Evaluation of possible traumatic thoracic aortic injury using aortography and CT

To identify and compare the methods of evaluation for suspected traumatic aortic rupture, 1,031 trauma charts from 1983-1989 were reviewed. Fifty-nine patients were evaluated for possible aortic injury. Patients who died before completion of the CT or aortogram were excluded. Widening of the mediastinum on chest x ray was the most frequent indication for follow-up studies. Twenty-five had a CT of the aortic arch alone. No study showed disruption. There were no false negative studies. Thirty patients had only aortography. Twenty-four were read as normal (one false negative). Six were read as positive (one false positive). In four, both studies were performed (CT/aortography--TP/TP, TN/TN, TP/FN, FP/FP). (FP = False Positive, TP = True Positive, FN = False Negative, TN = True Negative.) Six received surgical repair of the aortic injury (one death). In this experience, CT was used successfully as a screening tool for aortic disruption. It was highly sensitive in recognizing aortic injuries when present (100% vs. 75% for aortography) and in most cases did not require aortographic verification. False positive rates were comparable (CT = 3.8%, aortography = 7.7%). Specificity was also comparable (CT = 96%, aortography = 92%). Overall, four aortograms were inaccurate while only one CT was inaccurate. We recommend the use of CT for the evaluation of widened mediastinum in the stable patient.     

A postoperative analysis of the patient''s view of anaesthesia in a Netherlands'' teaching hospital

A postoperative questionnaire was used in 129 patients who had undergone a wide range of surgical procedures in order to investigate their personal experience of anaesthesia. The most frequent complaints were of feeling cold on waking up, sore throat, vomiting and muscle pains, all of which are capable of reduction by a change in anaesthetic technique. The total number of patients who had one or more complaints was 107 (82.9%). More than a third of the patients were afraid of the anaesthetic, as distinct from the operation. Most had received a pre-operative visit from the anaesthetist which was greatly appreciated. A few patients believed they could have been better informed of possible sequelae. More than 30% were not visited by the surgeon before the operation. A routine postoperative interview, using a preformulated questionnaire, is a good way to assess and maintain a high quality of anaesthesia.     

An outpatient anticoagulation protocol managed by a vascular nurse-clinician

Lifetime anticoagulation has become a therapeutic option for surgical patients with hypercoagulable states or prosthetic arterial bypass grafts. However, physicians may not achieve optimal anticoagulation or may attempt to limit the length of the therapy period because of the perceived morbidity from hemorrhagic complications of Coumadin therapy. A protocol for anticoagulant therapy monitored and regulated by a vascular nurse-clinician was reviewed. Coumadin was prescribed for 1,891 patient-months to 93 patients to maintain their prothrombin time 1.5 to 2 times control (range: 18 to 24 seconds). The mean (+/- SD) prothrombin time for the study population was 19.8 +/- 1.8 seconds. During follow-up, 472 (14%) of 3,479 prothrombin times measured were below the therapeutic range (n = 232) or prolonged (n = 240), prompting an adjustment in the Coumadin dose in 82 (88%) patients. Four patients developed recurrent vascular graft thrombosis while receiving anticoagulation. There were 6 major and 11 minor hemorrhagic complications. Patients with a chronic risk for arterial or venous thrombosis can have out-patient anticoagulant therapy administered at optimal intensity and regulated safely with a low incidence of hemorrhagic and thrombotic events.     

Spinal anaesthesia in a child with Job''s syndrome, pneumatoceles and empyema

We present a case of acute bowel obstruction in an immunocompromised child, who also had lobar pneumonia and a giant unilateral pneumatocele. She was successfully managed with subarachnoid anaesthesia for exploratory laparotomy to relieve a colonic obstruction. This proved to be a safe alternative to general anaesthesia with tracheal intubation in this patient and should be considered in infants and children in selected cases whenever a contraindication to general anaesthesia exists.     

Operative cholangiography

The value of operative cholangiography in the management of biliary tract disease has been questioned. To better define the role of cholangiography, we reviewed 579 consecutive cholecystectomies done by 1 group of surgeons in a small rural practice over 8 years. Cholangiography demonstrated unsuspected common bile duct disease in 5% of the procedures, while 12% of the patients were spared an unnecessary choledochotomy after a normal cholangiogram was obtained. There was no morbidity, mortality, or prolongation of the hospital stay attributed to the cholangiographic procedure. These findings bolster the argument for routine cholangiography as a safe, effective, and helpful screening examination for patients who are at risk for having common bile duct disease.     

