Search

Diagnostic peritoneal lavage (DPL) is used to diagnose intra-abdominal injury in patients with stab wounds and blunt trauma. Because exploratory celiotomy is routinely performed on patients with gunshot wounds to the abdomen, DPL is rarely employed. However, several studies have questioned routine exploration and have drawn attention to the associated morbidity of negative celiotomy. Diagnostic peritoneal lavage is an easily performed and inexpensive test that may be useful in this situation.To evaluate the performance of DPL in the diagnosis of intra-abdominal injury in hemodynamically stable patients with gunshot wounds to the abdomen.A prospective clinical trial.Two urban trauma centers.Patients with gunshot wounds to the abdomen and a systolic blood pressure of at least 90 mm Hg.Clinical predication of intra-abdominal injury in the emergency department and DPL performed in the operating room before the initiation of celiotomy. Injuries found during the celiotomy were recorded.The results of the clinical evaluation and DPL were compared with the findings of the celiotomy.Forty-four patients were enrolled into the study. Intra-abdominal injury was present in 32 (73%) of these patients. The senior surgery resident correctly predicted the presence of intra-abdominal injury in 36 (82%) of the patients (sensitivity = 90.0%, specificity = 58.3%, positive predictive value = 85.3%, negative predictive value = 63.6%, phi = 0.52, P.01) in the emergency department before DPL and celiotomy were performed. Diagnostic peritoneal lavage correctly identified the presence or absence of intra-abdominal injury in 40 (91%) of the patients (positive predictive value = 96.7%, negative predictive value = 78.6%, phi = 0.79, P.01).Clinical judgment is highly accurate in separating patients with tangential gunshot wounds to the abdomen from those with intra-abdominal injury but may miss patients with intra-abdominal hemorrhage. Diagnostic peritoneal lavage is highly predictive of the presence of intra-abdominal injury. The return of gross blood on aspiration or a lavage red blood cell count greater than 10 x 10(9)/L should prompt an urgent celiotomy. Missed injuries are rare and most likely to be bowel perforations. Diagnostic peritoneal lavage is an objective test that may augment clinical judgment in selecting hemodynamically stable patients with potential tangential gunshot wounds for observation and is especially useful in identifying intra-abdominal hemorrhage.

In Reply. —We apologize for not realizing the convention that in Hispanic culture the middle name is included as part of the surname, and thank Dr Benach for the correct citation of their retrospective study. In regard to Dr Cameron, we raise the possibility that persistent CNS infection may act as a sanctuary for B burgdorferi. We also clearly point out in the article that "DNA from both viable and nonviable organisms" are measured by PCR. Clearly, the issue of the significance of the CNS as a sanctuary will require carefully conducted prospective studies. Finally, although not included in the article, in all instances tested, the CSF red blood cell count was less than 5×106/L. This fact, together with the low level of bacteremia known to occur with Lyme borreliosis, make contamination highly unlikely.

REPORT OF A CASE A 77-year-old woman was admitted to the Institute of Medical Pathology in Genoa, Italy, with fever, fatigue, weight loss, and a bilateral cervical lymphadenopathy of two months' duration. She also exhibited an asymptomatic cutaneous eruption on her lower limbs that had begun at the same time as the general symptoms. Dermatologic examination revealed red-brown, slightly scaling follicular and perifollicular papules that coalesced in irregular plaques on her lower extremities, particularly on the legs and feet (Figs 1 and 2), and were more discrete on the trunk. There was a bilateral cervical lymphadenopathy; the lymph nodes were adherent to the skin and deeper tissues and tended to fluctuate. Laboratory findings were as follows: erythrocyte sedimentation rate, 116 mm/h; hemoglobin, 91 g/L (9.1 g/dL); red blood cell count, 3.2 × 10 12 /L (3.2/ mm 3 ); and white blood cell count, 4.3 × 10 9 /L (4320/ mm

Although "quality control" is a familiar concept in manufacturing, it is not a uniform practice in all medical laboratories. Many physicians do not realize that a test can be precise (repetitively getting the same number) without being accurate (correct in relation to an accepted standard). The sensitivity and range of given tests may also be tremendously influenced by the presence of other drugs or pharmacologically active metabolites. Intralaboratory control (internal) can check on the reproducibility but not guarantee accuracy. External quality control allows a laboratory to compare its precision and accuracy against other laboratories. This task is difficult enough when all agree on how to do the test and what reagents should be used. Then, too, more problems obviously exist in differential counting of white blood cells than in determination of the hemoglobin values, hematocrit values, and the red blood cell count. The introduction of mechanized equipment has improved the

