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Inpatient mental health readmission rates have increased dramatically in recent years, with a subset of consumers referred to as revolving-door patients. In an effort to reduce the financial burden associated with these patients and increase treatment efficacy, researchers have begun to explore factors associated with increased service utilization. To date, predictors of increased service usage are remarkably discrepant across studies. Further exploration, therefore, is needed to better explicate the relevance of "traditional" predictors and also to identify alternate strategies that may assist in predicting rehospitalization. One method that may be helpful in identifying patients at high risk is the development of a psychometric screening procedure. As a means to this end, the present study was designed to assess the potential usefulness of psychometric data in predicting mental health service utilization. The sample consisted of 131 patients hospitalized during an index period of 8 months at an acute-care psychiatric hospital. Number of readmissions was recorded in a 9 month post-index period. Measures completed during the index admission included the Brief Psychiatric Rating Scale-Anchored (BPRS-A), Symptom Checklist-90-Revised (SCL-90-R), Kaufman Brief Intelligence Test (K-BIT), and the Beck Depression Inventory (BDI). Results indicated that psychometric data accounted for significant variance in predicting past, present and future mental health service utilization. The BPRS-A, SCL-90-R, and BDI show particular promise as time efficient psychometric screening instruments that may better enable practitioners to identify patients proactively who are at increased risk for rehospitalization. Implications are discussed with regard to patient-treatment matching and discharge planning.

Laparoscopic cholecystectomy (LC) has rapidly become standard treatment of symptomatic cholelithiasis. Its advantages are well known, while its risks have not been well defined. The most common major complication of LC is bile duct injury. Over the past year, we have treated six patients for this problem. Injuries included: one partial laceration of the common bile duct; one partial laceration of the common hepatic duct; three complete common hepatic duct transections at the bifurcation, and one clip obstruction of the right hepatic duct. Intraoperative cholangiography was performed in two of six patients. Injury was recognized in these two cases, which were converted to celiotomy for immediate repair. One was repaired primarily; the other required a hepaticojejunostomy. Injuries were not identified at LC in four. Three of the four patients required biliary-enteric reconstruction procedures. With a mean follow-up period of 13 months, four of six patients remain symptomatic. LC does carry a real risk of bile duct injury. Routine intraoperative cholangiography may decrease this risk or at least allow early recognition and repair when it has occurred. Conversion to an open procedure is not a complication of LC but rather a sign of good surgical judgement. Patients not following the routine postoperative course must be evaluated for a possible bile duct injury to prevent the morbidity of delayed diagnosis.

Pancreatic duct drainage is an effective method of dealing with many of the surgical complications of chronic pancreatitis without sacrificing pancreatic endocrine or exocrine function. Between 65 and 90% of patients with intractable pain of chronic pancreatitis and a dilated pancreatic duct will have substantial pain relief with complete ductal drainage by a lateral pancreaticojejunostomy. The mortality of this procedure ranges from 0 to 5%. In spite of operation, late mortality of this disease remains high with 1/3 to 1/2 of patients dying within 10 years. Fixed biliary tract obstruction and upper gastrointestinal obstruction can also complicate chronic pancreatitis. We have combined drainage of the common bile duct and stomach with pancreaticojejunostomy to deal with these problems and have found no increase in morbidity or mortality. Pseudocysts occur more frequently in patients with chronic pancreatitis. We have also combined pseudocyst drainage with lateral pancreaticojejunostomy in 26 patients having both pseudocysts and chronic pancreatitis. These patients achieve the same degree of pain relief noted in patients undergoing lateral pancreaticojejunostomy alone without any increase in morbidity or mortality. Drainage procedures are safe and effective and are our preferred method of dealing with obstructive complications of chronic pancreatitis.

