Use of imaging in trauma decision-making.

Damage Control Radiology describes the process where imaging aids the decision making process in a trauma setting and is an important part of Damage Control Surgery and Resuscitation. This article outlines how radiology fits in to the primary and secondary surveys and discusses the role of imaging modalities such as ultrasound and CT. The importance of deployed radiology to aid rapid diagnosis and decision making is described.

Double-blind trials of azelastine nasal spray monotherapy versus combination therapy with loratadine tablets and beclomethasone nasal spray in patients with seasonal allergic rhinitis. Rhinitis Study Groups.

BACKGROUND: Azelastine hydrochloride is an H1-receptor antagonist with antiinflammatory properties that is available in the US as Astelin Nasal Spray for the treatment of seasonal allergic rhinitis. The symptoms of seasonal allergic rhinitis can initially be treated with monotherapy using either an antihistamine or an intranasal corticosteroid. Patients whose symptoms do not respond adequately are often prescribed a combination of both an antihistamine and an intranasal corticosteroid. OBJECTIVE: Three multicenter, randomized, double-blind studies were conducted to determine whether patients with moderate-to-severe symptoms of seasonal allergic rhinitis who had responded inadequately to monotherapy with either an oral antihistamine or an intranasal corticosteroid, and who were candidates for combination therapy with both an oral antihistamine and an intranasal corticosteroid, could be effectively treated with azelastine nasal spray monotherapy. METHODS: Following a 1- to 2-week washout period, patients were randomized to 7 days of double-blind treatment with either azelastine nasal spray (2 sprays per nostril bid, 1.1 mg/day) monotherapy or combination therapy with oral loratadine (Claritin, one 10-mg tablet/day) plus intranasal beclomethasone dipropionate monohydrate (Beconase AQ, 2 sprays per nostril bid, 336 microg/day). Efficacy was determined at the end of the study by both a physician assessment of the need for additional anti-rhinitis medication and a patient global evaluation of therapeutic effectiveness. The three studies were conducted at 71 investigational sites during the 1998 spring allergy season. Three separate studies were conducted to verify the reproducibility of the new study design. RESULTS: In all three studies a total of 1,070 patients were randomized to double-blind treatment. There were no statistically significant differences in the percentage of patients treated with azelastine nasal spray versus patients treated with a combination of loratadine tablets and beclomethasone nasal spray who did not require additional anti-rhinitis medication (32% to 45% and 39% to 46%, respectively). The patient global evaluation indicated that 77% to 84% of the patients treated with azelastine nasal spray had symptomatic improvement and 85% to 90% of the patients treated with loratadine tablets and beclomethasone nasal spray had symptomatic improvement. The most commonly reported adverse experience with azelastine nasal spray was a transient aftertaste (8%), while the most commonly reported adverse experience with loratadine tablets and beclomethasone nasal spray in combination was headache (6%). CONCLUSIONS: Based on the percentage of patients not requiring additional antirhinitis medication and the patient assessment of efficacy, azelastine nasal spray monotherapy was as effective as the combination of oral loratadine plus intranasal beclomethasone in treating moderate-to-severe symptoms of seasonal allergic rhinitis.

Impairment of the asialoglycoprotein receptor by ethanol oxidation.

It is well established that ethanol exposure impairs the process of receptor-mediated endocytosis in hepatic cells, although the molecular mechanism(s) and the physiological consequence(s) of this impairment are unclear. Because addressing these mechanistic questions is difficult in vivo, we have developed a recombinant cell line of hepatic origin capable of metabolizing ethanol. In this study, we have used these recombinant cells, designated HAD cells, to investigate the ethanol-induced impairment to the receptor-mediated endocytosis of the hepatic asialoglycoprotein receptor. Comparing the binding of the ligand asialoorosomucoid in both the parental Hep G2 cells and the recombinant HAD cells, maintained in the presence and absence of ethanol, revealed decreased ligand binding in the HAD cells. This impairment was accentuated by prolonging the ethanol exposure, reaching approximately 40% in both surface and total receptor populations by 7 days. Addition of the alcohol dehydrogenase inhibitor pyrazole to the ethanol-containing medium abolished this impairment, indicating that the decreased binding was a result of the alcohol dehydrogenase-mediated oxidation of ethanol. Furthermore, using antibody specific to the asialoglycoprotein receptor, it was demonstrated that the ethanol-induced impairment in ligand binding was a consequence of decreased ligand binding and not a result of diminished receptor numbers. These results indicated that ethanol oxidation was required for the ethanol-induced impairment in ligand binding, and that the reduced ligand binding was a result of a decrease in the ability of the ligand to bind to the receptor.

