Four forearm flexor muscles of the horse, Equus caballus: anatomy and histochemistry.

Two of the forearm flexors of the horse, the superficial and deep digital flexor muscles, are critical to support the digital and fetlock joints, exhibit differing insertions, and are passively supported by the proximal and distal check ligaments, respectively. These two muscles differ in histochemical composition and architecture. The differences are correlated with the different stress levels transmitted through their tendons, and the different frequencies of clinical breakdown that have been reported. Both muscles contain type I and type IIa fibers. A few type IIb fibers occurred in the deep digital flexor. The superficial digital flexor contained approximately 56% type I fibers, extremely short muscle fibers, and extensive connective tissue investment. In contrast, the deep digital flexor had three muscle heads: ulnar, radial, and "long" and "short" regions of the humeral head. The "long" and "short" regions of the humeral head contained 33% and 44% type I fibers, respectively, fiber lengths three to four times as long as those in the superficial digital flexor, and relatively less connective tissue investment. Flexor carpi radialis and flexor carpi ulnaris compared most closely with the humeral head of the deep digital flexor. These data suggest a correlation of the unique architecture of superficial digital flexor with its proposed elastic storage properties during locomotion in horses, and an explanation for the frequent breakdown of the superficial digital flexor in athletic horses.


Spermiophagy by the spermathecal epithelium of the salamander Eurycea cirrigera.

The spermathecae of Eurycea cirrigera are exocrine glands in the cloaca that secrete a substance that bathes sperm stored in the lumen after mating and prior to oviposition. Many sperm remain in the spermathecae after oviposition, and the spermathecal epithelium becomes spermiophagic. Pseudopodia enclose sperm into endocytic vacuoles. The vacuoles become associated with primary lysosomes in the cytoplasm. Following formation of secondary lysosomes and resulting condensation of the sperm fragments, residual bodies are exocytized into the surrounding connective tissue stroma. By the start of the next breeding cycle, most sperm remaining from the previous mating have been degraded, but some sperm remain in the lumen, and the viability of these sperm is unknown.


Basement membrane lectin binding sites are decreased in the esophageal endoderm during the arrival of presumptive muscle mesenchyme in the developing asteroid Pisaster ochraceus.

Basement membranes (BMs) of vertebrates and invertebrates have been shown to contain glycoproteins and proteoglycans, which include oligosaccharides and glycosaminoglycans. Lectin binding sites were characterized in the BM of gastrulating embryos of the starfish, Pisaster ochraceus. In early and mid-gastrulae, the fluorescein isothiocyanate (FITC)-lectin conjugates of concanavalin A (Con A) and wheat germ agglutinin (WGA) reveal the presence of mannose/glucose and glucosamine/sialic acid residues in the BM of all regions of the embryos. However, in the late gastrula embryo, an apparent reduction of these components is observed over the esophageal BM. Ultrastructural studies using the lectin-gold conjugates Con A, Limax flavus agglutinin (LFA), specific for sialic acid, and Dolichos biflorus agglutinin (DBA), specific for galactosamine, demonstrate that most mannose/glucose and galactosamine-containing residues lie in the lamina densa, whereas most sialic acid residues are located over the lamina lucida. In addition, a statistical analysis of lectin binding in the late gastrula embryo reveals that the amount of labelling with both Con A and LFA is significantly reduced in the esophageal region, suggesting that mannose/glucose and sialic acid residues are reduced in this region. These results confirm the observations of the FITC-lectin studies described above. They also confirm earlier studies that demonstrated a difference in BM morphology of the esophageal region (Crawford, '88). Mesenchyme cells, some of which arise from the forming coeloms (Crawford, '90), and which may represent a distinct population, colonize exclusively on this esophageal BM, where they later differentiate into muscle. Quantitative differences in BM glycoconjugates may act to direct the presumptive muscle cells to the region of the esophagus.


Comparative anatomy and phylogeny of the cloacae of salamanders (Amphibia: Caudata). VI. Ambystomatidae and Dicamptodontidae.

Histology of the cloacae of Rhyacotriton olympicus and representative species from the genera Ambystoma and Dicamptodon was examined by light microscopy. Females of Ambystoma possess sperm storage glands, the spermathecae, as well as ventral glands and dorsal glands, both of uncertain function. Females of Ambystoma examined from the subgenus Linguaelapsus differ from those in the subgenus Ambystoma by possessing more extensive ventral gland clusters and a shorter cloacal tube. Females of Dicamptodon possess spermathecae and ventral glands, but differ in cloacal conformation from females of Ambystoma and lack the dorsal glands. Females of R. olympicus possess more extensive epidermal lining in the cloaca than that found in females of Ambystoma and Dicamptodon, and the only glands present are spermathecae, which cluster around a tube in the dorsal roof. Males of Ambystoma, Dicamptodon, and R. olympicus possess five types of cloacal glands (dorsal pelvic glands, lateral pelvic glands, anterior ventral glands, posterior ventral glands, and Kingsbury's glands) that function in spermatophore formation, and vent glands that may produce a courtship pheromone. In Ambystoma and Dicamptodon, vent glands secrete along the medial borders of the cloacal orifice. Males of A. opacum and A. talpoideum differ from males of other species examined from the two genera by possessing more extensive vent glands. Males of R. olympicus possess unique vent glands in which tubules secrete onto the surface of vent lobes lateral to the posterior end of the cloacal orifice, and distal ends of the glands pass anteriorly, superficial to the fascia enclosing the other cloacal glands. The results from analysis of cloacal anatomy support other data indicating that Ambystoma and Dicamptodon are sister groups, and that Rhyacotriton olympicus is not closely related to either of the other two genera and merits placement in a separate family.


Healthchoice: a managed health-care program for low-income uninsured workers.

The period in which we practice medicine is unprecedented in terms of the enormous changes that are taking place within the profession. Perhaps foremost among the changes is the manner in which the practice of medicine is organized. Historically, over the last 30 years we have witnessed the transition of substantial proportions of physicians as solo practitioners to professionals employed in one form or another by institutional management care systems. Further, from all indications, this change is continuing unabatedly. There are now more than 600 health maintenance organizations (HMOs), and their enrollment rates have been steadily increasing. More than 60 million Americans or about 30% of the insured population receive their medical care through HMOs and preferred provider organizations (PPOs). Moreover, it is estimated that in the year 2000, 90% of all Americans will be receiving their medical care from managed care systems. Clearly, the driving force behind these changes is the desire of third-party payers and the public at large to control health-care costs. We, of course, share this goal and are committed to working with the public and private sectors to accomplish this aim. Deborah L. Scott, director of the Wayne County Patient Care Management Systems, writes about HealthChoice, a model managed-care program in Detroit, Michigan. Ms Scott's article is being published in lieu of the President's Column.


The changing perspectives of trauma care. The Sinkler Memorial Lecture.

Trauma and the management of injuries have changed considerably over the past century. A sound understanding of the factors that generate injuries and sophisticated systems that can be accessed immediately are now in place in most of the United States. The concept of a team approach to the management of multiple system injuries using specialists from all disciplines has resulted in the reduction of morbidity and mortality. Although many of the challenges of managing the trauma patient have been overcome, there are still a number of exciting areas that lend themselves to ongoing research. These changing perspectives allow for many exciting challenges for the trauma team.


Radiographic evidence of calcification in pulmonary hamartomas.

Eight cases of solitary intrapulmonary hamartomas are presented to show the unusually high frequency of calcification (75%, six of eight cases) in this series. Possible contributory factors were high percentage of chondromatous variant (seven of eight cases), large size of the tumors, and use of computed tomography.


Carcinoma of the male breast in Tanzania.

This is a retrospective study of male mammary carcinoma in Tanzania based on biopsy material received from 1974 to 1987 at the Tanzania Cancer Registry. In a series of 1104 cases of breast cancer, 76 or 6.5% were male. This compares with approximately 1% in Western literature, and a similar or higher percentage in some other African countries. In Africa, medical facilities are limited, and appropriate surgical treatment, radiotherapy, and chemotherapy are difficult to procure. By the time cases reach the main hospitals, the cancer is often in a very advanced stage. Thus, there is a need to ensure early referral of cases. Further, for disseminated carcinoma, the more frequent use of orchidectomy should be considered. Orchidectomy is a simple and potentially effective procedure that can be undertaken at any hospital.


Sunlight and age-related eye disease.

Within 50 years, if current trends continue, 50 million elderly Americans will suffer visual impairment from macular degeneration or cataract. However, available evidence indicates that this impending crisis of visual health can be minimized by a simple, safe, inexpensive, and practical means of prevention. Cataract and macular degeneration are the ultimate consequences of normal aging, a lifelong process of deterioration. Three major causes of ocular deterioration have been identified: oxygen, heat, and solar radiation. Among these, the radiation hazard is readily accessible to human intervention. The lens is damaged by ultraviolet radiation in sunlight, whereas the retina can be harmed by high-energy visible radiation (the "violet and blue"). Use of sunglasses that block all ultraviolet radiation and severely attenuate high-energy visible radiation will slow the pace of ocular deterioration and delay the onset of age-related disease, thereby reducing its prevalence. A 20-year delay would practically eliminate these diseases as significant causes of visual impairment in the United States.


Black males who always use condoms: their attitudes, knowledge about AIDS, and sexual behavior.

One hundred six black males completed a questionnaire concerning attitudes and knowledge about the use of condoms and acquired immunodeficiency syndrome (AIDS). Of the 106 males in the study, 27 (26%) reported that they "always" used condoms, 31 (29%) did not use condoms and had low intentions of using them, and 48 (45%) reported high intentions to use condoms. Results indicated that knowledge about AIDS was exceptionally high for black males in all three groups. Black males with low intentions to use condoms reported significantly more negative attitudes about the use of condoms (eg, using condoms is disgusting) and reacted with more intense anger when their partners asked about previous sexual contacts, when a partner refused sex without a condom, or when they perceived condoms as interfering with foreplay and sexual pleasure. A significantly larger percentage of low intenders were treated for gonorrhea, syphilis, herpes, and genital warts than males in the other groups. Drug use did not differentiate the three groups, although marijuana was used more often by males in the low-intender group. Finally, a larger percentage of black males in the low-intender group reported experiences with anal intercourse and sex with a prostitute, but considered themselves at lower risk for AIDS than did their high-intender or steady-user counterparts.


Improving access to a primary care medical clinic.

