Missed injury in major trauma patients

OBJECTIVES: To determine the incidence, aetiology and contributing factors to injuries being missed during the primary and secondary surveys in patients with major trauma managed on a general Adult Intensive Care Unit (AICU). METHODS: The records for patients admitted to the AICU following severe injury (defined as injury severity score (ISS) >16) over a 1-year period were reviewed. Diagnostic imaging performed during the resuscitation was reviewed in cases where missed injuries were discovered. RESULTS: Forty-five patients with a median injury severity score of 26 were included in the study. Twelve missed injuries were discovered in 10 patients during the intensive care admission; three required an additional surgical procedure. There was no significant difference in Glasgow Coma Score, revised trauma score, ISS or admission systolic blood pressure between patients with missed injuries and those patients where all injures were found at resuscitation (P > 0.05). Three quarters of the undetected injuries were orthopaedic. CONCLUSIONS: Significant injuries can be missed during the primary and secondary surveys in severely injured patients. A tertiary survey should be completed in all trauma patients admitted to an intensive care unit.     

Reinforcement-related brain potentials from medial frontal cortex: origins and functional significance

The development of the field of cognitive neuroscience has inspired a revival of interest in the brain mechanisms involved in the processing of rewards, punishments, and abstract performance feedback. One fruitful line of research in this area was initiated by the report of an electrophysiological brain potential in humans that was differentially sensitive to negative and positive performance feedback [J. Cogn. Neurosci. 9 (1997) 788]. Here we review current knowledge regarding the neural basis and functional significance of this feedback-evoked 'error-related negativity' (ERN). Our review is organized around a set of predictions derived from a recent theory, which holds that the ERN is associated with the arrival of a negative reward prediction error signal in anterior cingulate cortex.     

Chinese cultural influences on parental caregiving obligations toward children with disabilities

The author draws on the personal and public dilemmas that result when Chinese families care for children with disabilities. She employed an ethnographic approach to interview 15 Hong Kong Chinese families caring for children aged 5 to 16 with disabilities. Twelve of these families included sons with disabilities. The following themes emerged: disruptions to natural order, public opinions on what constitutes personhood and ordered bodies, and the establishment of moral reputations linked to shame and blame and the gendered division of parenting. The author highlights the centrality of parenthood in Chinese society as the acceptance of responsibility and its cyclic enactment, and emphasizes how the care of children with handicaps strains and violates the Chinese culturally expected order of parental obligations.     

Why is there an ERN/Ne on correct trials? Response representations, stimulus-related components, and the theory of error-processing

The ERN or Ne is a component of the event-related brain potential that occurs when human subjects make errors in reaction time tasks. It is observed in response-locked averages, time-locked to the execution of the incorrect response. Recent research has reported that this component is present on correct response trials, thereby challenging the idea that the component is specifically related to error-processing. In this paper, we argue that the ERN or Ne observed on correct trials can be attributed to one or both of two factors: either there is error-processing on correct trials, and/or the response-locked averages used to derive the ERN/Ne are contaminated by negative components evoked by the stimulus. For this reason, there is no reason to abandon theories that relate the ERN/Ne to error-processing.     

D2 lymphadenectomy in the management of gastric cancer

Background Gastric carcinoma is a significant cause of death in Ireland. Surgery offers the best option of cure, but the five-year survival following resection remains dismal at 10–15%. Experience from Japan and from some Western units suggest that an extended (D2) lymphadenectomy in association with gastrectomy increases the prospect of cure, but concern about the morbidity and mortality of this operation and lack of evidence from randomised studies has limited its acceptance. Aims This study reports the experience of a specialist upper gastrointestinal unit with D2 gastrectomy in a four-year audit. Methods Sixty-two resections were performed for gastric cancer. Results Nineteen patients were deemed unsuitable for the D2 procedure and underwent a more limited lymphadenectomy (DO or D1). Forty-three patients underwent D2 resection, 12 with an oesophagogastrectomy, 22 with total gastrectomy and nine with a sub-total distal resection. Eight patients undergoing D2 resection had extended resections, five with splenectomy and three with a distal pancreatectomy. Post-operative complications occurred in 31% of patients. Thirty-day and 90-day mortality were zero. Median survival was 822 days in the D2 group (range 120–1,320). Conclusions These results show that a D2 gastrectomy can be performed with a low morbidity and mortality and a median survival of greater than two years.     

