7
antibodies induced a humoral and cellular immune response against a colorectal carcinoma-associated antigen in patients. Proc Natl Acad Sci U S A 1995;92: 4773– 4777. 7. Fearon ER, Pardoll DM, Itaya T, et al. Interleukin-2 production by tumor cells bypasses T helper function in the generation of an antitumor response. Cell 1990;60:397– 403. 8. McLaughlin JP, Abrams S, Kantor J, et al. Immunization with a syngeneic tumor infected with recombinant vaccinia virus expressing granulocyte-macrophage col- ony-stimulating factor (GM-CSF) induces tumor regression and long-lasting sys- temic immunity. J Immunother 1997;20:449 – 459. 9. Kantor J, Abrams S, Irvine K, et al. Specific immunotherapy using a recombinant vaccinia virus expressing human carcinoembryonic antigen. Ann N Y Acad Sci 1993;690:370 –373. 10. Hodge JW, McLaughlin JP, Kantor JA, Schlom J. Diversified prime and boost protocols using recombinant vaccinia virus and recombinant non-replicating avian pox virus to enhance T-cell immunity and antitumor responses. Vaccine 1997;15:759 –768. 11. Fries LF, Tartaglia J, Taylor J, et al. Human safety and immunogenicity of a canarypox-rabies glycoprotein recombinant vaccine: an alternative poxvirus vec- tor system. Vaccine 1996;14:428 – 434. 12. Rosenberg SA, Lotze MT, Yang JC, et al. Experience with the use of high-dose interleukin-2 in the treatment of 652 cancer patients. Ann Surg 1989;210:474 – 485. 13. Lafreniere R, Rosenberg SA. Successful immunotherapy of murine experimental hepatic metastases with lymphokine-activated killer cells and recombinant inter- leukin 2. Cancer Res 1985;45:3735–3741. Trauma Firearm Violence in the United States: An Overview Guest Reviewers: Daniel G. Davis, DO, and James E. Barone, MD THE MEDICAL COSTS OF GUNSHOT INJURIES IN THE UNITED STATES. Cook PJ, Lawrence BA, Jens L, Miller TR. JAMA 1999;282:447– 454. Objective: To develop reliable estimates of the medical costs of treating gunshot injuries in the United States and to present national estimates for the sources of payment for treating these injuries. Design: Cost analysis of discharge data from hospitals and national data base sources. Setting: Sanford Institute of Public Policy, Duke University, Durham, North Caro- lina; National Public Services Research Institute, Landover, Maryland; and George- town Public Policy Institute, Georgetown University, Washington, District of Colum- bia. Participants: Hospitals in Maryland, South Carolina, and New York; data from the REVIEWER COMMENTS This study demonstrated the huge finan- cial costs incurred in the treatment of vic- tims of firearms-related injuries in the United States each year. The study is the first nationally representative estimate for the sources of payment for medical costs that are specific to gunshot injuries. Other studies have looked at individual states and the impact firearm violence has had. The sample size in this study is more than twice the size of those in previous studies looking at gunshot injuries, and 32 CURRENT SURGERY • Volume 57/Number 1 January/February 2000

Firearm violence in the United States: an overview

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antibodies induced a humoral and cellular immune response against a colorectalcarcinoma-associated antigen in patients. Proc Natl Acad Sci U S A 1995;92:4773–4777.

7. Fearon ER, Pardoll DM, Itaya T, et al. Interleukin-2 production by tumor cellsbypasses T helper function in the generation of an antitumor response. Cell1990;60:397–403.

8. McLaughlin JP, Abrams S, Kantor J, et al. Immunization with a syngeneic tumorinfected with recombinant vaccinia virus expressing granulocyte-macrophage col-ony-stimulating factor (GM-CSF) induces tumor regression and long-lasting sys-temic immunity. J Immunother 1997;20:449–459.

