[ATLS course in emergency medicine for physicians?]

Implementation of Advanced Trauma Life Support (ATLS) skills among practicing physicians and its perceived utility in their civilian practices, as well as in their potential army combat assignments, was evaluated. 177 physicians in various subspecialties, who were graduates of ATLS training courses, answered a specially designed telephone questionnaire. An unexpectedly high percentage of physicians (47%) had used their ATLS training when called to treat trauma victims. 67% of physicians stressed the contribution of the ATLS course to enhancing their skills. We believe that a properly designed ATLS course for general practitioners would be very beneficial for trauma victims.

Abdominal injuries without hemoperitoneum: a potential limitation of focused abdominal sonography for trauma (FAST)

BACKGROUND

Focused abdominal sonography for trauma (FAST) relies on hemoperitoneum to identify patients with injury. Blunt trauma victims (BTVs) with abdominal injury, but without hemoperitoneum, on admission are at risk for missed injury.

METHODS

Clinical, radiologic, and FAST data were collected prospectively on BTVs over a 12-month period. All patients with FAST-negative for hemoperitoneum were further analyzed. Examination findings and associated injuries were evaluated for association with abdominal lesions.

RESULTS

Of 772 BTVs undergoing FAST, 52 (7%) had abdominal injury. Fifteen of 52 (29%) had no hemoperitoneum by admission computed tomographic scan, and all had FAST interpreted as negative. Four patients with splenic injury underwent laparotomy. Six other patients with splenic injury and five patients with hepatic injury were managed nonoperatively. Clinical risk factors significantly associated with abdominal injury in BTVs without hemoperitoneum include: abrasion, contusion, pain, or tenderness in the lower chest or upper abdomen; pulmonary contusion; lower rib fractures; hemo- or pneumothorax; hematuria; pelvic fracture; and thoracolumbar spine fracture.

CONCLUSIONS

Up to 29% of abdominal injuries may be missed if BTVs are evaluated with admission FAST as the sole diagnostic tool. Consideration of examination findings and associated injuries should reduce the risk of missed abdominal injury in BTVs with negative FAST results.

Intravenous line diameter: is bigger really better?

OBJECTIVE

To determine whether the size of an intravenous catheter influences the cannulation success rate and procedure duration among military medics.

METHODS

According to a prospective, randomized, controlled crossover study design, 114 military medic cadets were paired and inserted 14-gauge (14G) and 16G intravenous catheters into veins in the antecubital fossa. Success rate and procedure duration were determined.

RESULTS

The overall success rate for 14G and 16G catheters was 80 and 86%, respectively. Average procedure duration was 33 +/- 14.7 and 35.2 +/- 14.9 seconds, respectively. No significant differences were found in either success rate or procedure duration between the examined catheter sizes.

CONCLUSION

Successful intravenous cannulation was unaffected by catheter size. Therefore, 14G intravenous catheters are recommended for use by military medics on the battlefield.

The impact of advanced trauma life support course on graduates with a non-surgical medical background

The aim of this study was to assess advanced trauma life support (ATLS) and combat trauma life support (CTLS) skills implementation among general practising physicians, its perceived utility in their routine daily practice as well as in their potential army combat assignments. One hundred and ten physicians, graduates of ATLS and CTLS courses, from the subspecialties of geriatrics, psychiatry and family medicine, were surveyed by telephone, to answer a specially designed questionnaire. The response rate was 82%. Professional distribution was: 6.6% geriatrics; 46.7% family physicians; and 46.7% psychaitrists. The number of trauma events treated by these physicians in their post-course practise was: geriatrics-three; family physicians-30; psychiatrists-18. We believe that a properly designed ATLS course, executed and applied to general practitioners, can be highly beneficial to trauma victims.

NMR solution structure of an oxidised thioredoxin h from the eukaryotic green alga Chlamydomonas reinhardtii

NMR solution structures of a cytosolic plant thioredoxin h (112 amino acids, 11.7 kDa) from the green alga Chlamydonmonas reinhardtii have been calculated on the basis of 1904 NMR distance restraints, which include 90 distances used to restrain 45 hydrogen bonds, and 44 phi dihedral restraints. The structure of C. reinhardtii thioredoxin h was solved in its oxidised form, and the ensemble of 23 converged structures superpose to the geometric average structure with an atomic rmsd of 0.080 nm +/- 0.016 for the (N, C(alpha), C) backbone atoms of residues 4-110. Comparisons with other thioredoxins, such as thioredoxin from the bacterium Escherichia coli, thioredoxin 2 from a cyanobacterium of the Anabaena genus, and human thioredoxin, showed that thioredoxin h models share more structural features with human thioredoxin than with other bacterial thioredoxins. Examination of the accessible surface around the redoxactive peptide sequence indicates that a potent thioredoxin-h-substrate interaction could be similar to the vertebrate thioredoxin-substrate interactions.

