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Biomedical subjects

R Rutledge

Publications and source records attributed to R Rutledge.

At least 55 records · Page 3Linked to original sources
PubMed1995

A statewide, population-based time-series analysis of the increasing frequency of nonoperative management of abdominal solid organ injury.

UNLABELLED: Emergency operative intervention has been one of the cornerstones of the care of the injured patient. Over the past several years, nonoperative management has increasing been recommended for the care of selected blunt abdominal solid organ injuries. The purpose of this study was to utilize a large statewide, population-based data set to perform a time-series analysis of the practice of physicians caring for blunt solid organ injury of the abdomen. The study was designed to assess the changing frequency and the outcomes of operative and nonoperative treatments for blunt hepatic and splenic injuries. METHODS: Data were obtained from the state hospital discharge data base, which tracks information on all hospitalized patients from each of the 157 hospitals in the state of North Carolina. All trauma patients who had sustained injury to a solid abdominal organ (kidney, liver, or spleen) were selected for initial analysis. RESULTS: During the 5 years of the study, 210,256 trauma patients were admitted to the state's hospitals (42,051 +/- 7802 per year). The frequency of nonoperative interventions for hepatic and splenic injuries increased over the period studied. The frequency of nonoperative management of hepatic injuries increased from 55% in 1988 to 79% in 1992 in patients with hepatic injuries and from 34% to 46% in patients with splenic injuries. The rate of nonoperative management of hepatic injuries increased from 54% to 64% in nontrauma centers compared with an increase from 56% to 74% in trauma centers (p = 0.01). In patients with splenic injuries, the rate of nonoperative management increased from 35% to 44% in nontrauma centers compared with an increase from 33% to 49% in trauma centers (p < 0.05). The rate of nonoperative management was associated with the organ injury severity, ranging from 90% for minor injuries to 19%-40% for severe injuries. Finally, in an attempt to compare blood use in operatively and nonoperatively treated patients, the total charges for blood were compared in the two groups. When compared, based on organ injury severity, the total blood used, as measured by charges, was lower for nonoperatively treated patients. CONCLUSIONS: This large, statewide, population-based time-series analysis shows that the management of blunt injury of solid abdominal organs has changed over time. The incidence of nonoperative management for both hepatic and splenic injuries has increased. The study indicates that the rates of nonoperative management vary in relation to the severity of the organ injury. The rates increase in nonoperative management were greater in trauma centers than in nontrauma centers. These findings are consistent with the hypothesis that this newer approach to the care of blunt injury of solid abdominal organs is being led by the state's trauma centers.

Humans↗
PubMed1995

Field triage of trauma patients based upon the ability to follow commands: a study in 29,573 injured patients.

UNLABELLED: If a trauma system is to deliver "the right patient to the right hospital at the right time," a simple triage tool that can be used in the field to rapidly identify patients with a significant risk of morbidity and mortality is vital. OBJECTIVE: The purpose of this study was to evaluate the effectiveness of the Glasgow Coma Scale's Motor Response Component (GMR) in identifying such patients. METHODS: From patient records in a well established state trauma registry, the predictive power of the Glasgow Motor Score was compared with the predictive power of the Injury Severity Score (ISS), Trauma Score, and whole Glasgow Coma Scale Score (GCS), using discriminant analysis and logistic regression. RESULTS: Complete data were available for analysis for 29,573 patients. Nine percent died. The analyses demonstrated that the GMR was almost as good as the TS and better than the other scores in identifying patients at risk of dying. The highest discriminant accuracy was obtained by predicting that patients with a GMR of 6 would live and that all others (GMR 1-5) were at risk of dying. This means separating patients according to whether or not they follow simple commands. CONCLUSIONS: The study demonstrated the GMR to be a good predictor of mortality in injured patients. Patients at risk of dying can best be identified by separating patients into those who cannot follow simple commands (GMR 1-5) from all others. This rapid and simple assessment could be useful as a prehospital tool to identify patients at risk of dying. First responders and nonmedical personnel not skilled in the use of the Trauma Score can easily determine if victims are able to follow commands and potentially identify the patients who are likely to require urgent trauma center care.

Glasgow Coma Scale↗
PubMed1995

Injury severity and probability of survival assessment in trauma patients using a predictive hierarchical network model derived from ICD-9 codes.