Patients presenting to an episodic care walk-in clinic often warrant prompt but not necessarily emergency attention. Legitimate reasons often prohibit these patients from attending regularly scheduled daytime weekday clinics. Most patients interviewed thought that having a single primary care provider was important to ensure continuity of care. Access to primary care can be improved by scheduling clinics and ancillary services on nontraditional times and days. Enhanced communication can help patients differentiate routine from urgent from emergency conditions. Printed and audiovisual materials can be used to increase awareness of the benefits of comprehensive care.


Massive upper gastrointestinal bleeding in a patient with a duodenal diverticulum: a case report and review of the literature.

Diverticula of the duodenum occur in approximately 2% to 5% of individuals who have had upper gastrointestinal (GI) series; the majority of these patients are asymptomatic. These diverticula occasionally result in the obstruction of the biliary and pancreatic ducts, which leads to jaundice and pancreatitis. Other complications such as hemorrhage, perforation, sepsis, and death can occur. This article reports a case of upper GI bleeding in a patient who was found to have duodenal diverticula by upper GI series and endoscopy. Diverticulectomy was performed, and microscopic examination of the specimen showed dilated blood vessel suggestive of angiodysplasia.


Uterine leiomyosarcoma with intracerebral metastasis: a case report.

A case of a 36-year-old woman with a past history of uterine leiomyosarcoma and an intracerebral metastasis is reported. The patient presented with a 24-hour history of severe headache with coma, and the CT findings were consistent with a metastatic lesion. Pathological examination of the operative specimen showed features of a leiomyosarcoma. Uterine leiomyosarcoma is an uncommon tumor and metastasis to the brain is rare.


The prognostic significance of race and survival from laryngeal carcinoma.

Surveillance, Epidemiology, and End Results (SEER) program data suggest that blacks with laryngeal carcinoma have a significantly lower 5-year survival rate than whites. Most of this difference persists despite adjustment for "crude stage." To evaluate possible factors contributing to this residual survival deficit, 190 white and 23 black patients treated at the Martinez Veterans Administration Hospital between 1968 and 1988 were studied. The independent impact of race on survival rate was analyzed with respect to various prognostic factors including treatment delay, elapsed time (diagnosis to treatment), age, stage, cancer subsites, and type of therapy. No independent prognostic significance could be attributed to race. The differences noted in SEER data probably reflect a tendency for the use of crude stage to underestimate the impact of prognostic groups within the categories of "local" and "regional" disease, the independent prognostic significance of subsites (glottic versus supraglottic), and the variable distribution of these subsites in different populations. This study suggests that when stage, subsite, and quality of care are adequately considered, survival from laryngeal cancer in blacks is comparable to that of whites.


Review of prostatic surgical procedures at a predominantly black hospital: a 22-year study.

This article reports the results of a pathoepidemiological study of a cohort of black men who had prostatic surgery at Howard University Hospital between 1968 and 1989. The median age of patients at diagnosis of prostate cancer increased by 8 years during the study period, indicating either a delay in seeking medical care or a true delay in onset of the disease. The trends of prevalence of biopsies with cancer in various age groups suggested a sharp rise in the incidence of prostate cancer after the age of 70. The significant increase in popularity of needle biopsy during the period 1982 to 1989 after a 7-year plateau is an indication of increased perceived value of this procedure with experience and technical improvement. The prevalence of biopsies with cancer in all successive time periods of the study showed a bimodal distribution with an early hump in the 50- to 54-year-old age group. This hump is analogous to the break in the rising incidence of breast cancer between the ages of 47 and 52 (Clemmesen hook). This similarity could be explained on the basis of hormonal dependence of the two cancers.


The public's attitude toward physicians and the care of AIDS patients in the state of Maryland.

A telephone survey of 1477 households in Maryland examined the public's attitudes toward physicians and the treatment of AIDS patients. The results indicated that most respondents (86%) want to know their physician's human immunodeficiency virus (HIV) status and that 65% would change physicians if that physician had acquired immunodeficiency syndrome (AIDS). Approximately 50% did not know if their doctor treated AIDS patients, but the majority (68%) responded they would not change doctors because they treated AIDS patients. Significant differences were found in respondents' opinions related to age and education. It was also found that the majority of respondents (57%) received their information about AIDS from the mass media and that very few received their information from medical or other health sources.


The effects of acute test anxiety on NBME Part I performance.

This study examined the associated effects of acute test-taking anxiety on the performance of a class of second-year medical students who took Part I of the National Board of Medical Examiners (NBME) Examination. The study is a follow-up of a previous study that examined the related effects of chronic anxiety on NBME Part I performance. The purpose of this study was to observe whether there was a relationship between acute anxiety and NBME performance and, further, if there were distinguishable differences in the effects of acute and chronic test anxiety on NBME performance. The first study indicated a significant relationship between chronic anxiety and NBME performance. The results of the present study indicate a relationship between acute test anxiety and NBME performance, but not to the extent associated with chronic anxiety, thus chronic test anxiety may be a more critical factor affecting test performance on critical examinations such as the NBME. Implications concerning anxiety and test performance are discussed.


Cholecystectomy in patients with sickle cell disease: experience at a regional hospital in southeast Georgia.

The treatment of patients with sickle cell disease and cholelithiasis is controversial. This retrospective study assesses the outcome of preoperative transfusion and timely cholecystectomy in symptomatic sickle cell disease patients. Fourteen patients who had undergone cholecystectomy were determined to have sickle cell disease. The patients' mean age was 17.9 years. Eleven patients were female. Thirteen patients had complained of abdominal pain. Ultrasound confirmed the diagnosis of cholelithiasis in 12 of 13 patients tested. Hemoglobin before treatment averaged 7.7 g/dL. Transfusion or exchange transfusion was given to 12 patients, raising the average hemoglobin to 10.3 g/dL. Postoperative morbidity was 14%: one patient had a urinary tract infection and another a left-lower-lobe pneumonia. No sickle cell crises or deaths occurred. Postoperative hospital stay averaged 4.4 days. With judicious use of preoperative transfusion, early cholecystectomy for symptomatic gallstones was well tolerated by sickle cell disease patients and is advisable to avoid the morbid sequelae of acute cholecystitis and peroperative sickle cell crisis.


Interaction of nutrition and infection: effect of copper deficiency on resistance to Trypanosoma lewisi.

The copper-deficient rat-trypanosome system was used to study copper deficiency in Sprague Dawley rats infected with Trypanosoma lewisi. Throughout the observational period, animals on the deficient diet had lower plasma and liver copper concentrations compared with complete and pair-fed animals. In all dietary groups, the food intake and body weight changes of rats inoculated with T lewisi showed significant increases over the noninoculated controls. The rate of these indices were significantly less in the copper-deficient animals compared with the animals fed complete diets. Copper-deficient and pair-fed control rats showed greater numbers of parasites than controls throughout the infection. The duration of the trypanosomal infection was longer in copper-deficient rats compared with other groups. In all of the dietary groups, severe depression in the primary and secondary antibody responses (IgM and IgG) to in vivo immunization with sheep erythrocytes was observed in infected animals over noninfected controls. The results of the present study indicate that during copper deficiency, there are significant changes in food consumption and body weight and enhanced susceptibility to infection as measured by an increased parasitemia and depression in the antibody responses.


Hyperparathyroidism in black patients: an update.

Cervical exploration with removal of the pathologic gland or glands is effective treatment for parathyroid adenomas and hyperplasia. This article reports the results of a retrospective study of 41 patients who underwent elective cervical exploration for primary hyperparathyroidism at Howard University Hospital between 1974 and 1989. Preoperative localization studies for primary neck exploration consisted of an ultrasound of the neck. Removing the diseased gland/glands resulted in the resolution of the patients' symptoms and the return of calcium levels to normal. Complications included transient hypocalcemia, a wound hematoma, and a postoperative death.


A chronicle of racism: the effects of the white medical community on black health.

At no time in history has the health of black Americans equaled that of white Americans. This distinction is particularly evident in the South, where blacks have been subjected to governmental policies promoting discrimination and segregation. The explanations offered for this difference in health status are numerous. The argument presented in this article is that the health status of blacks in the United States has been greatly affected by the attitudes and perceptions of white physicians. From the days of slavery to 1992, the policies and practices of the white medical community have had an enormous impact on the health of blacks. Black physicians have played a large role in changing the delivery of health-care services to the black population. Their fight was a microcosm of the Civil Rights activities taking place in the world around them. This article describes the history of medical care as it relates to black patients and physicians. The progress that has been made over the past century is analyzed, and the need for continued education and persistence is emphasized. Legalized segregation may have been outlawed in the 1960s, but the nation's vital statistics indicate that equality has yet to be achieved.


Retrograde extrapolation of blood alcohol data: an applied approach.

Retrograde extrapolation is a mathematical process, based on sound scientific principles, that is used routinely in pharmacology, toxicology, and clinical medicine. This process may be applied to the situation of ethyl alcohol consumption with reliability when reasonable assumptions are made concerning absorption rates, elimination rates, and patterns of alcohol consumption, including drinking duration and volume consumed. By utilizing an established range of values for the elimination rate of alcohol of 0.015-0.020 g/dl/h, a relatively narrow range of extrapolated blood alcohol concentrations (BACs) can be determined in situations where the time frame in question is after peak alcohol absorption into the blood. A wider range of elimination rates of 0.01-0.03 g/dl/h may be applied and will satisfy the possibility of nonlinear kinetics within an individual; however, this wider range will have little practical effect on the predicted BACs. When the time point in question is prior to peak absorption, a wider range of predicted BAC values will result. The extent of this range will be influenced by the amount of information available concerning the temporal pattern of alcohol consumption. Reported drinking volumes are notoriously inaccurate and, in fact, are of little practical use. Given the parameters of body weight and time duration between initiation of drinking and determination of the BAC, the number of "drinks" consumed may be reliability calculated. Retrograde extrapolation is applicable in the forensic setting with scientific reliability when reasonable and justifiable assumptions are utilized.


Calorimetry: a new quantitative in vitro method in cell toxicology. A dose/effect study of alveolar macrophages exposed to particles.

A short-term toxicological test has been developed using a calorimetric method. The metabolic activity, observed as the heat exchange rate, was monitored from alveolar rabbit macrophages in monolayers exposed to different metal and non-metal particles. Calorimetric activity indices and viability indices were introduced, from which toxic effects could be assessed. Manganese dioxide particles were found to be cytotoxic. In contrast, titanium dioxide particles seemed to be harmless. The results were in accordance with the cell survival found by use of a fluorescein ester staining method and measured by an image analyzer. Toxic effects from quartz in the form of increased metabolic activity of exposed cells could be detected by the calorimeter in contradiction to the use of the image analyzer. This latter result supports the hypothesis that silica particles cause chronic modification of the macrophage function and that this change in the alveolar macrophage function may be the first of a series of processes leading to pulmonary fibrosis.