A double blind, randomized, controlled trial has been conducted in 11 Veterans Administration hospitals during a 49-month period to compare the relative efficacies of immune serum globulin (ISG) and an albumin placebo for the prevention of post-transfusion hepatitis (PTH). A total of 2204 patients, of whom 1094 received ISG, participated in the study. The results indicate that ISG significantly reduced the incidence of icteric type non-B hepatitis only (inferred to be also type non-A hepatitis). Adverse reactions were rare, and the ISG did not significantly alter the incubation period or duration of the disease. The data suggest, however, that a similar reduction in type non-A, non-B hepatitis would have occurred had commercial blood been excluded from use. Analysis of the 241 patients who developed hepatitis indicates that type B hepatitis constituted less than 20% of the cases each year of the study. Furthermore, the efficacy of the ISG, manufactured in 1944, against apparent type non-A, non-B hepatitis suggests that this overlooked disease has existed from at least that time. Host- and transfusion-related factors that might have modified the development of PTH were examined. The use of commerical blood was observed to be the most important risk factor. It is concluded that the PTH incidence can be most effectively reduced by eliminating commercial donor blood, and continuing to screen volunteer donors for hepatitis B surface antigen (HBsAg) by sensitive procedures. Of prime importance is the need to define the agent(s) responsible for type non-A, non-B hepatitis.

The optimal management of severe ascites in patients with alcoholic cirrhosis has not been defined. in a 5 1/2-year study, we randomly assigned 299 men with alcoholic cirrhosis, who had persistent or recurrent severe ascites despite a standard medical regimen, to receive either intensive medical treatment or peritoneovenous (LeVeen) shunting. We identified three risk groups: Group 1 had normal or mildly abnormal results on liver-function tests, Group 2 had more severe liver dysfunction or previous complications, and Group 3 had severe prerenal azotemia without kidney disease. For the patients who received the medical treatment and those who received the surgical treatment combined, the median survival times were 1093 days in Group 1, 222 days in Group 2, and 37 days in Group 3 (P less than or equal to 0.01) for all comparisons). For all the groups combined, the median time to the resolution of ascites was 5.4 weeks for medical patients and 3.0 weeks for surgical patients (P less than 0.01). Within each risk group, mortality during the initial hospitalization and median long-term survival were similar among patients receiving either treatment. However, the median time to the recurrence of ascites in Group 1 was 4 months in medical patients, as compared with 18 months in surgical patients (P = 0.01); in Group 2 it was 3 months in medical patients as compared with 12 months in surgical patients (P = 0.04). The median duration of hospitalization was longer in medical patients than in surgical patients (6.1 vs. 2.4 weeks in Group 1 [P less than 0.001] and 5.0 vs. 3.1 weeks in Group 2 [P less than 0.01]). Group 3 was too small to permit a meaningful comparison. During the initial hospitalization, the incidence of infections, gastrointestinal bleeding, and encephalopathy was similar among the medical and surgical patients. We conclude that peritoneovenous shunting alleviated disabling ascites more rapidly than medical management. However, survival was closely related to the severity of the illness at the time of randomization and was not altered by shunting.

We present measurements of the differential cross section for the production of massive muon pairs in 225-GeV/c ${\ensuremath{\pi}}^{\ensuremath{-}}$-nucleus collisions. We have used the data between the $\ensuremath{\psi}$ and $\ensuremath{\Upsilon}$ resonances in the framework of the Drell-Yan quark-antiquark annihilation model to predict the behavior of the cross section in the high-mass (${m}_{\ensuremath{\mu}\ensuremath{\mu}}g11$ GeV/${\mathit{c}}^{2}$) region. The data are consistent with this extrapolation provided that a QCD leading-logarithmic evolution is included in the structure functions.

A 56-year-old white male with abdominal pain, vomiting, and jaundice was found on exploration to have squamous cell carcinoma of the hepatic ducts with metastasis to the liver. He was treated with palliative procedure consisting of dilation of tumor and placement of T-tube past the lesion. After recovering from surgery, patient was begun on radiation therapy to the liver and hilum, but his postoperative course was of progressive liver failure. This first necessitated cessation of radiation therapy and finally ended with the death of the patient three months after diagnosis.

