Search

Understanding the biomechanics of road traffic collision injuries is important for diagnosing and managing road traffic injured patients. As road traffic collisions may entail high-energy trauma, the degree of injury will depend on the mass and speed of the collided vehicles. Collisions can be front impact, back impact, side impact; the vehicle may turn over or the patient may be ejected from the vehicle. Each of these mechanisms has a specific pattern of injury. The injury will vary depending on whether the passenger was restrained with a seat belt or not. Seat belts tend to reduce head injuries and increase the abdominal injuries. Compression injuries of the intestines and urinary bladder tend to be more severe, causing rupture of these hollow organs if pressure within these organs was high. Pedestrian injuries consist of three phases: the bumper impact, hood and windscreen impact, and ground impact. The injury pattern and impact of motor vehicle collisions with large animals will depend on the size, height and weight of the animal. Clinical examples of road traffic collision patients will highlight the value of understanding biomechanics in patient management.

Introduction: The objective of this study was to study the clinical course and outcome of warfarinised patients who were hospitalised because of head trauma., Methods: 13 patients (ten males and three females; median age 69 years) who presented to the Royal Perth Hospital, Australia and who had suffered a head injury between July 1994 and June 2000 while concurrently taking warfarin, were studied., Results: Confusion was the commonest presenting symptom (four patients). Five patients presented after more than 24 hours of the injury. Eight patients were anticoagulated for thromboembolic disease and five for atrial fibrillation. The patients had a median injury severity score of 25 (range 1-43). The median international normalised ratio was 2.4 (range 1.8-10) on admission and 1.8 (range 1.0-10) on discharge. 11 of the 13 patients had computed tomography of the head. Intracerebral bleeding was the commonest injury (nine patients). The median length of hospital stay was six days (range 3-30). Five patients died (38.5%)., Conclusion: Warfarinised patients who sustain minor head trauma should be hospitalised for close neurological observation and should have a low threshold for performing computed tomography.

Actinomycosis of the anterior abdominal wall is rare. We report a 50-year-old diabetic man who presented with a left hypochondrial mass of three weeks duration associated with fever. Abdominal computed tomography showed a 2 x 4 cm mass projecting from the internal abdominal wall associated with surrounding inflammation. The mass did not decrease after a week of intravenous antibiotics. Excision of the mass and primary closure of the abdominal wall were performed. The mass involved the deep muscles of anterior abdominal wall. The omentum was adherent to the parietal peritoneum underneath the mass. Microscopical examination of the mass was consistent with actinomycosis. The postoperative period was uneventful and the patient recovered completely. The patient received penicillin for six months.

A 39-year-old woman who had a left radical nephrectomy for a renal chondrosarcoma presented 18 years later with a large epigastric mass and deep jaundice. The patient was very dyspnoeic and had a feeling of continuous pressure on her chest. Computed tomography arterioportography of the abdomen showed that the mass involved both lobes of the liver. Multiple non-anatomical resections of tumour masses were performed, including a mass arising from the falciform ligament, left lateral segment, and segments VII and VIII. The largest resected mass weighed 2.5kg and had a diameter of 15cm. Histopathology of the hepatic metastasis was similar to the original renal chondrosarcoma. The patient was followed up for 24 months postoperatively and had symptomatic relief. Our case demonstrates the slow-growing nature of this tumour and the usefulness of palliative surgery despite large tumour load.

Aim of Study: This study was aimed at evaluating the pattern of instructional skills of surgical tutors in a university hospital and the effect of feedback on this pattern., Method: Students who followed three clinical rotations at the Department of Surgery, Mubarak Al-Kabeer Teaching Hospital, Kuwait, responded anonymously to a structured questionnaire on the instructional skills of their tutors immediately after the rotation was completed. The questionnaire included six statements related to teacher-centred instructional skills and six statements related to student-centred instructional skills. The students indicated their perception on a five-point rating scale (very poor, poor, fair, good and very good). A summary of students' opinions was made available to the teachers soon after each rotation., Results: The percentage of good/very good categories was significantly higher in the teacher-centred skills compared with the student-centred skills (median (range), 87.05% (85.9-91.7) compared with 79.6% (76.6-80.6), (p = 0.004, Mann Whitney U test). This difference was significant in the first two rotations (p < 0.005) but not in the third rotation (p=0.59)., Conclusions: This study shows that behaviours of teachers which dealt directly with the learner's role in learning received lower emphasis than the teacher-centred activities and that feedback may modify this behaviour.

