Search

Background “Academic surgeon” describes a member of a medical school department of surgery, but this term does not fully define the important role of such physician-scientists in advancing surgical science through translational research and innovation. Methods The curriculum vitae and self-descriptive vignettes of the records of achievement of seven surgeons possessing documented records of academic leadership, innovation, and dissemination of knowledge were reviewed. Results Out analysis yielded seven attributes of the archetypal academic surgeon: 1) identifies complex clinical problems ignored or thought unsolvable by others, 2) becomes an expert, 3) innovates to advance treatment, 4) observes outcomes to further improve and innovate, 5) disseminates knowledge and expertise, 6) asks important questions to further improve care, and 7) trains the next generation of surgeons and scientists. Conclusion Although alternative pathways to innovation and academic contribution also exist, the academic surgeon typically devotes years of careful observation, analysis, and iterative investigation to identify and solve challenging or unexplored clinical problems, ideally leverages resources available in academic medical centers to support these endeavors.

Damage-control resuscitation is the prevailing trauma resuscitation technique that emphasizes early and aggressive transfusion with balanced ratios of red blood cells (RBCs), plasma (FFP), and platelets (Plt) while minimizing crystalloid resuscitation, which is a departure from Advanced Trauma Life Support (ATLS) guidelines. It is unclear whether the newer approach is superior to the approach recommended by ATLS.With these recent changes pervading resuscitation protocols, we performed a systematic review to determine if the shift in trauma resuscitation from ATLS guidelines to damage control resuscitation has improved mortality in patients with penetrating injuries.A systematic search of PubMed, the Cochrane Library, and the Current Controlled Trials Register was performed for studies comparing mortality in massively transfused penetrating trauma patients receiving either balanced ratios of blood transfusion per damage control resuscitation tenets or undergoing an alternate blood volume resuscitation strategy. Studies were deemed appropriate for inclusion if they had a Newcastle-Ottawa Scale score of 6 or greater as well as at least 30% penetrating trauma. Twenty studies that reported on a total of 12,154 patients were included.Transfusion ratios varied widely, with 1:1 and 1:2 ratios of FFP:RBC most often defined as high ratios for purposes of comparison with other low ratio groups. Fourteen of 20 studies found significantly lower 30-day mortality when higher transfusion ratios of FFP, RBC, and/or Plt were used; six of 20 studies found mortality to be similar between higher and lower transfusion ratios.Patients with penetrating injuries who require massive transfusion should be transfused early using balanced ratios of RBC, FFP, and Plt. Randomized, controlled trials are needed to determine optimal ratios for transfusion.

A recent large civilian randomized controlled trial on the use of tranexamic acid (TXA) for trauma reported important survival benefits. Subsequently, successful use of TXA for combat casualties in Afghanistan was also reported. As a result of these promising studies, there has been growing interest in the use of TXA for trauma. Potential adverse effects of TXA have also been reported. A US Department of Defense committee conducted a review and assessment of knowledge gaps and research requirements regarding the use of TXA for the treatment of casualties that have experienced traumatic hemorrhage. We present identified knowledge gaps and associated research priorities. We believe that important knowledge gaps exist and that a targeted, prioritized research effort will contribute to the refinement of practice guidelines over time.

Traumatic coagulopathy manifests as a hypocoagulable state associated with hypothermia, acidosis, and coagulation factor dilution. The diagnosis must be made clinically because traditional coagulation tests are neither sensitive nor specific and take too long to be used for intraoperative monitoring. We hypothesized that the activated coagulation time (ACT) would reflect the global coagulation status of traumatized patients and would become elevated as coagulation reserves become exhausted. A prospective protocol was used to study 31 victims of major trauma who underwent immediate surgical intervention. Victims of major head trauma were excluded and patients were selected at random over an 8-month period. At least two serial intraoperative blood samples were obtained at 15-min intervals via indwelling arterial catheters. A Hemochron model 801 coagulation monitor was used to measure the ACT. Of the 31 patients studied, 7 became clinically coagulopathic and 24 did not. The ACT measurements of coagulopathic and noncoagulopathic trauma patients were significantly different by multiple statistical comparisons. Both groups differed from normal, nontraumatized patients. The coagulopathic trauma patients had significantly elevated values when compared with other trauma patients or to normal values. We conclude that a low ACT reflects the initial hypercoagulability associated with major trauma and an elevated ACT is an objective indicator that the coagulation system reserve is near exhaustion. An elevated ACT may represent an indication for considering damage control maneuvers or more aggressive resuscitation.

