Non-operative management for penetrating splenic trauma: how far can we go to save splenic function?

BACKGROUND

Selective non-operative management (NOM) for the treatment of blunt splenic trauma is safe. Currently, the feasibility of selective NOM for penetrating splenic injury (PSI) is unclear. Unfortunately, little is known about the success rate of spleen-preserving surgical procedures. The aim of this study was to investigate the outcome of selective NOM for penetrating splenic injuries.

METHODS

A dual-centre study is performed in two level-one trauma centres. All identified patients treated for PSI were identified. Patients were grouped based on the treatment they received. Group one consisted of splenectomised patients, the second group included patients treated by a spleen-preserving surgical intervention, and group three included those patients who were treated by NOM.

RESULTS

A total of 118 patients with a median age of 27 and a median ISS of 25 (interquartile range (IQR) 16-34) were included. Ninety-six patients required operative intervention, of whom 45 underwent a total splenectomy and 51 underwent spleen-preserving surgical procedures. Furthermore, 22 patients (12 stab wounds and 10 gunshot wounds) were treated by NOM. There were several anticipated significant differences in the baseline encountered. The median hospitalization time was 8 (5-12) days, with no significant differences between the groups. The splenectomy group had significantly more intensive care unit (ICU) days (2(0-6) vs. 0(0-1)) and ventilation days (1(0-3) vs. 0(0-0)) compared to the NOM group. Mortality was only noted in the splenectomy group.

CONCLUSIONS

Spleen-preserving surgical therapy for PSI is a feasible treatment modality and is not associated with increased mortality. Moreover, a select group of patients can be treated without any surgical intervention at all.

Treatment effects of high-dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation

BACKGROUND

Disseminated intravascular coagulation (DIC) is a serious complication of sepsis that is associated with a high mortality.

OBJECTIVES

Using the adapted International Society on Thrombosis and Haemostasis (ISTH) diagnostic scoring algorithm for DIC, we evaluated the treatment effects of high-dose antithrombin (AT) in patients with severe sepsis with or without DIC.

PATIENTS AND METHODS

From the phase III clinical trial in severe sepsis (KyberSept), 563 patients were identified (placebo, 277; AT, 286) who did not receive concomitant heparin and had sufficient data for DIC determination.

RESULTS

At baseline, 40.7% of patients (229 of 563) had DIC. DIC in the placebo-treated patients was associated with an excess risk of mortality (28-day mortality: 40.0% vs. 22.2%, P < 0.01). AT-treated patients with DIC had an absolute reduction in 28-day mortality of 14.6% compared with placebo (P = 0.02) whereas in patients without DIC no effect on 28-day mortality was seen (0.1% reduction in mortality; P = 1.0). Bleeding complications in AT-treated patients with and without DIC were higher compared with placebo (major bleeding rates: 7.0% vs. 5.2% for patients with DIC, P = 0.6; 9.8% vs. 3.1% for patients without DIC, P = 0.02).

CONCLUSIONS

High-dose AT without concomitant heparin in septic patients with DIC may result in a significant mortality reduction. The adapted ISTH DIC score may identify patients with severe sepsis who potentially benefit from high-dose AT treatment.

Traumatic abdominal wall hernia--four cases and a review of the literature

OBJECTIVE

To review blunt traumatic abdominal wall hernias (TAWHs) in our institution.

METHOD

Retrospective review of blunt abdominal trauma cases over a 6-month period.

RESULTS

Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery.

CONCLUSION

This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.

Endovascular management of traumatic cervicothoracic arteriovenous fistula

BACKGROUND

This study evaluated a single-centre experience with endovascular repair of traumatic arteriovenous fistula in the cervicothoracic region.

METHODS

Endovascular repair of 27 traumatic cervicothoracic arteriovenous fistulas was attempted between August 1998 and December 2001. Patients with active bleeding or end-organ ischaemia were excluded. Follow-up was accomplished with clinical, duplex Doppler and arteriographic evaluation after 1 month and then every 3 months.

