Biomedical subjects
Publications and source records attributed to R J Mullins.
For more than five years, a patient suffered recurrent episodes of abdominal pain accompanied by diarrhoea, nausea and vomiting. An angiotensin converting enzyme (ACE) inhibitor causing visceral oedema was eventually implicated.
OBJECTIVE: To measure the prevalence of and characterize coagulopathy in patients with blunt brain injury. DESIGN: Retrospective observation study based on review of medical records. SETTING: Acutely injured patients admitted to a level I trauma center. PATIENTS: One hundred fifty-nine patients with evidence of blunt head trauma who had computed tomography of the brain during initial evaluation and a coagulopathy score assigned based on 5 laboratory tests: platelet count, prothrombin time, partial thromboplastin time, fibrinogen level, and D-dimer level. The disseminated intravascular coagulation score ranged from 0 (no coagulopathy) to 15 (severe coagulopathy). Only individuals with intracranial injury based on computed tomography of the brain were designated as brain injured. MAIN OUTCOME MEASURES: Presence of coagulopathy, progression of brain injury, and death. RESULTS: Among the 91 patients with brain injury, 41% had coagulopathy (disseminated intravascular coagulation score > or = 5). Of the 68 patients without brain injury, 25% had coagulopathy. The patients with brain injury who developed profound depletion of fibrinogen did so within 4 hours of injury. There were 28 deaths (26 in the group with brain injury and 2 in the group without brain injury). Among patients with brain injury, those with coagulopathy more frequently died (P < .05 by chi 2 analysis). Patients with brain injury and coagulopathy deteriorated more frequently based on computed tomography criteria. CONCLUSIONS: After blunt brain injury, a disseminated intravascular coagulation syndrome can lead to consumptive coagulopathy that is associated with a higher frequency of death. The syndrome develops within 1 to 4 hours after injury. Therapeutic interventions need to be implemented immediately to be effective.
BACKGROUND: The goal of this study was to evaluate two modes of mechanical ventilation in patients with pulmonary contusion: pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV). METHODS: One hundred and thirty-five patients with pulmonary contusion, defined as an infiltrate on admission chest x-ray and hypoxemia, were treated over 45 months; 59 patients who required more than 48 hours of mechanical ventilation were initially managed with VCV. RESULTS: Twenty patients were converted from VCV to PCV when pulmonary function deteriorated. With PCV, peak inspiratory pressure decreased from 49 +/- 1 to 31 +/- 1 cm H2O, the alveolar-arterial oxygen difference decreased from 491 +/- 36 mm Hg to 300 +/- 36 mm Hg. These findings were significantly different (P < 0.05, by Student's paired t-test). Twenty patients managed with PCV had equivalent duration of mechanical ventilation and days in intensive care units to 39 patients with less pulmonary dysfunction managed with VCV. None of the 10 patients who died expired from pulmonary failure. CONCLUSIONS: PCV is an alternative mode to VCV in patients with poorly compliant lungs after pulmonary contusion.
Injuries to major abdominal arteries and veins frequently are associated with exsanguinating hemorrhage and visceral ischemia. Expeditious management is the key to survival and good outcome. Knowledge of anatomic relationships between viscera and vessels forms the basis for directed dissection, optimal exposure, and lasting repair of vessels. Although penetrating mechanism of injury remains the most common cause of these injuries, trauma surgeons must be familiar with patterns of blunt trauma-mediated injury to avoid the devastating consequences of delayed management.
OBJECTIVE: Evaluate the influence of implementing the Oregon statewide trauma system on admission distribution and risk of death. DESIGN: Retrospective pre- and posttrauma system analyses of hospital discharge data regarding injured patients with one or more of the following injuries: head, chest, spleen/liver, pelvic fracture, and femur/tibia fracture. MATERIALS AND METHODS: Risk-adjusted odds ratio of admission to Level I or II (tertiary care) trauma centers, and odds ratio of death were determined using hospital discharge abstract data on 27,633 patients. Patients treated in 1985-1987, before trauma system establishment, were compared to patients treated in 1991-1993 after the trauma system was functioning. MEASUREMENTS AND MAIN RESULTS: After trauma system implementation, the odds ratio of admission to Level I or II trauma centers increased (odds ratio 2.36, 95% confidence interval 2.24-2.49). In addition, the odds ratio of death for injured patients declined after trauma system establishment (odds ratio 0.82, confidence interval 0.73-0.92). CONCLUSIONS: The Oregon trauma system was successfully implemented with more patients with index injuries admitted to hospitals judged most capable of managing trauma patients. The Oregon trauma system also appears beneficial since trauma system establishment is associated with a statewide reduction in risk of death.
