Description and rationale of a new operation for chronic pancreatitis

An operation is described that is useful in the management of patients with chronic pancreatitis and its complications. The operation features duodenal-preserving resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas. The operation has application to patients with pain or complications of chronic pancreatitis with dilated ducts in the body and tail of the pancreas who have small strictured ducts and/or small pseudocysts or ducts impacted with calculi in a markedly enlarged fibrotic pancreatic head. It also has application to patients with chronic pancreatitis complicated by common duct obstruction from small pseudocysts, fibrosis, or inflammation in the head of the pancreas. With this procedure, the common duct can often be freed up from the structures compressing it within the substance of the pancreas doing away with the necessity of a separate biliary bypass. The operation also has application to patients with a previous longitudinal pancreaticojejunostomy who have recurrent or persistent pain associated with small strictured ducts in an enlarged fibrotic pancreatic head with or without common bile duct obstruction.

A review of ankle arthrodesis: predisposing factors to nonunion

The purpose of this study was to review 15 years of experience with ankle fusions, specifically addressing the underlying etiology of ankle pathology, incidence of nonunion, and associated predisposing conditions that can lead to nonunion. Seventy-eight ankle fusions, performed between 1975 and 1990, were reviewed for this study. The average follow-up was 4 years. Patients with nonunion were evaluated separately to look at the predisposing factors that may have lead to nonunion. Factors associated with nonunion included fracture type, evidence of avascular necrosis, infection, major medical problems, and open injuries. Factors that were not associated with nonunion included age, past history of subtalar or triple arthrodesis, and technique.

Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis

Fifteen centers for orthopaedic treatment of the foot and ankle participated in a prospective randomized trial to compare several nonoperative treatments for proximal plantar fasciitis (heel pain syndrome). Included were 236 patients (160 women and 76 men) who were 16 years of age or older. Most reported duration of symptoms of 6 months or less. Patients with systemic disease, significant musculoskeletal complaints, sciatica, or local nerve entrapment were excluded. We randomized patients prospectively into five different treatment groups. All groups performed Achilles tendon- and plantar fascia-stretching in a similar manner. One group was treated with stretching only. The other four groups stretched and used one of four different shoe inserts, including a silicone heel pad, a felt pad, a rubber heel cup, or a custom-made polypropylene orthotic device. Patients were reevaluated after 8 weeks of treatment. The percentages improved in each group were: (1) silicone insert, 95%; (2) rubber insert, 88%; (3) felt insert, 81%; (4)stretching only, 72%; and (5) custom orthosis, 68%. Combining all the patients who used a prefabricated insert, we found that their improvement rates were higher than those assigned to stretching only (P = 0.022) and those who stretched and used a custom orthosis (P = 0.0074). We conclude that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device.

Pancreatectomy for chronic pancreatitis

Of one hundred and forty-nine patients (101 male and 48 female) 4-67 years of age, 117 were alcoholics and underwent pancreatectomy because of episodic or continuous abdominal pain or complications or chronic pancreatitis. Nineteen patients underwent pancreaticoduodenectomy, seventy-seven 80-95% distal resection, anf fifty-three 40-80% distal pancreatic resection. There were 3 operative death and 30 late deaths 6 months to 11 years post pancreatectomy. Twenty-one patients were lost to followup, 1 to 11 years post pancreatectomy. Ninety-five patients are known to be alive, 4 of whom are institutionalized. Indications for pancreatectomy in addition to abdominal pain include recurrent or multiple pseudocysts, failure to relieve pain after decompression of a pseudocyst, pseudoaneurysm of the visceral arteries associated with a pseudocyst, recurrent attacks of pancreatitis unrelived by non-resective operations, duodenal stenosis and left side portal hypertension. The choice between pancreaticoduodenectomy or distal resection of 40-80% or 80-95% of the pancreas should be based on the principle site of inflammation whether proximal or distal in the gland, the size of the common bile duct, the ability to rule out carcinoma, and the anticipated deficits in exocrine and endocrine function. The risk of diabetes is very significant after 80-95% distal resection and of steatorrhea after pancreaticoduodenectomy. When the disease process can be encompassed by 40-80% distal pancreatectomy this is the procedure of choice.

