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This study was to extrapolate potential roles of augmented reality goggles as a clinical support tool assisting in the reduction of preventable causes of death on the battlefield. Our pilot study was designed to improve medic performance in accurately placing a large bore catheter to release tension pneumothorax (prehospital setting) while using augmented reality goggles. Thirty-four preclinical medical students recruited from Morehouse School of Medicine performed needle decompressions on human cadaver models after hearing a brief training lecture on tension pneumothorax management. Clinical vignettes identifying cadavers as having life-threatening tension pneumothoraces as a consequence of improvised explosive device attacks were used. Study group (n = 13) performed needle decompression using augmented reality goggles whereas the control group (n = 21) relied solely on memory from the lecture. The two groups were compared according to their ability to accurately complete the steps required to decompress a tension pneumothorax. The medical students using augmented reality goggle support were able to treat the tension pneumothorax on the human cadaver models more accurately than the students relying on their memory (p < 0.008). Although the augmented reality group required more time to complete the needle decompression intervention (p = 0.0684), this did not reach statistical significance., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

Acute epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. Though a benign and often self-limiting condition, EA's ability to mimic other disease processes makes it an important consideration in patients presenting with acute abdominal symptoms. Careful evaluation of abdominal CT scan findings is crucial in the accurate diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention. We report a case of a 29-year-old male presenting with a two day history of generalized abdominal pain. Physical exam revealed a diffusely tender abdomen with hypoactive bowel sounds. The patient had a leukocytosis of 18,000 and abdominal CT scan revealed right lower quadrant inflammatory changes suggestive of acute appendicitis. Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction. Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal appearing appendiceal structure supero-lateral to the area of inflammation. The patient recovered uneventfully with resolving leukocytosis. We present a case of cecal epiploic appendagitis mimicking acute appendicitis and review the current literature on radiographic findings, diagnosis, and treatment of this often misdiagnosed condition. General surgeons should be aware of this self-limiting condition and consider this in the differential diagnosis.

Skeletal metastases are often complicated by progression to impending or pathologic fracture and fixation with polymethylmethacrylate (PMMA) bone cement is used for stabilization and pain relief. Adjuvant therapy involving the delivery of PMMA composites mixed with antibiotic or chemotherapeutic agents requires an understanding of the rate of drug diffusion from the cement in addition to measurement of its mechanical properties pre- and postelution of drug. We have developed a method for the analysis of drug diffusion rate and mechanical properties of drug-cement composites using PMMA/methotrexate as a model system. The analysis method revealed the addition of methotrexate to PMMA in concentrations of 1.8 g methotrexate per 40 g PMMA did not change the compression modulus of the cement pre- or postelution of drug. The PMMA/methotrexate composites displayed an average diffusion rate of 50 ng/(mm2)(hour) during the first 6 hours, which decreased to 10 ng/(mm2)(hour) by 36 hours. Diffusion modeling predicts the 20 x 13-mm cylindrical PMMA/methotrexate samples used by the method deliver 10% of the total methotrexate content within 80 hours and 25% of the total within 133 days.

Adrenal myelolipoma is a rare benign tumor composed of mature lipomatous and hemopoietic tissue. Although it is often discovered as an incidental finding on imaging of the abdomen for some other reason or at autopsy, adrenal myelolipoma has been reported to present with symptoms such as flank pain resulting from tumor bulk, necrosis, or spontaneous retroperitoneal hemorrhage. Myelolipomas are hormonally inactive but have also been reported to coexist with other hormonally active tumors of the adrenal gland. They are usually unilateral but may be bilateral and may also develop in extraadrenal sites like the retroperitoneum, thorax, and pelvis. We report a patient with symptomatic adrenal myelolipoma diagnosed on computed tomography scan and confirmed on computed tomography-guided biopsy. The patient underwent surgical resection for symptomatic relief. We also review the literature to evaluate the presentation and optimal management of this rare adrenal tumor that is not encountered by most general surgeons and therefore not well known to most surgeons.

Video capsule endoscopy (VCE) is a novel diagnostic tool for noninvasively visualizing the lumen of the entire small intestine. It is especially useful in identifying the source of obscure small intestinal bleeding. However, VCE is not always optimal for localizing small bowel lesions. Several studies show VCE to be markedly superior to standard diagnostic techniques although the true clinical relevance of many of the capsule endoscopic findings remain unknown. We present two case reports of VCE findings that resulted in surgical intervention but were found to be benign lesions on definitive pathological examination. The actual clinical relevance of many of the lesions found on VCE thus remains to be demonstrated.