Purpose: This study aimed at evaluating the educational value of the morbidity mortality meeting and benefits obtained from it so as to implement changes that can improve it., Methods: Surgeons (n = 13) at a university hospital responded anonymously to a questionnaire which was structured to monitor the educational activity of the morbidity mortality meeting. They indicated their perceptions on a five-point scale (very poor, poor, fair, good and very good). Depending on the results of the first questionnaire, these changes were made: 1) Standardisation of the notice of the Meeting 2) Organization of the meeting 3) Review of the literature on the specific problems encountered. The participants were not aware of the results of the first questionnaire. Nine weeks later, the same questionnaire was repeated (n=12). Mann-Whitney test was used to compare the ratings of the two questionnaires., Results: The attributes which showed significant improvement between the first and second questionnaires were a) organization (p = 0.004; (median (range) 3 (2-5) compared with 5 (3-5)) b) knowledge is up-to-date (p < 0.005; (median (range) 3 (2-4) compared with 4 (3-5)), c) discussion related to the problem (0.01; (median (range) 3 (1-4) compared with 4 (3-5)) and d) notice of the meeting (p < 0.026; (median (range) 3 (2-4) compared with 4 (2-5))., Conclusions: This study showed that specific actions can improve the educational quality of the morbidity mortality meeting.

Intestinal ischaemia is implicated in the pathogenesis of severe acute pancreatitis, a disorder characterized by acinar necrosis. To study the relationship between pancreatic and intestinal microvascular perfusion during 40 min of intestinal ischaemia and 30 min of reperfusion in rodents with acute pancreatitis, a model utilizing laser Doppler flowmetry was developed. It is reported here together with practical solutions for (1) a modified method of vessel cannulation; (2) a novel method for the temperature-controlled optical coupling between laser Doppler probes and rodent tissues, and (3) a simple technique of inducing intestinal ischaemia-reperfusion while continuously monitoring the microvascular perfusion in both pancreas and intestine. The utility of the model is demonstrated in a pilot study that showed that the pancreatic perfusion fell acutely to 58% (p = 0.029) of baseline during the intestinal reperfusion phase. This reduced perfusion continued for 30 min despite recovery of both the intestinal perfusion and the mean arterial blood pressure to baseline levels., (Copyright 2001 S. Karger AG, Basel)

Aim: To evaluate the surgical seminars given for medical students at Auckland University and factors affecting them, so as to define areas for improvement., Methods: A confidential questionnaire was completed by fourth-year medical students for each surgical seminar they attended during an academic year. The seminars were repeated four times during the year. The questionnaire consisted of five statements relating to whether the seminar was stimulating, problem- oriented, patient-centred, evidence-based and interactive. The students rated each statement on a 7-point scale., Results: 556 questionnaires evaluating 28 clinical teachers were collected. A generalized linear model showed that the clinical teachers (F=4.16, P = 0.0001), the attachment (F=4.39, P=0.005) and the interaction between the seniority and institute (F=6.38, P=0.019) had a significant effect on the rating of the seminars. University consultants and hospital registrars had the highest overall least-squares mean, followed by hospital consultants, while university lecturers had the lowest overall least-squares mean (5.56, 5.4, 5.18, and 4.36, respectively). Ratings for problem-oriented approach improved over the studied period, while ratings of evidence-based and patient-centred approaches remained lower. University consultants and hospital registrars had the best patient-centred approach compared with hospital consultants and university lecturers (least-squares means 5.52, 5.4, 5.01, 4.18, respectively). Hospital registrars showed the best interactive ability ratings (least-squares mean 5.51) while university lecturers had the least stimulating seminars (least-squares mean 4.46)., Conclusions: Surgical seminars which were introduced to cover surgical topics had acceptable ratings in each of the teaching domains, although there is a need for improvement in the patient-centred and evidence-based approaches.

