摘要:

BackgroundClinical factors do not adequately explain why some patients develop severe sepsis after trauma and why others do not. We sought to determine whether genetic factors contribute to this risk.MethodsPatients admitted to a single Level I trauma center were enrolled and DNA was isolated from leukocytes. The risk for severe sepsis and for death associated with polymorphism in the tumor necrosis factor-&agr; promoter was determined by multivariate analysis.ResultsOne hundred fifty-two patients had a 24% incidence of severe sepsis and a 13% case fatality rate. The A-allele was most common at the −308 position (n = 35). A-allele carriage at this location was associated with an adjusted odds ratio of 4.6 (95% confidence interval, 1.9–10.9) for severe sepsis and of 2.1 (95% confidence interval, 0.6–7.3) for death.ConclusionThe A-allele at the −308 position in the tumor necrosis factor-&agr; promoter increases the risk for severe sepsis and possibly for death after trauma.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundImproved survival after injury has been demonstrated with trauma system implementation and designation of trauma centers. Local designating health authorities or national verification (United States) or accreditation (Canada) programs audit trauma center performance. The relative importance of designation versus accreditation with respect to improved outcomes is not clear. The purpose of this study was to measure outcomes within a single regional trauma system after designation of trauma centers and to compare outcomes in the one accredited center to the nonaccredited centers.MethodsData from three trauma centers were studied. All were large, university-affiliated regional medical centers, integrated into a regional trauma system and served by a single ambulance service. The study period was 1992 to 1999, immediately after trauma center designation in 1991. The British Columbia Trauma Registry was used to identify trauma patients, mechanism of injury, length of stay, case mix, case volume, acuity, pediatric caseload, and proportion of transfers at each center. A questionnaire was circulated to each hospital to determine the level of institutional support and programmatic development for trauma. The Trauma Registry was used to calculatezscores (TRISS methodology) for each center and TRISS-adjusted mortality odds ratios between institutions. Differences in covariables were controlled for in subgroup analysis.ResultsTwo centers (hospitals A and C) had a high trauma caseload; one (hospital B) had a small and diminishing caseload. Only one center (hospital A) developed a trauma program consistent with Canadian accreditation criteria;zscores for center A were consistently better than at hospital B or C and survival odds ratios were significant. This finding applied to the total trauma population, blunt adult trauma patients (whether or not transfers and hip fracture patients were excluded), and in the more severely injured blunt trauma subgroups. There were no differences between hospitals for the relatively small number of patients with penetrating trauma.ConclusionDifferences between hospitals were apparent from the outset of the trauma system. However, designation as a trauma center does not appear to necessarily improve survival in large regional medical centers. Development of a trauma program and commitment to meeting national guidelines through the accreditation process does appear to be associated with improved outcome after injury.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundNo data are available regarding the characteristics of the trauma directors of Level I trauma centers.MethodsQuestionnaires were mailed to 102 directors of Level I trauma centers. Data were analyzed in a blinded fashion.ResultsSeventy-two directors responded. All were men, with a mean age of 48 ± 6 years. Fifty-eight percent of directors were fellowship trained. Directorship was assumed 7.3 ± 6.1 years after training and the average time on the job was 8.6 ± 6.1 years. Directors work in urban (93%), university-affiliated (67%) institutions that admit 1,000 to 2,000 patients annually (50%). Practice time distribution is as follows: trauma clinical care, 33%; general surgery, 20%; administrative work, 18%; critical care delivery, 17%; and research, 11%. Directors take 6.6 ± 2.2 night calls per month, with half of them taking in-house call. Eighty-eight percent of directors are involved in research. Seventy-eight percent of directors earn $200,000 to $325,000 per year, with the largest group making $225,000 to $250,000. Salary is derived from clinical revenues (42%) and hospital (37%) or university (20%) support. Compensation is higher in community hospitals and tends to be higher in the Midwest.ConclusionThe profile of the trauma director at a Level I trauma center was described. This may be important in trauma career and systems development.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundIn the current health care climate, trauma centers face particular economic challenges. Statewide trauma systems provide a network for referral of critically injured patients to academic Level I trauma centers, but favorable reimbursement in states such as Colorado results in intense competition for patients. We hypothesized that a comprehensive Outreach Trauma Program would facilitate our mission as a key resource facility in our trauma system, and would increase referrals of critically injured patients to our center from outside our metropolitan area.MethodsThe Colorado statewide trauma system was formalized in 1995; our Outreach program—including providing visiting trauma call, continuing medical education lectures, 24-hour/7-day immediate consultation and transfers, and public relations/marketing—was fully implemented in 1997. We audited our trauma registry from January 1994 to July 2001 to determine the impact on patient volume and acuity as well as academic productivity.ResultsAnnual overall trauma admissions have remained stable. Since 1997, high-acuity patients (i.e., Injury Severity Score > 15, intensive care unit admissions, those requiring surgery) have increased 27% to 51%, attributable largely to an approximately 300% increase in high-acuity Outreach patients. In 2000, Outreach patients constituted 8% of our total trauma admissions, but 21% of intensive care unit trauma admissions; notably, they accounted for 25% of our center’s trauma charges. Meanwhile, our group’s academic productivity has not suffered; in fact, we had 57 publications in 2000, compared with an average of 35 per year from 1993 through 1997.ConclusionThe Outreach Trauma Program has proven clinically, academically, and financially rewarding. Our program may serve as a model whereby academic trauma centers, through a demonstrated commitment to serving the clinical and educational needs of their referral base, can satisfy their mission while ensuring their survival.