Increased expression of interleukin-9, interleukin-9 receptor,and the calcium-activated chloride channel hCLCA1 in the upper airways of patients with cystic fibrosis

OBJECTIVES/HYPOTHESIS: Mucus overproduction is commonly found in airway disease in patients with cystic fibrosis. Interleukin-9 (IL-9) has been shown to mediate airway hyper-responsiveness and mucus overproduction. Recently, the calcium-activated chloride channel hCLCA1 has been described to be upregulated by IL-9 and has been thought to regulate the expression of soluble gel-forming mucins. We sought to examine the expression of IL-9, interleukin-9 receptor (IL-9R), and hCLCA1 in the upper airway of patients with cystic fibrosis in comparison to healthy control subjects and to demonstrate the relationship of IL-9, IL-9R, and hCLCA1 expression with mucus production. STUDY DESIGN: Prospective design. METHODS: Biopsy samples from nasal polyps of four patients with cystic fibrosis, nasal mucosa of six patients with cystic fibrosis, sinus mucosa of eight patients with cystic fibrosis, and nasal mucosa of six healthy control subjects were stained with periodic acid-Schiff (PAS) to identify mucus glycoconjugates. IL-9, IL-9R, and hCLCA1 expression was determined by immunocytochemical study. RESULTS: We demonstrated significant increases in IL-9, IL-9R, and hCLCA1 immunoreactivity in the mucosa of patients with cystic fibrosis compared with that found in control subjects (P <.05). There were no significant differences between the different locations (nasal polyps, nasal mucosa, and sinus mucosa) in the patient group (P >.05). We also observed a significant increase in the number of mucus-producing cells in biopsy specimens from patients with cystic fibrosis in comparison to control subjects. A positive correlation was found between hCLCA1-positive cells and IL-9-positive cells (correlation coefficient [r] = 0.79, P <.05) or IL-9R-positive cells (r = 0.92, P <.05). Moreover, a positive correlation was also present between PAS-positive (mucus-producing) cells and hCLCA1-positive cells (r = 0.64, P <.05) or IL-9R-positive cells (r = 0.64, P <.05). CONCLUSIONS: Increased expression of IL-9 and IL-9R, as well as upregulation of hCLCA1, in mucus-overproducing epithelium of patients with cystic fibrosis supports the hypothesis that IL-9 contributes to mucus overproduction in cystic fibrosis. Expression of hCLCA1 may also be responsible, in part, for the overproduction of mucus. These preliminary findings suggest that hCLCA1 might be an interesting new therapeutic target to control mucus overproduction in airway disease in patients with cystic fibrosis.     

The use of the fluorescein disappearance test in the management of childhood epiphora

PURPOSE. The fluorescein disappearance test (FDT) is reported to be an objective measure of lacrimal outflow in congenital non-canalisation of the nasolacrimal system. We introduced FDT into our evaluation of children with epiphora to investigate its sensitivity/specificity with regard to symptoms in a prospective study. We also examined the FDT against findings at syringing and probing (S&P) and persistence or resolution of symptoms on follow-up. METHODS. Over a period of 16 months, 88 consecutive children (median age 12 months; range 2.5-192) with epiphora were reviewed and FDT measured at 5 and 10 minutes; 66 FDT were evaluated for inter-observer variation in a masked fashion. S&P were scheduled on the basis of symptoms, abnormal FDT and age "1 year. Normal FDT prompted review. Younger children were observed for natural history and possible resolution with repeat FDT. Equivocal symptoms and normal FDT initiated discharge and telephone review. RESULTS. Inter-observer correlation coefficient = 0.86. Sensitivity/specificity of FDT was 76/76% at 5 minutes and 63/89% at 10 minutes, respectively. In patients under 1 year of age undergoing follow-up (29 patients; 38 eyes) FDT at 10 minutes correctly predicted persistence of symptoms in 65% and resolution in 66% of eyes (follow-up 3-14 months; mean 6); 23 patients (mean age 27 months; range 12-72) underwent S&P with positive surgical findings in 20 (87%). On review, symptoms had improved in 64% eyes (20/31). CONCLUSION. FDT at 5 minutes is an objective measure of symptoms with high inter-observer agreement and agreement with surgical findings. FDT read at 10 minutes may be useful to indicate the persistence or resolution of symptoms and guide patient management.     

