A multicenter evaluation of whether gender dimorphism affects survival after trauma.

BACKGROUND: The frequency of women who have sustained severe injuries has increased over the past 30 years. The purpose of this study was to evaluate whether severely injured women have a survival advantage over men. To address this issue, we undertook a multicenter evaluation of the effects of gender dimorphism on survival in trauma patients. METHODS: Patient information was collected from the databases of three level I trauma centers. We included all consecutive patients who were admitted to these centers over a 4-year period. We evaluated the effects of age, gender, mechanism of injury, pattern of injury, Abbreviated Injury Score (AIS), and Injury Severity Score (ISS) on survival. RESULTS: A total of 20,261 patients were admitted to the three trauma centers. Women who were younger than 50 years of age (mortality rate 5%) experienced a survival advantage over men (mortality rate 7%) of equal age (odds ratio 1.27, P <0.002). This advantage was most notably found in the more severely injured (ISS >25) group (mortality rate 28% in women versus 33% in men). This difference was not attributable to mechanism of injury, severity of injury, or pattern of injury. CONCLUSIONS: Severely injured women younger than 50 years of age have a survival advantage when compared with men of equal age and injury severity. Young men have a 27% greater chance of dying than women after trauma. We conclude that gender dimorphism affects the survival of patients after trauma.

Evolution in the treatment of complex blunt liver injuries.

Over the last decade, major changes in the treatment of patients with blunt liver injuries have occurred, specifically with the nonoperative treatment of more complex injuries. These major changes can be summarized as follows: 1. Patients with blunt liver injuries are screened expeditiously by surgeon-performed ultrasonography. Depending on the initial findings and response to resuscitation, further decisions are made regarding the further evaluation. 2. Computed tomographic scanning is the mainstay of diagnosis for hepatic injuries after blunt trauma; the initial CT findings will help the trauma surgeon to determine the nonoperative treatment. 3. Liver injuries of grades I through III can be observed safely in a monitored unit and not necessarily in an ICU setting. Patients with injuries of grades IV and V are best initially observed in an ICU. 4. More than two thirds of patients with injuries of grades IV and V can be treated nonoperatively. However, 50% of these patients will require some type of interventional treatment, but not necessarily a laparotomy. 5. Initial findings on the CT scan can help to identify those patients who will need some type of interventional treatment and to identify associated injuries. 6. Elderly patients or patients with associated medical comorbidities can also be treated nonoperatively if strict guidelines are followed. 7. Complications in patients with complex blunt liver injuries are not uncommon. However, most of the complications can be safely treated by less invasive procedures.

Common and external iliac artery injuries associated with pelvic fractures.

BACKGROUND: Common and external iliac artery injuries associated with pelvic fractures are uncommon. The diagnosis of such injuries is based on clinical findings and confirmed by arteriography. DESIGN: Retrospective chart review. SETTING: University Level I trauma center. PATIENTS: Five men and three women, aged seventeen to seventy-six years, with injuries to the common and external iliac arteries associated with pelvic fractures. RESULTS: All patients sustained complex pelvic fractures associated with multiple blunt injuries. Five injuries occurred on the right side. Two patients had an associated right vertical shear pelvic fracture. In five patients, vascular injury was diagnosed in the first six hours after admission. One patient presented with an aneurysm of the right common iliac artery two months after his initial injury. All patients underwent surgical repair with an interposition graft, which failed in two patients, who underwent vascular reconstruction ten hours after the injury. One patient died of associated injuries. CONCLUSIONS: Arterial hyperextension with intimal damage seems to be the most likely cause of this injury. Ideally, an extraperitoneal approach should be attempted to minimize blood losses and, due to the size of the iliac vessels, an interposition graft should be used for reconstruction.

Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries.

BACKGROUND: Nonoperative management has become the standard of care for hemodynamically stable patients with complex liver trauma. The benefits of such treatment may be obviated, though, by complications such as arteriovenous fistulas, bile leaks, intrahepatic or perihepatic abscesses, and abnormal communications between the vascular system and the biliary tree (hemobilia and bilhemia). METHODS: We reviewed the hospital charts of 135 patients with blunt liver trauma who were treated nonoperatively between July 1995 and December 1997. RESULTS: Thirty-two patients (24%) developed complications that required additional interventional treatment. Procedures less invasive than celiotomy were often performed, including arteriography and selective embolization in 12 patients (37%), computed tomography-guided drainage of infected collections in 10 patients (31%), endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and biliary endostenting in 8 patients (25%), and laparoscopy in 2 patients (7%). Overall, nonoperative interventional procedures were used successfully to treat these complications in 27 patients (85%). CONCLUSION: In hemodynamically stable patients with blunt liver trauma, nonoperative management is the current treatment of choice. In patients with severe liver injuries, however, complications are common. Most untoward outcomes can be successfully managed nonoperatively using alternative therapeutic options. Early use of these interventional procedures is advocated in the initial management of the complications of severe blunt liver trauma.

