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Infection remains a major cause of posttrauma morbidity. We retrospectively reviewed 2 cohorts of trauma patients admitted to a regional trauma center before and after a policy change integrating prospective microbiologic surveillance and infectious disease (ID) consultation into management of trauma admissions. Primary interests were effects of this policy change on antimicrobial use and diagnostic precision (particularly differentiation of infection from colonization). Associated costs, microflora, survival, and disability were also compared. Patients were stratified for risk of infection. ID consultation was associated with a 49% increased odds that an infection diagnosis was microbiologically based (P=.006) and 57% reduction of antibiotics costs per hospitalized day (P=.0008). Costs of consultation and an 86% increase (P<10(-6)) in total cultures combined to minimally exceed that financial saving. The observed improvements in diagnostic precision and antimicrobial usage, however, suggest consideration of prospective microbiologic surveillance and multidisciplinary physician teams including ID physicians for high-risk trauma patients.

Background: Blunt cerebrovascular injuries are rare injuries causing substantial morbidity and mortality. The appropriate screening methods and treatment options for these injuries are controversial. We examined our experience with these injuries at a community Level I Trauma center over a 51 month period., Study Design: A retrospective review and analysis was done of all patients with the diagnosis of a blunt cerebrovascular injury during this period., Results: Fourteen patients had blunt carotid injury (0.40%) and three had blunt vertebral injury (0.09%) out of 3,480 total blunt admissions. The overall incidence of blunt cerebrovascular injury was 0.49%. The most common associated injuries were to the head (59%) and chest (47%) regions. The overall mortality rate was 59% (10 of 17), with death occurring in 8 of 14 (57%) blunt carotid injury patients and 2 of 3 (67%) blunt vertebral injury patients. Eight of ten (80%) deaths were directly attributable to the blunt cerebrovascular injury. Median time until diagnosis was 12.5 h (range 1-336 h) for the entire group and 19.5 h for nonsurvivors. Diagnosis was delayed > 24h in 7 patients and > 48h in 5 patients. All five patients whose diagnoses were delayed > 48 h developed complications, and four (80%) of these patients died., Conclusions: Blunt cerebrovascular injury is uncommon, but lethal; particularly when the diagnosis is delayed. Aggressive screening protocols based on mechanism of injury, associated injuries, and physical findings are justified to minimize morbidity and mortality. Head and chest injuries may serve as markers for blunt cerebrovascular injury. Most deaths are directly attributable to the blunt cerebrovascular injury and not to associated injuries.

Purpose: To determine the image portrayed in the media of nurses and particularly nurse practitioners (NPs) compared with other health care providers., Data Sources: An analysis of advertisements and articles in popular magazines aimed at female, male, and gender-neutral audiences was conducted between 12/99 and 06/00. Relationships between target audience and content of advertisements and articles, as well as portrayal of health care providers were also explored., Conclusions: A review of 100 consecutive advertisements for health-related products and 96 consecutive health-related articles in popular magazines revealed that the media continues to overwhelmingly depict and promote physicians as the source of health care and health-related advice., Implications for Practice: Because when there are few references to a group, such as NPs, it is reasonable to assume group members have little influence, standing, and authority, NPs should be concerned about the implications of these findings. Strategies for increasing the visibility of NPs as credible and valuable members of the health care team are shared.

Background: Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). The purposes of this study are to evaluate the safety of PDT in a non-university hospital setting and to compare our results with those published in the literature., Methods: The study was done by retrospective chart review., Results: Over a 6-year period, 300 PDTs were done in two community hospitals in Tyler, Texas. There was one death and 12 complications. Comparison of our results and those reported in five recently published articles in the literature showed no significant difference in mortality rate, pneumothorax, bleeding, paratracheal placement, dislodgement, or cellulitis. There was a trend toward a significantly lower incidence of paratracheal placement using bronchoscopic guidance., Conclusion: Bedside PDT with bronchoscopic guidance can be safely done in a community hospital setting.

