Alaska's statewide trauma registry: a useful surveillance tool for injury prevention planning and evaluation

The state of Alaska is unique because it is one of a small number of states with a surveillance system that collects trauma information from every hospital in the state. The Alaska Trauma Registry (ATR) collects up to 144 data elements for every injured patient. Information from the ATR is useful as an injury surveillance tool for federal, state, and local governments and other agencies and organizations when planning and evaluating injury prevention programs. Combining trauma registry data with Bureau of Vital Statistics cause of death data provides complete, statewide, population-based data on all injuries serious enough to result in death or hospitalization.

Barriers to black women's participation in cancer clinical trials

This study examines attitudes that may deter black women from participating in cancer research. Subjects were recruited from women who did not respond to the initial recruitment mailing for the Women's Health Initiative. Each subject was administered a 7- to 10-minute telephone survey. One third (29) of the 80 subjects were black. Fifty-six percent of black women and 71% of white women had positive attitudes toward cancer clinical trials. More than 80% of the women surveyed agreed that clinical research benefits society and increases medical knowledge. However, almost one third of the black women agreed that scientists cannot be trusted while only 4% of whites responded similarly. Additionally, 29% of black women agreed that researchers did not care about them compared with 14% of white women. Only 28% of black women felt that clinical research in the United States was ethical, and 37% had a preference to be treated by a black scientist compared with 2% of whites. Controlling for other covariates, black women had more negative altitudes overall to clinical trials than white women. These findings support the likelihood that barriers exist for the participation of blacks and other minorities in clinical research. These barriers may impact the involvement of black women in cancer clinical trials. Improving trust and creating a perception of a caring attitude from investigators are important to overcoming these barriers. The inclusion of more black scientists as leaders of cancer clinical trials also may help improve these participation rates.

Caregiver issues and AIDS orphans: perspectives from a social worker focus group

This study examines social workers' perceptions of the needs of families coping with acquired immunodeficiency syndrome (AIDS). This research investigates the problems of family caregivers of children orphaned by human immunodeficiency virus (HIV)-related death of their parents. A qualitative semistructured interview format was used in a focus group of 18 social workers. Four questions were designed to assess family needs and resources, as well as to evaluate the social workers' perspectives of governmental policies affecting these families. A list of four problems and two recommendations for change evolved from the focus group. Inadequate finances to house and care for the children was the primary cause for distress in these families. The major governmental policy that hindered the social workers' ability to assist families pertained to the low financial entitlement for caregivers who are related to the orphaned child. It was noted that unrelated caregivers receive substantially more money for the care of these children than family caregivers receive. Recommendations were made to change this policy and to develop guardianship laws that facilitate families' abilities to provide care to AIDS orphans. Family caregivers of AIDS orphans are bombarded with great demands and limited resources. This analysis of their situation from the social workers' perspective is a positive step toward the improvement of support services for these families. Further research should include individual qualitative interviews assessing the needs of the caregivers and AIDS orphans.

The Aer protein and the serine chemoreceptor Tsr independently sense intracellular energy levels and transduce oxygen, redox, and energy signals for Escherichia coli behavior

We identified a protein, Aer, as a signal transducer that senses intracellular energy levels rather than the external environment and that transduces signals for aerotaxis (taxis to oxygen) and other energy-dependent behavioral responses in Escherichia coli. Domains in Aer are similar to the signaling domain in chemotaxis receptors and the putative oxygen-sensing domain of some transcriptional activators. A putative FAD-binding site in the N-terminal domain of Aer shares a consensus sequence with the NifL, Bat, and Wc-1 signal-transducing proteins that regulate gene expression in response to redox changes, oxygen, and blue light, respectively. A double mutant deficient in aer and tsr, which codes for the serine chemoreceptor, was negative for aerotaxis, redox taxis, and glycerol taxis, each of which requires the proton motive force and/or electron transport system for signaling. We propose that Aer and Tsr sense the proton motive force or cellular redox state and thereby integrate diverse signals that guide E. coli to environments where maximal energy is available for growth.

Comparison of digital subtraction and cut film arteriography in the evaluation of suspected thoracic aortic injury

PURPOSE

To determine whether intraarterial digital subtraction arteriography (DSA) is as sensitive and specific as cut film arteriography (CFA) in the evaluation of suspected aortic injury resulting from blunt chest trauma.

