Ashis K. Mandal

Penetrating stab wounds of the chest: experience with 200 consecutive cases.

The incidence of penetrating wounds of the chest is rising rapidly. Opinions continue to differ on their management. Our experience with 200 consecutive cases of stab wounds of the chest between 1972 and 1975 were reviewed. There were 176 males and 24 females. The average age was 31 years; about two-thirds of the patients were under 30. About 74% presented with hemothorax or hemopneumothorax; 21 presented with pneumothorax. Eleven per cent had associated intra-abdominal injuries. Seventy-nine per cent were successfully treated with tube thoracostomy. About 15% underwent thoracotomy, with three deaths (mortality, 10%); the mortality for cardiac wounds was 16%; overall mortality was 1.5%. The overall complication rate was 5.5%, most occurring in patients with cardiac wounds and associated intra-abdominal injuries. The average period of hospitalization was 6.5 days. Treatment was individualized. Indications for each course of therapy are discussed.

Traumatic Thoracobiliary (Pleurobiliary and Bronchobiliary) Fistulas: Clinical and Review Study

Thoracobiliary fistulas are rare complications of thoracoabdominal trauma, with high morbidity and potentially high mortality. Our experience with four cases and 12 other cases collected from the literature are reviewed. All patients were male and average age was 25 years. Five had blunt trauma, three had stab wounds, and eight, gunshot wounds. All had diaphragmatic and hepatic injuries. Bronchobiliary fistulas with biliptysis developed in seven patients. Fever, cough, chest and RUQ pains were the most common presenting symptoms. Pleural effusion and elevated right hemidiaphragm were the most common X-ray findings. Bile empyema developed in 2/3 of the patients. Early diagnosis, tube thoracostomy with adequate drainage of all subphrenic billious collections, and secure closure of all diaphragmatic perforations are essential in successful management of most of these fistulas. Thoracotomy, however, is indicated in chronic and complicated fistulas, and should not be delayed beyond 3 weeks. Judicious use of appropriate antibiotics is a necessary adjunct to adequate surgical management of these fistulas. All 16 patients survived.

In vivo assessment of 99mTc-labeled hematoporphyrin derivative in tumor-bearing animals

The efficacy of 99mTc-labeled hematoporphyrin derivative in localizing neoplasms has been investigated with tumor-bearing animal models. Spontaneous mammary adenocarcinomas of outbred CFW strain Swiss-Webster white mice and chemical carcinogen induced breast tumors in female Sprague-Dawley white rats were clearly visualized in the scintigrams. Mice tissue distribution data demonstrate favourable tumor to organ ratios sufficiently high to permit tumor detection. [99mTc]HPD appears promising as a tumor imaging agent.

Rapid detection of acute appendicitis with Tc-99m-labeled intact polyvalent human immune globulin.

BACKGROUNDnAcute appendicitis remains problematic for emergency clinicians. A rapid and definitive test is needed for detecting acute appendicitis before surgical intervention. The purpose of this clinical trial was to determine the efficacy of Tc-99m-labeled intact polyvalent human immune globulin (Tc-99m IgG) in the evaluation of acute appendicitis.nnnSTUDY DESIGNnThirty-five patients with clinically suspected acute appendicitis were evaluated with Tc-99m IgG. After the intravenous injection of 25 mCi (92.5 MBq) of Tc-99m IgG, anterior flow, single photon emission computerized tomography (SPECT) and planar delayed images of the abdomen were obtained. Any abnormal focal uptake of Tc-99m IgG in the right lower quadrant was considered to be a positive scan.nnnRESULTSnTwenty-one patients with a positive Tc-99m IgG scan underwent laparotomy and were found to have acute appendicitis. Of the 14 patients who had negative scans, 7 underwent surgery. In this series, Tc-99m IgG study yielded 21 true-positive, 12 true-negative, and 2 false-negative results with a sensitivity, specificity, and accuracy of 91%, 100%, and 94%, respectively. The positive and negative predictive values were 100% and 86%, respectively. There were no false-positive results.nnnCONCLUSIONSnTc-99m IgG scintigraphy can provide the clinicians a simple, rapid, and definitive test for the diagnosis of acute appendicitis.

Ninety-eight penetrating vascular injuries: a review of a two and one-half year experience.

In a review of 55 patients with 98 penetrating vascular injuries over more than 2 years (most were gunshot wounds), the mortality rate was 46% in patients with intra-abdominal vascular injuries and 7% in those with extra-abdominal injuries. There were no major amputations. One patient had two fingers amputated.

Endotoxin shock in the beagle dog

The hemodynamic and metabolic responses to endotoxemia were assessed in seven splenectomized, chronically instrumented, conscious but lightly sedated beagle dogs. Measurements included: cardiac output (CO), right and left atrial pressures (RAP, LAP), systemic and pulmonary arterial pressures (SAP, PAP), and heart rate (HR). Arterial blood samples were measured for blood gas tensions, pH, lactate, and pyruvate. After a brief control period, 1 mg/kg endotoxin (Difco 026:B6) was given as an intravenous bolus. Two hours later, each animal was treated with low-molecular weight dextran (LMDX), 2 ml/kg/min for 15 minutes. Endotoxin initially produced a precipitate decline in CO, HR, RAP, LAP, and SAP with concurrent pulmonary hypertension; both pulmonary and systemic vascular resistance increased significantly, then declined to control values as the animal partially recovered. A progressive metabolic acidosis with excess lactate accumulation developed. LMDX produced a significant increase in CO, SAP, PAP, and LAP with a decrease in HR; RAP increased slightly. With hydration, hemodilution was noted along with relief of the metabolic acidosis and the oxygen debt. We conclude (1) neither pulmonary nor systemic vasconstriction persisted in the shocked dog, (2) the response of the pulmonary and systemic vascular beds to endotoxin was qualitatively similar, and (3) oncotic fluid therapy appeared to restore the hemodynamic and metabolic parameters to preshock values.

Reappraisal of low-velocity gunshot wounds of the aorta and inferior vena cava in civilian practice.

Eighteen low-velocity gunshot wounds of the abdominal aorta and inferior vena cava were analyzed. Injury to the aorta and inferior vena cava occurred in 9.2% of all penetrating abdominal injuries due to gunshot wounds in our series. The mortality rate was 33% for the suprarenal and 25% for the infrarenal inferior vena cava, 50% for the infrarenal aorta, 100% for the suprarenal aorta and for the combined injuries. Control of active bleeding is more closely related to survival than any other single factor.

Is Penicillin Alone Effective in Enterococcal Endocarditis

Enterococcal endocarditis in man is traditionally treated with penicillin and an aminoglycoside. Whether penicillin alone is adequate has not been fully evaluated. Experimental enterococcal endocardit