Neurodevelopment at age 5.5 years according to Ages & Stages Questionnaire at 2 years' corrected age in children born preterm: the EPIPAGE-2 cohort study

OBJECTIVE

To report neurodevelopment at age 5.5 years according to developmental delay screening with the Ages & Stages Questionnaire (ASQ) in late infancy in preterm-born children.

DESIGN

Population-based cohort study, EPIPAGE-2.

SETTING

France, 2011-2017.

PARTICIPANTS

2504 children born at 24-26, 27-31 and 32-34 weeks, free of cerebral palsy, deafness or blindness at 2 years' corrected age.

MAIN OUTCOME MEASURES

Moderate/severe, mild or no disability at age 5.5 years using gross and fine motor, sensory, cognitive and behavioural evaluations. Results of the ASQ completed between 22 and 26 months' corrected age described as positive screening or not.

RESULTS

Among 2504 participants, 38.3% had ASQ positive screening. The probability of having moderate/severe or mild disability was higher for children with ASQ positive versus negative screening: 14.2% vs 7.0%, adjusted OR 2.5 (95% CI 1.8 to 3.4), and 37.6% vs 29.7%, adjusted OR 1.5 (1.2 to 1.9). For children with ASQ positive screening, the probability of having neurodevelopmental disabilities at age 5.5 years was associated with the number of domain scores below threshold, very low gestational age and severe neonatal morbidities. For children with ASQ negative screening, this probability was increased for boys and children born small-for-gestational age. For both groups, maternal level of education was strongly associated with outcomes.

CONCLUSION

In preterm-born children, ASQ screening at 2 years' corrected age was associated with neurodevelopmental disabilities at age 5.5 years. However, other factors should be considered when interpreting the ASQ data to draw further follow-up.

TRIAL REGISTRATION NUMBER

2016-A00333-48.

Five-year outcomes for extremely preterm babies with active perinatal management: A clinical prediction model

OBJECTIVE

To develop and validate a clinical prediction model for outcomes at 5 years of age for children born extremely preterm and receiving active perinatal management.

DESIGN

The EPIPAGE-2 national prospective cohort.

SETTING

France, 2011.

POPULATION

Live-born neonates between 24+0 and 26+6  weeks of gestation who received active perinatal management (i.e. birth in a tertiary-level hospital, with antenatal steroids and resuscitation at birth).

METHODS

A prediction model using logistic modelling, including gestational age, small-for gestational-age (SGA) status and sex, was developed. Model performance was assessed through calibration and discrimination, with bootstrap internal validation.

MAIN OUTCOME MEASURES

Survival without moderate or severe neurodevelopmental disability (NDD) at 5 years.

RESULTS

Among the 557 neonates included, 401 (72%) survived to 5 years, of which 59% survived without NDD (95% CI 54% to 63%). Predicted rates of survival without NDD ranged from 45% (95% CI 33% to 57%), to 56% (95% CI 49% to 64%) to 64% (95% CI 57% to 70%) for neonates born at 24, 25 and 26 weeks of gestation, respectively. Predicted rates of survival without NDD were 47% (95% CI 18% to 76%) and 62% (95% CI 49% to 76%) for SGA and non-SGA children, respectively. The model showed good calibration (calibration slope 0.85, 95% CI 0.54 to 1.16; calibration-in-the-large -0.0123, 95% CI -0.25 to 0.23) and modest discrimination (C-index 0.59, 95% CI 0.53 to 0.65).

CONCLUSIONS

A simple prediction model using three factors easily known antenatally may help doctors and families in their decision-making for extremely preterm neonates receiving active perinatal management.

Survival and neurodevelopmental impairment of outborn preterm infants at 5.5 years of age: an EPIPAGE-2 prospective, matched study using multiple imputation

OBJECTIVE

To determine whether birth outside a level-3 centre (outborn) is associated with a difference in the combined outcome of mortality or moderate-to-severe neurological impairment at 5.5 years of age compared with birth in a level-3 centre (inborn) when antenatal steroids and gestational age (GA) are accounted for.

DESIGN

Individual matched study nested within a prospective cohort. Each outborn infant was matched using GA and antenatal steroids with a maximum of four inborns. Conditional logistic regression was used to calculate ORs before being adjusted using maternal and birth characteristics. Analyses were carried out after multiple imputation for missing data.

SETTING

EPIPAGE-2 French national prospective cohort including births up to 34 weeks GA inclusive.

PATIENTS

Outborn and inborn control infants selected between 24 and 31 weeks GA were followed in the neonatal period and to 2 and 5.5 years. 3335 infants were eligible of whom all 498 outborns and 1235 inborn infants were included-equivalent to 2.5 inborns for each outborn.

MAIN OUTCOME MEASURE

Survival without moderate-to-severe neurodevelopmental impairment at 5.5 years.

RESULTS

Chorioamnionitis, pre-eclampsia, caesarian birth and small-for-dates were more frequent among inborns, and spontaneous labour and antepartum haemorrhage among outborns. There was no difference in the main outcome measure at 5.5 years of age (adjusted OR 1.09, 95% CI 0.82 to 1.44); sensitivity analyses suggested improved outcomes at lower GAs for inborns.

CONCLUSION

In this GA and steroid matched cohort, there was no difference in survival without moderate-to-severe neurodevelopmental impairment to 5.5 years of age between inborn and outborn very preterm children. This suggests steroids might be important in determining outcomes.

Effects of the SARS-CoV-2 pandemic on perinatal activity in Yorkshire and the Humber region during 2020: an interrupted time series analysis

OBJECTIVE

To assess the impact of public health measures taken during the COVID-19 pandemic on perinatal health indicators.

DESIGN

Interrupted time series analysis comparing periods of the pandemic with the previous 5 years.

SETTING

Yorkshire and the Humber region, England (2015-2020).

MAIN OUTCOME MEASURES

Relative risk (RR) of stillbirth, extreme preterm (EPT, <27 weeks' gestational age) delivery, hypoxic ischaemic encephalopathy (HIE) and meconium aspiration syndrome (MAS), antenatal transfer for threatened EPT delivery and postnatal transfer for EPT birth, HIE or MAS.

RESULTS

Stillbirths fell from 3.7/1000 deliveries prepandemic to 2.9/1000 afterwards; EPT births decreased from 2.5/1000 to 1.8/1000 live births. Following adjustment, during the first lockdown there were decreased antenatal transfers (RR 0.74, 95% CI 0.57 to 0.94) with non-statistically significant increased stillbirth (RR 1.08, 95% CI 0.78 to 1.51) and decreased EPT admissions (RR 0.88, 95% CI 0.60 to 1.29). Over the entire pandemic period, antenatal transfer (RR 0.64, 95% CI 0.55 to 0.76) and EPT birth (RR 0.73, 95% CI 0.56 to 0.94) decreased; stillbirths showed non-statistically significant increases overall (RR 1.21, 95% CI 0.98 to 1.49) but with increasing trend through the pandemic (RR 1.11, 95% CI 1.00 to 1.22). No changes were seen for HIE, MAS, postnatal transfers or in subgroup analyses by ethnicity.