Steroid synthesis in ovarian homogenates from hypophysectomized adult female mice treated with diethylstilbestrol in neonatal life.

Eight-week-old female NMRI-mice treated with 5 micrograms diethylstilbestrol (DES) or vehicle (olive oil) from d 1 to 5 after birth were hypophysectomized or sham operated. Thirty days after the operation, homogenates were prepared from the ovaries and incubated at 37 degrees C in the presence of [3H]pregnenolone for 1 h. In parallel experiments ovaries were taken for histology. In control ovaries regressing corpora lutea were still present 4 wk after hypophysectomy (Hx). Ovaries from DES females had no corpora lutea, but showed degeneration of the pre-Hx hypertrophic interstitial tissue. Steroids synthesized during the incubation were extracted and separated in a two-dimensional thin-layer chromatography system. After Hx, the amount of extractable [3H]testosterone, [3H]progesterone, and [3H]androstenedione recovered from homogenates of vehicle-treated females increased, but the amount of recovered [3H]-17 alpha-hydroxyprogesterone was not significantly altered. In contrast, in DES-treated females Hx significantly decreased levels of [3H]androstenedione and [3H]-17 alpha-hydroxyprogesterone, but did not affect [3H]progesterone or [3H]testosterone. The persistent difference in steroid synthetic activity after Hx could be linked to the difference in morphology between different ovarian tissue compartments of control and DES-treated females.


Exposure assessment for heavy metal ingestion from a sport fish in Puerto Rico: estimating risk for local fishermen.

Sport or subsistence fishermen sometimes underestimate the risks from eating local fish and distrust authorities regarding potential hazards from fish. We report on lead, cadmium, selenium, and mercury levels in snook, locally called robalo (Centropomus spp.), consumed by local fishermen in Puerto Rico, who ate up to 23 fish/wk. Median levels (in ppb, dry weight) for muscle, adipose, and liver ranged from 683 to 780 for lead, 37 to 600 for cadmium, 50 to 146 for mercury, and 361 to 3986 for selenium. Lead levels were similar in all tissues, and selenium and cadmium levels were highest in the liver. Mercury was higher in muscle than in liver. Computing exposure via ingestion for the average fisherman indicated that if one were to consume robalo throughout the year one would be exposed in excess of the EPA Reference Dose (RfD) for mercury. Using a widely accepted maximum consumption of 200 g/d for fishermen yielded hazard indices (daily consumption/RfD) below 1 for all four metals, with a value approaching 1 for mercury in adults, and over 1 for 16-kg children. The possibility that in certain localities and cultures sport or subsistence fishermen may consume fish at levels substantially above 200 g/d should be investigated in performing risk assessments, particularly outside the continental United States.


Dermal penetration of 14C-labeled diisopropyl methylphosphonate in swine.

Diisopropyl methylphosphonate (DIMP) has been identified as a groundwater contaminant on or near sites of former chemical warfare production facilities. The material is a by-product of GB (or Sarin) manufacture and does not occur naturally in the environment. The present study measured the dermal absorption of 14C-labeled DIMP in swine to establish the basis for estimating health risk from this portal of entry. Yorkshire cross swine were treated by sc injection of labeled DIMP to measure the efficiency of bioelimination. Additional pigs each received a single percutaneous (pc) exposure of 400, 40, or 4 micrograms/cm2 of labeled DIMP. Absorption through 7 d was measured by the appearance of 14C label in the urine and feces. Tissue specimens, collected at necropsy, were assessed for residual radioactivity. The results showed that between 3 and 7% of cutaneous DIMP was absorbed through 7 d. Urinary elimination accounted for about 95% of the absorbed dose in the first 24 h. No significant tissue deposition was observed. Pigs treated by the sc route excreted nearly 100% of the injected material demonstrating an extremely efficient metabolic process. It was concluded that humans may be expected to absorb less than 10% of an unoccluded single dermal exposure to DIMP. Absorbed dose would likely be metabolized to isopropyl methylphosphonic acid and excreted primarily in the urine within 24 h. Significant evaporation of the material from the open skin surface would be expected to occur.


Fetal detriment used as an index of effects of diethylene glycol on Syrian hamster fetuses.

The effect of diethylene glycol (digol, diEG; specific gravity = 1.12) on the embryo was studied in the pregnant Syrian hamster at dosages from 2 1/4 to 4 ml/kg (2.52-4.48 g/kg). The hamsters were dosed by (single) intraperitoneal injection because previous experiments had indicated that oral dosing in the drinking water (and therefore possibly gavage dosing also) causes the hamsters to drink less. The digol was diluted with distilled water and injected on d 8 of pregnancy. Distilled water was used for the controls. At all dosages, fetuses from treated animals examined at autopsy on d 15 were found to be lighter than those from control animals. Abnormalities were seen at all dosages, mainly neural-tube defects (exencephaly, cranial bleb, and myelomeningocele). No neural-tube defects were observed in control animals. A dosage-related deficit in the number of live, externally nonmalformed fetuses was observed and was matched by a dosage-related increase in the number of live externally abnormal fetuses. Few dead full-term fetuses were found, but there was a dosage-related increase in the "late" resorption rate. A new summarizing measure, the fetal detriment (FD), the deficit from control expectations of live, nonmalformed litter mass per live litter, was found to be proportional to the square of the dose-rate D, the regression through the origin in this study being FD = (0.934 +/- 0.329)D2. The 50% attrition dosage, the AD50, was 2.90 ml/kg (3.25 g/kg) in the hamster, with 95% confidence interval 2.21-5.41 ml/kg (2.48-6.06 g/kg). Diethylene glycol in high dosage produces damage to the fetuses of pregnant Syrian hamsters. It is not known whether this is an indirect result of the maternal toxicity, which was observed even at the lowest dosage used, or is the effect of digol or of its metabolites on the conceptus.


Acute and "long-term" genotoxic effects of CdCl2 on testes of mice.

The effects of Cd administered ip in a single carcinogenic dose (1 mg Cd/kg body weight) into male CFLP mice were investigated on the histological and cytogenetic status of the testes of the animals on d 3 and 6 mo after the Cd injection. There were some characteristic histological changes in the testes of the mice on d 3 after Cd treatment: the presence of interstitial hemorrhages, the death of Leydig cells, sterile necroses of tubular elements, and numerous atypical mitoses of the spermatocytes. A significant increase compared with the control was found only in the number of numerical chromosome aberrations in the Cd-treated group. Six months later, a significant difference compared with the control was found only in the relative weight of the testes in the treated group. There were soon no detectable effects of Cd on the histological picture of the testes and on the spermatocytes.


Toxicity and toxicokinetics of carbaryl in chickens and rats: a comparative study.

Carbaryl, a carbamate insecticide, exerts its toxic effect in animals by inhibiting the activity of neural acetylcholinesterase. Differences in sensitivity of this enzyme to inhibition were studied after intraperitoneal administration to chickens and rats. A dose of 900 mg/kg to chickens and 70 mg/kg to rats caused equivalent inhibition of brain cholinesterase activities (57% +/- 6 and 47% +/- 4, respectively) 60 min after administration, which was the time of maximal cholinergic signs. Signs of toxicity (salivation, respiratory distress, muscle tremors and weakness) were more pronounced in rats than in chickens when brain acetylcholinesterase was inhibited to the same extent in both species. Carboxylesterase activities in brain, liver, and plasma were also inhibited 60 min after administration of carbaryl to chickens and rats. Activities of enzymes associated with hepatic microsomes were unaffected. Specific activities of brain esterases, including acetylcholinesterase, carboxylesterase and neurotoxic esterase, were higher in untreated chickens than in untreated rats. Specific activities of liver esterases (carboxylesterase, A-esterase) were, however, 4- and 10-fold lower in untreated chickens than in untreated rats. Total clearance of carbaryl in the chicken, determined after intravenous administration of 5 mg/kg, was 0.26 +/- 0.02 l/kg/min. This value is 5.7 times higher than that reported for the rat, indicating that the relatively lower activities of esterases in the liver of chickens did not affect the clearance of this chemical in the avian species.


Thrombocytopenia and leukocytosis induced by single intravenous injections of cadmium-saturated metallothioneins-I and -II in rats.

To comparably investigate hemotoxic potentials of CdCl2, cadmium-saturated metallothioneins-I (Cd-MT-I) and -II (Cd-MT-II), rats received single intravenous injections of one of those dissolved in saline with equivalent concentrations of Cd (0, 0.1, 0.3 and 1.0 mg Cd/kg body weight), and blood for hematological examinations was sampled at 1 and 5 days (Days 1 and 5) after the administrations. The counts of white blood cells showed dose-dependent increments in the 0.3 and 1.0 mg Cd/kg groups in Cd-MT-I and Cd-MT-II at Day 1, and returned to the normal levels at Day 5. The counts of platelets showed dose-dependent decrements in the three-doses groups of Cd-MT-I and Cd-MT-II at Day 1, and did a returning- and further increasing tendency at Day 5. The counts of red blood cells, values of hematocrit, hemoglobin, mean corpuscular volume, mean corpuscular hemoglobin and mean corpuscular hemoglobin concentration, showed only slight and sporadic changes at Days 1 and 5. As to that thrombocytopenia and leukocytosis were dose-dependently brought by Cd-MTs and not by CdCl2, and as to that CdCl2 and Cd-MTs hardly affected erythrocytes regarding their counts, sizes, hemoglobin contents etc., etiological mechanism (s) remains to be explored. However, our findings should be clinically emphasized in relation to Itai-Itai disease and Cd-intoxication.


Disturbance or relatively important actions of antihypertensives, antifungal agent and opiate antagonist to the testicular steroidogenesis in rat.

