Age and gender effects on injury outcome for restrained occupants in frontal crashes: a comparison of UK and US data bases

Field accident data from NASS/CDS in the US and CCIS in the UK are compared. The UK sample is deliberately weighted to conform to the same AIS proportions (within AIS 2-6) as the weighted NASS data so that crash severity distributions can be compared for various selected outcomes. Age and gender have a significant effect on the delta V distributions and median delta V values. These differences are documented both for overall AIS 2-6, 3-6, and 4-6, and also for body regions of the head, neck, chest, abdomen and upper and lower extremities. Anomalies between the two samples are profound which raises doubts about the recording of belt use in NASS and the calculation of delta V at lower crash severities.

Benign acute childhood myositis: laboratory and clinical features

BACKGROUND

Benign acute myositis of childhood is a disorder of midchildhood, typically affecting boys. Symptoms include calf pain and difficulty walking after a viral illness. There is an epidemiologic association with influenza.

OBJECTIVES

To describe the clinical and laboratory features of benign acute myositis.

RESULTS

Thirty-eight children (32 boys, 6 girls) were seen with 41 episodes of myositis between 1978 and 1997. Two were siblings and three had recurrent episodes. Mean age at onset of symptoms was 8.1 years. Children remained ambulant during 33 of 41 episodes. Two characteristic gaits were noted: toe-walking in 13, with a wide-based stiff-legged gait in another 7. Muscle tenderness was isolated to the gastrocnemius-soleus muscles in 82% of episodes. Recovery occurred within 1 week. Creatine kinase levels were elevated during all episodes. Viral studies were positive in 10 of 24 episodes, 5 because of influenza B.

CONCLUSION

Benign acute myositis is a syndrome of midchildhood that can be differentiated from more serious causes of walking difficulty by the presence of calf tenderness, normal power, intact tendon reflexes, and elevated creatine kinase. The gait patterns noted may minimize power generation of the calf muscles by splinting the ankles. Onset in childhood may reflect an age-related response to viral infection, and occurrence primarily in boys may reflect a genetic predisposition or an as-yet unknown metabolic defect.

Protamine-like sperm nuclear basic proteins in the primitive frog Ascaphus truei and histone reversions among more advanced frogs

Sperm nuclear basic proteins (SNBPs) that condense chromatin are very diverse. In animals, evolution of SNBPs has proceeded from lysine-rich histone H type in sponges to more arginine-rich protamine-like PL and protamine P types. Yet sporadic PL/P to H reversions are known to occur in both protostomes and deuterostomes. To determine why this is the case, we have examined SNBPs in eleven anuran species. We find that sperm of the primitive, internally fertilizing archeobatrachian frog A. truei (family Ascaphidae) has PL/P type (42 mol % arginine), with an electrophoretic profile similar to SNBPs in another archeobatrachian, externally fertilizing Leiopelma hochstetteri (family Leiopelmatidae). Cytochemistry of sperm nuclei in the advanced, externally fertilizing neobatrachian frogs Crinia signifera and C. deserticola (family Myobatrachidae) indicates that they have reverted to H type SNBPs. This is also known to be the case in externally fertilizing Rana (family Ranidae) and Silurana, a subgenus of Xenopus (family Pipidae). Such a trend, from PL/P type SNBPs in two archeobatrachians to sporadic reversions to H type in more advanced frogs, parallels the ultrastructural simplification from complex A. truei introsperm to neobatrachian aquasperm that Jamieson et al. (1993. Herpetologica 49:52-65) attribute as a secondary reversion to external fertilization.