Background: Venous thromboembolism (VTE) is a frequent and potentially life-threatening complication after trauma. The purpose of this study is to investigate the effectiveness of enoxaparin in preventing deep venous thrombosis (DVT) and pulmonary embolism (PE) after injury in patients who are at high risk for developing VTE., Study Design: A prospective single-cohort observational study was initiated for seriously injured blunt trauma patients admitted to a Level I trauma center during a 7-month period. Patients were eligible for the study if time hospitalized was > or = 72 hours, Injury Severity Score (ISS) was > or = 9, enoxaparin was started within 24 hours after admission, and one or more of the following high risk criteria were met: age > 50 years, ISS > or = 16, presence of a femoral vein catheter, Abbreviated Injury Score (AIS) > or = 3 for any body region, Glasgow Coma Scale (GCS) Score < or = 8, presence of major pelvic, femur, or tibia fracture, and presence of direct blunt mechanism venous injury. Patients with closed head injuries and nonoperatively treated solid abdominal organ injuries were also potential participants. The primary outcomes measured were thromboembolic events--either a documented lower extremity DVT by duplex color-flow doppler ultrasonography or a PE documented by rapid infusion CT pulmonary angiography or conventional pulmonary angiography., Results: There were 118 patients enrolled in the study. Two patients (2%) developed DVT, one of which was proximal to the calf (95% confidence interval, 0% to 6%). Two of 12 patients (17%) with splenic injuries who received enoxaparin failed initial nonoperative management. There were no other bleeding complications, and no clinical evidence or documented episodes of PE. One patient died from multiple system organ failure., Conclusions: Enoxaparin is a practical and effective method for reducing the incidence of VTE in high risk, seriously injured patients. This study supports further investigation into the safety of enoxaparin prophylaxis in patients with closed head injuries and nonoperatively treated solid abdominal organ injuries.

Objective: To determine the incidence of tracheal stenosis, voice and breathing changes, and stomal complications after percutaneous dilatational tracheostomy (PDT)., Methods: From December 1992 through June 1999, 420 critically ill patients underwent 422 PDTs. There were 340 (81%) long-term survivors, 100 (29%) of whom were interviewed and offered further evaluation by fiberoptic laryngotracheoscopy (FOL) and tracheal computed tomography (CT). Tracheal stenosis was defined as more than 10% tracheal narrowing on transaxial sections or coronal and sagittal reconstruction views. Forty-eight patients agreed to CT evaluation; 38 patients also underwent FOL. CT and FOL evaluations occurred at 30 +/- 25 (mean +/- standard deviation) months after PDT., Results: Twenty-seven (27%) patients reported voice changes and 2 (2%) reported persistent severe hoarseness. Vocal cord abnormalities occurred in 4/38 (11%) patients, laryngeal granuloma in 1 (3%) patient, focal tracheal mucosal erythema in 2 (5%) patients, and severe tracheomalacia/stenosis in 1 (2.6%) patient. CT identified mild (11-25%) stenosis in 10 (21%) asymptomatic patients, moderate (26-50%) stenosis in 4 (8.3%) patients, 2 who were symptomatic, and severe (>50%) stenosis in 1 (2%) symptomatic patient. Ten patients (10%) reported persistent respiratory problems after tracheal decannulation, but only four agreed to be studied. Two patients had moderate stenosis, and one had severe stenosis. One patient's CT scan was normal. No long-term stomal complications were identified or reported., Conclusions: Subjective voice changes and tracheal abnormalities are common after endotracheal intubation followed by PDT. Long-term follow-up of critically ill patients identified a 31% rate of more than 10% tracheal stenosis after PDT. Symptomatic stenosis manifested by subjective respiratory symptoms after decannulation was found in 3 of 48 (6%) patients.

