S-100B in serum and urine after traumatic head injury in children.

J Trauma. 2010 Aug;69(2):284-9

Authors: Hallén M, Karlsson M, Carlhed R, Hallgren T, Bergenheim M

BACKGROUND: Children with head trauma are frequently seen in many emergency units. The clinical evaluation of these patients is difficult for a number of reasons and improved diagnostic tools are needed. S-100B, a protein found in glial cells, has previously been shown to be a sensible marker for brain damage after head injury in adults, but few studies have focused on its use in children. METHODS: In this study, 111 children with head trauma were included and venous blood and urine samples were taken at arrival (S1 and U1) and 6 hours later (S2 and U2). S-100B levels were analyzed. Clinical and radiologic evaluations were performed according to hospital routine. Two groups were identified- group 1: no computed tomography (CT) scan performed ora CT scan without any sign of trauma-related intracranial pathology (n = 105). Group 2: A CT scan with signs of trauma-related intracranial pathology (n = 6). RESULTS: In group 1, the median (inter quartile range) serum S-100B value in S1-samples was 0.111 microg/L (0.086-0.153), and in group 2, it was 0.282 microg/L (0.195-1.44) (p < 0.01). Also, S2 values significantly differed between the two groups. Urine values were, however, not significantly differing between the groups. CONCLUSIONS: Serum S-100B values within 6 hours after head trauma in children were significantly higher in patients with intracranial pathology compared with those without intracranial complications. Identification of these high-risk patients already in the emergency department is of major importance, and we suggest that S-100B could be a valuable diagnostic tool in addition to those used in clinical practice today.

PMID: 20734463 [PubMed - in process]

Delaware’s Inclusive Trauma System: Impact on Mortality.

J Trauma. 2010 Aug;69(2):245-52

Authors: Tinkoff GH, Reed JF, Megargel R, Alexander EL, Murphy S, Jones MS

BACKGROUND:: The impact of implementing an inclusive state trauma system on injury-related mortality for patients with life-threatening injuries was assessed. METHODS:: Using the state trauma registry, trauma patients evaluated in all of Delaware’s acute care hospitals from 1998 to 2007 were identified. Patients were categorized by injury severity score (ISS) groups (1-9, 10-15, 16-24, and >24). Each category was analyzed by mortality and interfacility transfer rate to the Level I trauma center for each year. An analysis of the National Trauma Data Bank (NTDB) for these ISS groups and mortality was performed to provide a comparative benchmark. chi and analysis of variance were used where appropriate (p </= 0.05). RESULTS:: A total of 40,063 entries were identified within the state trauma registry for the 10-year study period. Mortality rates did not significantly differ for ISS categories except for ISS >24 group. For this group, there was an incremental mortality decrease from 45.7% (1998) to 20.5% (2007) (p </= 0.0005). This rate of decrease in mortality was significantly greater than that displayed in the NTDB. The rate for the aggregate of all interfacility transfers and ISS >24 group managed at the Level I hospital significantly increased over the same period. CONCLUSION:: Since its inception, Delaware’s trauma system, in which all acute care hospitals participate, has been associated with an incremental, significant decrease in mortality of the most critically injured patients. This decrease is more substantial than that experienced nationally as depicted within the NTDB. These findings and our evolving experience support the concept and benefits of an “inclusive” trauma system.

PMID: 20699731 [PubMed - in process]

Inefficiencies in a rural trauma system: the burden of repeat imaging in interfacility transfers.

J Trauma. 2010 Aug;69(2):253-5

Authors: Gupta R, Greer SE, Martin ED

BACKGROUND:: Local hospitals (LHs) transferring patients to regional trauma centers (TCs) often obtain CT scans to diagnose injuries and justify transfer. However, these imaging studies are often repeated at the receiving TCs. This study was performed to examine how frequently computed tomography (CT) scans were repeated in interfacility transfers in a rural trauma system and to identify the most common reason for repeating the studies. METHODS:: Patients transferred to a rural Level I TC from October 2007 through February 2008 were prospectively evaluated. Data abstracted included CT scans performed at LHs and CT scans repeated at the TC. Additionally, the reason for repeating each study was recorded as follows: (1) scan not sent, (2) software not compatible, (3) inadequate technique (no intravenous contrast), (4) inadequate technique (no reconstructions), and (5) clinically indicated. RESULTS:: During the study period, 138 patients were transferred to the TC. Of these, 104 (75%) underwent CT imaging before transfer. Sixty of these patients (58%) underwent repeat CT imaging at the TC. Overall, 98 of 243 (40%) scans were repeated. Head CT scans were repeated predominantly because of clinical indications. All other body region CT scans were repeated predominantly because of inadequate technique at the LHs. CONCLUSIONS:: CT scans were repeated in 58% of interfacility transfers. Repeat CT scans inevitably result in increased radiation exposure to patients as well as additional charges and may be an important patient safety and cost issue for trauma systems.

PMID: 20699732 [PubMed - in process]

Applying Composite Performance Measures to Trauma Care.

J Trauma. 2010 Aug;69(2):256-262

Authors: Willis CD, Stoelwinder JU, Lecky FE, Woodford M, Jenks T, Bouamra O, Cameron PA

BACKGROUND:: To investigate the association between a number of hospital level composite index methodologies developed from trauma indicators with inhospital mortality. METHODS:: Data from January 2001 to December 2006 were extracted from the Victorian State Trauma Registry (Australia) and the Trauma Audit and Research Network (United Kingdom). Three composite methods were explored, including two denominator-based weight approaches and a factor analysis technique. The association between the composite measures and the count of inhospital mortality was investigated using Poisson regression models adjusting for expected deaths per hospital using the Trauma Injury Severity Score methodology. RESULTS:: Composite scores were calculated per hospital, per year. The composite score was entered in statistical models as a raw score, and the mortality difference across the central 50% of the composite index was ascertained. In total, 9,218 patients were included and were distributed across 14 hospitals. Composite scores demonstrated an inverse relationship with risk-adjusted inhospital mortality. From the 25th to the 75th percentile of each composite, mortality decreased by 11.99%, 13.58%, and 16.13% (p < 0.05). CONCLUSION:: Trauma composite indices demonstrate construct validity when used as measures of hospital level process and represent potentially useful methods of analyzing and reporting quality indicators.

PMID: 20699733 [PubMed - as supplied by publisher]

Trauma center designation correlates with functional independence after severe but not moderate traumatic brain injury.

J Trauma. 2010 Aug;69(2):263-9

Authors: Brown JB, Stassen NA, Cheng JD, Sangosanya AT, Bankey PE, Gestring ML

BACKGROUND:: The mortality of traumatic brain injury (TBI) continues to decline, emphasizing functional outcomes. Trauma center designation has been linked to survival after TBI, but the impact on functional outcomes is unclear. The objective was to determine whether trauma center designation influenced functional outcomes after moderate and severe TBI. METHODS:: Trauma subjects presenting to an American College of Surgeons (ACS) Level I or II trauma center with a Glasgow Coma Score (GCS) </=12 who survived to discharge were identified using the National Trauma Databank (2002-2006). Outcomes were functional independence (FI) defined as a modified functional independence measure (FIM) of 12, and independent expression (IE) defined as a FIM component of 4. These were compared between Level I and Level II centers in subjects with both moderate (GCS 9-12) and severe (GCS </=8) TBI using stepwise logistic regression to adjust for demographics, injuries, and comorbidities. RESULTS:: Analysis identified 25,170 subjects (72% severe TBI). After adjusting for covariates, ACS Level I designation was associated with FI (odds ratio: 1.16; confidence interval: 1.07-1.24, p < 0.01) and IE (1.10; 1.03-1.17, p < 0.01) after severe TBI. Trauma center designation was not associated with FI or IE after moderate TBI. CONCLUSIONS:: ACS trauma center designation is significantly associated with FI and IE after severe, but not moderate TBI. Prospective study is warranted to verify and explore factors contributing to this discrepancy.

PMID: 20699734 [PubMed - in process]

Cranioplasty after postinjury decompressive craniectomy: is timing of the essence?

J Trauma. 2010 Aug;69(2):270-4

Authors: Beauchamp KM, Kashuk J, Moore EE, Bolles G, Rabb C, Seinfeld J, Szentirmai O, Sauaia A

BACKGROUND:: The appropriate timing of cranioplasty after decompressive craniectomy for trauma is unknown. Potential benefits of delayed intervention (>6 weeks) for reducing the risk of infection must be balanced by persistent altered cerebrospinal fluid dynamics leading to hydrocephalus. We reviewed our recent 5-year experience in an effort to improve patient throughput and develop a rational decision making plan. METHODS:: A 5-year query (2003-2007) of our level I neurotrauma database. From 2,400 head injuries, we performed a total of 350 craniotomies. Of the 350 patients who underwent craniotomy for trauma, 70 patients (20%) underwent decompressive craniectomy requiring cranioplasty. Timing of cranioplasty, cranioplasty material, postoperative infections, and incidence of hydrocephalus were evaluated with logistic regression to study potential associations between complications and timing, adjusted for risk factors. RESULTS:: No specific time frame was predictive of hydrocephalus or infection, and logistic regression failed to identify significant predictors among the collected variables. CONCLUSION:: In our experience, the prior practice of delayed cranioplasty (3-6 months postdecompressive craniectomy), requiring repeat hospital admission, does not seem to lower postcranioplasty infection rates nor the need for cerebrospinal fluid diversion procedures. Our current practice emphasizes cranioplasty during the initial hospital admission, as soon as there is resolution on computed tomography scan of brain swelling outside of the cranial vault with concurrent clinical examination. This occurs as early as 2 weeks postcraniectomy and should lower the overall cost of care by eliminating the need for additional hospital admissions.

PMID: 20699735 [PubMed - in process]

Pentobarbital Coma For Refractory Intra-Cranial Hypertension After Severe Traumatic Brain Injury: Mortality Predictions and One-Year Outcomes in 55 Patients.

J Trauma. 2010 Aug;69(2):275-283

Authors: Marshall GT, James RF, Landman MP, Oʼneill PJ, Cotton BA, Hansen EN, Morris JA, May AK

OBJECTIVE:: To identify predictors of mortality and long-term outcomes in survivors after pentobarbital coma (PBC) in patients failing current treatment standards for severe traumatic brain injuries (TBI). This is a retrospective cohort study of severe TBI patients receiving PBC at Level I Trauma Center and tertiary university hospital. METHODS:: Four thousand nine hundred thirty-four patients were admitted to the trauma intensive care unit with severe TBI (head Abbreviated Injury Scale >/= 3) between April 1998 and December 2004. Six hundred eleven received intracranial pressure (ICP) monitoring and 58 received PBC. Three patients underwent craniotomy for intracranial mass lesion and were excluded. The study group received standardized medical management for severe TBI including opiates, benzodiazepines, elevation of the head of bed, avoidance of hypotension and hypercapnia and hyperosmolar therapy (HOsmRx). In addition, 31 of 55 patients (56%) underwent placement of intraventricular catheters for cerebrospinal fluid drainage. If routine medical management and cerebrospinal fluid diversion failed to control ICP, then the patient was determined to have refractory intracranial hypertension (RICH) and PBC treatment was initiated. PBC was performed with pentobarbital infusion with continuous electroencephalogram monitoring to ensure adequate burst suppression. The measurements include serum sodium (Na) and osmolality (Osm) were assessed as indicators for initiation of PBC and to estimate the 50% mortality cut-points when controlling for ICP. Follow-up functional outcomes were assessed using the Glasgow Outcome Scale and stratified according to admission Glasgow Coma Scale score and Marshall computed tomography classification. Of the 55 PBC patients, 22 (40%) survived at discharge. 19 of 22 had long-term follow-up (1 year or more) available. Of these, 13 (68%) were normal or functionally independent (Glasgow Outcome Scale score 4 or 5). Serum Na and Osm were associated with death (p < 0.05) when controlling for ICP. The 50% mortality cut-points were Na of 160 mEq/L and Osm of 330 mOsm/kg H2O. Median minimum cerebral perfusion pressure after PBC was 42 mm Hg in survivors and 34 mm Hg in nonsurvivors (p = 0.013). CONCLUSIONS:: In patients with severe TBI and RICH, survival at discharge of 40% with good functional outcomes in 68% of survivors at 1 year or more can be achieved with PBC after failure of HOsmRx. Based on 50% mortality cut-points, analysis suggests the limits of HOsmRx to be Na of 160 mEq/L and Osm of 330 mOsm/Kg H2O. Maintenance of higher cerebral perfusion pressure after PBC is associated with survival. PBC treatment of RIH may be even more important when other treatments of RIH, such as decompressive craniectomy, are not available.

PMID: 20699736 [PubMed - as supplied by publisher]

Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis.

J Trauma. 2010 Aug;69(2):294-301

Authors: Davis DP, Peay J, Sise MJ, Kennedy F, Simon F, Tominaga G, Steele J, Coimbra R

BACKGROUND:: Emergent endotracheal intubation (ETI) is considered the standard of care for patients with severe traumatic brain injury (TBI). However, recent evidence suggests that the procedure may be associated with increased mortality, possibly reflecting inadequate training, suboptimal patient selection, or inappropriate ventilation. OBJECTIVE:: To explore prehospital ETI in patients with severe TBI using a novel application of Trauma Score and Injury Severity Score methodology. METHODS:: Patients with moderate-to-severe TBI (head Abbreviated Injury Scale score 3+) were identified from our county trauma registry. Demographic information, pre-resuscitation vital signs, and injury severity scores were used to calculate a probability of survival for each patient. The relationship between outcome and prehospital ETI, provider type (air vs. ground), and ventilation status were explored using observed survival-predicted survival and the ratio of unexpected survivors/deaths. RESULTS:: A total of 11,000 patients were identified with complete data for this analysis. Observed and predicted survivals were similar for both intubated and nonintubated patients. The ratio of unexpected survivors/deaths increased and observed survival exceeded predicted survival for intubated patients with lower predicted survival values. Both intubated and nonintubated patients transported by air medical crews had better outcomes than those transported by ground. Both hypo- and hypercapnia were associated with worse outcomes in intubated but not in nonintubated patients. CONCLUSIONS:: Prehospital intubation seems to improve outcomes in more critically injured TBI patients. Air medical outcomes are better than predicted for both intubated and nonintubated TBI patients. Iatrogenic hyper- and hypoventilations are associated with worse outcomes.

PMID: 20699737 [PubMed - in process]

Smoking in trauma patients: the effects on the incidence of sepsis, respiratory failure, organ failure, and mortality.

J Trauma. 2010 Aug;69(2):308-12

Authors: Ferro TN, Goslar PW, Romanovsky AA, Petersen SR

BACKGROUND:: There is a high percentage of smokers among trauma patients. Cigarette smoking has been associated with the development of acute lung injury and the adult respiratory distress syndrome in critically ill patients. It is also known that nicotine exerts immunosuppressive and anti-inflammatory effects with chronic use. Trauma patients who are smokers usually go through acute nicotine withdrawal after the traumatic event and during their stay in ICU. How the smoking status and acute nicotine withdrawal affect outcomes after trauma is unknown. This question was addressed in this study by analyzing the incidence of sepsis, septic shock and multiple organ dysfunction syndrome, and other outcomes in smoking and nonsmoking trauma patients. METHODS:: A retrospective cohort of trauma patients who met the criteria was randomly selected from the trauma registry. Individual charts were reviewed to confirm documented smoking status. Criteria for selection included the following: Injury Severity Score >/=20, age 18 to 65 years, hospital length of stay >72 hours. Patients with COPD/emphysema, diabetes mellitus, cardiac disease, malignancy, pregnancy, or steroid use were excluded. RESULTS:: Overall, 327 patient charts were reviewed: 156 smokers and 171 nonsmokers. Men outnumbered women in the smoking group fourfold (p = 0.003 versus nonsmokers). Age, Injury Severity Score, the presence of shock on admission, the type of trauma (blunt or penetrating), ICU and hospital length of stay, and the duration of ventilator support were similar between smokers and nonsmokers. There were no differences in the incidence of sepsis, pneumonia, adult respiratory distress syndrome, or multiple organ dysfunction syndrome. Mortality was low (1.2% in smokers; 0.6% in nonsmokers) and did not differ significantly between the groups. CONCLUSIONS:: The smoking status plays a minimal role in the outcome of healthy trauma patients. This suggests that the acute nicotine withdrawal that usually occurs in critically ill patients has no clinically significant implications after injury.

PMID: 20699738 [PubMed - in process]

What is the safety of nonemergent operative procedures performed at night? A study of 10,426 operations at an academic tertiary care hospital using the american college of surgeons national surgical quality program improvement database.

J Trauma. 2010 Aug;69(2):313-9

Authors: Turrentine FE, Wang H, Young JS, Calland JF

BACKGROUND:: Ever-increasing numbers of in-house acute care surgeons and competition for operating room time during normal daytime business hours have led to an increased frequency of nonemergent general and vascular surgery procedures occurring at night when there are fewer residents, consultants, nurses, and support staff available for assistance. This investigation tests the hypothesis that patients undergoing such procedures after hours are at increased risk for postoperative morbidity and mortality. METHODS:: Clinical data for 10,426 operative procedures performed over a 5-year period at a single academic tertiary care hospital were obtained from the American College of Surgeons National Surgical Quality Improvement Program Database. The prevalence of preoperative comorbid conditions, postoperative length of stay, morbidity, and mortality was compared between two cohorts of patients: one who underwent nonemergent operative procedures at night and other who underwent similar procedures during the day. Subsequent statistical comparisons utilized chi tests for comparisons of categorical variables and F-tests for continuous variables. RESULTS:: Patients undergoing procedures at night had a greater prevalence of serious preoperative comorbid conditions. Procedure complexity as measured by relative value unit did not differ between groups, but length of stay was longer after night procedures (7.8 days vs. 4.3 days, p < 0.0001). CONCLUSIONS:: Patients undergoing nonemergent general and vascular surgery procedures at night in an academic medical center do not seem to be at increased risk for postoperative morbidity or mortality. Performing nonemergent procedures at night seems to be a safe solution for daytime overcrowding of operating rooms.

PMID: 20699739 [PubMed - in process]

Packed red blood cells suppress T-cell proliferation through a process involving cell-cell contact.

J Trauma. 2010 Aug;69(2):320-9

Authors: Bernard A, Meier C, Ward M, Browning T, Montgomery A, Kasten M, Snow C, Manning E, Woodward J

BACKGROUND:: Packed red blood cell (PRBC) transfusion suppresses immunity and increases morbidity and mortality. Leukocyte reduction has failed to abrogate these effects, thus implicating red blood cells themselves or their components. PRBC impair proliferation of immortal (Jurkat) T cells by depleting arginine from the extracellular environment. The effect of PRBC on isolated ex vivo T-cell proliferation has not been reported. We hypothesize that PRBCs depress mitogen-stimulated proliferation in isolated human and mouse T cells. METHODS:: Human peripheral T cells were isolated by Ficoll-Hypaque gradient, purified by magnetic separation, and stimulated with anti-CD3 or anti-CD28. DO11.10 transgenic mouse splenic T cells were stimulated with ovalbumin. Cells were cultured at 1 x 10/mL in 96-well plates or in 24-transwell plates in the presence of PRBC (0.015-5% by volume, stored for 4-6 weeks). In culture media, arginine and citrulline were varied. Proliferation was measured at 72 hours by thymidine incorporation. T-cell viability, apoptosis, and receptor zeta chain were measured by flow cytometry. RESULTS:: PRBC significantly depressed human peripheral and mouse splenic T-cell proliferation in a dose-dependent manner. PRBC arginase blockade by N-omega-hydroxy-nor-l-arginine only partly restored proliferation. Cell contact was required in both cell types for maximal effect. Depressed zeta chain in human peripheral T cells was partly restored by arginase blockade. Salvage by high-dose arginine and citrulline was unsuccessful. Decreased proliferation was not related to cell death. CONCLUSION:: PRBC suppresses mitogen-stimulated human and antigen-stimulated mouse T-cell proliferation by mechanisms independent of arginine depletion. This is a novel mechanism for transfusion-associated immune suppression.