RESULTS

Twelve patients with a major vessel injury were treated by stent-graft placement. Vessels involved were the subclavian (eight), common carotid (three) and internal carotid (one) arteries. Subclavian artery side branches were embolized in three of the eight patients. Four patients developed early type 4 endoleaks but all resolved. Treatment with stent-grafts was ultimately successful in all 12 patients. Three patients were lost to follow-up. During mean follow-up of 21 (range 3-36) months, one of the remaining patients developed a graft stenosis. Fifteen patients with minor vessel injuries were treated with arterial embolization. Vessels embolized were subclavian artery branches (four), external carotid artery and branches (seven) and vertebral arteries (four). Successful embolization was accomplished in ten of 15 patients.

CONCLUSION

Endovascular therapy is a promising alternative to surgery for selected patients with cervicothoracic arteriovenous fistula.

Laparoscopic versus open surgical exploration in premenopausal women with suspected acute appendicitis

OBJECTIVES

To assess the utility of laparoscopic versus conventional surgical exploration in premenopausal women with suspected acute appendicitis.

METHOD

Female patients aged 15-45 years in whom an independent decision to undertake surgical exploration had been made, were randomised to laparoscopic or open procedures. Comparison of patient groups was conducted on an intention-to-treat basis.

RESULTS

Eighteen patients underwent laparoscopic exploration, with 1 procedure requiring conversion to lower midline laparotomy. Open surgical exploration was performed primarily in 16 patients. Postoperative complications (3 patients versus 1 patient) and diagnostic errors (5 patients versus 1 patient) were more frequent in patients undergoing open surgical procedures. Laparoscopic procedures tended to be of longer duration than open operations, but were generally associated with slightly more favourable indices of postoperative recovery (analgesic requirement, postoperative hospitalisation, return to normal activity, return to work). In patients found not to have acute appendicitis, the difference in mean postoperative hospitalisation following laparoscopic intervention (2.6 days) and conventional surgery (3.4 days) approached statistical significance (p < 0.1).

CONCLUSIONS

Laparoscopy may carry some diagnostic advantage over open surgery in premenopausal women with suspected acute appendicitis. Patients found not to have acute appendicitis have a marginally shorter period of hospitalisation after laparoscopic intervention. The outcome following laparoscopic appendicectomy for confirmed acute appendicitis is at least equivalent to that achieved with conventional appendicectomy. Laparoscopic exploration is an acceptable option in premonopausal women requiring surgery for suspected acute appendicitis.

Caring for the critically ill patient. High-dose antithrombin III in severe sepsis: a randomized controlled trial

CONTEXT

Activation of the coagulation system and depletion of endogenous anticoagulants are frequently found in patients with severe sepsis and septic shock. Diffuse microthrombus formation may induce organ dysfunction and lead to excess mortality in septic shock. Antithrombin III may provide protection from multiorgan failure and improve survival in severely ill patients.

OBJECTIVE

To determine if high-dose antithrombin III (administered within 6 hours of onset) would provide a survival advantage in patients with severe sepsis and septic shock.

DESIGN AND SETTING

Double-blind, placebo-controlled, multicenter phase 3 clinical trial in patients with severe sepsis (the KyberSept Trial) was conducted from March 1997 through January 2000.

PATIENTS

A total of 2314 adult patients were randomized into 2 equal groups of 1157 to receive either intravenous antithrombin III (30 000 IU in total over 4 days) or a placebo (1% human albumin).

MAIN OUTCOME MEASURE

All-cause mortality 28 days after initiation of study medication.

RESULTS

Overall mortality at 28 days in the antithrombin III treatment group was 38.9% vs 38.7% in the placebo group (P =.94). Secondary end points, including mortality at 56 and 90 days and survival time in the intensive care unit, did not differ between the antithrombin III and placebo groups. In the subgroup of patients who did not receive concomitant heparin during the 4-day treatment phase (n = 698), the 28-day mortality was nonsignificantly lower in the antithrombin III group (37.8%) than in the placebo group (43.6%) (P =.08). This trend became significant after 90 days (n = 686; 44.9% for antithrombin III group vs 52.5% for placebo group; P =.03). In patients receiving antithrombin III and concomitant heparin, a significantly increased bleeding incidence was observed (23.8% for antithrombin III group vs 13.5% for placebo group; P<.001).

