Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: The Rapid Early Action for Coronary Treatment (REACT) Trial

CONTEXT

Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality.

OBJECTIVE

To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use.

DESIGN AND SETTING

The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states.

PARTICIPANTS

A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis.

INTERVENTION

One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801).

MAIN OUTCOME MEASURES

Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs.

RESULTS

General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly.

CONCLUSIONS

In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program

OBJECTIVES

The Minnesota Heart Health Program is a 13-year research and demonstration project to reduce morbidity and mortality from coronary heart disease in whole communities.

METHODS

Three pairs of communities were matched on size and type; each pair had one education site and one comparison site. After baseline surveys, a 5- to 6-year program of mass media, community organization, and direct education for risk reduction was begun in the education communities, whereas surveys continued in all sites.

RESULTS

Many intervention components proved effective in targeted groups. However, against a background of strong secular trends of increasing health promotion and declining risk factors, the overall program effects were modest in size and duration and generally within chance levels.

CONCLUSIONS

These findings suggest that even such an intense program may not be able to generate enough additional exposure to risk reduction messages and activities in a large enough fraction of the population to accelerate the remarkably favorable secular trends in health promotion activities and in most coronary heart disease risk factors present in the study communities.

Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence

OBJECTIVES

Project Northland is an efficacy trial with the goal of preventing or reducing alcohol use among young adolescents by using a multilevel, communitywide approach.

METHODS

Conducted in 24 school districts and adjacent communities in northeastern Minnesota since 1991, the intervention targets the class of 1998 (sixth-grade students in 1991) and has been implemented for 3 school years (1991 to 1994). The intervention consists of social-behavioral curricula in schools, peer leadership, parental involvement/education, and communitywide task force activities. Annual surveys of the class of 1998 measure alcohol use, tobacco use, and psychosocial factors.

RESULTS

At the end of 3 years, students in the intervention school districts report less onset and prevalence of alcohol use than students in the reference districts. The differences were particularly notable among those who were nonusers at baseline.

CONCLUSIONS

The results of Project Northland suggest that multilevel, targeted prevention programs for young adolescents are effective in reducing alcohol use.

Community-wide prevention of cardiovascular disease: education strategies of the Minnesota Heart Health Program

The Minnesota Heart Health Program (MHHP) is a research and demonstration project of population-wide primary prevention of cardiovascular disease. Study goals are to achieve reductions in cardiovascular disease risk factors and morbidity and mortality in three education communities compared with three reference communities. The program in the first of the three intervention communities, Mankato, has been operating for 3 of the planned 5 years. Early objectives of the program have been achieved based on data obtained from population-based random samples surveyed in education and comparison communities. After 2 years of participation, Mankato was significantly more exposed to activities promoting cardiovascular disease prevention. In this town of 38,000 inhabitants, 190 community leaders were directly involved as program volunteers, 14,103 residents (over 60% of adults) attended a screening education center, 2,094 attended MHHP health education classes, 42 of 65 physicians and 728 other health professionals participated in continuing education programs offered by MHHP, and distribution of printed media averaged 12.2 pieces per household. These combined educational strategies have resulted in widespread awareness of MHHP and participation by the majority of the Mankato adult population in its education activities.

Patient delay in seeking care for heart attack symptoms: findings from focus groups conducted in five U.S. regions

BACKGROUND

Patient delay in seeking health care for heart attack symptoms is a continuuing problem in the United States.

METHODS

Investigators conducted focus groups (N = 34; 207 participants) in major U.S. regions (NE, NW, SE, SW, MW) as formative evaluation to develop a multi-center randomized community trial (the REACT Project). Target groups included adults with previous heart attacks, those at higher risk for heart attack, and bystanders to heart attacks. There were also subgroups reflecting gender and ethnicity (African-American, Hispanic-American, White).

FINDINGS

Patients, bystanders, and those at higher risk expected heart attack symptoms to present as often portrayed in the movies, that is, as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. Patients and those at higher risk also unrealistically judge their personal risk as low, understand little about the benefits of rapid action, are generally unaware of the benefits of using EMS/9-1-1 over alternative transport, and appear to need the "permission" of health care providers or family to act. Moreover, participants reported rarely discussing heart attack symptoms and appropriate responses in advance with health care providers, spouses, or family members. Women often described heart attack as a "male problem," an important aspect of their underestimation of personal risk. African-American participants were more likely to describe negative feelings about EMS/9-1-1, particularly whether they would be transported to their hospital of choice.

