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Autotransfusion is a potentially valuable tool in the resuscitation of hypovolemic trauma patients; its acceptance in this setting has been limited by fears of the induction of coagulopathic and septic complications. It has been inferred that the addition of a cell washing step would obviate these concerns but at the cost of speed. To assess the validity of these concerns, we have retrospectively compared two autotransfusion devices: one without (the modified Bentley device) and one with (the Baylor Rapid Autologous Transfusion system) a cell washing step, over a 48-month period. In the Bentley group (n = 13), the mean estimated blood loss was 8,423 ml and the mean amount of blood autotransfused was 1,826 ml. Overall, the device returned 0.54 units of whole blood for every unit of banked blood used. Sixty-two per cent of these severely injured individuals died. Among survivors, there was a 20 per cent incidence of significant complications. In the BRAT group (n = 13), the mean estimated blood loss was 11,177 ml and the mean amount of blood autotransfused was 3,681 ml. Overall, the device returned 0.82 units of washed, packed red blood cells for every unit of banked blood used. Overall mortality was 26 per cent, and 30 per cent of survivors had complications. While we have been unable to demonstrate an advantage of the cell washing step, there is no evidence that this step in this unit limited the rate or volume of autologous blood replacement.

Seventy-three pediatric patients with acute hepatitis and 19 control patients without liver disease living in Cairo, Egypt, were evaluated with a newly developed Western blot assay for IgM antibody to hepatitis E virus (IgM anti-HEV). The mean age of acute hepatitis patients was 6.4 years (range, 1-13 years); 56% were male. Among the 73 acute cases, hepatitis A was diagnosed in 30 (41%), possible acute hepatitis B in three (4%), hepatitis E in nine (12%), and by exclusion, non-A, non-B hepatitis in 29 (40%). Two additional acute cases were positive for both IgM anti-HAV and IgM anti-HEV. None of the 19 control subjects had IgM anti-HEV. Parenteral risk factors were associated with cases of non-A, non-B hepatitis but were not associated with acute hepatitis E. Contact with a family member with jaundice was associated with acute hepatitis A. In contrast to prior epidemics of enterically-transmitted non-A, non-B hepatitis, HEV was found to be a common cause of acute hepatitis in a pediatric population. This study provides additional evidence that HEV may be a frequent cause of acute sporadic hepatitis among children living in some developing countries.

A newly developed Western blot assay for antibody to hepatitis E virus (anti-HEV) was used to evaluate 39 cases of acute pediatric hepatitis and 39 control patients in Khartoum, Sudan. The mean age of cases was 6.5 years (range, 2-14); 64% were male. Acute hepatitis A (IgM anti-HAV-positive) was diagnosed in 13 cases, acute hepatitis B (IgM anti-HBc-positive) in 1, and acute hepatitis E (positive for IgM anti-HEV) in 23 (59%). None of the cases with IgM anti-HAV or IgM anti-HBc had IgM anti-HEV; 3 controls had IgM anti-HEV. Acute hepatitis E was associated with recent contact with a family member or acquaintance with jaundice and the presence of indoor plumbing. The newly developed hepatitis E assay appeared to be specific for the diagnosis of acute icteric non-A, non-B hepatitis. Hepatitis E was found to be the most common cause of acute sporadic hepatitis in children living in an urban area of Africa.

Traumatic bilateral renal artery thrombosis is a rare injury. We found 15 cases previously reported. An additional case report of a 54-year-old man is presented with a review of the literature. The diagnosis was made by computed tomography and confirmed by angiography. Successful revascularization was performed. A high index of suspicion, early diagnosis, and prompt revascularization are essential in obtaining optimal results without hypertension or permanent impairment of renal function.

Aggressive nutritional support in the critically ill surgical patient is essential if improved outcome is to be realized. An understanding of the metabolic alterations of trauma and sepsis provides the foundation for a nutritional prescription for the individual patient. Careful nutritional assessment; titration of fluid, electrolytes, and micronutrients; provision of adequate calories and nitrogen to meet metabolic needs; and the selective use of specialized formulations are important components of nutritional management in the ICU.

