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Whole blood (WB) transfusion for trauma patients with severe hemorrhage has demonstrated early successful outcomes compared to conventional component therapy. The objective of this study was to demonstrate WB transfusion in the non-trauma patient. Consecutive adult patients receiving WB transfusion at a single academic institution were reviewed from February 2018 to January 2020. Outcomes measured were mortality and transfusion-related reactions. A total of 237 patients who received WB were identified with 55 (23.2%) non-trauma patients. Eight patients (14.5%) received pre-hospital WB. The most common etiology of non-traumatic hemorrhage was gastrointestinal bleeding (43.6%, n = 24/55). Approximately half of the non-trauma patients (n = 28/55) received component therapy. Transfusion-related events occurred in 3 patients. This study demonstrated that non-trauma patients could receive WB transfusions safely with infrequent transfusion-related events. Future studies should focus on determining if outcomes are improved in non-trauma patients who receive WB transfusions and defining specific transfusion criteria for this population., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Whole blood (WB) use has become increasingly common in trauma centers across the United States for both in-hospital and prehospital resuscitation. We hypothesize that prehospital WB (pWB) use in trauma patients with suspected hemorrhage will result in improved hemodynamic status and reduced in-hospital blood product requirements., Methods: The institutional trauma registries of two academic level I trauma centers were queried for all patients from 2015-2019 who underwent transfusion upon arrival to the trauma bay. Patients who were dead on arrival or had isolated head injuries were excluded. Demographics, injury and shock characteristics, transfusion requirements, including massive transfusion protocol (MTP) (>10 U in 24 hours) and rapid transfusion (CAT3+) and outcomes were compared between pWB and non-pWB patients. Significantly different demographic, injury characteristics and pWB were included in univariate followed by stepwise logistic regression analysis to determine the relationship with shock index (SI). Our primary objective was to determine the relationship between pWB and improved hemodynamics or reduction in blood product utilization., Results: A total of 171 pWB and 1391 non-pWB patients met inclusion criteria. Prehospital WB patients had a lower median Injury Severity Score (17 vs. 21, p < 0.001) but higher prehospital SI showing greater physiologic disarray. Prehospital WB was associated with improvement in SI (-0.04 vs. 0.05, p = 0.002). Mortality and (LOS) were similar. Prehospital WB patients received fewer packed red blood cells, fresh frozen plasma, and platelets units across their LOS but total units and volumes were similar. Prehospital WB patients had fewer MTPs (22.6% vs. 32.4%, p = 0.01) despite a similar requirement of CAT3+ transfusion upon arrival., Conclusion: Prehospital WB administration is associated with a greater improvement in SI and a reduction in MTP. This study is limited by its lack of power to detect a mortality difference. Prospective randomized controlled trials will be required to determine the true impact of pWB on trauma patients., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Major trauma frequently occurs in the deployed, combat setting and is especially applicable in the recent conflicts with explosives dominating the combat wounded. In future near-peer conflicts, we will likely face even more profound weapons including mortars and artillery. As such, the number of severely wounded will likely increase. Hypocalcemia frequently occurs after blood transfusions, secondary to the preservatives in the blood products; however, recent data suggests major trauma in and of itself is a risk factor for hypocalcemia. Calcium is a major ion involved in heart contractility; thus, hypocalcemia can lead to poor contractility. Smaller studies have linked hypocalcemia to worse outcomes, but it remains unclear what causes hypocalcemia and if intervening could potentially save lives. The objective of this study is to determine the incidence of hypocalcemia on hospital arrival and the association with survival. We are seeking to address the following scientific questions, (1) Is hypocalcemia present following traumatic injury prior to transfusion during resuscitation? (2) Does hypocalcemia influence the amount of blood products transfused? (3) To what extent is hypocalcemia further exacerbated by transfusion? (4) What is the relationship between hypocalcemia following traumatic injury and mortality? We will conduct a multicenter, prospective, observational study. We will gather ionized calcium levels at 0, 3, 6, 12, 18, and 24 hours as part of scheduled calcium measurements. This will ensure we have accurate data to assess the early and late effects of hypocalcemia throughout the course of resuscitation and hemorrhage control. These data will be captured by a trained study team at every site. Our findings will inform clinical practice guidelines and optimize the care delivered in the combat and civilian trauma setting. We are seeking 391 patients with complete data to meet our a priori inclusion criteria. Our study will have major immediate short-term findings including risk prediction modeling to assess who is at risk for hypocalcemia, data assessing interventions associated with the incidence of hypocalcemia, and outcome data including mortality and its link to early hypocalcemia.

