Climate change and the green energy paradox: the consequences for twaite shad Alosa fallax from the River Severn, U.K.

A stock-recruitment model with a temperature component was used to estimate the effect of an increase in temperature predicted by climate change projections on population persistence and distribution of twaite shad Alosa fallax. An increase of 1 and 2° C above the current mean summer (June to August) water temperature of 17·8° C was estimated to result in a three and six-fold increase in the population, respectively. Climate change is also predicted to result in an earlier commencement to their spawning migration into fresh water. The model was expanded to investigate the effect of any additional mortality that might arise from a tidal power barrage across the Severn Estuary. Turbine mortality was separated into two components: (1) juvenile (pre-maturation) on their out migration during their first year and on their first return to the river to spawn and (2) post-maturation mortality on adults on the repeat spawning component of the population. Under current conditions, decreasing pre-maturation and post-maturation survival by 8% is estimated to result in the stock becoming extinct. It is estimated that an increase in mean summer water temperature of 1° C would mean that survival pre and post-maturation would need to be reduced by c. 10% before the stock becomes extinct. Therefore, climate change is likely to be beneficial to populations of A. fallax within U.K. rivers, increasing survival and thus, population persistence.

Effect of the duration of symptoms, transport time, and length of emergency room stay on morbidity and mortality in patients with ruptured abdominal aortic aneurysms.

BACKGROUND: Despite improvements in emergency medical services, surgical technology, and postoperative critical care, ruptured abdominal aortic aneurysm (AAA) is associated with constantly high morbidity and mortality. To determine the effect of the duration of symptoms, transport time to hospital, and length of emergency department assessment on outcome, we evaluated 124 consecutive patients with ruptured AAA treated during the past decade. METHODS: The medical records for 122 patients were abstracted for preoperative hypotension, cardiopulmonary resuscitation (CPR), blood loss, and three time intervals: symptom onset to operation, transport time to hospital, and emergency department assessment. RESULTS: Intraoperative mortality was 26% (n = 32), 30-day mortality was 51% (n = 63), and cumulative hospital mortality was 56% (n = 69). Death occurred in 52 (64%) of 81 patients with hypotension compared with 14 (35%) of 40 patients without hypotension (p < or = 0.01). Hypotension was present in 37 (82%) of 45 patients who arrived in the operating room in 2 hours or less compared with 26 (60%) of the 43 patients who arrived later than 2 hours (p < or = 0.05). Death followed in 21 (91%) of 23 patients who received CPR compared with 46 (46%) of 99 patients who did not receive CPR (p < or = 0.01). Bowel ischemia was observed in 18 (30%) of 60 patients who received more than 10 units of blood compared with 3 (5%) of 61 patients who received 10 units or less (p < or = 0.01). CONCLUSIONS: For patients with ruptured AAA, prolonged presurgical time was associated with a more hemodynamically stable patient and a lower mortality. Progressive bleeding in those hemodynamically stable patients was reflected by a larger blood transfusion requirement. Such patients exhibited an increased incidence of ischemic bowel complications, perhaps caused by splanchnic arterial ischemia augmented by preexisting atherosclerosis, as well as extrinsic compression by mesenteric hematomas.

Shock-associated right colon ischemia and necrosis.

Ischemic complications associated with hemorrhagic shock after blunt or penetrating trauma can result in acute renal, pulmonary, or hepatic failure. Less well described is the association between hemorrhagic shock and ischemic necrosis of the right colon, with only 14 cases reported in the literature. Herein, we report three previously healthy young trauma victims with shock-associated right colon necrosis. Each patient suffered a period of hypotension after injury. Diagnosis and operation took place within 2 days of initial injury in all three cases. In each patient, a right colectomy and primary anastomosis was performed without complication. Pathologic examination of the resected specimens showed ischemic necrosis, but no evidence of vascular thrombosis or embolic occlusion of the mesenteric vessels. The etiology of this type of ischemic colitis is not clear, but seems to represent a form of nonocclusive mesenteric ischemia. Knowledge of this disease process will lead to early recognition, prompt treatment, and a satisfactory outcome.

Soft tissue abscesses associated with parenteral drug abuse: presentation, microbiology, and treatment.