The three dimensions of headache impact: pain, disability and affective distress

It is increasingly recognized that pain measures alone provide incomplete information about the impact of pain on functioning or quality-of-life. A wide range of measures that promise to provide additional information about the impact of pain on people's lives are thus coming into use. In order to clarify the construct of headache impact, we attempted to identify the dimensions assessed by a set of 22 headache-impact measures and to identify the specific measures that best assessed each of these headache-impact dimensions. Adults (n=329) with frequent benign headache disorders completed a comprehensive assessment battery that included 22 headache-impact measures. Factor analysis was then used to identify dimensions underlying the headache-impact measures. Three factors labeled Affective Distress, Pain Density and Disability best accounted for correlations among headache-impact measures. Interfactor correlations ranged between 0.37 and 0.20, suggesting three correlated but separable impact dimensions. These results suggest the construct of headache impact needs to be broadened beyond pain and disability to include affective distress. An adequate assessment of the impact of recurrent headache disorders in clinical trials and other research may require measures from all three of the headache-impact dimensions identified here.     

Translation of questionnaires and issues of equivalence

The validity of studies using translated instruments may be questioned when there is a lack of attention to and/or minimal explanation of the procedures used for determining the equivalence between the primary and secondary language tool. Ensuring equivalence of a translated Chinese version of the Menstrual Distress Questionnaire is an important prerequisite for identifying culturally specific expressions of concepts under investigation and for cross-cultural comparisons. This paper examines the principles and procedures for determining equivalence of translated tools and their application to the development of an equivalent Chinese version of the Menstrual Distress Questionnaire. Translation and back-translation were used to develop a Chinese version of the Menstrual Distress Questionnaire. Bilingual university students completed both versions of the Menstrual Distress Questionnaire. Most of the Menstrual Distress Questionnaire items had an acceptable Kappa of >0.4. Intraclass correlation coefficients indicated moderate to high levels of equivalence for total scores and all scales. Improvement in the translation of some items is needed to further enhance the equivalence of the Chinese version of the Menstrual Distress Questionnaire.     

ENDOTHELIAL CELL CULTURE AND SEEDING OF PROSTHETIC VASCULAR GRAFTS: AN EXPERIMENTAL STUDY

Current synthetic vascular prostheses do not acquire lining of vascular endothelium in humans or dogs. Endothelial seeding of vascular grafts has been proposed as a means of reducing the thrombogenicity of these grafts. We examined feasibility of cultivating endothelial cells (EC) by tissue culture technique and their subsequent seeding onto small diameter polytetra fluoroethylene (PTFE) grafts. Twenty adult dogs underwent common carotid artery interposition with 4 mm PTFE grafts. Ten dogs received seeded and the remaining ten received unseeded grafts. Grafts were removed at 4 and 12 weeks and their gross/morphological features compared. Cumulative patency rates for seeded grafts were 70% as compared to unseeded ones 30%. Seeded grafts were completely surfaced with a mono-layer of endothelium by 4 weeks. Small graft patency appears to be related to the establishment of an endothelial surface, the development of which is clearly facilitated by seeding with autogenous endothelium.KEY WORDS: Endothelial cell seeding, Vascular grafts