[Israel's ATLS program: summary and outlook]

In recent years a vigorous effort has been made to improve quality of primary trauma care in Israel. Advanced trauma life support courses (ATLS) were given to physicians throughout the country, regardless of their specialties. In 7 years 4229 physicians participated in 202 courses with an average success rate of 76%. In the future, issues such as mandatory vs. voluntary training, language barriers, and continuous decline of knowledge should be addressed if momentum is to be maintained.

Cognitive knowledge decline after Advanced Trauma Life Support courses

OBJECTIVE

To assess the cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) program in Israel, to compare the rate of decline between surgeons and nonsurgeons, and to recommend appropriate timing for refresher courses.

METHODS

A prospective study based on multiple-choice question test results of 220 ATLS course graduates was conducted 3 to 60 months after course completion. These results were then compared with the examination results immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the study groups.

RESULTS

A significant decline of cognitive knowledge over time among ATLS graduates was demonstrated. This decline was significantly greater in the nonsurgical group. A critical point of 20% cognitive knowledge loss among 50% of the examined physicians was observed around the 180th week after completion of the course.

CONCLUSION

Physicians taking the ATLS course lose a significant part of their acquired cognitive knowledge after 3.5 years. Surgeons retain their cognitive knowledge for longer periods of time. Based on the study results, the optimal timing for a refresher course is between 3 and 4 years after the initial ATLS course.

Health services use by urban women with or at risk for HIV-1 infection: the HIV Epidemiology Research Study (HERS)

OBJECTIVE

To characterize health services use by urban women with or at risk for HIV-1 infection enrolled in a prospective multicenter study.

METHODS

1310 women 16 to 55 years of age who were at risk for HIV-1 infection were recruited between April 1993 and January 1995 at four urban centers (Baltimore, Maryland; The Bronx, New York; Detroit, Michigan; and Providence, Rhode Island). HIV-1-seropositive women without AIDS-defining illness were oversampled in a ratio of 2:1 in comparison with HIV-1-seronegative women. At a baseline study visit, the women received physical and laboratory examinations, including CD4+ counts, and were interviewed regarding HIV risk behavior, health services use, and clinical data.

RESULTS

863 women were HIV-1-seropositive and 430 were HIV-1-seronegative. Fifty-two percent of the women reported injection drug use (IDU) since 1985, and 48% acquired HIV through sexual contact. Seventy-seven percent were African American, 23% were white, and 16% were Hispanic. The median age was 35 years. HIV-seronegative women were significantly less likely to have health insurance (19%) than were HIV-seropositive women (30%; p < .001). Among the HIV-seropositive women, 68% had CD4+ cell counts of <500/microl, and 64% were asymptomatic. Sixty-four percent of the HIV-seronegative women had had an outpatient hospital visit in the past 6 months, as had 86% of HIV-seropositive women (p < 0.001). Hospitalization in the past 6 months was also higher in HIV-seropositive women (22% vs. 12%; p < .001). Despite heavy use of health services, only 49% of women with CD4+ counts of <200/microl reported current use of antiretroviral therapy, and only 58% reported current use of Pneumocystis carinii pneumonia (PCP) prophylaxis. Among HIV-seropositive women, and after adjusting for CD4+ count, HIV symptoms, race, and study site, IDUs were significantly less likely to have a regular doctor and a recent outpatient visit and more likely to be hospitalized and use the emergency department (ED) than were non-IDUs. In multivariate analyses of HIV-seropositive persons, African American women had similar access to care and use of antiretroviral therapy and PCP prophylaxis than did white women but were less likely to have an outpatient department visit in the previous 6 months and to be taking PCP and opportunistic infection (OI) prophylaxis. Health services access and use of HIV-related therapies did not significantly differ between Hispanic and white women with HIV infection.

CONCLUSION

Although both HIV-seropositive and HIV-seronegative women had high levels of use of medical services, current use of antiretrovirals and OI prophylaxis was low throughout, and IDUs used HIV-related primary health services less and were more likely to receive emergency or episodic care. IDU and African American race were independently associated with decreased use of medical services.

Retained Aspergillus-contaminated contact lens inducing conjunctival mass and keratoconjunctivitis in an immunocompetent patient

PURPOSE

A 66-year-old woman presented with a 1-month history of prominent mucoid discharge and foreign body sensation in her left eye.

