Traumatic aortic rupture: recent outcome with regard to neurologic deficit.

BACKGROUND: Traumatic aortic rupture is highly lethal, and its surgical treatment is complicated by a high rate of paraplegia. METHODS: The charts of 263 patients with traumatic aortic rupture from vehicular accidents treated between 1971 and 1998 were reviewed. Patients were grouped according to four periods: group 1, 1971 to 1975, (n = 31); group 2, 1976 to 1985, (n = 83); group 3, 1986 to 1994, (n = 82); and group 4, 1994 to 1998 (n = 67). Seventy-one patients died of exsanguination before definitive care. One hundred-ninety two patients had surgical repair with the following techniques: clamp and sew, 6 in group 1, 22 in group 2, 54 in group 3, none in group 4; shunt, 23 in group 1, 39 in group 2, 2 in group 3; cardiopulmonary bypass, 2 in group 1, 1 in group 3. Forty-three patients had partial bypass with the centrifugal pump and heparin-coated circuits in group 4. RESULTS: Operative mortality was 6 of 31 (19%) in group 1, 22 of 61 (36%) in group 2, 15 of 57 (26%) in group 3, and 7 of 43 (16%) in group 4. There was one case of paraplegia in group 1 (4%), ten in group 2 (18%), 11 in group 3 (26%), and none in group 4. This difference of paraplegia between the groups was significant (p<0.002). Significant factors for paraplegia were intraoperative hypotension (p<0.000002), cross-clamp time longer than 30 minutes (p<0.008), pump versus no pump (p<0.008), and younger age group (28+/-11 versus 39+/-17 years) (p<0.03). CONCLUSIONS: There were no statistically significant improvements in mortality rate over the four periods, although, the mortality rate was lowest in the last period when partial bypass with the centrifugal pump was used exclusively. Further, the use of the centrifugal pump with heparin-coated circuits, with femoral vein cannulation into the right atrium and distal aortic perfusion, reduced paraplegia significantly.

A comparison of dopamine and homovanillic acid excretion, as prognostic indicators in malignant phaeochromocytoma.

The urinary excretion of dopamine and its metabolite homovanillic acid (HVA) were compared in 15 patients with malignant phaeochromocytoma. Six patients with increased dopamine and HVA excretion had disseminated malignancy and the poorest prognosis. Four patients with increased urinary dopamine levels but normal HVA excretion also had widespread metastases and poor prognosis. The best prognosis was for 5 patients who had normal excretion of dopamine and HVA, and minimal disease. When dopamine and HVA excretion were considered separately, it was found that duration of survival was significantly better for patients with normal dopamine excretion than those with increased dopamine excretion (p less than 0.003). There was no significant difference in survival time between patients with normal and increased HVA excretion. In this study dopamine excretion appeared to be a more discriminating biochemical index of malignancy, prognosis and disease progression than HVA excretion.

Gender differences in adverse outcomes after blunt trauma.

BACKGROUND: High testosterone and low estradiol levels induce immunosuppression and adverse outcome after trauma in male animals. Gender-based outcome differences in human trauma have not been investigated. In order to test our hypothesis that female gender is associated with improved outcome after trauma, we conducted an inception cohort study at the R. Adams Cowley Shock Trauma Center, the adult trauma resource center for the state of Maryland. METHODS: All were blunt trauma patients (18,892) admitted from 1983 to 1995, stratified by Injury Severity Score (ISS) and age. Gender differences in mortality; nosocomial infection; and preinjury diabetes and cardiac, pulmonary, and liver diseases were determined. RESULTS: No significant differences in preinjury diseases were identified. Death and gender were independent variables in all groups except for patients who developed pneumonia. Male patients had a higher incidence of pneumonia in all groups except age 18 to 45, with an ISS < 15. The association between male gender and pneumonia was strongest in the age 46 to 65, ISS > 30 subgroup (p < 0.01). Among those with pneumonia, female patients were at 2.8 to 5.6 times higher risk for death than were male patients. CONCLUSION: These data suggest that gender has no relation to mortality in blunt trauma patients who do not develop pneumonia. In contrast, male gender was significantly associated with an increased incidence of pneumonia after injury, and female patients with pneumonia were at significantly higher risk for mortality.