Pictures of the aftermath of the earthquake in Haiti have led to questions about the relief effort. Charles Krin and colleagues offer some advice for prospective volunteers

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.

Hurricane Katrina produced a surge of patient referrals to our facility for cardiac surgery. We sought to determine the impact of this abrupt volume change on operative outcomes. Using our cardiac surgery database, which is part of the Department of Veterans Affairs' Continuous Improvement in Cardiac Surgery Program, we compared procedural outcomes for all cardiac operations that were performed in the year before the hurricane (Year A, 29 August 2004–28 August 2005) and the year after (Year B, 30 August 2005–29 August 2006). Mortality was examined as unadjusted rates and as risk-adjusted observed-to-expected ratios. We identified 433 cardiac surgery cases: 143 (33%) from Year A and 290 (67%) from Year B. The operative mortality rate was 2.8% during Year A (observed-to-expected ratio, 0.4) and 2.8% during Year B (observed-to-expected ratio, 0.6) (P = 0.9). We identified several factors that enabled our institution to accommodate the increase in surgical volume during the study period. We conclude that, although Hurricane Katrina caused a sudden, dramatic increase in the number of cardiac operations that were performed at our facility, good surgical outcomes were maintained.

From 1980 to 1989, 240 adult patients underwent splenorrhaphy at one urban trauma center. This represents 43.4% of all splenic injuries seen during this time interval. Splenic injuries were graded I to V, and splenorrhaphy was attempted except when the spleen was shattered or when multiple injuries with associated hypotension were present. Penetrating wounds, blunt trauma, or iatrogenic/unknown etiologies were present in 54.2%, 41.6%, and 4.2% of patients, respectively. Grade I or II injuries were present in 51.7% of patients, grade III in 34.6%, grade IV or V in 9.6%, and unknown grade in 4.1%. The technique of splenorrhaphy was simple suture (usually chromic) with or without the addition of topical hemostatic agents in 200 patients (83.3%), topical agents alone in 12 (5%), unknown type of repair in 12 (5%), compression, cautery, or nonbleeding injury in 9 (3.8%), and partial or hemisplenectomy in 7 (2.9%). Postoperative rebleeding occurred in three patients (1.3%) with grade II, III, and IV injuries, respectively, and led to splenectomy at reoperation. In another patient who had a hemisplenectomy performed for a grade IV injury, subphrenic abscesses and septic shock led to the death of the patient. Splenorrhaphy can be safely performed in properly selected adult patients after a variety of injuries. The risk of rebleeding is practically nil when the spleen is fully mobilized and visualized during repair.

Background Although aortography has been the long-held "gold standard" for diagnosis of traumatic blunt aortic injury, advances in imaging technology offer less-invasive, more-rapid, and potentially more cost-effective evaluation. The purpose of this study was to review this hospital's experience with the screening and diagnosis of blunt aortic injury with emphasis on the critical evaluation of computed tomography (CT) scans for defining descending thoracic aortic injury. Methods A retrospective single-center analysis of all patients undergoing aortography to evaluate for blunt aortic injury between January 1, 1997, and August 31, 2004, was performed. A policy of relying on CT scans to definitively diagnose blunt aortic injury was not in force, and all patients with positive, equivocal, and negative screening CT scans with significant injury mechanism underwent subsequent aortography; this contributed to an unbiased analysis. A subgroup of patients imaged with the latest generation multislice CT scanners (July 1, 2003, to August 31, 2004) was separately analyzed with rapid three-dimensional reconstruction. Results Of 856 aortograms, 206 (24.1%) were preceded by chest CT scan. Of 31 patients with confirmed aortic injury, 20 had undergone CT scan with 16 positive for definite injury, 3 positive for possible injury, and 1 false-negative study. Of the 206 patients scanned, 114 (55.3%) showed possible injury, 76 (36.9%) were negative, and 16 (7.8%) were positive. Only 3 of the 114 with possible injury (2.6%) were true positives whereas 1 of the 76 negative scans (1.3%) was a false negative and all 16 positive scans were true positives. These data for CT scan imaging result in a sensitivity of 95%, a specificity of 40%, a positive predictive value of 15%, and a negative predictive value of 99%. Conclusions Chest CT is an acceptable screening tool based on prerequisite high sensitivity and ease of performance in the trauma patient suspected of having a descending thoracic aortic injury. Although the excellent negative predictive value resulted in an algorithm change at this institution, there were a significant number of equivocal scans that required subsequent aortography. Three-dimensional software reconstruction of the aorta can aid in diagnosing blunt aortic injury when findings are equivocal, but there will continue to be artifacts and limitations that require aortography for clarification.