MATERIALS AND METHODS

Both CFA and DSA images of the thoracic aorta were obtained in the right posterior oblique (RPO) projection in 100 of 103 consecutive patients undergoing arteriography after blunt chest trauma. Diagnoses based on blinded separate review of both studies (CFA vs DSA) by four independent reviewers were compared. Reviewers graded their confidence in their diagnoses from 1 (certain) to 10 (uncertain).

RESULTS

Eleven of 100 patients had aortic or great vessel injuries confirmed by operation (n = 10) or transesophageal echocardiography (n = 1). Three hundred eighty-eight of 400 diagnoses based on RPO CFA and 390 of 400 diagnoses based on RPO DSA agreed with the correct diagnoses. The sensitivity, specificity, and diagnostic accuracy of CFA versus DSA were not significantly different. The reviewers' confidence in their diagnoses was equivalent between CFA (average confidence score, 1.373) and DSA (average confidence score, 1.375).

CONCLUSION

DSA and CFA yield equivalent sensitivity, specificity, and diagnostic accuracy in the evaluation of blunt chest trauma.

Oxygen-dependent growth of the obligate anaerobe Desulfovibrio vulgaris Hildenborough

Desulfovibrio vulgaris Hildenborough, a sulfate-reducing bacterium classified as an obligate anaerobe, swam to a preferred oxygen concentration of 0.02 to 0.04% (0.24 to 0.48 microM), a level which also supported growth. Oxygen concentrations of 0.08% and higher arrested growth. We propose that in zones of transition from an oxic to an anoxic environment, D. vulgaris protects anoxic microenvironments from intrusion of oxygen.

Magneto-aerotaxis in marine coccoid bacteria

Magnetotactic cocci swim persistently along local magnetic field lines in a preferred direction that corresponds to downward migration along geomagnetic field lines. Recently, high cell concentrations of magnetotactic cocci have been found in the water columns of chemically stratified, marine and brackish habitats, and not always in the sediments, as would be expected for persistent, downward-migrating bacteria. Here we report that cells of a pure culture of a marine magnetotactic coccus, designated strain MC-1, formed microaerophilic bands in capillary tubes and used aerotaxis to migrate to a preferred oxygen concentration in an oxygen gradient. Cells were able to swim in either direction along the local magnetic field and used magnetotaxis in conjunction with aerotaxis, i.e., magnetically assisted aerotaxis, or magneto-aerotaxis, to more efficiently migrate to and maintain position at their preferred oxygen concentration. Cells of strain MC-1 had a novel, aerotactic sensory mechanism that appeared to function as a two-way switch, rather than the temporal sensory mechanism used by other bacteria, including Magnetospirillum megnetotacticum, in aerotaxis. The cells also exhibited a response to short-wavelength light (< or = 500 nm), which caused them to swim persistently parallel to the magnetic field during illumination.

Incidence and management of arterial emboli from hemodialysis graft surgical thrombectomy

PURPOSE

To determine the incidence and significance of arterial emboli resulting from surgical thrombectomy/revision of hemodialysis grafts. This information may help in determining the significance and management of similar emboli resulting from percutaneous hemodialysis graft thrombolysis.

PATIENTS AND METHODS

Patients undergoing surgical thrombectomy/revision of clotted hemodialysis grafts are studied with postoperative fistulography per institutional protocol whenever possible. For this retrospective study, all postoperative fistulograms from a 1-year period were reviewed for the presence of arterial emboli. Patients with documented arterial emboli were examined for evidence of hand/digital ischemia; only those patients with signs or symptoms of ischemia were treated. At clinical follow-up, repeated evaluation for hand/digital ischemia was performed.

RESULTS

Ninety-one thrombectomy/revision procedures were performed during the study period. Postoperative fistulograms were obtained after 67 of these procedures in 32 patients. One patient complained of hand pain during dialysis prior to acquisition of the postoperative fistulogram. Arterial emboli were documented in eight patients (12%; brachial, n = 3; radial, n = 2; ulnar, n = 2; radial/ulnar, n = 1). The single symptomatic brachial embolus was percutaneously removed; no intervention was undertaken in the remainder. At mean follow-up of 14 months, no patient had developed hand or digital ischemia. Subsequent fistulograms demonstrated partial (n = 2) or complete (n = 2) resolution of the untreated emboli.

