ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveIn 1987, the article "The Demographics of Trauma in 1995" (DT95) attempted to predict the future needs of trauma centers based on changing population distributions. This article foresaw a relative increase in the number of injuries to the elderly and a relative decrease in total injuries. Based on these predictions, the paper recommended increasing the capabilities of existing trauma centers rather than developing new facilities. We compared these predictions to actual experience to validate this use of demographic data in trauma system planning.MethodsThe predictions of DT95 were compared with the available population and injury data from the U.S. Census Bureau and the Centers for Disease Control and Prevention using age-related cohort analysis.ResultsAs predicted, the highest-growing segment was the population older than 65 years, which increased 18% to 33.5 million. Also, the rate of injury-related deaths per 100,000 decreased from 61.20 in 1985 to 57.98 in 1995. The number of fatal motor vehicle crashes decreased from 45,958 in 1985 to 43,484 in 1995. Against predictions, the number of firearm deaths in 1994 increased from 31,566 to 35,957. Accurate predictions were thus made for most trauma demographic categories using a combination of census predictions and existing trauma demographic patterns. The increase in firearm deaths, however, was not anticipated using these sources and suggested the potential development of a more violent society.ConclusionsDemographic projections assist in predicting the number and type of future injuries. Sociologic and economic factors also need to be considered in any predictive determinations of the true demand for trauma centers.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundCyclooxygenase-2 (COX-2) is a key enzyme in the production of prostaglandin E2(PGE2) from activated macrophages. PGE2is increased during trauma and sepsis and has been implicated as a negative immunomodulator. The objective of this study was to determine the therapeutic benefits of a COX-2 inhibitor (NS-398) on survival and leukocyte production in a murine model of burn sepsis.MethodsTo determine the in vitro ability of NS-398 to inhibit macrophage production of PGE2, peritoneal elicited macrophages were stimulated for 18 hours with medium alone, endotoxin (ETX) (1 [micro sign]mol/L), or ETX plus NS-398 (0.3 [micro sign]mol/L). Macrophage supernatant PGE2levels were determined by an enzyme immunoassay. To test the in vivo efficacy of NS-398, mice subjected to a 15% dorsal scald burn plus 1,000 colony-forming units of topical Pseudomonas aeruginosa received either 10 mg/kg NS-398 intraperitoneally or placebo 4 to 6 hours after infection and twice daily for 3 days. Survival was measured up to 14 days, and circulating white blood cell (WBC) count and absolute neutrophil count (ANC) were determined 3 days after injury.ResultsMacrophage PGE2production was significantly increased in the ETX-treated group compared with the medium-alone group, and this increase was completely normalized with the addition of NS-398. NS-398 also augmented WBC count (4,288 +/- 649 vs. 7,866 +/- 435 per mm3; p < 0.01) and ANC (1,068 +/- 255 vs. 3,663 +/- 474 per mm3) after burn infection and attenuated macrophage depression of hematopoietic proliferation. Finally, NS-398 treatment significantly improved survival after burn infection, from 0 to 45.5%.ConclusionInhibition of the COX-2 isoform of cyclooxygenase with NS-398 inhibited macrophage PGE2production, restored ANC, and improved survival during burn infection. NS-398, therefore, has potential therapeutic benefits in septic patients who have developed neutropenia.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveTo investigate the effect of methylene blue, an inhibitor of oxygen radicals, on lung injury caused by reperfusion of ischemic tissue.MethodsIntestinal ischemia-reperfusion injury was induced in rats by clamping the superior mesenteric artery for 1 hour. Thereafter, the experimental group was administered 1% methylene blue intraperitoneally and the control group received saline. After 4 hours, pulmonary histopathologic features were assessed, and lung wet-weight to dry-weight ratios and tissue xanthine oxidase were determined.ResultsThe control group suffered from severe pulmonary parenchymal damage, compared with slight damage in the experimental group. The number of sequestered neutrophils was significantly higher in the control group (319 +/- 60 polymorphonuclear cells per 10 high-power fields) than in the methylene blue-treated group (91 +/- 8 polymorphonuclear cells per 10 high-power fields; p < 0.001). The wet-weight to dry-weight ratio was significantly increased in the saline-treated rats compared with the methylene blue-treated group (6.19 +/- 0.28 vs. 5.07 +/- 0.21; p < 0.001). Xanthine oxidase activity was similar in both groups.ConclusionMethylene blue attenuated lung injury after intestinal ischemia-reperfusion. Inhibition of oxygen free radicals may be the protective mechanism.