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A molecular epidemiology study of HIV-1 infection was conducted in one hundred diagnosed and untreated HIV-1-infected patients in Cyprus between 2010 and 2012, representing 65.4% of all the reported HIV-1 infections in Cyprus in this three-year period, using a previously defined enrolment strategy. Eighty-two patients were newly diagnosed (genotypic drug resistance testing within six months from diagnosis), and eighteen patients were HIV-1 diagnosed for a longer period or the diagnosis date was unknown. Phylogenetic trees of the pol sequences obtained in this study with reference sequences indicated that subtypes B and A1 were the most common subtypes present and accounted for 41.0 and 19.0% respectively, followed by subtype C (7.0%), F1 (8.0%), CRF02_AG (4.0%), A2 (2.0%), other circulating recombinant forms (CRFs) (7.0%) and unknown recombinant forms (URFs) (12%). Most of the newly-diagnosed study subjects were Cypriots (63%), males (78%) with median age 39 (Interquartile Range, IQR 33–48) reporting having sex with other men (MSM) (51%). A high rate of clustered transmission of subtype B drug-sensitive strains to reverse transcriptase and protease inhibitors was observed among MSM, twenty-eight out of forty-one MSM study subjects (68.0%) infected were implicated in five transmission clusters, two of which are sub-subtype A1 and three of which are subtype B strains. The two largest MSM subtype B clusters included nine and eight Cypriot men, respectively, living in all major cities in Cyprus. There were only three newly diagnosed patients with transmitted drug resistant HIV-1 strains, one study subject from the United Kingdom infected with subtype B strain and one from Romania with sub-subtype A2 strain, both with PI drug resistance mutation M46L and one from Greece with sub-subtype A1 with nonnucleoside reverse transcriptase inhibitors (NNRTI) drug resistance mutation K103N. © 2018 Kostrikis et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

This work reports the utility of inexpensive and disposable pencil-lead graphite as a substrate for bismuth-film electrodes (BFEs) for the simultaneous determination of Cd(II), Pb(II) and Zn(II) by square-wave anodic stripping voltammetry (SWASV). The BFE was generated in situ by depositing simultaneously the bismuth film and the metal cations by reduction at −1.4 V on the pencil graphite substrate. Then, the preconcentrated metals were oxidised by scanning the potential of the electrode from −1.4 to 0 V using a square-wave waveform. The stripping current arising from the oxidation of each metal was related to the concentration of each metal in the sample. The parameters for the simultaneous determination of the three metals were investigated with the view to apply this type of voltammetric sensor to real samples containing traces of these metals. Using the selected conditions, the limits of detection were 0.3 μg l−1 for Cd and 0.4 μg l−1 for Zn and Pb at a preconcentration time of 10 min and these values could be further decreased by the use of Nafion-covered pencil-lead BFEs. Finally, the pencil-lead BFEs were successfully applied to the determination of Pb and Zn in tap water with results in satisfactory statistical agreement with atomic absorption spectroscopy.

Eight patients (13ft) with progressive neuromuscular planovalgus foot deformity, underwent an extraarticular subtalar arthrodesis with the combined Batchelor–Grice procedure. All patients were ambulant and received conservative treatment with braces and special orthopaedic shoes prior to operation. Postoperatively the feet were immobilized in short casts for six weeks. Evaluation was based on the appearance of the feet, the clinical symptoms and X-ray measurements. Solid fusion and sustained correction, took place in all feet. Foot appearance and mobility of the patients were improved, while preoperative complaints were reduced. The gap at the graft donor site was bridged with new bone in all cases.

A 1/4-in.diameter two-column Isola spinal system implanted in a 13-year-old girl suffering from cerebral palsy and a severe neuromuscular scoliosis of 120°, was replaced 22 months after primary implantation. The system was removed due to fracture of the lower left (concave) bar, between its two cross connectors (i.e., the distal bypass connector and a transverse cross link), as a result of a postoperative infection and a subsequently developed pseudarthrosis. The retrieved implants were analyzed with the use of a multitechnique characterization procedure involving macroscopic and microscopic examination, micro-multiple internal reflectance FTIR spectroscopy, X-ray fluorescence (XRF) spectrometry, roughness measurement, and mechanical testing of the constituent material and components. Findings suggest that the spinal system failed due to in vivo loosening of a two-set screw tandem connector and subsequent overloading of the contralateral bar. © 2002 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 64B: 6–12, 2003

The evaluation of mediastinal trauma has undergone some important changes in the last few years. Electrocardiography (ECG) combined with troponin measurements have become the standard of evaluation of suspected blunt cardiac trauma. Spiral computerized tomography (CT) scan has largely replaced angiography for suspected blunt aortic rupture. There is good evidence that with a suspicious mechanism of injury the thoracic aorta should be evaluated irrespective of chest X-ray findings. In penetrating trauma the introduction of trauma ultrasound in the emergency room has revolutionized the early diagnosis of cardiac tamponade. Most mediastinal gunshot wounds in haemodynamically stable patients can safely be managed non-operatively. Evaluation of the direction of the bullet tract by means of spiral CT scan has replaced angiography and oesophageal studies in about 75% of patients with mediastinal gunshot wounds who are haemodynamically stable.

