Selective management of blunt abdominal trauma in children--the triage role of peritoneal lavage

The evolution of selective laparotomy in children sustaining blunt abdominal trauma has been highly controversial. This report describes our experience and policy change during this transitional period. Emergency laparotomies performed in the pediatric age group (less than 14 yr) between 1980 and 1984, based on peritoneal lavage, were reviewed. Of 16 such patients, six (37.5%) had injuries identified at laparotomy necessitating operation, (four greater than Grade III spleen, one hepatic vein, one small bowel). The remaining ten patients (67.5%) had injuries which probably could have been managed nonoperatively (eight less than or equal to Grade II spleen, two less than or equal to Grade II liver). We additionally reviewed 46 peritoneal lavages done in children during 1984, and noted a 100% sensitivity but 86% specificity when considering essential laparotomies. Based on these data, we established a selective management protocol and initiated a prospective study in January 1985. The protocol consisted of: 1) routine peritoneal lavage (DPL) in children at high risk for abdominal injury, 2) immediate laparotomy for DPL positive for blood in conjunction with hemodynamic instability, 3) selective laparotomy for DPL positive for blood in a stable child, additionally evaluated by abdominal CT scan (major mechanism) or liver/spleen scan (minor mechanism), and 4) mandatory laparotomy for DPL effluent positive by criteria other than blood. This policy reduced unnecessary laparotomy, otherwise warranted by DPL, to 18% (2/11); both patients had Grade II splenic injuries. Five children sustaining low-energy trauma were managed nonoperatively following peritoneal aspiration of gross blood with L-S scan confirming minor solid visceral injury.(ABSTRACT TRUNCATED AT 250 WORDS)     

Miconazole: a cost-effective antifungal genitourinary irrigant

Miconazole was used as a fungistatic genitourinary irrigant in the management of 10 patients with persistent candiduria. All patients were in the older age group, with a mean age of 77.6 years, and they were debilitated by a variety of medical problems, including major surgery, neoplasia, recurrent bacterial infection, diabetes or other metabolic dysfunction. Miconazole at a concentration of 50 mcg. per ml. was administered continuously during 24 hours for 5 consecutive days via a urethral catheter. Candiduria resolved in 8 of the 10 patients, with 1 requiring a second course of miconazole at a concentration of 100 mcg. per ml. Two patients manifested other foci of infection, necessitating intravenous and intravesical amphotericin B. Stability studies showed that the miconazole irrigation solutions maintain their antifungal activity for 11 days at room temperature. The 5-day cost (drug and materials) of the miconazole irrigation at 50 mcg. per ml. was $17.75 versus $76.75 for an equal course of therapy with amphotericin B. In addition, compared to amphotericin B as an antifungal genitourinary irrigant, miconazole is prepared more easily, requires less labor and preparation time, and does not require refrigeration or protection from light. These clinical observations indicate that miconazole is a cost-effective antifungal genitourinary irrigant.     

Evaluation of tumor measurements in oncology: use of film-based and electronic techniques.

PURPOSE: To evaluate the variability in bidimensional computed tomography (CT) measurements obtained of actual tumors and of tumor phantoms by use of three measurement techniques: hand-held calipers on film, electronic calipers on a workstation, and an autocontour technique on a workstation. MATERIALS AND METHODS: Three radiologists measured 45 actual tumors (in the lung, liver, and lymph nodes) on CT images, using each of the three techniques. Bidimensional measurements were recorded, and their cross-products calculated. The coefficient of variation was calculated to assess interobserver variability. CT images of 48 phantoms were measured by three radiologists with each of the techniques. In addition to the coefficient of variation, the differences between the cross-product measurements of tumor phantoms themselves and the measurements obtained with each of the techniques were calculated. RESULTS: The differences between the coefficients of variation were statistically significantly different for the autocontour technique, compared with the other techniques, both for actual tumors and for tumor phantoms. There was no statistically significant difference in the coefficient of variation between measurements obtained with hand-held calipers and electronic calipers. The cross-products for tumor phantoms were 12% less than the actual cross-product when calipers on film were used, 11% less using electronic calipers, and 1% greater using the autocontour technique. CONCLUSION: Tumor size is obtained more accurately and consistently between readers using an automated autocontour technique than between those using hand-held or electronic calipers. This finding has substantial implications for monitoring tumor therapy in an individual patient, as well as for evaluating the effectiveness of new therapies under development.     