Controversy about the appropriate evaluation of penetrating abdominal, flank, and back injuries prompted this retrospective review of 311 patients at an urban level 1 trauma center over 5 years. Seventy-five (24%) patients sustained gunshot wounds to the abdomen. All patients with gunshot wounds underwent exploratory laparotomy; results of 67 laparotomies (89%) were positive. Of 236 patients sustaining stab wounds (140 abdominal wounds, 51 flank wounds, 26 back wounds, and 19 wounds to multiple sites), 147 were treated according to a selective protocol, based on results of physical examination, wound exploration, peritoneal lavage, and ancillary diagnostic studies. No injuries were found at celiotomy in three (2%) of these 147 patients. One false-negative result of evaluation of a flank wound occurred. Significant injuries were found in 13 patients (68%) with stab wounds to multiple sites, 61 patients (44%) with abdominal stab wounds, 15 patients (29%) with flank stab wounds, and four patients (15%) with back stab wounds. Mandatory exploration of gunshot wounds is justified. Physical findings of intra-abdominal injury or positive results of peritoneal lavage identify stab wound victims likely to benefit from surgical exploration. A policy of mandatory observation or routine celiotomy for treatment of stab wounds is not justified.

In this prospective study of 40 patients sustaining blunt chest trauma, the value of single-photon-emission computed tomography (SPECT)-thallium scanning in the prediction of morbidity due to cardiac contusion was examined. Twelve patients developed cardiac complications--arrhythmias, ventricular conduction defects, and pericarditis. The sensitivity of SPECT-thallium scans was 55.6%, and the specificity was 32.1%, with an accuracy of 37.8%. Accuracy of the initial electrocardiogram (ECG) was 85%, with a sensitivity of 91.7% and a specificity of 82.1%. Patients with a normal ECG on admission rarely developed cardiac complications. It is concluded that SPECT-thallium is not a useful screening tool in this patient population.

Eighty consecutive cases of acute viral hepatitis and 80 controls selected from a public pediatric clinic were entered into a study of acute sporadic hepatitis in Khartoum, Sudan. Study subjects were 14 years of age or younger and were mainly from a low socioeconomic level. Non-A, non-B hepatitis was diagnosed by exclusion in 35 (43.8%) patients, hepatitis A in 27 (33.8%), acute hepatitis B in 8 (10.0%), possible Epstein-Barr virus (EBV) hepatitis in 1 patient; and dual hepatitis A and B infection in 1 patient. Eight acute cases were positive for HBsAg but negative for anti-HBc IgM and anti-HAV IgM. Delta hepatitis was not identified in any study subject. A household case of jaundice and acquaintance with an individual outside of the household with jaundice during the prior 6 months were associated with non-A, non-B hepatitis. There was no association between parenteral exposure and non-A, non-B hepatitis. These findings suggest that enterically transmitted non-A, non-B hepatitis may be a major cause of acute sporadic hepatitis in children in this area, as well as a cause of epidemic hepatitis.

The indications for thoracic aortography in the blunt chest trauma patient remain controversial. Clinical and radiographic findings in 102 patients seen at a Level I Trauma Center over a five-year period were reviewed to evaluate criteria predictive of major thoracic vascular injury. Five patients had positive aortograms. There was no significant correlation with Revised Trauma Score, symptoms, or associated thoracic injuries, although patients with aortic rupture did have a higher incidence of extrathoracic injuries (P less than 0.001). A blinded review of admitting chest radiographs for five major findings (widened mediastinum, aortic arch abnormalities, aortopulmonary window opacification, left apical capping, and right apical capping) revealed a significant difference between patients with and without aortic injury (0.98 +/- 1.24 findings in the negative aortogram group and 3.00 +/- 0.71 findings in the positive aortogram group) (P less than 0.001). All patients with aortic rupture had at least two major positive findings on admitting chest radiographs. Admission chest x-ray evidence of at least one major abnormality is a safe method of screening blunt chest trauma patients for thoracic aortography.

