Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results.

BACKGROUND: Rosacea is a common skin condition but the treatments currently available are not satisfactory. OBJECTIVES: To assess the efficacy of intense pulsed light (IPL) for treatment of stage I rosacea (flushing, erythema and telangiectasia). METHODS: Thirty-four patients were treated, 25 women and nine men, mean age 47 years. The treatment employed was IPL 515-1200 nm, with a 560 nm cut-off filter. The fluence range was 24-32 J cm(-2). Four treatments were administered on the face at 3-week intervals. Erythema values were measured at baseline and at the end of the treatment period on the cheeks and chin. Digital photographs were assessed by a consultant dermatologist on a 10-point visual analogue scale (VAS). Patients' assessments were also made using a 10-point VAS. Outcome measures were repeated 6 months after treatment. RESULTS: After four treatments the mean reduction of the erythema values was 39% on the cheeks (P < 0.001) and 22% on the chin (P < 0.001). This was confirmed by photographic assessment where erythema improved by 46% and telangiectasia by 55% (P < 0.001). The severity of rosacea was reduced on average by 3.5 points on the 10-point VAS. Patients' and physicians' assessments of the overall improvement of rosacea were similar: more than 50% improvement was noticed in 73% and 83% of patients, respectively (P < 0.001). The results were sustained at 6 months. Side-effects were minimal and self-limiting. CONCLUSIONS: IPL significantly reduces erythema and telangiectasia of rosacea and this is sustained for at least 6 months.

Families' perception of the value of timed daily "family rounds" in a trauma ICU.

Daily communications between the ICU trauma patients' families and the trauma team are often limited due to the unpredictable nature of subsequent patient admissions and operative procedures. In order to improve the lines of family-physician communication and educate residents regarding family communication, our level I trauma center instituted daily "Family Rounds" (FR). FR occur at the same time every day, in the patient's ICU room. The purpose of this study was to determine whether families valued the scheduled daily FR, to establish whether FR improved the family-physician relationship, and to delineate strengths and weaknesses of the present structure of our FR. We mailed surveys to family members of trauma patients hospitalized in the trauma ICU for > or = 3 days. A total of 55 (22%) families responded. Combining "excellent" and "good" responses, 86.5 per cent of families looked forward to having a specific time of day to meet with the trauma team, and 90 per cent liked having rounds in the ICU room with the patient. However, 36 per cent did not like having only scheduled time for FR. The majority, 75 per cent, believed that all concerns were addressed during FR, and 84.9 per cent rated their overall experience as either excellent or good. Scheduled FR appear to improve communication between trauma surgeons and patients' families, enhance the family-physician relationship, and strengthen our surgical residency teaching program.

Accelerated degradation of aldicarb and its metabolites in cotton field soils.

The degradation of aldicarb, and the metabolites aldicarb sulfoxide and aldicarb sulfone, was evaluated in cotton field soils previously exposed to aldicarb. A loss of efficacy had been observed in two (LM and MS) of the three (CL) field soils as measured by R. reniformis population development and a lack of cotton yield response. Two soils were compared for the first test-one where aldicarb had been effective (CL) and the second where aldicarb had lost its efficacy (LM). The second test included all three soils: autoclaved, non-autoclaved and treated with aldicarb at 0.59 kg a.i./ha, or not treated with aldicarb. The degradation of aldicarb to aldicarb sulfoxide and then to aldicarb sulfone was measured using high-performance liquid chromatography (HPLC) in both tests. In test one, total degradation of aldicarb and its metabolites occurred within 12 days in the LM soil. Aldicarb sulfoxide and aldicarb sulfone were both present in the CL soil at the conclusion of the test at 42 days after aldicarb application. Autoclaving the LM and MS soils extended the persistence of the aldicarb metabolites as compared to the same soils not autoclaved. The rate of degradation was not changed when the CL natural soil was autoclaved. The accelerated degradation was due to more rapid degradation of aldicarb sulfoxide and appears to be biologically mediated.

Infectious disease consultation and microbiologic surveillance for intensive care unit trauma patients: a pilot study.

Infection remains a major cause of posttrauma morbidity. We retrospectively reviewed 2 cohorts of trauma patients admitted to a regional trauma center before and after a policy change integrating prospective microbiologic surveillance and infectious disease (ID) consultation into management of trauma admissions. Primary interests were effects of this policy change on antimicrobial use and diagnostic precision (particularly differentiation of infection from colonization). Associated costs, microflora, survival, and disability were also compared. Patients were stratified for risk of infection. ID consultation was associated with a 49% increased odds that an infection diagnosis was microbiologically based (P=.006) and 57% reduction of antibiotics costs per hospitalized day (P=.0008). Costs of consultation and an 86% increase (P<10(-6)) in total cultures combined to minimally exceed that financial saving. The observed improvements in diagnostic precision and antimicrobial usage, however, suggest consideration of prospective microbiologic surveillance and multidisciplinary physician teams including ID physicians for high-risk trauma patients.

