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We investigated teacher ratings of the impact of parental divorce on academic achievement of children between 6 and 12 years old up to 12 months after their parents divorced. A purposive sample of 120 children attending four different primary schools in a small South African town took part in the study. One third (n 40) of the children had experienced parental divorce (male 14, female 26) while two thirds had not. Teachers rated participating children in their class on academic performance on the Conners rating scale ranging from 0 to 3. In addition, teachers ob tained the average term score of each of the participating children in key academic areas, which were converted to the Conners scale for classification. Chi square tests were used to analyse the data. Results showed that the academic performance of children from non intact families within the age range of 6 9 was inferior to that of their counterparts from intact families suggesting that the experience of parental divorcee had a negative impact on children’s academic achievement. It is recommended that future research compare teacher ratings with children’s ratings on standardised tests.

Eight patients over an 8-year period required operation for spontaneous hemorrhage as a complication of a pancreatic pseudocyst. Three patients presented with abdominal pain or jaundice and bled in hospital while undergoing work-up. Four patients were admitted with upper gastrointestinal bleeding and one with intraperitoneal bleeding. Five patients were managed by pancreatic resection (two of the head and three of the tail) and three were managed by arterial ligation and internal drainage. There was one death (mortality rate, 12.5%). The first four patients in the series had their operations delayed secondary to a perceived need for further work-up or an inability to make an exact diagnosis of the bleeding site. All rebled, necessitating an emergency operation. The last four patients underwent an expedited workup and operation. Successful treatment of bleeding pancreatic pseudocysts requires good surgical judgment, especially when nonoperative methods fail or aren't applicable. The risk of recurrent hemorrhage is high, suggesting the need for immediate intervention once the diagnosis is made. Resection provides definitive control, although selected patients with easily accessible vessels may be managed more conservatively with ligation and drainage.

The charts of 124 consecutive patients with extremity shotgun injuries managed over an 8-year period were reviewed to assess the results of a uniform protocol. This consisted of liberal use of arteriography, prompt exploration, wide debridement or fasciotomy, and frequent operating room dressing changes for large wounds. Thirty-three patients had arterial injuries and 16 had major venous injuries. Twenty patients had major soft tissue wounds and there were 15 significant long bone injuries. Results overall were excellent with over 95 per cent of patients retaining an intact and functional limb. Of the six limb amputations, three were done primarily and three were performed for late septic complications. Two of these late amputations were done following inadequate initial revascularization at referring hospitals. Early wound closure, liberal use of arteriography and fasciotomy, early fracture stabilization, and repair of all significant vascular injuries contribute to a successful outcome in patients with extremity shotgun wounds.

To assess the relationships between core temperature (T) and other factors relating to operating room (OR) blood loss and mortality following abdominal injury, the records of 122 patients undergoing laparotomy for trauma at Detroit Receiving Hospital over a 1-year period (1989) were reviewed. Most injuries were penetrating (86%) and the mortality rate was 8.2%. Overall, 57 of 122 (47%) had hypothermia (T < or = 35 degrees C) upon arrival in the OR. There was a significant correlation between admission blood pressure and lowest intraoperative temperature (r = 0.60; p < 0.001). Multiple regression analysis revealed that the patient's lowest temperature (p < 0.001) and Trauma Score (TS); p < 0.0015), but not Abdominal Injury Severity Score (AISS) (p = 0.25) correlated with OR blood loss. The 28 patients with high TS (15 or 16) and AISS > or = 9 had significantly less blood loss when the OR temperature was maintained above 35 degrees C versus 33 degrees-35 degrees C (540 +/- 580 mL vs. 1820 +/- 1160 mL; p < 0.003). This suggests that hypothermia may exacerbate OR blood loss independent of degree of physiologic or anatomic injury. Thus hypothermia is common in patients undergoing a laparotomy for trauma. Trauma scores and the presence of shock preoperatively correlate with the development of intraoperative hypothermia. Hypothermic patients with similar injury severity have greater blood loss. Prevention and rapid correction of hypothermia during resuscitation and surgery appear to be extremely important in reducing blood loss in this patient population.

