Impact of Non-Automobile Rollover Accidents on Patient Outcomes at an Appalachian Level I Trauma Center.

The objective of this study was to evaluate outcomes of patients involved in rollover accidents in non-automobile vehicles in a rural level I trauma center. This was a retrospective study including a total of 127 patients over 5 years who were admitted to our level I trauma center following rollover accidents in either of the following: ATV, lawnmower, or tractor. Patients were significantly older in the tractor and lawnmower rollover groups, and patients less than 65 years old were significantly more likely to sustain an injury in a rollover accident when compared to those greater than 65. Patients with extremity fractures secondary to tractor rollovers were more likely to be older, and patients who sustained spinal injuries secondary to tractor rollovers were more likely to be younger. Non-automobile rollovers have the potential to cause traumatic injuries; however, there does not appear to be 1 vehicle type that is more prone to injury.

A National Survey Assessing the Variability in the Management of Traumatic Cardiac Arrest.

BACKGROUND: Resuscitation of traumatic cardiac arrest (TCA) is variable, with approaches that overlap Advanced Trauma Life Support (ATLS) and Advanced Cardiac Life Support (ACLS) algorithms. There is no standard algorithm for TCA, with some withholding ACLS protocols given abysmal outcomes. This study aims to assess surgeon practices and attitudes toward resuscitation practices in TCA. MATERIALS AND METHODS: A 16-question web-based survey was distributed to the membership of a national trauma association. Respondent demographics and management of TCA were analyzed. Chi-squared tests determined statistical significance. Open-ended responses were coded and analyzed inductively. RESULTS: Two hundred and three surveys were completed. 73.4% of respondents reported utilizing ACLS, while 26.6% reported they never utilized ACLS. A statistically significant difference in the performance of ACLS was found based on number of years in practice (P = .025) and the state of practice (P = .006). There was no significant difference in self-reported survival rates or legal, ethical, or interpersonal conflicts. Qualitative data highlighted themes of interpersonal conflict and futility. DISCUSSION: This study shows that one-quarter of respondents never utilize ACLS in TCA. Of those that utilize ACLS, there was variability in the technique, indication, and duration of resuscitation. Despite significant variability in technique, there appears to be similar survival rates and incidence of conflict. The association between years in practice and ACLS use suggests this may represent an emerging change in practice. The low response rate limits generalizability; however, there is significant variability in practice, highlighting a need for evidence-based guidelines.

Extended Experience of Lower Dose Sapropterin in Irish Adults with Mild Phenylketonuria.

Adherence to dietary and treatment recommendations is a long-standing concern for adults and adolescents with PKU and treating clinicians. In about 20-30% of PKU patients, Phe levels may be controlled by tetrahydrobiopterin (BH4) therapy. The European PKU 2017 Guidelines recommends treatment with BH4 for cases of proven long-term BH4 responsiveness, with a recommended dosage of Sapropterin 10-20 mg/kg/day.We report four young Irish patients with mild PKU, known to be BH4 responsive, who were treated with lower doses of Sapropterin for over 7 years.Case 1: Female, currently age 20. Genotype p. 165T/p/F39L, c.[194T>C]; [117C>G]. Newborn Phe: 851 µmol/L. Pre-Sapropterin Phe tolerance: 600 mg Phe/day to maintain Phe levels <400 µmol/L. Commenced on Sapropterin 400 mg (6.5 mg/kg/day) with increase in Phe tolerance to 800 mg/day.Case 2: Female, currently age 23. Genotype p. 165T/pF39L; c.[194T>C]; [117C>G]. Newborn Phe: 714 µmol/L. Pre-Sapropterin Phe tolerance: 700 mg Phe/day. Commenced on Sapropterin 400 mg (8 mg/kg/day) with increase in Phe tolerance to 800 mg/day.Case 3: Male, currently age 22. Genotype p. 165T/p.S349P; c.[194T>C][1045T>C]. Newborn Phe: 1,036 µmol/L. Pre-Sapropterin Phe tolerance: 600 mg Phe/day. Commenced on Sapropterin 400 mg (5.4 mg/kg/day). Increased to 1,600 mg Phe/day.Case 4: Female, currently age 29. Genotype p.R408W/p/p.Y414C; c.[1222C>T], [1241A>G]. Newborn Phe: 1,600 µmol/L. Pre-Sapropterin tolerance: 450 mg/day. Commenced on Sapropterin 400 mg (5.0 mg/kg/day). Increased to 900 mg Phe/day.Almost 7 years of surveillance for these four patients has shown that this dose of Sapropterin (range 5-8 mg/kg day) was well tolerated and effective with a significant response to treatment and a marked improvement in quality of life at these lower Sapropterin doses.

