Mesenteric ischemia: an unusual presentation of traumatic intrahepatic arterioportal fistula.

Traumatic hepatic arterioportal fistulae (APF) are described infrequently as sequelae of hepatic trauma. These anomalies are usually associated with blunt hepatic trauma or iatrogenic injury. The majority of APF present within weeks to months of injury with gastrointestinal hemorrhage, hemobilia, abdominal pain, and diarrhea. When presenting remotely APFs are associated with portal hypertension, heart failure, gastrointestinal hemorrhage, ascites, and splenomegaly. We report an unusual case of mesenteric ischemia due to an APF that resulted from a penetrating liver injury 20 years before presentation. Successful treatment of the APF was achieved by intravascular catheter occlusion resulting in resolution of symptoms.

Polymerase chain reaction for the detection of bacteremia.

Analysis of blood by polymerase chain reaction (PCR) is a more rapid and sensitive method to detect bacteremia than blood culture. The PCR was performed on blood obtained from patients during blood culture draws and on blood from normal volunteers. Eighty-seven patients provided 125 blood samples for blood culture comparison with PCR. Specific PCR primers for Staphylococcus aureus and Escherichia coli that targeted conserved regions common to gram-positive and gram-negative bacteria were used. Selective stringency conditions identified other gram-positive and gram-negative bacteria. The blood culture agreed with the PCR in 93 of the 125 patient specimens (74%). In 29 of these specimens the PCR was positive yet the blood culture was negative. When clinical information was included with positive blood culture to define sepsis in these patients and their specimens were added to the positive blood cultures the statistical accuracy of PCR was 93 per cent. Only three of the 78 specimens with negative PCR had positive blood cultures. The PCR was negative in all but one of the 50 volunteers. PCR is more sensitive than blood culture, and it can quickly rule out bacteremia.

The synthesis of water soluble prodrugs analogs of echinocandin B.

A facile synthesis of phosphonate and phosphate ester prodrugs on the phenolic hydroxy of two echinocandin semisynthetic derivatives is reported. The water solubility and stability profiles of the ECB compounds varied with the choice of alkyl group used. In some cases, the ester prodrugs with small aliphatic side chains retained antifungal activity while enhancing water solubility.

Gamma-probe-guided resection of the sentinel lymph node in breast cancer.

Regional lymph node metastases in patients with breast cancer have fundamental staging, prognostic, and treatment implications. Classically, axillary lymph node sampling requires a dissection under general anesthesia. The concept that a primary, or sentinel, lymph node is the first node to receive drainage from a tumor has been established in patients with malignant melanomas using radiolabeled tracers and vital dyes. This study proposed two hypotheses: (1) radiolabeled sentinel lymph nodes can be identified in most patients with breast cancer, and (2) radiolabeled sentinel lymph node biopsy accurately predicts axillary lymph node metastases in those patients. Patients with operable breast cancer had Tc-99 sulphur colloid injected around their breast tumors 1-6 hours preoperatively. Patients underwent gamma probe identification of sentinel lymph nodes that were biopsied. All patients underwent axillary lymphadenectomy in conjunction with lumpectomy or mastectomy. Fifty female patients ages 26 to 90 years underwent lumpectomies with axillary dissections (40 patients) or modified radical mastectomies (10 patients). Sentinel lymph nodes were identified in 42 of 50 patients (84%). Eight patients (16%) had metastases to the axillary lymph nodes. In 7 patients, sentinel lymph nodes correctly predicted the status of the axillary nodes. There was one false negative result. A total of 550 lymph nodes were resected for an average of 11.2 nodes per patient. Sentinel lymph node scintigraphy and biopsy accurately predicted the axillary lymph node status in 41 of 42 patients (98%). Scintigraphy can identify sentinel lymph nodes in a large majority of patients. Sentinel lymph node biopsy is an accurate predictor of axillary lymphatic metastases.

Workers' compensation past, present, and future: a model for reform.

The author describes the volatile and highly complex nature of workers' compensation programs and details the successful evolution of Kentucky's system.

Photoaffinity analog of the semisynthetic echinocandin LY303366: identification of echinocandin targets in Candida albicans.

The echinocandins are a family of cyclic lipopeptides with potent antifungal activity. These compounds inhibit the synthesis of BETA-1,3-glucan in fungi. The new semisynthetic echinocandin LY303366 was derivatized to produce a photoactivatable cross-linking echinocandin analog with antifungal activity. This analog was radioiodinated and used as a probe in microsomal membrane preparations of Candida albicans which contain glucan synthase activity. The photoaffinity probe identified two major proteins of 40 and 18 kDa in both membrane preparations. Labeling of these proteins was specific in that it required irradiation with UV light and was effectively competed against with unlabeled echinocandin analogs. In addition, the abilities of echinocandin analogs to compete with the photoaffinity probe correlated to their relative antifungal potencies and glucan synthase inhibition. The 40-kDa protein was isolated, and partial sequences were obtained from internal peptide fragments of the protein. Analysis of the sequences of these internal peptides of the 40-kDa protein revealed that it was a new protein not previously described as being involved in glucan synthesis or the mode of action of echinocandins.