PMID: 20699740 [PubMed - in process]

Prestorage Leukoreduction Ameliorates the Effects of Aging on Banked Blood.

J Trauma. 2010 Aug;69(2):330-337

Authors: Phelan HA, Gonzalez RP, Patel HD, Caudill JB, Traylor RK, Yancey LR, Sperry JL, Friese RS, Nakonezny PA

BACKGROUND:: Previous studies have demonstrated that the transfusion of older blood is independently associated with higher rates of infectious complications, multiple organ failure, and mortality. Putative mechanisms implicate leukocytes in stored blood that generate immunomodulatory mediators as the stored blood ages. The purpose of this retrospective cohort study was to describe the effect of prestorage leukoreduction (PS-LR) on the detrimental clinical effects of increasing age on blood products used in trauma patients. METHODS:: All patients receiving >/=6 units of packed red cells and surviving >/=48 hours since May 1999 when institutional universal PS-LR was begun were identified. Transfusion requirements, demographic data, and causes of death were collected. Blood bank records were reviewed to determine the age of each unit of blood transfused. Multivariate logistic regression was used to determine the relationship between the age of PS-LR transfused blood and mortality after adjusting for total transfusion requirement, patient age, Injury Severity Score, head Abbreviated Injury Score, mechanism of injury, and gender. A subgroup analysis was performed excluding those patients in whom care was withdrawn at 48 hours to 72 hours postinjury for brain death or neurologic devastation. RESULTS:: A total of 399 patients, receiving 6,603 units of blood, met inclusion criteria. Mortality analysis showed that increasing Injury Severity Score, patient age, head Abbreviated Injury Score, and number of units of packed red cells transfused were all independently associated with an increased risk of death. When mean age of blood was analyzed as a continuous variable, a significant reduction in the risk of death with increasing mean age of transfused PS-LR blood was noted (odds ratio [OR], 0.959; 95% confidence interval [CI], 0.924-0.996). Both of these findings persisted when the mean age of blood was dichotomized at 14 days (OR, 0.426; 95% CI, 0.182-0.998) and 21 days (OR, 0.439; 95% CI, 0.225-0.857). The area under the curve for the receiver operating characteristics of our mortality model was 0.90. After excluding 13 patients in whom care was withdrawn 48 hours to 72 hours postinjury for brain death or neurologic devastation, the mortality analysis still showed that increasing injury severity, number of units of packed red cells transfused, and age were all independently associated with an increased risk of death. The protective effect of receiving older blood seen in the all-cause mortality analysis disappeared because no association was found between odds of dying and increasing age of packed red blood cells units transfused. This was true whether the mean age of transfused blood was dichotomized at 14 days (OR, 0.93; CI, 0.30-2.83) or at 21 days (OR, 0.54; CI, 0.25-1.16). CONCLUSION:: Our data suggest that the deleterious effects of aging on banked blood are ameliorated by PS-LR. We are currently conducting a prospective observational study in an effort to duplicate the findings of this retrospective investigation.

PMID: 20699741 [PubMed - as supplied by publisher]

Hematopoietic Progenitor Cell Mobilization Is Mediated Through beta-2 and beta-3 Receptors After Injury.

J Trauma. 2010 Aug;69(2):338-43

Authors: Beiermeister KA, Keck BM, Sifri ZC, Elhassan IO, Hannoush EJ, Alzate WD, Rameshwar P, Livingston DH, Mohr AM

BACKGROUND:: Hematopoietic progenitor cells (HPCs) are mobilized into the peripheral blood (PB) and then sequestered in injured tissue after trauma. Nonselective beta-adrenergic blockade (BB) has been shown to cause a decrease in mobilization of HPCs to the periphery and to injured tissue. Given the vast physiologic effects of nonselective BB, the aim of this study is to delineate the role of selective BB in HPC growth and mobilization. METHODS:: Rats underwent daily intraperitoneal injections of propranolol (Prop), atenolol (B1), butoxamine (B2), or SR59230A (B3) for 3 days to induce BB. All groups then underwent lung contusion (LC). HPC presence was assessed by GEMM, BFU-E, and CFU-E colony growth both in injured lung and bone marrow (BM). Flow cytometry, using c-kit and CD71, was used to determine mobilization into PB. RESULTS:: LC alone decreased BM HPC growth in all erythroid cell types and increased their number in injured lung (all *p < 0.05). beta-Blockade with Prop, B2, and B3 blockades restored BM HPC growth to control levels and decreased HPCs recovered in the injured lung. Similarly, Prop, B2, and B3 blockade prevented HPC mobilization to PB. B1 blockade with atenolol had no impact on HPC growth and mobilization following LC. CONCLUSIONS:: Nonselective BB reduced suppression of HPC growth in BM after injury and prevented the mobilization and subsequent sequestration of HPCs in injured tissue. Our data have shown that this effect is mediated through the B2 and B3 receptors. Therefore, after trauma, treatment with selective B2 or B3 blocker may attenuate the BM suppression associated with tissue injury.

PMID: 20699742 [PubMed - in process]

Global Differences in Causes, Management, and Survival After Severe Trauma: The Recombinant Activated Factor VII Phase 3 Trauma Trial.

J Trauma. 2010 Aug;69(2):344-352

Authors: Christensen MC, Parr M, Tortella BJ, Malmgren J, Morris S, Rice T, Holcomb JB,

BACKGROUND:: Little is known about international variation in mortality after severe trauma. This study examines variation in mortality, injury severity, and case management among countries from a recent prospective multinational trauma trial. METHODS:: This trauma trial was a prospective, randomized, double-blinded, multicenter comparison of recombinant activated factor VII versus placebo in severely injured bleeding trauma patients. Differences in baseline patient characteristics, case management, and clinical outcomes were examined for the 11 countries recruiting most patients. Between-country differences in mortality were examined using regression analysis adjusting for case mix and case management differences. Global predictors of mortality were also identified using multivariate regression analysis. RESULTS:: Significant differences were observed between countries in unadjusted mortality rates at 24 hours (p = 0.025) and 90 days (p < 0.0001). When adjusting for differences in case mix and case management, the between country differences in mortality at 24 hours and 90 days remained significant. Consistent independent predictors of 24-hour, 24-hour to 90-day, and 90-day mortality were admission lactate >/=5 mmol/L (odds ratio: 9.06, 3.56, and 5.39, respectively) and adherence to clinical management guidelines (odds ratio: 4.92, 5.90, and 3.26, respectively). On average, the damage control surgery guideline was less well adhered to than the RBC transfusion and ventilator guidelines. There was statistically significant variation between countries with respect to adherence to the RBC transfusion guideline. CONCLUSIONS:: Considering international variation in mortality when designing or interpreting results from multinational trauma studies is important. Significant differences in mortality persisted between patients from different countries after case mix and case management adjustment. Adherence to clinical guidelines was associated with improved survival. Stratification, case mix adjustment, and use of guidelines on damage control surgery, transfusion, and ventilation may mitigate country-driven variation in mortality.

PMID: 20699743 [PubMed - as supplied by publisher]

Use of Recombinant Factor VIIa in US Military Casualties for a Five-Year Period.

J Trauma. 2010 Aug;69(2):353-9

Authors: Wade CE, Eastridge BJ, Jones JA, West SA, Spinella PC, Perkins JG, Dubick MA, Blackbourne LH, Holcomb JB

BACKGROUND:: Two prospective randomized trauma trials have shown recombinant factor VIIa (rFVIIa) to be safe and to decrease transfusion requirements. rFVIIa is presently used in 22% of massively transfused civilian trauma patients. The US Military has used rFVIIa in combat trauma patients for five years, and two small studies of massively transfused patients described an association with improved outcomes. This study was undertaken to assess how deployed physicians are using rFVIIa and its impact on casualty outcomes. METHODS:: US combat casualties (n = 2,050) receiving any blood transfusion from 2003 to 2009 were reviewed to compare patients receiving rFVIIa (n = 506) with those who did not (n = 1,544). Propensity-score matching (primary analysis) and multivariable logistic regression were used to compare outcomes. Differences were determined at p < 0.05. RESULTS:: Twenty-five percent of patients received rFVIIa. Significant differences were noted between groups in indices of injury severity (Injury Severity Score, Abbreviated Injury Scale score, and Glasgow Coma Scale score), admission physiology (systolic blood pressure, diastolic blood pressure, heart rate, temperature, base deficit, hemoglobin, and international normalization ratio), and use of blood products, indicating that patients treated with rFVIIa were more severely injured, in shock, and coagulopathic. For propensity-score matching, factors associated with death were used: Injury Severity Score, Glasgow Coma Scale score, heart rate, systolic blood pressure, diastolic blood pressure, Hgb, and total packed red blood cell. A total of 266 patients per group were matched; 52% of the rFVIIa group. After pairing, there were no significant differences in any of the demographics, including incidence of massive transfusion (53% vs. 51%). There was no difference in the rate of complications (21% vs. 21%) or mortality (14% vs. 20%) for patients not treated or receiving rFVIIa, respectively. CONCLUSION:: In military casualties, rFVIIa is used in the most severely injured patients based on physician selection rather than on guideline criteria. Use of rFVIIa is not associated with an improvement in survival or an increase in complications. The undetected bias of physician selection of patients for treatment with rFVIIa, likely, has an impact on case matching to achieve equivalence similar to that of randomized control studies. This inability to match populations, thus, prevents definitive interpretation of this study and others studies of similar design. This problem emphasizes the need to develop entry criteria to identify patients who could potentially benefit from use of rFVIIa and the need to subsequently perform efficacy studies.

PMID: 20699744 [PubMed - in process]

Reducing leukocyte trafficking preserves hepatic function after sepsis.

J Trauma. 2010 Aug;69(2):360-7

Authors: Huynh T, Nguyen N, Keller S, Moore C, Shin MC, McKillop IH

INTRODUCTION:: Leukocyte trafficking may induce hepatic dysfunction in sepsis. Herein, we hypothesize that reduction in leukocyte adhesion and, hence, leukocyte-endothelial interaction by activated protein C (aPC) may preserve hepatic function after sepsis. METHODS:: Rats underwent sham or cecal ligation and puncture, followed by saline or aPC (1 mg/kg intravenously) infusion, twice daily for 4 days. Cytokine levels were determined by enzyme-linked immunosorbent assay. Liver function and injury were assessed by bile production and plasma aspartate transaminase, respectively. In parallel experiments, neutrophils were labeled with Rhodamine 6G, and trafficking determined by cell motion tracking using intravital microscopy. Leukocyte trafficking and traveling velocity were computed at baseline and at 10 minutes and 40 minutes after endothelin-1 infusion. RESULTS:: Sepsis induced 90% mortality and elevated levels of interleukin (IL)-2 (167 pg/mL +/- 39 pg/mL vs. 68 pg/mL +/- 2 pg/mL, p < 0.05), IL-6 (5,806 pg/mL +/- 3,389 pg/mL vs. 0 pg/mL +/- 0 pg/mL, p < 0.05), and IL-8 (492 pg/mL +/- 22 pg/mL vs. 21 pg/mL +/- 17 pg/mL, p < 0.05). Aspartate transaminase levels increased (227 IU/L +/- 14 IU/L vs. 51 IU/L +/- 7 IU/L, p < 0.05) in cecal ligation and puncture animals, whereas bile production decreased by fivefold compared with sham (436 mug/kg/h +/- 247 mug/kg/h vs. 2,357 mug/kg/h +/- 147 mug/kg/h, p < 0.05). Hepatic leukocyte adhesion increased threefold in septic animals (42.7 WBC per image +/- 7.3 WBC per image vs. 14.8 WBC per image +/- 3.8 WBC per image, p < 0.01), whereas leukocyte velocity decreased compared with sham (10.5 mum/s +/- 2.2 mum/s vs. 22.3 mum/s +/- 2.4 mum/s, p < 0.01). By contrast, aPC treatment reduced mortality to 60%, attenuated inflammatory cytokines, reduced leukocyte trafficking, and preserved hepatic function. CONCLUSIONS:: Our data demonstrate that sepsis may, in part, induce hepatic dysfunction by augmenting leukocyte trafficking into hepatic sinusoids. Treatment with aPC attenuated leukocyte trafficking and, in doing so, preserved hepatic function and improved survival. Collectively, these data suggest an important role for protein C-dependent leukocyte-endothelial interaction in sepsis.

PMID: 20699745 [PubMed - in process]

Pulmonary injury risk assessment for long-duration blasts: a meta-analysis.

J Trauma. 2010 Aug;69(2):368-74

Authors: Rafaels KA, ‘dale’ Bass CR, Panzer MB, Salzar RS

BACKGROUND:: Long-duration blasts are an increasing threat with the expanded use of thermobaric and other novel explosives. Other potential long-duration threats include large explosions from improvised explosive devices, weapons caches, and other explosives including nuclear explosives. However, there are very few long-duration pulmonary blast injury assessments, and use of short-duration exposure injury metrics is inappropriate as the injury mechanism for long-duration exposures is likely different from that of short-duration exposures. METHODS:: This study develops an injury model for long-duration (>10 milliseconds positive overpressure phase) blasts with sharp rising overpressures. For this study, data on more than 2,730 large animal experiments were collected from more than 55 experimental studies on blast. From this dataset, nearly 850 large animal experiments were selected with positive phase overpressure durations of 10 milliseconds or more. Various models were evaluated to determine the best fit of injury risk as a function of pressure and duration. A linear logistic regression was performed on the experimental data for threshold injury and lethality in terms of pressure and duration. The effects of mass, pressure, and duration scaling were all evaluated, and two goodness-of-fit indicators were used to assess the different models. RESULTS AND CONCLUSIONS:: New injury risk assessment curves were determined for both incident and reflected pressure conditions for reflecting surface and free-field exposures. Position dependent injury risk curves were also determined. The resulting curves are an improvement to existing assessments, because they use actual data to demonstrate theoretical assumptions on the injury risk.

PMID: 20699746 [PubMed - in process]

Cardiopulmonary effects of matching positive end-expiratory pressure to abdominal pressure in concomitant abdominal hypertension and acute lung injury.

J Trauma. 2010 Aug;69(2):375-83

Authors: da Silva Almeida JR, Machado FS, Schettino GP, Park M, Azevedo LC

BACKGROUND:: To evaluate the cardiopulmonary effects of positive end-expiratory pressure (PEEP) equalization to intra-abdominal pressure (IAP) in an experimental model of intra-abdominal hypertension (IAH) and acute lung injury (ALI). METHODS:: Eight anesthetized pigs were submitted to IAH of 20 mm Hg with a carbon dioxide insufflator for 30 minutes and then submitted to lung lavage with saline and Tween (2.5%). Pressure x volume curves of the respiratory system were performed by a low flow method during IAH and ALI, and PEEP was subsequently adjusted to 27 cm . H2O for 30 minutes. RESULTS:: IAH decreases pulmonary and respiratory system static compliances and increases airway resistance, alveolar-arterial oxygen gradient, and respiratory dead space. The presence of concomitant ALI exacerbates these findings. PEEP identical to AP moderately improved oxygenation and respiratory mechanics; however, an important decline in stroke index and right ventricle ejection fraction was observed. CONCLUSIONS:: Simultaneous IAH and ALI produce important impairments in the respiratory physiology. PEEP equalization to AP may improve the respiratory performance, nevertheless with a secondary hemodynamic derangement.

PMID: 20699747 [PubMed - in process]

Vascular arginase contributes to arteriolar endothelial dysfunction in a rat model of hemorrhagic shock.

J Trauma. 2010 Aug;69(2):384-91

Authors: Johnson RA, Durante W, Craig T, Peyton KJ, Myers JG, Stewart RM, Johnson FK

BACKGROUND:: Hemorrhagic shock causes hypoperfusion of peripheral tissues and promotes endothelial dysfunction, which may lead to further tissue injury. Trauma increases extrahepatic activity of arginase, an enzyme which competes for l-arginine with nitric oxide synthase, and plays a key role in the development of endothelial dysfunction during aging, hypertension, and diabetes. However, the role of arginase in hemorrhage-induced endothelial dysfunction has not been studied. This study tests the hypothesis that arginase inhibition improves endothelial function after hemorrhage. METHODS:: Male Sprague-Dawley rats were implanted with indwelling arterial catheters for blood pressure measurements and blood removal. Awake animals were subjected to a 45% fixed volume controlled hemorrhage and blood pressure was monitored. Unbled rats served as controls. Skeletal muscle arterioles were isolated 24 hours after hemorrhage and cannulated in a pressure myograph system. To study endothelial function, arterioles were exposed to constant midpoint, but altered endpoint pressures, to establish graded levels of luminal flow and internal diameter was measured. RESULTS:: Hemorrhage lowered mean arterial pressure that spontaneously recovered to 78% and 88% of baseline in 2 hours and 20 hours, respectively. Vascular arginase II and blood glucose levels were elevated, whereas hemoglobin and insulin levels were decreased 24 hours after blood loss. In posthemorrhage arterioles, flow-induced dilation was abolished. Acute in vitro treatment with an inhibitor of arginase, N-hydroxy-nor-l-arginine, restored flow-induced dilation to unbled control levels. Similarly, the arginase and nitric oxide synthase substrate, l-arginine, but not the inactive isomer, d-arginine, restored flow-induced dilation. CONCLUSIONS:: These results indicate that arginase contributes to endothelial dysfunction in resistance vessels after significant hemorrhage.

PMID: 20699748 [PubMed - in process]

Application of the Chemokine CXCL12 Expression Plasmid Restores Wound Healing to Near Normal in a Diabetic Mouse Model.

J Trauma. 2010 Aug;69(2):392-8

Authors: Restivo TE, Mace KA, Harken AH, Young DM

BACKGROUND:: CXCL12 is a chemokine involved in postinjury leukocyte chemotaxis, migration, and homing of stem cells. We hypothesized that by increasing the level of the chemokine CXCL12 in wounds of diabetic mice, we would increase stem cell recruitment to the wound and, thus, accelerate time to wound closure. METHODS:: Eighteen Lepr db-/db- (B6.Cg-m +/+ Leprdb/J; Jackson Labs, Bar Harbor, ME) and their nondiabetic littermates were wounded and treated either with an empty plasmid or a plasmid containing the CXCL12 gene. Wounds were measured approximately every 5 days until they closed completely and were analyzed using planimetry. Wounds were harvested, and relative expression of CXCL12 mRNA was measured using an ABI Prism SDS 7000. To study stem cells affected by this, the plasmid’s affect on stem cell recruitment, we used flow cytometry. RESULTS:: The diabetic wounds contain a significantly decreased level of CXCL12 mRNA at day 7 postwounding, and these wounds take 55 days to heal. Application of a CXCL12 plasmid to diabetic wounds significantly increases CXCL12 mRNA at day 7, and these wounds heal in 23 days. CONCLUSIONS:: Lack of CXCL12 in diabetic wounds contributes to delayed wound healing and can be reversed via single application of a CXCL12-containing plasmid.