During the past decade, the field of forensic psychological assessment entered a period of standard setting, reflected in the publication of specialty guidelines for practice and in the proliferation of educational opportunities, training programs, and credentialing and certification procedures for forensic examiners. Representing significant efforts to advance the quality of psychological assessments in legal contexts, these developments foreshadow the promise of forensic assessment. During this same time period, new evidence emerged regarding the quality of forensic practice. This article reviews this evidence and evaluates current practice against the promise of forensic assessment. Forensic reports appear to be of higher quality than those described by commentators in the 1970s and early 1980s; nevertheless, the level of practice falls far short of professional aspirations for the field. The review identifies significant areas of weakness that demand the attention of professional organizations, accrediting agencies, educators, lawmakers, practitioners, and consumers.

Skills in consultation are a core competency for nurses practicing in advanced roles. Although changes in the healthcare delivery system are creating a growing need and increasing opportunities for nurses to provide consultation services, nurse educators have been slow to respond to the need for students to have formal education in consultation concepts and processes. The author describes a graduate-level course in nursing consultation. Suggestions are given for incorporating consultation content into other courses at both the graduate and undergraduate level.

With their special training and assessment skills, psychiatric consultation-liaison nurses have a long history of making important contributions to patient care and staff development. This article reviews how psychiatric consultation-liaison nurses have traditionally approached and implemented the nursing consultation process. Issues facing psychiatric consultation-liaison nurses are discussed. Opportunities such as focusing on subspecialization; expanding practice settings; dealing with organization-based, rather than patient-based mental health issues; and entering intra- and entrepreneurial practice are also explored.

Although advanced practice nurses (APNs) are accustomed to providing consultation about patient care issues, they may be less comfortable seeking consultation and working with consultants. Being a savvy consumer of consultation services, however, is an essential skill for APNs and can help them avoid problems that may arise when practicing outside their realm of expertise. Consultants can also help APNs develop intra- and entrepreneurial practice opportunities. This article describes how to determine the necessity of a consultation, how to choose a consultant, and how to get the most out of a consulting relationship.

In the current rapidly changing healthcare environment, nurse executives are likely to find themselves seeking and hiring consultants, as well as working with consultants who have been hired by others. Because working with a consultant entails a certain amount of risk and involves a commitment of both personal and organizational resources, nurse executives need to know how to be effective buyers and users of consultation services. The author presents guidelines for developing effective working relationships with consultants.

The Social Support Apgar (SSA), developed as a user-friendly tool for screening for perceptions of adequacy of social support among perinatal women, provides a profile of perceived satisfaction with five types of support from five different sources. The results of psychometric analyses from three separate studies involving the SSA are reported. Cronbach's alphas of.88 to .93 were obtained. A positive relationship between SSA scores and favorable pregnancy outcomes and a negative relationship between SSA scores and life stress proved some evidence of validity. The SSA's clinical utility is suggested by its ease of completion and the finding of no relationship between client and nurse ratings. These results suggest that the tool holds promise for use as a screening instrument with prenatal clients in busy clinical settings.

Background: Bedside percutaneous dilational tracheostomy, a relatively new method of tracheal cannulation, provides safe and ready access to the trachea to relieve airway obstruction and tracheopulmonary secretions. The dilational technique has undergone various modifications during the past decade. Complications of this procedure are primarily related to the lack of direct visualization during tracheostomy tube placement and to poor patient selection., Objective: To report the utility of percutaneous dilational tracheostomy with bronchoscopic guidance in 162 critically ill patients., Main Outcome Measures: Mortality rates and complications associated with this technique., Results: Twenty-five patients (15.4%) died while hospitalized. No deaths were related to tracheostomy. There were four (2.5%) major complications: one pneumothorax and three posterior tracheal tears, which healed spontaneously. There were five (3.1%) minor complications: one posterior mucosal disruption, one minor bleeding episode, and three minor episodes of cellulitis. One hundred thirty-seven patients (84.6%) were discharged. Twenty-nine patients (21.2%) were available for follow-up and were experiencing no significant problems or complications following the procedure. Compared with standard open tracheostomy, charges were reduced by $1628.20 per patient ($263,768.40 total savings)., Conclusions: Bedside percutaneous tracheostomy with bronchoscopic guidance is safe and cost-effective. Complications compare favorably with that of open tracheostomy. Major complications should be avoided with continuous bronchoscopic observation during the procedure.

