Spatial and temporal variation in lead levels related to body condition in the Mississippi Valley population of Canada geese.

Concern over lead poisoning led to progressive prohibition of toxic shot to harvest waterfowl in the 1980's. Nevertheless, waterfowl remain susceptible to ingestion of lead shot because illegal use continues and spent shot persists in soil and wetland substrates. While mortality due to lead toxicosis has subsided, sublethal effects may still affect survival and reproduction. We measured liver lead levels and body condition in 732 Canada geese (Branta canadensis interior) during July 1984 to April 1989 in southern Illinois (USA), east-central Wisconsin (USA), and northern Ontario (Canada). Although we sampled only individuals that were visibly healthy, 55 of 732 (7.5%) geese had elevated liver lead levels (> 2 ppm). Lead levels of 46 (6.3%) geese indicated subclinical poisoning (2-6 ppm) and 9 (1.2%) geese had lead levels indicative of clinical poisoning (> 6 ppm). A greater proportion of juveniles (14.3%) had elevated lead levels than did adults (6.0%), but there was no difference between genders. Lead levels were highest in autumn and winter in southern Illinois, but were low during nesting and summer, despite legal use of lead shot in northern Ontario during our study. Lead poisoning (> or = 5% of the population) was still evident during all seasons in juveniles, and during autumn and winter in adults, 5 to 10 yr after toxic shot was banned from areas where we collected geese during migration and winter. Elevated lead levels did not affect total body mass, lipid reserves, or mineral levels of geese we collected. Protein levels also were unaffected below 10 ppm, but there was evidence of decline at higher concentrations. Thus, it seems unlikely that lead exposure currently affects survival or reproduction of Mississippi Valley Population (MVP) geese via body condition, although other sublethal effects cannot be discounted.

Ophthalmic thermal injuries.

Reflex lid closure often protects the eyes during facial burns. Although corneal burns are uncommon, other ophthalmic injuries occur more frequently. Ophthalmic burns are usually associated with marked facial damage and possible inhalation injury. Failure to recognize and appropriately treat ophthalmic burns can lead to catastrophic sequelae. We performed a 2-year survey of all facial burns in our burn unit. Forty-four patients with thermal facial burns were identified. Sixteen patients had ophthalmic injuries. Corneal injury was detected in 13 per cent (2/16). Intubation was required in 43.75 per cent (7/16) of patients with ophthalmic injuries. Mortality was 25 per cent (4/16). We conclude that patients with facial burns severe enough to cause ophthalmic injuries may be associated with other lethal injuries, and a high index of suspicion should be maintained until all lethal injuries are ruled out. All ophthalmic injuries should be evaluated by an ophthalmologist.

Giant leiomyoma of the small intestine with free perforation into the peritoneal cavity.

Leiomyomas involving the small bowel are rare benign tumors comprising 0.2% to 1.8% of all gastrointestinal tumors. We have presented a case with the rare complication of a free perforation between the tumor and the peritoneal cavity, causing an acute abdomen.

A method for rapid intracompartmental pressure measurement.

A compartmental syndrome arises in situations where increased pressure within a limited space restricts the circulation by lowering the arteriovenous gradient and function of tissues within that space. Hypotension, hemorrhage, arterial occlusion, and limb elevation all appear to reduce the tolerance of limbs for increased tissue pressure. In early cases, patients with decreased levels of consciousness or when clinical evaluation is equivocal, pressure measurements become mandatory. Usually a single pressure measurement at the appropriate time will reveal the need for decompression, although in equivocal cases, a constant pressure measurement becomes necessary. The Wick catheter method has been widely used for this type of measurement, but we have developed a simpler system which is described in this article.

Effects of the lithotomy position on arterial blood flow in the lower extremities.

The lithotomy position is known to decrease venous blood flow and predispose to lower extremity venous thrombosis. However, arterial thrombosis secondary to surgical positioning has rarely been discussed. One hundred patients underwent measurements of their ankle-arm index, the ratio of their ankle systolic pressure compared to their brachial blood pressure, preoperatively (AAI); immediately after being placed in the lithotomy position (AAII); and immediately prior to returning to the supine position (AAIII). Comparison of all the ankle-arm indexes revealed significant drops between preoperatively and immediately after being placed in the lithotomy position, and between preoperatively (p less than .01) and immediately prior to the supine position (p less than .05). When only preoperative ankle-arm indexes of 0.99 were examined, a very significant drop of p less than .005 was obtained. No significant drop was seen in the group with preoperative ankle-arm indexes less than 0.99. In view of this pressure drop, standard lithotomy stirrups, such as those usually utilized for OB procedures, should be used with caution for procedures requiring prolonged lithotomy position.