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundBreakdown of intestinal repair and enteric leakage after trauma laparotomy can have dire consequences. Factors contributing to these failures when stratified according to location of intestinal injury and method of repair were examined.MethodsWe retrospectively reviewed all intestinal injuries occurring in a recent 2-year time span in adult patients surviving for more than 48 hours at a Level I trauma center. Data included Injury Severity Score, Abdominal Trauma Index score, site (stomach, duodenum, small and large intestine), and type of repair (enterorrhaphy vs. resection and anastomosis). Physiologic parameters within 48 hours of repair were assessed. Non-parametric analysis was used with significance assessed at the 95% confidence interval.ResultsTwo hundred twenty-two intestinal repairs in 171 patients were evaluated. All repairs but one were performed at the initial surgery. Eleven (5%) of these failed in 11 patients (6.4%)-four duodenum, four small bowel, and three colon-and were not recognized for an average of 15 days. Breakdown of repair occurred in patients with higher Injury Severity Scores and Abdominal Trauma Index scores (30 vs. 21 and 29 vs. 14, respectively; p < 0.001) and higher intraoperative blood and fluid administration (8.8 vs. 2.2 U and 11.5 vs. 5.1 L, respectively; p < 0.05). This was associated with longer intensive care unit and hospital stays (15.1 vs. 1.9 and 68.4 vs. 10.4 days, respectively; p < 0.001). All small bowel leaks occurred after resection and anastomosis versus enterorrhaphy (p < 0.05). All anastomotic breakdowns (four small bowel, one colon) occurred in the setting of massive blood and fluid administration versus those that did not leak (12.5 vs. 1.7 U and 12.7 vs. 5.8 L, respectively; p < 0.05). Four of 12 duodenal enterorrhaphies failed. All were associated with pancreatic injury versus none without (p < 0.05). The abdominal compartment syndrome occurred in three patients. In each case, breakdown of a small bowel anastomosis occurred.Conclusions(1) Stomach repair and small bowel and large-bowel enterorrhaphy may be safely accomplished in any setting. (2) Associated pancreatic injury is a risk factor for disruption of duodenorrhaphy. (3) In patients with massive blood and fluid administration, delay of bowel anastomoses should be considered. (4) Disruption of small bowel anastomoses is associated with abdominal compartment syndrome.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundRisk stratification of patients in the intensive care unit (ICU) is an important tool because it permits comparison of patient populations for research and quality control. Unfortunately, currently available scoring systems were developed primarily in medical ICUs and have only mediocre performance in surgical ICUs. Moreover, they are very expensive to purchase and use. We conceived a simple risk-stratification tool for the surgical ICU that uses readily available International Classification of Diseases, Ninth Revision, codes to predict outcome. Called ICISS (International Classification of Disease Illness Severity Score), our score is the product of the survival risk ratios (obtained from an independent data set) for all International Classification of Diseases, Ninth Revision, diagnosis codes.MethodsA total of 5,322 noncardiac patients admitted to a surgical ICU during an 8-year period had their Acute Physiology and Chronic Health Evaluation (APACHE) II scores compared with their ICISS as predictors of outcome (survival/non-survival, length of stay, and charges).ResultsICISS proved to be a much better predictor of survival than APACHE (receiver operating characteristic (ROC) APACHE = 0.806; Hosmer-Lemeshow (HL) APACHE = 22.56; ROC ICISS = 0.892; HL ICISS = 12.06) or the APACHE survival probability (ROC = 0.836; HL = 34.47). These differences were highly statistically significant (p < 0.001). ICISS was also better correlated with ICU length of stay (APACHE R2= 0.06; ICISS R2= 0.32) and ICU charges (APACHE R2= 0.07; ICISS R2= 0.39). When combined in a logistic model with ICISS, APACHE II added slightly to the predictive power of ICISS alone (combined ROC = 0.903) but degraded the calibration of the model (combined HL = 16.29; p = 0.038).ConclusionBecause ICISS is both more accurate and much less expensive to calculate than APACHE II score, ICISS should replace APACHE II score as the standard risk stratification tool in surgical ICUs.