Increasing volume of patients at level I trauma centres: Is there a need for triage modification in elderly patients with injuries of low severity?

INTRODUCTION: Since the introduction of a regionalized trauma system in Quebec in 1993, patient loads at level I trauma centres have been increasing gradually. We aimed to investigate the type of patient presenting to 4 tertiary trauma centres in Quebec, the nature of their injuries and whether there was a need to modify triage protocols. METHODS: The study consisted of a review of major trauma patients entered into a regional trauma registry between Apr. 7, 1993, and Mar. 31, 2000. A total of 29 669 patients fulfilled the eligibility criteria. We compared patient demographics, injury type and severity and mechanism of injury. RESULTS: During the 7 years of the study, there was an increase in the volume and presentation of patients injured in falls (p < 0.01), patients with extremity injuries (p < 0.01), single injuries (p < 0.01) and injuries to single body regions (p < 0.01). Young patients were mostly injured in motor vehicle collisions and had multiple injuries of high severity whereas elderly patients were mostly injured in falls and experienced isolated extremity injuries of low severity. CONCLUSIONS: The proportion of elderly patients injured in falls, experiencing isolated extremity injuries of low severity and being treated at tertiary trauma centres in Quebec is overwhelmingly high. Revision of pre-hospital triage protocols should be considered and studied in order to transport trauma patients to appropriate facilities.     

不同方法共移植的嗅鞘细胞和雪旺氏细胞在损伤脊髓内的迁移和对轴突再生的影响

目的:观察经不同方法共移植的嗅鞘细胞和雪旺氏细胞在脊髓内的迁移特点和对轴突再生的影响.方法:将8只75±1d雌性SD大鼠随机分为2组,每组4只,利用NYU打击器制作TIO脊髓损伤模型,打击高度25mm,打击杆重量10g.造模后2周,一组采用联合移植,雪旺氏细胞移植于损伤鄢位中心,嗅鞘细胞移植于距离损伤中心0.5mm处的头侧和尾侧的脊髓中线上;另一组采用混合移植,将嗅鞘细胞和雪旺氏细胞混合后移植于距离损伤中心0.5mm处的头侧和尾侧的脊髓中线上.每个部位注射4个点,深度为1.75mm,1.25mm、1mm、0.5mm.注射速度为0.1μl/min.联合移植组嗅鞘细胞晕每点0.5μl含5×10~4个,雩旺氏细胞晕为每点1μl含10~5个雪旺氏细胞;混合移植组为每点1μl含嗅鞘细胞和雪旺氏细胞各5×10~4个.细胞移植后1周和8周时各组分别取2只大鼠.以损伤部位为中心取包含细胞移植部位的脊髓,荧光和共聚焦显微镜下观察细胞迁移情况,利用神经丝(neurofilment,NF)和乍长相关蛋白-43(growth associated protein-43,GAP-43)免疫荧光染色观察移植细胞对轴突再生的影响.结果:两组中均可见嗅鞘细胞迁移,主要在灰质和白质内沿脊髓纵轴向损伤部位迁移,还分别有一小部分沿中央管和蛛网膜下腔迁移;但雪旺氏细胞仅存与嗅鞘细胞混合移植于距离损伤中心0.5mm处的头侧和尾侧脊髓时才可见有限距离的迁移.联合移植时,NF阳性(NF+)和GAP-43阳性(GAP-43+)纤维伴随嗅鞘细胞迁移而沿脊髓纵轴延伸,雪旺氏细胞移植处可处NF+纤维从各个方向长入损伤部位(移植部位)并互相缠绕;混合移植时,大量NF+纤维伴随移植细胞迁移而延伸,损伤部佗虽然NF+纤维较少,但没有互相缠绕现象.结论:雪旺氏细胞在损伤脊髓内迁移能力差;嗅鞘细胞不仅具有良好的迁移能力,而且可促进雪旺氏细胞迁移.无论是联合移植还是混合移植,移植细胞均能促进轴突再生,但联合移植时雪旺氏细胞移植处再生纤维互相缠绕、无法延伸.     

