Trauma center maturation: quantification of process and outcome.
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BACKGROUND AND OBJECTIVE: The regional trauma system with the trauma center as its center is a model for health care networks. However, trauma center maturation has not been defined in the literature. The authors' hypothesis was that maturation of the trauma center would affect quantitatively both process and patient outcome. MATERIALS AND METHODS: A total of 15,303 trauma patients were admitted from 1987 to 1995. Annual admissions increased from 813 to 2669. Resources were generated as patient volume increased. Time to the operating room, length of stay, and complications were determined. TRISS methodology was used to calculate z scores and w values to compare actual with predicted mortality rates. RESULTS: Time to the operating room for laparotomy decreased from 62+/-73 to 35+/-47 minutes, from 32+/-32 to 20+/-17 minutes in hypotensive patients, and for craniotomy decreased from 88+/-54 to 67+/-49 minutes. The incidence of infectious, airway, neurologic, orthopedic, respiratory, gastrointestinal, and procedure-related complications declined significantly. Z scores and w values increased for penetrating and blunt injuries. Deaths for patients with ISS >15 declined significantly. Hospital length of stay decreased for all ranges of injury severity. CONCLUSIONS: As the trauma center matured, the process of delivering patient care became more efficient. The result was improved survival, fewer complications, and a shorter length of stay. (+info)
Gene expression pattern in human monocytes as a surrogate marker for systemic inflammatory response syndrome (SIRS).
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BACKGROUND: Systemic inflammatory response syndrome (SIRS) is a mild inflammatory episode which, in a minority of patients, may deteriorate into septic shock. In the mouse, injection of bacteria or bacterial endotoxin induces systemic inflammation through the activation of blood monocytes, which leads to lethal shock. A number of intervention strategies have been shown to prevent progression to shock in mouse model systems. However, recent clinical trials of a number of these therapeutic strategies in patients have been uniformly disappointing. In contrast to the situation in the mouse models, there may be many different ways to initiate systemic inflammation in patients and not all of them need necessarily involve activation of blood monocytes. If there is no unifying mechanism behind the induction of systemic inflammation in patients and no common rules governing its development, then it is unlikely that generally applicable therapeutic strategies will be found that can prevent progression into shock. MATERIALS AND METHODS: We used differential display to compare gene expression patterns in monocytes of recent-admission multi-trauma patients with clinically diagnosed SIRS to the patterns in monocytes of healthy controls. RESULTS: Of seven differentially displayed bands that were recovered and sequenced, five were associated with SIRS and two were preferentially expressed in the monocytes of healthy controls. CONCLUSION: The data show that monocytes of SIRS patients are in an activation state that is different from that of monocytes from the healthy controls, that monocytes from many individual patients share similar patterns of differentially expressed sequences, and that by this criterion, the multi-trauma SIRS patients are a remarkably coherent group. (+info)
Fatal work-related farm injuries in Canada, 1991-1995. Canadian Agricultural Injury Surveillance Program.
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BACKGROUND: Studies from other developed countries have shown that agriculture is among the most dangerous occupational sectors in terms of work-related deaths. The authors describe the occurrence of fatal work-related farm injuries in Canada and compare these rates with those in other Canadian industries. METHODS: The authors present a descriptive, epidemiological analysis of data from the recently established Canadian Agricultural Injury Surveillance Program. The study population comprised Canadians who died from work-related farm injuries between 1991 and 1995. Crude, age-standardized, age-specific and provincial rates of such injuries are presented, as are overall death rates in other Canadian industries. Other factors examined were the people involved, the mechanism of injury, and the place and time of injury. RESULTS: There were 503 deaths from work-related farm injuries during the study period, for an overall annual rate of 11.6 deaths per 100,000 farm population. Modest excesses in this rate were observed in Ontario, Quebec and the Atlantic provinces. High rates were observed among men of all ages and among elderly people. Among the cases that listed the person involved, farm owner-operators accounted for 60.2% of the people killed. There was no substantial increase or decrease in the annual number of deaths over the 5 years of study. The leading mechanisms of fatal injury included tractor rollovers, blind runovers (person not visible by driver), extra-rider runovers, and entanglements in machinery. Compared with other industries, agriculture appears to be the fourth most dangerous in Canada in terms of fatal injury, behind mining, logging and forestry, and construction. INTERPRETATION: Canada now has a national registry for the surveillance of fatal farm injuries. Farming clearly is among the most dangerous occupations in Canada in terms of fatal work-related injuries. Secondary analyses of data from this registry suggest priorities for prevention, continued surveillance and in-depth research. (+info)
Community-based injury prevention: effects on health care utilization.