Giant adult malignant sacrococcygeal teratoma. Successful treatment by combined abdominosacral resection.

This report describes the successful removal of the largest adult sacrococcygeal teratoma (18.75 kg) the authors could find on record. The patient was 58 years of age. The tumor had been present at birth and had been biopsied at the time of her cesarean section 34 years earlier without further treatment. Special planning was necessary for moving and positioning the patient for operation to prevent injury due to the size and weight of the tumor. A combined abdominosacral resection with preliminary ligation of the internal iliac arteries and a diversionary colostomy were performed without difficulty or undue blood loss. The defect was closed primarily and drained. The tumor proved to be malignant on pathologic examination.

Practice model for choledochoscopy.

Proficiency and expertise with any highly specialized technique demands practice, particularly before performance on the human being. In order to teach the technique of choledochoscopy to residents and surgeons interested in continuing medical education, we designed a canine model for instruction and practice in which a segment of the inferior vena cava, which greatly resembles the size, consistency, and branching pattern of the human common bile duct, is used. This model has been utilized successfully for this purpose for several years. Model preparation is simple and effective and is applicable to any surgical research laboratory.

Smoking and cough syncope: follow-up in 45 cases.

A follow-up review of 45 patients with cough syncope was performed to ascertain the effect of therapy in relieving symptoms. These patients constituted 2.5% of all Mayo Clinic patients evaluated over a 3-year period for syncope. Cough syncope patients were predominantly male (43:2), the average weight was 96.1 kg, and the average age was 53.2 years. Eighty-two percent were current or ex-smokers at the time of the initial evaluation and 86% of those having pulmonary function tests demonstrated findings consistent with obstructive lung disease. Treatment was determined by their primary physician and, in general, was aimed at decreasing the cough. Cough-related symptoms were abolished or improved in 97% of patients. Smoking cessation was closely associated with decreased symptoms. Although felt by both patient and physician to be a benign disorder, cough syncope can result in severe bodily injury. Patients with a vigorous cough, especially smokers, should be questioned thoroughly about cough syncope. Treatment of cough is effective in relieving symptoms.

Idiopathic retroperitoneal fibrosis. A sometime surgical problem.

The study was undertaken to focus attention on idiopathic retroperitoneal fibrosis, which may confront any surgeon operating in the abdomen or retroperitoneal area. Eleven patients, six men and five women varying in age from 35 to 76 years, were treated from 1969 to 1983. Two patients gave a history of methysergide and one gave a history of ergotamine ingestion. Two patients had associated aortic aneurysms and two had renal artery stenosis. Symptoms were related to entrapment of retroperitoneal structures, primarily the ureter, vena cava, gonadal veins, the aorta and its branches. Abdominal and costovertebral angle pain, testicular pain and swelling, and renovascular hypertension were the most common symptoms. The most common differential diagnostic problem was retroperitoneal tumor. Intravenous or retrograde pyelography were suggestive of the diagnosis in five patients, ultrasonography in two, and computerized axial tomography in another. Treatment consisted of ureterolysis and intraperitoneal transplantation or omental wrapping of the ureter in five, nephrostomy in two, renal-iliac arterial bypass graft in two, and renal autotransplantation in one. One patient was treated conservatively. Good results were achieved in eight, fair results in two, and one patient died postoperatively. Idiopathic retroperitoneal fibrosis should be kept in mind diagnostically in patients with unexplained abdominal pain and/or retroperitoneal lesions, and the surgeon prepared to employ appropriate operative measures for relief when it is encountered.

Review of colostomy in a community hospital.

