Gunshot wounds below the popliteal fossa: a contemporary review.

The management of extremity injuries above the knee has been well described, but the evaluation and treatment guidelines for penetrating injuries below the popliteal crease has received less attention. A 6-year retrospective review of 100 patients who sustained isolated below-knee gunshot wounds. Patients with proximal extremity, torso, or head wounds were excluded from review so that we could focus on principles of managing below-knee wounds. All patients were evaluated with complete physical examination, ankle-brachial index, and plain X-rays. One patient presented with hemodynamic instability. Twenty-four patients underwent arteriography based on physical examination, an ankle-brachial index less than 0.9, or both. Twenty-two vascular injuries were identified in 19 patients, and an additional injury was found in a patient who went directly to surgery for pulsatile bleeding. Six of these 22 vascular injuries required treatment for bleeding or arteriovenous fistula. Treatment was by embolization in 5 and surgical ligation in 1. Thirteen patients had compartment syndromes. Thirty-five patients had fractures, and ten (29%) of these had an associated vascular injury. Four patients had peroneal nerve injuries, and three of these had long term disability. No limb loss or death occurred. We conclude that patients with low-velocity below-knee gunshot wounds sustain fractures, vascular injuries, compartment syndromes, and nerve injuries, in decreasing order of frequency. Arteriography and embolization may be useful to control bleeding; vascular reconstruction was unnecessary in our experience, and limb loss did not occur.

Risk of major hemorrhage for outpatients treated with warfarin.

OBJECTIVE: To determine the incidence of major hemorrhage among outpatients started on warfarin therapy after the recommendation in 1986 for reduced-intensity anticoagulation therapy was made, and to identify baseline patient characteristics that predict those patients who will have a major hemorrhage. DESIGN: Retrospective cohort study. SETTING: A university-affiliated Veterans Affairs Medical Center. PATIENTS: Five hundred seventy-nine patients who were discharged from the hospital after being started on warfarin therapy. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was major hemorrhage. In our cohort of 579 patients, there were 40 first-time major hemorrhages with only one fatal bleed. The cumulative incidence was 7% at 1 year. The average monthly incidence of major hemorrhage was 0.82% during the first 3 months of treatment and decreased to 0.36% thereafter. Three independent predictors of major hemorrhage were identified: a history of alcohol abuse, chronic renal insufficiency, and a previous gastrointestinal bleed. Age, comorbidities, medications known to influence prothrombin levels, and baseline laboratory values were not associated with major hemorrhage. CONCLUSIONS: The incidence of major hemorrhage in this population of outpatients treated with warfarin was lower than previous estimates of major hemorrhage measured before the recommendation for reduced-intensity anticoagulation therapy was made, but still higher than estimates reported from clinical trials. Alcohol abuse, chronic renal insufficiency, and a previous gastrointestinal bleed were associated with increased risk of major hemorrhage.

The high risk heart donor: potential pitfalls.

BACKGROUND: The use of potentially infected donor hearts has been advocated to extend the supply of available hearts for transplantation. METHODS: To determine whether bacterial transmission from donor to recipient can occur with heart transplantation, we reviewed our experience with the 347 patients who received 360 heart transplants in the Utah Transplant Affiliated Hospitals from 1988 to 1993. RESULTS: During this time, nineteen donors had positive blood cultures before harvest. Sixteen donors had gram-positive bacteremia: Staphylococcus epidermidis (n = 9), Staphylococcus aureus (n = 5), streptococcus (n = 2). Two donors had gram-negative bacteremia: serratia (n = 1) and acinetobacter (n = 1). One donor had blood cultures positive for both Escherichia coli and streptococcus. Infectious complications occurred in two of three recipients who received a heart from a donor with gram-negative bacteremia: Escherichia coli endocarditis, mediastinitis, sepsis and death in one, and serratia sepsis and mediastinitis in another. In each case the organisms and sensitivities were identical between donor and recipient. No infectious complications related to the donor heart occurred among the 16 recipients who received hearts from donors with gram-positive bacteremia. CONCLUSIONS: (1) Bacterial transmission from donor heart to recipient can occur, (2) bacterial transmission appears to be more common with gram-negative organisms, and (3) infection of the recipient with a gram-negative organism from the donor heart is associated with significant morbidity and mortality.

Effects of sentence context on recognition of words through lipreading by deaf children.

Twenty monosyllabic nouns (10 animate, 10 inanimate) were presented in isolation and in three different positions in sentences to 15 profoundly deaf children to determine the effect of context on word intelligibility through lipreading. Isolated words were more intelligible (80%) than were words in sentences (46%). Animate nouns were more intelligible (70%) than inanimate nouns (33%) when used in initial position (as subjects) in sentences. Teacher ratings of children's "general lipreading ability" were correlated more highly with their recognition of words in the test sentences (r = 0.93) than with their recognition of words presented in isolation (r = 0.53). The results indicate that teachers of deaf children could enhance the intelligibility of important words by isolating them from sentences. The results also suggest that some speech-perception difficulties of deaf children could be diagnosed through lipreading tests which are scored on the basis of correctness of "key words" in sentences.