PMID: 20699749 [PubMed - in process]

Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures.

J Trauma. 2010 Aug;69(2):405-10

Authors: Willett K, Al-Khateeb H, Kotnis R, Bouamra O, Lecky F

BACKGROUND:: The aim of the study was to determine the relative contributions to mortality of a unilateral or a bilateral femoral fracture in patients with or without injuries to other body regions. STUDY DESIGN:: An observational cohort study of the prospectively recorded England and Wales Trauma Registry data (Trauma Audit Research Network) from 1989 to 2003. METHODS:: Patients were divided into the following groups: UFi (isolated unilateral femur injury), BFi (isolated bilateral femur injury), and UFa and BFa, if an associated injury was present. Injury and treatment data were collected for each patient. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. RESULTS:: Patients in group BFa had an increased mortality rate (31.6% vs. 9.8%) than patients in isolated bilateral femur injury group. Group BFa patients had an increased number of associated injuries (80%) than group UFa patients. Bilateral fracture, even in isolation, significantly increased the odds of mortality by 3.07. Intramedullary nailing was the method of fracture fixation associated with the lowest patient mortality overall. When assessing patient mortality in the BFa group with an New Injury Severity Score of >40, seven other fracture fixation regimens were associated with a lower mortality. CONCLUSIONS:: The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.

PMID: 20699750 [PubMed - in process]

Effects of hybrid plating with locked and nonlocked screws on the strength of locked plating constructs in the osteoporotic diaphysis.

J Trauma. 2010 Aug;69(2):411-7

Authors: Doornink J, Fitzpatrick DC, Boldhaus S, Madey SM, Bottlang M

BACKGROUND:: Hybrid plating (HP) may improve fixation strength of locked plating (LP) constructs by combining the use of locked and nonlocked screws within a bone segment. This biomechanical study evaluated whether a hybrid bridge plating construct provides greater fixation strength than an all-locked construct in the osteoporotic diaphysis. METHODS:: LP and HP constructs were applied to a validated surrogate of the osteoporotic femoral diaphysis in a bridge plating configuration. In LP constructs, plates were applied with three locking screws on each side of the fracture gap and remained 1 mm elevated. In HP constructs, plates were applied with two conventional screws complemented by a single locked screw on each side of the fracture. Constructs were tested under dynamic loading to failure in bending, torsion, and axial loading to analyze construct strength and failure mechanism in each loading mode. RESULTS:: Compared with the LP construct, the HP construct was 7% stronger in bending (p = 0.17), 42% stronger in torsion (p < 0.001), and 7% weaker in axial compression (p = 0.003). In bending, constructs failed by periprosthetic fracture. In torsion, LP constructs failed by screw breakage, and HP constructs failed by periprosthetic fracture or breakage of the locking screw. In axial compression, all constructs failed by screw migration. CONCLUSIONS:: HP delivered similar bending strength and higher torsional strength than an all-locked bridge plating construct, while causing only a small decrease in axial strength. It may therefore provide an attractive alternative to an all-locked construct for plate fixation in the osteoporotic diaphysis.

PMID: 20699751 [PubMed - in process]

Repositioning Osteotomy for Intra-Articular Malunion of Distal Radius With Radiocarpal and/or Distal Radioulnar Joint Subluxation.

J Trauma. 2010 Aug;69(2):418-22

Authors: Hsieh MK, Chen AC, Cheng CY, Chou YC, Chan YS, Hsu KY

BACKGROUND:: Intra-articular malunion of the distal radius may be complicated with radiocarpal and radioulnar joint subluxation, which may result in joint stiffness and loss of function. Conventional corrective osteotomy emphasizes on the restoration of the articular step-off. However, little information is available concerning the restoration of a concentric functioning joint through osteotomy. METHODS:: From 2002 to 2007, 12 patients with chronic intra-articular distal radius fractures were evaluated at an average follow-up of 33.6 months after repositioning osteotomy. The average time from initial injury to reconstructive operation was 11.3 months. The indication for osteotomy included dorsal or volar subluxation of the radiocarpal joint, distal radioulnar joint, or both in addition to articular incongruity. A preoperative computed tomography scan or rapid prototyping (RP) models were performed as part of the surgical planning. Operation was preceded by volar, dorsal, or both approaches. Repositioning osteotomy and internal fixation were also performed. Radiographic analysis and the Disability of Arm, Shoulder and Hand score were used for the outcome assessment. RESULTS:: All osteotomy sites healed and all events of radiocarpal and radioulnar subluxation were corrected. The average correction was 13.8 degrees (palmar tilt of the radius) and 1.9 mm in ulnar variance. The mean Disability of Arm, Shoulder and Hand score improved from 64 to 18. DISCUSSION:: Conventional corrective osteotomy via an extra-articular approach was favorably performed to correct an extra-articular malalignment or nascent intra-articular malunion. Problems of abnormal architecture after an intra-articular fracture of the radius are complicated with subluxation of carpus or distal radioulnar joint, which require repositioning via precise articular approach. Both reconstructed computed tomography images and rapid prototyping models are very useful tools in preoperative planning for intra-articular osteotomy. Simulated osteotomy and joint repositioning can be performed in solid models before commencement of actual operation. CONCLUSION:: Repositioning osteotomy consistently restores joint alignment and achieves functional improvement either in cases of nascent simple malunion or complex intra-articular malunion.

PMID: 20699752 [PubMed - in process]

The study of plate-screw fixation in the posterior wall of acetabulum using computed tomography images.

J Trauma. 2010 Aug;69(2):423-31

Authors: Wu X, Chen W, Zhang Q, Su Y, Guo M, Qin D, Wang L, Zhang Y

OBJECTIVE:: The article aims to delineate the width of posterior column, the thickness of posterior wall, and safe angles for screw placement in the posterior wall to avoid intraarticular screw penetration. METHODS:: The computed tomography (CT) images of 32 cadaveric adult bony hemipelvic specimens were initially obtained for the purpose of the study. Each specimen was sectioned at 1-cm intervals, and each plane of the crosssection was perpendicular to the surface of posterior column. By analyzing the CT images postprocessed with multiplanar reconstruction, the width of posterior column, the thickness of posterior wall, and the modified safe angle for screw placement in the posterior wall were measured and recorded. To validate the data obtained from the cadaveric model, this method was applied on 30 adult volunteers. The corresponding data were recorded and compared with those acquired from the cadaveric bony hemipelvis. In efforts to approve the usefulness of this method in practice, we have performed screw insertions in another 10 acetabular specimens and two operative cases by using the data from analyzing the CT images. RESULTS:: The width of posterior column, the thickness of posterior wall, and the safe angles for screw insertion in the posterior wall were measured and recorded in both specimens and volunteers. Comparison of the corresponding data was made between specimens and volunteers, and no significant difference was found in the same gender and side (p > 0.05). The corresponding width of posterior column, thickness of posterior wall, and safe angles for screw placement was found to be statistically different between males and females in both specimens and volunteers (p < 0.05). In specimens group, the safe angles for the entry points 0.5, 1.0, 1.5, 2.0, 2.5, and 3.0 cm medial to the lateral acetabular brim were 49.23 degrees +/- 11.54 degrees , 42.48 degrees +/- 8.97 degrees , 29.53 degrees +/- 7.86 degrees , 23.68 degrees +/- 6.20 degrees , 18.42 degrees +/- 5.41 degrees and 15.91 degrees +/- 4.37 degrees in males and the corresponding angles for the entry points 0.5, 1.0, 1.5, 2.0, and 2.5 cm medial to the lateral acetabular brim were 45.02 degrees +/- 8.82 degrees , 35.98 degrees +/- 7.60 degrees , 23.77 degrees +/- 6.29 degrees , 19.96 degrees +/- 4.36 degrees , and 14.68 degrees +/- 3.48 degrees in females, respectively. CT images of 10 acetabular specimens and two cases with posterior wall fractures show all screws were inserted into the posterior wall without penetration into the joint space. CONCLUSIONS:: The oblique multiplanar reconstruction images perpendicular to the surface of posterior column were selected to describe the safe angle for screw insertion into posterior wall, which can provide consistent results in both specimens and volunteers. The method can be applied in practice both on acetabular specimens and operative cases and is helpful to make individual perioperative planning for safer fixation of posterior wall fracture.

PMID: 20699753 [PubMed - in process]

Motion in the unstable cervical spine during hospital bed transfers.

J Trauma. 2010 Aug;69(2):432-6

Authors: Conrad BP, Rechtine G, Weight M, Clarke J, Horodyski M

BACKGROUND:: Hospital bed transfers, moves to examination room, X-ray, hospital bed, and/or surgery, have the potential of causing harm to a patient with an unstable cervical spine. This study evaluated motion generated in an unstable segment of the cervical spine during hospital bed transfers. A secondary goal purpose was to assess reduction in cervical motion using three collars and a no collar condition. METHODS:: Cervical spine instability was created at C5-C6 in cadavers. A repeated measures design was used to compare bed transfer techniques: manual transfer performed by six trained individuals and a transfer made by two people using the On3 lateral transfer device. Both techniques were tested under four collar conditions. Cervical spine motion was measured using an electromagnetic motion analysis device with sensors fixed to the anterior bodies of C5 and C6. RESULTS:: No significant differences were observed between transfer techniques (flexion, [p = 0.325]; axial rotation [p = 0.590]; lateral bending [p = 0.112]). Nor were there significant differences among the three collars used (flexion [p = 0.462]; axial rotation [p = 0.434]; lateral bending [p = 0.250]). For all transfers, using no collar resulted in more motion than using a collar; but was not statistically significant. CONCLUSIONS:: Bed transfers made with a lateral transfer device seem to be as safe as those made by the lift and slide manual transfer. None of the collars tested were significantly better at preventing cervical spine motion during a transfer, but each allowed less movement than no collar.

PMID: 20699754 [PubMed - in process]

A Comparison of the Diagnostic Performances of Visceral Organ-Targeted Versus Spine-Targeted Protocols for the Evaluation of Spinal Fractures Using Sixteen-Channel Multidetector Row Computed Tomography: Is Additional Spine-Targeted Computed Tomography Necessary to Evaluate Thoracolumbar Spinal Fractures in Blunt Trauma Victims?

J Trauma. 2010 Aug;69(2):437-446

Authors: Kim S, Yoon CS, Ryu JA, Lee S, Park YS, Kim SS, Lee YH, Suh JS

BACKGROUND:: It remains to be determined whether spine-targeted computed tomography (thoracolumbar spine computed tomography [TLS-CT]) images and visceral organ-targeted CT (abdominopelvic [AP]-CT) images are comparable for the evaluation of thoracolumbar spinal fractures using 16-channel multidetector row CT. The elimination of an additional spine-targeted CT protocol would substantially reduce time, the storage burden, and potential patient radiation exposure. METHODS:: A total of 420 vertebrae in 72 consecutive patients who underwent AP-CT to assess blunt traumatic injury and an additional CT examination using a TLS-CT protocol to evaluate spinal fractures were retrospectively evaluated. The AP-CT set (set A, reconstructed with using a wide display field of view [FOV] and a soft algorithm) and the TLS-CT set (set S, reconstructed using a narrow display FOV and a hard algorithm) were composed of axial plus reformatted sagittal or coronal images or both. Three radiologists independently reviewed all CT data retrospectively. Performances for detecting and typing fractures were compared by using areas under receiver operating characteristic curves and by determining concordance rates. RESULTS:: The overall areas under the curves for sets S and A for fracture detection were 0.996 and 0.995, respectively; no significant difference was found between the two sets. Concordance rates for typing performance also showed no statistical significance between the two sets for any of the three observers. CONCLUSION:: Sixteen-channel multidetector row CT images reconstructed using a soft algorithm and a wide display FOV that cover the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in trauma patients, given that multiplanar-reformatted images are provided.

PMID: 20699755 [PubMed - as supplied by publisher]

The combination of an online organ and tissue registry with a public education campaign can increase the number of organs available for transplantation.

J Trauma. 2010 Aug;69(2):451-4

Authors: Salim A, Malinoski D, Schulman D, Desai C, Navarro S, Ley EJ

BACKGROUND:: A persistent shortage of organs and inexhaustible waiting lists continue to result in many people dying while awaiting transplantation. On July 1, 2006, the California Department of Motor Vehicles joined forces with California’s Online Organ and Tissue Registry and launched a campaign to increase donation rates. This campaign included intense public and media education. The efficacy of such a campaign on donor demographics has not been studied. METHODS:: Retrospective analysis was conducted of organ donor referrals and donations from all southern California hospitals covered by a regional organ procurement agency. Organ donor demographics from 2 years before (pretime: 2004-2005) and 2 years after (posttime: 2007-2008) were compared. RESULTS:: Pretime included 6,112 referrals, 1,548 potential donors with 696 actual donors. Posttime included 7,119 referrals, 1,409 potential donors, and 699 actual donors. Consent for donation improved to 51.0% from 47.5% (p = 0.064), family decline decreased to 32.6% from 44.1% (p < 0.0001), and conversion rates improved to 49.6% from 45.0% (p = 0.011). Coroners also declined donation less frequently during posttime (1.8% vs. 0.6%, p = 0.004). Extended criteria donors improved to 9.5% from 3.8% (p < 0.0001), and donor after cardiac death improved to 3.0% from 1.4% (p = 0.002). A decrease in organs per donor was noted (3.57% vs. 3.14%, p < 0.0001) most likely because of the increase in extended criteria donors and donor after cardiac death. CONCLUSIONS:: Public and media education significantly improved organ donor demographics. Although this study compares only 2 years before with 2 years after the donation campaign, the results are extremely favorable. Therefore, a public donation campaign and an organ donor registry are effective promotions that could help increase the number of organs available for transplantation.

PMID: 20699756 [PubMed - in process]

The flexible chain saw during the american civil war.

J Trauma. 2010 Aug;69(2):455-8

Authors: Johnson RS, Sippo DA, Swan KG

PMID: 20699757 [PubMed - in process]

Three-step approach to the harvest of the fibula osteoseptocutaneous flap.

J Trauma. 2010 Aug;69(2):459-65

Authors: Wong CH, Tan BK

INTRODUCTION:: The ability to reliably include a skin paddle with the fibula osteoseptocutaneous (OSC) flap is crucial both from the perspective soft tissue reconstruction and flap monitoring. In this study, we describe a three-step approach to the harvest of the fibula OSC flap that is reliable and versatile. METHODS AND MATERIALS:: Step 1 starts by exploring the posterior crural septum from the anterior incision of the skin island with the aim being to identify the septocutaneous vessels that will supply the skin. Step 2 proceeds from the posterior aspect of the skin island. The septocutaneous vessel is traced to its origin, and the peroneal artery is detached from flexor hallucis longus that covers the posterior aspect of the artery. Finally, step 3 entails detaching all muscles attached to the fibula from anteriorly and can be expediently completed as vessels supplying the skin component have already been secured. RESULTS:: This technique was used successfully in 52 flap harvests. Absent septal vessels was noted in 4% of cases. In both cases, musculocutaneous perforators arising from the soleus muscle was used to supply the skin component. In one case, the septocutaneous vessel was noted to arise from the posterior tibial artery. Flap harvest was successful in all cases. CONCLUSION:: The three-step approach allowed us to reliably harvest the fibula OSC flap. We were able to visualize the anatomy clearly with this technique, and this has enabled us to detect anomalous anatomy early on in the dissection. These were successfully managed by using musculocutaneous perforators to the skin island that would normally be cut.

PMID: 20699758 [PubMed - in process]

Helpful maneuvers for controlling bleeding from operative or traumatic vascular injuries.

J Trauma. 2010 Aug;69(2):466-7

Authors: Alameddine AK, Deaton DW, Alimov VK, Rousou JA

PMID: 20699759 [PubMed - in process]

Intermediate-term follow-up of patients treated with percutaneous embolization for grade 5 blunt renal trauma.

J Trauma. 2010 Aug;69(2):468-70

Authors: Stewart AF, Brewer ME, Daley BJ, Klein FA, Kim ED

BACKGROUND:: The short-term efficacy and safety of percutaneous embolization for the treatment of hemodynamically unstable patients with grade 5 renal injuries secondary to blunt trauma has been previously established; however, there has been no published intermediate-term follow-up. The purpose of this study is to report intermediate-term follow-up and complications for this treatment modality. METHODS:: A retrospective study was performed to determine intermediate-term outcomes in an observational cohort of patients who underwent percutaneous embolization for the management of grade 5 blunt renal trauma. Demographic and perioperative data were obtained. Follow-up was performed via mail and/or phone questionnaires. RESULTS:: Between October 2004 and July 2008, 10 hemodynamically unstable patients with grade 5 blunt renal trauma were treated with percutaneous embolization. Mean age of the cohort was 29 years (range, 5-50). Mean follow-up via phone and/or mail questionnaires was 2.7 years (1.5-5.1 years). One patient reported a new diagnosis of hypertension, which is well controlled by a single antihypertensive medication. There were no reported complications of refractory hypertension, altered renal function, new urolithiasis, chronic pain, urine leak, arteriovenous fistula, or pseudoaneurysm. No other procedures were required after the initial embolization for their renal trauma. CONCLUSIONS:: Management of grade 5 renal injuries with percutaneous embolization is safe and is not associated with intermediate-term adverse events.

PMID: 20699760 [PubMed - in process]

Training and Certification in Surgical Critical Care: A Position Paper by the Surgical Critical Care Program Directors Society.

J Trauma. 2010 Aug;69(2):471-474

Authors: Alam HB, Chipman JG, Luchette FA, Shapiro MJ, Spain DA, Cioffi W,

Delivery of Surgical Critical Care in the United States is facing multiple challenges including increasing complexity of care, escalating costs, shortage of well-trained physicians, and controversies about appropriate training and credentialing methods. In this position paper, the Surgical Critical Care Program Directors Society discusses some of these important issues and suggests a number of possible solutions.

PMID: 20699761 [PubMed - as supplied by publisher]

Traumatic rupture of two giant hepatic hemangiomas-a case report.

J Trauma. 2010 Aug;69(2):476

Authors: Chan WH, Huang HJ, Chen HC, Lee PC, Chan CP, Chang HC, Chen YL

PMID: 20699762 [PubMed - in process]

Traumatic rupture of bilateral huge renal angiomyolipomas in tuberous sclerosis complex.

J Trauma. 2010 Aug;69(2):477

Authors: Tsai CK, Lin YT, Lin TC

PMID: 20699763 [PubMed - in process]

Small change, big impact: prevention of vole captive bolt device hand injuries.

J Trauma. 2010 Aug;69(2):478

Authors: Frank M, Ekkernkamp A

PMID: 20699764 [PubMed - in process]

Re: heart period variability monitoring in trauma and hemorrhage.

J Trauma. 2010 Aug;69(2):479-80

Authors: Rickards CA

PMID: 20699765 [PubMed - in process]

Mixed martial warts.

J Trauma. 2010 Aug;69(2):479

Authors: Wells JJ, Wells J

PMID: 20699766 [PubMed - in process]

Response to the letter to the editor entitled “heart period variability monitoring in trauma and hemorrhage”.

J Trauma. 2010 Aug;69(2):480

Authors: Batchinsky AI, Cancio LC

PMID: 20699767 [PubMed - in process]

Meetings/Courses.

J Trauma. 2010 Aug;69(2):481

Authors:

PMID: 20699768 [PubMed - in process]

Body Cooling Ameliorating Spinal Cord Injury May Be Neurogenesis-, Anti-inflammation- and Angiogenesis-Associated in Rats.