Background: Previous work has demonstrated that intestinal ischemia increases plasma amylin concentration. This study examined the relationship between the degree of intestinal ischemia injury and plasma amylin in an experimental rat model., Methods: Wistar rats were divided into a control group (n = 6); a sham-operated group (n = 9); and 3 intestinal ischemia-reperfusion groups (n = 8 in each), which underwent clamping of the superior mesenteric artery for either 15, 30, or 45 minutes followed by 15 minutes of reperfusion. Samples were then collected for intestinal histology and measurement of amylin, insulin, and glucose., Results: There was a positive correlation between the histologic score of the intestinal injury and the measured plasma amylin concentration (R = 0.48, P =.007). The median plasma concentration of amylin was 62 pmol/L (range, 42-97 pmol/L) in the 30-minute intestinal ischemia group and 58 pmol/L (42-86 pmol/L) in the 45-minute intestinal ischemia group. Both these groups were increased compared with the sham-operated group (29 pmol/L; range, 22-57 pmol/L; P <.001 and P <.005, respectively) and the control group (28 pmol/L; range, 26-42 pmol/L; P <.001 and P <.0005, respectively). The median plasma concentration of insulin in the 30-minute intestinal ischemia group was 4230 pmol/L (range, 1360-5770 pmol/L), which was increased compared with both the control group (950 pmol/L; range, 550-1510 pmol/L; P <.005) and the sham-operated group (720 pmol/L; range, 280-4180 pmol/L; P<.005). There were no differences between any of the other groups either for glucose, insulin, or amylin., Conclusions: Plasma amylin concentration is related to the severity of intestinal ischemic injury.

We describe a refined model of intravenous caerulein-induced pancreatitis by using osmotic infusion pumps in the conscious unrestrained Wistar rat. The volume of caerulein required for the 6-h infusion is loaded into PE-55 catheter tubing attached to an Alzet (Alza Corporation, Palo Alto, CA) implantable osmotic pump that has been primed with saline. The technique has reliably induced mild edematous pancreatitis, which we verified histologically. Our refined model has the advantages of unrestrained animals, reduced animal handling and acclimation, and decreased cost.

Objective: To test the hypothesis that elevated interleukin (IL)-10 plasma concentration relative to IL-6 and IL-8 in patients with acute pancreatitis is associated with improved clinical outcome., Design: Case series., Setting: University hospital surgical and intensive care unit., Patients: Patients with mild (n = 18) and severe (n = 14) acute pancreatitis were recruited within 12 hrs of admission and studied for 5 days., Interventions: None., Measurements and Main Results: The plasma concentration of IL-10 was significantly elevated in patients with severe pancreatitis during the 5 days and especially so in those who died compared with survivors on day 5 (p <.03). The ratio of IL-10/IL-6 was decreased in patients with severe pancreatitis on day 5 (p < .01). There was a significant decrease in the ratio of IL-10/IL-8, but not of IL-10/IL-6, during the first 5 days (p < .014)., Conclusions: The findings are consistent with the hypothesis that an increase in plasma IL-10 relative to IL-6 or IL-8 is associated with improved clinical outcome.

Ultrasonography has been proposed as a screening method for blunt abdominal trauma, but its specific role in comparison with other diagnostic modalities has yet to be defined. The aim of the present retrospective study was to compare the results of ultrasonography and CT of the abdomen in blunt trauma in a district general hospital. The hospital records of 25 patients who were admitted with blunt abdominal trauma to Southland Hospital, Invercargill, New Zealand, between January 1991 and November 1996 and who had both ultrasound and CT of the abdomen within 48 h of admission were reviewed. Ultrasound missed seven lesions in seven patients (7/25, 28%) compared with CT. Three of these were intestinal lesions that needed laparotomy. Ultrasound had a usefulness index of 1, 0.76, 0.72, 0.69 and 0, respectively, for detecting lesions of the kidneys, free intraperitoneal fluid, the liver, the spleen, and intestines. Although ultrasound can be used as an initial screening method for blunt abdominal trauma, CT is still the imaging modality of choice for detecting intra-abdominal lesions for stable patients in a district general hospital.

The incidence of abdominal tuberculosis is increasing and the familiarity with its clinical presentation shortens its diagnostic time and improves its management. Gallbladder tuberculosis has unique considerations regarding its pathology, diagnosis and surgical management. The authors report a case of gallbladder tuberculosis in a 40 year-old female who presented with a clinical picture of acute cholecystitis. Abdominal ultrasound showed a dilated gallbladder with a large gall stone located in the neck region. Several lymph nodes were seen in the hilum of the liver compressing the portal vein which were associated with smaller retroperitoneal lymph nodes. The diagnosis of gallbladder tuberculosis was reached only during surgery and was proven by histopathology. The gallbladder was adherent to the surrounding tissues and covered with multiple tuberculous nodules. The patient had a retrograde open cholecystectomy and treated with anti-tuberculous drugs. The literature on this topic is reviewed.