9. Kantor J, Abrams S, Irvine K, et al. Specific immunotherapy using a recombinantvaccinia virus expressing human carcinoembryonic antigen. Ann N Y Acad Sci1993;690:370–373.

10. Hodge JW, McLaughlin JP, Kantor JA, Schlom J. Diversified prime and boostprotocols using recombinant vaccinia virus and recombinant non-replicatingavian pox virus to enhance T-cell immunity and antitumor responses. Vaccine1997;15:759–768.

11. Fries LF, Tartaglia J, Taylor J, et al. Human safety and immunogenicity of acanarypox-rabies glycoprotein recombinant vaccine: an alternative poxvirus vec-tor system. Vaccine 1996;14:428–434.

12. Rosenberg SA, Lotze MT, Yang JC, et al. Experience with the use of high-doseinterleukin-2 in the treatment of 652 cancer patients. Ann Surg 1989;210:474–485.

13. Lafreniere R, Rosenberg SA. Successful immunotherapy of murine experimentalhepatic metastases with lymphokine-activated killer cells and recombinant inter-leukin 2. Cancer Res 1985;45:3735–3741.

Trauma

Firearm Violence in the United States:An OverviewGuest Reviewers: Daniel G. Davis, DO, and James E. Barone, MD

THE MEDICAL COSTS OF GUNSHOT INJURIES IN THE UNITED STATES.Cook PJ, Lawrence BA, Jens L, Miller TR. JAMA 1999;282:447–454.

Objective: To develop reliable estimates of the medical costs of treating gunshotinjuries in the United States and to present national estimates for the sources ofpayment for treating these injuries.

Design: Cost analysis of discharge data from hospitals and national data base sources.

Setting: Sanford Institute of Public Policy, Duke University, Durham, North Caro-lina; National Public Services Research Institute, Landover, Maryland; and George-town Public Policy Institute, Georgetown University, Washington, District of Colum-bia.

Participants: Hospitals in Maryland, South Carolina, and New York; data from the

REVIEWER COMMENTS

This study demonstrated the huge finan-cial costs incurred in the treatment of vic-tims of firearms-related injuries in theUnited States each year. The study is thefirst nationally representative estimate forthe sources of payment for medical coststhat are specific to gunshot injuries.Other studies have looked at individualstates and the impact firearm violence hashad. The sample size in this study is morethan twice the size of those in previousstudies looking at gunshot injuries, and

32 CURRENT SURGERY • Volume 57/Number 1 • January/February 2000

Page 2: Firearm violence in the United States: an overview

National Electronic Injury Surveillance System, the National Spinal Cord Injury Sta-tistical Center, and the 1994 Vital Statistics census.

Methods: Estimated national acute care and follow-up treatment costs and paymentsources for 134,445 gunshot injuries in the United States in 1994.

Results: At a mean medical cost per injury of about $17,000, the 134,445 (95%confidence interval [CI], 109,465 to 159,425) gunshot injuries in the United States in1994 produced $2.3 billion (95% CI, $2.1 billion to $2.5 billion) in lifetime medicalcosts (in 1994 dollars, using a 3% real discount rate), of which $1.1 billion (48%) waspaid by United States taxpayers. Gunshot injuries due to assaults accounted for 74% oftotal costs.

Conclusions: The authors concluded that gunshot injuries costs represent a substan-tial burden to the medical care system. Nearly half this cost is borne by the taxpayers ofthe United States.

MORTALITY AMONG RECENT PURCHASERS OF HANDGUNS. WintemuteGJ, Parham CA, Beaumont JJ, Wright M, Drake C. N Engl J Med 1999;341:1583–1589.

Objective: To study the risk of death among persons who have recently purchased ahandgun.

Design: Population-based cohort study.

Setting: Violence Prevention Research Program, University of California, Davis,California.

Participants: Persons (N 5 238,292) who purchased handguns in California in1991.