J Trauma. 2010 Aug 5;

Authors: Kao CH, Chio CC, Lin MT, Yeh CH

BACKGROUND:: Body cooling (BC) or mild hypothermia therapy (about 33 degrees C) is reportedly effective for spinal cord injury (SCI). However, the mechanisms underlying the beneficial effects of BC remain unclear, so does BC ameliorating SCI via promoting neurogenesis, anti-inflammation, and angiogenesis. METHODS:: The standard rat compression SCI model was tested hypothetically in two groups: one receiving BC (33 degrees C) and the other, normothermia (37 degrees C). Afterward, the effects of BC therapy on the hind limb locomotion, spinal cord infarction and apoptosis, angiogenesis, neurogenesis, and inflammation in these two groups of SCI were assessed. The other group of sham SCI was used as controls. RESULTS:: Apoptosis (evidenced by higher numbers of terminal deoxynucleotidyl- transferase-mediated and duDP-biotin nick end-labeling-positive cells), infarct, activated inflammation (evidenced by higher levels of tumor necrosis factor-alpha, interleukin-1beta, and myeloperoxidase), and hind limb locomotor dysfunction were inspected in the untreated (37 degrees C) SCI rats 4 days after SCI. When compared with those of untreated SCI rats, SCI rats receiving BC (33 degrees C) displayed lower levels of apoptosis, infarct volume, activated inflammation, and hind limb locomotor dysfunction. In addition, that BC promoted both angiogenesis (evidenced by increased numbers of both vascular endothelial growth factors and bromodeoxyuridine-positive endothelial cells) and neurogenesis (evidenced by increased numbers of both glial cell line-derived neurotrophic growth factors and bromodeoxyuridine-neuronal-specific nuclear protein double positive cells) in the injured spinal cord was evaluated 4 days after SCI. CONCLUSION:: BC (33 degrees C) improved SCI outcomes by promoting angiogenesis, neurogenesis, and anti-inflammation in a rat SCI model.

PMID: 20693909 [PubMed - as supplied by publisher]

Caveolin-1 siRNA Increases the Pulmonary Microvascular and Alveolar Epithelial Permeability in Rats.

J Trauma. 2010 Aug 5;

Authors: Gao C, Li R, Huan J, Li W

BACKGROUND:: Increased pulmonary microvascular and epithelial permeability are important contributors to pulmonary edema in acute lung injury. In this study, we used small interfering RNA (siRNA) to knock down caveolin-1 expression in rat lungs and to confirm the important role of caveolin-1 in regulating pulmonary edema. METHOD:: After pulmonary injection of siRNA against caveolin-1 messenger RNA incorporated in liposomes with three concentrations of 0.4, 0.8, and 1.2 mg/kg, the gene silencing rate and the effects of caveolin-1 siRNA on aquaporin (AQP)-1, AQP-5, and epithelial sodium channel (ENaC) were detected. For pulmonary permeability analysis, Evans blue fluorimetry, ratios of albumin concentrations between blood and bronchoalveolar lavage, and wet/dry weight ratios were measured. The impacts of caveolin-1 suppression on interendothelial junctions were evaluated by the performance of electron microscopy and the analysis of vascular endothelial (VE)-cadherin Western blot. Alveolar wall thickness analysis and chest fluoroscopy were performed to determine the pulmonary edema degree. RESULTS:: After 72 hours of injection, the gene silencing rate of caveolin-1 siRNA is about 87%. AQP-1, AQP-5, ENaC-alpha, ENaC-beta, ENaC-gamma, and VE-cadherin protein levels were decreased by 63%, 66%, 80%, 90%, 89%, and 50%, respectively. Caveolin-1 siRNA also resulted in increasing microvascular and epithelial permeability and pulmonary edema. CONCLUSION:: These data suggest that caveolin-1 plays an important part in regulating the pulmonary permeability by modifying AQP-1, AQP-5, ENaC, and VE-cadherin.

PMID: 20693910 [PubMed - as supplied by publisher]

Neurological and Functional Recovery in Multiple Injured Patients With Paraplegia: Outcome After 1-Year.

J Trauma. 2010 Aug 5;

Authors: Putz C, Schuld C, Akbar M, Grieser T, Wiedenhöfer B, Fürstenberg CH, Gerner HJ, Rupp R

BACKGROUND:: Injuries of thoracic vertebrae in multiple trauma patients are often accompanied by severe thoracic injuries and sensorimotor deficits. However, until now, it is not clear whether and how the severity of trauma influences the neurologic and functional outcome in paraplegic patients during the first year after the trauma. The aim of the study was to compare two cohorts of multiple injured paraplegic patients with and without conversion in the American Spinal Injury Association Impairment Scale (AIS) with regard to the severity of spinal trauma, the severity of thorax trauma, the type of fracture, and the functional outcome 1 year after the date of injury. METHODS:: Twenty-one traumatic paraplegic patients (neurologic level T1-T12) were included in the study based on a retrospective analysis of the Heidelberg European Multicenter Study about Spinal Cord Injury database (www.emsci.org) from 2002 to 2007. In all patients, the Polytraumaschluessel (PTS), the AO classification, the AIS, and the Spinal Cord Independence Measure were collected. Patients with no change in the AIS (group 1, n = 14) were compared with patients with AIS changes (group 2, n = 7), and t test and chi test were performed (p < 0.05). RESULTS:: Differences in both groups concerning fracture classification were confirmed (p = 0.046). A relation between neurologic improvement in the AIS and the severity of trauma (p = 0.058) after 1 year was not found. The subitem PTST in the thoracic area showed statistical significance comparing the two groups (p = 0.005). Both groups significantly improved functionally (Spinal Cord Independence Measure, p = 0.035) during the first year but with no significant difference between the groups after 1 year. CONCLUSIONS:: Our data suggest that functional improvement is achieved independently from neurologic recovery. The combined assessment of the PTS, the AO classification, and the AIS in multiple-injured paraplegic patients can contribute to provide a better prognostication of the neurologic changes during rehabilitation and the outcome after 1 year than the AIS alone.

PMID: 20693911 [PubMed - as supplied by publisher]

Altered Expression of the MicroRNAS and Their Potential Target Genes in the Soleus Muscle After Peripheral Denervation and Reinnervation in Rats.

J Trauma. 2010 Aug 5;

Authors: Hsieh CH, Jeng SF, Wu CJ, Lu TH, Yang JC, Chen YC, Lin CJ, Rau CS

BACKGROUND:: To profile the expression of microRNAs (miRNAs) and their potential target genes in the soleus muscles after denervation and reinnervation of the sciatic nerve in rats. MATERIALS AND METHODS:: The 4 months denervated and reinnervated soleus muscles were analyzed with Agilent Rat miRNA array to detect the expressed miRNAs against those from the sham control. These differentially expressed miRNAs were applied for hierarchical cluster analysis using average linkage and Pearson correlation as a measure of similarity. A combined approach using computational prediction by the miRanda algorithm and the Agilent Whole Rat Genome 4x 44K oligo microarray experiment was performed to indentify the potential target genes of these up-regulated miRNAs. Gene ontology (GO) analysis of these potential target genes into one of the three ontologies, biological process, molecular function, or cellular component, was performed and compared between the denervated and reinnervated muscles. RESULTS:: Thirty-six and 39 miRNAs of 350 rat miRNAs tested were significantly up-regulated in the denervated and reinnervated muscles, respectively. The expressed miRNAs in these two groups were similar but with different folds, and the unsupervised hierarchy clustering was able to separate the samples into denervation and reinnervation groupings. In the GO analysis, all three categories indicated a considerable reduced number of the potential target genes of the up-regulated miRNAs and less fraction of differentially expressed genes in most of the GO terms in the reinnervated muscle. CONCLUSIONS:: This study demonstrated a different involvement of miRNAs and their potential target genes in the soleus muscle after denervation and after reinnervation of the sciatic nerve in a rat model.

PMID: 20693912 [PubMed - as supplied by publisher]

Incidence and Predictors of Intracranial Hemorrhage After Minor Head Trauma in Patients Taking Anticoagulant and Antiplatelet Medication.

J Trauma. 2010 Aug 5;

Authors: Brewer ES, Reznikov B, Liberman RF, Baker RA, Rosenblatt MS, David CA, Flacke S

BACKGROUND:: The yield of head computed tomography (CT) for patients who suffered head trauma with a presenting Glasgow Coma Scale (GCS) score of 15 has been reported to be low, even in patients who are anticoagulated or on antiplatelet therapy. We undertook this study to (1) determine the frequency of intracranial hemorrhage in anticoagulated patients and patients on antiplatelet therapy and its impact on clinical management, (2) identify predictors of positive imaging findings, and (3) assess potential differences between anticoagulation and antiplatelet therapy. METHODS:: We conducted a retrospective review of the trauma registry at our institution, a Level II trauma center. All trauma registry patients with a minor head injury registered between the years 2004 and 2006 who were taking warfarin or clopidogrel, had a presenting GCS score of 15, and underwent head CT were included in this study. Intracranial hemorrhage on head CT was considered a positive result. RESULTS:: One hundred forty-one patients (male, n = 67; female, n = 74), mean age 79 years (range, 36-101 years), were included in this study. Forty-one patients (29%) were diagnosed with intracranial hemorrhage. Thirty-nine (95%) of these 41 patients underwent reversal and/or discontinuation of clopidogrel and/or warfarin. Five patients required surgical evacuation of an intracranial hemorrhage. Four patients died. Loss of consciousness (Wald = 7.468, beta = 1.179, p = 0.008) predicted a positive CT result. Type of medication (warfarin, aspirin, or clopidogrel) did not reach statistical significance as a predictor of positive result. CONCLUSION:: Despite a presenting GCS score of 15, patients with minor head injury from the trauma registry at our institution taking anticoagulation or antiplatelet therapy have a high incidence of intracranial hemorrhage especially after reported loss of consciousness.

PMID: 20693913 [PubMed - as supplied by publisher]

Mortality After Thermal Injury: No Sex-Related Difference.

J Trauma. 2010 Aug 5;

Authors: Steinvall I, Fredrikson M, Bak Z, Sjoberg F

BACKGROUND:: Young women have been reported to be more likely to survive than men after severe trauma. Girls also have less inflammation and hypermetabolism after major burns. Yet burned women have been found to have a twofold greater risk of death than men. Our aim was to find out if there is a sex-related difference in mortality after thermal injury, particularly in the age group between 16 years and 49 years, when hormonal differences would be most influential. METHODS:: All patients admitted to the Linköping University Hospital Burn Unit with thermal injuries during the years 1993-2008 were included and the variables percentage burned total body surface area (TBSA%), age, type of burn, mechanical ventilation, and year were included in a multiple regression (Poisson log) model. RESULTS:: Of 1,119 patients with thermal injury, 792 (71%) were men. Crude mortality was 5% among men, and 8% among women (p = 0.04). After adjustment for age and TBSA%, there was no correlation between mortality and sex, in any age group. Eight men and four women died in the group of young adults (16-49 years) in which TBSA% correlated with mortality (p < 0.01) but age did not. Mortality was 14% (32 of 221) among the men and 23% (23 of 102) of women in the group of older adults (50 years and older), and both age and TBSA% correlated with mortality (p < 0.001). CONCLUSIONS:: There is no relevant sex-related difference in survival after thermal injury. The conclusion is, however, tempered by the few deaths, particularly among younger adults.

PMID: 20693914 [PubMed - as supplied by publisher]

Prevalence of Posttraumatic Stress Disorder and Major Depression After Trauma Center Hospitalization.

J Trauma. 2010 Aug 5;

Authors: Shih RA, Schell TL, Hambarsoomian K, Belzberg H, Marshall GN

BACKGROUND:: Individuals hospitalized after physical trauma are at heightened risk for mental disorders. We examined prevalence rates of both posttraumatic stress disorder (PTSD) and major depression at 6 and 12 months in a sample of 677 individuals experiencing different types of trauma who were representative of physical trauma survivors hospitalized in Los Angeles County trauma centers. Demographic and injury-related risk factors for these disorders were also evaluated. METHODS:: Bivariate logistic regressions estimated risk for PTSD and depression at either 6 or 12 months associated with baseline risk factors. RESULTS:: At 6 months, 31% of participants met screening criteria for probable PTSD and 31% met criteria for probable depression. At 12 months, 28% and 29% met criteria for PTSD and depression, respectively. There were also high rates of comorbidity; depression and PTSD co-occurred in 21% of individuals at 6 months and in 19% of patients at 12 months. Bivariate logistic regressions indicated that preexisting disability and lower education were associated with higher odds of PTSD at either 6 or 12 months. African Americans and Hispanics had higher odds of PTSD compared with non-Hispanic Caucasians. Assault-related injury (versus accident), more severe injury, and longer hospitalizations were also associated with greater odds of PTSD. By contrast, higher odds of depression at 6 or 12 months were only associated with preexisting disability, losing consciousness, more severe injury, and longer hospitalizations. CONCLUSIONS:: Key demographic and injury characteristics may enhance identification of at-risk trauma survivors who would benefit from targeted screening, patient education, and early intervention efforts.

PMID: 20693915 [PubMed - as supplied by publisher]

Results of Dynamic Treatment of Fractures of the Proximal Phalanx of the Hand.

J Trauma. 2010 Aug 5;

Authors: Figl M, Weninger P, Hofbauer M, Pezzei C, Schauer J, Leixnering M

BACKGROUND:: The treatment of fractures of the proximal phalanx in three-phalanx fingers has for a long time been the domain of conservative static treatment in a plaster cast. After removal of the plaster, there was usually limitation of mobility of the interphalangeal joints. Fractures of the proximal phalanx are managed with conservative functional treatment in our clinic. The aim of this method is to achieve bony healing and free mobility at the same time and not in succession. We evaluated our treatment outcomes in a follow-up study. METHODS:: The dressing consists of a dorsopalmar plaster splint and a so-called finger splint. The wrist and metacarpophalangeal joints are immobilized with the plaster cast. The wrist is dorsiflexed 30 degrees, and the metacarpophalangeal joints are flexed 70 degrees to 90 degrees. In this intrinsic plus position, the extensor aponeurosis is taut and covers two-thirds of the proximal phalanx, thus leading to firm splinting of the fracture. RESULTS:: Sixty-five patients (46 men and 19 women) with 78 proximal phalanx fractures were followed up after an average of 23 months (12-69 months). The average age of the patients was 41 years (18-93 years). Among our patients, the ring finger was affected most often, with transverse fractures predominating. As regards the location, fractures in the proximal third were most frequent (51%). All fractures consolidated. Delayed fracture healing or pseudarthrosis was not observed. Sixty-seven fingers (86%) showed full range of motion at follow-up. In 11 cases (14%), there was limitation of finger joint movements, with inhibition of extension of the proximal interphalangeal joint in nine patients up to a maximum of 20 degrees. Two patients had limitation of flexion with a fingertip-palm distance of 1.1 cm. CONCLUSION:: The aim of functional treatment of proximal phalanx fractures is to achieve bony healing and free mobility at the same time and not in succession. Active exercises in the proximal and distal interphalangeal joints prevent limitations of mobility and the subsequent occurrence of rotational and axial deformities.

PMID: 20693916 [PubMed - as supplied by publisher]

Revision Internal Fixation and Nonvascular Fibular Graft for Femoral Neck Nonunion.

J Trauma. 2010 Aug 5;

Authors: Elgafy H, Ebraheim NA, Bach HG

BACKGROUND:: The rates of nonunion after internal fixation for femoral neck fractures have been reported to range from 0% to 59%. Existing treatment options are osteotomy (with or without graft), osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularized, and nonvascularized fibula), or arthroplasty. The objective of this study was to assess the outcome results of revision internal fixation and nonvascular fibular bone grafting for symptomatic aseptic femoral neck nonunion. METHODS:: This is a retrospective case series study involving 17 patients with symptomatic femoral neck nonunion that were treated with revision internal fixation and fibular bone graft. The inclusion criteria were aseptic symptomatic femoral neck nonunion with no or minimal varus alignment. There were eight men and nine women. The average age was 46 years (range, 24-58 years). Thirteen patients had autogenous fibular bone graft, and six patients had fibular allograft. RESULTS:: Of the 13 patients who had autogenous nonvascularized fibular bone grafts, four remained in nonunion. Fibular autograft had a 69.2% success rate with the mean time to union 4.8 months. Four of the six patients who had fibular allografts remained in nonunion. Fibular allograft had a 33.3% success rate with the mean time to union 13.3 months. CONCLUSION:: This study showed that revision internal fixation and fibular autograft have resulted into a better and faster union rate than fibular allografts.

PMID: 20693917 [PubMed - as supplied by publisher]

Mitigating Effects of Captopril and Losartan on Lung Histopathology in a Rat Model of Fat Embolism.

J Trauma. 2010 Aug 5;

Authors: McIff TE, Poisner AM, Herndon B, Lankachandra K, Molteni A, Adler F

BACKGROUND:: Fat embolization (FE) is an often overlooked and poorly understood complication of skeletal trauma and some orthopedic procedures. Fat embolism can lead to major pulmonary damage associated with fat embolism syndrome (FES). METHODS:: A model of FE in unanesthetized rats, using intravenous injection of the neutral fat triolein, was used to study the potential therapeutic effect on lung histopathology of altering the production of, or response to, endogenous angiotensin (Ang) II. Either captopril, an Ang I converting enzyme inhibitor, or losartan, an Ang II type 1 receptor blocker, was injected 1 hour after FE by triolein injection. After euthanasia at 48 hours, histopathologic evaluation was used to compare the drug-treated animals with control animals that received only triolein. RESULTS:: Histology of the lungs of rats treated only with triolein revealed severe, diffuse pathology. Alveolar septa showed severe, diffuse inflammation. Bronchial lumina showed severe mucosal epithelial loss. The media of the pulmonary small arteries and arterioles was thicker, and the lumen patency was reduced 60% to 70%. Trichrome staining confirmed the abundant presence of collagen in the media and adventitia, as well as collagen infiltrating the bronchial musculature. Both captopril and losartan treatments reduced the inflammatory, vasoconstrictor, and profibrotic effects present at 48 hours (p < 0.001). With treatment, the vascular lumen remained patent, and the fat droplets were reduced in size and number. There was a reduction in the number of infiltrating leukocytes, macrophages, myofibroblasts, and eosinophils, along with a significant decrease in hemorrhage and collagen deposition (p < 0.001). Pathologic changes in bronchial epithelium were also diminished. CONCLUSIONS:: The results suggest that the use of drugs that act on the renin-Ang system might provide an effective and targeted therapy for fat embolism syndrome.

PMID: 20693918 [PubMed - as supplied by publisher]

Carbon Monoxide-Releasing Molecule-2 Enhances Coagulation and Diminishes Fibrinolytic Vulnerability in Diluted Plasma In Vitro.