Tension pneumopericardium is a rare entity typically described in premature infants requiring positive-pressure ventilation. However, recent reports suggest an increase in its occurrence in adults. A case of delayed postoperative tension pneumopericardium in an adult patient is presented with a review of the history, pathophysiology, presentation, and treatment of this entity.

A case of blunt chest trauma resulting in anterior chondrosternal separation with right lung herniation and hemothorax is presented. The injury is related to the use of a seat belt restraint. The patient underwent surgical repair with polytetrafluoroethylene chest wall reconstruction. Postoperative recovery was complicated by respiratory insufficiency due to underlying pulmonary contusion and multiple rib fractures.

The nature of mankind is a concern for those in need. Disasters, both natural and manmade, have been with us since the beginning of recorded history but media coverage of them is a relatively new phenomenon. When these factors come together, there is great potential to both identify and serve the sick and injured. However, the mass media by its nature tends to enhance the humanistic aspect of rescue while minimizing the practical problems involved. We describe a recent scenario in Haiti that puts some of these complications into a practical perspective.

The triad of hypothermia, acidosis, and coagulopathy in critically injured patients is a vicious cycle that, if uninterrupted, is rapidly fatal. During the past 7.5 years, 200 patients were treated with unorthodox techniques to abruptly terminate the laparotomy and break the cycle. One hundred seventy patients (85%) suffered penetrating injuries and 30 (15%) were victims of blunt trauma. The mean Revised Trauma Score, Injury Severity Score, and Trauma Index Severity Score age combination index predicted survival were 5.06%, 33.2%, and 57%, respectively. Resuscitative thoracotomies were performed in 60 (30%) patients. After major sources of hemorrhage were controlled, the following clinical and laboratory mean values were observed: red cell transfusions--22 units, core temperature--32.1 C, and pH--7.09. Techniques to abbreviate the operation included the ligation of enteric injuries in 34 patients, retained vascular clamps in 13, temporary intravascular shunts in four, packing of diffusely bleeding surfaces in 171, and the use of multiple towel clips to close only the skin of the abdominal wall in 178. Patients then were transported to the surgical intensive care unit for vigorous correction of metabolic derangements and coagulopathies. Ninety-eight patients (49%) survived to undergo planned reoperation (mean delay 48.1 hours), and 66 of 98 (67%) survived to leave the hospital. With the exception of intravascular shunts, there were survivors who were treated by each of the unorthodox techniques. Of 102 patients who died before reoperation 68 (67%) did so within 2 hours of the initial procedure. Logistic regression showed that red cell transfusion rate and pH may be helpful in determining when to consider abbreviated laparotomy. The authors conclude that patients with hypothermia, acidosis, and coagulopathy are at high risk for imminent death, and that prompt termination of laparotomy with the use of the above techniques is a rational approach to an apparently hopeless situation.

We present a case in which a needle broke off during intravenous injection and embolized to the right heart. After cardiac perforation, the needle entered the pericardial space and ultimately caused chronic constrictive pericarditis, which presented as congestive heart failure. Pericardectomy and removal of the foreign body via a median sternotomy were successful. Early surgical removal of contaminated intrapericardial foreign bodies remains a safe and effective approach to preventing such complications.

The medical support for the coordinated effort for Harris County Texas (Houston) to rescue evacuees from New Orleans following Hurricane Katrina was part of an integrated collaborative network. Both public health and operational health care was structured to custom meet the needs of the evacuees and to create an exit strategy for the clinic and shelter. Integrating local hospital and physician resources into the Joint Incident Command was essential. Outside assistance, including federal and national resources must be coordinated through the local incident command.

