Comparison of two prognostic models in trauma outcome.

BACKGROUND: The Trauma Audit and Research Network (TARN) in the UK publicly reports hospital performance in the management of trauma. The TARN risk adjustment model uses a fractional polynomial transformation of the Injury Severity Score (ISS) as the measure of anatomical injury severity. The Trauma Mortality Prediction Model (TMPM) is an alternative to ISS; this study compared the anatomical injury components of the TARN model with the TMPM. METHODS: Data from the National Trauma Data Bank for 2011-2015 were analysed. Probability of death was estimated for the TARN fractional polynomial transformation of ISS and compared with the TMPM. The coefficients for each model were estimated using 80 per cent of the data set, selected randomly. The remaining 20 per cent of the data were used for model validation. TMPM and TARN were compared using calibration curves, measures of discrimination (area under receiver operating characteristic curves; AUROC), proximity to the true model (Akaike information criterion; AIC) and goodness of model fit (Hosmer-Lemeshow test). RESULTS: Some 438 058 patient records were analysed. TMPM demonstrated preferable AUROC (0·882 for TMPM versus 0·845 for TARN), AIC (18 204 versus 21 163) and better fit to the data (32·4 versus 153·0) compared with TARN. CONCLUSION: TMPM had greater discrimination, proximity to the true model and goodness-of-fit than the anatomical injury component of TARN. TMPM should be considered for the injury severity measure for the comparative assessment of trauma centres.

Psychological impact of fire disaster on children and their parents.

Six weeks following a major wildfire, children's psychosocial functioning was examined. Employing a multimethod assessment approach, the short-term mental health consequences of the fire were evaluated. Individual adjustment was compared between families who reported high levels of loss as a result of the fire (high-loss group) and families who reported relatively low levels of loss resulting from the fire (low-loss group). Standardized assessment procedures were employed for children and adolescents as well as their parents. In general, high-loss participants reported slightly higher levels of post-traumatic stress disorder (PTSD) symptoms and significantly higher scores on the Impact of Events Scale. PTSD symptoms reported by parents were generally significantly correlated with (but not concordant with) PTSD symptoms reported by their children. The high-loss group scored significantly higher on the Resource Loss Index than did the low-loss group. Preexisting and comorbid disorders and previous stressors are described. A methodological framework for future studies in this area is discussed.

The psychological effects of Hurricane Andrew on ethnic minority and Caucasian children and adolescents: a case study.

The impact of Hurricane Andrew on 212 African American, Caucasian, and Hispanic elementary and middle school children was examined at 6 months postdisaster. Using self-report instruments, this case study examined the predictive utility of several hypothesized mediators of children's reactions to disaster. Results showed higher levels of intrusive symptomatology for girls and for elementary school children as compared with their middle school counterparts. No differences were found with reference to race. The lack of findings concerning race is addressed, as well as implications for future studies.

Increased death receptor 5 expression by chemotherapeutic agents in human gliomas causes synergistic cytotoxicity with tumor necrosis factor-related apoptosis-inducing ligand in vitro and in vivo.

The intractability of malignant gliomas to multimodality treatments plays a large part in their extremely poor prognosis. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is a novel member of the tumor necrosis factor (TNF) family that induces apoptosis preferentially in tumor cells through binding to its cognate death receptors, DR4 and DR5. Here we show that the DNA-damaging chemotherapeutic drugs, cis-diamminedichloroplatinum(II) (CDDP) and etoposide, elicited increased expression of DR5 in human glioma cells. Exposure of such cells in vitro to soluble human TRAIL in combination with CDDP or etoposide resulted in synergistic cell death that could be blocked by soluble TRAIL-neutralizing DR5-Fc or the caspase inhibitors, Z-Asp-CH2-DCB and CrmA. Moreover, systemic in vivo administration of TRAIL with CDDP synergistically suppressed both tumor formation and growth of established s.c. human glioblastoma xenografts in nude mice by inducing apoptosis without causing significant general toxicity. The combination treatment resulted in complete and durable remission in 29% of mice with the established s.c. xenografts and also significantly extended the survival of mice bearing intracerebral xenografts. These results provide preclinical proof-of-principle for a novel therapeutic strategy in which the death ligand, TRAIL, is safely combined with conventional DNA-damaging chemotherapy.

An unusual presentation of emphysematous cystitis.

Emphysematous cystitis is a rare disorder most commonly seen in women and associated with urinary tract infections and poorly controlled diabetes mellitus. We report the case of a 76-year-old woman who presented with diarrhea and abdominal discomfort, and emphysematous cystitis was revealed on the abdominal X-ray series. This case is unique in that the patient had no evidence of urinary tract infection, diabetes, or recent instrumentation. As the patient was treated for emphysematous cystitis (bladder irrigation and intravenous antibiotics), the diarrhea rapidly resolved and the radiographic abnormalities of the emphysematous cystitis also resolved. This may suggest a causal relationship, although a specific mechanism is unknown.

Evaluation of two intervention strategies to stimulate quality improvement projects in the hospital: the H. pylori example.

A multistate quality improvement project conducted to improve the care of hospitalized Medicare patients with peptic ulcer disease is described. This randomized control study design compared the effectiveness of two intervention strategies (mailed information vs. on-site presentations with feedback) in stimulating hospitals to conduct diagnostic journeys to determine root causes for performance deficits and to develop and implement plans to improve performance.

Effectiveness of a dot-blot immunoassay of anti-Rickettsia tsutsugamushi antibodies for serologic analysis of scrub typhus.

We compared a commercially available dot-blot immunoassay system with the indirect immunofluorescence assay (IFA) in tests of known negative and known positive sera from scrub typhus cases. Using a panel of 100 sera from patients with various rickettsial and nonrickettsial infections, we observed that the IFA was 99% specific and the dipstick assay was 98% specific. In tests of 91 sera (30 negative and 61 positive for scrub typhus antibodies) from a study of febrile patients in Malaysia, using the standard of an IFA titer < 1:64 as negative, an IFA titer > 1:128 as positive, and an IFA titer = 1:64 as either positive or negative (supported by clinical records), dipsticks were 83% specific and 90% sensitive. The quantitative correlation of the dipsticks to IFA titers was confirmed by significant differences in geometric means of inverse IFA titers corresponding to the number of positive dipstick spots (no dots = 8.5, one dot = 43.3, two dots = 206.7, and three dots = 676.9). The assay would enable physicians and public health workers who deal with patients to quickly diagnose and appropriately treat most cases of the disease, especially in areas of high prevalence where the proportion of false-positive results to true-positive results would be low.