Prehospital stabilization of critically injured patients: a failed concept

Prehospital resuscitation and stabilization of major trauma victims is increasingly employed. To evaluate the benefits of one such maneuver, fluid administration, we reviewed 52 consecutive trauma cases in which patients had a blood pressure of less than 100 mm Hg either at the scene or on arrival to hospital. In all cases, transport time to hospital was less than IV establishment time. Fluid volume infused had little influence on final outcomes. A percentage of patients with correctable surgical lesions might have been salvaged had prompt transport been instituted. Field maneuvers in critically injured patients should be minimized to decrease ultimate mortality.

Multicenter evaluation of a broth macrodilution antifungal susceptibility test for yeasts

Thirteen laboratories collaborated to optimize interlaboratory agreement of results of a broth macrodilution procedure for testing three classes of antifungal drugs against pathogenic yeasts. The activities of amphotericin B, flucytosine, and ketoconazole were tested against 100 coded isolates of Candida albicans, Candida tropicalis, Candida parapsilosis, Candida lusitaniae, Torulopsis (Candida) glabrata, and Cryptococcus neoformans. Two starting yeast inoculum sizes (5 x 10(4) and 2.5 x 10(3) cells per ml) were compared, and readings were taken after 24 and 48 h of incubation. All other test conditions were standardized. The resultant turbidities in all tubes were estimated visually on a scale from 0 to 4+ turbidity, and MIC-0, MIC-1, and MIC-2 were defined as the lowest drug concentrations that reduced growth to 0, 1+, or 2+ turbidity, respectively. For flucytosine, agreement among laboratories varied between 57 and 87% for different inocula, times of incubation, and end point criteria. Agreement was maximized (85%) when the lower inoculum was incubated for 2 days and the MICs were defined as 1+ turbidity or less. For amphotericin B, variations in test conditions produced much smaller differences in interlaboratory agreement. For ketoconazole, interlaboratory agreement was poorer by all end point criteria. However, MIC-2 endpoints distinguished T. glabrata as resistant compared with the other species. Overall, the studies indicated that readings from the lower inoculum obtained on the second day of reading result in the greatest interlaboratory agreement. In combination with data from previous multicenter studies (National Committee for Clinical Laboratory Standards, Antifungal Susceptibility Testing: Committee Report, Vol. 5, No. 17, 1988; M. A. Pfaller, L. Burmeister, M. S. Bartlett, and M. G. Rinaldi, J. Clin. Microbiol. 26:1437-1441, 1988; M. A. Pfaller, M. G. Rinaldi, J. N. Galgiani, M. S. Bartlett, B.A. Body, A. Espinel-Ingroff, R.A. Fromtling, G.S. Hall, C.E. Hughes, F. C. Odds, and A. M. SUgar, J. Clin. Microbiol. 34:1648-1654, 1990), these findings will be used by the National Committee for Clinical Laboratory Standards to develop a standardized method for in vitro antifungal susceptibility testing for yeasts.

Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation

OBJECTIVE

In 1986, data from 25,000 major trauma outcome study patients were used to relate Trauma and Injury Severity Score (TRISS) values to survival probability. The resulting norms have been widely used. Motivated by TRISS limitations, A Severity Characterization of Trauma (ASCOT) was introduced in 1990. The objective of this study was to evaluate and compare TRISS and ASCOT probability predictions using carefully collected and independently reviewed data not used in the development of those norms.

DESIGN

This was a prospective data collection for consecutive admissions to four level I trauma centers participating in a major trauma outcome study.

MATERIALS AND METHODS

Data from 14,296 patients admitted to the four study sites between October 1987 through 1989 were used. The indices were evaluated using measures of discrimination (disparity, sensitivity, specificity, misclassification rate, and area under the receiver-operating characteristic curve) and calibration [Hosmer-Lemeshow goodness-of-fit statistic (H-L)].

MEASUREMENTS AND MAIN RESULTS

For blunt-injured adults, ASCOT has higher sensitivity than TRISS (69.3 vs. 64.3) and meets the criterion for model calibration (H-L statistic < 15.5) needed for accurate z and W scores. The TRISS does not meet the calibration criterion (H-L = 30.7). For adults with penetrating injury, ASCOT has a substantially lower H-L value than TRISS (20.3 vs. 138.4), but neither meets the criterion. Areas under TRISS and ASCOT ROC curves are not significantly different and exceed 0.91 for blunt-injured adults and 0.95 for adults with penetrating injury. For pediatric patients, TRISS and ASCOT sensitivities (near 77%) and areas under receiver-operating characteristic curves (both exceed 0.96) are comparable, and both models satisfy the H-L criterion.