The reflective and provocative book, Medicine, Preserving the Passion in the 21st Century, by Phil R. Manning and Lois DeBakey, is a breath of fresh air that focuses on the type of medicine and medical education some of us know and others remember, but hopefully all of us strive to maintain in an ever-changing and often frustrating and challenging environment. The focus for the physician is and must be the patient. Pursuit of knowledge that is patient-care–driven is knowledge that stays with you, transfers to other situations, and is ever growing. These tenets ring throughout the book. This edition, like the first, is beautifully written, making reading both inspiring and enjoyable. In Medicine, Preserving the Passion in the 21st Century, Drs. Manning and DeBakey have assembled experienced physicians who have passionately pursued their profession, and that pursuit is reflected in their written words. In each chapter, the importance of physicians approaching their profession as a lifelong learning adventure is underscored. An educational adventure, yes, but one that is disciplined, focused, and integrates modern technology with basics—selective reading, conversing with colleagues and experts, and the like. These authors share common traits—personal motivation and self-discipline—to go beyond the traditional classroom approach to education. It is from this foundation of drive and self-discipline that they write. Each alludes to changing the pace and mode of learning as technology advances and databases increase. They recognize and express concern over the changing “professionalism” in medicine and allude to an apprehension that medicine of the future could be transformed into something less if individual pursuit of excellence diminishes. The “reflections” of the contributors are well-rooted in their lives of passionate pursuit of excellence and attention to detail. The reader intuits from their words the hope that the education philosophies and dedication that have guided their personal and professional lives will not disappear. Documented throughout the book's 16 chapters are many examples of why this second edition is timely and necessary. Since the first edition of this book in 1987, medicine has experienced many changes including electronic availability of a wide array of information, managed care, increased regulation, computerized and therefore broader and more accessible patient databases, emphasis on data-driven evidence-based medicine, and an increasing number of specialty professional organizations; even e-mail and listservers have had impact. As we are creatures of habit, it is imperative that this “habit” of self-discipline and a passion for acquiring new information is established at the very earliest stages of our educational process. Some chapters should be mandatory reading for the beginning student of medicine. Chapter 16, “The Physician-Patient Relationship, Physical Examination, and New Procedures,” is a prime example. As a physician who has been a teacher throughout my career, Chapter 9 on “Learning by Teaching” was especially meaningful. I mention these two chapters, but if space permitted, I could cite each chapter for the author's incredible ability to point out the obvious, simplify the complicated, and inspire all readers, regardless of their medical professional level of training or area of interest. This book is a tailor-made answer to the recent NEJM article on the need for physicians who have been in practice for some time to stay abreast of the latest medical information. Preserving the Passion not only emphasizes the need to stay current, but also stresses the importance of reading critically to separate the valid from the invalid in publications. My hope is that the future leaders of medicine read this book, absorb every word, and be inspired to continue the “passion” for excellence expressed so aptly by its writers. In fact, I wish it were required reading for all entering the medical profession today. If it were, I believe it would help preserve the passion essential to preserving the guild of medicine.

Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso.We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure ofor = 90 mm Hg. The study setting was a city with a single centralized system of pre-hospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room.Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group.For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.

When a disaster occurs, it is for governments to provide the leadership, civil defense, security, evacuation, and public welfare. The medical aspects of a disaster account for less than 10% of resource and personnel expenditure. Hospitals and health care provider teams respond to unexpected occurrences such as explosions, earthquakes, floods, fires, war, or the outbreak of an infectious epidemic. In some geographic locations where natural disasters are common, such as earthquakes in Japan, such disaster practice drills are common. In other locations, disaster drills become pro forma and have no similarity to real or even projected and predicted disasters. The World Trade Center disaster on 11 September 2001 provides new information, and points out new threats, new information systems, new communication opportunities, and new detection methodologies. It is time for leaders of medicine to re-examine their approaches to disaster preparedness.

Victims of gunshot wounds may be noted to have bullets overlying the cardiac silhouette on roentgenogram. Direct cardiac penetration, bullet embolus to the heart, and missile proximity to the heart are all possibilities which must be differentiated. An unusual case of bullet embolism is presented in which thoracotomy was initially performed to rule out direct cardiac penetration. At the time of exploration, an intracardiac bullet embolus was fortuitously palpated and trapped within the apex of the right ventricle. Right ventriculotomy and embolectomy without cardiopulmonary bypass were performed to prevent retrograde or distal migration.