UNLABELLED: Accurate assessment of injury severity is critical for decision making related to the prevention, triage, and treatment of injured patients. Presently, the standard method of controlling for variations of injury severity between groups has been based upon the Injury Severity Score (ISS) and the Trauma Score and the Trauma and Injury Severity Score (TRISS) methodology. The purpose of this study was to attempt to build upon previous work using International Classification of Diseases, ninth revision (ICD-9) coded diagnosis, and procedure information available from standard hospital discharge abstracts (UB-82 Billing format) to create a hierarchical network to provide a tool for predicting injury severity and probability of survival. METHODS: Data were obtained for this analysis from the North Carolina Medical Database. Data were available on all trauma patients admitted to hospitals in North Carolina from January 1, 1988 until June 30, 1992. The dependent variable of interest was the patient's survival after injury, coded as live or die. The independent variables used in the study included the ISS derived using the technique described by MacKenzie Abbreviated Injury Score (AIS) and body system maximum AIS scores, mortality risk ratios derived from the ICD-9-DM primary, secondary, and tertiary diagnoses, primary and secondary procedures as described in previous work, age and gender. Network generation used a commercial software package, AIM (Abtech Corp., Charlottesville, Va.), which is a numeric modeling tool that automatically "learns" knowledge from a data base of examples. RESULTS: In the test data set an ISS and a prediction of survival based upon the derived network were calculated for each and every patient. The relative predictive power of these two scores were compared by calculating the overall accuracy, sensitivity, and specificity and the false positive and false negative rates. The receiver operator characteristic curves demonstrate that the network is a more effective tool in predicting the outcome of trauma patients. All the measures of predictive power show that the network was the better predictor of outcome than the ISS. CONCLUSIONS: Given the recognized limitations of the ISS, the widespread availability of the ICD-9 coded diagnoses and procedures, and the availability of many state and regional data bases that have no ISS or Trauma Score, the purpose of this study was to assess the ability of a network derived from limited but widely available hospital discharge data to predict the outcome of injured patients. The study confirms previous work showing that the ICD-9 codes were strongly associated with outcome. The study demonstrated that the network created from these data was a better predictor of outcome than the derived ISS. When the results of the network were compared with other published series, the network, created without access to physiologic information, was almost as accurate, sensitive, and specific as reported values for TRISS and A Severity Characterization of Trauma (ASCOT). Because the present study is the first of its type, further investigations are needed to validate these findings. If other studies corroborate this study, a network model based upon ICD-9 codes could become the principal method for grading injury severity. This would provide superior predictive power of injury severity with important cost savings and universal application.

Adult↗
PubMed1994

A population-based multivariate analysis of the association of county demographic and medical system factors with per capita pediatric trauma death rates in North Carolina.

OBJECTIVE: This study analyzed the association between demographic and medical system factors and the pediatric trauma death rate in North Carolina. SUMMARY BACKGROUND DATA: Trauma is the leading cause of death in children. Various medical system factors have been suggested to reduce pediatric morbidity and mortality rates, but the association with these rates has not been tested. METHODS: Data were obtained from the North Carolina medical examiner's database. The dependent variable was the county per capita pediatric trauma death rate. Twenty-one demographic and medical system measures were selected as independent variables. RESULTS: Nine hundred forty-one pediatric trauma deaths from 1986 to 1989 were included in our sample. Multivariate analysis identified the variables most highly associated with the dependent variables. The presence of advanced life support (ALS) training was the only medical system factor associated significantly with pediatric trauma death rates. Trauma centers, emergency (911) telephone access, and other medical resource variables had no significant association. CONCLUSIONS: The study confirms other reports showing that demographic factors have an important predictive association with the trauma death rate in children. Advanced life support was the only medical system resource associated significantly with pediatric trauma death rates. This study underlines the significance of pre-hospital care in the treatment of pediatric trauma.

Adolescent↗
PubMed1994

A population-based study of the association of medical manpower with county trauma death rates in the United States.

OBJECTIVE: To determine the association between measures of medical manpower available to treat trauma patients and county trauma death rates in the United States. The primary hypothesis was that greater availability of medical manpower to treat trauma injury would be associated with lower trauma death rates. SUMMARY BACKGROUND DATA: When viewed from the standpoint of the number of productive years of life lost, trauma has a greater effect on health care and lost productivity in the United States than any disease. Allocation of health care manpower to treat injuries seems logical, but studies have not been done to determine its efficacy. The effect of medical manpower and hospital resource allocation on the outcome of injury in the United States has not been fully explored or adequately evaluated. METHODS: Data on trauma deaths in the United States were obtained from the National Center for Health Statistics. Data on the number of surgeons and emergency medicine physicians were obtained from the American Hospital Association and the American Medical Association. Data on physicians who have participated in the American College of Surgeons (ACS) Advanced Trauma Life Support Course (ATLS) were obtained from the ACS. Membership information for the American Association for Surgery of Trauma (AAST) was obtained from that organization. Demographic data were obtained from the United States Census Bureau. Multivariate stepwise linear regression and cluster analysis were used to model the county trauma death rates in the United States. The Statistical Analysis System (Cary, NC) for statistical analysis was used. RESULTS: Bivariate and multivariate analyses showed that a variety of medical manpower measures and demographic factors were associated with county trauma death rates in the United States. As in other studies, measures of low population density and high levels of poverty were found to be strongly associated with increased trauma death rates. After accounting for these variables, using multivariate analysis and cluster analysis, an increase in the following medical manpower measures were associated with decreased county trauma death rates: number of board-certified general surgeons, number of board-certified emergency medicine physicians, number of AAST members, and number of ATLS-trained physicians. CONCLUSIONS: This study confirms previous work that showed a strong relation among measures of poverty, rural setting, and increased county trauma death rates. It also found that counties with more board-certified surgeons per capita and with more surgeons with an increased interest (AAST membership) or increased training (ATLS) in trauma care have lower per-capita trauma death rates.(ABSTRACT TRUNCATED AT 400 WORDS)

Black or African American↗
PubMed1994

American College of Surgeons trauma quality indicators: an analysis of outcome in a statewide trauma registry.