Abscess formation at the site of drug injection is the commonest infectious complication in drug addicts. This study characterizes the clinical presentation of the condition, its current microbiology, and treatment outcome. All patients presenting for treatment of soft tissue abscesses associated with parenteral drug abuse over a 21-month period were studied. Sixty-six patients with 70 subcutaneous abscesses after injection of cocaine (85%), heroin (5%), or unreported drugs (10%) were identified. Only 42% were febrile (T > 37.5 degrees C), 54 percent had leukocytosis, and 47 percent had wound fluctuance. Wound cultures (243 isolates in 57 patients) grew predominately anaerobes (143 isolates) and facultative gram-positive cocci (88 isolates). Twenty-six blood cultures were obtained, and five (19%) were positive, two with the same bacteria isolated from the wound. Of the patients tested, 29 percent were positive for hepatitis B surface antigen and 9 percent for HIV. Simple incision and drainage was effective in all cases. Classical signs and symptoms of infection and abscess formation may be absent in this patient population. Many of these patients carry other blood-borne infections which the health professional must guard against. Cocaine injection, and "mixed" aerobic-anaerobic infections predominated, in contrast to earlier reports, when narcotics and aerobes predominated. Simple incision and drainage is adequate treatment; antibiotics, when given, should cover gram-positive and anaerobic bacteria; gram-negative coverage is unnecessary.

Pyoderma fistulans sinifica (fox den disease): a distinctive soft-tissue infection.

Pyoderma fistulans sinifica (PFS, also referred to as fox den disease because its multiple fistulae and sinuses resemble the structure of a fox den) is a distinct chronic infectious disease in which epithelialized tracts form within the subdermal fatty tissue. PFS, which has not been previously described in the English-language literature, must be differentiated from hidradenitis suppurativa, pilonidal sinus, and perianal fistula. The fistulous tracts of PFS are always lined by stratified squamous-cell epithelium but, unlike those of hidradenitis, reach deep into the subcutaneous fat, run epifascially for long distances, and have no relation to skin appendices. We report on 10 men (mean age +/- SD, 36 +/- 5 years) with PFS (mean duration +/- SD, 11 +/- 7 years). Bacterial cultures of affected tissue from these patients yielded a total of 14 facultative and 31 obligate anaerobic species. Treatment consisted of wide en-bloc excision down to the fascia, including all fistulae. Antibiotic therapy temporarily reduced purulent discharge but did not eradicate the infection. Two patients who underwent fistulotomy without wide en-bloc excision developed recurrences.

Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians.

The objective of this prospective study was to determine the sensitivity, specificity, and accuracy of the rapid trauma ultrasound examination, performed by emergency physicians, for detecting free peritoneal and thoracic fluid in patients presenting to a level I trauma center with major blunt or penetrating torso trauma. Emergency medicine residents and faculty were trained to perform an ultrasound examination of the torso evaluating for free intraperitoneal, retroperitoneal, pleural, and pericardial fluid. In the 245 study patients, emergency physicians examined 975 intracavitary spaces and demonstrated 64 positive findings for free fluid as documented by computed tomography scan, diagnostic peritoneal lavage, exploratory laparotomy, chest radiography, tube thoracostomy, or formal two-dimensional echocardiography. The rapid trauma ultrasound examination was 90% sensitive, 99% specific, and 99% accurate. Ultrasonography can serve as an accurate diagnostic adjunct in detecting free peritoneal and thoracic fluid in trauma patients. Appropriately trained emergency physicians can accurately perform and interpret these trauma ultrasound examinations.

Cefotaxime and metronidazole in severe intra-abdominal infection.

To assess the efficacy of cefotaxime in the treatment of severe intra-abdominal infections, we reviewed the bacteriology of secondary peritonitis and evaluated the efficacy of cefotaxime and metronidazole in 79 patients undergoing staged abdominal repair. We were able to demonstrate that the combination of an aggressive surgical policy with an effective antimicrobial regimen eliminates pathogens from the previously infected peritoneal cavity. Additional improvement in results awaits further advances in supportive care and/or methods to reverse the cascades of the excessive inflammatory or cytokine responses.

Tracheoesophageal fistula after blunt chest trauma.

