Quality of life in patients with multiple injuries--basic issues, assessment, and recommendations.

BACKGROUND: While the primary goal of trauma care continues to be the preservation of life, interest has begun to focus on disability and quality of life of those who survive. Numerous instruments have been developed to measure personal well-being, impairment, or subjective life-satisfaction. But there is no consensus regarding which instruments are most appropriate to use in multiply injured patients, and comparison of results are difficult. OBJECTIVE: The objective of this multinational conference was to arrive at a consensus regarding the measurement of quality of life in survivors of multiple trauma. Specifically we sought to identify the best time intervals for measurement and a minimum set of instruments. METHOD: The group reviewed instruments currently in use for quality of life measurement in multiply injured patients. A structured discussion covered the following topics: definition of the population, the concept of quality of life, the importance of different domains of quality of life at different time points, the type of measures and their validity, consistency, and practicability, the mode of administration, subject burden, and availability of population norms. RESULTS: The group suggested three time points, after 3, 12 and 24 months, for the assessment of quality of life after multiple injury. The Glasgow Outcome Scale (GOS) was suggested as an overall global outcome measure including death and vegetative state. The EuroQol was proposed to permit economic analysis, and the SF-36 as a validated global quality of life measure. CONCLUSION: While most selected measures are psychometrically sound, many have had limited use in the setting of multiple injuries. Researchers and clinicians may use these suggestions as a source of information when developing a measurement strategy.

Perceived threat to life predicts posttraumatic stress disorder after major trauma: risk factors and functional outcome.

BACKGROUND: The importance of psychological morbidity after major trauma, such as posttraumatic stress disorder (PTSD), is continuing to gain attention in trauma outcomes research. The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL) and PTSD. The specific objectives of the present report are to examine risk factors for PTSD and to assess the impact on QoL at the 6-, 12-, and 18-month follow-up time points in the Trauma Recovery Project population. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay > 24 hours. QoL was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Early symptoms of acute stress reaction (SASR) at discharge were assessed using the Impact of Events Scale (score > 30 = SASR). PTSD at 6-month follow-up was diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. RESULTS: PTSD was diagnosed in 32% (261 of 824) patients at 6-month follow-up. Perceived threat to life predicted PTSD onset (odds ratio [OR], 1.6; p < 0.01) and early SASR (OR, 2.2; p < 0.001). PTSD was more frequent in women (39%) than in men (29%) and in younger low-income patients. Other major risk factors were penetrating trauma (OR, 2.3; p < 0.001) and assaults (OR, 1.5; p < 0.05). PTSD had a major impact on QoL at 6-, 12-, and 18-month follow-up (Quality of Well-being scale score: 6 months, 0.576 vs. 0.658; 12 months, 0.620 vs. 0.691; 18 months, 0.620 vs. 0.700; p < 0.0001). CONCLUSION: These results provide new and provocative evidence that perceived threat to life and mechanism predict PTSD after major traumatic injury. PTSD had a prolonged and profound impact on short- and long-term outcome and QoL.

The impact of major in-hospital complications on functional outcome and quality of life after trauma.

BACKGROUND: Little is known about the impact of major in-hospital complications on functional outcome in the short- and long-term period after serious injury. The Trauma Recovery Project (TRP) is a large, prospective, epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life and functional limitation. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to examine the effect of postinjury complications on functional outcomes at discharge and at 6-, 12-, and 18-month follow-up time points in the TRP population. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years or older; admission Glasgow Coma Scale score of 12 or greater; and length of stay greater than 24 hours. Quality of life was measured after injury using the Quality of Well-being (QWB) scale, a sensitive index to the well end of the functioning continuum (range, 0 [death] to 1.000 [optimum functioning]). Major in-hospital complications were assessed for 820 patients and were coded as pulmonary, cardiovascular, gastrointestinal, hepatic, hematologic, infections, renal, musculoskeletal, neurologic, and vascular, on the basis of standardized codes used in the Trauma Registry. RESULTS: Major in-hospital complications were present in 83 (10.1%) patients. Discharge QWB scores were significantly lower in patients with major complications (0.394 vs. 0.402, p < 0.05). QWB scores were also significantly lower at 6-month follow-up in patients with major complications (0.575 vs. 0.637, p < 0.0001). Types of major complications with significantly lower 6-month follow-up QWB scores were pulmonary, gastrointestinal, infections, and musculoskeletal. Patients with major complications also had significantly lower 12-month (0.626 vs. 0.674, p < 0.01) and 18-month (0.646 vs. 0.681, p < 0.05) follow-up QWB scores. Pulmonary major complications and infections were associated with significantly lower QWB scores at 12-month follow-up. CONCLUSION: These results provide new evidence that major in-hospital complications may have an important impact on functional outcomes after major trauma.