Today, surgeons are able to manage both blunt and penetrating wounds of the heart with increasing success, including those with associated intracardiac injuries. After diagnosis by cardiac catheterization, substantial intracardiac lesions are repaired using cardiopulmonary bypass. Among more than 300 patients treated for cardiac wounds in our city-county hospital in recent years, 15 were found to have marded intracardiac defects. These defects included ventricular septal defects, aorta--right ventricle fistulas, aortic valve injuries, a mitral valve injury, and a coronary artery--right ventricle fistula. Thirteen of the 15 patients required repair of the intracardiac defects. One was repaired acutely and 12 were repaired electively. All 15 patients were alive and asymptomatic at the time of writing.

From 1979 through 1981, 152 patients with penetrating injuries of the intra-abdominal gastrointestinal tract were placed on one of three different perioperative antibiotic regimens in a prospective randomized fashion. The three regimens were A) cefamandole 2 grams every 4 hours, B) cefoxitin 2 grams every 6 hours, and C) ticarcillin 3 grams every 4 hours and tobramycin 1.5 mg/kg every 8 hours. Antibiotics were administered intravenously before and for 48 hours following surgical exploration and repair. The three treatment groups were similar with respect to age, average number of organ injuries, and distribution of organ injuries. Cefoxitin-treated patients experienced uneventful recoveries more often than cefamandole-treated patients (94% vs. 80.3%, p less than 0.05) when the incidence of gram-negative wound infection and intra-abdominal abscess formation was considered, while the number of patients who experienced uneventful recoveries in the ticarcillin-tobramycin group was not statistically different from the other two groups of patients. Bacteroides fragilis was isolated from three of the six abscesses occurring in the cefamandole-treated group, while no anaerobes were isolated from abscesses in patients treated with either of the other two regimens. The results of this study suggest that the most effective perioperative antibiotic regimen for patients with penetrating gastrointestinal wounds should possess activity against both aerobic and anaerobic flora of the bowel.

The acutely injured patient may require emergency thoracotomy as an integral part of resuscitation. In critical circumstances, thoracotomy in the emergency center for control of hemorrhage, cardiac massage, and direct repair of crucial injuries can be lifesaving. Such an approach may be required for urgent repair of cardiac injuries. Between January, 1970, and December, 1973, over 6,000 emergency operations were performed for blunt and penetrating trauma at Ben Taub General Hospital. Emergency thoracotomy was required in more than 400 cases. Of these, 148 patients required thoracotomy in the Emergency Center due to rapid deterioration in their clinical condition. Forty-eight of these patients had injury to the heart. This aggressive approach allowed salvage of 67.5 per cent of these critically wounded patients with cardiac injuries who had any sign of life on arrival at the hospital. Autotransfusion, emergency cardiopulmonary bypass, and fine-screen filtration of transfused blood have been valuable adjuncts to this lifesaving measure. Thoracotomy in the Emergency Center should be considered as a primary modality in the management of moribund patients with penetrating wounds of the chest.

Controversy continues regarding the initial management of civilian colon injuries. The main issues are the safety of colostomy versus the desirability of primary repair and the role of exteriorized repair. From 1979 through 1984, 727 patients with injuries to the colon were treated at a large urban trauma center. Ninety-seven per cent of injuries were caused by penetrating wounds. Ten patients died in the operating room prior to repair of the colon wound. For patients who survived long enough to have their injury treated, 52.4% were treated by primary repair, 32.9% were treated with colostomies, and 14.6% were treated with exteriorized repair. Of the factors that have been stated to influence decision making, the extent of the colon injury was the most important. Location, number, and type of associated injuries, fecal contamination, and shock were less important. However, none of these latter factors mandated performance of a colostomy. The overall mortality rate for the series was 9.9%. Forty-one out of 70 deaths occurred within the first 48 hours and were due to shock and hemorrhage. The mortality rate for primary repair was significantly lower than that for colostomies (p less than 0.01). The presence of shock and age greater than 40 were significant factors influencing mortality (p less than 0.01). Mortality also was directly related to the number and type of associated abdominal injuries. Abdominal abscess also occurred significantly less often in patients treated with primary repair than in those with colostomies (p less than 0.01). The use of exteriorized repair was successful in avoiding colostomy in 59% of patients. Primary repair can be performed with minimal morbidity and mortality and should be the mainstay of treatment for civilian colon injuries.