METHODS

Ocular evaluation revealed a moderately severe superficial punctate keratitis involving the temporal half of the left cornea. The superior tarsal conjunctiva showed marked papillary reaction with an area of indentation temporally. A mass was present in the superior temporal aspect of the fornix, clinically resembling a pyogenic granuloma. At the posterior aspect of this mass and covered by mucoid material, was a soft contact lens.

RESULTS

Upon removal of the lens, without any additional therapy, the patient became asymptomatic and totally resolved her keratitis and mass lesion. Cultural identification of the soft contact lens was positive for Aspergillus fumigatus.

CONCLUSIONS

We hypothesize that the mucoid discharge and mass lesion represented a mechanism similar to allergic fungal sinusitis.

Structure and process components of trauma care services in Israeli acute-care hospitals

In recent years a vigorous effort has been made to improve primary trauma care in Israel. The Ministry of Health and other authorities have invested in new facilities in various hospitals which are engaged in trauma care. A survey was conducted in order to identify deficiencies in organization, personnel and equipment required to provide optimal trauma care. A cross-country survey was conducted by using a questionnaire that dealt with structure and process components of trauma care. The questionnaire was submitted to medical directors of emergency departments in all 24 acute-care hospitals in Israel. Additional information was obtained by a telephone poll when required. Inter-hospital variation concerning structure of trauma services, protocols and qualification of manpower responsible for primary care of the injured was found. The conclusions are that an increase in homogeneity in the field of trauma care is still needed. A continuous effort should be made in order to structurally and functionally further develop independent trauma units in all hospitals in Israel. Methods should be found to encourage young physicians to enter the field of trauma care. The establishment of a nationwide trauma registry system will undoubtedly contribute to future improvement in the initial care of the injured in Israel.

[ATLS course for surgery residents--should it be mandatory?]

Senior surgeons were asked about mandatory participation of general surgery residents in the advanced trauma life support (ATLS) course. Although trauma care in Israel is given by surgical residents, in the opinion of their senior mentors the course should continue to be mandatory for them.

Critical residues of Chlamydomonas reinhardtii ferredoxin for interaction with nitrite reductase and glutamate synthase revealed by site-directed mutagenesis

Incubation of wild-type ferredoxin (Fd) with Chlamydomonas reinhardtii crude extract in the presence of a carboxyl activator resulted in the formation of a unique 1:1 covalent complex with nitrite reductase. However, glutamate synthase was able to form two covalent complexes of Fd: GOGAT with 1:1 and 2:1 stoichiometries. These complexes were functional only when reduced methyl viologen was used as electron donor. Kinetic studies of complex formation suggested the presence of two Fd-binding domains with similar affinity for Fd in the glutamate synthase molecule. Using site-directed mutagenesis with recombinant Fd, we have shown that Fd-Glu91 is directly involved in Fd interaction with glutamate synthase and nitrite reductase. Moreover, a negative core of residues in the alpha1 helix of Fd was also critical in binding the enzymes. These data highlight the analogy in the Fd-binding sites of nitrite reductase and glutamate synthase, which may compete for the electrons coming from the photosynthetic chain.

Comparison of real-time virtual and fiberoptic bronchoscopy in patients with bronchial carcinoma: opportunities and limitations

OBJECTIVE

Both helical CT and fiberoptic bronchoscopy are used in the staging of pulmonary tumors for therapeutic decision making. The improved resolution offered by helical CT has led to the clinical use of three-dimensional reconstruction techniques such as virtual bronchoscopy. We tested this new simulated endoscopic view of inner organ surfaces and compared it with corresponding fiberoptic examinations of the tracheobronchial system.

SUBJECTS AND METHODS

Twenty patients with malignancies of the lung and mediastinum were examined with both virtual bronchoscopy and fiberoptic bronchoscopy. Both examinations were reviewed by radiologists and surgeons familiar with fiberoptic bronchoscopy. Virtual bronchoscopy was calculated and reconstructed from the cross-sectional images on a separate workstation. Stenoses and tumor infiltration were classified from the fiberoptic examination. These results were compared with the virtual bronchoscopy findings.

RESULTS

Virtual bronchoscopy of diagnostic quality was achieved in 19 of 20 patients. High-grade stenoses were revealed equally well with virtual and fiberoptic techniques. Virtual bronchoscopy offered the advantage of being able to visualize areas beyond even high-grade stenoses. However, on virtual bronchoscopy discrete infiltration or extraluminal impression was not visible in five patients. In another patient, strong heart pulsation produced motion artifacts that prevented evaluation of the reconstruction.

