A case control study for major trauma in geriatric patients.

This study analyzed age as a univariate factor in survival in a national group of 46,613 major trauma patients and compared 180 elderly major trauma patients (greater than or equal to 65 years) to a similarly injured group of 3,918 younger patients (less than 65 years). In the national group, mortality rose sharply between age 45 (10%) and 55 (15%) and doubled at age 75 years (20%). This age-dependent survival decrement occurred at all Injury Severity Score values, for all mechanisms of injury, and for all body regions. In the comparison study, mortality in the elderly group was nearly double that of mortality in the younger group (27% vs. 14%). The older patients had a markedly higher complication death rate, especially for pulmonary (14/100 vs. 6.1/1100) and infectious complications (4.6/100 vs. 0.7/100). The median length of stay was twice as long for the older patients (14 days vs. 7 days). Cost data showed that the DRG prospective payment system grossly underestimated the cost of care for these patients (mean loss of $2,177.14 per patient). To minimize mortality and morbidity, triaging elderly trauma victims to trauma centers at a much lower threshold than similarly injured younger patients is recommended. The current DRG system should be altered to account for age-dependent morbidity. Further study is needed to determine whether more rigorous infection prophylaxis, immunomodulation, and pulmonary therapy will augment survival in elderly patients.

Dum-dums, hollow-points, and devastators: techniques designed to increase wounding potential of bullets.

When considering the kinetic energy formula (KE = 1/2 MV2) to estimate wounding potential of bullets, bullet velocity has assumed the premier role as the determinant of wounding capability. Particular characteristics of the bullet such as mass have assumed positions of secondary importance or have been largely ignored. In recent years, however, important changes in bullet design have occurred that can markedly change the character of gunshot wounds. Dum-dum bullets, hollow-points, shot shells, and explosive bullets have been designed so as to cause delivery of greater kinetic energy to the victim. Surgeons managing gunshot wounds must be familiar with these types of bullets in order to properly care for the victims and to ensure their own safety during the process.

Cholecystectomy with and without drainage. A randomized, prospective study of 300 patients.

A randomized, prospective study of 300 cholecystectomies was undertaken to evaluate the merits of drainage through a standard Penrose or Chaffin-Pratt sump tube matched against no drainage at all. There was no difference in mortality or length of hospital stay. There was, however, a significantly higher incidence of postoperative pyrexia due to atelectasis and wound infection in the drainage groups. Neither drain fulfilled its objective of providing outflow for a subhepatic collection, thus avoiding bile peritonitis. This study suggests that surgical drainage after every uncomplicated cholecystectomy is unnecessary and unwise.

Trauma score.

The Trauma Score (TS), a simple physiological measure of injury severity, is presented as a modification of the previously reported Triage Index by consensus physician peer review. Performance of the Trauma Score is presented as an index of injury severity both alone and in combination with an anatomic index of injury severity, the Injury Severity Score (ISS) and patient age. The application of these tools for field triage and evaluation of care of the trauma victim is proposed.

Operative hemorrhoidectomy versus cryodestruction.

Twenty-six patients were treated for hemorrhoids by a combination of cryodestruction and closed operative hemorrhoidectomy. Patients were able to draw their own conclusions about the efficacies of these treatments. They had no difficulty in distinguishing exactly which area was causing pain. The operative site was a source of greater pain until the second day after the procedure, when the pain resulting from cryodestruction equalled surgical pain; then cryodestruction associated pain continued longer. Cryodestruction was associated with production of a foul discharge. Residual hemorrhoids were present in 50 per cent of patients' cryodestruction sites. Given the choice at the one year follow-up examination, 65 per cent preferred surgical treatment and 35 per cent preferred cryodestruction.

Surgical morbidity after mastectomy operations.

The records of 146 consecutive patients with mastectomy operations over a three year period were reviewed. Of these, ninety-three (63.6 per cent) had one or more complications secondary to surgery. There were 175 complications, of which complications, of which 107 (73.2 per cent) were wound-related. Seroma formation occurred most frequently but was of minor consequence. The incidence of flap necrosis was 19.1 per cent, with cellulitis or suppurative infection appearing in thirteen patients. Immediate postoperative edema of the arm was fairly rare (2.7 per cent) and appeared related to delayed wound healing. Postoperative complications after total, modified radical, and radical mastectomy present problems unique from those seen after other major surgery, in that local complications predominate. The very nature of the procedure, with the creation of large thin skin flaps, extensive axillary dissection, and an open wound for a prolonged period of time, predisposes to wound morbidity.

Efficacy of preoperative and postoperative bone scanning in the management of breast carcinoma.

With use of 99mtechnetium-labeled phosphates, we performed preoperative bone scans on 122 women with biopsy-proved breast carcinoma. Only two of the 110 patients with Stage I or II disease had scan abnormalities interpreted as bone metastases. Of 55 patients with normal preoperative scans, 20 later had changes suggesting bone metastases on the subsequent scans, most within 24 months of operation. In women with Stage I and II tumors, 13 of 48 (27 per cent) had scan evidence of bone metastasis of postoperative follow-up examination. Five of 23 with potential surgical cures (negative lymph nodes at operation) had bone metastasis within two years of operation. In Stage I and II patients, postoperative discovery of evolving metastases was most often (11 to 13) made by bone scan. Although the initial yield from preoperative bone scans is low, preoperative scanning combined with sequential postoperative scans constitutes one of the most sensitive indicators of evolving metastatic disease.

Familial retrocecal appendicitis.

A family pedigree containing sixteen individuals with acute appendicitis is presented. In all but one the position of the appendix was retrocecal. In two other members explored for abdominal pain wherein acute appendicitis was not the cause, the appendix was also found to be retrocecal. The anatomic retrocecal location of the appendix in this pedigree shows a degree of uniformity that implies a common predisposing factor inherited as a simple, dominant unit-character.

Transverse colon volvulus associated with scleroderma.

An unusual case of volvulus of the transverse colon associated with scleroderma is presented. The morphologic changes in the large bowel due to progressive systemic sclerosis, resulting in pseudo-obstruction, are considered in the etiology and pathogenesis of colonic torsion.

Citrate anticoagulation and cell washing for intraoperative autotransfusion in the baboon.

Extracorporeal citrate was used for anticoagulation during autotransfusion of baboons. A cell-washing plasmaphoresis procedure was added in one group of animals in order to remove activated clotting materials. Both groups became hypocoagulable, but the cell-washed group had less evidence of disseminated intravascular coagulation as well as lower plasma hemoglobin levels. Citrate anticoagulation plus cell washing is a potential alternative to heparinization for autotransfusion.

Liver scan and carcinoma of the breast.

The results of 100 liver scans obtained as part of the preoperative evaluation of patients known to be harboring a potentially resectable carcinoma of the breast were evaluated. Of the five positive results of these studies, four were found to be falsely positive. During the period included in the study, 317 other liver scans were performed on patients known to have recurrent, residual, or metastatic disease or on patients returning for routine postoperative evaluation. The information derived from these studies was of practical significance only in the group receiving therapy for the secondary tumor. On the basis of this small series, the routine use of the liver scan in evaluating the patient with carcinoma of the breast cannot be supported.