Circulating levels of platelet α-granule cytokines in trauma patients.

OBJECTIVE AND DESIGN: To elucidate whether platelets differentiate cytokine release following trauma, we prospectively measured three major platelet-derived cytokines in 213 trauma patients on hospital arrival. METHODS: We measured plasma levels of the anti-inflammatory ß-thromboglobulins (ßTGs), transforming growth factor-ß1 (TGFß1) and the pro-inflammatory platelet factor 4 (PF4) cytokines. We also measured soluble glycoprotein VI (sGPVI), procoagulant platelet microparticles (PMPs) and white blood cell (WBC) counts, and evaluated in vitro platelet function in primary and secondary haemostasis by aggregometry and thromboelastometry, respectively. We evaluated associations of each cytokine by multivariate regression including injury severity score (ISS), WBC counts, sGPVI and platelet counts as explanatory variables. RESULTS: Severely injured patients (ISS > 15) had higher levels of ßTGs and TGFß1 (both p < 0.01) but lower levels of PF4 (p = 0.02). GPVI and PMPs levels correlated with TGFß1 and PF4 whereas we found no significant association between cytokine levels and measures of haemostasis. By multivariate regression, a high WBC count was associated with high levels of TGFß1 (p = 0.01) and ßTGs (p < 0.01) but with low levels of PF4 (p = 0.03). CONCLUSION: Severely injured patients had higher levels of ßTGs and TGFß1 but lower levels of the PF4; a high WBC count predicted this anti-inflammatory profile of platelet cytokines.

Methodological issues in comparing injury incidence across countries.

The primary objective was to describe the methodological challenges and devise solutions to compare injury incidence across countries. The research design was a mixed methods study, consisting of a consultation with an expert group and comparison of injury surveillance systems and data from ten European countries. A subset of fractures, selected radiologically verifiable fractures and a method of checking the national representativeness of sample emergency department data were devised and are proposed for further development. These methodological considerations and developments will be further refined and tested and should prove useful tools for those who need to compare injury incidence data across countries.

Epidemiology of acute wrist trauma.

Epidemiological data on wrist injuries in a population can be used for planning by applying them to criteria for care and thus deriving estimates of provisions for care according to currently desirable standards. In a 1-year study all patients > or = 15 years with acute wrist trauma and treated in the emergency room were examined according to an algorithm until a diagnosis was established. The overall incidence of wrist trauma was 69 per 10,000 inhabitants per year. Incidence of wrist trauma requiring x-ray examination was 58 per 10,000 per year. The incidence of distal radius fractures was 27 per 10,000 per year (males, 16 per 10,000, females, 37 per 10,000 per year). In order to evaluate the completeness (defined as the proportion of patients with wrist injuries seen in the emergency room to all patients with wrist injuries in the catchment area) of the hospital-based data an analysis was performed using data from a population-based study. A completeness rate of 0.56 (95% confidence interval: 0.31-0.78) was found. An x-ray had been taken for all patients reporting a fracture thus justifying the use of fractures as an incidence measure when comparing groups of patients with wrist trauma.

Postoperative infection in a double-occupancy operating room. A prospective study of two thousand four hundred and fifty-eight procedures on the extremities.

The purposes of this study were to determine the rate of infection associated with elective outpatient operations on an extremity, performed in a double-occupancy operating room (one operating room designed to accommodate two separate operating teams), and to determine which factors influenced this rate. We evaluated the records of 2458 consecutive patients who had had such a procedure, performed by one of nine surgeons during a two and one-half-year period, and in whom the operative wound had been classified as clean (without a drain) or clean-contaminated (with a drain). The information regarding the factors associated with the operation and the operating-room environment was recorded for each patient at the time of the operation. Each wound was inspected periodically in the attending surgeon's office for at least thirty days postoperatively. Using definitions established by the Centers for Disease Control, the attending surgeon determined the presence of infection primarily by judging whether there was purulent drainage or whether erythema or swelling at the operative site was beyond that expected from the procedure. Of the 2458 patients, thirty-seven (1.5 per cent; 95 per cent confidence interval, 1.1 to 2.1 per cent) had infection of the operative wound. Only eight patients (0.3 per cent) had deep infection, with seven of the infections necessitating a reoperation. Infection developed in thirty of the 2311 clean wounds, a rate of 1.3 per cent (95 per cent confidence interval, 0.9 to 1.8 per cent), and in seven of the 147 clean-contaminated wounds, a rate of 4.8 per cent (95 per cent confidence interval, 2.3 to 9.5 per cent) (p = 0.001). No cross-contamination occurred between patients who had infection. The rate of infection was not related to the number of patients who were operated on in the same room at the same time. Logistic regression analysis, used to account for confounding factors, demonstrated a significant association between the classification of the wound (use of a drain) and a higher rate of infection (p = 0.006) as well as between the instillation of a topical steroid solution and a lower rate of infection (p = 0.04). It also demonstrated a significant difference, with respect to the rate of infection, among individual surgeons (p = 0.02).