Several temporary abdominal wall closure techniques have been described in the literature. We present our experience with an inexpensive and efficient method of temporary abdominal closure when bowel edema and distension preclude safe primary closure. Our technique is a variation of the silon (silo) closure used in the repair of gastroschisis and omphalocele, using a pre-gas-sterilized, soft 3-L plastic cystoscopy fluid irrigation bag cut to an oval shape and stapled or sutured to the skin edges of the wound.

We conducted a retrospective review to determine the early effects of implementing the American College of Surgeons (ACS) level II criteria on the number of transferrals and survival rates of trauma patients in a rurally based hospital. Data were collected from time period "B" (13 months before) and time period "A" (14 months after) implementing ACS criteria. Patient data parameters included age, sex, Revised Trauma Score, Glasgow Coma Scale score, Injury Severity Score, number of days hospitalized, diagnoses, place of injury (i.e., local county or transfer from another county), outcome, and probability of survival. There was a significant increase in the number of patients with Injury Severity Score > or = 15 from period B to period A (189 vs. 297, p = 0.002). A much higher percentage of these patients were transfers from out of county (period B = 33% vs. period A = 59.5%, p = 0.0001). Despite a higher percentage of transferred patients with probability of survival < or = 25% (period B = 25% vs. period A = 58%, p = 0.002), the survival rate in this group improved from 7.5% during time period B to 25.5% after implementing level II criteria (p = 0.0303). This data suggest that implementing level II ACS guidelines has the early beneficial effects of increasing transfers of seriously injured patients and improving survival in the most critically injured group.

Penetrating thoracic injury from BB shot remains an innocuous event in most patients, but factors including location, proximity, gun type, and patient weight may identify groups at risk. The following cases demonstrate morbidity and mortality in two patients, and this experience may suggest the need for reassessment of this injury.

Background: This study was done to determine the safety and success of orotracheal intubation with planned neuromuscular blockade in patients who are severely injured. The study was performed at Carle Foundation Hospital, designated Level I trauma center located in east central Illinois., Study Design: A retrospective review of the trauma registry and medical records of all patients requiring emergency airway control from September 1, 1987 to September 30, 1991 was performed. Two hundred twenty-nine patients who were critically injured were reviewed, the mean injury severity score was 29 (range of 3 to 75), the mean revised trauma score was 9 (range of 3 to 12), the mean Glasgow Coma Scale was 9 (range of 3 to 15), and the mean age was 31 years (range of one to 94 years)., Results: Indications for intubation included hemodynamic instability or altered level of consciousness (66.4 percent), or both, combative or uncooperative behavior (33.2 percent), and need to secure airway for transport (0.4 percent). Two hundred twenty-three (97.4 percent) patients were successfully intubated. Six (2.6 percent) patients required cricothyroidotomy and one (0.4 percent) patient was aspirated during intubation. Eight (3.5 percent) patients had cervical spine injuries but had no complications from orotracheal intubation. In the combative group, 32 (42 percent) patients had significant head injuries and 17 (22 percent) had other potentially life-threatening injuries., Conclusions: Orotracheal intubation with planned neuromuscular blockade and in-line cervical traction is a safe, effective method for airway control in patients who are severely injured. This technique is also indicated to expedite therapy in combative, uncooperative patients because of the high incidence of significant life-threatening injuries to the brain and other organs.

