Three-dimensional facial architecture in normodivergent class I Caucasian subjects.

INTRODUCTION: The aims of this study were to (1) define facial architecture in Caucasian patients with normodivergent, skeletal and dental class I using Treil's cephalometric analysis, which is based on computed tomography (CT), and (2) develop a scheme to determine individual balance or normality in relation to linear, angular and volumetric parameters. MATERIAL AND METHODS: The CT data of 60 adult subjects were equally divided between both genders. Based on anatomical points located along the trigeminal neuro-matricial facial growth axes, a three-dimensional maxillo-facial architecture was constructed. RESULTS: Volumetric and linear parameters were greater in males (0.000 < p < 0.044) except for the anterior and posterior mandibular width. Sexual dimorphism was not observed with angular parameters. There was no correlation between volumetric and angular parameters. The correlation tests showed that the total volume of the frame increases with infraorbital depth, supraorbital depth, posterior mandibular width and facial height (0.526 < r < 0.777), while it was not associated with the maxillo-orbital width (0.252 < r < 0.389). Total and orbital volumes were more correlated with posterior than with anterior mandibular width. Maxillo-mandibular volume of the frame was more cor-related with orbital depth (0.591 < r < 0.742) than the orbital volume (0.482 < r < 0.589). CONCLUSIONS: The results allowed us to establish three-dimensional cephalometric standards, and to replace the tenet of normality, which is a mean value of calculated parameters, by the concept of individual balance among volumetric entities. While sagittal and vertical dimensions affect volumetric changes of the frame, the transverse dimension does not.

Three-dimensional assessment of facial bone cavities in Class I occlusion with normodivergent skeletal pattern.

INTRODUCTION: The aims of our study are to measure the volume of the facial cavities based on a three-dimensional tomodensitometric acquisition in normodivergent, skeletal and dental Class I subjects; to quantify volumetric normality and generate an individual normality concept of these cavities. MATERIAL AND METHODS: The study was performed on a sample of 60 subjects equally divided between both genders. Based on the X, Y, Z coordinates of the anatomic landmarks and structural contours selected on the native slices and with the help of the GammaCepha software, we were able to compute the volume of the different cavities. RESULTS: The ratio of the different volumes compared to the total volume is 20.9% for males, 19.1% for females in maxillary sinuses ; 13.4% for males, 14.7% for females in orbital cavities; 29.7% for males, 30.2% for females in ethmoido-nasal cavity and 36% for males, 36% for females in oral cavity. CONCLUSION: This new method of calculating volumes of the different facial cavities is an original approach to three-dimensional biometrics. To our knowledge, the criteria of normality chosen in this study, which have not been defined until present, have allowed us to establish standards of volumetric facial cavities. This will allow identifying individuals in comparison to a normal volume reference, and define an individual balance regarding facial volumes.

Preventative antibiotics for penetrating abdominal trauma--single agent or combination therapy?

In this open, prospective, comparative study, 75 patients who sustained penetrating abdominal trauma were randomised to receive 1 of 3 antibiotic regimens preoperatively and for 3 to 5 days postoperatively. Group I received cefotaxime 2g 8-hourly, group II received cefoxitin 2g 6-hourly and group III received clindamycin (900 mg 8-hourly) and gentamicin 3 to 5 mg/kg/day in divided doses 8-hourly. The 3 groups were not statistically different in terms of age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions or positive intra-operative cultures. Septic complications occurred in 8% of patients in group I, in 4% of group II patients and in 8% of group III patients. Cefotaxime was the least costly regimen, followed by cefoxitin, then clindamycin and gentamicin. It may be concluded that single agent therapy with a broad spectrum cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, less toxicity and lower costs.

Complications of attempted central venous injections performed by drug abusers.

