Effect of weekend admission on geriatric hip fractures

BACKGROUND

The care discrepancy for patients presenting to a hospital on the weekend relative to the work week is well documented. With respect to hip fractures, however, there is no consensus about the presence of a so-called “weekend effect”. This study sought to determine the effects, if any, of weekend admission on care of geriatric hip fractures admitted to a large tertiary care hospital. It was hypothesized that geriatric hip fracture patients admitted on a weekend would have longer times to medical optimization and surgery and increased complication and mortality rates relative to those admitted on a weekday.

AIM

To determine if weekend admission of geriatric hip fractures is associated with poor outcome measures and surgical delay.

METHODS

A retrospective chart review of operative geriatric hip fractures treated from 2015-2017 at a large tertiary care hospital was conducted. Two cohorts were compared: patients who arrived at the emergency department on a weekend, and those that arrived at the emergency department on a weekday. Primary outcome measures included mortality rate, complication rate, transfusion rate, and length of stay. Secondary outcome measures included time from emergency department arrival to surgery, time from emergency department arrival to medical optimization, and time from medical optimization to surgery.

RESULTS

There were no statistically significant differences in length of stay (P = 0.2734), transfusion rate (P = 0.9325), or mortality rate (P = 0.3460) between the weekend and weekday cohorts. Complication rate was higher in patients who presented on a weekend compared to patients who presented on a weekday (13.3% vs 8.3%; P = 0.044). Time from emergency department arrival to medical optimization (22.7 h vs 20.0 h; P = 0.0015), time from medical optimization to surgery (13.9 h vs 10.8 h; P = 0.0172), and time from emergency department arrival to surgery (42.7 h vs 32.5 h; P < 0.0001) were all significantly longer in patients who presented to the hospital on a weekend compared to patients who presented to the hospital on a weekday.

CONCLUSION

This study provided insight into the “weekend effect” for geriatric hip fractures and found that day of presentation has a clinically significant impact on delivered care.

The Intensive Care Unit Perspective of Becoming a Level I Trauma Center: Challenges of Strategy, Leadership, and Operations Management

The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU) level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1) leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2) preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3) intensivist staffing changes; (4) roles for and training of advanced practice practitioners; (5) graduate medical education issues; (6) optimizing interactions with closely related services; (7) nursing, staffing, and training issues; (8) bed allocation issues; and (9) reconciling the advantages of a “unified adult critical care service” with the realities of the central relationship between trauma and surgical critical care.

A comparative assessment of public opinion toward immigrants and immigration policies

"This article is part of a larger study of public attitudes toward immigration in seven countries that historically and currently have had different policies and practices vis-a-vis immigration. The countries involved are Australia, Canada, France, Germany, Great Britain, Japan and the United States. The time frame for which most of the public opinion data will be reported is from 1970 through 1995. The data have been collected from national surveys that were conducted in each of the countries."

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma

BACKGROUND

Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy.

METHODS

Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended.

RESULTS

There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically.

CONCLUSION

An aggressive laparoscopic program can improve patient management after PAT.

Hemorrhage exacerbates bacterial translocation at low levels of intra-abdominal pressure

BACKGROUND

It has been shown previously that the adverse cardiopulmonary sequelae of increased intra-abdominal pressure (IAP) are worsened by hemorrhage and resuscitation. Bacterial translocation (BT) to the mesenteric lymph nodes (MLNs), liver, and spleen has also been shown to occur with increased IAP.

OBJECTIVE

To investigate the hypothesis that BT associated with elevated IAP would be significantly increased after hemorrhage and resuscitation.

MATERIALS AND METHODS

Anesthetized adult male rats had femoral artery and vein catheters placed, and an intra-abdominal catheter placed to measure IAP. Group 1 underwent surgery only and served as controls. Group 2 had IAP raised to 10 mm Hg by infused lactated Ringer's solution for 40 minutes. Group 3 had a 25% hemorrhage, followed by resuscitation by infused lactated Ringer's solution and shed blood. Group 4 first had a 25% hemorrhage, resuscitated using infused lactated Ringer's solution and shed blood, and then had IAP raised to 10 mm Hg by infused lactated Ringer's solution for 40 minutes. All groups were killed after 2 hours, and had MLNs, liver, and spleen harvested for quantitative cultures.

RESULTS

Hemorrhage and resuscitation alone did not increase BT to the MLNs, liver, or spleen. An increase in IAP to 10 mm Hg resulted in a significant level of BT to the MLNs and liver on MacConkey II agar (P<.05), and a significant increase in the level of BT only to the liver on trypticase soy agar with 5% sheep's blood (P<.05). Hemorrhage and resuscitation did increase the level of BT to the liver and spleen when IAP was increased to 10 mm Hg (P<.05).

CONCLUSIONS

In this model, hemorrhage and resuscitation alone did not increase BT to the MLNs, liver, or spleen. However, hemorrhage and resuscitation increased BT to the liver and spleen when IAP was increased to 10 mm Hg. This supports the concept that prior hemorrhage and resuscitation exacerbates the effects of increased IAP.

Effect of hemorrhage on superior mesenteric artery flow during increased intra-abdominal pressures

BACKGROUND

Elevations in intra-abdominal pressure (IAP) adversely affect organ function. Prior hemorrhage and resuscitation exacerbates the cardiac and pulmonary effects of IAP. We have recently shown that superior mesenteric artery flow (SMAF) is reduced with increasing IAP. This study was designed to determine whether and how hemorrhage and resuscitation affects SMAF with increasing IAP.

METHODS

Ten pigs were divided into two groups after placement of a Doppler flow probe around the proximal SMA and insertion of a pulmonary artery (PA) catheter. Group 1 underwent intraperitoneal infusion of fluid to increase IAP to 10, 20, 30, and 40 mm Hg followed by a 20-minute equilibration period at each IAP. Group 2 was hemorrhaged 20% of circulating volume followed by standard resuscitation. After equilibration, this group had IAP increased in the same manner as group 1. Cardiac output (CO), PA pressures, and SMAF were recorded 1 hour after laparotomy and after equilibration at each IAP. Comparisons were made using repeated measures of analysis of variance, Student's t test, and linear regression analysis.