Pancreaticoduodenectomy has been decried as a means of managing combined pancreatic and duodenal trauma. In order to test this harsh assessment, we have reviewed our experience with this procedure in this setting. Six young males with a mean injury severity score of 15.4 underwent pancreaticoduodenectomy for trauma. Four patients sustained penetrating trauma and two patients suffered blunt injuries; each was felt by clinical assessment to have pancreatic ductal disruption combined with significant duodenal injury. Four patients underwent pancreaticoduodenectomy primarily, while two patients underwent initial drainage and diverticulization. The four patients undergoing immediate resection had a mean hospital stay of 28 days (18-42 days) and did not require further surgical intervention. All are alive and well six months to nine years later. The two patients with drainage and repair of their injuries had a mean hospital stay of 115 days (84-147 days) and required additional laparotomies for pancreatic leaks, enterocutaneous fistulae, or drainage of abscesses. Pancreaticoduodenectomy was ultimately performed in each case, and both have survived. Pancreaticoduodenectomy continues to have a role in the management of combined pancreatic and duodenal injuries.

Medical and surgical house physicians at three teaching hospitals with different antibiotic control programs (ACPs) were surveyed to determine their attitudes about and preferences for these programs. Questionnaires were mailed to resident physicians who had trained at all three hospitals. One hospital had no antibiotic prescribing policy (open prescribing), one employed an infectious-disease physician consultant who discussed antibiotic orders for certain reserved drugs with prescribing physicians but did not otherwise restrict access to the drugs (educational ACP), and the third hospital required approval of an infectious-disease physician for dispensing of reserved drugs by the pharmacy department (restrictive ACP). The survey response was 77% after one follow-up mailing to nonrespondents. Regardless of hospital type, physicians preferred the educational ACP to either open prescribing or the restrictive ACP. Based on personal experiences, significantly fewer physicians encountered patient-care problems with the educational ACP than with either open antibiotic prescribing or the restrictive ACP. Significantly more physicians perceived that the educational ACP was more beneficial for patient antibiotic therapy and will be more beneficial for future antibiotic prescribing than the restrictive ACP. Most respondents believed that ACPs save hospitals money, that ACPs can be implemented without compromising either patient care or physician performance, and that they would encounter similar ACPs in the future. Educational ACPs should be considered at teaching hospitals with interested infectious-disease consultants.

A seroepidemiologic survey was conducted among 773 male soldiers living in five urban locations in Sudan to study the prevalence of and risk factors for HIV-1 and hepatitis B transmission. Twenty-eight per cent of the study population were born and raised in southern Sudan, an area bordering Kenya, Zaire and Uganda, whilst 72% of the study subjects were from northern Sudan. Seventy-eight per cent of the study population had serologic evidence of past hepatitis B infection, and 13 soldiers were confirmed positive for HIV-1 antibody. All 13 HIV-positive soldiers had recently been deployed in southern Sudan. Multivariate analysis indicated an association between living in southern Sudan and both hepatitis B (odds ratio 8.2) and HIV-1 infection (odds ratio 14). Additionally, sexual relations with prostitutes (odds ratio 1.5) and medical injections for schistosomiasis (odds ratio 2.72) were independent predictors of hepatitis B markers in this military population. The findings of this study suggest that sexual promiscuity is a risk factor for hepatitis B transmission in Sudan. They also indicate one possible route for the spread of HIV-1 from central to northern Africa.

A serosurvey was conducted in Port Sudan and Suakin, Sudan in October and March 1987 to determine the prevalence and risk factors associated with the transmission of hepatitis B, human immunodeficiency virus type 1 (HIV-1), and syphilis among sexually active heterosexuals on the coast of Sudan. A total of 536 subjects, including 202 female prostitutes, 95 long-distance truck drivers, 103 soldiers, 72 Ethiopian refugees, and 54 Sudanese outpatients, were enrolled in the study. Seventy-eight percent (202/259) of the female study subjects were engaged in prostitution, and 57% (157/277) of the men admitted to prior sexual relations with prostitutes. Serologic markers for hepatitis B and syphilis were detected in 68% and 17% of the entire study population, respectively. In contrast, antibody to HIV-1 was detected in none of the 536 sera tested. Risk factors found to be independently predictive of hepatitis B infection by multivariate analysis included prostitution, positive serology for syphilis, and a history of anti-schistosomal therapy. The absence of HIV-1 infection among the prostitutes enrolled in this study is in marked contrast to the current AIDS epidemic in neighboring sub-Saharan countries, suggesting that HIV-1 has not been widely introduced on the coast of Sudan. The high prevalence of serologic markers to hepatitis B and syphilis, however, indicates a potential for HIV-1 in this region.