CONCLUSIONS

Lower rates of antenatal transfer and extreme preterm birth were identified, alongside an apparent increase in stillbirth over time. The findings provide evidence that effects on perinatal activity related to the pandemic changed over time.

Neurodevelopmental outcomes at age 5 among children born preterm: EPIPAGE-2 cohort study

OBJECTIVES

To describe neurodevelopment at age 5 among children born preterm.

DESIGN

Population based cohort study, EPIPAGE-2.

SETTING

France, 2011.

PARTICIPANTS

4441 children aged 5½ born at 24-26, 27-31, and 32-34 weeks MAIN OUTCOME MEASURES: Severe/moderate neurodevelopmental disabilities, defined as severe/moderate cerebral palsy (Gross Motor Function Classification System (GMFCS) ≥2), or unilateral or bilateral blindness or deafness, or full scale intelligence quotient less than minus two standard deviations (Wechsler Preschool and Primary Scale of Intelligence, 4th edition). Mild neurodevelopmental disabilities, defined as mild cerebral palsy (GMFCS-1), or visual disability ≥3.2/10 and <5/10, or hearing loss <40 dB, or full scale intelligence quotient (minus two to minus one standard deviation) or developmental coordination disorders (Movement Assessment Battery for Children, 2nd edition, total score less than or equal to the fifth centile), or behavioural difficulties (strengths and difficulties questionnaire, total score greater than or equal to the 90th centile), school assistance (mainstream class with support or special school), complex developmental interventions, and parents' concerns about development. The distributions of the scores in contemporary term born children were used as reference. Results are given after multiple imputation as percentages of outcome measures with exact binomial 95% confidence intervals.

RESULTS

Among 4441 participants, 3083 (69.4%) children were assessed. Rates of severe/moderate neurodevelopmental disabilities were 28% (95% confidence interval 23.4% to 32.2%), 19% (16.8% to 20.7%), and 12% (9.2% to 14.0%) and of mild disabilities were 38.5% (33.7% to 43.4%), 36% (33.4% to 38.1%), and 34% (30.2% to 37.4%) at 24-26, 27-31, and 32-34 weeks, respectively. Assistance at school was used by 27% (22.9% to 31.7%), 14% (12.1% to 15.9%), and 7% (4.4% to 9.0%) of children at 24-26, 27-31, and 32-34 weeks, respectively. About half of the children born at 24-26 weeks (52% (46.4% to 57.3%)) received at least one developmental intervention which decreased to 26% (21.8% to 29.4%) for those born at 32-34 weeks. Behaviour was the concern most commonly reported by parents. Rates of neurodevelopment disabilities increased as gestational age decreased and were higher in families with low socioeconomic status.

CONCLUSIONS

In this large cohort of children born preterm, rates of severe/moderate neurodevelopmental disabilities remained high in each gestational age group. Proportions of children receiving school assistance or complex developmental interventions might have a significant impact on educational and health organisations. Parental concerns about behaviour warrant attention.

Comprehensive health assessment of green turtles Chelonia mydas nesting in southeastern Florida, USA

Important indicators of population health needed for large-scale sea turtle population recovery efforts include demographics, disease and mortality trends, condition indices, and baseline blood data. With this comprehensive health assessment of adult female green sea turtles Chelonia mydas nesting on Juno Beach, Florida, USA, we (1) established comprehensive baseline health indices; (2) identified individuals with evidence of infection by chelonid alphaherpesviruses 5 and 6 (ChHV5, ChHV6), which are implicated in fibropapillomatosis and respiratory and skin disease, respectively; and (3) compared measured health indices between turtles that did versus those that did not test positive for ChHV5 and/or ChHV6. All 60 turtles included in the study were in good body condition with no external fibropapillomatosis tumors. Hematological and biochemical reference intervals were established. Via quantitative PCR (qPCR), 5/60 turtles (8%) tested positive for ChHV5, and all turtles were negative for ChHV6. Of 41 turtles tested for antibodies to ChHV5 and ChHV6, 29% and 15% tested positive, respectively, and 10% tested positive for antibodies to both viruses. Notably, there were no statistically significant differences between health variables for nesting turtles that tested positive for ChHV5 DNA versus those that tested negative; and also no differences between turtles that tested positive for ChHV5 or ChHV6 antibodies and those that did not. This suggests that these viruses are enzootically stable in Florida’s adult green turtles. This study provides a health profile of nesting green turtles in southeastern Florida applicable to temporal and spatial investigations of this and other populations.

Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study

Background

Perinatal decision-making affects outcomes for extremely preterm babies (22–26 weeks’ gestational age (GA)): more active units have improved survival without increased morbidity. We hypothesised such units may gain skills and expertise meaning babies at higher gestational ages have better outcomes than if they were born elsewhere. We examined mortality and morbidity outcomes at age two for babies born at 27–28 weeks’ GA in relation to the intensity of perinatal care provided to extremely preterm babies.

Methods

Fetuses from the 2011 French national prospective EPIPAGE-2 cohort, alive at maternal admission to a level 3 hospital and delivered at 27–28 weeks’ GA, were included. Morbidity-free survival (survival without sensorimotor (blindness, deafness or cerebral palsy) disability) and overall survival at age two were examined. Sensorimotor disability and Ages and Stages Questionnaire (ASQ) result below threshold among survivors were secondary outcomes. Perinatal care intensity level was based on birth hospital, grouped using the ratio of 24–25 weeks’ GA babies admitted to neonatal intensive care to fetuses of the same gestation alive at maternal admission. Sensitivity analyses used ratios based upon antenatal steroids, Caesarean section, and newborn resuscitation. Multiple imputation was used for missing data; hierarchical logistic regression accounted for births nested within centres.

Results

633 of 747 fetuses (84.7%) born at 27–28 weeks’ GA survived to age two. There were no differences in survival or morbidity-free survival: respectively, fully adjusted odds ratios were 0.96 (95% CI: 0.54 to 1.71) and 1.09 (95% CI: 0.59 to 2.01) in medium and 1.12 (95% CI: 0.63 to 2.00) and 1.16 (95% CI: 0.62 to 2.16) in high compared to low-intensity hospitals. Among survivors, there were no differences in sensorimotor disability or ASQ below threshold. Sensitivity analyses were consistent with the main results.

Conclusions

No difference was seen in survival or morbidity-free survival at two years of age among fetuses alive at maternal hospital admission born at 27–28 weeks’ GA, or in sensorimotor disability or presence of an ASQ below threshold among survivors. There is no evidence for an impact of intensity of perinatal care for extremely preterm babies on births at a higher gestational age.

