Sternoclavicular joint infection: a case report.

Infection of the sternoclavicular joint (SJI) is a rare problem accounting for approximately 1 % of cases of septic arthritis. Patients typically present with symptoms of localized pain lasting a period of several weeks with or without systemic signs of fever and chills. Confirmation is made by aspirating the joint, and broad spectrum antibiotics should be tailored to treat the identified organisms. SJI can be treated conservatively with intravenous antibiotics and repeat imaging, but surgical intervention is required if patients present with an abscess, osteomyelitis or mediastinitis.

Total parenteral nutrition in infants and children.

The current literature on pediatric parenteral alimentation, including some of its newer modifications, was reviewed. In light of this review, a 1-year experience with 20 patients on the pediatric surgical service of the Mayo Clinic who received total parenteral nutrition for a variety of life-threatening problems is reported. Our data confirm that premature infants, infants with intractable diarrhea, and both infants and adolescents with surgical problems precluding enteral feeding can be given sufficient parenteral kilocalories to regain lost weight and continue to grow, and that this can be done with a minimal rate of complications.

Pyloric antral mucosal webs.

The current literature on pyloric antral mucosal webs was reviewed. In addition, seven patients in the Mayo Clinic experience with pyloric antral mucosal webs are reported on. In recent years, four patients with significant obstructive symptoms thought to be caused by a mucosal web have had the diagnosis confirmed at surgery and have had excellent results from a variety of surgical procedures.

Correlation of immunologic and nutritional status with infectious complications after major abdominal trauma.

Examination of the response of injured patients' lymphocytes to the mitogen phytohemagglutin in a defined medium provides a mechanism to define the relationship between alteration in immune function and septic complications. Lymphocytes from 30 victims of gunshot wounds to the abdomen were examined. Response to mitogen was measured by incorporation of [3H]-thymidine as a function of lymphocyte concentration, with a constant amount of mitogen phytohemagglutinin and a standard incubation period. A saturation curve was obtained, and lymphocyte response was expressed as the concentration necessary for half-maximal incorporation of radioactive label, L1/2. Lymphocyte transformation was compared with that found in a group of 50 healthy volunteers. On arrival in the emergency center, the in vitro lymphocyte response of patients was markedly diminished. There were seven patients for whom a lymphocyte curve could not be generated, i.e., L1/2 greater than 1 X 10(6). For the other 23 patients, L1/2 = 4.75 X 10(5) (SEM - 7.5 X 10(4)) compared with L1/2 = 1.5 X 10(5) (SEM - 5 X 10(4)) for normal volunteers (p less than 0.01). Measurement of skin test response, white blood cell count, anthropometric measurements, and albumin level were not predictive of patient course. In contrast the in vitro lymphocyte viability corresponded to the degree of injury, and recovery of lymphocyte function was associated with improvement in the patient's clinical course.

Gallstone pancreatitis. The question of time.

Two hundred consecutive patients with gallstone pancreatitis were treated during a 6-year period; 92 patients were operated on after the acute attack subsided but during the same admission (group 1), 102 patients were discharged after recovery and scheduled for elective surgery (group 2), and the conditions of 6 patients deteriorated and they underwent emergency operation (group 3). All patients in group 3 had hemorrhagic pancreatitis. Mortalities for groups 1, 2, and 3 were 0%, 0%, and 50%, respectively. Although the outcome of patients in groups 1 and 2 was similar, only 60 of 102 patients in group 2 had their treatment completed. Furthermore, 29 (44%) of 65 patients who were followed up in group 2 suffered recurrent pancreatitis or biliary tract disease before elective surgery. The timing of surgery in patients whose conditions improve is not critical; however, patients whose conditions deteriorate after admission have severe disease with high morbidity and mortality.

Severe duodenal injuries. Treatment with pyloric exclusion and gastrojejunostomy.