CONCLUSIONS

High-dose antithrombin III therapy had no effect on 28-day all-cause mortality in adult patients with severe sepsis and septic shock when administered within 6 hours after the onset. High-dose antithrombin III was associated with an increased risk of hemorrhage when administered with heparin. There was some evidence to suggest a treatment benefit of antithrombin III in the subgroup of patients not receiving concomitant heparin.

Endovascular repair of occluded subclavian arteries following penetrating trauma

PURPOSE

To describe the endovascular repair of 2 subclavian arteries occluded due to penetrating trauma.

CASE REPORTS

Two male patients were admitted with zone-I neck stab wounds. Both were hemodynamically stable and had absent pulses in the ipsilateral upper limb with decreased Doppler pressures. There were no signs of critical ischemia or active bleeding. On arteriography, complete occlusion of the second segment of the left subclavian arteries in both patients was demonstrated. Stent-graft repair and embolectomy under local anesthesia were successfully performed. No procedure-related complications occurred, and both patients were discharged after 2 days. At 1-year follow-up, stent-graft patency was demonstrated in both patients.

CONCLUSIONS

Endovascular repair is a feasible and safe option in the management of occluded subclavian arteries due to penetrating trauma. This may represent another indication for stent-grafting in the expanding role of this technique.

Consented testing of newborns and childbearing women for human immunodeficiency virus through a newborn metabolic screening program

OBJECTIVE

In this program a postpartum woman could consent to receive her newborn's human immunodeficiency virus test result from the New York State Newborn Screening Program.

STUDY DESIGN

By state regulation each postpartum woman was counseled and offered her newborn's human immunodeficiency virus test result. With the mother's consent, newborn human immunodeficiency virus antibody test results from the Newborn Screening Program were sent to the baby's pediatrician; otherwise, test results were blinded. Data were analyzed for births from August 1, 1996, to January 31, 1997.

RESULTS

Overall, 92.5% of women offered newborn human immunodeficiency virus testing consented to receive the result. Among 444 human immunodeficiency virus-positive women offered newborn testing, consented testing resulted in a 21.4% increase in knowledge of human immunodeficiency virus status from 72.3% (n = 321) at delivery to 93.7% (n = 416) after newborn testing; 6.3% (n = 28) of human immunodeficiency virus-positive women delivered of infants who did not consent apparently remained unaware of their human immunodeficiency virus status.

CONCLUSION

Combined prenatal and consented newborn testing identified 94% of human immunodeficiency virus-positive mothers and exposed newborns, allowing early entry into care. Such testing may provide an opportunity for women not previously tested for the human immunodeficiency virus to learn their status but is not a substitute for universal prenatal human immunodeficiency virus counseling and consented human immunodeficiency virus testing.

Endovascular treatment of penetrating thoracic outlet arterial injuries

OBJECTIVES

to establish the feasibility of stent-graft treatment of penetrating thoracic outlet arterial injuries.

DESIGN

prospective study.

MATERIALS AND METHODS

forty-one patients with penetrating injuries to the carotid, subclavian and proximal axillary arteries admitted between August 1998 and May 1999 were studied. Patients requiring urgent surgical exploration for active bleeding (n=26) were excluded. Remaining patients underwent arteriography to assess suitability for stent-graft placement. After successful stent-graft treatment clinical and sonographic follow-up were done at 1 month and thereafter 3-monthly.

RESULTS

of the 15 patients considered, 10 patients qualified for stent-graft treatment (seven male, three female, mean age 27 years). The vessels involved were subclavian artery (seven), carotid artery (two) and axillary artery (one). Seven had arteriovenous fistulae and three, pseudoaneurysms. Stent-graft treatment was successful in all 10 patients with no procedure-related complications. On mean follow-up of 7 months no complications were encountered.

CONCLUSION

endovascular treatment shows promise as a treatment modality for thoracic outlet arterial injuries. Long-term follow-up is required for comparison to the results of standard surgical repair.

Acute acalculous cholecystitis--a clinical-pathological disease spectrum

OBJECTIVE

To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC).