RESULTS

In group 2, a reduction in SMAF was noted at 30 and 40 mm Hg of IAP when compared with baseline (p = 0.009). This reduction was not seen in group 1. There was also a significant (p = 0.001) reduction in CO between baseline and all levels of increased IAP in group 2. This decrease was again not seen in group 1. The correlation between CO and SMAF in group 2 was r = 0.74, r2 = 0.55, p = 0.0001. There was no significant correlation between CO and SMAF in group 1.

CONCLUSION

SMAF and CO are reduced with increasing IAP to a greater degree when preceded by hemorrhage and resuscitation. Although there is a strong correlation between the reductions in CO and SMAF, the reduction in SMAF is greater than the reduction in CO. This finding suggests that optimizing cardiac function alone during periods of even moderate levels of increased IAP may be inadequate to normalize SMAF. This lends further support for early abdominal decompression in the treatment of trauma patients with increased IAP.

Crystal structure of chemically synthesized [N33A] stromal cell-derived factor 1alpha, a potent ligand for the HIV-1 "fusin" coreceptor

Stromal cell-derived factor-1alpha (SDF-1alpha ) is a member of the chemokine superfamily and functions as a growth factor and chemoattractant through activation of CXCR4/LESTR/Fusin, a G protein-coupled receptor. This receptor also functions as a coreceptor for T-tropic syncytium-inducing strains of HIV-1. SDF-1alpha antagonizes infectivity of these strains by competing with gp120 for binding to the receptor. The crystal structure of a variant SDF-1alpha ([N33A]SDF-1alpha ) prepared by total chemical synthesis has been refined to 2.2-A resolution. Although SDF-1alpha adopts a typical chemokine beta-beta-beta-alpha topology, the packing of the alpha-helix against the beta-sheet is strikingly different. Comparison of SDF-1alpha with other chemokine structures confirms the hypothesis that SDF-1alpha may be either an ancestral protein from which all other chemokines evolved or the chemokine that is the least divergent from a primordial chemokine. The structure of SDF-1alpha reveals a positively charged surface ideal for binding to the negatively charged extracellular loops of the CXCR4 HIV-1 coreceptor. This ionic complementarity is likely to promote the interaction of the mobile N-terminal segment of SDF-1alpha with interhelical sites of the receptor, resulting in a biological response.

Intestinal permeability correlates with severity of injury in trauma patients

BACKGROUND

Increased intestinal permeability (IP) and the release of toxic intraluminal materials have been implicated in the systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) observed in patients after severe trauma. Previous studies of intestinal permeability have failed to demonstrate a correlation between early measurements of IP and indicators of injury severity. This study examines the relationship between standard measures of injury severity and the early (day 1) and delayed (day 4) changes in IP. Associations between IP and the development of SIRS, MOF, and infectious complications were also studied.

METHODS

The metabolically inactive markers lactulose (L) and mannitol (M) were used to measure IP in 29 consecutive patients who sustained injuries that required admission to the surgical intensive care unit and in 10 healthy control subjects. Measurements were made within 24 hours of admission and on hospital day 4. Severity of injury was assessed by A Severity Characterization of Trauma (ASCOT), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Acute Physiology and Chronic Health Evaluation (APACHE) II score. Postinjury infections and parameters of SIRS and MOF were recorded.

RESULTS

The IP of healthy volunteers (L/M, 0.025 +/- 0.008) was within the normal range (L/M < or = 0.03), whereas the average IP in injured patients was increased both within 24 hours (L/M, 0.139 +/- 0.172) and on the fourth hospital day (L/M, 0.346 +/- 0.699). No significant correlation between severity of injury and increased IP was seen within 24 hours of injury. A significant correlation was seen on hospital day 4, however, with all severity indices measured (ASCOT: r = 0.93, R2 = 0.87, p < 0.001; TRISS: r = 0.93, R2 = 0.87, p < 0.001; ISS: r = 0.84, R2 = 0.70, p < 0.001; RTS: r = 0.68, R2 = 0.47, p = 0.002; APACHE II score: r = 0.51, R2 = 0.26, p = 0.04). Patients with markedly increased IP (L/M > or = 0.100) experienced a significant increase in the development of SIRS (83 vs. 44%; p = 0.03) and subsequent infectious complications (58 vs. 13%; p = 0.01) and showed close correlation with the multiple organ dysfunction scores (r = 0.87, R2 = 0.76, p < 0.001).

CONCLUSION

These observations demonstrate that the increased IP observed after trauma correlates with severity of injury only after 72 to 96 hours and not within the initial 24 hours of injury. A large increase in IP is associated with the development of SIRS, multiple organ dysfunction, and an increased incidence of infectious complications.

Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome

OBJECTIVE

To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS).

METHODS

Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H2O) was treated by bedside or operating room laparotomy.

RESULTS

Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11 patients, eight patients (72.7%) had acidotic pHi (7.10 +/- 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure.

CONCLUSIONS

IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

Intra-abdominal hypertension and the abdominal compartment syndrome

IAH causes multiple and profound physiologic abnormalities both within and outside the abdomen. IAP monitoring is easily performed by bladder measurements. Careful monitoring and prompt recognition and treatment of IAP are critical in patients after damage control surgery because IAH is extremely common in these patients. Use of mesh fascial prostheses at the initial celiotomy in high-risk patients may prevent the deleterious effects of IAH. IAH should be considered an earlier manifestation of ACS. Surgical intervention should be indicated by IAH and not delayed until ACS is clinically apparent.

Hemorrhage lowers the threshold for intra-abdominal hypertension-induced pulmonary dysfunction

BACKGROUND

Intra-abdominal hypertension has been associated with pulmonary and cardiac dysfunctions. We have noted in the clinical scenario of hemorrhagic shock and resuscitation that avoidance of even moderate levels of increased intra-abdominal pressure, using prophylactic decompression, improves outcomes when compared with patients who were decompressed when intra-abdominal pressures went over 20 cm H2O. We hypothesized that prior hemorrhage and resuscitation exacerbates the cardiopulmonary dysfunction associated with intra-abdominal hypertension.