Accuracy and significance of fine-needle aspiration and frozen section in determining the extent of thyroid resection.

The records of 46 patients were retrospectively reviewed to determine the accuracy and significance of fine-needle aspiration (FNA) and intraoperative frozen section (FS) in planning the extent of thyroid resection. For all 46 patients, both FNA and FS diagnoses were available for comparison with the final pathologic diagnosis. The sensitivity value for detection of malignancy by means of FNA was 90% compared with 60% by means of FS, although FS diagnoses were more specific (97%) than FNA diagnoses (56%). FNA diagnoses of benign conditions were correct in 20 of 21 (95%) patients. FS diagnoses of benign conditions were correct in 19 of these 21 patients (90%) but, more important, it did not alter the extent of resection or improve the accuracy of diagnosis. Five patients had findings at FNAs that were positive for malignancy. Frozen section confirmed this diagnosis in all five patients but, again, did not alter the extent of resection. Twenty patients had FNA findings that were "suspicious" for malignancy, with 12 of the tumors diagnosed as benign on FS and only one of four (25%) papillary carcinomas diagnosed as positive on FS. Only four of 20 (20%) FNA results that were "suspicious"--but not diagnosed as malignant--were confirmed as malignant on permanent section, whereas 70% of the FS diagnoses were correct in these 20 patients. Overall, only 16 of 46 (35%) FS diagnoses were helpful in determining the extent of thyroid resection. If a diagnosis of a benign or definitely malignant condition has been made by means of FNA preoperatively, FNA alone provides sufficient information for determining the extent of thyroid resection. Frozen section may be helpful if FNA results are suspicious, but it does not have sufficient sensitivity for determining the extent of resection, which should be deferred until permanent sections have been analyzed.

Outcomes following injury in a predominantly rural-population-based trauma center.

OBJECTIVE: To determine the incidence, severity, and outcomes of injury in patients treated in a rural-based level I trauma center and to compare the outcomes with a nationally indexed patient population--the Major Trauma Outcome Study. DESIGN: Retrospective evaluation of trauma registry data. SETTING: State of Illinois designated level I trauma center located in Urbana. PATIENTS: A total of 2246 trauma patients admitted from August 1989 through August 1992, with a mortality cohort of 158 patients. There were 1735 patients (77%) with Injury Severity Scores less than or equal to 19 and 511 patients (23%) with more severe injuries (Injury Severity Scores > or = 20). MAIN OUTCOME MEASURES: Mortality rates using the TRISS method, the Major Trauma Outcome Study, and final patient dispositions. RESULTS: The overall mortality rate, excluding those patients who were pronounced dead on arrival, was 125/2213 (5.6%). Eighty-six (69%) of these 125 patients had neurological Abbreviated Injury Scores of 3 or greater, with neurotrauma being a major contributor to their deaths. The m-statistic was 0.99 and the z-statistic was -3.30 for the entire group. The observed probability of survival met or exceeded the expected probability of survival when compared with the Major Trauma Outcome Study in all categories. CONCLUSION: Acceptable mortality rates compared with the Major Trauma Outcome Study can be achieved in a rural-community-based level I trauma center despite relatively small numbers of critically injured patients. Such outcomes may assist in justifying resource allocation for trauma centers in rural areas.

Hyperamylasemia due to poorly differentiated adenosquamous carcinoma of the ovary.

In a patient with poorly differentiated ovarian carcinoma, the symptomatology was mistaken for acute pancreatitis. A review of the pertinent literature argues in favor of the early use of amylase isoenzymes in patients whose history, objective signs, and routine diagnostic studies fail to disclose pancreatic disease.

Bedside percutaneous tracheostomy with bronchoscopic guidance in critically ill patients.