Residue Glu-91 of Chlamydomonas reinhardtii ferredoxin is essential for electron transfer to ferredoxin-thioredoxin reductase

The [2Fe-2S] soluble ferredoxin from Chlamydomonas reinhardtii was mutated by site directed mutagenesis, using PCR and the expression plasmid pET-Fd as a template. The recombinant mutated proteins were purified to homogeneity and tested in the activation of NADP-malate dehydrogenase, a light dependent reaction in which ferredoxin thioredoxin reductase (FTR) and thioredoxin are involved. The mutation of residue Glu-91 (E92 in spinach, E94 in Anabaena) alone, either to Gln (E91Q) or to Lys (E91K), was found to completely abolish the reaction of the enzyme light activation. On the other hand, the mutants (E92Q) or (E92K) were as efficient as the wild type ferredoxin in this reaction whereas the double mutants (E91Q/E92Q) or (E91K/E92K) had no activity. In addition, a triple mutant (D25A/E28Q/E29Q) was also found to be inactive for this redox dependent light activation. All these mutations had much weaker effects on the ferredoxin/ferredoxin NADP reductase interaction as measured by the cytochrome c reduction assay. These results indicate that there is a recognition site for FTR in the C terminus part of ferredoxin, but also that a core of negatively charged residues in the alpha1 helix of ferredoxin might be important in the general process of light activation.

The trimodal death distribution of trauma victims: military experience from the Lebanon War

INTRODUCTION

Mortality in war is traditionally divided into two categories: killed in action and died of wounds. Mortality in civilian trauma is generally divided into three categories: immediate death (50%), early death (30%), and late death (20%). Can we identify a trimodal death distribution among war victims?

METHODS

We analyzed data for casualties in the Lebanon War from June 6 to September 20, 1982. During this period a total of 1,950 soldiers were injured; 351 (18%) of them died. Time of injury and time of death of the victims was determined from real-time recordings during the battle and from hospital files.

RESULTS

Analyzing the time of death revealed that 329 of the soldiers (93.7%) died within the first hour after injury, 7 soldiers died 1 to 4 hours after injury (2%), and 15 soldiers died 24 hours to 75 days after injury (4.3%). The most common causes of death during the first hour after injury were central nervous system (CNS) injuries 31%, exsanguination 30%, incineration 21%, and combined CNS injury and exsanguination 10.9%. Exsanguination was the leading cause of death 1 to 4 hours after injury (86%). CNS injury was the most common cause of late death (60%). Only 1.1% of the soldiers who reached the hospital alive died of their wounds.

CONCLUSIONS

A trimodal mortality distribution with different causes of death in each peak can be identified in the mortality pattern of Israeli soldiers during the Lebanon War. The relative height of the different peaks and the causes of death in the third peak are different from those found in civilian trauma. We believe that prompt medical treatment and expeditious evacuation from the battle zone led to a very low death rate among the wounded soldiers who had reached the hospital alive. The same factors may have increased the relative portion of CNS injuries as a cause of late death.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median) and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

[Autologous keratinocyte culture on hyaluronic acid ester membranes: an alternative in complicated wound management?]

Cultivation and transplantation of autologous keratinocytes has been used in the last 15 years to treat complicated wounds of different origin. In spite of excellent technical advancements and clinical experiences cultured keratinocyte grafting still is associated with practical limitations. Application of hyaluronic acid ester membranes as carrier substrate for the transfer of keratinocytes allows improved graft handling: reduces total time required for tissue cultivation and furthermore enhances vitality of the keratinocytes because of possible grafting at semiconfluence.

Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions

OBJECTIVES

To compare injury patterns resulting from explosions in the open air versus within confined spaces.

METHODS

Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale score > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations.

RESULTS

A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001).

CONCLUSION

Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.

