Maximal activities of glutaminase and some enzymes of glycolysis and ketone body utilization and rates of utilization of glutamine, glucose and ketone bodies by intestinal mucosa after burn injury

1. 1. The effects of burn injury (33 per cent of body surface area) on the activities of key enzymes in the metabolism of glucose, glutamate and ketone bodies in the epithelial cells of the small intestine and the rates of utilization of glucose, glutamine and ketone bodies by isolated enterocytes have been investigated.

2. 2. Burn injury decreased the maximal activities of hexokinase and 6-phosphofructokinase and increased those of glucose 6-phosphatase plus fructose bisphosphatase (in duodenum, jejunum and ileum) over the first 5 days post-injury.

3. 3. After injury there are decreases in the rates of glucose utilization and lactate formation by incubated enterocytes.

4. 4. The maximal activities of citrate synthase and oxoglutarate dehydrogenase were increased during the first 5 days post-injury, whereas the ketone-body-utilizing enzymes were unchanged.

5. 5. An increase in the maximal activity of phosphate-dependent glutaminase was observed during the whole of the post-injury period studied (20 days).

6. 6. After burn injury there is an increased rate of glutamine utilization and increased rates of formation of glutamate and alanine by incubated enterocytes.

     

The total number of burn injuries in a Scandinavian population—a prospective analysis

During the period 1 September 1982 to 31 August 1983 the total number of burn injuries in the municipality of Copenhagen was recorded prospectively. The social changes and the constitution of the population are illustrated.

The total number of burn injuries showed a decrease of 33 per cent compared to the investigation in 1974/75. Scalds are still the most frequent cause of burn accidents, small children are especially vulnerable. Seventy-two per cent of all accidents occurred at home. Only a few patients required ‘antishock’ therapy. No patients with work-related burn injuries died.

Preventive measures have eliminated or reduced the number of some types of thermal injury.     

Mortality of burn injuries in Jordan

Three hundred and ninety patients who died following fire burns and scalds between 1973 and 1982 were subjected to autopsy examination at the departments of Forensic Medicine in the Ministry of Health and Jordan University Hospital. Flame burns caused 82 per cent of the deaths. Most of the burn injuries occurred at home and most of the accidents may have been avoidable. Seventy-six per cent of the patients were children and young adults (0–29 years). Suicide caused 13·5 per cent of the deaths. The most common causes of death were septicaemia and hypovolaemia.     

Survival in major burn injuries treated by one bathing in cerium nitrate.

Sixty-four patients aged 16-74 years with total body surface area burns (TBSA) ranging from 30 to 90 per cent, were given one bathing in 0.04 M cerium nitrate within 4 h of admission to hospital. Of 21 patients aged 16-30 years, one died (aged 28 with 90 per cent TBSA), and of those aged 31-74 years, two died, one (aged 50 years with 55 per cent TBSA) had multiple internal injuries, the other (aged 51 years with 55 per cent TBSA) had a pulmonary embolism at day 19. Two risk scores, developed from data on 11,200 burn patients treated by standard methods (Roi et al. 1983), were applied to the analysis of risk for 59 patients for whom both total burn surface (TB) and full thickness (FT) areas had been recorded. About 20 patients bore risk of 0.8 or greater on the FT scale and 1.0 on the TB scale, yet instead of 80 per cent deaths among these, only two died. No FT assessment had been made on the multiple injury death whose TB risk score was 0.66. Such survival results in high-risk patients should encourage the use of cerium nitrate for treating serious burn injury.     