CONCLUSIONS

In this age of health care decisions influenced by outcome evaluations, ASCOT's more precise description of anatomic injury and its improved calibration with actual outcomes argue for its adoption as the standard method for outcome prediction.

Endoscopic cholecystectomy. An analysis of complications

We analyzed our initial 381 endoscopic cholecystectomies with particular emphasis on postoperative complications. The rate of conversion to open cholecystectomy was 3%. A technical complication occurred in 2% and a non-technical complication in 4%, for a total complication incidence of 6%. There were three postoperative fatalities (0.9%). Two fatal technical complications consisted of unrecognized intestinal injuries at the time of endoscopic cholecystectomy that were obvious when the abdomen was opened. One patient died of a cerebrovascular accident. Nonfatal technical complications included five bile leaks that required treatment. There were no common bile duct injuries, but excessive caution to prevent common bile duct injury may have contributed to the high incidence of bile leaks. Examination of the case numbers of the technical complications and conversion to open cholecystectomy suggests that the learning curve is real and somewhat prolonged, and that a willingness to convert to open cholecystectomy is necessary if technical complications are to be avoided.

American Orthopaedic Foot and Ankle Society women's shoe survey

Shoes have been implicated as being responsible for the majority of foot deformities and problems that physicians encounter in women. A total of 356 women were studied in this investigation to evaluate trends in women's shoe wear and their effect on the development of foot deformities and pain. The majority of women in this study wore shoes that were too small for their feet, had foot pain and deformity, and had increased shoe size since the age of 20. Few women had their feet measured in over 5 years. The women without foot pain or deformities also wore shoes that were smaller than their feet but to a lesser degree.

Pancreatic pseudocyst--operative strategy

The experience with 131 patients with 157 pseudocysts is reported. One hundred and twenty patients with 146 pseudocysts underwent 165 operations. There were ten operative deaths (8.3%) three of which were not attributable to the pseudocyst or its operative management. Sixteen patients died six months to 14 years after operation. Deaths in six of the 16 patients were in part attributable to pancreatitis or complications of pseudocyst management. The operative mortality was highest in patients undergoing incision and drainage and cystoduodenostomy. Other factors influencing mortality unfavorably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or fistulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pseudoaneurysms associated with their pseudocysts. Incision and drainage of pseudocysts is associated with a high rate of recurrence of the cyst and continued pain. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. The presence of a pseudoaneurysm visualized on preoperative visceral angiography is an indication for an excisional operation as are the presence of multiple cysts, compression of the common duct or duodenum by the cyst, evidence of left sided portal hypertension, recurrent cysts or evidence of chronic pancreatitis.

Nutrition risk screening characteristics of rural older persons: relation to functional limitations and health care charges

This study was intended to characterize a rural population of older persons through nutrition screening and relate screening items to functional limitations and health care charges. There were 5373 participants (2522 males and 2851 females, mean age 71 y) screened over a 22-mo period by using a self-administered questionnaire adapted from the Nutrition Screening Initiative. Height and weight and cholesterol and albumin concentrations were measured, and health care claims data were obtained. The most frequent screening items reported were use of > or = 3 medications (41%) and food group intakes below recommended frequencies (> 50%). There were significant (P < 0.05) sex differences in affirmative responses to screening items and in likelihood of exceeding proposed threshold values for risk status assigned for body mass index (BMI; in kg/m2), albumin, or cholesterol. Overweight status was notable, with one-half of all subjects having BMIs > 27. Stepwise modeling procedures were used to identify screening items with the ability to predict self-reported functional limitation (logistic regression) and monthly average recorded health care charges (linear regression on logged charges). Age > or = 75 y, use of > or = 3 medications, and an albumin concentration < 35.0 g/L were significant predictors of both functional limitation and health care charges. Poor appetite, eating problems, income < $6000/y, eating alone, and depression were significant predictors of functional limitation but not health care charges. Being male, loss of 10 lb (4.5 kg), BMI > 27, cholesterol concentration < 4.14 or > 6.21 mmol/L, and functional limitation were significant predictors of health care charges only. These findings suggest that selected screening items may have be useful in the identification of subjects at potential risk for these outcomes.

Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist?