FOUR patients having acute obstruction due to volvulus of the sigmoid and 1 patient having acute obstruction due to volvulus of the cecum have served to emphasize certain diagnostic and therapeutic points. In volvulus of the sigmoid, in older patients, there is usually a history of repeated attacks of partial obstruction or of constipation, while in younger patients the acute obstruction often occurs without any previous history.1The obstruction may be of many hours' duration, but the patient is not so sick as one might expect with carcinoma. The hemoglobin value and the red blood cell count are usually not much below normal. The abdomen is apt to be markedly distended. There may be little vomiting. There is pain over the dilated loop and especially where the twist puts a pull on the root of the mesentery. This pain will be severe if there is much interference with circulation.

Most clinical laboratory workers have from time to time encountered annoying incidents in connection with the simple procedure of doing a leukocyte or red blood cell count. The rubber tubing has at times been punctured in the process of being used to wrap the ends of the counting pipet, and the contents have escaped in transit from the bedside to the laboratory. The accompanying illustration shows an implement which is a combination of holder and aspirator for the ordinary blood-counting pipet, and is self-explanatory. This instrument was made experimentally by Edward P. Dolbey & Co. of Philadelphia and may now be obtained from that firm.

MASSIVE gastrointestinal bleeding causes dramatic signs and symptoms for the patient and presents a challenge to the internist, the surgeon, and the radiologist. The source of such bleeding often remains obscure to the very end, and the mortality is high. A review of available data from several centers shows considerable variation in the incidence of massive bleeding, in the source of the bleeding, and in the mortality resulting from it. In order to obtain information bearing on these variables, the records of patients admitted to City Hospital of Cleveland because of gastrointestinal bleeding between the years 1941 and 1951 inclusive were reviewed and analyzed. DEFINITION As emphasized by the work of Stewart 1 and his associates, interpretation of data concerning massive gastrointestinal hemorrhage must be qualified by a definition of the term. Welch 2 showed, for instance, that by taking a red blood cell count of 2,500,000 per cubic millimeter

That a typical diuresis follows the ingestion of large amounts of water has been known for some time, but the mechanism by which the water is conveyed from the intestine to the kidneys and the factors stimulating the kidneys to action, whether they are hormone, vascular, nervous, or physicochemical, are not yet proved beyond question. Engel and Scharl,1using the refractive index of the serum, Macallum and Benson,2using the red blood cell count, Haldane and Priestley,3and Adolf,4using hemoglobin determinations, found that no dilution of the blood is measurable by these methods when large amounts of water are drunk, although a marked diuresis is produced. Priestley5did not find any dilution of the hemoglobin, but a decrease of from 2 to 5 per cent in the conductivity of the serum, indicating a proportionate dilution of the plasma electrolytes. He also found that when an almost istonic salt solution

The color index, taken as the ratio of the percentage of hemoglobin (compared to "normal") to the red blood cell count (compared to "normal") has been a useful clinical figure in differentiating iron deficiency from other types of anemia. However, the lack of single "normal" figures for the percentage of hemoglobin and red blood cell counts, as well as the differences in males and females, has always made the number somewhat arbitrary. With the advent of hemoglobinometers in which 100 per cent corresponds to 13.5, 14, 15.6 or 17 Gm., the problem is further complicated by the difference in readings of the percentages. These would give the same person different percentages on the different instruments. The same person could have a "normal" color index with one instrument, a high index with another and a low index with a third. To avoid these discrepancies and still obtain a figure which would

This study is based on observations in twenty-five typical cases of pernicious anemia treated during the past two years with liver and liver extract. With a few exceptions the patients have at the beginning of treatment been admitted to the Albany Hospital for a period of from three to four weeks. Our criteria for diagnosis have been rigid. In making the diagnosis of pernicious anemia, emphasis has been placed on (1) clinical history, especially the presence of a sore tongue and paresthesias of the extremities; (2) the exclusion of obvious cases of secondary anemia, and (3) the confirmatory laboratory data of achlorhydria, high color index, macrocytosis and high icterus index. No case was included in the series which was in a state of frank remission. Cases presenting an initial red blood cell count above 2,800,000 were excluded, together with borderline cases in which the diagnosis was uncertain and those in

Data from 129 selected patients with pernicious anemia in relapse, adequately treated with liver extract intramuscularly, and twenty-one patients treated with desiccated, defatted stomach tissue have been analyzed to note the rate of increase in the red blood cell count. The dosage of liver extract averaged the equivalent of from 1 to 2 units daily, and the desiccated stomach dosage was usually 40 Gm. daily for the first two weeks. In chart 1 the red blood cell count at the beginning of intramuscular liver extract therapy is plotted against the red blood cell count at the end of one, two, three and four weeks. A separate line is drawn for each week. The lines have been smoothed and corrections have been made for deviations due to manifest abnormalities and inadequate data at various points, as indicated by evident interpolations. Data from more than 500 cases were available for such changes.