A review of fatal road accidents in Oxfordshire over a 2-year period

The records of 131 road accident fatalities which occurred in Oxfordshire over a 2-year period were reviewed. Aspects of the accident circumstances, the injuries incurred and the cause of death were examined. The majority of fatal accidents occurred during daylight hours and in dry weather. Deaths were mainly due to cerebral injury (34.4 per cent) or uncontrollable (mainly thoracic) haemorrhage (25.2 per cent), or a combination of both (8.4 per cent). A number of deaths occurred in hospital from complications rather than from the injury itself. In addition to this, there were four deaths from natural causes. Where death occurred at the scene of the accident, blood alcohol levels were determined. Almost 50 per cent of the drivers for whom a level was obtained had measurable alcohol in their bloodstream, and 28 per cent of such drivers were over the legal limit. Three cases who reached hospital alive were, on review, assessed to have potentially survivable injuries, and a further two patients died in the post-accident period of potentially survivable complications.     

Fatal road accidents in Birmingham: Times to death and their causes

The intervals between injury and death in the 254 fatalities after road traffic accidents in Birmingham during 1969 and 1970 were analysed and correlated with other data. Sixty-three per cent were pedestrians and 23 per cent were passengers and drivers of vehicles. In round figures, about a third of the series died within half an hour, a half by 2 hours, two-thirds by 24 hours, and three-quarters by 2–4 days. The patterns of survival-time could be divided into three phases. There was an early steep decline, with 36 per cent dying during the first half-hour and 44 per cent within 1 hour of the accidents. This was followed by a longer stage during which the rate of dying decreased progressively in logarithmic fashion. The cumulative tolls were 51 per cent by 2 hours, 58 per cent by 4 hours, 68 per cent by 24 hours, and 83 per cent by 7 days. The curve then flattened into a prolonged tail. Between 7 and 28 days another 10 per cent died, making 93 per cent by 28 days. The remaining 7 per cent succumbed during the subsequent weeks and months, 3 patients surviving longer than a year.

Fifty-six per cent of vehicle occupants and 40 per cent of pedestrians died within an hour of injury, and the excess of rapid deaths among vehicle occupants was mainly due to a higher proportion of rupture of the aorta. All the ruptured aortae in vehicle occupants occurred after accidents at night or the early hours of the morning. Many of the affected drivers and passengers had consumed alcohol and their injuries were more rapidly lethal than after accidents at other times. Serious cerebral trauma dominated all groups of road users and multiple injuries were common. Included among the fatality tail was a group of subjects, mainly pedestrians, with relatively modest injuries who might have survived had they not developed pulmonary embolism, respiratory infection, or other complications.     

Treatment of thoracoabdominal gunshot wounds in civilian practice. Experience with forty-four cases

Forty-four acute cases of thoracoabdominal injuries in civilian practice are presented. Injury to multiple abdominal organs occurred in 50 per cent. The mortality in those with multiple organ injuries was 33 per cent whereas among those with injury to a solitary organ it was 4.5 per cent. The liver was injured in 61 per cent of cases. Although intercostal tube drainage (50 per cent) usually suffices in the management of the chest injury, thoracotomy was indicated in a number of cases. We advocate preservation of the thoracoabdominal barrier, by making a separate thoracic and abdominal wound, to prevent thoracic contamination, diaphragmatic hernia, and to achieve a thorough abdominal exploration. The total complication rate is 25 per cent. There were nine deaths (20 per cent) in the entire series, eight of which were directly related to the thoracoabdominal injury, yielding a corrected mortality of 18 per cent. One patient died from a separate gunshot wound to the brain.     

Management of candida septicaemia in a regional burn unit

Sepsis due to candida infection is a major cause of mortality and morbidity on our unit. Over a period of 3 years and 4 months, 29 cases of candida septicaemia, diagnosed by blood cultures, were encountered at the burn unit at Augusta Regional Medical Center.

Factors known to predispose to fungal sepsis were present in all cases. All patients had large burns (14–98 per cent total body surface (TBSA) with a mean of 48.3 per cent). All but one patient had at least one central venous line. Respiratory problems requiring ventilator support were present in 24 patients.

Sixteen patients had Candida albicans sepsis, two in association with another fungal sepsis. Candida parapsilosis was encountered in nine patients, one in combination with another species. Four patients had Candida tropicalis.