This review of 193 colostomies was carried out to assess the procedure in our institution from standpoints of indications, technique, complications, and results. The study revealed colostomy was most commonly performed for obstruction, abdominoperineal resection, and infection or fistula associated with carcinoma, diverticulitis, and trauma in that order of frequency. The mortality rate was 2.6 per cent. Complications were observed in 22 per cent with 11 per cent being directly related to the colostomies themselves. Colostomy closure was accompanied by a 17 per cent complication rate and 1.5 per cent mortality. These overall results compare well with those of other investigators. Higher complication rates were found for colostomy for diverticulitis vs carcinoma; abscess or fistula vs obstruction or abdominoperineal resection; and for colostomy in the operative incision vs separate incision. The lowest rate was for colostomy for trauma. No significant difference in complication rate between transverse and sigmoid colostomies and colostomy closure by resection and anastomosis vs simple closure were noted.

Studies on Alternaria allergens. IV. Biologic activity of a purified Alternaria fraction (Alt-I).

We have previously isolated a purified Alternaria fraction (Alt-I) by means of immunochemical (RAST) assays to document allergenicity. In the present study we investigated the allergenicity of Alt-I by in vivo and in vitro biologic tests in a selected group of 16 nonimmunized Alternaria-sensitive patients, all of whom had positive skin tests to crude Alternaria extract; a control group of eight nonallergic individuals was also studied. Intradermal skin-test titration endpoints to Alt-I ranged from 60 pg/ml to 60 ng/ml in the Alternaria-sensitive patients. Alt-I induced greater than 30% in vitro leukocyte histamine in all Alternaria-sensitive patients at submicrogram concentrations. Alt-I did not produce positive skin tests or induce significant leukocyte histamine release in nonallergic individuals. In 14 of 16 Alternaria-sensitive patients bronchoprovocation testing produced greater than 20% fall in forced expiratory volume in one second at Alt-I test concentrations of 0.6 to 60 micrograms/ml. In a separate prospective study of 100 unselected individuals, concordant skin-test reactions were noted to crude Alternaria extract and Alt-I in 96 instances. These results confirm that the Alt-I fraction is a biologically active, major allergenic component of crude Alternaria extract.

Splenic pseudocysts: report of two cases and review of the literature.

Two cases of pseudocyst of the spleen are discussed. The first case presented preoperatively as a pelvic mass, thought to be ovarian in origin. No history of trauma was present. The second case, also without trauma, was definitively diagnosed by computerized axial tomography. This patient was hypertensive due to compression of the renal artery by the splenic cyst. A review of the literature is given. The causes of splenic cysts, clinical manifestations, diagnosis, treatment, and complications are discussed.

The small bowel tumor problem: an assessment based on a 20 year experience with 116 cases.

Documented rarity, diagnostic difficulty and poor results stimulated this study of 79 malignant and 37 benign small bowel tumors in order to emphasize these lesions, determine their symptomatology and improve diagnosis and results, particularly in the malignant group. Chief symptoms were recurrent abdominal pain and tenderness, signs of obstruction and gastrointestinal bleeding. Fourteen cases were asymptomatic. The mean symptom-diagnosis interval was 6.6 months. Roentgenographic contrast studies were helpful in diagnosing 33 of 43 patients, with false negatives in 10. Laboratory studies were usually not helpful. Metastases were present at the time of surgery in approximately 58%. In the malignant group curative procedures were performed in 36 and palliative in 43, with an operative mortality of 10%. Five and 10 year survival rates were respectively 21/51 (41.2%) and 8/38 (21.2%) for malignancies. Individual 5 and 10 year survival rates were respectively as follows: carcinoid 11/15, 4/8; undifferentiated carcinoma 3/5, 1/3; lymphoma 3/11, 1/9; leiomyosarcoma 2/7, 1/6 and adenocarcinoma 2/13, 1/12. In the benign group results were excellent, except for one death from pulmonary embolism. The study suggests that if results with malignant small bowel tumors are to be improved, prompt diagnostic study and early consideration of laparotomy in patients with suggestive symptoms is mandatory.