Subcapsular hematoma of the spleen is a rare complication of pancreatitis despite its close proximity to the pancreas. Pancreatic pseudocyst involving the tail of the pancreas may erode into the splenic hilum causing hilar vessel bleeding with subcapsular dissection and hematoma formation. The management of such complication is still controversial. It has been suggested that most of these complications spontaneously regress and therefore can be managed conservatively. A case of spontaneous splenic subcapsular hematoma resulting from pancreatitis was managed conservatively with a good outcome.

The sub-Saharan region of Africa is home to more of the ills of mankind than any other region on earth. Nowhere is the aggregate of disease, political turmoil, inadequate resources and a crumbling infrastructure so completely packaged in a seemingly "escape proof" pod as in sub-Saharan Africa. This continent is a kaleidoscope of people and problems derived from artificial boundaries drawn by European colonial powers, resulting in a litany of problems that have flourished for many decades. In the immediate postcolonial era, there was some oversight by the departed powers, but this has changed recently with decreasing interest in African affairs and only episodic worldwide news coverage because of other world events that overshadow Africa and its problems. The end of the cold war also eliminated the attention Africa received when the superpowers were courting nations. The American Medical Team for Africa has conducted medical missionary work throughout Africa for over a decade and, through its observations, has developed recommendations that are germane to all of sub-Saharan Africa. The organization thinks that this might warrant the attention of governments, international pharmaceutical houses, foundations, the United Nations and all international aid agencies concerned about the plight of healthcare in Africa. These recommendations should enable these countries to re-establish an affordable, efficient and sustainable infrastructure for basic hospital services so that they can diagnosis, monitor, treat and manage disease populations. In some areas, Africa needs to be retrofitted with technology from the past, while in others it needs to be fast-forwarded into the future. The purpose of this manuscript is to try putting the various healthcare challenges into one of these two categories.

Religious and other secular organizations have been involved with medical missionary work in sub-Saharan Africa for centuries, especially in remote provinces and villages. In times past, most of these countries were under the control of foreign powers. Private volunteer organizations operated within a structured environment, which, perhaps, facilitated their mission and their ability to review and evaluate their effectiveness because of the tight control the colonial powers maintained over every facet of native life. However, the transition from colonialism to independence has resulted in a different environment in which healthcare is fragmented and a low priority in most countries because of financial constraints. The lack of standardization, vintage laboratory equipment, a manual medical record system, lack of a subsidized transportation system, infrequent postal service and the absence of phone systems in the remote provinces and villages make treatment and tracking of patients, monitoring therapy and measuring outcomes/results difficult. Therefore, judging the effectiveness of an initiative in remote district hospitals and village clinics can be difficult. This manuscript addresses some of these issues and provides solutions to some that have been effective for one organization.

Low-grade lymphoma arising in mucosa-associated lymphoid tissue (MALT) of the duodenum represents a very rare neoplasm. We report an unusual presentation of primary duodenal MALT lymphoma in a 78-year-old man. The patient initially presented with a suspected pulmonary embolus and was anticoagulated, which precipitated a major gastrointestinal hemorrhage. A large atypical ulcer with narrowing of the duodenum beyond the bulb was seen on endoscopy. Biopsies revealed atypical lymphoid cells. Abdominal CT scan revealed a mass in either the duodenum or head of the pancreas. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which revealed a normal pancreatic duct with a large calculus in the common bile duct, which was extracted after sphincterotomy. Elective surgery was planned for suspected lymphoma of the duodenum. The patient developed severe nausea, vomiting, and fullness after meals. The patient underwent pancreaticoduodectomy for a neoplastic mass causing duodenal obstruction. Pathological examination of the resected specimen revealed a low-grade B-cell lymphoma (MALToma) arising in the duodenum and invading the pancreas. Flow cytometry confirmed the phenotype typical of MALT lymphoma. Celiac, peripancreatic, pelvic, and cervical nodes were also involved with tumor. Bone marrow was also positive for metastasis. The patient was postoperatively treated with chemotherapy for stage IV disease.