Assessing the risk of early unplanned rehospitalisation in preterm babies: EPIPAGE 2 study

Background

Gaining a better understanding of the probability, timing and prediction of rehospitalisation amongst preterm babies could help improve outcomes. There is limited research addressing these topics amongst extremely and very preterm babies. In this context, unplanned rehospitalisations constitute an important, potentially modifiable adverse event. We aimed to establish the probability, time-distribution and predictability of unplanned rehospitalisation within 30 days of discharge in a population of French preterm babies.

Methods

This study used data from EPIPAGE 2, a population-based prospective study of French preterm babies. Only those babies discharged home alive and whose parents responded to the one-year survey were eligible for inclusion in our study. For Kaplan-Meier analysis, the outcome was unplanned rehospitalisation censored at 30 days. For predictive modelling, the outcome was binary, recording unplanned rehospitalisation within 30 days of discharge. Predictors included routine clinical variables selected based on expert opinion.

Results

Of 3841 eligible babies, 350 (9.1, 95% CI 8.2–10.1) experienced an unplanned rehospitalisation within 30 days. The probability of rehospitalisation progressed at a consistent rate over the 30 days. There were significant differences in rehospitalisation probability by gestational age. The cross-validated performance of a ten predictor model demonstrated low discrimination and calibration. The area under the receiver operating characteristic curve was 0.62 (95% CI 0.59–0.65).

Conclusions

Unplanned rehospitalisation within 30 days of discharge was infrequent and the probability of rehospitalisation progressed at a consistent rate. Lower gestational age increased the probability of rehospitalisation. Predictive models comprised of clinically important variables had limited predictive ability.

Volume of Neonatal Care and Survival without Disability at 2 Years in Very Preterm Infants: Results of a French National Cohort Study

OBJECTIVES

To investigate the relation between neonatal intensive care unit (NICU) volume and survival, and neuromotor and sensory disabilities at 2 years in very preterm infants.

STUDY DESIGN

The EPIPAGE-2 (Etude Epidémiologique sur les Petits Âges Gestationnels-2) national prospective population-based cohort study was used to include 2447 babies born alive in 66 level III hospitals between 24 and 30 completed weeks of gestation in 2011. The outcome was survival without disabilities (levels 2-5 of the Gross Motor Function Classification System for cerebral palsy with or without unilateral or bilateral blindness or deafness). Units were grouped in quartiles according to volume, defined as the annual admissions of very preterm babies. Multivariate logistic regression analyses with population average models were used.

RESULTS

Survival at discharge was lower in hospitals with lower volumes of neonatal activity (aOR 0.55, 95% CI 0.33-0.91). Survival without neuromotor and sensory disabilities at 2 years increased with hospital volume, from 75% to 80.7% in the highest volume units. After adjustment for gestational age, small for gestational age, sex, maternal age, infertility treatment, multiple pregnancy, principal cause of prematurity, parental socioeconomic status, and mother's country of birth, survival without neuromotor or sensory disabilities was significantly lower in hospitals with a lower volume of neonatal activity (aOR 0.60, 95% CI 0.38-0.95) than in the highest quartile hospitals.

CONCLUSIONS

These results suggest that lower neonatal intensive care unit volume is associated with lower survival without an increase in disabilities at 2 years. These results could be useful to generate improvements of perinatal regionalization.

The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study

OBJECTIVE

To estimate the effect of the provision of a one-to-one nurse-to-patient ratio on mortality rates in neonatal intensive care units.

DESIGN

A population-based analysis of operational clinical data using an instrumental variable method.

SETTING

National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing, and Clinical Outcomes Project.

PARTICIPANTS

43 tertiary-level neonatal units observed monthly over the period January 2008 to December 2012.

INTERVENTION

Proportion of neonatal intensive care days or proportion of intensive care admissions for which one-to-one nursing was provided.

OUTCOMES

Monthly in-hospital intensive care mortality rate.

RESULTS

Over the study period, the provision of one-to-one nursing in tertiary neonatal units declined from a median of 9.1% of intensive care days in 2008 to 5.9% in 2012. A 10 percentage point decrease in the proportion of intensive care days on which one-to-one nursing was provided was associated with an increase in the in-hospital mortality rate of 0.6 (95% CI 1.2 to 0.0) deaths per 100 infants receiving neonatal intensive care per month compared with a median monthly mortality rate of 4.5 deaths per 100 infants per month. The results remained robust to sensitivity analyses that varied the estimation sample of units, the choice of instrumental variables, unit classification and the selection of control variables.

CONCLUSIONS

Our study suggests that decreases in the provision of one-to-one nursing in tertiary-level neonatal intensive care units increase the in-hospital mortality rate.

The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study

OBJECTIVE

To examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting.

DESIGN

A retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses.

SETTING

165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project.

PARTICIPANTS

20 554 infants born at <33 weeks completed gestation (17 995 born at 27-32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009-31 December 2011.

INTERVENTION

Tertiary designation or high-volume neonatal care at the hospital of birth.

OUTCOMES

Neonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge.

RESULTS

Infants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation.

CONCLUSIONS

High-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units.

Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study

BACKGROUND

Expertise and resources may be important determinants of outcome for extremely preterm babies. We evaluated the effect of place of birth and perinatal transfer on survival and neonatal morbidity within a prospective cohort of births between 22 and 26 weeks of gestation in England during 2006.

METHODS

We studied the whole population of 2460 births where the fetus was alive at the admission of the mother to hospital for delivery. Outcomes to discharge were compared between level 3 (most intensive) and level 2 maternity services, with and without transfers, and by activity level of level 3 neonatal unit; ORs were adjusted for gestation at birth and birthweight for gestation (adjusted ORs (aOR)).

FINDINGS

Of this national birth cohort, 56% were born in maternity services with level 3 and 34% with level 2 neonatal units; 10% were born in a setting without ongoing intensive care facilities (level 1). When compared with level 2 settings, risk of death in level 3 services was reduced (aOR 0.73 (95% CI 0.59 to 0.90)), but the proportion surviving without neonatal morbidity was similar (aOR 1.27 (0.93 to 1.74)). Analysis by intended hospital of birth confirmed reduced mortality in level 3 services. Following antenatal transfer into a level 3 setting, there were fewer intrapartum or labour ward deaths, and overall mortality was higher for those remaining in level 2 services (aOR 1.44 (1.09 to 1.90)). Among level 3 services, those with higher activity had fewer deaths overall (aOR 0.68 (0.52 to 0.89)).

INTERPRETATION

Despite national policy, only 56% of births between 22 and 26 weeks of gestation occurred in maternity services with a level 3 neonatal facility. Survival was significantly enhanced following birth in level 3 services, particularly those with high activity; this was not at the cost of increased neonatal morbidity.

Abstract P4-19-05: Breast cancer campaign tissue bank human cell culture programme: Generating new biomaterials for breast research

Background:

In-vitro model systems provide an important tool in breast cancer research and, over recent years, there have been considerable advances in their construction. However, despite these advances, the majority of models still employ a narrow range of established cell lines, which frequently are not appropriate for the in-vivo cell type they are representing1.