BACKGROUND: Two cases of allergic (IgE-mediated) reaction to bovine collagen are described. Both patients developed conjunctival oedema in response to the topical application of highly purified bovine collagen to the eye during opthalmic surgery (corneal shields and catgut suture material). One patient developed periocular angioedema and angioedema of the throat after the ingestion of bovine collagen in the form of gelatin-containing foods. METHODS: The presence of allergen-specific IgE was evaluated by skin prick testing with collagen-derived products, and by topical challenge with a highly purified bovine collagen-derived corneal shield. RESULTS: In both patients, application of collagen to the eye reproduced the original subconjunctival oedema. In one patient, skin testing with purified and crude extracts of bovine collagen in the form of a corneal shield, catgut suture material and edible gelatin demonstrated evidence of collagen-specific IgE. CONCLUSIONS: Clinical reactions to collagen are rare. Nevertheless, patients with a history of allergic reactions to bovine collagen-derived products should be investigated because of the widespread use of collagen-derived therapeutic devices, the potential for immunological cross-reactivity with dietary collagen (gelatin) and the potential for anaphylaxis.
OBJECTIVE: The goal of this study was to determine patient and injury characteristics that predict undertriage and overtriage. DESIGN: This study was a retrospective analysis of admissions for acute injury. MATERIALS AND METHODS: All admissions for acute injuries in a 2 1/2-year period were included (N = 26,025). ICD-9 clinical modification codes were converted to Injury Severity Scores. MAIN RESULTS: Seventy-nine percent of severely injured patients were admitted to level I trauma centers. Severely injured patients admitted to other hospitals (undertriage) were more likely elderly (odds ratio = 5.44) and less likely had multisystem injuries (odds ratio = 0.55). One-fourth of patients with minor injuries were admitted to level I trauma centers (overtriage). Overtriaged patients were more likely intoxicated, obese, or had an injury to the head or face. CONCLUSIONS: In a developed trauma system, severely injured elderly trauma patients (especially females) are at risk for undertriage. The characteristics of patients at risk for overtriage reflect the difficulties of prospective out-of-hospital triage.
STUDY OBJECTIVE: To document the validity of a Hospital Discharge Index (HDI) as a data base on injured patients. DESIGN: Patient information in trauma registries was compared with information in HDI. POPULATION: Injured patients admitted to trauma centers. METHODS: Patients in HDI were crossmatched with individuals in one or two trauma registries using deterministic matching techniques. Agreement regarding the presence and severity of injury was assessed. RESULTS: A comprehensive trauma registry from a level I trauma center and HDI agreed on the presence of an injury in each of 6 body regions over a range of kappa values from 0.17 to 0.71. The severity of injury score assigned by the two data bases demonstrated agreement over a range of intraclass correlation values from 0.12 to 0.82. CONCLUSION: HDI provides adequate information concerning injury for the majority of hospitalized patients, but was primarily limited by incomplete information. Efforts to improve HDI should focus on guidelines for data abstraction.