Ultrasound has proven invaluable in detecting and evaluating pancreatic pseudocysts, and it is now a standard test to rule out complications of pancreatitis. In reviewing the authors' experience with 122 patients treated surgically for a pancreatic pseudocyst, five patients were identified in whom an ultrasound demonstrated a pseudocyst that was associated with an unexpected cancer at the time of operation. A sixth patient, with a pseudocyst documented by ultrasound, died prior to surgery and was found at autopsy to have metastatic common bile duct carcinoma. There was little difference in presenting symptoms, age, frequency of alcoholism, or physical findings compared with patients with pseudocysts secondary to pancreatitis. In two patients, pseudocysts were found in the tail of the pancreas at operation, in addition to carcinoma. In the other three patients, no pseudocyst was found; however, a subcapsular splenic hematoma was present in one. Five patients had metastatic disease, three from pancreatic adenocarcinoma, one from islet cell carcinoma, and one from a common bile duct carcinoma. One patient with a pancreatic adenocarcinoma confined to the head underwent a Whipple procedure and has no evidence of disease 6 months later. Malignancy may cause or coexist with pancreatic pseudocysts. Ultrasound is often not helpful in distinguishing pseudocysts associated with malignancy from those associated with pancreatitis. Biopsy should be performed to rule out malignancy when operating for pancreatic pseudocysts.

Fibrosis of chronic pancreatitis can cause obstructive jaundice by compressing the intrapancreatic portion of the common bile duct. The frequency and clinical manifestations of common bile duct stricture from symptomatic chronic pancreatitis have been evaluated in 26 patients undergoing lateral pancreaticojejunostomy for intractable pain between 1974 and 1980. Four patients (15%) had a stricture with partial obstruction of the common duct in addition to pancreatic duct obstruction. Three of the four strictures were identified prior to operation by ERCP. The fourth developed biliary obstruction six months after pancreaticojejunostomy. Slight elevation of alkaline phosphatase was common and occurred in 12 of 22 patients with chronic pancreatitis without biliary obstruction. Alkaline phosphatase was elevated greater than four times normal in three of the four patients with a biliary stricture. Elevation of total and direct serum bilirubin occurred only in patients with stricture of the distal common duct. A waxing and waning picture of jaundice was seen in these four patients. When a fixed smooth stricture of the common duct is demonstrated in a patient with symptomatic chronic pancreatitis, drainage of the biliary tree should be combined with pancreatic duct drainage in order to prevent cholangitis, biliary cirrhosis, diagnostic confusion with pancreatic carcinoma, and persistence of pain.

Between the years of 1970 and 1984, a total of 96 patients underwent biliary enteric bypass to alleviate distal common bile duct obstruction from benign and all malignant disease. Cholecystoenterostomy (CCE) was performed in 13 patients (chronic pancreatitis 7, carcinoma 6), choledochoduodenostomy (CDD) was performed in 35 patients (stones 9, chronic pancreatitis 17, carcinoma 8, and fistula 1), cholecystojejunostomy (CDJ) was performed on 48 patients (stones 1, pancreatitis 21, carcinoma 25 and stricture 1). Operative mortality was 7 per cent and morbidity occurred in 12 per cent of the patients. Symptomatic improvement was measured by relief of pain and sepsis and decrease of bilirubin and alkaline phosphatase to normal. Overall improvement was seen in 73 per cent of patients (CCE 50%, CDD 8%, CDJ 65%), 27 per cent of the patients did not improve (CCE 50%, CDD 12%, CDJ 35%), 83 per cent of the poor results were in patients with advanced malignancy. Thirty-one per cent of patients undergoing CCE required conversion to CDD or CDJ. Cholecystoduodenostomy was associated with failure in 50 per cent of patients. CCD and CDJ are safe and reliable means of relieving distal common duct obstruction due to biliary or pancreatic disease. Cholecystojejunostomy may be performed in the terminal patient with advanced carcinoma requiring a short-term biliary bypass.