Aims: Bedside ultrasound is not widely practised by emergency physicians in Australasia despite its use in Europe, Asia and North America, and an extensive medical literature on the subject. A workshop was organised at Auckland Hospital, aiming to introduce emergency physicians to the basics of emergency ultrasound. This article summarises the content of the programme, the responses from the participants and the principles that emerged at this workshop., Methods: A standardised, 16-hour, emergency ultrasound curriculum was offered to 23 participants. Lectures with syllabus material were used to cover the following topics: basic ultrasound physics, pelvis, right upper quadrant, renal, aorta, trauma and echocardiography. Each participant received eight hours of hands-on ultrasound instruction. On completion of the course participants responded anonymously to a course appraisal questionnaire., Results: Twenty-one participants responded to the questionnaire (91% response rate). Delegates found the course informative and the material was considered relevant. Workshop objectives were met and the venue was appropriate. Most participants thought the practical sessions could be improved by decreasing the ratio of delegates to human models., Conclusions: The first Australasian workshop on bedside ultrasound in the Emergency Department held in Auckland (February 1998) was successful in achieving its objectives. Focused emergency ultrasound can be taught to detect free intraperitoneal or pericardial fluid in trauma patients. There is a need for appropriate quality assurance and credentialling guidelines as more Australasian emergency departments consider the application of focused ultrasound.

The purpose of this study was to determine whether plasma von Willebrand factor concentrations are correlated with the degree of intestinal ischaemia-reperfusion injury. Forty-six anaesthetised adult Wistar rats were divided into five groups. The sham-operated group (S, n=10) had laparotomy and isolation of the superior mesenteric artery without clamping. Three ischaemia-reperfusion groups (n=10 in each) had clamping of the superior mesenteric artery for 15, 30, and 45 minutes, respectively, and reperfusion for 15 minutes. A control group (C, n=6) had direct puncture of the heart to sample blood. Mean arterial pressure was measured continuously. Blood was collected at the end of the study to measure von Willebrand factor. The small bowel injury was graded histologically. There was a significant systemic hypotension after declamping in all ischaemia-reperfusion groups, which had a high negative correlation with the histological score (R=-0.46, F=10.1, p<0.003, simple linear regression). Plasma von Willebrand factor was significantly elevated in the three ischaemia-reperfusion groups compared with the control group but not significantly different from the sham-operated group (mean von Willebrand factor concentration (SEM): 156 (29), 283 (29), 295 (25), 381 (44), and 366 (40)% in C, S, ischaemia-reperfusion 15, ischaemia-reperfusion 30, and ischaemia-reperfusion 45 groups, respectively). The concentration of von Willebrand factor was not correlated to the histological score (R=0.22, F=1.83, p<0.2) or the degree of hypotension after the removal of the clamp (R=-0.22, F=1.8, p<0.2, simple linear regression). This study shows that von Willebrand factor concentration does not correlate with the degree of intestinal ischaemia-reperfusion injury. It is unlikely that von Willebrand factor can be used as a predictor of disease severity.

Objectives: To find out whether plasma concentrations of protein carbonyl (a specific marker of oxidative damage of proteins) are increased during intestinal ischaemia-reperfusion and whether they are correlated with von Willebrand's factor (vWF, a marker of endothelial injury) or myeloperoxidase (a marker of neutrophil activation)., Design: Randomised experimental study., Setting: University department of surgery, New Zealand., Animals: Thirty anaesthetised adult Wistar rats., Interventions: The sham operated group (n = 10) had laparotomy and isolation of the superior mesenteric artery without clamping. The ischaemia-reperfusion group (IR, n = 10) had the superior mesenteric artery clamped for 1 hour and reperfusion for 15 minutes. The control group (n = 10) had direct puncture of the heart to sample blood., Main Outcome Measures: Plasma concentrations of protein carbonyl, vWF, and myeloperoxidase., Results: Plasma protein carbonyl concentrations were significantly higher in the IR group than in the sham group (p < 0.02, Mann-Whitney test, median (range) 0.187 (0.141-0.242) compared with 0.144 (0.121-0.185) nmol/mg) and in the control group (p < 0.01, Mann-Whitney test, median (range) 0.187 (0.141-0.242) compared with 0.136 (0.108-0.175) nmol/mg). There was a significant correlation between protein carbonyl and vWF concentrations (r = 0.54, F = 10.9, p < 0.003, linear regression) but not with those of myeloperoxidase., Conclusion: Intestinal ischaemia-reperfusion caused an increase in the plasma protein carbonyl concentration, which is possibly produced by endothelial cells.

