 1.40, contrasted with 0.44 for nonsurvivors (p less than 0.001). To minimize the effects of age, patients over 60 years old were considered separately. Discriminant analysis applied to this subgroup confirmed that WCI was an accurate predictor of mortality. The system provides an accurate record of changes in the burn wound. The WCI gives an objective measure of wound closure which correlates with survival.

The fate of the left kidney after division of its vein.

The effect of dividing the left renal vein was studied in Sprague-Dawley rats. Immediately after the left renal vein is divided near the renal hilum, the left kidney becomes markedly edematous and dusky. Twenty-four hours later, the kidney remains edematous and boggy. In contrast, the edema that immediately follows division of the left renal vein adjacent to the inferior vena cava is much less dramatic and virtually resolves within 24 hours. When the left renal vein was divided near the hilum simultaneously with right nephrectomy, all animals died within 48 hours. When the vein was divided adjacent to the vena cava with simultaneous nephrectomy, all animals survived. The effect of dividing the renal vein on perfusion of the left kidney was studied in Sprague-Dawley rats using intra-arterial injection of copper pigment. Division of the left renal vein reduced perfusion of that kidney to 68.9 per cent of control levels. This reduction was demonstrated to be totally reversible within 10 days.

The effect of splenectomy on gram-negative bacteremia.

Both clinical and laboratory studies have demonstrated an increased risk of fatal sepsis after splenectomy. The importance of the spleen in clearing a bacterial challenge from pneumococci or other encapsulated organisms is now well accepted. The role of the spleen in handling a bacteremia due to nonencapsulated (Gram negative) organisms is not well established. Rats were subjected to either sham operation or splenectomy. Two weeks after surgery, all animals received 10(6) E. coli by intraperitoneal injection. Tail vein blood samples for quantitative culture were obtained at multiple time intervals after the bacterial challenge. All animals developed a bacteremia. Initially, the mean bloodstream bacterial counts were comparable in the sham and splenectomy groups. Sham-operated rats cleared all bacteria from the bloodstream within 240 minutes. In contrast, 240 minutes after bacterial injection, E. coli could still be recovered from the blood of asplenic rats at levels comparable to those noted at the start of the experiment. The present study shows that splenectomy does impair the animal's ability to clear a Gram-negative bacteremia.

Effects of oxidized cellulose and microfibrillar collagen on infection.

Topical hemostatic agents may be used to control bleeding from a variety of surgical sites. Oxidized cellulose (Surgicel), gelatin sponge (Gelfoam), and microfibrillar collagen (Avitene) are the hemostatic agents in widest use. Oxidized cellulose has previously been shown to be superior to gelatin sponge with respect to infection. Microfibrillar collagen has not been studied in this regard. Contamination of experimental wounds with an inoculum of 3.2 to 3.6 X 10(4) colony-forming units of Staphylococcus aureus did not produce any infection. The addition of 20 mg of oxidized cellulose to wounds that received the same level of bacterial contamination resulted in nine infected wounds of 20 (45%). When the wounds were treated with 20 mg of microfibrillar collagen prior to contamination, 18 of 20 (90%) developed infection. The observed difference between the two hemostatic agents was significant (P less than 0.008). When 5 and 10 mg of oxidized cellulose was added to experimentally contaminated wounds, infection did not ensue. The incidence of infection increased strikingly when the amount of oxidized cellulose employed was increased to 20 and 30 mg. No such dose effect was observed for microfibrillar collagen. Infection developed even when very small quantities of the agent were used. Both oxidized cellulose and microfibrillar collagen may promote infection. The present study, in which a subcutaneous wound model was used, suggests an advantage of oxidized cellulose as compared with microfibrillar collagen from the standpoint of infection. Further studies with these agents in other body sites seem warranted.

Appendicitis: factors that influence the frequency of perforation.

The mortality from perforating appendicitis has decreased, but the incidence of perforation has not changed in 30 years. We found that among 335 consecutive patients treated for acute appendicitis, 108 (32%) had evidence of perforation. No significant differences between the groups were noted with respect to race, sex, educational level, family income, health insurance coverage, availability of transportation, and possession of a telephone. Perforation was more likely in patients who lived more than 20 miles from the hospital and in patients under age 10 years or over age 60. Patients with perforation were ill for a mean of 2.5 days before seeking medical attention, compared to a mean of 1.5 days for those without perforation (P < .001). Yet, approximately 75% of patients in each group stated that they had a "family doctor." Patients with perforation had significantly more physician visits before hospital admission (mean 1.61 vs 1.33, P < .005); 54.3% of patients with perforation had previous contact with a physician who failed to make the correct diagnosis.