Pneumococcal arthritis in the wrist and ankle. A case report and short review of the literature.

In this paper we report a 48-year-old man with septic arthritis of the wrist and ankle due to Streptococcus pneumoniae. No known predisposing factor was found. Only about 300 cases of pneumococcal arthritis have been reported in the literature since 1888 and less than 10% of these affect the wrist. The management of bacterial arthritis is reviewed.

Fracture of the carpal scaphoid: frequency and distribution in a well-defined population.

The incidence, location, and type of scaphoid fractures found in a well-defined population is described. Fractures of the carpal scaphoid (n = 442) were identified during an eight-year period, of which 19 (5%) were nonunions. At the initial radiographic examination the fractures were visible on PA views in 70% of the cases (true lateral 10%, scaphoid view neutral 77%, scaphoid view ulnar deviated 73%, and scaphoid view with the X-ray tube tilted 30 degrees distally 71%). Among inhabitants living in the Odense Municipality (population at risk 170648 in 1983 to 174948 in 1989) 222 males and 51 females (age range 9-87 year) sustaining scaphoid fractures during a seven-year were period used for computation of incidences. During the survey, there was an average annual incidence of scaphoid fracture of 8 per 100000 females, and 38 per 100000 males. All patients (except a 9-year-old male) were aged 10 years or over. In the age-group 10-14 years there was an average annual incidence of 3 per 100000 females, and 39 per 100000 males. Average annual incidence per 100000 inhabitants of carpal scaphoid fractures according to the location was proximal 6, middle 15, and distal (fractures of the tuberosity included) 2. Average annual incidence per 100000 inhabitants of carpal scaphoid fractures according to type was transverse 7, horizontal oblique 9, vertical oblique 1, avulsion/fracture of the tuberosity 5, and not stated 1.

Fatal motorcycle accidents in the county of Funen (Denmark).

A study of motorcycle fatalities in the period 1977-1983 in the county of Funen, Denmark was compared with an analysis of data obtained from the Accident Register at the Odense University Hospital. Among the operators killed one fifth were illegally operating the motorcycle. A remarkable statistical difference in distribution of accidents involved motorcycles and the total distribution of motorcycles in the county was reported, thus finding an over-representation of heavy motorcycles in the present study. No important differences were found in the distribution of type of accidents compared to other studies. In the present study all but one victim were tested for blood-alcohol concentration (BAC). The results differ from previous studies in as much as 50% of the killed operators of an accident involving motorcycles had a BAC above 0.08%. The reported distribution by age, licensing experience and size of motorcycle in fatal motorcycle accidents seem to support introduction of a graduated licence depending on motorcycle size as well as operator age. Furthermore a limitation in the right to carry a pillion passenger should be considered, and the operator of the motorcycle carrying a pillion passenger should be held responsible for the passenger wearing a helmet.

Fatal motorcycle accidents and alcohol.

A series of fatal motorcycle accidents from a 7-year period (1977-1983) has been analyzed. Of the fatalities 30 were operators of the motorcycle, 11 pillion passengers and 8 counterparts. Of 41 operators 37% were sober at the time of accident, 66% had measurable blood alcohol concentration (BAC); 59% above 0.08%. In all cases where a pillion passenger was killed, the operator of the motorcycle had a BAC greater than 0.08%. Of the killed counterparts 2 were non-intoxicated, 2 had a BAC greater than 0.08%, and 4 were not tested. The results advocate that the law should restrict alcohol consumption by pillion passengers as well as by the motorcycle operator. Suggestions made to extend the data base needed for developing appropriate alcohol countermeasures by collecting sociodemographic data on drivers killed or seriously injured should be supported.