CONCLUSIONS

Interventions to reduce patient delay need to address expectations about heart attack symptoms, educate about benefits and appropriate actions, and provide legitimacy for taking specific health care-seeking actions. In addition, strategy development must emphasize the role of health care providers in legitimizing the need and importance of taking rapid action in the first place.

Self-assembly of "patchy" nanoparticles: a versatile approach to functional hierarchical materials

The solution-phase self-assembly or “polymerization” of discrete colloidal building blocks, such as “patchy” nanoparticles and multicompartment micelles, is attracting growing attention with respect to the creation of complex hierarchical materials.

The solution-phase self-assembly or “polymerization” of discrete colloidal building blocks, such as “patchy” nanoparticles and multicompartment micelles, is attracting growing attention with respect to the creation of complex hierarchical materials. This approach represents a versatile method with which to transfer functionality at the molecular level to the nano- and microscale, and is often accompanied by the emergence of new material properties. In this perspective we highlight selected recent examples of the self-assembly of anisotropic nanoparticles which exploit directional interactions introduced through their shape or surface chemistry to afford a variety of hierarchical materials. We focus in particular on the solution self-assembly of block copolymers as a means to prepare multicompartment or “patchy” micelles. Due to their potential for synthetic modification, these constructs represent highly tuneable building blocks for the fabrication of a wide variety of functional assemblies.

Social capital and health: civic engagement, community size, and recall of health messages

OBJECTIVES

We explored the effects of community integration and pluralism on recall of cardiovascular disease health information messages.

METHODS

With 1980-1983 data from the Minnesota Heart Health Program, we examined whether ties to community groups were associated with recall of health messages, and whether this relation was modified by size and degree of differentiation of the community.

RESULTS

A higher level of civic engagement through ties to community groups was associated with better recall of health messages. Ties to community groups independently contributed to better message recall even after control for gender, education, and other variables. The moderating role of community size was non-significant but intriguing.

CONCLUSIONS

Community group membership could increase exposure to health messages, providing a critical pathway for social capital to influence health promotion and, thus, public health outcomes.

Community ownership and program continuation following a health demonstration project

Community ownership and maintenance of heart health programs was a major study goal of the Minnesota Heart Health Program (MHHP), a community-based National Heart, Blood and Lung Institute (NIH)-funded demonstration project. A partnership between the University of Minnesota and three Upper Midwest intervention communities was initiated in 1981. Local citizen boards were instrumental in planning, implementing and incorporating programs. Through an 8 year process of community organization, training and volunteer involvement, MHHP educational program responsibility was transferred to existing community-based groups and organizations. In 1989, when federal funding was withdrawn, 70% of all heart health intervention programs initiated by MHHP were being continued by local sponsors and supported by local funds. By 1992, maintenance of programs had decreased to an average 60%. Differential results of program incorporation among the three intervention communities are presented including findings on community sectors that most frequently sponsored programs. Factors that facilitate or impede local ownership are discussed. Research on longer-term maintenance of heart health programs in the three communities continues.

Extending the Scope of "Living" Crystallization-Driven Self-Assembly: Well-Defined 1D Micelles and Block Comicelles from Crystallizable Polycarbonate Block Copolymers

Fiber-like block copolymer (BCP) micelles offer considerable potential for a variety of applications; however, uniform samples of controlled length and with spatially tailored chemistry have not been accessible. Recently, a seeded growth method, termed "living" crystallization-driven self-assembly (CDSA), has been developed to allow the formation of 1D micelles and block comicelles of precisely controlled dimensions from BCPs with a crystallizable segment. An expansion of the range of core-forming blocks that participate in living CDSA is necessary for this technique to be compatible with a broad range of applications. Few examples currently exist of well-defined, water-dispersible BCP micelles prepared using this approach, especially from biocompatible and biodegradable polymers. Herein, we demonstrate that BCPs containing a crystallizable polycarbonate, poly(spiro[fluorene-9,5'-[1,3]-dioxan]-2'-one) (PFTMC), can readily undergo living CDSA processes. PFTMC- b-poly(ethylene glycol) (PEG) BCPs with PFTMC:PEG block ratios of 1:11 and 1:25 were shown to undergo living CDSA to form near monodisperse fiber-like micelles of precisely controlled lengths of up to ∼1.6 μm. Detailed structural characterization of these micelles by TEM, AFM, SAXS, and WAXS revealed that they comprise a crystalline, chain-folded PFTMC core with a rectangular cross-section that is surrounded by a solvent swollen PEG corona. PFTMC- b-PEG fiber-like micelles were shown to be dispersible in water to give colloidally stable solutions. This allowed an assessment of the toxicity of these structures toward WI-38 and HeLa cells. From these experiments, we observed no discernible cytotoxicity from a sample of 119 nm fiber-like micelles to either healthy (WI-38) or cancerous (HeLa) cell types. The living CDSA process was extended to PFTMC- b-poly(2-vinylpyridine) (P2VP), and addition of this BCP to PFTMC- b-PEG seed micelles led to the formation of well-defined segmented fibers with spatially localized coronal chemistries.