Structure of the human VIPR2 gene for vasoactive intestinal peptide receptor type 2

The VPAC(2) (vasoactive intestinal peptide (VIP)(2)) receptor is a seven-transmembrane spanning G protein-coupled receptor which responds similarly to VIP and pituitary adenylate cyclase activating polypeptide (PACAP) in stimulating cAMP production. Recently, we reported the localisation of the human VPAC(2) receptor gene (VIPR2) to chromosome 7q36.3 (Mackay, M. et al. (1996) Genomics 37, 345-353). Here, we describe the characterisation of the VIPR2 gene structure and promoter region. The VIPR2 gene is encoded by 13 exons, the initiator codon of the 438 amino acid open reading frame is located in exon 1 and the termination signal and a poly-adenylation signal sequence are located in exon 13. The 5' untranslated region extends 187 bp upstream of the initiator codon and is extremely GC-rich (80%). The poly-adenylation signal is located 2416 bp downstream of the stop codon. Intron sizes range from 68 bp (intron 11) to 45 kb (intron 4) and the human gene spans 117 kb.

Evaluation of a nurse-delivered smoking cessation intervention for hospitalized patients with cardiac disease

OBJECTIVE

To determine the effect of a nurse-delivered smoking cessation intervention for hospitalized smokers on smoking cessation rates and smoking cessation self-efficacy at 6 months after enrollment.

DESIGN

A quasi-experimental design was used; specifically, a nonequivalent control group design was implemented.

SETTING

A 450-bed major teaching and research tertiary care hospital, serving patients from across the province of British Columbia, Canada.

SUBJECTS

Smokers with a cardiac diagnosis (n = 102) who were admitted to 1 of 2 inpatient cardiac units for medical or surgical treatment.

OUTCOME MEASURES

Self-reported smoking status and self-reported smoking cessation self-efficacy.

INTERVENTION

Two structured, in-hospital contacts, followed by 3 months of telephone support. The interventions focused on problem-solving and reinforcing the patient's self-efficacy.

RESULTS

Of the patients enrolled, 86 completed 6-month follow-up questionnaires. When subjects who were lost to follow-up were assumed to be smokers, 46% of the intervention group, compared with 31% of the control group, were nonsmokers. When key variables were controlled, we found that those subjects in the control group were 3 times more likely to relapse and begin smoking than those who received the intervention. There were no significant differences in follow-up smoking cessation self-efficacy scores in the treatment and control groups. When background variables were controlled, self-efficacy related to positive/social situations and habit/addictive situations were noted to be significantly higher in the intervention group.

CONCLUSION

The findings of this research are encouraging; they suggest that a nurse-delivered smoking cessation intervention improved the smoking cessation rate in patients with cardiac disease.

Congenital muscular dystrophy, white-matter abnormalities, and neuronal migration disorders: the expanding concept

The congenital muscular dystrophies are a heterogeneous, recessively inherited group of disorders that have been subclassified on the basis of clinical central nervous system involvement. We report two children with "pure" congenital muscular dystrophy, one merosin negative and one merosin positive with extensive white matter and occipital cortical neuromigration abnormalities on magnetic resonance imaging (MRI). The first patient (merosin-negative congenital muscular dystrophy) presented with hypotonia and weakness in the neonatal period and subsequently was found to have a leukoencephalopathy and occipital cortical dysplasia on magnetic resonance imaging. The second patient presented with developmental delay without definite weakness. Initial investigations revealed a leukoencephalopathy and cortical dysplasia, but the patient subsequently was shown to have merosin-positive congenital muscular dystrophy. These patients illustrate that white-matter changes are not specific for merosin-negative congenital muscular dystrophy alone and that extensive cortical abnormality can be found in both groups of patients. In addition, our second patient illustrates a nonmuscular mode of congenital muscular dystrophy presentation that should be considered in patients with a "nonprogressive leukodystrophy."

Functional outcome after the L'Episcopo procedure

A study was undertaken to assess functional outcome in 11 patients undergoing latissimus dorsi and teres major transfer (L'Episcopo procedure) for external rotation deficient shoulders. The mean age was 37 years (range 18 to 48 years). All of the patients had adult-onset brachial plexus injuries. The mean time for injury to operation was 32 months. Patients were evaluated by questionnaire, measurement of the range of motion, strength testing, and an overhead work simulation. Of the patients studied, 10 of the 11 patients were working (8 returned to their preinjury employment). The cumulative postoperative mean activities of daily living score was 20 (maximum possible 33) compared with 14 before surgery. No complications occurred. Ten patients reported confidence in the limb and believed the procedure was worthwhile. Mean active external rotation of the shoulder at 0 degrees and 90 degrees elevation was 28 degrees (range 15 degrees to 55 degrees and 36 degrees (range 0 degrees to 90 degrees), respectively. Postoperative external rotation strength was 0.32 that of the control side with the arm at the side. Seven of the nine patients tested were able to complete the Valpor overhead work simulation. The L'Episcopo muscle-tendon transfer reliably improves functional outcome in the late functional reconstruction of adult-onset brachial plexus lesions.