Low titer type O Rh-D + whole blood (LTO + WB) has become a first-line resuscitation medium for hemorrhagic shock in many centers around the World. Showing early effectiveness on the battlefield, LTO + WB is used in both the pre-hospital and in-hospital settings for traumatic and non-traumatic hemorrhage resuscitation. Starting in 2018, the San Antonio Whole Blood Collaborative has worked to provide LTO + WB across Southwest Texas, initially in the form of remote damage control resuscitation followed by in-hospital trauma resuscitation. This program has since expanded to include pediatric trauma resuscitation, obstetric hemorrhage, females of childbearing potential, and non-traumatic hemorrhage. The objective of this manuscript is to provide a three-year update on the successes and expansion of this system and outline resuscitation challenges in special populations., (© 2022 AABB.)

Background: While massive transfusion protocols (MTPs) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion with all other pediatric trauma patients to identify triggers for MTP activation in injured children., Methods: Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and Injury Severity Scores. Statistical significance was determined using Mann-Whitney U test and χ2 test. p Values of less than 0.05 were considered significant., Results: Thirty-nine (1.9%) of the 2,035 pediatric patients met the criteria for MT. All-cause mortality in MT patients was 49% (19 of 39 patients) versus 0.01% (20 of 1996 patients) in non-MT patients. The two groups significantly differed in Injury Severity Score, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) of <100 mm Hg and shock index (SI) of >1.4 were found to be highly specific for MT with specificities of 86% and 92%, respectively. The combination of SBP of <100 mm Hg and SI of >1.4 had a specificity of 94%. The positive and negative predictive values of SBP of <100 mm Hg and SI of >1.4 in predicting MT were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP of <100 mm Hg and SI of >1.4 were 7.2 times more likely to require MT than patients who did not meet both of these vital sign criteria., Conclusion: Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher SIs and lower pulse pressures. We found that SI and SBP are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion., Level of Evidence: Therapeutic/care management, level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Andros Island, The Bahamas, composed of porous carbonate rock, has about 175 inland blue holes and over 50 known submerged ocean caves along its eastern barrier reef. These ocean blue holes can have both vertical and horizontal zones that penetrate under the island. Tidal forces drive water flow in and out of these caves. King Kong Cavern has a vertical collapse zone and a deep penetration under Andros Island that emits sulfidic, anoxic water and masses of thin, mucoid filaments ranging to meters in length and off-white turbid water during ebb flow. Our objective was to determine the microbial composition of this mucoid material and the unconsolidated water column turbidity based on the concept that they represent unique lithoautotrophic microbial material swept from the cave into the surrounding ocean. Bacterial DNA extracted from these filaments and surrounding turbid water was characterized using PCR that targeted a portion of the 16S rRNA gene. The genus Arcobacter dominated both the filaments and the water column above the cave entrance. Arcobacter nitrofigilis and Arcobacter sp. UDC415 in the mucoid filaments accounted for as much as 80% of mapped DNA reads. In the water column Arcobacter comprised from 65% to over 85% of the reads in the depth region from about 18 m to 34 m. Bacterial species diversity was much higher in surface water and in water deeper than 36 m than in the intermediate zone. Community composition indicates that ebb flow from the cavern influences the entire water column at least to within 6 m of the surface and perhaps the near surface as well., Competing Interests: The authors have declared that no competing interests exist.

