Negative laparotomy in trauma: are we getting better?

One of the trauma surgeons' daily challenges is the balancing act between negative laparotomy and missed abdominal injury. We opted to characterize the indications that prompted a negative trauma exploratory laparotomy and the rate of missed abdominal injuries in an effort to optimize patient selection for laparotomy. At the Los Angeles County + University of Southern California Medical Center, negative laparotomies and missed injuries are consecutively captured and reviewed at the weekly mortality + morbidity (MM) conferences. All written reports of the MM meetings from January 2003 to December 2008 were reviewed to identify all patients who underwent a negative laparotomy or a laparotomy as a result of an initially missed abdominal injury. Over the 6-year study period, a total of 1871 laparotomies were performed, of which 73 (3.9%) were negative. The rate of missed injuries requiring subsequent laparotomy was 1.3 per cent (25 of 1871). The negative laparotomy rate and the rate of missed injuries did not vary significantly during the study period (2.8 to 4.7%, P = 0.875, and 0.7 to 2.9%, P = 0.689). Penetrating mechanisms accounted for the majority of negative laparotomies (58.9%). The primary indication for negative laparotomy was peritonitis (54.8%) followed by hypotension (28.8%) and suspicious computed tomographic scan findings (27.4%). The complication rate after negative laparotomy was 14.5 per cent, and of these, 10.1 per cent were directly related to the procedure. A low but steady rate of negative laparotomies and missed abdominal injuries after trauma remains. Negative laparotomies and missed abdominal injuries when they occur are still associated with significant complication rates and a prolonged length of stay.

Biochemical profile and outcomes in trauma patients subjected to open cardiopulmonary resuscitation: a prospective observational pilot study

The predictive factors to regain a heartbeat following emergency department resuscitative thoracotomy (EDT) for trauma are poorly understood. The objective of the present study was to prospectively assess the electrolyte profile, coagulation parameters, and acid-base status from intracardiac blood samples in trauma patients subjected to open cardiopulmonary resuscitation (CPR) in the presence of established cardiac arrest.

Efficacy of panoramic radiographs in the preoperative planning of posterior mandibular implants: a prospective clinical study of 1527 consecutively treated patients

OBJECTIVES: Various imaging techniques, including conventional radiography and computed tomography, are proposed to localize the mandibular canal prior to implant surgery. The aim of this study is to determine the incidence of altered mental nerve sensation after implant placement in the posterior segment of the mandible when a panoramic radiograph is the only preoperative imaging technique used. MATERIAL AND METHODS: The study included 1527 partially and totally edentulous patients who had consecutively received 2584 implants in the posterior segment of the mandible. Preoperative bone height was evaluated from the top of the alveolar crest to the superior border of the mandibular canal on a standard panoramic radiograph. A graduated implant scale from the implant manufacturer was used and 2 mm were subtracted as a safety margin to determine the length of the implant to be inserted. RESULTS: No permanent sensory disturbances of the inferior alveolar nerve were observed. There were two cases of postoperative paresthesia, representing 2/2584 (0.08%) of implants inserted in the posterior segment of the mandible or 2/1527 (0.13%) of patients. These sensory disturbances were minor, lasted for 3 and 6 weeks and resolved spontaneously. CONCLUSIONS: Panoramic examination can be considered a safe preoperative evaluation procedure for routine posterior mandibular implant placement. Panoramic radiography is a quick, simple, low-cost and low-dose presurgical diagnostic tool. When a safety margin of at least 2 mm above the mandibular canal is respected, panoramic radiography appears to be sufficient to evaluate available bone height prior to insertion of posterior mandibular implants; cross-sectional imaging techniques may not be necessary.

Cladophialophora bantiana: a rare cause of fungal brain abscess. Clinical aspects and new therapeutic options

Black molds or dematiaceous fungi are rare etiologic agents of intracerebral abscesses and such infections carry a high mortality of up to 70% despite combined surgical and antifungal therapy. While the growing use of immunosuppressive therapies and organ transplantation have caused an increase in the incidence of rare fungal cerebral infections, occurrence in immunocompetent hosts is also possible. We describe a 60-year-old female patient with a cerebral abscess caused by Cladophialophora bantiana. The case illustrates the clinical and radiological similarities between glioblastomas and brain abscesses and emphasizes the need to perform histological and microbiological studies prior to the initiation of any form of therapy. Long-term survival from cerebral black mold abscesses has been reported only when complete surgical resection was possible. The recommended antifungal treatment involves the use of amphotericin B combined with a triazole and, if possible, flucytosine. Highly-active new generation triazole antifungal compounds (voriconazole or posaconazole) are likely to offer improved survival rates for patients with rare mold infections. In particular, posaconazole could be a new therapeutic option given its better tolerance, lower toxicity and fewer drug-drug interactions. We discuss clinical, microbiological and practical pharmacological aspects and review current and evolving treatment options.