Background: Prehospital intubation and airway control is routinely performed by paramedics in critically injured patients. Despite the advantages provided by this procedure, numerous potential risks exist when this is performed in the field. We reviewed the outcome of patients with severe head injury, to determine whether prehospital intubation is associated with an improved outcome. Methods: A retrospective review of registry data of patients admitted to an urban trauma center with severe head injury (field Glasgow Coma Scale score of ≤8 and head Abbreviated Injury Scale score of ≥3) was performed. Patients were stratified by methods of airway control performed by prehospital personnel: not intubated, intubated, or unsuccessful intubation. Mortality was determined for each group. To control for significant variables between these populations, matching and multivariate analysis were performed. Results: Patients requiring prehospital intubation or in whom intubation was attempted had an increased mortality (81% and 77%, respectively) when compared with nonintubated patients (43%). The mortality for patients who had prehospital intubation performed did not demonstrate an improved survival using matching. In fact, intubated patients had a significantly higher relative risk (RR) of mortality when compared with nonintubation (RR = 1.74, p < 0.001) and unsuccessful intubation patients (RR = 1.53, p = 0.008) Conclusion: For patients with severe head injury, prehospital intubation did not demonstrate an improvement in survival. Further prospective randomized trials are necessary to confirm these results.

The classical abdominal compartment syndrome, which is characterized by abdominal distention, and cardiorespiratory and renal function compromise, is a late manifestation of intra-abdominal hypertension. Significant organ dysfunction occurs much earlier and it is important to recognize and treat the problem at its early stages. Prolonged hypotension requiring massive fluid resuscitation or other conditions associated with bowel hypoperfusion are the most critical factors in the development of intra-abdominal hypertension, even in the absence of abdominal trauma. Close monitoring by means of clinical examination and bladder pressure measurements are essential for all patients at risk. Decompression by means of laparotomy and temporary abdominal wall closure with a prosthetic material should be performed as early as possible.

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6–54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P < 0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Methylmethacrylate has been used as an external fixator on 52 bones in 36 children and adolescents. There were 36 osteotomies and 16 selected fractures of long bones. The application of the acrylic cement onto 229 half-pins was performed with the use of flexible plastic tubes, in all but two patients. Union in the desired position was achieved in 51 bones. Delayed union occurred in one and required internal fixation. In the rest of the cases, there were only a few minor complications. The methylmethacrylate appears to be a stable fixator for osteotomized and fractured bones in young patients. The method is practical, easily performed, and of low cost.

Experience with 250 cases of hypospadias over the 6-year period 1986–1992 at the Athen's Childrens Hospital Aghia Sophia is presented. A successful outcome was seen in 87%, 13% developed complications, most of which were urethral fistulae. The operative techniques and methods of treating the fistulae are described. Patients received treatment in the preschool age group in one or two stages, depending on the method used and the presence or absence of chordee. The goals of the urethroplastic operation, penile straightening and the formation of a new urethra to permit normal urination with a wide range, were accomplished in the majority of cases.

Penetrating neck injuries (PNI) are notoriously difficult to evaluate and manage because of the complex anatomy and the dense concentration of numerous vital structures in a small anatomical area. The clinical evaluation can challenge the skills of the less experienced physicians and significant injuries may easily be missed. The radiological evaluation of these injuries has undergone major changes in the last fewyears and shifted from invasive diagnostic procedures to noninvasive methods, but the selection of the most appropriate investigation remains a controversial issue. New advances in interventional radiology have revolutionized the management of some complex vascular injuries. The concept of selective nonoperative management in selected patients has gained considerable acceptance. This chapter discusses these issues in detail and provides practical guidelines and algorithms for the safe evaluation and initial management of PNI.