Objective: To determine the incidence, severity, and outcomes of injury in patients treated in a rural-based level I trauma center and to compare the outcomes with a nationally indexed patient population--the Major Trauma Outcome Study., Design: Retrospective evaluation of trauma registry data., Setting: State of Illinois designated level I trauma center located in Urbana., Patients: A total of 2246 trauma patients admitted from August 1989 through August 1992, with a mortality cohort of 158 patients. There were 1735 patients (77%) with Injury Severity Scores less than or equal to 19 and 511 patients (23%) with more severe injuries (Injury Severity Scores > or = 20)., Main Outcome Measures: Mortality rates using the TRISS method, the Major Trauma Outcome Study, and final patient dispositions., Results: The overall mortality rate, excluding those patients who were pronounced dead on arrival, was 125/2213 (5.6%). Eighty-six (69%) of these 125 patients had neurological Abbreviated Injury Scores of 3 or greater, with neurotrauma being a major contributor to their deaths. The m-statistic was 0.99 and the z-statistic was -3.30 for the entire group. The observed probability of survival met or exceeded the expected probability of survival when compared with the Major Trauma Outcome Study in all categories., Conclusion: Acceptable mortality rates compared with the Major Trauma Outcome Study can be achieved in a rural-community-based level I trauma center despite relatively small numbers of critically injured patients. Such outcomes may assist in justifying resource allocation for trauma centers in rural areas.

A retrospective chart review was conducted to examine the prescription and administration of analgesics with and without caudal analgesia to inpatient preverbal children within the first 48 hours after surgery. The 75 subjects were between birth and 24 months of age and had undergone various operative procedures. Seventy (93%) of these subjects were prescribed analgesics, but 8 of them had only acetaminophen prescribed. Of the 70 subjects who had a medication prescribed, 64 (91%) patients received analgesics. Morphine was the most frequently administered analgesic. The prescribed and administered mean dosages were less than the minimum recommended dosage for morphine. The mean prescribed and administered dosage for other analgesics exceeded the minimum recommended dosage. Preverbal children who had caudal analgesia during surgery were more likely to receive fewer dosages of analgesics and to receive lower dosages of narcotics even after 24 hours postoperatively than children who had not had caudal analgesia.

Objective: To describe characteristics and pregnancy outcomes of participants in a maternity support program and to compare these characteristics and outcomes with those for women who were eligible for, but did not participate in, the program., Design: Descriptive, ex post facto., Setting: An inland northwest city., Participants: Two hundred twenty postpartum patients who received Medicaid during their pregnancy., Main Outcome Measure: Quantitative data were obtained from a structured interview that gathered demographic information. Subjects also completed the Social Support Apgar, an investigator-designed instrument., Results: Demographic characteristics and overall pregnancy outcomes were similar for program participants and nonparticipants; however, more program participants than nonparticipants quit smoking during their pregnancy., Conclusions: Findings are consistent with results documented by other researchers on the effectiveness of similar programs in different locales. The findings support the need for continued efforts to better define appropriate target populations, interventions, and expectations for these programs.

Early diagnosis and rapid treatment of lethal aortic injuries associated with blunt trauma remain a challenge for trauma surgeons. The following case demonstrates the use of transesophageal echocardiography for definitive diagnosis of an aortic injury from blunt trauma. A summary of current diagnostic modalities is also presented.

One hundred and ninety-one triple lumen central venous catheters were placed into 107 sites in 81 surgical and trauma patients who were prospectively studied to determine the rate of catheter related infection using a subcutaneous cuff of biodegradable collagen containing bactericidal silver and a guide wire exchange protocol. Thirty-seven sites in 36 nonseptic patients (group 1) were compared with 70 sites in 45 septic patients (group 2). The data were also compared with data consecutively collected one year earlier, using the same exchange protocol without the cuff. Fourteen of 70 sites in group 2 had catheter related infections, with seven causing bloodstream infection. Five of 14 were the result of fungus, with three causing fungemia. Two of 37 sites in group 1 had catheter related infections (p = 0.044), with no associated bacteremia. The number of triple lumen catheter related infections and associated bacteremia or fungemia are higher in septic patients compared with nonseptic critically ill surgical and trauma patients. The cuff significantly prolongs time of catheter site use in patients who are nonseptic, but may be of no benefit in reducing infection rates or prolonging site use time in patients who are septic and may predispose to fungal colonization.