Intravenous abuse of drugs has become an integral part of various subcultures within American communities. The continued use of peripheral veins in this setting eventually leads to their obliteration through a sclerotic or infectious process. Inveterate drug abusers often turn to using larger veins in the groin and neck. Some real or imagined technical aspects of subclavian and internal jugular venous injections are well known to drug abusers in many locales. Undoubtedly as these skills are passed from one user to another, the fine points of anatomy and needle positioning are distorted with resultant mishaps. Twelve patients have been seen with complications arising from attempted supra- or subclavicular injections of drugs in the "street" setting: unilateral pneumothorax, six cases; bilateral pneumothorax, one case; mycotic subclavian carotid artery aneurysm, two cases; neck abscesses, three cases (one also listed under pneumothorax); and paraplegia, one case. Since this type of injury may occur in greater frequency due to increasing drug abuse, recognition and proper treatment of these potentially life-threatening problems may prevent mortality and reduce morbidity.

The role of contrast radiography in presumed bowel obstruction.

A retrospective review of 229 patients with a final diagnosis of small-bowel obstruction was undertaken to evaluate the role of contrast radiography in the management of their conditions. In 84 patients (37%) the clinical findings and plain abdominal roentgenograms were sufficient for diagnosis and subsequent management. Of the remaining 145 patients with equivocal findings, 27% had an upper gastrointestinal series, 29% a barium enema, and 44% had both. Useful information (complete obstruction, unobstructed passage of contrast, or diagnosis other than adhesional obstruction) was obtained from 86% of the radiographic studies. Three patients had negative contrast studies yet eventually underwent adhesiolysis (enterolysis) and were classified as false-negative. Two patients had evidence of high-grade obstruction yet had nonoperative resolution and were classified as false-positive. The mortality in the contrast group (7%) was not statistically different than that in the no-contrast group (7%). Contrast radiography is a safe and effective means of increasing diagnostic accuracy in patients with presumed small-bowel obstruction.

Resuscitative thoracotomy for patients with traumatic injury.

The clinical course and final outcome were determined for 63 trauma victims who underwent resuscitative thoracotomy (RT) for hypovolemic cardiac arrest in the Department of Emergency Medicine during a 24-month period. The objectives of the study were to determine the efficacy of and indications for RT and to define the prognostic signs for survival. Of 63 patients, six were successfully resuscitated (9.5%), and five of these were discharged from the hospital (7.9%). The presence of pupillary reactions was an extremely reliable indicator of successful outcome (P = 0.0009), as was the presence of some respiratory effort (P = 0.025). None of the victims of blunt trauma (n = 6) or severe head injury (n = 13) survived. Three of 17 patients (17.6%) with stab wounds and two of 36 (5.6%) with gunshot wounds survived the procedure. RT was beneficial in 13.6% of patients who had isolated organ system injuries, but no patient with injuries to more than two organ systems survived. Victims of isolated penetrating thoracic trauma had an 11.8% survival rate, as opposed to a 0% survival rate for those with abdominal trauma. The best prognosis was in victims with penetrating cardiac injuries, who had a 22.7% survival rate. The cost of RT averaged $1660 per patient, exclusive of physician charges. In our experience, RT is most beneficial for victims of penetrating thoracic trauma, especially those with cardiac injuries. However, routine use of this high cost/low benefit procedure cannot be recommended for patients who have cardiac arrest secondary to blunt trauma or severe head injuries. Also, it is not recommended for patients whose pupillary reflexes and respiratory movements are absent.

Increases in intra-abdominal pressure affect pulmonary compliance.