The aim of this study was to evaluate the influence of colostomy type on morbidity during the treatment of anorectal malformations.Sixty-eight infants (male: female ratio 1.3:1) with anorectal malformations that required colostomy were treated in our clinics during the period 1991-2001. Of these patients, 26 had received a loop colostomy: 14 of these underwent posterior sagittal anorectoplasty (PSARP) at the age of 9-12 months (Group A), and 12 underwent PSARP at the age of 2-4 months (Group B). Forty-two infants received a separated-stomas colostomy and underwent PSARP at the age of 9-12 months (Group C). The incidence of complications among groups was compared using the 2 sided Fisher's exact test.Eight cases from group A were complicated with prolapse of the stomas, perianal wound infection, pull-through dehiscence, and anal fibrotic stricture. The only complication observed in groups B and C was perianal wound infection, which occurred in 1 case from each group. A statistically significant difference was observed in the incidence of complication between groups A and C (p0.001) and between groups A and B (p=0.014). The results from groups B and C did not differ significantly (p=0.398). When the cases complicated with colostomy prolapse were removed from the statistical analysis, groups A and C still differed significantly (p=0.001) but groups A and B did not (p=0.069).As the incidence of complications increases with time after a loop colostomy, we encourage either an early corrective procedure or the modification into separated-stomas colostomy (SSC) before PSARP is performed for those cases that would involve definitive surgery in late infancy.

After severe trauma, physicians frequently use multiple antibiotics for prolonged periods of time to prevent sepsis, based on intuition rather than scientific evidence. Over a 1-year period (January-December 1999) we included prospectively 112 critically injured patients who required an operation and/or chest tube insertion and stayed for more than 2 days in the intensive care unit (ICU). Of these patients, 46 received a single prophylactic antibiotic for 24 hours (group SING+SHORT), and 66 received one or more prophylactic antibiotics for more than 24 hours (group MULT+LONG), based on physician discretion. Twenty-seven outcome parameters were collected to compare the effect of the different prophylactic antibiotic regimens. The two groups were similar in regard to overall injury severity, age, gender, mechanism of injury, and physiologic condition on admission. However, more SING+SHORT patients had an abdominal operation (83% versus 62%, P = 0.02), and more MULT+LONG patients had an orthopedic operation (35% versus 15%, P = 0.03). There was no difference in sepsis (41% versus 42%, P = 1.0), organ failures (37% versus 50%, P = 0.18), mortality (7% versus 12%, P = 0.52), ICU stay (14 +/- 2.5 versus 16 +/- 2 days, P = 0.57), hospital stay (26 +/- 3 versus 28 +/- 2 days, P = 0.53), or any other outcome parameter. Independent risk factors for sepsis were blunt mechanism of trauma, Injury Severity Scoreor = 25, and more than two units of blood transfused over the first 24 hours, but not the amount of prophylactic antibiotics given. In conclusion, we found that 24-hour prophylaxis with a single broad-antibiotic is as effective as prophylaxis for longer periods of time with multiple spectrum antibiotics for critically injured patients at high risk for sepsis.

Background: The standard evaluation of mediastinal gunshot wounds usually requires angiography and either esophagoscopy or esophagography. In the present study, we have evaluated the role of helical computed tomographic (CT) scanning in reducing the need for angiographic and esophageal studies. Methods: This was a prospective study of patients with mediastinal gunshot wounds who were hemodynamically stable and would otherwise require angiography and esophageal evaluation. All patients underwent CT scan of the chest with intravenous contrast to delineate the missile trajectory. If the missile tract was in close proximity to the aorta, great vessels, or esophagus, then traditional evaluation with angiographic or esophageal evaluation was pursued. Results: A total of 24 patients met the inclusion criteria and underwent CT scan evaluation of their mediastinal gunshot wounds. One patient was taken for sternotomy to remove a missile embedded in the myocardium solely on the basis of the result of the CT scan. Because of proximity of the bullet tract, 12 patients required additional evaluation with eight angiograms and nine esophageal studies. One of these patients had a positive angiogram (bullet resting against the ascending aorta) and underwent sternotomy for missile removal; all other studies were negative. The remaining 11 patients were found to have well-defined missile tracts that approached neither the aorta nor the esophagus, and no additional evaluation was pursued. There were no missed mediastinal injuries in this group. Overall, 12 of 24 patients (50%) had a change in management (either received an operation or avoided additional radiographic or endoscopic evaluation) on the basis of the CT scan. Conclusion: The helical CT scan provides a rapid, readily available, noninvasive means to evaluate missile trajectories. This permits accurate assessment of potential mediastinal injury and reduces the need for routine angiographic and esophageal studies.

Trauma in pregnancy places the mother and fetus at risk. The objective of this study is to identify risk factors independently associated with acute termination of pregnancy and/or fetal mortality after trauma. The medical and trauma registry records of 80 injured pregnant patients were reviewed. Data were collected and then analyzed by univariate and multivariate analysis. Three patients died (3.7%), 23 had the pregnancy acutely terminated (30%), and 14 suffered fetal death (17.5%). The only independent risk factors for fetal mortality were an Injury Severity Score (ISS)or =9 and a nonviable pregnancy (23 weeks). The combination of both risk factors increased the likelihood of fetal mortality by fivefold over that of patients without either risk factor. Maternal hemodynamic parameters did not predict fetal loss. Two patients lost their fetuses despite insignificant trauma (ISS = 1) and normal hemodynamic parameters, whereas eight delivered normal babies despite major trauma (ISSor = 16). Hemodynamic stability on admission does not predict fetal mortality. Although the presence of moderate to severe injuries (ISSor = 9) increases the likelihood of fetal mortality, this complication may occur even with insignificant trauma. Close maternal and fetal monitoring is justified, regardless of maternal hemodynamic presentation or severity of injury.

