Visceral injury without hemoperitoneum: A limitation of screening abdominal sonography for trauma

Abdominal sonography for the detection of hemoperitoneum has become increasingly popular as a screening test for visceral injury after blunt trauma. The purpose of this study was to determine the frequency, severity, and clinical significance (outcome) of abdominal organ injuries that occur without hemoperitoneum on the initial evaluation of blunt abdominal trauma patients.During a 12-month period, 3392 blunt trauma patients were admitted to our center. Sonographic studies were performed as an initial screening evaluation to determine the presence of hemoperitoneum in 772 (22.7%) of these patients. Abdominal visceral injuries were verified by computed tomography (CT) or surgery in 196 (5.8%) of all blunt trauma admissions. Sonography, CT, and operative findings were reviewed to determine the presence or absence of hemoperitoneum in patients with abdominal injury. Patients with abdominal visceral injury without hemoperitoneum were further analyzed to identify the type of injury and the management required.A total of 246 abdominal injuries were identified in 196 patients. Fifty (26%) patients with abdominal visceral injuries diagnosed by admission CT scan had no evidence of hemoperitoneum. Admission sonography performed in 15 (30%) of these 50 patients also showed no evidence of hemoperitoneum. Visceral injuries detected by CT in the patients without hemoperitoneum included 22 of 100 splenic injuries (22%), 18 of 91 hepatic injuries (20%), 12 of 26 renal injuries (46%), and 1 of 9 mesenteric injuries (11%). Surgery was required to manage injuries in 10 of these patients.Up to 26% of blunt trauma patients with abdominal visceral injuries do not have associated hemoperitoneum identified on admission abdominal CT or sonography. Dependence on hemoperitoneum as the sole criterion of abdominal visceral injury after blunt trauma will result in falsely negative examinations and will miss potentially significant injuries.     

The prevalence and prognostic significance of spontaneous bacterial peritonitis in severe acute hepatitis with ascites.

The prevalence and prognostic significance of spontaneous bacterial peritonitis were prospectively studied in a series of 82 acute hepatitis patients decompensated with ascites. The in-hospital prevalence of spontaneous bacterial peritonitis was 31.7% (26 of 82 patients). Twenty cases were culture positive, including one with multiple isolates, and six cases were culture negative. E. coli and Klebsiella pneumoniae were the most common pathogens, accounting for 71.4% (15 of 21) of the total isolates, whereas only 9.5% were gram-positive organisms. No significant difference in the age, sex, cause of acute hepatitis, liver biochemistry, prothrombin time and ascites fluid concentration of total protein was noted between patients with spontaneous bacterial peritonitis and those without spontaneous bacterial peritonitis, except that bacteremia was recognized significantly more frequently in the former (57.7% or 15 of 26 patients) than in the latter (25.0% or 14 of 56 patients, p less than 0.005). In addition, patients with spontaneous bacterial peritonitis, when compared with those without spontaneous bacterial peritonitis, were more likely to have kidney failure (57.7% vs. 30.4%, p less than 0.05) and had a significantly higher mortality rate (73.1% vs. 39.3%, p less than 0.01). Among patients without spontaneous bacterial peritonitis, the prevalence of kidney failure and gastrointestinal hemorrhage and the mortality rate in patients with bacteremia (57.1%, 64.3% and 71.4%, respectively) were significantly higher than in those without bacteremia (21.4%, 19.0% and 28.6%, respectively; p less than 0.05, p less than 0.01 and p less than 0.01, respectively). In conclusion, 31.7% of severe acute hepatitis patients with ascites were recognized as having spontaneous bacterial peritonitis; the other 17.1% had bacteremia.(ABSTRACT TRUNCATED AT 250 WORDS)     

In vivo proton magnetic resonance spectroscopy detection of human alcohol tolerance

Alcohol tolerance was ascertained with in vivo proton magnetic resonance spectroscopy (MRS) in men who regularly consumed either large (10–20 drinks/week) or small (2–4 drinks/week) amounts of beverage alcohol. Brain ethanol concentrations were determined by MRS, and blood ethanol levels were measured by gas chromatography after controlled ethanol administration (0.8 g/kg). Brain-blood ethanol concentration ratios for heavy drinkers were significantly greater than ratios for occasional drinkers (P < 0.002). Inasmuch as ethanol tolerance covaries with the severity of dependence, MRS procedures may facilitate our understanding of alcohol tolerance and treatment of alcoholism.     