J Trauma. 2010 Aug 5;

Authors: Nielsen VG, Green P, Green M, Martin-Ross A, Khan ES, Kirklin JK, George JF

BACKGROUND:: A carbon monoxide-releasing molecule (tricarbonyldichlororuthenium (II) dimer; CORM-2) enhances coagulation and attenuates vulnerability to fibrinolysis in normal and hemophiliac human plasma. We tested the hypothesis that plasma diluted with resuscitative fluids would demonstrate improved coagulation and decreased fibrinolytic vulnerability after exposure to CORM-2. METHODS:: Normal, platelet-poor plasma was diluted 0%, 20%, 30%, 40%, or 50% with 0.9% NaCl (NS) or low-molecular-weight hydroxyethyl starch (VOL) and, subsequently, exposed to 0 mumol/L or 100 mumol/L CORM-2 before activation with tissue factor (n = 4 per condition). Additional plasma samples diluted with NS or VOL (0% or 30%) were exposed to 0 mumol/L or 100 mumol/L CORM-2 and 0 U/mL or 100 U/mL tissue-type plasminogen activator to assess fibrinolytic vulnerability (n = 8 per condition). Thrombelastographic data were collected until either clot strength stabilized or clot lysis occurred, as appropriate. RESULTS:: CORM-2 exposure maintained normal to supranormal velocity of clot formation and strength in plasma diluted up to 40% with NS. In contrast, although CORM-2 exposure improved coagulation kinetics, dilution with VOL markedly degraded thrombus formation kinetics. Similarly, fibrinolytic vulnerability to tissue-type plasminogen activator was markedly improved by CORM-2 exposure in samples diluted with NS, whereas VOL-diluted thrombi were still abnormally weak and easily lysed compared with undiluted samples despite CORM-2 exposure. CONCLUSIONS:: CORM-2 exposure attenuated the decrease in coagulation kinetics and enhancement of fibrinolytic vulnerability associated with hemodilution. Extensive preclinical investigation remains to be performed to determine the route of administration, safety, and efficacy of CORM-2 and other CORMs to treat trauma-associated bleeding.

PMID: 20693919 [PubMed - as supplied by publisher]

Triage and Trauma Workload in Mass Casualty: A Computer Model.

J Trauma. 2010 Aug 5;

Authors: Hirshberg A, Frykberg ER, Mattox KL, Stein M

BACKGROUND:: The aim of this study was to quantitatively analyze the impact of hospital triage on the workload of trauma teams in the Emergency Department during a mass casualty incident, using a computer model. METHODS:: The inflow and triage of casualties into an Emergency Department with 5 trauma teams was modeled using the Monte Carlo method. Triage was represented as a binary classification task performed in one or two sequential steps. The input variables were triage accuracy (specificity and sensitivity) and casualty load, and the key output variable was the time to saturation (TTS) of the trauma teams, which was computed from the available and needed team minutes. RESULTS:: The relationship between an increasing casualty load and the TTS describes a sigmoid-shaped curve. Improving triage accuracy extends the TTS and shifts the curve to the right. Switching to sequential competent triage (80% accuracy) results in TTS that is similar to perfect single-step triage (100% accuracy) but at the cost of investing less team time in urgent casualties. The optimal ratio of trauma teams to urgent casualties in sequential mode is 1:8, indicating that the treatment of urgent casualties must be delegated to reinforcement staff. CONCLUSIONS:: This study introduces innovative tools for quantitative analysis of hospital triage in mass casualty incidents and shows how triage accuracy and mode affect the ability of trauma teams to cope with heavy casualty loads. These tools can be used to optimize the hospital response to future threats.

PMID: 20693920 [PubMed - as supplied by publisher]

Denervation Dynamically Regulates Integrin alpha7 Signaling Pathways and Microscopic Structures in Rats.

J Trauma. 2010 Aug 5;

Authors: Tsai FC, Pai MH, Chiu CC, Chou CM, Hsieh MS

BACKGROUND:: Peripheral nerve injury causes serious problems in orthopedic and plastic surgeries. Cell adhesion molecules such as integrin alpha7 provoke cell binding and signaling pathways within myofibers. Expression profiles of integrin alpha7 signaling pathways and the molecule’s microscopic structure were assessed to investigate the long-term dynamic changes in denervated rat skeletal muscle. METHODS:: A denervated rat skeletal muscle model was established by severing the sciatic nerve for 1 week, 2 weeks, 4 weeks, 8 weeks, 12 weeks, 20 weeks, and 26 weeks. Molecular expressions were investigated by mRNA and Western blot. The structural alterations were detected by immunohistochemistry, scanning electron microscopy, and transmission electron microscopy. RESULTS:: The denervated muscle atrophy presented the following dynamic molecular alterations: an initial increase around postdenervation in week (PIW) 8 and then a subsequent decay of integrin alpha7, integrin downstream signaling pathway (Ras or Raf or, ERK1/2), Akt, cleaved caspase-3, fast myosin heavy chain (MHC), beta actin, and RhoA. We demonstrated that the expressions of multiple signaling molecules were highly upregulated at PIW 8 (p < 0.01). Scanning electron microscopy findings of the surface textures of myofibers showed more severe damage at PIW 8 and subsequently became smoother. Inner structures of myofibers separated with discontinuity on transmission electron microscopy examinations. CONCLUSION:: Our novel finding showed that time-series alterations of integrin alpha7 signaling molecules and surface microstructures in the long-term denervated rat skeletal muscle are biphasic and coherently dynamic. Persisted p-Akt elevation suggested that denervated muscle may regenerate if reinnervation or other treatment was performed.

PMID: 20693921 [PubMed - as supplied by publisher]

Intraabdominal Vascular Injury: Are We Getting Any Better?

J Trauma. 2010 Aug 5;

Authors: Paul JS, Webb TP, Aprahamian C, Weigelt JA

BACKGROUND:: Intraabdominal vascular injury (IAVI) as a result of penetrating and blunt trauma carries a high mortality rate. This study was performed to compare current mortality rates with a previously reported historic control. METHODS:: The experience at our institution from 1970 to 1981 was previously reported with an overall mortality rate of 32% in 112 patients with penetrating IAVI. In a retrospective analysis, this historic cohort was compared with 248 patients with penetrating and blunt IAVI during a 138-month interval ending in June 2007. RESULTS:: Overall mortality rate was 28.6%. The most commonly injured arteries were the iliac artery, aorta, and superior mesenteric artery. The most commonly injured veins were the inferior vena cava, iliac vein, and portal vein. Injury to the aorta, IVC, and portal vein had the highest mortality rates of 67.8%, 42.1%, and 66.6%, respectively. One hundred forty-four patients with one vessel injured had a mortality rate of 18.7%, whereas those with more than one vessel injured had a mortality rate of 48.7% (p < 0.001). A total of 46% of 117 patients in shock died compared with 9.6% of 104 patients not in shock (p < 0.001). Patients with a base deficit of less than -15 had a mortality rate of 72%, whereas those with a base deficit of 0 to -15 (p < 0.001) had a mortality rate of 18.9%. There was no difference in the overall mortality rate for penetrating trauma compared with the previous study. CONCLUSIONS:: Although over 20 years have passed, no significant changes have occurred in the mortality associated with IAVI. Patients presenting in shock with IAVI continue to have a high mortality rate.

PMID: 20693922 [PubMed - as supplied by publisher]

Early Administration of l-Arginine in Experimental Acute Spinal Cord Injury Impairs Long-Term Motor Function Recovery.

J Trauma. 2010 Aug 5;

Authors: Esquivel-Aguilar A, Castañeda-Hernández G, Martínez-Cruz A, Franco-Bourland RE, Madrazo I, Guízar-Sahagún G

BACKGROUND:: Recently, we reported that l-arginine, a nitric oxide precursor, reverses altered drug disposition induced by acute spinal cord injury (SCI) by increasing hepatic blood flow, without affecting mean arterial pressure and heart rate, whereas others have shown that it produces neuroprotection in several models of acute neurologic damage. Its use as a therapeutic agent for microcirculatory alterations associated with spinal shock seems promising. Therefore, here we have tested its influence on long-term morphofunctional neurologic outcome. METHODS:: Intravenous l-arginine (300 mg/kg per dose) was administered to adult rats after SCI of moderate intensity according to the following schemes (n = 6): (1) single dose at 1 hour, (2) single dose at 24 hour, and (3) repeated doses first at 24 hour and then daily for 7 days. Control injured rats received the vehicle (saline solution). RESULTS:: Contrary to our expectations, locomotor function, assessed using the Basso-Beattie-Bresnahan scale for 8 weeks, was significantly worse in the l-arginine treated groups compared with the control group. Areas of both spared white matter and myelin stain at the epicenter seemed reduced in rats that received l-arginine as a single dose at 1 hour after injury but were not significantly different from the control group. CONCLUSIONS:: l-arginine as used here interfered with the functional outcome of rats subjected to SCI, suggesting that l-arginine or its metabolic products may be neurotoxic. Because of its potential utility for acute SCI suggested in the past, strategies should be designed to block its apparent neurotoxicity.

PMID: 20693923 [PubMed - as supplied by publisher]

Volar Locking Plates Versus K-Wire Fixation of Dorsally Displaced Distal Radius Fractures-A Functional Outcome Study.

J Trauma. 2010 Aug 5;

Authors: Hull P, Baraza N, Gohil M, Whalley H, Mauffrey C, Brewster M, Costa ML

BACKGROUND:: Fractures of the distal radius are common. As the population of the western world ages, their incidence is set to increase further. There are various methods of treating these fractures, but optimal management remains controversial. In the United Kingdom, the most common surgical treatment of closed distal radius fractures is by Kirschner-wires (K-wires) or volar locking plate. In this study, we compared long-term functional outcomes of volar locking plates with those of K-wires. METHODS:: A retrospective comparative study of 71 patients with dorsally displaced distal radius fractures treated contemporaneously in two independent hospitals was performed. One group was treated with a volar locking plate (n = 36) and the other group with manipulation and K-wire fixation (n = 35). There was no difference between the two groups in terms of demographics or grade of fracture. Outcome was measured 15 months to 27 months post surgery using the Disabilities of the Arm, Shoulder and Hand score and the Patient-Rated Wrist Evaluation score. RESULTS:: We found no statistical difference between the two groups in the Patient-Rated Wrist Evaluation score or Disabilities of the Arm, Shoulder and Hand score at 1 year to 2 years postsurgery. CONCLUSION:: We have been unable to demonstrate a clinically relevant advantage of using volar locking plates over K-wires at 1 year to 2 years postoperatively.

PMID: 20693924 [PubMed - as supplied by publisher]

Directness of Transport of Major Trauma Patients to a Level I Trauma Center: A Propensity-Adjusted Survival Analysis of the Impact on Short-Term Mortality.

J Trauma. 2010 Aug 5;

Authors: Garwe T, Cowan LD, Neas BR, Sacra JC, Albrecht RM

BACKGROUND:: Whether severely injured patients should be transported directly to tertiary trauma centers, bypassing closer nontertiary facilities, or be transported first to nearby, less-specialized facilities for immediate care and stabilization has been studied with mixed findings. Differences in study locale, case mix, and variation in the structure and level of maturation of the trauma system may explain some of the discrepancy in findings. In addition, risk adjustment strategies used in these studies did not take into account prehospital baseline characteristics as well as time since injury. METHODS:: This was a retrospective cohort study of 1,998 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. Propensity-adjusted survival analyses were used to compare short-term mortality outcomes in transferred versus directly transported major trauma patients. RESULTS:: A total of 1,398 patients were transported directly to the Level I trauma center and 600 patients were transferred from lower level facilities. After adjusting for the propensity to be transported directly, age, injury severity score, severe head injury, emergency medical service or emergency department intubation, comorbid conditions, and time to definitive Level I trauma care, the 2-week mortality risk in transferred patients was almost three-fold that of patients transported directly to a Level I trauma center (hazard ratio, 2.7; 95% confidence interval, 1.31-5.6). CONCLUSION:: Transferred patients in a predominantly rural region are at an increased risk of short-term mortality. This suggests that severely injured patients should be transported directly to tertiary trauma centers. For patients requiring immediate stabilization at nontertiary facilities, this should be performed promptly without unnecessary delays.

PMID: 20693925 [PubMed - as supplied by publisher]

The Effects of Injury Magnitude on the Kinetics of the Acute Phase Response.

J Trauma. 2010 Aug 5;

Authors: Bauzá G, Miller G, Kaseje N, Wigner NA, Wang Z, Gerstenfeld LC, Burke PA

BACKGROUND:: The acute-phase response (APR) is critical to the body’s ability to successfully respond to injury. A murine model of closed unilateral femur fractures and bilateral femur fracture were used to study the effect of injury magnitude on this response. METHODS:: Standardized unilateral femur fracture and bilateral femur fracture in mice were performed. The femur fracture sites, livers, and serum were harvested over time after injury. Changes in mRNA expression of cytokines, hepatic acute-phase proteins, and serum cytokines overtime were measured. RESULTS:: There was a rapid and short-lived hepatic APR to fracture injuries. The overall pattern in both models was similar. Both acute-phase proteins’ mRNA (fibrinogen-gamma and serum amyloid A-3) showed increased mRNA expression over baseline within the first 48 hours and their levels positively correlated with the extent of injury. However, increased severity of injury resulted in a delayed induction of the APR. A similar effect on the gene expression of cytokines (interleukin [IL]-1beta, IL-6, and tumor necrosis factor-alpha) at the fracture site was seen. Serum IL-6 levels increased with increased injury and showed no delay between injury models. CONCLUSIONS:: Greater severity of injury resulted in a delayed induction of the liver’s APR and a diminished expression of cytokines at the fracture site. Serum IL-6 levels were calibrated to the extent of the injury, and changes may represent mechanisms by which the local organ responses to injury are regulated by the injury magnitude.

PMID: 20693926 [PubMed - as supplied by publisher]

Treatment of Complex Elbow Injuries With a Postoperative Custom-Made Progressive Stretching Static Elbow Splint.

J Trauma. 2010 Aug 5;

Authors: Liu HH, Wu K, Chang CH

BACKGROUND:: Complex elbow injuries consist of fractures of one or several of the bony stabilizers of the elbow, including the radial head, proximal ulna, coronoid process, collateral ligaments, and capsular complex. These injuries, if not properly treated, were reported to have a poor prognosis with recurrent instability, stiffness, posttraumatic arthrosis, and pain. This study was conducted to review clinical outcomes after fracture stabilization and ligament repair with a postoperative custom-made progressive stretching (CMPS) elbow splint in the treatment of complex elbow injuries. METHODS:: From December 2001 to October 2006, 14 patients with complex elbow fractures or instability underwent surgery in Far Eastern Memorial Hospital by Chang Chih-Hung, using suture anchors. All patients used our CMPS static elbow splint postoperatively. No hinged elbow external skeletal fixator was necessary. The results were reviewed retrospectively. RESULTS:: The patients were followed up for an average of 14 months. The mean (standard deviation) flexion-extension range of motion (ROM) was 116-degree angle (23-degree angle). The mean Mayo Elbow Performance Score was 92 points; the results were excellent in 10 patients, good in three patients, and fair in one patient. CONCLUSION:: The dilemma in managing complex elbow injuries is that extended immobilization leads to stiffness, but without proper reconstruction of the stabilizer, joint instability recurs. Our surgical protocol included removal of all loose bodies within the joint, stable fixation of fracture fragments if possible, and use of suture anchors to repair medial or lateral ulnar collateral ligaments. CMPS static elbow splints provided both postoperative protection and ROM movement. In our experience, if the stabilizers were reconstructed, hinged elbow external skeletal fixator is usually not necessary, and progressive stretching by CMPS splint can result in good ROM.

PMID: 20693927 [PubMed - as supplied by publisher]

Facial Fractures in the Elderly: A Retrospective Study in a Hospital in Belo Horizonte, Brazil.

J Trauma. 2010 Aug 5;

Authors: Ramos Chrcanovic B, Napier Souza L, Freire-Maia B, Guimarães Abreu MH

BACKGROUND:: An increasing incidence of maxillofacial trauma in the elderly has been noted, as a consequence of increased longevity, resulting in a higher percentage of elderly people in the population. METHODS:: A retrospective study was undertaken to assess facial fractures in elderly presenting during the period 2000 to 2002 in Belo Horizonte, Brazil. The data collected included age, gender, etiology, date of trauma, maxillofacial trauma, anatomic site of fracture, and treatment. The statistical analysis involved evaluation of measures of central tendency and variability and calculation of proportions. RESULTS:: It encountered 165 facial fractures in 122 elderly aged 60 years or older. The majority of fractures were sustained by elderly in the age group 60 years to 69 years. Falls was the major cause of trauma followed by car accidents. The mandible was found to be the most common fractured bone in the facial skeleton, followed by the zygomatic complex. A conservative approach was accomplished in the most of cases. CONCLUSION:: Gender was associated with the presence or absence of fractures and with the etiology. There was no association between age and fractures. No association was found between etiology and age for women and men. The proportion of fractures of the zygomatic arch, mandible body, and parasymphysis treated surgically were statistically higher than the same proportion among the cases of other fractures. The fractures of the nose were more often treated conservatively than other fractures.

PMID: 20693928 [PubMed - as supplied by publisher]

Combination of Guided Osteogenesis With Autologous Platelet-Rich Fibrin Glue and Mesenchymal Stem Cell for Mandibular Reconstruction.

J Trauma. 2010 Jul 20;

Authors: Liao HT, Chen CT, Chen CH, Chen JP, Tsai JC

BACKGROUND:: This study examined whether a combination of autologous platelet-rich fibrin glue (PRFG) with mesenchymal stem cells (MSCs) and MEDPOR as guided tissue regeneration (GTR) could act as an osteogenic substitute and whether this treatment yields faster new bone formation than MEDPOR alone or PRFG plus MSC. MATERIAL:: MSCs were harvested and isolated from the bone marrow of dog ilium. Full-thickness bony defects (1.5 x 1.5 cm) were created in the bilateral mandible angles of the dog. Treatments for bone defect in each group were as follows: group I (n = 4), MEDPOR sheet as GTR and autologous PRFG/MSCs admixtures; group II (n = 4), autologous PRFG/MSCs admixtures; group III (n = 4), MEDPOR sheet as GTR; and group IV (n = 4), control (empty defect). The percentage of new bone regeneration in computerized tomography at 2 months and 4 months was calculated by Analyze version 7.0 software. The mandibles were harvested from all specimens at 4 months, and the grafted sites were evaluated by gross, histologic, and X-ray examination. RESULTS:: By radiographic analysis at 16 weeks posttransplantation, it was shown that an average of 72.8% +/- 8.02% new bone formation in group I, 53.34% +/- 6.87% in group II, 26.58% +/- 6.41% in group III, and 15.14% +/- 2.37% in group IV. Histologic examination revealed that the defect was repaired by typical bone tissue in groups I and II, whereas only minimal bone formation with fibrous connection was observed in the groups III and IV group. Besides, muscle incarceration was found in groups II and IV without MEDPOR as GTR. CONCLUSION:: Autologous PRFG plus osteoinduced MSCs have good potential for bone regeneration. In combination with MEDPOR as GTR, bone regeneration is enhanced by preventing soft tissue ingrowth hindering bone regeneration.

PMID: 20664370 [PubMed - as supplied by publisher]

Psychological Distress After Severe Trauma: A Prospective 1-Year Follow-Up Study of a Trauma Intensive Care Unit Population.