Reliability and role of plain film radiography and CT in the diagnosis of small-bowel obstruction.

OBJECTIVE: We compare the reliability and define the role of plain film radiography and CT in the assessment of various severities of small-bowel obstruction. MATERIALS AND METHODS: A blinded retrospective analysis was done on 78 patients who underwent plain abdominal radiography, CT, and enteroclysis to assess for suspected small-bowel obstruction. The findings at enteroclysis and the clinical outcomes were used as standards of reference. RESULTS: The sensitivity of plain film radiography for revealing small-bowel obstruction was 69% (44/64), and its specificity was 57% (8/14). Overall accuracy of plain film radiography was 67% (52/78). The sensitivity and specificity of CT were 64% (41/64) and 79% (11/ 14), respectively. Overall accuracy of CT was 67% (52/78). When obstructions were classified as low- and high-grade partial obstruction, plain film radiography and CT had sensitivities of 86% (24/28) and 82% (23/28), respectively, for high-grade obstruction and 56% (20/36) and 50% (18/36), respectively, for low-grade obstruction. CT revealed the cause of the small-bowel obstruction in 95% (39/41) of those patients in who CT correctly showed the obstruction. CONCLUSION: Plain film radiography and CT had similar overall accuracies in showing small-bowel obstruction of various severities. Plain film radiography should remain the initial method of imaging patients with suspected small-bowel obstruction. The ability of CT to show the cause of small-bowel obstruction makes CT an important additional diagnostic tool when specific management issues must be addressed.

Semisynthetic chemical modification of the antifungal lipopeptide echinocandin B (ECB): structure-activity studies of the lipophilic and geometric parameters of polyarylated acyl analogs of ECB.

Echinocandin B (ECB) is a lipopeptide composed of a complex cyclic peptide acylated at the N-terminus by linoleic acid. Enzymatic deacylation of ECB provided the peptide "nucleus" as a biologically inactive substrate from which novel ECB analogs were generated by chemical reacylation at the N-terminus. Varying the acyl group revealed that the structure and physical properties of the side chain, particularly its geometry and lipophilicity, played a pivotal role in determining the antifungal potency properties of the analog. Using CLOGP values to describe and compare the lipophilicities of the side chain fragments, it was shown that values of > 3.5 were required for expression of antifungal activity. Secondly, a linearly rigid geometry of the side chain was the most effective shape in enhancing the antifungal potency. Using these parameters as a guide, a variety of novel ECB analogs were synthesized which included arylacyl groups that incorporated biphenyl, terphenyl, tetraphenyl, and arylethynyl groups. Generally the glucan synthase inhibition by these analogs correlated well with in vitro and in vivo activities and was likewise influenced by the structure of the side chain. These structural variations resulted in enhancement of antifungal activity in both in vitro and in vivo assays. Some of these analogs, including LY303366 (14a), were effective by the oral route of administration.

Intravenous cholangiography and the management of choledocholithiasis prior to laparoscopic cholecystectomy.

The preoperative diagnosis of choledocholithiasis simplifies the laparoscopic management of biliary tract disease. Slow infusion intravenous cholangiography (SI-IVC) may be an accurate and cost-effective screening test for choledocholithiasis, and it is safer than traditional intravenous cholangiography. Forty-nine patients underwent SI-IVCs for suspected choledocholithiasis. These patients subsequently had endoscopic retrograde cholangiograms (ERC) or intraoperative cholangiograms (IOC) during laparoscopic cholecystectomies. Sixteen SI-IVCs demonstrated choledocholithiasis; 13 were confirmed by ERCs or by IOCs. The remaining 33 patients with negative SI-IVCs had negative ERCs or IOCs. The sensitivity, specificity, and accuracy of detecting choledocholithiasis by SI-IVC were 100%, 92%, and 94%. Only one patient had a mild reaction to the contrast agent. In our hospital the cost of an SI-IVC is $324, the cost of an IOC is $393 (including operating room and anesthesia costs), and the cost of an ERC is $1,085. SI-IVC is an accurate method of preoperative screening for choledocholithiasis. It is safe and cost-effective.

Nutrition considerations in the management of ventilator-dependent patients.