Methods: The authors conducted a population-based cohort study to compare mor-

REVIEWER COMMENTS

This study highlights one of the growingcontroversies over handgun ownershipand the risks of violent death. The au-thors studied the risks in relation to re-cent handgun purchases. They foundthat purchasers of handguns are at an in-creased risk for suicide, especially imme-diately after purchase. There was a nearabsence of suicides by firearm during thewaiting period, which for this study was15 days, followed by a marked increase insuicides the first month. Women wereespecially at risk during this period.

REVIEWER COMMENTS (Con’t)

the study also included a sample of casestreated in the emergency department.

A study such as this consists of compil-ing data sets and making assumptions toarrive at estimates that may not be per-fect. However, with the available infor-mation from such networks as the Na-tional Electronic Injury SurveillanceSystem, the National Spinal Cord InjuryStatistical Center (NSCISC), and the Vi-tal Statistics data base, the ability to esti-mate the impact of gunshot injuries inthe United States has improved. The au-thors admit that one of the limitations ofthe study was that their estimated costsfor hospital treatment came from datafrom only 2 states, as no other states re-quire hospitals to code for injury-relateddischarges and provide information thatcan identify actual medical costs. An-other possible confounding factor in thestudy was that cost data were provided byone state and the data from the otherstate were based on charges. Another im-portant limitation was the estimate oflifetime medical costs. This was based onone form of injury, spinal cord injury, forwhich the NSCISC data base providedinformation. Other types of injuries werebased on dated information that did notdistinguish between gunshot injuries andother injuries within the same Interna-tional Classification of Diseases (ninthrevision) diagnosis code. Despite its in-herent limitations, the study points outthat gunshot injuries result in huge finan-cial costs and that improved surveillanceand cost data are necessary if these esti-mates are to be improved.

CURRENT SURGERY • Volume 57/Number 1 • January/February 2000 33

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tality among the persons who purchased handguns in California with the general adultpopulation in that state from 1991 through 1996. The standardized mortality ratio(the ratio of the number of deaths observed among handgun purchasers to the numberexpected on the basis of age- and sex-specific rates among adults in California) was theprincipal outcome measure.

Results: In the first year after the purchase of a handgun, suicide was the leadingcause of death among handgun purchasers, accounting for 24.5% of all deaths and51.9% of deaths among women 21 to 44 years old. The increased risk of suicide by anymethod among handgun purchasers (standardized mortality ratio 5 4.31) was attrib-utable entirely to an excess risk of suicide with a firearm (standardized mortality ratio 57.12). In the first week after the purchase of a handgun, the rate of suicide by means offirearms among purchasers (644/100,000 person years) was 57 times as high as theadjusted rate in the general population. Mortality from all causes during the first yearafter the purchase of a handgun was greater than expected for women (standardizedmortality ratio 5 1.09), and the entire increase was attributable to the excess numberof suicides by means of a firearm. As compared with the general population, handgunpurchasers remained at increased risk for suicide by firearm over the study period of upto 6 years, and the excess risk among women in this cohort (standardized mortalityratio 5 15.50) remained greater than that among men (standardized mortality ratio 53.23). The risk of death by homicide with a firearm was elevated among women(standardized mortality ratio at 1 year 5 2.20, standardized mortality ratio at 6 years 52.01) but low among men (standardized mortality ratio at 1 year 5 0.84, standardizedmortality ratio at 6 years 5 0.79).

Conclusions: The purchase of a handgun is associated with a substantial increase inthe risk of suicide by firearm and by any method. The increase in the risk of suicide byfirearm is apparent within a week after the purchase of a handgun and persists for atleast 6 years.

REVIEWER COMMENTS (Con’t)

Women were also at greater risk for deathby homicide committed by an intimatepartner with a firearm than for that com-mitted by a stranger. They also foundthat the risk of death from homicide waslower among male purchasers of hand-guns than among men in the generalpopulation. This finding conflicts withprevious studies, probably because of dif-ferences in the study populations. Thecurrent study included only those wholegally purchased handguns, had passed abackground check, and had no potentialrisk factors for violence. The expense oflegally purchasing a handgun possiblyplaces the study group into a higher so-cioeconomic group and would not repre-sent the population as a whole, and there-fore the homicide rate may notnecessarily be the same in the generalpopulation.