Emotional States of Athletes Prior to Performance-Induced Injury

Psychological states experienced by athletes prior to injured, best and worst performances were investigated retrospectively using a mixed methodology. Fifty-nine athletes volunteered to complete an individualized assessment of performance states based on the Individual Zones of Optimal fFunctioning (IZOF) model. A subsection (n = 30) of participants completed a standardized psychometric scale (Brunel Mood Rating Scale: BRUMS), retrospectively describing how they felt before best, worst, and injured performances. IZOF results showed similar emotion states being identified for injured and best performances. Analysis of BRUMS scores indicated a significant main effect for differences in mood by performance outcome, with post-hoc analyses showing best performance was associated with lower scores on depression and fatigue and higher vigor than injured performance and worst performance. Worst performance was associated with higher fatigue and confusion than injured performance. Results indicate that retrospective emotional profiles before injured performance are closer to successful performance, than unsuccessful, and confirm differences between successful and unsuccessful performance. Qualitative and quantitative approaches used to retrospectively assess pre-performance emotional states before three performance outcomes, produced complimentary findings. Practical implications of the study are discussed.

Key Points

• Psychological states experienced by athletes prior to injured, best and worst performances were investigated retrospectively using a mixed methodology.
• Results indicate that retrospective emotional profiles before injured performance are closer to successful performance, than unsuccessful, and confirm differences between successful and unsuccessful performance, a finding that occurred using both methods.
• Future research should further examine the emotional antecedents of injury and that applied sport psychologists recognize the potential risk of injury associated with emotional profiles typically linked with best performance.

Key words: Emotion, mood, success, injury, measurement, performance     

Does a colostomy alter quality of life in patients with spinal cord injury? A controlled study.

STUDY DESIGN: Prospective controlled comparative analysis. OBJECTIVE: To determine whether a colostomy changes quality of life in patients with a spinal cord injury. METHOD: A previously validated questionnaire designed to assess quality of life in spinal injured patients (Burwood Questionnaire) was sent to 26 spinal cord injured patients with colostomies and 26 spinal cord injured patients without colostomy. The two groups were matched for level of injury, completeness of injury, length of time since injury, age (+/- 5 years) and gender. RESULTS: There was 100% completion of the questionnaire. There was no significant difference (P > 0.05) in the two groups of patients in regard to their general well being, emotional, social, or work functioning. CONCLUSIONS: Patients with colostomy following spinal injury are no worse off in regard to quality of life, than those without. The inference is that perhaps a colostomy should be considered earlier in patients with major bowel dysfunction following spinal cord injury. SPONSORSHIP: Financial support for Dr AC Lynch was provided by Royal Australian College of Surgeons with a Foundation Scholarship and Grant in aid by the Burwood International Spinal Trust. Mr N Randell was supported by the Canterbury Medical Research Foundation with a summer studentship.     

Hit-and-runs more common with pedestrians lying on the road: Analysis of a nationwide database in Japan

Purpose: To determine the trends with fatally or otherwise injured pedestrians lying on the road and the relationship to hit-and-run incidents in Japan. Methods: We extracted data for 2012e2016 from the records of the Institute for Traffic Accident Research and Data Analysis, Japan, a nationwide traffic accident database. All the injured and fatally injured pedestrians were selected. We examined the levels of pedestrian injury, vehicle speed immediately before the collision, whether or not the pedestrian was lying on the road, and hit-and-run incidents. Chi-square test was employed to make a statistical comparison between the two groups. Results: The database contained data on 286,383 pedestrian casualties and 7256 fatalities; 8.3% of fatalities (602 persons) and 0.6% of casualties (1827 persons) involved pedestrians lying on the road. The rates of fatalities and severe injuries were significantly higher for pedestrians who were lying on the road than for those who were not. Hit-and-run incidents were evident in 4.0% of casualties and 7.3% of fatalities. The rate of hit-and-run cases was also significantly higher among pedestrians who were lying on the road. Among fatally injured pedestrians not lying on the road, the rates with speeds of 30 km/h did not differ significantly between hit-and-run and other cases. However, when the pedestrians were lying on the road, the rate was significantly increased in hit-and-run cases. Conclusion: This is the first report to focus on pedestrians lying on the road and being involved in hitand-run incidents. In addition to preventing hit-and-run incidents, prevention of pedestrians lying on the road could also decrease fatalities.     

Critical care of the severely injured child

It is the responsibility of the surgeon committed to care of these critically injured patients to understand the nature of injuries being treated, and to orchestrate this treatment in a manner that maximizes recovery, avoids unnecessary morbidity, and assures the injured child the best quality of life humanly possible.     

