A rupture of both atrioventricular valves after blunt chest trauma: the usefulness of transesophageal echocardiography for a life-saving diagnosis.

Survival after the rupture of the both mitral and tricuspid valves in blunt thoracic trauma is uncommon and requires prompt diagnosis and treatment. We present a case in which transesophageal echocardiography performed in the operating room by the anesthesiologist identified the etiology of hemodynamic instability and facilitated successful emergency replacement of both valves.

Alterations in endothelial thrombomodulin expression in zymosan-induced lung injury.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is characterized by endothelial damage, neutrophil infiltration, and microvascular thrombosis. Products of the coagulation cascade, particularly thrombin, activate the endothelium with resulting polymorphonuclear neutrophil accumulation and thrombosis. This study assessed the changes in lung tissue endothelial thrombomodulin (TM) expression in a rat model of zymosan-induced remote lung injury. METHODS: Rats were randomized into three groups: control, low-dose intraperitoneal zymosan, and high-dose intraperitoneal zymosan. The animals were killed 28 days later. Lungs were assessed for histopathology, immunohistochemically stained for TM, and analyzed for TM mRNA. RESULTS: Animals developed a triphasic illness with ARDS in phase III. The lungs demonstrated normal TM immunoreactivity in areas of noninflamed lung but an almost complete absence of TM in areas of inflammation. Tissue TM mRNA decreased in association with the dose of zymosan. CONCLUSION: Zymosan-induced lung injury is associated with decreased TM expression in areas of injury. This finding may be of pathophysiologic significance in human ARDS, and it needs to be further explored. We hypothesize that down-regulation of TM leads to a hypercoagulable endothelium, increased microvascular thrombosis, and subsequent lung injury.

The negative impact of the repeal of the Arkansas motorcycle helmet law.

BACKGROUND: On July 1, 1997, Arkansas became the first state in 14 years to repeal their adult helmet law. We examined the clinical and financial impact of this repeal. METHODS: A 6-year retrospective review was conducted of the University of Arkansas for Medical Sciences trauma registry including the 3 years before and the 3 years after the repeal of the helmet law. A head and neck Abbreviated Injury Scale (AIS) score >or= 3 was considered severe. All patients admitted to the hospital or who died in the emergency department were included in the study. The database of the Arkansas Highway and Transportation Department was also used to determine the number of crashes and fatalities occurring statewide (1995-1999). RESULTS: Although total and fatal crashes in Arkansas were not significantly different (1995-1996 vs. 1998-1999), nonhelmeted deaths at the scene of a crash significantly increased from 19 of 48 (39.6%) (1995-1996) to 40 of 53 (75.5%) (1998-1999) (p < 0.0001). Before repeal, 25% of nonfatal crash admissions were nonhelmeted (18 of 73). This significantly increased to 54% (52 of 96, p< 0.001) after repeal. Overall, patients who were nonhelmeted had significantly higher AIS scores for head and neck, significantly more severe head injuries (AIS score >or= 3), 47% (33 of 70) versus 20% (20 of 99), and significantly longer length of intensive care unit stay. Financially, patients without helmets had significantly higher unreimbursed charges compared with their helmeted counterparts, resulting in a total of 982,560 dollars of additional potentially lost revenue over the length of the study. CONCLUSION: Repeal of the mandatory helmet law was associated with an increase in the nonhelmeted crash scene fatality rate. After the repeal, there was a disproportionately higher admission rate for nonhelmeted motorcycle crash survivors. These patients had an increased use of hospital resources and poorer reimbursement of charges compared with their helmeted counterparts. This resulted in significantly higher unreimbursed charges. States considering repeal of their mandatory adult helmet laws should consider the potential negative financial impact on their health care system and the increased morbidity associated with nonhelmeted motorcycle riders involved in a crash.