Nutrition support of the patient with ventilatory failure is an important adjunct to recovery. Malnutrition and respiratory failure are frequently interrelated. Ventilator dependence occurs when the patient cannot independently sustain oxygenation, carbon dioxide removal, or acid-base balance. Nutrition assessment, determination of energy requirements, and provision of nutrient solutions utilizing the most appropriate route of administration should be initiated early in the ventilator-dependent patient's hospital course. Careful assessment will identify patients needing repletion along with maintenance calories, as well as special macronutrient and micronutrient needs. The nutrient prescription is designed to provide carbohydrate, protein, and fat in amounts for optimal substrate utilization. Body fluid balance, micronutrient needs, electrolyte homeostasis, and acid-base balance affect respiratory muscle function and must also be considered in developing the nutrition regimen. Properly constructed enteral or parenteral nutrition plans begun early offer the best support for ventilator-dependent patients.

Equations for the estimation of energy expenditures in patients with burns with special reference to ventilatory status.

There are advantages to the use of easily assessed variables for the prediction of energy expenditures of patients with burns. The purpose of this study was to determine whether height, age, sex, weight, ventilatory status, and diagnosis could be correlated with measured energy expenditures of hospitalized patients. With the use of data from 200 patients, stepwise, multivariate regression analysis derived the following equations: EEE(v) = 1925 - 10(A) + 5(W) + 281(S) + 292(T) + 851(B) (R2 = 0.43); EEE(s) = 629 - 11(A) + 25(W) - 609(O) (R2 = 0.50); where EEE = estimated energy expenditure (kcal/day), v = ventilatory dependency, s = spontaneously breathing, A = age (yr), W = body weight (kg), S = sex (male = 1, female = 0), diagnosis of T = trauma, B = burn, O = obesity present = 1, absent = 0). The equations were tested on 100 patients. Measured energy expenditures were not significantly different from calculated EEE(s) or EEE(v) (paired t test, p greater than 0.25). Energy expenditures can be accurately estimated in a variety of patients, including those with major burns with the use of easily attained information.

Intraarterial drug abuse: new treatment options.

Accidental, intraarterial injections of abused substances continue to be difficult management problems because of severe vascular complications. Vasospasm probably plays an important role in the pathophysiology of this injury, in addition to the more accepted roles of thrombosis and endarteritis. Three patients with severe, upper extremity ischemia after intraarterial injection of heroin, methamphetamine, and meperidine were treated with intraarterial tolazoline and streptokinase, along with intravenous heparin. All three patients had improved perfusion, assessed both clinically and by angiography. The responses to treatment in these patients demonstrated the roles of vasospasm and thrombosis in the origin of this injury and the therapeutic benefits of appropriately administered vasodilators and thrombolytic agents.

Actual or ideal body weight: which should be used to predict energy expenditure?

Assessing energy expenditure in obese people is problematic. Two questions arise: Can we predict energy expenditure accurately? Does actual or ideal body weight better predict energy expenditure? Two groups of obese subjects--65 hospitalized adults and 65 nonhospitalized adults--were studied. Both groups had actual body weights that were at least 30% above ideal body weights. For both groups, energy expenditure was measured by indirect calorimetry and calculated using the variables sex, actual and ideal body weight, age, and ventilatory status. All but three patients were receiving nutrition support by the enteral route (either orally or by tube) or by the parenteral route (with hypertonic dextrose, amino acid, and fat). The nonhospitalized subjects fasted during measurements of energy expenditure. Regression equations were derived to predict energy expenditure. Actual body weight better predicted energy expenditure than did ideal body weight. We conclude that actual weight should be used to predict energy expenditure in obese individuals.

Postoperative nutritional support of patients with abdominal trauma.

The response to major trauma is characterized by a significant erosion of the body cell mass. Intensive nutritional support can decrease morbidity and mortality. Preservation and restoration of the body cell mass involves amino acid synthesis into protein, and this process requires nutrient energy. Newer methods of assessing energy expenditure have revised traditional concepts about energy requirements following trauma. The use of fat to meet some of the caloric requirements may obviate problems with ventilatory distress, glucose intolerance, and hepatic steatosis that occur with glucose-based nutritional regimens. Selection of the delivery method for intensive nutritional support should consider gastrointestinal integrity, physiologic tolerance, and cost. Enteral nutrition is superior to parenteral nutrition in maintaining gastrointestinal mucosal integrity, hormonal balance, and nutrient utilization. Furthermore, it is safer, more convenient, and more economical than parenteral nutrition.

Successful treatment of early, postoperative, necrotizing infection of the abdominal wall.

Unique treatment of a necrotizing infection of the abdominal wall, using a temporary closure with polyvinyl, led to survival in a patient with a stab wound, who developed extensive abdominal myofascial necrosis. A large abdominal wall defect was repaired later with polypropylene mesh and a split-thickness autograft.