This is a retrospective review of 49 subtalar arthroscopies performed between 1989 and 1996. Patients were evaluated in the following areas: (1) preoperative diagnosis, (2) preoperative tests and clinical evaluation, (3) intraoperative findings, (4) postoperative diagnosis,(5) complications, and (6) clinical outcome. Particular attention was paid to the accuracy of the preoperative diagnosis, subtalar instability, intraoperative findings in sinus tarsi syndrome, and clinical outcome. Overall, this study demonstrated a success rate of 94% good and excellent results in the treatment of various types of subtalar pathologic conditions with arthroscopic techniques. The Workers' Compensation cases reported 90% good and excellent results. The complication rate was low, with five minor complications reported. The most common complication was a transient neuropraxia involving branches of the superficial peroneal nerve. Of the 14 feet that had a preoperative diagnosis of sinus tarsi syndrome, all the diagnoses were changed at the time of arthroscopy. The postoperative diagnoses included 10 interosseous ligament tears, two cases of arthrofibrosis, and two degenerative joints. Based on these findings, "sinus tarsi syndrome" seems to be an inaccurate term that should be replaced with a specific diagnosis. Arthroscopy is the tool that will allow the orthopaedic surgeon to make a more accurate diagnosis.

Major arterial hemorrhage: a complication of pancreatic pseudocysts and chronic pancreatitis

Twelve patients (11 men, one woman), aged 18 to 68 years, had major arterial hemorrhage as a direct complication of pancreatic pseudocysts and chronic pancreatitis. Chronic alcoholism (11 patients) and blunt abdominal trauma (one patient) were the basis for pancreatic disease. Spontaneous hemorrhage occurred in eight patients. Bleeding occurred into the gastrointestinal tract (eight patients), into the peritoneal cavity (four patients), and was intracystic (one patient). Splenic, pancreaticoduodenal, gastroduodenal, and gastroepiploic arteries were sources of hemorrhage. Operative procedures included local control of bleeding (six patients), distal pancreatectomy (three patients), and pancreaticoduodenectomy (one patient). Four patients died of hemorrhagic complications of pancreatic disease, including one not subjected to operation. Extirpation of diseased pancreatic tissue may lessen the morbidity and mortality attributed to this complication of pancreatitis.

An Exercise in Improving Suicide Reporting in Print Media

This study was conducted to support the publication of guidelines for media reporting on suicide. First, quantitative and qualitative aspects of suicide reporting in Swiss print media were surveyed over a time span of 8 months. The results were presented at a national press conference, and written guidelines for suicide reporting were sent out to all newspaper editors. The results of the survey and the guidelines were discussed in a personal meeting with the Editor-in-Chief of the main tabloid. After the publication of the guidelines a second, identical survey was conducted. The main variables regarding frequency, form, and content of the newspaper reports before and after the press conference were compared. The number of articles, on the one hand, increased over the 3 years between the first and second survey, but the quality of reporting clearly improved on the other. The personal contact with the editor of the tabloid was probably the most effective means of intervention.

Anatomic study of arthroscopic portal sites of the ankle

Numerous anatomic structures are at risk when performing ankle arthroscopy through the more commonly utilized portals. The purpose of this paper was to demonstrate the relative safety of each of the arthroscopic portal and Acufex external ankle distractor pin sites by measuring their proximity to the neurovascular structures surrounding the ankle joint. Six fresh cadaver specimens and 12 fresh-frozen, below-knee amputations were utilized for this study. An Acufex ankle distractor was applied using the standard technique. Anteromedial, anterolateral, anterocentral, posterolateral, and posteromedial portals were placed using an 11-blade scalpel to make 5-mm longitudinal incisions. The joint capsule was penetrated and a 3-mm arthroscope was placed into the ankle joint. The skin surrounding each of the portals was carefully removed and the proximity of any nerves or vessels was measured with respect to the arthroscope. At least one incidence of contact or penetration of a nerve or vessel was noted for each site. The anterocentral portal was at greatest risk for nerve or vessel damage. The anterolateral, anteromedial, and posterolateral portals were the safest areas for portal placement, with no penetration of neurovascular structures in any case.

Diagnosis and treatment of pancreatic injuries. An analysis of management principles

Ninety-one pancreatic injuries, 47 from blunt trauma, were reviewed with respect to management principles stressed in qi previous reviews. The pancreatic complication rate was 25%. Blunt injury was suspected preoperatively in only 30%. Even short-term observation led to morbidity. Operations done more than 6 hours after admission had a higher complication rate (45%) than those done less than 6 hours after admission (18%). Penrose drainage without a sump was not associated with increased complications. Distal pancreatectomy was done 32 times; splenectomy was done in only 18 patients. Individual duct ligation was rarely done and did not result in a high fistula rate. Pancreatic stump oversew with nonabsorbable suture was associated with a higher rate of pancreatic complications than absorbable suture (58% vs 30%). Only 56% of patients receiving distal pancreatectomy required hyperalimentation. Postoperative serum amylase values were not useful, and amylase values from drainage fluid predicted complications only when they were above 100,000 U/L. Details of pancreatic trauma management are less important than early operation in minimizing morbidity.

