Obstructive and enteropathic syndromes after jejunoileal bypass surgery

Small bowel bypass procedures for morbid obesity have been associated with many postoperative complications. With the use of the Scott procedure, the bypassed or excluded small bowel segment has recently been the focus of 2 syndromes — bypass enteritis and defunctioned bowel syndrome. We describe these postoperative complications and present their significant radiologic features.     

Application of the medical anti-shock trouser (MAST) increases cardiac output and tissue perfusion in simulated,mild hypovolaemia

We have studied the haemodynamic effects of the application of the medical anti-shock trouser (MAST) in 10 healthy subjects in the semi-upright position in order to simulate mild hypovolaemia. Left ventricular end diastolic dimension (EDD) was measured by M-mode echocardiography and cardiac output (CO) by the Doppler ultrasound technique. Forearm blood flow (FBF) was measured by plethysmography and blood pressure (BP) by the standard cuff technique. Systematic increases in MAST pressure of up to 80 mm Hg were applied. EDD increased to a maximum of 9.3% (p0.01) which was associated with a maximum increase in CO of 31.7% (p0.05). FBF increased by a maximum of 54.2% (p0.001) whilst BP increased by a maximum of 12% (p0.001). These results demonstrate that the application of the MAST is an effective means of transferring blood to the central circulation by compression of the capacitance vessels resulting in significant increases in cardiac output and tissue perfusion. At high pressures there was evidence of compression of resistance vessels, which may be useful in reducing blood loss. The ease and rapidity with which his suit can be applied suggests that it may be useful in the short term treatment of hypovolaemia.     

Echo-guided percutaneous puncture: A safe and valuable therapeutic tool for amebic liver abscess

To clarify the therapeutic role of echo-guided percutaneous puncture (EPP) in management of amebic liver abscess, 20 patients (24 abscesses) received metronidazole plus EPP. Fluid was aspirated through Chiba needles under real-time sonographic guidance so as to reduce cavity size to less than 3 cm. Not more than two EPPs were necessary in the majority of cases and no complication followed the procedure.This scheme resulted in a shortening of time of both hospitalization (20 days) and liver lesion healing as assessed by ultrasound (4 months).It is concluded that EPP is a valuable and safe therapeutic tool for hepatic amebic abscess.     

Hypochloruria associated with hypovolemia

Hypochloruria is proposed as an indicator of hypovolemia in ICU non cardiac patients. Twelve of 13 patients presenting with Cl_u20 mmol·l^-1 and Na_u20 mmol·l^-1 or twice the Cl_u value had a CVP 0 mmHg. This pattern occurred in those with a metabolic alkalosis or acidosis, renal insufficiency or normal renal function, in the presence or absence of dopamine and/or diuretic administration and with or without controlled ventilation. Hypochloruria may be a better indicator of hypovolemia than a low urinary Na in ICU patients.     

Multiple reflective channels in the spleen: A sonographic sign of portal hypertension

We consistently observed small reflective channels (RCs) in the splenic parenchyma in patients with portal hypertension (PHT). The purpose of this study was to investigate the frequency of this sign in PHT and in splenic disorders unrelated to PHT compared to normal controls. The significance of this sign in the diagnosis of PHT and in differentiating PHT splenomegalies from others was also assessed. A total of 337 patients underwent sonographic examination of the spleen: 147 normal, 75 non-PHT splenic pathologies, and 115 with PHT. The RCs were scored from grade 0 to 3 by counting the number in an area of 12 mm² in the splenic parenchyma. Of 222 normal and non-PHT spleens, 174 (78%) showed grade 0, 44 (20%) grade 1, four grade 2 (1%), and none showed grade 3 RCs. Of 115 PHT cases, 17 showed grade 0, 25 grade 1, 44 grade 2, and 29 showed grade 3 RCs. The sensitivity of this sign was 0.85 with a specificity of 0.77 and an accuracy of 0.80 in detecting PHT (p<0.001). The interobserver and intraobserver variation for grading was insignificant (p>0.1). The RCs could be explained by periarterial fibrosis and dilatation of venous sinuses with increased collagen in their walls, which is known to occur in PHT. The vascular nature on ultrasound (US) was confirmed by the presence of flow on color Doppler. This sign is readily differentiated from the calcifications of tuberculosis, histoplasmosis, sickle cell infarcts, and phleboliths; it serves as a useful aid in diagnosing and differentiating PHT splenomegaly from non-PHT splenomegaly.     