Method:

As part of the Breast Cancer Campaign Tissue Bank, we have developed a cell culture programme which feeds into the main tissue collection and involves the systematic generation of materials from normal, high-risk, cancer-containing and malignant breast tissue in order to make available a breadth of material to the research community.

Following informed patient consent, fresh tissue is retrieved and, using tissue digestion and magnetic bead technology2, purified cell populations are isolated, characterized and frozen down, or further processed for DNA and RNA isolation.

Results:

We have isolated purified populations of luminal epithelial, myoepithelial and fibroblast cells from normal breast, risk-reduction (BRCA1 and BRCA2 mutated) breast and from morphologically normal breast tissue surrounding breast cancer. We have generated matched surround and tumour-associated fibroblasts, as well as matched tumour epithelial and tumour-associated fibroblast cell isolates.

These cells have been incorporated into 2- and 3-D culture models and we have demonstrated successful genetic manipulation, with siRNA gene knockdown and gene over-expression through retroviral transduction. Immortalisation of selected cell populations is currently underway.

Intact organoids and tissue explants have also been generated for in-vitro experimentation. Matched frozen and FFPE samples are available, together with full clinicopathological data. The research community can access these biomaterials via a web-based search portal, with full user support.

Conclusion:

Through this cell culture programme we aim to make available a wider and more appropriate range of materials for breast research, which should allow more clinically relevant model systems to be developed and add value to breast cancer biobanking.

References:

1. Thompson A., et al. Evaluation of the current knowledge limitations in breast cancer research: a gap analysis. Breast Cancer Research 2008; 10: R26.

2. Gomm J.J. et al. Isolation of pure populations of epithelial and myoepithelial cells from the normal human mammary gland using immunomagnetic separation with Dynabeads. Analytical Biochemistry 1995; 226: 91-99.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-19-05.

Health impact modelling of active travel visions for England and Wales using an Integrated Transport and Health Impact Modelling Tool (ITHIM)

Background

Achieving health benefits while reducing greenhouse gas emissions from transport offers a potential policy win-win; the magnitude of potential benefits, however, is likely to vary. This study uses an Integrated Transport and Health Impact Modelling tool (ITHIM) to evaluate the health and environmental impacts of high walking and cycling transport scenarios for English and Welsh urban areas outside London.

Methods

Three scenarios with increased walking and cycling and lower car use were generated based upon the Visions 2030 Walking and Cycling project. Changes to carbon dioxide emissions were estimated by environmental modelling. Health impact assessment modelling was used to estimate changes in Disability Adjusted Life Years (DALYs) resulting from changes in exposure to air pollution, road traffic injury risk, and physical activity. We compare the findings of the model with results generated using the World Health Organization's Health Economic Assessment of Transport (HEAT) tools.

Results

This study found considerable reductions in disease burden under all three scenarios, with the largest health benefits attributed to reductions in ischemic heart disease. The pathways that produced the largest benefits were, in order, physical activity, road traffic injuries, and air pollution. The choice of dose response relationship for physical activity had a large impact on the size of the benefits. Modelling the impact on all-cause mortality rather than through individual diseases suggested larger benefits. Using the best available evidence we found fewer road traffic injuries for all scenarios compared with baseline but alternative assumptions suggested potential increases.

Conclusions

Methods to estimate the health impacts from transport related physical activity and injury risk are in their infancy; this study has demonstrated an integration of transport and health impact modelling approaches. The findings add to the case for a move from car transport to walking and cycling, and have implications for empirical and modelling research.

A new cervical spine clearance protocol using computed tomography

OBJECTIVE

The purpose of this study was to assess a cervical spine clearance protocol for blunt trauma patients using helical computed tomographic (CT) scan of the cervical spine (C-spine).

METHODS

A protocol using CT scan of the C-spine was implemented and the first 6 months of use reviewed. Patients requiring a CT scan of the head had the C-spine evaluated by lateral C-spine radiography and a helical CT scan. Patients without indication for CT scan of the head had the C-spine evaluated by three-view radiography (anteroposterior, lateral, and odontoid) with selective CT scan of the C-spine for imaging areas not well visualized or those with abnormalities identified by radiography or by clinical examination alone.

RESULTS

Three hundred twenty-four patients were admitted to the trauma center after blunt trauma during the first 6 months of protocol implementation. Head CT scans were obtained in 158 patients and lateral cervical spine radiography in conjunction with helical CT scanning evaluated the C-spine. The other 166 patients had the cervical spine cleared by three-view radiography series or by clinical examination alone. For patients in whom a head CT scan was not indicated, CT scanning was used only when plain radiographs failed to adequately visualize the entire C-spine. A total of 15 injuries (4.6% of the group) were detected. Seven injuries were suspected or detected by lateral plain radiographs and confirmed by CT scan. Six patients had an injury not detected by radiography but diagnosed by CT scan, and one patient had a false-positive radiograph. Of the remaining two injuries, one was diagnosed by magnetic resonance imaging and the other by CT scan outside of the protocol. Lateral plain radiographs alone failed to detect 46% (n = 6) of all injuries.

CONCLUSION

In our series, the selective use of helical CT scanning with plain radiography increased the accuracy with which cervical spine injury was detected from 54% to 100%. The protocol allowed for more rapid evaluation in many patients as well. We recommend that practice guidelines include the use of helical CT scan of the entire C-spine as the diagnostic procedure for those blunt trauma patients undergoing CT scanning of the head.

Impact of a hospital-based antimicrobial management program on clinical and economic outcomes

Inappropriate use of antimicrobial agents results in unnecessary exposure to medication, persistent or progressive infection, emergence of resistance, and increased costs. We implemented a program to control use of restricted agents while improving care. This study compared 2 major mechanisms for improving use of antimicrobial agents: (1) recommendations made by the Antimicrobial Management Team (AMT), which included a clinical pharmacist backed up by a physician from the Division of Infectious Diseases (ID), and (2) recommendations made by ID fellows. Outcome measures included appropriateness of recommendations, cure rate, number of treatment failures, and cost of care, which were assessed for 180 patients. The AMT outperformed the ID fellows in all outcomes examined by the study (including appropriateness [87% vs. 47%; P<.001], cure rate [64% vs. 42%; P=.007], and treatment failures [15% vs. 28%; P=.03]), although the differences in economic outcomes between cases managed by the AMT and those managed by the ID fellows were not statistically significant. In an academic setting with a restricted formulary, the AMT demonstrated better antimicrobial prescribing than ID fellows.

Toward an understanding of violence: neurobehavioral aspects of unwarranted physical aggression: Aspen Neurobehavioral Conference consensus statement

OBJECTIVE

Violence is a global problem that poses a major challenge to individuals and society. This document is a consensus statement on neurobehavioral aspects of violence as one approach to its understanding and control.