Toxoplasma gondii in Switzerland: a serosurvey based on meat juice analysis of slaughtered pigs, wild boar, sheep and cattle

Toxoplasmosis is one of the most important zoonotic diseases worldwide and is caused by the protozoan Toxoplasma gondii. Besides vertical infection during pregnancy, humans can get infected post-natally either by peroral uptake of sporulated Toxoplasma oocysts or by ingestion of tissue cysts upon consumption of raw or undercooked meat. The aim of this study was to approximate the risk of human infection via meat consumption by estimating the seroprevalence of T. gondii in slaughtered animals in Switzerland and to compare data with prevalences assessed 10 years ago. The study included pigs, cattle, sheep and wild boar of different age groups and housing conditions whenever possible and applicable. A P-30-ELISA was used to detect T. gondii-specific antibodies and to determine seroprevalences in meat juice of slaughtered animals. A total of 270 domestic pigs (120 adults, 50 finishing, 100 free-ranging animals), 150 wild boars, 250 sheep (150 adults, 100 lambs) and 406 cattle (47 calves, 129 heifers, 100 bulls, 130 adult cows) were tested. Seropositivity increased with the age of the assessed animals. Independent of the age-group, the overall seroprevalence was lowest in wild boars (6.7%), followed by pigs (23.3%), cattle (45.6%) and sheep (61.6%), respectively. Conventional fattening pigs and free-ranging pigs surprisingly had comparable seroprevalences (14.0% and 13.0%, respectively). Unlike in other European countries, where generally a decrease in the number of seropositive animals had been observed, we found that the prevalence of seropositive animals, when compared with that of 10 years ago, had increased for most species/age groups. Conclusively, the results demonstrated a high seroprevalence of T. gondii in animals slaughtered for meat production and revealed that increasing age of the animals is a more important risk factor than housing conditions in Switzerland.

Foot health and shoewear for women

Females are different from males in structure and biomechanics. The foot in the female tends to have a narrower heel in relationship to the forefoot and overall is narrower than a man's foot relative to length. Females tend to pronate their feet more and have smaller Achilles tendons than males, both factors having implications for shoe fit. Although shoes have been worn for thousands of years for the main purpose of protecting feet from the environment, recent studies have implicated shoes as the principal cause of forefoot disorders seen in females. Several authors have reported the harmful effects of shoewear and the greatest factor is a shoe that is improperly fit. With respect to foot disorders in the female, the current study will explore anatomy, biomechanics, common forefoot disorders, and shoewear through the ages, athletic shoewear, and a toe strengthening program.

Prevalence and genotypes of Toxoplasma gondii in feline faeces (oocysts) and meat from sheep, cattle and pigs in Switzerland

The protozoan parasite Toxoplasma gondii infects almost all warm blooded animal species including humans, and is one of the most prevalent zoonotic parasites worldwide. Post-natal infection in humans is acquired through oral uptake of sporulated T. gondii oocysts or by ingestion of parasite tissue cysts upon consumption of raw or undercooked meat. This study was undertaken to determine the prevalence of oocyst-shedding by cats and to assess the level of infection with T. gondii in meat-producing animals in Switzerland via detection of genomic DNA (gDNA) in muscle samples. In total, 252 cats (44 stray cats, 171 pet cats, 37 cats with gastrointestinal disorders) were analysed coproscopically, and subsequently species-specific identification of T. gondii oocysts was achieved by Polymerase Chain Reaction (PCR). Furthermore, diaphragm samples of 270 domestic pigs (120 adults, 50 finishing, and 100 free-range animals), 150 wild boar, 250 sheep (150 adults and 100 lambs) and 406 cattle (47 calves, 129 heifers, 100 bulls, and 130 adult cows) were investigated by T. gondii-specific real-time PCR. For the first time in Switzerland, PCR-positive samples were subsequently genotyped using nine PCR-restriction fragment length polymorphism (PCR-RFLP) loci (SAG2, SAG3, BTUB, GRA6, c22-8, c29-2, L358, PK1 and Apico) for analysis. Only one of the cats shed T. gondii oocysts, corresponding to a T. gondii prevalence of 0.4% (95% CI: 0.0-2.2%). In meat-producing animals, gDNA prevalence was lowest in wild boar (0.7%; 95% CI: 0.0-3.7%), followed by sheep (2.0%; 95% CI: 0.1-4.6%) and pigs (2.2%; 95% CI: 0.8-4.8%). The highest prevalence was found in cattle (4.7%; 95% CI: 2.8-7.2%), mainly due to the high prevalence of 29.8% in young calves. With regard to housing conditions, conventional fattening pigs and free-range pigs surprisingly exhibited the same prevalence (2.0%; 95% CI: 0.2-7.0%). Genotyping of oocysts shed by the cat showed T. gondii with clonal Type II alleles and the Apico I allele. T. gondii with clonal Type II alleles were also predominantly observed in sheep, while T. gondii with mixed or atypical allele combinations were very rare in sheep. In pigs and cattle however, genotyping of T. gondii was often incomplete. These findings suggested that cattle in Switzerland might be infected with Toxoplasma of the clonal Types I or III, atypical T. gondii or more than one clonal Type.