1997 Volvo Award winner in clinical studies. Degenerative lumbar spondylolisthesis with spinal stenosis: a prospective, randomized study comparing decompressive laminectomy and arthrodesis with and without spinal instrumentation

STUDY DESIGN

This prospective study analyzed the influence of transpedicular instrumented on the operative treatment of patients with degenerative spondylolisthesis and spinal stenosis.

OBJECTIVES

To determine whether the addition of transpedicular instrumented improves the clinical outcome and fusion rate of patients undergoing posterolateral fusion after decompression for spinal stenosis with concomitant degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Decompression is often necessary in the treatment of symptomatic patients who have degenerative spondylolisthesis and spinal stenosis. Results of recent studies demonstrated that outcomes are significantly improved if posterolateral arthrodesis is performed at the listhesed level. A meta-analysis of the literature concluded that adjunctive spinal instrumentation for this procedure can enhance the fusion rate, although the effect on clinical outcome remains uncertain.

METHODS

Seventy-six patients who had symptomatic spinal stenosis associated with degenerative lumbar spondylolisthesis were prospectively studied. All patients underwent posterior decompression with concomitant posterolateral intertransverse process arthrodesis. The patients were randomized to a segmental transpedicular instrumented or noninstrumented group.

RESULTS

Sixty-seven patients were available for a 2-year follow-up. Clinical outcome was excellent or good in 76% of the patients in whom instrumentation was placed and in 85% of those in whom no instrumentation was placed (P = 0.45). Successful arthrodesis occurred in 82% of the instrumented cases versus 45% of the noninstrumented cases (P = 0.0015). Overall, successful fusion did not influence patient outcome (P = 0.435).

CONCLUSIONS

In patients undergoing single-level posterolateral fusion for degenerative spondylolisthesis with spinal stenosis, the use of pedicle screws may lead to a higher fusion rate, but clinical outcome shows no improvement in pain in the back and lower limbs.

The challenges of clinical nursing research: strategies for successful conduct

Although the literature is replete with stringent methodological guidelines for designing experimental and quasi-experimental studies, there is a paucity of literature addressing the challenges of conducting these studies in the "real world" of the clinical setting. This article describes the challenges experienced by a team of researchers conducting a study in the acute care setting, including those associated with navigating organizational restructuring and managing within a climate of uncertainty. The study focused on the evaluation of a nurse-delivered smoking cessation intervention for hospitalized cardiac patients. As each particular challenge emerged, strategies were developed. By explicating these challenges and strategies, we hope to help clinical researchers deal with challenges proactively rather than reactively.

Occipital condyle fractures

OBJECTIVE

Occipital condyle fractures (OCFs) are infrequently recognized. Three recent cases of OCF in our center prompted a review of the incidence, clinical presentation, diagnosis, and treatment of this entity.

METHODS

A retrospective review of medical records and radiographic results was performed for 93 of 316 consecutive patients who were victims of trauma, who presented at the Toronto Hospital during a 13-month period, and who had undergone computed tomography of the occiput.

RESULTS

A review of the literature regarding OCF revealed that cranial nerve deficits occurred in 31% of the patients with OCFs; of those, the deficits were delayed in 38%. Three new cases of OCF, with neck pain but without cranial nerve deficits, have been reported. The cervical spine x-rays revealed nothing abnormal in 96% of the reported cases. In our retrospective review, asymptomatic OCF was revealed by computed tomography for 1 of the 93 patients.