Synchronous squamous carcinoma of the anus and adenocarcinoma of the rectum.

Recent literature has reported several series of synchronous adenocarcinoma of the colon, but there has not been a reported case of synchronous squamous carcinoma of the anus and adenocarcinoma of the rectum. This article describes a patient with a large squamous carcinoma of the anus along with a large adenocarcinoma of the rectum, and also discusses a current review of the etiology and treatment of squamous carcinoma of the anus.

Primary aortoenteric fistulas.

Aortoenteric fistulas were first reported in 1822. Primary aortoenteric fistulas are uncommon (less than 200 cases reported). Secondary aortoenteric fistulas are a well-recognized complication of prosthetic grafts (incidence from 0.4 to 2.4%). Atherosclerosis, gallstones, foreign bodies, carcinomas, and diverticular disease are the most common etiologies. Diagnosis is difficult with most studies being nondiagnostic. A high incidence of suspicion is required to successfully diagnosis preoperatively. Surgical repair is required for survival of the patients and should consist of the following: 1) primary closure of the intestinal defect, 2) either primary anatomical repair with a prosthetic graft or extra-anatomical vascular reconstruction, depending upon the presence or absence of infection, and 3) treatment with appropriate antibiotics. One of the largest series of primary aortoenteric fistulas from a single institution consisting of three cases secondary to aneurysmal and granulomatous disease is discussed.

Carcinoma of the male breast: a 27-year community experience.

Carcinoma of the male breast is relatively rare and the prognosis is usually more ominous than in the female. Radical mastectomy is advocated for optimal therapy but lesser procedures are used for a variety of reasons. After observing several recent cases of male breast cancer, we reviewed the tumor registries for the past 27 years at Marshall University affiliated hospitals. Thirteen cases were found and evaluated. This article presents treatment, survival and a review of the current therapy.

Extramedullary plasmacytoma of the soft palate.

A 59-year-old white male presented with symptoms of an upper respiratory infection and the sensation of nasal fullness or obstruction. There were no constitutional symptoms or history of previous oropharyngeal neoplasms. Examination revealed a fleshy tan-pink 2 cm. x 1 cm. pedunculated lesion at the base of the uvula posteriorly, extending into the posterior soft palate. Indirect laryngoscopy confirmed extension of the lesion base onto the posterior soft palate. There was no palpable cervical adenopathy. CT scan of the sinuses and neck revealed no abnormality except the soft tissue mass in the area of the uvula and soft palate. Excisional biopsy of the lesion revealed a plasmacytoma which produced a monoclonal lambda chain immunoglobulin. Hemoglobin was 17.2 g/d. Serum electrophoresis and immunophoresis, Bence-Jones protein, bone marrow, and bone scan were normal. Twenty-six months later, a 1.5 cm. pedunculated lesion was noted at the site of original tumor, which was demonstrated to be recurrent plasmacytoma on excisional biopsy. No other lesions were identified on direct laryngoscopy and skeletal survey was normal. Repeat laboratory studies were normal except for a slight hypergammaglobulinemia (total protein 6.4 g/d., albumin 51.5 percent, alpha 1 globulin 4.0 percent, alpha 2 globulin 11.4 percent, beta globulin 12.8 percent, and gamma globulin 20.2 percent). The patient refused further treatment and has had no further recurrences at one year.

Flexible sigmoidoscopy screening for asymptomatic colorectal disease in patients with and without inguinal hernia.

Several studies have evaluated the diagnostic value of flexible sigmoidoscopy for screening asymptomatic patients before hernia repair. All have shown a 16% to 28% incidence of neoplastic (malignant or premalignant) lesions. None of these studies compared a similar group of asymptomatic patients without hernia to determine whether the incidence is increased in patients with hernias. We reviewed 87 consecutive cases of male surgical patients without hernia or any anorectal disease who had flexible sigmoidoscopy between June 1986 and December 1989 (group 1) and compared them with a group of hernia patients that we previously reported (group 2). Patients with stool positive for occult blood were excluded from this study. Examinations in both groups were done under the direct supervision of an attending surgeon (W.W., C.S.C., or J.K.). No significant difference was noted between group 1 and group 2 in mean age (mean 65.6 vs 59.7 years), rate of normal findings (68% vs 63%), and incidence of neoplastic lesions (14% vs 22%). All patients tolerated the procedure well, and there were no complications.

Effect of admission nutritional status on length of hospital stay.