Determination of left ventricular mass by three-dimensional echocardiography: in vitro validation of a novel quantification method using multiple equi-angular rotational planes for rapid measurements

Measuring left ventricular mass by m-mode echocardiography or two-dimensional echocardiography is limited by the fact that calculations are based on assumptions, which describe left ventricular shape by simple geometric figures. The ability of three-dimensional echocardiography (3-DE) to accurately assess left ventricular mass has been shown previously, but 3-DE approaches to quantitative analysis of ventricular mass required multiple tomographic sectioning, manual tracing in various cut planes and were time consuming and laborious. We investigated the accuracy of a novel, rapid method of 3-DE mass quantification using multiple rotational planes in left ventricles in vitro. Methods: Three-dimensional data sets of 10 fixed pig hearts were obtained using a TomTec 3-DE system. For 3-DE mass calculations, a rotational axis in the center of the ventricle (apical–basal orientation) was defined and 3, 6 and 12 equi-angular rotational planes were created. The endocardial and epicardial contour of the left ventricle was traced in each cut plane and the volume of the corresponding myocardial wedge was automatically calculated. Mass was calculated by multiplying the resulting myocardial volume by the specific weight of myocardial tissue. The measurements were performed by two investigators blinded to the anatomic true mass and were analyzed for interobserver and intraobserver variability. Results: The anatomic left ventricular mass was measured 73–219 (168 ± 50) g. 3-DE mass ranged from 88–247 (207 ± 51) g (three planes), 84–250 (205 ± 52) g (six planes) and 86–241 (202 ± 50) g (12 planes) respectively. The correlation between 3-DE mass and anatomic LV mass measurements (r = 0.92) and between two observers (r = 0.97–0.98) was good. True mass was slightly overestimated by 3-DE measurement (SEE = 22–23 g). The intraobserver and interobserver variabilities were 4 and 7% respectively for all measurements. Conclusion: This new 3-DE method of left ventricular mass quantification with rotational approach provides accurate and reproducible measurements. In normal shaped left ventricles even three planes were sufficient to provide accurate mass measurements in vitro.     

Computed tomography of pyonephrosis

Computed tomographic (CT) findings of 17 pyonephrotic and 20 uninfected hydronephrotic kidneys were reviewed. Parameters evaluated included: renal pelvic wall thickness (none; grade 1, 2 mm; grade 2, 3–5 mm; and grade 3, >5 mm), renal pelvic contents, parenchymal, and perirenal findings. All patients underwent subsequent percutaneous nephrostomy within 1 week of CT. Common CT findings suggesting pyonephrosis include increased pelvic wall thickness and more severe perirenal fat changes than are seen in uninfected hydronephrosis. However, for any one patient, these findings are often not diagnostic. The presence of clinical signs of infection with hydronephrosis on CT is a more sensitive indicator of pyonephrosis than most CT findings.     

New Measures of Defensiveness,Empathy, and Cognitive Distortions for Sexual Offenders Against Children

Treatment of child molesters emphasizes three interrelated constructs: denial, empathy, and cognitive distortions. Thirty child molesters, 30 nonsexual offenders, and 30 controls answered three new tests of denial, empathy, and cognitive distortions anonymously; 30 other child molesters were instructed to fake good, and 44 child molesters who were seeking parole were also tested. The Sexual Social Desirability Scale (SSDS) measures attitudes about sex, sexual activities, and intimate sexual relationships. All offender groups attributed significantly more (p .05) positive characteristics to themselves than did controls. All sexual offender groups denied significantly more (p .05) negative characteristics than did the control and nonsexual offender groups. Even sexual offenders asked to fake good did not significantly differ in denial from those sexual offenders who answered anonymously or those in assessment for parole. For sexual offenders, denial was not significantly affected by demand characteristics. The Empathy (Empat) scale tested for lack of empathy specific to sexual abuse victims and general lack of empathy. Sexual offenders, even those faking good, showed less sexual abuse empathy than controls (p .05). In contrast, sexual offender scores of general empathy equaled controls'. The Child Molester Scale (CMS) was developed in an attempt to reduce the effects of socially desirable responding. Sexual offenders assessed for parole reported significantly more (p =.0026) cognitive distortions regarding adult–child sexual activity than did the control group but not less than nonsexual offenders. The SSDS, Empat, and CMS were significantly correlated.     

Rectal carcinoma: Preoperative staging and detection of postoperative local recurrence with transrectal and transvaginal ultrasound

Transrectal ultrasound (TRUS) was performed preoperatively in 35 patients with rectal carcinoma and the results were compared to histologic findings. In the same group, postoperative studies were performed in 22 patients; in women, transvaginal ultrasound (TVUS) was added to the transrectal study. According to Duke's classification modified by Astler-Coller, in relation to the T parameter, TRUS correctly staged 33 of 35 neoplasms (accuracy, 94.3%); one was overstaged and one was understaged. In detection of lymph node involvement, accuracy was 74% (sensitivity 69%, specificity 73.9%). Recurrent local tumors, histologically confirmed, developed in two of 22 postoperative patients who had undergone curative anterior resection. This study demonstrates that TRUS is an accurate method in preoperative staging of rectal carcinoma. In the prospective study, the role of follow-up TRUS and TVUS in detection of local recurrences is evaluated.     