Some of antihypertensives, opiate antagonist and antifungal agent can interfere with sexual function in both men and women. Drug-related effects on sexual function may be difficult to distinguish from the direct action of gonadal function. Clinically well known those agents to have sexual dysfunction were selected and examined the direct effect on rat's testicular steroidogenesis in vitro. Donryu rats were decapitated at 11 weeks old and isolated testes were decapsulated and preincubated with Krebs-Ringer-phosphate buffer (KRP) added with 1 micrograms/flask of LH for 60 min at 37 degrees C. Then, incubation was made with prazosin (1 micrograms), clonidine (5 micrograms), verapamil (10 micrograms), naloxone (5 micrograms) and ketoconazole (150 micrograms), 37 degrees C for 180 min in fresh KRP-buffer, respectively. Steroids were analysed with RIA, and microfluorometry after purification with quantitative thin layer chromatography. Prazosin had a tendency to produce dihydrotestosterone (DHT) indicating a facilitation of 5 alpha-reductase, and clonidine showed a significant production of estradiol (E2) with a slight production of DHT indicating a significant facilitation of aromatase. Verapamil had a action to produce significantly E2 with a slight production of DHT, and naloxone showed a significant production of both DHT and E2. Thus, these two agents showed facilitation of both 5 alpha-reductase and aromatase. Ketoconazole had a significant production of both delta 4-androstenedione (delta 4-A) and E2 while it had a significant inhibition of DHT-production, thus this had a significant production of both aromatase and C17,20-lyase while had a significant inhibitory action of 5 alpha-reductase. These findings indicates that comparatively large doses of central-nervous system depressants are one of the factors that interfere with sexual function, but it is not necessary to have direct action to testicular function, however present study revealed that some of them can cause gonadal damage and consequently progressive loss of libido.


Chronic toxicity of microencapsulated bromodichloromethane administered in the diet to Wistar rats.

A chronic feeding study was carried out in Wistar rats using microencapsulated bromodichloromethane. The test substance was administered in the diet at doses of 0, 0.014, 0.055 and 0.22% for 24 months. Rats were sacrificed after 6, 12, 18 and 24 months of continuous dosing. The results showed a suppression of body weight gain in the 0.22% group for both males and females. Dose related changes were clearly observed in the liver with histopathological findings including fatty degeneration in the 0.014% or higher dose male groups, and fatty degeneration and granuloma in the 0.055 and 0.22% group females, as well as bile duct proliferation and cholangiofibrosis in the 0.22% group for both males and females. No significant differences in incidences or numbers of neoplastic changes were seen between control and any of the treatment groups. There were no dose-related non-neoplastic lesions in the kidneys of either sex. Lowest-observed-adverse-effect-level was determined to be 6.1 mg/kg/day under the present experimental conditions.


Behavioral evaluation of psycho-pharmacological and psychotoxic actions of methylxanthines by ambulatory activity and discrete avoidance in mice.

The behavioral effects of methylxanthines, caffeine, theophylline and theobromine, were compared by means of ambulatory activity and discrete lever-press avoidance response in mice. The single oral administration of 10-100 mg/kg of caffeine, 30-300 mg/kg of theophylline, and 10 mg/kg of theobromine significantly increased the mouse's ambulatory activity. However, 1000 mg/kg of theobromine decreased the activity. The ambulation-increasing effect of methamphetamine (2 mg/kg s.c.) was enhanced by coadministration with caffeine (3-100 mg/kg), theophylline (10-300 mg/kg), and theobromine (10-100 mg/kg). On the other hand, comparatively higher doses of caffeine (up to 30 mg/kg) slightly but significantly decreased the avoidance rate without eliciting any significant change in the response rate. Theobromine significantly decreased the response rate at higher than 300 mg/kg, and the avoidance rate at higher than 100 mg/kg. Furthermore, 1000 mg/kg of theobromine was much toxic for mice, i.e., half mice died within a few hr after the end of the 1-hr avoidance session. Theophylline did not produce any significant change in the avoidance response at the dose range of 3-300 mg/kg. These results may indicate the relative order of the centrally stimulant and/or behavioral toxic actions of methylxanthines in human.


The baseball bat: a popular mechanism of urban injury.

From January 1989 through December 1990, 74 patients were admitted to our urban level I trauma center with injuries inflicted by baseball bats. We investigated the demographics and dynamics of injury in these patients by retrospective analysis of the patient's medical record and Trauma Registry data. The average victim was 30 years old. Ninety-two percent of the patients were male, and approximately 89% tested positive for substance abuse. Injury to both the head and body occurred in 80% of our patients, isolated head injury occurred in 42%. Twenty percent suffered injury to the body only. On admission, 7% went directly to the operating suite, 16% were admitted to the trauma ICU, one patient was admitted to the pediatric ICU, and the remainder were admitted to the floor shock/trauma unit. These patients had a length of stay (LOS) that was not significantly different than the LOS for patients with penetrating trauma or the general trauma population. The mean Trauma Score was 13.8 (range, 6-16), and the average Injury Severity Score was 10.5 (range, 1-34). The mortality in our study was 3%. Four percent of the patients were left with some degree of permanent disability. Intentionally inflicted injury is most commonly seen in the thorax and abdomen. In contrast, head injury was evident in 80% of our patients with baseball bat injury. This represents a departure from classic patterns of violent injury.


Induced immunoglobulin secretion by T-cell-replacing products from blunt trauma patients.

The capacity to induce immunoglobulin (Ig) secretion by soluble T-cell-replacing (TCR) factors derived from alloantigen-stimulated T lymphocytes of blunt trauma patients (n = 15, mean ISS = 24) was examined in Staphylococcus aureus (SAC)-activated normal B-cell cultures. The majority of the patients studied demonstrated a profound suppression of the T-cell-dependent, pokeweed-mitogen-induced Ig production. However, the activity to induce Ig secretion associated with TCRs from the same patients was not reduced compared with that of TCRs from normal subjects. IgM synthesis was normal and IgG secretion induced by TCRs was within the control range (in 6 of 15 patients) or significantly higher (p less than 0.05) than that in the remaining patients. Both patient-derived and control TCRs failed to induce Ig synthesis in cultures of resting B cells and had comparable mitogenic effects on normal SAC-activated and phytohemagglutinin A-activated B and T lymphocytes, respectively. Thus, the intrinsic ability of T lymphocytes to produce B-cell helper factors appears to be unaffected following blunt trauma. Suppression of the T-cell-regulated Ig secretion in traumatized patients may therefore reflect an altered B lymphocyte response to such factors.


Osteosynthesis of irreducible fractures of the clavicle with 2.7-MM ASIF plates.

Thirty-six patients with Allman group-2 fractures of the clavicle were treated by ORIF with 2.7-mm ASIF dynamic compression plates. The indications for surgery were an open fracture in one patient, ipsilateral fractures of the arm or the ribs in five patients, bilateral clavicular fractures in one patient, and an inability to reduce the fracture in all other patients. There were no instances of deep infection. One patient suffered a refracture after plate removal; three patients developed pseudarthrosis because plates that were too short were used. The total failure rate was 12%. It is concluded that the 2.7-mm DCP is the method of choice for internal fixation of midshaft clavicular fractures and that a minimum of three screws should be placed in each fragment.


Traumatic injury to the diaphragm: timely diagnosis and treatment.

Traumatic injury to the diaphragm is a relatively uncommon injury with potential for considerable morbidity if the diagnosis is delayed or missed. This review of cases of traumatic diaphragmatic injury was undertaken in order to emphasize methods and timing of diagnosis and treatment. From 1986 through 1990, 43 cases of traumatic diaphragmatic injury were admitted to the trauma unit at Sunnybrook Health Sciences Centre, for an incidence of 2% of all new multiple trauma admissions. All patients were evaluated and treated by a dedicated trauma team. The left hemidiaphragm was injured in 32 patients, the right hemidiaphragm was injured in eight cases, and the injury was bilateral in three patients. Thirty-four patients had blunt trauma. The mean Injury Severity Score for all patients was 32. The diagnosis of diaphragmatic injury was made radiologically in 21 cases and at surgery in 22 cases. The diagnosis in all cases with penetrating trauma was made at the time of surgery. The interval between injury and definitive surgery was less than 12 hours in 39 of 43 patients. The diagnosis of diaphragmatic injury was delayed by more than 12 hours in only one patient. The other three patients were diagnosed soon after injury but their definitive surgery was delayed for other reasons. Surgical repair of the diaphragm was performed via laparotomy in 40 of 43 cases. Only one patient was repaired in a delayed fashion by thoracotomy for thoracic complications. A clear contrast can be drawn between blunt injuries and penetrating trauma.(ABSTRACT TRUNCATED AT 250 WORDS)


The Integrated Trauma Program: a model for cooperative trauma triage.

The Integrated Trauma Program (ITP) is the cooperative trauma triage service of the University of Toronto trauma and burn hospitals and the Ontario Ministry of Health. It provides physicians in referring hospitals direct access to a trauma team leader (TTL) in one of several trauma centers through a single phone number. Three adult trauma centers, one pediatric trauma center, and one burn center, all affiliated with the University of Toronto, participate in this program. This article describes the system during the first two years of operation. From July 1989 to June 1991, 1530 requests for patient transfers from a total of 97 hospitals were processed. Of these transfer requests, 77% were accepted by the TTL to a trauma service as multiple trauma cases, 16% were accepted directly to a surgical service without involving the trauma team, 4% were refused by the TTL as inappropriate referrals, and 3% of requests were cancelled by the referring physician. The transfer requests are distributed to a specific trauma center by request of the referring physician (10%), according to a rotation (70%), or as selected by the ITP (20%) when the scheduled hospital is not readily available. Closure of all adult trauma centers occurred on 43 occasions. During these closures, 48 patients bypassed the Toronto trauma centers and were transferred to other cities. The ITP office also keeps an ongoing data base of patients transferred. The mechanism of injury in the majority of cases is vehicular crashes. The mean Injury Severity Score is 24 for adults and 17 for children.(ABSTRACT TRUNCATED AT 250 WORDS)


Standardized mortality ratio analysis on a sample of severely injured patients from a large Canadian city without regionalized trauma care.

Flora's Z statistic and standardized mortality ratios (SMRs) as indicators of excess mortality were calculated for a sample of 355 patients with major trauma. A statistically significant overall excess mortality was observed in this sample (Z = 6.77, SMR = 1.81, p less than 0.05). Advanced life support provided by physicians at the scene (MD-ALS) was not associated with reduced excess mortality. A significant trend toward lower excess mortality was associated with a higher level of trauma care at the receiving hospital (p less than 0.05). Total prehospital time over 60 minutes was associated with a significant increase in excess mortality (p less than 0.001). These results support regionalization of trauma care and failed to show any benefit associated with MD-ALS.


Is a full team required for emergency management of pediatric trauma?