OBJECTIVE: To determine the accuracy of the Baxt Trauma Triage Rule (TTR: systolic blood pressure < 85 mm Hg; Glasgow Coma Scale-motor score < 5; or penetrating trauma to head, neck, or trunk) for prediction of major trauma in an independent data set of blunt trauma patients. METHODS: Retrospective evaluation of the TTR in a cohort of patients identified by Oregon Trauma System entry criteria. Accuracy for prediction of "major trauma" victims was measured using resource-based definitions of major trauma. Participants included 626 adult, blunt trauma patients at a level-I trauma center serving a metropolitan center of more than one million people. RESULTS: Of 524 patients with sufficient registry data to apply the TTR, 95 (18%) and 63 (12%) patients met the criteria for major trauma suggested by Baxt et al. and Emerman et al., respectively. Using the Baxt definition of major trauma, the TTR had a sensitivity of 74% (95% CI: 0.65-0.83) and a specificity of 84% (95% CI: 0.81-0.88). There were 25 significant false-negative results, including 12 patients requiring urgent laparotomy and four patients requiring emergency airway procedures. Using the Emerman definition of major trauma, sensitivity improved modestly to 76% (95% CI: 0.65-0.87) and specificity decreased slightly to 80% (95% CI: 0.77-0.84). CONCLUSIONS: In this blunt trauma population, the Baxt TTR failed to identify a significant number of severely injured patients. Slight alterations in the definition of "major trauma" can significantly affect the performance characteristics of triage instruments.
OBJECTIVE: To review all bicycle crash-related injuries reported to the Oregon Injury Registry for 1989 to compare patterns of injury and other features in adults vs children and adolescents. METHODS: A retrospective descriptive study was conducted using data from the Oregon Injury Registry. For 1989, this registry included all injury-related deaths and approximately 75% of hospital admissions of 24 hours or more for injury in the State of Oregon. Deaths, helmet use, neurologic injuries, and concurrent ethanol use were evaluated for all patients and for the two age groups. RESULTS: There were 311 bicycle-related injured patients in the registry for 1989; 122 (40%) were adults (age > or = 21 years) and 189 (60%) were children/adolescents (age < 21 years). Approximately 69% of both age groups were male. All of the 15 deaths involved male patients and most deaths [10/15 (67%)] involved injured adults. Bicycle vs motor vehicle collisions accounted for 14 (93%) deaths and 106 (34%) of all registry entries. While only 19 (15%) of the injured adults had elevated blood alcohol levels, half the adults who died had been intoxicated. Helmet use was rare with only 12 (4%) of all the injured riders known to have been helmeted; no rider who died was known to have been helmeted. Neurologic injuries were common. In children, 27 (14%) had sustained skull fractures, 36 (19%) intracranial injuries, and one (0.5%) a spinal injury. In adults, 13 (10%) had sustained skull fractures, 32 (26%) intracranial injuries, and three (2%) spinal injuries. CONCLUSIONS: Although children account for 60% of the serious bicycle injuries in Oregon, adults account for 67% of the deaths. Helmet use is rare, brain injuries are frequent, and alcohol use appears to be a contributing factor in cycling deaths among adults. Public education efforts should be directed to both adult and pediatric populations, emphasizing safe cycling practices and helmet use.
The importance of thyrotropin receptor (TSHR) agonist antibodies in the manifestations of Graves' disease (GD) is recognized. There are, however, no convincing reports of TSHR-specific T cells. We have previously cloned T cells specific for thyroglobulin and thyroid peroxidase (TPO) from GD lymphoid infiltrates and used autologous EBV-transformed B cell lines (EBVL) transfected with an expression vector encoding TPO to efficiently detect TPO-specific T cells. Here we used EBVL transfected with TSHR to seek TSHR-specific T cells in the GD infiltrates, after cloning the in vivo activated T cells without antigen. 3 out of 30 clones responded vigorously and reproducibly to EBVL-TSHR, with a mean stimulation index > 7. Their release of IL-2, IL-4, and IL-10 after stimulation with soluble anti-CD3 and phorbol ester was indistinguishable from the other clones from this thyroid. However, they produced relatively little IFN gamma (median IL-4/IFN gamma ratio of 0.80) compared with the other clones (median IL-4/IFN gamma ratio 0.06). Thus, this new potent method of antigen presentation, using autoantigen-transfected EBVL, has permitted the first unequivocal identification of TSHR T cells in GD thyroid, with distinct Th0/Th2 characteristics, unlike previously cloned TPO-responsive cells which have Th1 characteristics.