Single breath N2 washout in papain-induced pulmonary emphysema

Single breath nitrogen washout tests were analyzed in dogs (n=8) with healthy lungs and after development of emphysema. The animals were in the supine position and studied during anaesthesia and mechanical ventilation (F_iO₂=0.4, F_iN₂=0.6). During controlled expiration with constant flow (V_E=0.15 1/s) onset of phase IV of the alveolar plateau was related to airway closure of dependent lung regions (closing volume CV). In the control state, CV accounted for 6.2±1.5% VC, and closing capacity (CC) was lower than functional residual capacity (FRC). Likewise, gas exchange was normal in all animals (PaO₂=24.7±3.32 kPa, PaCO₂=5.18±0.53 kPa, P_A-aO₂=2.6±0.3 kPa). Panlobular emphysema (PLE) was induced by inhalation of papain (100 mg/kg). After three weeks development of PLE was documented by messurements of lung volumes (functional residual capacity (FRC), expired vital capacity (EVC), total lung capacity (TLC), residual volume (RV)), pulmonary mechanics (dynamic and static compliance (C_dyn, C_stat), mean airway resistance (R_aw)), gas exchange (PaO₂, PaCO₂, P_A-aO₂), and by radiomorphological analysis. In the PLE-group, FRC and RV (p0.05), and C_stat (p0.01) were significantly elevated. CV increased to 16.2±2.7% VC (p0.01) and CC exceeded FRC by 80 ml, indicating that tidal volume breathing took place within the range of closing volume. Oxygenation was significantly impaired (PaO₂=18.6±3.72 kPa, P_A-aO₂-6.5±1.1 kPa, p0.05), but not CO₂-elimination. Pathological analysis by radiomorphological means showed dissiminate parenchymal lesions compatible with emphysema of grade II severity located predominantly in subpleural areas. In dogs with papain-induced PLE, premature closure of dependent airways is enhanced, which is due to structural changes and a loss of elastic recoil in the lungs.     

Weaning and extubation in the intensive care unit

Objective To assess the outcome of a clinical judgementbased approach to weaning and extubation and to adduce the predictive accuracy of various mechanical respiratory indices measured in parallel.Design Prospective study.Setting Multidisciplinary intensive care unit at a university teaching hospital.Patients 163 consecutive mechanically ventilated patients, excluding tracheotomy, for weaning trial and extubation.Interventions Using bedside clinical assessment, aided by arterial gas analysis, patients were weaned from mechanical ventilation to spontaneous ventilation via the continuous positive airway pressure (CPAP) circuit (with pressure support) of a microprocessor-controlled ventilator. Extubation occurred from the CPAP circuit at 7 cmH₂O pressure support, fractional inspired oxygen (FIO₂)0.5 and CPAP level of 5 cmH₂O, such that the partial pressure of oxygen in arterial blood (PaO₂) was 65 mmHg. Before extubation, observation for a 1-h (T₀ and T₆₀) trial period allowed measurement of vital capacity (VC), expired minute volume (VE), respiratory rate/tidal volume (f/V_T) and maximal inspiratory pressure (MIP) using a one-way valve technique over 25 s.Measurements and main results Over 7 months, 163 patients (62 females and 101 males; mean(SD) age 64(15) years) were considered. There were 91 surgical (18 with chronic obstructive pulmonary disease; COPD) and 72 medical (28 with COPD) patients. Ventilation was for 1 day (median 5 days, range 1–31) in 115 [group I; APACHE II score 23(8)] and 1 day in 48 [Group II; APACHE II score 17(6)]. Three patients (all Group I: 2 surgical, 1 medical) were reintubated within 24 h, an overall extubation failure rate of 1.8%. In group I, at T₀, PaO₂/FIO₂ was 238(65), f/VT 50(26), MIP 44(21) cmH₂O, VE 10.6(3.7) l/min, VC 13(5) ml/kg. Cardiorespiratory variables did not change significantly in either group, T₀ to T₆₀. For prediction of reintubation (n=163), only VE (threshold >10 l/min) and f/V_T (threshold >100) demonstrated moderate sensitivity and specificity at T₆₀67 and 52% and 33 and 94%, respectively.Conclusions Bedside clinicla judgement of weaning and extubation produces satisfactory outcomes. As a routine, mechanical predictive indices have limited utility.     

