Annals of surgery
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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.
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Randomized Controlled Trial Clinical Trial
Steroids in the treatment of clinical septic shock.
A prospective (Part I) and a retrospective (Part II) study were used to determine the safety and efficacy of corticosteroids in the treatment of septic shock. In Part I, 172 consecutive patients in septic shock admitted over an 8-year period were treated with either steroid or saline: 43 received dexamethasone (DMP), 43 received methylprednisolone (MPS), and 86 received saline. The study was double-blind and randomized, and the three groups were compared for age, severity of shock, presence of underlying disease, and year of study. ⋯ Again, the two groups of patients were compared for severity of shock, underlying disease, age, and year of study. Mortality among patients treated without steroid was 42.5% (68/160) and among patients treated with steroid was 14% (24/168); there was no significant difference in mortality rate between DMP- and MPS-treated patients. In Parts I and II combined, complications occurred in 6% of steroid-treated patients with no significant difference between DMP- and MPS-treated groups.
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A patient with multiple pyogenic abscesses in both lobes of the liver secondary to asymptomatic sigmoid diverticulitis is presented. The rarity of this illness is noted. It is suggested that barium enema be performed in patients who present with pyogenic liver abscess of unknown etiology because of the association with asymptomatic sigmoid diverticulitis.