Is it time for a new injury score?
Explore the source record for details and available documents.
Humans↗
Biomedical subjects
D B Hoyt
Publications and source records attributed to D B Hoyt.
Hypertonicity regulates the function of human neutrophils by modulating chemoattractant receptor signaling and activating mitogen-activated protein kinase p38.
Excessive neutrophil activation causes posttraumatic complications, which may be reduced with hypertonic saline (HS) resuscitation. We tested if this is because of modulated neutrophil function by HS. Clinically relevant hypertonicity (10-25 mM) suppressed degranulation and superoxide formation in response to fMLP and blocked the activation of the mitogen activated protein kinases (MAPK) ERK1/2 and p38, but did not affect Ca2+ mobilization. HS did not suppress oxidative burst in response to phorbol myristate acetate (PMA). This indicates that HS suppresses neutrophil function by intercepting signal pathways upstream of or apart from PKC. HS activated p38 by itself and enhanced degranulation in response to PKC activation. This enhancement was reduced by inhibition of p38 with SB203580, suggesting that p38 up-regulation participates in HS-induced enhancements of degranulation. HS had similar effects on the degranulation of cells that were previously stimulated with fMLP, but had no effect on its own, suggesting that HS enhancement of degranulation requires another signal. We conclude that depending on other stimuli, HS can suppress neutrophil activation by intercepting multiple receptor signals or augment degranulation by enhancing p38 signaling. In patients HS resuscitation may reduce posttraumatic complications by preventing neutrophil activation via chemotactic factors released during reperfusion.
Calcium-Calmodulin-Dependent Protein Kinases↗
Lethal injuries and time to death in a level I trauma center.
BACKGROUND: The purpose of this study was to identify the causes and time to death of all trauma victims who died at a level I trauma center during an 11-year period. STUDY DESIGN: Autopsies were performed on all patients who died secondary to trauma. Retrospective review of these autopsies was carried out and appended to existing trauma registry data. Standard definitions were used to attribute the cause of death in each case. Preventable deaths were determined by a standardized peer review process. RESULTS: Between January 1985 and December 1995, a total of 900 trauma patients died. This represented 7.3% of all major trauma admissions (12,320). Seventy percent of these patients died within the first 24 hours of admission. Thoracic vascular and central nervous system (CNS) injuries were the most common causes of death in the first hour after admission to the hospital. CNS injuries were the most common causes of death within the 72 deaths after admission. Acute inflammatory processes (multiple organ failure, acute respiratory distress syndrome, and pneumonia) and pulmonary emboli were the leading causes of death after the first 72 hours. Overall, 43.6% (393 of 900) of all trauma deaths were caused by CNS injuries, making this the most common cause of death in our study. The preventable death rate was 1%. CONCLUSIONS: The first 24 hours after trauma are the deadliest for these patients. Primary and secondary CNS injuries are the leading causes of death. Prevention, early identification, and treatment of potentially lethal injuries should remain the focus of those who treat trauma patients.
Accidents, Traffic↗
The first randomized trial of human polymerized hemoglobin as a blood substitute in acute trauma and emergent surgery.
BACKGROUND: Human polymerized hemoglobin (PolyHeme) is a universally compatible, disease-free, oxygen-carrying resuscitative fluid. This is the first prospective, randomized trial to compare directly the therapeutic benefit of PolyHeme with that of allogeneic red blood cells (RBCs) in the treatment of acute blood loss. STUDY DESIGN: Forty-four trauma patients (33 male, 11 female) aged 19-75 years with an average Injury Severity Score (ISS) score of 21+/-10 were randomized to receive red cells (n = 23) or up to 6 U (300 g) of PolyHeme (n = 21) as their initial blood replacement after trauma and during emergent operations. RESULTS: There were no serious or unexpected adverse events related to PolyHeme. The PolyHeme infusion of 4.4+/-2.0 units (mean +/- SD) resulted in a plasma [Hb] of 3.9+/-1.3 g/dL, which accounted for 40% of the total circulating [Hb]. There was no difference in total [Hb] between the groups before infusion (10.4+/-2.3 g/dL control vs. 9.4+/-1.9 g/dL experimental). At end-infusion the experimental RBC [Hb] fell to 5.8+/-2.8 g/dL vs. 10.6+/-1.8 g/dL (p < 0.05) in the control, although the total [Hb] was not different between the groups or from pre-infusion. The total number of allogeneic red cell transfusions for the control and experimental groups was 10.4+/-4.2 units vs. 6.8+/-3.9 units (p < 0.05) through day 1, and 11.3+/-4.1 units vs. 7.8 +/-4.2 units (p = 0.06) through day 3. CONCLUSIONS: PolyHeme is safe in acute blood loss, maintains total [Hb] in lieu of red cells despite the marked fall in RBC [Hb], and reduces the use of allogeneic blood. PolyHeme appears to be a clinically useful blood substitute.
