Identification of the high-risk population for serious burn injuries

The incidence of serious burn injuries has been determined for the Commonwealth of Virginia during a 21-month period. The data set included all patients with burn injuries who entered the hospital and were considered serious enough to require inpatient treatment. The risk for burn injury was calculated by age, race and sex. Examination of the data identified a high-risk population that was prone to serious burn injuries. The demographic characteristics of the burn population has been correlated with their socio-economic status.     

Blunt abdominal trauma: Exploratory laparotomy or peritoneal lavage?

In contrast to other series purporting advantages of routine lavage [20], our data support the position that, in patients with blunt abdominal trauma, certain criteria eliminate the need for peritoneal lavage and make this procedure an unwise investment of valuable time on a routine basis. Criteria such as evidence of hollow organ rupture on radiologic studies, gross abdominal wall defects (excluding simple lacerations), rapidly increasing abdominal distention, uncorrectable hypotension and isolated rigidity on abdominal examination in an otherwise intact and cooperative patient, should be considered indications for laparotomy. In a stable patient with associated injuries or altered central nervous system status, abdominal examination should be viewed as suspect and peritoneal lavage considered mandatory. However, in over one fourth of cases, positive lavage may fail to correlate with intraabdominal injury of a degree that necessitates operative repair. In patients admitted for observation of abdominal injuries with concurrent alterations in central nervous system status or associated injuries that hinder accurate abdominal examination when no urgency exists, we support the opinion that selective use of peritoneal lavage will save unnecessary delay in diagnosis and operative treatment. The highly lethal nature of multiple injuries and central nervous system damage is confirmed by our data, verifying reports by Davis et al [6] of a 70 percent or greater mortality rate among comatose patients hospitalized with multiple trauma.     

A Simple,Rapid Technique for Operative Closure of Patent Ductus Arteriosus in the Premature Infant

A rapid, simplified clip technique for operative closure of the ductus arteriosus in premature infants is presented.     

An intensive vascular surgical skills and simulation course for vascular trainees improves procedural knowledge and self-rated procedural competence

Background

Surgical skills and simulation courses are emerging to meet the demand for vascular simulation training for vascular surgical skills, but their educational effect has not yet been described. We sought to determine the effect of an intensive vascular surgical skills and simulation course on the procedural knowledge and self-rated procedural competence of vascular trainees and to assess participant feedback regarding the course.

Relation of therapeutic response to nifedipine to coronary anatomy and motion of S-T segment during unstable angina pectoris

Of 77 patients hospitalized for unstable angina pectoris and failure of oral, dermal, or intravenous nitrates and/or beta blockade, 81 percent with negligible or single-vessel disease and 55 percent with two- or three-vessel disease showed response (p < 0.05) to nifedipine therapy. Patients with either S-T elevation or no change during pain responded better (31 of 45) than those with any S-T depression (16 of 32; p < 0.05). Patients with negligible or singlevessel disease had a higher prevalence of S-T elevation ( 13 of 16) than patients with two- or three-vessel disease (15 of 31; p = 0.004). S-T motion did not predict response in patients with two- or three-vessel disease, but did predict response in patients with negligible or single-vessel disease. On follow-up study at 9 ± 8 (range one to 33) months, 39 of 42 who had shown response were free from pain. Three died from infarction without unstable angina. Five who showed response had elective bypass surgery. The addition of nifedipine abolished or reduced pain episodes by more than 50 percent in 61 percent of patients with refractory unstable angina pectoris. Patients with negligible or single-vessel disease with S-T elevation benefit most. In patients with two- or three-vessel disease, the type of S-T motion did not predict response. Follow-up of all those with response indicated sustained amelioration by nifedipine therapy. Failure of nifedipine therapy should not be accepted until a dose of 120 mg per day has been achieved, or until intolerable side effects appear.     

Methodologic problems of exercise testing for coronary artery disease: Groups,analysis and bias

To determine why exercise testing remains controversial as a diagnostic test for coronary artery disease, a methodologic review was undertaken of 33 studies comprising 7,501 patients who had undergone both exercise tests and coronary angiography. Of seven methodologic standards for research design, only one received general compliance: the requirement for an adequate variety of anatomic lesions. Less than half of the studies complied with any of the remaining six standards: adequate identification of the groups selected for study; adequate analysis for relevant chest paln syndromes; avoidance of a limited challenge group; and avoidance of work-up bias, diagnostic review bias and test review bias. Only one study met as many as five standards.These methodologic problems may explain the wide range of sensitivity (35 to 88 percent) and specificity (41 to 100 percent) found for exercise testing, because the variations could not be attributed to the usual explanations: definition of anatomic abnormality, stress test technique or definition of an abnormal test. Determining the true value of exercise testing requires methodologic improvements in patient selection, data collection and data analysis.     

Determinants of reperfusion cardiac electrical activity after cold cardioplegic arrest during coronary bypass surgery

In a prospective study of 99 patients with coronary artery disease, reperfusion of the heart after a period of ischemia (protected by contemporary techniques of myocardial preservation) resulted in spontaneous resumption of cardiac electrical activity in 53%, spontaneous defibrillation in 10%, reperfusion ventricular fibrillation (VF) in 32% and indeterminate rhythm in 5%. In hearts spontaneously developing rhythms excluding VF (as opposed to hearts requiring direct-current shock), factors significantly associated were a higher plasma potassium concentration (5.2 vs 4.8 mEq/liter), shorter reperfusion time (1 vs 4 minutes), higher plasma magnesium concentration (1.36 vs 1.25 mg/dl) and a lower myocardial temperature (27 vs 32 degrees C). The duration of ischemia, arterial blood gas levels, plasma catecholamine levels, plasma ionized calcium levels, volume of cardioplegia and mean arterial pressure did not relate to occurrence of spontaneous episodes. However, VF developed in 39 of 52 patients (75%) with spontaneous resumption of electrical activity. This event was associated with lower myocardial temperature. Thus, direct-current shocks were ultimately required in 77 of the 99 patients (78%). Although certain thermal, biochemical and hemodynamic variables facilitate spontaneous resumption of cardiac rhythm, the development of VF may negate the potential benefit of this event in the prevention of myocardial damage from direct-current defibrillation.