Annals of surgery
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Retroperitoneal space abscesses are unusual clinical problems encountered by general surgeons, internists, and surgical subspecialists. An insidious, occult illness marked by diagnostic delay, inadequate drainage, and considerable morbidity and mortality is common. Anatomic reviews detailing the complex extraperitoneal spaces have been published, but less attention has been focused on diagnostic and drainage techniques useful to the practicing surgeon. ⋯ A strikingly high mortality was associated with positive blood cultures and persistent fever within 48 hours of drainage (75% and 71%, respectively). Computed tomography has greatly enhanced the diagnosis of extraperitoneal abscesses, and radiologic drainage in selected cases appears to be a useful initial approach. A simplified anatomic classification and treatment plan is proposed to facilitate comparison between clinical series.
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Baboons that were subjected to systemic hypothermia at 32 C had an arm skin temperature of 27.3 C and bleeding time of 5.8 minutes. With local warming of the arm skin to 34 C, the bleeding time was 2.4 minutes. In normothermic baboons with arm skin temperature of 34.6 C, the bleeding time was 3.1 minutes. ⋯ There was a significant positive correlation between the thromboxane B2 level in the shed blood and the arm skin temperature. Both in-vivo and in-vitro studies have shown that the production of thromboxane B2 by platelets is temperature-dependent, and that a cooling of skin temperature produces a reversible platelet dysfunction. Data also suggest that when a hypothermic patient bleeds without surgical cause, skin and wound temperature should be restored to normal before the administration of blood products that are not only expensive but may also transmit disease.
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In order to assess the specific effects of inhalation injury and pneumonia on mortality in burn patients, the records of 1058 patients treated at a single institution over a five-year period, 1980-1984, were reviewed. Of these patients, 373 (35%) had inhalation injury diagnosed by bronchoscopy and/or ventilation perfusion lung scan. Of the 373 patients, 141 (38%) had subsequent pneumonia. ⋯ Inhalation injury alone increased mortality by a maximum of 20% and pneumonia by a maximum of 40%, with a maximum increase of approximately 60% when both were present. The influence on mortality was maximal in the midrange of expected mortality without these complications for any age group. These data indicate that inhalation injury and pneumonia have significant, independent, additive effects on burn mortality and that these effects vary with age and burn size in a predictable manner.
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A method of quantifying the anatomic extent of injury to the heart, Penetrating Cardiac Trauma Index, (PCTI) and other thoracic organs has been proposed. The total extent of thoracic injury, Penetrating Thoracic Trauma Index (PTTI), was measured. When associated abdominal injury was present, it was assessed by the Penetrating Abdominal Trauma Index (PATI) of Moore et al. ⋯ Analysis of 112 patients with penetrating cardiac injuries (1973-1983) revealed that the indices, PCTI and PI, showed an excellent correlation with survival (R2 = 0.827 and 0.928, respectively) as did the total extent of trauma (PTI). A composite prognostic score of the sum of PI and PTI demonstrated a significant separation of survivors from nonsurvivors (p less than 0.001). It is concluded that these anatomic (PCTI and PTI) and physiologic (PI) indices are valid and, with additional confirmation, may provide an objective method of evaluating penetrating cardiac injuries.
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Thirty-nine renal allograft recipients were prospectively studied to determine the quantitative effects of different immunosuppression protocols on T-cell subsets (total lymphocytes [T3], helper/inducer [T4] and suppressor/cytotoxic [T8]). Eighteen patients were initially immunosuppressed with only azathioprine and prednisone but required subsequent treatment for rejection by the addition of antithymocyte globulin (ATG) (Upjohn, Kalamazoo, MI) or conversion to cyclosporine. Three of these patients had ATG-resistant rejections and were treated with the monoclonal antibody ORTHO OKT3 (ORTHO Pharmaceuticals, Raritan, NJ). ⋯ This depression was independent of the plasma level of cyclosporine. Finally, the pan T-cell monoclonal antibody OKT3 led to severe depletion of all T-cell subsets but resulted in a normal T4/T8 ratio. In conclusion, immunosuppressive agents have a variable effect on T-lymphocytes and their subsets that cannot be adequately characterized by the T4/T8 ratio alone, but which should be quantitatively assessed by examining all subsets.