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This review focuses on the use of palliative care in trauma patients in low-income countries. There is very limited use of palliative medicine in low-income countries for any disease condition. The use of palliative medicine for trauma in low-income is not addressed in the medical literature. This review article highlights many changes that need to occur to offer high-level palliative care for all needs, including trauma. The author has made many medical mission trips both as a trauma surgeon and a palliative medicine physician. Personal observation is included.

There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.

Shared decision making requires the exchange of information from the patient and the surgeon (and ideally involves the expertise of the entire multidisciplinary team) to determine the medical and/or surgical treatment that best aligns with the patient's goals and values. Should the surgical patient wish to transition to end-of-life care, the transition to comfort-focused care is within the scope of practice for surgeons. Incorporating the expertise of other health care professionals is an important consideration for whole-patient care. Integrating primary palliative care into surgical practice can help mitigate unnecessary suffering and allow a smoother transition to comfort-focused care.

There will be a 46 per cent shortage of intensivists by 2030. Currently, only 3 per cent of U.S. critical care is provided by surgeon-intensivists. Measurement of the current workload is needed to understand the ramifications of the expected shortage of surgeon-intensivists. The purpose of this study is to evaluate the self-reported workload of U.S. surgeon-intensivists. Over a 2-month period, a voluntary and anonymous survey of the surgery section of the Society of Critical Care Medicine was performed using Survey Monkey. Only surgeons were invited to participate. We assessed personnel resources and surgeon-intensivists workload in the intensive care unit (ICU) and on their postcall day. Two hundred sixty-two persons responded. Sixty-nine per cent had administrative responsibilities and 42 per cent covered bed allocation/transfer center duties while in the ICU. Seventy-six per cent covered trauma and general surgery call and 72 per cent covered the outpatient clinic or had elective surgery cases while responsible for the ICU. Only 14 per cent had no other responsibilities. Twenty-one per cent did not round with residents and 50 per cent did not round with a fellow. Thirty-six per cent did not work with advanced practitioners. The majority of surgeon-intensivists have significant responsibilities in addition to providing ICU care. This workload should be factored into the expected shortage of surgical intensivists relative to the expected increase in critical care demand.

As the American population grows larger in terms of weight and body mass index each year, a greater percentage of patients admitted to the trauma service are overweight or obese. Obese patients do not have the same injury patterns or outcomes of normal-weight patients. This article reviews some of the latest data regarding the injury patterns, outcomes, and areas of further studies in the obese trauma population.

Ethical issues in the ICU seem to be growing with the increasing complexity of medical treatments. Despite many bioethicists, clinicians, academicians, and others attempting to resolve these conflicts, we don’t seem to be any closer to solutions. This chapter will review several key principles and ethical situations in the ICU including withdrawing and withholding, DNR, futility, advance directives and POLST, artificial nutrition and hydration, dialysis, and organ donation. This chapter will also discuss the differences between resources available to help resolve these conflicts: ethics consults, palliative medicine, and conflict resolution.

Background: Genetic differences associated with individual's immune responses appear to be a major contributing factor to the development of trauma-induced sepsis. Thus, effective treatment of sepsis requires the identification of the patients who are at increased risk for sepsis. Methods: Sixty-eight patients, of which the majority had an injury severity score >15, and 118 controls from the same geographic region were genotyped. Cytokine and Toll-like receptor (TLR) genotypes and expressions were tested using polymerase chain reaction (PCR). Results: Fifty percent of African American and 42% of Caucasian patients developed posttrauma sepsis. Frequency distribution of the polymorphism for some cytokine genes such as Interleukin (IL)-10 low/high and interferon (IFN)-y low producer were statistically different between the septic and aseptic patients, for others, such as tumor necrosis factor (TNF)-a, IL-6, and IL-18, there was no statistical difference. The TLR-2 genotypes (A/G) were considered a sepsis risk marker as compared with A/A (62.5% versus 37.5%,p < 0.03; relative risk = 2.5) in African American patients. Cytokine mRNA levels correlated with genotype definition, particularly, for IL-10, IL-6, IL-18, and TNF-a. A time course study demonstrated a significant difference in cytokines expression profile in septic and aseptic patients before the development of sepsis. Conclusion: Monitoring cytokine expression levels before the disease might predict the outcome of sepsis. A large cohort study is needed to assess the diagnostic potential of the genotypes.