Adult↗
Hypertonic saline resuscitation reduces neutrophil margination by suppressing neutrophil L selectin expression.
UNLABELLED: Hypertonic saline (HS) reduces hemorrhage-induced lung injury by suppressing the neutrophil oxidative burst and reducing lung neutrophil influx. This study investigated whether this is caused by the effects of HS on endothelial adhesion molecule expression, the production of chemoattractants in the lung, or a direct effect of HS on neutrophil selectin expression. METHODS: BALB/c mice were made to hemorrhage to 40 mm Hg for 1 hour and resuscitated with shed blood and either 4 mL/kg 7.5% HS or two times the shed blood volume of lactated Ringer's solution (LRS). Neutrophil L selectin expression was determined by flow cytometry, total neutrophil counts were obtained by differential staining, and pulmonary endothelial P and E selectin expression was evaluated by immunohistochemistry. Chemoattractants in lung lavages were determined with a modified Boyden chamber migration assay. RESULTS: Chemotactic activity of lavage fluid of HS-treated animals was not significantly different from that of LRS-treated animals, and endothelial P and E selectin expression was not altered by HS resuscitation. Neutrophils of HS-treated animals, however, expressed significantly less L selectin than those of LRS-treated mice. Concomitantly, circulating neutrophil counts of LRS-treated animals were significantly decreased compared with those of HS-treated mice. CONCLUSION: HS had little effect on endothelial selectin expression and chemoattractant production in the lung. HS significantly decreased neutrophil L selectin expression, however. This suggests that HS resuscitation may reduce lung injury by preventing neutrophil L selectin expression and endothelial adhesion.
Animals↗
Trauma in pregnancy: maternal and fetal outcomes.
OBJECTIVE: Pregnancy imposes significant physiologic demands that may confuse and complicate the evaluation, resuscitation, and definitive management of pregnant women who sustain trauma. Accurate prediction of fetal outcome after trauma remains elusive. The objective of this study was to characterize patterns of injury in pregnant women, to determine if pregnancy affects maternal morbidity and mortality after trauma, and to identify predictors of fetal death. METHODS: We performed a retrospective, case-control analysis of all injured pregnant patients admitted to the Trauma Service at the University of California San Diego Medical Center from 1985 to 1995. RESULTS: We identified 114 injured pregnant patients. Motor vehicle crashes accounted for 70% of injuries, and of these, 46% of patients were not using seat belts or helmets. Violence accounted for 12% of injuries. Injured pregnant women with Injury Severity Scores > 8 demonstrated similar mortality, morbidity, and length of stay to matched nonpregnant control patients. Pregnant women were more likely to sustain serious abdominal injury and were less likely to sustain severe head injury. Identified risk factors for fetal loss include maternal death, overall maternal injury severity, the presence of severe abdominal injury, and the presence of hemorrhagic shock. CONCLUSION: There appears to be a group of pregnant women in San Diego at high risk for traumatic injury who should be targeted for preventative strategies including improved seat belt use. Pregnancy does not increase mortality or morbidity after trauma but influences the pattern of injury. Maternal death, high Injury Severity Score, serious abdominal injury, and hemorrhagic shock are risk factors for fetal loss.
Abdominal Injuries↗
Outcome after major trauma: discharge and 6-month follow-up results from the Trauma Recovery Project.