Plasmid ColE1 conjugal mobility: the nature of bom, a region required in cis for transfer

Conjugal mobility of ColE1 and related plasmids is promoted by a wide range of conjugative plasmids. ColE1 produces trans-acting products and has a region required in cis (bom ; basis of mobility) for such mobility. Here we show that plasmid pBR322 contains a functional bom sequence located within a 141 bp HhaI fragment. This bom region is functional for conjugation promoted by several different conjugative plasmids and is highly conserved in ColE1 and contains nic the putative origin of transfer. The orientation and position of bom with respect to the ColE1 vegetative origin of replication can be changed without affecting the frequency of conjugal mobility promoted by R64drd11.

Improving global health education: development of a Global Health Competency Model

Although global health is a recommended content area for the future of education in public health, no standardized global health competency model existed for master-level public health students. Without such a competency model, academic institutions are challenged to ensure that students are able to demonstrate the knowledge, skills, and attitudes (KSAs) needed for successful performance in today's global health workforce. The Association of Schools of Public Health (ASPH) sought to address this need by facilitating the development of a global health competency model through a multistage modified-Delphi process. Practitioners and academic global health experts provided leadership and guidance throughout the competency development process. The resulting product, the Global Health Competency Model 1.1, includes seven domains and 36 competencies. The Global Health Competency Model 1.1 provides a platform for engaging educators, students, and global health employers in discussion of the KSAs needed to improve human health on a global scale.

Background, conceptualization and design of a community-wide research program on adolescent alcohol use: Project Northland

Project Northland is a community-wide research program funded by the National Institute on Alcoholism and Alcohol Abuse, for a 5-year period (1990-95). The aim of the study is to prevent or delay onset of alcohol use among young adolescents, as well as to reduce use among those who are already drinkers. Twenty communities were recruited in northeastern Minnesota, an area referred to as the Northland, Arrowhead or Iron Range region, and then were randomly assigned to either Education or Delayed Program conditions. The 10 Education school districts have agreed to participate in 3 years of intervention programs in schools, with parents and in the community-at-large. One group of young adolescents, the Class of 1998 (sixth grade students in the 1991-92 school year), form the study cohort. Surveys (1991-94) of the Class of 1998, their parents, community leaders and alcohol merchants are the primary components of the program's evaluation. Many conceptual and methodological questions emerged during the development of the research protocols for Project Northland over the past 2 years. These questions are the impetus for this article. Specifically, the focus on young adolescents and alcohol use was selected, as contrasted with older adolescents or with multiple problem behaviors. The project was designed using a community-wide model that addresses both supply and demand issues, rather than limited to a school-based model. Intervention strategies and evaluation methods were chosen that could address community-level as well as individual-level behavior change, which required the development and application of new technologies. The rationale for these decisions may be useful to others considering community-wide health promotion efforts.

Individual and neighborhood socioeconomic status effects on adolescent smoking: a multilevel cohort-sequential latent growth analysis

OBJECTIVES

We examined the prospective effects of parental education (as a proxy for individual socioeconomic status [SES]) and neighborhood SES on adolescent smoking trajectories and whether the prospective effects of individual SES varied across neighborhood SES.

METHODS

The study included 3635 randomly recruited adolescents from 5 age cohorts (12-16 years) assessed semiannually for 3 years in the Minnesota Adolescent Community Cohort study. We employed a cohort-sequential latent growth model to examine smoking from age 12 to 18 years with predictors.

RESULTS

Lower individual SES predicted increased levels of smoking over time. Whereas neighborhood SES had no direct effect, the interaction between individual and neighborhood SES was significant. Among higher and lower neighborhood SES, lower individual SES predicted increased levels of smoking; however, the magnitude of association between lower individual SES and higher smoking levels was significantly greater for higher neighborhood SES.

