All patients with truncal gunshot wounds deserve trauma team activation

BACKGROUND: Traditional criteria for trauma team activation (TTA) include hypotension, tachycardia, tachypnea, and unresponsiveness. In a recent revision of the Resources for Optimal Care of the Trauma Patient, gunshot wound to the trunk (GSWT) was recommended as an independent criterion for major resuscitation and TTA. To validate this suggestion, we reviewed records of patients with GSWT to see if patients not meeting standard TTA criteria had serious injuries that would benefit from TTA. METHODS: This study was a retrospective trauma registry study at a large Level I trauma center. Records of all patients over an 8.5-year period with GSW to chest, back, or abdomen/pelvis were included in the study. Patients who died in hospital, required ICU admission within 24 hours, had non-orthopedic operation within 24 hours, or had ISS > 15 were considered severely injured, and were assumed to benefit from TTA. RESULTS: Between January 1993 and June 2000, 4,198 patients were admitted with GSWT, 94% of whom met traditional TTA criteria. Sixty-one percent of patients meeting traditional TTA criteria had severe injury, compared with 45.7% for those without TTA criteria. Of the 234 patients who did not meet traditional TTA criteria, 9.4% required early ICU admission, 29.5% required non-orthopedic operation within 24 hours, and 1.3% died. CONCLUSION: Patients with GSWT often require high-level care, even when physiologic TTA criteria are absent on admission. Gunshot wound to the trunk should be an independent criterion for TTA.     

Leukocytosis after posttraumatic splenectomy: a physiologic event or sign of sepsis?

HYPOTHESIS: Although elevations in white blood cell count (WBC) and platelet count (PC) after splenectomy for trauma constitute a physiologic event, certain WBC and PC patterns help differentiate patients with from those without sepsis. DESIGN: Medical record and trauma registry record retrospective review. SETTING: Academic level I trauma center. PATIENTS: From February 1997 through May 2001, 118 trauma patients underwent splenectomy. Sixty patients developed postoperative sepsis (pneumonia, abdominal infection, septicemia, or severe urinary tract infection) (septic group) and 58 did not (nonseptic group). MAIN OUTCOME MEASURES: White blood cell count, PC, and PC/WBC. RESULTS: After the fifth postoperative day, the WBC of patients with sepsis remained consistently greater than 15 x 10(3)/microL and the PC/WBC remained consistently less than 20. In patients without sepsis, these values remained less than 15 x 10(3)/microL and greater than 20, respectively. Stepwise regression analysis identified 3 independent predictors of sepsis: (1) day 5 PC/WBC less than 20, (2) Injury Severity Score greater than 16, and (3) day 5 WBC greater than 15 x 10(3)/microL. According to a statistical prediction model, the probability of sepsis when all 3 predictors were present was 97.4%; when all 3 were absent, it was 2.5%. CONCLUSIONS: At and after the fifth postoperative day, a WBC greater than 15 x 10(3)/microL and a PC/WBC less than 20 are highly associated with sepsis and should not be considered as part of the physiologic response to splenectomy. In view of the seriousness of postsplenectomy sepsis, these values may be used to increase vigilance and prompt early aggressive treatment.     

Rel/NF-kappa B/I kappa B signal transduction in the generation and treatment of human cancer

In order to improve the sensitivity of our previously established thyroid carcinogenesis model and to clarify whether endocrine disrupting chemicals with weak estrogenic activity have any modifying effects on the development of thyroid proliferative lesions, 6-week-old female castrated F344 rats were first given a single subcutaneous injection of 2000 mg/kg body weight of N-bis(2-hydroxypropyl)nitrosamine. From 1 week later, they received diets with: no supplement (basal diet (BD) group); cholesterol pellets containing 0.5 mg 17 beta-estradiol 3-benzoate (EB); or diet admixed with 1000 ppm methoxychlor (MXC) or 10,000 ppm bisphenol A (BPA) for 20 weeks. Furthermore, additional groups were administered 200 ppm sulfadimethoxine (SDM) in the drinking water simultaneously with the BD, EB, MXC or BPA treatments. Thyroid follicular cell hyperplasias, adenomas and/or carcinomas were induced only in the EB+SDM group, the incidences of non-malignant lesions being significantly increased, as compared with the BD+SDM group values. Furthermore, the serum level of thyroid stimulating hormone (TSH) was significantly increased in this group. No significant variation in quantitative values for thyroid proliferative lesions or TSH levels were observed in the other treated groups. The results of the present study convincingly indicate that EB, with strong estrogenic activity, but not MXC and BPA, with weak estrogenic activities, exerts promoting effects on thyroid carcinogenesis in rats. The present modified rat two-stage thyroid carcinogenesis model appears to have advantages over our previous model for screening purposes.     