Cardiovascular risk factors identified in major studies of children include a family history of heart disease, smoking, blood pressure, dietary factors, exercise or fitness level, and stress. The purpose of this descriptive study was to identify differences in children's physical measurements with regard to six cardiovascular risk factors. A descriptive design using three questionnaires and physical measurements was used. The questionnaires included the Bloomsday Cardiovascular Fitness Questionnaire, the Coronary Risk Profile, and the Diet Habit Survey. Physical measurements included blood pressure readings, weight, total serum cholesterol, and high-density lipoprotein levels. A convenience sample of 78, predominantly Caucasian children between the ages of 7 and 18 years (M = 13.13, SD = 2.79) participated. Results indicated that differences in physical measurements were significantly for children with respect to the cardiovascular risk factors, including dietary factors, blood pressure, exercise, and stress. Nursing implications for thorough assessment and intervention through education are discussed.

An increasing number of infants and children suffer from respiratory and neuromuscular diseases that render them ventilator-dependent. These patients spend months in pediatric intensive care units (PICUs) until they are either extubated or are stable enough to tolerate home ventilation. The critical nature of the PICU and its emphasis on meeting short-term goals is not readily compatible with the long-term and dynamic needs of developing children. In order to prevent the delays in growth and development that often occur during prolonged hospitalizations, this article addresses the impediments to normal growth and development in the PICU and offers specific suggestions on how the environment and nursing care can be changed to support the development of ventilator-dependent children and their families.

Blunt abdominal trauma which resulted in isolated avulsion of the ureter in a 19-month-old boy prompted a review of the literature to determine the pathophysiology and frequency of this injury. Fifty-four patients were identified and delay in diagnosis was the most common problem (33%). The authors discuss the controversies in management of this injury and recommend steps to ensure prompt recognition of ureteral avulsion from blunt trauma.

One hundred fifty-six triple-lumen central venous catheters placed into 65 different sites in 52 surgical or trauma patients were prospectively evaluated to determine the frequency of catheter-related infection and the efficacy of multiple guidewire exchanges. Thirty-four anatomic sites in 33 patients without clinical signs of sepsis were compared to 31 anatomic sites in 19 patients with a clinical diagnosis of sepsis based on clinical, microbiologic, and radiologic evaluation. Anatomic sites were used indefinitely unless a positive semiquantitative catheter culture (greater than or equal to 15 cfu) or catheter-associated bacteremia developed. Seven catheter-related infections developed in five septic patients (26.3%) while no infections developed in the nonseptic group (p = 0.004). Three of 31 anatomic sites (9.6%) were associated with bacteremia. The number of hospital days to initial catheter insertion and the length of catheter site use were considerably higher in the septic patients compared to the nonseptic group. We conclude that triple-lumen catheter-related infections are uncommon in patients with no evidence of infection and can be safely guidewire-exchanged to prolong site use. Catheter-related infections in septic patients are much more frequent and unpredictable. Although guidewire exchange has a role in septic patients, multiple exchanges cannot routinely be recommended.

Fibrocystic breast disease (FBD) is a benign condition that afflicts at least 50% of women of childbearing age. Because of the occurrence rate, the condition is sometimes referred to as a nondisease. The cause of FBD remains unknown, and treatment is only empirical. This article reviews normal breast anatomy and physiology, describes the morphological changes apparent in FBD, discusses current etiological theories and treatment modalities, and identifies nursing interventions relative to women with FBD.

The hospital and ICU course of 98 patients who required mechanical ventilatory support longer than 72 h was reviewed to determine if mortality rates were influenced by admitting diagnosis. Patients with malignant diagnoses were compared to patients with nonmalignant diagnoses and to those admitted to the ICU after myocardial infarction or cardiorespiratory arrest. Although there was no significant intergroup difference in incidence of multiple organ system failure, age, and length of ICU and hospital stay, there was a much higher incidence of sepsis (p less than .05) and mortality (p less than .01) in the cancer group. Cancer patients and their families should be made aware of the extremely poor prognosis if prolonged acute respiratory failure develops.