Falls account for a significant proportion of pediatric injuries and deaths. A retrospective review of pediatric patients (age 0-14 years) was performed to determine whether patterns of injuries and outcomes could be predicted on the basis of the height of the fall. In addition we evaluated the triage criterion "fall greater than 15 feet" for transport of patients to a trauma center. Patients were stratified by the height of the fall: greater than or less than 15 feet. The end points for analysis were the associated injuries and survival. Patients who fell less than 15 feet had a higher incidence of intracranial injuries (and fewer extremity fractures than patients who fell more than 15 feet). Skull fractures were the most frequent injury and were associated with an increase in intracranial injuries in both subgroups. In conclusion low-level falls are associated with significant intracranial injuries. The evaluation of patients sustaining low-level falls should not be limited on the basis of the height of the fall. Using falls of greater than 15 feet as a triage criterion for transport to a trauma center needs to be prospectively evaluated to ensure that critically injured patients are triaged appropriately.

Angiographic embolization of bleeding pelvic vessels is increasingly used in patients with pelvic injuries. Temporary angiographic embolization of bilateral internal iliac arteries (TAEBIIA) is occasionally necessary. From November 1991 to March 1998, 30 consecutive patients (mean age of 43 years, mean Injury Severity Score of 25) with complex pelvic fractures underwent TAEBIIA to control severe hemorrhage not responding to subselective embolization. Angiography revealed multiple sources of pelvic bleeding in 28 (93%) patients. In the two remaining patients, no bleeding was identified but TAEBIIA was done empirically. Thirteen patients had laparotomies before TAEBIIA with unsuccessful bleeding control, and the remaining 17 had TAEBIIA as the primary treatment. After TAEBIIA 90 per cent of patients had successful clinical (27 of 30) and radiographic (25 of 28) control of bleeding. Of the three patients who continued to bleed after TAEBIIA two were successfully re-embolized and one died of acute cardiac failure before any further intervention was attempted. TAEBIIA had a success rate of 97 per cent (29 of 30) in controlling pelvic hemorrhage without significant complications related to it. TAEBIIA is a safe and effective alternative to subselective embolization in controlling retroperitoneal bleeding in selected patients with blunt pelvic trauma.

Pulmonary artery catheterization is usually not available to critically injured patients before admission to the intensive care unit, where action to correct values derived from such monitoring may be too late. Methods allowing hemodynamic monitoring during the early stages after trauma need to be explored. We used non-invasive monitoring systems (bioimpedance cardiac output monitoring, pulse oximetry and transcutaneous oximetry) to evaluate early temporal hemodynamic patterns after blunt trauma, and compared these to invasive PA monitoring. We included prospectively 134 patients monitored shortly after admission to the emergency department. The non-invasive impedance cardiac output estimations under extenuating emergency conditions approximated those of the thermodilution method: r = 0.83, r2 = 0.69, P0.001; bias and precision were -0.02+/-0.78 l/min/m2. In the intensive care unit, these values improved further to: r = 0.91, r2 = 0.83, P0.001; bias and precision = 0.36+/-0.59 l/min/m2. Monitoring revealed episodes of hypotension, low cardiac index, arterial hemoglobin desaturation, low transcutaneous oxygen and high transcutaneous carbon dioxide tensions, and low oxygen consumption during initial resuscitation. Low flow and poor tissue perfusion were more pronounced in non-survivors by both methods. Multicomponent non-invasive monitoring systems give continuous on-line, real-time displays of physiological data that allow early recognition of circulatory dysfunction. Such systems provide information similar to that provided by the invasive thermodilution method, and are easier and safer to use.