Intestinal ischaemia-reperfusion and hyperamylinaemia are both associated with severe acute pancreatitis. The aim of this study was to examine the relationship between intestinal-ischaemia reperfusion and plasma amylin in an experimental model. Wistar rats (n = 24, 400-450 g) were divided into three groups: (1) a sham (S)-operated group (n = 7) that underwent laparotomy and isolation (without clamping) of the superior mesenteric artery, (2) an ischaemia-reperfusion (IR) group (n = 7) that had clamping of the superior mesenteric artery for 60 min followed by 15 min reperfusion, and (3) a control (C) group (n = 10) that underwent no surgery. Amylin was significantly elevated in the IR group (median 39 pM, range 30-44) compared with the S group (19 pM, range 15-45; Mann-Whitney U, p < 0.05) and the C group (24 pM, range 15-55; p < 0. 01). Insulin was significantly elevated in the IR group (2,060 pM, range 1,000-4,650) compared with the S group (558 pM, range 424-2, 020; p < 0.01). There was a significant positive correlation between amylin and insulin (R = 0.82, F = 46.6, p < 0.0001), but not between amylin and glucose or insulin and glucose. Intestinal histology was consistent with an ischaemia-reperfusion injury, whereas pancreatic histology was normal. The unique finding that plasma amylin concentration is increased with intestinal ischaemia-reperfusion injury warrants further investigation., (Copyright 1999 S. Karger AG, Basel)

Recent evidence has suggested that ischemia-reperfusion injury is fundamental to the pathogenesis of acute pancreatitis. This study was designed to determine whether acute pancreatitis is associated with elevated serum manganese superoxide dismutase (MnSOD), a key antioxidant enzyme, considered a marker of ischemia-reperfusion injury in myocardial infarction. Thirty-four patients with acute pancreatitis had measurements of MnSOD on days 0, 2, and 5 after recruitment. The patients were recruited within 12 h of admission to hospital and had measurements of MnSOD on days 0, 2, and 5. Patients with severe acute pancreatitis had significantly elevated serum MnSOD concentrations on days 2 and 5 compared with patients with mild acute pancreatitis, but not on the day of recruitment. Elevated serum MnSOD correlated with peripheral plasma markers of lipid peroxidation (malondialdehyde) and neutrophil activation (myeloperoxidase) and was associated with decreased plasma ascorbic acid concentrations. The serial measurement of serum MnSOD may prove useful as a marker of the effectiveness of treatment designed to limit ischemia-reperfusion injury in patients with severe acute pancreatitis.

This study aimed at evaluating the role of platelet-activating factor (PAF) on cardiovascular dysfunction in postischemic shock in pigs. Sixteen pigs were randomly allocated to two groups of eight each. Their aorta was clamped above the celiac axis for 45 min and then declamped. The animals were studied for 2 h after declamping. They were given a continuous infusion of Hartmann's solution 6.75 ml/kg/h throughout the experiment. The experimental group was given a potent specific PAF receptor antagonist 15 min before reperfusion (BB-882 1 mg/kg bolus followed by continuous infusion of 1 mg/ kg/h till the end of the experiment). The control group was given vehicle instead. Reperfusion in the control group caused prolonged hypotension (mean arterial pressure (SEM): 29 (1) mm Hg, immediately after declamping, compared with 74 (3) at baseline), an increase in pulmonary vascular resistance (491.6 (51.5) dyn.s.cm-5, 2 h after declamping, compared with 274.2 (19.4) dyn.s.cm-5 at baseline), a reduction in cardiac output (1.75 (0.15) liters/min, 2 h after declamping, compared with 2.8 (0.21) liters/min at baseline), hyperglycemia (13.7 (0.8) mmol/l, immediately after declamping, compared with 6.26 (0.6) mmol/l at baseline), and lactic acidemia (11.28 (0.5) mmol/l, immediately after declamping, compared with 4.55 (0.67) mmol/l at baseline). BB-882 did not improve any of these variables. PAF does not play a major role on cardiovascular dysfunction in postischemic shock in pigs.