Pediatric trauma centers often do not meet the guidelines requiring a trauma team as recommended by the American Academy of Pediatrics (AAP). We reviewed our experience with a team consisting of a pediatric emergency physician, resident, nurse, and respiratory therapist. The surgical and pediatric critical care residents and staff were available within 5 minutes. We conducted a retrospective chart review of 146 patients (aged 8.1 +/- 4.8 years) between 1987 and 1989, with Injury Severity Scores (ISS) greater than or equal to 16 or admitted to the pediatric critical care unit. The time of presentation, surgical services consulted, and the nature of the injury were obtained from chart review. The Pediatric Trauma Score (PTS), the Revised Trauma Score (RTS), the Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, and Pediatric Risk of Mortality (PRISM) were used to determine the severity of insult and physiologic derangement on admission. The Modified Injury Severity Score (MISS) was determined and the Delta score for Disability Assessment was assigned at discharge. The Delta score was also determined at 3-month intervals up to one year. The probability of survival (Ps) was calculated, using the ISS and RTS. The Z statistic for this group of patients was then determined, using the Major Trauma Outcome Study (MTOS) methodology. The percentages of patients who were normal, disabled, and dead were 61%, 31.5%, and 7.5%, respectively, at 6 months follow-up. Eleven deaths were expected based on PRISM and TRISS analysis. Our mortality and morbidity figures were comparable with those of centers with teams based on AAP guidelines.(ABSTRACT TRUNCATED AT 250 WORDS)


Injury severity score, head injury, and patient wait days: contributions to extended trauma patient length of stay.

The ability of level I trauma units to operate efficiently may be hampered by the presence of a number of patients with an excessive length of stay (LOS). In an attempt to determine causes for and suggest potential solutions to the long-term occupation of beds in an acute care trauma facility, the cases of patients with extended LOSs in a level I trauma unit were examined. Study patients were survivors admitted between January 1, 1986, and December 31, 1989. Patients with a LOS greater than one standard deviation above the mean (n = 221) were assigned to the Long LOS group, and the remaining 1250 patients to the Short LOS group. Long and Short LOS patient groups were compared on a number of variables including injury Severity Score, number of body systems injured, surgical procedures required, blood products used, AIS scores per body region, and patient wait days. Both an increased severity of injury and a lack of available chronic and rehabilitation beds for the head-injured patients contributed to excessive patient LOS in this acute care setting. Additional rehabilitation and chronic care beds are required to free acute care beds for the efficient operation of a level I trauma unit.


The effects of ischemia and ischemia-reperfusion on bacterial translocation, lipid peroxidation, and gut histology: studies on hemorrhagic shock in pigs.

The bacterial translocation hypothesis was tested in two studies (acute and subacute) in a porcine model of hemorrhagic shock. Male pigs (30-40 kg each) under general anesthesia had their femoral vein, femoral artery, and portal vein catheterized. After stabilization (1 hour) they were bled (40% of blood volume) over 30 minutes, then maintained in the hypotensive state (MAP = 30-40 mm Hg) for 2 hours, following which, according to randomization, they entered the control group or were resuscitated with whole blood (WB group) or with lactated Ringer's solution (LR group). In the acute study, the mesenteric efferent lymphatic was also cannulated, the control group was not resuscitated, and the animals remained under general anesthesia to the end of the experiment (8.5 hours), when gut tissue was obtained for histologic study and measurement of lipid peroxidation. In the subacute study, the control group was not bled, the animals were awakened at 6.5 hours, and the portal vein catheter remained in situ until 48 hours. In both studies, samples of portal blood were obtained for culture at regular intervals and on completion, samples from mesenteric lymph nodes (MLNs) for culture were taken in the acute study, and in the subacute study samples from MLNs, spleen, and liver were obtained. In the acute study significant bacterial translocation to the MLNs and portal blood did not occur among the controls (n = 3), the LR group (n = 5), and the WB group (n = 6). Significant evidence of lipid peroxidation was found in both the LR and WB groups. Histologic assessment showed no difference among the groups.(ABSTRACT TRUNCATED AT 250 WORDS)


Body habitus as a predictor of injury pattern after blunt trauma.

The records of obese and nonobese victims of blunt trauma were compared to determine if obese individuals are predisposed to a specific injury pattern. Prospectively collected data on 6368 adults admitted to a level I trauma center over a 4-year period were analyzed. Twelve percent (743 patients) met Body Mass Index (weight/height2) criteria for obesity (greater than or equal to 30 kg/m2). The obese group was older (p less than 0.01) and had lower ISSs (p less than 0.05) and higher GCS scores (p less than 0.01). More obese patients were injured in vehicular crashes (62.7% vs. 54.1% [p less than 0.01]). The obese victims were more likely to have rib fractures, pulmonary contusions, pelvic fractures, and extremity fractures and less likely to have incurred head trauma and liver injuries (p less than 0.05). Obese people injured in vehicular crashes had a similar injury pattern with no difference in seating position, direction of impact, seat belt use, and ejection.


The cardiorespiratory effects of increased intra-abdominal pressure in diaphragmatic rupture.

The cardiorespiratory effect of gastric herniation in diaphragmatic rupture with and without increased intra-abdominal pressure (produced by inflation of a pneumatic antishock garment [PASG] to an intraperitoneal pressure of 40 mm Hg) was studied in 16 anesthetized spontaneously breathing (80% oxygen) piglets. Four additional animals had similar measurements after PASG inflation but without diaphragmatic rupture. Arterial blood pressure (BP), cardiac output, arterial blood gases, position of the stomach relative to the diaphragm (as measured on fluoroscopy), and mortality were assessed. Gastric herniation without the PASG (group I: 8 animals) produced slight cardiorespiratory deterioration, with PO2 falling from a baseline measurement of 429 +/- 60 mm Hg to 316 +/- 5 mm Hg at 1 hour. Over this period pH decreased from 7.39 +/- 0.05 to 7.30 +/- 0.02 and PCO2 increased from 39 +/- 5 to 46 +/- 2 mm Hg. With PASG inflation (group II: 8 animals) PO2 decreased to a greater extent, from 410 +/- 30 mm Hg at baseline to 48 +/- 10 mm Hg by 1 hour; pH decreased from 7.38 +/- 0.06 to 6.8 +/- 0.2 and PCO2 increased from 39 +/- 4 to 88 +/- 6 mm Hg. Animals without diaphragmatic rupture (group III: 4 animals) showed a smaller decrease in PO2, from 480 +/- 34 mm Hg at baseline to 320 +/- 50 mm Hg by 1 hour after PASG inflation.(ABSTRACT TRUNCATED AT 250 WORDS)


Significance of myocardial contusion following blunt chest trauma.

A prospective study was undertaken at a regional trauma unit (RTU) to determine the significance of cardiac complications in patients with blunt chest trauma. Radionuclide angiographic (RNA) imaging was performed as soon as possible after admission and Holter monitors were applied for 72 hours. Routine investigations included serial cardiac enzyme measurements and 12-lead electrocardiograms. Dysrhythmias were classified and ventricular dysrhythmias were stratified by ventricular ectopic score (VES) as ventricular tachycardia (4) or greater than 100 premature ventricular contractions (PVCs)/hour (3). Three hundred twelve patients were entered into the study. Analysis of dysrhythmias revealed 18 patients with a VES of 4 and nine patients with a VES of 3; there were no serious consequences. The most significant dysrhythmia as a marker of outcome was atrial fibrillation (n = 9); five of these patients died, but all of associated noncardiac injuries. A review of abnormal RNAs revealed that all associated mortalities were attributed to noncardiac injuries. A review of postmortem reports and hospital records revealed that no deaths were attributed to cardiac failure or dysrhythmia. Thus the incidence of clinically significant dysrhythmias or other cardiac complications resulting from blunt trauma to the heart may be overestimated.


Neurophysiologic diagnosis in uncooperative trauma patients: confounding factors.

Median, ulnar, and posterior tibial nerve somatosensory evoked potential (SSEP) studies were performed on a total of 239 comatose or uncooperative trauma patients with head injuries. Twenty-six of those patients were suspected of having an additional spinal cord injury. One patient had more than one suspected spinal cord injury and two patients had a suspected spinal cord injury and a suspected peripheral nerve injury. Eleven of the suspected spinal cord injuries were confirmed and 13 were not confirmed by the SSEP studies. In three patients the SSEP study proved inadequate to add further information on the suspected spinal cord injury. Sixteen patients with suspected spinal cord injuries were able to cooperate with a neurologic examination approximately 6 months after injury and the SSEP findings were clinically verified in all 16 patients. Eleven patients were suspected of having an additional peripheral nerve injury. Four injuries were confirmed and seven not confirmed by the SSEP studies. Eight of those patients were able to cooperate with the follow-up neurologic examination, and the SSEP findings were clinically verified in all eight. Two patients suspected of having an additional spinal cord injury had unsuspected peripheral nerve injuries discovered by the SSEP studies. One patient was cooperative at follow-up and the SSEP findings were clinically verified. In our experience, SSEP studies have been an important diagnostic tool in the study of uncooperative trauma patients.


The physical, psychological, and socioeconomic costs of pediatric trauma.

This prospective study examined the physical, psychological, and socioeconomic effects of injuries on children and their immediate families. Ninety-two injured children admitted with minor (ISS less than 16) or major (ISS greater than or equal to 16) injuries were compared with a control group of 59 children admitted during the same period with acute appendicitis. The two populations were similar in mean age, sex ratio, parental age and work status, and number of siblings. The parents of the injured children had a lower level of education than those of the controls. Fifty-four percent of the minor injury patients and 71% of the major injury patients had persistent physical limitations at 12 months in contrast to none of the controls. Thirty-eight percent of minor injury patients had pre-existing behavioral disturbances compared with 14% of major injury patients and 10% of controls. Behavioral disturbances among major trauma patients showed a sharp rise to 41% at 12 months and tended to persist in cases with continuing physical limitations. The major injury patients and those with significant head injuries exhibited a decrease in academic performance; minor injury patients and those without head injury showed no change. Maternal malaise rose sharply to about 40% in both injury groups in contrast to 7% in the controls and was more common in the presence of persistent physical limitations. Only 73% of families in the major injury group had returned to normal family life compared with 87% of the minor injury group and 100% of controls.(ABSTRACT TRUNCATED AT 250 WORDS)


Trends in hospital care of burns in Canada.

A review of burn admission patterns to Canadian hospitals from 1966 to 1991 from Statistics Canada data was prompted by a decrease to 125 burn patients admitted to Vancouver General Hospital in 1990 after a plateau at 180-195 per year for 6 years. The total number of fires from Fire Commissioner's data and data from 20 of the 27 Canadian burn units was analyzed. Canadian burn admissions decreased from 57 per 100,000 in 1966 to 23 per 100,000 in 1989. The admission rate is three times greater for children 0-4 years of age but has decreased parallel with the total. The number of fires decreased from 370 to 270 per 100,000 in the last decade. In 1981, 1986, and 1989 15 Canadian units treated a constant 15% share of hospitalized burns, while nine units reported a constant 7% of burn patients who also required ventilation for associated smoke inhalation injury. These trends forecast a 2%-4% decrease in hospitalized burns per capita per year.


