Small bowel obstruction in the elderly.

The records of 56 consecutive patients, age 70 years or older, who were operated on for mechanical small bowel obstruction were reviewed to determine the effect of early operation versus delayed operation. Delayed operation was defined as a laparotomy performed more than 48 hours after admission. Excluding the 13 patients with hernias, there were no significant differences between the early operation and delayed operation groups in regard to age, cause of small bowel obstruction, duration of prehospitalization symptoms, degree of underlying disease, or physical findings on presentation--with the exception of a significantly higher number of patients in the early operation group who had abdominal tenderness. There were no differences between mortality and small bowel infarction rates in the two groups. There was an increase in the complication rate (60 vs 24%, P less than .05) and the mean length of stay (29.6 vs 20.0 days, P less than 0.05) in the delayed operation group. This increased mean length of stay was directly related to the higher number of complications caused by delay in operation. Advanced age in a patient with complete small bowel obstruction should not stay the surgeon's hand because delay only leads to a prohibitive increase in complications and length of hospitalization.

The poor man's isoamylase analysis (wheat inhibitor). Does it work?

The value of a wheat inhibitor assay to measure the pancreatic isoamylase fraction in the serum was evaluated in a clinical trial. Fifty-four patients with a variety of disorders and wide range in serum amylase levels were studied comparing pancreatic isoamylase levels measured by both cellulose acetate membrane electrophoresis and wheat inhibitor assay. The overall correlation was excellent (r = 0.96), and was best when the total serum amylase was high. The predominate serum isoamylase was correctly predicted in 45 of 54 (83%) patients, with an overall specificity of 73 per cent and sensitivity of 96 per cent. Because it is easy to perform, the test is recommended for clinical use by those without access to more sophisticated forms of isoamylase analysis.

Burns of the lymphoedematous extremity.

In most patients with lymphoedema, neither a medical nor a surgical approach can provide a cure. Due to the progressive nature of the disease, it is imperative that every attempt should be made at controlling oedema and preventing infection. As burn injury to the lymphoedematous extremity is associated with significant morbidity, we report a patient with deep burns affecting a lymphoedematous extremity.

Use of a glycerin-based gel sheeting in scar management.

Management of hypertrophic and keloid scars can be difficult. This article presents an initial report on use of a glycerin-based gel sheeting to manage or prevent these scars. The results were comparable to those achieved with silicone sheeting, a typical treatment. Clinically, the glycerin-based sheeting was well tolerated, appeared to be effective, and was less expensive than the silicone sheeting. A prospective study will be done to confirm these findings.

Mandibular fractures in an urban trauma center.

The hospital records of 307 patients sustaining mandibular fractures between 1980 and 1984 were reviewed. The patient population consisted of 79% males, with precipitating events usually being fist fights (47%) and assaults with a blunt object (18%). The most common fracture involved the body (30%), followed by the angle (21%) and the condyles (19%). Intermaxillary fixation (IMF) was the preferred method of treatment (42%); however, a large number of patients were treated by internal fixation (31%) or external stabilization (11%). Despite the large number with internal fixation procedures, the complication rate was relatively low (18%). This review suggests changing trends in mandibular fractures. Motor vehicle accidents no longer comprise the most common etiology, so that condylar fractures are no longer the most common, and fractures of the body and angle are more common. Although most patients still are initially treated by intermaxillary fixation, the number of open reductions appears to be increasing. Despite this trend, the complication rate has remained relatively low.

Primary adenocarcinoma of the esophagus.

Of 163 patients with carcinomas of the esophagus seen between 1975 and 1982, 11 (6.7%) had a primary adenocarcinoma. Although the high ratio of men to women (10:1) was similar to that seen in patients with squamous cell carcinoma of the esophagus, the mean age of those with adenocarcinoma was younger (57 years). In contrast to squamous cell carcinomas, which predominantly involve blacks, esophageal adenocarcinomas in these patients involved only Caucasians. The great majority of lesions were found in the lower third of the esophagus. Only 3 (27%) of the patients with adenocarcinomas gave a history of a large daily alcohol consumption and only 2 (18%) had a Barrett's esophagus. Although various combinations of surgery, chemotherapy, and radiotherapy could control the primary tumor rather well, the final results were poor. All patients have now expired; median survival time was 16 months.

Interpretation of serum amylase levels in the critically ill patient.

To understand better the incidence and meaning of hyperamylasemia in the intensive care setting, cellulose acetate membrane electrophoresis was used to measure the isoenzymes of serum amylase in 192 patients with a variety of critical illnesses. Seventy of these patients had elevated serum amylase levels, but none had clinical or biochemical evidence of acute pancreatitis or renal failure. Of the 70 patients who had hyperamylasemia, in only 18 (26%) was it due solely to an elevation of the pancreatic isoamylase fraction. The remaining 52 patients were hyperamylasemic due to elevations in the nonpancreatic isoamylase fraction or elevations in both pancreatic and nonpancreatic isoamylase fractions. These data indicate that hyperamylasemia in the absence of clinical pancreatic disease is common in the ICU and is frequently caused by nonpancreatic production of serum amylase. Caution is, therefore, advised in interpreting elevated serum amylase levels in critically ill patients.

Drug injection injuries of the upper extremity.

The increasing incidence of illicit intravenous drug abuse has reached epidemic proportions in western society. Although the accompanying infectious complications such as hepatitis and acquired immunodeficiency syndrome receive the most notoriety, injection injuries are causing an increasing number of problems. A retrospective review of patients requiring admission for acute or chronic drug injection injuries of the upper extremities was made at the Detroit Receiving Hospital from 1980 through 1985. The demographical, historical, physical, microbiological, and follow-up data were analyzed. The majority of the injuries involved subcutaneous injections into the hand with accompanying inflammatory or infectious complications. The bacteriological data revealed unique characteristics and did not reflect patterns expected from inoculation of normal skin flora. A treatment regimen based on the data is proposed.