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In a continuation of a trial for which preliminary results were reported in the Journal two years ago, a total of 64 patients with Child Class C cirrhosis and variceal hemorrhage requiring six or more units of blood were randomly assigned to receive either a portacaval shunt (32 patients) or endoscopic sclerotherapy (32 patients). The duration of initial hospitalization and the total amount of blood transfused during hospitalization were significantly less in the patients receiving sclerotherapy (P less than 0.001). There was no difference in short-term survival (50 percent of the sclerotherapy group were discharged alive, as compared with 44 percent of the shunt-surgery group). Both groups were followed for a mean of 530 days after randomization. Rebleeding from varices, the duration of rehospitalization for hemorrhage, and transfusions received after discharge were all significantly greater in the sclerotherapy group (P less than 0.001). Forty percent of the sclerotherapy-treated patients discharged alive (7 of 16 patients) ultimately required surgical treatment for bleeding varices, despite a mean of 6.1 treatment sessions. Health care costs and long-term survival did not differ significantly between the groups (P greater than 0.05). We conclude that although endoscopic sclerotherapy is as good as surgical shunting for the acute management of variceal hemorrhage in poor-risk patients with massive bleeding, sclerotherapy-treated patients in whom varices are not obliterated and bleeding continues should be considered for elective shunt surgery. [ABSTRACT FROM AUTHOR]

Background: S-nitrosocysteine is a carrier form of nitric oxide that can be delivered intravenously. S-nitrosocysteine is rapidly metabolized by plasma (half-life = 2-3 seconds), forming nitric oxide and cysteine. With its short half-life and potent vasodilatory properties, S-nitrosocysteine may be useful as a pulmonary vasodilating agent in cases of postoperative and chronic pulmonary hypertension., Objective: Our objective was to determine the hemodynamic properties of S-nitrosocysteine on the pulmonary and systemic circulations to assess its potential utility as a pulmonary vasodilatory agent., Methods: Eleven adult swine were anesthetized. Thermodilution (Swan-Ganz; Baxter International, Inc, Deerfield, Ill) and arterial catheters were inserted. Flow probes were placed around the coronary, renal, superior mesenteric, and iliac arteries. Incremental infusion doses of S-nitrosocysteine (5-80 nmol. kg(-1). min(-1)) were delivered into the right atrium. Cardiac output, right and left heart pressures, heart rate, Pao(2), and iliac, renal, coronary, and mesenteric blood flow rates were recorded at baseline and at each infusion dose of S-nitrosocysteine., Results: Low-dose S-nitrosocysteine infusion decreased mean pulmonary artery pressure (15%, P =.013) without a significant reduction in mean systemic artery pressure. Higher dose infusions produced further dose-dependent declines in pulmonary vascular resistance and measurable reductions in systemic vascular resistance (P =.01). At an S-nitrosocysteine dosage of 40 nmol. kg(-1). min(-1), there was a significant reduction in renal (P <.001) and mesenteric (P =.003) blood flow but no change in iliac (P >.2) or coronary (P >.2) blood flow. Cardiac output remained constant up to infusion rates of 40 nmol. kg(-1). min(-1) (P >.2). Doses higher than 5 nmol. kg(-1). min(-1) resulted in a substantial dose-dependent reduction in Pao(2) (P <.001), suggesting dilation of atelectatic areas of the lung., Conclusion: S-nitrosocysteine is a potent vasodilatory agent capable of overcoming the hypoxic vasoconstrictive response of the lung. Our results suggest it may prove useful as a pulmonary vasodilatory agent at low doses. Higher dose infusions reduce mean systemic pressure and lead to compensatory reductions in renal and mesenteric blood flow without a decrease in cardiac output.

Since World War II, multiple changes have occurred in medicine that are now affecting academic health centers and department of surgery chairpersons. None of these changes by themselves were intended to adversely affect department of surgery chairpersons, but the sum total effect constitutes a negative external force. In addition, there are internal forces in the schools of medicine and university hospitals that may negatively affect department of surgery chairperson in fulfilling the stated goals of excellent patient care, teaching, and research. Many of the problems brought about by these negative forces cannot be solved by a single department chairperson. However, individual department chairs can contribute to the solution by returning to the values taught to them by the role models of their surgical training.