Computed tomography as an adjunct to ultrasound in the diagnosis of acute acalculous cholecystitis

The sonographic and computed tomographic (CT) findings were reviewed in 17 patients with acute acalculous cholecystitis (AAC) over a 6-year period from 1984 to 1989. Of the six patients in whom both ultrasound and CT were performed, CT revealed marked gallbladder (GB) wall abnormalities, including perforation, and pericholecystic fluid collections in five patients not demonstrated by sonography. Of the total group, five patients had GB wall thicknesses of 3 mm (normal) at pathologic examination, which demonstrated a spectrum of disease ranging from acute hemorrhagic/necrotizing, to gangrenous acalculous cholecystitis with perforation. Sonography was falsely negative or significantly underestimated the severity of AAC in seven of the 13 patients examined by sonography. CT because of its superior ability to assess pericholecystic inflammation may provide additional diagnostic information even after a thorough sonographic study in cases of AAC.     

Computed tomography in the differential diagnosis of the enlarged retrorectal space

The value of computed tomography (CT) in the differentiation of an enlarged retrorectal space was analyzed in 132 cases. Classification of barium enema findings into those with simultaneous mucosal alterations and those without any visible lesions of the rectal mucosa seems to be useful. Computed tomography helps in those cases without mucosal changes to differentiate between retrorectal fibrosis, tumorous masses, and inflammatory diseases of the colon. It also demonstrates the lack of pathologic lesions in equivocal cases of pelvic lipomatosis and so-called normal variants. If simultaneous mucosal involvement on barium enema — especially in rectal carcinoma or recurrent carcinoma of the rectum — is found, CT may show the perirectal extension of tumorous masses and thus help to clarify local operability.     

MRI of abdominal hydatid disease

Seventy hydatid cysts in 30 patients were studied with magnetic resonance imaging (MRI) and computed tomography (CT); all cases were confirmed surgically. MRI detected all cysts when confined to solid organs, whereas small-sized cysts (2 cm) may be missed when located in the peritoneal cavity. Hydatid cysts of less than 3 cm (noncomplicated) present no specific findings of hydatid disease. MRI findings suggesting hydatid disease demonstrate a relatively thick hydatid cyst wall, daughter cysts, and germinal membrane detachment. T2-weighted images proved to be superior to T1 or PD-weighted images in demonstrating hydatid cyst wall thickness, germinal membrane detachment, and daughter cysts. In all spin-echo sequences, the maternal cystic content presented much higher signal intensities than that of daughter cysts. This difference in signal intensity is more obvious in T2 weighted images, except in complicated, infected cases. CT proved to be superior to MRI in demonstrating wall calcifications.     

Bronchial hyperresponsiveness following acute severe asthma

Objective To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA).Design: Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period.Setting University teaching ICU and pneumonology department.Patients 41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age.Measurement and results Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV₁) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV₁ above 60% predicted. PD AC (g) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC100 g) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100>PD AC500 g); and 3 ASA versus 14 control patients had moderate BHR (>500 g). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO₂ value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV₁ value.Conclusion BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyperresponsiveness.     

The influence of premature ventricular contractions on left ventricular function in asymptomatic children without structural heart disease: an echocardiographic evaluation

Background: Isolated monomorphic premature ventricular contractions (PVCs) are not uncommon in the pediatric population. The degree of cardiac dysfunction caused by PVCs in children without structural heart disease is unknown. Purpose: To investigate the influence of PVCs on echocardiographic left ventricular (LV) systolic function in children without structural heart disease. Methods: Forty asymptomatic children with isolated monomorphic PVCs without structural heart disease were selected. The median age was 6 years, range of 3–12 years. The following subgroups were compared: frequent vs. infrequent PVCs (> or 10/min); short vs. long coupling interval (RR/RR ratio or >0.6); and short vs. long QT interval (QT or >400 ms). Using echocardiography the left ventricular ejection fraction (LVEF in percentage) and cardiac index (CI in L/min/m²) were measured for both normal sinus beats (SB-LVEF and CI), PVCs (PVC-LVEF and CI) and the average LVEF and CI were calculated. All values were expressed as means ± SD. Results: In all children LV dimensions and the SB-LVEF and CI were within normal limits. The PVC-LVEF (48 ± 5) and PVC-CI (1.57 ± 0.19) were significantly decreased and the average CI was 2.41 ± 0.29. In 27 pts with >10 PVCs/min the average LVEF and CI decreased to 53 ± 5 and 2.08 ± 0.24 respectively. In 16 pts with PVCs and a short coupling interval (RR/RR 0.6) the PVC-LVEF and PVC-CI was 43 ± 0.03 and 1.50 ± 0.14, which was significantly lower than in 24 pts with a long coupling interval (58 ± 4, 1.88 ± 0.11). In 11 pts with a prolonged QT interval (>400 ms) the PVC-LVEF and PVC-CI was significantly lower than in the 29 children with a shorter QT interval, 41 ± 5 vs. 55 ± 4 and 1.46 ± 0.13 vs. 1.86 ± 0.15 respectively (all p < 0.01). Conclusion: In asymptomatic children with isolated monomorphic PVCs the average ejection fraction and cardiac output is markedly reduced if PVCs are frequent (>10/min), have a short coupling interval or a prolonged QT interval.     