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BACKGROUND: Worldwide, an estimated 78 million people are disabled each year because of unintentional injuries and about 3 million die. The WHO Safe Community model is a framework for community-based injury prevention programmes. The aim of this study is to evaluate the outcome on health care utilization of a Safe Community programme. METHODS: The incidence of injuries treated at health care facilities in an intervention municipality (pop. 41,000) was compared to the injury incidence in a control municipality (pop. 26,000). The incidence was recorded immediately before and one year after programme implementation from registrations made during all first-contact health care visits and from examination of hospital discharge registers. RESULTS: The incidence of health care treated injuries in the intervention area had decreased by 13% (95% CI: 9-16%) from 119 (95% CI: 115-122) per 1000 population-years to 104 (95% CI: 101-107). In the control area, the corresponding injury incidences were 104 (95% CI: 100-108) and 106 (95% CI: 102-109). The hospital-treated injuries in the intervention area decreased by 15% (95% CI: 7-24%) from 19 (95% CI: 17-20) per 1000 population-years to 16 (95% CI: 15-17), while in the control area, the incidences remained at 13 (95% CI: 11-14) per 1000 population-years. Utilization of acute care in the intervention area for reasons other than injuries increased by 8% (95% CI: 6-10%), while in the control area, the number of visits did not show significant change. CONCLUSION: This first controlled evaluation showed that an injury prevention programme based on local action groups can significantly reduce injuries requiring health care in a community. Local prevention can provide a complement to national level campaigns. (+info)
Sex steroids regulate pro- and anti-inflammatory cytokine release by macrophages after trauma-hemorrhage.
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Studies indicate that macrophage immune responses in males are depressed after trauma-hemorrhage, whereas they are enhanced in females under such conditions. Nonetheless, the involvement of male and female sex steroids in this gender-dependent dimorphic immune response after trauma-hemorrhage remains unclear. To study this, male C3H/HeN mice were castrated and treated with pellets containing either vehicle, 5alpha-dihydrotestosterone (DHT), 17beta-estradiol, or a combination of both steroid hormones for 14 days before soft tissue trauma (i.e., laparotomy) and hemorrhagic shock (35 +/- 5 mmHg for 90 min followed by adequate fluid resuscitation) or a sham operation. Twenty-four hours later the animals were killed, plasma was obtained, and Kupffer cell and splenic and peritoneal macrophage cultures were established. For DHT-treated mice, we observed significantly decreased releases of the proinflammatory cytokines interleukin 1beta (IL-1beta) and IL-6 by splenic macrophage (-50 and -57%, respectively) and peritoneal macrophage (-51 and -52%, respectively) cultures after trauma-hemorrhage compared with releases by cultures of cells from mice subjected to a sham operation; in contrast, responses of splenic and peritoneal macrophage cultures from other groups subjected to trauma-hemorrhage did not change significantly. In addition, only DHT-treated animals exhibited increased Kupffer cell IL-6 release (+634%). The release of IL-10 in DHT-treated hemorrhaged animals was increased compared with that in sham-operated animals but was decreased in estrogen-treated mice under such conditions. These results suggest that male and female sex steroids exhibit divergent immunomodulatory properties with respect to cell-mediated immune responses after trauma-hemorrhage. (+info)
Drinking pattern and alcohol-related medical disorders.