To date, no study shows a decrease in postoperative abscess with the use of irrigation during appendectomy. Postoperative abscess rate for laparoscopic and open appendectomy is 3.3 and 2.6 per cent. The purpose of this study is to determine if irrigation at appendectomy decreases the postoperative intra-abdominal abscess rate. Retrospective chart review of 176 consecutive appendectomies, open (39%) and laparoscopic (61%), at a university affiliated tertiary care facility from July 2007 to November 2008 for use of intraoperative irrigation was performed. Patients under age 18 were excluded. There were no differences between the irrigation groups in regards to age, sex, or weight. Perforation was observed in 28 per cent (50/176), of which 86 per cent (43/50) of patients received intraoperative irrigation. Eleven patients (9.6%) with irrigation developed postoperative abscess compared with two (3.3%) patients without irrigation ( P = 0.22). Our results do not show decrease in postoperative intra-abdominal abscess with use of intraoperative irrigation. Thirteen patients developed postoperative abscess: 11 with irrigation, two without irrigation. Ten of 13 patients who developed abscess were perforated; nine with irrigation and one without. These results suggest routine use of intraoperative irrigation for appendectomies does not prevent intra-abdominal abscess formation, adds extra costs, and may be avoided.

Acute post-operative hemorrhage in the ICU can be difficult to diagnose accurately and in a timely fashion. There are many diagnostic studies available, some of which may delay timely diagnosis and treatment. This section reviews the diagnostic tests available and those that are most useful in the acute ICU setting of suspected post-operative or intraabdominal hemorrhage.

Transplantation of human cancers into immunologically deficient mice is widely used to study potential therapeutic interventions in vivo. For brain tumor research, however, several factors limit more widespread application of this animal model. First, only a minority of human glioma-derived cell lines are tumorigenic in nude mice. In addition, even for tumorigenic cell lines, tumor take is variable and growth is often slow for tumors derived from cell inoculums. Reconstituted components of tumor basement membrane (matrigel) have been found to improve the growth in nude mice of several types of human tumors originating outside the central nervous system when premixed with the tumor cells before subcutaneous inoculation. We investigated the ability of matrigel to enhance the growth in nude mice of tumors derived from the human glioma cell lines U-251 MG, U-373 MG, SNB-78 and SNB-101. Athymic nude mice (NIH Swiss background, nu/nu genotype) were inoculated subcutaneously with 1.0 x 10(6) tumor cells alone or after premixing with an equal volume of liquid matrigel. U-251 and U-373 cells were tumorigenic, with palpable tumors present by about 2 to 3 weeks. Co-injection of these cell lines with matrigel resulted in higher tumor-take rates, from 6/10 to 8/8 animals for U-251 at 60 days, and from 9/12 to 11/11 animals for U-373 at 60 days. Matrigel also enhanced tumor growth, with tumors at 45 days significantly larger than those formed in the absence of matrigel, for both cell lines (p < 0.01). SNB-78 and SNB-101 cells did not give rise to progressively enlarging solid tumors with or without matrigel. Matrigel enhances the growth of tumorigenic human gliomas in athymic nude mice. This technique provides a model with more consistent tumor take and more rapid growth kinetics for human glioma cell lines that are tumorigenic in nude mice.

The evaluation and management of blunt abdominal trauma is primarily nonoperative. Previous attempts to identify parenchymal solid-organ injury with sonography have been unsatisfactory. The use of Perflutren Lipid Microsphere (Definity) contrast-enhanced ultrasound (DUS) may provide an additional modality for evaluation of solid-organ injury with decreased risk of radiation exposure and contrast-related complications.Injured patients admitted to a state-designated Level I trauma center (January 2008 to July 2009), who showed evidence of solid-organ injury after blunt abdominal trauma on initial computed tomography (CT) were eligible for entry into the study. Patients underwent DUS examinations within 12 hours of initial CT. Ultrasound images were then compared with findings of CT for organ location, size, and grade of injury.Twenty patients with evidence of solid-organ injury on CT were evaluated with DUS. DUS correctly identified five of eight liver lesions, with a sensitivity of 62.5%. DUS correctly identified all nine splenic lesions demonstrating a sensitivity of 100%. DUS correctly identified one of two kidney injuries, demonstrating a sensitivity of 50%. Overall, the positive predictive value for all solid-organ injuries was 100%, with negative predictive value of 20%. The overall sensitivity for DUS was 79% (15 of 19 patients), and specificity was 100% (15 of 15 patients).Contrast-enhanced sonography is a potential new modality for the evaluation of solid-organ injury for patients with blunt abdominal trauma. With further research, DUS may provide a safe and accurate alternative to CT.Diagnostic study, level IV.