CONCLUSION

OCF is a diagnostic challenge. We suggest that computed tomographic scans of O-C2 be obtained in the following circumstances: presence of lower cranial nerve deficits, associated head injury or basal cranial fracture, or persistent severe neck pain despite normal radiographic results. We propose a new classification system for the management and treatment of OCF based on the stability of the O-C1-C2 joint complex reflected by the presence of displacement of the condyle, computed tomographic or radiographic evidence of O-C1-C2 instability, and magnetic resonance evidence of ligamentous injury. OCFs are divided into the following types: Type 1 (stable), undisplaced fracture; Type 2A (stable), displaced fracture with no ligamentous instability; and Type 2B (unstable), displaced fracture with ligamentous instability.

Effect of muscle glycogen availability on maximal exercise performance

This investigation determined the influence of pre-exercise muscle glycogen availability on performance during high intensity exercise. Nine trained male cyclists were studied during 75 s of all-out exercise on an air-braked cycle ergometer following muscle glycogen-lowering exercise and consumption of diets (energy content approximately 14 MJ) that were either high (HCHO(80% CHO) or low (LCHO-25% CHO) in carbohydrate content. The exercise-diet regimen was successful in producing differences in pre-exercise muscle glycogen contents [HCHO: 578(SEM 55) mmol x kg(-1) dry mass; LCHO: 364 (SEM 58) P < 0.05 mmol x kg(-1) dry mass]. Despite this difference in muscle glycogen availability, there were no between trial differences for peak power [HCHO 1185 (SEM 50)W, LCHO 1179 (SEM 48)W], mean power [HCHO 547 (SEM 5)W, LCHO 554 (SEM 8)W] and maximal accumulated oxygen deficit [HCHO 54.4 (SEM 2.3) ml x kg(-1), LCHO 54.6 (SEM 2.0) ml x kg(-1)]. Postexercise muscle lactate contents (HCHO 95.9 (SEM 4.6) mmol x kg(-1) dry mass, LCHO 82.7 (SEM 12.3) mmol x kg(-1) dry mass, n = 8] were no different between the two trials, nor were venous blood lactate concentrations immediately after and during recovery from exercise. These results would indicate that increased muscle glycogen availability has no direct effect on performance during all-out high intensity exercise.

Chromosomal localization in mouse and human of the vasoactive intestinal peptide receptor type 2 gene: a possible contributor to the holoprosencephaly 3 phenotype

The neuropeptides vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase activating polypeptide (PACAP) have been shown to act on a wide range of tissue and cell types, both in the central nervous system and in the periphery. Two distinct receptors for VIP, the VIP receptor type 1 (VIPR1) and the VIP receptor type 2 (VIPR2), have recently been cloned, each of which binds PACAP and VIP with equal affinity. We report here the chromosomal mapping of the human and mouse VIPR2 genes by fluorescence in situ hybridization. The VIPR2 gene maps to the human chromosomal region 7q36.3 and to the F2 region of mouse chromosome 12. Our localization of the human gene places it in the region where the locus for the craniofacial defect holoprosencephaly type 3 (HPE3) maps. Further mapping experiments, carried out on cell lines derived from patients with HPE or HPE microforms and associated 7q deletions, have led us to redefine the distal extent of the HPE3 minimal critical region, originally characterized by Gurrieri et al. (1993, Nature Genet. 3: 247-251.) The VIPR2 gene lies within this new HPE3 minimal critical region. Our results suggest that deletion of the VIPR2 gene is not the sole factor responsible for the HPE3 phenotype. However, it is possible that monosomy at the VIPR2 locus may contribute to the phenotype observed in many cases of HPE3.

Head injuries in lateral impact collisions

Individual non-minor injuries (Abbreviated Injury Scale (AIS) > or = 2) to the head that occurred to belted and unbelted drivers and front seat passengers on the stuck side of impacted vehicles were examined. Injury type, injury combination, collision severity in relation to type of injury as well as contact sources were assessed. Forty-eight percent of injuries were moderate in severity (AIS 2). The most common type of injury was the diffuse brain injury, typically marked by a short period of unconsciousness, which occurred in collisions of lower severity than focal brain and skull fracture injuries. One-hundred and five out of 216 (48.6%) of contact sources for all injury types originated from outside the vehicle and such exterior sources were more likely to result in high severity injuries. Thirty percent of injuries resulted from head contacts with other vehicles. The most frequent vehicle interior contact source was the side window glass. Diffuse injuries tended to occur independently of other injury types and were more likely to originate from an interior rather than exterior contact. Preventative measures for head injury reduction in lateral collisions are discussed. Overall, the data show that proposed and present European and U.S. lateral impact test methods do not address many head injury problems such as those included in this study.