The substantial morbidity and mortality associated with severe acute pancreatitis has led to a variety of therapeutic approaches. We reviewed the records of 40 patients who had undergone the "triple-tube" procedure (gastrostomy, cholecystostomy, and jejunostomy) with drainage of the lesser sac and retroperitoneum. Cardiovascular, respiratory, renal, and hepatic dysfunction were common, and reoperation was required in 35% (14) of the cases. Gastrostomies and jejunostomies were associated with numerous complications, and cholecystostomies were rarely of benefit except when biliary tract disease was present. Debridement and drainage of necrotic pancreatic and retroperitoneal tissue afforded a higher survival rate in the small population in which they were employed. The overall mortality was 55% (22), reflecting and severity of the disease at the time of surgery. Early recognition and limited surgical debridement may be beneficial in this high-risk group.

Pinosylvin methyl ether (PME), a toxic phenol, is a potent deterrent to showshoe hare feeding on green alder. Concentrations of PME found in green alder parts can account for the low palatability of winter-dormant foliar buds and staminate catkins but cannot affect internode palatability. The lack of a PME-related defense system in internodes suggests that green alder has at least a two-level defense system: defense of growth stages and defense of parts within growth stages.

We investigated the effects of nitrogen fertilization upon the concentrations of nitrogen, condensed tannin and phenolic glycosides of young quaking aspen (Populus tremuloides) leaves and the quality of these leaves as food for larvae of the large aspen tortrix (Choristoneura conflictana), a Lepidopteran that periodically defoliates quaking aspen growing in North America. Nitrogen fertilization resulted in decreased concentrations of condensed tannin and phenolic glycosides in aspen leaves and an increase in their nitrogen concentration and value as food for the large aspen tortrix. These results indicate that plant carbon/nutrient balance influences the quality of aspen leaves as food for the large aspen tortrix in two ways, by increasing the concentrations of positive factors (e.g. nitrogen) and decreasing the concentrations of negative factors (eg. carbon-based secondary metabolites) in leaves. Addition of purified aspen leaf condensed tannin and a methanol extract of young aspen leaves that contained condensed tannin and phenolic glycosides to artificial diets at high and low levels of dietary nitrogen supported this hypothesis. Increasing dietary nitrogen increased larval growth whereas increasing the concentrations of condensed tannin and phenolic glycosides decreased growth. Additionally, the methanol extract prevented pupation. These results indicate that future studies of woody plant/insect defoliator interactions must consider plant carbon/nutrient balance as a potentially important control over the nutritional value of foliage for insect herbivores.

Conflicting anecdotal reports about the efficacy of topical linoleate in managing essential fatty acid deficiency prompted this prospective study of 10 critically ill surgical patients receiving continuous total parenteral nutrition (TPN). Ten ml of corn oil (4800 mg of linoleate) were massaged into the skin daily commencing after 7.7 +/- 3.8 (mean +/- SD) days of fat-free intake. Plasma samples were obtained weekly. Total lipids were extracted and methylated, and fatty acids were quantitated by gas-liquid chromatography. The triene:tetraene ratio (20:3 omega 9/20:4 omega 6) increased progressively in patients despite corn oil therapy. In 89% of patients the ratio exceeded 0.2, which is diagnostic of essential fatty acid deficiency (EFAD). Topical application of corn oil does not prevent or treat EFAD in patients on TPN.

Common emergency room practice mandates cervical spine (C-spine) films in all trauma patients with potential injuries. With the increasing costs of medical care, such liberal criteria may not be justified. This 1-year prospective study of 860 patients who presented to a Level I Trauma Center was undertaken to determine the signs and symptoms that would select the patients at risk of C-spine injury. The clinical presentation of each patient was correlated with the presence of C-spine fracture. Twenty-four patients (2.8%) had injuries demonstrated by plain film radiography. The incidence of fracture in 536 symptomatic patients was 4%. A significant likelihood of C-spine fracture was seen in patients with respiratory compromise (100%), motor dysfunction (54.5%), and altered sensorium (8.9%) (p less than 0.001). No fractures were seen in asymptomatic patients (p less than 0.001). Cervical spine radiography should be performed in patients with abnormal neurologic findings or symptoms referable to the neck. In alert asymptomatic patients, cervical spine radiography may be omitted.