The importance of gender on outcome after major trauma: functional and psychologic outcomes in women versus men.

BACKGROUND: Outcome after major trauma is an increasingly important focus of injury research. The effect of gender on functional and psychological outcomes has not been examined. The Trauma Recovery Project is a large, prospective, epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life, functional outcome, and psychological sequelae such as depression and early symptoms of acute stress reaction. The specific objectives of the present report are to examine gender differences in short- and long-term functional and psychological outcomes in the Trauma Recovery Project population. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay greater than 24 hours. Quality of life was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Depression was assessed using the Center for Epidemiologic Studies Depression scale and early symptoms of acute stress reaction were assessed using the Impact of Events scale. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. RESULTS: Functional outcome was significantly worse at each follow-up time point in women (n = 313) versus men (n = 735). Quality of Well-being scale scores were markedly and significantly lower at 6-month follow-up in women compared with those in men (0.606 vs. 0.646, p < 0.0001). This association persisted at 12-month (0.637 vs. 0.6685, p < 0.0001) and 18-month (0.646 vs. 0.6696, p < 0.0001) follow-up. Women were also significantly more likely to be depressed at all follow-up time points (discharge odds ratio [OR] = 1.4, p < 0.05; 6-month follow-up OR = 2.2, p < 0.01; 12-month follow-up OR = 2.0, p < 0.01; 18-month follow-up OR = 2.2, p < 0.01) and to have early symptoms of acute stress reaction at discharge (OR = 1.4, p < 0.05). These differences remained significant and independent after adjusting for injury severity, mechanism, age, and sociodemographic factors. CONCLUSION: Women are at risk for markedly worse functional and psychological outcomes after major trauma than men, independent of injury severity and mechanism. Gender differences in short- and long-term trauma outcomes have important implications for future studies of recovery from trauma.

Outcome after major trauma: 12-month and 18-month follow-up results from the Trauma Recovery Project.

BACKGROUND: The importance of outcome after major injury has continued to gain attention in light of the ongoing development of sophisticated trauma care systems in the United States. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the 12-month and 18-month follow-ups in the TRP population and to examine the association of putative risk factors with functional outcome. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older; (2) Glasgow Coma Scale score on admission of 12 or greater; and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) Scale, an index sensitive to the well end of the functioning continuum (0 = death, 1.000 = optimum functioning). Follow-up at 12 months after discharge was completed for 806 patients (79%), and follow-up at 18 months was completed for 780 patients (74%). Follow-up contact at any of the study time points (6, 12, or 18 months) was achieved for 926 (88%) patients. RESULTS: The mean age was 36 +/- 14.8 years, and 70% of the patients were male; 52% were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living together. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). At the 12-month follow-up, there were very high levels of functional limitation (QWB mean score, 0.670 +/- 0.137). Only 18% of patients followed at 12 months had scores above 0.800, the norm for a healthy population. There was no improvement in functional limitation at the 18-month follow-up (QWB mean score, 0.678 +/- 0.130). The majority of patients (80%) at the 18-month follow-up continued to have QWB scores below the healthy norm of 0.800. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days were significant independent predictors of 12-month and 18-month QWB outcome. CONCLUSION: This study demonstrates a prolonged and profound level of functional limitation after major trauma at 12-month and 18-month follow-up. This is the first report of long-term outcome based on the QWB Scale, a standardized quality-of-life measure, and provides new and provocative evidence that the magnitude of dysfunction after major injury has been underestimated. Postinjury depression, PTSD, serious extremity injury, and intensive care unit days are significantly associated with 12-month and 18-month QWB outcome.

Outcome after major trauma: discharge and 6-month follow-up results from the Trauma Recovery Project.