During a 12-year period, 313 patients with duodenal injuries were treated. Primary repair, pyloric exclusion, and gastrojejunostomy were used in 128 patients (41%) with severe duodenal and pancreaticoduodenal injuries, to reduce "duodenal" morbidity and mortality. The duodenal fistula rate was 2.2% overall, and 5.5% in the patients undergoing exclusion. Only two deaths were due to fistulas. Forty-two patients underwent upper gastrointestinal tract examinations after operation. In patients examined 21 days or more after operation, 94% had a patent pylorus. Marginal ulceration was infrequent (four patients), as were complications associated with the procedure (3%). Pyloric exclusion with gastrojejunostomy is a quick and simple procedure that allows return of pyloric patency and is associated with a low incidence of duodenal fistulas. When fistulas do develop, they are usually easily controlled and are associated with a low mortality. We believe pyloric exclusion with gastrojejunostomy to be the procedure of choice in patients with severe duodenal and pancreaticoduodenal trauma.

Injury to popliteal vessels.

Between 1969 and 1981, 61 patients with 85 popliteal vascular injuries were seen. In the nine patients who required amputation, common risk factors included (1) extensive time delays (greater than 36 hours) between injury and repair, (2) associated bone and soft-tissue injuries leading to postoperative wound infection. amd (3) early occlusion of popliteal artery repair or delay in performance of fasciotomy. The low amputation rate in patients without operative delay or associated bone and soft-tissue injuries (2/54 = 3.7%) was attributed to the careful application of standard vascular surgery techniques in combination with early use of leg fasciotomy when indicated. Polytetrafluoroethylene grafts as substitute vascular conduits in the popliteal artery have an excellent patency rate and seem to be an acceptable prosthesis when segmental resection of the artery is necessary.

The catecholamine response to multisystem trauma.

We studied the catecholamine response in two groups of patients with multisystem injuries according to the presence (group 1, N = 124) or absence (group 2, N = 82) of head injury. Markers of injury severity included the injury Severity Score, the Glasgow Coma Scale, the need for intubation, admission hypotension, the amount of blood products and fluid expanders administered during the first 24 hours, and patient outcome. In group 1, higher norepinephrine levels always and epinephrine concentrations usually were associated with worsening indexes of injury severity. The best correlations were between the Injury Severity Score and the Glasgow Coma Scale and norepinephrine concentrations. In group 2, despite elevated catecholamine levels, such associations were seldom present. Thus, circulating catecholamine levels, especially norepinephrine levels, significantly correlated with the severity of injury in patients who had suffered multisystem injury, but only if the injury included the brain.

Lymphocyte function and abdominal operations. Trauma vs elective surgery.

An alteration of in vitro phytochemagglutinin-induced lymphocyte transformation immediately following abdominal trauma has been demonstrated. In this study the results of lymphocyte transformation in 30 patients who had suffered abdominal trauma (27 laparotomies; three observed) were compared with those of 20 patients who had undergone laparotomy for elective surgical problems. Response to mitogen was measured by incorporation of tritiated thymidine as a function of lymphocyte concentration, with a constant amount of phytochemagglutinin and a standard incubation period. A saturation curve was obtained, and lymphocyte response was measured as the concentration necessary for half-maximal incorporation of the radioactive label. No alteration of in vitro lymphocyte response was present in patients after elective abdominal or abdominal wall operations. In contrast, lymphocyte transformation was markedly depressed in patients who underwent surgery following abdominal trauma.

Emergency center arteriography in the evaluation of suspected peripheral vascular injuries.

From January 1982 through June 1983, 488 patients with suspected peripheral vascular injuries were examined with the use of 515 emergency center arteriograms performed by surgical residents via hand injection of contrast material using a single roentgenographic film. A total of 130 (25%) abnormal arteriograms resulted, including vascular spasm in nine instances and occlusion of noncritical arteries in 19 instances. One hundred two (20%) operations resulted from these abnormal emergency center arteriograms. A diminished pulse rate was the indication for performing 76 arteriograms, 52 (68%) of which were abnormal; however, only 43 patients from this group required surgery. Anatomic proximity to a major vessel was the sole indication for performing 352 arteriograms, 59 (17%) of which were abnormal. There was one false-normal arteriogram, one delayed development of an arteriovenous fistula, and four false-abnormal arteriograms. No complications of arteriography occurred during examination or at the time of clinic follow-up. Single-injection arteriography in the emergency center is a simple, sensitive, accurate, and cost-effective technique for the examination of patients with potential peripheral vascular injuries.

An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient.

BACKGROUND: The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected. STUDY DESIGN: An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification. RESULTS: One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery. CONCLUSIONS: Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.