Amphotericin B was prescribed therapeutically in 25 patients, in seven together with fluconazole. Two patients received fluconazole only and two received no antifungal therapy.

There were eight deaths all attributed to sepsis and all of whom had multiple organ failure. Five of those who died had completed a course of amphotericin B therapy, two were receiving treatment at the time of death, and one patient died before culture data became available. Early and aggressive therapy is advised and amphotericin B appears to be the drug of choice.     

Deaths associated with snow skiing in Colorado 1980-1981 to 2000-2001 ski seasons

Objectives: To investigate the trend and injury patterns of deaths associated with snow skiing in Colorado between 1980 and 2001.

Methods: Death certificates were searched electronically and reviewed manually. Total skier ticket sales were used to calculate death rates. Types of injuries and characteristics of those who died were investigated.

Results: A total of 274 skier deaths occurred between 1980 and 2001 in Colorado. Death rates ranged from 0.53 to 1.88 per million skier visits. The majority of deaths were among males (>81%). Ages ranged from 7 to 77 years with an average of 32 years. The greatest number of deaths associated with downhill skiing (76 deaths) occurred between 10:00 a.m. and 2:00 p.m. while the greatest number of deaths associated with cross-country skiing happened between 2:00 and 6:00 p.m. About 65% of deaths associated with downhill skiing (133 cases) died of traumatic injuries resulting from collisions.

Conclusions: A slight increase in the rate of ski-related deaths was observed. The role of collisions in ski-related deaths warrants further investigation to reduce the risk of this activity for all skiers. Further work is needed to determine the efficacy of helmet use to reduce the risk of head injuries in the skiing population.     

Preventability of death from penetrating injury in England and Wales

A total of 1000 deaths from injury in England and Wales have been reviewed to establish the incidence and pattern of penetrating injury and the adequacy of its management. Of the 1000 deaths, 71 (7.1 per cent) were due to penetrating injury. There were 32 knife wounds and 30 firearm injuries. Most of the latter were suicides. Only 17 patients (24 per cent) reached hospital alive. Of these cases, 10 had extracranial injury and all 10 deaths were considered to have been potentially preventable when reviewed by four external assessors. One of seven patients with cranial injury was considered to have been a potentially preventable death. The median age of the 11 cases of potentially preventable death was 37 years (range: 7-61 years). Of these, three did not have any surgery for surgically treatable injuries. Seven patients underwent operation and difficulty was encountered in six of these. It appears from our figures that whilst penetrating injury is an uncommon cause of death, it is poorly managed. The implications of this finding for systems of injury care in the United Kingdom are discussed.     

Hyperextension-dislocation injuries of the cervical spine

Between 1965 and 1991, 132 patients with vertebral dislocation following hyperextension injury of the cervical spine were treated at the Spinal Injury Department of the Metropolitan Rehabilitation Centre in Konstancin, Poland. The series accounted for over 25 per cent of patients with hyperextension injuries and for about 7 per cent of all cervical-spine-injured patients treated during these years. These changes are most commonly found in two situations:

1. (1) Injuries of the upper cervical spine.

2. (2) Injuries sustained by individuals with advanced pathological changes in the spine. Such conditions are found in advanced spondylosis and ankylosing spondylitis. Such changes were noted in nearly 65 per cent of the patients in the series analysed.

The improved results seen in surgically treated patients encourage the wider application of surgery in such groups of patients.     

近10年3911例烧伤病例分析

检索了１９８３年１月～１９９２年１２月收治的３９１１例烧伤病人的病历资料，对一般情况、年龄分布、致伤原因、烧伤面积、复合伤、常见并发症、休克发生率、死亡率及死亡原因等进行了统计分析。结果显示，在１３２例死亡病人中，９１．７％有吸入伤、内脏并发症和全身性感染。提示吸入伤、内脏并发症和全身性感染仍是烧伤病人的三大主要死亡原因。     