BACKGROUND: The study of both short-term and long-term outcomes after major trauma has become an increasingly important focus of injury research because of the improved survival rates attributable to the evolution of sophisticated trauma care systems. The Trauma Recovery Project (TRP) is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma in adults aged 18 years and older, including quality of life, functional outcome, and psychologic sequelae such as depression and posttraumatic stress disorder (PTSD). Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge. The specific objectives of the present report are to describe functional outcomes at the discharge and 6-month follow-up time points in the TRP population and to examine the association of putative risk factors with functional outcome. METHODS: Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the TRP study. The admission criteria for patients were as follows: (1) age 18 years or older, (2) Glasgow Coma Scale score on admission of 12 or greater, and (3) length of stay greater than 24 hours. Functional outcome after trauma was measured before and after injury using the Quality of Well-Being (QWB) scale, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional outcome was also measured using a standard activities of daily living (ADL) scale (range, 13 = full function to 47 = maximum dysfunction). Follow-up at 6 months after discharge was completed for 826 patients (79%). RESULTS: The mean age was 36 +/- 14.8 years; 70% of the patients were male; 52% of the patients were white, 30% were Hispanic, and 18% were black or other. Less than 40% of study participants were married or living with a partner. The mean Injury Severity Score was 13 +/- 8.5, with 85% blunt injuries, and a mean length of stay of 7 +/- 9.2 days. QWB scores before injury reflected the norm for a healthy adult population (mean, 0.810 +/- 0.171). After major trauma, QWB scores at discharge showed a significant degree of functional limitation (mean, 0.401 +/- 0.045). At 6-month follow-up, QWB scores continued to show high levels of functional limitation (mean, 0.633 +/- 0.122). Limitation measured using the standard ADL scale found only moderate dysfunction at discharge (mean, 30.0 +/- 7.7) and at 6-month follow-up (mean, 15.0 +/- 4.2). Postinjury depression, PTSD, serious extremity injury, and length of stay were significant independent predictors of 6-month QWB outcome. CONCLUSION: Postinjury functional limitation is a clinically significant complication in trauma patients at discharge and a 6-month follow-up. The QWB yields a more sensitive assessment of functional status than traditional ADL instruments. Postinjury depression, PTSD, serious extremity injury, and length of stay are significantly associated with 6-month QWB outcome.
Activities of Daily Living↗
Lactated ringer's is superior to normal saline in a model of massive hemorrhage and resuscitation.
BACKGROUND: Previous models comparing normal saline (NS) with lactated Ringer's solution (LR) for resuscitation use only mild or moderate hemorrhage and do not address the clinical situation of massive hemorrhage and resuscitation (MHR). This work compares NS and LR by using a new rat model of MHR. METHODS: NS and LR were compared by using both a traditional model of moderate pressure-controlled hemorrhage and a model of MHR. Moderate hemorrhage animals were bled to mean arterial pressure (MAP) = 60 mm Hg x 2 hour then resuscitated with crystalloid (NS or LR) for 1 hour. MHR animals were bled at a rate of 1 estimated blood volume (EBV) per hour for 2 hours with simultaneous resuscitation by using washed red blood cells (B) and crystalloid (LR+B or NS+B). MAP was kept at 60 mm Hg during the 2 hours of hemorrhage. Bleeding was then stopped, and animals were resuscitated for 1 additional hour with blood and crystalloid to MAP more than 90 mm Hg or until 10x EBV was given. Group means were compared with Student's t test (p < 0.01 significant) and 2-week survival rates were compared by using Fisher's exact test (p < 0.05 significant). RESULTS: The moderate hemorrhage group was bled 36% of EBV. In this setting, resuscitation with NS and LR was equivalent. The final hematocrit, pH, and base excess were not different, and all animals survived in both groups. MHR animals were bled 218% of EBV. Animals resuscitated with NS+B were significantly more acidotic than animals resuscitated with equal volumes of LR+B (pH 7.14+/-.06 vs. 7.39+/-.04, respectively) and had significantly worse survival (50% vs. 100%, respectively). CONCLUSION: With moderate hemorrhage, NS and LR are equivalent, but in the setting of massive hemorrhage and resuscitation, significantly more physiologic derangement and mortality occurs with NS than LR. LR is superior to NS for use in massive resuscitation.
