Outcome of major cardiac injuries at a Canadian trauma center

BACKGROUND: Canadian trauma units have relatively little experience with major cardiac trauma (disruption of a cardiac chamber) so injury outcome may not be comparable to that reported from other countries. We compared our outcomes to those of other centers. METHODS: Records of patients suffering major cardiac trauma over a nine-year period were reviewed. Factors predictive of outcome were analyzed. RESULTS: Twenty-seven patients (11 blunt and 16 penetrating) with major cardiac trauma were evaluated. Injury severity scores (ISS) were similar for blunt (49.6 ± 16.6) and penetrating (39.5 ± 21.6, p = 0.20) injuries. Five of 11 blunt trauma patients, and 9 of 16 penetrating trauma patients, had detectable vital signs on hospital arrival (p = 0.43). Ten patients underwent emergency department thoracotomy and 11 patients had cardiac repair in the operating theatre. Eleven patients survived and 16 died. Survivors had a lower ISS (33.7 ± 15.4) than non-survivors (50.4 ± 20.4; p = 0.03). Two of 11 blunt trauma patients and 9 of 16 penetrating trauma patients survived (p = 0.06). Eleven of 14 patients with detectable vital signs survived; all 13 without detectable vital signs died (p = 0.00003). Ten of eleven patients treated in the operating theatre survived, while only one of the other 16 patients survived (p = 0.00002). CONCLUSIONS: Patients with major cardiac injuries and detectable vital signs on hospital arrival can be salvaged by prompt surgical intervention in the operating theatre. Major cardiac injuries are infrequently encountered at our center but patient survival is comparable to that reported from trauma units in other countries

Hyper-IgG4 disease: report and characterisation of a new disease

BACKGROUND: We highlight a chronic inflammatory disease we call 'hyper-IgG4 disease', which has many synonyms depending on the organ involved, the country of origin and the year of the report. It is characterized histologically by a lymphoplasmacytic inflammation with IgG4-positive cells and exuberant fibrosis, which leaves dense fibrosis on resolution. A typical example is idiopathic retroperitoneal fibrosis, but the initial report in 2001 was of sclerosing pancreatitis. METHODS: We report an index case with fever and severe systemic disease. We have also reviewed the histology of 11 further patients with idiopathic retroperitoneal fibrosis for evidence of IgG4-expressing plasma cells, and examined a wide range of other inflammatory conditions and fibrotic diseases as organ-specific controls. We have reviewed the published literature for disease associations with idiopathic, systemic fibrosing conditions and the synonyms: pseudotumour, myofibroblastic tumour, plasma cell granuloma, systemic fibrosis, xanthofibrogranulomatosis, and multifocal fibrosclerosis. RESULTS: Histology from all 12 patients showed, to varying degrees, fibrosis, intense inflammatory cell infiltration with lymphocytes, plasma cells, scattered neutrophils, and sometimes eosinophilic aggregates, with venulitis and obliterative arteritis. The majority of lymphocytes were T cells that expressed CD8 and CD4, with scattered B-cell-rich small lymphoid follicles. In all cases, there was a significant increase in IgG4-positive plasma cells compared with controls. In two cases, biopsies before and after steroid treatment were available, and only scattered plasma cells were seen after treatment, none of them expressing IgG4. Review of the literature shows that although pathology commonly appears confined to one organ, patients can have systemic symptoms and fever. In the active period, there is an acute phase response with a high serum concentration of IgG, and during this phase, there is a rapid clinical response to glucocorticoid steroid treatment. CONCLUSION: We believe that hyper-IgG4 disease is an important condition to recognise, as the diagnosis can be readily verified and the outcome with treatment is very good

Are NFL Coaches Risk and Loss Averse? Evidence from Their Use of Kickoff Strategies

Quantitative analysis of football play calling suggests that NFL coaches do not choose their strategies optimally. They tend to be overly cautious. One possible explanation for this finding is that NFL coaches are averse to risk and loss. We propose a prospect theory based model of coaches' utility and estimate the model's parameters using kickoff data from the 2009 NFL season. Using an outcome measure of points scored on the initial post-kickoff possession we analyze two strategic kickoff decisions that involve risk-reward tradeoffs: the decision to kick a surprise onside kickoff or a regular kickoff, and the decision to accept a touchback or run the ball out of the endzone. Surprise onside kickoffs may yield a more favorable mean points scored value for the kicking team than a regular kickoff, yet surprise onside kickoffs are infrequently used (and thus the same size is small and the p-value of significance test is 0.68). Coaches appear averse to the possible loss involved in the surprise onside kickoff. Running the ball out yields a higher mean points scored for the receiving team than accepting a touchback, but it entails some risk (fumbles are lost in 2 percent of returns). Nevertheless, declining the touchback option and running the ball out is very common. Coaches do not appear excessively risk averse when presented with this choice over possible gains. Prospect theory models allow for risk aversion over possible gains, as in traditional expected utility theory, and in addition they permit an asymmetric aversion to losses. A prospect theory model therefore seems suitable for our analysis of kickoff strategies. We estimate a risk aversion coefficient value of 0.66 and a loss aversion coefficient value of 1.55, where values 1 indicate risk and loss aversion, respectively. Our analysis supports the notion that NFL coaches are both modestly risk averse and loss averse. In other words, coaches display diminishing sensitivity to changes in scoring outcomes as they move further from a reference point (zero), and for scoring gains and losses of equal magnitude they suffer more from a loss than they enjoy from a gain. This result may explain their propensity for making conservative strategic choices that, at first glance, appear sub-optimal.

Modafinil for the treatment of cocaine dependence

Modafinil was tested for efficacy in facilitating abstinence in cocaine-dependent patients, compared to placebo. This was a double-blind placebo-controlled study, with 12 weeks of treatment and a 4-week follow-up. Six outpatient substance abuse treatment clinics participated in the study. There were 210 treatment-seekers randomized, having a diagnosis of cocaine dependence; 72 participants were randomized to placebo, 69 to modafinil 200 mg, and 69 to modafinil 400 mg, taken once daily on awakening. Participants came to the clinic three times per week for assessments and urine drug screens, and had one hour of individual psychotherapy weekly. The primary outcome measure was the weekly percentage of cocaine non-use days. The GEE regression analysis showed that for the total sample, there was no significant difference between either modafinil group and placebo in the change in average weekly percent of cocaine non-use days over the 12-week treatment period ( p > 0.79). However, two secondary outcomes showed significant effects by modafinil 200 mg: the maximum number of consecutive non-use days for cocaine ( p = 0.02), and a reduction in craving ( p = 0.04). Also, a post hoc analysis showed a significant effect of modafinil that increased the weekly percentage of non-use days in the subgroup of those cocaine patients who did not have a history of alcohol dependence ( p < 0.02). These data suggest that modafinil, in combination with individual behavioral therapy, was effective for increasing cocaine non-use days in participants without co-morbid alcohol dependence, and in reducing cocaine craving