Objectives: To study the role of platelet-activating factor (PAF) antagonism in posthemorrhage septic shock in pigs., Design: Experimental study., Materials and Methods: Twelve anesthetized pigs were bled, kept with a mean arterial pressure of 30 mm Hg for 30 minutes, and then resuscitated with 50 mL/kg of isotonic saline. A continuous infusion of Escherichia coli endotoxin 36 micrograms/kg/hour was given intravenously for 3.5 hours starting 30 minutes after resuscitation. The animals were divided into two groups of six each. One group received I mg/kg of BB-882 (a potent specific PAF receptor antagonist) as a bolus during resuscitation, followed by a continuous infusion of BB-882 1 mg/kg/hour. The other group received vehicle alone., Measurements and Main Results: The measured variables were blood temperature, heart rate, intravascular pressures, cardiac output, systemic and pulmonary vascular resistance, lung-thorax compliance, blood gases, hemoglobin oxygen saturation, packed cell volume and blood sugar and serum lactic acid concentrations. The group treated with BB-882 had significantly higher intracardiac pressures and cardiac output, and had less increase in systemic vascular resistance. The BB-882 group had significantly less lactic acidemia than the control group (p < 0.05, analysis of variance appropriate for repeated measurement design). BB-882 had no effect on endotoxin-induced hypoxia or reduced lung-thorax compliance., Conclusions: PAF antagonism reduced the increase in systemic vascular resistance, improved cardiac output, and reduced lactic acidemia in posthemorrhage septic shock in pigs, but it did not improve hypoxia or reduced lung-thorax compliance.

Objective: To study the effects of platelet activating factor (PAF) antagonism on cardiovascular function in Escherichia coli endotoxaemia in non-hypotensive anaesthetised pigs., Design: Experimental study., Setting: Trauma research unit, Sweden., Material: 24 Domestic juvenile pigs., Interventions: 18 Pigs received a continuous infusion of E coli endotoxin in a dose of 36 micrograms/kg/hour for 5 hours. They were allocated to two groups of 9 each. The first group (BB-882 group) received a continuous infusion of BB-882 (a novel potent PAF antagonist) 33 mg/kg/hour 30 minutes before the endotoxin while the second group (placebo group) received vehicle alone. Another 6 pigs (control group) received only BB-882., Major Outcome Measures: Blood temperature, rigors, heart rate, intravascular pressure, cardiac and stroke volume indices and systemic vascular resistance., Results: Animals in the BB-882 group had significantly fewer rigors (p < 0.001) and episodes of tachycardia (p < 0.001) than the placebo group. BB-882 significantly reduced the endotoxin-induced systemic hypertension (p < 0.001) and the rise in systemic vascular resistance (p < 0.001). BB-882 group had significantly higher central venous pressure (p < 0.05), pulmonary capillary wedge pressure (p < 0.001), cardiac index (p < 0.02), and stroke volume index (p < 0.001)., Conclusions: Pretreatment with a potent PAF receptor antagonist improved the cardiovascular function during non-hypotensive E coli endotoxaemia in pigs.

Objective: To evaluate the role of ultrasonography in screening for blunt abdominal trauma in a general hospital., Design: Prospective study., Setting: University hospital, Kuwait., Subjects: 53 patients (44 male and nine female) with suspected blunt abdominal trauma or decreased consciousness were studied in the period between March 92 and April 93., Interventions: Real time ultrasonography of the abdomen during resuscitation., Main Outcome Measures: The sensitivity and specificity of ultrasonography as an investigative tool and predictor of clinical outcome., Results: Ultrasonography was 85% sensitive, 100% specific, and 96% accurate. The positive predictive value was 100% and the negative predictive value was 95%. The sensitivity was less in the hands of the surgeon than the radiologist (67% compared with 90%)., Conclusion: Ultrasonography is an accurate, safe method for screening patients with blunt abdominal trauma even in general hospitals.

The effects of bolus doses (0.2-2 micrograms) of platelet-activating factor (PAF) on systemic and pulmonary arterial pressures were tested in five juvenile pigs, and were demonstrated to have a biphasic effect. There was an initial drop in the mean systemic arterial pressure within seconds, followed by an increase within 1-2 min., whereas mean pulmonary arterial pressure only rose. The response was dose-related and did not include tachyphylaxis. The pressures returned to baseline within 10 min. After confirming these results a novel specific PAF receptor antagonist (BB-882) was given as a 1 mg/kg bolus followed by a continuous infusion of 2 mg/kg/hr, and a third dose response curve was repeated with ten-fold higher PAF doses (2-20 micrograms). BB-882 effectively counteracted these effects. Six pigs were given a continuous infusion of BB-882 33 mg/kg/hr for 5 hr and were compared with another group of five pigs given vehicle only. In this high dose BB-882 did not affect the intravascular pressures. These results indicate that BB-882 is a potent PAF receptor antagonist in juvenile pigs.