BACKGROUND

This consensus group was convened under the auspices of the Aspen Neurobehavioral Conference, an annual consensus conference devoted to the understanding of issues related to mind and brain. The conference is supported by the Brain Injury Association and by individual philanthropic contributions. Participants were selected by conference organizers to represent leading opinion in neurology, neuropsychology, psychiatry, trauma surgery, nursing, evolutionary psychology, medical ethics, and law.

METHODS

A literature review of the role of the brain in violent behavior was conducted and combined with expert opinion from the group. The major goal was to survey this field so as to identify major areas of interest that could be targeted for further research. Additional review was secured from the other attendees at the Aspen Neurobehavioral Conference.

RESULTS

The group met in the spring of 1998 and 1999 for two 5-day sessions, between which individual assignments were carried out. The consensus statement was prepared after the second meeting, and agreement on the statement was reached by participants after final review of the document.

CONCLUSIONS

Violence can result from brain dysfunction, although social and evolutionary factors also contribute. Study of the neurobehavioral aspects of violence, particularly frontal lobe dysfunction, altered serotonin metabolism, and the influence of heredity, promises to lead to a deeper understanding of the causes and solution of this urgent problem.

Nosocomial blood stream infection in Auckland Healthcare hospitals

AIM

To report the epidemiology of nosocomial bloodstream infections in Auckland Healthcare Hospitals.

METHODS

From January 1995 to December 1997 every positive blood culture result was followed up by an infection control nurse who recorded relevant clinical, laboratory and treatment information on a data collection sheet. The clinical significance of each isolate was determined and the most likely source recorded.

RESULTS

During the three year study period, there were 1,046 nosocomial blood stream infections yielding 1,147 isolates. The most common isolates/groups were: coagulase negative staphylococci 19%, S. aureus 18%, E. coli 12%, streptococci 10%, other Enterobacteriaceae 10%, Enterobacter spp. 7%, Pseudomonas spp. 5%, anaerobes 2%, and yeasts 4%. The most common sources were: intravascular lines 40%, urinary tract 8%, skin/soft tissue 8%, gastrointestinal 7%, and unknown 25%. The overall results were strongly influenced by the neonatal intensive care unit at National Women's Hospital where 58% of blood stream infections had intravascular-lines as the source and 53% of the isolates were coagulase negative staphylococci. The overall blood stream infection rate was approximately 6/1,000 admissions. Rates per 1,000 inpatient days for haematology, intensive care, oncology, neonatal and all other patients were 13, 11, 3, 3 and 1 respectively.

CONCLUSIONS

Surveillance data that are clinically relevant are useful in identifying areas where infection prevention strategies can be implemented. Because of the importance of lines as a source of nosocomial blood stream infections all aspects of line care are being reviewed with the aim of reducing these devices as a source of blood stream infection.

Factors affecting oral feeding with severe traumatic brain injury

Safe and adequate nutrition, vital to the recovery from a traumatic brain injury, can be severely compromised by the presence of dysphagia. This study identified injury severity and swallowing factors that were associated with impaired oral intake in patients with severe brain injury. An admitting Glasgow Coma Scale (GSC) 3-5; a Rancho Los Amigos Scale of Cognitive Functioning (RLA) Level II; a computed tomography (CT) scan exhibiting midline shift, brainstem involvement, or brain pathology requiring emergent operative procedures; or ventilation time >/=15 days identified patients at highest risk for abnormal swallowing, aspiration, and delay in initiation of oral feeding and achievement of total oral feeding. When combined in multivariate models, RLA Level, CT scan, ventilation time and aspiration emerged as significant independent predictors of impaired oral intake.

Causes and complications associated with swallowing disorders in traumatic brain injury

A major complication commonly seen in persons with severe brain injury is swallowing dysfunction. The neuropathology leading to impaired swallowing is discussed. In addition, Other risk factors associated with dysfunctional swallowing, such as tracheostomy and the need for prolonged ventilatory support, are discussed. Within the intensive care environment, the consequences of impaired swallowing leading to aspiration-a major cause of pneumonia-are discussed.

Swallowing disorders in severe brain injury: risk factors affecting return to oral intake

OBJECTIVE

To determine the incidence and type of swallowing disorders that accompany severe brain injury and to identify factors that affect oral intake.

DESIGN

Inception cohort study.

SETTING

Level I trauma center.

PATIENTS

Consecutively admitted patients with severe brain injury who achieved cognitive levels during admission to assess swallowing and who did not sustain injuries preventing swallowing assessment (n = 54).

MAIN OUTCOME MEASURES

Type of swallowing abnormalities and presence of aspiration evident on videofluoroscopic swallow studies (VFSS), days to initiation and achievement of oral feeding, ventilation days, presence of a tracheostomy, and cognitive levels at initiation and achievement of oral feeding.

RESULTS

Sixty-one percent of subjects exhibited abnormal swallowing. Loss of bolus control and reduced lingual control occurred most commonly. Aspiration rate was 41%. Normal swallowers achieved oral feeding in 19 days versus 57 days for abnormal swallowers. Rancho Los Amigos (RLA) Level IV was needed for initiation of oral feeding; Level VI was needed for total oral feeding. Risk factors for abnormal swallowing included: lower admission Glasgow Coma Scale (GCS) and RLA scores, presence of a tracheostomy, and ventilation time longer than 2 weeks. Risk factors for aspiration were lower admission GCS and RLA scores.

CONCLUSIONS

Swallowing disorders and behavioral/cognitive skills are frequently present in patients with severe brain injury and significantly affect oral intake of food. Persons who swallow abnormally take significantly longer to start eating and to achieve total oral feeding, and they require nonoral supplementation three to four times longer than those who swallow normally.

Round window administration of gentamicin: a new method for the study of ototoxicity of cochlear hair cells

Damage to inner ear sensory hair cells after systemic administration of ototoxic drugs has been documented in humans and animals. Birds have the ability to regenerate new hair cells to replace those damaged by drugs or noise. Unfortunately, the systemic administration of gentamicin damages both ears in a variable fashion with potentially confounding systemic drug effects. We developed a method of direct application of gentamicin to one cochlea of hatchling chickens, allowing the other ear to serve as a within-animal control. We tested variables including the vehicle for application, location of application, dosage, and duration of gentamicin exposure. After 5 or 28 days survival, the percent length damage to the cochlea and regeneration of hair cells was evaluated using scanning electron microscopy. Controls consisted of the opposite unexposed cochlea and additional animals which received saline instead of gentamicin. Excellent damage was achieved using gentamicin-soaked Gelfoam pledgets applied to the round window membrane. The percent length damage could be varied from 15 to 100% by changing the dosage of gentamicin, with exposures as short as 30 min. No damage was observed in control animals. Regeneration of hair cells was observed in both the base and apex by 28 days survival.

