Ablative surgery for necrotizing pancreatitis.

We have confirmed again that bile and trypsin injected in dogs under high pressure produce highly lethal necrotizing pancreatitis responsive to fluid resuscitation. Animals undergoing pancreatectomy show a reduction in serum amylase levels and hemoconcentration (reflected in hematocrit levels) after pancreatectomy, an effect that may be related to removal of the source of vasoactive substances liberated in pancreatitis. Qualitatively, survivors of pancreatectomy exhibit accelerated convalescence. Pancreatectomy, however, does not increase survival once the disease process is established and may be harmful. This experimental study does not support the clinical use of pancretectomy but rather emphasizes the utility of adequate fluid resuscitation in the treatment of severe pancreatitis.     

Preoperative prophylactic cephalothin fails to control septic complications of colorectal operations: results of controlled clinical trial. A Veterans Administration cooperative study.

Data obtained from a survey of the membership of the Society for Surgery of the Alimentary Tract and the American Society of Colon and Rectal Surgeons indicated that concomitant administration of oral neomycin-erythromycin base and systemic cephalothin, together with mechanical colon cleansing, was the most popular method of colon preparation. We designed a prospective double blind clinical trial to compare administration of intravenous cephalothin, oral neomycin-erythromycin base, and the combination of both the intravenous and oral antibiotics. Intake of patients to the intravenous cephalothin group was stopped because the data indicated that this method of prophylaxis resulted in significantly higher numbers of septic complications. The incidence of wound infection was 30 per cent and the overall incidence of septic complications was 39 per cent in patients receiving only intravenous cephalothin combined with mechanical colon cleansing. The incidence of wound infection and the overall incidence of septic complications was only 6 per cent in the comparison group, and the differences are highly significant.     

Electromotor feeding responses of primate ileum and colon

Serosal bipolar electrodes to record spike discharges and strain gauge force transducers to record circular muscle contractions were placed in pairs on the terminal ileum, cecum, right colon at the ileocecal valve, ascending colon, and proximal transverse colon of sixteen primates. After an overnight fast, electromotor responses to continued fasting or to ingestion of a meal (randomized order) were recorded in awake animals.Feeding led to increased spike discharges and increased frequency of muscle contractions at all sites. The onset of these responses usually was within 6 minutes after feeding; the responses increased progressively during 30 to 45 minutes and then remained more or less at a constant plateau of increased activity. Atropine completely blocked the postcibal responses of ileum and proximal colon for up to 30 minutes.Transit time data of labeled meals excluded direct stimulation by a food bolus as the mechanism of the observed postcibal colonic response. The pattern of response was consistent with humoral mediation.     

The relationship of glucagon and insulin to sequential changes in metabolic fuel utilization in shock

Previous studies in the dog have demonstrated significant alterations in the mobilization of metabolic fuel during shock. In particular, mobilization of depot fat is markedly depressed. The present study examines the sequential utilization of nonlipid fuels over a 24-hr shock period. Metabolic rates were unchanged from controls. Skeletal muscle glycogen fell exponentially from 7.0 ± 0.5 to 2.7 ± 0.2 mg/g (P < 0.001) after 24 hr of shock. Protein breakdown as reflected by urea production was linear throughout the period and increased 50% over controls (P < 0.001). Lactate levels did not reflect changes in metabolic rate but fell to nearly normal levels once muscle glycogen was depleted. The contribution of CHO and protein combined to CO₂ production fell from 70% in early shock to 42% in the final 12 hr of the 24-hr shock period. This compares to 23% in controls. Protein catabolism alone accounted for an average of 32% of CO₂ production in shock. While insulin levels rose slightly in early shock and then fell, glucagon rose rapidly in the first 5 hr of shock and then remained significantly and constantly elevated throughout the entire shock period. The insulin-glucagon molar ratio remained in the severely catabolic range throughout.     

An appreciation of Robert Moors Smith MD,an icon of pediatric anesthesiology

Robert Moors Smith M.D. passed away recently at the age of 97. During his chairmanship of the Department of Anesthesiology at Children’s Hospital Boston from 1946 to 1980 he gained world prominence for his contributions to the anesthetic care of children and the education of generations of pediatric anesthesiologists. His dedicated and earnest approach, reflected in tribute and in his own words, provide a window on pediatric anesthesia during its development into a recognized subspecialty in the 20th century.     

Giant insulinoma.