近10年3911例烧伤病例分析

检索了1983年1月～1992年12月收治的3911例烧伤病人的病历资料,对一般情况、年龄分布、致伤原因、烧伤面积、复合伤、常见并发症、休克发生率、死亡率及死亡原因等进行了统计分析。结果显示,在132例死亡病人中,91.7％有吸入伤、内脏并发症和全身性感染。提示吸入伤、内脏并发症和全身性感染仍是烧伤病人的三大主要死亡原因。     

Accidental burn deaths to Egyptian women of reproductive age

Among women of reproductive age in Menoufia, Egypt, deaths from burns constitute a major public health problem. Burns account for 9 per cent of the deaths occurring to women aged 15-49, and were the third cause of death (after disease of the circulatory system and complications of pregnancy and childbirth). Nearly two-thirds of the burns were caused by kerosene cooking stoves. The data were obtained from a population-based survey of all deaths to women of reproductive age. There were 1691 deaths from all causes during the 3 years of the study, 152 of these were due to burns. Information on the cause of death was gathered from interviews with surviving family members; interviews were reviewed by physicians and a cause of death established. Although hospital-based studies provide valuable information for the management of burn injuries presenting for treatment, establishing rates of injury, comparing the incidence in one population group relative to another, or comparing the incidence of burns relative to other forms of injury requires a population-based study.     

Death in hospital after head injury without transfer to a neurosurgical unit: who, when, and why?

Most studies of hospital deaths after head injury have been in patients transferred to neurosurgical units (NSU), but over 90 per cent of hospitalized head-injured patients are not transferred and some of these die. To assess the effectiveness of triage of seriously head-injured patients in Glasgow, we studied 270 patients who died after head injury in any of the six Glasgow general hospitals during 1979-1988 and who were not transferred to the regional NSU. The proportion of fatal cases of head injury who had not been to the NSU fell from 69 per cent in 1971-1975 to 45 per cent in 1979-1988. Most of the untransferred patients were elderly, and most died from irremediable injuries or complications. Although 31 (11 per cent) had a significant intracranial haematoma, only seven of these might have been salvaged by neurosurgical intervention. Seven other patients died from potentially preventable extracranial injuries or complications. These findings suggest that a relatively satisfactory level of triage of seriously head-injured patients has been achieved, by promoting effective communication between neurosurgeons and other specialists, and by a continuous programme of audit and education.     

Occupational burn injuries

The epidemiology of occupational burns injuries in a well-defined population is analysed. Although a total of 371 persons sustained an injury, only a few were inpatients and just one required anti-shock treatment. The mean burn surface area was 0.66 per cent and 14 patients had full thickness burn injuries. There were no deaths. Men were found to be more prone than women to injury, especially young workers. The distribution by categories of work and causes of burn are illustrated. Scalds and contact burns were dominant, particularly in restaurants. The work by the National Labour Inspection is acknowledged.     

Trauma deaths in the south west Thames region.

This is an epidemiological study based on Coroners' records analysing mode of injury and place and cause of death. The aim of the study is to provide data on the incidence and patterns of death from trauma and to assess the need for changes in trauma management. All traumatic deaths occurring in the South West Thames Region during 1988 were studied. We analysed 434 of these deaths (mean age 52 years) in some detail. Of the deaths, 59 per cent occurred before arrival at hospital. Road traffic accidents are the commonest cause of death from trauma, being most prevalent in the areas containing major trunk roads. The majority of deaths due to chest injury (79 per cent) and multiple injuries (70 per cent) occurred before arrival at a hospital, whereas the majority of deaths due to head injury (63 per cent) occurred after admission. The majority of deaths from trauma occur before arrival at a hospital, particularly in the semi-rural areas. Improvements in hospital trauma care could have only a limited effect on the death rate in existing circumstances. If important reductions in deaths from severe injury are to be made then prevention and prehospital care need to be improved.     