Objectives: to compare the clinical course and outcome of mesenteric vein thrombosis due to known causes and mesenteric vein thrombosis of unknown aetiology., Design: a retrospective study., Setting: two major general hospitals in Kuwait., Subjects: 12 patients who had mesenteric vein thrombosis due to known causes and seven patients who had mesenteric vein thrombosis of unknown aetiology were treated over eight years., Chief Outcome Measures: severity of clinical findings and outcome., Results: There was no statistical difference between the two groups in the clinical presentation or in outcome., Conclusion: 36% of mesenteric vein thrombosis occurred without an obvious cause although the disease appeared to be the same. More work on the aetiology of this condition is required.

This study aimed at evaluating the role of platelet-activating factor (PAF) antagonism in haemorrhagic shock in juvenile pigs. The animals were bled to a mean arterial pressure of 30 mm Hg which was maintained for 30 min, then they were resuscitated using normal saline 50 ml/kg. Seven pigs received BB-882 (a potent novel PAF antagonist) 1 mg/kg as bolus during resuscitation followed by continuous infusion of 1 mg/kg/h. Seven pigs received only vehicle. The group treated with BB-882 had significantly higher central venous pressure, mean pulmonary artery pressure and pulmonary capillary wedge pressure. The mean arterial pressure and cardiac output were similar in the two groups, while the systemic vascular resistance was significantly reduced by the drug. The BB-882 group had significantly more tachycardia and less arterial pH. Oxygen delivery and consumption and lactic acidaemia were similar in the two groups. These effects were not attributed to anaerobic metabolism and may indicate that PAF antagonism protected against ischaemia and improved the microcirculation in the haemorrhagic shock in pigs.

Endotoxemia was induced by intravenous infusion of Escherichia coli endotoxin in 18 anesthetized pigs in a dose of 36 micrograms/kg/hr. Nine pigs were pretreated with BB-882, a novel platelet-activating factor (PAF) antagonist, 33 mg/kg/hr, starting 30 min before endotoxin, and nine pigs received a similar volume of vehicle. Normotension was maintained with intravenous crystalloid resuscitation. Six pigs received only BB-882 and served as controls. Endotoxemia induced an acute transient 300% increase in pulmonary vascular resistance, identical in both groups. The initial increase was followed by a second, more gradual, rise in resistance, which was significantly attenuated by BB-882 (P < 0.01, repeated measurements ANOVA). Endotoxin-induced arterial deoxygenation and fall in lung/thorax compliance was not significantly altered by BB-882. Hematocrit was less in endotoxic pigs receiving BB-882 (P < 0.02). There were no significant changes compared to baseline in the control group. The results indicate that PAF is a minor determinant of early pulmonary dysfunction in nonhypotensive porcine endotoxemia.

A case of torsion of a large appendicular mucocele presenting as acute abdomen in a 38-week pregnant woman is reported. Ultrasound showed a localized cystic lesion with internal echoes on the right side of the abdomen. It was diagnosed preoperatively as twisted ovarian cyst. The patient was treated surgically with cesarean section and curative appendectomy.

An opinion survey of a five-year postgraduate training programme in general surgery was conducted using a questionnaire. The residents who responded indicated that the use of learning objectives needed to be given greater emphasis. They felt that learning objectives should be more clearly defined and be communicated with the learners and the instructors at an early stage in the programme. While the opportunity for learning theoretical concepts in surgery was rated as a strong feature of the programme, learning practical skills, it was pointed out, needed augmenting.

A rare kind of obstructive jaundice caused by compression on the common bile duct due to an inflated Foley catheter balloon placed in the duodenum after Suguira surgery for bleeding esophageal vesicles secondary to portal hypertension is presented. After deflating the balloon, the obstruction was relieved. Tc-99m HIDA studies were helpful in the diagnosis of obstruction of the common bile duct and the response following the deflation.

