Arch Surg Chicago
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Review Case Reports
Cytomegalovirus appendicitis in a patient with human immunodeficiency virus infection. Case report and review of the literature.
We report a case of chronic abdominal pain with subsequent development of acute right lower quadrant tenderness in a patient infected with the human immunodeficiency virus. Ultrasonography and computed tomography revealed an enlarged appendix. ⋯ The course of cytomegalovirus appendicitis in these patients was prolonged and atypical compared with noncompromised patients with acute appendicitis. Because perforation may occur, surgery is advocated when this diagnosis is suspected in the patient infected with human immunodeficiency virus.
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After thermal injury, alterations in intestinal permeability have been demonstrated and have correlated with subsequent infections. We measured intestinal permeability on the second day after severe trauma and hemorrhagic shock (ruptured abdominal aneurysm). The mean (+/- SD) lactulose-mannitol (L/M) excretion ratio was 0.012 +/- 0.005 in seven healthy control subjects, 0.069 +/- 0.034 in 11 severely traumatized patients, and 0.098 +/- 0.093 in eight patients with aneurysm, indicating a significant increase of intestinal permeability in both patient groups. ⋯ In six patients endotoxemia was present immediately after admission and before the L/M test. However, during the L/M test and 1 day afterward no circulating endotoxin was observed. The present data provide evidence for the hypothesis that increased intestinal permeability and subsequent infectious complications are independent phenomena, frequently seen in patients after severe trauma or hemorrhagic shock.
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To identify all patients with serious intracranial injury, current treatment strategies include admission and/or computed tomographic evaluation of all patients with head injuries. However, the majority of patients with head injuries who are awake do not require subsequent intervention. A review of 407 consecutive patients with head injuries treated at an adult regional trauma center identified 310 patients with Glasgow Coma Scores of 15 in the emergency department, all of whom were admitted. ⋯ All five patients had skull fractures and/or neurologic deficits. Based on this and other studies, criteria for discharge from the emergency department are a Glasgow Coma Score of 15, no deficit except amnesia, no signs of intoxication, and no evidence of basilar fracture on clinical examination or linear fracture on screening skull roentgenography. Safe discharge without universal computed tomographic evaluation or admission is possible and cost-efficient.
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Multicenter Study
Blood transfusion increases the risk of infection after trauma.
To determine whether blood transfusion influences infection after trauma, we analyzed data on 5366 consecutive patients hospitalized for more than 2 days at eight hospitals over a 2-year period. The incidence of infection was significantly related to the mechanism of injury: penetrating injuries, 8.9%; blunt injuries, 12.9%; and low falls, 21.4%. ⋯ Blood transfusion in the injured patients is an important independent statistical predictor of infection. Its contribution cannot be attributed to age, sex, or the underlying mechanism of severity of injury.
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Early identification of sepsis can be difficult in severe burns because of the systemic changes that routinely accompany these burns. This review examined the value of a falling platelet count in predicting the development of sepsis. Thirty-two pediatric patients who sustained lethal burn injuries were compared with 32 patients with similar burns who survived. ⋯ A platelet count below 0.1 x 10(12)/L for more than 4 days was uniformly associated with death. All patients who died succumbed to multisystem organ failure, consistent with sepsis. These results emphasize platelet count as an independent predictor of sepsis and death.