To the Editor:— The paper by Judy and Price entitled "Hemoglobin Level and Red Blood Cell Count Findings in Normal Women," ( J. A. M. A. 167 :563-566 [May 31] 1958) is of great interest. Establishing normal values is an important but a very difficult task. The authors indicate that their stimulus for undertaking the study came from their frustration in attempts "to bring hemoglobin level and red blood cell count on women up to the previously established standards of 14 Gm. and of 4,800,000." This led them to question the generally accepted normal values for blood counts of women. While it is, indeed, futile to attempt to raise every patient's hemoglobin level to the average, this is inherent in the concept of the average and does not appear to me to be a reason to challenge the validity of the established mean. Nonetheless, as methods improve, periodic reevaluation of the

[Note.—The preceding letter was referred to Dr. Isaacs, who replies:] To the Editor:— Dr. Murphy assumes that the average "normal" hemoglobin and erythrocyte levels are 15.5 Gm. and 5,200,000 for males and 14.5 Gm. and 4,800,000 for females. This illustrates my point exactly and demonstrates just what I wished to avoid. These standards of normal (1) are purely arbitrary and (2) differ with different workers and authors and in different parts of the country. I certainly agree with Dr. Murphy that the reporting of hemoglobin in grams is more desirable than in percentage, and my formula was merely a way by which a physician without a slide rule could get a mental image of whether the number of grams was high, low or comparable to the changes in the individual patient's red blood cell count. It is easy to multiply the number of grams of hemoglobin by 3 and

A knowledge of the relative size of the red blood cells may be of definite value in differentiating between the types of anemia. This information may be obtained by a careful study of the red blood cells in a stained smear made from the patient's blood. Determinations of the mean diameter of the red blood cells by actual measurement of a number of cells, as suggested by Price-Jones, 1 or by a modification of this method, have been made use of frequently; but this method is rather too time-consuming to be used extensively. Pijper 2 and others have suggested a diffraction method for determining the size of the red blood cells. Haden 3 suggested the determination of the volume of the average red blood cell by means of a simple calculation based on a knowledge of the red blood cell count and the total percentage volume of cells as determined by means of

An unusually high blood platelet count of more than 2,500,000 is the reason for this report. A Scandinavian woman, aged 65, was admitted to the Ancker Hospital in March 1935 because of recurrent extensive subcutaneous hemorrhages and shortness of breath on exertion. She had been in the same hospital five months before because of the same shortness of breath. This was thought to be due to a hypertension with slight decompensation and possibly a coexisting nephritis. In November 1934 the red blood cell count being 5,800,000 and the blood platelet count 1,000,000, venesection was performed at the Ancker dispensary with some subjective relief. Following this, subcutaneous hemorrhages began to appear and on one occasion a severe epistaxis. On examination the patient's complexion suggested a polycythemia although it was not the typical brick red color. The lips were definitely cyanotic. There were large areas of

Mattie A., aged 38, was admitted to Mercy Hall Cancer Hospital on March 9, 1945. She had been operated on at Woman's Hospital by Dr. W. E. Johnston in July 1941. Dr. Johnston, Dr. Don M. Beaver and Dr. Frances Ford supplied the notes from the latter hospital admission. Prior to her admission to Woman's Hospital the patient had complained of pain and tenderness underneath the right costal margin for one year and of jaundice for two weeks. She had weighed 90 pounds (40.8 Kg.) and had a hemoglobin content of 60 per cent and a red blood cell count of 3,250,000. At abdominal exploration on July 25, 1941, the head of the pancreas had been found to be the size of a large plum, round and hard. The gallbladder had been distended and the common duct dilated. There had been no evidence of disease of the gallbladder. Cholecystogastrostomy had