Malnutrition is a large problem among patients admitted to U.S. hospitals and is an area of increasing concern for GI health care professionals. We conducted a prospective assessment of the admission nutritional status of 500 consecutive patients admitted to the Huntington Veterans Affairs Medical Center. Admission nutritional status was compared to the length of hospital stay (LOS). Nutritional status was calculated based on three equally weighted and easily obtained parameters--serum albumin, total peripheral blood lymphocyte counts and unintentional weight loss over time. A significant difference (p less than 0.01) was noted for the LOS between patients with normal, mildly abnormal and moderately abnormal nutritional status as compared with the patients with severe malnutrition. The length of hospital stay progressively increased with deterioration of nutritional status. The GI practitioner is in a key position to assess nutritional status of hospitalized patients. If malnutrition can be documented on hospital admission, attempts can be made to reverse the malnutrition and hopefully diminish LOS.

Giant basal cell carcinoma of the back.

Basal cell carcinoma accounts for 65-75 per cent of all skin carcinomas. We describe the case of a basal cell carcinoma of the back that was allowed to grow to a giant size. Even when this size, basal cell carcinomas rarely metastasize.

Inappropriate antibiotic use and the development of Clostridium difficile colitis.

A three-year, retrospective, community-wide study reviewed all patients (n = 60) with positive Clostridium difficile stool cytotoxin assays. The appropriateness of antibiotic administration in hospitalized patients (n = 48) who developed antibiotic-associated colitis (AAC) was studied. Only 25 per cent had antibiotics used appropriately with positive culture results and organisms susceptible to the antibiotic(s) given. Another 25 per cent of cases had positive cultures, but the organisms were not susceptible to the antibiotics used. Cultures exhibited no growth or were not obtained in 50 per cent of cases, but empiric antibiotic administration led to the development of AAC. Our results point toward inappropriate antibiotic use as being a major factor in the development of AAC. AAC is rarely fatal but has significant morbidity, and is expensive to treat. Judicious use of antibiotics may decrease the incidence of AAC.

Cancer of the gallbladder.

We have reported a case of primary carcinoma of the gallbladder and reviewed 42 other cases seen at the Marshall University School of Medicine affiliated hospitals over the last 27 years. Most of the patients were female (74.5%) and elderly (mean age 66.9 years), and had metastatic or locally invasive disease (79%); 95% had adenocarcinoma. Preoperative diagnosis of gallbladder malignancy is rare, and long-term survival depends upon early detection. Radical surgery, chemotherapy, and radiation have not improved survival.

Diverticular disease of the appendix.

We have discussed a case of appendiceal diverticulitis diagnosed at laparotomy, and reviewed the histologic and clinical findings. Although infrequently encountered, appendiceal diverticulitis must be entertained in the differential diagnosis of pain in the right lower quadrant, especially in the adult patient.

Quantitation of rate of wound closure and the prediction of death following major burns.

Data were obtained from 100 consecutive patients requiring hospitalization for 2 weeks or more for treatment of major burns. Age, total percentage burn, mechanism of injury, presence or absence of inhalation injury, and outcome were recorded. Serial weekly burn wound maps were used to calculate the wound closure index (WCI), previously defined as the slope of a straight line fitted to percentage burn as a function of time by linear regression analysis. Logistic regression analysis was used to construct an equation incorporating age, percentage burn and WCI. Addition of the WCI significantly improved the discriminant ability of the logistic regression model. The composite index correctly predicted survival in 97 percent of patients. Rapid wound closure, as measured by the WCI, correlated with survival.

Venous aneurysms.

We report the case of a large venous aneurysm of a 22-year-old white man. After evaluation and diagnosis, the aneurysm was resected without difficulty. Cause, diagnosis, treatment, and possible complications are discussed.

Flexible sigmoidoscopy as a screening procedure for asymptomatic colorectal carcinoma in patients with inguinal hernia.

In patients about to have hernia repair, preoperative screening studies for early colorectal cancer using the rigid proctosigmoidoscope and barium enema have previously shown minimal cost effectiveness and poor patient acceptance. Flexible sigmoidoscopy may be more acceptable to patients and of greater diagnostic value. Between October 1980 and December 1983, 100 consecutive asymptomatic male surgical patients were examined using the Olympus 60 flexible proctosigmoidoscope. All patients were admitted for elective hernia repair. Age ranged from 21 to 88 years (mean 59.7). All patients with stool positive for occult blood on admission were excluded from this study. In addition, patients with any gastrointestinal symptoms, history of colorectal disease, or family history of colorectal polyps or carcinoma were excluded. Examinations were done under direct supervision of an attending surgeon (W.W. or C.S.C.). Of the 22 patients who had one or more benign polyps, three had villous adenomas. Two additional patients had carcinoma. Results of examination were completely normal in 63, while 13 patients were found to have hemorrhoids or diverticular disease. There were no complications and the procedure was well tolerated by all patients.