OBJECTIVES: To determine the effect of increased intra-abdominal pressure (IAP) on pulmonary compliance and to determine an effective means to measure IAP. DESIGN: A prospective study. SETTING: An urban tertiary care hospital. PATIENTS: Twenty-six adult patients undergoing laparoscopic cholecystectomy. INTERVENTIONS: Intra-operative management of laparoscopic cholecystectomy requiring endotracheal intubation with general anesthesia, nasogastric and urinary bladder catheters, and position changes. Additional interventions included use of a rectal manometer and a respiratory pressure module inserted within the ventilator circuit. MAIN OUTCOME MEASURES: Correlation of changes in IAP with changes in dynamic pulmonary compliance, measured as tidal volume/(end inspiratory pressure--end expiratory pressure) and comparison of three different measurement techniques (bladder, rectal, and gastric) with a standard technique (insufflation pressure) in three different positions (supine, Trendelenburg's, and reverse Trendelenburg's). RESULTS: Compliance was significantly related to insufflation pressure (P < .001) by analysis of variance. In the gas insufflation model, the mean increment in bladder pressure reflected most closely the IAP increment in the supine position (5.7 vs 6 mm Hg) but not in the Trendelenburg (2.1 vs 6 mm Hg) and reverse Trendelenburg positions (3.4 vs 6 mm Hg). Rectal and gastric pressures were also position dependent and technically less reliable. CONCLUSIONS: Increased IAP has a major influence on pulmonary compliance (50% decrease at 16 mm Hg). Measurements of IAP by intraorgan manometry are position dependent and may not accurately reflect the intraperitoneal pressure.

Inaccuracy of diagnostic peritoneal lavage in penetrating colonic trauma.

As part of an ongoing study of the operative treatment of colon injuries, 33 patients proved to have colon injury at operation had diagnostic peritoneal lavage as part of their preoperative examination. Gunshot wounds were the cause of injury in 22 (67%) of these patients and stab wounds in 11 patients (33%). The lavage was positive in only 23 (70%) of the 33 patients with operatively proved penetrating injuries of the colon. Lavage was accurate in 16 (73%) of 22 patients with gunshot wounds of the colon and seven (64%) of 11 patients with stab wounds. The overall false-negative rate for this series of patients was 30%. This study indicates that diagnostic peritoneal lavage is relatively inaccurate in the evaluation of colonic injury secondary to penetrating abdominal trauma.

Bilharzial portal hypertension.

Schistosomiasis is a major world health problem that is being encountered more frequently in North America as the immigration patterns from endemic areas change. At Henry Ford Hospital in Detroit, only two admissions for active schistosomiasis were recorded before 1970, but since then there have been 43 such cases. Of these 45 patients, six required seven portasystemic shunts, primarily to treat the complication of esophageal variceal hemorrhage, which is associated with portal hypertension secondary to presinusoidal hepatic fibrosis. No operative deaths occurred, and follow-up averaging 6.6 years revealed no late deaths and minimal encephalopathy. These excellent results are attributed to successful portal decompression and the well-preserved liver function that is typical of these patients. Bilharzial portal hypertension should be suspected in immigrants from endemic areas who have bleeding esophageal varices.

Catheter aspiration for simple pneumothorax. Experience with 114 patients.

Between 1983 and 1987, 114 adult patients with 131 pneumothoraces were treated utilizing catheter aspiration for simple pneumothorax as an alternative to tube thoracostomy. The causes of simple pneumothorax were as follows: 79 needle-induced, 36 spontaneous, and 16 traumatic. Thirty-eight of the pneumothoraces were small (less than 20% of volume), 55 were moderate (20% to 40% of volume), 36 were large (greater than 40% of volume), and 2 were of unknown size. Overall, catheter aspiration for simple pneumothorax was successful in 90 patients (69%). The success rate was 75% with needle-induced, 53% with spontaneous, and 75% with traumatic pneumothoraces. Small pneumothoraces were successfully managed with catheter aspiration for simple pneumothorax in 87% of patients, moderate-sized in 60%, and large in 61%. There were three complications (2.3%), including one hemothorax and two retained sheared catheter tips. The average cost per patient was +868 for catheter aspiration, and $6402 for a tube thoracostomy. These data support catheter aspiration as a safe, cost-effective, and successful technique for managing simple pneumothorax.

Antibiotics for penetrating abdominal trauma: a prospective comparative trial of single agent cephalosporin therapy versus combination therapy.