Tumor efficacy and bone marrow-sparing properties of TER286, a cytotoxin activated by glutathione S-transferase

TER286 is a latent drug activated by human glutathione S-transferase (GST) isoforms P1-1 and A1-1 to produce a nitrogen mustard alkylating agent. M7609 human colon carcinoma, selected for resistance to doxorubicin, and MCF-7 human breast carcinoma, selected for resistance to cyclophosphamide, both showed increased sensitivity to TER286 over their parental lines in parallel with increased expression of GST P1-1. In primary human tumor clonogenic assays, the spectrum of cytotoxic activity observed for TER286 was both broad and unusual when compared to a variety of current drugs. In murine xenografts of M7609 engineered to have high, medium, or low GST P1-1, responses to TER286 were positively correlated with the level of P1-1. Cytotoxicity was also observed in several other cell culture and xenograft models. In xenografts of the MX-1 human breast carcinoma, tumor growth inhibition or regression was observed in nearly all of the animals treated with an aggressive regimen of five daily doses. This schedule resulted in a 24-h posttreatment decline in bone marrow progenitors to 60% of control and was no worse than for a single dose of TER286. These studies have motivated election of TER286 as a clinical candidate.

Glutathione based approaches to improving cancer treatment

The use of cytotoxic chemotherapy for cancer therapy has been very successful in the treatment and often cure of patients with particular neoplasms, such as testicular carcinomas and some lymphomas. In addition, the use of adjuvant chemotherapy in patients whose primary tumor has been surgically removed contributes significantly to cure rates in some of the more common malignancies such as breast carcinoma and colon cancer. Nonetheless, for most patients with metastatic malignancies, current antineoplastic drugs provide only brief remissions with few or no long term cures. In addition, the side effects of therapy lead to substantial morbidity in nearly all patients. Insights derived from model system studies on two glutathione based lead compounds, TER286 and TER199, suggest new clinical strategies and raise interesting basic research questions regarding the cell biology foundations of cancer chemotherapy.

Impact of a vancomycin restriction policy on use and cost of vancomycin and incidence of vancomycin-resistant Enterococcus

OBJECTIVE

To review the appropriateness of vancomycin therapy, changes in vancomycin use, and the incidence of vancomycin-resistant Enterococcus (VRE) after implementation of a limited restriction policy requiring approval from the Infectious Diseases Approval service to continue vancomycin therapy beyond 72 hours.

DESIGN

A prospective chart review was conducted in April 1995. Pharmacy billing data and infection control data were compared before and after policy implementation.

SETTING

A 725-bed university teaching institution.

PATIENTS

All patients receiving vancomycin during April 1995.

MAIN OUTCOME MEASURES

Appropriateness of use was based on the Centers for Disease Control and Prevention (CDC) recommendations for prudent vancomycin use.

RESULTS

A total of 333 courses of vancomycin therapy were reviewed. Vancomycin use was appropriate in 219 (66%) courses. Of the 114 courses that did not meet the CDC guidelines, 76 (67%) were for empiric use, 35 (31%) were for prophylactic use, and 3 (3%) were for therapeutic use. Overall, the total number of grams used decreased 9%, grams per 1000 patient-days decreased by 10, and the total number of patients exposed to vancomycin decreased 0.5%. Several services had large decreases in vancomycin use. Vancomycin expenditures decreased by $15788 for the 7-month time period. The incidence of VRE remained unchanged, at 30% of all enterococcal isolates 2 years after policy implementation.

CONCLUSIONS

The limited restriction policy was effective in decreasing the total grams of vancomycin used. However, one-third of vancomycin therapy was inappropriate and the incidence of VRE was unchanged. A more stringent restriction policy could potentially increase appropriate use, further decrease the amount of vancomycin used, and decrease the incidence of VRE.

Design, synthesis, and evaluation of latent alkylating agents activated by glutathione S-transferase

In search of compounds with improved specificity for targeting the important cancer-associated P1-1 glutathione S-transferase (GST) isozyme, new analogs 4 and 5 of the previously reported glutathione S-transferase (GST)-activated latent alkylating agent gamma-glutamyl-alpha-amino-beta-[[[2-[[bis[bis(2-chloroethyl)amino]ph osp horyl]oxy]ethyl]sulfonyl]propionyl]-(R)-(-)-phenylglycine (3) have been designed, synthesized, and evaluated. One of the diastereomers of 4 exhibited good selectivity for GST P1-1. The tetrabromo analog 5 of the tetrachloro compound 3 maintained its specificity and was found to be more readily activated by GSTs than 3. The GST activation concept was further broadened through design, synthesis, and evaluation of a novel latent urethane mustard 8 and its diethyl ester 9. Interestingly, 8 showed very good specificity for P1-1 GST. Cell culture studies were carried out on 4, 5, 8, and 9 using cell lines engineered to have varying levels of GST P1-1 isozyme. New analogs 4 and 5 exhibited increased toxicity to cell lines with overexpressed GST P1-1 isozyme. The urethane mustard 8 and its diethyl ester 9 were found to be not as toxic. However, they too exhibited more toxicity to a cell line engineered to have elevated P1-1 levels, which was in agreement with the observed in vitro specificity of 8 for P1-1 GST isozyme. Mechanistic studies on alkaline as well as enzyme-catalyzed decomposition of latent mustard 3 provided experimental proof for the hypothesis that 3 breaks down into an active phosphoramidate mustard and a reactive vinyl sulfone. The alkylating nature of the decomposition products was further demonstrated by trapping those transient species as relatively stable diethyldithiocarbamic acid adducts. These results substantially extend previous efforts to develop drugs targeting GST and provide a paradigm for development of other latent drugs.

Isozyme-specific glutathione S-transferase inhibitors potentiate drug sensitivity in cultured human tumor cell lines

Novel glutathione (GSH) analogs, previously shown to inhibit glutathione S-transferase (GST) activity at about 1 microM in vitro, were tested for their ability to potentiate the killing of cultured tumor cells by chemotherapeutic drugs. When tested at doses up to 200 microM, the analogs were neither toxic nor capable of potentiating drug toxicity unless the diethyl ester (DEE) form was used for treatment of the cells. HPLC analysis revealed rapid internalization of the DEE and intracellular conversion to a monoethyl ester form that accumulated in the cell, followed by a more gradual loss of the second ester to generate the active parent form. For the four GSH analogs tested, the ability of the DEE forms to potentiate chlorambucil (CMB) toxicity in HT-29 human colon adenocarcinoma cells strongly correlated with the in vitro ability of the parent form to inhibit recombinant human P1-1. This isozyme is the dominant form of GST present in HT-29 cells. Of the four analog DEEs tested, gamma-glutamyl-S-(benzyl)cysteinyl-R(-)-phenyl glycine (TER 117) DEE was the most effective in potentiating CMB toxicity in several cell lines: HT-29, HT4-1 (HT-29 subclone), SKOV-3 ovarian carcinoma, and SK VLB (vinblastine-resistant variant of SKOV-3) cells. gamma-Glutamyl-S-(octyl)cysteinyl-glycine (TER 143) DEE potentiated mitomycin C (MTC) toxicity in HT4-1 and SK VLB cells while TER 117 DEE did not. TER 117 DEE enhanced melphalan effects on xenografts of HT4-1 in mice to a similar extent as that achieved with the previously described nonspecific GST inhibitor, ethacrynic acid. Taken together, our results indicate that cell-permeable analogs of GSH can potentiate cytotoxicity of common chemotherapeutic drugs and this effect has a strong positive correlation with the ability of the analogs to inhibit specific GST isozymes.