METHODS

Ten anesthetized pigs underwent placement of arterial and pulmonary artery catheters and a Silastic intra-abdominal catheter for measuring and manipulating intra-abdominal pressure. Group 1 animals (n = 5) were subjected to increasing intra-abdominal pressures at 10 mm Hg increments up to a level of 40 mm Hg. Group 2 animals (n = 5) were exposed to a severe hemorrhage and resuscitation before the increasing intra-abdominal pressure protocol.

RESULTS

Compared with baseline, hemorrhage and resuscitation caused a significant deterioration in cardiac output at intra-abdominal pressures of 10 mm Hg and above. Oxygenation was reduced at 30 and 40 mm Hg. These changes were not seen in group 1 animals. A significant difference was found between groups 1 and 2 in VT, PaCO2, and PaCO2/FIO2 ratio at an intra-abdominal pressure of 20 mm Hg. This difference was not seen at lower or higher pressures.

CONCLUSIONS

Prior hemorrhage and resuscitation caused an earlier decline in cardiopulmonary function in the setting of increased intra-abdominal pressure. These data suggest that, when interpreting intra-abdominal pressures, the clinical scenario must be considered. Prior hemorrhage and resuscitation produce the adverse consequences of intra-abdominal hypertension at lower pressures than when intra-abdominal hypertension is the only insult.

Types of criminal acts women are likely to commit

In their article, Trice and Lamb misrepresented my 1975 work on women and crime by suggesting that I predicted that there would be a big increase in violent crime among young women as they become more "masculinized." In fact, what was predicted was that as more women entered the labor force, there would be a significant increase in property offenses, mostly white collar and financial crimes on the part of women.

A prospective randomized study of end points of resuscitation after major trauma: global oxygen transport indices versus organ-specific gastric mucosal pH

BACKGROUND

Gastric tonometry, as a method of organ-specific monitoring of the status of the splanchnic circulation, has demonstrated prognostic and therapeutic implications in critically ill patients. The experience with this method in patients with trauma has been limited.

STUDY DESIGN

Fifty-seven patients were prospectively randomized into two groups: group 1, n = 30, normalization and maintenance of gastric mucosal pH (pHi) at or above 7.3 and group 2, n = 27, maintenance of oxygen delivery index of 600 or an oxygen consumption index of greater than 150. The groups had statistically similar injury severity scores, lactate levels, and base deficits.

RESULTS

Of the 44 patients with pHi greater than 7.3 at 24 hours, three (6.8 percent) died of multiple organ dysfunction syndrome as compared with seven (53.9 percent) of 13 in whom pHi was not optimized, p = 0.006. Optimization times for oxygen delivery index, oxygen consumption index, lactate levels, and base excess were similar between survivors and nonsurvivors. The time for pHi optimization was significantly longer in nonsurvivors. Multiple organ dysfunction syndrome points were significantly higher in patients who did not have pHi optimized within 24 hours (6.08 compared with 2.5, p = 0.03). Optimization time for pHi was predictive of mortality on multiple regression. Persistently low pHi was frequently associated with systemic or intra-abdominal complications. It was the first finding in all the nonsurvivors at least 48 to 72 hours before death.

CONCLUSIONS

Gastric mucosal pH may be an important marker to assess the adequacy of resuscitation. Monitoring of pHi may provide early warning for systemic complications in the postresuscitation period.

Complex duodenal injuries

Duodenal trauma, with early diagnosis and prompt treatment, can be managed effectively by simple surgical techniques. Severe duodenal injuries and those associated with major destruction of adjacent structures (the pancreaticobiliary complex or abdominal vessels) require a more thoughtful strategy that incorporates a careful consideration of the physiologic stability of the patient and the extent of local destruction. Figure 8 summarizes these concepts in an algorithm.

A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study

This prospective study assessed the role of Doppler pressure indices (Ankle-Brachial Index [ABI] or Brachial Brachial Index [BBI]) in the evaluation for occult arterial injury from penetrating proximity extremity trauma (PET). A total of 258 patients with 323 PETs were evaluated by physical examination and Doppler pressure (ABI/BBI) determination. An ABI/BBI of < 0.9 was considered abnormal. The findings were compared with those of arteriography in all patients. Eleven injuries (3.4%) found on arteriography were associated with normal indices. Five of these injuries were treated by repair (4 patients) or angiographic embolization of a bleeding vessel (1 patient), all in lesions proximal to the knee or elbow joints. The other six lesions were observed without intervention. All of the 29 injuries associated with abnormal indices had positive arteriographic findings. The 4 lesions that were treated operatively were proximal and the remaining 25, all with distal penetration, were observed without observation. As compared to angiography, Doppler indices yielded the following results: 283 true-negative, 11 false-negative, 29 true-positive, and 0 false-positive, for a sensitivity of 72.5%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 96%. These data suggest that Doppler indices should be an integral part of the physical examination and can screen patients with proximal injuries for further studies such as duplex sonography or arteriography.

Gastric mucosal pH and oxygen delivery and oxygen consumption indices in the assessment of adequacy of resuscitation after trauma: a prospective, randomized study

OBJECTIVE

To compare gastric mucosal pH (pHi) and global oxygen variables [Oxygen Delivery Index (DO2I) and Oxygen Consumption Index (VO2I)] as indicators of adequacy of resuscitation after major trauma.

METHODS

Twenty-seven patients were prospectively randomized into two groups: group 1 (n = 11), normalization and maintenance of pHi at or above 7.30; and group 2 (n = 16), maintaining a DO2I of 600 and a VO2I of > 150. The groups had statistically similar injury severity scores, lactate, and base deficit.

