Vena cava injuries during laparoscopic cholecystectomy.

Two instances of vena cava injury occurring during insertion of a new trocar for laparoscopic surgery are presented. The mechanism of injury in each case was identical. These injuries are extremely rare, and fortunately both patients survived. Any new instrument that is purported to be an improvement over existing ones should be critically evaluated so that needless and unnecessary injuries such as these can be avoided.

Migration of Salmonella typhi through intestinal epithelial monolayers: an in vitro study.

This study characterizes the transmigration of enteroinvasive Salmonella typhi in vitro, using a human intestinal epithelial cell line as a model of small intestinal epithelium. C2BBe cells, a subclone of CACO-2 with a highly differentiated enterocytic phenotype, were grown to maturity on Transwell filters. S. typhi Ty2 and the vaccine strain, Ty21a, the S. typhi mutant X7344 and parent strain SB130, and S. typhimurium 5771 in logarithmic phase were introduced to the upper chamber of the filter units. Numbers of bacteria in the lower chamber, TER and permeability of the monolayer to mannitol were measured over time. Monolayers were examined by light, electron and confocal microscopy to determine the pathway of bacterial transmigration, and intracellular bacteria were estimated by gentamicin assay. Epithelial cell injury was quantified by light microscopy. S. typhi transmigrated earlier and in larger numbers than S. typhimurium, inducing marked changes in electrical resistance and permeability. Unlike S. typhimurium, S. typhi selected epithelial cells in small number and caused their death and extrusion from the monolayers leaving holes through which S. typhi transmigrated. Ty2 consistently transmigrated in larger numbers and with more injury to monolayers than Ty21a. S. typhi crosses the monolayers of C2BBe cells by a paracellular route in contrast to the transcellular pathway described for other Salmonellae. This may be related to the unique pathophysiology of S. typhi infection and the restricted host specificity of this pathogen. In these assays the vaccine strain, Ty21a, is slightly less invasive than its parent, though more invasive than S. typhimurium.

Long-term consequences of minimal brain injury: loss of consciousness does not predict memory impairment.

This study evaluated the memory and intellectual function of 32 adults following minimal brain injury. All patients had a Glasgow Coma Scale score of 15 upon evaluation in the Emergency Room, negative findings on radiographic examination, and negative history of prior neurologic disease or injury. Seventeen of these had experienced a loss of consciousness. Patients suffering a loss of consciousness postinjury obtained significantly lower mean verbal intelligence quotients than those obtained by patients who remained conscious following their accidents. Both groups exhibited memory impairments. This could indicate that loss of consciousness predicts intellectual impairment, but not degree of memory dysfunction. An alternative interpretation of these data is that patients referred for examination after a head injury that did not involve a loss of consciousness included a disproportionate number of patients from upper socioeconomic levels who have greater access to medical delivery systems or greater sophistication regarding cognitive function.

Analysis of trauma intubations.

The timing of trauma patient intubation is dependent on clinical presentation and clinician judgment. We sought to correlate the timing of intubation with the presenting of physiologic parameters and clinical outcome to identify potential quality assurance audit filters. Patients (n = 82) were grouped by timing of intubation: PREHOSPITAL, paramedic intubation; IMMEDIATE, within 10 minutes of arrival; DELAYED, beyond 10 minutes but within 2 hours of arrival; and NONURGENT, beyond 2 hours or at the time of surgery. While mean revised trauma scores and Glasgow Coma Scale (GCS) scores differed for the groups, the mean length of hospital stay and the incidence of aspiration pneumonia were not significantly different. In the DELAYED group, 80% of those who developed aspiration pneumonia had a GCS < or = 13. Patients in the NONURGENT group were older and commonly presented with tachypnea. The survival rate for the NONURGENT group was lower than predicted by the TRISS method (P = .004). A GCS < or = 13 and age greater than 50 years with presenting respiratory rates of more than 25 breaths/min represent potential trauma intubation audit filters.

An assessment of time following trauma resuscitation: the transitional evaluation and monitoring phase.

Trauma resuscitation for 431 major trauma patients averaged 24 +/- 0.61 minutes. Further analysis of the care of 350 of these patients documented a transitional evaluation and monitoring phase (TEMP), with a physician and nurse in attendance, for an additional 158 +/- 12 minutes until arrival at the operating room, surgical intensive care unit (SICU), hospital ward, or discharge. The duration of TEMP did not vary according to severity of injury (R2 = 0.02). Arrival time (days: 167 +/- 23 minutes; evenings: 142 +/- 13 minutes; and nights: 147 +/- 30 minutes) had minimal effect on TEMP duration. The TEMP for 67 patients undergoing an operation was significantly less than for patients admitted to the hospital ward or SICU (112 +/- 19 minutes vs. 171 +/- 20, p less than 0.05). These 350 patients underwent 582 activities during TEMP including radiologic evaluation (265), CT scan (173), and other activities (144). Extrapolating TEMP time for the 1,800 major trauma patients seen annually, this represents 4,740 hours each of nursing and physician time. A better understanding of TEMP is needed to provide appropriate support and organization during this critical period of trauma care.