Trends in burn admissions in Scotland during 1970–1992

This retrospective study involved analysis of the data of the inpatients discharged with a diagnosis of burns, from various hospitals in Scotland, during the period 1970–1992. There were 51350 such inpatients all over Scotland, with an average annual rate of 2233 cases. Overall burn incidence in actual numbers was 43.7 per cent in < 15 year olds, 41.2 per cent in 15–64 year olds and 15.1 per cent in ≥ 65 year olds. Burn rates per 100 000 population were highest in < 15 year olds and lowest in 16–64 year olds.

The pattern of burn admissions has changed. Since 1987 the highest numbers of burn inpatients were the 16–64 year olds, followed by children, then the elderly. There has been a gradual but sustained fall in burns admissions in all age categories. The downward trend was statistically significant (t = 8.48, 21 d.f., P < 0.001). Though the population of the elderly (≥ 65 year olds) increased by about 13 per cent, the burn admissions and all deaths due to burns did not reveal an upward trend. The population of the old (81 + year olds) increased by 60 per cent during the same period. The incidence of burns was above average when > 80 year olds were considered separately, approaching the levels found in children. However the rate and incidence of burns in the 65–80 year olds resembled that of the younger age group (16–64 year olds).

The total number of deaths due to burns and/or smoke inhalation has declined in all age groups and the decline has been statistically significant (chi-squared = 19.62, 1 d.f., P < 0.001). Maximum number of deaths occurred in ≥ 65 year olds (44 per cent), followed closely by 16–64 year olds (43.5 per cent), and 12.5 per cent of deaths in adolescents and children. The decline was due to improved management of burns and a decrease in the number of patients having large body surface area burns.     

Emergency laparotomy for abdominal trauma

We have retrospectively reviewed our experience of 153 consecutive patients who underwent emergency laparotomy for suspected intraabdominal injury over a 10-year period.

The commonest cause of injury was road traffic accidents (61 per cent), and the commonest indication for operation was signs of peritoneal irritation (35 per cent). Peritoneal lavage was performed in 62 patients (41 per cent). The liver was the organ most frequently injured (52 patients, 34 per cent) and 52 per cent of these patients died. Splenic injuries occurred in 46 patients (30 per cent). The negative laparotomy rate was 16 per cent. Forty-five patients died (29 per cent) and five of these had negative laparotomies. The Injury Severity Score (ISS) of all patients who died was > 16.     

Head injury‐related road crash mortality in rural Western Australia

Background: The aim of the present paper was to assess the incidence of, and identify factors associated with road crash (RC)‐related fatal head injuries in rural and metropolitan Western Australia. Methods: Examination of demographics, driving behaviour and RC characteristics for RC fatalities involving a head injury (Abbreviated Injury Scale (AIS) ≥ 2) between 1 January 1998 and 31 December 1999 was carried out using the State Coronial ­Database. Results: There were 328 deaths. The median age was 28 years and 74.1% of cases were male. Seventy per cent died at the scene. Of scene survivors, 89% were transferred to a metropolitan hospital before dying. Sixty per cent of total RC and 65% of at‐scene deaths occurred in rural areas. Single‐vehicle crashes comprised 45% of total crashes, of which 72.8% occurred in rural locations. Poor driver behaviour was identified in 53% of deaths. Ethanol was implicated in 29.8% of deaths, other intoxicating drugs were implicated in 19.2%, speeding was implicated in 19.5%, and lack of safety restraints/devices was implicated in 22%. Poor driver behaviour was identified in 72% of single‐vehicle deaths, compared with 38% of multivehicle crashes (P < 0.001). Rural people comprised 61% of rural crash victims. Ninety‐one per cent of rural victims died in rural crashes. The incidence of RC death associated with head injury in the rural population is 13.4 deaths/100 000 per year, more than double that for the metropolitan population (6.4 deaths/100 000 per year; P < 0.001). Conclusion: The rural population of Western Australia is overrepresented in head injury‐related RC deaths. Single‐vehicle crashes where unsafe driving behaviour is implicated comprise a large proportion of these. Strategies to reduce unsafe driving practices aimed at rural drivers are necessary.