DESIGN

Analysis of prospectively accumulated clinical data. Blinded histopathological review. LOCATION OF STUDY: Tygerberg Hospital, Western Cape.

PATIENTS

Fifty-seven consecutive patients with AAC treated over a 9-year period.

MAIN OUTCOME MEASURES

Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction.

RESULTS

Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology.

CONCLUSION

The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.

Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus

BACKGROUND

The Pediatric AIDS Clinical Trials Group Protocol 076 reported a reduction in the rate of perinatal transmission of the human immunodeficiency virus (HIV) from 25.5 percent to 8.3 percent with a three-part regimen of zidovudine given ante partum, intra partum, and to the newborn. We examined the effects of abbreviated zidovudine regimens on perinatal HIV transmission using data from the HIV polymerase-chain-reaction (PCR) testing service of the New York State Department of Health. Pregnant women who received abbreviated regimens rather than the recommended regimens did so because of limited prenatal care or by choice.

METHODS

The requisition form used by the PCR testing service included information on the demographic characteristics of the infants and the timing of any perinatal treatment with zidovudine. We also analyzed data on the timing of zidovudine prophylaxis collected by chart review in a subgroup of 454 infants as a means of validating the results in the entire cohort.

RESULTS

From August 1, 1995, through January 31, 1997, specimens from 939 HIV-exposed infants who were 180 days of age or younger were submitted for PCR testing. The rates of perinatal HIV transmission varied depending on when zidovudine prophylaxis was begun. When treatment was begun in the prenatal period, the rate of HIV transmission was 6.1 percent (95 percent confidence interval, 4.1 to 8.9 percent); when begun intra partum, the rate was 10.0 percent (3.3 to 21.8 percent); when begun within the first 48 hours of life, the rate was 9.3 percent (4.1 to 17.5 percent); and when begun on day 3 of life or later, the rate was 18.4 percent (7.7 to 34.3 percent). In the absence of zidovudine prophylaxis, the rate of HIV transmission was 26.6 percent (21.1 to 32.7 percent).

CONCLUSIONS

These results confirm the efficacy of zidovudine prophylaxis and suggest that there are reductions in the rates of perinatal transmission of HIV even with the use of abbreviated regimens that are begun intra partum or in the first 48 hours of life.

Toxic epidermal necrolysis in a burn patient complicated by acute pancreatitis

This report concerns a previously healthy patient who presented with 8% total body surface area burn wounds to his face and neck. Even though his burn wounds healed quickly, his course was complicated by the development of toxic epidermal necrolysis affecting 60% total body surface area due to a drug reaction. During the recovery period he subsequently developed jaundice and pancreatitis -- a rare and interesting course that is not well described in the literature.

Carcinoma of the gallbladder--a possible regional predisposition in the western Cape and northern Cape

An analysis of 19 patients with confirmed carcinoma of the gallbladder who were treated over a period of 68 months emphasised known clinical features of the disease, i.e. nonspecific symptomatology, late presentation and poor prognosis. Comparison with 883 patients undergoing surgery for benign calculous biliary tract disease during the same period identified a more advanced mean age (67.0 v. 55.3 years), larger mean maximum stone diameter (20.3 v. 11.9 mm) and a higher proportion of patients resident in the Cape interior and west coast region (57.8% v. 11.8%) as features associated with carcinoma of the gallbladder. Further investigation of the regional predisposition suggested by this study may identify new factors linked to the development of gallbladder cancer.

Antibiotic monotherapy with meropenem in the surgical management of intra-abdominal infections

In an open, multicentre, randomised study, the efficacy and safety of meropenem monotherapy as adjuvant antibiotic therapy in the surgical management of intra-abdominal infection was compared with that of the combination of cefotaxime and metronidazole. A total of 160 hospitalised adult patients with intra-abdominal infection requiring surgery were treated intravenously with either meropenem 1 g every 8 h (by bolus injection or infusion; n = 77) or cefotaxime 2 g and metronidazole 500 mg every 8 h (n = 83). Clinical and bacteriological responses to antibiotic therapy were assessed at the end of treatment and at 2-4 weeks' follow-up after treatment. The clinical response rates at the end of treatment and follow-up were 91% and 96%, respectively, for meropenem and 100% and 97%, respectively, for cefotaxime plus metronidazole. The bacteriological response rates were 90% and 93%, respectively, for meropenem and 92% at both time points for cefotaxime plus metronidazole. Both treatments were well tolerated. In this study, meropenem monotherapy was effective and as well tolerated as cefotaxime plus metronidazole. Meropenem monotherapy should, therefore, prove a useful alternative to standard combination therapy for the empirical treatment of intra-abdominal infections.