Another limitation with the studypopulation is that it consists of only onestate and its firearm regulations. Statessuch as New York and New Jersey havevery long waiting periods for handgunpurchases, and the rate of suicide in thisstudy may not be as high in these states.Also, there are many states that do nothave strong laws regarding handgun pur-chasing among persons with previoushistory of violence, and therefore the rateof violent death may be higher in thesestates than in those in the study group.The study also did not look at the poten-tial risk factors for suicidal behavior inthe study group. The findings do notdemonstrate that the purchase of a hand-gun caused suicidal behavior. It is knownthat the most common cause of firearm-related deaths in the United States is sui-cide. The debate over handgun owner-ship and the laws regulating purchasingwill continue. Thoroughly investigatingthe risk factors such as a history of vio-lence, drug or alcohol abuse, and mentalillness is imperative prior to the purchaseof a handgun.

34 CURRENT SURGERY • Volume 57/Number 1 • January/February 2000

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PRIOR MISDEMEANOR CONVICTIONS AS A RISK FACTOR FOR LATERVIOLENT AND FIREARM-RELATED CRIMINAL ACTIVITY AMONG AUTHO-RIZED PURCHASERS OF HANDGUNS. Wintemute GJ, Drake CM, Beaumont JJ,Wright MA, Parham CA. JAMA 1998;280:2083–2087.

Objective: To determine whether authorized handgun purchasers with prior mis-demeanor convictions are more likely than those with no criminal history to be chargedwith new crimes, particularly offenses involving firearms and violence.

Design: Retrospective cohort study.

Setting: Violence Prevention Research Program, University of California, Davis,California.

Participants: A total of 5923 authorized purchasers of handguns in California in1977 who were younger than 50 years, identified by random sample.

Methods: The study population was identified by random sampling from a com-puterized registry of all persons who purchased a handgun in 1977. Entries werestratified by a notation that indicated that the purchaser had a record on file with theDepartment of Justice and may have had a criminal history. The main outcome was theincidence and relative risk of first charges for new criminal offenses after handgunpurchases.

Results: Of the 5923 authorized purchasers, 3128 had at least 1 conviction for amisdemeanor offense before handgun purchase, and 2795 had no prior criminal his-tory. Follow-up to the end of the 15-year observation period or to death was availablefor 77.8% of study subjects and for a median of 8.9 years for another 9.6%. Handgunpurchasers with at least 1 prior misdemeanor conviction were more than 7 times aslikely as those with no prior criminal history to be charged with a new offense afterhandgun purchase (relative risk [RR], 7.5; 95% confidence interval [CI], 6.6 to 8.7).Men with 2 or more prior convictions for misdemeanor violence were at greatest riskfor nonviolent firearm-related offenses such as weapon carrying (RR, 11.7; 95% CI,6.8 to 20.0), violent offenses generally (RR, 10.4; 95% CI, 6.9 to 15.8), and ViolentCrime Index offenses (murder or nonnegligent manslaughter, forcible rape, robbery,or aggravated assault; RR, 15.1; 95% CI, 9.4 to 24.3).

Conclusions: Handgun purchasers with prior misdemeanor convictions are atincreased risk for future criminal activity, including violent and firearm-relatedcrimes.

SUPPORT FOR NEW POLICIES TO REGULATE FIREARMS. Teret SP, WebsterDW, Vernick JS, et al. N Engl J Med 1998;339:813–818.

Objective: To assess public opinion on new gun policy options.

Design: Two telephone surveys that focused on innovative gun-related policies.

Setting: Johns Hopkins Center for Gun Policy and Research, Johns Hopkins Schoolof Public Health, Baltimore, Maryland.