RESULTS

The goals of therapy were achieved within 24 hours of admission in 10 of the 11 patients in group 1 and in 15 of the 16 patients in group 2. One patient (9.1%) in group 1 died. This patient had transient stabilization of pHi to 7.3 and subsequently had persistent mucosal acidosis. Of the 10 patients with pHi > 7.3 at 24 hours, 9 survived. In group 2, 5 (31.3%) died. Four of the 5 nonsurvivors had achieved DO2I and VO2I goals, but had pHi < 7.3 at 24 hours. A comparison of time taken for optimization of DO2I, VO2I, lactate, base excess, and pHi showed pHi and lactate as the variables different in survivors and nonsurvivors. Six of the 8 patients who developed multiple organ dysfunction syndrome had pHi < 7.3 at 24 hours. Persistently low pHi was the first sign of bacteremia (3 patients), small bowel gangrene or pregangrene (2 patients), intestinal anastomotic leak (2 patients), intra-abdominal hypertension (4 patients), and intra-abdominal abscess (5 patients). It was the first finding in all the nonsurvivors at least 72 hours before death.

CONCLUSIONS

pHi may be an important marker to assess the adequacy of resuscitation. pHi monitoring may provide early warning for systemic complications in the postresuscitation period.

Peptide aldehyde inhibitors of hepatitis A virus 3C proteinase

Picornaviral 3C proteinases are a group of closely related thiol proteinases responsible for processing of the viral polyprotein into its component proteins. These proteinases adopt a chymotrypsin-like fold [Allaire et al. (1994) Nature 369, 72-77; Matthews et al. (1994) Cell 77, 761-771] and a display an active-site configuration like those of the serine proteinases. Peptide-aldehydes based on the preferred peptide substrates for hepatitis A virus (HAV) 3C proteinase were synthesized by reduction of a thioester precursor. Acetyl-Leu-Ala-Ala-(N,N'-dimethylglutaminal) was found to be a reversible, slow-binding inhibitor for HAV 3C with a Ki* of (4.2 +/- 0.8) x 10(-8) M. This inhibitor showed 50-fold less activity against the highly homologous human rhinovirus (strain 14) 3C proteinase, whose peptide substrate specificity is slightly different, suggesting a high degree of selectivity. NMR spectrometry of the adduct of the 13C-labeled inhibitor with the HAV-3C proteinase indicate that a thiohemiacetal is formed between the enzyme and the aldehyde carbon as previously noted for peptide-aldehyde inhibitors of papain [Lewis & Wolfenden (1977) Biochemistry 16,4890-4894; Gamcsik et al. (1983) J. Am. Chem. Soc. 105, 6324-6325]. The adduct can also be observed by electrospray mass spectrometry.

Evaluation of subxiphoid pericardial window used in the detection of occult cardiac injury

We critically evaluated several diagnostic modalities (clinical criteria, subxiphoid pericardial window (SPW) and laparoscopy) used in the detection of occult cardiac injury in haemodynamically stable patients at high risk of cardiac injury. Over 5 years, 122 patients were admitted to a Level I trauma centre with such an injury. They sustained 69 stab wounds, and 53 gunshot wounds. Sites of penetration were: precordial (81), right chest (25), lateral chest (13), thoracoabdominal (40) and abdominal (19). Vital signs in the emergency room were (mean +/- SD): systolic BP, 111 +/- 23.2 mmHg; HR, 106 +/- 18.7; GCS, 13.6 +/- 1.3; and CVP, 17 +/- 7.8 cmH2O. SPW was performed in all patients and was positive for haemopericardium in 26 patients, 24 (92 per cent) of whom had a cardiac injury at operation. Two patients had pericardial lacerations without cardiac injury. In addition, 14 patients with lower precordial and thoracoabdominal wounds underwent laparoscopy. At laparoscopy, the pericardium was evaluated by transdiaphragmatic inspection in 10 patients. The presence (two) or absence (eight) of blood within the pericardium was accurately predicted and verified by SPW. Univariate and multiple logistic regression analysis of clinical data failed to reveal any significant predictor of cardiac injury. SPW remains the standard means of diagnosing occult cardiac injury in high-risk patients. Since the incidence of occult cardiac injury in haemodynamically stable patients is 20 per cent, SPW should be used liberally. Laparoscopy may have a role in evaluating the pericardium in the subgroup of patients with lower chest wounds, and it facilitates inspection of intra-abdominal viscera and diaphragm at the same time.

Current concepts in the use of cavitary endoscopy in the evaluation and treatment of blunt and penetrating truncal injuries

The use of thoracoscopy in the patient with penetrating injury to the thorax is in its infancy. Although it is used mainly for diagnosis, evidence suggests that it will become a therapeutic tool during the initial management of the traumatized patient and in the postinjury period (early evacuation of retained hemothorax and the treatment of empyema). Although its role in injuries to the superior chest is clear, its role has not been established in the evaluation of the diaphragm. Both laparoscopy and thoracoscopy offer advantages in this area that must be considered when contemplating diagnosis and treatment. Further studies help define the place of these procedures for injuries in the thoracoabdominal area. The indications for cavitary endoscopy after truncal injury are summarized in Table 2. It must be remembered that experience in this field is rapidly increasing, and indications will change with new studies and new technology.

Discovery of nanomolar ligands for 7-transmembrane G-protein-coupled receptors from a diverse N-(substituted)glycine peptoid library

Screening a diverse, combinatorial library of ca. 5000 synthetic dimer and trimer N-(substituted)glycine "peptides" yielded novel, high-affinity ligands for 7-transmembrane G-protein-coupled receptors. The peptoid library was efficiently assembled using readily available chemical building blocks. The choice of side chains was biased to resemble known ligands to 7-transmembrane G-protein-coupled receptors. All peptides were screened in solution-phase, competitive radioligand-binding assays. Peptoid trimer CHIR 2279 binds to the alpha 1-adrenergic receptor with a Ki of 5 nM, and trimer CHIR 4531 binds to the mu-opiate receptor with a Ki of 6 nM. This represents the first example of the discovery of high-affinity receptor ligands from a combinatorial library of non-natural chemical entities.

Hypercapnia: is there a cause for concern?