Living with Differences: From Everyday Fundamentalisms to Invitational Communication

This project examines fundamentalism understood as an everyday way of living poorly with difference. It demonstrates that the fundamentalist is not reducible to stereotypes of the terrorist, extremist, irrational madman, or religious zealot. All of these characterizations--common in mainstream media--depict the fundamentalist as them, and rarely, if ever, as us. Rather, this project understands fundamentalism in terms of fundamental interpretive constructs that constrain our ways of being-with others, skew our interpretive and responsive possibilities, distort our perceptions of difference, and affirm our poor treatment of others. Following Martin Heidegger's conception of the hermeneutic structure of existence, this dissertation calls attention to the ways in which such fundamentalisms filter our interpretation. Yet the hermeneutic character of existence also highlights the incompleteness of any particular frame of interpretation and indicates the possibility of alternative interpretive responses. The project turns to a feminist theological hermeneutic in order to indicate more hopeful and liberating ways of living with difference, ways that point beyond everyday fundamentalism toward invitational communication. Through new readings of familiar biblical narratives, this dissertation revisits the fundamentalisms that trigger these narratives in order to draw out an alternative feminist theological hermeneutic, or what is termed here an invitational hermeneutic. Each story offers unique ways of making sense of being-with and sharing the world with others of difference that redress the impoverished and fundamentalist forms of self-preserving care and understanding. By examining the well-loved stories of the Good Samaritan, Ruth and Naomi, Queen Esther, and the Apostle Paul and Lydia, the dissertation identifies interpretive and responsive possibilities that together issue an alternative hermeneutical invitation: to understand difference compassionately, to engage strangers and family members alike with rehabilitative care and concernful reticence, and to extend graceful hospitality to others. In these ways, the dissertation indicates possibilities beyond the horizon of fundamentalism, invitational possibilities of living and communicating with difference.

The Amplifier - v. 1, no. 9

In this issue...Dr. Van Pelt, Lydia's, Old Faithful, Yellowstone National Park, U. S. Gypsum Plant, Stanolind Oil & Gas Company, Coach Olsen, Great Falls Brewery

The Amplifier - v. 2, no. 11

In this issue...State Board of Education, Helen Allen, Drama Club, Galen Hospital, Lydia's, Butte, Montana, convocation, Marion White Arts Society, Professor William W. Chance

The Amplifier - v. 4, no. 11

In this issue...Mike Freebourn, seismograph, Mine Rescue course, Lydia's, Chess Club, Butte Daily Post, Butte Elks Lodge, State Board of Education, Gordon Parker

The Amplifier - v. 5, no. 11

In this issue...April Fool, MSM Boosters, Montana Power, Theta Tau, Engineering Day, Lydia's, The Anaconda Company, St. James Hospital, Museum Hall, Orediggers

The Amplifier - v. 5, no. 12

In this issue...Library Week, Mines Club, Gene Trimble, Boulevard Fire Hall, Mineral Club, Commencement, Mel Bennett, Butte Kiwanis Club, Circle Club, Lydia's, Mines Bowling Team

The Amplifier - v. 5, no. 15

In this issue...The Anaconda Company, Gary Alexander, Mountain Climbing, Slugfest, Chester H. Steele, Copper Guards, Manuel Munoz, tennis, Lydia's

The blood-brain and the blood-cerebrospinal fluid barriers: function and dysfunction

The central nervous system (CNS) is tightly sealed from the changeable milieu of blood by the blood-brain barrier (BBB) and the blood-cerebrospinal fluid (CSF) barrier (BCSFB). While the BBB is considered to be localized at the level of the endothelial cells within CNS microvessels, the BCSFB is established by choroid plexus epithelial cells. The BBB inhibits the free paracellular diffusion of water-soluble molecules by an elaborate network of complex tight junctions (TJs) that interconnects the endothelial cells. Combined with the absence of fenestrae and an extremely low pinocytotic activity, which inhibit transcellular passage of molecules across the barrier, these morphological peculiarities establish the physical permeability barrier of the BBB. In addition, a functional BBB is manifested by a number of permanently active transport mechanisms, specifically expressed by brain capillary endothelial cells that ensure the transport of nutrients into the CNS and exclusion of blood-borne molecules that could be detrimental to the milieu required for neural transmission. Finally, while the endothelial cells constitute the physical and metabolic barrier per se, interactions with adjacent cellular and acellular layers are prerequisites for barrier function. The fully differentiated BBB consists of a complex system comprising the highly specialized endothelial cells and their underlying basement membrane in which a large number of pericytes are embedded, perivascular antigen-presenting cells, and an ensheathment of astrocytic endfeet and associated parenchymal basement membrane. Endothelial cell morphology, biochemistry, and function thus make these brain microvascular endothelial cells unique and distinguishable from all other endothelial cells in the body. Similar to the endothelial barrier, the morphological correlate of the BCSFB is found at the level of unique apical tight junctions between the choroid plexus epithelial cells inhibiting paracellular diffusion of water-soluble molecules across this barrier. Besides its barrier function, choroid plexus epithelial cells have a secretory function and produce the CSF. The barrier and secretory function of the choroid plexus epithelial cells are maintained by the expression of numerous transport systems allowing the directed transport of ions and nutrients into the CSF and the removal of toxic agents out of the CSF. In the event of CNS pathology, barrier characteristics of the blood-CNS barriers are altered, leading to edema formation and recruitment of inflammatory cells into the CNS. In this review we will describe current knowledge on the cellular and molecular basis of the functional and dysfunctional blood-CNS barriers with focus on CNS autoimmune inflammation.