Characterization of EspC, a 110-kilodalton protein secreted by enteropathogenic Escherichia coli which is homologous to members of the immunoglobulin A protease-like family of secreted proteins

Enteropathogenic Escherichia coli (EPEC) secretes at least five proteins. Two of these proteins, EspA and EspB (previously called EaeB), activate signal transduction pathways in host epithelial cells. While the role of the other three proteins (39, 40, and 110 kDa) remains undetermined, secretion of all five proteins is under the control of perA, a known positive regulator of several EPEC virulence factors. On the basis of amino-terminal protein sequence data, we cloned and sequenced the gene which encodes the 110-kDa secreted protein and examined its possible role in EPEC signaling and interaction with epithelial cells. In accordance with the terminology used for espA and espB, we called this gene espC, for EPEC-secreted protein C. We found significant homology between the predicted EspC protein sequence and a family of immunoglobulin A (IgA) protease-like proteins which are widespread among pathogenic bacteria. Members of this protein family are found in avian pathogenic Escherichia coli (Tsh), Haemophilus influenzae (Hap), and Shigella flexneri (SepA). Although these proteins and EspC do not encode IgA protease activity, they have considerable homology with IgA protease from Neisseria gonorrhoeae and H. influenzae and appear to use a export system for secretion. We found that genes homologous to espC also exist in other pathogenic bacteria which cause attaching and effacing lesions, including Hafnia alvei biotype 19982, Citrobacter freundii biotype 4280, and rabbit diarrheagenic E. coli (RDEC-1). Although these strains secrete various proteins similar in molecular size to the proteins secreted by EPEC, we did not detect secretion of a 110-kDa protein by these strains. To examine the possible role of EspC in EPEC interactions with epithelial cells, we constructed a deletion mutant in espC by allelic exchange and characterized the mutant by standard tissue culture assays. We found that EspC is not necessary for mediating EPEC-induced signal transduction in HeLa epithelial cells and does not play a role in adherence or invasion of tissue culture cells.

Congenital toxoplasmosis transmitted from an immunologically competent mother infected before conception

Congenital transmission of Toxoplasma gondii from a mother who was apparently immunologically competent and who had toxoplasmic lymphadenitis 2 months before conception is described. Since no T. gondii-specific serological data were available for this mother from the time her lymph node biopsy specimen was obtained, the specimen was studied by polymerase chain reaction (PCR) to determine whether the T. gondii B1 gene was present. The predictive diagnostic value of histologic findings previously considered to be classic signs of T. gondii lymphadenitis also was studied. This was done by correlation of serological tests diagnostic of acute acquired T. gondii infection and presence of characteristic findings in biopsy specimens from persons without known immunocompromise. Both PCR and review of the characteristic features of her lymph node biopsy specimen confirmed the diagnosis of preconceptual infection in the mother. We also discuss two other cases in which apparently immunologically competent mothers with preconceptually acquired infection transmitted this parasite to their fetuses.

Enteropathogenic E. coli exploitation of host epithelial cells

Enteropathogenic E. coli (EPEC) is a leading cause of neonatal diarrhea worldwide. These organisms adhere to the intestinal cell surface, causing rearrangement in the epithelial cell surface and underlying cytoskeleton, resulting in a structure termed an attaching/effacing (A/E) lesion. A/E lesion formation is thought necessary for EPEC-mediated disease. EPEC secretes several proteins that trigger signal transduction, intimate adherence, and cytoskeletal rearrangements in epithelial cells. Additionally, it produces intimin, an outer membrane product that mediates intimate adherence. Together these various bacterial molecules contribute to the intimate relationship that is formed by EPEC with host epithelial cells which results in A/E lesion formation and diarrhea.

Treatment efficacy: aphasia

This article presents a brief overview of aphasia, followed by a summary of research studies and program evaluation data addressed to answering the question of the efficacy of treatment for aphasia. Selected studies are reviewed in terms of the quality of evidence they present. In addition, a number of questions that remain unanswered are also presented. Several tables, designed to provide clarifying information concerning several aspects of research design (number and types of patients studied, examples of well-designed small-group or single-subject studies, clinical techniques for which efficacy data are available), are included. The conclusion of this review is that, generally, treatment for aphasia is efficacious.

