Military training at civilian trauma centers: the first year's experience with the Regional Trauma Network.

The Regional Trauma Network was launched in 1996 to provide trauma training opportunities for Army surgeons in the Southeast Regional Medical Command. Training directors at eight civilian level I trauma centers agreed to allow military surgeons to function at the fellowship level of responsibility for up to 30 days at a time. In the first year, 7 surgeons participated in rotations at five different centers and 13 surgeons attended nationally recognized trauma symposia. The response from participating civilian and military participants has been overwhelmingly positive as confidence and enthusiasm for treating seriously injured patients are refreshed. Significant lessons were learned in providing good clinical training experiences, administering a regional program, and measuring the costs and benefits of additional readiness training. Although the data collection processes were devised to capture both the actual and the opportunity costs of training at civilian centers, more participants are needed before a conclusive analysis can be made. A joint services effort on a regional basis and support throughout the chain of command are key to strengthening the surgical readiness training program.

Thigh pain and total hip arthroplasty: scintigraphy with 2.5-year followup.

From January 1988 to May 1990, 60 patients underwent 68 total hip arthroplasties at the Eisenhower Army Medical Center. The authors excluded 11 patients (11 hips) in whom infection developed, who were lost to followup, or who had incomplete records, leaving 49 patients (57 hips) as the study population. The 35 uncemented and 22 cemented femoral stems were evaluated with technetium bone scans at 1 week, 6 months, 1 year, and 2.5 years after surgery. Patients with uncemented femoral stems had markedly more thigh pain and more radiopharmaceutical uptake around the stem tip at 2.5 years followup than did patients with cemented femoral stems. In addition, patients with thigh pain had more uptake around the stem tip and a higher incidence of bone hypertrophy around the stem tip than did those without thigh pain, suggesting stress transfer as a cause of thigh pain.

Pneumocystis carinii pneumonia presenting as focal bibasilar uptake on gallium scan during aerosolized pentamidine prophylaxis.

Radionuclide imaging with gallium is commonly performed in the evaluation of patients with suspected Pneumocystis carinii pneumonia (PCP) and is known to be highly sensitive for detection of PCP. We present a patient with acquired immunodeficiency who developed PCP in the bases of both lungs while on aerosolized pentamidine prophylaxis. A gallium scan demonstrated focal uptake in the lung bases, a pattern generally not associated with PCP, and was extremely useful in guiding bronchoscopy. An aerosol ventilation scan performed after complete resolution of the clinical illness demonstrated prominent ventilatory defects in the lung bases corresponding to the regions of previous gallium uptake. We speculate that the underlying ventilatory abnormality may have contributed to poor drug delivery to the lung bases. Pneumocystis carinii pneumonia must be considered with any focal area of gallium accumulation in patients receiving aerosolized pentamidine.

False-positive radionuclide arthroscintigraphy with a porous-coated total hip prosthesis.

The evaluation of a painful hip prosthesis for suspected loosening frequently requires a multi-modality approach. Radionuclide arthroscintigraphy is a valuable adjunct to contrast arthrography, demonstrating greater sensitivity than contrast arthrography in detecting loosening of the femoral component of the prosthesis. Despite its reliability in the evaluation of cemented hip prostheses, the value of arthroscintigraphy in patients with uncemented or porous-coated prostheses is undetermined. The case of a false-positive radionuclide arthroscintigram in a patient with an uncemented prosthesis is reported. The literature is briefly examined, and the potential implications regarding interpretation of arthroscintigraphy in patients with porous-coated prostheses are discussed.

Treatment of radiation- and chemotherapy-induced stomatitis.