BACKGROUND: The study of both short-term and long-term outcomes after major trauma has become an increasingly important focus of injury research because of the improved survival rates attributable to the evolution of sophisticated trauma care systems. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the discharge and 6-month follow-up time points in the TRP population and to examine the association of putative risk factors with functional outcome. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older, (2) Glasgow Coma Scale score on admission of 12 or greater, and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) scale, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional outcome was also measured using a standard activities of daily living (ADL) scale (range, 13 = full function to 47 = maximum dysfunction). Follow-up at 6 months after discharge was completed for 826 patients (79%). RESULTS: The mean age was 36 +/- 14.8 years; 70% of the patients were male; 52% of the patients were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living with a partner. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries, and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). After major trauma, QWB scores at discharge showed a significant degree of functional limitation (mean, 0.401 +/- 0.045). At 6-month follow-up, QWB scores continued to show high levels of functional limitation (mean, 0.633 +/- 0.122). Limitation measured using the standard ADL scale found only moderate dysfunction at discharge (mean, 30.0 +/- 7.7) and at 6-month follow-up (mean, 15.0 +/- 4.2). Postinjury depression, PTSD, serious extremity injury, and length of stay were significant independent predictors of 6-month QWB outcome. CONCLUSION: Postinjury functional limitation is a clinically significant complication in trauma patients at discharge and a 6-month follow-up. The QWB yields a more sensitive assessment of functional status than traditional ADL instruments. Postinjury depression, PTSD, serious extremity injury, and length of stay are significantly associated with 6-month QWB outcome.

Trauma among Hispanic children: a population-based study in a regionalized system of trauma care.

We studied 1164 injured Hispanic and 2560 injured non-Hispanic White children newborn through 14 years triaged to the San Diego County Regionalized Trauma System from 1985 through 1990. Incidence rates did not differ by ethnic group. Hispanic children were more likely to be struck as pedestrians (odds ratio [OR] = 1.5) and less likely to be injured in falls (OR = 0.7) than non-Hispanic White children. For motor vehicle and pedal cycle injuries, Hispanic children were more likely not to have been restrained by seatbelts (OR = 4.0) or car seats (OR = 3.7).

An 18-year prospective study of dietary calcium and bone mineral density in the hip.

The object of this study was to determine whether a single 24-hour diet recall of calcium intake obtained an average of 18 years previously would predict bone mineral density (BMD) in the hip in older men and women. A prospective population-based cohort study was done in Rancho Bernardo, California. Between 1973 and 1975, a 24-hour diet recall was obtained in 140 men and 220 women aged 45 and older by a trained interviewer using food models and containers. Responses were coded by the Nutrition Coordinating Center, University of Minnesota. Between 1988 and 1991, BMD in the femoral neck, trochanter, and intertrochanter was measured using dual-energy x-ray absorptiometry. Results showed that age-adjusted mean BMD levels increased significantly with increasing tertile of calcium intake at all hip sites in women, with the most striking difference at the femoral neck. These associations persisted after adjustment for body mass index, smoking, exercise, alcohol intake, use of estrogen replacement therapy, and number of years postmenopausal. No significant trends were seen for men at any hip site. It is concluded that low dietary calcium predicts low BMD in older women independent of other major determinants of BMD.

Lifetime milk consumption and bone mineral density in older women.

This study examined the relationship between lifetime milk consumption both axial and appendicular bone mineral density in 581 postmenopausal White women. Positive significant, graded associations between milk consumption in adulthood and bone mineral density at the spine, total hip, trochanter, intertrochanter, and midradius, but not the ultradistal wrist or femoral neck, were observed. Adolescent milk consumption showed similar, statistically significant associations (spine and midradius). Associations were independent of age, body mass index, years postmenopausal, thiazide, estrogen and alcohol use, smoking, and exercise. Regular milk consumption in youth and adulthood is associated with better bone mineral density at cortical and trabecular sites in elderly women.

Functional limitation after major trauma: a more sensitive assessment using the Quality of Well-being scale--the trauma recovery pilot project.

Little is known about the degree of disability and quality of life of patients after major trauma. We conducted a prospective study to examine the incidence and predictors of functional limitation (FL). Between January 1, 1990 and March 30, 1990, 61 eligible trauma patients were enrolled in the study (admission GCS score > or = 12, LOS > 24 hours). Functional limitation after trauma was measured at discharge and 3 months after discharge using the Quality of Well-being (QWB) scale, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional limitation was also measured using a standard ADL scale (range, 17 = full function to 41 = maximum dysfunction). Risk factors measured were injury severity, body region, depression (CES-D) scale, and social support. Follow-up was achieved in 42 patients (70%). The mean age was 30 years, 74% were male, 52% white, 41% hispanic, and 3% other. The mean ISS was 15, with 69% blunt injuries and a mean LOS of 12 days. The QWB scores improved between discharge and follow-up; discharge mean = 0.457 (+/- 0.048), follow-up mean = 0.613 (+/- 0.118), but the mean QWB score at follow-up still reflected a significant degree of functional limitation. The mean percentage of change in QWB scores was 34.5% (+/- 25.5%) with a range of -6.34% to 103.8%. The discharge mean FDS was 29 (+/- 6.2) while the follow-up FDS mean was 17 (+/- 3.8), reflecting that most patients at follow-up reported near-perfect ADL functioning.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for mortality after failed coronary angioplasty: an anesthesia perspective.