Somatostatinomas are extremely rare periampullary malignant neuroendocrine tumors that may be associated with von Recklinghausen disease or type-I neurofibromatosis. Duodenal somatostatinomas are distinguished from pancreatic somatostatinomas by their frequent association with type-I neurofibromatosis and typically absence of somatostatinoma syndrome. We report a very rare and atypical case of malignant duodenal somatostatinoma presenting with somatostatinoma syndrome in association with type-I neurofibromatosis.

Percutaneous endoscopic gastrostomy (PEG) has been popular since it was introduced in 1980. Gastrostomy tubes left in place for long periods often result in unusual complications. Complications may also result from simply replacing a long-term indwelling tube. Five patients who had gastrostomy tubes in place for as long as 4 years are presented and their complications reviewed. Various methods used in treating these complications are discussed, and suggestions for their prevention are given. Gastrointestinal erosion and jejunal perforation following migration of the gastrostomy tube, persistent abdominal wall sinus tracts, and separation of the flange head with small bowel obstruction were encountered. Reinsertion of a gastrostomy tube through a tract prior to adequate maturation was also noted to lead to complications. Complications may result from gastrostomy tubes left in place for extended periods of time and during replacement procedures. Awareness of such complications along with education of caregivers and timely intervention by the endoscopist may prevent such occurrences. In some cases one can only hope to minimize morbidity.

Unilateral renal agenesis occurs infrequently. However, it has been associated with malignancies at multiple primary sites, anomalies of the genitourinary system, and supernumerary limbs. We present the case of a 60-year-old man with an incarcerated left inguinal hernia and renal insufficiency. At herniorrhaphy, he had squamous cell carcinoma in the hernia sac. A postoperative evaluation revealed unilateral renal agenesis, stage IV squamous cell carcinoma of the urinary bladder, and urolithiasis. The clinician should consider the genitourinary system as a primary site when patients present with the unusual finding of squamous cell carcinoma in the abdominal cavity and unilateral renal agenesis.

Lymphedema after mastectomy occurs with a frequency as high as 30%. The incidence increases with more radical surgical dissection, as was often seen with radical mastectomies in the late 1800s. This is one aspect of breast surgery that has been greatly neglected. Surgery has often been deemed a success if the malignancy is eradicated. Patients may complain of symptoms as minor as arm heaviness to major ones such as massive chronic swelling, as was the case with our patient. The patient presented here had increasing lymphedema during a 14-year period after modified radical mastectomy and radiation therapy for advanced breast cancer. This condition had progressed to incapacitation of the extremity and a patient who as a result had become an invalid. The massively edematous extremity revealed no signs of recurrent disease or malignant degeneration. She underwent surgical intervention and physical therapy as procedures of choice to restore function.

Solid-pseudopapillary tumor of the pancreas is a very rare low-grade malignancy, predominantly occurring in adolescent girls and young women. Accurate diagnosis of this unusual tumor is important because the prognosis after surgical resection is excellent. We report a rare case of solid-pseudopapillary tumor of the pancreas in a 22-year-old woman that was misdiagnosed as a pancreatic pseudocyst on abdominal CT scan. This case emphasizes the importance of biopsying the pseudocyst wall at the time of drainage procedure if misdiagnosis is to be avoided. CT scan findings alone can not reliably rule out malignant cystic lesions of the pancreas.

Stercoral perforation of the colon is a rare phenomenon with fewer than 90 cases reported in the literature to date. The pathogenesis of stercoral ulceration is thought to result from ischemic pressure necrosis of the bowel wall caused by a stercoraceous mass. Stercoral perforation in more than 90 per cent of cases involves the sigmoid or rectosigmoid colon with associated fecal mass causing localized mucosal ulceration and bowel wall thinning due to localized pressure effect. We report the case of a 45-year-old woman who presented with a 12-hour history of epigastric pain. Significant comorbidities included systemic lupus erythematosus, sarcoidosis, hypertension, and previous history of congestive heart failure. The patient was also on prednisone and a nonsteroidal anti-inflammatory drug for joint pains. On physical examination the patient had signs of generalized peritonitis. Chest X-ray showed significant free air under the diaphragm. Emergency laparotomy revealed localized perforation over the antimesenteric border of the sigmoid colon with associated stercoral mass at the site of perforation. A segmental resection of the sigmoid colon with end colostomy (Hartmann's procedure) was performed. The patient made an uneventful recovery. Stercoral perforation is often a consequence of chronic constipation; however, there are other predisposing factors as the condition is rare compared with the frequency of severe constipation. One of the hypotheses includes the association of nonsteroidal anti-inflammatory drugs (NSAIDs) with stercoral perforation of the colon. Our case report lends support to this association with NSAID use; thus there need to be greater awareness and caution when using NSAIDs in chronically constipated patients.