Deletion of the alpha(1,3)galactosyl transferase (GGTA1) gene and the prion protein (PrP) gene in sheep.

Nuclear transfer offers a cell-based route for producing precise genetic modifications in a range of animal species. Using sheep, we report reproducible targeted gene deletion at two independent loci in fetal fibro-blasts. Vital regions were deleted from the alpha(1,3)galactosyl transferase (GGTA1) gene, which may account for the hyperacute rejection of xenografted organs, and from the prion protein (PrP) gene, which is directly associated with spongiform encephalopathies in humans and animals. Reconstructed embryos were prepared using cultures of targeted or nontargeted donor cells. Eight pregnancies were maintained to term and four PrP-/+ lambs were born. Although three of these perished soon after birth, one survived for 12 days. These data show that lambs carrying targeted gene deletions can be generated by nuclear transfer.

Pneumonia and psychotropic drug use in elderly psychiatric patients.

A study of the use of psychotropic drugs among 30 elderly psychiatric patients with pneumonia (15 of whom died), in comparison to the general elderly population of the hospital, revealed a negative association between the use of psychotropic agents and the development of pneumonia. The factors of age, sex, pre-existing illness, and organism virulence/patient resistance were all associated with death from pneumonia. However, the present findings do not support the hypothesis that psychotropic drugs are implicated in pneumonia deaths among elderly psychiatric patients.

Quantitative assessment of hemoglobin-induced endothelial barrier dysfunction.

Hemoglobin (Hb)-based O2 carriers (HBOC) are undergoing extensive development as potential "blood substitutes." A major problem associated with these molecules is an increase in microvascular permeability and peripheral vascular resistance. In this paper, we utilized bovine lung microvascular endothelial cell monolayers and simultaneously measured Hb-induced changes in transendothelial electrical resistance, diffusive albumin permeability, and diffusive Hb permeability (PDH) for three forms of Hb: natural tetrameric human Hb-A and two polymerized recombinant HBOCs containing alpha-human and beta-bovine chains designated Hb-Polytaur (molecular mass: 500 kDa) and Hb-(Polytaur)n (molecular mass: approximately 1,000,000 Da), respectively. Hb-Polytaur and Hb-(Polytaur)n are being evaluated for clinical use as HBOCs. All three Hb molecules induce a rapid decline of transendothelial electrical resistance to 30% of baseline. Diffusive albumin permeabiltiy increases, on average, approximately ninefold (2.78 x 10(-7) vs. 2.47 x 10(-6) cm/s) in response to Hb exposure. All three Hb molecules induce an increase in their own permeability, a process that we have called Hb-induced Hb permeability. The magnitude of change of PDH is also related to Hb size. When PDH is corrected for the diffusive coefficient for each Hb species, no evidence of restricted diffusion is found. Immunofluorescent images demonstrate Hb-induced actin stress fiber formation and large intercellular gaps. These data provide the first quantitative assessment of the effect of polymerized HBOC on their own diffusion rates over time. We discuss the importance of these findings in terms of Hb extravasation rates, molecular sieving, and clinical consequences of HBOC use.

Comparative responses to alpha,beta-methylene-ATP in cat pulmonary, mesenteric, and hindquarter vascular beds.