Background: Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion., Study Design and Methods: A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed., Results: A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05)., Discussion: This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed., (© 2021 AABB.)

Background: Traumatic injury can lead to a compromised intestinal epithelial barrier, decreased gut perfusion, and inflammation. While recent studies indicate that the gut microbiome (GM) is altered early following traumatic injury, the impact of GM changes on clinical outcomes remains unknown. Our objective of this follow-up study was to determine if the GM is associated with clinical outcomes in critically injured patients., Methods: We conducted a prospective, observational study in adult patients (N = 67) sustaining severe injury admitted to a level I trauma center. Fecal specimens were collected on admission to the emergency department, and microbial DNA from all samples was analyzed using the Quantitative Insights Into Microbial Ecology pipeline and compared against the Greengenes database. α-Diversity and β-diversity were estimated using the observed species metrics and analyzed with t tests and permutational analysis of variance for overall significance, with post hoc pairwise analyses., Results: Our patient population consisted of 63% males with a mean age of 44 years. Seventy-eight percent of the patients suffered blunt trauma with 22% undergoing penetrating injuries. The mean body mass index was 26.9 kg/m. Significant differences in admission β-diversity were noted by hospital length of stay, intensive care unit hospital length of stay, number of days on the ventilator, infections, and acute respiratory distress syndrome (p < 0.05). β-Diversity on admission differed in patients who died compared with patients who lived (mean time to death, 8 days). There were also significantly less operational taxonomic units in samples from patients who died versus those who survived. A number of species were enriched in the GM of injured patients who died, which included some traditionally probiotic species such as Akkermansia muciniphilia, Oxalobacter formigenes, and Eubacterium biforme (p < 0.05)., Conclusion: Gut microbiome diversity on admission in severely injured patients is predictive of a variety of clinically important outcomes. While our study does not address causality, the GM of trauma patients may provide valuable diagnostic and therapeutic targets for the care of injured patients., Level of Evidence: Prognostic and epidemiological, level III.

Background: Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion., Methods: Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables., Results: Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively., Conclusions: Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion., Level of Evidence: Therapeutic/care management, level V.

Background: Traumatic injury can lead to a compromised intestinal epithelial barrier and inflammation. While alterations in the gut microbiome of critically injured patients may influence clinical outcomes, the impact of trauma on gut microbial composition is unknown. Our objective was to determine if the gut microbiome is altered in severely injured patients and begin to characterize changes in the gut microbiome due to time and therapeutic intervention., Methods: We conducted a prospective, observational study in adult patients (n = 72) sustaining severe injury admitted to a Level I Trauma Center. Healthy volunteers (n = 13) were also examined. Fecal specimens were collected on admission to the emergency department and at 3, 7, 10, and 13 days (±2 days) following injury. Microbial DNA was isolated for 16s rRNA sequencing, and α and β diversities were estimated, according to taxonomic classification against the Greengenes database., Results: The gut microbiome of trauma patients was altered on admission (i.e., within 30 minutes following injury) compared to healthy volunteers. Patients with an unchanged gut microbiome on admission were transfused more RBCs than those with an altered gut microbiome (p < 0.001). Although the gut microbiome started to return to a β-diversity profile similar to that of healthy volunteers over time, it remained different from healthy controls. Alternatively, α diversity initially increased postinjury, but subsequently decreased during the hospitalization. Injured patients on admission had a decreased abundance of traditionally beneficial microbial phyla (e.g., Firmicutes) with a concomitant decrease in opportunistic phyla (e.g., Proteobacteria) compared to healthy controls (p < 0.05). Large amounts of blood products and RBCs were both associated with higher α diversity (p < 0.001) and a β diversity clustering closer to healthy controls., Conclusion: The human gut microbiome changes early after trauma and may be aided by early massive transfusion. Ultimately, the gut microbiome of trauma patients may provide valuable diagnostic and therapeutic insight for the improvement of outcomes postinjury., Level of Evidence: Prognostic and Epidemiological, level III.