CONCLUSION

Virtual bronchoscopy represents a new noninvasive method for evaluating helical CT findings. In comparison with fiberoptic bronchoscopy, virtual bronchoscopy offers the advantage of being able to visualize areas beyond even high-grade stenoses. In addition to the limited view of fiberoptic bronchoscopy, extraluminal causes of lumen compressions can be analyzed in the cross-sectional images and evaluated together with the virtual representation. However, it was not possible to detect small infiltrations with virtual bronchoscopy. This new representation of helical CT data might be helpful for postoperative follow-up examinations, such as after stent implantation, and can be carried out without additional risk to the patient. Radiologists do need special fiberoptic bronchoscopy knowledge and experience with three-dimensional-reconstructions to differentiate between real stenoses and artificial stenoses that might be caused by pulsation artifacts.

Structural and functional roles of a conserved proline residue in the alpha2 helix of Escherichia coli thioredoxin

Proline 40 in Escherichia coli thioredoxin is located close to the redox active site (Cys32-Cys35) within the alpha2 helix. The conservation of this residue among most of the thioredoxins suggests that it could play an important role in the structure and/or function of this protein. We have substituted Pro40 for Ala by using site-directed mutagenesis and expressed the mutant P40A in E.coli. The effects of the mutation on the biophysical and biological properties of thioredoxin have been analyzed and compared with molecular dynamics simulations. Modeling predicted that the replacement of Pro40 by Ala induced a displacement of the active site which exposes Trp31 to the solvent and opens a cleft located between helices alpha2 and alpha3. The solvation free energy (SFE) calculation also indicated that P40A became more hydrophobic as W31 became more accessible. These predictions were totally in agreement with the experimental results. The mutant P40A exhibited chromatographic behavior and fluorescence properties very different from those of the wild-type (WT) protein, in relationship with the displacement of W31. The determination of the free energy of unfolding of P40A showed that the mutant was globally destabilized by 2.9 kcal/mol. However, the effect of the mutation on the transition curve was highly unusual as the midpoint of the unfolding transition increased, indicating that some local structures were actually stabilized by the mutation. Despite these structural modifications, neither the ability of the protein to reduce a chloroplastic enzyme nor its reactivity with the bacterial reductase decreased. The only functional difference was the higher stability of P40A in light activation of NADP-malate dehydrogenase under air, which suggests that the mutant was less rapidly re-oxidized than WT. Therefore, it can be concluded that Pro40 is not essential for maintaining the redox function of thioredoxin but rather is required for the stability of the protein.

Enteropathogenic E. coli (EPEC) transfers its receptor for intimate adherence into mammalian cells

Enteropathogenic E. coli (EPEC) belongs to a group of bacterial pathogens that induce epithelial cell actin rearrangements resulting in pedestal formation beneath adherent bacteria. This requires the secretion of specific virulence proteins needed for signal transduction and intimate adherence. EPEC interaction induces tyrosine phosphorylation of a protein in the host membrane, Hp90, which is the receptor for the EPEC outer membrane protein, intimin. Hp90-intimin interaction is essential for intimate attachment and pedestal formation. Here, we demonstrate that Hp90 is actually a bacterial protein (Tir). Thus, this bacterial pathogen inserts its own receptor into mammalian cell surfaces, to which it then adheres to trigger additional host signaling events and actin nucleation. It is also tyrosine-phosphorylated upon transfer into the host cell.

Measurement of anti-inflammatory effects of glucocorticoids on human keratinocytes in vitro. Comparison of normal human keratinocytes with the keratinocyte cell line HaCaT

There are only few objective in vitro methods available for the testing of anti-inflammatory pharmaceutical products. One possibility is in the stimulation of cytokine production in cultivated human keratinocytes by UV light and the subsequent testing of suppressing activities. From the dermatological aspect the interleukins 6 and 8 are especially interesting because they are elevated in psoriatic skin. In the present work three glucocorticoids were tested in cultures of normal human keratinocytes and in the permanent keratinocyte cell line HaCaT. Both cell species produced IL-6 and IL-8 spontaneously, albeit in very small amounts. After UV irradiation the interleukin production increased in a dose dependent manner. The IL-6 and IL-8 induction could be suppressed by each of the glucocorticoids tested. The thymidine incorporation rate of the cells was not affected by the glucocorticoids indicating that the observed suppression of cytokine induction was not the result of a generalised cell damage. The response of both HaCaT keratinocytes and primary human keratinocytes to UV irradiation and glucocorticoid application was similar indicating the possible use of the generally available HaCaT cells for the pharmacological testing of anti-inflammatory activities in vitro.

