Long-term stability of self-assembled monolayers on 316L stainless steel.

316L stainless steel (316L SS) has been extensively used for making orthopedic, dental and cardiovascular implants. The use of phosphonic acid self-assembled monolayers (SAMs) on 316L SS has been previously explored for potential biomedical applications. In this study, we have investigated the long-term stability of methyl (-CH(3)) and carboxylic acid (-COOH)-terminated phosphonic acid SAMs on 316L under physiological conditions. The stability of SAMs on mechanically polished and electropolished 316L SS was also investigated as a part of this study. Well-ordered and uniform -CH(3)- and -COOH-terminated SAMs were coated on mechanically polished and electropolished 316L SS surfaces. The long-term stability of SAMs on 316L SS was investigated for up to 28 days in Tris-buffered saline (TBS) at 37 degrees C using x-ray photoelectron spectroscopy, atomic force microscopy and contact angle goniometry. A significant amount of phosphonic acid molecules was desorbed from the 316L SS surfaces within 1 to 7 days of TBS immersion followed by a slow desorption of molecules over the remaining days. The -COOH-terminated SAM was found to be more stable than the -CH(3)-terminated SAM on both mechanically and electropolished surfaces. No significant differences in the desorption behavior of SAMs were observed between mechanically and electropolished 316L SS surfaces.

Computers in surgical education and the operating room.

Medicine has gone through major changes over the last 50 years. Today it is recognized that medical knowledge doubles every 6-8 years. It is also true that with the advent of many new medical procedures, surgeons must continue to learn new techniques throughout their careers; this was not the case in the past. Significant changes have also occurred during the same period in computers. It has recently become apparent that there exists a synergy between these two industries - computers can be used to assist surgeons in both initial education and in learning new skills. The National Capital Area Medical Simulation Center is a unique resource that makes use of state-of-the-art computer resources to teach resuscitation and other skills. Both computerized mannequins and virtual reality training devices are used to teach surgical principles and technical procedures. The natural progression of this technology will be for virtual reality simulations to be used for selecting, training, certifying, and recertifying surgeons. Ultimately, surgeons will practice operative procedures using 3D data sets of the patients they plan to operate the next day and then use recordings to play back their optimal procedure robotically on their patients.

Differences in mortality between elderly and younger adult trauma patients: geriatric status increases risk of delayed death.

BACKGROUND: Elderly patients suffer higher mortality rates after trauma than younger patients. This increased mortality is attributable to age, preexisting disease, and complications as well as injury severity. METHODS: Records from 5,139 adult patients from a Level I trauma center were retrospectively reviewed. Injury Severity Score (ISS), Revised Trauma Score (RTS), early mortality (<24 hours), and late mortality (>24 hours) were determined for elderly (> or =65 years) and younger (16-64 years) patients. Preexisting diseases and complications were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis coding. RESULTS: Mortality in elderly patients was twice that in younger patients despite equivalent injury severity (p < 0.001), and elderly patients were more likely to suffer later death than younger patients (p < 0.005). The prevalence of preexisting disease was greater in the elderly, as was the incidence of complications. Using logistic regression, ISS, RTS, preexisting cardiovascular or liver disease, the development of cardiac, renal, or infectious complications, and geriatric status were all independently predictive of late mortality (p < 0.05). CONCLUSION: Elderly trauma patients more frequently suffer late mortality than younger patients because of the combination of injury and increased preexisting disease and complications after injury. Aggressive treatment of the elderly trauma patient is warranted; however, in the face of significant preexisting disease or complications, survival is less likely. Predictive models of survival can be developed, taking into account preexisting disease and complications as well as admission parameters such as age, ISS, and RTS, and specific risk of mortality quantitated.

A population-based study of trauma recidivism.