CONCLUSIONS

We found evidence for differential effects of individual SES on adolescent smoking for higher and lower neighborhood SES. The group differences underscore social conditions as fundamental causes of disease and development of interventions and policies to address inequality in the resources.

Rapid early action for coronary treatment: rationale, design, and baseline characteristics. REACT Research Group

OBJECTIVE

Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay.

METHODS

Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed.

RESULTS

Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86).

CONCLUSIONS

REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Surgical treatment for invasive lobular carcinoma of the breast

The management and outcome of 131 women with infiltrating lobular carcinoma treated in the Belfast City Hospital between October 1987 and February 1999 were reviewed. Two patients had primary hormonal treatment and were excluded from the statistical analysis, and 129 patients were followed up. Fifty-four patients (41%) had initial breast conservation surgery, which was followed by re-excision of margins in eight patients (14.8%) and completion total mastectomy in 26 patients (48.1%). The breast conservation surgery group, 28 patients (21.7%), was compared with the total mastectomy group, 101 patients (78.2%), after a median follow-up period of 90 months (range 24-160 months). The overall survival was 68.7%. Survival analysis was performed using Kaplan-Meier and Cox regression which showed that lymph node involvement and tumour grade were the only variables affecting survival (P<0.0001, and 0.01, respectively). The type of surgery performed did not affect survival (P=0.42). The total number of patients who developed local recurrence was 17 patients (13.1%, 12 patients in the breast conservation surgery group and five patients in the total mastectomy group, P<0.0001). Kaplan-Meier analysis of local recurrence showed that the type of surgery (P<0.0001), patient age (P=0.02), tumour grade (P=0.002), adjuvant radiotherapy (P=0.013), chemotherapy (P=0.031) and hormonal treatment (P=0.003) significantly affected local recurrence. Cox regression analysis showed that the only factor significantly affecting local recurrence was the type of surgery performed (P=0.02). Patients who underwent mastectomy had less local recurrence than those who had breast conservation surgery. Local recurrence after breast conservation surgery is high, even with clear surgical margins and post-operative radiotherapy. The authors believe that total mastectomy for infiltrating lobular carcinoma is a safer option to control local disease, especially in younger patients and those with high-grade tumours. Overall survival is not affected by the type of surgical treatment. Local recurrence can be a late event and a long-term follow-up is recommended.

In Situ Visualization of Block Copolymer Self-Assembly in Organic Media by Super-Resolution Fluorescence Microscopy

Analytical methods that enable visualization of nanomaterials derived from solution self‐assembly processes in organic solvents are highly desirable. Herein, we demonstrate the use of stimulated emission depletion microscopy (STED) and single molecule localization microscopy (SMLM) to map living crystallization‐driven block copolymer (BCP) self‐assembly in organic media at the sub‐diffraction scale. Four different dyes were successfully used for single‐colour super‐resolution imaging of the BCP nanostructures allowing micelle length distributions to be determined in situ. Dual‐colour SMLM imaging was used to measure and compare the rate of addition of red fluorescent BCP to the termini of green fluorescent seed micelles to generate block comicelles. Although well‐established for aqueous systems, the results highlight the potential of super‐resolution microscopy techniques for the interrogation of self‐assembly processes in organic media.

A randomized community trial to increase mammography utilization among low-income women living in public housing

BACKGROUND

A randomized trial was conducted to evaluate the impact of a community-based intervention on mammography use among low-income women living in public housing.

METHODS

All 41 public housing high-rise buildings were randomized to treatment and delayed treatment (control) conditions. After a cross-sectional baseline survey, an intervention called Friend to Friend was conducted in the treatment buildings by American Cancer Society and building resident volunteers. The intervention consisted of a health professional talk, small group discussions, and an opportunity to request assistance in obtaining a mammogram or mammogram reminder. A second cross-sectional survey was conducted to measure differences in screening rates between the study groups.

RESULTS

Participation in the intervention averaged 27%. The study groups were equivalent at baseline. At follow-up, the proportion of women age 50-79 years who reported mammography screening in the previous 15 months was significantly higher in the treatment group (64%) than in the control group (52%). Breast cancer knowledge, attitudes, and beliefs did not differ between groups.

CONCLUSIONS

These findings suggest that a multidimensional intervention which reaches women within their social environment and uses community volunteers can increase mammography utilization among women in public housing.