REVIEWER COMMENTS

The firearm policy in the United States isunder considerable debate now morethan ever. Regulation of firearms is a hottopic that raises controversy from bothsides of the issue. Supporters of handgunownership cite the Second Amendment

REVIEWER COMMENTS

Evidence continues to mount againsthandgun purchasing by persons at highrisk for violence. The study by the Vio-lence Prevention Research Program atUniversity of California, Davis has foundevidence that prior misdemeanor convic-tions are another risk factor for futurecriminal activity after handgun purchase.The study included 3128 handgun pur-chasers with at least 1 misdemeanor con-viction and 2795 handgun purchaserswith no history of convictions. The strik-ing finding that the group with history of1 conviction is 7 times as likely to com-mit a future criminal activity is probablyconservative. The authors state thathandgun purchasers with prior misde-meanor convictions in other states wouldhave been classified by the study as hav-ing no prior criminal history if the con-victions did not appear on the Californiacriminal record. The findings are evenmore impressive when the history ofcriminal activity increases. Persons withmore than 1 offense are 10 times as likelyto be charged with new criminal activityand 15 times as likely to be charged withmurder, rape, robbery, or aggravated as-sault.

Even though the risk of new violentoffenses is nothing new for those whohave a history of violent crimes, the au-thors show evidence that commission ofnonviolent crimes is also a risk factor.The current federal law does not includemisdemeanor crimes (with the exceptionof crimes of domestic violence) as a factor toprohibit handgun sale. The study providesevidence that even misdemeanors shouldbe included in the federal law criteria forprohibiting handgun sale.

CURRENT SURGERY • Volume 57/Number 1 • January/February 2000 35

Page 5: Firearm violence in the United States: an overview

Participants: Twelve hundred adults in the United States.

Methods: Two telephone surveys of 1200 adults each in the United States wereconducted in 1996 and 1997–1998. Cognitive interviews and pretests were used in thedevelopment of the survey instruments. Potential participants were then contacted byrandom-digit telephone number dialing.

Results: A majority of the respondents favored safety standards for new handguns.These standards included childproofing (favored by 88% of respondents), personal-ization (devices that permit firing only by an authorized person; 71%), magazinesafeties (devices that prevent firing after the magazine or clip is removed; 82%), andloaded-chamber indicators (devices that show whether the handgun is loaded; 73%).There was strong support for policies prohibiting persons convicted of specific misde-meanors from purchasing a firearm. Support for such prohibitions was strongest forcrimes involving violence or the illegal use of a firearm (83% to 95%) or substanceabuse (71% to 92%). There was also widespread support for policies designed toreduce the illegal sale of guns, such as mandatory tamper-resistant serial numbers(90%), a limit of 1 handgun purchase per customer per month (81%), and mandatoryregistration of handguns (82%). Even among the subgroup of respondents who weregun owners, a majority were in favor of stricter gun regulations with regard to 20 of the22 proposals covered in the poll.

Conclusions: Strong public support, even among gun owners, for innovative strat-egies to regulate firearms suggests that these proposals warrant serious consideration bypolicymakers.

REVIEWER SUMMARY

An estimated 1.2 million firearm-related violent crimes occurred in the United Statesin 1995, more than 80% of which involved handguns.1–3 The United States leads theworld in deaths by firearms, with more than 30,000 deaths each year as reported by theCenters for Disease Control and Prevention. Injuries from firearms are the secondleading cause of death for Americans 15 to 24 years of age, and the number of nonfatalfirearm injuries is estimated at over 80,000 annually.4

The abstracts presented in this overview of firearm violence reveal the epidemicproportions that we as a nation face. Each article chosen for review highlighted theconcerns over firearms in the United States. The study by Cook and colleagues esti-mated the lifetime medical costs of gunshot injuries at $2.3 billion and cost to thetaxpayers at least $1.1 billion. The victims are theoretically responsible for the remain-ing costs. Another study found that the victims are nearly 6 times more likely tobecome bad debts and ultimately be covered by other sources.5 The enormous cost hasprompted legal actions against the gun industry by some cities in the United States.The outcomes of these suits are yet to be determined.