Seventy-two malignant and 19 benign tumors were seen at the Veterans Administration Hospital, Hines, Illinois, from 1950 to 1976. Of these, 44 malignant and 14 benign tumors were seen in the clinical setting--the remainder were found at autopsy. Carcinoid tumors were the most common malignant tumors, followed by adenocarcinoma, lymphoma and leiomyosarcoma. Patients with malignant tumors usually presented with abdominal pain, vomiting and weight loss. The most common clinical signs were anemia, abdominal tenderness and abdominal distention. The most useful diagnostic tests were upper GI series and plain x-ray of the abdomen. Twenty-one (50%) five year survivals and 14 (33%) ten year survivals were obtained with small bowel malignancies. The majority of the five and ten year survivals were patients who had carcinoid tumors and lymphoma. Various theories on the causation of small bowel malignancies are discussed.

Seventy-three patients with small bowel obstruction due to metastatic carcinoma were seen in the years 1960 to 1979. Twenty-nine patients were seen in the first decade and 44 patients in the second. The most common primary tumor causing metastatic small bowel obstruction was colonic carcinoma, followed by gastric carcinoma. Plain x-ray examinations supplemented by an upper gastrointestinal series with small bowel follow-through were the most useful diagnostic tests. Seventy per cent (51/73) of these patients were initially treated with intravenous fluids and gastrointestinal decompression using a short (32/51) or long (19/51) tube. In eight of 51 patients, nasogastric decompression relieved the obstruction, but in all but one of these patients symptoms and signs of obstruction recurred promptly after tube removal. At laparotomy, the majority of patients underwent either a bypass procedure or resection. The mean survival for the patients bypassed varied from four to seven months; for those that had resection it varied from five to nine months. The mortality rate was high--41 per cent in the first decade and 25 per cent in the second. Of the last 12 patients, eight received hyperalimentation before and after surgery. The operative mortality rate was 12.5 per cent and the mean survival was eight months. It is concluded that: 1) Colonic carcinoma is the most common primary tumor causing metastatic small bowel obstruction. 2) Tube decompression is rarely effective and surgical relief is necessary in the vast majority of cases. 3) Operative mortality has been reduced, partially because of more vigorous support, i.e., hyperalimentation, but the mean duration of survival has not changed significantly.

Hepatitis B immune globulin (HBIG) and immune serum globulin (ISG) were examined in a randomized, double-blind trial to assess their relative efficacies in preventing type B hepatitis after needle-stick exposure to hepatitis B surface antigen (HBsAG)-positive donors. Clinical hepatitis developed in 1.4% of HBIG and in 5.9% of ISG recipients (P = 0.016), and seroconversion (anti-HBs) occurred in 5.6% and 20.7% of them respectively (P less than 0.001). Mild and transient side-effects were noted in 3.0% of ISG and in 3.2% of HBIG recipients. Available donor sera were examined for DNA polymerase (DNAP) and e antigen and antibody (HBeAg; anti-HBE). Both DNAP and HBeAg showed a highly statistically significant correlation with the infectivity of HBsAg-positive donors. Hepatitis B immune globulin remained significantly superior to ISG in preventing type B hepatitis even when the analysis was confined to these two high-risk subgroups. The efficacy of ISG in preventing type B hepatitis cannot be ascertained because a true placebo group was not included.

To evaluate the safety and efficacy of cystoduodenostomy, the cases of 117 patients operated on for pancreatic pseudocysts during the last 14 years have been reviewed. Eleven patients were treated with cystoduodenostomy. They included ten men and one woman whose ages ranged from 26 to 56 years (mean 41 years). The etiology of pancreatitis was alcohol abuse in nine patients, alcohol abuse and gallstones in one, and trauma in one. Three patients had another cyst located within the body or tail of the pancreas which was identified preoperatively by ultrasound. Each patient underwent transduodenal cystoduodenostomy and three had a concomitant cystogastrostomy for a second pseudocyst. There was no operative mortality. Morbidity included postoperative pancreatitis in one patient, a wound infection and pancreatic fistula in one, and excessive bleeding from the cyst in one. There were no injuries to the common bile duct. Upon follow-up, which ranges from 6 months to 8 years, none of the patients has had a persistent or recurrent pseudocyst. This has been confirmed by ultrasound or computerized tomography (CT scan) in nine patients. Transduodenal cystoduodenostomy is a safe, reliable means of internal drainage for mature pseudocysts that are located in the head of the pancreas adjacent to the duodenum. Preoperative evaluation of the pancreas to rule out multiple pseudocysts and intraoperative care to avoid injury to the common bile duct are important factors in obtaining these good results.