An algorithm for acute wrist trauma. A systematic approach to diagnosis.

A systematic approach to the acute traumatized wrist is of importance to achieve early diagnosis, with efficient use of advanced imaging modalities. In a 6-month period 641 patients aged 15 years or over were examined using an algorithm for acute wrist trauma in order to secure early and appropriate treatment. In 293 (46%) cases routine radiographic examination supplied sufficient information to establish a fracture diagnosis. All 33 scaphoid fractures (including five scaphoid non-unions) were demonstrated on the initial X-ray examination. In 56 patients (9%) scintigraphy proved useful for selecting cases in need of further radiographic examination. Among 31 patients with focal activity on bone scintigraphy, CT and/or tomography revealed eight distal radial fractures, one fracture of the ulnar styloid, and eight fractures of carpal bones. Fractures were revealed using tomography and/or "hot spot views" in patients with negative CT examinations suggesting that further examinations should be performed in cases with increased focal activity on bone scintigraphy and a negative CT examination.

Dislocation of the lunate, triquetral, and hamate bones. Case report.

A patient sustained multiple injuries during a road traffic accident, including closed palmar luxation of the lunate together with dislocation of the triquetrum and hamulus of the hamate bone. Initially the injury was treated closed, but redislocation necessitated closed reduction and stabilisation with K-wires. Three years later movement was painless and slightly restricted despite persisting palmar dislocation of the lunate and triquetral bones as well as ulnar translocation.

[Epidemiology of acute wrist injuries]. / Akutte håndledstraumers epidemiologi.

Epidemiological data on wrist injuries in a population can be used for planning by applying them to criteria of care and thus deriving estimates of needs for care according to currently desirable standards. In a one-year study all patients 15 years or older with acute wrist trauma and treated at the emergency room were examined according to an algorithm until a diagnosis was established. The overall incidence of wrist trauma was 69 per 10,000 inhabitants per year. Incidence of wrist trauma requiring radiographic examination was 58 per 10,000 per year. The incidence of fractures of the distal radius was 27 per 10,000 per year (males, 16 per 10,000, females, 37 per 10,000 per year). In order to evaluate the completeness (defined as the proportion of patients with wrist injuries seen at the emergency room out of all patients with wrist injuries in the catchment area) of the hospital based data an analysis was performed using data from a population based study. A completeness rate of 0.56 (95% confidence interval 0.31-0.78) was found. A radiographic examination had been performed in all patients reporting a fracture, justifying the use of fractures as an incidence measure when comparing groups of patients with a wrist trauma.

[Ambulance services in Copenhagen, Odense and Ringkøbing County. Results of the spot test conducted by the Ministry of Health and the County Councils Association in 1990. 1. Epidemiological data]. / Ambulanceudrykning i København, Odense og Ringkøbing Amt. Resultater fra Sundhedsministeriets og Amtsrådsforeningens stikprøveundersøgelse 1990. 1. Epidemiologiske data.

In 1990, The Danish Ministry of Health and the County Council Association undertook a spot test investigation of the activities in connection with 3,182 emergency ambulance services (AU) in the Municipality of Copenhagen (a city), the Odense district (a large provincial town) and the County of Ringkøbing (a mixed rural and urban region). The investigation included data collected by the ambulance staff before hospitalization and the diagnoses on discharge from casualty and hospital departments. The frequency of AU per 1,000 population was found to be 101 annually in Copenhagen, 44 in Odense and 19 in the County of Ringkøbing. More than 10% of the services in all three regions did not result in transport of the patient to hospital treatment. The average age of the patients was 52 years in Copenhagen compared with 44 years in the other two regions. The age-specific frequency of AU for patients aged 0-4 year-old was nine times as great in Copenhagen than in Odense and the County of Ringkøbing and, where patients aged more than 80 years were concerned, the frequency was 4-10 times as great. In all three regions, the activities of ambulance services were most numerous between 6-16 hours and lowest during the period 0-6 hours. Services to patients' homes constituted 44-46% and to traffic regions 32-40%. Services on account of illness constituted 41-45% and, on account of accidents, 27-35%. In cases of rapid emergency transport (using signals), 78% of the ambulances had reached the patient within five minutes in Copenhagen as compared with 44% in Odense and the County of Ringkøbing.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ambulance services in Copenhagen, Odense and Ringkøbing County. Results from the spot test conducted by the Ministry of Health and the County Councils Association in 1990. 2. Treatment by ambulance staff, medical support and pattern of diagnoses]. / Ambulanceudrykning i København, Odense og Ringkøbing Amt. Resultater fra Sundhedsministeriets og Amtsrådsforeningens stikprøveundersøgelse 1990. 2. Ambulancemandskabets behandling, laegestøtte og diagnosemønster.