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe Trauma Evaluation and Management (TEAM) module was devised by the American College of Surgeons for teaching senior medical students trauma management principles. This article reports on the teaching effectiveness of this module.MethodCognitive skills (by 20 item multiple-choice question examination on trauma topics) and clinical trauma management skills performance, using the Objective Structured Clinical Examination, were compared between two groups of 16 randomly selected final year medical students who had completed the standard curriculum including trauma topics. One group had the TEAM (TEAM group) and the other did not (no-TEAM group). Objective Structured Clinical Examination score (percentage), Priority score (range, 1–7), Organized Approach score (range, 1–5), and Global Pass status were assigned at each station. The students also completed a five-part questionnaire.ResultsResults of the questionnaire showed that on a scale of 1 to 5, with 5 being excellent, 96.8% assigned a score of 4 or greater, indicating the objectives were met, 83.8% that trauma knowledge was improved, 51.6% that clinical skills were improved, 90.3% that the module should be mandatory, and 83.9% overall satisfaction with the program.ConclusionThe TEAM module is very effective in teaching trauma management principles to senior medical students, by whom the program was very well received. Consideration should be given to adopting this program more widely in our medical undergraduate curriculum.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundEffective use of damage control in trauma hinges on an early decision to use it. Bullet trajectory has never been studied as a marker for damage control. We hypothesize that this decision can be predicted by an artificial neural network (ANN) model based on the bullet trajectory and the patient’s blood pressure.MethodsA multilayer perceptron ANN predictive model was developed from a data set of 312 patients with single abdominal gunshot injuries. Input variables were the bullet path, trajectory patterns, and admission systolic pressure. The output variable was either a damage control laparotomy or intraoperative death. The best performing ANN was implemented on prospectively collected data from 34 patients.ResultsThe model achieved a correct classification rate of 0.96 and area under the receiver operating characteristic curve of 0.94. External validation showed the model to have a sensitivity of 88% and specificity of 96%. Model implementation on the prospectively collected data had a correct classification rate of 0.91. Sensitivity analysis showed that systolic pressure, bullet path across the midline, and trajectory involving the right upper quadrant were the three most important input variables.ConclusionBullet trajectory is an important, hitherto unrecognized, factor that should be incorporated into the decision to use damage control.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundMotor vehicle collision–related blunt thoracic aorta injury (BAI) is rare and highly lethal. Vascular disease as related to advancing age potentially subjects older adults to increased risk of BAI; the mechanisms associated with such injuries may be different as compared with younger adults. The goal of the present study is to test this hypothesis using population-based data.MethodsThe 1995 to 1999 National Automotive Sampling System data files were used. The National Automotive Sampling System is a national probability sample of passenger vehicles involved in police-reported tow-away crashes. BAI was defined according to the Abbreviated Injury Scale codes. Among those with BAI, information on occupant (age, seating position, restraint use), collision (collision type, delta-V, vehicle intrusion), and outcome characteristics were obtained and compared according to age.ResultsThe overall incidence of BAI was 6.8 per 10,000 occupants and there was a steady increase in the BAI rate for advancing decades of life. The proportion of occupants with BAI who die at the scene of the collision is relatively consistent across all age groups (∼85%). Among those who survive to receive medical care, ultimate survival is lowest among those aged 60 and older. Near-side collisions were responsible for more BAI among older adults than other age groups (50% vs. 20.6%,p≤ 0.05). Older adults sustained BAI in collisions with lower delta-V values compared with younger persons (p≤ 0.05).ConclusionOlder adults have the highest rate of motor vehicle collision–related BAI, and their injuries tend to occur in less severe collisions. A high level of suspicion for BAI among older adults should not be reserved for high-energy collisions only.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundResuscitation from hemorrhagic shock causes profound immunologic changes. The tonicity of fluids used for resuscitation clearly influences the immune response. Our study was designed to determine whether isotonic and hypertonic fluids exert their differential effects on immune response by altering the cytokine gene profile of human leukocytes. The cDNA array method was used to profile transcriptional responses after exposure to hypertonic and isotonic fluids.MethodsBlood from seven healthy volunteers was incubated for 30 minutes with isotonic (10% dextran-40 and lactated Ringer’s [LR] solution) and hypertonic (7.5% hypertonic saline and hypertonic dextran [HTD]) fluids. The volumes of isotonic fluids used were equal to the volume of blood, whereas the volumes of hypertonic fluids were adjusted to keep the salt load identical to the LR group. The cDNA array technique was used to measure the gene expression of 23 common cytokines.ResultsIncreased gene transcription of proinflammatory cytokines (interleukin [IL]-1&agr;, IL-6, IL-10, and tumor necrosis factor-&agr;) as well as others (IL-5, IL-7, and IL-16) was found after incubation with resuscitation fluids. Variances were noted depending on the type of fluid: HTD and LR solution did not induce expression of IL-5, and HTD also did not induce IL-1&bgr; expression. Genes encoding IL-1&agr;, IL-6, IL-9, and tumor necrosis factor-&agr; had low level baseline expression in leukocytes isolated from unstimulated blood, and their expression increased markedly after exposure to resuscitation fluids. The inducible transcripts included IL-1&bgr;, IL-7, IL-10, and IL-16. However, there was no difference in cytokine expression profile between isotonic and hypertonic fluids.ConclusionExposure of human leukocytes to resuscitation fluids causes an increase in cytokine gene expressions compared with undiluted blood. This expression profile is largely independent of the type of fluid used.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