Appropriate frontal barrier tests for belted occupants

Vehicle damage from frontal impacts was classified and investigated together with injuries sustained by belted front seat occupants. The sample consisted of 1872 frontal crashes from the Midlands of England. Analysis focused on impacts with broad objects that might conceivably be simulated by a barrier test. Two asymmetrical front-end damage patterns were commonly identified, and these gave the greatest rates of non-minor (Abbreviated Injury Scale (AIS) > or = 2) injuries in a range of Estimated Test Speeds from 35 to 52km/h which is the regime of current legislative crash tests. The most injurious type involved oblique damage caused by a substantial overlap of the struck object. The other type was from a small overlap. Objects struck and passenger compartment intrusions were compared. Appropriate asymmetrical and deformable barrier concepts were discussed. Other findings were connected with the future role of full face barriers as used in current tests such as Federal Motor Vehicle Safety Standard 208. Fuller overlaps (> 50%) tended to give more torso injuries rated > or = AIS 2 caused by seat belt loads and, at high speeds (53-79km/h), caused the most fatalities. Full overlaps (100%) rarely resulted in symmetrical intrusion into the passenger compartment.

The transport of acidic amino acids and their analogues across monolayers of human intestinal absorptive (Caco-2) cells in vitro

The X-AG system, a sodium-dependent, acidic amino-acid transport system has been implicated in the transport of L-aspartate and L-glutamate across monolayers of human Caco-2 cells, an in vitro model of intestinal absorption. This system, which shares many properties with the L-glutamate carrier present in the human jejunum, is highly saturable (> 95% at 50 microM), vectorial (apical-to-basolateral >> basolateral-to-apical) and sodium-, pH- and temperature-dependent. L-Aspartate was also transported against a 10-fold reverse concentration gradient. These data are consistent with a major (saturable) carrier-mediated pathway superimposed onto a minor non-saturable (diffusional) pathway. The carrier has an absolute sodium-dependence and the Michaelis constants for the sodium-dependent transport component (Km) for L-aspartate and L-glutamate were 56 +/- 3 microM and 65 +/- 6 microM, respectively. Cross-inhibition studies showed that strong interaction with the carrier was limited to close analogues of the natural substrates. Potent inhibitors included L-aspartate, D-aspartate (Ki, 70 microM), L-glutamate (Ki 180 microM) and threo-beta-hydroxy-DL-aspartate (Ki, 55 microM), while partial inhibitors included alpha-methyl-DL-aspartate, D-glutamate, L-asparagine, L-proline and L-alanine. Replacement of the side-chain -COO- group (aspartate) with -SO-3 (L-cysteate, Ki, 65 microM) or -(H)P(O)O- (DL-3-(hydroxyphosphoryl)alanine, Ki, 60 microM) maintained strong interaction with the carrier while -As(O)(OH)O- (DL-3-arsonoalanine, Ki, 1100 microM) and -P(O)(OH)O- (DL-3-phosphonoalanine, Ki, 3270 microM) were much more weakly bound, with the larger, but probably less ionised, arsono analogue being more tightly bound than the phosphono compound. The corresponding analogues of glutamate (homologous extension of the methylene chain) showed negligible interaction. We conclude that Caco-2 monolayers are a relevant experimental model for the study of the transport of acidic amino acids and their analogues in man.