CONCLUSION

Arterial emboli are a relatively common occurrence with surgical thrombectomy/revision. Conservative management appears to be indicated in asymptomatic patients.

How do bacteria avoid high oxygen concentrations?

Bacteria, such as Escherichia coli and Azospirillum brasilense, avoid microenvironments with elevated oxygen concentrations, not by sensing reactive oxygen derivatives, but by sensing a metabolic down-shift that results from elevated oxygen levels. A novel protein, Aer, and the chemotaxis serine receptor, Tsr, have recently been identified as transducers for aerotaxis which monitor internal energy levels in the bacteria.

Successful treatment of an iatrogenic infrarenal aortic dissection with serial Wallstents

We report a patient who presented with acute lower extremity ischemia 13 days following removal of an intraaortic balloon pump. Dissection of the infrarenal aorta, extending into the left iliac artery, was found at operation. The patient's recent myocardial infarction, prolonged ischemia with compartment syndrome, otherwise normal aortoiliac and infrainguinal arteries and the necessity for suprarenal aortic clamping for surgical repair, were all factors in the decision for endovascular repair of the dissection. Infrarenal aortic and left iliac Wallstents, placed intraoperatively, successfully occluded the false lumen of the dissection. The patient was discharged after an uncomplicated recovery and is asymptomatic with palpable pedal pulses and triphasic pedal Doppler waveforms 1 year following the procedure.

Fluoride-induced lesions in the teeth of the short-tailed field vole (Microtus agrestis): a description of the dental pathology

The effect of fluoride on the appearance of the teeth of the short-tailed field vole, Microtus agrestis, was investigated in both wild animals collected from field sites affected by different levels of industrial fluoride contamination and laboratory-reared animals consuming experimental grass diets of known fluoride concentration or with known fluoride concentrations in drinking water. The extent and severity of lesions on the surface and structure of both incisors and molars are described as six lesion types and related to the amount of biologically available orally ingested fluoride. In the incisors of voles consuming relatively low fluoride diets, lesions are mainly confined to those resulting from disruption of enamel pigmentation expressing itself as concentric bands of pigmentation-free areas on incisor surfaces. The visible effects on molars at low fluoride levels are confined to minor alterations in surface appearance. At higher levels of available dietary fluoride, effects on enamel pigmentation are superseded by alterations in the formation, composition, and strength of both enamel and dentine. The incisors exhibit a marked to severe increase in the cutting tip erosion rates with comparable increases in the extent of abnormal surface changes (enamel hypoplasia) and the loss of enamel pigmentation. The grinding surfaces of molars from animals exposed to high levels of dietary fluoride exhibit increasingly severe erosion of outer enamel regions, combined with cavitation and staining of the exposed central dentine. The mechanisms through which fluoride elicits increasingly visible and pathological alterations to the surface and subsurfaces of rodent teeth are discussed.

Outcome of tunneled hemodialysis catheters placed via the right internal jugular vein by interventional radiologists

PURPOSE

To assess the outcome of interventional radiologic placement of tunneled hemodialysis catheters via the right internal jugular vein.

MATERIALS AND METHODS

In 194 patients, the catheter was placed via the right internal jugular vein unless thrombosis was present. Real-time ultrasound-guided puncture and fluoroscopic guidance were used. Patients were followed up until catheter removal or death. Outcomes evaluated included infection, thrombosis, and catheter malfunction.

RESULTS

In 175 patients, 250 consecutive catheters were placed via the right internal jugular vein with 100% success. All catheters functioned immediately after placement. Procedural complications were limited to clinically unimportant air embolus (n = 2). No instances of pneumothorax, hemothorax, or substantial bleeding complications occurred. Follow-up was available in 173 (99%) patients. Mean and median "catheter duration" were 87 and 56 days, respectively. Catheter-related symptomatic venous thrombosis or stenosis was not observed. The rate of infection was 0.08 per 100 catheter days, and the rate of malfunction that necessitated removal was 0.22 per 100 catheter days. Definite or possible catheter thrombosis that necessitated removal occurred at a rate of 0.16 per 100 catheter days.