Animals↗
Hypertonic saline resuscitation diminishes lung injury by suppressing neutrophil activation after hemorrhagic shock.
UNLABELLED: Hypertonic saline (HS) resuscitation after hemorrhage and sepsis has been shown to markedly reduce the development of lung injury in animals, compared with traditional resuscitation with lactated Ringer's (LR). These experiments examined the effect of HS on lung injury after hemorrhage without sepsis. The effects of HS and LR resuscitation on neutrophil trafficking, neutrophil adhesion, and neutrophil oxidative burst were studied. METHODS: BALB/c mice were hemorrhaged to a mean arterial pressure of 40 torr for 1 h. Animals were resuscitated with shed blood and either 4 mL/kg of 7.5% HS or LR in twice the volume of the shed blood. Lung histology was examined 24 h after hemorrhage. Lung myeloperoxidase content and bronchoalveolar lavage fluid neutrophil counts were obtained. Peripheral blood smears were obtained to determine the neutrophil percentage. Peripheral blood neutrophil CD11b expression and neutrophil H2O2 production were assayed by flow cytometry. RESULTS: HS animals had less lung injury than LR animals. The mean myeloperoxidase activity in HS versus LR animals was 1.79+/-1.33 U/100 mg versus 3.0+/-1.33 U/100 mg, respectively. The percentage of neutrophils in the bronchoalveolar lavage fluid of HS animals (3.8%+/-.8) was significantly less than that of LR animals (10.8%+/-2.1). This corresponded to a significantly higher peripheral blood neutrophil count in HS animals compared with LR animals, 41% vs. 20%, respectively. There was no difference in neutrophil expression of the CD11b integrin between the HS and LR groups. The neutrophils of LR animals had basal H2O2 production that was 107% greater than that of controls; HS suppressed this hemorrhage-induced activation by > 60%. HS resuscitation after hemorrhagic shock protects against the development of lung injury. This protection is due, in part, to suppression of the hemorrhage-induced neutrophil oxidative burst. HS resuscitation offers immunomodulatory potential after hemorrhagic shock.
Animals↗
Regulating managed care in an integrated health system environment.
Explore the source record for details and available documents.
Health Services↗
Trauma deaths in a mature urban vs rural trauma system. A comparison.
OBJECTIVE: To compare the timing, severity, and injury characteristics of patients dying from trauma in an urban vs a rural setting. DESIGN: Retrospective review of autopsy database (urban) and medical examiner database (rural), with selected medical chart review. SETTING: An organized urban trauma system with 6 trauma centers and a rural state with no formal trauma system and 1 trauma center. PATIENTS: All trauma fatalities occurring in an urban (n = 612) and a rural (n = 143) setting during a 1-year period. RESULTS: In the urban system, 248 patients (40.5%) died at the scene of injury compared with 103 (72%) patients in a rural environment. During the first 24 hours of hospitalization 243 (39.7%) urban patients died compared with 23 (16%) rural patients. Eighty-nine urban patients (14.5%) and 17 rural patients (11.8%) survived for more than 24 hours but later died in the hospital. The mean age of those who died was significantly greater in the rural trauma system than in the urban trauma system (P < .001), and the Injury Severity Score was significantly less in the rural trauma system than in the urban trauma system (P < .01). In the patients who died after being admitted to the hospital for more than 24 hours there was a significantly higher rate of preexisting comorbidity in the rural patients than in the urban patients (P < .05). The most frequent cause of death in the rural setting was multisystem organ failure; head injury was the most common cause of death in the urban setting. CONCLUSIONS: Patients who die in a rural area without a formal trauma system are more likely to die at the scene, are less severely injured, and are older. Rural trauma patients who are admitted to a hospital and who survived for at least 24 hours before dying are older, less severely injured, have significantly more comorbidities, and are more likely to die of multisystem organ dysfunction than their urban counterparts. These differences reflect the different patient populations and injury patterns that confront urban and rural trauma centers. The higher proportion of scene deaths in the rural environment may reflect the longer discovery and transport times that occur in a rural setting.