Violence prevention program targeting Connecticut adolescents: description and preliminary results

Recent statistics show that adolescents are increasingly becoming both the perpetrators and the victims of violent crime in our nation. At our institution, we have developed a violence prevention program specifically targeting adolescents. This three-hour workshop utilizes a multimedia style of presenting information that we believe is well suited to young audiences. To date, over 1,000 adolescents from all over the state have participated in our program. In addition to describing the program, we also summarize the results of program evaluations and demographic profiles completed by audience members. Most participants report that the program was successful in educating them about the causes and consequences of violent injury and offered them alternatives to violence in resolving difficult situations. It is our hope that the education we provide will translate into fewer violent injuries within the state of Connecticut.

Factors associated with early onset pneumonia in the severely brain-injured patient

An analysis of 125 patients with closed head injury was completed in order to identify the risk factors involved in the development of early pneumonia. Pneumonia was diagnosed in 60% of the patients. Early pneumonia developed in 47.8% of the patients. Brain-injured patients who developed early pneumonia were found to have a lower Glasgow Coma Scale (GCS) score. Early pneumonia was found more often in patients with swallowing disorders and evidence of aspiration. Patients who had been intubated in the field were found to be at greater risk for the development of early pneumonia than those intubated in the hospital. Patients with early pneumonia had prolonged intubation times, intensive care unit stays, and hospital stays. This study suggests that a GCS score less than 5, evidence for swallowing disorders and aspiration, and field intubation are risk factors for early pneumonia in the brain-injured patient.

Significance of scapular fracture in the blunt-trauma patient

STUDY OBJECTIVE

To determine the significance of scapular fractures in blunt-trauma patients compared with blunt-trauma patients without scapular fractures.

DESIGN

Retrospective chart review of 11,500 blunt-trauma patients with a control group matched for age, sex, and mechanism of injury.

SETTING

Two Level I trauma centers.

PARTICIPANTS

Ninety-two blunt-trauma patients with scapular fractures and 81 control patients.

RESULTS

Mortality, neurovascular injury, and injury severity scores were compared for blunt-trauma patients with scapular fractures with those of the control group. Analysis revealed a 1% incidence of scapular fractures in blunt trauma with no neurovascular injury and no mortality. Scapular fractures were associated with thoracic injury in 49% of the patients, compared with 6% in the control group (difference, 43%; 95% confidence interval, 31.6 to 51.4; P < .001, Fisher's exact test).

CONCLUSION

Scapular fractures are not a significant marker of greater mortality or of neurovascular morbidity in blunt-trauma patients.

Hypopituitarism secondary to transfacial gunshot wound

Hypopituitarism secondary to penetrating head trauma is extremely rare, and its diagnosis may be delayed for several years. We present a patient who developed hypopituitarism secondary to a transfacial gunshot wound and who experienced damage to the hypophysis secondary to transmission of energy and bullet fragments. The importance of a computerized tomographic scan of the head in facial gunshot wound is discussed.

Glutathione-S-transferase activates novel alkylating agents

Alkylating agents which are activated by glutathion-S-transferases (GSTs) have been designed and synthesized. The model compound gamma-glutamyl-alpha-amino-beta-[(2-ethyl N,N,N',N'-tetraethylphosphorodiamidate) sulfonyl]propionylglycine (1) and the nitrogen mustards gamma-glutamyl-alpha- amino-beta-[[2-ethyl N,N,N',N'-tetrakis (2-chloroethyl)phosphorodiamidate] sulfonyl]propionylglycine (2) and gamma-glutamyl-alpha-amino-beta-[[2-ethyl-N,N,N',N'-tetrakis(2- chloroethyl)phosphorodiamidate]sulfonyl]-propionyl-(R)-(-)-phenylg lycine (3) were prepared via multistep chemical synthesis. The compounds were tested with recombinant human A1-1, M1a-1a and P1-1 GSTs. HPLC studies showed that the compounds were differentially and catalytically cleaved by biologically relevant concentrations of the GSTs. Mass spectral studies of the cleavage mixture of 2 showed that M1a-1a GST liberated the cytotoxic phosphate moiety needed for efficacy as an alkylating agent. Cell culture studies with MCF-7 breast cancer cells showed that 1 was not toxic at 200 microM, while 2 and 3 showed IC50S of 40.6 and 37.5 microM, respectively, for the same cell line. MCF-7 cells transfected to overexpress P1-1 GST showed enhanced sensitivity with 2 and 3, with IC50S of 20.9 and 9.5 microM, respectively. This result correlates well with the rates of cleavage of 2 and 3 by P1-1 GST observed in vitro and demonstrates that higher levels of cellular P1-1 GST will give increased sensitivity to these drugs.

Risk factors for infection in the trauma patient

The most common cause of late death following trauma is sepsis. The traumatized patient has a significant increased risk of infection. Transfusion, hypotension, and prolonged ventilatory support are predictive of septic complications. In addition, the trauma patient has a higher predisposition to pneumonia than nontrauma patients (18% versus 3% incidence of pneumonia, P < .001). Additional risk factors include the degree of nutrition status and the type of medications used during surgery. Immunologic depression may be an additional risk factor. There is mounting evidence that trauma can result in host defense abnormalities. To prevent the significant mortality caused by sepsis, close surveillance must be maintained, nutritional status must be optimal, and liberal use of antibiotics should be discouraged. Their use should be guided by appropriate cultures and sensitivities.

Portable ultrasonography in critical care

A 2-year retrospective analysis of portable ultrasound examinations in the intensive care unit was conducted to evaluate the indications and efficacy of portable sonography. A total of 86 examinations were performed on 79 patients. Of these, 22 per cent of the examinations supported the suspected diagnosis and contributed to treatment. Seventy per cent of the examinations excluded the suspected diagnosis. There was a 9 per cent incidence that yielded unsuspected information that contributed to treatment. Only 8 per cent of the examinations were misleading or proven false. The authors found that with an overall sensitivity of 79 per cent and specificity of 97 per cent, portable ultrasonography is a valuable, relatively inexpensive test in the critical care setting.

Early intervention in severe head injury: long-term benefits of a formalized program

With traumatic brain injuries numbering more than two million per year, health professionals are faced with the challenges of restoring and maximizing quality of life. This study quantifies the benefits of a formalized head injury program, including the concept of trauma rehabilitation, defined as early, aggressive rehabilitation during acute hospitalization. Thirty-eight severely head injured patients received treatment at the same rehabilitation facility. Twenty-one of these patients received acute care services at ten different hospitals without formalized traumatic brain injury programs, and 17 received services at a hospital with a formalized early intervention program. Comparison of outcome data for the two programs revealed that patients in the formalized program had comas and rehabilitation stays approximately one third the length of patients in nonformalized programs (18.9 vs 53.8 days and 106.5 vs 239.5 days, respectively). Mean cognitive levels at discharge from the acute hospitals (5.6 vs 4.0) and the rehabilitation facility (7.4 vs 6.7) were significantly higher for the formalized program, and they facilitated a significantly higher percentage of discharges to home vs extended care facility (94% vs 57%).