Handgun ownership has also been linked to the increased risk of suicides andhomicides.6–8 It is estimated that guns are used in 62% of suicide attempts among menand 39.3% among women, with death in approximately 85% of cases. Guns were usedin 41% of the homicides. The data from these studies were geographically limited and

REVIEWER COMMENTS (Con’t)

to the United States Constitution as con-firming their right to bear arms. Guncontrol proponents cite the ready avail-ability of handguns and injuries anddeaths caused by them. New policy op-tions have been proposed to attempt toachieve a reasonable agreement betweenthe 2 groups and to treat and regulatehandguns as consumer products. The au-thors conducted a study to assess publicopinion on the innovative gun policy op-tions. The findings will be utilized by guncontrol supporters, but one must realizethat the survey involved only 2400 peo-ple.

The study suggests that the majority ofthose questioned, and even the majorityof handgun owners, favor treating hand-guns as consumer products. Strongersafety standards would make firearms lessdangerous and still allow the right to owna firearm. The study gives some supportto those who feel that the federal govern-ment needs to act now to control thisproblem and offers somewhat of a com-promise that stops short of a completeban on handguns. Opponents of guncontrol would argue that devices such asgun and personalization locks have neverbeen shown to be effective.

36 CURRENT SURGERY • Volume 57/Number 1 • January/February 2000

Page 6: Firearm violence in the United States: an overview

only 1 study related the risk of death to handgun ownership.7 The study by Wintemuteand colleagues published in 1999 found the risk of suicide to be greater among newpurchasers of handguns, especially during the first week, and to persist for at least 6years. More women are victims of homicide, which is often committed by an intimatepartner. The authors were unable to determine whether the handguns that were actu-ally purchased were involved in the deaths, but there was definitely a greater risk ofdeath among recent handgun purchasers.

The risk factors associated with firearm violence have also been shown to be a majorcontributing cause of the increase in deaths. Laws prohibit the purchase of guns bypersons at high risk for violence. According to the Gun Control Act of 1968, personswith prior felony convictions, fugitives from justice, persons adjudicated to be mentallyill, and persons found guilty of misdemeanors involving domestic violence are prohib-ited from firearm purchase. The study by Wintemute and colleagues published in 1998provides evidence that persons with prior misdemeanors are at increased risk for futurecriminal activity, including violent and firearm-related crimes. The study supports newpolicies for handgun regulation, including prohibiting all persons convicted of a crimefrom ever purchasing a gun.

Encouraging news comes from the Centers for Disease Control and Prevention,which have shown that firearm-related injuries and deaths are declining in the UnitedStates but still remain high.4 Physicians have emphasized that firearm violence is apublic health epidemic. The Violence Prevention Task Force formed by the EasternAssociation for the Surgery of Trauma looked at firearm violence and made recom-mendations that are intended to reduce firearm-related injury and death. The policiesrecommended have been endorsed by other large physician groups, and prevention hasbeen the goal. Innovative policies to aid in firearm violence prevention have beenpresented. Teret and colleagues’ study determined that there was strong public sup-port, even among gun owners, for innovative strategies to regulate firearms. Firearmsneed to be regulated as a consumer product and subject to the same safety and designcriteria as other products. Identifying and prohibiting sales of guns to persons with riskfactors and innovative policies for handgun regulation may help decrease firearmviolence.

DANIEL G. DAVIS, DOJAMES E. BARONE, MDDepartment of SurgeryThe Stamford HospitalStamford, Connecticut

PII S0149-7944(00)00150-1

REFERENCES

1. Taylor BM. Changes in criminal victimization, 1994–1995 (NCJ Publication No.162032). Washington, DC: Bureau of Justice Statistics, 1997.

