Pulmonary contusion: review of the clinical entity

Pulmonary contusion is a common lesion occurring in patients sustaining severe blunt chest trauma. Alveolar hemorrhage and parenchymal destruction are maximal during the first 24 hours after injury and then usually resolve within 7 days. The diagnosis of traumatic lung injury is usually made clinically with confirmation by chest x-ray films. The chest computed tomography scan is highly sensitive in identifying pulmonary contusion and may help predict the need for mechanical ventilation. Respiratory distress is common after lung trauma, with hypoxemia and hypercarbia greatest at about 72 hours. Although management of patients with pulmonary contusion is supportive, pneumonia and adult respiratory distress syndrome with long-term disability occur frequently.     

Pediatric cardiopulmonary resuscitation: a collective review

Little information is available about the effects of CPR in children, although it is known that the outcomes are dismal. Examples of unanswered questions include which advanced life support (ALS) procedures should be performed out-of-hospital, whether high-dose epinephrine improves survival, and the true prevalence of ventricular fibrillation as a presenting rhythm. Children differ from adults as to the cause and pathophysiology of cardiopulmonary arrest, but prehospital EMS and hospital resuscitation teams were initially designed for the care of adults. Because pediatric cardiopulmonary arrest is rare, prospective data are difficult to gather, and there are few large published studies. The purpose of this collective review was to review the current body of knowledge regarding survival rates and outcomes in pediatric CPR and, based on this review, to outline a course for future research.     

Pulmonary hemorrhage associated with balloon flotation catheters: report of a case and review of the literature

The development of the flow-directed balloon catheter has greatly facilitated the monitoring of seriously ill patients. As the use of this catheter has increased, so have the reports of complications, the most serious of which is fatal pulmonary hemorrhage. Eleven cases of pulmonary hemorrhage have been described in the literature, and we have reported an additional case. The presenting symptom in 10 patients was hemoptysis, and the course of eight of these patients was rapidly fatal. The most frequent significant finding at autopsy was a laceration of a small peripheral pulmonary artery, usually at a bifurcation. The pathogenesis, prophylaxis, and management of this complication are discussed.     

Relaparotomies for abdominal sepsis--why, when, how? A collective review

Life tables are seldom derived at the local level, despite a shift toward health service planning to that level. We calculated life tables by sex for the 42 public health units in Ontario, using 1988 1992 mortality files. Traditional methods of life table construction were compared and validated. Data quality, particularly geographical coding of death certificates, poses the greatest difficulty in deriving accurate life tables for comparison between areas. Migration will affect estimates, but it is best considered during the interpretation of results. Except for the final age interval, methods of modelling life tables have little impact on final life expectancy estimates. It is feasible to calculate local level life tables with data and tools that are readily available. The results highlight the importance of examining such life tables, as variations within a province in life expectancy at birth may be as important as the differences between provinces.     

Visual evoked potentials in Alzheimer''s disease: investigations in a PET-defined collective

Evidence indicates that the lipoxygenase (LO) pathway of arachidonic acid is a key mediator of angiotensin II (AII)-induced aldosterone synthesis in adrenal glomerulosa cells. Although protein kinase C (PKC) may play a role in AII action, the precise PKC isoforms involved and whether LO products can activate PKC is not clear. We therefore evaluated the effect of AII and LO products such as 12- and 15-hydroxyeicosatetraenoic acids (HETEs) on PKC activation in isolated rat adrenal glomerulosa cells. PKC activity was measured by the phosphorylation of a PKC specific peptide while the PKC isoforms were identified by Western immunoblotting using antibodies that recognize the alpha, beta, gamma or epsilon isoforms of PKC. Treatment of the cells for 15 min with AII (10[-8]M) or the LO products 12- or 15-HETE caused a marked increase in PKC activity in membrane fractions with reciprocal decreases in the cytosolic PKC activity. Rat glomerulosa cells expressed only the alpha, and epsilon isoforms of PKC. AII increased membrane bound levels of both PKC-alpha and -epsilon (1.9- and 1.5-fold, respectively), whereas the LO products predominantly activated PKC-epsilon. Reciprocal decreases in immunoreactive cytosolic PKC levels were seen. AII-induced aldosterone synthesis was blocked by H-7 and retinal as well as by a PKC-specific pseudosubstrate inhibitor, PKC(19-36). These results suggest that AII and LO pathway-induced actions in the adrenal glomerulosa may be mediated by specific PKC isoforms.     

Cardiac contusion in a 2 1/2-year-old child

This case was unique in that we were seeing signs and symptoms of a cardiac contusion 11 hours after injury, when cellular edema was causing lethal bradyarrhythmias and hypotension. Keeping the possibility of a cardiac contusion in mind when caring for pediatric patients with trauma and including a 12-lead EKG more routinely for pediatric patients with chest trauma would increase identification of potential problems as early as possible. Although cardiac contusion is not common in children, it must not be overlooked.     