Autologous EBV-transformed B cell lines (EBVL) from a patient with Graves' disease (GD) were transfected with the expression vector pREP4 encoding thyroid peroxidase (TPO), the thyroid-stimulating hormone receptor (TSHR), or chloramphenicol acetyl transferase. The relevant proteins were expressed. The capacity of EBVL to present transfected Ag was assessed by using EBVL transfected with TPO (EBVL-TPO) to stimulate TPO-specific T cells cloned from autologous thyroid tissue; stimulation indices greater than 100 were consistently obtained, even at low APC:T cell ratios. EBVL-TPO and EBVL transfected with TSHR (EBVL-TSHR) were used to characterize the Ag specificity of five thyroid epithelial cell-specific T cell clones. Despite previous unresponsiveness to recombinant TPO or purified thyroglobulin, four of these clones responded vigorously to EBVL-TPO but none responded to EBVL-TSHR. Experiments were then performed to determine whether transfected EBVL were presenting endogenously synthesized TPO, or were taking up and reprocessing exogenous Ag shed from the surface of adjacent cells. The stimulatory capacity of EBVL-TPO was not transferable to untransfected EBVL by cell-free culture supernatant and to only a minor degree by EBVL-TPO-derived cell membrane fragments, indicating that the majority of the TPO presented by the transfected EBVL is endogenously synthesized. The clear and reproducible proliferative responses obtained illustrate the usefulness and potency of this method of Ag presentation to T cells. Because this system obviates the need for large numbers of autologous APC or purified recombinant Ag, it will be useful for obtaining autoantigen-reactive T cells and to help define the autoantigenic epitopes recognized.
OBJECTIVE: To review the outcomes of patients with open pelvic fractures. DESIGN: Retrospective review of medical records. SETTING: Patients admitted from the injury scene or transferred within 24 hours to a level 1 trauma center. PATIENTS: Thirty-three patients sustaining blunt trauma had pelvic fractures and adjacent wounding. INTERVENTIONS: Treatment protocol that included selective fecal diversion, measures to arrest hemorrhage and prevent wound sepsis, manage associated pelvic injuries, and provide optimal orthopedic outcomes. MAIN OUTCOME MEASURES: Death and sepsis. RESULTS: Exsanguination occurred in one patient and death owing to head injuries occurred in five patients. Wound sepsis occurred in 31% of patients with colostomy and 19% without colostomy. CONCLUSIONS: Management of open pelvic fractures requires a well-coordinated group using several techniques. Selected patients with open pelvic fractures do not require fecal diversion. Incisions for orthopedic surgery should be considered when decisions are made regarding fecal diversion.
Coagulation component transfusions in trauma patients given more than 10 units of AS-1 red cells during the first 24 hours after injury were studied. Serial coagulation tests were obtained to direct component therapy. Coagulopathy developed in more than 70% of patients. Patients with blunt or penetrating trauma had similar coagulation abnormalities during massive transfusions. More than 40% of patients with either exsanguinating hemorrhage from penetrating trauma or blunt trauma with associated brain injuries had abnormal coagulation tests on admission. In contrast, patients with blunt trauma, but without brain injury, did not have coagulopathy on admission. Patients received an average of 25 units (range, 10-77) of AS-1 red cells and were exposed to an average of 80 (range, 11-252) donors. Exsanguination and brain injuries primarily caused death in 57%. Abnormal coagulation tests will be frequent and profound during a massive transfusion with AS-1 red cells. Serial coagulation testing is recommended.
A knitted mesh of polyglycolic acid was used successfully in 59 critically ill patients to bridge abdominal wall defects and prevent evisceration after celiotomy. Polyglycolic acid knit mesh was used in 31 patients who had extraordinary visceral edema after resuscitation and the mesh was inserted to avoid excessive tension in the wound closure, 15 patients who had abdominal wall defects after adequate débridement for necrotizing fasciitis, and 13 patients who had losses of abdominal wall tissue caused by trauma or after resection of tumor. There were 14 hospital deaths among the seriously ill patients. Thirteen patients had enterocutaneous fistulas, seven of which occurred after meshes were inserted. The mesh material was strong, pliable and easily inserted in large abdominal wall defects. The polyglycolic acid knit mesh was infiltrated by granulation tissue within three weeks, including in heavily contaminated wounds. Two to three months after insertion, the material was absorbed. Hernia defects were common four to six months after the meshes were inserted and repairs were performed electively after patients had recovered from the primary problems. We conclude that absorbable polyglycolic acid knit mesh can be a useful technique for quickly achieving a secure tension-free closure of abdominal wounds.