2. Crime in the United States, 1995. Washington, DC: Federal Bureau of Investiga-tion, 1996.

3. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatalfirearm-related injuries: beyond the tip of the iceberg. JAMA 1995;273:1749–1754.

4. Cherry D, Annest JL, Mercy JA, Kresnow M, Pollock DA. Trends in nonfatal andfatal firearm-related injury rates in the United States, 1985–1995. Ann Emerg Med1998;32:51–59.

5. Weissman JS, Lukas CVD, Epstein AM. Bad debt and free care in Massachusettshospitals. Health Aff (Millwood) 1992;11:148–161.

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6. Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gunownership. N Engl J Med 1992;327:467–472.

7. Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS. Theassociation between the purchase of a handgun and homicide or suicide. Am JPublic Health 1997;87:974–978.

8. Bailey JE, Kellermann AL, Somes GW, et al. Risk factors for violent death ofwomen in the home. Arch Intern Med 1997;157:777–782.

Trauma

Spinal Cord Injury: Are There Groundsfor New Hope?Guest Reviewer: Michael H. Metzler, MD

COMBINED MEDICAL AND SURGICAL TREATMENT AFTER ACUTE SPINALCORD INJURY: RESULTS OF A PROSPECTIVE PILOT STUDY TO ASSESS THEMERITS OF AGGRESSIVE MEDICAL RESUSCITATION AND BLOOD PRES-SURE MEASUREMENT. Vale FL, Burns J, Jackson AB, Hadley MN. J Neurosurg1997;87:239–246.

Objective: To determine if aggressive volume replacement and blood pressure man-agement of spinal cord injury patients, coupled with selective surgical decompressionand stabilization, improved outcome at 18 months postinjury.

Design: Prospective treatment protocol for spinal trauma from 1992 to 1997; his-toric controls.

Setting: University teaching hospital, Division of Neurosurgery and Department ofRehabilitative Medicine, University of Alabama, Birmingham, Alabama.

Participants: Seventy-seven patients with acute cervical (45) and thoracic (32) spi-nal cord injuries.

Methods: Initial neurologic examinationss were performed by 2 examiners. Swan–Ganz and arterial catheters were inserted. Volume and vasopressors were used to keepmean arterial pressure (MAP) greater than 85 mm Hg for 7 days (unless MAP . 85mm Hg could be maintained without pressors). All patients received methylpred-nisolone according to National Acute Spinal Cord Injury Study II guidelines for 24hours. Early fracture-dislocation reduction and stabilization was performed if cordcompression was noted on magnetic resonance imaging, and patient was thoughtmedically stable. Full rehabilitation was begun on discharge from acute care. Detailedneurologic assessments were performed at 6, 12, and 18 months postinjury. Mean fol-low-up was 17 months; 64 patients were followed at least 12 months. All patients weregraded by the American Spinal Injury Association (ASIA) as to completeness of neurologicfunction and motor index score.

Results: At last follow-up, 60% of patients with initial complete cervical cord injuryhad improved at least 1 ASIA grade over initial evaluation; 33% were able to walk, and20% had bladder control. Thirty-three percent of complete thoracic cord injuriesimproved at least 1 ASIA grade; 10% could walk and had bladder control. Incompletecervical lesion patients had a 92% clinical improvement rate: 92% regained ability towalk; 88% had bladder function.

REVIEWER COMMENTS

This article emphasizes aggressive use ofinvasive monitoring, volume loading,and use of pressors to maintain MAPabove an arbitrary value of 85 mm Hg for7 days postinjury (this value extrapolatedfrom treatment data of cerebral perfusionpressure in brain injury studies designedto prevent secondary brain injury). Fortyto 90% of patients required pressors, de-pending on whether they had incompleteor complete ASIA grade injuries. It is notclear how the Swan–Ganz catheter wasused, except as a method of preload de-termination. It may have been possible todo this with central venous pressuremonitoring. The outcomes are ratherspectacular.

38 CURRENT SURGERY • Volume 57/Number 1 • January/February 2000