During 1982, 312 patients with 408 vascular injuries and 48 cardiac injuries were seen. Two or more vascular or cardiac injuries were present in 34% of patients. Over 87% of injuries were secondary to gunshot wounds, stab wounds, or shotgun wounds. Vascular injuries were most commonly seen in the extremities (39.9%) or abdomen (31.9%). The most common arterial injuries occurred in the brachial artery (39 patients), while the most common venous injuries occurred in the internal jugular vein (26 patients). Arterial injuries were treated by the insertion of substitute vascular conduits (33.9%), ligation (22.6%), lateral arteriorrhaphy (18.6%), or end-to-end anastomosis (15.4%). Venous injuries were treated by lateral venorrhaphy (63.7%) or ligation (25.1%). In the 272 patients admitted with only vascular injuries, survival was 84.2%. Cardiac injuries in 38 patients most commonly occurred in the right ventricle (50%) and right atrium (25%). In the 34 patients who had only cardiac injuries and less than 4 minutes of prehospital cardiopulmonary arrest prior to arrival in the emergency center, survival was 64.7%.

Twenty-five cases of Haemophilus parainfluenzae endocarditis have been reported in the past 10 years, providing a better current perspective of this disease. We have recently diagnosed and treated two patients with H. parainfluenzae endocarditis, and both underwent surgical intervention for complications of their disease. H. parainfluenzae and the other Haemophilus species causing endocarditis often present with a subacute course, often escape early cultural detection and mimic fungal endocarditis in the propensity for large vessel embolization. Multiple emboli and occlusion of major arterial vessels are especially notable features of H. parainfluenzae endocarditis and have occurred in approximately 30 per cent of the cases reported in the past 10 years. In contradistinction to other types of bacterial endocarditis, the most common cause of death in this series has been neurologic complications following embolization. Development of large vegetations appears to be common and may be an intrinsic property of the Haemophilus species, but it is likely that it also reflects the duration of the disease. Delay in recovery of the organism from blood cultures is characteristic of H. parainfluenzae endocarditis and may be due to the strict requirement for V factor exhibited by some strains. Echocardiography has proved useful in suggesting the diagnosis of endocarditis when blood cultures are negative. Optimal antibiotic therapy of H. parainfluenzae endocarditis has not been determined, but the reported clinical experience suggests that combination therapy with ampicillin and an aminoglycoside is the current treatment of choice. Failure to eradicate the organism after a prolonged trial of appropriate antibiotic therapy is not unusual. Indications for surgery in H. parainfluenzae endocarditis may have to be amended to include potential embolization, especially if large vegetations are demonstrated on echocardiography.

During the period from 1961 to 1981, 40 pulmonary embolectomies were performed in 39 patients who were in extremis at the time of initiation of cardiopulmonary bypass. In a 460-bed hospital with more than 17,000 acute admissions and 4,000 operations per year, this small number represents the few patients who are potentially salvageable by urgent embolectomy. Preoperative angiography was performed in 57% of the cases, and in another ten patients suspected of having pulmonary emboli, angiography prevented unnecessary thoracotomy. Despite their moribund condition, 43% of the embolectomy patients lived. Excluding two patients with tumor occlusion of the pulmonary arteries and three patients with chronic cor pulmonale from old pulmonary emboli, the survival rate was 50%. Ten patients died because of hypoxemia and hypotension prior to initiation of cardiopulmonary bypass, and seven died of myocardial depression of multiple etiologies. Portable cardiopulmonary bypass affords the possibility of survival in moribund patients with acute massive pulmonary embolism. Preoperative angiography is recommended to guide appropriate surgical management.

From 1979 to 1984, 1000 patients with hepatic injuries were treated at one urban trauma center. Penetrating wounds were present in 86.4% of patients. Simple hepatorrhaphy, use of topical hemostatic agents, or drainage alone were the only forms of therapy required in 881 patients, and 65 (7.3%) died. Extensive hepatorrhaphy or hepatotomy with selective vascular ligation, resectional debridement or resection, selective hepatic artery ligation, or perihepatic packing were required, often in combination, in 119 patients, and 40 (33.6%) died. Uncomplicated recoveries occurred in 798 of the 918 patients (86.9%) surviving greater than 48 hours. In the remaining 13.1% of patients, intra-abdominal abscess formation was the most common late complication (32/918 = 3.5%). Mortality for the entire series of 1000 patients was 10.5%, with 78.1% (82/105) of all deaths occurring in the perioperative period from shock or transfusion-related coagulopathies.