Adolescent↗
Endotracheal intubation in the field improves survival in patients with severe head injury. Trauma Research and Education Foundation of San Diego.
OBJECTIVE: To measure the effect of prehospital endotracheal intubation on outcome in patients with severe head injury and the percentage of these patients intubated in the field under existing protocol. DESIGN: Retrospective case-control study. SETTING: Countywide urban trauma system. PATIENTS: Trauma patients with blunt injury and scene Glasgow Coma Score of 8 or less, transported by ground ambulance with advanced life support capabilities from January 1, 1991, to December 31, 1995. Severe head injury was defined as head or neck Abbreviated Injury Scale score of 4 or greater. Isolated severe head injury was defined as head or neck Abbreviated Injury Scale score of 4 or greater with no other Abbreviated Injury Scale component greater than 3. One thousand ninety-two patients met initial criteria; of these, 671 had severe head injury, and 351 had isolated severe head injury. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Mortality and functional status sufficient for discharge to home. RESULTS: Field intubation was associated with significant decreases in mortality from 36% to 26% in the full study group, from 57% to 36% in patients with severe head injury, and from 50% to 23% in patients with isolated severe head injury. Rate of discharge to home was unaffected by field intubation. Between 50% and 60% of study patients were intubated under current paramedic protocol, compared with intubation rates of 85% to 92% for similar patients transported by aeromedical teams operating under expanded indications for intubation. CONCLUSIONS: Prehospital endotracheal intubation was associated with improved survival in patients with blunt injury and scene Glasgow Coma Score of 8 or less, especially those with severe head injury by anatomic criteria. Broadening indications for intubation by paramedical personnel has great potential to improve outcome in patients with severe head injury.
Adult↗
Clinical practice guidelines.
Clinical practice guidelines are becoming an important determinant of how we practice medicine and surgery. They are the strategy of our federal agencies to reduce variability in care, improve quality, measure outcomes, and reduce costs. The payors and entrepreneurs of medicine have endorsed the use of practice guidelines as the most efficacious way to manage costs, and variability. This economic force alone will perpetuate their development in the foreseeable future. It could be tempting to recoil from these pressures that may seem outside the realm of the individual surgeon trying to do the best for the individual patient. However, when viewed as a way to work with our colleagues and use scientific evidence and expert opinion to achieve consensus about best practice, this effort is very much in line with the way we practice surgery. The surgical community should not be concerned with participating but, in fact, should lead. The surgical tradition with outcomes assessment-the Morbidity and Mortality Conference-is a fundamental principle used to improve care. The process of practice guideline development is designed to do the same to continuously improve care.
General Surgery↗
Is operating room resuscitation a way to save time?
BACKGROUND: Direct admission to the operating room (OR) can shorten the time to incision. A protocol for operating room resuscitation was established with patient triage based on (1) cardiac arrest, (2) hypotension unresponsive to field fluid resuscitation, or (3) uncontrolled external hemorrhage. METHODS: Operating room resuscitation over 11 years was reviewed to determine whether the triage criteria correctly identified patients requiring operation. Survival was analyzed and compared with the probability of survival (Ps) determined at the scene. RESULTS: Operating room resuscitation patients were more likely to require a major operation regardless of mechanism of injury. Of 476 patients with penetrating injury, 170 patients had persistent low blood pressure (<90 mm Hg), and 146 (85.9%) of these required major operative intervention. The mean time to incision in this group was 21.7-67.5 minutes less than for patients not receiving OR resuscitation. Observed survival was significantly greater than that predicted for this group. CONCLUSIONS: Field triage criteria are able to reliably identify patients who require immediate major operative intervention. Direct admission to the OR results in a more timely initiation of operative therapy for patients requiring emergency surgical procedures.
Adult↗
CRRT in the area of cost containment: is it justified?
