Pyogenic hepatic abscess. Changing trends over 42 years.

Objective: The authors document changes in the etiology, diagnosis, bacteriology, treatment, and outcome of patients with pyogenic hepatic abscesses over the past 4 decades.

Summary Background Data: Pyogenic hepatic abscess is a highly lethal problem. Over the past 2 decades, new roentgenographic methods, such as ultrasound, computed tomographic scanning, direct cholangiography, guided aspiration, and percutaneous drainage, have altered both the diagnosis and treatment of these patients.

Training of care givers for our aging population.

We cannot rely on geriatricians, internists, and family practitioners alone in the medical community to provide all of the geriatric care. Even though there are alternatives to the use of specialists, we cannot afford to ignore the largest group of current physician trainees who will provide a great deal of geriatric medical care in the future. We need to help make the basic principles of geriatric care part of every training program for every resident, whether in general or specialty programs.

Evaluating changes in land cover and their importance for global change.

During recent years, much progress has been made in integrating traditional natural science disciplines and in the developmnet of multidisciplinary models. This is crucial for an increased understanding of the dynamics of the Earth system. The domination of human activities in altering these dynamics is still increasing.

On the supply of physicians.

The congressionally created Council of Graduate Medical Education is conducting a study to assess the adequacy of the current and future supply of physicians in six specialties. The study is revising and updating the needs-based method used by the Graduate Medical Education National Advisory Committee and using this method to project the requirements for physicians for the next two decades. Projections on the supply of physicians will be based on the latest data from the federal government's Bureau of Health Profession's health manpower model.

Preventing postoperative acute bleeding of the upper part of the gastrointestinal tract.

Two hundred and ninety-eight critically ill patients at risk for the development of postoperative stress ulcers and bleeding were randomized into three groups. The first group comprised 85 patients who received meciadanol, a new bioflavonoid, 500 milligrams every six hours through a nasograstric tube; the second group comprised 100 patients who received sucralfate (crushed tablets), 1,000 milligrams every six hours through a nasogastric tube, and the third group comprised 113 patients who received an antacid (Maalox [magnesium aluminum hydroxide gel]) through a nasogastric tube at an initial dose of 15 milliliters every hour. The gastric pH was measured hourly and titrated to a pH greater than or equal to 4.

Closed-suction versus Penrose drainage after cholecystectomy. A prospective, randomized evaluation.

Closed-suction drainage was compared prospectively to open, passive drainage (Penrose drains) in 128 patients undergoing cholecystectomy. Patients were randomized at the time of operation to receive either closed-suction drains (Group I, 67 patients) or Penrose drains (Group II, 61 patients). The preoperative clinical parameters of the two groups were similar.

Experimental pancreatic allotransplantation in large animals. The role of donor kidney and cyclosporine in modifying rejection.

Experiments were carried out in outbred dogs and pigs to evaluate the relative immunogenicity of pancreatic islets and segmental pancreas grafts, and whether these could be ameliorated by transplanting a kidney simultaneously from the same donor animal. Various immunosuppressive regimens were also studied. Pancreatic islet allografts never normalized blood glucose in totally pancreatectomized recipients despite the use of cyclosporine (CsA) in high doses (40 mg/kg/day) and the simultaneous transplantation of a kidney from the same donor.

Covert splenic abscess: a continuing challenge.

Although splenic abscess is a rare cause of intra-abdominal sepsis, the mortality rate remains high especially in patients with silent or covert lesions. The clinical presentation and course of five patients with overt splenic abscess and seven patients with covert splenic abscess seen during a thirty year period were analyzed. Average age of patients with overt lesions was 44.

The effect of vascular fellowships on general surgical residency training.

To answer the controversial question of whether or not vascular fellowships detract from general surgical training, questionnaires were sent to directors of 41 approved vascular fellowship programs, 41 residency directors in the same institutions, and 40 residency directors in university programs without approved fellowships. Overall response rate was 74% (93% of vascular fellowship directors, 63% of same-institution residency directors, and 65% of residency directors without vascular fellowships). Thirty-four per cent of fellowship directors and 38% of same-institution residency directors indicated that the fellowship has reduced the vascular surgery case load of residents.

Management of hemobilia associated with transhepatic internal biliary drainage catheters.

Hemobilia developed as a complication in nine patients with transhepatic biliary drainage catheters. Arteriography revealed pseudoaneurysms of the hepatic artery in five patients and hepatic arterio-portal venous fistulas in three patients. In one patient no arteriographic abnormality was seen.

Documentation of care and prospective payment. One hospital's experience.

Hospitals are now being reimbursed by Diagnosis Related Group (DRG) for Medicare patients. The Johns Hopkins Hospital has worked successfully under this system for the past 5 years, with cost increases being maintained well below the national average. Allowable revenue varies considerably by diagnosis depending on such factors as secondary diagnoses, procedure, and patient age.

The use of intraperitoneal xenon for early diagnosis of acute mesenteric ischemia.

We evaluated the technique of intraperitoneal use of xenon Xe 133, previously described for the diagnosis of early intestinal strangulation obstruction in rats and dogs, for the recognition of acute mesenteric vascular occlusion in these animals. 133Xe was injected intraperitoneally into five groups of six rats: control, sham operation, superior mesenteric artery (SMA) ligation, superior mesenteric vein ligation, and portal vein ligation. Residual gamma-activity was monitored by external counting and camera imaging.

Reasons for delay of the diagnosis of acute appendicitis.

The essence of the problem, as previously reported, indicated that few complications of acute appendicitis occur as long as the infection is contained within the appendix, but once the invading bacteria have penetrated the peritoneal appendicular surface or have invaded the regional circulation, any one or more of a series of serious complications can develop. Thus, rightfully, emphasis has been placed upon early removal of the inflamed appendix before penetration has occurred as the best method of preventing complications. We have shown that early appendectomy is predicated on early diagnosis and that diagnostic delay is not limited to extremes of age.

Intraperitoneal xenon for the detection of early intestinal ischemia: effect of ascites, adhesions, and misdirected injections.

Significant delay in the washout of intraperitoneal xenon (133Xe) in rats and dogs with decreased splanchnic blood flow (bowel strangulation, superior mesenteric artery and vein occlusion) has been previously demonstrated as the basis for radionuclide imaging to detect early (prenecrotic) intestinal ischemia. In this study, the effect of ascites, adhesions, and misdirected injections on the validity of this technique is evaluated. Xenon-133 (0.

Percutaneous transhepatic management of complex biliary problems.

A series of 27 patients with complex biliary problems secondary to previous biliary operations is presented. The patients are divided into two groups: (1) patients with acute perioperative biliary problems; all had biliary leak with abscess, biliary cutaneous fistula, and/or stricture following cholecystectomy or common duct exploration and (2) patients with chronic postoperative biliary problems; all had previous repair of biliary stricture or injuries with late stricture formation. Early management of all patients included placement of a percutaneous biliary stent.