Sympathectomy for causalgia: experience with military injuries.

BACKGROUND: Causalgia is a rare disease in civilian practice, and most reports regarding causalgia in the literature are from major extended wars. To increase awareness of this syndrome, our wartime experience with this disease is presented. METHODS: The charts of patients with causalgia referred to two university hospitals for treatment from 1985 to 1989 were retrospectively studied. Characteristics of the cause, clinical manifestations, and the response to therapy were evaluated. RESULTS: Among 1,564 patients with peripheral nerve injuries, there were 54 cases (3.4%) of causalgia. All of the patients, except five, were injured in battle by high-velocity bullets or missiles. Upper extremities were involved in 28 patients (52 %) and lower extremities in 26 patients (48%). The most common presenting symptoms were as follows: burning pain, 100%; wet extremity, 100%; cold extremity, 93%; sensitivity to cold, 89%; paresthesia, 78%; and color changes in the extremities, 55%. In 48 patients (89%), pain was relieved by sympathetic block (3 patients had permanent cure). Six patients had no response to the blocks (11%). Of 45 patients who had temporary relief, all underwent sympathectomy. All of these patients had complete relief of symptoms in the immediate postoperative period and for follow-up from 1 to 6 years. CONCLUSION: Causalgia is essentially a war casualty disease. The condition is associated with burning pain, hyperesthesia, and symptoms of sympathetic overactivity. Sympathectomy is effective and the treatment of choice, particularly for patients who respond temporarily to sympathetic blocks.

The clinical significance of flow cytometry crossmatching in heart transplantation.

BACKGROUND: Flow cytometry crossmatching is more sensitive than cytotoxic methods in identifying preformed antibodies to donor alloantigens. However, the significance of a positive flow crossmatch remains unknown for a recipient of a heart transplant who has a negative anti-human globulin crossmatch. METHODS: Flow crossmatching was performed retrospectively for 92 recipients of a primary cardiac allograft who underwent transplantation with a negative AHG crossmatch. RESULTS: Forty-six patients were flow crossmatch-positive for alloantibody: 20 were positive on both T and B lymphocytes, 12 were positive only on B lymphocytes, and 13 were positive only on T lymphocytes. Eleven had autoantibody invalidating the flow crossmatch with donor cells. Thirty-six patients had negative flow crossmatch. A significantly higher incidence of graft dysfunction with vascular rejection by 6 months was found for patients who had a positive flow crossmatch on B lymphocytes. This group also had an increased incidence of mortality within this same period. Patients who were flow crossmatch-positive on T and B lymphocytes were more likely to experience greater than two episodes of treated cellular rejection within the first 6 months. Flow crossmatch-positive patients stayed longer in the hospital in comparison to the other two groups, although the increases were not statistically significant. There were no differences between groups with regard to time to first rejection, absence of rejection episodes, episodes of decreased cardiac index (<2.3 L/m2), depressed left and right ventricular ejection fraction, or development of transplant atherosclerosis. CONCLUSION: A positive flow crossmatch identified a subset of patients who are predisposed to development of vascular rejection or are more likely to have frequent cellular rejection.

Is hypothermia in the victim of major trauma protective or harmful? A randomized, prospective study.

OBJECTIVE: The purpose of this randomized, prospective clinical trial was to determine whether hypothermia during resuscitation is protective or harmful to critically injured trauma patients. SUMMARY BACKGROUND DATA: Hypothermia has both protective and harmful clinical effects. Retrospective studies show higher mortality in patients with hypothermia; however, hypothermia is more common in more severely injured patients, which makes it difficult to determine whether hypothermia contributes to mortality independently of injury severity. There are no randomized, prospective treatment studies to assess hypothermia's impact as an independent variable. METHODS: Fifty-seven hypothermic (T < or = 34.5 C), critically injured patients requiring a pulmonary artery catheter were randomized to a rapid rewarming protocol using continuous arteriovenous rewarming (CAVR) or to a standard rewarming (SR) control group. The primary outcome of interest was first 24-hour blood product and fluid resuscitation requirements. Other comparative analyses included coagulation assays, hemodynamic and oxygen transport measurements, length of stay, and mortality. RESULTS: The two groups were well matched for demographic and injury severity characteristics. CAVR rewarmed significantly faster than did SR (p < 0.01), producing two groups with different amounts of hypothermia exposure. The patients who underwent CAVR required less fluid during resuscitation to the same hemodynamic goals (24,702 mL vs. 32,540 mL, p = 0.05) and were significantly more likely to rewarm (p = 0.002). Only 2 (7%) of 29 patients who underwent CAVR failed to warm to 36 C and both died, whereas 12 (43%) of 28 patients who underwent SR failed to reach 36 C, and all 12 died. Patients who underwent CAVR had significantly less early mortality (p = 0.047). CONCLUSION: Hypothermia increases fluid requirements and independently increases acute mortality after major trauma.