A survey of South African endoscopic surgical practice

To coincide with the first annual meeting of the South African Society of Endoscopic Surgeons (SASES), a postal survey of the endoscopic surgical practices of 98 registered specialist surgeons was undertaken. A response rate of 73.5% was achieved, and 94.5% of respondents had personally performed endoscopic surgical procedures. Cholecystectomy (4,557) was the most commonly performed endoscopic surgical procedure and was associated with a postoperative mortality rate of 0.13% and morbidity of 3.5%. Twelve bile duct injuries were reported (0.26%). In descending order of frequency, other procedures reported were diagnostic laparoscopy (1,404), dorsal sympathectomy (412), appendicectomy (396), inguinal hernia repair (146), anti-reflux procedures (83) and diagnostic thoracoscopy (51). No postoperative deaths were recorded and complication rates varied from zero for diagnostic thoracoscopy to 4.8% for inguinal hernia repair and anti-reflux procedures. The selected sample of South African surgeons canvassed appears to have adopted endoscopic surgical techniques with enthusiasm and with complication rates that compare favourably with those reported elsewhere.

Thoracoscopic evaluation of the diaphragm in patients with knife wounds of the left lower chest

The role of thoracoscopy in assessing the status of the diaphragm in penetrating knife wounds of the left lower chest was studied prospectively in 55 patients. Those with positive thoracoscopic findings (n = 22) proceeded to exploratory laparotomy and those with an uninvolved diaphragm (n = 32) were observed. Thoracoscopy was inconclusive in one patient and two were lost to follow-up. With operative findings or 30-month follow-up data as evaluation endpoints, thoracoscopy in 52 patients was 100 per cent sensitive, 90 per cent specific and 94 per cent accurate. A projected negative laparotomy rate of 63 per cent would have occurred with a policy of mandatory laparotomy; using thoracoscopy the actual rate was 6 per cent. Thoracoscopy is a safe and reliable method of evaluating the diaphragm in patients with left lower thoracic stab wounds.

Elective cholecystectomy via a 5 cm subcostal incision

This report describes a technique whereby elective cholecystectomy is performed through a 5 cm abdominal incision. Initial results in 18 patients compared with 112 historical control patients undergoing conventional cholecystectomy suggest an encouraging reduction in postoperative hospitalisation time, analgesic requirements and period of recuperation. The procedure takes no longer to perform than conventional cholecystectomy and obesity is not a limiting factor, as originally thought. This technique deserves a place alongside laparoscopic and conventional cholecystectomy in future studies seeking the optimal method of managing symptomatic cholelithiasis.

Dissection of the uncinate process during pancreatoduodenectomy

An alternative approach to the dissection of the uncinate process during pancreatoduodenectomy is described. This involves mobilisation of the midgut superiorly and bringing the uncinate process into an antero-inferior position within the operative field. Access to, and visualisation of, the posterior aspect of the superior mesenteric vessels is considerably improved. This approach may avoid many of the potential problems associated with freeing of the uncinate process during pancreatic resection.

Small vessel occlusion in acute acalculous cholecystitis

Ischemia is one mechanism implicated in the pathogenesis of acute acalculous cholecystitis. Gallbladder specimen arteriography was performed to define the comparative status of cystic artery runoff in the macroscopically normal gallbladder (n = 10), in acute gallstone-associated cholecystitis (n = 10), and in acute acalculous cholecystitis (n = 7). Standardized film exposure and quantity of contrast medium administered permitted objective intergroup comparison. Compared to the macroscopically normal gallbladder, specimens of acute gallstone-associated cholecystitis exhibited arterial dilatation and extensive venous filling. In contrast, multiple arterial occlusions, with absent or minimal venous filling, were consistent features of acute acalculous cholecystitis; the degree of arteriographic abnormality for acute acalculous cholecystitis corresponded to the severity of gallbladder pathologic findings. Small vessel occlusion, on the basis of low splanchnic flow or intravascular coagulation, may be a fundamental element in the pathogenesis of acute acalculous cholecystitis.