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Although heavy alcohol intake is known to be one of the most common causative factors of liver disease, pancreatitis, upper gastrointestinal and neurological disorders, the influence of the drinking pattern is largely unknown. The study investigated the relationship of alcohol-related medical disorders in alcoholics and their drinking pattern. Two hundred and forty-one chronic alcoholics were referred consecutively for detoxification and their drinking pattern was sufficient for them to be included in this study. History of alcohol abuse as well as drinking behaviour in the last 6 months were assessed by a semi-structured interview. Findings included intensive clinical examination with abdominal ultrasound in most subjects. Heavy drinking with frequent inebriation was most often found in our sample (44.4%), whereas continuous heavy alcohol consumption without intoxication (33.6%), and an episodic drinking style (22.0%) were less frequent. The heavy drinkers suffered more often from pancreatitis, oesophageal varices, polyneuropathy or erectile dysfunction than episodic drinkers. They also showed more upper gastrointestinal disorders, although the estimated life-time alcohol intake was comparable to continuous drinkers. No difference relating to withdrawal delirium or seizures could be found between the groups of alcoholics. Frequent heavy drinkers showed a trend to more alcohol-related medical disorders than alcoholics with a different drinking pattern, although they were younger and their estimated life-time alcohol intake was comparable to that of continuous drinkers. Thus, the drinking pattern, particularly frequent inebriation, has an influence on the occurrence of alcohol-related disorders. (+info)
Cause, prevalence, and response to occupational musculoskeletal injuries reported by physical therapists and physical therapist assistants.
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BACKGROUND AND PURPOSE: Physical therapists (PTs) and physical therapist assistants (PTAs) are susceptible to occupational musculoskeletal injuries. The purpose of this study was to examine the reported causes and prevalence of occupational musculoskeletal injuries to PTs and PTAs during a 2-year period. SUBJECTS: A questionnaire was mailed to 500 PTs and 500 PTAs randomly selected from the American Physical Therapy Association 1996 active membership list. Six hundred sixty-seven questionnaires were returned, giving a response rate of 67%. METHOD: Based on a literature review and a pilot study, an occupational injury questionnaire was constructed and mailed. Self-reports of injuries were obtained. RESULTS: Thirty-two percent of the PTs and 35% of the PTAs reported sustaining a musculoskeletal injury. The highest prevalence of injury was to the low back (62% of injured PTs and 56% of injured PTAs). The PTs reported the upper back and the wrist and hand as having the second highest prevalence (23%). The PTAs reported the upper back as having the second highest prevalence (28%). The PTs and PTAs reported making changes in their work habits of improved body mechanics, increased use of other personnel, and frequent change of work position. The majority of PTs and PTAs reported they did not limit patient contact time or area of practice after sustaining an injury. CONCLUSION AND DISCUSSION: Although PTs and PTAs are recognized to be knowledgeable in prevention and treatment of musculoskeletal injuries, they are susceptible to sustaining occupational musculoskeletal injuries because of performing labor-intensive tasks. (+info)
Effect of closed circuit television on urban violence.
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OBJECTIVE: To evaluate the effect of city and town centre closed circuit television (CCTV) surveillance on violence in terms of accident and emergency (A&E) department and police assault data. METHODS: A&E department and local police assault data in three centres in Wales (Cardiff, Swansea, and Rhyl) two years before and two years after the installation of CCTV were studied. British Crime Survey and police crime statistics were used as control data. RESULTS: A&E records of 24,442 assault patients and 3228 violent offences recorded by the police were studied. Data from two A&E departments (Swansea (+3%) and Rhyl (+45%)) showed increases in recorded assaults after CCTV installation but a decrease (12%) in the largest centre, Cardiff. There was an overall reduction in town/city centre violence from the A&E department perspective of 1% in the two years after CCTV installation. In contrast, police data demonstrated changes in the opposite direction (-44%, -24%, and +20% respectively) contributing to an overall decrease of 9%. British Crime Survey and police statistics for England and Wales demonstrated no overall change and a 16% increase respectively. CONCLUSIONS: City centre CCTV installation had no obvious influence on levels of assaults recorded in A&E departments. There was a negative relationship between police and A&E recording in all three centres. A&E departments are important and unique sources of information about community violence. (+info)