The management of duodenal injuries is a subject of ongoing debate. In this study we attempt to describe duodenum-related morbidity (DRM) after primary repair or complex repair (CR) and to identify risk factors for development of complications. The medical records of 145 consecutive patients admitted to Los Angeles County + University of Southern California Medical Center with duodenal injuries between January 1991 and December 1997 were reviewed. Fifty-four (37%) died within 24 hours of admission because of associated injuries. The remaining 91 were subjected to univariate and multivariate analysis. Of them, 66 (72.5%) developed complications and 3 (3%) died. CR was used in 32 (35%) patients and with increasing frequency as the grade of duodenal injury increased. DRM rate was overall low (9%) and not different between low-grade and high-grade duodenal injuries. This occurred despite a significant increase in Injury Severity Score and abdominal Abbreviated Injury Score in patients with more severe duodenal injuries. Patients with overall complications had higher Injury Severity Scores, higher abdominal Abbreviated Injury Scores, and more severe duodenal injuries. We conclude that duodenal injuries are frequently associated with other highly lethal injuries. Liberal use of CR in patients with more severe duodenal injuries prevents DRM.

Shotguns cause a wide variety of injuries, depending on the weapon-victim distance and the type of the gun and pellets. It has been suggested that the probability of significant internal injuries cannot be predicted using physical examination alone, and several wound classification systems have been proposed to facilitate clinical decision-making.To evaluate the sensitivity of clinical examination and assess the role of a new classification system to detect significant injuries caused by shotguns.The medical records of 56 consecutive patients admitted to a Level I trauma center with shotgun wounds from January 1994 to December 1996 were reviewed. Clinical examination was the main tool to select patients for emergency operation or nonoperative management. Wounds were classified by the number of body areas (abdomen, chest, head and neck, extremities) involved: grade I involved more than two areas, grade II two adjacent areas, and grade III one area.Twelve patients had type I wounds, 25 had type II wounds, and 19 had type III wounds. Nineteen major operations for intrathoracic, intra-abdominal or peripheral vascular injuries were done on 16 patients, as well as 10 orthopedic, ophthalmological and urological procedures and three emergency room thoracotomies,. No differences were found in the incidence of operations, morbidity, mortality, or length of hospital stay among the three groups. Clinical examination was 100% sensitive and 93% specific in identifying the presence of significant organ injuries and need for emergency operation. Three patients had unnecessary abdominal explorations because they received anesthesia for other procedures and could not be reliably followed up clinically.Clinical examination is the most reliable tool to identify patients who require emergency operation after shotgun wounds. Classification systems provide only crude information and do not predict reliably the presence of significant internal injuries.

Infection and organ failure are the most common causes of death or serious complication in trauma patients surviving initial resuscitation and operation. Of the many possible causes of these complications, bacterial translocation and release of harmful cytokines and oxygen free radicals may play an important role in the pathogenesis of the complications associated with traumatic hemorrhage. Recombinant human bactericidal/permeability-increasing protein (rBPI21) has antibacterial and antiendotoxin properties, reduces cytokine levels, and increases survival in animal models of hemorrhagic shock. The primary objective of this study was to evaluate the safety and efficacy of prophylactic rBPI21 infusion in patients with hemorrhage due to trauma.This was a phase II, multicenter, randomized, double-blind, placebo-controlled trial. Patients who required at least 2 U of blood were randomized to receive rBPI21 (4 mg x kg(-1) x d(-1) for 2 consecutive days) or an equivalent volume of placebo by continuous infusion within 12 hours of injury. The primary efficacy end point was mortality or serious complication occurring during the first 15 days of the study. Safety was monitored clinically and by laboratory panels during the study period.A total of 401 patients were treated (202 in the rBPI21 group and 199 in the placebo group). The composite end point rate of mortality or serious complication through day 15 was 46% in the placebo group and 39% in the rBPI21 group (hazard ratio = 0.79; p = 0.13). Secondary analysis, which adjusted for age, mechanism of injury, Injury Severity Score (1990 version), and units of blood received before study drug infusion showed similar results (hazard ratio = 0.79; p = 0.14). The proportion of patients who developed at least one serious organ dysfunction was 22% in the placebo group and 16% in the rBPI21 group (hazard ratio = 0.71; p = 0.14). The proportion of patients who developed either pneumonia or acute respiratory distress syndrome was 32% in the placebo group and 22% in the rBPI21 group (hazard ratio = 0.66; post hocp = 0.03). The beneficial trends of rBPI21 were observed in both blunt and penetrating trauma and were generally observed across different age groups, Injury Severity Scores, and units of blood transfused. No treatment difference was observed in mortality or resource utilization in this phase II study.rBPI21 was well-tolerated and demonstrated a favorable trend in reducing the composite primary end point of mortality or serious complication through day 15, especially respiratory complications, in patients with hemorrhage due to trauma. A phase III study is currently in progress.