Objective: Focused transthoracic echocardiography (FTTE) is an emerging tool in the management of critically ill patients, but the lack of adequate training models has limited the expansion of this technology. Although basic FTTE training courses have been shown to be sufficient in developing echocardiography skills, limited data exist regarding skill retention. In an effort to develop an adequate FTTE training model, we sought to determine the degree of skill retention after FTTE training., Design: A prospective, observational study., Setting: An academic center., Participants: Surgical residents and medical students: 31 subjects were enrolled from February to June 2016., Results: Participants underwent a 2-hour FTTE course including didactics and a hands-on session measuring ejection fraction of left ventricle (LV) and inferior vena cava (IVC) diameter. Written knowledge and performance examinations applying FTTE were conducted before the course, immediately after, and at 1- and 3-month intervals, which were evaluated on a 0 to 9 scale and analyzed with paired t-tests. Performance examination scores obtaining the LV and IVC views preinitial and postinitial training increased from 1.7 to 6.5 (LV) and from 2.0 to 6.8 (IVC) (p < 0.01), decreased to 5.0 and 4.8, respectively, at 1 month (posttraining vs 1 month, p < 0.01), and did not significantly change at 3 months (5.4 and 5.0, respectively). Written examination scores increased from 42% to 62% (pretraining vs posttraining, p < 0.01), decreased to 48% in 1 month (posttraining vs 1 month, p < 0.01), and further decreased to 34% at 3 months (1 month vs 3 month, p < 0.01)., Conclusions: Although a short training course appears sufficient to impart basic FTTE skills and knowledge, skills are significantly decayed at 1 month and knowledge continually decreases at 1 and 3 months. Future FTTE training models should consider the rapid degradation of knowledge and skills in determining frequency of refresher training and ongoing evaluation., (Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Mass casualty incidents (MCIs) are events resulting in more injured patients than hospital systems can handle with standard protocols. Several studies have assessed hospital preparedness during MCIs. However, physicians and trauma surgeons need to be familiar with their hospital's MCI Plan. The purpose of this survey was to assess hospitals' and trauma surgeon's preparedness for MCIs. Online surveys were e-mailed to members of the American College of Surgeons committee on Trauma Ad Hoc Committee on Disaster and Mass Casualty Management before the March 2012 meeting. Eighty surveys were analyzed (of 258). About 76 per cent were American College of Surgeons Level I trauma centers, 18 per cent were Level II trauma centers. Fifty-seven per cent of Level I and 21 per cent of Level II trauma centers had experienced an MCI. A total of 98 per cent of respondents thought it was likely their hospital would see a future MCI. Severe weather storm was the most likely event (95%), followed by public transportation incident (86%), then explosion (85%). About 83 per cent of hospitals had mechanisms to request additional physician/surgeons, and 80 per cent reported plans for operative triage. The majority of trauma surgeons felt prepared for an MCI and believed an event was likely to occur in the future. The survey was limited by the highly select group of respondents and future surveys will be necessary.

Background: We previously found that regardless of the animal injury model used resuscitation strategies that minimize fluid administration requirements lead to better outcomes. We hypothesized that a resuscitation regimen that limited the total volume of fluid administered would reduce morbidity and mortality rates in critically ill trauma patients., Methods: We performed a double-blind randomized trial to assess the safety and efficacy of adding vasopressin to resuscitative fluid. Subjects were hypotensive adults who had sustained acute traumatic injury. Subjects were given fluid alone (control group) or fluid plus vasopressin (experimental group), first as a bolus (4 IU) and then as an intravenous infusion of 200 ml/h (vasopressin 2.4 IU/h) for 5 h., Results: We randomly assigned 78 patients to the experimental group (n=38) or the control group (n=40). The groups were similar in age, sex, preexisting medical illnesses, and mechanism and severity of injury. Serum vasopressin concentrations were higher in the experimental group than in the control group at admission, after infusion of vasopressin (p=0.01), and 12 h later. The experimental group required a significantly lower total volume of resuscitation fluid over 5 days than did the control group (p=0.04). The mortality rate at 5 days was 13% in the experimental group and 25% in the control group (p=0.19). The rates of adverse events, organ dysfunction, and 30-day mortality were similar., Conclusions: This is the first trial to investigate the impact of vasopressin administration in trauma patients. Infusion of low-dose vasopressin maintained elevated serum vasopressin levels and decreased fluid requirements after injury.