A randomised, double-blind, controlled trial has been undertaken to compare the efficacy of hepatitis B immune globulin (H.B.I.G.) with that of immune serum globulin (I.S.G.) for the prophylaxis of viral hepatitis. Participants in the trial were individuals exposed accidentally to material infectious for hepatitis (primarily viral B hepatitis). Preliminary evaluation of the first 302 of the 561 individuals entered into the study indicates that H.B.I.G. significantly reduced the frequencies of both clinical and subclinical hepatitis during the first 3--4 months after the injection. Less than 10% of H.B.I.G. recipients had detectable anti-HBs at the sixth month after the injection, suggesting that H.B.I.G. might need to be given every 3--4 months to continually exposed individuals. Further long-term evaluation is required in order to define more clearly those most likely to benefit from H.B.I.G.

Chronic alcoholism is the etiologic factor leading to most instances of chronic pancreatitis and its complications. Impairment of exocrine and endocrine function parallels the severity of the chronic pancreatitis. Ultrasound and CT scan are the most accurate tests for the identification of gross anatomic changes in the pancreas. ERCP is critical in the evaluation of pancreatic ductal anatomy. Severe, persistent abdominal and back pain requiring narcotics is significantly relieved in approximately 80 percent of patients receiving a pancreatic drainage operation. Pancreatic resection is an acceptable alternative procedure if pancreatic ductal dilation is absent or if the disease is concentrated in the body and tail of the pancreas. A high incidence of insulin-dependent diabetes remains the main drawback of pancreatic resection, a problem often difficult to manage in the alcoholic. Late mortality is high, and is primarily related to diseases associated with chronic alcoholism. Internal drainage of pancreatic pseudocysts is favored whenever possible. If the contents of the pseudocyst are infected or the cyst walls are immature, external drainage is indicated. Resection of the pseudocyst and the contiguous pancreas effectively treats the pseudocyst but at the price of higher morbidity and mortality. The role of percutaneous aspiration of pseudocysts has not yet been adequately tested. The correction of pancreatic ascites and pancreatic pleural effusions is directed at internal drainage or resection of the leaking pseudocyst or disrupted pancreatic duct. Additional complications involving the biliary tract and gastrointestinal tract require an individual approach based on the site and cause of the problem. Generally, treatment is directed initially at the pseudocyst, if one is present. On the other hand, if biliary or gastrointestinal tract obstruction is secondary to long-standing chronic pancreatitis, a bypass procedure will probably be necessary to correct the problem.

During the five-year interval from January 1, 1971 to January 1, 1976 118 seriously ill adults received 2916 patient days of TPN therapy with an average infection rate of 7.6%. All patients received the benefit of a well-defined TPN catheter care protocol which emphasized regular (every 48 hours) catheter dressing changes. The lowest risk of infection, 2.7%, was seen in 73 patients who received an amino acid-glucose solution through a silicone elastomer catheter protected by an iodophor dressing. When catheter-related sepsis occurred, Staphlylococcus aureus and Candida albicans were the most common organisms cultured.

At present, tuberculosis of the intestinal tract is rare in the United States. When gastrointestinal disease is seen, 85--90% of cases involve the ileocecal area. A case of tuberculosis of the duodenum unassociated with pulmonary disease is described. Although fiberoptic enndoscopy, abdominal ultrasonography and computerized axial tomography were used, the diagnosis required laprotomy with biopsy. The clinical manifestations, diagnostic investigations and treatment of the 49 previously reported cases of duodenal tuberculosis are also reviewed.