There is considerable debate between the proponents of open and closed diagnostic peritoneal lavage (DPL). A prospective study was undertaken on 130 patients submitted to DPL. We performed 55 (42.3%) closed and 75 (57.7%) open lavages with sensitivity and specificity of 100 and 96.6% for the former and 92.2 and 100% for the latter. The mean time for insertion of the catheter and initiation of fluid infusion was significantly less in the closed DPL group, and so were the number of cases with prolonged procedures. No intra-abdominal or wound complications were detected with either method, but there were 10 DPL failures due to inability to conclude the procedure successfully and derive a definite result. Eight of these (10.6%) belonged to the open group and two (3.6%) to the closed (P0.05). Our findings suggest closed DPL is as equally sensitive and specific as closed DPL, but is more expeditious and offers inconclusive results less often. Both procedures are useful and should be parts of surgical training.

A prospective study was undertaken at a Level I trauma center to evaluate the prevalence of substance use among victims of major trauma, along with the impact on clinical outcome. Five hundred sixteen patients had urine toxicology and blood alcohol screens performed and correlated with pattern and severity of injury, hospital course, and outcome. Three hundred seventy-one patients (71%) screened positive for alcohol or drugs, or both. Fifty-two per cent had positive alcohol screens, and 42 per cent had positive drug screens (cocaine and opiates represented 91% of positive drug screens). Univariate analysis revealed patterns of alcohol/drug use varied among subgroups according to demographics (less use among patients older than 55 years, females and Asians; more drug use in blacks; more alcohol use in Hispanics), mechanism of injury (non-use in blunt trauma patients and use of both in penetrating trauma patients) and body region injured (non-use in head-injured patients). Septic complications and mortality were more correlative with severity of injury, but not with use or non-use of alcohol or drugs. We conclude that alcohol and drug use remains a major comorbid factor in major trauma, and that injury prevention efforts should include a strong focus on counseling regarding these lifestyle choices.

We examined the recent experience of a large urban trauma center to identify overall morbidity and factors predictive of outcome in patients undergoing colostomy closure after trauma.We did a retrospective analysis of 40 patients who underwent colostomy closure after trauma at our institution between January 1992 and August 1996.The mechanism of injury was a gunshot wound in 30 patients (75%), a motor vehicle accident in 6 (15%), a stab wound in 3 (7.5%), and a rectal foreign body in 1 (2.5%). Loop colostomies were performed in 28 patients (70%) and end colostomies were performed in 12 patients (30%). Mean time until colostomy closure was 8 months (range, 0.5 to 28 months). Five patients underwent same admission colostomy closure (SACC). Contrast enemas were performed in 36 patients and found to be abnormal in 2 (6%) patients who were found during planning for SACC to have leaks from rectal trauma at 12 and 19 days after injury. Sixteen complications occurred in 12 patients (30%). Intraoperative complications occurred in two patients (5%) who sustained small and large bowel enterotomies. There were 4 major complications (1 fecal fistula, 1 anastomotic stricture, and 2 small bowel obstructions) in 3 patients (7.5%) and 10 minor complications (25%), 7 prolonged ileus and 3 superficial wound infections. Morbidity was significantly higher for patients whose initial injury involved the colon (11 of 20; 55%) as compared with those whose injury involved the rectum (2 of 16; 12.5%). The demographic, injury, and operative characteristics in the 12 patients with complications and the 28 patients without complications were compared to identify predictors of morbidity. The presence of a colon injury (RR = 7.70; p = 0.009) was a statistically significant predictor of morbidity after colostomy closure. The presence of an initial rectal injury, in contrast, was a predictor of low morbidity after closure (RR = 0.22; p = 0.024). No statistically significant differences were found with respect to age, gender, mode of injury, colostomy type, type of repair, need for laparotomy, or right- versus left-sided colostomy. Clinical trends were noted in five groups in whom the relative risk was greater than 2.0: age older than 30 versus less than 30 years (RR = 2.71; p = 0.079), end versus loop colostomy (RR = 2.33; p = 0.130), operative time greater than 2 versus less than 2 hours RR = 2.80; p = 0.141), estimated blood loss greater than 150 versus less than 150 cc (RR = 2.77; p = 0.079), and right- versus left-sided colostomy (RR = 2.00; p = 0.211). Patients with complications had significantly longer mean operative times (3.84 versus 2.46 hours; p = 0.02), higher mean blood loss (468 versus 142 cc; p = 0.006), and longer mean time until closure (11.3 versus 6.33 months; p = 0.02).Colostomy closure after trauma remains associated with significant morbidity. The patients in whom a colon injury was the indication for initial colostomy experienced high morbidity (55%) after subsequent closure. Patients who had a colostomy for rectal injury had a low morbidity after closure (6.25%). Intraoperative difficulties (longer operative times, higher blood loss) and long delays until colostomy closure increase complication rates. Timely closure may improve outcome after operation for bowel continuity restoration. Morbidity associated with colostomy closure should be considered additional evidence for performing primary repair of colonic injuries. Because the morbidity of colostomy closure after rectal injuries is low, proximal colostomy for extraperitoneal rectal injuries should remain the treatment of choice.