STUDY PURPOSE: To determine if adult minor injury trauma admissions to small hospitals have a mean length of stay (LOS) and fatality rate similar to those of admissions to larger hospitals. POPULATION: The first 10,000 Oregon hospital trauma discharges during 1987. Exclusions were age of 17 years or younger, an Injury Severity Score (ISS) of more than 10, transfer to another health care facility, and leaving against medical advice. There were 6,739 patients meeting study criteria. METHODS: This study was a retrospective cohort analysis of a hospital discharge data base. Outcome measures were LOS for survivors and fatality rate. Predictor variables included patient age, hospital bed size, Level I or II trauma facility, designation, and county population. Chi 2 and analysis of variance were used to test significance (P less than .05). RESULTS: Two of 72 hospitals were US-government-sponsored facilities and showed a longer mean LOS (21.3 and 16.4 vs 5.5 days for all other hospitals; P less than .005). Mean LOS correlated positively with patient age, ISS, and hospital bed size (P less than .0001). There were 136 deaths in this low-ISS population. The fatality rate was independent of hospital size and trauma facility designation. Age was significantly greater for patients who died versus survivors (76.2 vs 49.1 years; P less than .0001). CONCLUSION: For minor trauma patients, smaller hospitals have a shorter mean LOS and a similar fatality rate when compared with larger hospitals and Level I and II trauma facilities. Despite a low ISS, admitted elderly patients have a higher death rate regardless of hospital size.
Peripheral blood mononuclear cells (PBM) obtained from leprosy patients and healthy controls were cultured with Mycobacterium leprae and the control antigens, BCG and SKSD. Parallel cultures were supplemented with additional interleukin-2 (IL-2). On the basis of the level of response to M. leprae, leprosy patients could be divided into low, intermediate and high responders. The addition of IL-2 resulted in enhanced proliferation to antigen only by cells from intermediate responders. This effect was neither antigen specific nor was it confined to cells from leprosy patients. When limiting dilution analyses were performed on cells from 26 patients across the leprosy spectrum, no M. leprae-reactive lymphocytes were detected in cells from subjects with lepromatous disease. The precursor frequency for cultures containing M. leprae plus IL-2 was no greater than that of cultures containing IL-2 alone, thereby excluding the possibility of clonal anergy reversible with IL-2. This was observed in both untreated patients and those on long-term treatment, which made sequestration of antigen-reactive cells within leprosy lesions an unlikely explanation. On the other hand, M. leprae-reactive lymphocytes were detected in patients with tuberculoid and borderline tuberculoid disease and in two subjects with borderline lepromatous leprosy in type I reversal reaction. IL-2 reactive cells were detected in all patients regardless of clinical classification. Three 'suppressor' curves were obtained but were not confined to cells from lepromatous patients. Taken together, these findings suggest that the non-responsiveness to M. leprae characteristic of the great majority of multibacillary patients is due to an absence of antigen-sensitive T cells.
We created a decision analysis model of the nonsurgical management of traumatic splenic injuries to clarify the risk of hospital survival, overwhelming postsplenectomy infection (OPSI) deaths, and transfusion-related deaths. We reviewed 72 cases of splenic injury at our institution to identify our transfusion requirements for successful observation (0.5 units), observation failure (1.0 units), and surgical splenic management (1.6 units). Using our model and baseline probabilities determined from the literature, we compared the nonsurgical management of splenic injuries with immediate laparotomy and found an increase in hospital survival with observation, but an over two-fold increase in the risk of transfusion-related death. The OPSI deaths were not markedly different between the two strategies. Overall, we found decision analysis useful in identifying important variables such as the probability of nontherapeutic laparotomy death or missed injury, and in clarifying the risk of the nonsurgical management of splenic injuries with regard to transfusion-related deaths and OPSI deaths.