Morbidity and mortality rates in major blunt trauma to the upper chest

It is widely believed that fractures of the first rib are associated with more severe injuries than fractures of other ribs. To confirm or refute that belief, we conducted a retrospective review of 168 patients with major blunt trauma resulting in fractures of the upper ribs treated at the North Carolina Baptist Hospital. A comparison of morbidity and mortality rates in relation to highest rib fractured showed essentially no correlation. We concluded that all patients with deceleration or crushing injuries involving upper-rib fractures must be suspected of having significant multiple organ system trauma and evaluated accordingly.

Malignant lymphoma of the thyroid gland with plasma cell differentiation (plasmacytoma)

An unusual case of malignant lymphoma of the thyroid is reported. The predominant appearance of the neoplasm was that of a large cell ("histiocytic") lymphoma, but a discrete portion of the tumor showed features typical of plasmacytoma. Electron microscopy revealed a wide spectrum of cell types, ranging from very immature lymphoid cells to relatively well-developed plasma cells. The findings support the concept that the neoplastic process represents an immunoblastic sarcoma composed of proliferating transformed B lymphocytes (immunoblasts) and their progeny (plasma cells) rather than two distinct lymphoid neoplasms occurring simultaneously.

Paraganglioma of the thyroid gland

A case of a paraganglioma located within the thyroid gland is reported, and the light- and electron-microscopic features are described. Review of the literature reveals only one other case of intrathyroidal paraganglioma, which was associated with bilateral carotid body tumors. Regarding the present case, no similar tumors have been noted elsewhere. The findings support the view that the thyroid gland should be included among the unusual sites at which primary paragangliomas may occur.

Staging laparotomy in Hodgkin's disease

Staging laparotomy (multiple liver and lymph node biopsies and splenectomy) was performed at the North Carolina Baptist Hospital in 123 patients with Hodgkin's disease. There were no deaths. Wound, pulmonary, intra-abdominal or urinary tract complications developed in 17 patients. Of those complications, one case each of pelvic abscess, subphrenic abscess, small bowel obstruction, staphylococcal peritonitis and subphrenic hematoma required a major intra-abdominal operation. The patients were classified on the basis of histopathology; nodular sclerosis--40, mixed cellularity--44, lymphocyte predominant--24, lymphocyte depleted--13, and undetermined--2. The pathological stage following laparotomy was unchanged from the clinical stage in 62%, reduced in 15%, and advanced in 23%. Subsequent therapy, therefore, was altered in 38% of the patients. Lymphangiography, done in 108 patients, showed lymph node involvement in 46 patients and no involvement in 62 patients. Of those lymphangiographic findings, 79% were confirmed histopathologically, 19% were falsely positive, and 1.8% were falsely negative. There were positive findings of Hodgkin's disease in the spleen in 42% of patients. The staging laparotomy continues to be a valuable tool in the staging and treatment of Hodgkin's disease.

Carcinoma of the parathyroid

We report on eight cases of parathyroid carcinoma seen at the Bowman Gray School of Medicine, Winston-Salem, NC, since 1969. Diagnosis of a parathyroid disorder was made on the basis of elevated serum calcium levels and associated disorders such as renal calculi, peptic ulcer disease, pancreatitis, and demineralization of bone. Six of the involved glands were on the left side. In seven patients, the disease was localized to the gland or adjacent structures; one patient had cervical lymph node invasion. Except for the last patient, in whom radical neck dissection and wide excision was done, local excision with adequate margins was the only procedure done. The patient with metastases died of his disease four years later. One patient died of myocardial infarction two years later, but had been normocalcemic in the interval between operation and death, and one patient is hypercalcemic and has had two local recurrences within a 3 1/2 year period. The other five patients are alive and well. The routine use of automated serum level determinations of all hospitalized patients has led to early detection of this malignancy, while it is still a stage I lesion in many instances. On the basis of this material, we conclude that radical neck dissection can no longer be advocated as a routine measure in the treatment of parathyroid carcinoma.

A randomized prospective evaluation of orally administered antibiotics in operations on the colon

In this randomized, prospective study of 91 patients undergoing operations on the colon, we found that neomycin, neomycin-phthalylsulfathiazole and neomycin-erythromycin base all provided adequate intestinal antisepsis. Wound infection rates for all groups were also similar and close to the national average for operations on the colon. A detailed analysis of the wound infections in our series revealed that 60 per cent of these infections were from organisms different from those found on the colonic mucosa. This evidence indicates the possible advantage of parenteral antibiotic therapy to achieve adequate tissue levels of antibiotics not presently possible with orally administered agents.

Agenesis of the gallbladder--an inherited defect?

Agenesis of the gallbladder is a rare anomaly believed to be an organogenetic failure. This is the third instance of familial agenesis of the gallbladder reported in the literature. The diagnosis of agenesis of the gallbladder can only be made during exploratory celiotomy and must be confirmed by an intraoperative needle cholecystogram. This congenital anomaly should be suspected when oral cholecystography shows a nonvisualizing gallbladder in relatives of any patient with proven agenesis of the gallbladder.

Ruptured abdominal aortic aneurysms: review of 33 cases treated surgically and discussion of prognostic indicators

Over an eight-year peroid at NCBH, 33 patients were operated for ruptured abdominal aortic aneurysm. Factors associated with an increased mortality included preoperative blood urea nitrogen levels of more than 20 mg per cent, severe preoperative hypotension, duration of symptoms of less than 24 hours, free peritoneal rupture and blood transfusions of greater than 19 units. Preoperative hypotension was the most selective preoperative prognostic parameter. From a review of this and other reported series, it was concluded that reduced mortality from ruptured abdominal aortic aneurysm can best be achieved by prompt diagnosis followed by surgical treatment before cardiovascular collapse can occur.

Diagnosis and management of occult gastrointestinal bleeding: visualization of the small bowel lumen by fiberoptic colonoscope

In 95 per cent of patients, the source of gastrointestinal bleeding can be determined by the usual roentgenographic and endoscopic methods. In the remaining five per cent of patients, the source of bleeding is obscure and special diagnostic procedures will be necessary. Among the special procedures that have been reported are the fluorescein string test, stepwise aspiration of intestinal contents, detection of radioactive red blood cells by stepwise aspiration, Geiger counter or scanning, and selective visceral angiography. An additional procedure, reported here, combines exploratory celiotomy with total endoscopic examination of the bowel.

Etiologic factors and consequences of splenic vein obstruction

Images

Central venous pressure monitoring: misinterpretation, abuses, indications and a new technic

Images