Intensive care accounts for at least 25% of health care costs. One third of this goes to 10% of patients who, in general, have combined respiratory and renal failure. The cost of renal replacement therapy is, therefore, of major importance. Continuous renal replacement therapy (CRRT) has many potential advantages over intermittent hemodialysis (IHD). These include better nutritional support, better volume maintenance, reduction of extravascular lung water, and potential clearance of inflammatory mediators. To date, noncomparative trials have suggested a trend toward decreased mortality. Randomized trials have suggested a CRRT mortality and morbidity benefit, but only when comparing long-term renal recovery. Acute mortality benefit has not been clearly established and, as such, cost comparison is of increased interest. Cost comparison trials are complicated, but some recent studies have led to the conclusion that costs are comparable. Others have concluded that CRRT is slightly more expensive. When comparing randomized patients in a recent prospective trial, aggregate costs for renal replacement therapy were comparable. The advantages of better nutrition, better fluid balance, easier management of hemodynamics, and more complete renal recovery, as suggested by this study, should continue to make it valuable. Physician acceptance of CRRT advantages has been established and suggests clinical benefit despite any potential increased cost.
Clinical Trials as Topic↗
Prospective study of blunt aortic injury: Multicenter Trial of the American Association for the Surgery of Trauma.
BACKGROUND: Blunt aortic injury is a major cause of death from blunt trauma. Evolution of diagnostic techniques and methods of operative repair have altered the management and posed new questions in recent years. METHODS: This study was a prospectively conducted multi-center trial involving 50 trauma centers in North America under the direction of the Multi-institutional Trial Committee of the American Association for the Surgery of Trauma. RESULTS: There were 274 blunt aortic injury cases studied over 2.5 years, of which 81% were caused by automobile crashes. Chest computed tomography and transesophageal echocardiography were applied in 88 and 30 cases, respectively, and were 75 and 80% diagnostic, respectively. Two hundred seven stable patients underwent planned thoracotomy and repair. Clamp and sew technique was used in 73 (35%) and bypass techniques in 134 (65%). Overall mortality was 31%, with 63% of deaths being attributable to aortic rupture; mortality was not affected by method of repair. Paraplegia occurred postoperatively in 8.7%. Logistic regression analysis demonstrated clamp and sew (p = 0.002) and aortic cross clamp time of > or = 30 minutes (p = 0.01) to be associated with development of postoperative paraplegia. CONCLUSIONS: Rupture after hospital admission remains a major problem. Although newer diagnostic techniques are being applied, at this time aortography remains the diagnostic standard. Aortic cross clamp time beyond 30 minutes was associated with paraplegia; bypass techniques, which provide distal aortic perfusion, produced significantly lower paraplegia rates than the clamp and sew approach.
Adolescent↗
Hypertonic saline activates protein tyrosine kinases and mitogen-activated protein kinase p38 in T-cells.
OBJECTIVES: In previous in vitro studies, we have found that hypertonic saline (HTS) can augment T-cell proliferation and restore the function of suppressed T-cells. Our animal models have shown that HTS resuscitation reverses immunosuppression after hemorrhage and reduces mortality from sepsis. In the present study, we investigated if and how HTS may influence T-cell signaling and function on a subcellular level. DESIGN: Human peripheral blood mononuclear cells (PBMC) were used to determine the effect of HTS on T-cell interleukin 2 (IL-2) production and proliferation. Human Jurkat T-cells were used to study the effects of HTS on T-cell signal transduction, IL-2 mRNA transcription, and IL-2 expression. MATERIAL AND METHODS: The effect of HTS on T-cell proliferation and IL-2 production was measured with PBMC and Jurkat T-cells. IL-2 mRNA transcription in HTS-treated Jurkat cells was measured by reverse transcriptase polymerase chain reaction. HTS-induced protein tyrosine phosphorylation in Jurkat T-cells was determined by immunoblotting with anti-phosphotyrosine antibodies. Expression in Jurkat cells of the mitogen-activated protein kinase p38 (MAPK p38), a signal transduction protein that is activated by osmotic stress, was determined by immunoblotting with anti-MAPK p38 antibodies. HTS-induced MAPK p38 activation in Jurkat cells was measured with an immune-complex kinase assay using ATF-2 as a substrate. MEASUREMENTS AND MAIN RESULTS: Proliferation of activated human PBMC increased significantly upon addition of HTS to the culture medium. This effect of HTS was paralleled by enhanced IL-2 production of activated PBMC and Jurkat cells and IL-2 mRNA transcription of Jurkat cells. HTS exposure of Jurkat cells caused tyrosine phosphorylation of a number of cellular proteins. We found that Jurkat T-cells expressed MAPK p38 and that it was activated in the presence of HTS. All these effects of HTS on T-cell signaling and function were observed at NaCl concentrations that were within physiologically relevant levels (20-100 mmol/L hypertonicity). CONCLUSIONS: In T-cells, HTS triggers a signaling pathway that includes increased tyrosine phosphorylation of several cellular proteins and activation of MAPK p38. HTS alone does not result in IL-2 mRNA transcription, IL-2 expression, or T-cell proliferation. However, in combination with other stimuli, HTS augments T-cell IL-2 expression and proliferation. We speculate that HTS could "resuscitate" suppressed T-cells in trauma patients by circumvention of, or substituting for, blocked signaling pathways.