Control cultures were taken at laporatomy of the stomach or stomach remnant, jejunum, and ileum of 26 adult dogs, 8 of which had had gastric surgery 1 yr earlier. Two wk after the control cultures were taken, 17 of the 26 dogs, including all 8 which had had prior surgery, were treated with anthelmintics, niclosamide, dichlorophene, methylbenzene, and arecoline hydrobromide. Two wk after the anthelmintic treatment, or 4 wk after the control cultures were taken, the 26 dogs were recultured. Samples of microbial flora were obtained by direct needle aspiration employing anaerobic precautions. These samples were processed both quantitatively and qualitatively using both anaerobic and aerobic technics. The specific sites cultured were the lower stomach or stomach remnant, proximal jejunum 15 cm distal to the ligament of Treitz, and distal ileum 45 cm proximal to the ileocecal valve. Bacteria isolated were predominately facultative aerobes. No fungi were isolated. Cultivation of spirochetes was not attempted. The results showed that there was no significant qualitative or quantitative alteration of microbial flora caused by the anthelmintic treatment.

To test the hypothesis that prolonged freedom from clinically detectable ascites after peritoneovenous shunt insertion is the result of continued drainage of ascitic fluid through the shunt, the authors studied shunt patency and function in 26 of the 27 survivors of 59 alcoholic cirrhotic patients operated upon 2-6 years previously for massive ascites resistant to medical therapy. Twenty-three patients were without clinically detectable ascites (minimal ascites--Group A), and three had large ascites (Group B). In 20 Group A patients the shunts were patent and functioning. The other three Group A patients had completely occluded shunts without demonstrable ascitic fluid flow. In one Group B patient with a daily fluid intake of 5-6 L, the shunt was partially obstructed but flow was rapid; in the other two, shunts were completely occluded. One subject in Group B with a completely obstructed shunt was resistant to medical treatment after 6 years of freedom from ascites, whereas the other two were controlled medically. In the three in Group A who had nonfunctioning shunts and required no diuretics, the severity of the ascites had decreased so that artificial drainage was no longer necessary. Thus, freedom from clinically significant ascites does not always indicate that the shunt continues to function.

A double blind, randomized, controlled trial has been conducted in 11 Veterans Administration hospitals during a 49-month period to compare the relative efficacies of immune serum globulin (ISG) and an albumin placebo for the prevention of post-transfusion hepatitis (PTH). A total of 2204 patients, of whom 1094 received ISG, participated in the study. The results indicate that ISG significantly reduced the incidence of icteric type non-B hepatitis only (inferred to be also type non-A hepatitis). Adverse reactions were rare, and the ISG did not significantly alter the incubation period or duration of the disease. The data suggest, however, that a similar reduction in type non-A, non-B hepatitis would have occurred had commercial blood been excluded from use. Analysis of the 241 patients who developed hepatitis indicates that type B hepatitis constituted less than 20% of the cases each year of the study. Furthermore, the efficacy of the ISG, manufactured in 1944, against apparent type non-A, non-B hepatitis suggests that this overlooked disease has existed from at least that time. Host- and transfusion-related factors that might have modified the development of PTH were examined. The use of commercial blood was observed to be the most important risk factor. It is concluded that the PTH incidence can be most effectively reduced by eliminating commercial donor blood, and continuing to screen volunteer donors for hepatitis B surface antigen (HBsAg) by sensitive procedures. Of prime importance is the need to define the agent(s) responsible for type non-A, non-B hepatitis.

Between the years 1950 and 1976, 76 patients with carcinoid tumors of the gastrointestinal tract were seen at the Hines Veterans Administration Hospital, Hines, Illinois; of these, 48 tumors were recognized clinically. Five- and ten-year survivals were 56 and 44 per cent, respectively. The best survivals were seen in patients with carcinoids originating in the appendix, followed by the small bowel, rectum, and then the colon.

We have measured the atomic-mass dependence of the P/sub T/ distribution of massive muon pairs produced in 225-GeV/c ..pi../sup -/-nucleus collisions at Fermilab. We find that is consistent with being independent of the atomic mass A, with the value of 1.69 +- 0.10 (GeV/c)/sup 2/ for muon pairs of mass between 4.0 and 8.5 GeV/c/sup 2/. When the dependence of on A is parametrized as = a+bA/sup 1/3/, we find that b = -0.079 +- 0.073 (GeV/c)/sup 2/ which corresponds to an upper limit of 0.015 (GeV/c)/sup 2/ at the 90% confidence level.