Nonoperative salvage of computed tomography-diagnosed splenic injuries: utilization of angiography for triage and embolization for hemostasis.

OBJECTIVES: The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. METHODS: Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. RESULTS: Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). CONCLUSIONS: (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Perforation of the ileum secondary to Enterobius vermicularis report of a rare case.

An isolated ileal perforation is presented in a 12-yr-old patient. Microscopic examination revealed granulomatous inflammation due to Enterobius vermicularis (pinworm). This is only the third documented report of intestinal perforation involving pinworms. Although infestation with this parasite is generally considered to be relatively harmless, on rare occasions, it can be a significant cause of morbidity due to its potential ability to invade the tissues.

How reliable is a single measurement of urinary flow in the diagnosis of obstruction in benign prostatic hyperplasia?

Twenty-six elderly patients with obstructive symptomatology and an initial low peak urinary flow rate (< 15 ml/s) were observed for 6 to 12 months. Repeated assessments were made of flow rates and residual volumes. Within patients variation of the maximal urinary flow was significant; the standard deviation (SD) varied from 0.8 to 5.5 ml/s. The SD varied with the mean peak flow rates and this suggests that the precision of a single determination of a patient's peak flow is inversely related to the peak flow itself. In all, 333 determinations of peak flow were obtained. Only 80% were below 2 SD of the mean Siroky nomogram. Multiple determinations were used to estimate the sensitivity rate for each patient, i.e. the proportion of peak flows that were less than 2 SD below the mean of Siroky's nomogram. The average sensitivity for all of the flow values was 0.813 when applied to voided volumes and increased only slightly to 0.838 when applied to total bladder volume. Given a prevalence of 0.70 of obstruction ascribed to benign prostatic hyperplasia (BPH) among elderly men, the positive predictive value of an abnormally low peak flow was 0.97. A single low peak flow based on assessment of voided volume may serve as an almost sure indication of obstruction. If a patient has a single normal peak flow rate, he still has a 0.31 probability of having evidence of obstruction in his following uroflow determinations. Using total bladder volume does not make a difference in most patients and is not worth the effort and discomfort. The only patients who require accurate residual measurements are those with a normal uroflow but clear-cut obstructive symptomatology or with borderline peak flow. The results of this study are relevant to everyday clinical practice and to the evaluation of studies on alternatives to surgery in BPH.

Validity and Reliability of the LIDO Active Isokinetic System.

No grant monies were used for this research. When evaluating a strength testing method, reliability rather than validity, the most critical component, is most frequently addressed. The purpose of this study was to assess the validity and reliability of the LIDO Active system in the isokinetic mode. Velocity and torque were continuously monitored while torques of 10.4, 25.6, 30.6, and 89.6 ft-lb were applied to the actuator with the speed set at 5 degrees /sec. This was done through a 200 degrees arc of motion concentrically and eccentrically. The procedure was repeated one week later to determine reliability. Analysis of variance revealed no significant variance associated with the date of measurement regarding angular velocity. The maximum deviation of angular velocity from the selected speed was 0.02 degrees /sec. Pearson's r values for measured torque averaged r = 1.00 using paired data from the two test dates. The mean correlation coefficient relating observed to expected torques was Rho = 0.98. These results demonstrate that the LIDO Active system is both valid and reliable within the torque and velocity limitations described. J Orthop Sports Phys Ther 1992;15(1):32-36.

Inhibition of serotonergic dorsal raphe neurons by systemic and iontophoretic administration of buspirone, a non-benzodiazepine anxiolytic drug.

Extracellular single-unit recordings were made from serotonergic dorsal raphe neurons in chloral hydrate anesthetized male Sprague-Dawley rats. Buspirone, a clinically effective non-benzodiazepine anxiolytic drug, caused inhibition of firing of these neurons when given by intravenous (ED50 = 0.011 mg/kg, i.v.), intraperitoneal (ED50 = 0.088 mg/kg, i.p.), and intragastric (effective dose = 1.0-20.0 mg/kg, i.g.) injection. Buspirone also inhibited these cells when it was administered to the outside of recorded neurons by microiontophoresis (effective currents = 2-15 nA). Iontophoretically applied buspirone did not potentiate nor block the effects of iontophoretically applied GABA. Systemic administration of two putative buspirone metabolites (1,2-pyrimidinyl piperazine and 5-hydroxy buspirone) in relatively high doses had a weak effect and no effect, respectively, on dorsal raphe neuronal firing. It is concluded that buspirone potently and directly inhibits the firing of serotonergic dorsal raphe neurons in the rat. Since buspirone inhibits the firing of serotonergic dorsal raphe neurons and binds to 5-HT1A receptors, the present study supports the notion that central serotonergic systems may be involved in the therapeutic effects of anxiolytic drugs.

Employment and stress.

Tension and anxiety are part of the adventure of work. Management and labor are working closely to make the workplace safe and the job rewarding, but growing numbers of bureaucrats and societies cannot replace the family physician. Bureaucrats and regulations are ever-changing. The worker must know how to use emotions to advantage, and remain on the job from teens to retirement. Pain and stress need not produce the diseases of stress. `Tough love' techniques, organized by labor-management teams, confining their interests to the individual's problems, will flourish and cut out the family physician unless he works closely with these successes. Family physicians are encouraged to join Boards of Trade and Safety Councils to gain experience in prevention.