Identification of vehicle components associated with severe thoracic injury in motor vehicle crashes: a CIREN and NASS analysis

INTRODUCTION

Thoracic trauma secondary to motor vehicle crashes (MVC) continues to be a major cause of morbidity and mortality. Specific vehicle features may increase the risk of severe thoracic injury when striking the occupant. We sought to determine which vehicle contact points were associated with an increased risk of severe thoracic injury in MVC to focus subsequent design modifications necessary to reduce thoracic injury.

METHODS

The National Automotive Sampling System (NASS) databases from 1993 to 2001 and the Crash Injury Research and Engineering Network (CIREN) databases from 1996 to 2004 were analyzed separately using univariate and multivariate logistic regression stratified by restraint use and crash direction. The risk of driver thoracic injury, defined as an abbreviated injury scale (AIS) of score > or =3, was determined as it related to specific points of contact between the vehicle and the driver.

RESULTS

The incidence of severe chest injury in NASS and CIREN were 5.5% and 33%, respectively. The steering wheel, door panel, armrest, and seat were identified as contact points associated with an increased risk of severe chest injury. The door panel and arm rest were consistently a frequent cause of severe injury in both the NASS and CIREN data.

CONCLUSIONS

Several vehicle contact points, including the steering wheel, door panel, armrest and seat are associated with an increased risk of severe thoracic injury when striking the occupant. These elements need to be further investigated to determine which characteristics need to be manipulated in order to reduce thoracic trauma during a crash.

A novel CEA vaccine stimulates T cell proliferation, γIFN secretion and CEA specific CTL responses

Carcinoembryonic antigen (CEA) is a cell surface protein over-expressed by a wide range of tumours. The mouse anti-idiotypic antibody, 708, mimics CEA and can induce both antibody and T cell responses that specifically recognise this antigen. Sequence analysis of 708 revealed homology with a previously identified HLA-A3 T cell epitope in CEA but not to other closely related molecules. 708 was chimerised to a human IgG1 to allow Fc targeting of APCs and was deimmunised to remove unwanted T cell epitopes. The chimerised and deimmunised, but not the mouse 708, could stimulate CTL, proliferation and gammaIFN responses in vitro in normal (HLA-A3, DR1) individuals. Furthermore, the CTLs killed tumour cells expressing CEA suggesting that this deimmunised antibody could be a useful vaccine for solid tumours.

Correlation of head injury to vehicle contact points using crash injury research and engineering network data

Head injury is the most common cause of morbidity and mortality in motor vehicle crashes. Efforts to improve vehicle design, which minimize forces exerted to the occupant's head, may lead to a reduction in the frequency and severity of head injury. We therefore set out to identify mechanisms producing severe head injury in motor vehicle crashes (MVC) derived from the crash injury research and engineering network (CIREN) database. CIREN combines crash site analysis, vehicle damage assessment, and occupant kinematics in relation to the occupant's injuries. From the Seattle CIREN database of 101 cases, compiled from 1997 to 1998, we selected those crashes in which the occupant sustained severe head injury (abbreviated injury score, AIS>or=4) for analysis. We examined crash mechanism, energy transfer, point of head contact, vehicle intrusion and resulting injuries. There were 15 cases with severe head injury. These were primarily due to side impacts (n=10) in comparison to front impacts (n=5). The average net change in velocity (delta velocity, DV) was 15 mile/h (range 4-29 mile/h). In cases where the primary point of head contact could be elucidated the B-pillar predominated (4 cases, 33.3%) followed by the striking external object (2 cases, 16.7%), A- (1 case, 8.3%) and C- (1 case, 8.3%) pillars, roof side rail (1 case, 8.3%), windshield header (1 case, 8.3%), windowsill (1 case, 8.3%) and airbag (1 case, 8.3%). In this series the predominant mechanism of head injury was lateral impacts, especially those in which the victims' heads struck the B-pillar. The need for improved head protection from lateral impacts is indicated.

The effect of abrupt cessation of total parenteral nutrition on serum glucose: a randomized trial

The common clinical practice of gradually tapering total parenteral nutrition (TPN) to prevent hypoglycemia may be unnecessary. This randomized prospective study assessed the blood glucose profiles of patients whose TPN was abruptly discontinued in comparison with those whose TPN was gradually tapered to determine whether abrupt cessation can be performed safely. Patients were randomized into the abrupt cessation or the tapered protocol. A symptomatic hypoglycemic questionnaire was administered at regular intervals. Fingerstick glucose sampling was performed at 30-minute intervals and compared prospectively. From October 1996 through July 1997, 21 patients receiving TPN consented to participate in this study. Inclusion criteria included 1) duration of TPN infusion >24 hours, 2) age >18 years, and 3) establishment of enteral feeding at the time of TPN discontinuation. Patients had a baseline blood glucose level followed by repeat glucose measurements at 30-minute intervals until 90 minutes after TPN was completely discontinued in the tapered group and 120 minutes after cessation in the abrupt group. The rate of TPN tapering was in 25 per cent increments over 90-minute intervals. Ten patients were randomized into the tapered group and 11 patients in the abrupt group. None of the patients developed symptomatic hypoglycemia. There was no difference between the lowest blood glucose in the abrupt group in comparison with that of the tapered group (108.6+/-11.5 vs 108.2+/-9.8 respectively; P = 0.98). No patient had a significant change in hypoglycemia questionnaire score. There was no significant difference in age, duration of TPN, steroid use, or enteral caloric intake between the two groups. We conclude that there was no symptomatic hypoglycemia, and glucose profiles returned to a similar baseline level in those whose TPN was abruptly stopped when compared with those in the tapered group. These data demonstrate that patients receiving TPN can have parenteral nutrition abruptly stopped without the development of significant hypoglycemia.