Our objective was to identify a set of readily available and easily obtainable parameters that would predict prolonged mechanical ventilation in the critically injured patient. A surgical intensive care unit of an academic Level I trauma center. Prospectively collected data were retrospectively analyzed on all critically injured patients receiving mechanical ventilation for more than 2 days between January and December 1994. Prolonged mechanical ventilation (PMV) was defined as the need for mechanical ventilatory support for more than 7 days. One hundred and nineteen patients entered the final analysis. Of these, 63 remained on the ventilator for 7 days or less and 56 for more than 7 days. The Injury Severity Score (ISS), partial arterial oxygen tension (PaO2)/inspired fraction of oxygen (FiO2), net fluid balance, and use of Swan-Ganz were significantly different between the two groups when calculated 48 hours after surgical intensive care unit admission. Furthermore, we dichotomized these four variables across cutpoints that were determined by statistical analysis (ISS more or less than 20, PaO2/FiO2 more or less than 250, fluid retention more or less than 2000 cc, and presence or absence of Swan-Ganz). Again, significantly more patients required PMV if they had any one of the following: Swan-Ganz, ISS more than 20, PaO2/FiO2 less than 250, or fluid retention more than 2000 cc at 48 hours. An easily calculated five-point risk score (0-4 points) for predicting PMV based on these four variables was developed. Among the 35 patients at the extremes of the risk score (0 or 4 points), 33 (94.3%) were correctly prognosticated as to their needs for PMV. The need for an easily calculated score, which is derived from readily available parameters and can reliably identify patients with prolonged needs for ventilatory support, is obvious in the trauma setting. We describe a five-point risk score by which we can predict the need for PMV early in the course of the disease. Resource utilization and personnel allocation issues, as well as important therapeutic procedures, can be planned based on this score.

Penetrating injuries to the thoracic great vessels have been diagnosed with increased frequency because of the escalating use of automatic weapons. The overall incidence is 5.3% of gunshot wounds and 2% of stab wounds to the chest. Most of these patients reach the hospital dead or in severe shock. The overall mortality of thoracic aortic injuries is higher than 90% and in subclavian vascular injuries higher than 65%. In the prehospital phase, the "scoop and run" policy offers the best chances of survival and no attempts should be made for any form of stabilization. Investigations should be reserved only for fairly stable patients. Angiography, color flow Doppler, and transesophageal echocardiography may be useful in selected cases. Patients in cardiac arrest or imminent cardiac arrest may benefit from an emergency room thoracotomy. The surgical approach to specific thoracic great vessels is described.

Large databases allow for rapid access to large volumes of data. To convert raw data to information, large numbers of data points must be correlated into a descriptive pattern that can be interpreted by the user. Databases must be constructed so as to allow reliable extraction of the raw data into a format that supports analysis of events in a meaningful, objective, and reproducible manner. Databases must be responsive to a variety of users. They must not demand unrealistic amounts of effort on those responsible for data entry. Standard protocols in various stages of development will make databases easier to use and more reliable. Database management tools such as the Internet and the National Library of Medicine will become more integrated into the practice of critical care medicine at all levels, including administration, clinical care, and research. This article provides an overview of the capabilities and difficulties associated with large databases. The major areas of use of large databases in the hospital setting are administration, bibliographic, patient care, research, and education. Each of these areas has different requirements and is supported by different types of databases. The advantages and disadvantages of linear, relational, and object-oriented databases are discussed. Issues relating to methods of data entry and the accuracy and reliability of data are discussed. The challenges involving integration of various sources of data and the interfacing of devices are reviewed.

The aim of the present study was to explore methods, concepts, and techniques that provide recognition of circulatory deficiencies at the earliest possible time in the patient's illness. We used both the standard invasive pulmonary artery thermodilution catheter and noninvasive hemodynamic monitoring systems consisting of a new bioimpedance cardiac output device, pulse oximetry, transcutaneous oxygen (PtCO2) and carbon dioxide tensions as well as the transcutaneous oxygen tension/fraction of inspired oxygen ratio (PtCO2/FIO2). These three noninvasive systems were used to evaluate cardiac function, pulmonary function, and tissue perfusion, respectively. This approach to early noninvasive monitoring is based on recent evidence suggesting that poor tissue perfusion and oxygenation initiate circulatory dysfunction that leads to shock and organ failure. We studied 303 acute episodes of circulatory dysfunction and shock in 261 patients in a university-run county hospital; 75 were acute traumatic injuries and 109 acute nontrauma medical emergencies on admission to the emergency department, and 77 ICU patients with an acute illness or exacerbation of their current illness. The study was a prospective, descriptive study to identify early abnormal circulatory patterns reflecting the cardiac, pulmonary, and perfusion functions associated with death and with survival. We described noninvasively monitored patterns in individual illustrative cases, in common etiologic groups, and in physiologic categories representing various abnormal functional patterns. We found that hypotensive shock usually was preceded by episodes of high flow followed by low flow and inadequate tissue perfusion indicated by reduced PtCO2; this frequent pattern was modified by associated co-morbid conditions, especially hypovolemia, limited cardiac reserve capacity, age, hypertensive states, and increased body metabolism from infection, trauma, stress, exercise, temperature, and endocrine disorders. Reduced pulmonary function occurred in 18% of emergency patients; these were usually patients with thoracic trauma, severe hypovolemia, head injuries, chronic obstructive pulmonary disease, asthma, drug overdose, and central nervous system failure (massive stroke and coma). We concluded that noninvasive measurements identify early circulatory problems reliably and provide objective criteria for physiologic analysis as well as for definition of therapeutic goals and titration of therapy.