Chest radiographs (CXRs) are frequently obtained in surgical intensive care unit (SICU) patients when a diagnosis of ventilator-associated pneumonia (VAP) is suspected. The purpose of this study was to determine if the interpretation of the CXR correlated with a diagnosis of VAP in SICU patients. Prospective evaluation of 20 SICU patients clinically suspected of VAP was performed from July 1997 through December 1998. All patients required mechanical ventilation for at least 48 hours, and antibiotic use was discontinued 24 hours before entry into the study. Bronchoscopy with protected specimen brush (PSB) sampling of secretions from the right and left lung was performed. A positive PSB was present if quantitative analysis yielded > or = 10(4) colony-forming units/mL of bacteria. VAP was diagnosed if either the right or left PSB was positive and ruled-out if both the right and left PSB yielded < 10(4) colony-forming units/mL. Twelve of 20 patients (60%) were diagnosed to have VAP by PSB criteria. Eight of 20 patients (40%) had CXRs interpreted as negative for infiltrates; four patients had VAP by PSB criteria. There were four patients with focal infiltrates; two patients had VAP. The remaining eight patients had radiographs interpreted as bilateral infiltrates (one) or pulmonary edema (seven); of these, six patients (75%) had VAP. The sensitivity of the CXR in determining the presence of VAP was 25 per cent, the specificity was 75 per cent, and the accuracy was 0.45. The CXR does not improve the clinician's ability to diagnose VAP: a normal CXR does not exclude the presence of VAP and the finding of a focal infiltrate does not confirm the diagnosis of VAP.

Increased intracranial pressure is often relieved by a ventriculoperitoneal shunt. The shunt has a one-way valve which can withstand pressures of 300 mmHg and prevent reflux of intraabdominal fluid. We have utilized laparoscopy for cholecystectomy in four patients with VP shunts. In all patients the peritoneal cavity was free of adhesions. When CO2 insufflation pressure was as high as 10-15 mmHg cerebrospinal fluid was still noted to flow from the end of the shunts. In three patients the entire procedure was performed laparoscopically. In the fourth patient the procedure was converted to an open cholecystectomy because of extensive inflammation surrounding a gangrenous gallbladder. Postoperatively the shunts remained intact and functional. There were no central nervous system sequelae. None of the shunts became infected. Elective laparoscopic cholecystectomy in patients with VP shunts can be done safely without a need for clamping or other manipulation of the shunt.

Young blacks with colon cancer continue to have a poor survival rate for reasons that remain undetermined. Medical records of blacks with colon cancer diagnosed at an inner-city hospital during a 10-year period were reviewed. The cohort consisted of 118 indigent, nonmigratory patients grouped by age. Group 1 consisted of 11 patients under age 50, and group 2 consisted of 107 patients age 50 and over. Admission symptoms were significantly different between groups. Patients in group 1 presented with abdominal pain more often than patients in group 2, and none of the patients in group 1 had anemia or obstruction, which comprised 14% and 11%, respectively, of the presenting symptoms in group 2 patients. Overall, survival difference was significant; the survival rate was 22.8 months for group 1 and 64.2 months for group 2 (P < .02). There was no difference in stage at presentation to account for the decreased survival in group 1. It is possible that the overwhelming majority (45%) of patients in group 1 with abdominal pain actually had more virulent disease, which accounts for the short survival. These individuals must be targeted for more aggressive patient education, surveillance, early detection and treatment, and follow-up.

Acts of violence within a statewide prison population were reviewed to determine the incidence, types of injuries, surgical procedures required, persons involved in the trauma, and weapons used to inflict the injuries. The objective was to identify trends to aid in developing methods of prevention. Over a 3-year period, 1600 prisoners from the state of Tennessee were hospitalized at our institution. The majority were from the maximum security unit. There were 133 episodes of trauma. Our study focused on the first admission of 94 inmates. Fourteen (15%) of the injuries were self-inflicted, including seven self-inflicted penetrating wounds. Nineteen different weapons were used to inflict trauma. Prison cafeteria utensils and workshop utility and office devices may need to be redesigned because these items are frequently used in acts of violence. Victims subjected to repeated episodes of violence should be relocated. Lastly, self-mutilators may need to be transferred to an institution for the mentally impaired for their own protection.

