Urgent and emergent thoracotomy for penetrating chest trauma

BACKGROUND: Resuscitative thoracotomy (TCY) after trauma has an overall dismal survival rate, yet patients with isolated penetrating chest wounds have the best chance of meaningful recovery. Although the major factor in outcome is presenting physiology, the site of the TCY may influence survival, with the operating room offering a superior environment to the emergency room. PURPOSE: The purpose of this study was to evaluate the impact of location of TCY on outcome after penetrating chest injury. METHODS: This was a multicenter study of patients admitted with either stab (SW) or gunshot wound (GSW) to the chest, with systolic blood pressure < or = 90 mm Hg, and who underwent TCY within 60 minutes of arrival. Time to TCY, Injury Severity Score, location of TCY (emergency room, operating room, or resuscitation room), and detectable systolic pressure at admission were among the factors studied. RESULTS: Over a 4-year period, 78 SW and 140 GSW victims underwent TCY. GSW victims had greater Injury Severity Scores (39.4 +/- 23.1 for GSW vs. 27.2 +/- 15.7 for SW, p < 0.001) and mortality (69% for GSW vs. 37% for SW, p < 0.001). No parameter studied was found to be significantly associated with survival after SW. After GSW, survival was 13.5 times more likely if TCY was performed in the resuscitation room (confidence interval, 3.3-54.6) and 22 times more likely if it was performed in the operating room (confidence interval, 6.7-73.7). CONCLUSION: Although patient selection is the primary factor determining outcome, there may be an independent benefit for performing TCY after GSW in a specialized resuscitation room or the operating room.     

Lysine requirements of healthy adult Indian subjects receiving long-term feeding,measured with a 24-h indicator amino acid oxidation and balance technique

BACKGROUND: The mean lysine requirement of healthy Indian subjects was estimated from short-term experimental diet periods to be 29 mg x kg(-1) x d(-1), which is higher than the 1985 FAO/WHO/UNU upper requirement of 12 mg x kg(-1) x d(-1). OBJECTIVE: Our objective was to confirm our proposed requirement of 29 mg x kg(-1) x d(-1) by extending the diet period to 21 d and by using 4 test lysine intakes (12, 20, 28, and 36 mg x kg(-1) x d(-1)) and a 24-h indicator amino acid oxidation and balance approach. DESIGN: During two 21-d diet periods, 18 healthy Indian men were randomly assigned to receive 12 and 28 or 20 and 36 mg lysine x kg(-1) x d(-1) as part of an L-amino acid diet. At 1800 on days 6 and 20, [(13)C]leucine was infused over 24 h to assess leucine oxidation and daily leucine balance at each test intake. RESULTS: Leucine oxidation, balance, and flux did not differ significantly between days 7 and 21. Twenty-four-hour leucine oxidation was lower at lysine intakes of 28 and 36 mg than at 12 and 20 mg. Leucine balances at lysine intakes of 12 and 20 mg were negative and significantly less than equilibrium (P < 0.01) and lower (P < 0.02) than balances at 28 and 36 mg lysine. Two-phase regression analysis indicated a breakpoint at 31 mg lysine x kg(-1) x d(-1) in the relation between lysine intake and 24-h leucine oxidation and balance. CONCLUSIONS: Full adaptation to a low lysine intake occurs within 7 d. The previously proposed tentative mean lysine requirement for Western subjects of 30 mg x kg(-1) x d(-1) is confirmed for healthy Indian adults.     

Atypical calcific tendinitis with cortical erosions

Objective. To present and discuss six cases of calcific tendinitis in atypical locations (one at the insertion of the pectoralis major and five at the insertion of the gluteus maximus). Patients and results. All cases were associated with cortical erosions, and five had soft tissue calcifications. The initial presentation was confusing and the patients were suspected of having infection or neoplastic disease. Conclusion. Calcific tendinitis is a self-limiting condition. It is important to recognize the imaging features of this condition to avoid unnecessary investigation and surgery. Received: 2 May 2000 Revision requested: 8 June 2000 Revision received: 31 July 2000 Accepted: 8 August 2000     

Aqueduct stenosis due to venous ectasia with a dural arteriovenous fistula

We report aqueduct compression by venous ectasia in a 65-year-old man with a dural arterio-venous fistula in the posterior cranial fossa draining into a superior vermian vein. Conventional and phase-contrast MRI showed the aqueduct stenosis and the causative dilated vein. Received: 9 November 1998 Accepted: 2 August 1999     

Constrictive pericarditis causing extrinsic mitral stenosis and a left heart mass

Constrictive pericarditis is a fibrotic process involving both layers of the pericardium and is known to give rise to obstruction to blood flow in the right heart. We report a patient with constrictive pericarditis who had echocardiographic features of mitral stenosis caused by a fibrocalcific mass lesion involving the mitral annulus with infiltration into the base of the posterior mitral leaflet. To our knowledge, this has not been reported in the literature.     

After rehydration: what happens to the child?

Three-hundred infants and toddlers with diarrhoea were followed up for 5 days after initial rehydration with oral rehydration solution (ORS). When an average of 300-340 ml per day was given at home (520 ml if the diarrhoea was watery), only two children required re-hospitalization; one other child died whose voluminous losses should not have been treated at home. Fifteen per cent of the children still had watery diarrhoea and vomiting by the fifth day, perhaps as a result of multiple drug therapy. Continued feeding, especially breast milk and cereal grains, should reduce the duration of diarrhoea and vomiting (and perhaps the number of drugs). The amount of time a mother can spend giving ORS ultimately limits the amount a child receives.     

Assessment of age-related changes in left ventricular structure and function by freehand three-dimensional echocardiography

To determine age-related changes in left ventricular (LV) structure and function, the authors used freehand three-dimensional echocardiography, a previously validated tomographic technique, to measure LV mass, volumes, and derived parameters in 94 sedentary, but ambulatory and clinically healthy, adult male and female volunteers aged 20-94. LV volumes and mass were significantly greater in men than in women (p<0.001) and remained greater after adjustment for body surface area and height (p<0.05). Declines in end-diastolic and stroke volumes with age were reduced or absent after accounting for body size. By multivariate analysis, age accounted for only about 6%-11% of the variance among LV volumes and mass, in comparison with body surface area and gender, which accounted jointly for about 46%-77% of the variance. In conclusion, changes occur in LV structure and function with normal aging, but these changes are relatively minor when body size and gender are taken into account.     

Standards of education, regulation, and market control: perspectives on complementary and alternative medicine in Ontario, Canada

This paper provides a contemporary analysis of the issues and questions surrounding the regulation and standardization of education with respect to two complementary and alternative medicine (CAM) professions, namely Chinese traditional medicine and homeopath in Ontario, Canada. Rather than taking a standard of education for granted, the assumption that standardizing professional education is a positive move is critiqued because it is claimed to ensure public safety and uniformity within the profession. It is argued that such an assumption fails to deconstruct the power relations involved with setting a standard of education and continues to ignore the fact that setting a standard of education in CAM is part and parcel of biomedical dominance, competition, turf wars and survival. At the end of this paper, some critical questions regarding setting standards of education by the health professions in general are raised.