Impact of trauma attending surgeon case volume on outcome: is more better?

OBJECTIVE: To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. METHODS: The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. RESULTS: There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. CONCLUSIONS: Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.

Ventral striatopallidothalamic projection: IV. Relative involvements of neurochemically distinct subterritories in the ventral pallidum and adjacent parts of the rostroventral forebrain.

Retrograde and anterograde tract-tracing studies were carried out to determine whether the capacity of the nucleus accumbens to influence the thalamic mediodorsal nucleus via ventral striatopallidothalamic connections disproportionately favors the shell over the core subterritory. After injections of Fluoro-Gold into the mediodorsal thalamic nucleus, retrogradely labeled neurons were detected in sections also processed for calbindin-D 28-kD and neurotensin immunoreactivities to facilitate identification of subterritories in the ventral pallidum. Fluoro-Gold-labeled cells were counted in series of sections cut through the ventral pallidum, rostral globus pallidus, nucleus of the vertical limb of the diagonal band, preoptic region, lateral hypothalamus, and the sublenticular gray region, including parts of the extended amygdala. Data were expressed as cells/unit area and as percentages of all labeled forebrain cells. Mediodorsal nucleus-projecting rostroventral forebrain neurons were most numerous in the ventromedial part of the subcommissural ventral pallidum and pallidal parts of the olfactory tubercle. Few were observed in the dorsolateral part of the subcommissural ventral pallidum. In addition, following injections into the ventral pallidum, anterogradely transported biotinylated dextran amine was evaluated in sections processed for calbindin or tyrosine hydroxylase immunoreactivities. Injection into the ventromedial part of the subcommissural ventral pallidum resulted in robust anterograde labeling of the medial segment of the mediodorsal nucleus and ventral tegmental area and weak labeling of the substantia nigra and subthalamic nucleus. Conversely, after injection into the dorsolateral part of the subcommissural ventral pallidum, anterograde labeling was weak in the mediodorsal nucleus and ventral tegmental area, but robust in the substantia nigra and subthalamic nucleus. The results are consistent with a predominant accumbens shell influence on the mediodorsal nucleus and with cortico-ventral striatopallidal-thalamocortical pathways that begin and end in different parts of the frontal lobe.

Specificity in the projection patterns of accumbal core and shell in the rat.

The efferent projections of the core and shell areas of the nucleus accumbens were studied with a combination of anterograde and retrograde tract-tracing methods, including Phaseolus vulgaris-leucoagglutinin, horseradish peroxidase and fluorescent tracers. Both the core and shell regions project to pallidal areas, i.e. ventral pallidum and entopeduncular nucleus, with a distinct topography in the sense that the core projection is located in the dorsolateral part of ventral pallidum, whereas the shell projects to the medial part of the subcommissural ventral pallidum. Both regions of the accumbens also project to mesencephalon with a bias for the core projection to innervate the substantia nigra-lateral mesencephalic tegmentum, and for the shell projection to reach primarily the ventral tegmental-paramedian tegmentum area. The most pronounced differences between core and shell projections exist in regard to the hypothalamus and extended amygdala. Whereas the core projects primarily to the entopeduncular nucleus including a part that invades the lateral hypothalamus, the shell, in addition, projects diffusely throughout the rostrocaudal extent of the lateral hypothalamus as well as to the extended amygdala, especially its sublenticular part. Both the core and shell of the accumbens have unmistakable striatal characteristics both histologically and in their connectional patterns. The shell, however, has additional features that are reminiscent of the recently described extended amygdala [Alheid G.F. and Heimer L. (1988) Neuroscience 27, 1-39; de Olmos J.S. et al. (1985) In The Rat Nervous System, pp. 223-334]; in fact, the possibility exists that the shell represents a transitional zone that seems to characterize most of the fringes of the striatal complex, where it adjoins the extended amygdala.