Effectiveness of a personalized fitness module on knowledge, attitude, and cardiovascular endurance of fifth-grade students: "heart smart"

The effectiveness of a Personalized Fitness Module was compared to a Traditional Fitness Unit, both of which were designed to develop knowledge, behavioral skills, fitness and positive attitudes. 95 students in Grade 5 and from intact physical education/health classes within two public schools participated in a seven-week cardiovascular fitness program. The experimental group of 48 participated in the personalized and noncompetitive fitness module. The control group of 47 participated in the traditional unit, a teacher-centered fitness module. Students received a total of 14 55-min. lessons over seven weeks. Pre- and posttest measurements included the Superkids-Superfit Knowledge Test, the Children's Attitudes Toward Physical Activity Inventory, and the one-mile run/walk. Data were analyzed using group mean gain scores on eight dependent variables (knowledge, six subscales of attitude, and one-mile run/walk) followed by a multivariate analysis of variance. A significant difference between groups led to a discriminant function analysis as a post hoc test. Findings indicated that the use of the personalized unit can substantially improve one-mile run/walk time. The use of modules of this type in health and physical education programs may promote life-long exercise patterns and fitness.

Plantar fasciitis in runners. Treatment and prevention

Plantar fasciitis is a common overuse injury found in runners. The plantar fascia, which is responsible for maintaining the integrity of the longitudinal arch, becomes irritated, inflamed or torn by repetitive stresses placed upon it. Commonly cited predisposers of plantar fasciitis are excessive pronation, a flat or cavus foot, tight Achilles tendon, type of training shoes worn, and errors in the training routine. Once the plantar fascia becomes irritated a myriad of conservative measures may be used, including everything from rest, ice and elevation to steroid injections and, if all else fails, surgery. In most cases conservative treatment of one kind or another will alleviate the symptoms of plantar fasciitis. However, it is essential to determine and correct the cause of the problem in order for the runner to resume normal activity levels. Controlling anatomical/biomechanical inefficiencies of the feet, stretching and strengthening exercises for the lower extremity, proper training shoes, and reasonable training routines will alleviate the symptoms of plantar fasciitis in a large percentage of sufferers. To prevent this injury, runners should be aware of the potential overuse injury and take precautionary measures, e.g. seek a biomechanical/anatomical evaluation from a qualified practitioner. The practitioner can then offer suggestions as to the specific steps the runner should follow to prevent the injury condition.

Phaeochromocytoma in pregnancy. A report of 3 cases

The coincidence of phaeochromocytoma and pregnancy is rare and potentially lethal. Three cases are reported; in 2 the fetus had died before the patient presented. With early diagnosis and appropriate treatment there should be no maternal mortality, and the fetal mortality rate should be reduced to less than 20%.

Determining predictor variables for running-related pain

The purpose of this study was to determine whether specific predictor variables exist for particular running-related injuries. Data on 134 patients with running-related injuries were evaluated to establish the factors that were associated with specific pain sites. Patient data consisted of a brief running history and measurements of 72 anatomical variables that have been cited in the literature as predisposers to running-related injuries. The descriptive statistics indicated certain associations of variables with each pain group. A factor analysis was used to eliminate multicollinearity and to reduce the 72 variables to 9 factors. The results of a discriminant function analysis using factor scores indicated that patients' membership in one of six pain groups could be predicted correctly in 29.1% of the cases. We concluded that the factors used in this study were not good predictors of pain groups. Physical therapists, however, should publish their data on runners' injuries, treatment, and rehabilitation to supplement the published data that relate anatomical and biomechanical factors to running-related injuries.