Orally active trifluoromethyl ketone inhibitors of human leukocyte elastase

This paper describes the development a series of peptidyl trifluoromethyl ketone inhibitors of human leukocyte elastase which are found to have excellent pharmacological profiles. Methods have been developed that allow for the synthesis of these inhibitors in stereochemically pure form. Two of these compounds, 1k and 1l, have high levels of oral bioavailability in several species. Compound 1l has entered development as ZD8321 and is presently undergoing clinical evaluation. These compounds demonstrate that peptidyl trifluoromethyl ketone inhibitors can achieve high levels of oral activity and bioavailability, and therefore they may prove useful as therapeutic agents in the treatment of diseases in which elastase is implicated.

Benign extraovarian mimics of ovarian cancer. Distinction with imaging studies

Imaging of the pelvis via computed tomography (CT), ultrasound, or magnetic resonance (MR) provides excellent anatomical detail and superb resolution. Despite this, radiologists often have difficulty reaching a specific diagnosis in evaluating adnexal masses. A wide spectrum of benign extraovarian pathology may closely resemble ovarian cancer. Fallopian tube disease such as hydrosalpinx, tuboovarian abscess, and chronic ectopic pregnancy may mimic cystic or solid ovarian neoplasm. Pedunculated uterine leiomyomas may imitate ovarian lesions. Gastrointestinal causes of adnexal masses include mucocele, abscess, and hematoma. These entities may appear similar to ovarian lesions, thus requiring close attention to specific anatomical detail in order to help differentiate them. Similarly, peritoneal disease including tuberculous peritonitis and peritoneal pseudocyst may simulate ovarian tumor. While ultrasound represents the initial imaging modality in the evaluation of most pelvic disease, MR's multiplanar capability and improved tissue characterization make it a valuable modality in many circumstances.

Characterization of two virulence proteins secreted by rabbit enteropathogenic Escherichia coli, EspA and EspB, whose maximal expression is sensitive to host body temperature

Enteropathogenic Escherichia coli (EPEC) and rabbit EPEC (RDEC-1) cause unique histopathological features on intestinal mucosa, including attaching/effacing (A/E) lesions. Due to the human specificity of EPEC, RDEC-1 has been used as an animal model to study EPEC pathogenesis. At least two of the previously identified EPEC-secreted proteins, EspA and EspB, are required for triggering host epithelial signal transduction pathways, intimate adherence, and A/E lesions. However, the functions of these secreted proteins and their roles in pathogenesis have not been characterized. To investigate the function of EspA and EspB in RDEC-1, the espA and espB genes were cloned and their sequences were compared to that of EPEC O127. The EspA proteins showed high similarity (88.5% identity), while EspB was heterogeneous in internal regions (69.8% identity). However, RDEC-1 EspB was identical to that of enterohemorrhagic E. coli serotype O26. Mutations in RDEC-1 espA and espB revealed that the corresponding RDEC-1 gene products are essential for triggering of host signal transduction pathways and invasion into HeLa cells. Complementation with plasmids containing EPEC espA or/and espB genes into RDEC-1 mutant strains demonstrated that they were functionally interchangeable, although the EPEC proteins mediated higher levels of invasion. Furthermore, maximal expression of RDEC-1 and EPEC-secreted proteins occurred at their respective host body temperatures, which may contribute to the lack of EPEC infectivity in rabbits.

Reoperation. Planned and unplanned

Reoperation is an integral part of the damage control sequence. Each type of reoperation represents an entirely different operative profile with different tactical considerations. This article discusses in detail the key decisions and techniques of planned and unplanned reoperation.

The accumulated experience of the Israeli Advanced Trauma Life Support program

BACKGROUND

Between January 1990 and May 1995 one faculty in Israel taught Advanced Trauma Life Support (ATLS) courses to 3,700 physicians. Two types of courses were given to three subpopulations. We studied the influence of demographic variables on students' achievements in the course and compared students' achievements as a function of their course type.