Between January 1970 and December 1980, 65 patients sustaining 85 vascular injuries of the axillary artery and/or vein were managed at the Ben Taub General Hospital in Houston, Texas. Concomitant injuries of the subclavian and/or brachial vessels were noted in 34 per cent of patients. A variety of exposure techniques was used in approaching the axillary vessels. Emphasis upon preservation of collateral vessels led to an increased use of substitute vascular conduits over end-to-end anastomosis. The ready availability of prosthetic conduits, absence of graft infection, and excellent short-term patency have made them a primary choice for axillary arterial reconstruction in our recent experience. Associated brachial plexus injury (35%) accounted for the most significant long-term morbidity. The operative mortality was 3.1%, and one patient required upper extremity amputation following failure of repeated revascularization attempts.

One hundred consecutive patients with injuries to the extraperitoneal rectum were treated over a ten-year period at an urban trauma center. The mechanisms of injury included firearms in 82 patients, stab wounds in 3 patients, a variety of other penetrating injuries in 10 patients, and in 5 patients the injuries resulted from blunt trauma. Treatment of the rectal injury was determined by the bias of the operating surgeon, the condition of the patient, and the magnitude of the rectal injury. Proximal loop colostomies were performed in 44 patients, diverting colostomies in 51 patients, Hartmann's procedure in 4 patients, and an abdominoperineal resection in 1 patient. Extraperitoneal rectal perforations were closed in 21 patients and the rectum was irrigated free of feces in 46 patients. Transperineal, presacral drainage was used in 93 patients. Infectious complications potentially related to the management of the rectal wound occurred in 11 patients (11%) and included abdominal or pelvic abscesses (4 patients), wound infections (6 patients), rectocutaneous fistulas (3 patients), and missile tract infections (2 patients). Four patients (4%) died as a result of their injuries. Of the therapeutic options available, statistical analysis revealed that only the failure to drain the presacral space increased the likelihood of infectious complications (p = 0.03); however, as it could not be determined with certainty that the use of, or failure to use, any particular therapeutic option had an effect on the risk of death. It is concluded that colostomy and drainage are the foundations of the successful treatment of civilian injuries to the extraperitoneal rectum. The use of adjuncts such as diverting colostomies, repair of the rectal wound, and irrigation of the rectum has little effect on mortality and morbidity.

Police records of reported rape, compiled for the Federal Bureau of Investigation Uniform Crime Reports, in Houston, Texas for 1974 and 1975, were analyzed in relation to ethnicity and age of victim/offender, and time and place of occurrence. Blacks had the highest race-specific rates for both victims and offenders; the majority of all rapes were intraracial. The high-risk age group for both victims and offenders was from 20 to 24 years. Rapes increased slightly during the summer months, peaked during the hours of darkness, and were fairly evenly distributed among the days of the week. The weekend calculated as from 4:00 pm Friday to 8:00 am Monday accounted for 43.6 per cent of all rape occurrences. The majority of rape events involved the use of a lethal weapon and took place in a residence.

Controversy persists concerning the role of early surgical intervention in severe infective endocarditis (IE). We therefore reviewed 163 episodes of well-documented IE in which 32 cardiac operations were performed during the active phase of IE. Congestive heart failure (CHF) was the principal indication for surgery in 88% (28/32); systemic emboli, 1/32; and persisting sepsis, 3/32. Staphylococcus and enterococcus were the most common infecting organisms in the operative group (44% and 16% respectively). Surgical mortality (11/32,37%) did not differ (p greater than 0.05) from medical mortality (26/131,20%). All 11 operative deaths occurred in patients moribund prior to surgery, including three with preoperative cardiac arrest. Surgical patients undergoing preoperative cardiac catheterization demonstrated marked CHF: a mean left ventricular end-diastolic pressure of 25.3 mm Hg. The mean cardiac index in 8/11 surgical deaths was lower (p less than 0.05) vs surgical survivors: 2.21/min/m2 vs. 3.21/min/m2. Postoperative complications were rare in the 21 surgical survivors. There were no episodes of continued infection, prosthetic dehiscence, or advanced heart block; only one paravalvular leak; and one systemic embolus. These findings emphasize the high medical and surgical mortality in patients with IE, suggest that delayed operative intervention may be a major causative factor resulting in a high surgical mortality, and justify an aggressive surgical approach in patients with valve dysfunction and heart failure. These data indicate that survivors of surgical intervention during active IE have eradication of infection and few postoperative complications.