A patient with an extremely large insulinoma but short duration of symptoms is reported on. Fasting hypoglycemia, hyperinsulinism, and angiography were the modalities used to diagnose and locate the tumor.     

The pronator quadratus in motions and in stabilization of the radius and ulna at the distal radioulnar joint.

Based upon the findings of dissections of 15 forearms and clinical observations in patients with disturbed architecture of the distal radioulnar joint, the pronator quadratus was found to be composed of two heads. A superficial head originated from the ulna and passed transversely to its insertion into the radius. It averaged 5.1 cm. in length, 4.5 cm. in width, 0.2 cm. in thickness, with a cross-sectional area of 0.95 cm.2 and a contractile volume of 2.6 cm.3. The deep head ran obliquely from a more proximal origin on the ulna to a distal insertion on the radius, with an average length of 4.0 cm., average width of 3.2 cm., and a thickness of 0.4 cm. Its average cross-sectional area was 1.64 cm.2 and its contractile volume 2.5 cm.3. A group of fibers occasionally was noted deep to both heads, running at right angles to them and paralleling the direction of the fibers of the interosseous membrane. The superficial head initiates pronation while the deep head coapts the joint surfaces and stabilizes the joint.     

Robert Goddard Young,DC, ND: Searching for a better way

This biographical study tracks the life of Robert Goddard Young; a member of the Canadian Memorial Chiropractic College’s (CMCC) Class of 1950. The paper begins with an overview of Robert Young’s origins, his childhood and early training, moves to his tour of duty in World War II, followed by his education at CMCC, before converging on the core of this matter; Robert Young’s professional career, which spanned over half a century. Now in his twilight years, the paper ends with a discussion on the substance of Dr. Young’s largely-forgotten contributions.     

Bovine graft arteriovenous fistula for hemodialysis

Repeated failure of conventional methods for hemodialysis has prompted the use of bovine arterial grafts as conduits in arteriovenous fistulas. Complications encountered in the use of the graft have been infrequent and have been attributed to technical difficulties that arose in four of the first five patients operated on. After revision of the operative technic no additional complications have been seen in the remaining twenty patients. These results are encouraging and the procedure warrants further investigation. The use of the modified bovine carotid artery graft in the construction of subcutaneous arteriovenous fistulas for chronic hemodialysis may be the procedure of choice.     

Steven Johnson Syndrome and Toxic Epidermal Necrolysis in a burn unit: A 15-year experience

IntroductionThe diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25% to 70%, including a considerable morbidity. However, our experience over a 15-year period from 2000 to 2015 with 40 patients found a mortality rate of only 10% (4/40). The purpose of this paper is to discuss our treatment algorithm as a model for other centers treating SJS/TENs patients.MethodsRecords were reviewed for all patients admitted to the LAC + USC burn unit between 2000 and 2015 and 40 patients were identified with biopsy-proven SJS or TENS. These cases were reviewed for age, gender, initial and greatest TBSA, causative drug, pre-existing medical conditions, and morbidity and mortality. All data were entered into the SPSS statistical software package and all statistical analyses were performed using this program.ResultsOur treatment algorithm focused on early referral to a specialty burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. Average time to transfer to a burn unit was 3.36 days. Silver-releasing antimicrobial dressings were applied to the affected skin surface and changed every 3 days. Mupirocin coated petroleum gauze was used for facial involvement. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. All patients received fluid resuscitation and the majority received supplemental tube feedings (69%). Average length of total stay was 17.1 days and length of ICU stay 15.9 days. While 44% were transferred to another facility for further rehabilitative care, 37% of patients discharge to home. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days.DiscussionWith our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a relatively low mortality rate. The demographic data from our study largely aligns with the existing literature, and we therefore feel that our low mortality rate is due to our treatment algorithm, rather than to a less severe pathology in our patient population. This claim is supported by a standard mortality ratio of 1.68. This ratio proves a significantly improved mortality than would be expected based on disease severity on admission.     

Arteriovenous fistula secondary to rupture of atherosclerotic abdominal aortic aneurysm: Report of five cases

Five patients with an acute spontaneous arteriovenous fistula as a result of rupture of abdominal aortic aneurysms into the inferior vena cava of iliac vein are presented. A high mortality usually accompanies this rather infrequent complication of abdominal aortic aneurysms. The pathologic and physiologic aspects of this catastrophic event are discussed with emphasis on the variation of operative management necessary for a successful outcome.