CONCLUSION

Interventional radiologic placement of tunneled hemodialysis catheters via the right internal jugular vein showed equal or better long-term results than those reported for surgical placement. Interventional radiologic placement should be the method of choice.

Glycerol elicits energy taxis of Escherichia coli and Salmonella typhimurium

Escherichia coli and Salmonella typhimurium show positive chemotaxis to glycerol, a chemical previously reported to be a repellent for E. coli. The threshold of the attractant response in both species was 10(-6) M glycerol. Glycerol chemotaxis was energy dependent and coincident with an increase in membrane potential. Metabolism of glycerol was required for chemotaxis, and when lactate was present to maintain energy production in the absence of glycerol, the increases in membrane potential and chemotactic response upon addition of glycerol were abolished. Methylation of a chemotaxis receptor was not required for positive glycerol chemotaxis in E. coli or S. typhimurium but is involved in the negative chemotaxis of E. coli to high concentrations of glycerol. We propose that positive chemotaxis to glycerol in E. coli and S. typhimurium is an example of energy taxis mediated via a signal transduction pathway that responds to changes in the cellular energy level.

The three-dimensional structure at 2.4 A resolution of glycosylated proteinase A from the lysosome-like vacuole of Saccharomyces cerevisiae

The crystal structures of glycosylated native proteinase A, an aspartic proteinase found in the vacuole of Saccharomyces cerevisiae, and its complex with a difluorostatone-containing tripeptide have been determined by molecular replacement to 3.5 A and 2.4 A resolutions, respectively. Superposition of the bound and native forms gave an r.m.s. difference of 0.6 A largely reflecting the poor resolution of the native crystal structure. The secondary and tertiary structures are highly similar to those found in porcine pepsin and lysosomal cathepsin D; superposition of the structure of proteinase A bound to the difluorostatone inhibitor on those of pepsin and cathepsin D gave pairwise r.m.s. differences for C(alpha) atoms of 1.36 A and 0.88 A. Most differences occur in loop regions. Comparison of the structure of the proteinase A-difluorostatone complex with that of endothiapepsin bound with the same inhibitor shows that the conformation and hydrogen bond interactions of the inhibitor in the active site are very similar, even though the enzymes have only 27% sequence identity. Electron density for the crystal structure of the proteinase A complex reveals five residues of the oligosaccharide structure attached to Asn67: Man-(1 --> 2)-alpha-Man-(1 --> 3)-beta-Man-(1 --> 4)-beta-GlcNAc-(1 --> 4)-beta-GlcNAc-Asn-67. The first three residues of the oligosaccharide cover the same region of the protein surface as those of the oligosaccharide attached to the equivalent position in cathepsin D. The second carbohydrate attachment site is disordered beyond the first carbohydrate residue in both enzymes.

Acute oral toxicity study of pyridostigmine bromide, permethrin, and DEET in the laboratory rat

This study investigated the lethal interaction of pyridostigmine bromide (PB), permethrin, and DEET when given to adult male rats by gavage and was separated into two phases. Phase I determined the acute oral lethal dose-response relationship of each compound with the vehicle, propylene glycol. Phase II was divided into two portions: a dose-response study using probit units obtained from phase I [lethal dose (LD) 16, 30, 50, 70, and 84], and an interaction study that contained low levels (calculated LD16, additive LD32) of the two compounds while the concentration of the third compound was varied. Rats were fasted overnight, dosed, and observed for 14 d. A significant increase in lethality occurred when PB, permethrin, and DEET were given concurrently when compared to expected additive values. Furthermore, solutions containing PB and permethrin or PB and DEET also caused a significant increase in lethality when compared to expected additive values. This information suggests that lethality in this study was more than an additive effect.