Concern that barotrauma may lead to further deterioration in pulmonary function in patients with ARDS has stimulated interest in developing methods of reducing it. These new modalities have had limited acceptance. The reasons for this include technical difficulties, associated complications, and the hypercapnia produced by the reduction in minute ventilation associated with diminished peak inspiratory pressure (PIP). Recent reports have shown that hypercapnia does not produce many of the adverse effects previously attributed to it. We studied the effects of moderate levels of hypercapnia produced by inverse ratio ventilation with low tidal volumes in patients with severe pulmonary dysfunction (Lung Injury Score > or = 2.5). The mean peak PaCO2 and PIP of the group were 63.3 +/- 15.7 mm Hg and 44.0 +/- 12.4 cm H2O, respectively. We found no adverse effects on cardiac function, oxygen utilization, or long-term neurologic function in patients after hypercapnia. We conclude that moderate levels of hypercapnia are safe, and may be permitted in the care of patients with severe pulmonary dysfunction.

Selective celiotomy for missile wounds of the abdomen based on laparoscopy

The role of laparoscopy in the selective management of gunshot wounds (GSW) of the abdomen was prospectively investigated in 38 patients. All the patients were hemodynamically stable and had equivocal evidence of intraabdominal penetration. Laparoscopy was performed in the operating room under anesthesia. The site of penetration was in the thoracoabdominal area in 13, epigastrium in 7, and lower quadrants in 18. Twenty-three (60.5%) had nonpenetration on laparoscopy and a laparotomy was avoided. The remaining patients had injuries to the liver (4 patients), spleen (two patients), diaphragm (3 patients), hemoperitoneum or retroperitoneal hematoma (6 patients), and hollow viscus injuries (5 patients). Laparoscopy was also helpful in determining the need for laparotomy vs thoracotomy in lower chest wounds. The negative laparoscopy group (no penetration) had a significantly lower hospital stay compared to hemodynamically stable patients who had negative laparotomy without laparoscopy for nonpenetrating GSW. There were no complications related to laparoscopy. Laparoscopy is a useful modality in the evaluation of hemodynamically stable patients with abdominal missile wounds.

Synthesis, molecular modelling, and NMR structure determination of four cyclic peptide antagonists of endothelin

A combined distance geometry and molecular mechanics/dynamics (MM/MD) protocol was unable to predict the active conformation of the cyclic pentapeptide inhibitor of endothelin-1 receptor, BQ-123, and two analogues. However, the MM/MD method alone is sufficient to predict the solution conformation of a third analogue. In that one case, the combination of proline at residue 3 and an N alpha-methyl substitution at residue 5 provides enough internal constraints to eliminate conformational flexibility seen in the other three analogues. For this constrained analogue, the 50 lowest energy conformations (out of a set of 500 DGEOM-generated, MM/MD minimized conformations) differ by no more than 3.9 kcal/mol. Thirty three of these 50 conformations have backbone atom RMSDs of less than 0.33 A, relative to the lowest energy conformation. The accuracy of this MM/MD model is verified by determining the solution structure of each of the four analogues with 2D NMR techniques. Each of the cyclic pentapeptides has a well defined solution conformation where a proline residue is clearly in a gamma-turn, leaving the remaining residues in a loose beta-turn. All four experimental NMR conformations agree closely with the MM/MD model.

A prospective reappraisal of primary repair of penetrating duodenal injuries

Based on a retrospective analysis of 100 penetrating duodenal injuries, the role of primary repair or resection and anastomosis was assessed prospectively in 66 patients (1986-1992). Duodenal exclusion was reserved for extensive combined pancreato-duodenal injuries. Seven of the 66 patients died from extensive abdominal trauma (mean Abdominal Trauma Index, ATI 70) within 48 hours of admission. Fifty-six patients had primary repair, while pyloric exclusion was performed for three patients with extensive pancreatico-duodenal injuries. Three patients (5.1%) developed duodenal fistula, two being in the primary repair group (3.6%). All three patients had associated injury to the head of the pancreas. Four of the 59 patients died, one attributed to the duodenal repair, for a duodenal mortality of 1.7 per cent. Of the anatomic (ATI, duodenal, vascular, and pancreatic injury scores) and physiologic variables (shock, transfusions) analyzed, the ATI, the Duodenal Injury Score, and the Colon Injury Score were significantly higher in the fistula group. We conclude that the vast majority of penetrating duodenal injuries should be managed by primary repair or resection and anastomosis. Complex duodenal decompression or diverticulization rarely are necessary. Complex procedures should be considered for patients with ATI > 40, Duodenal Injury Score > 12, and the presence of injury to the head of the pancreas.

Early management of civilian gunshot wounds to the face

We analyzed 54 civilian patients (1988-1992) with gunshot wounds (GSWs) of the face to review the management principles and results. Urgent airway control was needed in 18 cases (33%): by orotracheal intubation in 13, cricothyroidotomy in two, tracheostomy in two, and nasotracheal intubation in one. Central nervous system injury was seen in 12 (22%): 40% with orbital, 38% with mid-face, and 0% with lower face injuries. Two patients died of intracranial injuries (mortality, 4%). Vascular injury was present in five patients (9%), all detected by angiography. The local complication rate was 39% in the presence of intra-oral injury and 0% without intra-oral injury (p < 0.001). The maxilla was the most commonly fractured facial bone (41%) followed by the mandible in 28%. All maxillary, orbital, and zygomatic fractures were treated without reduction. One of the seven nasal fractures required open reduction for deformity. Six of the 15 mandible fractures were treated without reduction. Of eight patients treated with closed reduction, one developed nonunion. One patient treated with immediate open reduction developed osteomyelitis of the mandible and nonunion. Five patients (9%) had palate injuries. Two of them later developed intraoral fistulas following conservative treatment. The airway needs immediate attention in GSWs of the face. Computed tomographic scanning of the head or spine should be done when the bullet trajectory is above the lower face (the level of the mandible). Angiography is indicated when the trajectory of the bullet is suggestive. A conservative approach that effectively reduces the fractures is the procedure of choice. Open reductions should not be performed in the initial treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