How to improve satisfaction with hospital stay of severely injured patients

Background In the context of medical quality assurance, patient satisfaction with medical and organisational aspects of health care service is considered to be a relevant outcome of patient surveys after a stay in hospital. Within quality research, it is assumed that assessments of patient satisfaction represent a direct measure of the quality of health care received. Furthermore, there is evidence that satisfied patients demonstrate higher levels of compliance for the course of their treatment and that the probability of successful treatment completion thus considerably increases. The present analysis aims to identify determinants of satisfaction of seriously injured patients with regard to their acute hospitalisation. Materials and methods One hundred twenty-one seriously injured survivors of work-related or traffic-related accidents treated in two hospitals in Cologne during the years 1996 to 2001 were sent a survey questionnaire. In addition to socio-demographic details, the survey covered the subjective evaluation of organisational and structural aspects of the acute hospitalisation and the psychosocial care provided by the medical staff. Results Employing the “tailored design method”, a response rate of 74.4% (n = 90) was obtained. Three highly significant factors influencing the satisfaction of seriously injured patients were identified by means of logistic regression: (1) patients’ perception of being involved in treatment, (2) patients’ feeling of being neglected by physicians and (3) patients’ perception of trust in physicians. Conclusions In the present study, the perceived quality of psychosocial care proved to have a significant effect on patients’ satisfaction with their hospital stay. Results of the current analysis thus indicate that psychosocial aspects of physician–patient interaction are of considerable importance in the medical care of seriously injured patients. Although this study is mainly based on subjective patient reported outcome, there is evidence that the subjective view of a patient is relevant in many aspects of medical treatment and outcome. These results already gave the motivation to develop a prospective interventional study with a training programme of communication skills to improve subjective and objective outcome parameters of severely injured patients.     

Efficiency of activation of the trauma team in a Norwegian trauma referral centre.

OBJECTIVE: To evaluate the efficiency (sensitivity, specificity, positive predictive value, overtriage, and undertriage) of activation of the trauma team in a Norwegian trauma referral centre. DESIGN: A cohort study with univariate and multivariate analysis. SETTING: A primary trauma hospital and trauma referral centre, Norway. SUBJECTS: 3391 injured patients admitted during a 12 months period, starting January 15th, 1996. MAIN OUTCOME MEASURES: Activation of the trauma team for severely injured patients and factors associated with correct activation. RESULTS: Of the 3383 injured patients admitted, 283 (8%) were classified as severely injured. Of 507 activations of the trauma team, 240 (47%) were for severely injured patients (sensitivity 85%, undertriage 15%, specificity 91%, overtriage 9%, positive predictive value 0.47). The system of activation was significantly more efficient for patients admitted by anaesthetist-manned ambulances than by ordinary ground ambulances (sensitivity 94% compared with 83%, corresponding positive predictive value 0.55 and 0.33, p < 0.05). Female sex and age over 70 years were independent factors associated with significantly less use of the trauma team in severely injured patients (p < 0.05). CONCLUSION: The undertriage rate of 15% and a positive predictive value of only 0.47 indicates a need for improvement of our activation system. Female sex and age over 70 years were significantly associated with undertriage in severely injured patients. Our protocol for triage and the initial treatment of severely injured patients has been revised in the light of these findings, and we have established a trauma registry.     

Recurrent trauma in elderly patients

HYPOTHESIS: Older patients (those aged > or = 70 years) who have experienced trauma have an increased risk of recurrent trauma. Demographic, medical, and functional factors are potential contributors to the risk of subsequent trauma among injured elderly patients. DESIGN: Retrospective follow-up study. PARTICIPANTS: Study participants were derived from the Longitudinal Study of Aging, an extension of the 1984 National Health Interview Survey focusing on persons who were aged 70 years and older in 1984. A cohort of elderly patients participating in the Longitudinal Study of Aging and hospitalized for injury in 1985 (n = 100) was identified using Medicare hospital discharge data. An uninjured cohort (n = 401) was also identified from the Longitudinal Study of Aging and matched for age (1 year) and sex. MAIN OUTCOME MEASURES: Risk of admission for trauma among the injured cohort compared with the uninjured cohort and associations between demographic, medical, and functional characteristics and trauma recurrence. RESULTS: Following adjustment for potential confounding factors, the injured cohort was 3.25 times more likely (95% confidence interval, 1.99-5.31) to be hospitalized for injury during the follow-up period compared with the uninjured cohort. Among the injured cohort, those at greatest risk of subsequent trauma included women and those with chronic medical conditions or functional impairments, the latter being the only factor independently associated with recurrence. CONCLUSIONS: Elderly patients who have experienced trauma are at increased risk of subsequent injury. Interventions to reduce the likelihood of trauma recurrence should focus on those with chronic illnesses and functional impairments.     

