Annals of surgery
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Traumatic hemobilia is an uncommon complication of blunt or penetrating liver injury and is characterized by jaundice, biliary colic, gastrointestinal hemorrhage, and a recent history of abdominal trauma. The clinical diagnosis of hemobilia is confirmed by endoscopy and selective arteriography. Selective hepatic artery angiography will locate the site of bleeding, and determine the extent of liver injury. ⋯ The treatment of massive or persistent hemobilia is surgical drainage of hematoma and ligation of bleeding sites. Non-massive hemobilia may be treated conservatively with liver healing documented by serial selective arteriograms. The nonoperative treatment of a case of non-massive hemobilia with a good result is presented.
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Clinical Trial Controlled Clinical Trial
Environmental air and airborne infections.
The results of a study on the epidemiology of airborne (aerobic) surgical infections are presented. The first phase of the study was carried out in a surgical suite which contained no environmental or traffic control systems. The second phase of the study took place within a modern "up to date" operating room suite containing multiple air screens as well as an elaborate ventilation system utilizing HEPA type filters which provided the operating room with clinically sterile air. ⋯ The results of the study support the conclusion that the most common source of infecting organisms in surgical infections is thepatient or those around him. The most common time of contamination is during the surgical procedure itself. Surgical infections can best be minimized by meticulous observation of fundamental principles of antisepsis rather than by dependence on elaborate and costly ventilation and air control systems.
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Mortality and morbidity in fire victims is largely a function of injury due to heat and/or smoke. While degree and area of burn together constitute a reliable numerical measure of cutaneous injury due to heat, as yet no satisfactory measure of inhalation injury has been developed. In this study, with fluid resuscitation and pulmonary infection eliminated as variables, dose-response curves were constructed as a measure of inhalation injury by exposing burned and unburned animals to smoke of constant temperature and toxicity under conditions similar to the fire situation. ⋯ While fluid resuscitation and pulmonary contamination with bacterial pathogens may be eliminated experimentally, such is not the case with the vast majority of fire victims admitted to burn services with associated inhalation injury. Fluid resuscitation and inhalation of a Pseudomonas aeruginosa aerosol were therefore included serially in a study of animals with inhalation injury and burns large enough to require fluid resuscitation. In these animals it was demonstrated that: 1) pulmonary edema occurred in association with too little rather than too much fluid therapy; 2) after aerosol inoculation, fatal bacterial pneumonia was difficult to produce when inhalation injury was associated with no or only small burns, but common when associated with no or only small burns, but common when associated with a burn large enough to require fluid resuscitation.
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The serum from 109 traumatized patients was examined for immunosuppressive activity which might explain diminished host immune responsiveness following operative or accidental injury. Twenty-eight fo 31 (90%) severely tralmatized patients, 25 of 60 (42%) moderately traumatized patients, and 0 of 18 minimally traumatized patients developed serum which suppressed the response of normal human lymphocytes to phytohemagglutinin. The degree and duration of serum immunosuppressive activity paralleled the severity of the clinical course but did not correlate with serum cortisol or barbiturate levels. ⋯ The immunosuppressive factor(s) was contained in a low molecular weight (less than 10,000 daltons) peptide fraction and was present in 5--10 times the amount recoverable from normal serum. By size and activity the trauma serum factor resembled immunoregulatory alpha globulin, a naturally-occurring serum inhibitor of T-lymphocyte reactions. Thus, depressed immunoreactivity following trauma may be due in part to high concentrations of an endogenous immunosuppressive polypeptide.
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Historical Article
Renal transplantation: a twenty-five year experience.
Boston has played a significant role in the development of renal transplantation. In Boston was performed the first successful isograft between identical twins (1954) the first successful allograft between fraternal twins (1959) and the first successful allograft from a cadaveric donor (1962). An immunosuppressive drug was also described in Boston by hematologists Schwartz and Dameschek (1959) and modified for renal transplantation in dogs (1961) and used for the first time in a human recipient in March 1962. ⋯ One hundred and ninety-five of 295 (68%) with living-related donor transplants still have functioning allografts; 104/265 (39%) with cadaveric donor transplants have functioning grafts currently. Since 1968 transplants from living-related donors have an 80% one year survival whereas cadaveric donor transplants have approximately a 50% one year survival. Seventy-nine per cent of all one year survivors have had excellent psycho-social rehabilitation.