The purpose of palliative medicine is to prevent and relieve suffering and to help patients and their families set informed goals of care and treatment. Palliative medicine can be provided along with life-prolonging treatment or as the main focus of treatment. Increasingly, palliative medicine has a role in the surgical intensive care unit (SICU) and trauma. Data show involving palliative medicine in the SICU results in decreased length of stay, improved communication with families and patients, and earlier setting of goals of care, without increasing mortality. The use of triggers for palliative medicine consultation improves patient-centered care in the SICU.

Splenic abscess is an uncommon complication of splenic trauma. Splenic abscess presents within several months of the trauma. We report a case of a splenic abscess 10 years after trauma and review the current understanding of splenic abscesses.

SINCE its introduction in the early 1980s, pulse oximetry has been one of the most rapidly diffusing electronic monitoring technologies in medicine.1Use of pulse oximetry during procedures requiring general anesthesia quickly became standard practice in the United States because it is noninvasive, requires no special training, gives continuous realtime estimates of arterial oxygen saturation (SaO2) in the range of 70% to 100%, and gives early warning of loss of pulse.1-3This report provides background information concerning the development of oximetry technology and its use during "conscious sedation," a state of minimally depressed consciousness elicited by sedating agents used during certain procedures. HISTORY Oximetry originated in Germany in the 1930s with the work of Nicolai, Kramer, and Matthes.4They studied the kinetics of tissue oxygenation and applied the Beer Lambert law, which relates the concentration of a solute to the intensity of light transmitted through the

The mortality and morbidity of women who terminated their pregnancy before the 1973 Supreme Court decision in Roe v Wade are compared with post— Roe v Wade mortality and morbidity. Mortality data before 1973 are from the National Center for Health Statistics; data from 1973 through 1985 are from the Centers for Disease Control and The Alan Guttmacher Institute. Trends in serious abortion-related complications between 1970 and 1990 are based on data from the Joint Program for the Study of Abortion and from the National Abortion Federation. Deaths from illegally induced abortion declined between 1940 and 1972 in part because of the introduction of antibiotics to manage sepsis and the widespread use of effective contraceptives. Deaths from legal abortion declined fivefold between 1973 and 1985 (from 3.3 deaths to 0.4 death per 100 000 procedures), reflecting increased physician education and skills, improvements in medical technology, and, notably, the earlier termination of pregnancy. The risk of death from legal abortion is higher among minority women and women over the age of 35 years, and increases with gestational age. Legal-abortion mortality between 1979 and 1985 was 0.6 death per 100 000 procedures, more than 10 times lower than the 9.1 maternal deaths per 100 000 live births between 1979 and 1986. Serious complications from legal abortion are rare. Most women who have a single abortion with vacuum aspiration experience few if any subsequent problems getting pregnant or having healthy children. Less is known about the effects of multiple abortions on future fecundity. Adverse emotional reactions to abortion are rare; most women experience relief and reduced depression and distress. ( JAMA . 1992;268:3231-3239)

DURING the past 20 years rates of suicide,1illicit drug use,2sexually transmissible diseases (STDs),3and births to single mothers4have increased dramatically among adolescents. The changing nature of adolescent morbidity and mortality makes it critical that they receive medical care on a timely basis, and that barriers to care are removed.5One such barrier for many adolescents is their concern about whether sensitive information shared in private with their physician will remain confidential. See also p 1404. This report reviews adolescents' need for confidential health services and support by physicians and organized medicine for confidential care. Examined are two major barriers to confidential medical care: the prerogative to provide informed consent for medical treatment and payment for health services. The report describes how physicians can balance parental involvement and adolescents' needs for privacy in health care decisions and strategies to allay parental concerns and

PHYSICIANS who practice clinical ecology believe that exposure to low levels of environmental substances present in the air or ingested from food and liquids causes in susceptible individuals a variety of ill-defined symptoms affecting nearly every organ system. MULTIPLE CHEMICAL SENSITIVITY SYNDROME Most physicians who practice clinical ecology (clinical ecologists) maintain that a number of patients have the multiple chemical sensitivity syndrome (MCSS) (also called clinical ecological illness, environmental illness, chemical AIDS [acquired immunodeficiency syndrome], 20th-century disease, environmental hypersensitivity disease, total allergy syndrome, and cerebral allergy). 1-10 Clinical ecology has been defined as the orientation in medicine in which physicians primarily work with patients to uncover the cause-and-effect relationship between their ill health and food or low-level chemical exposure. 9 Other definitions have been offered and no general agreement exists that clinical ecology and MCSS are synonymous. 8-10 The lack of a clear definition or diagnostic test for MCSS has