Airbag deployment and eye perforation by a tobacco pipe

Airbags have been shown to reduce injuries and save the lives of car occupants in a crash. Like any protection system, airbags potentially introduce some new risks if no appropriate countermeasures are taken. A case of a relatively moderate frontal impact is described where the driver of an airbag-equipped car suffered a severe penetrating eye injury after the airbag deployed. Since the airbag fabric itself was excluded as an injury-producing structure, other objects such as eyeglasses, a wrist-watch, a bracelet, and a large finger ring had to be assessed. The investigation of the car interior as well as the morphologic details of the injuries to the eye and the face revealed that the most likely candidate for the injury was a tobacco pipe, which was probably being held in one hand and was broken apart by the deploying airbag and projected into the face of the driver. This case illustrates the hazard of having any rigid object between the occupant and the deploying airbag. The desirability of warning car occupants of the potential hazards which can result from today's protection systems is also discussed.

Posterior portals for arthroscopic surgery of the knee

Posterolateral and posteromedial portals are necessary for certain arthroscopic procedures of the knee. Many surgeons hesitate to use portals. A cadaveric study was performed to identify the structures at risk in establishing these portals. These include the saphenous vein and nerve, popliteal vessels, lateral superior and inferior genicular arteries, and peroneal nerve. Two basic techniques can be used to visualize the posterior compartments--from the same side or diagonally across the intracondylar notch. A clinical review of 179 patients in which posterior portals were used showed no serious complications. In three cases there was residual numbness in the distribution of the saphenous nerve and in two cases the saphenous vein was punctured. In three cases, the posterior compartments could not be safely visualized. In 87 cases the posterior compartment was visualized from the ipsilateral side; in the remaining 92 cases we used the contralateral technique placing the arthroscope diagonally across the intracondylar notch.

Engineering in accidents: vehicle design and injuries

This review has touched superficially on the various mechanisms of injuries to the main classes of road-user casualties, and illustrated some of the desirable vehicle design characteristics which can minimize road trauma. There is still much to be gained by better vehicle design. For occupants, enhanced performance from restraint systems, supplementary airbags, better structural integrity and better compatibility between cars and lorries are obvious areas where known solutions are waiting to be applied. For pedestrians there is an extensive literature outlining the characteristics of friendly vehicle exteriors; many current models of cars are exhibiting some of these properties but better agreement on an optimum specification for the car's exterior is still required. For motorcyclists there is the promise of improved leg protection from energy-absorbing fairings although substantial technical debate still surrounds these proposals. For the clinician, a more accurate appreciation of the likely injuries which occur in given collision circumstances can help in diagnosis and treatment. It is for these reasons that some understanding of vehicle design and crash-worthiness is worthwhile.

The transport of two iron chelators, desferrioxamine B and L1, across Caco-2 monolayers

The transport of two iron chelators, desferrioxamine B (DFO) and L1 (1,2-dimethyl-3 hydroxypyridin-4-one) has been studied in vitro using the human adenocarcinoma cell line, Caco-2. The transport of DFO and L1 has also been compared with that of their iron-bound complexes, ferrioxamine (FO) and L1(3)-Fe, respectively. We report an apparent permeability coefficient (Papp) value for DFO of 0.170 x 10(-7) +/- 0.080 cm s-1. The Papp value of L1 was 1.297 x 10(-5) +/- 0.133 cm s-1. The Papp values of their iron bound complexes FO and L1(3)-Fe are 0.230 x 10(-7) +/- 0.065 cm s-1 and 2.356 x 10(-6) +/- 0.365 cm s-1, respectively. We have shown that the transport of DFO and FO is similar in the Caco-2 cell system. The transport of L1, however, is greatly reduced when complexed to iron. The value for total uptake after 60 min for DFO into the Caco-2 cells was 1.49 +/- 0.09 x 10(-3) nmol per filter. The values for total uptake after 60 min for L1 and L1(3)-Fe were 0.37 +/- 0.03 nmol per filter and 0.04 +/- 0.01 nmol per filter, respectively. Our results indicate that the poor oral bioavailability of DFO can be attributed to the low epithelial permeability of the molecule coupled with its size (mol wt 656). In contrast, the oral bioavailability observed with L1 is due to the high lipophilicity and low molecular weight (mol wt 139) of the molecule. We believe that these differences between the two molecules account for L1 being better orally absorbed than DFO.