The thalassemias constitute a group of inherited anemias characterized by defective hemoglobin synthesis, without obvious structural change in the preponderant type of circulating hemoglobin. Different defects in hemoglobin synthesis may be responsible in different families. The author delineates 11 varieties of thalassemia, and suggests that there may be more. Clinical severity ranges from increased red blood cell count and no clinical manifestations, to fetal death with hydrops. There is often an increase in minor hemoglobin components. The globin of normal hemoglobin, type A, contains two alpha and two beta chains, α2β2. Fetal (type F) and A2 hemoglobins, normal minor components, are similarly designated α2γ2 and α2δ2, and in some thalassemias, elevations of one or both may be found. In others there may be abnormal chain combinations, H (β4), Bart's (δ4), or Lepore (fusion or crossing-over of portions of β and δ chains). While these syndromes are more common in Mediterranean

To the Editor.— The excellent article by Drs. Perry and Winkelmann on bullous pyoderma gangrenosum and leukemia in theArchives(106:901, 1972) prompts us to report a case of ours. In this case, there has been recent development of pyoderma gangrenosum while the patient was receiving treatment for acute lymphoblastic leukemia. The lesions, which were resistant to most drugs, eventually cleared up with administration of rifampin. Report of a Case A 13-year-old Chinese schoolgirl was found to have acute lymphoblastic leukemia in September 1971. She was anemic, but was otherwise well. There was a hepatomegaly of 3 cm below the right costal margin. The other organs were not enlarged. Hematologic studies showed the following results: total red blood cell count, 3 million/cu mm; hemoglobin, 9.0 gm/100 ml; total leukocyte count, 26,700/ cu mm, with 63% blast cells, 31% lymphocytes, and 6% neutrophils; platelet count, 20,000/cu mm; reticulocyte count, 2%; packed

Patients afflicted with pernicious anemia present many symptoms which differ strikingly from those of secondary anemia. One is the discrepancy between the general appearance of a patient with pernicious anemia and his blood count. Patients with secondary anemia having a red blood cell count of 2,000,000 or less, are not only weak and ill enough to be in bed, but have a pallor so marked as to be noticeable even to the most casual observer. In contrast with this, patients who have pernicious anemia may be up and around and may have color in the face and lips which is so good that one is often surprised at the finding of an extremely low red blood cell count, from 1,000,000 to 1,500,000. In fact, often their color is so good that the anemia is overlooked by their physicians. The pallor may be partly obscured by the lemon yellow tinge of

The term massive melena means the passage of large amounts of blood by rectum, frequently producing shock and a low hemoglobin and red blood cell count. This condition may necessitate several transfusions. Occasionally a patient who has had repeated gastrointestinal studies and exploratory celiotomies which have failed to reveal the source of bleeding comes for treatment of massive melena. This problem has been discussed by others, particular Stone,1of Baltimore, and such a case has been presented previously from this clinic by Norcross and Cattell.2In this paper, the problem of obscure massive melena will be reviewed, diagnostic methods evaluated, and a plan of management proposed. With such patients the immediate treatment consists of restoring the blood volume by repeated transfusions. Another attempt is then made by diagnostic methods to determine the location and nature of the lesion. The physical examination will aid in ruling out any systemic

Few quantitative determinations of blood used in the clinic afford the same opportunity for cross checking of the accuracy of two methods as do the determinations of erythrocytes and of hemoglobin values, since in normal individuals the relationship between these values, usually referred to as the color index (Peters and Van Slyke 1 color: count ratio) is constant. It follows that abnormal color index values are of significance only when it is certain that they are abnormal. In spite of this opportunity for constant checking of data without additional effort, the values for hemoglobin and for color index remain, in most hospitals, only of relative significance, and data accumulated in one clinic, in most instances, cannot be safely compared with data from another clinic. There are two primary reasons for this unsatisfactory condition in regard to unusually important clinical laboratory data. The first reason is the confusion arising from the

During a recent study of a group of patients with hemolytic jaundice before, during and after splenectomy, we 1 have been disturbed on two occasions because of unfavorable reactions following transfusion of whole blood. A general review of the voluminous literature on hemolytic jaundice failed to reveal a single title referable to this complication, but submerged in the detailed study of case reports there are warnings of its occurrence and possibility. As a result of our experience, it seemed feasible to focus attention on the subject and to present the clinical manifestations and the possible cause. REPORT OF CASES Miss M. B., a housemaid, aged 25, entered the University Hospital for the third time Nov. 30, 1936, with symptoms of a severe crisis of hemolytic jaundice. On the two previous hospital admissions, four years before, she had been in similar crises with a red blood cell count of about one