J Trauma. 2010 Jul 20;

Authors: Tøien K, Myhren H, Bredal IS, Skogstad L, Sandvik L, Ekeberg O

BACKGROUND:: The aim of the study was to investigate the level of psychologic distress after trauma and intensive care unit (ICU) stay, memory from the ICU, and predictors for psychologic distress at 12 months. METHODS:: Prospective single center study in a trauma referral center for Eastern and Southern Norway. Participants were 150 trauma patients treated in an ICU for >24 hours. Assessments were performed after discharge, at 3 months, and at 12 months using the Impact of Event Scale, Hospital Anxiety and Depression Scale, ICU memory tool, and Life Orientation Test-Revised. RESULTS:: At baseline, the mean Impact of Event scores were 22.7 decreasing to 18.4 at 12 months (p = 0.039). At 1-year follow-up, mean anxiety scores were 5.5 (95% confidence interval [CI]: 4.6-6.4) and depression scores 3.8 (95% CI: 3.1-4.5). Factual memories from ICU (odds ratio [OR] 6.58, [95% CI: 2.01-21.52], p = 0.002), low educational level (OR 0.29, [95% CI: 0.10-0.86] p = 0.025), not having care of children (OR 0.14, [95% CI: 0.04-0.47] p = 0.002), and female gender (OR 2.95, [95% CI: 1.04-8.34] p = 0.042) predicted posttraumatic stress symptoms at 12 months. Anxiety at 12 months was predicted only by pessimism (OR 0.83, [95% CI: 0.75-0.93] p = 0.001). Depression at 12 months was predicted by being out of work before the injury (OR 3.64, [95% CI: 1.11-11.94] p = 0.033) and pessimism (OR 0.83, [95% CI: 0.73-0.93] p = 0.002). CONCLUSIONS:: Many patients suffer from posttraumatic stress symptoms, anxiety, and depression after trauma and ICU stay. The strongest predictors of psychologic distress 12 months after discharge were having factual memories from the ICU stay, being pessimistic, and being out of work before the injury.

PMID: 20664371 [PubMed - as supplied by publisher]

Mortality Decreases by Implementing a Level I Trauma Center in a Dutch Hospital.

J Trauma. 2010 Jul 20;

Authors: Spijkers AT, Meylaerts SA, Leenen LP

BACKGROUND:: Trauma centers are designed to improve survival and outcome of the injured patient. The implementation of these centers in the United States has shown to reduce the number of preventable deaths from serious injuries. This study compares outcomes of trauma patients during two separate time periods in a Dutch Level I trauma center, before and after obtaining the trauma center status. METHODS:: Prospectively, patient data were collected from an automated database in the years 1996 through 1998 (period 1) and 2003 through 2005 (period 2) in the University Medical Center in Utrecht. The patients included and analyzed were adult trauma victims admitted to our trauma center. RESULTS:: A total of 4,069 patients in total were included, 2,348 in period 1 and 1,721 in period 2. Mean age was 45.9 years and 48.1 years, respectively (p < 0.001). Men comprised 62% and 64%, respectively (not significant). After obtaining the trauma center status, more severely injured patients were admitted (mean Injury Severity Score was 9.6 in group 1 vs. 12.4 in group 2, p < 0.001). Adjusted for age and injury severity, the inhospital mortality was lower (odds ratio: 0.606, p < 0.05) in the second group. Adjusted for age, Injury Severity Score, and mortality, the hospital stay was shorter (p < 0.001) in the second group. Fewer patients were admitted to the intensive care unit (p < 0.001), but the length of stay appeared longer (p = 0.055) after trauma center designation. CONCLUSION:: This study implies that the implementation of a trauma center reduces mortality, shortens hospital stay, and decreases the number of intensive care unit admittances in Utrecht, the Netherlands.

PMID: 20664372 [PubMed - as supplied by publisher]

The Anatomic Sites of Disruption of the Mucus Layer Directly Correlate With Areas of Trauma/Hemorrhagic Shock-Induced Gut Injury.

J Trauma. 2010 Jul 20;

Authors: Lu Q, Xu DZ, Sharpe S, Doucet D, Pisarenko V, Lee M, Deitch EA

BACKGROUND:: The intestinal mucus layer is an important but understudied component of the intestinal barrier. Consequently, we tested the hypothesis that the anatomic sites of loss of the mucus layer would directly correlate with sites of intestinal villous injury after trauma-hemorrhagic shock (T/HS) and may, therefore, serve as loci of gut barrier failure. Consequently, to investigate this hypothesis, we used Carnoy’s fixative solution to prepare fixed tissue blocks where both the gut morphology and the mucus layer could be assessed on the same tissues slides. METHODS:: Male Sprague-Dawley rats were subjected to a laparotomy (trauma) and 90 minutes of sham shock (T/SS) or 35 mm Hg x 90 minutes of actual shock (T/HS). Three hours after resuscitation, the rats were killed, and samples of the terminal ileum were processed by fixation in Carnoy’s solution. Gut injury was evaluated by determining the percentage of villi injured. The status of the intestinal mucus layer was quantified by determining the percentage of the villi covered by the mucus and the mucus thickness. RESULTS:: Histologic analysis of gut injury showed that the incidence of gut injury was approximately 10-fold higher in the T/HS than the T/SS rats (T/SS = 2.5% +/- 0.5% vs. T/HS = 22.4% +/- 0.5% of injured villi; p < 0.01). The T/SS rats had 98% of their ileal mucosa covered with a mucus layer, and this was decreased after T/HS to 63% +/- 3% (T/HS vs. T/SS; p < 0.001). Furthermore, loss of the mucus layer was found to directly correlate with villous injury with a regression coefficient of r = 0.94 (p < 0.001). CONCLUSION:: This study shows that T/HS significantly reduces the intestinal mucus layer and causes villous injury and that a correlation exists between specific anatomic sites of T/HS-induced loss of the mucus layer and gut injury.

PMID: 20664373 [PubMed - as supplied by publisher]

Comparison of Plates versus Intramedullary Nails for Fixation of Displaced Midshaft Clavicular Fractures.

J Trauma. 2010 Jul 20;

Authors: Liu HH, Chang CH, Chia WT, Chen CH, Tarng YW, Wong CY

BACKGROUND:: We compare the use of plate and screws versus intramedullary nails in the operative management of patients with displaced midclavicular fractures. METHODS:: Between March 2006 and June 2007, we performed a retrospective comparison of a demographically balanced sample of 110 patients (aged 16-65 years) who had received either plates or nails for completely displaced midshaft clavicular fractures. RESULTS:: We selected 59 plate-fixed and 51 nail-fixed patients. There was no significant difference between the groups with respect to age, gender, height, dominant arm, fracture angulation, fracture shortening, total fracture displacement, or mechanism of injury. Outcomes were significantly higher in the plate group compared with the nail group for the length of hospital stay (4.6 days +/- 2.1 days vs. 5.9 days +/- 2.6 days, p = 0.006), operative blood loss (67.5 mL +/- 36.2 mL vs. 127.9 mL +/- 48.8 mL, p < 0.0001), and size of surgical wound (11.9 cm +/- 4.4 cm vs. 22.3 cm +/- 4.5 cm, p < 0.0001). There was no significant difference in operative time, time to union, restoration of mobility (forward flexion, abduction, external rotation, and internal rotation), number of nonunions, number of malunions, infection, need for hardware removal, early mechanical failure, time to return to work, and Constant Shoulder and Disabilities of the Arm, Shoulder, and Hand functional scores. CONCLUSION:: Our results demonstrate no significant differences in functional outcome and nonunion rates between nails and plates fixation for displaced midshaft clavicular fractures.

PMID: 20664374 [PubMed - as supplied by publisher]

Upper Extremity Injuries in Restrained Front-Seat Occupants After Motor Vehicle Crashes.

J Trauma. 2010 Jul 20;

Authors: Chong M, Broome G, Mahadeva D, Wang S

BACKGROUND:: Prior studies identified that crash severity (delta V), occupant position, and restraint systems as reliable predictors of crash injuries to lower extremity, but very little have been written on the subject of upper extremity. METHOD:: This is a retrospective analysis of Crash Injury Research and Engineering Network database in a Level I trauma center focusing on severe upper extremity injuries. The aim was to investigate the relationship between types of the “crash” and “occupant” factors on the pattern and severity of upper extremity injuries after a frontal collision. RESULTS:: Majority of the injuries were soft tissues nature (67.6% soft tissue vs. 32.4% fractures). There were 144 fractures to the upper extremity, 12.5% were “open” fractures; 74.5% of the fractures sustained in the upper extremity occurred distal to the elbow, whereas soft tissue injuries predominated in the humerus. Also noted that occupants who sustained fractures were on average 6.7 kg lighter than those who sustained soft tissue injuries (84.5 kg soft tissue vs. 77.86 kg fracture, p < 0.05). We postulate that there may be a protective effect of “soft tissue cushion” toward protecting the content from serious harm, in this case the humerus. Instrument panel, airbag, and seat belts were the main injury source. After adjusting for other modifiers, occupants who sustained fractures had a significantly higher Injury Severity Scores (mean Injury Severity Scores 21.88 vs. 17.68, p < 0.05). This implied that those who sustained fractures to upper extremity most likely had associated significant injuries to other body region, necessitating further medical attention. CONCLUSION:: Further improvement in vehicle safety performance in the form of “depowered” airbag and efficient energy absorbing material within the vehicle interior is warranted.

PMID: 20664375 [PubMed - as supplied by publisher]

Investigation of Head Response to Blast Loading.

J Trauma. 2010 Jul 20;

Authors: Lockhart P, Cronin D, Williams K, Ouellet S

BACKGROUND:: Head injury resulting from blast loading, specifically mild traumatic brain injury, has been identified as a possible and important blast-related injury for soldiers in modern conflict zones. A study was undertaken to evaluate head response to blast loading scenarios using an explicit finite element numerical model and to comment on the potential for head injury. METHODS:: The blast loading and simplified human body numerical models were validated using impulse, peak acceleration and the Head Injury Criterion from experimental blast test data. A study was then undertaken to evaluate head response at varying distances and orientations from the explosive. RESULTS:: The accelerations and injury metrics for the head increased with decreasing distance to the explosive, as expected, but were also significant at intermediate distances from the explosive for larger charge sizes and intermediate heights of burst. Varying lateral position with constant standoff did not have a significant effect on the head kinematic response. CONCLUSIONS:: The head injury criteria considered were exceeded in close proximity to the explosive (<35 charge radii) and depended on the height of burst for the range of charge sizes considered. The injury criteria were also exceeded at intermediate distances for larger charge sizes because of the influence of the mach stem. Although the injury criteria used in this study are typically applied to longer duration events, and may not be applicable for shorter duration blast loading, aggressive loading is predicted at small standoff distances and confirmed by the resulting head kinematics.

PMID: 20664376 [PubMed - as supplied by publisher]

Effects of Increased Bone Formation on Fracture Healing in Mice.

J Trauma. 2010 Jul 20;

Authors: Beil FT, Barvencik F, Gebauer M, Beil B, Pogoda P, Rueger JM, Ignatius A, Schinke T, Amling M

BACKGROUND:: Fracture healing is a complex and sequential process. One important step in fracture healing is callus remodeling. As we could previously show, an increase of osteoclast bone resorption as a result of estrogen deficiency impairs the fracture healing process. Therefore, the aim of our study was to analyze whether an increased bone formation, as the counterpart of bone resorption in callus remodeling, would accelerate the fracture healing process. METHODS:: Standardized femoral fractures were produced in 10-week-old control, leptin-deficient (ob/ob), and leptin receptor-deficient (db/db) mice using a guillotine-like fracture device. Accordingly, the fractures were intramedullary stabilized. The ob/ob and db/db mice are known to have a twofold increase in bone formation in comparison with normal wildtype mice. At different stages of fracture healing, contact X-ray, histologic, and biomechanical analyses were performed. RESULTS:: We observed that a twofold increase in bone formation leads to an accelerated periosteal callus formation followed by callus remodeling. As compared with the control group, chondrocytes area was increased, and the subsequent mineralization appeared earlier. In the late stage of fracture healing, the ob/ob and db/db mice showed a thinner but increased mineralized cortex. Biomechanical testing confirmed the beneficial effects of an increased bone formation on restoration of biomechanical competence. CONCLUSION:: These results indicate that bone formation is of major importance in all stages of fracture healing. A twofold increase in bone formation is able to significantly accelerate the fracture healing process of long bones at least in mice. Therefore, an increase in bone formation would be a possible pharmaceutical target to enhance fracture healing.

PMID: 20664377 [PubMed - as supplied by publisher]

The Effects of Magnetic Resonance Imaging on Surgical Staples: An Experimental Analysis.

J Trauma. 2010 Jul 20;

Authors: Gayton JC, Sensiba P, Imbrogno BF, Venkatarayappa I, Tsatalis J, Prayson MJ

BACKGROUND:: Surgical staples are commonplace in repairing surgical incisions. Staples allow for expeditious closure and removal compared with suture materials. However, there are clinical concerns when obtaining a magnetic resonance imaging (MRI) scan with staples present. This study examined two issues related to MRI scanning in the presence of surgical staples: skin surface temperature change and staple displacement. METHODS:: Thirty pig feet had 3-cm surgical incisions repaired with five surgical staples. Once placed, each skin staple position was marked for later referencing. A surface temperature laser device recorded prescan skin surface temperature. A 35-minute MRI scan was performed with a 1.5-Tesla magnet and standard knee coil for each pig foot. Immediately afterward, the skin surface temperature and displacement measurements were recorded. The paired t test was used to analyze temperature change from prescan to postscan. RESULTS:: The prescan mean temperature was 16.45 degrees C (standard deviation: 0.70 degrees C), and the range was 14.60 degrees C to 18.20 degrees C. After scanning, the mean temperature was 16.02 degrees C (standard deviation: 0.63 degrees C), and the range was 15.00 degrees C to 17.60 degrees C. The decrease of 0.43 degrees C in skin surface temperature was statistically significant (p = 0.001). No change in staple position was measurable or evident by visual inspection for any of the pig feet. CONCLUSION:: This study found no increase in skin surface temperature or displacement of staple position after a standard extremity MRI scan. Based on our findings, MRI scanning in the presence of stainless steel surgical staples seems safe.

PMID: 20664378 [PubMed - as supplied by publisher]

Evaluation of the Effectiveness of Systematized Training of Advanced Trauma Life Support Protocol in the Interpretation of Cervical Spine and Chest Radiographs in Three Different Emergency Services.

J Trauma. 2010 Jul 20;

Authors: Job PM, Von Bahten LC, de Oliveira-Junior N

INTRODUCTION:: Most Brazilian hospitals have no medical radiologists for emergencies. The radiologic evaluation is provided by doctors with heterogeneous generalist training. The objective is to demonstrate the need for systematization in the care of trauma in the interpretation of cervical spine and chest radiographs. Is it possible that, through a continuing education program, generalist doctors could be trained in the evaluation of these radiographs? MATERIALS AND METHODS:: Twenty-five doctors of various specialties were evaluated in the mid region of Santa Catarina Stage, in three stages. Initially, the doctors evaluated seven cervical spine radiographs and seven chest radiographs (stage I). After this evaluation (without knowing the results of the examinations), the doctors received advanced trauma life support protocol training for the interpretation of cervical spine and chest radiographs, through an exhibition class (stage II). Three weeks later, the same doctors were evaluated again, interpreting the same radiographs. RESULTS:: The mean percentage of correct answers was 60.73% in the first interpretation of cervical radiographs and 65.25% for the chest radiographs. None of the participant had reached 100%. In stage III, the average success rates in cervical spine and chest radiographs were 86.95% and 87.53%, respectively, an improvement of 21.72% and 26.18% (p < 0.001). During evaluation in the stage III, seven doctors obtained 100% success in the evaluation of cervical spine radiographs and two doctors achieved 100% success in the evaluation of chest radiographs. CONCLUSION:: The systematized training, through the advanced trauma life support protocol, significantly increased the success rate of the evaluation of cervical spine and chest radiographs.

PMID: 20664379 [PubMed - as supplied by publisher]

Triage hyperglycemia as a prognostic indicator of major trauma.

J Trauma. 2010 Jul;69(1):41-5

Authors: Paladino L, Subramanian RA, Nabors S, Bhardwaj S, Sinert R

BACKGROUND: To test the diagnostic utility of the triage serum glucose in differentiating major from minor injuries. METHODS: Prospective database at Kings County Hospital, a Level I trauma center, from August 2005 to August 2008. Inclusion criteria: trauma patients 13+ years. Exclusion criteria: diabetes or obvious life-threatening injuries requiring immediate surgery, isolated head trauma, or transferred or dead on arrival. We recorded age, sex, injury mechanism, base deficit (BD), lactate (LAC), and serum glucose and calculated Injury Severity Scores. Major injury: a change in hematocrit >10, blood transfused within 24 hours, or Injury Severity Score >15. Data were reported as mean differences (95% confidence interval [CI]). Groups were compared by Student’s t test; receiver operator characteristic curves were compared by Wilcoxon test (two-tailed, [alpha] = 0.05). RESULTS: One thousand six hundred forty-nine patients with an average age of 35.5 years (13-95 years), 79.5% male, and 50% blunt trauma were studied. Patients with major (n = 278) compared with minor injury (n = 1371) had significantly (p < 0.0001) lower BD and higher LACs (p < 0.0001). Major injury patients had significantly (p < 0.0001) higher serum glucose levels (8.33 mMol/L, 95% CI: 7.94-8.69 mMol/L) compared with patients with minor injuries (6.49 mMol/L, 95% CI: 6.39-6.66 mMol/L). Areas under the curve for glucose (0.73, 95% CI: 0.70-0.76) are similar to BD (0.72, 95% CI: 0.68-0.76) and LAC (0.71, 95% CI: 0.67-0.75). CONCLUSIONS: Serum glucose was as discriminating as BD or LAC in differentiating minor from major injury. An initial glucose >/=11.1 mMol/L had a low sensitivity (15%) but a high specificity (94%) for major injury.

PMID: 20665990 [PubMed - in process]

The value of trauma center care.

J Trauma. 2010 Jul;69(1):1-10

Authors: Mackenzie EJ, Weir S, Rivara FP, Jurkovich GJ, Nathens AB, Wang W, Scharfstein DO, Salkever DS

BACKGROUND:: The cost of trauma center care is high, raising questions about the value of a regionalized approach to trauma care. To address these concerns, we estimate 1-year and lifetime treatment costs and measure the cost-effectiveness of treatment at a Level I trauma center (TC) compared with a nontrauma center hospital (NTC). METHODS:: Estimates of cost-effectiveness were derived using data on 5,043 major trauma patients enrolled in the National Study on Costs and Outcomes of Trauma, a prospective cohort study of severely injured adult patients cared for in 69 hospitals in 14 states. Data on costs were derived from multiple sources including claims data from the Centers for Medicare and Medicaid Services, UB92 hospital bills, and patient interviews. Cost-effectiveness was estimated as the ratio of the difference in costs (for treatment at a TC vs. NTC) divided by the difference in life years gained (and lives saved). We also measured cost-effectiveness per quality-adjusted life year gained where quality of life was measured using the SF-6D. We used inverse probability of treatment weighting to adjust for observable differences between patients treated at TCs and NTCs. RESULTS:: The added cost for treatment at a TC versus NTC was $36,319 per life-year gained ($790,931 per life saved) and $36,961 per quality-adjusted life years gained. Cost-effectiveness was more favorable for patients with injuries of higher versus lower severity and for younger versus older patients. CONCLUSIONS:: Our findings provide evidence that regionalization of trauma care is not only effective but also it is cost-effective.

PMID: 20622572 [PubMed - in process]

A population-based analysis of injury-related deaths and access to trauma care in rural-remote northwest british columbia.