Responses to the P2X-purinoceptor agonist alpha,beta-methylene-ATP (alpha,beta-MeATP) were investigated in the pulmonary, hindquarter, and mesenteric vascular beds in the cat. Under constant-flow conditions, injections of alpha,beta-MeATP caused dose-related increases in perfusion pressure in the pulmonary and hindquarter beds and a biphasic response in the mesenteric circulation. In the pulmonary vascular bed, the order of potency was alpha,beta-MeATP > U-46619 > angiotensin II, whereas, in the hindquarters, the order of potency was angiotensin II > U-46619 > alpha,beta-MeATP. The order of potency was similar in the hindquarter and mesenteric beds when the pressor component of the response to alpha,beta-MeATP was compared with responses to angiotensin II and U-46619. The P2X-receptor antagonist pyridoxal-phosphate-6-azophenyl-2',4'-disulfonic acid attenuated the pressor response to alpha,beta-MeATP in the hindquarter circulation and the pressor component in the mesenteric vascular bed. Pressor responses to alpha,beta-MeATP were not altered by cyclooxygenase, alpha-adrenergic, or angiotensin AT(1) antagonists. These data show that alpha,beta-MeATP has potent pressor activity in the pulmonary circulation, where it was 100-fold more potent than angiotensin II. In contrast, alpha,beta-MeATP had modest pressor activity in the systemic bed, where it was 1,000-fold less potent than angiotensin II. These data suggest that responses to alpha,beta-MeATP are dependent on the vascular bed studied and may be dependent on the density of P2X receptors in the vascular bed.

Influence of HOE 140, A Bradykinin Receptor Antagonist, in the Isolated Mesenteric Vascular Bed of the Rat.

The inhibitory effects of HOE 140 (D-Arg-[Hyp(3),Thi(5),D-Tic(7), Oic(8)]bradykinin), a novel bradykinin B(2)-receptor antagonist, on mesenteric vascular bed vasodilator responses to bradykinin (BK) were investigated under constant-flow conditions in the isolated blood-perfused rat mesenteric vascular bed. During baseline conditions, injections of BK produced dose-related decreases in mesenteric arterial perfusion pressure which were reproducible with respect to time. HOE 140, in a dose of 50 &mgr;g/kg intravenously, decreased vasodilator responses to BK but had no significant effect on mesenteric vasodilator responses to albuterol, acetylcholine, levcromakalim, or to nitroglycerin. These results suggest that BK has significant vasodilator actions which are mediated by the activation of kinin B(2)-receptors in the mesenteric vascular bed of the rat. HOE 140 caused a significant increase in baseline mesenteric arterial perfusion pressure. These data indicate that HOE 140 is a highly selective, BK B(2)-receptor antagonist in the mesenteric vascular bed of the rat, and the elevation of baseline mesenteric arterial tone by HOE 140 suggests that BK plays a role in maintaining normal vascular tone in the mesenteric circulation. These results also suggest that HOE 140 is a useful probe for studying the role of BK in the mesenteric vascular bed under physiologic and pathophysiologic conditions.

Inhibitory Effects of LY301875 on Responses to Angiotensin Peptides in Pulmonary Vascular Bed of the Cat.

The effects of the nonpeptide angiotensin receptor antagonist LY301875 on responses to angiotensin II, angiotensin III, and angiotensin IV were investigated in the pulmonary vascular bed of the intact cat chest. Under conditions of controlled blood flow, injections of the angiotensin peptides into the perfused lobar artery caused dose-related increases in lobar arterial pressure, and LY301875 decreased pressor responses to angiotensin II, angiotensin III, and angiotensin IV. The duration of the blockade was related to the dose of the antagonist, and LY301875 had no significant effect on pressor responses to U-46619, norepinephrine, serotonin or BAY K 8644. LY301875 caused minimal decreases on mean baseline systemic arterial pressures and did not significantly affect lobar arterial pressure in the cat. These results indicate that LY301875 is a potent selective long-acting angiotensin receptor antagonist and suggest that this agent may be useful in the investigation of the role of angiotensin peptides in physiological and pathophysiological processes in the pulmonary vascular bed.

Reducing door-to-needle time: treatment delay versus presentation delay.