Calcium-Calmodulin-Dependent Protein Kinases↗
Comparison of the Injury Severity Score and ICD-9 diagnosis codes as predictors of outcome in injury: analysis of 44,032 patients.
INTRODUCTION: Appropriate stratification of injury severity is a critical tool in the assessment of the treatment and the prevention of injury. Since its inception, the Injury Severity Score (ISS) has been the generally recognized "gold standard" for anatomic injury severity assessment. However, there is considerable time and expense involved in the collection of the information required to calculate an accurate ISS. In addition, the predictive power of the ISS has been shown to be limited. Previous work has demonstrated that the anatomic information about injury contained in the International Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in trauma patients. The goal of this study was to utilize the San Diego County Trauma Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive power of the ISS with the predictive power of the information contained in the injured patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios derived from patients' ICD-9 diagnoses codes would be equal or better predictors of survival than the Injury Severity Score. The implications of such a finding would have the potential for significant cost savings in the care of injured patients. METHODS: Data for the test population were obtained from the SDTR, which contains data from 1985 through 1993 from five participating hospitals. Four data sources were utilized to estimate the expected survival rate/mortality rate for each ICD-9 code in the SDTR. These were (1) the SDTR patients themselves, (2) the North Carolina State Hospital Discharge Database, (3) the North Carolina Trauma Registry Database, and (4) the Agency for Health Care Policy Research's Health Care Utilization Project Database. Each of these data sources was separately utilized to develop a survival risk ratio (SRR) for each ICD-9 diagnoses code. The SRR was calculated by dividing the number of survivors for patients with each ICD-9 code by the total number of all patients with the particular ICD-9 diagnoses code. The four groups of SRRs derived from our four data sources were used as predictors of survival and the ability of the SRRs to predict survival was compared with the predictive power of the ISS using measures of accuracy, sensitivity, specificity, and receiver operator characteristic curves. RESULTS: During the years 1985 through 1993, complete data were available for analysis on 44,032 patients. Of these, 2,848 patients died during their hospitalization (6%). Survival risk ratios were calculated for each of the diagnoses in the data base. Logistic regression, using the SAS System for statistical analysis, was used to assess the relative predictive power of the ISS and the survival risk ratios derived from the ICD-9 diagnoses codes from each of the four data bases. The analyses demonstrated that the regression models using the SRRs were generally as good or better than ISS as predictors of survival. The predictive power of the SRRs derived from the SDTR data, the North Carolina Trauma Registry data and the Health Care Utilization Report data were the best. In a subsequent analysis, the SRR values and the ISS were added to the patient's age and the revised Trauma Scores to create new predictive models in the mode of TRISS methodology. The analyses again indicated that the models using SRRs had as good or better predictive power than the model using the ISS. CONCLUSIONS: The present study confirms previous work showing that survival risk ratios derived from injured patients' ICD-9 diagnoses codes are as good as or better than ISS as predictors of survival.
Abbreviated Injury Scale↗