This article has tried to provide some perspective on the results of surgical and percutaneous drainage of intra-abdominal abscesses and the impact of CT localization on the successful management of this problem. It is most likely that the recent decrease in mortality for intra-abdominal abscesses over the past decade is due to a variety of factors, including better antibiotics, more aggressive critical care, and earlier diagnosis and treatment of the intraabdominal problem. These factors combined to reduce the incidence of pre-drainage organ failure and the degree of physiologic derangement of these patients at the time of their abscess drainage. Percutaneous drainage and surgical drainage techniques should not be considered competitive but rather complementary. If an abscess is accessible by percutaneous techniques, it is reasonable to consider a nonoperative approach to the problem. It is also clear that patients should respond promptly to whatever technique is employed to drain their intra-abdominal abscess. An improvement should be seen clinically within 24 to 48 hours following drainage. Should improvement not be forthcoming, the patient must be aggressively re-evaluated with repeat CT and decisions made by the responsible surgeon in consultation with the radiologist as to the next appropriate course of action. As our review of the Wayne State University experience suggested, patients are never too sick for an appropriate operation. Although it appears that most abscesses can be successfully treated by percutaneous drainage, pancreatic abscesses with pancreatic necrosis should generally be treated by surgical debridement, usually accompanied by repeated explorations. In addition, splenectomy has not yet been replaced by percutaneous drainage of splenic abscesses.

A case is presented of a 41-year-old man admitted for obstructive jaundice. Work-up revealed a pseudocyst of the pancreatic head which contained a large pseudoaneurysm of the gastroduodenal artery. After an unsuccessful attempt at embolization, the patient was treated with an uncomplicated pancreaticoduodenectomy.

Major hemorrhage arising from a pseudocyst in the head of the pancreas is a rare and difficult clinical problem. Successful management of this condition by pancreaticoduodenectomy is presented. Arteriographic embolization of the bleeding inferior pancreaticoduodenal artery was not technically possible. Review of the literature suggests pancreaticoduodenectomy constitutes the best definitive management of this problem when embolization is not possible.

We report two cases of complications after percutaneous endoscopic gastrostomy (PEG) removal. The first was persistence of a gastrocutaneous fistula that required operative closure. The second patient developed pneumoperitoneum after an attack of vomiting 3 weeks after PEG removal. Laparotomy showed separation of the stomach from the posterior abdominal wall, with peritonitis. These cases highlight the need for careful monitoring of patients even after tube removal.

Objective: To evaluate the use of serum lactic acid values to predict flow-dependent increases in oxygen consumption (VO2) in response to increasing oxygen delivery (DO2) after blood transfusion in surgical sepsis., Design: Prospective study., Setting: Tertiary care, trauma center., Patients: Twenty-one patients, postsurgical or posttrauma, judged septic by defined criteria., Interventions: Serum lactic acid concentrations, DO2, and VO2 were measured before and after transfusion therapy., Measurements and Main Results: Overall, the DO2 increased from 532 +/- 146 to 634 +/- 225 (SD) mL/min.m2 (p less than .001), and the VO2 increased from 145 +/- 39 to 160 +/- 56 mL/min.m2 (p = .02). These changes occurred with an Hgb increase from 9.3 +/- 1.1 to 10.7 +/- 1.5 g/dL (p less than .001). The patients were grouped by their pretransfusion serum lactic acid values. In those patients with normal (less than 1.6 mmol/dL) serum lactic acid (n = 10), DO2 increased from 560 +/- 113 to 676 +/- 178 mL/min.m2 (p less than .02), and VO2 increased from 150 +/- 25 to 183 +/- 46 mL/min.m2 (p less than .02). However, in the increased serum lactic acid group (n = 17), VO2 was not significantly changed after transfusion (143 +/- 46 to 146 +/- 58 mL/min.m2) despite increased DO2 (515 +/- 163 to 609 +/- 251 mL/min.m2, p less than .01)., Conclusions: Blood transfusion can be used to augment DO2 and VO2 in septic surgical patients. Increased serum lactic acid values do not predict patients who will respond. The absence of lactic acidosis should not be used in this patient population to justify withholding blood transfusions to improve flow-dependent VO2. Patients who have increased lactate concentrations may have a peripheral oxygen utilization defect that prevents improvement in VO2 with increasing DO2.

The APACHE II Score was used to stratify retrospectively severity of illness in 91 patients postoperatively undergoing drainage of intra-abdominal abscesses. The method of initial abscess drainage (percutaneous or operative) was selected by the attending physician. The two groups of patients, those whose initial drainage was performed percutaneously versus operatively were similar with respect to age, sex, abscess location and, most importantly, severity of illness as assessed by the APACHE II score calculated on the day of their abscess drainage. Over-all, the mortality rate was 29 per cent (26 of 91 patients). Only 1.7 per cent of the patients with an APACHE II score of less than 15 died compared with 78 per cent when APACHE II was equal to or more than 15 (p less than 0.0001). Only 8 per cent of patients with APACHE II equal to or more than 15 undergoing percutaneous drainage survived compared with 30 per cent of patients who underwent surgical drainage procedures. While chi-square analysis demonstrated independence between outcome and drainage technique, outcome was dependent upon severity of illness (p less than 0.0005). Paradoxically, despite the attractiveness of a percutaneous technique for abscess drainage in the most ill patients, in this series, a better, although not statistically improved, chance for survival was noted with surgical treatment. We recommend that an objective severity scoring system be used whenever assessing results of treatment of intraabdominal infection and that surgical treatment not be avoided because the patient is considered to be too ill.