Advances in the molecular genetic analysis of the flax-flax rust interaction

The L6 and M rust-resistance genes, representing two of the five rust-resistance gene loci in flax (Linum usitatissimum), have been cloned. The molecular data are fully consistent with earlier genetic data: the L locus is a single gene with multiple alleles expressing different rust resistance specificities, and the M locus is complex, containing an array of about 15 similar genes. Thus, while L6 and M resistance genes have 86% nucleotide identity, their locus structure is very different. These genes encode products belonging to the nucleotide binding site-leucine-rich repeat class of disease-resistance proteins. Analysis of alleles from the L locus and chimeric genes is providing evidence suggesting that important specificity determinants occur in the C-terminal half of the proteins, the region containing the leucine-rich repeats. The isolation and characterization of the rust (Melampsora lini) avirulence genes that correspond to the cloned rust-resistance genes is one of the major challenges remaining to the understanding of this system.

Project Northland high school interventions: community action to reduce adolescent alcohol use

Project Northland is a randomized community trial initially implemented in 24 school districts and communities in northeastern Minnesota, with goals of delaying onset and reducing adolescent alcohol use using community-wide, multiyear, multiple interventions. The study targets the Class of 1998 from the 6th to 12th grades (1991-1998). The early adolescent phase of Project Northland has been completed, and reductions in the prevalence of alcohol use at the end of 8th grade were achieved. Phase II of Project Northland, targeting 11th- and 12th-grade students, uses five major strategies: (1) direct action community organizing methods to encourage citizens to reduce underage access to alcohol, (2) youth development involving high school students in youth action teams, (3) print media to support community organizing and youth action initiatives and communicate healthy norms about underage drinking (e.g., providing alcohol to minors is unacceptable), (4) parent education and involvement, and (5) a classroom-based curriculum for 11th-grade students. This article describes the background, design, implementation, and process measures of the intervention strategies for Phase II of Project Northland.

Knowledge of heart attack symptoms in 20 US communities. Results from the Rapid Early Action for Coronary Treatment Community Trial

BACKGROUND

Effective treatment for patients with acute myocardial infarction is limited by patient delay in seeking care. Inadequate knowledge of heart attack symptoms may prolong delay. An intervention designed to reduce delay was tested in the Rapid Early Action for Coronary Treatment (REACT) Community Trial. In this report, the impact on knowledge of heart attack symptoms is presented.

METHODS

Twenty communities were randomized to intervention or comparison status in a matched-pair design. Intervention strategies included community organization, public education, professional education, and patient education. The main outcome measures were based on information regarding knowledge of symptoms collected in a series of four random-digit-dialed telephone surveys.

RESULTS

Knowledge of REACT-targeted symptoms increased in intervention communities. No change was observed in comparison communities. The net effect was an increase of 0.44 REACT-targeted symptoms per individual (P<0.001). The intervention effect was greater in ethnic minorities, persons with lower household incomes, and those with family or spouse history of heart attack (P<0.05).

CONCLUSIONS

The REACT intervention was modestly successful in increasing the general public's knowledge of the complex constellation of heart attack symptoms. The intervention program was somewhat more effective in reaching disadvantaged subgroups, including ethnic minorities and persons with lower income. Despite these successes, the post-intervention level of knowledge was suboptimal.

Thoracoscopic drainage and decortication as definitive treatment for empyema thoracis following penetrating chest injury

PURPOSE

The purpose of this study is to describe our experience with thoracoscopic drainage and decortication as definitive treatment for empyema thoracis following penetrating chest trauma.

METHODS

Over a 9-month period, eight patients at two institutions were treated for empyema thoracis that developed following penetrating chest injury. Seven patients sustained gunshot wounds and one a stab wound. All were treated for hemothorax with a closed tube thoracostomy. Associated injuries included six spinal cord injuries, a liver and diaphragmatic injury, a subclavian injury, and a carotid injury. Each patient subsequently developed an empyema. All patients underwent one thoracoscopic drainage and decortication of the empyema.

RESULTS

In all patients, complete resolution of the empyema was achieved with the thoracoscopic technique. Chest tubes were removed a median of 8.5 days after the procedure. Median blood loss was 200 mL. The average duration of the operation was 110 minutes. There were two complications, a persistent air leak and a trapped lung, both treated with thoracoscopic intervention.

CONCLUSION

Thoracoscopic drainage and decortication offers an alternative to thoracotomy for definitive therapy of empyema thoracis developing after penetrating chest trauma.