In this prospective, comparative study, 129 patients who sustained penetrating abdominal trauma were randomized to receive preoperatively, and for 3-5 days postoperatively, one of three antibiotic regimens: Group I--cefotaxime (CTX) (2 Gm Q8H), Group II--cefoxitin (2 Gm Q6H), or Group III--clindamycin (900 mg Q8H) and gentamicin (3-5 mg/kg/day in divided doses Q8H). The three groups were similar in terms of the following: age, sex, severity of injury, number of organs injured, colon injuries, shock, blood transfusions, or positive intraoperative cultures. Septic complications occurred as follows: Group I--6.9%, Group II--2.3%, and Group III--6.9%. The three regimens ranked as follows in terms of therapy costs: CTX less than cefoxitin less than clindamycin and gentamicin. It is concluded that single agent therapy with a cephalosporin is preferable to combination therapy on the basis of equivalent effectiveness, lower toxicity, and lower costs.

Cost-effectiveness of enoxaparin versus low-dose heparin for prophylaxis against venous thrombosis after major trauma.

We attempted to determine health and economic outcomes from the perspective of an integrated health system of administering enoxaparin 30 mg twice/day versus heparin 5000 U twice/day for prophylaxis against venous thrombosis after major trauma. A decision-analytic model was developed from best literature evidence, institutional data, and expert opinion. We assumed that 40% of proximal deep vein thromboses (DVTs) and 5% of distal DVTs are diagnosed and confirmed with initial or repeat duplex scanning; 50% of undiagnosed proximal DVTs result in pulmonary embolism; 2% and 1% of undiagnosed proximal DVTs will lead to readmission for DVT and pulmonary embolism, respectively, and pulmonary embolism-related mortality rates range from 8-30%. Length of hospital stay data and 1996 institutional drug use and acquisition cost data were used to estimate the cost of enoxaparin and heparin therapy. Diagnosis and treatment costs for DVT and pulmonary embolism were derived from institutional charge data using cost:charge ratios. A second analysis of patients with lower extremity fractures was completed. One-way and multiway sensitivity analyses were performed. For 1000 mixed trauma patients receiving enoxaparin versus heparin, our model showed that 62.2 (95% CI -113 to -12) DVTs or pulmonary emboli would be avoided, resulting in 67.6 (8 to 130) life-years saved at a net cost increase of $104,764 (-$329,300 to $159,600). Enoxaparin versus heparin resulted in a cost of $1684 (-$3600 to $9800) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $2303 (-$8100 to $19,000). For 1000 patients with lower extremity fractures, enoxaparin versus heparin resulted in a cost of $751 (-$4200 to $3300) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $1017 (-$10,200 to $6300). Although enoxaparin increases overall health care costs, it is associated with a cost/additional life-year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life-year saved. The cost-effectiveness ratio is more favorable in patients with lower extremity fractures than in the general mixed trauma population.

Perforation of the small bowel after insertion of feeding jejunostomy: a case report.

Feeding jejunostomy has become a useful method of feeding many patients with upper digestive tract dysfunction from a variety of causes. Although problems infrequently do occur with the tube itself, such as dislodgement or obstruction, most patients tolerate the procedure well. We report here a case of perforation of the jejunum that was caused by the tube itself and required reoperation. As with many problems in surgery, careful attention to technical details should help prevent this and other problems after feeding tube insertion.

The management of massive lower gastrointestinal bleeding.

To evaluate what has been the most effective surgical treatment for massive lower gastrointestinal bleeding, we reviewed the records of 31 patients who underwent colon resection for hemodynamic instability and/or the need for continued transfusions. These 31 patients underwent either segmental colectomy (21 patients) or subtotal colectomy (10 patients). Resections were performed for diverticular disease (19 patients), angiodysplasia (eight patients), acute ulceration (three patients), and polyps (one patient). The re-bleeding rate (mean follow-up 1 year) for subtotal colectomy was 0 per cent, segmental resection with positive angiography was 14 per cent, and segmental resection with negative angiography was 42 per cent. The complication rate including myocardial infarction, ARDS, pneumonia, and renal failure was highest (83 per cent) in those patients receiving segmental resection with a negative angiogram. The mortality rate was also highest for segmental resection patients with negative angiography (57 per cent). The results of this review suggest that segmental resection should be performed when the bleeding site is identified angiographically. Subtotal colectomy should be reserved for massive bleeding with negative angiography.