Analysis of 46 intra-abdominal aortic injuries from blunt trauma: case reports and literature review

Blunt trauma causing aortic injury is infrequent and primarily involves the thoracic aorta. Abdominal aortic injury after blunt trauma is much less frequent and has a varied presentation. Within a 3-month period, our trauma unit diagnosed and treated two cases of abdominal aortic injury secondary to blunt trauma. One was a belted passenger in a motor vehicle accident, and one was secondary to a crush injury. The addition of these two cases brings the number found in the literature to 46. Reviewing these cases has emphasized the need for prompt recognition and treatment of this vascular catastrophe.

Characteristics of blunt and personal violent injuries

This study was designed to analyze the characteristics and behavior patterns of individuals involved in nonfatal, traumatic injuries. There were 547 patients included in the study with 363 sustaining blunt trauma injuries, 144 sustaining personal violence injuries, and 40 being burn victims. Motor vehicle accident victims tended to be young, single, white, employed males: substance use was detected in 32%, and 57% were unbelted. Motorcycle accident victims tended to be young, single, unemployed males: substance use was detected in 25% and 90% were not wearing helmets. Pedestrians struck tended to be single, unemployed males. Penetrating injuries involved mostly young, single, black males: substance use was detected in 35% of patients and most incidents occurred from 4:00 P.M. to 8:00 A.M. Assault victims were mostly young, single, black males with substance use detected in 48%. Suicide patients tended to be white males. The incidence of repeat victims was one out of ten for blunt trauma, and one out of five for personal violence injuries and burns.

Traumatic brain injury: improving functional recovery

Most physical injuries in this country are the result of motorized vehicle accidents. Head trauma accounts for one fourth of all trauma deaths, and the cost to treat patients with head trauma is $83 billion. The author discusses injury patterns, methods of resuscitating patients with head injuries, surgical management and monitoring, and the clinical course and prospects for rehabilitation. An interdisciplinary approach to the management of such patients is encouraged, and the medical and surgical interventions undertaken at one institution are reviewed.

Xenografting of fetal pig ventral mesencephalon corrects motor asymmetry in the rat model of Parkinson's disease

A suspension of cells from embryonic day 21 fetal pig ventral mesencephalon was transplanted into the striatum of 20 immunosuppressed rats with 6-hydroxydopamine-induced lesions of the nigrostriatal dopamine pathway. Of these rats, 15 showed reduction of amphetamine-induced ipsilateral rotation by 9 weeks and complete reversal of rotation by 14-17 weeks. Animals maintained stable reversal of rotations (contralateral direction) until cessation of Cyclosporin A (CyA) treatment at 15-20 weeks. Within 4-9 weeks after CyA removal, these rats showed exclusively ipsilateral rotations during behavioral testing which were comparable to pre-transplant levels, suggesting that the grafts were rejected upon cessation of CyA treatment. Rats were sacrificed and tyrosine hydroxylase (TH) immunohistochemistry was performed at several time points, both on and off CyA, to examine a possible correlation between the degree of rotational behavior and the number of TH-positive surviving grafted cells. Staining showed large numbers (230-12,329) of TH-positive surviving cells in animals displaying a high degree of rotational correction (1.6 to -9.6 net ipsilateral rotations/min) after cessation of CyA treatment. Two control groups, those transplanted with non-neuronal cells from the pig ventral mesencephalon (n = 5) and those receiving only daily CyA injections (n = 4) showed no significant reduction of net ipsilateral rotations throughout the experiment. No TH-positive surviving cells were seen in the one non-neuronal transplant analyzed. This data demonstrates long-term retention of xenografted tissue with immunosuppression and its concomitant restoration of normal motor behavior in the rat model of Parkinson's disease.

Sternal fractures--the natural history

A five-year retrospective study was undertaken to analyze the natural history of sternal fractures and to scrutinize the current method of management. Sixty-six patients with documented sternal fractures were evaluated. The most common mechanism of injury was motor vehicle accidents (59%). Most of these victims did not wear seat belts. Thirty-five patients (53%) had associated injuries, of which rib fractures were the most common. Thirty-one patients (47%) had sternal fractures with no associated injury. The incidence of myocardial contusion in our study was 18%. Of the patients without associated injuries, the incidence of myocardial contusion was 6%. There were no mortalities in our study population, and there was no significant morbidity necessitating mechanical or pharmacologic support. The majority of these patients were managed by admission, observation, IV therapy, and placement of monitored beds. Our findings of no life-threatening sequelae suggest that we might question the necessity of current management criteria. This proves to be of special interest in view of the economic restraints imposed on health care today.

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.

A prospective randomized study evaluating periumbilical versus infraumbilical peritoneal lavage: a preliminary report. A combined hospital study

Peritoneal lavage has been proved to be a fairly safe and reliable diagnostic tool in evaluating blunt abdominal trauma. However, the operation is not always a simple procedure. In an attempt to determine the ease and reliability of the procedure, the authors conducted a combined hospital approach, prospectively randomizing the performance of periumbilical and infraumbilical approaches to the peritoneal lavage. To date, 53 lavages have been performed. Reliability of the procedures appears to be equal. The greatest differences in the techniques are with regard to the greater efficacy and performer acceptance of the periumbilical approach. The operative approaches are discussed in detail and literature regarding peritoneal lavage is reviewed.

Flexible choledochoscopy and removal of impacted stones of the common bile duct

A technique of direct, piecemeal removal of impacted stones of the common bile duct is described. This routine eliminates the need for performance of an isolated Kocher maneuver or one done in conjunction with duodenotomy and sphincteroplasty. In addition, all stone fragments are removed under direct vision without damage to ductal structures.

Blunt injury to the diaphragm: an analysis of 44 patients

Forty-four patients sustaining blunt trauma with resultant diaphragmatic rupture during a 5 1/2-year period are presented. In 41 (93%), the diagnosis was established within 6 hours of admission. The correct diagnosis was made preoperatively in 19 patients operated on acutely (42%), in 22 (53%), ruptured diaphragm was an incidental finding at celiotomy or thoracotomy. The admission chest roentgenography, diagnostic peritoneal lavage, UGI contrast studies, and computed tomography were the most useful diagnostic aids. The transabdominal operative approach was utilized in 39 patients (89%). All patients had associated extra-abdominal injuries and 26 patients (59%) had associated intra-abdominal injuries. The mortality rate was 20.4%; early deaths were attributable to hemorrhage and severe head injury, late deaths to sepsis and progressive multiorgan failure.