The spleen at risk after penetrating trauma

In contrast to blunt splenic trauma where nonsurgical management is an option, splenorrhaphy is the current preferred approach for penetrating trauma. Splenectomy, however, may be required because of hemodynamic instability, the extent of the trauma, or when a pancreatic injury requires distal pancreatectomy. We evaluated our attempts at splenic preservation in 69 patients (1988-1992) in whom the spleen was at risk for removal. Fifty-seven patients had penetrating injury to the spleen and 12 patients had distal pancreatectomy. Splenic Trauma (n = 57): 6 patients (mean Abdominal Trauma Index 45) died within 24 hours of extensive injuries. All had splenectomy. Thirty-seven of the remaining 51 (72.5%) had successful splenorrhaphy, 85% with stab wounds (SWs) and 65.5% with gunshot wounds (GSWs). Splenic salvage was 100%, 100%, 92%, 37%, and 0%, respectively, for grades I-V injuries. Absorbable mesh splenorrhaphy improved splenic salvage in grade III and IV injuries from 67% and 0% in previous years (1983-1987) to 92% and 37% in recent years (1988-1992), p < 0.01. The use of the mesh did not increase septic complications, even in the presence of enteric perforation. Distal Pancreatectomy (n = 12): 1 died intraoperatively. The spleen was not injured in 6 and was preserved in all 6. The overall 54.5% splenic salvage rate was achieved without increasing morbidity or the number of transfusions.

CONCLUSIONS

(1) Splenorrhaphy should be possible in the great majority of stable patients after penetrating trauma. (2) Absorbable mesh is a valuable adjunct that may facilitate the repair of more severe grades of splenic trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Candiduria as an early marker of disseminated infection in critically ill surgical patients: the role of fluconazole therapy

The significance of candiduria in critically ill patients remains unclear. It may represent harmless colonization or a potentially life-threatening infection. We analyzed 47 patients in the surgical intensive care unit (SICU) (trauma: 20, general surgery: 15, neurosurgery: 12) who had candiduria, defined by a colony count greater than 100,000/mL. Twenty-seven of these patients were studied retrospectively. Twenty were evaluated prospectively. All patients were receiving broad-spectrum antibiotics for bacterial infections. Retrospective group: ten patients (group A) did not develop disseminated candidiasis, whereas 17 patients (group B) did. Group B had higher APACHE II scores on admission (13.4 +/- 7.8) and at the time of candiduria (13.7 +/- 4.4) when compared with group A [admission: 5.0 +/- 4.6; candiduria: 6.7 +/- 3.6 (p < 0.02)]. In group B, disseminated candidiasis was not diagnosed and treated until 9.9 +/- 4.4 days after development of candiduria. Prospective group: twenty patients with candiduria were treated with systemic fluconazole (group C) at the time of candiduria. The APACHE II scores of group C on admission (12.8 +/- 3.9) and at the time of candiduria (10.5 +/- 4.0) were comparable with those of group B. No patient in Group C developed disseminated candidiasis. The septic mortality rates of groups A, B, and C were 0%, 53%, and 5%, respectively (p < 0.05-0.0001). In patients exhibiting ongoing sepsis and organ failure (high APACHE scores), candiduria may be an early indicator of systemic infection. Diagnosis of disseminated infection and its treatment may be delayed if conventional criteria for candidiasis (positive blood cultures, multiple site isolation) are awaited.(ABSTRACT TRUNCATED AT 250 WORDS)

A critical evaluation of laparoscopy in penetrating abdominal trauma

One hundred hemodynamically stable patients with penetrating abdominal trauma (65, stab wounds, 35, gunshot wounds) were evaluated with laparoscopy. Sixty percent of the patients had wounds in the thoracoabdominal area or the upper abdominal quadrants and 25% had injuries located in the lower abdomen and flanks. Fifteen percent had epigastric wounds. Twenty-two stabs and 21 gunshots had not penetrated the peritoneum (negative laparoscopic results). Fifty-seven patients had peritoneal penetration and were noted to have hemoperitoneum only (n = 14), hemoperitoneum and solid organ injuries (n = 23), diaphragmatic lacerations (n = 17), and hollow viscus injuries (n = 2) on laparoscopic examination. Three of the 57 patients, one with omental herniation only and two with low grade nonbleeding lacerations of the liver, were managed uneventfully without laparotomy. The remaining 54 patients underwent laparotomy with confirmation of the laparoscopic findings. Seven patients (three with stab wounds and four with gunshots) had additional GI tract injuries seen at laparotomy. The diagnostic accuracy of laparoscopy was excellent for hemoperitoneum, solid organ injuries, diaphragmatic lacerations, and retroperitoneal hematomas. For GI injuries, laparoscopy was found to have a 100% specificity but only a 18% sensitivity. The majority of these discordant findings occurred in epigastric SWs and flank and lower quadrant GSWs, all in patients with undetected hollow viscus injuries. The major role of laparoscopy in penetrating abdominal trauma is in avoiding unnecessary laparotomy in tangential SWs and GSWs. It is excellent for evaluating the diaphragm in thoracoabdominal wounds. Caution is urged in excluding hollow viscus injuries based on laparoscopy.

