John H. Davis

Trauma center-related biases in injury research.

OBJECTIVES Most studies from trauma centers analyze and present combined data on patients from their surrounding communities and patients referred for specialized services from service areas of other hospitals. Information is needed about the effect of combining data from the two groups on conclusions about injury in the community. METHOD All injured patients seen in a trauma center emergency department of 30% of days over one year were studied concerning referral status, age, sex, type of activity when injured, injury type and severity, hospitalization, and prior medical history. RESULTS Combining data for both groups suggested an older, more medically impaired population, with more severe injuries, more frequent hospitalization, more serious head and spine injuries, fewer extremity fractures, and fewer household-related and more transportation-related injuries than were actually occurring in the community. CONCLUSIONS Data from local and out-of-area referred patients at trauma centers should be analyzed and presented separately in studies from this source if an accurate representation is to be provided of the role of injury in the population at large of the community.

The peritoneal fluid in strangulation obstruction. The role of the red blood cell and E. coli bacteria in producing toxicity.

Summary An extensive investigation of the lethal properties of peritoneal fluid obtained from dogs dying of experimental strangulation obstruction of the small intestine has been carried out. Similar studies were also carried out on fluid obtained from a human with strangulation obstruction. The rat was used as a recipient animal, and the results obtained were then confirmed in the dog. It was found that the toxicity of strangulation fluid appears to be due to the presence of a hemoglobin concentration greater than 1 gm, per cent and a level of {ulE. coli} of 10 7 organisms per milliliter or higher. These findings were true of strangulation fluid from a human as well as strangulation fluid obtained from dogs. Furthermore, it was found posible to create a fluid of similar toxicity and physiologic action by growing {ulE. coli} in nutrient broth containing whole blood or saline washed red blood cells. The major portion of the toxicity of the red blood cell appears to reside in the soluble fraction of hemolyzed cells rather than in the red cell stroma. It is felt that a further understanding of the manner in which the red blood cell or its constituents interfere with the normal defense mechanisms in the peritoneal cavity may shed additional light on the problem of host resistance as a whole.

The injury impairment scale as a measure of disability

Scores on the Injury Impairment Scale (IIS) were compared with reported disability for work or school, household activities, and activities of daily living during the first 18 months after injury for 2,194 persons treated in an emergency department or hospitalized for their injuries. Persons whose most severe injury was more life-threatening or who had larger numbers of injuries more often had higher IIS scores for their most life-threatening injury than did persons with fewer or less life-threatening injuries. Hospitalized patients had higher IIS injuries more often than did emergency department patients. As IIS increased, duration of disability also increased. However, many high IIS patients either reported no disability or disability of only short duration, suggesting only limited association between disability and IIS as it is currently designed.

Dose dependency of granulocyte-macrophage colony stimulating factor for improving survival following burn wound infection.

Infections remain a serious problem following injury. Immune modulation offers an additional strategy for the treatment of infections. We evaluated the ability of a multilineage hematopoietic growth factor, granulocyte-macrophage colony-stimulating factor (GM-CSF), to improve survival following burn injury with a superimposed burn wound infection. Groups of 12 BDF1 mice received a 15% total body surface area (TBSA) thermal injury by immersion in 100 degrees C water; 6 x 10(3) Pseudomonas was then applied to the burn wound. The GM-CSF was injected subcutaneously B.I.D. for 7 days. Mice receiving the 10-ng dose of GM-CSF had significantly improved survival compared with the controls; other doses had no significant effect on survival. Clinical trials to assess the ability of GM-CSF to reduce infectious complications following burn injury are underway and these data suggest selecting a specific dose may be critical in achieving maximal benefit.

Emergency department care and hospitalization as predictors of disability.

Duration of complete and partial disability for work, school, and home activities and activities of daily living during the first 18 months after injury were compared for 2,043 emergency department (ED) patients and 151 hospitalized patients from 22 northwestern Vermont communities who received their initial medical care for injury at the Medical Center Hospital of Vermont and were subsequently interviewed. Larger proportions of hospitalized patients than ED patients had any disability or prolonged disability. During almost all time frames, and even among patients who still had ongoing disability at 18 months, the majority of persons with disability had required ED treatment only. These data suggest that, based on disability, ED patients should not necessarily be considered to have merely minor injuries.

Adult respiratory distress syndrome (ARDS), sepsis, and extracorporeal membrane oxygenation (ECMO).

This report presents data obtained in the care of 830 patients requiring assisted ventilation. When these patients were divided into groups by the severity of their respiratory failure as defined by the duration of ventilatory assistance (greater than 48 hours, less than 48 hours) and level of positive end expiratory pressure (PEEP) required (greater than 5 cm HoH, less than 5 cm HoH), it was found that evidence of concurrent bacterial infection was present in the majority of patients with severe respiratory failure. This finding could not be explained by infection acquired after the onset of respiratory failure. In addition, this analysis demonstrated the important association of active pulmonary infection with the occurrence of barotrauma in these patients. Case analysis of patients subjected to extracorporeal membrane oxygenation has led to the suggestion that underlying sepsis in patients failing to respond to conventional ventilatory assistance similarly limits the usefulness of membrane oxygenator support.

Prolonged warm ischemia and limb survival : case report

A 21-year-old woman sustained a supracondylar crush injury of her arm. The extremity underwent severe ischemia for more than 16 hours after an unsuccessful brachial artery repair. The forearm muscles became rigid and the fingers could not be extended passively. Clinically these findings were felt to be similar to rigor mortis. Despite this dismal picture, secondary revascularization resulted in a highly functional hand with no loss of digits. Desperate attempts at revascularization in isolated extremity injury may be successful, despite prolonged warm ischemia time.

Results in the treatment of meningococcic meningitis with antitoxin and sulfonamide drugs

Summary An over-all mortality rate of 13.2 per cent was obtained in 309 patients treated with a combination of sulfonamide drugs and antitoxin. A corrected mortality rate of 8.8 per cent was obtained when we excluded those patients who were dead on arrival or who were moribund and died within forty-eight hours. This mortality rate of 8.8 per cent would be even less (that is 7.6 per cent) if we would exclude such patients as actually died from some other conditions although the latter were initiated by the infection itself. In general practice, physicians should strive for the same low mortality rate as obtained by the military, but it must be remembered that the civilian patient may be of any age and have an underlying pathologic condition which makes recovery almost impossible.

THE CHANGING OF THE GUARD

Associate Editors STANLEY M. AWRAMIK University of California, Santa Barbara JOHN A. BARRON United States Geological Survey ANNA K. BEHRENSMEYER Smithsonian Institution CARLTON E. BRETT University of Rochester KIYOTAKA CHINZEI Kyoto University A.A. EKDALE University of Utah FRANZ T. FURSICH Universitat Wurzberg ROBERT A. GASTALDO Auburn University DOUGLAS S. JONES Florida Museum of Natural History SUSAN M. KIDWELL University of Chicago GILBERT KLAPPER University of Iowa KENNETH G. MILLER Rutgers University SIMON CONWAY MORRIS Cambridge University GUY M. NARBONNE Queens University JUDITH TOTMAN PARRISH University of Arizona GREGORY J. RETALLACK University of Oregon ROBERT W. SCOTT Precision Stratigraphy Associates PETER M. SHEEHAN Milwaukee Public Museum ROGER D.K. THOMAS Franklin and Marshall College