BACKGROUND: Bedside percutaneous dilational tracheostomy, a relatively new method of tracheal cannulation, provides safe and ready access to the trachea to relieve airway obstruction and tracheopulmonary secretions. The dilational technique has undergone various modifications during the past decade. Complications of this procedure are primarily related to the lack of direct visualization during tracheostomy tube placement and to poor patient selection. OBJECTIVE: To report the utility of percutaneous dilational tracheostomy with bronchoscopic guidance in 162 critically ill patients. MAIN OUTCOME MEASURES: Mortality rates and complications associated with this technique. RESULTS: Twenty-five patients (15.4%) died while hospitalized. No deaths were related to tracheostomy. There were four (2.5%) major complications: one pneumothorax and three posterior tracheal tears, which healed spontaneously. There were five (3.1%) minor complications: one posterior mucosal disruption, one minor bleeding episode, and three minor episodes of cellulitis. One hundred thirty-seven patients (84.6%) were discharged. Twenty-nine patients (21.2%) were available for follow-up and were experiencing no significant problems or complications following the procedure. Compared with standard open tracheostomy, charges were reduced by $1628.20 per patient ($263,768.40 total savings). CONCLUSIONS: Bedside percutaneous tracheostomy with bronchoscopic guidance is safe and cost-effective. Complications compare favorably with that of open tracheostomy. Major complications should be avoided with continuous bronchoscopic observation during the procedure.

The safety of emergency neuromuscular blockade and orotracheal intubation in the acutely injured trauma patient.

BACKGROUND: This study was done to determine the safety and success of orotracheal intubation with planned neuromuscular blockade in patients who are severely injured. The study was performed at Carle Foundation Hospital, designated Level I trauma center located in east central Illinois. STUDY DESIGN: A retrospective review of the trauma registry and medical records of all patients requiring emergency airway control from September 1, 1987 to September 30, 1991 was performed. Two hundred twenty-nine patients who were critically injured were reviewed, the mean injury severity score was 29 (range of 3 to 75), the mean revised trauma score was 9 (range of 3 to 12), the mean Glasgow Coma Scale was 9 (range of 3 to 15), and the mean age was 31 years (range of one to 94 years). RESULTS: Indications for intubation included hemodynamic instability or altered level of consciousness (66.4 percent), or both, combative or uncooperative behavior (33.2 percent), and need to secure airway for transport (0.4 percent). Two hundred twenty-three (97.4 percent) patients were successfully intubated. Six (2.6 percent) patients required cricothyroidotomy and one (0.4 percent) patient was aspirated during intubation. Eight (3.5 percent) patients had cervical spine injuries but had no complications from orotracheal intubation. In the combative group, 32 (42 percent) patients had significant head injuries and 17 (22 percent) had other potentially life-threatening injuries. CONCLUSIONS: Orotracheal intubation with planned neuromuscular blockade and in-line cervical traction is a safe, effective method for airway control in patients who are severely injured. This technique is also indicated to expedite therapy in combative, uncooperative patients because of the high incidence of significant life-threatening injuries to the brain and other organs.

A potentially expanded role for enoxaparin in preventing venous thromboembolism in high risk blunt trauma patients.

BACKGROUND: Venous thromboembolism (VTE) is a frequent and potentially life-threatening complication after trauma. The purpose of this study is to investigate the effectiveness of enoxaparin in preventing deep venous thrombosis (DVT) and pulmonary embolism (PE) after injury in patients who are at high risk for developing VTE. STUDY DESIGN: A prospective single-cohort observational study was initiated for seriously injured blunt trauma patients admitted to a Level I trauma center during a 7-month period. Patients were eligible for the study if time hospitalized was > or = 72 hours, Injury Severity Score (ISS) was > or = 9, enoxaparin was started within 24 hours after admission, and one or more of the following high risk criteria were met: age > 50 years, ISS > or = 16, presence of a femoral vein catheter, Abbreviated Injury Score (AIS) > or = 3 for any body region, Glasgow Coma Scale (GCS) Score < or = 8, presence of major pelvic, femur, or tibia fracture, and presence of direct blunt mechanism venous injury. Patients with closed head injuries and nonoperatively treated solid abdominal organ injuries were also potential participants. The primary outcomes measured were thromboembolic events--either a documented lower extremity DVT by duplex color-flow doppler ultrasonography or a PE documented by rapid infusion CT pulmonary angiography or conventional pulmonary angiography. RESULTS: There were 118 patients enrolled in the study. Two patients (2%) developed DVT, one of which was proximal to the calf (95% confidence interval, 0% to 6%). Two of 12 patients (17%) with splenic injuries who received enoxaparin failed initial nonoperative management. There were no other bleeding complications, and no clinical evidence or documented episodes of PE. One patient died from multiple system organ failure. CONCLUSIONS: Enoxaparin is a practical and effective method for reducing the incidence of VTE in high risk, seriously injured patients. This study supports further investigation into the safety of enoxaparin prophylaxis in patients with closed head injuries and nonoperatively treated solid abdominal organ injuries.