BACKGROUND: Patients with repeat presentations to acute care hospitals for new injuries are trauma recidivists. Prospective identification of those patients at greatest risk will permit focusing of limited hospital prevention resources. METHODS: A population-based analysis of patients with recurrent trauma presenting to all hospitals in Nevada during a 5-year period was conducted. Records of 10,355 presentations representing 10,137 patients were analyzed. RESULTS: Recidivist trauma patients were younger than non-recidivists, with patients aged 20 to 24 years having significantly higher rates of recidivism. Males were 1.53 times more likely than females to become recidivists. Cutting/piercing and machinery-related injuries were most frequently associated with recidivism. Cutting/piercing wound survivors were 7.06 times more likely to be recidivists than were gunshot wound survivors. Recidivists in motor vehicles crashes were 1.92 times less likely to wear seat belts than nonrecidivists. Recidivism was also significantly associated with positive blood alcohol levels and longer initial hospital stays. CONCLUSION: The rate of trauma recidivism in this study was 2.0%. Population-based data can be used to identify cohorts at risk of recidivism.

Data elements for emergency department systems, release 1.0 (DEEDS): a summary report. DEEDS Writing Committee.

Variations in the way that data are entered in ED record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product. Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations.

Data elements for emergency department systems, release 1.0 (DEEDS): a summary report. DEEDS Writing Committee.

Variations in the way that data are entered in emergency department record systems impede the use of ED records for direct patient care and deter their reuse for many other legitimate purposes. To foster more uniform ED data, the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control is coordinating a public-private partnership that has developed recommended specifications for many observations, actions, instructions, conclusions, and identifiers that are entered in ED records. The partnership's initial product, Data Elements for Emergency Department Systems, Release 1.0 (DEEDS), is intended for use by individuals and organizations responsible for ED record systems. If the recommended specifications are widely adopted, then problems--such as data incompatibility and high costs of collecting, linking, and using data--can be substantially reduced. The collaborative effort that led to DEEDS, Release 1.0 sets a precedent for future review and revision of the initial recommendations.

Usefulness of thrombelastography in assessment of trauma patient coagulation.

OBJECTIVE: Thrombelastography (TEG) is used to rapidly assess coagulation abnormalities in cardiac and transplant surgery. The purpose of this study was to investigate TEG in the initial assessment of trauma patient coagulation. METHODS: TEG was performed on 69 adult blunt trauma patients during their initial evaluation. Demographics, history of inherited coagulopathies, medications, TEG parameters, platelet count, prothrombin time/partial thromboplastin time, Revised Trauma Score (RTS), Injury Severity Score (ISS), use of blood products, and outcome were recorded. RESULTS: Mortality was 4.3%. Fifty-two patients demonstrated coagulation abnormalities by TEG; of these, 45 were hypercoagulable (mean ISS 13.1), and seven were hypocoagulable (mean ISS 28.6). Six of the seven hypocoagulable patients received blood transfusions within the first 24 hours. Mean ISS of the 17 patients with normal TEG parameters was 3.7. Logistic regression of ISS, Revised Trauma Score, prothrombin time/partial thromboplastin time, and TEG on use/nonuse of blood products within the first 24 hours demonstrates that only ISS (p < 0.001) and TEG (p < 0.05) are predictive of early transfusion. CONCLUSIONS: The majority of blunt trauma patients in this series were hypercoagulable. TEG is a rapid, simple test that can broadly determine coagulation abnormalities. TEG is an early predictor of transfusion in blunt injury patients.

Motor vehicle crashes, restraint use, and severity of injury in children in Nevada.

INTRODUCTION: Data from the population-based Nevada State Trauma Registry were used to examine rates and determinants of restraint use in children who were involved in a car crash and seriously injured. Patterns of injuries in these children are also assessed. METHODS: Data were obtained from children 14 years of age or younger who entered the Nevada State Trauma Registry because of a serious injury caused by a car crash. The study period was from January 1, 1989, to December 31, 1992. RESULTS: Average annual age-specific crash injury rates per 100,000 were higher in rural areas than in urban areas. In children younger than two years old, 61% were restrained at the time of the crash; however, only about one third of all children over the age of three were restrained. In ages 0-4 years, only 5.3% of the African-American children were restrained at the time of the crash compared with 47.2% of the Caucasian children. Children who were not restrained were more likely to have more adverse outcomes and to have different types of injury compared with their restrained counterparts. CONCLUSIONS: The use of restraining devices in children who suffer a serious injury in a motor vehicle crash continues to be low and appears to be related to specific demographic characteristics. The findings indicated that restraint use at the time of the crash was related to less severe injury as indicated by certain outcome variables.