Surgical repair of traumatic tricuspid insufficiency: report of three cases.

Traumatic tricuspid insufficiency (TTI) is a rare lesion but is classically encountered as a "steering-wheel injury" in nonbelted car divers. This lesion is often not diagnosed because of its subtle clinical manifestations at first and the presence of associated injuries in multiple trauma. The majority of patients reported were treated with valve replacement but, more recently, successful repair of the native valve has made the latter the treatment of choice. Three patients were referred to us with a delayed diagnosis of TTI 2, 4, and 8 years after being involved in motor vehicle crashes (MVCs). Surgery was required and consisted of resuspension of the valvular leaflet with autogenous pericardium and ring annuloplasty. Two-dimensional echocardiography confirmed tricupid valve competence and the patients remained symptom free at a mean follow-up of 25 months.


Effect of increased intra-abdominal pressure on hepatic arterial, portal venous, and hepatic microcirculatory blood flow.

The effects of increased intra-abdominal pressure (IAP) on hepatic perfusion were studied in five anesthetized pigs. Doppler flow probes were used to measure hepatic artery blood flow (HABF) and portal venous blood flow (PVBF), and laser Doppler flowmetry was used to assess changes in hepatic microvascular blood flow (HMVBF). Hepatic blood flow responses to 10, 20, 30 and 40 mm Hg increases in IAP were assessed while the mean arterial BP (MAP) was maintained at baseline levels with IV crystalloid infusions. Although cardiac output and MAP were normal, HABF and HMVBF fell significantly with 10 mm IAP, and at 20 mm Hg IAP, HABF was 45% of the control value, PVBF was 65% of the control value, and HMVBF was 71% of the control value (p less than 0.05). At 30 and 40 mm Hg, hepatic blood flow was reduced even more. Thus, modest increases in IAP can cause significant impairment of hepatic perfusion despite a normal BP and cardiac output.


High-level positive end-expiratory pressure management in trauma-associated adult respiratory distress syndrome.

This study evaluated the effect of high-level positive end-expiratory pressure (PEEP) on mortality, barotrauma, intrapulmonary shunt (Qsp/Qt), and oxygen delivery (DO2) in posttraumatic adult respiratory distress syndrome (ARDS). All hypoxemic trauma patients admitted to the surgical intensive care unit (SICU) in 1989-1990 who received PEEP greater than 15 cm H2O were included. The PEEP was titrated to achieve an intrapulmonary shunt (Qsp/Qt) of approximately 0.20, and FIO2 was weaned to less than 0.50. Hemodynamic and pulmonary variables at four distinct intervals were recorded. Fifty-nine patients received PEEP greater than 15 cm H2O. Of these, 19 patients died of severe head injury or uncontrollable hemorrhage (16 within 48 hours). Forty (29 male, 11 female) were evaluated in detail. The PEEP levels ranged from 18-50 cm H2O with a mean of 27. PaO2/FIO2 ratios and Qsp/Qt improved as PEEP therapy was titrated. Cardiac index and oxygen delivery were maintained or improved throughout PEEP therapy by transfusion and fluid resuscitation, with a mean maximum positive fluid balance of 21.1 L and an average of 51 units of blood and blood products transfused per patients during their SICU stay. Twenty-nine (73%) had evidence of barotrauma, the majority being pneumothoraces clearly related to the initial trauma. Only three (7.5%) had evidence of barotrauma not related to trauma or line insertion. Eight of 40 patients (20%) died. Mean ISS and RTS for the entire group were 32 and 5.88, respectively. We conclude that titration of PEEP to achieve a Qsp/Qt of approximately 0.20 is an attainable goal. This was accomplished with minimal hemodynamic effects or barotrauma and a low mortality rate.


Inter-rater reliability of preventable death judgments. The Preventable Death Study Group.

This study examined the inter-rater reliability of preventable death judgments for trauma. A total of 130 deaths were reviewed for potential preventability by multiple panels of nationally chosen experts. Deaths involving a central nervous system (CNS) injury were reviewed by three panels, each consisting of a trauma surgeon, a neurosurgeon, and an emergency physician. Deaths not involving the CNS were reviewed by three panels, each consisting of two trauma surgeons and an emergency physician. Cases for review were sampled from all hospital trauma deaths occurring in Maryland during 1986. Panels were given prehospital and hospital records, medical examiner reports, and autopsy reports, and asked to independently classify deaths as not preventable (NP), possibly preventable (POSS), probably preventable (PROB), or definitely preventable (DEF). Cases in which there was disagreement about preventability were discussed by the panel as a group (via conference call). Results indicated that overall reliability was low. All three panels reviewing non-CNS deaths agreed in only 36% of the cases (kappa = 0.21). Agreement among panels reviewing CNS deaths was somewhat higher at 56% (kappa = 0.40). Most of the disagreements, however, were in judging whether deaths were NP or POSS. Agreement was higher for early deaths and less severely injured patients. For non-CNS deaths agreement was also higher for younger patients. When both autopsy results and prehospital care reports were available reliability increased across panels. A variety of approaches have been used to elicit judgments of preventability. This study provides information to guide recommendations for future studies involving implicit judgments of preventable death.


Lack of relevance of the Bohr effect in optimally ventilated patients with acute brain trauma.

The relationship between jugular bulb oxyhemoglobin saturation (SjO2) and oxygen tension (PjO2) during hyperventilation was prospectively evaluated in 37 adults with acute brain injuries. Hyperventilation was optimized in all patients, based on measured values of the arteriojugular oxyhemoglobin saturation difference, or cerebral extraction of oxygen (CEO2). Most patients initially had variable CEO2 values, in 578 observations carried out in the acute phase. Overall, there was a strong positive correlation between SjO2 and PjO2 at all levels of arterial pH. In 31 (5.3%) of the 578 observations, where the arterial pH was greater than 7.6, the SjO2 was disproportionally higher than the PjO2, despite a good SjO2-PjO2 correlation (moderate Bohr effect). In only 5 of these 31 observations (0.8%) did the SjO2 and PjO2 largely change in opposite directions (marked Bohr effect) during profound hypocapnia. The present findings support the current practice of continuous or intermittent SjO2 monitoring and management, and of optimized hyperventilation for control of intracranial hypertension, provided that hyperventilation is optimized according to the CEO2 values. Only on rare occasions (arterial pH greater than 7.6) is it advisable to replace SjO2 measurements by those of PjO2, because the latter is not affected by the Bohr effect.


D-dimer levels correlate with pathologic thrombosis in trauma patients.

Pathologic thrombosis, in the form of pulmonary embolism (PE) and deep venous thrombosis (DVT), causes significant morbidity and mortality in trauma patients and presents a diagnostic and therapeutic challenge because of associated conditions in these patients. This study examines the measurement of D-dimer crosslinked fibrin degradation products (D-dimer XDPs) as an indicator of hypercoagulability that places a trauma patient at risk of developing pathologic thrombosis. The time course of changes in D-dimer values after trauma normally involves an initial increase with a rapid decrease of D-dimer XDP levels to normal. Patients who then demonstrate a second rise in D-dimer values are at risk for pathologic thrombosis. Forty-one trauma patients were studied, in two groups, to evaluate the potential use of D-dimer XDP levels in evaluating the risk of pathologic thrombosis. A secondary increase in D-dimer XDP levels was found to occur in patients with PE, although sepsis and adult respiratory distress syndrome can also cause a late increase. However, D-dimer determinations appear to provide an easy, relatively inexpensive means of evaluating trauma patients for the risk of pathologic thrombosis.


Comparison between TRISS and ASCOT methods in controlling for injury severity.

ASCOT was developed by Champion et al. to address known limitations to TRISS. The present research attempted to validate ASCOT using an independent trauma registry. Data were collected by the Institute for Trauma and Emergency Care (ITEC), New York Medical College, between July 1, 1987 and June 30, 1989; 5685 trauma patients admitted to three level I trauma centers or five non-trauma center hospitals were included. Information was gathered by trained nurse-abstractors using all available prehospital and hospital records. ASCOT and TRISS were compared using sensitivity, disparity, misclassification rates, and the Hosmer-Lemeshow goodness-of-fit statistics. Disparity and sensitivity rates were relatively low for both indexes, particularly among blunt injury patients. Total numbers of patients misclassified by TRISS and by ASCOT were similar; most misclassifications were made by both TRISS and ASCOT and involved nonsurvivors. Each method had advantages in predicting the outcomes of particular subgroups of patients; ASCOT with regard to predicting outcomes among patients with head injuries and in correctly classifying blunt injured patients; TRISS in correctly classifying survivors. We conclude (1) the relatively small gain in predictive accuracy by ASCOT over TRISS is largely offset by its complexity and increased computer processing requirements; (2) Hosmer-Lemeshow tests indicate that neither index provides good statistical agreement between predicted and actual outcomes among either blunt or penetrating injury patients. Future models should include additional variables, stratify patients by several injury causes, and use decision rules to select variables and variable weights.


Coma in Mozambican gravidas: causes and perinatal outcome.

Ninety-one consecutive cases of coma were identified among gravidas at Maputo Central Hospital. The commonest causes were eclampsia (70 cases), cerebral malaria (six cases), and meningitis (five cases). Fetal mortality in eclampsia was 23 per cent and maternal mortality 10 per cent. There was a markedly higher incidence of eclampsia during the colder months.


Use of a recombinant antigen (OC 3.6 cDNA) for the serological diagnosis of onchocerciasis in exposed Nigerian children.

We evaluated a recombinant antigen (OC 3.6 cDNA) expressed in pMAL TM vector for the diagnosis of onchocerciasis in children living in an endemic focus of forest-type onchocerciasis in Nigeria. Using the Western blot with the maltose-binding fusion protein as antigen, 91 per cent of mf-positive children and 24 per cent of endemic normal children were positive. Furthermore, age was not a limitation to the assay. The practical limitations of the assay for field diagnosis of onchocerciasis is discussed.


Early diagnosis of cystic fibrosis in Jordanian children.

