J Trauma
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Following resuscitation from shock, the clinical phase of persistent hypermetabolism is entered from which a substantial number of patients transcend into progressive organ failure and expire. The available epidemiologic, physiologic, and metabolic data are consistent with the position that a persistent degree of microcirculatory hypoxia, although it may be present in amounts that are below the sensitivity of current detection systems, becomes an increasingly less important etiologic factor as the organ failure disease progresses. ⋯ There is an increasing body of evidence that cytokine release systemically, and increased cell-cell interaction through cytokines and prostanoids locally, may alter not only parenchymal function in the proximity of these mononuclear cells, but organ function at distant sites. If this latter hypothesis continues to be substantiated, it implies that the underlying cell and organ dysfunction may indeed be reversible if appropriate counter-regulatory mechanisms could be developed and the appropriate timing of their application understood.
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The investigation of wound healing is dependent on the use of various models. This paper reviews several methods used to study wound healing, particularly in regard to connective tissue metabolism. The usefulness and potential pitfalls of cell culture are discussed. ⋯ Histologic methods are available to evaluate the cellular and matrix details within the wound. Additionally, methods developed in molecular biology are becoming applicable to healing studies and a safe means of investigating collagen metabolism in humans by the use of a stable oxygen isotope is being developed. The study of fetal wound healing provides an excellent example of the utility of many of these methods in achieving an understanding of the biology of this remarkable scarless process.
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Comparative Study
Do trauma centers improve outcome over non-trauma centers: the evaluation of regional trauma care using discharge abstract data and patient management categories.
Development of regional medical care systems to treat patients who sustain major accidental injuries (trauma victims) has been based on autopsy studies which demonstrate that hospitals that meet certain accepted criteria of readiness (trauma centers) can prevent needless deaths of trauma victims. However, since only autopsy data have been available from non-trauma centers, it has not previously been possible to compare morbidity data between trauma centers and non-trauma hospitals. This study examines discharge abstract data and a new patient classification system called patient management categories (PMC) which are generated from this abstract data to evaluate length of stay (LOS), complications, and death to compare morbidity and mortality data from trauma centers and non-trauma centers. ⋯ Patients treated in trauma centers had significantly fewer complications (21% vs. 33%; p less than 0.001) and lower mortality rates (p less than 0.05) than those treated in non-trauma centers. Associated injuries, age, complications, and/or delay in time to OR significantly increased intensity and length of stay in both trauma and non-trauma centers. This significantly increased the cost of care provided to these patients in both types of centers.(ABSTRACT TRUNCATED AT 250 WORDS)
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Comparative Study
Supplemental emergent chest computed tomography in the management of blunt torso trauma.
The efficacy of conventional chest X-ray (CXR) in comparison to chest computed tomography (CCT) in acutely injured blunt trauma patients was examined. Over a 21-month period, 50 patients underwent CXR and CCT according to a standard protocol, and their films and records were reviewed retrospectively. Hemo- and/or pneumothorax (HPTX) was noted in 12 patients (five by CXR, 12 by CCT). ⋯ Atelectasis was a common CCT finding (58% incidence). Chest X-ray is less sensitive than chest computed tomography in the detection of HPTX (42% vs. 100%) and PC (40% vs. 100%). Emergent chest computed tomography is recommended in stable patients with: 1) blunt high-energy torso trauma, 2) "cross-body" injury pattern, and/or 3) a mechanism of injury suggestive of chest trauma.
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The records of 57 patients presenting with flail chest injury from 1981 through 1987 were reviewed to determine factors affecting morbidity and mortality. Fifteen patients (26%) had 8+ rib fractures with a unilateral flail and seven (12%) had multiple rib fractures with a bilateral flail. Thirty-two (56%) had moderate-severe pulmonary contusions and 44 (77%) required chest tubes for hemo-pneumothorax. ⋯ An adverse outcome occurred in 15 (28%); nine required ventilatory assistance greater than or equal to 14 days and six died of sepsis with pneumonia. The main factors associated with an adverse outcome were: an ISS greater than or equal to 31 (p less than 0.001), moderate-severe associated injuries (p less than 0.001), and blood transfusions (p less than 0.005). Although the primary determinants of an adverse outcome were the associated injuries and blood loss, a bilateral flail (p less than 0.01) and age greater than or equal to 50 years (p less than 0.02) were contributing factors.