Tracheoesophageal fistula is a very rare but potentially life-threatening complication of blunt chest trauma. Prior reviews have revealed that the victims were all young men involved in deceleration or crush injuries. Of those involved in motor vehicle accidents, most were thrown against the steering wheel. Herein, we review the world literature on this injury and include our own report of 1 of the few cases of traumatic tracheoesophageal fistula involving a female victim. In this case, the victim was an unrestrained driver thrown against an air bag.

Emergency airway management in hanging victims.

STUDY OBJECTIVE: To determine the incidence, demographics, clinical indicators of survival, and frequency of cervical-spine fractures to define appropriate emergency airway management in hanging victims. DESIGN: Medical examiner records, paramedic reports, and emergency department and hospital medical records were reviewed retrospectively for the period January 1, 1978, to January 1, 1990. SETTING: Urban paramedic system with nine receiving hospitals. PARTICIPANTS: A total of 160,724 medical examiner and paramedic records were reviewed to identify a total study population of 306 hanging victims. One hundred eighty-two victims (59%) were found dead at the scene, and the emergency medical system was not notified. An additional 57 (19%) were seen by paramedics and declared dead at the scene. Sixty-seven (22%) were treated and transported to nine receiving EDs; 39 of these 67 received oral or nasal endotracheal intubation. RESULTS: The incidence of hanging was 0.19% of all medical examiner cases and paramedic runs during the 12-year study. Those hanging victims who survived to receive paramedic transport and treatment by physicians were typically male and attempted suicidal hanging in a public place (most frequently jail) with available bedding or clothes. No hanging victim treated and transported by paramedics had documentation of cervical-spine or spinal cord injury. CONCLUSION: In nonjudicial hanging victims seen by paramedics and transported to an ED, cervical-spine injury is rare. Cerebral hypoxia rather than spinal cord injury is the probable cause of death and should be the primary concern in treatment of this patient population. Following external stabilization of the neck, nasal or oral endotracheal intubation is appropriate emergency airway management in hanging victims.

Motorboat propeller injuries in Wisconsin: enumeration and prevention.

STUDY OBJECTIVE: To ascertain the nature and extent of motorboat propeller injuries in Wisconsin. DESIGN: Retrospective study of deaths and injuries from outboard motor propellers reported to the Wisconsin Division of Health, Vital Statistics, and reported by a statewide retrospective survey of emergency departments. RESULTS: For the study period 1987 through 1989, three fatalities were found in Vital Statistics and Emergency Department records and 14 nonfatal injuries reported by respondents to the Wisconsin emergency department survey. Thirty-six percent (5 of 14) of the nonfatal injuries occurred in water skiers. Injuries involved the lower extremities in 10 of 14 nonfatal cases (71%), frequently in association with other anatomic areas. At least three cases involved very severe injuries, with mean acute care medical charges of more than $100,000 per case. CONCLUSIONS: Where boating is common, fatal and severe injuries from propellers occur with regularity. These injuries are often severe, requiring complicated and expensive treatment. The authors urge improved documentation of the incidence of propeller injuries, and an active exploration of prevention strategies including fitting motorboat propellers with guards.

A profile of geriatric trauma in southeastern Wisconsin.

The purpose of this study was to profile geriatric trauma in southeastern Wisconsin, including injury mechanisms, severity of injury, outcome, hospital lengths of stay, and total cost. We conducted a retrospective chart review of trauma victims over age 65 admitted to the Milwaukee County Medical Complex between July 1991 and October 1992. Cases were excluded if the patients had sustained isolated head or orthopedic injuries, thermal burns, or penetrating trauma. A total of 65 cases were studied. The population had a mean age of 75.8 +/- 8.2 years; 53.8% were women and 46.2% were men. The leading mechanisms of injury were in decreasing order were motor vehicle crashes, falls, and auto-pedestrian injuries. The mortality rate was 29.2%. The mean length of stay in the hospital was 13.5 days. The total charge was approximately $1.3 million dollars. Motor vehicle crashes accounted for 61.5% of injuries. Safety devices and driver awareness programs may be under used in this population. The mortality rate is high with a moderate level of injury severity.

Fatal childhood injury patterns in an urban setting.