The records of 57 patients presenting with flail chest injury from 1981 through 1987 were reviewed to determine factors affecting morbidity and mortality. Fifteen patients (26%) had 8+ rib fractures with a unilateral flail and seven (12%) had multiple rib fractures with a bilateral flail. Thirty-two (56%) had moderate-severe pulmonary contusions and 44 (77%) required chest tubes for hemo-pneumothorax. Ventilatory assistance was used in 36 (63%). The major factors determining the need for ventilatory assistance were: an ISS greater than or equal to 23, blood transfusions in the first 24 hours, moderate-severe associated injuries (fractures, head injuries or truncal organs requiring operation), and shock on admission (p less than 0.001). An adverse outcome occurred in 15 (28%); nine required ventilatory assistance greater than or equal to 14 days and six died of sepsis with pneumonia. The main factors associated with an adverse outcome were: an ISS greater than or equal to 31 (p less than 0.001), moderate-severe associated injuries (p less than 0.001), and blood transfusions (p less than 0.005). Although the primary determinants of an adverse outcome were the associated injuries and blood loss, a bilateral flail (p less than 0.01) and age greater than or equal to 50 years (p less than 0.02) were contributing factors.

Large soft-tissue defects following close-range shotgun blasts remain a major technical challenge to trauma surgeons. During the period 1980 through 1988, 43 patients who survived greater than 48 hours following this injury were managed in our center. The locations of their soft-tissue defects were: extremity, 22; abdomen/chest, 18; and head/neck, three. All patients underwent immediate surgical exploration and wide debridement of all devitalized tissue along with repair of associated injuries. Management included mandatory frequent dressing changes, debridement, irrigation in the operating room, and the perioperative administration of broad-spectrum antibiotics. Four patients whose abdominal wall defects could not be initially closed had temporary placement of rayon cloth to prevent evisceration. Overall, four patients underwent delayed primary closure, eight were covered with split-thickness skin grafts, nine had closure with myocutaneous flaps, and 19 closed by secondary intent. Two patients, who were transferred to us following initial management, developed wound sepsis due to inadequate debridement and both eventually required amputation as did one patient who developed early myonecrosis following lengthy arterial repair. Frequent operative dressing changes, adequate debridement, and irrigation minimize sepsis following close-range shotgun blasts and should be the treatment of choice for this devastating injury. Techniques of wound closure need to be individualized to the particular situation.

The current treatment of civilian rectal injuries stems from military practice. Five principles have evolved: 1) complete fecal diversion, 2) debridement and closure, 3) rectal stump irrigation, 4) presacral drainage, and 5) broad spectrum antibiotics. To assess our practice results, the records of 52 consecutive patients with rectal injury seen at Detroit Receiving Hospital from 1980-88 were reviewed. Etiologies were gunshot (40), shotgun (9), anal assault (2), and stab (1). There were no blunt injuries and no deaths. Treatment consisted of celiotomy (52), diverting colostomy (51), presacral drains (35), rectal stump irrigation (26), and primary closure (1). Broad spectrum antibiotics were administered in all patients. Despite lack of universal application of the "standard" principles, only five patients had postoperative complications and none were related to the rectal injury. Our results demonstrate that a single approach may not be justified, as excellent outcome was achieved with low morbidity and no mortality despite selective management. The universal application of colostomy, repair, irrigation, drainage, and antibiotics cannot be supported.

The records of 239 patients surviving more than 24 hours with full-thickness intraperitoneal colonic injuries over a 7-year period were reviewed. During the first 3 years, 29% (31/106) of the patients were managed by primary repair without colostomy. In the next 4 years, almost twice as many patients, 56% (75/133), with similar colonic trauma were treated without fecal diversion (p less than 0.05). Although there was no difference in the mean Trauma Score in the patients with primary repair in the two time periods, the Injury Severity Score (mean +/- sd) in the patients without colostomy in the later periods was significantly higher (17.8 +/- 2.1 vs. 20.2 +/- 5.1) (p less than 0.001). No patient suffered because of the increased incidence of primary repairs. These patients had five abdominal abscesses and only one leak, whereas the patients with colostomy had 15 intraperitoneal abscesses. Because of the safety when primary repair is performed, more liberal use of primary colonic repair following penetrating trauma is warranted.