Definitive treatment of colon injuries: a prospective study

The results of a prospective protocol for penetrating injuries of the colon in 252 patients are presented. The protocol emphasized definitive management of the injury by repair, resection and anastomosis or exteriorized repair. Colostomy was reserved for left colon injuries requiring resection or for delayed treatment. Two hundred nineteen patients (86.9%) had definitive treatment by repair (N = 159), resection and anastomosis (N = 26), or exteriorized repair. This was successful in 205 patients (93.6%). Three patients had anastomotic leak after repair or ileocolostomy. Eight of the 34 patients with exteriorized repair had suture-line breakdown and 26 (76.5%) patients avoided a colostomy. Injury severity indices (anatomic: Abdominal Trauma Index and Flint grading of colon injury) were higher in the exteriorized repair than in the repair group. Postoperative abdominal abscesses occurred in 43 patients (17.1%). A multiple regression analysis identified the Abdominal Trauma Index (P < 0.0001) and the presence of colostomy (P < 0.0004) as significant independent factors in association with this complication. Mortality from sepsis was 2.4 per cent (6 patients) and in only one patient was the death directly related to colon injury management. We conclude that the majority of colon injuries can be managed by repair or resection with anastomosis. End colostomy is unavoidable in Flint 3 injuries of the left colon. In other situations, ileocolic or colocolic anastomoses appear to be safe in hemodynamically stable patients. Loop colostomy has a role in delayed treatment, but can be replaced by an exteriorized repair in Grade 2 colon injuries that do not require resection.

Central and regional hemodynamics determine optimal management of major venous injuries

Controversy continues in the selection of optimal management of major venous injuries. We analyzed our experience with 191 major venous injuries in 163 patients (1986 to 1991). The mechanism of injury was gunshot (112), stab (44), blunt (six), and iatrogenic (one). Eighteen cervicothoracic, 51 caval, 30 iliac, 36 visceral, and 56 extremity veins were involved. Of the 191 injuries, 105 (54.9%) were repaired (lateral repair 76, end-to-end anastomosis 15, vein patch four, vein graft five, Gore-Tex graft four, and compilation one). Of the remaining venous injuries, 64 were ligated as a result of hemodynamic instability. Twenty-two injuries in 18 patients did not receive treatment because 16 of 18 patients died before vascular control or repair. The overall amputation rate was 1.2%, and the mortality rate was 28.2% (46/163). The highest mortality rate occurred in those patients who required resuscitative thoracotomy (100%, p < 0.00001), retrohepatic caval injuries (90%, p < 0.0004), and multiple venous injuries (81.8%, p < 0.00001). Seventeen patients underwent fasciotomies (15 prophylactic and two therapeutic). Clinical or measured venous hypertension by stump pressure assisted in deciding for venous repair in 20 patients. A significant decrease in venous stump pressure (p < 0.000001) was noted after venous reconstruction. Thus the decision to ligate or repair venous injuries correlated primarily with (1) hemodynamic stability, and in stable patients, with (2) extent and location of injury and (3) clinical and measured venous hypertension. Venous ligation in clinically stable patients did not increase the need for fasciotomy or amputation.(ABSTRACT TRUNCATED AT 250 WORDS)

Peptoids: a modular approach to drug discovery

Peptoids, oligomers of N-substituted glycines, are described as a motif for the generation of chemically diverse libraries of novel molecules. Ramachandran-type plots were calculated and indicate a greater diversity of conformational states available for peptoids than for peptides. The monomers incorporate t-butyl-based side-chain and 9-fluorenylmethoxy-carbonyl alpha-amine protection. The controlled oligomerization of the peptoid monomers was performed manually and robotically with in situ activation by either benzotriazol-1-yloxytris(pyrrolidino)phosphonium hexafluorophosphate or bromotris(pyrrolidino)phosphonium hexaflurophosphate. Other steps were identical to peptide synthesis using alpha-(9-fluorenylmethoxycarbonyl)amino acids. A total of 15 monomers and 10 oligomers (peptoids) are described. Preliminary data are presented on the stability of a representative oligopeptoid to enzymatic hydrolysis. Peptoid versions of peptide ligands of three biological systems (bovine pancreatic alpha-amylase, hepatitis A virus 3C proteinase, and human immunodeficiency virus transactivator-responsive element RNA) were found with affinities comparable to those of the corresponding peptides. The potential use of libraries of these compounds in receptor- or enzyme-based assays is discussed.

Analysis of organ procurement failure at an urban trauma center and the impact of HIV on organ procurement at a regional transplantation center

A 42-month experience with 100 patients with fatal head injuries was analyzed to identify areas of organ procurement failure. Thirty-six patients were ineligible for organ donation. Reasons for exclusion included advanced age (7), sepsis (16), hepatitis (1), systemic illnesses (3), and HIV infection or risk (9). Resuscitation failure (17 patients) and late deaths from failed support (16 patients) left 31 potential donors. Of the 30 families asked to donate, 17 consented (56.7%). Annual consent rates were 25%, 71%, 75%, and 67%. Efforts to improve organ procurement should focus on resuscitation and physiologic support of potential donors. To assess the impact of HIV infection or risk on organ procurement, a 3-year experience of the regional transplantation center (RTP) was reviewed. Of 1,714 referrals to the RTP from 102 hospitals, 1,120 were from trauma centers. The incidence of rejection because of HIV risk or infection was significantly higher in the trauma center group than in the group from non-trauma centers, 17.2% versus 10.2% (p less than 0.004). A similar difference was noted between metropolitan and suburban hospitals (p less than 0.0001). Hepatitis risk was comparable, 3.9% vs. 3.2%. The risk of HIV infection is emerging as a factor limiting organ donation at urban trauma centers.

Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury

Penetrating trauma to the intrathoracic abdomen is a difficult clinical problem, especially with reference to the detection of diaphragmatic injuries. A retrospective analysis of 657 laparotomies for penetrating abdominal trauma at our institution revealed 78 laparotomies with negative results. The majority (44.8%) were for wounds in the lower chest and upper abdomen. The role of laparoscopy in evaluating these difficult areas was studied in 40 (34 stab wounds and 6 gunshot injuries) patients. Fifteen stab wounds and five gunshot wounds were nonpenetrating. Laparoscopy revealed eight clinically unsuspected diaphragmatic lacerations in seven patients. Twenty patients had hemoperitoneum. Five patients with omental bleeding and abdominal wall bleeding and four with nonbleeding liver lacerations underwent nontherapeutic laparotomies. One patient with a nonbleeding liver laceration was observed successfully without laparotomy. Ten of the 20 patients with hemoperitoneum had therapeutic laparotomies. The incidence of diaphragmatic lesions discovered by laparoscopy in this series was comparable with that reported after a mandatory laparotomy for thoracoabdominal wounds. It is concluded that laparoscopy is an excellent modality for the evaluation of the intrathoracic abdomen and the diaphragm.