Myocarditis: a review

BACKGROUND AND OBJECTIVES: Although pediatric sedation (PS) is widely used in emergency departments (ED), the practice of PS in general community hospital (GH) ED has not been described. We surveyed PS practice patterns in pediatric hospitals (CH) and GH and compared frequency and usage between the two groups. METHODS: All CH (n = 115) and 400 randomly selected GH were surveyed. Alcohol and drug detoxification, psychiatric, chronic care, rehabilitation, and specialty facilities were excluded. Data were collected on hospital type (pediatric or community), location (urban, suburban, rural), annual visits, academic affiliation (presence of an emergency medicine residency or pediatric emergency medicine fellowship in the hospital), and sedation agents used. RESULTS: Of 515 hospitals surveyed, 238 responded [84/115 CH (73%), 154/400 GH (39%)] yielding an overall response rate of 46%. Of the responding CH the majority were urban [57 (68%) were urban, 15 (18%) suburban, and 12 (14%) rural]. GH were more evenly distributed by location [44/153 (29%) were urban, 49/153 (32%) suburban, and 60/153 (39%) rural]. Eight (5%) GH had emergency medicine residencies, while 39 (46%) CH had pediatric emergency medicine fellowships. The mean annual pediatric volume was 38,000 for CH and 6500 for GH. For the four specified clinical scenarios, representing the most common ED procedures using sedation (laceration repair, fracture reduction, radiologic imaging), GH performed significantly fewer sedations than CH when matched for pediatric volume. PS was less frequently used among rural GH compared to suburban (P < 0.01) and urban GH (P < 0.01). Midazolam was listed as the most frequently used drug in all three geographic locations for both CH and GH. CH listed fentanyl as a second agent, while GH preferred meperidine. Fentanyl and ketamine were listed as preferred agents only in CH. For cranial computerized tomography, chloral hydrate was listed as the drug of choice by both CH and GH. Both CH and GH listed "relief of pain and anxiety" as the first and "agitation control" as the second most common reason for using sedation. CH and GH listed "the risks outweigh the benefits" as the primary reason and "ED too busy/takes too much time" as the secondary reason for not using sedation. CONCLUSIONS: GH performed fewer sedations than did CH when matched for pediatric volume in all geographic locations and for the most common ED procedures using sedation. Since 1989, sedation patterns have shifted in CH to include the short-acting agents, while GH (with the exception of midazolam) continue to prefer the long-acting agents. Midazolam is now the most frequently used sedation agent for ED procedures in both CH and GH.     

Hysteroscopy: a review

3 chemicals were selected for mutagenicity testing from a priority list, based on production volume and available mutagenicity data. Propargyl alcohol (PA), 2-nitroaniline (2NA), and 5-methyl-1H-benzo-triazole (MBT) were selected for testing using the approach recommended in the Health Protection Branch Genotoxicity Guidelines. The battery of tests included the Salmonella/mammalian microsome mutation assay, the in vitro chromosomal aberration assay, and the bone-marrow micronucleus assay. The results indicate that 2 of the 3 chemicals, PA and 2NA, were clastogenic in vitro. Both PA and 2NA induced chromosomal aberrations in CHO cells in vitro with and without metabolic activation, while none induced reverse mutations detectable with the Salmonella/mammalian microsome assay. Because PA and 2NA were found to be in vitro clastogens, they also were tested in the mouse bone-marrow micronucleus assay. 2NA induced a small increase in micronuclei in males but not females. PA did not induce an increase in micronuclei.     

Teleradiology: a review

The Biographical Personality Interview (BPI) was applied to 179 subjects (158 psychiatric patients and 21 probands from the general population); 100 patients and 20 healthy controls served as a validation sample; the others had been interviewed during the training period or did not meet the inclusion criteria for the validation of the BPI. The acceptance of the interview was high, the inter-rater reliability of the ratings of premorbid personality structures ("types") varied between 0.81 and 0.88 per type. Concurrent validity of the typological constructs as assessed by means of the BPI was inferred from the intercorrelations of type scores and correlations of these scores with questionnaire data and proved to be adequate. Clinical validity of the assessment was indicated by statistically significant differences between diagnostic groups. Problems and further developments of the instrument and its application are discussed.     

Moxonidine: a review

Moxonidine is an imidazoline compound which acts on I1 imidazoline 'receptors' in the central nervous system to reduce blood pressure. This novel mechanism of action is claimed to lead to fewer adverse effects than the older centrally-acting agents such as clonidine. In this review we examine the drug's pharmacology, clinical pharmacokinetics, efficacy as an antihypertensive agent including comparative studies with pre-existing drugs, and adverse effect profile. With a growing number of effective antihypertensive agents already available to the clinician, it is not yet clear whether moxonidine represents a significant advance in hypertension management.