Comprehensive management of acute necrotizing pancreatitis and pancreatic abscess

Achieving reduced mortality rates in patients with necrotizing pancreatitis and pancreatic abscess is possible by employing a comprehensive management plan. Components of the plan include (1) rapid evaluation and assessment of the degree of physiologic and anatomic derangement, the latter by the prompt use of vascular enhanced computed tomographic scan; (2) adequate fluid resuscitation determined by early institution of advanced hemodynamic monitoring; (3) attempts to identify and document septic foci via computed tomography-guided percutaneous aspiration; and (4) aggressive surgical debridement. Close adherence to these policies allowed us to keep mortality in this seriously ill group of patients to 14%. Most deaths occurred in patients who were referred to this service late in the course of their disease. The Acute Physiology and Chronic Health Enquiry (APACHE) II severity of illness index applied at the time of admission proved an accurate predictor of mortality. A score of 25 or greater was highly predictive of death, and a lesser score, of survival.

Pyogenic liver abscess. Diagnostic and therapeutic strategies

A retrospective review of 26 adult patients admitted to University of California, Davis, Medical Center (UCDMC) with pyogenic liver abscess (1980-1986) was performed to ascertain the impact of rapid diagnosis and percutaneous drainage. Ultrasonographic examinations and computed tomography (CT) scans were highly sensitive and noninvasive imaging modalities. Sixteen patients had solitary abscesses and seven had multiple microscopic abscesses. The median time interval from admission to diagnosis and therapy was 2 and 3 days, respectively. Origin of the abscess was determined in 22 patients, the biliary tree being the most common source. Medical therapy was successful in three patients with microabscesses but failed in two. Nine patients had percutaneous drainage; two required repetitive percutaneous catheter placement, and two proceeded to surgical drainage. Twelve patients had surgical drainage; one required repetitive surgical drainage. Postdrainage complications were minimal in all groups. Overall mortality role was 11.5% (two patients). Deaths were related to delay in diagnosis, gram-negative sepsis at presentation, and biliary origin of the abscess.

Effect of preinjury illness on trauma patient survival outcome

Data from 11,156 patients treated at the four Major Trauma Outcome Study controlled sites were used to estimate the effect on survival of each APACHE II preinjury illness condition (PIC). A case-control methodology was applied; 544 patients (4.8%) had one or more PICs. For each patient with a specific PIC we identified a set of matching patients with no PICs. A patient matches a PIC patient if both have the same mechanism of injury, the same coding of Revised Trauma Score variables (Glascow Coma Scale score, systolic blood pressure, respiratory rate), the same coded age per A Severity Characterization of Trauma) (ASCOT), and if they differ by no more than 0.5 for A, B, and C (the ASCOT components for serious injuries). The estimated survival probability for a PIC patient is either the survival rate for the patient's matched set or, if there are no matches, the patient's ASCOT survival probability. The survival probabilities were used to compare the actual and predicted numbers of survivors for each PIC, using z and W statistics. Computations of z and W were also made using ASCOT survival probabilities for each PIC patient. The results indicate profound effects of five PICs (hepatic, cardiovascular, respiratory, renal, diabetes) on trauma patient outcomes.

CONCLUSION

Pre-existing organ dysfunction has a profound effect on patient outcome even after controlling for age, anatomic and physiologic severity, and mechanism of injury. But, because of their relatively low incidence in this sample, PICs did not strongly influence institutional outcome performance as measured by z and W values.