Severe stomatitis is a common problem encountered during either radiation therapy or chemotherapy. Most therapeutic regimens are empirical, with no scientific basis. The purpose of this study is to determine the efficacy of various topical solutions in the treatment of radiation- or chemotherapy-induced stomatitis. Eighteen patients were entered into a prospective double-blinded study to test several topical solutions: (1) viscous lidocaine with 1% cocaine; (2) dyclonine hydrochloride 1.0% (Dyclone); (3) kaolin-pectin solution, diphenhydramine plus saline (KBS); and (4) a placebo solution. Degree of pain relief, duration of relief, side effects, and palatability were evaluated. The results showed that Dyclone provided the most pain relief. Dyclone and viscous lidocaine with 1% cocaine provided the longest pain relief, which averaged 50 minutes This study provides objective data and defines useful guidelines for treatment of stomatitis.

The acetabulum: a prospective study of three-phase bone and indium white blood cell scintigraphy following porous-coated hip arthroplasty.

Although few studies address the use of three-phase bone scanning (TPBS) and indium-111-labeled white blood cell scintigraphy (111In-WBC) in hip arthroplasty utilizing a porous-coated prosthesis, the literature suggests that scintigraphic patterns in the uncomplicated patient may differ form that seen with the cemented prosthesis. In an attempt to determine the scintigraphic natural history, 25 uncomplicated porous-coated hip arthroplasties in 21 patients were prospectively studied with serial TPBS and 111In-WBC at approximately 7 days, and 3, 6, 12, 18, and 24 mo postoperatively. This report deals with findings related to the acetabulum. All 25 prostheses (144 of 144 scans) demonstrated increased uptake on the bone-phase images. Although this activity decreased with time, 76% had persistent uptake at 24 mo. Twenty-three of 25 prostheses (126 of 140 scans) showed increased uptake on 111In-WBC scintigraphy, invariably decreasing with time, but with 37% having significant uptake at 24 mo. Scintigraphic patterns in the uncomplicated porous-coated hip arthroplasty patient appear to differ from patterns described in cemented prostheses.

Three-phase bone scan and indium white blood cell scintigraphy following porous coated hip arthroplasty: a prospective study of the prosthetic tip.

Although few reports address the use of three-phase bone scanning (TPBS) and 111In-labeled white blood cell (In-WBC) scintigraphy in hip arthroplasty utilizing a porous coated prosthesis, the literature suggests that scintigraphic patterns in the uncomplicated patient may differ from that seen in the cemented prosthesis. In an attempt to determine the scintigraphic natural history, 25 uncomplicated porous coated hip arthroplasties in 21 patients were prospectively studied with serial TPBS and In-WBC at approximately 7 days, and at 3, 6, 12, 18, and 24 mo postoperatively. This report deals with findings related to the prosthetic tip. Only one of 136 flow studies were abnormal and only two of 136 blood-pool images demonstrated focally increased activity. All 25 prostheses (120 of 143 scans) demonstrated increased uptake on the bone phase images. The area about the tip was divided into three segments; increased uptake at 24 mo was noted in the medial, distal, and lateral segments in 16%, 72%, and 56% of prostheses, respectively. Twenty of 25 prostheses (82 of 142 scans) showed uptake on In-WBC scintigraphy, being noted in 48% of prostheses at 24 mo. We conclude that scintigraphic patterns in the uncomplicated patient with a porous coated prosthesis appear to differ from patterns described in cemented prostheses.

Intrapleural tetracycline in malignant pleural effusions. A randomized study.

Intrapleural instillation of tetracycline (TCN) has been shown to be effective in preventing the recurrence of malignant pleural effusions. Although the precise mechanism of action is unknown, it has been postulated that the pH of the TCN solution may be an important factor. Thirty patients with malignant pleural effusions were randomized in a double-blind trial to receive intrapleural administration of either 500 mg of tetracycline in solution (pH = 2.8) or a solution of similar pH and appearance. All patients had chest tube drainage of their effusion. There were 24/30 patients evaluable. There were 9/13 patients in the TCN group and 1/9 patients in the control group who had no reaccumulation of fluid (P less than 0.05). These results would suggest that the efficacy of TCN as a sclerosing agent is not related to its acidic pH and that intrapleural TCN is more effective than chest tube drainage alone for control of malignant effusions.