Surgical treatment of myasthenia gravis in two major Middle East teaching hospitals: factors influencing outcome.

BACKGROUND: The results of thymectomy on patients with generalised myasthenia gravis have been widely reported. However, there is no information on whether the experience of western countries can be generalised to the population of the Middle East. The purpose of this study was to evaluate the safety and efficacy of thymectomy in patients with myasthenia gravis in a Middle East patient population and to identify clinical and histopathological factors associated with improved long term outcome of surgery. METHODS: In a prospective study, sixty three patients (aged 1.5-51 years) were treated in two university teaching hospitals between 1984 and 1991 and followed up for a mean of four years. Close communication was established with neurologists to obtain early referral. Radical anterior mediastinal dissection through a median sternotomy was performed in all patients. The response was evaluated by modified Osserman's classification. RESULTS: Eighteen patients achieved complete remission and a further 39 improved, producing an overall response rate of 90.5%. Patients with milder disease (stage II) had a higher response rate (97%) than those with more advanced disease (78%). Patients operated on with less than three years of symptoms had a better outcome (94%) than those with longer duration of preoperative symptoms, especially in non-thymomatous patients. Age and sex had no effect on the outcome. There was no effect on response rate if patients had hyperplastic or non-specific thymic histological findings, but patients with thymoma fared worse. CONCLUSIONS: These results are comparable with reports from the western world and represent the first prospective study from the Middle East. Thymectomy is indicated for all patients suffering from generalised myasthenia gravis soon after the diagnosis is made, regardless of age, stage, thymic pathology, and preoperative clinical status.

Traumatic visceral artery aneurysm: presentation as massive hemorrhage from perforation into an adjacent hollow viscus.

BACKGROUND: While diagnosis of extremity pseudoaneurysm is usually straightforward, pseudoaneurysms arising from visceral arteries may be occult. Perforation of a visceral artery pseudoaneurysm into an adjacent hollow viscus with subsequent hemorrhage has been rarely reported. OBJECTIVE AND DESIGN: To retrospectively evaluate the cause, clinical presentation, and outcome of patients with bleeding traumatic visceral artery aneurysms. MATERIALS AND METHODS: Records of nine patients with visceral hemorrhage due to posttraumatic arterial aneurysms. RESULTS: All had penetrating torso trauma 2 to 52 (mean, 12.3) weeks before presentation to our facility and had undergone 1 to 5 (mean, 2.2) prior operations. They had 2 to 15 episodes of hemorrhage into the gastrointestinal (seven cases), respiratory (one case), and urinary (one case) tracts. All underwent emergent surgery with ligation of the involved artery and resection of the corresponding portion of viscus. Evidence of prior attempts at hemostasis with multiple heavy ligatures was evident in all cases. All patients recovered without further complications. CONCLUSIONS: Traumatic visceral artery aneurysms are usually due to penetrating trauma. They present as episodes of massive bleeding through one of the hollow viscera, and may stop bleeding without direct intervention only to occur again. Prompt operative therapy is usually necessary.

The impact of hypothermia on dilutional coagulopathy.

UNLABELLED: The control of hemorrhage in hypothermic patients with platelet and clotting factor depletion is often impossible. Determining the cause of coagulopathic bleeding (CB) will enable physicians to appropriately focus on rewarming, clotting factor repletion, or both. OBJECTIVE: To determine the contribution of hypothermia in producing CB and ascertain if simultaneous hypothermia and dilutional coagulopathy (DC) interact synergistically. METHOD: Prothrombin time, partial thromboplastin time, and platelet function were determined at assay temperatures of 29 degrees to 37 degrees C on normal and critically ill, noncoagulopathic (NC) individuals. Dilutional coagulopathy was created using buffered saline and the assays repeated. RESULTS: Hypothermic assay at < or = 35 degrees C significantly prolonged coagulation times. The effect of hypothermia on NC and DC samples was not different. CONCLUSION: Assays performed at 37 degrees C underestimate coagulopathy in hypothermic patients. The effect of hypothermia on NC and DC is not different, indicating the lack of a synergistic effect. Normalization of clotting requires both rewarming and clotting factor repletion.