STUDY DESIGN

This study was conducted as a concurrent longitudinal study.

RESULTS

Achievements of 3,700 students were analyzed. The precourse grade, type of course, and their interaction were found to have a significant effect on the postcourse grades. Physicians practicing surgical subspecialties, in general, did better, as did students educated in English-speaking countries. Students who took part in the Combat Trauma Life Support (CTLS) course, which included the entire ATLS course and additional lectures and exercises, also ended with better scores.

CONCLUSIONS

Physician's country of origin and clinical subspecialty have a significant effect on the cognitive achievement in the ATLS course provided in Israel. An expanded ATLS course (CTLS), to include additional military trauma topics as well as additional skill station training, can improve the results of the postcourse grades.

Combat trauma life support training versus the original advanced trauma life support course: the impact of enhanced curriculum on final student scores

BACKGROUND

Within a military framework, the trauma course student, a young medical officer, is trained to become a trauma team leader and the first provider of medical aid. By adding battlefield medicine-related subjects to the basic Advanced Trauma Life Support (ATLS) course, as well as exercises tailored to the distinctive demands of military medicine, we could develop a special teaching unit: Combat Trauma Life Support (CTLS). The curriculum is basically the complete unchanged ATLS course of the American College of Surgeons enriched with lectures and practicums to fill the gap between the essentially civilian emergency department character of the ATLS course and the military tasks of the medical officer.

PURPOSE OF STUDY

To compare the cognitive knowledge achievements of trauma course participants in the Israel Defence Force Medical Corps and to delineate the impact of the course type on students' written test results.

DESIGN

A retrospective comparison analysis of pre- and post-course written test scores of 2,614 physicians who had participated in the ATLS and CTLS courses in the Israel Defence Force School of Military Medicine between 1990 and 1993.

RESULTS

The analysis indicated that students who undertook the CTLS course achieved statistically better results in written tests (87.9 +/- 8.7 vs. 79.6 +/- 11.4, R2 = 0.33).

CONCLUSIONS

We conclude that the CTLS comprehensive curriculum provides an improved training basis for the complex task of army battlefield trauma care support.

Enteropathogenic Escherichia coli protein secretion is induced in response to conditions similar to those in the gastrointestinal tract

The pathogenicity of enteropathogenic Escherichia coli (EPEC) is associated with the expression and secretion of specific bacterial factors. EspB is one such secreted protein which is required to trigger host signaling pathways resulting in effacement of microvilli and cytoskeletal rearrangements. These events presumably contribute to the ensuing diarrhea associated with EPEC infections. EPEC encounters several environmental changes and stimuli during its passage from the external environment into the host gastrointestinal tract. In this paper we show that the secretion of EspB is subject to environmental regulation, and maximal secretion occurs under conditions reminiscent of those in the gastrointestinal tract. Thus, secretion is maximal at 37 degrees C, pH 7, and physiological osmolarity. In addition, maximal secretion requires the presence of sodium bicarbonate and calcium and is stimulated by millimolar concentrations of Fe(NO3)3. The secretion of the four other EPEC-secreted proteins appears to be modulated in a manner similar to that of EspB. Our results also show that secretion is not dependent on CO2, as originally reported by Haigh et al. (FEMS Microbiol. Lett. 129: 63-67, 1995), but that CO2 more likely acts as a component of the medium buffering system, since CO2 dependence was abolished by the use of alternative buffers.

Interhospital patient transfer: a quality improvement indicator for prehospital triage in mass casualties

The need for interhospital patient transfer after mass casualties may be a consequence of triage errors. Indications for interhospital patient transfer following seven suicidal bus bombings in Israel were reviewed to identify possible errors in triage at the scene. Medical records of victims arriving to hospitals were analyzed for age, injury description, injury Severity Score (ISS), and indication and destination of interhospital transfer. A total of 473 victims were involved, 74 of whom died at the scene (15.6%). Mean victim age was 29 +/- 16 (SD) years. Interhospital transfer was necessary for 29 patients. Indications for transfer included (1) mandatory lifesaving procedures on route to trauma center (n = 14), (2) underdiagnosis at the scene (n = 1), (3) insufficient local resources (n = 9), and (4) triage-related errors (n = 5). The ratio between interhospital transfer due to triage errors and the victim population who may need to be transferred is suggested as quality assurance (QA/QI) indicator for triage.