Penetrating pancreatic injuries, 1978-1983.

During the review period, 41 trauma service patients were found to have penetrating pancreatic injuries. The cause of injury was a gunshot wound in 25 patients, stab wound in 13 patients, and shotgun wound in 3 patients. All patients had at least one other intra-abdominal organ injured, and 19 (46%) were admitted in shock. The pancreatic injury was managed by resection in 21 patients, drainage in 19 patients, and diverticulization in 1 patient. Complications related to the pancreatic injury developed in 11 (52%) treated by resection. By comparison pancreatic complications were seen in only three (16%) patients managed with drainage (P = 0.04). The mortality rate for resection was 19 per cent compared to 11 per cent for drainage (N.S.). Differences in morbidity observed could not be clearly accounted for by severity of injury. Based on these data, the authors recommend drainage for the majority of penetrating pancreatic injuries and suggest resection be reserved for injuries requiring debridement for hemostasis.

Penetrating injuries of the mediastinum.

This study reviews 47 patients who were operated on for acute penetrating mediastinal wounds. These included 40 cases of cardiac tamponade, 2 mediastinal hematomas, 1 contused myocardium, 3 esophageal wounds, and 1 VSD. Stab wounds were most common (73%) followed by gunshot wounds (23%), and shotgun wounds (4%). When measured, central venous pressure was 15 cm or greater in 28 out of 32 patients (87.5%) with proven tamponade. By contrast, Beck's criteria (distended neck veins, distant heart sounds, hypotension) were noted in only 19 (48%) of 40 cases of tamponade. Emergency room pericardiocentesis resulted in improvement in 20 of 22 cases (91%), affording time for definitive operative therapy. The majority of entrance wounds (85%) occurred in the anterior mediastinal region. Peritoneal lavage in 15 cases yielded 5 true positive, 9 true negative, and 1 false positive tests. Most commonly injured areas were right ventricle (20 patients), left ventricle (11 patients), pericardium (5 patients), and right atrium (4 patients). Isolated esophageal injuries occurred in 3 of 11 gunshot wounds (27%). Complications were numerous (70%) and mortality ranges as follows: GSW 27% SW 15% SGW 0%. Central venous pressure determination and early pericardiocentesis are useful in suspected cases of tamponade. In GSW, an esophagogram is indicated to rule out isolated injury. Median sternotomy is the operative exposure of choice for mediastinal injuries causing cardiac tamponade.

Endotracheal aminoglycosides in gram negative pneumonia. A preliminary report.

Five postoperative patients with respiratory failure and gram negative pneumonia unresponsive to systemic antimicrobials were treated with endotracheally instilled aminoglycosides. Sputum cultures in four patients grew Pseudomonas aeruginosa and, in the fifth, Enterobacter cloacae. The five patients had been treated systemically for an average of 13 days (range 9 to 19 days) without improvement prior to endotracheal antibiotic administration. The gram negative organisms disappeared from the sputum cultures in all patients within an average of 4 days (range 2 to 8 days) following initiation of endotracheal antibiotics. All five patients had continued clinical improvement manifest by improved chest radiographs, improved oxygenation, and absence of the offending organisms from sputum cultures. None of the patients died from their gram negative pneumonia. This success coupled with data from other investigators suggests that endotracheal antibiotics should be considered in life-threatening gram negative pneumonias that are unresponsive to conventional systemic antimicrobials.

Acute penetrating arterial injuries of the forearm. Ligation or repair?