Although intravenous drug abuse is endemic in urban America, only 19 cases of pneumothorax from neck injections have been reported. For this reason, the experience at Detroit Receiving Hospital was reviewed. Data collected included patient demographics, size of pneumothorax, use of antibiotics, and complications related to tube thoracostomy. Of 525 diagnoses of pneumothorax between January 1, 1982 and December 31, 1984, 113 (21.5%) occurred as a result of drug abuse in 84 patients. Average patient age was 32 years (range 20 to 55 years). Thirty-eight (45%) were female. The number of admissions per year has increased, and 11 patients showed multiple admissions over the 3-year study period. Nine patients had bilateral collapse. One hundred six pneumothoraces (94%) were treated with closed thoracostomy with a tube-related hospital stay of 5 days, overall stay averaging 7 days. Only six patients received antibiotics for chest tube prophylaxis, and no in-hospital tube-related infections were identified. Thirteen patients developed residual pneumothorax following tube removal, but only two required a new tube. Pneumothorax in drug abusers is a serious urban problem and one with which physicians need be familiar.

Untreated septic shock results in depletion of extracellular fluid, cellular swelling, increased intracellular sodium, and decreased intracellular potassium concentrations in primate skeletal muscle. The Langer rabbit heart interventricular septal preparation was used to determine whether similar changes occur in cardiac muscle during sepsis. Rabbit septa (n = 17) were perfused with control and septic rabbit plasma plus red blood cells. Tissue contractility (developed tension [DT] and rate of tension change [dP/dt]) was followed, plasma cations were measured (Na+, K+, Ca2+, H+), perfusion pressure (PP) was monitored, and 42K efflux was determined. The effect on 42K efflux caused by the addition of potassium chloride to control plasma was determined. During perfusion with septic plasma there was significant decline of septal function (P less than 0.001). In 12/17 experiments DT fell 77.8 +/- 21.4% and dP/dt fell 75.8 +/- 24.8% from control values (means +/- 1 SD). All septa recovered when perfusion with control plasma was resumed. If [K+] was increased in control plasma during 42K washout, the percentage increase of effluent counts per minute per minute correlated with the percentage rise of control plasma [K+] (r = 0.95, P less than 0.001). During perfusion with septic plasma there was no similar correlation (r = 0.277). 42K efflux increased during septic plasma perfusion independent of the differences between control and septic plasma [K+], demonstrating abnormal myocardial K+ efflux. An abnormal efflux of K+ is seen during septic plasma perfusion similar to that described in primate skeletal muscle. It is associated with and may be a mechanism of action for the observed fall of contractility.

In the past decade 93 patients with duodenal injury were treated at a trauma center. By chart review, the age, sex, mechanism of injury, time to initial exploration (and the reason for delay), laboratory results, associated injury, extent of duodenal injury, operative repair, use of drains and tube decompression, morbidity, and cause of death were tabulated in order to improve management of these injuries. Of 87 patients surviving until the time of operative repair 73% required no repair (four) or primary closure (59). The remainder had either resection with primary anastomosis (ten), diverticulization (12), or pancreaticoduodenectomy (two). All patients with penetrating trauma were immediately explored. Patients with blunt trauma were explored on the basis of the judgment of house staff and faculty. Overall mortality was 18%. Significant morbidity occurred in 49% of survivors. This urban experience was heavily weighted toward penetrating injury. In this group early death usually resulted from associated vascular injuries. Blunt duodenal injury was less frequently associated with immediate exsanguination. Mortality associated with blunt duodenal injury was usually the result of delayed diagnosis. In blunt duodenal trauma peritoneal lavage is not diagnostic and may often be misleading; in this series 50% of lavages were false negatives. Blunt duodenal trauma, particularly when combined with pancreatic injury or delayed repair, was a lethal combination. A high index of suspicion and aggressive diagnostic evaluation (CT contrast study/amylase) in the emergency department is required in equivocal cases to avoid morbidity and mortality.

Previous studies from this laboratory described myocardial depression in an arterially perfused rabbit interventricular septum following perfusion with acute septic plasma. Calcium is critical for maintenance of cardiac contractility on a beat-to-beat basis. We have investigated calcium flux in the septal tissue to determine whether altered calcium flux explains the impaired cardiac function during sepsis. Twenty-two rabbit septa were perfused with control and septic perfusate (cryo-precipitated plasma + RBCs) and calcium flux determined in seven experiments. Perfusate cations (Ca++, Na+, K+, and H+) were measured, tissue function and arterial pressure were monitored. Developed tension decreased 46%, acceleration of tension change fell 42%, and arterial pressure decreased 26%, all highly significant. All septa recovered after return to control perfusate. The septic perfusate Ca++ was significantly lower than control perfusate, while K+ and H+ were significantly elevated. Ion flux studies, however, could not demonstrate altered calcium flux associated with the depressed contractility.