Computed tomography (CT) grading systems are often used clinically to forecast the need for interventions after abdominal trauma with solid organ injuries. We compared spleen and liver CT grading methods to determine their utility in predicting the need for operative intervention or angiographic embolization. Abdominal CT scans of 300 patients with spleen injuries, liver injuries, or both were evaluated by five trauma faculty members blinded to clinical outcomes. Studies were graded by American Association for the Surgery of Trauma criteria, a novel splenic injury CT grading system, and a novel liver injury grading system. The sensitivity and specificity of each methodology in predicting the need for intervention were calculated. The kappa statistic was used to determine interrater variability. Twenty-one per cent (39/189) of patients with splenic injuries visible on CT scans required interventions, whereas 14 per cent (21/154) of patients with liver injuries visible on CT required interventions. The overall sensitivity of all grading systems in predicting the need for surgery or angioembolization of the spleen or liver was poor; the specificity seemed to be fairly good. When evaluators were compared, the strength of agreement for the various scoring systems was only moderate. Anatomic CT grading systems are ineffective screening tools for excluding the need for operation or embolization after splenic or hepatic trauma. Although insensitive, CT is a good predictor (highly specific) of the need for intervention if certain definitive abnormalities are identified. Considerable inconsistency exists in interpretation of abdominal CT scans after trauma, even among experienced clinicians.

Background: Few graduating residents seek surgical critical care (SCC) fellowships; fewer than half of positions fill. We hypothesized substantial differences exist in practice patterns and attitudes between SCC surgeons in academic practice (ACs) and in private practice (PVTs)., Study Design: A survey instrument was sent to 1,544 board-certified SCC intensivists in North America., Results: Of those invited, 489 responded (32% response rate). Respondents were mostly men (88%) and Caucasian (86%), with a mean age of 48 years; 60% were ACs, 28% were PVTs, and 12% reported "other;" 94% currently practiced SCC. PVTs (50%) were more likely than ACs (18%) to provide SCC for only their own patients, less likely (24% versus 74%) to function as an "ICU attending," and less likely to work with residents (36% versus 91%) and fellows (4% versus 60%; all p < 0.001). PVTs (48%) spent more time performing elective operations than ACs (27%; p < 0.001). They were more likely than ACs to relinquish management of SCC patients to medical consultants: infectious disease (34% versus 12%), cardiology (31% versus 12%), and pulmonary (23% versus 3%; all p < 0.001). Conflicts with medical specialists were a bigger problem for PVTs (43%) than for ACs (17%; p < 0.001)., Conclusions: Private practice surgical intensivists are more likely than academic intensivists to provide critical care for only their own patients and to use consultants to avoid conflicts.