Predicting plantar fasciitis in runners

Ninety-one runners were studied to determine whether specific variables were indicative of runners who had suffered with plantar fasciitis either presently or formerly vs runners who had never suffered with plantar fasciitis. Each runner was asked to complete a running history, was subjected to several anatomical measurements, and was asked to run on a treadmill in both a barefoot and shoe condition at a speed of 3.35 mps (8 min mile pace). Factor coefficients were used in a discriminant function analysis which revealed that, when group membership was predicted, 63% of the runners could be correctly assigned to their group. Considering that 76% of the control group was correctly predicted, it was concluded that the predictor variables were able to correctly predict membership of the control group, but not able to correctly predict the presently or formerly injured sufferers of plantar fasciitis.

Congenital choledochal cyst. A case report

A congenital choledochal cyst presented as an upper abdominal mass in a non-jaundiced woman; at laparotomy total cystectomy was performed and biliary enteric continuity re-established by a hepaticojejunostomy Roux-en-Y anastomosis.

Characterization studies of a rat hepatic cytosolic androgen-binding protein

A rat hepatic cytosolic [3H]methyltrienolone (R1881) binding protein was studied under various conditions. This protein was also compared with the male-specific high capacity--low affinity estrogen-binding protein derived from the same cytosolic fraction. Analysis of the R1881 binding protein in adult (60-85 days old) male rat liver cytosol indicated the presence of a high affinity--low capacity binding site (Kd = 0.3 nM; Bmax = 5.9 fmol/mg) and a lower affinity--higher capacity component (Kd = 10.4 nM; Bmax = 131 fmol/mg). The latter component was eliminated by addition of triamcinolone or cortisol to the assay mixture. Steroid binding to the high affinity R1881 site was specific for testosterone, dihydrotestosterone, androstenedione, and mibolerone, with a moderate specificity to cyproterone acetate, flutamide hydroxide, and estradiol. Saturation studies indicated that these steroids were binding to the same or a similar high affinity component except for flutamide hydroxide which produced nonsaturable displacement. The high affinity site had no specificity for progesterone, diethylstilbestrol, or cortisol. Like the high capacity--low affinity protein, this protein was not present in the immature, adult, or 10-day ovariectomized adult female. However, unlike the high capacity--low affinity protein, it was present in low quantities in the immature male. In addition, castration of the adult for 18 h, 4 days, or 10 days or hypophysectomy for 10-17 days did not have a significant effect on the high affinity component compared with the controls. Testosterone administration to these animals did not alter this protein binding. These studies indicate that a specific, high affinity--low capacity androgen-binding protein exists in rat hepatic cytosol. Furthermore, this protein shows age and sex dependency, but its presence is not affected by altering gonadal or hypophyseal factors in the adult male.

Effects of chronic mestranol and (or)norethindrone treatment on ethanol-associated decreases in hepatic benzo[a]pyrene hydroxylase activity and increases in central vein fat accumulation in the female Wistar rat

Female Wistar rats were fed a liquid diet, Sustacal, which contained ethanol (40% of calories) or isocaloric sucrose. Mestranol and norethindrone in pharmacological doses were also administered via this diet. Hepatic microsomal benzo[a]pyrene (BP) hydroxylase, epoxide hydrase, aniline hydroxylase, and aminopyrine-N-demethylase activities were measured after 3 and 6 months treatment. In addition, hepatic histology and electron microscopic studies were carried out in an attempt to monitor ethanol-associated fat accumulation in the central vein region. Mestranol or norethindrone alone for 3 months produced an elevation of BP hydroxylase activity which was no longer present after 6 months treatment. When compared with the 3-month time period, BP hydroxylase activity was significantly decreased in livers of animals which had ingested ethanol (group 10 vs. group 2), ethanol plus mestranol (group 12 vs. group 4), and ethanol plus norethindrone (group 14 vs. group 6) for 6 months. However, in the steroid-treated groups, the ethanol associated decreases were not as large as that seen without ethanol over the 3-month time period (group 11 vs. group 3; group 13 vs. group 5). No decrease was observed in the combined steroid plus ethanol-treated groups. Ethanol treatment for 6 months increased hepatic epoxide hydrase activity in both the nonsteroid and mestranol-treated group. Aniline hydroxylase was increased by ethanol in the combined steroid-treated animals. Otherwise there were no significant changes in the enzyme activities measured. Hepatic histology studies carried out on the 6-month ethanol-treated animals provided evidence of fat accumulation in the central vein region of the liver lobule, as expected. However, the steroid- plus ethanol-treated groups exhibited less apparent fat accumulation in the central vein region. These data do not support the hypothesis that mestranol and (or) norethindrone will accentuate the inhibition of liver BP hydroxylase or the central vein fat accumulation produced by chronic ethanol ingestion in the female rat.

