Determinants of survival after inferior vena cava trauma

Inferior vena cava (IVC) injuries continue to be associated with mortality rates of 21 to 66 per cent despite advances in prehospital, surgical, and critical care. The purpose of this study was to evaluate outcome of patients with IVC injury after treatment at a major urban trauma center and to identify factors predictive of survival. Between 1989 and 1995, 158 patients presented to the Los Angeles County + University of Southern California Medical Center with IVC injuries. One hundred thirty-six patient records were available for review, and 69 data points were collected and analyzed. Mean age was 26 years (range, 6-54), and 122 (90%) patients were male. Mechanism of injury included gunshot in 88 (65%) patients, stab in 23 (17%) patients, shotgun in 7 (5%) patients, and blunt trauma in 18 (13%) patients. The mean Injury Severity Score was 25. Seventy (52%) patients were hypotensive. Eleven (8%) patients died before surgical intervention, and 25 (18%) patients died before operative repair. Repair (79), ligation (20), or observation (1) was accomplished in 100 (74%) patients. Overall survival was 48 per cent and 65 per cent in the 100 patients surviving to operative repair, including 5 of 20 patients requiring IVC ligation. Significant differences (P<0.001) between survivors and nonsurvivors included Injury Severity Score, Glasgow Coma Score, hematocrit, hypotension, emergent thoracotomy, blood loss, level of injury, tamponade, and associated aortic injury. Logistic regression analysis identified hypotension, anatomic level of injury, and associated aortic injury as significant predictors of outcome (P = 0.001). Survival is predominantly determined by severity and anatomic accessibility of the IVC injury and by the absence of associated major vascular injuries. Ligation may control otherwise exsanguinating injuries and should be considered early in the management of complex injuries.

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.

Management options in vertebral artery injuries

The treatment of 22 patients with vertebral artery injuries was reviewed. Only four patients required an emergency operation. Most of the injuries (13 of 22) were successfully managed by observation. Five patients were managed by angiographic embolization which was successful in three. In three patients with an aneurysm and arteriovenous fistula, proximal embolization of the vascular lesion was not adequate and a suboccipital craniectomy was required for distal ligation. Most vertebral artery injuries can safely be managed without an operation, or by angiographic embolization. Surgical intervention should be reserved for patients with severe bleeding or where embolization has failed.

The effects of alloplastic implant onlays on bone in the rabbit mandible

The relative importance of the factors that contribute to the bone erosion seen underlying alloplastic implants remains unknown. This study was designed to examine the effects of different alloplastic onlays on the mandible in a rabbit animal model. Three alloplastic materials (soft solid silicone, methyl methacrylate, and porous polyethylene) were examined to determine the importance of implant composition in bone resorption. Thin (1.5-mm) and thick (6-mm) onlays were used to determine the relative importance of implant thickness. Fluorescent markers were administered at different time intervals to evaluate the patterns of new bone formation. A total of 96 implants placed on the mandibles of 16 animals were examined grossly, histologically, and under fluorescent microscopy after 12 and 24 weeks. The frequency and degree of bone erosion were related both to the type of alloplast and to the thickness of the implant. Silicone implants were associated with the greatest amount of bone resorption (p < 0.01). Thicker silicone implants were associated with a greater degree of thinning (p < 0.05). Bone resorption beneath the implants was documented by the presence of osteoclasts actively eroding bone and by changes in the normal patterns of the fluorescent markers. Both the thin methyl methacrylate and the thin porous polyethylene implants had a low incidence of bone thinning. The thick methyl methacrylate implants caused more erosion than the thin implants of the same material, although this was less than the silicone groups. Increasing the thickness of porous polyethylene implants did not adversely affect the underlying bone.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin, growth factors, and cancer cell energy metabolism: an hypothesis on oncogene action

The hexokinase-mitochondrial acceptor theory provides a model of insulin action which unifies the metabolic effects of this hormone and suggests that these result from insulin's stimulatory effect on mitochondrial ATP synthesis. There are similarities between these changes in cells exposed to insulin and in mitochondria of transformed cell lines and cancer cells, where an increased binding of hexokinase to mitochondria is observed. This phenomenon may play a key role in the high rates of glycolysis sustained by cancer cells under aerobic conditions. Structural and functional evidence support the hypothesis that certain growth factors and oncogenes act through stimulation of oxidative phosphorylation via promoting HK binding to mitochondria.

Prescribing of psychoactive drugs for chronically ill elderly patients

The prescribing of psychoactive drugs for 1431 chronically ill elderly patients being assessed for long-term institutional or community care was surveyed. Psychoactive drugs had been prescribed for about one quarter of the patients; benzodiazepines were the most frequently prescribed group. Judging from the extensive prescribing of flurazepam and chloral hydrate, commonly used hypnotics, the main reason psychoactive drugs were prescribed was to provide night-time sedation. Antidepressants and drugs promoted as useful in improving cognitive function were infrequently prescribed. Commendable prescribing practices included the infrequent use of "cerebral vasodilators" and barbiturates. Questionable prescribing practices included the infrequent use of tricyclic antidepressants in severely depressed patients and the use of tranquilizers in patients described by their attending physician as markedly or extremely withdrawn.