The mesohaline portion of the Chesapeake Bay is subject to annual summertime hypoxia and anoxia in waters beneath the pycnocline. This dissolved oxygen deficit is directly related to salinity-based stratification of the water column in combination with high levels of autochthonously produced organic matter and a very high abundance of metabolically active bacteria. Throughout the water column in the lower, mesohaline part of the bay, between the Potomac and Rappahannock rivers, near the southern limit of the mainstem anoxia, bacterial abundance often exceeded 10 x 10 cells per ml and bacterial production exceeded 7 x 10 cells per liter per day during summer. Bacterial biomass averaged 34% (range, 16 to 126%) of the phytoplankton biomass in summer. These values are equal to or greater than those found farther north in the bay, where the oxygen deficit is more severe. Seasonal variations in bacterial abundance and production were correlated with phytoplankton biomass (lag time, 7 to 14 days), particulate organic carbon and nitrogen, and particulate biochemical oxygen demand in spring; but during summer, they were significantly correlated only with dissolved biochemical oxygen demand. During summer, dissolved biochemical oxygen demand can account for 50 to 60% of the total biochemical oxygen demand throughout the water column and 80% in the bottom waters. There is a clear spring-summer seasonal shift in the production of organic matter and in the coupling of bacteria and autochthonous organic matter. The measurement of dissolved, microbially labile organic matter concentrations is crucial in understanding the trophic dynamics of the lower mesohaline part of the bay. The absolute levels of organic matter in the water column and the bacterial-organic carbon relationships suggest that a lower bay source of organic matter fuels the upper mesohaline bay oxygen deficits.

A 28-year-old male with hepatic actinomycosis presented with several months of anorexia, weight loss, fever, night sweats, and mild right upper quadrant abdominal tenderness. Despite normal liver function tests, hepatic involvement was demonstrated by imaging studies. A liver biopsy and ultrasound-guided aspirate were, however, unrewarding. Laparotomy was, therefore, necessary to establish a definitive diagnosis. The patients was then successfully treated with intravenous penicillin followed by oral clindamycin. This case is presented to illustrate the diagnostic difficulties that may be encountered in such patients with hepatic actinomycosis.

Copper was acutely toxic to the estuarine microbial community of Middle Marshes, N.C. Under ambient water quality conditions, 10 mug of added total copper [Cu(II)] liter reduced the CFU bacterial abundance by up to 60% and inhibited the amino acid turnover rate (AATR) by as much as 30%. Copper toxicity, however, was a quantitative function of free cupric ion (Cu) activity that was not directly related to Cu(II) or ligand-bound copper. By using a nitrilotriacetic acid-cupric ion buffer to control pCu (-log Cu activity), it was found that an in situ pCu of 10.1 was bactericidal, reducing the CFU by 60%, but inhibited the AATR by only about 10%. A bacterial bioassay that was used to estimate the pCu in Cu(II)-treated Middle Marshes samples indicated that less than 0.5% of added Cu(II) was in the free cupric ion form. CFU was a more sensitive indicator of low-level copper stress than was AATR. When tested at different times, native microbial community responses to acute cupric ion stress were quantitatively quite similar even when there were large differences in bacterial abundances and in situ metabolic rates. Variations were observed in response to Cu(II) treatments at different times, but these were likely due to differences in water quality, which would quantitatively influence the distribution of copper complexes that were present. Asymptotic response curves suggest that some degree of copper resistance exists in this community. At a pCu of 8, more than 2 orders of magnitude above the minimum inhibitory level, the CFU was still 5 to 10% and the AATR was about 3% of the control values.

Water collected at 12 sites in the Neuse River estuary of North Carolina was analyzed for total viable counts on three isolation media (Trypticase soy agar [TSA], marine agar 2216, Sabouraud agar) and total hydrocarbons by fluorescence spectroscopy. Counts of 3.9 X 10(1) to 3.8 X 10(3) cells/ml were found for total heterotrophs, well within the range commonly reported for marine and estuarine waters. Generally, marine agar 2216 gave higher counts than TSA at stations with salinities greater than 6.0 mg/ml; TSA gave higher counts than marine agar 2216 at sites with salinities less than 4.0 mg/ml. The microbial species isolated on the three media agree well with those previously reported for estuarine microbial communities. Water analyses, using XAD-2 resin and fluorescence spectroscopy, revealed petroleum hydrocarbon concentrations in the range of 5 to 79 ng/ml. Representatives of the microbial species isolated from these communities were tested individually for their ability to grow using kerosene as a sole source of carbon and energy. At all but two stations, the majority of the species isolated were able to grow on hydrocarbons, indicating that this ability is widespread even in environments not subjected to high levels of hydrocarbon pollution.