Incisional endometriosis: an underappreciated diagnosis in general surgery

BACKGROUND

Incisional endometriosis is a described dinical entity in the gynecologic literature, but it is not well recognized among general surgeons; only 32 cases have been reported in the general surgery literature. The preoperative diagnosis is often mistaken for a suture granuloma, lipoma, abscess, cyst, or incisional hernia.

STUDY DESIGN

We performed a retrospective review of 10 cases of incisional endometriosis at our institution to determine which, if any, clinical factors would suggest the diagnosis preoperatively. All general surgery patients who had the diagnosis of endometriosis in their pathology specimens from January 1990 to December 1998 were reviewed.

RESULTS

All 10 patients had previous cesarean sections through either a Pfannenstiel (n = 8) or a lower midline (n = 2) incision. Ages ranged from 27 to 41 years (mean 33.4 years). The most common presenting symptom was a slow-growing, painful lump in the lateral aspect of the Pfannenstiel incision. Two of the patients had a change in symptoms with their menstrual cycle. The duration of symptoms ranged from 2 months to 3 years. All patients underwent surgical excision. The size of the excised endometriomas ranged from 1.5 cm to 4.8 cm (mean 3.1 cm).

CONCLUSIONS

Incisional endometriosis may be more common than previously recognized. In all cases it was found to occur in women with a history of cesarean section. Most patients presented with a painful, slow-growing lump at the lateral edge of their incision. Cyclic changes in pain and size of the mass with menses was elicited in only two of these patients, but this may be from a lack of awareness and questioning on the part of the physician. If the diagnosis is made preoperatively, additional diagnostic studies may be avoided. An awareness of this disease process on the part of general surgeons is necessary to guide preoperative evaluation and therapy appropriately.

Right-sided diverticulitis: a difficult diagnosis

We report 12 cases of right-sided diverticulitis from January 1985 to May 1995 at our community hospital. The preoperative diagnosis of appendicitis was made in 11 of these patients. Only one patient was correctly diagnosed preoperatively. The mean age of patients at presentation was 48 years (range, 34-69). Six patients were male, and six were female. Eight patient (73%) presented with fever, seven (64%) had symptoms for greater than 24 hours, and 100 per cent of the patients had an elevated white blood cell count. All of the patients underwent surgery, without bowel preparation. In all cases, a normal appendix with cecal, ascending, or proximal transverse colon diverticulitis was found. Ten patients received a right hemicolectomy, and two had a cecectomy. The mean duration of hospital stay was 7 days (range, 5-13). There were no postoperative wound infections or anastomotic breakdowns. We conclude that the preoperative diagnosis of right-sided diverticulitis is difficult and should be sought if a normal appendix is discovered at the time of surgery. Furthermore, surgical resection of the right colon without preoperative bowel preparation was a safe procedure with complication in this series.

Innervation of motoneurons based on dendritic orientation

1. The distribution of terminals from vestibulospinal (VS) axons on the dendritic trees of neck motoneurons was determined by combining the anterograde transport of Phaseolus Vulgaris Leucoagglutinin (PHA-L) with intracellular staining techniques and three-dimensional reconstruction methods. 2. Contacts between VS axon terminals and dendrites were arranged in a nonuniform pattern that depended on the orientation (i.e., rostro-caudal vs. dorsolateral) of the dendrites. 3. This innervation pattern satisfies a critical structural condition necessary for selective nonlinear interactions between pairs of simultaneously active inputs to motoneurons.

Suppression of splenic macrophage interleukin-1 secretion following intracerebroventricular injection of interleukin-1 beta: evidence for pituitary-adrenal and sympathetic control

Intracerebroventricular (ICV) injections of interleukin-1 beta (IL-1 beta) produced a dose-dependent increase in plasma corticosterone and adrenocorticotropic hormone (ACTH) within 2 hr of injection and then declined over the next 24 hr. Using a potent steroidogenic dose of IL-1 beta (5 ng), ICV injection resulted in suppression of splenic macrophage IL-1 secretion following stimulation by LPS in vitro. Macrophage TGF-beta secretion was not affected, indicating a differential action of ICV IL-1 beta on macrophage cytokine production. Following adrenalectomy (ADX), the suppressive effect of ICV IL-1 beta was reversed and resulted in stimulation of macrophage IL-1 secretion, indicating that the suppression was mediated by adrenocorticol activation. However, surgical interruption of the splenic nerve to eliminate autonomic innervation of the spleen also prevented the macrophage suppressive signal in rats given ICV IL-1 beta. Furthermore, the combination of ADX and splenic nerve section resulted in a potent stimulatory effect of ICV IL-1 beta on splenic macrophage IL-1 secretion which was greater than either ADX or splenic nerve section alone. These results support the concept of a negative feedback on macrophage IL-1 secretion by the central action of IL-1 beta and indicate that both the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system mediate this effect.