Influence of Pulse Oximeter Settings on the Frequency of Alarms and Detection of Hypoxemia

Objective. The potential benefit of a reduced frequency of false pulse oximeter low oxyhemoglobin saturation (SpO₂) alarms is that the attention of personnel is only directed to patients who experience hypoxemia. The present study was undertaken to better understand the effects of different settings of the pulse oximeter on false (artifact) and true (hypoxemia) alarms. Methods. Using the original SpO₂ data of 200 postoperative patients, we calculated off-line the effects of five methods (artifact rejection, alarm delay (2–44 s, 2 s increments), averaging (10–90 s), median filtering (10–90 s) and decreasing the alarm limit from 90% to 85%) on the number of (true- and false) alarms. Results. 830 episodes of hypoxemia (SpO₂ 90%) and 73 episodes of severe hypoxemia (SpO₂ 85%) occurred. With a SpO₂ alarm limit of 90%, the alarm was triggered 1535 times (830 true, 705 false). Artifact rejection reduced alarms by almost 50%. An alarm delay of 6 s or an averaging or median filtering epoch of 10 s resulted in an alarm reduction of almost 50%. No differences were found in the reduction of alarms between averaging and median filtering. Changing the alarm limit to 85% reduced the number of alarms by 82%. A similar reduction of alarms was obtained with either an alarm delay of 18 s or an averaging or median filtering epoch of 42 s. However, an alarm limit of 85% reduced the number of false alarms less than the other three algorithms (p < 0.01). Conclusions. The data from the present study suggest that in order to effectively suppress false alarms caused by pulse oximeter artifacts, it may be preferable to use a longer filtering epoch of approximately 40 s, rather than to decrease the lower alarm limit.     

Early prediction of prognosis in out-of-hospital cardiac arrest

Of 347 victims of out-of-hospital cardiac arrest 196 (56.5%) died before and 109 (31.4%) after admission to hospital, while 42 patients (12.1%) were discharged alive. The 37 patients (10.7%) discharged without severe hypoxic brain damage were assigned to the group with good, the remaining 310 patients to the group with poor outcome. From results of stepwise logistic regression, a score was derived to specifically identify victims with poor prognosis (values in brackets=score points; cutpoint: score>3 points): age70 (0), 71–80 (1), >80 (2); ECG ventricular fibrillation (0), other (1); no aspiration (0), aspiration (1); pupils round (0), not round (1); gasping (0), apnea (1); bystander resuscitation — yes (0), no (1). Evaluation of the score revealed a specificity of 100% (0.95 confidence interval: 80%–100%) and predictive value of 100% (0.95 confidence interval: 95%–100%). A predictive score for specific identification of victims with poor prognosis can contribute to decision making in out-of-hospital cardiac arrest.     

Prognostic evaluation in meningococcal disease

A retrospective study of the medical records of 115 consecutive cases of menigococcal disease with 11 fatalites was carried out in order to evaluate the power of 15 clinical and laboratory variables available on admission in predicting a fatal outcome. On linear discriminant analysis, six variables showed a significant discriminating power in predicting death: low systolic blood pressure, low platelet count, extensive petechiae, high body temperature, low CSF polynuclear cell count and absence of meningism. From a stepwise linear discriminant analysis, two alternative procedures for prognostic evaluation were derived. If a large high risk group is accepted which will include practically all patients at risk of death, a prognostic evaluation based only on systolic blood pressure on admission is sufficient. Alternatively, if unconventional, potentially hazardous therapy is considered for high risk patients, a small high risk group may be defined. Patients with systolic blood pressure <100 mm Hg, platelet count 125x10⁹/l and body temperature >39° on admission constitute a small group with a very high mortality. A similar risk group was defined if platelet count 125x10⁹/l was substituted for extensive petechiae. The advantage of the latter procedure is that only a simple bedside examination is required for the prognostic evaluation.