In vitro production of PGI2 in canine gallbladders subjected to hypovolemic shock and Escherichia coli sepsis was studied to determine whether a precursor above arachidonic acid in the cyclooxyenase cascade might be operative in the production of prostacyclin, which, in turn, may play a role in the pathogenesis of acute acalculous cholecystitis (AC). L-alpha-phosphatidylcholine (LaP), an arachidonic acid precursor, was used as the test agent. LaP did not stimulate PGI2 production from either gallbladder surface in the hypovelimic animals or the mucosa of the septic shock group. However, it did stimulate PGI2 production from the SS serosa compared with controls, 1375 +/- 432 versus 633 +/- 198 pg/cm2/min (P less than .05). In conclusion, lack of stimulation of PGI2 in the hypovolemic model suggests that PGI2 does not play a role in AC. Alternatively, it may play a role in preventing this disease process in septic shock. This study demonstrates the use of precursors of arachidonic acid and the cyclooxygenase pathway as active participants in the production of PGI2, although it is unclear whether the prostacyclin produced helps prevent AC in septic shock.

Despite the fact that a significant national effort has been made over the past 10 years to improve the early detection and treatment of colorectal cancer, blacks have not had any change in their prognosis compared to whites, and their survival rate appears to be independent of stage at the time of diagnosis. The disease incidence is practically the same for both races, 49 per 100,000. We reviewed all patients with colorectal cancer in our Tumor Registry over a 10-year period to determine whether the experience at an all-black institution with a black patient base for much of its history would help clarify these crucial questions. There were 118 cases (73 women/45 men), and the mean age was 68 years (range: 29 to 93). The most common signs and symptoms were gross bleeding (34%) and abdominal pain (30%), with most patients presenting with a combination of symptoms. Remarkably, none were symptom-free. Of the 96 patients who were staged surgically and pathologically, 68 (71%) were beyond Duke's B staging at the time of diagnosis and surgery. The overall 5-year survival rate was 47%, significantly related to stage of disease at diagnosis (P less than .001). We concluded that blacks have not shared in the progress made in early diagnosis and treatment of colon cancer, and that special attention should be given to developing screening and surveillance methodology targeted specifically at blacks.

Although the mechanism of cyclosporin (CsA)-induced hypertension is unknown, it has been shown to inhibit prostacyclin (PGI2) production directly, which may be a factor. We determined whether CsA had a differential effect on PGI2 production from the carotid artery (CA) and internal jugular vein (JV) compared to that from the renal artery (RA) and vein (RV) as a possible contributing factor to renovascular hypertension based upon the ability of organs to regulate their own blood flow according to local circumstances. The neck and renal vessels were removed from anesthetized adult female dogs (N = 8) and placed in a stimulation chamber, with Cell I being control (Hepes buffer), Cell II containing 0.3 mg/ml CsA, and Cell III containing CsA and 25 microM arachidonic acid (AA). Following serial stimulation periods, the supernatant was evaluated for PGI2 production by radioimmunoassay. PGI2 production from CA was significantly higher than that from RA following control and AA stimulation, 1474 +/- 382 pg/cm2-min vs 733 +/- 173 pg/cm2-min (P less than 0.05) and 2236 +/- 347 vs 1090 +/- 217 (P less than 0.01), respectively. CsA-induced PGI2 production from the carotid arteries was significantly greater than that from the renal arteries, 2944 +/- 586 vs 1003 +/- 235 (P less than 0.005). However, stimulation with AA following CsA resulted in sustained PGI2 production in both arteries that was similar to stimulation with CsA alone, 3014 +/- 600 vs 2944 +/- 586 for the carotids and 1278 +/- 280 vs 1003 +/- 235 for the renal arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Brown recluse spider bites may result in extensive soft tissue injury, causing months of disability. We have described a patient who had a series of extensive surgical debridements after envenomation. Despite skin grafting, persistent cutaneous lesions and extensive satellitosis progressed to involve the entire lower extremity. A recent biopsy showed pseudoepitheliomatous hyperplasia and pyoderma gangrenosum complicating the original injury. Although the role of early surgical excision and newer forms of medical treatment including dapsone and antivenom are still in evolution, recent reports suggest that the majority of patients will respond to medical therapy and may not require any surgical intervention.