Treatment efficacy: cognitive-communicative disorders resulting from traumatic brain injury in adults

Traumatic brain injuries (TBI) may result in a broad array of cognitive-communicative impairments. Cognitive-communicative impairments are the result of deficits in linguistic and nonlinguistic cognitive functions. The speech-language pathologist functions as a member of the multidisciplinary team of professionals that collaboratively assess and treat individuals with TBI. The role of the speech-language pathologist includes assessment of all aspects of communication, as well as the communicative implications of cognitive deficits, and swallowing; treatment planning and programming, as determined by the individual's stage of recovery; client and family training/counseling; and interdisciplinary consultation. The effectiveness of speech and language intervention for specific cognitive deficits (e.g., attention, memory, executive functions) as well as general issues of social-skills training and early intervention are illustrated by scientific and clinical evidence from group-treatment and single-subject studies as well as case studies.

The Abbreviated Injury Scale. A valuable tool for forensic documentation of trauma

Anatomic trauma scoring systems are fundamental to trauma research. The Abbreviated Injury Scale (AIS) and its derivative, the Injury Severity Score (ISS), are the most frequently used scales. We assessed the applicability of the AIS and the ISS systems for postmortem forensic documentation of trauma. In a prospective study, all trauma autopsies performed between January 1 and June 30, 1993, were coded according to the AIS and ISS method. All cases were reviewed by a consultant in forensic medicine and a traumatologist. Cases were grouped in three categories according to ISS values: 0-14, 16-66, and 75. These categories represent minor, major, and incompatible-with-life injuries, respectively. All autopsy findings in which ISS was < or = 14 were peer-reviewed to establish mechanism and cause of death. In the 6-month period, 279 trauma-related autopsies were studied. Age at death averaged 37.1 +/- 18.7 (mean +/- SD). Eighty-six percent of the victims were male. Penetrating trauma was the mechanism of injury in 67%. ISS was 0-14 in 19 cases, 16-66 in 150 cases, and 75 in 110 cases. In conclusion, AIS and ISS scoring systems are applicable to trauma forensic documentation. Using these methods for coding postmortem findings may help in establishing a database for trauma research, and this information could constitute a major part of continuous quality improvement of trauma management. Low ISS values may serve as a warning, sometimes indicating preventable death.

Transaxial gunshot injuries

OBJECTIVE

To define the clinical characteristics of gunshot injuries across the truncal midline (transaxial injuries).

DESIGN

A retrospective case-control study

MATERIALS AND METHODS

Analysis of a consecutive series of 223 patients with gunshot injuries to the torso treated at one trauma center. Sixty-three patients with transaxial injuries were compared to 148 patients with unilateral bullet trajectories.

MAIN RESULTS

The incidence of cardiac (8%), vascular (17%), and spinal (29%) injuries and the mortality rate (29%) were significantly higher among the 63 patients with transaxial injuries compared with 148 patients with unilateral injuries. Initial operative access to the wrong visceral cavity (10%), missed injuries (14%), and early reoperations (19%) were also more common in the transaxial group.

CONCLUSIONS

A transaxial bullet trajectory identifies a distinct injury pattern associated with a high incidence of major visceral damage, intraoperative misadventures, and very high mortality.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median), and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

Pelvic abscesses: transvaginal US-guided drainage with the trocar method

The effectiveness of the trocar technique of catheter placement for transvaginal sonographically guided drainage of pelvic abscess was assessed in seven women who presented with pelvic pain, fever, and presumed pelvic abscess. Endovaginal ultrasound was performed to document fluid collection before drainage. All procedures were performed in less than 1 hour, without complications. Catheters were left in place for 1-3 days. Catheter placement was curative in six of seven patients (86%).

A pathogenic bacterium triggers epithelial signals to form a functional bacterial receptor that mediates actin pseudopod formation

Enteropathogenic E. coli (EPEC) belongs to a group of bacterial pathogens that induce actin accumulation beneath adherent bacteria. We found that EPEC adherence to epithelial cells mediates the formation of fingerlike pseudopods (up to 10 microm) beneath bacteria. These actin-rich structures also contain tyrosine phosphorylated host proteins concentrated at the pseudopod tip beneath adherent EPEC. Intimate bacterial adherence (and pseudopod formation) occurred only after prior bacterial induction of tyrosine phosphorylation of an epithelial membrane protein, Hp90, which then associates directly with an EPEC adhesin, intimin. These interactions lead to cytoskeletal nucleation and pseudopod formation. This is the first example of a bacterial pathogen that triggers signals in epithelial cells which activates receptor binding activity to a specific bacterial ligand and subsequent cytoskeletal rearrangement.