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectiveSome patients who survived severe hemorrhagic shock (HS) seem to exhibit persistent subtle neurobehavioral deficits. This finding is of concern if limited hypotensive fluid resuscitation is applied in hypotensive victims with penetrating trauma. This study was designed to determine whether subtle brain damage would occur in rats after severe prolonged HS. We hypothesized that rats surviving HS with mean arterial pressure (MAP) controlled at 40 mm Hg for 60 minutes would recover with slight permanent brain damage in terms of cognitive function without morphologic loss of neurons and that rats surviving HS with MAP at 30 mm Hg for 45 minutes (60 minutes were not tolerated) would have grossly abnormal brain function and loss of neurons.MethodsUnder light nitrous oxide-halothane anesthesia, spontaneously breathing rats underwent MAP-controlled HS (HS phase I), volume resuscitation to normotension and invasive monitoring to 60 minutes (resuscitation phase II), and observation to 10 days with detailed assessment of cognitive function (observation phase III). Five conscious rats served as normal controls. Three treatment groups were compared: group 1, shams (11 of 12 rats survived to 10 days); group 2, HS at MAP 40 mm Hg for 60 minutes (10 of 17 rats survived); group 3, HS at 30 mm Hg for 45 minutes (10 of 14 rats survived).ResultsOn post-HS day 10, all normal controls and all survivors of all three groups were functionally normal with overall performance category = 1 (normal) (overall performance category 1 = normal, 5 = death) and neurologic deficit scores <or=to7% (neurologic deficit scores 0-10% = normal, 100% = brain death). Post-HS beam balance, beam walking, and Morris water maze test results in HS groups 2 and 3 showed latencies not significantly different from those in shams and normal controls. Light microscopic scoring of five selectively vulnerable brain regions and other regions in five coronal sections revealed no ischemic (pyknotic, shrunken, eosinophilic) neurons in any of the survivors to 10 days. There was no statistical difference between normal controls, sham animals, and both HS groups in the number of normal neurons counted in the hippocampal CA-1 region in the 10-day survivors. All nonsurvivors died with intestinal necrosis.ConclusionHS at MAP 40 mm Hg for 60 minutes or MAP 30 mm Hg for 45 minutes does not cause subtle functional or histologic brain damage in surviving rats. Controlling MAP at 30 mm Hg carries a risk of sudden cardiac arrest. These data suggest that limited fluid resuscitation, to maintain MAP at about 40 mm Hg, as recommended for victims of penetrating trauma with uncontrolled HS, is safe for the brain.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundCortical reaming and intramedullary nail insertion injure the medullary vascular system. Little attention has been directed toward quantitative assessment of bone injury and repair after locked intramedullary nailing of long-bone fractures with and without reaming. The effects of reamed versus unreamed locked intramedullary nailing on cortical porosity and new bone formation were compared in a sheep fractured tibia model.MethodsAfter creation of a standardized spiral fracture by three-point bending with torsion, each tibia was stabilized by insertion of a locked intramedullary nail. Ten sheep were randomized into two groups, one that had reaming before nail insertion and one that did not. Fluorochromes were given 2 weeks (xylenol orange), 6 weeks (calcein green), and 12 weeks (tetracycline) postoperatively. All animals were killed at 12 weeks postoperatively. Cortical porosity and new bone formation were determined for the proximal diaphysis, fracture site, and distal diaphysis.ResultsOverall cortical porosity was greater with reamed nails than with unreamed nails (p = 0.02). Porosity in the inner cortex (18.3% (reamed) vs. 14.3% (unreamed); p = 0.09) and outer cortex (16.8% (reamed) vs. 12.2% (unreamed); p = 0.04) was greater in the reamed group. With reamed nails only, there was less new bone formation at 2 (p = 0.04) and 12 (p = 0.05) weeks in the inner cortex compared with the central cortex and outer cortex. Overall, there was no difference between reamed and unreamed nails in the amount of new bone formation at 2, 6, or 12 weeks.ConclusionsThis study demonstrates that greater injury or overall cortical porosity is associated with reamed nail insertion. There is no difference, however, between the amount of new bone formation after reamed and unreamed nail insertion. Nail insertion without reaming may be initially advantageous when tibial cortical vascularity is compromised, by limiting further injury to cortical bone. This may be important with open tibial fractures in which there is a significant risk of infection after injury. Between 2 and 12 weeks after injury, neither reamed nor unreamed nail insertion seems to have a significant advantage with respect to the amount of new bone formation that occurs.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