BackgroundThe standard lactated Ringer’s (LR) solution contains racemic lactate, an equal mixture of d(−)- and l(+)-isomers. The aim of this study was to investigate whether racemic LR solution (containing both isomers, dl-LR) differs from LR containing l-isomer only (l-LR).MethodsBlood from 20 volunteers was incubated for 30 minutes with lactated Ringer’s solutions containing the dl- or l-form of lactate, Hank’s balanced salt solu-tion, normal saline, and ketone Ringer’s (lactate replaced with ketone bodies). Neutrophil “oxidative burst” was measured using flow cytometry. Gene expression of 23 genes associated with leukocyte function was determined with cDNA array technique. The arraying procedure was repeated four times to obtain four sets of data.ResultsCompared with the l-LR and ketone Ringer’s, dl-LR causes an increased production of reactive oxygen spe-cies by neutrophils and affects expression of leukocyte genes known to be involved in inflammation, cell migration, and apoptosis.ConclusionLactated Ringer’s solution in commonly used formulation (racemic mixture, dl-LR) influences neutrophil function and leukocyte gene expression.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID

摘要:

ObjectiveOn the basis of the data of a multicenter study, the impact of prehospital intubation and ventilation in the therapy of severe thoracic trauma without manifest respiratory insufficiency was analyzed.MethodsData were collected prospectively in the Trauma Registry of the German Trauma Society. In a matched-pair analysis, patients with severe thoracic trauma (Abbreviated Injury Scale score of 4) with and without prehospital intubation were compared. Patients were paired with respect to age, injury severity, and prognosis (according to the TRISS method).ResultsFrom a total of 3,814 patients, two groups (with/without prehospital intubation) of 44 matched patients each with comparable average age (36 vs. 36 years), Injury Severity Score (29 vs. 29), and TRISS (95.2 vs. 95.3) were identified. No patient was unconscious at the scene (all Glasgow Coma Scale scores ≥ 8) or presented with severe respiratory insufficiency (all ≥ 10 breaths/min). Time between injury and hospital admission was significantly longer (73 minutes;p< 0.05) in the group with prehospital intubation compared with the nonintubated group (47 minutes). Furthermore, fluid requirements in the prehospital period were significantly higher in the intubated patients (3,000 mL vs. 1,000 mL). In the prehospital intubation group, the number of patients with mass transfusion (9 vs. 4) as well as with emergency operations (10 vs. 4) were not significantly different from the nonintubated group. The prehospital intubation group showed a similar incidence of lung failure (17 vs. 14), kidney failure (6 vs. 2), and circulation failure (13 vs. 5). Except for two of the primarily nonintubated patients, all were intubated during their stay in the emergency room or on the intensive care unit. Days of ventilation (median, 7 days) as well as the length of stay on the ICU (median, 11 days) were comparable in both groups. Mortality in the prehospital intubation group was not significantly different between groups (six vs. two deceased).ConclusionPrognosis with respect to organ failure, treatment time, and mortality is not adversely affected in the German trauma system, if patients with severe thoracic trauma without manifest respiratory insufficiency and without other indications for intubation are not treated with prehospital intubation.

ISSN:0022-5282    

出版商:OVID    

年代:2002

数据来源: OVID