Subunit- and brain region-specific reduction of GABAA receptor subunit mRNAs during chronic treatment of rats with diazepam

The mRNA levels for several GABA_A receptor subunits were measured by Northern blot analysis. Rats were treated for 3 wk by continuous release of diazepam (DZP) from subcutaneous reservoirs, and then sacrificed immediately or 48 h after removing the reservoirs. Poly(A)⁺ RNAs, isolated from cerebral cortex, cerebellum, and hippocampus, were hybridized with oligonucleotide probes for GABA_A receptor subunits and a cDNA probe for β-actin. Subunit mRNAs were expressed relative to the corresponding β-actin mRNA. DZP treatment decreased the α₁ subunit mRNA level 40% in hippocampus, but it was not changed in cortex or cerebellum. The α₅ subunit mRNA level was decreased in cerebral cortex (28%) and hippocampus (15%). The γ₂ subunit mRNA level was decreased (40%) only in cortex. DZP treatment did not affect α₂, α₃, α₄, β₂, or β₃ subunit mRNA levels. Decreases in mRNA levels had reversed within 48 h after stopping chronic treatment. Acute DZP did not change α₁, α₅, or γ₂ subunit mRNA levels. The decreases in GABA_A receptor subunit mRNA levels were specific to subunit and brain region. These results, coupled with those after chronic flurazepam treatment, also indicated that the effects on GABA_A receptor subunit mRNA levels are specific to the benzodiazepine (BZ) used for chronic treatment.     

Dynamic cardiomyoplasty for hemodynamic support during acute pulmonary hypertension. An experimental study.

The efficacy of dynamic cardiomyoplasty for hemodynamic support during acute pulmonary hypertension was studied. Five dogs underwent a right latissimus dorsi cardiomyoplasty. Each dog was later studied in a short-term experiment. A graded acute pulmonary hypertension was induced by infusion of glass microspheres into the pulmonary artery. This resulted in decrease in pulmonary artery flow, systemic pressure, and systemic flow. The cardiomyoplasty was then stimulated with a new R wave synchronous rate-responsive pulse-train stimulator (Prometheus system). This pacemaker delivers a pulse train with the duration of stimulation determined as a proportion of the RR interval. At an optimal level of hemodynamic impairment, the dynamic cardiomyoplasty was able to immediately improve pulmonary artery flow 26.4% +/- 5.84% (standard error of the mean) (p less than 0.005, paired t test), mean systemic arterial pressure 11.6% +/- 3.7% (p less than 0.05), and thoracic aortic flow 15.7% +/- 6.3% (p less than 0.05). The degree of improvement in hemodynamic variables could be correlated with the magnitude of hemodynamic impairment present (e.g., r = 0.78; p less than 0.005 for pulmonary blood flow). We conclude that a significant beneficial effect of dynamic cardiomyoplasty on hemodynamics in short-term canine pulmonary hypertension is demonstrated in this study. Thus cardiomyoplasty may be useful in patients with right heart failure associated with increased pulmonary vascular resistance.     

Paraneoplastic Pemphigus and Bronchiolitis Obliterans in a Patient with Splenic B-cell Lymphoma.

Paraneoplastic pemphigus (PNP), also called paraneoplastic autoimmune multiorgan syndrome, is a rare disorder associated with underlying neoplasia. The common underlying neoplasms include non-Hodgkins lymphoma, chronic lymphocytic leukemia, and Castlemans disease. Though B-cell lymphoma is the most common underlying malignancy, only one case associated with splenic B-cell lymphoma has been recognized. The prognosis of PNP is very poor, and PNP-associated bronchiolitis obliterans (BO) is not uncommon. Herein, we report a 44-year-old woman who initially presented with multiple oral ulcers, conjunctivitis, and numerous cutaneous blisters. Serial workup established the diagnosis of PNP and revealed an underlying splenic B-cell lymphoma. Although the mucocutaneous lesions gradually healed after splenectomy and chemotherapy, deteriorating respiratory function developed 7 months later with pathologically proven BO. She finally succumbed to respiratory failure 12 months after presentation despite intensive respiratory care.