Development of grating acuity in infants with regressed stage 3 retinopathy of prematurity

The acuity card procedure was used to measure grating acuity in 17 infants with regressed Stage 3 retinopathy of prematurity (ROP) who had no lasting anatomic changes in the retina or optic nerve. Results were compared with those of 28 healthy preterm infants and 28 infants matched by birth weight and gestational age who did not have Stage 3 ROP. Infants in the ROP group showed delayed grating acuity development until 2 years of age. This difference among groups was significant at the 3-5- and 10-12-month test ages but not at the 0-1-, 8-9-, and 16-18-month test ages. Post hoc analyses indicated that the delay in acuity development shown by the ROP group was due to the poor acuity scores of the infants in that group who had central nervous system abnormalities of periventricular leukomalacia or severe (Grade III or IV) intraventricular hemorrhage. When the data of these infants were removed from the analysis, the ROP group showed acuity development similar to that of both the healthy preterm group and the group of infants with matched birth weights and gestational ages who did not have Stage 3 ROP.     

The quantity of rhodopsin in human eyes

The content of rhodopsin in the eyes of 15 donors (30 eyes) was determined. Both retinal and pigment epithelial fractions were collected from each globe, extracted using 1% CTAB, and the rhodopsin difference spectrum of each fraction was obtained separately. The total amount of rhodopsin, obtained by summing the amounts recovered from the retinal and PE fractions, ranged from 2.00 to 11.94 (median: 6.40) nmoles/eye. Previously reported mean values of about 3.5 to 4.0 nmoles per retina have been obtained using a variety of methods. The present higher values, perhaps largely dependent on procedural details described herein, appear plausible given the known concentrations of rhodopsin in rod outer segments, rod outer segment volumes, and number of rods in the human retina.     

Relaxing retinotomies. Analysis of anatomic and visual results

The authors analyzed 100 consecutive eyes undergoing relaxing retinotomies to determine the anatomic and visual results associated with the use of this procedure. With a minimum follow-up of 6 months, 58 eyes were completely attached, 8 were partially attached (macula on), and 34 were detached. Thirty-four percent of all eyes and 50% of attached eyes obtained a visual acuity of 5/200 or greater at 6 months. At last examination, 29% of all eyes and 43% of attached eyes had a visual acuity of at least 5/200. Eyes that had circumferential relaxing retinotomies involving the entire temporal quadrant generally had lower visual acuities when compared with eyes that had relaxing retinotomies sparing the entire temporal quadrant. The use of a radial relaxing retinotomy also was associated with lower final visual acuity. The length of the relaxing retinotomy or the placement of the relaxing retinotomy either anterior or posterior to the encircling scleral buckle did not appear to influence the anatomic or visual results. Hypotony (intraocular pressure less than 5 mmHg) was seen in 43% of reattached eyes.     

Perceptions and behaviour among elderly hospital patients: description and explanation of age differences in satisfaction, knowledge, emotions and behaviour

In this study, it is first of all investigated whether elderly and younger hospital patients differ with respect to satisfaction with several aspects of their stay in the hospital, medical and hospital knowledge, emotional state, seeking information, discussing problems and engaging in self-care. Second, it is investigated whether age differences on these variables can be explained by demographic variables, previous hospitalization experience, information received and personality characteristics on which elderly and younger patients differ. Results show that compared to younger patients, elderly patients are more satisfied, have less knowledge and a smaller number of emotional problems and are less active during hospital admission. These differences covary with, a more positive assessment of the information received, a stronger level of external control, a higher level of social desirability and stronger feelings of gratitude among elderly patients. These results are in line with Taylor's concept of the 'good patient'. Finally, based on the findings, measures are suggested for health workers to promote the well-being of elderly hospital patients.     

Growth hormone enables effective nutrition by peripheral vein in postoperative patients: a pilot study

The purpose of this pilot study was to investigate the metabolic effects of growth hormone (GH) (Humatrope, Eli Lilly & Co., Indianapolis, IN) administration in postoperative (PO) patients receiving peripheral vein nutrition. Seven, well-nourished, nondiabetic patients undergoing elective surgical procedures were given either no drug (n = 3), GH 30 micrograms/kg/day (n = 2), or GH 60 micrograms/kg/day (n = 2) sub-Q daily until eating, up to 7 days PO. All the patients received 5% dextrose with electrolytes in the first 24 hours PO and then received calories at 80 +/- 5% of the measured resting energy expenditure (REE) and amino acid at 1 g/kg/day with electrolytes, vitamins, and minerals. There were no significant outcome differences between the 30 and 60 micrograms/kg/day groups and, therefore, these groups were analyzed together (n = 4). By day 6 of the study, the GH group had a significant reduction in the respiratory quotient (RQ) measured by indirect calorimetry; an increase in nitrogen retention; an increase in plasma transferrin concentrations; and an increase in plasma insulinlike growth factor (IGF1) concentration. There was no increase in blood glucose concentrations, or decrease in urinary 3-methylhistidine excretion; and no adverse effects occurred. We concluded that GH in PO patients on hypocaloric nutrition promoted protein synthesis, fat oxidation, and nitrogen retention. Effective parenteral nutritional support in postoperative adult patients can be achieved without the use of central vein access.