Electrostimulation for the prevention of deep venous thrombosis in patients with major trauma: a prospective randomized study

BACKGROUND: Current methods of posttraumatic thromboprophylaxis (heparins and sequential compression devices) are inadequate. New methods should be tested. Muscle electrostimulation (MEST) has been used over the years with mixed-but predominantly encouraging-results for a variety of conditions, including prevention of deep venous thrombosis (DVT). It has not been tested in multiple trauma patients. METHODS: Trauma patients with Injury Severity Score higher than 9 who were admitted to the intensive care unit and had a contraindication for prophylactic heparinization were randomized to groups MEST and control. MEST patients received 30-minute MEST sessions twice daily for 7 to 14 days. Venous flow velocity and venous diameter were measured by duplex venous scan. Venography-or, if not available, duplex-was used to evaluate the presence of proximal and peripheral DVT between days 7 and 15. RESULTS: After exclusions, 26 MEST and 21 control patients completed the study and received outcome evaluation by venography (25) or duplex (22). Three patients in each group developed proximal DVT (11.5% vs 14%, P = .79), and an additional 4 (15%) MEST group and 3 (14%) control group patients developed peripheral DVT ( P = .96). There was no difference in venous flow velocity or venous diameter between the groups. CONCLUSIONS: MEST was not effective in decreasing DVT rates in major trauma patients.     

Evaluation of povidone-iodine as vesical irrigant for treatment and prevention of urinary tract infections

This is a preliminary study evaluating diluted solutions of povidone-iodine (PVP-I) as urinary bladder irrigants for the treatment and prevention of urinary tract infection. Diluted povidone-iodine solutions were used as indwelling catheter irrigants and as instillations into the urinary bladder following intermittent catheterization. The diluted PVP-I solutions had no efficacy in either the treatment or prevention of urinary tract infections when used as indwelling urethral or suprapubic catheter irrigants. There was a suggestion of a slight decrease in the incidence of urinary tract infections during the use of PVP-I in the intermittent catheterization group in this uncontrolled study, but the percentage of positive urine cultures was greater than desired. The absence of any unfavorable data has led us to conclude that the diluted PVP-I caused no undesirable side effects in any of the patients treated with this agent. PVP-I bladder irrigation warrants further investigation in special cases such as lower urinary tract fungal infections.     

Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features

There are two histological types of pyogenic granuloma (PG) of the oral cavity: the lobular capillary hemangioma (LCH) and non-LCH type. The aim of the present study was to examine and compare the clinical features, etiological factors, diameter of vascular elements and immunohistochemical features of LCH and non-LCH histological types of PG to determine whether they are two distinct entities. Thirty cases of LCH and 26 cases of non-LCH PG were retrieved and retrospectively studied. Clinically, LCH PG occurred more frequently (66.4%) as sessile lesion whereas non-LCH PG occurred as pedunculated (77%). Non-LCH PG was associated more frequently (86.4%) with etiological factors. The lobular area of the LCH PG contained a greater number of blood vessels with small luminal diameter than did the central area of non-LCH PG. In the central area of non-LCH PG a significantly greater number of vessels with perivascular mesenchymal cells non-reactive for alpha-smooth muscle actin and muscle-specific actin was present than in the lobular area of LCH PG. The differences found in the present study suggest that the two histological types of PG represent distinct entities.     

Proposal for electroencephalogram standardization in aircrew selection

Current diagnostic electroencephalogram (EEG) investigations in aircrew selection and certification lack both standardization and reference to universally applicable criteria for their effective use. Extrapolation from clinical EEG studies may not be appropriate. Recent studies on serial EEGs in aircrew are lacking, whereas follow-up of individuals who failed certification is nonexistent. Population-based EEG studies in healthy subjects are generally underpowered to establish the significance of pathological EEG findings. Advanced digital video/EEG recording, in combination with standardization of data exchange formats and automated detection of pathological grapho-elements, is cost effective when carried out for extended periods, e.g., during flight simulator sessions. Extensive databases of serial video/EEG records in aircrew may thus be easily obtained and validated over time. Prognostic inferences on the significance of pathological EEG discharges may subsequently be derived from these databases.