Until recently the development of systems for trauma care in the United States has been inextricably linked to wars. During the Revolutionary War trauma care was based on European trauma principles particularly those espoused by the Hunter brothers. Surgical procedures were limited mostly to soft tissue injuries and amputations. The American Civil War was remarkable because of the contributions that were made to the development of systems for trauma care. The shear magnitude of casualties required extensive infrastructure to support the surgeons at the battlefield and to care for the wounded. For the first time in an armed conflict, anaesthetics were used on a routine basis. Despite these major contributions, hospital gangrene was a terrible problem and was the cause of many mortalities. World War I and World War II were noteworthy because of the contributions made by surgeons in the use of blood. One of the major lessons of World War II was the reemphasis of how frequently lessons have to be relearned regarding the treatment and care of wounds. Between the Korean Conflict and the Vietnam War the discovery was made of the tremendous fluid shifts into the cell after severe hemorrhagic shock. As a consequence, the treatment of patients with shock was altered during the Vietnam Conflict, which resulted in better outcomes and less renal failure. The first trauma centers for civilians were started in the United States in 1966. Since 1988 the number of states with mature trauma systems has expanded from two to 35. During the same period, many studies have documented the efficacy of trauma systems in reducing unnecessary mortality and disability.

Hypothesis: The management of geriatric injured patients admitted to a trauma center includes the selective decision to provide comfort care only, including withdrawal of therapy, and a choice to not use full application of standard therapies. The decision makers in this process include multiple individuals in addition to the patient., Design: Retrospective review of documentation by 2 blinded reviewers of the cohort of patients over a recent 5-year period (1993-1997)., Setting: Trauma service of a level I trauma center., Patients: A convenience sample of patients aged 65 years and older who died, and whose medical record was available for review., Main Outcome Measures: Patients were categorized as having withdrawal of therapy, and documentation in the medical record of who made the assessment decisions and recommendations, and to what extent the processes of care were documented., Results: Among 87 geriatric trauma patients who died, 47 had documentation interpreted as indicating a decision was made to withdraw therapy. In only a few circumstances was the patient capable of actively participating in these decisions. The other individuals involved in recommendations for withdrawal of therapy were, in order of prevalence, the treating trauma surgeon, family members (as proxy reporting the patient's preferences), or a second physician. Documentation regarding the end-of-life decisions was often fragmentary, and in some cases ambiguous. Copies of legal advance directives were rarely available in the medical record, and ethics committee participation was used only once., Conclusions: Withdrawal of therapy is a common event in the terminal care of geriatric injured patients. The process for reaching a decision regarding withdrawal of therapy is complex because in most circumstances patients' injuries preclude their full participation. Standards for documentation of essential information, including patients' preferences and decision-making ability, should be developed to improve the process and assist with recording these complicated decisions that often occur over several days of discussion.

The purpose of the present study was to determine whether human gastric mucous epithelial cells express a functional Ca2+-sensing receptor (CaR). Human gastric mucous epithelial cells were isolated from surgical tissues and cultured on glass coverslips, plastic dishes, or porous membrane filters. Cell growth was assessed by the MTT assay, CaR localization was detected by immunohistochemistry and confocal microscopy, CaR protein expression was assessed by Western immunoblotting, and intracellular Ca2+ concentration ([Ca2+]i) was determined by fura 2 spectrofluorometry. In paraffin sections of whole stomach, we found strong CaR immunohistochemical staining at the basolateral membrane, with weak CaR-staining at the apical membrane in mucous epithelial cells. Confocal microscopy of human gastric mucous epithelial cell cultures showed abundant CaR immunofluorescence at the basolateral membrane and little to no CaR immunoreactivity at the apical membrane. Western immunoblot detection of CaR protein in cell culture lysates showed two significant immunoreactive bands of 140 and 120 kDa. Addition of extracellular Ca2+ to preconfluent cultures of human gastric mucous epithelial cells produced a significant proliferative response. Changes in [Ca2+]i were also observed in response to graded doses of extracellular Ca2+ and Gd3+. The phospholipase C inhibitor U-73122 specifically inhibited Gd3+-induced changes in [Ca2+]i in the gastric mucous epithelial cell cultures. In conclusion, we have identified the localization of a functional CaR in human gastric mucous epithelial cells.