Adult respiratory distress syndrome remains one of the most lethal conditions treated in surgical and medical intensive care units. Mortality rates of 50 per cent are still reported in recent reviews. Many risk factors are linked with an increased incidence of ARDS, but sepsis and direct pulmonary injury from aspiration, pulmonary contusion, and other forms of trauma are the most commonly associated risk factors. Studies implicate various cellular and chemical mediators associated with acute lung injury. Many pharmacologic agents and various forms of high-frequency ventilation are being studied for their effectiveness in treating ARDS. We consider that the standard treatment continues to be PEEP and mechanical ventilation to reverse hypoxemia linked with the pathophysiologic changes of ARDS. There are no prospective randomized studies comparing the various end points of therapy used clinically at present. We believe, however, that early intervention, with institution of ventilatory support as soon as signs of acute respiratory failure develop, may eliminate some deaths due to progressive hypoxemia leading to the full adult respiratory distress syndrome. Therapy should be started at this time and maintained while the etiologic factors are identified and treated. Minimal ventilatory support should be continued until the primary diseases have resolved and the multisystem impact of the critical illness has lessened. Weaning from inspiratory (IMV) support, manipulation of expiratory pressures (PEEP), and airway control should then be more easily accomplished and more successful in practice.

The records of 205 patients who underwent appendectomy were reviewed to determine the incidence of recurrent and chronic appendicitis. Twenty-one patients (10 per cent) met the criteria for diagnosis of recurrent appendicitis. Three patients (1.5 per cent) had a diagnosis of chronic appendicitis based upon clinical history and pathologic findings of lymphocytic or eosinophilic infiltration of the appendiceal wall. The diagnosis of recurrent or chronic appendicitis should be considered in patients presenting with recurrent pain of the right lower abdominal quadrant.

Hepatic artery aneurysms are relatively infrequent lesions and may represent significant problems in both diagnosis and management. Indeed, as many as 30 to 50 per cent of cases are completely unsuspected and are discovered only at autopsy. A case of a very large hepatic artery aneurysm (greatest dimension of approximately 35 centimeters) presenting as an asymptomatic epigastric mass is reviewed, with emphasis on preoperative evaluation and operative technique. Selective arteriography was the cornerstone of diagnosis with other investigative modes proving not to be effective. Surgical therapy included obtaining proximal and distal control, meticulous ligation of the numerous feeding vessels, and finally evacuation and partial excision of the aneurysm sac with careful suture ligation obliteration of the orifice of each feeding vessel. Restoration of hepatic artery flow was not attempted and no compromise in liver function was seen in the postoperative period. The literature on hepatic artery aneurysms is reviewed to include typical presentation, diagnostic methods, surgical approach, and common complications. Only through a high index of suspicion and early angiography can this frequently fatal lesion be detected early in its course and subsequently be subjected to successful surgical management.

In a patient with poorly differentiated ovarian carcinoma, the symptomatology was mistaken for acute pancreatitis. A review of the pertinent literature argues in favor of the early use of amylase isoenzymes in patients whose history, objective signs, and routine diagnostic studies fail to disclose pancreatic disease.

One hundred twenty-three patients undergoing elective cholecystectomy at USAF Medical Center Keesler were studied in a prospective randomized manner to determine the differences in morbidity and mortality following drained and undrained cholecystectomies. The groups were compared for differences in mortality, wound infection, postoperative fever, and length of hospitalization. One death occurred due to an unrelated cause in an undrained patient. Three per cent of the undrained group developed wound infections as compared to five per cent in the drained group. This was not statistically significant. A significant difference occurred in postoperative fever between the drained (58%) and undrained (30%) groups. Postoperative hospitalization was also significantly shorter in the undrained group. This study suggests that drainage following elective cholecystectomy is not only unnecessary, but may add to postoperative morbidity and length of hospitalization.