Monitored anesthesia care (MAC) for percutaneous transluminal coronary angioplasty (PTCA), and anesthesia for emergent coronary artery bypass graft (CABG) surgery due to failed PTCA, have added relatively new challenges to the cardiac anesthesiologist in community practice. This study attempted to define easily identifiable preangioplasty and periangioplasty risk factors for mortality after failed PTCA. A total of 1,380 angioplasties performed in a single community hospital were retrospectively reviewed; 120 (8.7%) were attempted PTCAs requiring subsequent CABG during the same hospital stay. The 120 failures included 10 surgical mortalities (8.3%); multivariate analysis revealed several significant differences between the mortality and survivor groups. Mortality tended to be higher in insulin-dependent diabetics (P = 0.003), females (P = 0.005), and patients 70 years or over (P = 0.043). Previous CABG, decreased left ventricular ejection fraction, and number of vessels with significant disease did not differ between the groups. Patients who died required more vasopressor agents (P = 0.011) during PTCA and experienced cardiac arrests (P = 0.011) at significantly higher rates than survivors. Left system (left anterior descending or circumflex coronary artery) angioplasty, inability to pass the angioplasty guidewire, and antiarrhythmic drug use did not differ between groups. Data concerning endotracheal intubation in the catheterization laboratory and time from laboratory exit to initiation of cardiopulmonary bypass, while bivariately significant, were too sparse for multivariate analysis. The authors believe that several risk factors for postangioplasty surgical mortality are easily determined without access to diagnostic angiographic studies.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of alcohol consumption and bone mineral density.

OBJECTIVES: To study the effects of alcohol consumption on bone mineral density in a defined population. DESIGN: Prospective study of bone mineral density, measured during 1988-91, in a cohort who had given baseline data on alcohol intake in the previous week and in the previous 24 hours and other factors affecting bone mineral density during 1973-5. SETTING: Rancho Bernardo, California. SUBJECTS: 182 men and 267 women aged 45 and over at baseline, half having been randomly selected and half having been chosen for hyperlipidaemia, who gave baseline information on alcohol intake in one week. Of these subjects, 142 men and 220 women gave information on alcohol intake in 24 hours. MAIN OUTCOME MEASURES: Bone mineral density of the radial shaft, ultradistal wrist, femoral neck, and lumbar spine. RESULTS: Men and women were considered separately, and the tertiles of alcohol consumption were used to delineate low, medium, and high values of alcohol intake. With increasing alcohol intake in one week, bone mineral density (adjusted for age, body mass index, smoking, taking exercise, and oestrogen replacement therapy in women) increased significantly in the femoral neck of men (p < 0.01) and the spine of women (p < 0.01). With increasing alcohol intake in 24 hours, adjusted bone mineral density increased significantly in the radial shaft (p < 0.05) and spine (p < 0.001) of women. Similar, but not significant, patterns were seen at the other bone sites. CONCLUSIONS: Social drinking is associated with higher bone mineral density in men and women.

The epidemiology of traumatic death. A population-based analysis.

Despite the proliferation of trauma systems, there are no population-based data describing the epidemiology of traumatic death. To provide these data, we reviewed all trauma deaths occurring in San Diego (California) County during 1 year. There were 625 traumatic deaths during the study (27.3 deaths per 100,000 population per year). Motor vehicle trauma was the most common cause of injury leading to death (N = 344 [55.2%]; 15.0 annual deaths per 100,000 population). Central nervous system injuries were the most common cause of death (48.5%, or 13.2 deaths per 100,000 population per year). Sepsis was responsible for only 2.5% of the overall mortality. Based on life-table data, traumatic death resulted in an annual loss of 1091 years of life per 100,000 and an annual loss of 492 years of productivity per 100,000. Injury continues to account for an enormous loss of life despite improvements in survival wrought by trauma systems.