The aim of our study was to describe the characteristics of Xanthomonas infections in a population of critically ill surgical patients. The clinical records and microbiological data on 93 patients in a surgical intensive care unit (SICU) developing Xanthomonas infections were reviewed. Xanthomonas was isolated in 125 sites in the 93 patients. Their average age was 48 years (range, 14-94). Mortality occurred in 25 patients (26.9%) versus 10.3 per cent of SICU patients in general (P0.05). Patients were in the SICU for an average of 11.9 days before developing a positive Xanthomonas culture, and 87 per cent (81/93) of patients developed an infection at some other site before isolation of Xanthomonas. Trimethoprim sulfamethoxazole was the only drug to which the isolates were commonly sensitive (123/125 = 98.4%). We conclude that Xanthomonas 1) is associated with increased mortality; 2) is resistant to many of the drugs that usually cover Gram-negative infections; and 3) commonly complicates a prolonged intensive care stay, thus serving as a marker for severity of illness.

There continues to be difficulty making the clinical distinction between fungal colonization and systemic infection in critically ill surgical patients. This distinction is important, given the potential risks of aggressive antifungal therapy. In order to evaluate the significance of fungal infections by various sites, we retrospectively reviewed the clinical courses of patients with cultures positive for fungi (Candida species or Torulopsis glabrata) in the SICU of LAC + USC Medical Center from January 1992-December 1993. There were 129 patients who were culture positive for Candida (110 patients) or Torulopsis glabrata (19 patients). There were 187 positive cultures. Fifty-five patients (43%) had systemic fungal infections (two or more sites, or fungemia). The proportion of patients with positive cultures from any given site going on to develop systemic infections was similar (wound, 49 per cent; urine, 54 per cent; sputum, 57 per cent; drain, 68 per cent; P = 0.61, NS). The mortality for SICU patients with systemic fungal infection was significantly increased (36.3% versus 10.5%, P0.05) when compared with SICU patients in general. No significant increase in mortality was seen in patients with single site isolation (13.5% versus 10.5%, P = 0.52). This study suggests that although systemic fungal infection is associated with increased mortality in SICU patients, no single site of isolation is superior to others in predicting which patients are likely to develop systemic infection. Prospective studies with antifungal agents with reduced toxicity are justified in patients with single site isolation.

The clinical experience with gunshot injuries to the thoracic aorta at a large urban trauma center was reviewed. Of 1961 patients admitted with gunshot wounds to the chest, 20 sustained injuries to the thoracic aorta. Mortality occurred in 17 patients (85%), all of whom were hypotensive or moribund upon admission. The three patients (15%) presenting with a systolic blood pressure above 100 mm Hg survived; only one of these underwent surgery during the acute period. Only two patients were stable enough for aortography. Advances in the management of critically injured patients have not improved the outcome with this lethal injury.

Injury to the common iliac artery is very uncommon in blunt trauma. We report two cases of intimal tear that led to thrombotic occlusion of the left common iliac artery in victims of motor vehicle collisions.

A retrospective study was performed in order to evaluate early morbidity and mortality associated with non-therapeutic operations for penetrating trauma. Over a 3-year period, 1,062 operations were performed on 1,015 patients for penetrating injury: abdomen 860, chest 103, neck 40, and extremities 58. A total of 230 (21.7%) of these operations were non-therapeutic. The incidence of significant complications directly related to the anesthesia or operation in this group of patients was 8.2 per cent. One patient with an additional major thoracic injury died secondary to complications related to a non-therapeutic abdominal operation (0.4%). The average hospital stay for uncomplicated non-therapeutic operations was 5.1 days, and for patients with complications 11.9 days. We conclude that non-therapeutic operations for penetrating trauma are associated with significant morbidity and mortality that must be considered when designing management schemes for penetrating injury.