The records of 46 patients were retrospectively reviewed to determine the accuracy and significance of fine-needle aspiration (FNA) and intraoperative frozen section (FS) in planning the extent of thyroid resection. For all 46 patients, both FNA and FS diagnoses were available for comparison with the final pathologic diagnosis. The sensitivity value for detection of malignancy by means of FNA was 90% compared with 60% by means of FS, although FS diagnoses were more specific (97%) than FNA diagnoses (56%). FNA diagnoses of benign conditions were correct in 20 of 21 (95%) patients. FS diagnoses of benign conditions were correct in 19 of these 21 patients (90%) but, more important, it did not alter the extent of resection or improve the accuracy of diagnosis. Five patients had findings at FNAs that were positive for malignancy. Frozen section confirmed this diagnosis in all five patients but, again, did not alter the extent of resection. Twenty patients had FNA findings that were "suspicious" for malignancy, with 12 of the tumors diagnosed as benign on FS and only one of four (25%) papillary carcinomas diagnosed as positive on FS. Only four of 20 (20%) FNA results that were "suspicious"--but not diagnosed as malignant--were confirmed as malignant on permanent section, whereas 70% of the FS diagnoses were correct in these 20 patients. Overall, only 16 of 46 (35%) FS diagnoses were helpful in determining the extent of thyroid resection. If a diagnosis of a benign or definitely malignant condition has been made by means of FNA preoperatively, FNA alone provides sufficient information for determining the extent of thyroid resection. Frozen section may be helpful if FNA results are suspicious, but it does not have sufficient sensitivity for determining the extent of resection, which should be deferred until permanent sections have been analyzed.

Invasive phycomycotic fungal infections are life-threatening complications in patients with impaired immune response. A successful outcome usually depends on early aggressive treatment. Hyperbaric oxygen (HBO) therapy has been suggested as adjuvant therapy based on theoretical considerations and in vitro evidence of fungal growth retardation. A standard gas gangrene HBO protocol was used to treat a progressive necrotizing polymicrobial soft-tissue infection of the lower extremity in a patient with normal host defenses. Progression of the fungal infection was stopped only after radical surgical debridement. This Phycomycetes (Apophycomyces elegans) has not been previously reported as a pathogen in man.

Clinical parameters, intensive care unit (ICU) course, abdominal computed tomography (CT) scans, and the clinical decisions of 53 critically ill patients were reviewed to determine the influence of the CT scan. No scans were positive before the eighth day. Sensitivity was 48% and specificity, 64%. Seventeen (23%) scans of the 72 provided beneficial results: eight localized abscesses that were drained; nine were negative and not operated on. Five (7%) scans provided detrimental information: scan negative with abscess discovered or scan positive but negative laparotomy. Fifty (70%) scans were either of no help or not used in management. The mortality rate was 50% when CT led to an intervention, and 47% in the entire group. Hospital charges were +33,408. Personnel time and cost were 497 hours and +3658; of the total +37,066, 77% (+28,541) could be considered wasted. From these data, it was concluded that CT scans should be used to confirm abscesses, not to search for a source of sepsis.

The Adult Respiratory Distress Syndrome remains one of the most lethal complications in both surgical and medical intensive care units. Mortalities of 50 to 80 per cent are still reported in recent reviews. Many risk factors have been associated with an increased incidence of ARDS, but sepsis and direct pulmonary injury from aspiration, pulmonary contusion and near drowning are most commonly identified. Studies of physiopathologic factors of ARDS implicate granulocyte aggregation with the formation of oxygen free radicals and other cellular and chemical mediators. Pharmacologic agents and high frequency positive pressure ventilation are presently being investigated, but the accepted form of therapy combines increased inspired oxygen tensions, positive end expiratory pressure and some form of mechanical ventilation, if necessary.