Diagnosis of subtle Lisfranc injuries can be difficult for the examining clinician. Radiographs do not always reveal the full extent of tarsometatarsal injuries. We describe a clinical sign found in significant Lisfranc injuries that consists of a mid-foot ecchymotic area on the plantar aspect. This implies the potential for significant injury to the plantar tarsometatarsal ligaments. We call this the plantar ecchymosis sign. Patients with this injury and sign should be aggressively evaluated, with early consideration for stress radiographs and ORIF if indicated, as the prognosis of the undertreated Lisfranc injury is poor.
A B S T R A C T Multiple indicator dilution studies of the pulmonary circulation were carried out in conscious, resting and exercising, and anesthetized dogs under conditions where there was no pulmonary edema. Labeled red cells, water, and albumin were injected together into the pulmonary artery, and effluent dilution patterns were obtained from the descending thoracic aorta. The product of the mean transit time differences between labeled water and red cells, and the pulmonary water flow was used to estimate extravascular parenchymatous water; and this was expressed as a proportion of the water content of the blood-drained lung at postmortem examination. These estimates of the proportional water content were found to increase with flow, and to approach an asymptotic value. Reconsideration of the flow patterns in capillaries, however, led to the postulate that extravascular water should be calculated, utilizing as the appropriate vascular reference a substance that uniformly labels the water in red cells and plasma, and which is confined to the circulation, rather than a tracer that only labels red cells. The mean transit time of this substance is approximated by the sum of the mean transit times of labeled red cells and albumin, each weighted according to the proportion of the water content of blood present in that phase. The values for lung water content so computed also increased with flow, and appeared to approach an asymptote that corresponded to approximately two-thirds of the wet lung weight. The estimated values for the water space after pentobarbital anesthesia corresponded to the lower values obtained in the resting conscious animals. When the anesthetized animals were also bled, the estimated water space was disproportionately large, in relation to the previous values. These experimental results support the hypothesis that dilutional This work was presented in part at the 51st Annual
The purpose of this multicenter investigation was to determine the efficacy and safety of the alpha/beta-blocker labetalol versus the beta 1-selective beta-blocker atenolol in white and black patients with essential hypertension. Equal numbers of black and white patients were enlisted to form four treatment groups (white patients taking either labetalol or atenolol and black patients taking either labetalol or atenolol). Two hundred ninety-two patients (152 white and 140 black patients) with essential hypertension characterized by a standing diastolic blood pressure of 105 to 119 mm Hg (inclusive) were recruited for this trial. Patients were randomized to either labetalol (dosage titrated from 200 to 1600 mg/day) or atenolol (dosage titrated from 50 to 100 mg/day). The therapeutic goal was achievement of a standing diastolic blood pressure of 90 mm Hg or less or a fall of 15 mm Hg in diastolic pressure from baseline value at the end of the placebo run in period. At the end of the study there were no significant differences in blood pressure or heart rate changes in the supine position between the labetalol and atenolol groups. In contrast, labetalol produced greater reduction in both the standing systolic and diastolic blood pressure (-12/-13 mm Hg, respectively) compared with atenolol (-7/-9 mm Hg; p less than 0.05; p less than 0.005, respectively). The greatest decrease in blood pressure was observed in white patients receiving labetalol. In black patients the decrease in blood pressure was greater in those treated with labetalol compared with atenolol, particularly with respect to the systolic blood pressure. We conclude that the alpha 1-blocking property of labetalol provides an additional lowering of the blood pressure over that seen with beta 1-blockade alone, especially in the standing position, and this enhanced efficacy is not confined to one radical group.
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