In this investigation, the results from a spot test investigation comprising 3182 emergency ambulance services (AU) from three geographical regions with different degrees of urbanization are presented: The Danish capital (Municipality of Copenhagen), a large provincial town (Odense) and a rural district with smaller towns (the County of Ringkøbing). The conditions of the patients were assessed by the ambulance staff: 7-12% of the patients transported had visible haemorrhage, 5-8% were unconscious, 4-7% were cyanotic, 2-3% had seizures and 1-2% had pareses. The serious cases tended to be most frequent in the least urbanized regions. Registration of the therapeutic efforts by the ambulance staff prior to and during transport revealed that 15-33% of the patients did not receive any treatment. The commonest forms of treatment consisted of oxygen treatment (13-18%), treatment for shock (8-12%), Nato position (4-16%) and stopping of haemorrhage (7-12%). No differences were observed between the three geographic regions except that fewer patients in the capital received treatment. In cases of emergency ambulance services employing signals, medical support was available in 22% of the cases in Copenhagen, mainly by means of medically staffed ambulances. In the County of Ringkøbing, doctors, usually the doctor-on-call, participated in 27% of these services while medical support was only available in 2% of the cases in Odense. Registration of the diagnoses by the hospitals which received the patients revealed that the commonest group of diagnoses were injuries (36-44%) and cardiovascular disease (14-21%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Occupational accidents in road traffic]. / Arbejdsulykker i trafikken.

An emergency room material covering 13 years (1980-92) was analyzed to see whether occupational accidents in road traffic had been following special patterns revealing possibilities for prevention. Of 41,332 traffic accident victims, every year 2.3-4.2% had sustained their injuries during working hours. Males were overrepresented, the male to female sex ratio was 2.9 for occupational accidents, 1.6 for non-occupational accidents. The age group 15-19 years accounted for a relatively large share of both occupational and non-occupational accidents. There were no differences according to body distribution of injuries, severity or need for treatment between occupational and non-occupational accidents. In occupational accidents more automobiles but fewer bicycles and motorbikes were involved. No type of accident showed increasing tendency throughout the period. It is concluded, that occupational road traffic accidents do not seem to follow special patterns, and the proportion is not increasing. Although the younger age groups were overrepresented, the limited material does not give grounds for elevating the age limit for occupational car driving, as for extent of exposure in the single age groups is not known.

[Preventive effects of bicycle helmets]. / Praeventiv effekt af cykelhjelme.

The total number of persons injured following bicycle accidents in Denmark is estimated to be more than 50,000 annually. In half of the injured cyclists, lesions localized to the region of the head occur. Bicycle helmets provide considerable protection against brain injuries which constitute 13%. Several investigations from abroad and from Denmark have demonstrated that protection of the head can reduce the number of deaths and of acute brain injuries due to bicycle accidents. On the basis of the literature, it is concluded that bicycle helmets provide good protection of the head in connection with bicycle accidents. When a bicycle helmet is purchased, it is important to ensure that the helmet fits the head, that vision is not impeded and that the chinstrap secures the helmet correctly. Legislation is necessary to ensure that bicycle helmets sold in Denmark fulfill the minimum safety requirements.

[Medical cooperation in cases of detention. 1 year's experience in the Odense police district]. / Laegelig medvirken ved detentionsanbringelser. Et års erfaringer fra Odense politikreds.