We have described a patient with multiple hepatic abscesses caused by a perforated jejunal diverticulum with a presumed route of infection via the portal vein. Patients with hepatic abscesses and no known source of infection should be evaluated for a contained mesenteric perforation of the gastrointestinal tract. Finally, in patients who fail to respond promptly to percutaneous catheter drainage of a liver abscess, a continuing source of infection, such as perforation of a jejunal diverticulum, should be suspected.

A retrospective review was conducted to determine if there were identifiable racial markers in patients who were explored and misdiagnosed as having appendicitis. Between May 1983 and May 1987, 100 patients were explored for appendicitis. There were 65 whites and 35 blacks with a male predominance in each group. The age range was 4 to 70 years with a mean of 47 years; 30% of each group was in the pediatric age range (less than 17 years old). Eight patients had a normal appendix including two blacks: a 20-year-old male with no pathologic diagnosis and a 42-year-old female with a ruptured cornual pregnancy. Although the sample size was small, there was a trend toward a lower white blood cell count in blacks when appendicitis was confirmed at surgery (11,000 cells/microL +/- 3,000 v 17,000 cells/microL +/- 3,000). The following conclusions can be drawn: (1) the accuracy of diagnosis should be considerably lower than the 20% commonly quoted; (2) the likelihood of an incorrect diagnosis appears to be higher in adults in both groups without a sexual predilection; and (3) there may be a trend toward a higher initial white blood count in whites compared with blacks with acute appendicitis.

Improvements in biochemical assays, radiographic imaging, and perioperative monitoring; the availability of selective adrenergic blockers; and a better understanding of the pathophysiology of the disease have all contributed to the reduction in mortality and morbidity in patients with pheochromocytomas. Twenty-four-hour urinary catecholamines are more reliable than blood levels in detecting pheochromocytomas. The diagnosis may be confirmed by elevated epinephrine fractions when total catecholamine levels are normal. Computerized tomography is the preferred imaging tool, although ultrasound and magnetic resonance are preferred during pregnancy. 131I iobenguane scanning is useful in locating extra-adrenal disease and may have a role in the treatment of metastases. Total alpha-adrenergic blockade with phenoxybenzamine versus selective (alpha 1) blockage with prazosin are equally effective preoperatively. Invasive monitoring is necessary in all patients, and agents to control arrhythmias, hypertension, hypotension, and cardiac arrest are prepared in advance. Patients with benign lesions have an excellent cure rate, and those with malignancies have effective palliation of their symptoms.

Multiple synchronous primary intra-abdominal neoplasms involving more than one organ system are rare, particularly if the appendix is involved. We report a patient with synchronous primary lesions in the colon, appendix, and the kidney. We also discuss the incidence of this entity with respect to sex and age, the organs most often involved in instances of multiple primary lesions, and review the criteria for differentiation of synchronous versus metachronous lesions.

Myocardial function with ultrastructure and high energy phosphate levels in dogs was correlated after 24 hours of sepsis using live Klebsiella aerogenes. All animals developed progressive hemodynamic deterioration over a 24 hour period. Mean arterial pressure decreased from 148 +/- 7 mmHg to 85 (P less than 0.01) and cardiac output decreased from 3.43 +/- .31 to 1.6 +/- 0.5 L/min. Left ventricular stroke work decreased from 48.2 +/- 5 to 18.1 +/- 6 gm-meters (P less than 0.001). Systemic and pulmonary vascular resistances were increased at 24 hours (3,538 +/- 27 to 7,404 +/- 1,400 dyne/sec/cm-5 (P less than 0.01), and 185 +/- 20 and 619 +/- 90 dyne/sec/cm-5 (P less than 0.001), respectively. Left ventricular function curves at 24 hours showed a fixed low output. However, myocardial ultrastructure was preserved and high energy phosphate levels remained normal. These observations correlate well with the changes seen clinically in early gram negative sepsis in hypovolemic patients. Thus, this appears to be a suitable model for further investigation of the effects of gram negative sepsis on myocardial performance, ultrastructure, and maintenance of energy stores.