A fourth-year curriculum survey was forwarded to surgery resident program directors, clerkship directors, and residents. A 37 percent response rate was achieved with comparable representation of each respondent type from 130 institutions. The purpose of the survey was to determine how each of the 3 respondent types rated the importance of 42 subjects or clinical experiences to be taken in the fourth year of medical school for students pursuing surgical careers. The survey also included questions on such issues as externships, early match programs, and guidelines used at their institutions for their fourth year students. The results indicated a significantly high agreement among respondent types on what should comprise surgical students' fourth-year curriculum content. The majority feel the fourth year should be planned by students with an electives advisor to equally add breadth to their general professional education as well as provide prerequisite experiences in the career-chosen discipline.

Plasma fatty acid profiles of 33 critically ill surgical patients receiving fat-free parenteral nutrition were examined at weekly intervals up to 28 days. While plasma total fatty acid concentration remained relatively constant and within the normal range, marked compositional alterations were apparent. Levels of linoleate (18:2 omega 6), the major essential fatty acid in man, fell below normal values (754 +/- 259 micrograms/ml) in 67 percent of patients within 1 week after cessation of oral intake. Decreases in other omega 6 unsaturated fatty acids, derived from linoleate, were also apparent. In contrast, gradual increases were observed in levels of endogenously synthesized fatty acids, palmitate (16:0), palmitoleate (16:1) and oleate (18:1 omega 9). A fatty acid unique to essential fatty acid deficiency, 5,8,11 eicosatrienoate (20:3 omega 9), appeared in 25 percent of the patients during the first week and in all patients by the third week of study. Considering the rapid appearance and progression of these biochemical changes, early initiation of linoleate supplementation appears justified to forestall the development of related clinical sequelae.

A case demonstrating an obscure cause of backache is presented in which an obturator bladder hernia was diagnosed preoperatively and corrected surgically.

Four prisoners recently evaluated at a county hospital sustained self-inflicted paper clip stab wounds of the abdomen on 22 occasions. Guidelines for management based on physical examination, abdominal films and wound exploration with paper clip extraction and short-term admission for observation have been successful in avoiding laparotomy in most instances. Evaluation and surgical treatment of penetrating abdominal injuries are controversial. Some authors propose mandatory laparotomy for all stab wounds violating the peritoneum, while others recommend selective management based on physical findings, local exploration of the wound and subsequent peritoneal lavage. Recently, four prisoners have inserted sharpened paper clips into and through the abdominal wall on 22 occasions, raising questions about the appropriate treatment of these injuries. These wounds differ from other stab wounds in several respects: 1) underlying psychiatric disturbances and the self-inflicted nature of the wound increase the difficulty of patient management; 2) attempts are often multiple, precluding repeated peritoneal lavage for evaluation; 3) the foreign body may be completely intraperitoneal; and 4) peritoneal penetration is similar to that incurred during a peritoneal tap with an 18-gauge needle. The differing presentations of these patients are reported, and a plan for management of these injuries is proposed.

The recent introduction of triple lumen catheters has facilitated the care of seriously ill patients by providing multipurpose central venous access through a single percutaneous 7 French catheter. This prospective study was performed to examine the complications associated with the use of these catheters in patients receiving long-term total parenteral nutrition (TPN). Seventy-five patients undergoing catheterization were randomly separated into two groups: 36 patients underwent placement of a single lumen catheter (SLC), and 39 patients, a triple lumen catheter (TLC). The two groups were comparable with respect to concomitant infections, treatment with antibiotics, and need for intensive care. Patients in the SLC group received TPN for a mean of 9.7 days and in the TLC group, for a mean of 8.5 days (p = 0.427). However, after 5 days of catheterization, there was a marked increase in the number of TLC removed because of skin entry site infections. SLC were more likely to be used for the full duration of TPN administration (p = 0.025). Catheter tips were cultured by semiquantitative techniques. A higher incidence of catheter sepsis was seen with TLC, 12.8% vs 0% with SLC (p = 0.055). TLC used for TPN are associated with higher rates of catheter entry site infections and systemic sepsis. SLC should be used for TPN administration.