Familial multiple glomus tumors: report of a pedigree and literature review.

Glomus tumors are uncommon, benign soft tissue tumors that can occur in a familial or sporadic pattern. Only 15 pedigrees have been reported to date. We report a family with three generations developing multiple glomus tumors of the skin. Although controversy exists over pattern of inheritance, review of the published pedigrees plus this additional one suggests an autosomal dominant inheritance with incomplete penetrance and variable expressivity.

Validity of applying adult TRISS analysis to injured children.

Injury severity measures are becoming increasingly important for quality assurance and injury research. TRISS analysis, which uses the Revised Trauma Score (RTS) and Injury Severity Score (ISS) to predict survival, is an effective tool for comparing outcomes between trauma centers. It has been argued that blunt trauma outcome differs between children and adults, yet the Major Trauma Outcome Study (MTOS) adult data base (ages 15-54 years) regression weights have been used by others to calculate TRISS scores for injured children. This study appears to be the first to perform TRISS analysis on groups of children and adults treated by the same surgeons using the same treatment protocols to assess the validity of applying "adult" TRISS analysis to children. The charts of 346 consecutive children (ages 0-14) and 346 random adults (ages 15-54) admitted to a regional trauma center for isolated blunt trauma over a 30-month period were reviewed for demographics, mechanism of injury, RTS, ISS, and survival. Statistical evaluation included TRISS survival analysis and calculation of the Z statistic. The median ISS was 10 for both children and adults. The Z statistics for children and adults were similar (1.85 and 1.81). Analysis demonstrated the groups to be statistically identical with a nonsignificant trend toward improved survival compared with the MTOS baseline group. These data support the use of existing TRISS analysis for evaluation of pediatric trauma care.

Army trauma research: tapping the potential.

Trauma management is the primary mission of military surgeons. Since the Vietnam War, however, military surgeons have relinquished leadership in clinical trauma care to the civilian sector, particularly to urban university surgeons. In this paper we explore whether the Army's contribution to trauma research has also diminished. Using standard bibliometric analysis of publication counts, we have shown that few recent publications related to trauma have originated from U.S. Army Medical Centers, compared with adjacent civilian universities. In 1988, 16 papers originating from the eight Army Medical Centers had key words related to trauma. In contrast, eight universities adjacent to the Army's medical centers published 139 articles on trauma. Problems including lack of clinical exposure to trauma patients, lack of funding, and inadequate emphasis on staff research training have contributed to this decline. We review these factors and describe solutions that could reverse this trend.

Evaluation of the Pediatric Trauma Score.

A Pediatric Trauma Score (PTS) was recently developed and is rapidly gaining acceptance as a triage tool. This study examines the utility of the PTS as compared with the Revised Trauma Score, which is applicable to all ages. The charts of 376 children 0 to 14 years of age who were admitted to the trauma service of a level 1 trauma center were reviewed. Significant correlations were found for both the PTS and the Revised Trauma Score with survival, the Injury Severity Score, APACHE II score, vital signs, the Glasgow Coma Scale score, hematocrit, need for an operation, and number of days in an intensive care unit. The PTS was of no statistical advantage as compared with the Revised Trauma Score. Triage accuracy was 68.3% for the PTS and 78.8% for the Revised Trauma Score. The Revised Trauma Score is easy to use and universal in its applicability. The PTS involves learning a separate scoring system and is of no advantage.

Pediatric trauma: need for surgical management.

A recent proposal by some pediatricians is that they be primarily responsible for resuscitation and triage of injured children with surgical care being initiated only through consultation. To assess the need for operative intervention, a consecutive series of 376 children less than 15 years of age admitted to a regional trauma center was examined, in which 194 children had 254 operations. Mortality was 7.2%. Twenty-two children who presented with persistent hemodynamic instability (sys. BP less than 90 mm Hg) had a mortality of 73%. Children were divided into three severity groups based on the Revised Trauma Score (RTS). Of the severely injured children (RTS less than or equal to 6), 79% required emergent operative intervention; 42% and 14%, respectively, required emergent operation in the moderately (6 less than RTS less than 12) and minimally (RTS = 12) injured groups. The need for operative management is great, even in "minimally" injured children.