Cystic fibrosis (CF) is the most common fatal genetic disease in childhood. The high infant mortality rate in Jordan and many other developing countries is mostly due to an increased prevalence of malnutrition, diarrhoeal diseases, and chest infections, which are also recognized clinical features of CF. Reports of CF among Arabs in neighbouring countries have stimulated clinical studies to evaluate the prevalence and incidence of this disease among Jordanian children. In a prospective study, 7682 neonates from 10 different hospitals in Jordan were screened for CF using the BM test for meconium albumin. Four cases gave a positive reaction to BM test strips. Cystic fibrosis was confirmed in three by sweat chloride test using pilocarpine iontophoresis. This represents an incidence of 1:2560 live births. In spite of the recognized limitations for the use of the BM test on meconium for mass screening of CF, this study has contributed to the increased awareness of the occurrence of CF among Jordanian children.


Comparison of children and adults with tuberculous meningitis in Elaziğ, Turkey.

Retrospective evaluation of 16 cases of tuberculous meningitis revealed that BCG vaccination and tuberculin positivity were rare in pediatric as well as adult patients. Children with disease had developmental retardation and a high rate of maternal illiteracy as compared to normal controls.


Extra-pulmonary tuberculosis in BCG-vaccinated patients.

Six patients with extra-pulmonary tuberculosis who presented within a 2-year period to the Paediatric Department of the Faculty of Medicine, Galle, Sri Lanka, are presented. In spite of the BCG vaccination being given to all of them at birth, five patients subsequently developed miliary tuberculosis and one patient bone tuberculosis. The likely reasons for failure of BCG vaccination to prevent extra-pulmonary complications developing are discussed.


Pathogens in neonatalomphalitis.

During a 3-year study period, 33 neonates with omphalitis (with proven cultures) were encountered; aerobic and anaerobic cultures were obtained. An incidence of 2/1000 live births was recorded, with a high prevalence rate of 15.6/1000 admissions noted. Aerobes were isolated from 23 (70 per cent) specimens, whilst anaerobes were recovered alone in five (15 per cent) cases. There were 40 (1.2 per specimen) and 31 (0.9 per specimen) aerobic and anaerobic isolates, respectively. There was a significant detection of anaerobic pathogens such as the B. fragilis group (14), Gram-positive cocci (4) and Clostridium perfringens (3). Beta lactamase production was seen in 25 isolates, recovered from 25 newborns.


Host factors and acute lower respiratory infections in pre-school children.

The relationship between certain host-related variables and the short-term outcome of hospitalization for severe acute lower respiratory infections was studied prospectively in a cohort of 103 pre-school Nigerian children. The respective mean ages of those with bronchiolitis and croup were 3.2 months and 18.9 months while the corresponding M:F ratios were 2.5:1 and 1:1. It was highly significant that all the eight children that died were malnourished (P less than 0.01). Furthermore, malnourished subjects with pleural effusion, in whom bacteraemia was common, stayed longest in hospital while subjects with bronchiolitis and croup, in whom malnutrition was distinctly uncommon, had the shortest duration of admission. Multiple microbial identifications and bacteraemia were common in malnourished subjects with ALRI. Mortality was significantly higher in older children (P less than 0.05), but sex, immunization/breast-feeding status and co-existing measles or pertussis, were individually neither related to the admission outcome nor the duration. It is concluded that malnutrition is a strong predictor of ALRI-related death in the pre-school child. The significance of bacteraemia and multiple microbial identifications in malnourished children, and the ARI-control implications of the study are discussed.


Quantitative determination of urinary marker proteins: a model to detect intrarenal bioeffects after extracorporeal lithotripsy.

To detect the source of relevant acute intrarenal side effects after extracorporeal piezoelectric lithotripsy and its impact on repeat treatment, urinary excretion of highly specific marker proteins was determined before (day-1) and after (days 0, 1, 4, 7, 14 and 21) treatment. Marker proteins included high molecular weight alpha-2-macroglobulin, immunoglobulin G, albumin, alpha-1-microglobulin as well as the enzyme N-acetyl-beta-glucosaminidase. Of 50 patients who underwent 4,000 shock waves to caliceal stones (group 1) 15 were identically retreated after 5 (group 2) or 15 (group 3) days, respectively, to determine the shortest safe interval to repeat extracorporeal piezoelectric lithotripsy. The course of lithotripsy damage was also evaluated in 15 pre-damaged kidneys (group 4). The alpha-2-macroglobulin enhancement found in all groups on day 0 (p less than 0.005 to p less than 0.05) documented intrarenal bleeding from ruptured vessels. Ratios of alpha-2-macroglobulin/albumin greater than 2.00 on days 0 and 1 exclude a glomerular source of gross hematuria (groups 1 to 4). There was only slight acute tubular damage after extracorporeal piezoelectric lithotripsy (N-acetyl-beta-glucosaminidase increase, p less than 0.05 for groups 1 to 4). Retreatment after 5 days did not enhance the amount of proteinuria compared to the same patients from group 1 (statistically significant at p less than 0.45 to p less than 0.10). Group 3 also showed a similar elevation of proteinuria as the identical patients pretreated 15 days previously. Thus, the data seem to suggest that early repeat sessions of extracorporeal piezoelectric lithotripsy are as safe as delayed retreatments. The course of proteinuria in group 4 did not suggest enhancement of extracorporeal piezoelectric lithotripsy damage in pre-injured kidneys. The urinary marker alpha-2-macroglobulin detects intrarenal vessel ruptures, which are responsible for intrarenal hematomas, as evidenced by animal and human histology. A model is offered to understand and detect the most important parenchymal bioeffects to minimize the risk of injury.


Female fertility following extracorporeal shock wave lithotripsy of distal ureteral calculi.

This study was prompted by a spontaneous abortion in a 21-year-old woman following extracorporeal shock wave lithotripsy (ESWL ) of a distal ureteral calculus. To our knowledge, it is the first clinical retrospective study on the possible adverse effects of ESWL to the female reproductive tract. We analyzed treatment data and radiation exposure of 84 women in the reproductive period, and surveyed the patients by questionnaire, to which 67 (79.8%) responded. After ESWL 57 women (85.1%) practiced some form of contraception, while 10 childless women attempted to become pregnant. Overall 7 children with no malformations or chromosomal anomalies were born to 6 patients. Miscarriages were noted in 3 patients (4.5%) but they occurred at least 1 year after ESWL. Our data suggest that ESWL of lower ureteral calculi is a safe and effective procedure, and does not affect female fertility or lead to increased teratogenic risk.


Long-term followup after extracorporeal shock wave lithotripsy treatment of kidney stones in solitary kidneys.

A total of 64 treatments by the Dornier HM3 lithotriptor was performed on 52 solitary kidneys with stones. A slight increase but no significant variations in serum creatinine was noted in 15 patients without obstruction just after treatment (p greater than 0.05). No significant increases in serum creatinine were found even at the short-term, mid-term and long-term followup. After 12 to 56 months hypertension developed in only 1 previously normotensive patient. Of 37 patients at mid-term followup (12 to 24 months) 62% were stone-free, 24% had passable fragments, 8% had recurrent stones and 5% had regrowth of the residual fragments. At long-term followup (24 to 56 months) 50% of 26 patients were stone-free, 19% had dust or passable fragments, 19% had recurrences and 11% had regrowth of the residual fragments. The demonstrated effectiveness, small number of complications at the short-term followup, lack of sequelae at the long-term followup and relatively small number of recurrences confirm that extracorporeal lithotripsy is not only effective but also safe. It can be proposed as the treatment of first choice even when the stone is in a single remaining kidney.


Use of radionuclide renal imaging for clinical followup after extracorporeal shock wave lithotripsy of renal stones.

Patients treated by extracorporeal shock wave lithotripsy (ESWL) are usually evaluated by excretory urography within 1 month after treatment to determine the clearance of stone debris and rule out asymptomatic obstruction. In an attempt to obtain more precise functional information, we used 99mtechnetium-diethylenetriaminepentaacetic acid and 131iodine-hippurate radionuclide renal imaging studies, and a plain abdominal radiograph as the initial followup study after ESWL of 64 kidneys in 55 patients. Of 53 kidneys studied within 60 days after ESWL 42 had abnormal radionuclide renal imaging studies demonstrating pelviocaliceal stasis, excretory delay or poor function, 8 of which required subsequent interventions for obstructing stone debris. Five patients had excretory delay after ESWL that was unexpected based on a pre-ESWL excretory urogram showing normal function without dilation. A subset of 23 patients with large stone burden or anatomical deformity from a prior operation had baseline radionuclide renal imaging studies before ESWL; function improved in 4 and worsened in 5 by radionuclide renal imaging studies after completion of treatment. A total of 19 patients had radionuclide renal imaging studies earlier (within 17 days) after ESWL because of poor function and/or large stone burden, and as expected they had evidence of obstruction from stone debris, which necessitated further followup. Our experience suggests that followup of ESWL by radionuclide renal imaging studies provides specific functional information that is of particular value in the management of patients with obstructing stone debris and/or diminished renal function. Radionuclide renal imaging studies may also reveal unsuspected obstruction or functional impairment after ESWL of uncomplicated stones, and is recommended as routine followup after ESWL.


111Indium-oxine-labeled leukocytes and 67gallium-citrate as indicators of renal injury following extracorporeal shock wave lithotripsy.

To document the extent and persistence of traumatic inflammation after extracorporeal shock wave lithotripsy (ESWL), 15 patients were randomly chosen to have either 67gallium (67Ga)-citrate or 111indium (111In)-oxine scans within 24 to 48 hours of ESWL. Positive scans were repeated at 8 to 12 weeks. Nine patients had renal calculi, and 6 had ureteral calculi and acted as controls. Of the patients with renal calculi 6 were scanned with 67Ga-citrate and 3 with 111In-oxine. Four of the former and 2 of the latter scans showed evidence of renal injury. Followup scans were normal. There was no correlation between power index (number of shocks times accelerating voltage) and scan results. Half of the control subjects were scanned with 67Ga-citrate and the remainder with 111In-oxine and all scans were negative. 67Ga-citrate and 111In-oxine scans can show evidence of renal injury immediately after ESWL but abnormal scans 2 to 3 months later would be suggestive of a different inflammatory process.


Stone surface area determination techniques: a unifying concept of staghorn stone burden assessment.

The use of stone surface area measurements obtained from standard radiographs provides a more accurate and reproducible assessment of stone burden when reporting results and treatment recommendations for staghorn calculi. Techniques for determining stone surface area include use of graph paper, planimeter or computerized image analysis. The use of graph paper is inefficient while planimeters suffer from significant variation for areas less than 500 mm.2 (more than 5%). Computer image analysis is accurate, rapid and easiest to perform. Software programs compatible with microcomputers are readily available making assessment of stone surface area practical and inexpensive. Stone surface area showed close correlation to stone volume as measured by 3-dimensional computerized tomography (correlation coefficient 0.84, p = 0.005). Stone surface area determination enables more accurate reporting of treatment results and, thus, recommendations based upon stone burden. Comparison of data between institutions becomes more meaningful if stone surface area is used. Stone surface area also provides a useful basis to study and compare trends of treatment within a single institution.