Effect of human neural progenitor cells on injured spinal cord

Human central nervous system ( CNS) has verylimited regenerative potentials. Patients withsevere injuries in the CNS such as spinal cordinjury (SCI) frequently endure lifelong disability. Avariety of methods have been tried to prevent spinalcord from further injury and foster regeneration afterSCI. Despite these efforts, an effective treatment forthis disease is still lacking. Since neural progenitorcells have already committed to become neural cells inthe CNS, they appear to be a good c…     

吻合胫前或胫后远端血管逆行供血的胸脐皮瓣修复小腿创面

目的：解决小腿创伤后，胫前或胫后主要血管之一长段受损栓塞，同时小腿中上段大面积软组织缺损、胫骨外露的创面修复问题。方法：临床收治小腿中上段大面积软组织缺损、胫骨外露９例，其中７例有胫前或胫后血管长段受损栓塞。采取以小腿远端胫前或胫后血管远端与腹壁下血管吻合的胸脐皮瓣移植修复创面。结果：９例术后移植皮瓣全部成活，皮瓣色泽、质地良好，创面完全修复。结论：只要小腿胫前或胫后主要血管之一正常，受损血管远端正常，逆行供血良好，即可采用该法处理。其优点为在小腿清创的同时解剖出受区血管，不影响患肢血供，不需牺牲健肢血管，不需强迫体位固定；在小腿下段肌肉少，血管位置浅，容易解剖，吻合血管方便；修复小腿中上段创面，移植皮瓣血管蒂平直，不需翻转成角。     

Recent applications of regenerative medicine to urologic structures and related tissues

PURPOSE OF REVIEW: A severe shortage of donor tissues and organs exists, which is worsening yearly given the aging population. Currently, patients suffering from diseased and injured organs are treated with transplanted organs or cells. This paper reviews recent advances that have occurred in regenerative medicine and describes application of new technologies to treat diseased or damaged organs and tissues. RECENT FINDINGS: Although most current strategies for tissue engineering depend upon a sample of autologous cells from the diseased organ of the patient, biopsies from patients with extensive end-stage organ failure may not yield enough normal cells. In these situations, stem cells are envisioned as being an alternative source. Stem cells can be derived from discarded human embryos (human embryonic stem cells), from fetal tissue, or from adult sources (bone marrow, fat, skin). Therapeutic cloning offers a potentially limitless source of cells for tissue engineering applications. SUMMARY: Recently, scientists in the fields of regenerative medicine and tissue engineering have applied the principles of cell transplantation, material science, and bioengineering to construct biological substitutes that will restore and maintain normal function in diseased and injured tissues.     

AUGER INJURIES IN THE WIMMERA REGION 1987–95

Background: Eighteen cases of auger injuries in the Wimmera region of Victoria were treated over 8 years. Methods: The records of auger related injuries presenting to Wimmera Base Hospital from March 1987 to March 1995 were reviewed. Results: Five of these were severe injuries. Sixteen were male farmers. Their fingers were most commonly injured by being caught in the auger flight. Conclusions: Augers have numerous mechanical features which make them one of the most potentially dangerous pieces of farm equipment. This, combined with human error and fatigue, results in significant but preventable morbidity in a hardworking population.     

Possibilities for rehabilitation in spinal injuries with or without neurological deficit]

Generally spine injured persons without neurological deficits can--as long as the principles of industrial medicine are observed--be occupationally integrated without any particular rehabilitation measures within the limits of their remaining capacity. Spine injured persons, however, with remaining instabilities, serious static deficiencies and/or neurological deficits need further rehabilitation after their in-patient and immediate posthospital treatment. Spinal cord injured patients usually have to accept serious changes and limitation in all spheres of life. Rehabilitation measure in work, school and the social field are vital. Despite all efforts at rehabilitation limitations do remain among other things in work, mobility and social contacts. The preceding paper presents the tasks and results of rehabilitation of spinal cord injured persons, special consideration being given to spinal cord injured persons with supporting facts from long term studies.     

腹腔积液对闭合性腹外伤患者空腔脏器损伤的诊断价值

目的:探讨腹腔积液对闭合性腹外伤患者空腔脏器破裂的诊断价值。方法:采用腹腔穿刺、腹部X线透视、B超及CT检查闭合性腹部外伤患者中非实质性脏器损伤128例,分析腹腔积液在空腔脏器损伤时的发生率及其临床意义。结果:术前检查发现腹腔积液101例(78.9%),B超发现腹腔积液81例(63.3%)。腹腔游离气体27.3%。B超对腹腔积液有较高的确诊率。结论:腹腔积液是诊断腹部空腔脏器损伤的重要征象。     

Health outcomes of adults 3 months after injury

BACKGROUND: Injury is a leading cause of preventable mortality and morbidity in Australia and the world. Despite this there is little research examining the health related quality of life of adults following general trauma. METHODS: A prospective cohort design was used to study adults who presented to hospital following injury. Data regarding injury and demographic details was collected through the routine operation of the Queensland Trauma Registry (QTR). In addition, the short form 36 (SF-36) was mailed to patients approximately 3 months following injury. RESULTS: Participants included 339 injured patients who were hospitalised for >or=24h in March-June 2003. A secondary group of 145 patients completed the SF-36, but did not have QTR data collected due to hospitalisation being <24h. Both groups of participants reported significantly lower scores on all subscales of the SF-36 when compared to Australian norms. CONCLUSIONS: Health related quality of life of injured survivors is markedly reduced 3 months after injury. Ongoing treatment and support is necessary to improve these health outcomes.     