Guaiac testing in the diagnosis of rectal trauma: what is its value?

Rectal examination with guaiac testing is a standard part of the emergency department evaluation of acutely traumatized patients. Its major role is in the recognition of occult bowel injury. We questioned its efficacy in detecting occult rectal injury in patients with penetrating trauma. We reviewed the charts of 19 patients with suspected rectal injury. Ten injuries were to the abdomen, nine to the buttock, and three to the thigh. Guaiac testing was 69% (11/16) sensitive and 33% (1/3) specific. Rigid sigmoidoscopy was 100% (12/12) sensitive and 67% (2/3) specific. Sensitivity was 100% (8/8) when the two were combined. Our findings suggest that guaiac testing is not accurate enough to rule out the presence of occult rectal injury. The result of guaiac testing must not influence the decision to further evaluate patients with high-risk injuries.

Human embryo modulates placental function in the first trimester; effects of neural tissues upon chorionic gonadotropin and progesterone secretion

We investigated the effect of embryonal neural and adrenal tissues (7-14 weeks gestational age) upon beta hCG secretion by homologous placental explants in static and dynamic cultures. In static co-culture significant inhibition by SC and brain was noted at 7-9 weeks. Similarly, in superfusion, using a novel co-chambering technique there was a significant reduction in the area under the curve but not peak frequency of spontaneous pulsatile beta hCG secretion. Incubations with neural tissues 11 weeks and above caused a stimulatory effect upon beta hCG secretion in both models. The effect of adrenal tissue in static cultures was different, namely slightly inhibitory at 7-9 weeks and inhibitory at 11 weeks and above. In superfusion, the effect of adrenal tissue was not significant. Extracted neural tissue 7-9 weeks incubated with placental explants exhibited inhibitory effects upon beta hCG secretion as well. Buffer-based extracts of neural tissues effect was more pronounced than alcohol-based extracts regarding beta hCG secretion. The effect of extracts was dose-dependent and effects were noted up until a 2000-fold dilution. In contrast, the buffer SC extract had no effect on progesterone (P) secretion while the alcohol extract effect was inhibitory at 7-9 weeks and stimulatory at greater than 11 weeks. Superfused explants pattern of beta hCG secretion was inhibited by one minute pulse of the SC buffer extract. In conclusion, the human neural tissue of embryonal origin may modulate placental hCG and P secretion during early pregnancy.

Human embryonal extracts modulate placental function in the first trimester: effects of visceral tissues upon chorionic gonadotropin and progesterone secretion

We investigated the effect of human first trimester fetal visceral organ extracts upon placental function, as evidenced by secretion of human chorionic gonadotropin and progesterone in explant cultures of 7-10 weeks gestational age trophoblast. Certain alcohol/water or water extracted embryonal tissues, in highly diluted solutions (1:100-1:2,000 final) had significant effects upon secretion of both hormones. The alcohol/water extract produced an opposite effect. This inhibitory effect was also seen when pulses of the water extract were added to the superfused trophoblast. Both heat inactivation at 57 degrees C and treatment with 10 microM p-chloromercurobenzoate eliminated the inhibitory effect, which suggests that the compounds in question are proteinaceous. Also dialysis with exclusion of less than 8,000 daltons abolished the inhibitory effect seen with the untreated water extract. The alcohol/water lung extract at 9 weeks inhibited, while at 10 weeks it stimulated P4 secretion. The water extracted lung had no effect upon P4 secretion. The alcohol/water extract of kidney had no consistent effect upon hCG secretion. The water extract effect was inhibitory. The effect of alcohol/water extract at 9 weeks upon P4 secretion was inhibitory while at 11 weeks it was stimulatory. The water extract had no effect upon P4 secretion. Both alcohol/water and water extracted adrenal inhibited hCG secretion. The alcohol/water extract also increased P4 secretion, while the water extract had no effect. The alcohol/water and water extract liver had no effect upon hCG secretion. The effect of alcohol/water upon P4 secretion was markedly stimulatory, while the water extract had no effect. In conclusion, fetal visceral organs in very dilute concentrations have a significant effect upon placental hormonal secretion in vitro. In case of the lung, the active compound(s) appears to be a protein with a molecular weight of less than 8,000 daltons. The role of the human embryo in modulating early trophoblastic function is suggested.

Effect of supplemental vitamin A on colon anastomotic healing in rats given preoperative irradiation

We studied the effect of dietary supplementation with vitamin A on the healing of colon anastomoses in irradiated bowel. Rats were divided into two groups. Those in the first group were fed a standard chow diet and those in the second group were fed the same diet supplemented with 150 IU vitamin A/g of chow. The rats were maintained on their respective diets throughout the experiment. After 7 days, half the rats in each group underwent abdominal irradiation (200 rads). Seven days later, all of the rats underwent distal colon division and anastomosis under pentobarbital anesthesia. All rats were killed 7 days postoperatively, the colons excised, and bursting strength and hydroxyproline determinations performed on both the anastomotic segment and a normal proximal segment of adjacent colon. There was a significant decrease in the bursting strength at the colon anastomosis (p less than 0.02) and in the collagen content (p less than 0.02) after preoperative irradiation. This effect was mitigated by dietary vitamin A supplementation.

Pathways to the hospital for the geriatric psychiatric patient in New York and London

This communication examines the pathways of geriatric psychiatric patients in New York and London from the time of onset of a psychiatric episode to hospitalization. Informants of 50 patients in each city were interviewed with a semi-structured interview covering the events and the patient's activities prior to hospitalization. The results show that the time from the onset of the episode to hospitalization is significantly shorter in London than it is in New York. The major portion of this difference is accounted for by the longer time spent London the doctor is significantly more involved in New York between episode onset and initial medical contact. In the decision to hospitalize. In New York the main reason for hospitalization is harmful behavior, while in London it is psychiatric symptoms.