Objective: To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS)., Methods: On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing fascial closure at trauma celiotomy, surgeons graded their willingness to close the fascia in various scenarios on a scale of 1 to 5. The impact of six signs of clinical deterioration on willingness to perform abdominal decompression in a patient with postceliotomy elevated intra-abdominal pressure (IAP) was also queried. Of 292 members of the American Association for the Surgery of Trauma active in abdominal trauma management, 248 members (85%) had experience with ACS one or more times in the previous year., Results: Surgeons' responses to factors found at trauma celiotomy were divided into two distinct categories: factors decreasing willingness to close the fascia, and factors not changing or increasing willingness to close the fascia (p < 0.001). Factors disfavoring fascial closure were pulmonary or hemodynamic deterioration with closure, massive bowel edema, subjectively tight closure, planned reoperation, and packing. Factors not changing or favoring fascial closure were fecal contamination/peritonitis, massive transfusion, hypothermia, multiple abdominal injuries, acidosis, and coagulopathy. Five of the six signs of clinical deterioration increased surgeons' willingness to decompress a patient with elevated IAP (increased O2 requirement, decreased cardiac output, increased acidosis, increased airway pressures, and oliguria). Lowered gastric mucosal pH did not affect willingness. Seventy-one percent of surgeons indicated they would decompress elevated IAP in postceliotomy patient if one or two signs of clinical deterioration were present, but only 14% would decompress a patient for elevated IAP alone., Conclusion: A majority of expert American trauma surgeons have experience with ACS and would leave the abdomen open if ACS occurred. A majority would reopen a closed abdomen in cases of elevated IAP with signs of clinical deterioration. A minority would leave the abdomen open when there was only a risk of developing ACS.

Background: The specific paclitaxel dose or time course in the treatment of colon carcinoma without the disruption of normal colonic cell proliferation is currently not known. The aim of this study was to determine the effects of paclitaxel on the growth of human colonic epithelial cells using cultures of normal, polyposis, and cancerous cells., Methods: Normal, polyposis, and cancerous human colonic cells (Caco-2, T-84, and LoVo cell lines) were cultured, then treated with paclitaxel (10(-9)-10(-5) M) for 0-7 days.[AU: Please verify all dosages throughout.] Cell proliferation was assayed using either a Coulter-Counter or MTT-growth assay. Immunofluorescence and Western immunoblotting measured P-glycoprotein., Results: Low paclitaxel doses (1 x 10(-9)-10(-8) M) were more effective than higher paclitaxel doses (>1 x 10(-8) M) in the growth inhibition of polyposis, Caco-2, and LoVo cancer (but not T-84) cell lines. Low paclitaxel doses had little effect on normal colonic cell growth over 7 days. Higher paclitaxel doses (>1 x 10(-8)-10(-5) M) produced a dose-dependent inhibitory effect on the growth of normal human colonic epithelial cells over 7 days but had no effect on the growth of polyposis, Caco-2, and LoVo cells over 3-7 days of treatment. Immunofluorescence and Western immunoblotting of cultures showed that 1 x 10(-6) M paclitaxel increased P-glycoprotein expression in Caco-2 and LoVo cells. There was no effect of paclitaxel on P-glycoprotein expression in T-84 cancer cells, which were found to have high endogenous basal levels of P-glycoprotein. P-glycoprotein expression in Caco-2 cells was found on plasma membranes and in perinuclear areas., Conclusions: Lower paclitaxel doses are more effective over time for the growth inhibition of polyposis and cancerous colonic cells, with minimal effects on the growth of normal colonic epithelial cells. Increased P-glycoprotein expression appears to be correlated with paclitaxel resistance in polyposis and cancerous colonic cells.

A high-pressure liquid chromatography (HPLC) assay for measuring picomole quantities of nitrosothiol in biological samples was developed. The assay utilizes the catalytic reduction of nitrosothiol by mercuric cation (Hg2+). Released nitrogen oxide reacts with sulfanilamide (SA) and N-(1-napthyl)ethylenediamine (NNED) to form a stable azo dye. The azo dye is then separated from N-(1-napthyl)ethylenediamine and quantified by reversed-phase HPLC. In addition to nitrosothiol, nitrite and atmospheric nitrogen oxides are sources of nitrogen oxide that react with the reagents, SA and NNED, to form the azo dye. Therefore, a reference sample, which includes the nitrosothiol sample and all reagents except Hg2+, is utilized for the subtraction of nitrite and atmospheric nitrogen oxides which "contaminate" the nitrosothiol sample and reagents. This method is a sensitive (approximately 3 pmol; approximately 10(-1) microM) and accurate means to measure nitrosothiol concentration in biologic samples.