On 22.5.1987, a law was introduced in Denmark according to which persons under the influence of alcohol detained by the police should, as a rule, be medically examined. In Denmark (not including the Faroe islands and Greenland), 40% out of 26,598 persons placed in detention were medically examined in 1988. Out of 918 persons placed in detention in the Odense police district, 66% were medically examined and of these 5% were referred to hospital for further examination and/or treatment. Four of these were admitted, three of whom had life-threatening poisonings and one on account of a potentially disabling condition. No deaths occurred in detention in Odense. It seems reasonable that all persons placed in detention should be seen by a doctor and, similarly, the protective function of detention should be emphasized.

[Structure of emergency units in Denmark 1985-1992]. / Skadestuestrukturen i Danmark 1985-1992.

The aim of the study was to investigate the changes in trauma treatment structure in Denmark during the period 1985-1992. The design was a repeated cross-sectional analysis performed as a questionnaire in 1985, 1989 and 1992 given to the heads of the medical staff of all accident and emergency departments in Denmark. The analysis showed that the number of accident and emergency departments was reduced from 81 in 1985 to 69 in 1992. The median number of annual patient contacts increased from 5911 (150-50,000) to 8757 (150-47,000) over the period. The median number of inhabitants in the uptake-areas of the accident and emergency departments increased from 50,000 (4500-230,000) to 67,000 (4500-230,000). Only at 12 accident and emergency departments (with 1,183,000 inhabitants) was prehospital treatment given by medical doctors to trauma patients. Only one accident and emergency department used trauma scores routinely, and 29 (42%) used the Glasgow Coma Scale as a routine. It is concluded that there has only been a minor centralisation in trauma treatment structure in Denmark over the period 1985-1992, and there are still many accident and emergency departments with relatively few annual patient contacts. Prehospital treatment by medical doctors is still not routine in most areas of Denmark.

[Scaphoid fractures. Fracture types and localization]. / Scaphoideumfraktur. Frakturtyper og knoglelokalisation.

The incidence, localization, and type of scaphoid fractures found in a well-defined population is described. Fractures of the carpal scaphoid (n = 442) of which 19 (5%) were nonunions were identified during an eight-year period. Among inhabitants living in the Odense Municipality (population at risk 170,648 in 1983 to 174,948 in 1989) 222 males and 51 females who sustained scaphoid fractures during a seven-year period were used for computation of incidence. During the survey, there was an average annual incidence of scaphoid fracture of eight per 100,000 females, and 38 per 100,000 males. The average annual incidence per 100,000 inhabitants of carpal scaphoid fractures according to the location was proximal two, middle 15, and distal six. Average annual incidence per 100,000 inhabitants of carpal scaphoid fractures according to type was transverse seven, horizontal oblique nine, vertical oblique one, avulsion/fracture of the tuberosity five, and not stated one.

[External causes of accidents. How do the new registration rules function?]. / Ydre årsager til skader. Hvordan fungerer de nye registreringsregler?

On January 1, 1987 a new codification system was introduced in Denmark to replace the former E-codification. The function of the codification system was investigated by comparing two parallel registers comprising the same group of patients. During a one-year period from January 1 1987 to December 31 1987, a total of 1,475 patients were admitted to an orthopaedic department. Complete agreement between the two registers was found in 53% of all patients. The result of the investigation stresses the need for careful instruction to those who carry out the registration. The purpose of the registration is that it should be usable in the health care system as an instrument for registration of external causes of injury. The registration should also be a tool for the planning and managing of the resources spent on health services. This purpose is only partly achieved in the present registration.

[Traumatology. Scoring systems and their use]. / Traumatologi. Scoringssystemer og deres anvendelse.

Centralized trauma care is developing in Denmark, and is producing an increasing interest in the scoring systems used in traumatology. A large number of scoring systems have been developed within the trauma field. After reviewing the literature, we recommend the Revised Trauma Score at strategic intervals during admission, and scoring of the Abbreviated Injury Scale (AIS) according to the 1990 revision at discharge or by autopsy. This will allow calculation of the Injury Severity Scale (ISS) and The Trauma Score--Injury Severity Score (TRISS) making scientific studies in accordance with international standards possible.