Selection of patients with chronic bilharzial uropathy (CBU) for surgery is a difficult problem due to the presence of grossly dilated urinary tracts without a significant obstruction in most of the cases. In this prospective study of 40 patients with CBU, the time-activity curve (TAC) patterns of the pre- and postoperative Tc-99m DTPA diuretic renography (RDR) studies were compared with the corresponding parenchymal transit time indices (PTTI). The aims were to find out which of these renographic parameters was more accurate in identifying obstruction and which was better in predicting the outcome of surgery. PTTI was more sensitive than TAC in identifying obstruction (96% and 92%, respectively) but it was less specific (78% and 98%). The detection accuracy of RDR for obstruction using TAC patterns was 96% compared to 84% using PTTI. Being independent of renal uptake function, PTTI could not predict the outcome of surgery as TAC could. In contrast to PTTI, TAC patterns could differentiate obstructed kidneys from severely nephropathic kidneys. However, PTTI was useful in identifying kidneys with residual nephropathy.

A young female who had been investigated for vague abdominal complaints and marked loss of weight was discovered only after laparotomy, carried out for acute appendicitis, to have primary tuberculosis of the vermiform appendix with perforation. The rarity of tuberculosis of the appendix, the types of presentation and the pitfalls of diagnosis are discussed. The literature on appendicular tuberculosis is reviewed.

Left renal cell carcinoma extending into the right atrium was treated by angioinfarction, removal of right atrial tumour using cardiopulmonary bypass and ten days later abdominal radical nephrectomy and inferior vena cava thrombectomy. Twenty four months later the patient remains well with no evidence of tumour recurrence.

There is no simple analytical test. Radionuclide diuretic renography (RDR), being a dynamic imaging study reflecting the function of the kidney and the urodynamics of the urinary tracts, has the potential to predict the outcome of surgery in obstructive uropathy. In 12 sheep, we occluded one ureter for a maximum of seven weeks and followed up for a maxim of five weeks after release of occlusion. Repeated Tc-99m DTPA diuretic renography studies were performed and the results were correlated with the duration of complete ureteric occlusion. The renal uptake percentage and the extraction slope of the time activity curve (TAC) showed progressive and steady decrease over the period of the occlusion. By the fifth week there was very low uptake (less than 18%) and the TAC was almost flat, suggestive of severe nephropathy. The parenchymal transit time index (PTTI) showed immediate rise after occlusion but with no progressive increase in its value. By the fifth week it dropped down to normal. After release, the recovery of function showed good correlation with the renal uptake percentage and extraction slope of TAC before release of occlusion. Therefore both these parameters, rather than PTTI, can be used to predict the outcome of surgery before the release of complete obstruction of the ureter.

Complete ureteric occlusion produces various pathophysiological changes that can be monitored externally by technetium 99m diethylenetriamine penta-acetic acid (99mTc-DTPA) diuretic renography (RDR). Being a dynamic imaging study, it reflects the function of the kidneys and the urodynamics of the urinary tract. The aim of this study was to correlate the changes in parameters of RDR with the histological changes before and after the release of complete ureteric occlusion. In 9 sheep, RDR studies were performed serially after various periods of complete ureteric occlusion (up to 7 weeks) and after release of the occlusion (up to 5 weeks). The histological changes were correlated with changes in RDR. The progressive decrease in renal flow seen on renal images and flow time-activity curves (TACs) was explained by the development of endarteritis and thrombosis of small renal arteries. The progressive decrease in the renal uptake as indicated by the percentage renal uptake and the extraction slope of TAC is related to the progressive damage to the renal parenchyma, initially affecting the collecting ducts and tubules, with increasing interstitial fibrosis in the later stages. Obstruction for 3 weeks or less was associated with moderate damage to the parenchyma from which recovery was possible. Obstruction for 7 weeks was associated with marked damage without chance of recovery. The RDR is a non-invasive technique that can be used to monitor kidney damage after various periods of complete ureteric occlusion and to predict the outcome of surgery before the release of occlusion.

Nine cases of solitary caecal diverticulitis treated in Kuwait are presented and the literature is reviewed. The preoperative diagnosis was acute appendicitis in all cases, but diverticulitis was detected during surgical exploration and histologically confirmed. The surgical management in seven cases was simple excision of the diverticulum with closure of resultant defect or invagination of the mucosal bulge with suture of the colonic wall. Right hemicolectomy was performed in two cases because of gangrenous patches in the caecal wall and suspicion of carcinoma. Recognition of solitary caecal diverticulitis requires considerable experience, especially in order to avoid more radical procedures such as right hemicolectomy. Solitary caecal diverticulum does not seem to occur in the indigenous people of Kuwait. All nine patients were of other nationalities, including five from countries of the Far East.