The association of lifetime weight and weight control patterns with bone mineral density in an adult community.

We examined the association of lifetime weight and weight change to bone mineral density (BMD) at four skeletal sites, the radial shaft, the ultradistal wrist, the total hip and lumbar spine, in a community-based population of 1043 older white men and women. In those currently overweight (body mass indices (BMI) > 26), the age-adjusted mean BMD at all sites was significantly higher than in those with BMI less than 26. Lifetime maximum BMI was also positively and significantly associated with a higher age-adjusted BMD at all sites except the ultradistal wrist in men. Weight gain or fluctuation of 10 lbs or more between the ages of 40 and 60 was associated with significantly higher age-adjusted mean BMD at all sites compared to weight loss or no weight change in both men and women. Weight at age 18 was unassociated with BMD but weight gain after age 18 was associated with significantly higher age-adjusted mean BMD at all sites. Conversely, dieting, weight loss or a lifetime maximum BMI of less than 24 were all associated with markedly lower BMD at all sites in both sexes. Weight patterns were closely correlated with current BMI; most of these trends persisted but were no longer statistically significant after controlling for current weight.

Sex differences in osteoporosis in older adults with non-insulin-dependent diabetes mellitus.

OBJECTIVE: To describe the association of non-insulin-dependent diabetes mellitus (NIDDM) with bone mineral density (BMD). DESIGN: A survey of men and women from an established epidemiologic cohort who were separately screened for diabetes by oral glucose tolerance test between 1984 and 1987 and for osteopenia by BMD measured in 1988-1989. SETTING: A community-based population of older adults, Rancho Bernardo, Calif. PARTICIPANTS: The first 627 consecutively seen white men and women aged 55 to 88 years. MAIN OUTCOME MEASURES: Bone density measured by single photon absorptiometry at the ultradistal wrist and midradius and by dual x-ray absorptiometry at the femoral neck and lumbar spine. MAIN RESULTS: Among the 236 men and 391 women, whose average age was 72 years, 41 men and 39 women had NIDDM, 56 men and 110 women had impaired glucose tolerance, and 139 men and 242 women had normal glucose tolerance. Men with diabetes had BMD levels similar to those men with normal glucose tolerance, whereas women with diabetes had significantly higher BMD levels at all sites than women with normal glucose tolerance. The increased bone density in diabetic women was unexplained by age, obesity, cigarette smoking, alcohol intake, regular physical activity, and the use of diuretics and estrogen. The multiply adjusted mean BMD in women with NIDDM compared with normoglycemic women was 0.600 g/cm2 vs 0.548 g/cm2 at the midradius; 0.265 g/cm2 vs 0.230 g/cm2 at the ultradistal wrist; 0.654 g/cm2 vs 0.610 g/cm2 at the femoral neck; and 0.962 g/cm2 vs 0.859 g/cm2 at the spine. The sex differences were unexplained by survivor bias, prior obesity, or duration of diabetes. Differences were seen in women (but not men) whose diabetes was first detected at the screening evaluation, ie, before drug or dietary treatment. Similarly, in women (but not men) without diabetes increasing BMD levels at all four sites were associated with increasing postchallenge glucose levels independent of age and body mass index. CONCLUSIONS: Older women with NIDDM or hyperglycemia had better BMD than women with normal glucose tolerance, independent of differences in obesity and many other risk factors. No differences in bone density by diabetic status were observed in men. We hypothesize that the sex differences may be explained by the greater androgenicity reported in women with hyperglycemic and hyperinsulinemic conditions.

Base deficit as a sensitive indicator of compensated shock and tissue oxygen utilization.

To determine the relationship of the arterial base deficit (BD) to physiologic indicators of shock and resuscitation--heart rate, mean arterial pressure (MAP), cardiac output (CO), arteriovenous oxygen difference (AVO2), mixed venous oxygen saturation (VSAT) and oxygen delivery to consumption ratio (RATIO)--16 swine were monitored invasively, bled 40 per cent of their calculated blood volume and resuscitated with crystalloid and blood. During hemorrhage, the MAP, CO, VSAT and RATIO decreased and the BD and AVO2 increased. One hour after hemorrhage, but before crystalloid infusion, the MAP, VSAT and RATIO had increased significantly from previous levels and the AVO2 had narrowed significantly, while the BD showed no significant change. All parameters returned to baseline with resuscitation. BD accurately reflected the hemodynamic and tissue perfusion changes associated with hemorrhagic shock and resuscitation in this model. BD can be used as an indicator of the severity of the shock state and the efficacy of resuscitation when invasive monitoring is impractical or not available. BD was more reflective of the true volume deficit during compensated shock than other physiologic variables in this study.