STUDY OBJECTIVE: To describe fatal childhood injury patterns in an urban county and evaluate the use of the emergency medical services system. DESIGN: Retrospective chart review of medical examiner files, prehospital and hospital records, and police and fire personnel reports. SETTING: Milwaukee County, Wisconsin, an urban county with a population of approximately 1 million. PARTICIPANTS: All children 15 years old or younger who sustained a fatal injury in 1989 or 1990 (70). RESULTS: House fires were the leading cause of death by injury (34%), followed by firearms (19%), and drowning (11%). Motor vehicle occupant deaths occurred less frequently (7%). One-third of deaths were homicides (48% firearms and 30% assault). Twenty-four percent of deaths were pronounced at the scene, 12% were dead-on-arrival (no emergency department resuscitative efforts), and 37% were dead-on arrival ED resuscitations. Only 27% of victims survived to become inpatients (84% died within 72 hours). Mean scene time (16.1 +/- 7.9 minutes), transport time (9.5 +/- 5.1 minutes), and success rates for prehospital peripheral IV insertion (72%), endotracheal intubation (91%), and intraosseous line (86%) were not significantly different among those who were dead-on-arrival, dead-on-arrival failed resuscitations, or eventual inpatients. CONCLUSION: Fatal childhood injury patterns in this urban setting differed from reported national injury patterns. This study found a higher percentage of deaths from fire, gunshot wounds, and homicides but a lower percentage of motor vehicle-related deaths. Prevention strategies need to address the injury patterns of a particular community. Only a small percentage of victims survived to receive inpatient care following their injuries, suggesting that primary prevention of injury may be the most effective intervention.

Human immunodeficiency virus and infectious considerations.

In summary, HIV is a retrovirus with devastating consequences for those infected. Primary modes of transmission are through sexual contact and parenteral exposure to infected blood and body fluids. Prevalence of the virus among trauma patients, risk of exposure, and infection of health care workers are variable and to a large extent not known. Existing HIV infection and AIDS have both direct and indirect effects on care and outcome of trauma patients. Caring for these patients presents many challenges. Manifestations and complications of each condition may mask, mimic, or compound the other. Optimal care and outcome depend on knowledge of both diseases, and the specific nuances of their management. As with all trauma patients, a team approach coordinated by an identified team leader is indicated. Finally, to protect both the patient and the care giver, policies that effectively reduce exposure must be formulated, promulgated, and practiced.

Characteristics of trauma centers and trauma surgeons.

We surveyed directors of trauma at 408 trauma centers (as indicated by the state chairmen of the American College of Surgeons' Committee on Trauma [ACSCOT]). Of the 408 trauma directors 290 (71%) responded with information relative to their hospitals and the 1537 general surgeons taking trauma call. Altogether, 75% of the surgeons worked on an identified trauma service, 80% belonged to a cadre of surgeons identified as expert, 52% were viewed as full time, 25% provided in-house staff coverage, and 76% had completed an ATLS course. Six percent of the entire group were 60 to 73 years old and demonstrated a commitment to trauma equal to that of their younger cohorts. As a group, the older surgeons took less call, but when community or the institutional call needs were identified, the older surgeons met the challenge.

Laparoscopic closure of gastric stab wounds: a case report.

For years laparoscopy has been used selectively in the diagnosis of blunt and penetrating injuries to the abdomen. Recent advances in instrumentation have taken laparoscopy beyond its limited role in diagnosis. Use of the laparoscope for therapeutic intervention in selected cases of abdominal trauma is now possible. Here we report the use of laparoscopic techniques to diagnose and treat two stab wounds to the anterior wall of the stomach.

A burr-like device to facilitate temporary abdominal closure in planned multiple laparotomies.

OBJECTIVE: To describe and test a method for temporary closure of the abdomen. DESIGN: Open laboratory and clinical studies. SETTING: Department of Surgery, Medical College of Wisconsin, USA. SUBJECTS: 11 patients who underwent planned relaparotomy. MATERIAL: The burr consists of two adherent sheets of polyamide and polypropylene, which may be trimmed to accommodate any wound. One sheet consists of micro-mushrooms, the second of multiple slings. The two sheets stick to each other upon pressure and can easily be separated to open the wound. INTERVENTION: Planned relaparotomy or staged abdominal repair. OUTCOME MEASURES: Measurements of tensile strength and microbiological cultures. RESULTS: The shearing force required to separate the burr is 150 +/- 27 N/5 cm2 when gas sterilized and 77 +/- 11 N/5 cm2 when used in five subsequent laparotomies. No adverse microbiological effects were seen. CONCLUSION: The artificial burr can be used for temporary closure of the abdomen. It circumvents the problems that occur with zip fasteners, Marlex mesh, slide fasteners, and towel clips.