BackgroundIntramedullary nailing with and without reaming leads to a reduction in cortical bone blood flow. The repair of the devascularized bone is mediated principally by the surrounding soft-tissue envelope. The objective of this study was to determine the effect on muscle blood flow of reamed and unreamed intramedullary nailing techniques.MethodsMidshaft tibial osteotomies to create a 2.5-cm segment of devascularized tibial cortex were performed in 19 adult canines. The tibia was stabilized with a locked intramedullary nail without reaming in 9 animals and with intramedullary reaming in 10 animals. In the unreamed group, the tibia was stabilized with a loosely fitting (n = 4) or a tightly fitting (n = 5) locked nail. In the reamed group, limited reaming (n = 5) or standard reaming (n = 5) was performed. Muscle perfusion was measured in the anterior compartment musculature of the hindlimb using laser Doppler flowmetry.ResultsOverall muscle perfusion was greater in the reamed group than in the unreamed group at the conclusion of the nailing procedure (p = 0.0001) and at 5 weeks (p = 0.0008) and 11 weeks after nailing (p = 0.001). The degree of canal fit of the intramedullary nails and the extent of reaming before nail insertion did not further influence muscle circulation.ConclusionThe results of this study demonstrate that in the presence of an intact soft-tissue envelope, intramedullary reaming of the canine tibia has a major effect on increasing the circulation to the surrounding muscles. The increased extraosseous circulation may have implications for fracture healing.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID

摘要:

ObjectivesDetermine the relative frequency with which guns in the home are used to injure or kill in self-defense, compared with the number of times these weapons are involved in an unintentional injury, suicide attempt, or criminal assault or homicide.MethodsWe reviewed the police, medical examiner, emergency medical service, emergency department, and hospital records of all fatal and nonfatal shootings in three U.S. cities: Memphis, Tennessee; Seattle, Washington; and Galveston, Texas.ResultsDuring the study interval (12 months in Memphis, 18 months in Seattle, and Galveston) 626 shootings occurred in or around a residence. This total included 54 unintentional shootings, 118 attempted or completed suicides, and 438 assaults/homicides. Thirteen shootings were legally justifiable or an act of self-defense, including three that involved law enforcement officers acting in the line of duty. For every time a gun in the home was used in a self-defense or legally justifiable shooting, there were four unintentional shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides.ConclusionsGuns kept in homes are more likely to be involved in a fatal or nonfatal accidental shooting, criminal assault, or suicide attempt than to be used to injure or kill in self-defense.

ISSN:0022-5282    

出版商:OVID    

年代:1998

数据来源: OVID