The high morbidity of blunt cerebrovascular injury in an unscreened population: more evidence of the need for mandatory screening protocols.

BACKGROUND: Blunt cerebrovascular injuries are rare injuries causing substantial morbidity and mortality. The appropriate screening methods and treatment options for these injuries are controversial. We examined our experience with these injuries at a community Level I Trauma center over a 51 month period. STUDY DESIGN: A retrospective review and analysis was done of all patients with the diagnosis of a blunt cerebrovascular injury during this period. RESULTS: Fourteen patients had blunt carotid injury (0.40%) and three had blunt vertebral injury (0.09%) out of 3,480 total blunt admissions. The overall incidence of blunt cerebrovascular injury was 0.49%. The most common associated injuries were to the head (59%) and chest (47%) regions. The overall mortality rate was 59% (10 of 17), with death occurring in 8 of 14 (57%) blunt carotid injury patients and 2 of 3 (67%) blunt vertebral injury patients. Eight of ten (80%) deaths were directly attributable to the blunt cerebrovascular injury. Median time until diagnosis was 12.5 h (range 1-336 h) for the entire group and 19.5 h for nonsurvivors. Diagnosis was delayed > 24h in 7 patients and > 48h in 5 patients. All five patients whose diagnoses were delayed > 48 h developed complications, and four (80%) of these patients died. CONCLUSIONS: Blunt cerebrovascular injury is uncommon, but lethal; particularly when the diagnosis is delayed. Aggressive screening protocols based on mechanism of injury, associated injuries, and physical findings are justified to minimize morbidity and mortality. Head and chest injuries may serve as markers for blunt cerebrovascular injury. Most deaths are directly attributable to the blunt cerebrovascular injury and not to associated injuries.

Ventilatory support in patients with ARDS.

Adult respiratory distress syndrome remains one of the most lethal conditions treated in surgical and medical intensive care units. Mortality rates of 50 per cent are still reported in recent reviews. Many risk factors are linked with an increased incidence of ARDS, but sepsis and direct pulmonary injury from aspiration, pulmonary contusion, and other forms of trauma are the most commonly associated risk factors. Studies implicate various cellular and chemical mediators associated with acute lung injury. Many pharmacologic agents and various forms of high-frequency ventilation are being studied for their effectiveness in treating ARDS. We consider that the standard treatment continues to be PEEP and mechanical ventilation to reverse hypoxemia linked with the pathophysiologic changes of ARDS. There are no prospective randomized studies comparing the various end points of therapy used clinically at present. We believe, however, that early intervention, with institution of ventilatory support as soon as signs of acute respiratory failure develop, may eliminate some deaths due to progressive hypoxemia leading to the full adult respiratory distress syndrome. Therapy should be started at this time and maintained while the etiologic factors are identified and treated. Minimal ventilatory support should be continued until the primary diseases have resolved and the multisystem impact of the critical illness has lessened. Weaning from inspiratory (IMV) support, manipulation of expiratory pressures (PEEP), and airway control should then be more easily accomplished and more successful in practice.

Laparoscopic diaphragm rupture repair.

Diaphragm rupture is an infrequently encountered but well-documented injury in the multiply injured patient. Only a few cases in which minimally invasive techniques were used for repair have been reported thus far. Herein we describe the repair of a diaphragm rupture in a 36-year-old man who was injured in a motor vehicle accident. In a 10-year review of the literature, we were able to locate seven journal articles reporting 10 patients. We conclude that in appropriate stable patients with diaphragm rupture, minimally invasive techniques offer a reasonable alternative to open laparotomy or thoracotomy.

Continuous monitoring of mixed venous oxygen saturation during aortofemoral bypass grafting.

Measurement of mixed venous oxygen saturation (SvO2) may be helpful in the care of critically ill patients. Serial determinations of SvO2 give an index of the relationship between oxygen delivery and tissue oxygen consumption. Continuous monitoring of SvO2 is now readily available with the Shaw Oximetrix pulmonary artery catheter (Oximetrix Inc., Mountain View, CA). This system has provided useful information in the high risk cardiac surgery patient. Continuous monitoring of mixed venous saturation may be helpful in high risk or critically ill general and peripheral vascular surgery patients both in the intensive care unit and in the operating room. The following clinical report is presented to illustrate the usefulness of continuous SvO2 monitoring in a high risk vascular surgery patient.

Hepatic artery aneurysm. Report of an unusual case and review of the literature.