J Trauma. 2010 Jul;69(1):11-9

Authors: Simons R, Brasher P, Taulu T, Lakha N, Molnar N, Caron N, Schuurman N, Evans D, Hameed M

BACKGROUND: Injury rates and injury mortality rates are generally higher in rural and remote communities compared with urban jurisdictions as has been shown to be the case in the rural-remote area of Northwest (NW) British Columbia (BC). The purpose of study was to identify: (1) the place and timing of death following injury in NW BC, (2) access to and quality of local trauma services, and (3) opportunities to improve trauma outcomes. METHODS: Quantitative data from demographic and geographic databases, the BC Trauma Registry, Hospital discharge abstract database, and the BC Coroner’s Office, along with qualitative data from chart reviews of selected major trauma cases, and interviews with front-line trauma care providers were collated and analyzed for patients sustaining injury in NW BC from April 2001 to March 2006. RESULTS: The majority of trauma deaths (82%) in NW BC occur prehospital. Patients arriving alive to NW hospitals have low hospital mortality (1.0%), and patients transferring from NW BC to tertiary centers have better outcomes than matched patients achieving direct entry into the tertiary center by way of geographic proximity. Access to local trauma services was compromised by: incident discovery, limited phone service (land lines/cell), incomplete 911 emergency medical services system access, geographical and climate challenges compounded by limited transportation options, airport capabilities and paramedic training level, dysfunctional hospital no-refusal policies, lack of a hospital destination policies, and lack of system leadership and coordination. CONCLUSION: Improving trauma outcomes in this rural-remote jurisdiction requires a systems approach to address root causes of delays in access to care, focusing on improved access to emergency medical services, hospital bypass and destination protocols, improved transportation options, advanced life support transfer capability, and designated, coordinated local trauma services.

PMID: 20622573 [PubMed - in process]

Socioeconomic disparities in infant mortality after nonaccidental trauma: a multicenter study.

J Trauma. 2010 Jul;69(1):20-5

Authors: Rangel EL, Burd RS, Falcone RA,

BACKGROUND: While disparities in abuse-related mortality between minority and white infants have been reported, the influence of socioeconomic status on outcome has not been evaluated. The goal of this study was to determine the impact of socioeconomic status and race on outcomes for abused infants using multiinstitutional data. METHODS: Data on infants (<12 months old) with abusive injuries over a 5-year period were obtained from nine U.S. pediatric trauma centers. Demographics, insurance status, Injury Severity Scores, Glasgow Coma Scale scores, median household income and outcomes were recorded. Logistic regression was used to evaluate the impact of race, income and insurance status on mortality. RESULTS: There were 867 patients identified with a mortality of 8.8%. Patients without private insurance had a 3.8 times greater odds (give 95% confidence interval) of dying. Those in the lower three quartiles of income also had a higher odds of death even after controlling for race, injury severity, and Glasgow Coma Scale. Although African American infants had a higher overall mortality than whites (11.2% vs. 7.8%, p = 0.14), race was not an independent predictor of mortality (p = 0.98). CONCLUSIONS: There are significant differences in mortality among abused infants associated with insurance status and income even after controlling for injury severity. These associations show a need to better understand and address socioeconomic variations in outcome.

PMID: 20622574 [PubMed - in process]

The years after an injury: long-term consequences of injury on self-rated health.

J Trauma. 2010 Jul;69(1):26-30

Authors: Toft AM, Møller H, Laursen B

BACKGROUND:: Knowledge on long-term consequences of injury on health is vital when injury prevention policies and emergency care are planned. However, few studies have described lasting health consequences associated with injury. This study analyses the relationship between injury and self-assessed health up to 10 years after the injury. METHODS:: The study makes use of a public health research database linking health interview survey information with data from national health registries. Using this database, the health of a group of Danish patients with injury events during 1995 to 2005 was compared with a noninjured group up to 10 years after the injury. The association between self-assessed general health and self-reported depression and injury-related factors were estimated using logistic regression analysis. RESULTS:: When patients with injuries compared with noninjured, the odds ratios of poor self-assessed general health and self-reported depression were 1.83 (confidence level, 1.53-2.19) and 1.33 (confidence level, 1.14-1.54), respectively. Although decreasing with time, the effect of injury on general health was significant up to 10 years after the injury. The injury type was significantly related to health, and in particular, patients with back, head, and neck injuries reporting poor general health. No gender differences were found in the effect of injury on self-assessed health. CONCLUSIONS:: Injuries have lasting consequences for physical and mental health up to 10 years after the injury event, in particular, for people sustaining head, neck, and back injuries. Sustaining an injury has the same effect on general health in men and women.

PMID: 20622575 [PubMed - in process]

1H-NMR-Based Metabolic Signatures of Clinical Outcomes in Trauma Patients-Beyond Lactate and Base Deficit.

J Trauma. 2010 Jul;69(1):31-40

Authors: Cohen MJ, Serkova NJ, Wiener-Kronish J, Pittet JF, Niemann CU

The determination of reliable biomarkers capable to predict clinical outcome of a trauma patient remains essential toward better therapeutic management of the patient in the intensive care unit. Assessment of global metabolic profiling using quantitative nuclear magnetic resonance (NMR)-based metabolomics offers an attractive modern methodology for fast and comprehensive determination of multiple circulating metabolites and for establishing metabolic phenotype of survivors versus nonsurvivors. Multivariate data analysis on 43 quantitative metabolic parameters identified three lipid metabolites, triacylglycerol, glycerol heads of phospholipids, and monounsaturated fatty acids, as being the most discriminative markers to separate survivors versus nonsurvivors at the time of admission. Glucose and glutamate were intermediate predictors, followed by lactate and hydroxybutyrate as two low-weight predictors. Ultimately, cellular and subcellular failure in nonsurviving trauma patients results in multiple systemic biochemical effects and in changes in circulating metabolites in the blood that are characteristic for decreased lipid synthesis and urea cycle activity in the liver, and for increased hyperglycemia, lactic, and ketoacidosis.

PMID: 20622576 [PubMed - in process]

Damage control resuscitation in combination with damage control laparotomy: a survival advantage.

J Trauma. 2010 Jul;69(1):46-52

Authors: Duchesne JC, Kimonis K, Marr AB, Rennie KV, Wahl G, Wells JE, Islam TM, Meade P, Stuke L, Barbeau JM, Hunt JP, Baker CC, McSwain NE

BACKGROUND:: Damage control laparotomy (DCL) improves outcomes when used in patients with severe hemorrhage. Correction of coagulopathy with close ratio resuscitation while limiting crystalloid forms a new methodology known as damage control resuscitation (DCR). We hypothesize a survival advantage in DCL patients managed with DCR when compared with DCL patients managed with conventional resuscitation efforts (CRE). METHODS:: This study is a 4-year retrospective study of all DCL patients who required >/=10 units of packed red blood cells (PRBC) during surgery. A 2-year period after institution of DCR (DCL and DCR) was compared with the preceding 2 years (DCL and CRE). Univariate analysis of continuous data was done with Student’s t test followed by multiple logistic regression. RESULTS:: One Hundred twenty-four and 72 patients were managed during the DCL and CRE and DCL and DCR time periods, respectively. Baseline patient characteristics of age, Injury Severity Score, % penetrating, blood pressure, hemoglobin, base deficit, and INR were similar between groups. There was no difference in quantity of intraoperative PRBC utilization between DCL and CRE and DCL and DCR study periods: 21.7 units versus 25.5 units (p = 0.53); however, when compared with DCL and CRE group, patients in the DCL and DCR group received less intraoperative crystalloids, 4.7 L versus 14.2 L (p = 0.009); more fresh frozen plasma (FFP), 18.2 versus 6.4 (p = 0.002); a closer FFP to PRBC ratio, 1 to 1.2 versus 1 to 4.2 (p = 0.002); platelets to PRBC ratio, 1:2.3 versus 1:5.9 (0.002); shorter mean trauma intensive care unit length of stay, 11 days versus 20 days (p = 0.01); and greater 30-day survival, 73.6% versus 54.8% (p < 0.009). The addition of DCR to DCL conveyed a survival benefit (odds ratio; 95% confidence interval: 0.19 (0.05-0.33), p = 0.005). CONCLUSION:: This is the first civilian study that analyses the impact of DCR in patients managed with DCL. During the DCL and DCR study period more PRBC, FFP, and platelets with less crystalloid solution was used intraoperatively. DCL and DCR were associated with a survival advantage and shorter trauma intensive care unit length of stay in patients with severe hemorrhage when compared with DCL and CRE.

PMID: 20622577 [PubMed - in process]

Damage control laparotomy: a vital tool once overused.

J Trauma. 2010 Jul;69(1):53-9

Authors: Higa G, Friese R, O’Keeffe T, Wynne J, Bowlby P, Ziemba M, Latifi R, Kulvatunyou N, Rhee P

BACKGROUND: Trauma surgery is in constant evolution as is the use of damage control laparotomy (DCL). The purpose of this study was to report the change in usage of DCL over time and its effect on outcome. METHODS: Trauma patients requiring laparotomies during a 3-year (2006-2008) period were reviewed. DCL was defined as laparotomy when fascia was not closed at the first operation. RESULTS: There were 14,534 trauma patients evaluated, and 843 laparotomies were performed on 532 patients during the study period. The number of patients requiring open laparotomies slightly increased while the demographics and Injury Severity Score were similar during the study period. The number of patient requiring DCL significantly decreased from 36.3% (53 of 146) in 2006 to 8.8% (15 of 170) in 2008 (p < 0.001). During this same time period, the mortality rate for patients requiring open laparotomy significantly decreased from 21.9% in 2006 to 12.9% in 2008 (p = 0.05). The decreased use of DCL resulted in a 33.3% reduction in the number of laparotomies performed. The decrease in average costs and charges is projected to result in savings of $2.2 million and $5.8 million, respectively. CONCLUSIONS: The use of DCL was significantly decreased by 78% during the study with significantly improved outcome. The improved outcome and decreased resource utilization can reduce health care costs and charges. Although DCL may be a vital aspect of trauma surgery, it can be used more selectively with improved outcome.

PMID: 20622578 [PubMed - in process]

Prolonged prothrombin time after recombinant activated factor VII therapy in critically bleeding trauma patients is associated with adverse outcomes.

J Trauma. 2010 Jul;69(1):60-9

Authors: McMullin NR, Wade CE, Holcomb JB, Nielsen TG, Rossaint R, Riou B, Rizoli SB, Kluger Y, Choong PI, Warren B, Tortella BJ, Boffard KD,

BACKGROUND: In trauma patients with significant hemorrhage, it is hypothesized that failure to normalize prothrombin time (PT) after recombinant activated factor VII (rFVIIa) treatment predicts poor clinical outcomes and potentially indicates a need for additional therapeutic interventions. METHODS: To assess the value of PT to predict outcomes after rFVIIa or placebo therapy, we performed a post hoc analysis of data from 169 severely injured, critically bleeding trauma patients who had 1-hour postdose PT measurements from two randomized clinical trials. Baseline characteristics and outcome parameters were compared between subjects with 1-hour postdose PT >or=18 seconds and PT <18 seconds. RESULTS: In rFVIIa-treated subjects, prolonged postdose PT values >or=18 seconds were associated with significantly higher 24-hour mortality (60% vs. 3%; p < 0.001) and 30-day mortality, increased incidence of massive transfusion, and fewer intensive care unit-free days compared with postdose PT values <18 seconds. Recombinant rFVIIa-treated subjects with postdose PT >or=18 seconds had significantly lower baseline hemoglobin levels, fibrinogen levels, and platelet counts than subjects with postdose PT values <18 seconds even though they received similar amounts of blood products before rFVIIa dosing. Placebo-treated subjects with postdose PT >or=18 seconds had significantly increased incidence of massive transfusion, significantly decreased intensive care unit-free days, and significantly lower levels of fibrinogen and platelets at baseline compared with subjects with postdose PT values <18 seconds. CONCLUSIONS: The presence of prolonged PT after rFVIIa or placebo therapy was associated with poor clinical outcomes. Because subjects with postdosing PT >or=18 seconds had low levels of hemoglobin, fibrinogen, and platelets, this group may benefit from additional blood component therapy.

PMID: 20622579 [PubMed - in process]

More operations, more deaths? Relationship between operative intervention rates and risk-adjusted mortality at trauma centers.

J Trauma. 2010 Jul;69(1):70-7

Authors: Shafi S, Parks J, Ahn C, Gentilello LM, Nathens AB

INTRODUCTION:: The Trauma Quality Improvement Project has demonstrated significant variations in risk-adjusted mortality rates across the designated trauma centers. It is not known whether the outcome differences are related to provider-level clinical decision making. We hypothesized that centers with good outcomes undertake critical operative interventions aggressively, thereby avoiding complications and deaths. METHODS:: The previously validated Trauma Quality Improvement Project risk-adjustment algorithm was used to measure observed-to-expected mortality rates (O/E with 90% confidence intervals [CI]) for 152 Level I and II trauma centers participating in the National Trauma Data Bank (version 7.0). Adult patients (>/=16 years) with at least one severe injury (Abbreviated Injury Scale score >/=3) were included (N = 135,654). Operative intervention rates for solid organ injuries (spleen, liver, and kidney) were compared between the centers classified as high mortality (O/E with CI > 1, n = 35 centers) versus low mortality (O/E with CI < 1, n = 37 centers) using nonparametric tests. RESULTS:: Low- and high-mortality trauma centers were similar in designation level, hospital and intensive care unit beds, teaching status, and number of trauma, orthopedic, and neurosurgeons. Despite a similar incidence and severity of solid organ injuries, low-mortality centers were less likely to undertake operative interventions. CONCLUSION:: Trauma centers with higher risk-adjusted mortality rates are more likely to undertake operative interventions for solid organ injuries. Hence, there is a need to focus quality improvement efforts on medical decision-making and perioperative processes of care.

PMID: 20622580 [PubMed - in process]

Intra-abdominal pressure and the morbidly obese patients: the effect of body mass index.

J Trauma. 2010 Jul;69(1):78-83

Authors: Wilson A, Longhi J, Goldman C, McNatt S

BACKGROUND:: Abdominal compartment syndrome and intra-abdominal hypertension cause morbidity and mortality. Body mass index (BMI) may affect intra-abdominal pressure (IAP). Knowledge of the baseline IAP in the obese and the effect of BMI are not clearly defined. METHODS:: IAPs were measured in 37 morbidly obese patients undergoing elective gastric bypass. Measurements were obtained via bladder pressure using a standard technique. IAP was measured after intubation (P1) and postoperatively after extubation (P2). Data collected included age, gender, BMI, previous surgeries, comorbidities, IAP, and laparoscopic versus open procedure. RESULTS:: Mean BMI was 47.7 kg/m (range, 37-71.8 kg/m), and mean age was 45 years (range, 32-64 years). P1 mean was 9.4 mm Hg +/- 0.6 mm Hg, and P2 mean was 10.0 mm Hg +/- 0.6 mm Hg. Laparoscopic versus open procedure was unrelated to postoperative IAP. Previous surgeries and comorbidities were unrelated to IAP. P1 increased as BMI increased. For each unit increase of BMI, IAP increased by 0.14 mm Hg +/- 0.07 mm Hg (p = 0.05). Higher BMI and age were independent predictors of increased P2, with IAP increased 0.23 mm Hg +/- 0.07 mm Hg for each unit BMI (p = 0.0015) and 0.20 mm Hg +/- 0.06 mm Hg for each year increase in age (p = 0.0014). CONCLUSIONS:: Baseline IAP in the obese is greater than normal weight population (0-6 mm Hg), but not in range of intra-abdominal hypertension (>12 mm Hg). Postoperative status is unrelated to IAP. Elevated BMI does impact IAP, but the incremental value is small. Markedly increased IAP should not be attributed solely to elevated BMI and should be recognized as a pathologic condition.

PMID: 20622581 [PubMed - in process]

A diagnostic delay of 5 hours increases the risk of death after blunt hollow viscus injury.

J Trauma. 2010 Jul;69(1):84-7

Authors: Malinoski DJ, Patel MS, Yakar DO, Green D, Qureshi F, Inaba K, Brown CV, Salim A

BACKGROUND: Hollow viscus injuries (HVI) are uncommon after blunt trauma, and accomplishing a timely diagnosis can be difficult. Time to operative intervention has been implicated as a risk factor for mortality, but reports are conflicting. METHODS: All blunt trauma admissions to an academic level 1 trauma center from January 1992 to September 2005 were retrospectively reviewed. Patients with a diagnosis of blunt HVI were included. Patients who died within 24 hours were excluded. Data regarding patient demographics, injuries, time from admission until laparotomy, length of stay, and mortality were recorded, and a multivariate analysis to determine independent risk factors for mortality was carried out. A p < 0.05 was considered significant. RESULTS: Of 35,033 blunt trauma admissions, there were 195 (0.6%) HVI patients with the following characteristics (data expressed as mean +/- 1 SD): mean age of 35 years +/- 16 years, Injury Severity Score of 17 +/- 11, time from admission to laparotomy of 5.9 hours +/- 5.8 hours, operative blood loss of 1500 mL +/- 1800 mL, and length of stay of 19 days +/- 23 days. Twelve percent presented with a systolic pressure <90 mm Hg and 9% died. Independent risk factors for mortality were age (odds ratio [OR] = 1.04, p = 0.005), Abdominal Abbreviated Injury Score (OR = 2.5, p = 0.011), the presence of a significant extra-abdominal injury (OR = 3.4, p = 0.043), and a delay of more than 5 hours between admission and laparotomy (OR = 3.2, p = 0.0499). Eighty-six percent of the deaths in patients who had a delay of >5 hours were because of abdominal-related sepsis. CONCLUSION: HVI occurred in less than 1% of all blunt trauma admissions. Delays in operative intervention are associated with an increased mortality. A high index of suspicion is needed to make a timely diagnosis and minimize risk.

PMID: 20622582 [PubMed - in process]

Should Age Be a Factor to Change From a Level II to a Level I Trauma Activation?

J Trauma. 2010 Jul;69(1):88-92

Authors: Shifflette VK, Lorenzo M, Mangram AJ, Truitt MS, Amos JD, Dunn EL

BACKGROUND:: Elderly trauma patients have a higher incidence of medical comorbidities when compared with their younger cohorts. Currently, the minimally accepted criteria established by the Committee on Trauma for the highest level of trauma activation (Level I) does not include age as a factor. Should patients older than 60 years with multiple injuries and/or a significant mechanism of injury be considered as part of the criteria for Level I activation? Would these patients benefit from a higher level of activation? METHODS:: The National Trauma Data Bank was queried for the period of January 1, 1999, to December 31, 2008, for all trauma patients and associated injury severity score (ISS). The data abstracted were based on age and ISS. RESULTS:: The National Trauma Data Bank contained 802,211 trauma patients. Seventy-nine percent were younger than 60 years, and 21% were older than 60 years. Our analysis shows that in all levels of injury, patients older than 60 years have an increased risk for morbidity and mortality. We found a threefold increase in morbidity and a fivefold increase in mortality among the older (age >60 years) population with a minor ISS. Elderly patients with a major ISS demonstrated a twofold increase in morbidity and a fourfold increase in mortality. CONCLUSION:: Patients with an ISS between 0 and 15 are often triaged to Level II activation. Our data would suggest that patients older than 60 years should be a criterion for the highest level of trauma activation.

PMID: 20622583 [PubMed - in process]

Long-term survival and return on investment after nonneurologic injury: implications for the elderly trauma patient.