One of the primary goals of the current American College of Cardiology/American Heart Association guidelines for treating patients with AMI is reduction of treatment delay. Delays consist of three phases: time from onset of symptoms to call for help, prehospital care and transportation, and door-to-treatment time. In turn, door-to-treatment time, the delay probably most amenable to change, consists of three distinct intervals: door-to-data, or diagnosis; data-to-decision (which therapy); and decision-to-drug administration. Care should be initiated in the emergency department (ED). Along with ready accessibility of electrocardiograms, interdepartmental protocols that facilitate diagnosis in the ED have been shown to reduce the door-to-data delay. Systems that expedite the exceptional cardiologist consult help speed the time to decision. Along with standing orders for standard care, orally obtained informed consent and availability of the drug in the ED can substantially decrease delay in drug delivery. By reducing unnecessary delays, standardization of protocols for diagnosing and treating patients with AMI in the ED may substantially decrease mortality and morbidity.

Pulmonary vascular responses to ma huang extract.

OBJECTIVE: To test the hypothesis that ma huang induces a pressor response in the pulmonary vascular bed of the cat by activating alpha(1)-adrenergic receptors DESIGN: Prospective vehicle-controlled study. SETTING: Research laboratory at Texas Tech University School of Medicine, Lubbock, TX. SUBJECTS: Intact chest preparation; adult mongrel cats. INTERVENTIONS: The effects of phentolamine, a nonselective alpha receptor blocker, and prazosin, an alpha(1) selective antagonist, were investigated on pulmonary arterial responses to ma huang, phenylepherine, norepinephrine, and U-46619, a thromboxane A(2) mimic. MEASUREMENTS AND MAIN RESULTS: Lobar arterial perfusion pressure was continuously monitored, electronically averaged, and recorded with constant flow in the isolated left lower lobe vascular bed of the cat. Phentolamine and prazosin significantly reduced vasoconstrictor pulmonary perfusion pressure increases induced by ma huang. CONCLUSIONS: Ma huang has significant vasopressor activity in the pulmonary vascular bed of the cat mediated predominantly by alpha(1)-adrenergic receptor activation.

Application of glass capillary columns to monitor petroleum-type hydrocarbons in marine sediments.

High resolution glass capillary columns coated with SE 52 liquid phase were used to resolve the indigenous hydrocarbons extracted from sediment samples collected from three outer continental shelf areas. The extracts were than spiked with small amounts of aliphatic or aromatic components isolated from a Louisiana crude oil and rechromatographed. The resolution was sufficient to separate almost all the isoprenoid, branched and cyclic alkanes associated with petroleum. Additionally, many of the key petroleum aromatics could also be resolved from naturally occurring organics. Such chromatographic procedures will aid in distinguishing between indigenous hydrocarbons of contemporary origin and those known to be associated with fossil hydrocarbon pollution of marine sediments.

Effect of muscle injection site and drug temperature on pre-anaesthetic sedation in pigs.

The responses of 83 Meishan gilts given azaperone (1.0 mg/kg) and ketamine (5 mg/kg) intramuscularly at one of four sites: the cervical muscles (20); the triceps muscle (m triceps brachii) (20); the middle gluteal muscle (m gluteus medius) (22); and the fascia lata muscle (m fascia lata) (21) were recorded. There were more reactions to the injection into the fascia lata muscle than to injections into the middle gluteal muscle and the triceps muscle (P = 0.024) and fewest after injections into the cervical muscles (P = 0.013). The injection site did not influence the time from injection to recumbency but there was least variability with the fascia lata muscle. The degree of sedation achieved, and the response to venous cannulation were similar in all four groups. There were no long-term complications (lameness or abscess formation) associated with the injections at any of the sites. In a second study with 68 pigs the same drug mixture was injected into the triceps muscle at either 6 to 8 degrees C (23), 19 to 22 degrees C (23) or 38.5 to 40.5 degrees C (22). There was no significant difference (P = 0.078) between the numbers of responses to the injections at each temperature. Mean time to recumbency was shortest with the injections at the highest temperature although the differences were not statistically significant (P = 0.498). The degree of sedation achieved, the response to venous cannulation and the incidence of complications were similar in all three groups.