Pitfalls in the use of color-flow duplex ultrasound for screening of suspected arterial injuries in penetrated extremities.

We compared color-flow duplex ultrasonographic scanning (CFD) to arteriography in 67 patients who sustained 75 penetrating injuries to the extremities without obvious arterial injury. There were 72 negative and three (4.0%) positive CFD studies and no failed attempts. With arteriography as the "gold standard," CFD had a specificity of 99% and a sensitivity of 50%, positive and negative predictive values of 66% and 97%, and an accuracy of 96%. Small pseudoaneurysms were missed in an axillary and an aberrant radial artery, and a genicular artery pseudoaneurysm was misread as originating from the popliteal artery. Cautious interpretation of negative studies appears warranted, particularly in the axilla and in bifurcated arteries. Extremity arteries should be completely imaged to rule out aberrant anatomy. Questionable studies should be confirmed arteriographically. With these caveats, color-flow duplex scanning may be useful for screening extremities with penetrating injuries thought to harbor occult arterial injuries.

Evaluation of traumatic aortic injury: does dynamic contrast-enhanced CT play a role?

To investigate the value of 5-mm contrast material-enhanced computed tomography (CT) in patients with moderate to low probability of aortic laceration after a substantial deceleration injury, scans were obtained through the upper mediastinum in 160 consecutive patients. Thoracic angiography and aortography were performed in patients with evidence of mediastinal hemorrhage at CT. There was no evidence of mediastinal hemorrhage in 132 patients with normal admission chest radiographs. In the 28 patients with abnormal admission chest radiographs, CT helped exclude mediastinal hemorrhage in 22 patients (78%), and 19 patients (68%) were treated without undergoing angiography. Six patients had mediastinal hematoma at CT. Only one had an aortic laceration at angiography. The authors conclude that 5-mm contrast-enhanced CT can help exclude mediastinal hemorrhage and reduce the angiography rate in low-to-moderate-risk patients with a widened or indeterminate mediastinum. There were no unsuspected cases of mediastinal hemorrhage in patients with normal chest radiographs. Angiography is recommended for patients considered to be at high risk for aortic laceration.

Prehospital bicarbonate use in cardiac arrest: a 3-year experience.

The American Heart Association no longer recommends the routine use of sodium bicarbonate in cardiac arrests. Reasons cited include the lack of documented effect on clinical outcome and potential adverse effects of metabolic alkalosis and hypernatremia. We reviewed 36 months of experience with 619 nontrauma adult, prehospital cardiac arrest patients to identify 273 successful resuscitations who had emergency department blood gases and electrolytes performed. Determination of complications associated with prehospital intravenous sodium bicarbonate and its impact on survival in resuscitated patients was undertaken. Fifty-eight patients did not receive sodium bicarbonate (NO HCO3 group) and had short cardiopulmonary resuscitation (CPR) times (7.4 +/- 5.5 minutes). Two hundred fifteen patients did receive sodium bicarbonate (HCO3 group) and had significantly longer CPR times (23.3 +/- 13.5 minutes, P less than or equal to .001). Both groups demonstrated routine early chest compression and hyperventilation as evidenced by no significant difference in paramedic response time or rate of intubations. Initial emergency department blood gas results of both groups were not significantly different. No patients in the NO HCO3 group had hypernatremia (sodium [Na]+ greater than 150), whereas four patients (2%) in the HCO3 group were hypernatremic. Eight patients (14%) in the NO HCO3 group and 37 patients (17%) in the HCO3 group were alkalotic with pH values greater than 7.49 (P = NS). Six patients (10%) of the NO HCO3 group and 24 patients (11%) of the HCO3 group had a metabolic component to the alkalosis as defined by a positive base excess value (P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)