J Trauma. 2010 Jul;69(1):93-8

Authors: Zarzaur BL, Magnotti LJ, Croce MA, Haider AH, Fabian TC

BACKGROUND:: As the population of the United States ages and as the healthcare system undergoes significant change, cost effectiveness of care will become more important, particularly for older injured patients. The purpose of this study was to evaluate the cost per 2-year survivor stratified by age after moderate- to severe-nonneurologic injury. METHODS:: The trauma registry from a Level I trauma center was queried for adults (older than 18 years), discharged alive after blunt injury (Injury Severity Score >15), without significant neurologic injury, and with hospital charge data. Survival was determined using the Social Security Death Master File. Patients were stratified by age. Hospital costs were calculated by multiplying hospital charge by the cost to charge ratio. RESULTS:: One thousand nine hundred fourteen patients made up the study population. Mean hospital cost per patient was $10,021. Mean cost per 2-year survivor was $10,328. Overall 2-year survival was 97%. (*p < 0.05 vs. youngest). When broken down by age group, there were no significant differences in hospital costs. However, 2-year survival was significantly less in those who were 55.1 years to 75 years old and those older than 75 years, when compared with those aged 18 years to 25 years. Thus, median cost per 2-year survivor was highest in those older than 75 years ($8,911). CONCLUSION:: Although costs are similar by age at time of discharge, cost per 2-year survivor increases as age increases. However, cost per 2-year survivor does not exceed current cost-utility thresholds for any age group. Any future healthcare financing reforms should include aggressive funding for injury prevention efforts aimed at vulnerable populations instead of rationing care once an injury occurs.

PMID: 20622584 [PubMed - in process]

Effect of preinjury statin use on mortality and septic shock in elderly burn patients.

J Trauma. 2010 Jul;69(1):99-103

Authors: Fogerty MD, Efron D, Morandi A, Guy JS, Abumrad NN, Barbul A

BACKGROUND: Premorbid statin use has been associated with decreased mortality in septic and trauma patients. This has been ascribed to the pleiotropic, anti-inflammatory effects of HMG-CoA reductase inhibitors. This association has not been investigated in burn victims. METHODS: A retrospective review of 223 consecutive patients, aged 55 years and older admitted to Vanderbilt University Regional Burn Center from January 2006 to December 2008, was performed. Multivariate regression analysis determined odds ratios of death and sepsis by statin use, adjusting for cardiovascular comorbidities. RESULTS: Of 223 patients, 70 (31.4%) were taking statins before admission. Mean age and mean total body surface area burn were not significantly different by statin use. The odds ratio of inhospital death was 0.17 (95% confidence interval 0.05-0.57; p = 0.004) if on statins. The odds ratio of mortality when stratified by cardiovascular comorbidities did not change. Sepsis developed in 30 patients (13.5%), with an odds ratio in statin users of 0.50 (95% confidence interval 0.20-1.30; p = 0.155). CONCLUSION: Preinjury statin use was associated with an 83% reduction in the odds of death after thermal injury. The odds of sepsis decreased by 50%, although not statistically significant. Further study is warranted to investigate the potential benefits of statin therapy in the management of burn victims.

PMID: 20622585 [PubMed - in process]

Optimal thoracic and lumbar spine imaging for trauma: are thoracic and lumbar spine reformats always indicated?

J Trauma. 2010 Jul;69(1):119-21

Authors: Mancini DJ, Burchard KW, Pekala JS

BACKGROUND:: Computed tomography (CT) of the thoracic and lumbar (T/L) spine with reformats has become the imaging modality of choice for the identification of T/L spine fractures. The objective of this study was to directly compare chest/abdomen/pelvis CT (CAP CT) with CT with T/L reformats (T/L CT) for the identification of T/L spine fractures. METHODS:: Patients who had both a CAP CT scan (5-mm imaging spacing) and T/L CT reconstruction (2.5-mm image spacing with sagittal and coronal reformats) were selected. A “fracture” group (N = 35) and a “no fracture” group (N = 57) were identified. The type and level of fracture were recorded. RESULTS:: The CAP CT correctly identified all 35 patients with a thoracolumbar fracture (100% sensitivity; 95% confidence interval: 88-100%). A total of 80 separate fracture sites were present in the 35 patients. The CAP CT accurately identified 78 of those fractures (97.5% sensitivity; 95% confidence interval: 90.4-99.6%). The two fractures not identified on the CAP CT were both the transverse process fractures in patients with multiple fractures at different levels. CONCLUSION:: Patients who have a CAP CT do not require reformats for clearance of the T/L spine.

PMID: 20622586 [PubMed - in process]

The application of the axial view projection of the s1 pedicel for sacroiliac screw.

J Trauma. 2010 Jul;69(1):122-7

Authors: Hou Z, Zhang Q, Chen W, Zhang P, Jiao Z, Li Z, Smith WR, Pan J, Zhang Y

BACKGROUND:: The objective of this study was to position the iliosacral screws speedily, easily, and safely, we sought to delineate readily reproducible radiographic anatomic clues of the pedicel of S1 for the iliosacral screw placement. METHODS:: We used eight normal adult pelvic specimens lying on the operation table in the prone position. First, the C-arm fluoroscope unit is positioned for the lateral view of the body of S1. We gradually changed the angle of the C-arm to ventral and cephalad. When a clear oval track image appears, we fix the angle of the C-arm. With the assistance of the C-arm projection, the starting point for the guide pin is centered on the oval track, and the orientation is adjusted. When the projection of the guide pin became a point inside of the oval track, the guide pin is inserted using battery-powered equipment. The accuracy and angle of pin placement is assessed using computed tomography scans in all cases. RESULTS:: In all the pelves, the oval track has been successfully found, and the guide pins are accurately inserted using the sacral pedicel axial view. In the angular orientations by the computed tomography scan, the transverse plane inclination to the ventral of the guide pin is approximately 38.3 degrees +/- 1.9 degrees, and the frontal plane inclination to the cephalad is approximately 29.6 degrees +/- 2.0 degrees. CONCLUSION:: The sacral pedicel axial view projection is a optimal radiographic technique for percutaneous placement of iliosacral screws in clinical practice. We can get the limpid axial view of pedicel of S1 to applicate this project method, which provides a speedier method with less radiation exposure for percutaneous placement of iliosacral screws.

PMID: 20622587 [PubMed - in process]

Stabilization of the posteromedial fragment in bicondylar tibial plateau fractures: a mechanical comparison of locking and nonlocking single and dual plating methods.

J Trauma. 2010 Jul;69(1):148-55

Authors: Yoo BJ, Beingessner DM, Barei DP

BACKGROUND:: The objective of this study is to compare locking and nonlocking single and dual plating constructs in maintaining posteromedial fragment reduction in a bicondylar tibial plateau fracture model. We hypothesized that posteromedial fragment fixation with medial and lateral nonlocked constructs would tolerate higher loads than with lateral locked constructs alone. METHODS:: Thirty composite tibiae were fractured (AO 41-C1.3). Six constructs were tested: (1) lateral 3.5-mm conventional nonlocking proximal tibial plate (CP); (2) CP + posteromedial 3.5-mm limited contact dynamic compression plate; (3) CP + posteromedial 1/3 tubular plate (CP + 1/3 tubular); (4) 3.5-mm Zimmer Proximal Tibial Locking plate; (5) 3.5-mm Synthes Locking Compression plate; and (6) Less Invasive Stabilization System tibial plate. Specimens were cyclically loaded to failure or a maximum of 4000 N. RESULTS:: Failure occurred at the posteromedial fragment first. The CP + 1/3 tubular had the highest average load to failure (3040 N). The CP + 1/3 tubular demonstrated higher load at failure compared with the 3.5-mm Synthes Locking Compression plate (p = 0.0060) and the Less Invasive Stabilization System (p = 0.0360). The CP + 1/3 tubular did not demonstrate a difference in load at failure when compared with the CP (p = 0.4225), the CP + posteromedial 3.5-mm limited contact dynamic compression plate (p = 0.4799), or the 3.5-mm Zimmer Proximal Tibial Locking plate (p = 0.1595). CONCLUSIONS:: The posteromedial fragment tolerated higher loads with the CP + 1/3 tubular plate construct. The superiority of this construct may be caused by unreliable penetration of this fragment by the lateral locking screws.

PMID: 20622588 [PubMed - in process]

The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up.

J Trauma. 2010 Jul;69(1):174-8

Authors: Borut LJ, Acosta CJ, Tadlock LM, Dye JL, Galarneau M, Elshire CD

BACKGROUND:: The use of temporary vascular shunts (TVS)s in the management of wartime extremity vascular injuries has received an increasing amount of attention. However, the overall impact of this adjunct remains incompletely defined. The objective of this study is to characterize outcomes of those patients who suffered wartime extremity vascular injuries managed with TVSs. METHODS:: This is a retrospective review of the Navy and Marine Corps Combat Trauma Registry examining peripheral vascular injuries treated during the military conflicts in the Middle East. Patient demographics, injury severity score, mechanism of injury, and vessels injured were recorded. Operative reports were reviewed for use of TVSs, type of definitive repair, the need for amputation, and survival. RESULTS:: Eighty patients were included. Forty-six (57%) had TVSs placed and 34 (43%) underwent repair at initial presentation. The mean injury severity score for the TVS group and the non-TVS groups were 15.0 +/- 5.05 and 12.9 +/- 10.18, respectively, (p = 0.229). There were a total of 13 amputations, 6 (13%) in the TVS group and 7 (21%) in the non-TVS group (p = 0.38). There was no difference in amputation rates between either group. There were no recorded mortalities in either group. Median patient follow-up was 24.5 months (range, 3-48 months). CONCLUSIONS:: This study demonstrates the importance and utility of TVSs in the management of wartime extremity vascular injury. When used to restore perfusion to an injured extremity, there seems to be no adverse effects or overall increase in limb loss rates and therefore a useful adjunct in the surgery for limb salvage.

PMID: 20622589 [PubMed - in process]

Protective effect of carbon monoxide inhalation on lung injury after hemorrhagic shock/resuscitation in rats.

J Trauma. 2010 Jul;69(1):185-94

Authors: Kanagawa F, Takahashi T, Inoue K, Shimizu H, Omori E, Morimatsu H, Maeda S, Katayama H, Nakao A, Morita K

BACKGROUND:: Hemorrhagic shock and resuscitation (HSR) induces pulmonary inflammation that leads to acute lung injury. Carbon monoxide (CO), a by-product of heme catalysis, was shown to have potent cytoprotective and anti-inflammatory effects. The aim of this study was to examine the effects of CO inhalation at low concentration on lung injury induced by HSR in rats. METHODS:: Rats were subjected to HSR by bleeding to achieve mean arterial pressure of 30 mm Hg for 60 minutes followed by resuscitation with shed blood and saline as needed to restore blood pressure. HSR animals were either maintained in room air or were exposed to CO at 250 ppm for 1 hour before and 3 hours after HSR. RESULTS:: HSR caused an increase in the DNA binding activity of nuclear factor-kappaB and activator protein-1 in the lung followed by the up-regulation of pulmonary gene expression of tumor necrosis factor-alpha, inducible nitric oxide synthase, and interleukin (IL)-10. HSR also resulted in an increase in myeloperoxidase activity and wet weight to dry weight ratio in the lung, and more prominent histopathologic changes including congestion, edema, cellular infiltration, and hemorrhage. In contrast, CO inhalation significantly ameliorated these inflammatory events as judged by fewer histologic changes, less up-regulation of inflammatory mediators, and less activation of nuclear factor-kappaB and activator protein-1. Interestingly, the protective effects against lung injury afforded by CO were associated with further increases in mRNA expression of IL-10 in the lung. CONCLUSIONS:: These findings suggest that inhaled CO at a low concentration ameliorated HSR-induced lung injury and attenuated inflammatory cascades by up-regulation of anti-inflammatory IL-10.

PMID: 20622590 [PubMed - in process]

Alcohol interventions for trauma patients are not just for adults: justification for brief interventions for the injured adolescent at a pediatric trauma center.

J Trauma. 2010 Jul;69(1):202-10

Authors: Ehrlich PF, Maio R, Drongowski R, Wagaman M, Cunningham R, Walton MA

BACKGROUND:: Research on the rates of alcohol and drug misuse as well as developmentally appropriate screening and intervention approaches in a hospitalized pediatric trauma population are lacking. The purpose of this study was to identify the rate of alcohol misuse in an admitted trauma population of adolescents aged 11 years to 17 years and to identify key correlates of alcohol misuse in this population including age, gender, and injury severity. METHODS:: A prospective clinical study of 230 injured youth (aged 11-17 years) comprising both hospitalized and emergency department (ED) population was performed, and the patients were screened for the Alcohol Use Disorders Identification Test (AUDIT), blood alcohol levels (BALs), and drinking and driving index. The main outcome measures were rates of alcohol misuse characterized by a positive BAL or a positive AUDIT. RESULTS:: Thirty percent hospitalized trauma patients screened positive for alcohol misuse. Five patients had a positive BAL without a positive AUDIT score. Binge drinking was the most commonly positive domain of the AUDIT tool. In hospitalized trauma patients who are older than 14 years (p = 0.005), it was significantly associated with a positive AUDIT score, but the injury severity score, gender, mechanism of injury, or positive BAL were not significant predictors. In the ED sample, 15.8% of patients had a positive AUDIT score. One-way analysis of variance among the ED group showed that age >/=14 was the single predictor of a positive AUDIT score. Twenty-three percent of hospitalized patients had been in a car, where the driver had been drinking. The average AUDIT scores in this group was 5.3 versus 1.0 (p < 0.001), compared with those who had not ridden in a car with a driver who had been drinking. CONCLUSIONS:: Injured youth admitted to a pediatric trauma center are a high-risk population. Alcohol misuse is a significant cofactor for trauma for these patients, and effective developmentally appropriate interventions are justified and needed.

PMID: 20622591 [PubMed - in process]

Practice Management Guidelines for the Diagnosis and Management of Injury in the Pregnant Patient: The EAST Practice Management Guidelines Work Group.

J Trauma. 2010 Jul;69(1):211-214

Authors: Barraco RD, Chiu WC, Clancy TV, Como JJ, Ebert JB, Hess LW, Hoff WS, Holevar MR, Quirk JG, Simon BJ, Weiss PM

Trauma during pregnancy has presented very unique challenges over the centuries. From the first report of Ambrose Pare of a gunshot wound to the uterus in the 1600s to the present, there have existed controversies and inconsistencies in diagnosis, management, prognostics, and outcome. Anxiety is heightened by the addition of another, smaller patient. Trauma affects 7% of all pregnancies and requires admission in 4 of 1000 pregnancies. The incidence increases with advancing gestational age. Just over half of trauma during pregnancy occurs in the third trimester. Motor vehicle crashes comprise 50% of these traumas, and falls and assaults account for 22% each. These data were considered to be underestimates because many injured pregnant patients are not seen at trauma centers. Trauma during pregnancy is the leading cause of nonobstetric death and has an overall 6% to 7% maternal mortality. Fetal mortality has been quoted as high as 61% in major trauma and 80% if maternal shock is present. The anatomy and physiology of pregnancy make diagnosis and treatment difficult.

PMID: 20622592 [PubMed - as supplied by publisher]

Consensus Statement on the Adoption of the COPE Guidelines.

J Trauma. 2010 Jul;69(1):226

Authors:

PMID: 20622593 [PubMed - in process]

Indirect reduction of bilateral tilt fractures using a supra-acetabular pelvic external fixator.

J Trauma. 2010 Jul;69(1):227-30

Authors: Banerjee R, Verwiebe E, Cooper W

PMID: 20622594 [PubMed - in process]

Posttraumatic stress disorder: a primer for trauma surgeons.

J Trauma. 2010 Jul;69(1):231-7

Authors: Roberts JC, Deroon-Cassini TA, Brasel KJ

In 1980, posttraumatic stress disorder (PTSD) officially became classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition. Since then, there has been increasing recognition that PTSD is a prevalent disorder that may have significant impact on the quality of life for survivors of traumatic events. More recently, methodologically sound research has begun to provide important insight into this disorder. The following review serves to provide the trauma surgeons information on PTSD in terms of its diagnosis, prevalence, risk factors, treatment strategies, and outcomes, with the goal of minimizing the sequelae of PTSD and maximizing postinjury quality of life.

PMID: 20622595 [PubMed - in process]

Frontal Contusion Epidural Hematoma that Mimics a Tensioned Retrobulbar Hemorrhage in Clinical Presentation.

J Trauma. 2010 Jul;69(1):239

Authors: Chou EK, Cheng YK, Chen KT, Tai YT

PMID: 20622596 [PubMed - in process]

Suspended brain in a degraded bottom: bilateral subdural chronic hematomas with acute rebleeding.

J Trauma. 2010 Jul;69(1):240

Authors: Luque JC, Monsalve G

PMID: 20622597 [PubMed - in process]

Effect of low dose of ketamine in sepsis with gastrointestinal complication.

J Trauma. 2010 Jul;69(1):241-2

Authors: Medhi B, Kaur S, Sarangi SC

PMID: 20622598 [PubMed - in process]

Critical aspects on evaluation of autoregulation after a severe traumatic brain injury.

J Trauma. 2010 Jul;69(1):241

Authors: Grände PO, Bentzer P

PMID: 20622599 [PubMed - in process]

Meetings/Courses.

J Trauma. 2010 Jul;69(1):243

Authors:

PMID: 20622600 [PubMed - in process]

Pulsed Acoustic Cellular Treatment Induces Expression of Proangiogenic Factors and Chemokines in Muscle Flaps.

J Trauma. 2010 Jun 21;

Authors: Krokowicz L, Cwykiel J, Klimczak A, Mielniczuk M, Siemionow M

BACKGROUND:: Pulsed Acoustic Cellular Expression (PACE) treatment is a novel technology with potential to improve tissue perfusion, but the mechanism of this action is unknown. We assessed in vivo the effect of PACE therapy on muscle microcirculatory hemodynamics, neovascularization, and proangiogenic and proinflammatory gene expression. METHODS:: Cremaster muscles were prepared for standard intravital microscopy in 42 Lewis rats divided into five groups: (1) control (n = 10); acute PACE treatment 15 minutes before surgery with (2) 200 impulses (n = 8) and (3) 500 impulses (n = 8); and PACE treatment 24 hours before surgery with (4) 200 impulses (n = 8) and (5) 500 impulses (n = 8).Microcirculatory hemodynamics of red blood cell velocity and capillary perfusion were recorded for 4 hours. Gene expression levels of proinflammatory (inductible nitric oxide synthase [iNOS]) and proangiogenic factors (endothelial nitric oxide synthase [eNOS], vascular endothelial growth factor [VEGF], chemokine (C-X-C motif) ligand 5 [CXCL5], chemokine (C-C motif) ligand 2 [CCL2], and chemokine (C-C motif) receptor 2 [CCR2] were measured using Taqman real-time Polymerase Chain Reaction (PCR). Immunohistochemistry assessed expression of proangiogenic factors: VEGF, von Willebrand factor (vWF), and vessel density by CD31. RESULTS:: PACE treatment resulted in an increase of arteriolar diameters in acute groups 2 and 3 (p < 0.05). In group 5, vessel densities assessed by CD31, VEGF, and vWF expression increased significantly 24 hours after PACE treatment compared with control (p < 0.05). PACE application downregulated proinflammatory iNOS gene expression and upregulated proangiogenic genes expression of eNOS, VEGF, CXCL5, and CCL2. CONCLUSIONS:: Application of PACE treatment, applied as short time acting preconditioning and conditioning treatment, resulted in upregulation of proangiogenic chemokines gene expression in the muscle and showed upregulation of expression of proangiogenic factors such as VEGF and vWF on the vessel endothelium.

PMID: 20571448 [PubMed - as supplied by publisher]