Efficacy of ephedrine in the prevention of postoperative nausea and vomiting.

Although reported in the aerospace literature and anecdotally by anesthesiologists, the putative antiemetic effect of ephedrine remains unquantitated. We therefore prospectively studied ephedrine as an antiemetic agent in the perioperative setting in 97 patients undergoing general anesthesia for outpatient gynecologic laparoscopy. Patients were assigned in a double-blind randomized fashion to receive a standardized general anesthetic followed by an intramuscular dose of either ephedrine (0.5 mg/kg), droperidol (0.04 mg/kg), or saline before the conclusion of surgery. Nausea, retching, or vomiting, as well as the degree of sedation and discharge times, were assessed in the recovery room and for 24 h postoperatively. Ephedrine was found to have a significantly antiemetic effect (P less than 0.05) when compared with placebo and an antiemetic effect similar to that of droperidol. Sedation scores were also significantly less in the ephedrine group than in both placebo and droperidol groups. Finally, variations in mean arterial blood pressure among the three groups were not statistically significant. We conclude that ephedrine is an effective antiemetic agent with minimal sedative side effects in patients undergoing outpatient laparoscopy.     

Network structural dynamics and infectious disease propagation.

We aimed to relate dynamic changes in risk-network (sex and/or injecting drug) structure to observe STD/HIV transmission. We analysed macro- and micro-structural elements in 2 heterosexual networks, augmented by ethnographic observations. In a Colorado cohort of injecting drug users (n = 595), measures of subgroup formation and of density of activity show decrease of network cohesion over time; only one HIV transmission was observed in 3 years. In a group of adolescent heterosexuals in Georgia (n = 99), the reverse process (increase in structural cohesion) was associated with efficient syphilis transmission: 10 cases were observed. Changes in personal risk behaviours over time were modest. STD/HIV transmission patterns were associated with intensification or diminution of network cohesion. Network and ethnographic data suggest that enhanced connectivity facilitates transmission while segmentation impedes it, suggesting opportunities for interventions. These data also emphasize the need to re-evaluate purely behavioural explanations of STD/HIV transmission.     

Can skin wrinkling in a site that has received limited sun exposure be used as a marker of health status and biological age?

OBJECTIVES: to determine if skin wrinkling in a site that had received limited sun exposure may be a marker of health status and biological age. DESIGN: population-based, cross-sectional study. PARTICIPANTS: we evaluated the health status of representative samples of elderly Greek-born people living in Melbourne, Greeks living in rural Greece, Anglo-Celtic Australians living in Melbourne and Swedes living in Sweden. We carried out microtopographic assessment of their skin and measured plasma dehydroepiandrosterone concentrations. METHODS: we derived activities of daily living, well-being, memory and general health status scores from a cross-cultural questionnaire. We measured skin wrinkling using cutaneous microtopographic methods and plasma dehydroepiandrosterone by enzyme immuno-assay. RESULTS: skin wrinkling was positively correlated with age (r(s)=0.27, P<0.0001) and negatively with body mass index (r(s)=-0.19, P<0.0001). Therefore, all analyses were controlled for these variables. Plasma dehydroepiandrosterone was higher in smokers than non-smokers (2.86 vs 2.08; P<0.001) and men had significantly higher plasma dehydroepiandrosterone than women (2.74 vs 1.69; P<0.0001). In the pooled data, skin wrinkling was negatively associated with general health score (r(s)=-0.13, P<0.01) and activities of daily living score (r(s)=-0.14, P<0.05) after controlling for age, body mass index and smoking. These associations were more pronounced in women. Finally, those with the least skin wrinkling had the highest dehydroepiandrosterone level (r(s)=-0.12, P=0.06) after adjusting for age, smoking and sex. CONCLUSION: skin wrinkling in a site with limited sun exposure might be used as a marker of health status and, to some extent, biological age--particularly for women.     

Death and transfiguration of cortical thymocytes: a reconsideration

The fate of most cells in the mammalian thymus, namely CD4+CD8+ (double positive) cortical cells, is unknown. A fraction of the cells in this population serve as developmental intermediates, but the vast majority will die. In this article Ellen Rothenberg discusses how and when the cells are condemned or promoted to maturity, in the light of intriguing new data that suggests that they may be able to be rescued for longer than was previously thought.