Safety of glutamine-enriched parenteral nutrient solutions in humans.

To determine the safety of glutamine-enriched parenteral nutrition, seven normal volunteers were admitted to the Clinical Research Center for three 5-d study periods. The subjects received infusions of parenteral nutrients containing increasing doses of glutamine (0, 0.285, and 0.570 g.kg body wt-1.d-1) substituted for alanine and glycine. Each study period was preceded by greater than or equal to 2 wk of normal food intake. The diets were isocaloric (1.2X estimated basal metabolic rate) and isonitrogenous (1.5 g protein.kg-1.d-1) with nonprotein calories given as dextrose (38%) and fat emulsion (62%). The diets were all well tolerated and there were no untoward effects. Plasma glutamine concentrations increased significantly with glutamine administration but plateaued at concentrations approximately 25% above control values. Ammonia and glutamate, potentially toxic metabolites of glutamine, did not change significantly with glutamine enrichment. Nitrogen balance and hormonal concentrations were unchanged during the three dietary periods. Results of mental-status examinations and continuous performance testing were normal and unchanged throughout the three periods. Glutamine-enriched parenteral nutrient solutions are well tolerated with no associated signs of toxicity in normal humans.

Safety and metabolic effects of L-glutamine administration in humans.

A series of dose-response studies was conducted to evaluate the clinical safety, pharmacokinetics, and metabolic effects of L-glutamine administered to humans. Initial studies in normal individuals evaluated the short-term response to oral loads of glutamine at doses of 0, 0.1, and 0.3 g/kg. A dose-related increase in blood glutamine occurred after oral loading and elevation of amino acids known to be end products of glutamine metabolism occurred (including alanine, citrulline, and arginine). No evidence of clinical toxicity or generation of toxic metabolites (ammonia and glutamate) was observed. Glutamine was infused intravenously in normal subjects over 4 hr at doses of 0.0125 and 0.025 g/kg/hr. In addition, glutamine was evaluated as a component of parenteral nutrition solutions (0.285 and 0.570 g/kg/day) administered for 5 days to normal subjects. Intravenous administration of glutamine was well tolerated without untoward clinical or biochemical effects. Subsequent studies in patients receiving glutamine-enriched parenteral nutrition for several weeks confirmed the clinical safety of this approach in a catabolic patient population. In addition, nitrogen retention appeared to be enhanced when glutamine was administered at a dose of 0.570 g/kg/day in a balanced nutritional solution providing adequate calories (145% of basal) and protein (1.5 g/kg/day). Nitrogen balance in patients receiving lower doses of glutamine (0.285 g/kg/day) was similar to that in patients receiving standard formulations. Further controlled clinical trials of the metabolic efficacy, tolerance, and dose response of glutamine in other patient groups are necessary to determine the appropriate use of glutamine enrichment of nutrient solutions.

Technetium-thallium scintiscanning for localization of parathyroid adenomas and hyperplasia. A reappraisal.

The dual tracer nuclear scintiscan using technetium and thallium to localize enlarged or ectopic parathyroid tissue has been reported to be highly accurate and efficacious. Fourteen previous series reporting results of the technique have been compiled from the literature and analyzed. This analysis has revealed a total of 317 surgically confirmed scan results with a low false-positive rate (17 of 317 scans), a sensitivity rate of 82 percent, and an overall accuracy rate of 78 percent. Forty-five patients from five Portland area hospitals have been retrospectively studied. They had a total of 49 preoperative scans. In our experience with the scan, a higher false-positive rate (4 of 45 scans), a sensitivity rate of 78 percent, and an overall accuracy rate of 73 percent were noted. The scan's effectiveness in acknowledged areas of difficulty in parathyroid surgery, such as patients with ectopic adenomas, hyperplastic glands, and those with previous neck explorations, has been analyzed. We conclude that the scan is a useful preoperative localization tool, especially in patients with ectopic adenomas or with persistent hypercalcemia after neck exploration. However, it is less accurate than initially reported in complex patients, and additional localization techniques are frequently required.

Hepatic abscesses as a complication of the sump syndrome: combined surgical and endoscopic therapy. Case report and review of the literature.

The "sump syndrome" is an unusual complication of side-to-side choledochoduodenostomy in which the portion of the common bile duct distal to the anastamosis acts as a sump and may collect bile, stones, food, and other debris. Partial or complete obstruction of the stoma and resultant bacterial proliferation may result and lead to recurrent cholangitis or pancreatitis. A single hepatic abscess as a complication of the sump syndrome has been reported only once. We have recently seen a patient presenting with multiple hepatic abscesses as a complication of the sump syndrome. This is the first report of endoscopic treatment of this syndrome associated with a hepatic abscess. The literature on the endoscopic approach to this problem will be reviewed.

Evaluation of injury mechanism as a criterion in trauma triage.