Hepatic artery aneurysms are relatively infrequent lesions and may represent significant problems in both diagnosis and management. Indeed, as many as 30 to 50 per cent of cases are completely unsuspected and are discovered only at autopsy. A case of a very large hepatic artery aneurysm (greatest dimension of approximately 35 centimeters) presenting as an asymptomatic epigastric mass is reviewed, with emphasis on preoperative evaluation and operative technique. Selective arteriography was the cornerstone of diagnosis with other investigative modes proving not to be effective. Surgical therapy included obtaining proximal and distal control, meticulous ligation of the numerous feeding vessels, and finally evacuation and partial excision of the aneurysm sac with careful suture ligation obliteration of the orifice of each feeding vessel. Restoration of hepatic artery flow was not attempted and no compromise in liver function was seen in the postoperative period. The literature on hepatic artery aneurysms is reviewed to include typical presentation, diagnostic methods, surgical approach, and common complications. Only through a high index of suspicion and early angiography can this frequently fatal lesion be detected early in its course and subsequently be subjected to successful surgical management.

A prospective randomized study of drained and undrained cholecystectomies.

One hundred twenty-three patients undergoing elective cholecystectomy at USAF Medical Center Keesler were studied in a prospective randomized manner to determine the differences in morbidity and mortality following drained and undrained cholecystectomies. The groups were compared for differences in mortality, wound infection, postoperative fever, and length of hospitalization. One death occurred due to an unrelated cause in an undrained patient. Three per cent of the undrained group developed wound infections as compared to five per cent in the drained group. This was not statistically significant. A significant difference occurred in postoperative fever between the drained (58%) and undrained (30%) groups. Postoperative hospitalization was also significantly shorter in the undrained group. This study suggests that drainage following elective cholecystectomy is not only unnecessary, but may add to postoperative morbidity and length of hospitalization.

First Steps: participants and outcomes of a maternity support services program.

OBJECTIVE: To describe characteristics and pregnancy outcomes of participants in a maternity support program and to compare these characteristics and outcomes with those for women who were eligible for, but did not participate in, the program. DESIGN: Descriptive, ex post facto. SETTING: An inland northwest city. PARTICIPANTS: Two hundred twenty postpartum patients who received Medicaid during their pregnancy. MAIN OUTCOME MEASURE: Quantitative data were obtained from a structured interview that gathered demographic information. Subjects also completed the Social Support Apgar, an investigator-designed instrument. RESULTS: Demographic characteristics and overall pregnancy outcomes were similar for program participants and nonparticipants; however, more program participants than nonparticipants quit smoking during their pregnancy. CONCLUSIONS: Findings are consistent with results documented by other researchers on the effectiveness of similar programs in different locales. The findings support the need for continued efforts to better define appropriate target populations, interventions, and expectations for these programs.

Fibrocystic breast disease. An update and review.

Fibrocystic breast disease (FBD) is a benign condition that afflicts at least 50% of women of childbearing age. Because of the occurrence rate, the condition is sometimes referred to as a nondisease. The cause of FBD remains unknown, and treatment is only empirical. This article reviews normal breast anatomy and physiology, describes the morphological changes apparent in FBD, discusses current etiological theories and treatment modalities, and identifies nursing interventions relative to women with FBD.

Proximal ureteral avulsion from blunt abdominal trauma.

Blunt abdominal trauma which resulted in isolated avulsion of the ureter in a 19-month-old boy prompted a review of the literature to determine the pathophysiology and frequency of this injury. Fifty-four patients were identified and delay in diagnosis was the most common problem (33%). The authors discuss the controversies in management of this injury and recommend steps to ensure prompt recognition of ureteral avulsion from blunt trauma.

Conservative treatment for adenocarcinoma of the pancreas.

The records of 71 patients with the diagnosis of adenocarcinoma of the pancreas were reviewed. Seventeen patients were treated without surgery, 13 underwent exploratory laparotomy for diagnosis with no further palliative or curative operative procedure, six underwent pancreaticoduodenal resection, and 35 patients had a palliative gastric and/or biliary bypass procedure at initial operation. No preoperative signs or symptoms, routine laboratory tests, or radiologic evaluation were helpful as early diagnostic or prognostic indicators. Surgical mortality rates were not significantly different among the four groups; however, the survival time differences between the palliative group (4.8 mo) and the medically managed group (2.0 mo) was significant (p = 0.01 chi 2). Surgical morbidity did not differ significantly among the four groups of patients. The implications of these data in the treatment of patients with adenocarcinoma of the pancreas are discussed.