Background: Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown., Objective: To determine the current preferences of American trauma surgeons for colon injury management., Methods: Four hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons' characteristics on the choice of management was also surveyed., Results: Seventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p < 0.001) and PR less frequently (p < 0.001) than surgeons who managed six or more colon wounds per year., Conclusion: The prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.

The response of the United States to a perceived terrorist threat is dichotomous. The hyperbole and exaggeration often displayed by the media and general public lies in stark contrast to the relative indifference with which terrorism is regarded by the medical community. Quantitating the true nature of the terrorist threat in the United States is difficult, as it is not only poorly defined but rapidly changing. The intent of this commentary is to define what constitutes terrorism and what specific threats exist, including conventional, nuclear, biological, and chemical weapons. We will then outline recommendations for modest changes in our disaster medical planning to better prepare for these threats. Special attention will be directed at the emergence of nonconventional weapon use by terrorist organizations and how this might affect the civilian medical community.

The purpose of the present study was to examine the effects of some common herbicides and pesticides on the growth of normal intestinal and colonic epithelial cells. Preconfluent cultures of normal rat intestinal cells (IEC-6 cell line) and normal human colonic epithelial cells were treated with 0.05-50 microM doses of atrazine, diazinon, and endosulfan. After 3 days of treatment, the change in cell proliferation was quantified by cell counting or the MTT growth assay. Both intestinal and colonic epithelial cell cultures had increases in cell growth when treated with as little as 1.0 microM atrazine, diazinon, or endosulfan. The observed changes in both cultured intestinal and colonic cell growth rates were not due to the influence of the vehicle control dimethyl sulfoxide (DMSO). That is, the treatment of the cell cultures with concentrations of DMSO as high as 0.5% for 3 days resulted in no change in cell growth compared with untreated control cultures. A consistent observation with all three of the compounds was that the highest doses (50 microM) had the least "proliferative potential" in stimulating either IEC-6 cell or human colonic epithelial cell growth. Within the concentration range used, none of the herbicides or pesticides caused a decrease in cell proliferation below that of the untreated control cultures. Overall, treatment of IEC-6 cell cultures with atrazine, diazinon, or endosulfan produced a biphasic growth response, whereas the same treatment in the human colonic epithelial cell cultures produced a more sustained level of growth over the same period. This culture system may provide the basis for an in vitro model to further study the cellular and molecular basis of the effects of herbicides and pesticides on intestinal epithelial proliferation.

Objective: To determine whether prevention of the abdominal compartment syndrome after celiotomy for trauma justifies the use of absorbable mesh prosthesis closure in severely injured patients., Design: Retrospective analysis of case series from July 1, 1989, to July 31, 1996., Setting: University-based level I trauma center., Patients: Seventy-three consecutive trauma patients requiring celiotomy who received absorbable mesh prosthesis closure and 73 control patients matched for injury severity and trauma type who received celiotomy without a mesh prosthesis closure., Interventions: Absorbable mesh prosthesis closure was used in cases of excessive fascial tension, abdominal compartment syndrome, necrotizing fasciitis, traumatic defect, or planned reoperation., Main Outcome Measures: Demographics, Injury Severity Score, Abdominal Trauma Index, highest abdominal Abbreviated Injury Scale score, number of abdominal/pelvic injuries, highest head Abbreviated Injury Scale score, shock, indication for mesh closure, complications, number of operations and time required for closure, days in the intensive care unit, length of stay, and mortality were determined. The highest abdominal Abbreviated Injury Scale score was multiplied by the number of abdominal/pelvic injuries to calculate the abdominal pelvic trauma score., Results: Group 1 consisted of 47 patients who received mesh at initial celiotomy, and group 2, 26 patients who received mesh at a subsequent celiotomy. These 2 groups were statistically similar in demographics, injury severity, and mortality. However, group 2 had a significantly higher incidence of postoperative abdominal compartment syndrome (35% vs 0%), necrotizing fasciitis (39% vs 0%), intra-abdominal abscess/peritonitis (35% vs 4%), and enterocutaneous fistula (23% vs 11%) compared with group 1 (P < .001). Group 1 patients with preoperative abdominal compartment syndrome had more abdominal/ pelvic injuries and higher abdominal trauma index than matched controls (P < .05). There was a trend toward higher abdominal pelvic trauma score in patients who developed abdominal compartment syndrome. The Pearson coefficient of correlation between the abdominal trauma index and the more easily calculated abdominal pelvic trauma score was 0.91 (P < .001)., Conclusion: The use of absorbable mesh prosthesis closure in severely injured patients undergoing celiotomy was effective in treating and preventing the abdominal compartment syndrome.