Anesthesia and complications of extracorporeal shock wave lithotripsy of urinary calculi.

The techniques of anesthesia for extracorporeal shock wave lithotripsy of urinary calculi and the associated complications in 600 treatments with the second generation lithotriptor Siemens Lithostar were studied. General anesthesia was used in 17 treatments (2.8%) and epidural anesthesia was applied in 73 (12%), primarily in children and patients in need of simultaneous surgical auxiliary procedures. A total of 510 treatments (85%) was performed with a combination of local infiltration anesthesia and supplementary intravenous opiates. In 65% of the cases only 2 injections of opiates were sufficient for pain relief. There were no complications in 394 treatments (77%) and minor complications, such as arrhythmia (9.2%) and nausea/vomiting (7.6%), were easily treated. Respiratory depression was observed in 10 cases (2%) and this potentially dangerous complication was associated with simultaneous administration of opiates and midazolam. Only 9 treatments (1.8%) had to be terminated due to complications. It is concluded that most treatments of urinary calculi with this second generation extracorporeal shock wave lithotriptor can be performed with local infiltration anesthesia combined with supplementary short-acting opiates intravenously for pain relief and sedation. When administering supplementary midazolam for sedation the risk of respiratory depression should be considered.


The use of an abdominal compression belt to reduce stone movement during extracorporeal shock wave lithotripsy.

We used an abdominal compression belt in 50 patients undergoing extracorporeal shock wave lithotripsy with the Siemens Lithostar lithotriptor to limit diaphragmatic excursion and, therefore, renal calculus movement. Stone movement was measured on the monitor with and without the compression belt. Abdominal compression was found to decrease the range of stone movement by an average of 32% (-4 to 63%). This technique was less effective in patients with limited chest expansion. Abdominal compression was also found to be useful during treatment of renal and upper ureteral stones in reducing overall patient movement. The decreased stone movement during extracorporeal shock wave lithotripsy with abdominal compression may increase stone fragmentation and may decrease the number of shocks per treatment.


The use of a cystoscopically placed cobra catheter for directed irrigation of lower pole caliceal stones during extracorporeal shock wave lithotripsy.

As the general experience with extracorporeal shock wave lithotripsy (ESWL) for renal calculi broadens, it is increasingly evident that the clearance of stone fragments in lower pole calices needs to be improved. The stone-free rate after treatment for lower caliceal stones is consistently less than that for other upper tract locations. Use of a cystoscopically placed cobra catheter for directed irrigation during ESWL resulted in an increase of our lower caliceal stone-free rate at 1 and 3 months of followup to 71% (15 of 21) compared to 33% (8 of 24) of randomly selected controls at 1 month and 54% (13 of 24) at 3 months. We conclude that pre-ESWL placement of a cobra catheter into the lower pole calix and intermittent irrigation during the procedure are potentially useful adjuncts in the successful treatment of lower caliceal calculi.


Extracorporeal shock wave lithotripsy retreatment ("stir-up") promotes discharge of persistent caliceal stone fragments after primary extracorporeal shock wave lithotripsy.

A prospective randomized study was performed to compare the results of piezoelectric extracorporeal shock wave lithotripsy (ESWL) retreatment versus surveillance only in 50 patients with persistent caliceal stone fragments after primary ESWL for renal calculi. After a 3-month followup significant decreases in residual debris were observed in the retreated group, while changes in the control group were negligible. Considering the low morbidity of outpatient ESWL with a pain-free, second generation lithotriptor, ESWL retreatment of completely fragmented but persistent stone debris appears to be justified to render the kidney stone-free.


Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup.

We treated 19 selected patients with calculi in 21 caliceal diverticula with extracorporeal shock wave lithotripsy (ESWL). By limiting this treatment to patients with relatively small (less than 1.5 cm.) calculi associated with a radiographically patent diverticular neck, a stone-free state was initially achieved in 11 patients (58%). Of 14 patients with flank pain before ESWL 12 (86%) were rendered symptom-free or markedly improved, often independent of a stone-free state. Extended followup in 13 patients for 12 to 49 months (mean 23.8 months) after ESWL revealed recurrent stones or stone growth in only 1. Although pain relief has remained constant for those initially rendered symptom-free, recurrent infection has been documented in 6 (67%) of 9 patients with infection before ESWL. We conclude that ESWL for selected patients with calculi in caliceal diverticula can achieve a relatively high initial stone-free rate and that recurrent stones may not be inevitable. Treatment in this setting also may provide long-term symptomatic relief that is often independent of a stone-free state. However, recurrent infection is not unusual, especially when associated with residual calculi. Considering the relatively noninvasive nature of this approach, ESWL should be considered an acceptable form of primary management for selected patients with calculi in caliceal diverticula.


Clinical trials of the Northgate SD-3 dual-purpose lithotriptor for renal calculi.

The Northgate SD-3 is a bathless, portable shock wave lithotriptor made in the United States. It uses ultrasound localization and spark-gap, electrode-generated shock waves to fragment calculi in the upper urinary tract. Since October 1987, 312 treatments have been performed on 281 patients (286 kidneys) with stone burdens less than 2 cm. during clinical trials at 6 investigational sites in the United States. A fragmentation rate of 94% was achieved. Of the treatments 78% were judged successful (stone-free or fragments of less than 5 mm. remaining in an asymptomatic patient) and a 3-month stone-free rate of 58% was noted. The retreatment rate was 9% and the ancillary procedure rate was 5%. The complications (hematuria, ecchymosis, pain, obstruction) were mild and not unlike those seen in patients undergoing lithotripsy with other devices.


Efficacy of second generation lithotriptors: a multicenter comparative study of 2,206 extracorporeal shock wave lithotripsy treatments with the Siemens Lithostar, Dornier HM4, Wolf Piezolith 2300, Direx Tripter X-1 and Breakstone lithotriptors.

Extracorporeal shock wave lithotripsy (ESWL) has become the treatment of choice for urinary calculi. The good results of the first generation Dornier HM3 lithotriptor stimulated the development of second generation machines. A multicenter trial is presented involving the Siemens Lithostar, Dornier HM4, Wolf Piezolith 2300, Direx Tripter X-1 and Breakstone lithotriptor to compare the therapeutic efficacy of second generation machines. Treatment results were best for calculi less than 2 cm. in diameter. Although the second generation lithotriptors are comparable to each other, none of the machines provided a success rate comparable to that of the first generation unmodified Dornier HM3 lithotriptor. The 5 machines differed mainly in types of stones treated in relation to imaging system, use of anesthesia, use of auxiliary procedures and hospitalization but overall success rates were similar. We conclude that second generation ESWL is less effective than first generation ESWL.


Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy.

Percutaneous nephrostolithotomy with or without extracorporeal shock wave lithotripsy (ESWL) has been extensively used in the management of staghorn calculi, with stone-free rates varying from 23 to 86%. Explanations for the variability of such results include differences in stone burden, differences in percutaneous techniques and an overreliance on ESWL. The results and changing trends in the relative roles of percutaneous nephrostolithotomy and ESWL in the management of staghorn calculi at the Methodist Hospital of Indiana were examined. We reviewed 343 cases of staghorn calculi (partial and complete) with adequate followup data, which were managed with initial percutaneous nephrostolithotomy. Cases were divided into 2 groups: group 1 (252 cases) from 1984 to 1987 when access was performed by a radiologist and group 2 (91 cases) from 1988 to 1990 when access was performed by a urologist. Although stones in group 2 tended to be larger, a decreasing dependence on ESWL was noted (64.7% in group 1 compared to 35.2% in group 2, p less than 0.001). Despite the larger stone size in group 2, stone-free rates were similar (83.3% in group 1, 86.8% in group 2). In groups 1 and 2 percutaneous nephrostolithotomy alone achieved stone-free rates of 91% and 91.5%, respectively. The stone-free rate with the combination approach was 79.1% and 78.1% in groups 1 and 2, respectively. Technical refinements with percutaneous nephrostolithotomy in group 2 include accurate and carefully selected accesses (superior pole in 36.3%) for best approach to the stone, multiple accesses (13.3%) and improved skills in flexible nephroscopy. Blood transfusion has not been required in group 2 compared with 11.1% in group 1. Mean hospital stay was 12.4 days in group 1 and 10.3 days in group 2 (percutaneous nephrostolithotomy alone, 7.2 days). With careful attention to percutaneous nephrostolithotomy techniques, complex renal stones can be successfully managed endourologically, reducing the need for combination ESWL. Complications previously associated with percutaneous nephrostolithotomy have decreased.


Effect of extracorporeal shock wave lithotripsy on renal function and body height in pediatric patients.

Although extracorporeal shock wave lithotripsy (ESWL) is the preferred modality for treatment of most renal and upper ureteral calculi in adults, little is known about its effect on the pediatric population. We carefully followed 12 children 2.2 to 15.3 years old (mean age 9.4) treated with the Dornier HM3 lithotriptor. Effective renal plasma flow was obtained by quantitative 131iodine hippurate scan immediately preceding ESWL and at followup (range 74 to 238 weeks, mean 149). The treated kidney received an average of 1,702 shocks (range 1,000 to 2,200). Mean effective renal plasma flow increased in the treated kidney from 185 cc per minute before ESWL to 217 at followup (p = 0.016) and in the untreated kidney from 191 to 224 (p = 0.0013). Total effective renal plasma flow increased from 376 cc per minute before ESWL to 440 at followup (p = 0.0019). In the treated kidney mean and total effective renal plasma flow increased by 31 (expected 32) and 64 (expected 68) cc per minute, respectively, while in the nontreated kidney mean effective renal plasma flow increased by 33 (expected 36) cc per minute. None of the observed changes in effective renal plasma flow was significantly different from the expected changes using the paired t test at the 95% level. In addition, change in body height was evaluated using standard deviation scores. Mean body height (standard deviation) before ESWL was -0.39 (range -3.2 to 2.0) and at last followup it was -0.26 (range -2.6 to 2.4), which is not statistically significant (p = 0.37). Although these patients continue to be followed and caution is advised, this long-term study indicates that ESWL within the range of shocks delivered to this cohort does not statistically affect linear growth (body height) or renal function in the pediatric population.