Purpose: Chronic hepatitis is known to be a disease with substantial mortality. The purpose of this study was to identify prognostic factors in a large group of patients with chronic hepatitis. We also wanted to determine whether the aminopyrine breath test (ABT) is of additional prognostic value in evaluation of this disease., Patients and Methods: We studied 94 patients who had had a biopsy-proven diagnosis and an ABT between June 1, 1977, and June 30, 1981. Clinical features and biochemical test results at the time of diagnosis were retrieved from medical records, and histologic severity was assessed by reviewing all liver biopsy specimens under code. Survival was determined at a mean of 60 months. Data were studied with a Cox proportional hazards model to identify predictors of mortality and to control for confounding variables., Results: Cumulative mortality as of December 31, 1985, was 5 percent in chronic persistent hepatitis, 6 percent in chronic active hepatitis, 29 percent in chronic active hepatitis with bridging necrosis, and 53 percent in chronic active hepatitis with cirrhosis. Histologic severity was a predictor of death (p less than 0.005). Other predictors of mortality were disease caused by hepatitis B virus (p less than 0.005), a high alkaline phosphatase level (p less than 0.025), a low alanine aminotransaminase level (p less than 0.001), and a depressed ABT result (p less than 0.005)., Conclusion: The results suggest that patients with chronic hepatitis with one or more of these risk factors have an increased mortality and should be followed closely for liver failure, which may necessitate medical therapy or surgical intervention.

Microbial communities in water from Baltimore Harbor and from the mainstem of Chesapeake Bay were examined for sensitivity to mercuric chloride, monomethyl mercury, stannic chloride, and tributyltin chloride. Acute toxicity was determined by measuring the effects of [3H]thymidine incorporation, [14C]glutamate incorporation and respiration, and viability as compared with those of controls. Minimum inhibitory concentrations were low for all metals (monomethyl mercury, less than 0.05 microgram liter-1; mercuric chloride, less than 1 microgram liter-1; tributyltin chloride, less than 5 micrograms liter-1) except stannic chloride (5 mg liter-1). In some cases, mercuric chloride and monomethyl mercury were equally toxic at comparable concentrations. The Chesapeake Bay community appeared to be slightly more sensitive to metal stress than the Baltimore Harbor community, but this was not true for all treatments or assays. For culturable bacteria the opposite result was found. Thymidine incorporation and glutamate metabolism were much more sensitive indicators of metal toxicity than was viability. To our knowledge, this is the first use of the thymidine incorporation method for ecotoxicology studies. We found it the easiest and fastest of the three methods; it is at least equal in sensitivity to metabolic measurements, and it likely measures the effects on greater portion of the natural community.

Bacterial production and amino acid metabolism in aquatic systems can be estimated by simultaneous incubation of water samples with both tritiated methyl-thymidine and C-labeled amino acids. This dual-label method not only saves time, labor, and materials, but also allows determination of these two parameters in the same microbial subcommunity. Both organic carbon incorporation and respiration can be estimated. The results obtained with the dual-label technique are not significantly different from single-radiolabel methods over a wide range of bacterial activity. The method is particularly suitable for large-scale field programs and has been used successfully with eutrophic estuarine samples as well as with oligotrophic oceanic water. In the mesohaline portion of Chesapeake Bay, thymidine incorporation ranged seasonally from 2 to 635 pmol liter h and amino acid turnover rates ranged from 0.01 to 28.4% h. Comparison of thymidine incorporation with amino acid turnover measurements made at a deep, midbay station in 1985 suggested a close coupling between bacterial production and amino acid metabolism during most of the year. However, production-specific amino acid turnover rates increased dramatically in deep bay waters during the spring phytoplankton bloom, indicating transient decoupling of bacterial production from metabolism. Ecological features such as this are readily detectable with the dual-label method.