Chest wall trauma and rib fractures are significant sources of morbidity and mortality in countries in which motor vehicle accidents are prevalent. Physicians who care for injured patients should realize that patients with thoracic trauma are at significant risk for mortality, deterioration, and associated injuries. Care must be taken to avoid underestimation of the effect of the injury on subsequent respiratory mechanics. Armed with an understanding of chest injury epidemiology, biomechanics, and pain control, physicians can better serve these high-risk patients.

Background: During the years 1987-1991, a statewide trauma system was implemented in Oregon (Ore) but not in Washington (Wash). Incidence of hospitalization, frequency of death and risk-adjusted odds of death for injured children (< 19 years) in the two adjacent states were compared for two time periods (1985-1987 and 1991-1993)., Methods: State populations of injured children (International Classification of Diseases, 9th Revision-Clinical Modification, code 800-959) were identified through a Hospital Discharge Index. Hospitals in counties with a population density < 50 persons/square mile were designated rural. Incidence rates are events/10,000 pediatric population per year., Results: The pediatric population increased in both states (Ore: 687,000-758,000; Wash: 1,159,000-1,336,000). Incidence of hospitalization for all injured children in entire states declined (Ore: 66.5-38.5; Wash: 54-33); also in rural hospitals (Ore: 67.5-32; Wash: 48 to 31). Seriously injured children (score on the Injury Severity Scale > 15) had a lower incidence in 1991-1993 of admission to rural hospitals (Ore: 2.98; Wash: 2.82) compared with incidence for entire states (Ore: 4.61; Wash: 4.62); in 1985-1987 the incidence was not different. Furthermore risk adjusted odds of death for seriously injured children was significantly lower in Oregon than in Washington in the later time period., Conclusion: Both states show a similar temporal trend toward a declining frequency of death for children hospitalized with injuries. Injury prevention strategies appear to have reduced the number of serious injuries in both states. However, seriously injured children demonstrated a reduced risk of death in Oregon, consistent with benefit from a statewide trauma system.

Injuries to major abdominal arteries and veins frequently are associated with exsanguinating hemorrhage and visceral ischemia. Expeditious management is the key to survival and good outcome. Knowledge of anatomic relationships between viscera and vessels forms the basis for directed dissection, optimal exposure, and lasting repair of vessels. Although penetrating mechanism of injury remains the most common cause of these injuries, trauma surgeons must be familiar with patterns of blunt trauma-mediated injury to avoid the devastating consequences of delayed management.

Objective: Evaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death., Design: Retrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture., Materials and Methods: Risk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning., Measurements and Main Results: After trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92)., Conclusions: The Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.

Objective: The goal of this study was to determine patient and injury characteristics that predict undertriage and overtriage., Design: This study was a retrospective analysis of admissions for acute injury., Materials and Methods: All admissions for acute injuries in a 2 1/2-year period were included (N = 26,025). ICD-9 clinical modification codes were converted to Injury Severity Scores., Main Results: Seventy-nine percent of severely injured patients were admitted to level I trauma centers. Severely injured patients admitted to other hospitals (undertriage) were more likely elderly (odds ratio = 5.44) and less likely had multisystem injuries (odds ratio = 0.55). One-fourth of patients with minor injuries were admitted to level I trauma centers (overtriage). Overtriaged patients were more likely intoxicated, obese, or had an injury to the head or face., Conclusions: In a developed trauma system, severely injured elderly trauma patients (especially females) are at risk for undertriage. The characteristics of patients at risk for overtriage reflect the difficulties of prospective out-of-hospital triage.