Isolation and characterization of five actin cDNAs from the cestode Diphyllobothrium dendriticum: a phylogenetic study of the multigene family

Five cDNAs (pDidact2-pDidact6), representing different actin genes, were isolated from a Diphyllobothrium dendriticum cDNA library, and the DNA as well as the putative amino acid sequences were determined. The corresponding Didact2 and Didact4 genes code for peptides 376 amino acids long, with molecular weights 41,772 and 41,744 Da, respectively, while the deduced Didact3 protein is 377 amino acids long and weighs 41,912 Da. The pDidact5 and -6 cDNAs lack nucleotides corresponding to three to six amino acids at the amino-terminus. Two of the five cDNAs contain the conventional AATAAA as the putative polyadenylation signal, one has the common variant ATTAAA, whereas the hexanucleotide AATAGA is found 15 and 18 nucleotides, respectively, upstream of the poly(A) site in two of the cDNAs. Phylogenetic studies including 102 actin protein sequences revealed that there are at least four different types of cestode actins. In this study three of these types were found to be expressed in the adult D. dendriticum tapeworm. Structurally the cestode actin groupings differ from each other to an extent seen only among the metazoan actins between the vertebrate muscle and cytoplasmic isoforms. In the phylogenetic trees constructed, cestode actins were seen to map to two different regions, one on the border of the metazoan actins and the other within this group. It is, however, difficult to say whether the cestode actins branched off early in the metazoan evolution or if this position in the phylogenetic tree only reflects upon differences in evolutionary rate.

Methylated hexachlorocyclohexane in blue mussels (Mytilus edulis) from the Mersey and Dee Estuaries

Blue mussels (Mytilus edulis) from the Mersey and Dee Estuaries have been found to contain high concentrations of alpha-MHCH (methyl hexachlorocyclohexane) and gamma-MHCH (methyl lindane), and a series of other methylated isomers of MHCH. Mean values for SigmaMHCH in mussels declined serially from Rock Ferry (81.4 +/- 19.3 microg kg(-1)), the innermost site in the Mersey Estuary, to Egremont (49.0 +/- 8.6 microg kg(-1)) and New Brighton (11.1 +/- 3.8 microg kg(-1)); but the value for Crosby (67.0 +/- 10.2 microg kg(-1)) on the Liverpool shoreline was surprisingly high. Concentrations of alpha-HCH and gamma-HCH in M. edulis were consistently low, at <3.0 microg kg(-1). Comparisons between MHCH data for M. edulis and muscle tissue of both dab (Limanda limanda) and plaice (Pleuronectes platessa) give some evidence of food chain biomagnification of MHCH compounds, with adult plaice caught within the Mersey Estuary, where they feed on shellfish, showing very high levels of gamma-MHCH (18 +/- 9 microg kg(-1)) and MHCH (169 +/- 76 microg kg(-1)). Methylated analogues of HCH in biota are of potential regulatory interest and of substantial importance to the environmental management of the Mersey and Dee Estuaries.

The emergency medical services system response to a commercial airliner incident at the very remote location of Shemya, Alaska

INTRODUCTION

A multiple patient incident involving a commercial airliner is a challenge for any community EMS system. When the community is on a remote island in the North Pacific Ocean, where there is no hospital and only a small clinic staffed by just one physician and several nurses and technicians, the challenge is much greater. The incident described herein necessitated providing emergency care at the airport, and at the same time, activating a response capability from hundreds of miles away to transport the patients to definitive care. The situation was compounded further by the fact that most of those injured spoke little or no English. This paper reviews the events that occurred and the lessons learned.

OBJECTIVE

To identify the events that occurred when a commercial airliner, with more than 250 passengers and crew aboard, experienced an in-flight "upset" that resulted in many being injured. What was learned may help other areas be better prepared for such events.

STUDY POPULATION

A commercial airliner incident that occurred in April, 1993 resulted in the need for emergency medical care at the remote island location of Shemya, Alaska initially, and fixed-wing transport of the injured to definitive care in Anchorage, Alaska, USA, which is about 1,300 miles (2,130 km) from Shemya.

METHODS

A case review methodology was used that included interviews with key persons involved in the response to this incident to learn first-hand what occurred; by review of the National Transportation Safety Board (NTSB), reports, and by having agencies involved in the event review draft report materials to ensure accuracy.

RESULTS

This study showed how a remote site with a small cadre of medically trained personnel could organize and effectively provide initial emergency care for > 200 persons, and have them transported more than a thousand miles to definitive care.

CONCLUSIONS

Valuable lessons were learned from this incident that may help other areas be better prepared, particularly in remote areas, for large multiple patient events.