Triage of potentially injured patients to the appropriate trauma hospital was carried out using mechanism of injury as a triage criterion rather than physiologic changes (trauma score). Injury mechanism includes field evidence of high energy transfer, such as falls of more than 15 feet, automobile accidents with structural intrusion, extrication difficulties, passenger ejection, or death at the scene. Evaluation of triage decisions for a 3 month period in 631 patients showed an overtriage rate of 14 to 43 percent. Using the trauma score alone would have missed significant injuries in at least 8 to 36 percent of these patients using the injury severity score or clinical criteria. Methods of evaluation of overtriage and undertriage are presented, but accepted standards for these must be addressed in each trauma system. Injury mechanism as a primary trauma triage criterion is an acceptable means of identification of potential injury for transport to a trauma facility.

Gastrointestinal symptoms of marathon runners.

A survey of 707 participants in the 13th Annual Trail's End Marathon in Seaside, Oregon, showed a high incidence of gastrointestinal disturbances, predominantly of the lower tract, associated with long-distance running. The urge to defecate, both during and immediately after running, occurred in over a third of runners. Bowel movements (35%) and diarrhea (19%) were relatively common after running, and runners occasionally interrupted hard runs or races for bowel movements (18%) or diarrhea (10%). Lower gastrointestinal disturbances were more frequent in women than in men and in younger than in older runners. Awareness of the frequency and nature of gastrointestinal symptoms documented by this survey will assist physicians in evaluating abdominal complaints in runners.

Operation or observation for penetrating neck wounds? A retrospective analysis.

A review of 83 patients with penetrating neck wounds was performed to assess the relative merits of operation versus observation. Fifty patients (60 percent) underwent immediate surgery, 28 of whom (56 percent) had no significant neck injury. There were no deaths and only two complications (4 percent). Thirty-three patients (40 percent) were treated with initial observation, one of whom required subsequent surgery. In the latter group, there were also no deaths and two complications (6 percent). Length of hospital stay did not differ between patients with negative findings on exploration and those observed. When clinical signs as indications for surgery were present, management was more often correct than when signs were absent (82 and 52 percent, respectively), but the presence or absence of signs correctly predicted injury or lack of injury in over 80 percent of the patients. These data demonstrate the safety and efficacy of selective observation of patients with penetrating neck trauma, and confirm that clinical signs are a reliable indicator of significant injury.

Patterns of death, complication, and error in the management of motor vehicle accident victims: implications for a regional system of trauma care.

A nonautopsy, retrospective analysis of severe motor-vehicle accident trauma can provide valuable information in regard to volume of trauma and quality of care. In a 6-county region surrounding a large metropolitan area trauma care, as reviewed by this method, had deficiencies at all levels of delivery. Patients were taken to the nearest hospital. Hospitals then had not been classified or designated according to capability. Twenty-five per cent of the fatalities and 16% of all outcomes were considered inappropriate for the severity of injury incurred. A regional trauma system with categorization and designation of hospitals providing trauma care would have eliminated or improved these deficiencies, resulting in improved outcomes for a significant percentage of these patients.

Hyperparathyroidism and pregnancy.

Six pregnancies occurring in four mothers with hyperparathyroidism have been presented. Four of the pregnancies were completed without therapy; in two, parathyroidectomy was performed. The outcome of each of the pregnancies was satisfactory. The 49 cases previously reported are reviewed. This experience demonstrates that parathyroidectomy is indicated if the mother has symptomatic hypercalcemia, and it can be safely performed during the second trimester. Pregnant women with mild, asymptomatic hypercalcemia may be followed nonoperatively during pregnancy with satisfactory outcome to both the mother and fetus.

Clotting competence of intracavitary blood in trauma victims.

In order to assess more rationally the requirement for anticoagulation during intraoperative autotransfusion, the clotting competence of blood collected from the body cavities of 31 trauma victims entering our emergency department with indications for intraoperative transfusion was assessed. Blood was collected at thoracotomy or laparotomy prior to the institution of any anticoagulant measures and was assessed for clotting competence, the presence of fibrinogen, the presence of soluble fibrin monomere, and the appearance of fibrin degradation products. The prothrombin time, partial thromboplastin time, and thrombin time of this blood were markedly elevated; fibrinogen was absent; soluble fibrin monomer was absent; and fibrin degradation products were markedly elevated. Blood collected from body cavities is then incoagulable, and we suggest that in the autotransfusion of such a product the need for anticoagulation may be reduced.

Intraoperative choledochoscopy: an efficacious adjunct to common duct exploration in calculous biliary tract disease.

The authors review their experience with 59 consecutive patients undergoing common duct exploration for calculous biliary tract disease, 33 of whom underwent operative choledochoscopy. It is shown that choledochoscopy is not associated with an increase in the amount of time required to perform cholecystectomy and common duct exploration. It is similarly shown that there is no increase in the incidence of postoperative complications occurring in conjunction with the use of the choledochoscope. Because of the safety of the technique and the subjective satisfaction afforded by its use, the authors, now include choledochoscopy as a routine measure in common duct exploration.