A population-based comparison of quantitative dual-energy X-ray absorptiometry with dual-photon absorptiometry of the spine and hip.

Dual photon absorptiometry (DPA) is currently the most widely used method for noninvasive bone mineral density (BMD) measurement of the axial skeleton. Dual energy X-ray absorptiometry (DEXA) is a recently developed technique that uses an X-ray tube as a photon source; it has demonstrated several significant advantages over DPA in preliminary studies. We report here a quantitative comparison of the DEXA and DPA technologies using a Hologic DEXA (Hologic QDR model 1000, Waltham, MA) scanner and a Lunar DPA (Lunar Radiation DP3, gandolineum-153 source) scanner at both the proximal femur and lumbar spine sites using bone density measurements from a population-based sample of older white men and women who had complete DEXA and DPA measurements of the hip (n = 217) or the spine (n = 176). To examine the relationship of BMD measured by the DPA scanner to BMD measured on the DEXA scanner, normal least squares linear regression was used to regress the DPA BMD on the DEXA BMD for each site. DEXA values were consistently lower than DPA values, with an average difference of 16%. The squared multiple correlation (R2) values were at or above 0.95 for almost all sites, with Ward's triangle having the lowest value (0.89). The slope for all sites was similar, ranging from 0.94 to 1.1. Research and clinical centers that wish to change to DEXA technology because of its shorter examination time and greater precision can therefore compare DEXA with DPA values using representative conversion factors.

Base deficit as an indicator of significant abdominal injury.

OBJECTIVE: To determine the relative predictive value of the arterial base deficit (BD) as an indicator of intra-abdominal injury (AI) and to compare BD with other indicators (chest injuries, pelvic fractures) of AI. DESIGN: Retrospective case-control analysis. SETTING: University of California San Diego Medical Center. MEASUREMENTS AND MAIN RESULTS: Between January 1985 and July 1988, 3,223 blunt trauma patients were admitted, with complete records available on 3,011. Using a "best fit" multiple logistic regression, BD less than or equal to -6 was the single most important indicator of AI (P less than or equal to .0001), and the odds ratio for AI increased with each category of increasing severity of BD. Admission hypotension, major chest injury, pelvic fracture, and field hypotension (in odds ratio order) also were significantly associated with AI. CONCLUSION: BD is a powerful indicator of AI. A normal BD does not exclude AI, but the presence of a BD less than or equal to -6 in a blunt trauma patient should be considered a strong indication for objective evaluation of the abdomen (ie, diagnostic peritoneal lavage).

Calcium intake: covariates and confounders.

One common nutrient postulated to be protective against osteoporosis, hypertension, and colon cancer is dietary calcium. We report here nutrient patterns by calcium intake in older adult residents of a geographically defined community in Southern California. The analysis included all 426 men and 531 women aged 50-79 y with complete 24-h diet data. Nutrient-density-adjusted calcium intake was divided into tertiles: low intake (less than 284 mg/1000 kcal), mid intake (284-440 mg/1000 kcal), and high intake (greater than 440 mg/1000 kcal). The distribution of the reported 24-h nutrient density of protein, fat, fiber, caffeine, trace minerals, vitamin D, and vitamin C was examined in relation to the calcium-intake tertiles. In both men and women, the adjusted intakes of protein, saturated fatty acids, vitamin D, magnesium, and phosphorus were significantly higher in the high-calcium-intake group than in the low- and mid-calcium-intake groups. In both men and women, alcohol intake was significantly lower in the high-calcium-intake group. Studies postulating a protective role for calcium will need to consider the multicolinearity in the Western diet.

Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment.

Blunt carotid dissection (BCD) is a rare injury occurring in less than one in 1,000 victims of blunt injuries. Using a 4-year experience in a trauma system with 14 cases of BCD, we performed a matched blunt trauma patient case-control analysis to determine if there were patterns of injuries that were associated with increased risk of BCD. Patients with combinations of head, facial, and cervical spine injuries with or without extremity fractures proved to be at significantly increased risk for BCD. Duplex scanning appears to be a useful screening tool for these patients. Anticoagulation was the preferred treatment once neurologic deficits were present.