Pulmonary resection for massive bleeding was performed in 6 patients over a 5-year period at the Veterans Administration Hospital in Houston, Texas. A broad spectrum of diseases was represented, including 2 large lung cavities, 1 containing an aspergilloma, both of which were due to granulomatous processes; a metastatic sarcoma that was responding to cancer chemo-therapeutic drugs; 1 lobar atelectasis; 1 bronchiectasis; and 1 patient with persistent massive bleeding from an upper lobe that was normal on pathological examination. Our experience demonstrates that lung resection can control hemorrhage, but localizing the source of bleeding by bronchoscopy and limiting intrabronchial spread of blood during operation are important in the successful management of these patients.

The prevailing opinion that inlet (first and second) rib fractures carry a high rate of aortic-brachiocephalic injuries was tested in a retrospective analysis of radiographic, angiographic, and surgical records of 214 patients. Two patient populations were defined, identical in all traumatologic and radiologic aspects, except for the presence of inlet rib fractures in one group. Aortic/brachiocephalic trauma occurred at the same frequency in both populations. Because the contemporaneous occurrence of aortic-brachiocephalic wounding and inlet rib fractures is entirely a matter of coincidence, the presence of an inlet rib fracture alone should not constitute an indication for angiography. Vascular studies must be prompted by the presence of clinical signs or by radiographic findings suggesting a hematoma.

The advancements in extracorporeal cardiopulmonary support through oxygenation and pumping units have permitted the explosive development of heart surgery. A battery-powered portable cardiopulmonary bypass machine has been used in 39 patients whose conditions precluded transport to the operating room. Nineteen patients with massive pulmonary emboli, 10 with extensive cardiopulmonary trauma, who had sustained massive drug overdose, and 2 with cardiogenic shock from acute myocardial infarction were successfully placed on cardiopulmonary bypass at the bedside within 15 minutes of cardiac arrest using femoral artery and femoral vein cannulation. Six patients who had cardiac arrest and suspected massive pulmonary emboli were found to have no mechanical cause for their arrest. Thirteen of the patients with massive pulmonary emboli were saved. Eight of the 10 patients who required portable cardiopulmonary bypass for massive traumatic thoracic injuries had control of hemorrhage and repair, allowing bypass to be discontinued. Two of these 8 patients had sustained transection of the proximal left anterior descending coronary artery. Sixteen patients survived for more than 30 days, and there are 15 long-term survivors.

From 1980 to 1984, 326 patients requiring splenectomy or splenorrhaphy were treated at one urban trauma center. Splenic injuries were graded in severity from one to five at the time of celiotomy. Splenorrhaphy was attempted in all patients, except when the spleen was shattered or avulsed or when multiple injuries were present. The mechanisms of injury were: penetrating wounds in 51.2%, blunt trauma in 46%, and iatrogenic mishaps in 2.8% of patients. Grade 1 or 2 injuries were present in 23.9%, Grade 3, 4, or 5 injuries were present in 59.8%. Spleens removed or repaired with unknown grading or removed as part of distal pancreatectomies accounted for 16.3% of patients. Excluding uninjured spleens removed with pancreatectomies, 55.4% (169) of injured spleens required splenectomy and 44.6% (136) had a splenorrhaphy performed. Splenorrhaphy was most commonly performed with chronic suture with or without the addition of topical agents. Grade 1 and 2 injuries were repaired in 88.5%; Grade 3 injuries were repaired in 61.5%; and Grade 4 and 5 injuries were repaired in 7.7% of patients. Splenectomy is generally performed in patients with multiple associated intraabdominal injuries and the more severe grades of splenic injury, and has a mortality rate 13.5 times as great as that for patients undergoing splenorrhaphy. Splenorrhaphy can be performed in approximately 50% of patients with injured spleens and has practically no risk of rebleeding.