The I.V. In-stopper: A method to guard fingertip's K-Wires in children

Summary A simple device is presented to prevent children's fingertips from being injured by K-wires. It consists of a sterile I.V. “in-stopper”, having the following advantages: long standing; awareness of its presence by both the patient and his companions; sterile availability. This device might also be useful in adults.     

手法整复经皮锁定钢板内固定治疗胫腓骨中下段骨折

目的：探讨用手法整复,经皮锁定钢板内固定治疗胫腓骨中下段骨折的临床疗效。方法：2006年1月至2009年10月,采用闭合整复锁定钢板内固定治疗此类损伤46例,男27例,女19例;年龄17～56岁,平均39岁。骨折按AO分型：A型12例,B型24例,C型10例：入院至手术时间2h～3d,伤后患者患肢肿胀,疼痛,可及骨擦音。术后对患者伤口情况,患肢功能,骨折愈合方面进行观察,结果：术后所有病例切口I期愈合,未见感染。骨折的愈合时间为12-18周,平均14周。46例患者获得随访,随访时间12～18个月,平均15个月,疗效结果,治愈40例,好转4例,未愈2例。结论：手法整复锁定钢板内固定治疗此类骨折损伤小、固定可靠、骨折愈合快,功能恢复好．     

The presentation of gallstones and results of biliary surgery in a spinal cord injured population.

BACKGROUND: Since spinal cord injured patients lack visceral sensation, their clinical manifestations of gallstones could be relatively occult. A higher proportion of these individuals may present with advanced biliary disease compared with the general population. Prophylactic cholecystectomy for asymptomatic stones may therefore be justified. METHODS: All spinal cord injured patients seen at the Seattle Veterans Hospital over a 5-year period were retrospectively surveyed to define a set of patients who had undergone a cholecystectomy. The operative indications and results were compared with those from a series of cholecystectomies in neurologically intact patients. RESULTS: The presentation of biliary disease in spinal cord injured patients was not more advanced than that of neurologically intact patients. Patients with high cord injuries presented in a similar fashion to those with low injuries. CONCLUSIONS: Since most spinal cord injured patients with biliary disease present with typical findings, prophylactic removal of gallstones in these patients is not warranted.     

Outcomes after ruptured abdominal aortic aneurysms: the "halo effect" of trauma center designation

BACKGROUND: Trauma centers have an array of services available around the clock that help reduce mortality in injured patients. Having such services available can benefit patients other than those who are injured. We set out to determine whether patients hospitalized with ruptured abdominal aortic aneurysms experience lower morbidity and mortality at regional trauma centers than at other acute care hospitals. STUDY DESIGN: We conducted a retrospective cohort study with the exposure being care at a trauma center and outcomes either mortality or organ failure. We evaluated all patients 40 to 84 years of age with a diagnosis of a ruptured abdominal aortic aneurysm who underwent operation during 2001 in 20 US states with organized systems of trauma care. We determined the relative risk of either death or organ failure at regional trauma centers compared with nondesignated centers. RESULTS: Of 2,450 patients hospitalized for ruptured abdominal aortic aneurysm, 867 (35%) hospitalizations occurred at regional trauma centers. At trauma centers, 41.4% of patients died before hospital discharge, compared with 45.2% of patients at nondesignated hospitals (odds ratio [OR], 0.85; 95% CI, 0.71-1.02). After adjusting for payor, hospital beds, annual hospital admissions, annual inpatient operations, affiliation with a vascular surgery fellowship, and comorbid illnesses, the likelihood of death or organ failure was lower at trauma centers (OR, 0.72; 95% CI, 0.55-0.93). CONCLUSIONS: Care at regional trauma centers after operative repair of ruptured abdominal aortic aneurysm is associated with improved outcomes. We postulate that these benefits reflect the ability of both vascular and general surgeons to immediately mobilize resources for care of the patient requiring urgent operative intervention. The beneficial effects of trauma center designation might extend beyond caring for the critically injured.