Everything you wanted to know about Graves' disease.

Graves' disease is an autoimmune thyroid disease characterized by a genetic predisposition, an increased incidence in young women, the presence of thyroid-stimulating immunoglobulins, and an uncertain etiology. The onset occasionally follows a frightening episode in the patient's life or separation from a loved one. On physical examination, the patient has a diffuse goiter with secondary hyperthyroidism, a noninfiltrative/infiltrative ophthalmopathy, and, on occasion, an infiltrative dermopathy. Atypical symptoms, signs, and presentations such as "apathetic thyrotoxicosis" are not rare and may delay the diagnosis in some patients. The diagnosis is confirmed by elevations of bound thyroxine (T4), free T4, or bound triiodothyronine in the presence of thyroid-stimulating hormone levels of less than 0.1 mU/L. When the diagnosis is suspected, but unclear, the thyrotropin-releasing hormone stimulation test is indicated. Medical therapy must be long-term when propylthiouracil or methimazole is used, and results in only 25% to 50% remissions at 1 to 2 years. Radioactive iodine therapy has resulted in a need for retreatment in 25% to 33.7% of patients in the past, and hypothyroidism occurs in 70% to 100% of treated patients at 10 years, depending on the dose. Evolving changes in operative technique have led to a 95% to 100% cure rate with complications such as reoperation for hemorrhage (0% to 1.3%), recurrent nerve palsy (0% to 4.5%), and permanent hypocalcemia (0% to 0.6%) at extraordinarily low levels in experienced hands. Greater than 90% of patients have remained euthyroid 2 years after thyroidectomy in several series. Surgery continues to offer the highest cure rate in the shortest period of time.

Parathyroid pathology in an intrathyroidal position.

A systematic approach based on the embryology of the parathyroid glands should allow for the appropriate identification of both normal and abnormal glands at the time of parathyroidectomy. The exact role of subtotal thyroidectomy as part of this approach remains in question because of the low incidence of intrathyroidal adenomas reported in the past. From 1978 to 1992, 97 cervical explorations were performed in 96 patients (mean age: 56 years) with hyperparathyroidism. Four patients (4%) were found to have intrathyroidal parathyroid adenomas and were cured by ipsilateral partial or subtotal thyroid lobectomy on the side of a missing gland. One parathyroid adenoma completely replaced the right lobe of the thyroid, whereas two inferior and one superior intrathyroidal adenomas were found in the remaining three patients. The 4% incidence of intrathyroidal adenomas is higher than that reported in most series and suggests that this entity may be a more common cause of failed parathyroid explorations than is currently thought. Ipsilateral thyrotomy or subtotal thyroid lobectomy continues to be a potentially curative procedure for hyperparathyroidism when there is a missing and presumably diseased superior or inferior gland.

Vagaries of the lavage white blood cell count in evaluating abdominal stab wounds.

BACKGROUND: The clinical value of an elevated white blood cell (WBC) count on a diagnostic peritoneal lavage (DPL) performed in an asymptomatic patient with a penetrating abdominal stab wound is controversial. METHODS: We performed a comprehensive analysis of asymptomatic patients (no signs of peritonitis) with stab wounds who underwent an exploratory laparotomy based solely on a WBC count > 500/mm3 in the effluent of an open DPL. RESULTS: Twenty-eight patients, 25 with injury to the gastrointestinal (GI) tract and 3 with injury to the liver, obtained true-positive results from DPL. Their mean WBC count in lavage effluent obtained at a mean of 7.6 hours after the stab wound was 3,380/mm3 and their mean serum WBC count, obtained at the same time, was 12,324/mm3. Fifteen patients had false-positive results from DPL. They were lavaged at a mean of 7.2 hours after the stab wound, and had a mean lavage WBC count of 1,228/mm3 and a mean serum WBC count of 9,084/mm3. CONCLUSIONS: Patients lavaged at a mean 6 to 7 hours after an abdominal stab wound will have a significant incidence of false-positive studies based on an elevated WBC count alone. Lavage WBC counts > 3,000/mm3, particularly when associated with a serum WBC count > 11,000, are likely to be true positives and to indicate injury to the GI tract.

Arteriography performed in the emergency center.