Differential effects of diabetes on microsomal metabolism of various substrates. Comparison of streptozotocin and spontaneously diabetic Wistar rats

We have examined the effect of recent onset diabetes on several aspects of hepatic microsomal metabolism in both streptozotocin (STZ)-induced and spontaneously diabetic BioBreeding (BB) male and female Wistar rats. Differential alterations of the diabetic state on hepatic microsomal enzyme activities were observed. Female diabetic rats exhibited no change in benzo [a]pyrene (BP) hydroxylase activity, a decrease in testosterone delta 4-hydrogenase, and an increase in aniline hydroxylase. On the other hand, male diabetic rats demonstrated a decrease in hepatic BP hydroxylase activity, no change in testosterone delta 4-hydrogenase, and an increase in aniline hydroxylase. Insulin treatment corrected these effects. No change in kidney BP hydroxylase activity was apparent in either female or male diabetics. There were no marked differences between the chemically induced and genetic models of diabetes with respect to the metabolism studies. Serum testosterone levels were significantly lower than control in male BB diabetics, whereas no change was apparent in female diabetics. Light microscopy and serum insulin determinations indicated that the spontaneously diabetic animals we examined were not severely diabetic. From electrophoresis of hepatic microsomal proteins we determined that spontaneous diabetes of short duration does alter the protein distribution in the cytochrome P-450 region. We conclude that the acute effects of STZ-induced and spontaneous diabetes on hepatic microsomal metabolism are quantitatively and qualitatively similar, despite probable differences in etiology of the diabetic state.

Febrile morbidity following vaginal hysterectomy

The author suggests that each gynecological service determine the incidencd of febrile morbidity before adopting routine use of prophylactic antibiotics or vaginal cuff suction drainage.

Serum theophylline analysis by high-pressure liquid chromatography

We have developed and evaluated a rapid, high-pressure liquid-chromatographic method for theophylline in serum. Only 0.2 ml of serum is required for each determination, and the sensitivity of this method is 0.5 mg/liter. This method, involving liquid extraction and silica adsorption chromatography, provides adequate selectivity, accuracy, and precision for routine or research applications. Little sample preparation is required before chromatography. We found no endogenous or exogenous interferences. Use of beta-hydroxypropyl theophylline as the internal standard provides reproducible results for this micro-scale method.

Serum theophylline analysis by high-pressure liquid chromatography

We have developed and evaluated a rapid, high-pressure liquid-chromatographic method for theophylline in serum. Only 0.2 ml of serum is required for each determination, and the sensitivity of this method is 0.5 mg/liter. This method, involving liquid extraction and silica adsorption chromatography, provides adequate selectivity, accuracy, and precision for routine or research applications. Little sample preparation is required before chromatography. We found no endogenous or exogenous interferences. Use of beta-hydroxypropyl theophylline as the internal standard provides reproducible results for this micro-scale method.

Determination of serum copper by atomic absorption, with use of the graphite cuvette

We have established and evaluated a flameless graphite cuvette method for copper in serum. This atomic absorption method provides substantial improvement in sensitivity, adequate accuracy, and acceptable precision, and little sample preparation is required before the analysis. Standard addition studies and measurements of National Bureau of Standards materials indicated that the proposed method is accurate, but that sample pH must be kept between 2 and 3 for high accuracy. Cations and anions that frequently are present in protein-containing samples do not interfere significantly. Sample cross contamination in the syringe must be carefully avoided. Finally, when results for more than 100 patients' sera by this method were compared to those obtained by flame atomic absorption for the same samples, no substantial bias or inaccuracies could be attributed to this new micro-scale method for serum copper. Hence, this method is ideally suited for use on pediatric patients.