The management of forearm arterial trauma is controversial and follow-up data on such injuries is scant. A survey was made of 249 patients with penetrating forearm trauma to determine the incidence and outcome of arterial injury. Sixty-six patients (26.5%) sustained 69 arterial injuries documented at operation or with angiography. The clinical manifestations of arterial injury were often subtle; 42.4 per cent of the patients had normal pulses and only 7.6 per cent presented with distal ischemia. In 9.1 per cent of the patients there was no clinical evidence of vascular injury. The most frequent types of arterial injury were transection (72.5%) and partial laceration (14.5%). Arterial repair was performed in 84.8 per cent of the cases, and resection with end-to-end anastomosis was usually possible. Volar compartment fasciotomies were necessary in 18.2 per cent of the cases. The early postoperative complications seen were wound-related, and these were six times more frequent in the group undergoing arterial ligation (36% vs 6%). In 49 patients evaluated an average of 6 months after repair, the patency rate determined by clinical examination was 85.7 per cent. Because of a high incidence of associated nerve (56.1%) and tendon (54.5%) injuries, the functional status of the injured extremity was less satisfactory, with only 49.2 per cent of the patients having normal hand function. Since the forearm vessels can be repaired with minimal morbidity and acceptable results, arterial ligation is recommended only when repair is not readily accomplished, or when treatment of a more pressing associated injury demands priority.

Spectrum of myocardial contusion.

During a consecutive period of 26 months, 42 patients with blunt chest trauma were diagnosed as having a myocardial contusion on the basis of an abnormal electrocardiogram (ECG) in 36 patients, elevated creatine phosphokinase (CPK) in 39 patients, and positive CPK-Muscle Brain (CPK-MB) isoenzyme in 33 patients. Using these screening modalities, the incidence of myocardial contusion in patients with blunt chest trauma increased from 7 per cent when viewed retrospectively to 17 per cent when viewed prospectively. Eight patients had cardiac index determinations only; of these, three were less than 2.9 1/min/M2. An additional 21 patients underwent a standard fluid challenge of 500 cc of 5 per cent plasmanate infused over 30 minutes allowing construction of a Starling Curve. Five patterns of ventricular function curves were observed. Six patients had biventricular dysfunction, six patients had isolated right ventricular dysfunction, three patients had isolated left ventricular dysfunction, three patients had an "unslope-peak-downslope" pattern, and three patients had normal ventricular function studies. Multiple gated acquisition (MUGA) scans were abnormal in ten patients and normal in 12 patients. Major morbidity and mortality due to myocardial contusion occurred in 17 per cent of the (7/42) patients; of these, three had biventricular dysfunction, one had left ventricular dysfunction, and two had a low cardiac index. This experience suggests that screening tests are sensitive in detecting myocardial contusion in blunt chest trauma, but are not predictive of major morbidity or mortality. Only direct hemodynamic measurement with construction of a Starling Curve was useful in determining the severity of the myocardial injury and identifying those patients at greatest risk.

The relationship of scoring systems and mortality in the surgical intensive care unit.

To determine the relationship between severity of illness and mortality, therapeutic intervention score (TISS) and acute physiology score (APS) were determined on admission to the Surgical Intensive Care Unit (SICU). Patients were divided into survivors and nonsurvivors and differences were compared by chi-square analysis. The 1524 patients admitted to the SICU during a 12-month period had a mean TISS of 3.03 and a mean APS of 13. The average length of stay (LOS) was 3.75 days. Of the 1524 patients, 97 (6.4%) died. The number of nonsurvivors increased with higher TISS and APS scores (P less than 0.001). There were no deaths in the TISS Category 1 patients or in the APS 0-5 group. Mortality rates dramatically increased with APS greater than 20 (P less than 0.001). There were 1286 patients with APS less than 20, and 24 (2%) of these patients died, whereas 73 (31%) of 238 patients with APS greater than 20 died. Nonsurvivors had a mean TISS of 3.6, mean APS of 27, and LOS of 4.88 days, all of which totals were higher than the survivors' totals. In this study population, risk of death was one in three if the APS was greater than 20. These data indicate that TISS and APS scores are effective means of assessing mortality risk in SICU patients.