Arteriography is a sensitive, accurate diagnostic tool for the evaluation of suspected peripheral arterial injuries. A single hand injection study in the emergency center offers a simple, cost-effective, and time-saving maneuver for accomplishing this goal. It is noteworthy that the techniques described are performed with only a minimum of equipment and demand no special training on the part of the radiologic technician. Emergency center arteriography can be beneficial for ruling out suspected peripheral vascular injury in the massively injured patient who will require other extensive procedures. However, the procedure described is probably most beneficial for excluding potential injury in the patient who has no sign of arterial injury other than anatomic proximity of a blunt or penetrating injury to a peripheral vessel. It is true that many surgeons will not order formal arteriograms on an emergency basis for the asymptomatic patient with normal distal pulses, yet we have found that 13 percent of such patients require operative intervention for an arterial injury. It is in precisely this setting that the surgeon can perform a rapid arteriogram in the emergency center. After a negative arteriogram is obtained, the patient can be discharged from the emergency center or admitted for observation with the assurance that arterial injury is absent.

Injuries of the inferior vena cava.

Beginning in 1946, 577 patients with inferior vena cava injuries were managed at a single institution. After decreasing from 37 to 30 percent, the mortality rate showed a distinct increase in the last 7 years studied. This increase was related to an increasing percentage of patients who arrived in the emergency center in severe shock and required resuscitative thoracotomy. In-hospital care advances have not kept pace with improvements in prehospital care. Although venous complications have not been infrequent, morbidity has not been a significant long-term problem. Fatal pulmonary embolism occurred and was a special problem for patients over the age of 50. More basic research is needed to expedite diagnosis and vascular control in addition to understanding and treating the severe metabolic problems of patients dying from shock and hemorrhage.

Renovascular trauma.

One hundred fifty-four patients with renovascular injuries were analyzed to gain insight into the mortality, morbidity and indications for immediate nephrectomy versus arterial revascularization. Arterial revascularization is seldom indicated in patients with a normal contralateral kidney who have multiple associated injuries, hilar injuries, long segmental arterial injuries or prolonged renal ischemia. An attempt at renal artery revascularization is justified with bilateral injuries, when only one kidney is present or when a solitary artery injury can be repaired by simple lateral arteriorrhaphy.

Major complications of percutaneous subclavian vein catheters.

New and reportedly safet techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature [55--59]; yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal of unnecessary catheters, and improved equipment should help to prevent these complications in the future.

Intraabdominal abscess after penetrating abdominal trauma.

In 57 (2.4 percent) of 2,416 patients undergoing laparotomy for penetrating abdominal trauma from 1977 to 1980, an intraabdominal abscess developed in the postoperative period. Preoperative antibiotic administration, careful closure of gastrointestinal tract perforation with diversion as necessary, and copious irrigation of the peritoneal cavity at the completion of surgery were common factors in all operations. Over 80 percent of penetrating wounds leading to abscesses occurred in the upper quadrants, and common risk factors included multiple intraabdominal solid organ injuries requiring open drainage, coupled with gastrointestinal tract perforation. Physician delay in the recognition of patients with intraabdominal abscess and in reoperation was a common problem.

Delayed diagnosis of arterial injuries.

During an 8 1/2 year period, 28 patients with a delayed diagnosis of an arterial injury in an extremity or the neck were treated. The median delay between injury and diagnosis was 10 days. The tibio-peroneal arteries were the most commonly injured vessels. After extensive analysis of the records and arteriograms of the involved patients, the following conclusions were drawn: Arteriograms are mandatory for penetrating wounds proximal to major arteries of the extremities because of the 5 to 15 percent incidence of occult injuries; the timing of arteriography in the distal leg is critical if subtle injuries to the tibial and peroneal vessels are to be detected; when experienced radiologists are not available, interpretation of exclusion arteriograms is best performed by experienced trauma surgeons; false aneurysms, arteriovenous fistulas, or a combination of both continue to be the most common manifestations of missed arterial injuries; failure to find an injury previously diagnosed by a preoperative arteriogram mandates an intraoperative arteriogram and, on occasion, an arteriotomy; and, late arterial repairs usually require segmental resection with an end-to-end anastomosis or insertion of a graft.