Experience with the finger fracture technique to achieve intra-hepatic hemostasis in 75 patients with severe injuries of the liver.

The most important concept emerging from the management of complex hepatic trauma is that direct suture ligation of severed blood vessels and bile ducts is the most effective treatment. Three essential maneuvers are necessary: (1) the use of the finger fracture technique to expose the laceration widely, so that individual ligation of severed blood vessels and bile ducts can be accomplished under direct vision; (2) occluding the portal triad for 20 to 60 minutes; (3) closure of the hepatic incision over a viable omental pedicle. Two hundred consecutive patients with hepatic injuries were treated at the Trauma and Shock Unit of Bellevue Hospital between July 1976 and January 1982. One hundred and twenty-five injuries (63%) could be managed by superficial suture and drainage alone; 75 (37%) more extensive injuries required additional therapy; 47 of the 75 injuries required inflow occlusion for periods of up to 60 minutes, with the mean occlusion time of 30 minutes. All patients were pretreated with 30 to 40 mg/kg of Solu-Medrol prior to cross-clamping the portal triad. In addition, the liver was cooled to 27-32 degrees C topically by pouring 1 liter of iced Ringer's lactate directly on the liver surface, monitoring the temperature with an intra-hepatic probe. Ischemia time exceeded 20 minutes in 70%, 30 minutes in 40% and 60 minutes in 7% of patients. This approach, with complex hepatic trauma, has been dramatically effective. There were only four deaths (5.3%). One (1.3%) patient required reoperation for bleeding; three patients (4%) developed perihepatic abscesses; and two patients (3%) developed biliary fistulae that spontaneously closed. An extended right hepatectomy was necessary in the one patient who required reoperation for bleeding. This represents the only case of a formal hepatic resection in this series. Hepatic artery ligation was not employed in any case. These experiences strongly endorse the direct approach to the treatment of major hepatic lacerations by opening a lacerated liver sufficiently to ligate lacerated blood vessels and bile ducts, followed by closure over an omental pedicle. The wide-spread adoption of this technique will probably lower the mortality from massive liver injuries to 5-10%.     

Public health lessons learned from analysis of New York City subway injuries

Serious subway injuries are devastating to their young victims and have high rates of mortality and amputation. We identified the urban population at greatest risk for subway injuries and investigated the influence of local economies on injury rates. We propose using changes in social conditions as a "trigger" for increased vigilance and protective measures at times of higher risk.     

Effects of passive exercise on neurogenic atrophy in rat skeletal muscle

Passive exercise treatment for 23 days produced a retardation of type II muscle fiber atrophy in denervated extensor digitorum longus muscle of rat compared with denervated-nontreated animals. The type I muscle fibers of both denervated groups were similar to that of control rats.     

Evolving Concepts in Splenic Surgery: Splenorrhaphy versus Splenectomy and Postsplenectomy Drainage: Experience in 105 Patients

A major advance in recent years has been the demonstration in children that most injuries of the spleen can safely be repaired. There is, however, a relative paucity of data regarding primary suture repair of the spleen in adults. This report describes experience with the treatment of 27 consecutive injuries of the spleen between 1978-1980. Splenorrhaphy was successful in 24 of 27 patients. Eighteen of the 24 patients were older than 15 years of age. Seven injuries resulted from penetrating trauma, 13 from blunt trauma, and four from injuries during operation. Repair included debridement, partial splenectomy, and primary suture repair, often in conjunction with Avitene^®. There were no reoperations for bleeding or postoperative infection. Three splenectomies (11%) were necessary because of either complete destruction of the splenic pulp, or separation of the spleen from its blood supply at the hilum. A separate question for decades has been the influence of types of drainage on infection following splenectomy. To study this question, between 1976-1978, 78 patients undergoing splenectomy were randomized prospectively by sealed envelopes into three groups. Group I—no drainage (23 patients); Group II—closed drainage with Jackson-Pratt drains (30 patients); Group III—open drainage with Penrose drains (25 patients). All but three drains were removed within 48 hours. In these three patients, the drains were removed after 96 hours. In the 53 patients in Group I and II, there were no infections. In Group III (Penrose drains) there were two complications: evisceration of a loop of small bowel through the drain site, and one subphrenic abscess in a patient with a concomitant colonic injury. Present experience does not show any significant difference among the three groups. Concomitant enteric injuries and the duration of drainage maybe the most significant factors influencing infection. The presence or absence of drains per se does not seem significant.     

Brain regional angiogenic potential at the neurovascular unit during normal aging

Given strong regional specialization of the brain, cerebral angiogenesis may be regionally modified during normal aging. To test this hypothesis, expression of a broad cadre of angiogenesis-associated genes was assayed at the neurovascular unit (NVU) in discrete brain regions of young versus aged mice by laser capture microdissection coupled to quantitative real-time polymerase chain reaction (PCR). Complementary quantitative capillary density/branching studies were performed as well. Effects of physical exercise were also assayed to determine if age-related trends could be reversed. Additionally, gene response to hypoxia was probed to highlight age-associated weaknesses in adapting to this angiogenic stress. Aging impacted resting expression of angiogenesis-associated genes at the NVU in a region-dependent manner. Physical exercise reversed some of these age-associated gene trends, as well as positively influenced cerebral capillary density/branching in a region-dependent way. Lastly, hypoxia revealed a weaker angiogenic response in aged brain. These results suggest heterogeneous changes in angiogenic capacity of the brain during normal aging, and imply a therapeutic benefit of physical exercise that acts at the level of the NVU.     

Contrasting effects of recombinant human granulocyte-macrophage colony- stimulating factor (CSF) and granulocyte CSF treatment on the cycling of blood elements in childhood-onset cyclic neutropenia

Recombinant human granulocyte colony-stimulating factor (G-CSF) treatment has been shown to increase average neutrophil counts substantially in patients with childhood-onset cyclic neutropenia (or "cyclic hematopoiesis"), but not to eliminate the cyclic oscillations of neutrophil counts or those of other blood elements (monocytes, platelets, eosinophils, and reticulocytes) that are characteristic of this hematopoietic disorder. Indeed, oscillations of neutrophil counts are amplified during G-CSF treatment. We have compared the effects of recombinant granulocyte-macrophage-CSF (GM-CSF) with those of G-CSF in three patients with this disease (2 men and 1 woman, 17, 30, and 32 years of age). These patients were treated with GM-CSF (2.1 micrograms/kg/day, subcutaneously) for 6 weeks, preceded and followed by 6 to 13 weeks of detailed observation to document changes in the cyclic oscillations of blood neutrophils and other blood elements; two of the patients were subsequently treated with G-CSF (5.0 micrograms/kg/d, subcutaneously) and observed for comparable periods of time. Unlike G-CSF treatment, which increased average neutrophil counts more than 20-fold, GM-CSF increased neutrophil counts only modestly, from 1.6- to 3.9-fold, although eosinophilia of varying prominence was induced in each patient. However, at the same time, GM-CSF treatment dampened or eliminated the multilineage oscillations of circulating blood elements (neutrophils, monocytes, platelets, and/or reticulocytes) in each of the patients. In contrast, G-CSF treatment of the same patients markedly amplified the oscillations of neutrophil counts and caused the cycling of other blood elements (monocytes in particular) to become more distinct. These findings support the conclusion that the distinctive cycling of blood cell production in childhood-onset cyclic neutropenia results from abnormalities in the coordinate regulation of both GM-CSF-responsive, multipotential progenitor cells and G-CSF-responsive, lineage-restricted, neutrophil progenitors.