Initial experience with laparoscopic ultrasound-guided radiofrequency thermal ablation of hepatic tumours.

BACKGROUND AND STUDY AIMS: Radiofrequency (RF) thermal ablation has been applied almost exclusively through the percutaneous approach under radiological/external ultrasound guidance. We have embarked on a programme of laparoscopic ultrasound-guided RF ablation of hepatic tumours in view of the potential advantages of this approach, i. e. reduced heat sink effect, greater precision and improved assessment of the thermal ablative zone. PATIENTS AND METHODS: RF thermal ablation using the Zomed International generator and multielectrode probes in two patients with hepatoma arising on a background of cirrhosis and in eight patients with multiple deposits from primary colorectal cancer. RESULTS: Total ablation was performed in two patients with hepatoma and 7/8 patients with secondary deposits. Total ablation with a minimum of 0.5-cm margin was achieved in 32 lesions. No complications were encountered postoperatively and all patients were discharged within 2 days of the intervention. One patient in whom thermal ablation was not completed has since died of progressive disease, eight appear to be free of tumour (follow-up 6-20 months) but one patient has developed further secondary hepatic deposits. CONCLUSIONS: The initial experience with laparoscopic ultrasound-guided RF ablation of hepatic tumours indicates its safety and therapeutic potential in patients with inoperable hepatic tumours.

An epidemiologic study of prn/stat medication use in a state psychiatric hospital.

The prevalence of prn/stat psychotropic medication administration and the characteristics and concomitants of high use of these medications were examined via a retrospective medical record review in a 973-bed state hospital. While 22.9% of the total hospital population received at least 1 prn/stat dose during the study month, 27 patients (2.8% of the total population) received 44.4% of the prn/stat doses, averaging 9.7 doses per patient. Examination of high-prn/stat use patients whose disruptive behavior and prn/stat use was "intermittent" throughout the month (N = 16) vs those who exhibited these characteristic for only a "discrete period" with resolution (N = 11) suggested that the prescription of antipsychotic drugs as prn/stat doses as well as increases in or institution of these medications was significantly associated with the latter group's resolution of disruptive behavior. The findings suggest the need for clinical protocols as guides for clinicians in the establishment of effective pharmacotherapy for patients with agitated, threatening behavior, including the use of plasma levels to ensure adequate dosage of psychotropic medication.

A case-control study of rapid readmission in a state hospital population.

A case-control comparison of clinical and service system characteristics among chronic psychiatric patients with rapid readmission (within 90 days of discharge), patients with readmission after more than 90 days of community tenure, and nonreadmitted patients revealed several clinical variables (e.g., medication noncompliance, substance abuse, and disruptive behavior) to be associated with readmission regardless of community tenure. In contrast, two service system variables (discharge to a structured outpatient treatment program and adequacy of discharge planning) were more highly associated with rapid readmission than the other conditions, while availability of case management had no association with readmission, rapid or otherwise.

Effects of North Carolina's mandatory safety belt law on children.

OBJECTIVES: To assess the effect of the North Carolina law mandating that all front seat passengers use a safety belt on children 4 through 15 years of age. METHODS: North Carolina collision reports, completed by local police or the state highway patrol for crashes with greater than $500 worth of damage, were analyzed using time series analysis on the monthly percentage of deaths and serious injuries between January of 1980 and February of 1994. RESULTS: Following the 1985 implementation of the law, children 4 to 15 years of age experienced a 42% decline in deaths and serious injuries. CONCLUSIONS: The mandatory safety belt law in North Carolina has been associated with a decline in deaths and serious injuries. Additional research in needed to assess the seat belt behaviors of this age group as well as the specific effects of seat belt use using outcome measures more precise than those available in police crash reports.

A strategy for adaptive staffing of hospitals under varying environmental conditions.

With many hospitals facing periods of retrenchment or considerable uncertainty in workload and reimbursement policy, an adaptive management response seems to be required. A model is presented for the development and implementation of a system of flexible resource management that is useful for health service managers.