Quality assurance/quality improvement (QA-QI) is a priority for maintaining the highest standards of care in trauma systems. To be an effective tool for system review, the QA-QI indicators should identify patients with higher rates of morbidity and mortality from injury. While the American College of Surgeons (ACS) and the Joint Commission on Accreditation of Health Care Operations have identified certain audit filters within the trauma system, there are few data to substantiate the value of these audit filters for trauma care. The purpose of this study was to analyze the ability of the ACS trauma indicators to predict adverse patient outcome following injury requiring review. The study population consisted of 44,019 patients from the North Carolina State Trauma Registry from 1987 to 1992. Of the 22 audit filters nine were available for analysis. Mortality rate, length of stay, and total charges were used as measures of outcome. The hypotheses tested were that patients who met the indicator criteria would have higher mortality rates and worse outcomes than the non-indicator group. Student's t test and Chi-square analysis were used to test the differences between the group which met the criteria for the indicator and those without. Of the nine audit filters tested, only three were found to have significantly worse outcomes than their non-indicator comparison group: gunshot wound to the abdomen with non-surgical management, femur fracture without fixation, and complications from pulmonary embolism-deep vein thrombosis-decubitus ulcer (p < 0.05). Contrary to expectations, four of the audit filters, coma without intubation, laparotomy > 2 hours, transfer > 6 hours, and admission to non-surgical service, actually had significantly better outcomes than their non-indicator counterpart. Scene time > 20 minutes, laparotomy > 2 hours after arrival, and craniotomy > 4 hours after arrival may be indicators of patients at risk for morbidity. This study demonstrates that several ACS clinical indicators, as currently written, are not useful in identifying patients at higher risk for poor outcome. The indicators need further definition to be of value in the quality review process. Specifically, the study suggests that audit filters should be data driven and based upon analyses of large populations of injured patients and their outcomes to be valid QA-QI tools.

General Surgery↗
PubMed1994

Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients.

The relative impact of inhalation injury, burn size, and age on overall outcome following burn injury was examined in 1447 consecutive burn patients over a five and a half year period. The overall mortality for all patients was 9.5% (138 of 1447). The presence of inhalation injury, increasing burn size, and advancing age were all associated with an increased mortality (p < 0.01). The incidence of inhalation injury was 19.6% (284 of 1447) and correlated with increasing percent total body surface area (%TBSA) burn (r = 0.41, p < 0.01) and advancing age (r = 0.15, p < 0.01). The overall mortality for patients with inhalation injury was 31% (88 of 284) compared with 4.3% (50 of 1163) for those without inhalation injury. Using multivariate analysis inhalation injury was found to be an important variable in determining outcome, but the most important factor in predicting mortality was %TBSA burn (accuracy = 92.8%) or a combination of %TBSA burn and patient age (accuracy = 93.0%). Adding inhalation injury only slightly improved the ability to predict mortality (accuracy = 93.3%). The presence of inhalation injury is significantly associated with mortality after thermal injury but adds little to the prediction of mortality using %TBSA and age alone.

Adolescent↗
PubMed1994

Report on the clinical workstation and clinical data repository utilization at UNC Hospitals.

On December 1, 1993, we implemented version 2.1 of the Clinical Workstation-Clinical Data Repository application in the Ambulatory Care Center. This version of the workstation allowed access of laboratory data from the clinical data repository that had been populated by a real-time HL7 interface between the Clinical Data Repository and the Laboratory Information System. This implementation completed a major part of the Clinical Workstation project. Also in December, we implemented a security system that records the date and time, user logon code, clinical workstation functions used, and the patient medical record number on whom data were displayed. In addition to the security function, this system has proven to be a valuable tool in evaluating the utilization of the clinical workstation and is the source of the data presented in this paper.

Clinical Laboratory Information Systems↗
PubMed1994

Incidence, management, and outcome of femoral shaft fracture: a statewide population-based analysis of 2805 adult patients in a rural state.

UNLABELLED: Early surgical management of femoral shaft fracture (FSF) is considered the standard but patients are still treated nonsurgically. The purpose of this study was to analyze the results of management of FSF in a large population based data base. METHODS: Data were obtained from a statewide hospital discharge data base for 1989-1992. Adults having a FSF were stratified by ISS (ISS < 15 vs. ISS > or = 15) and management (nonsurgical, surgery within 1 day, surgery at 2-4 days, or surgery at > 4 days). Mortality rates and mean length of hospital stay were compared among groups. RESULTS: 2805 patients had FSFs: 69% were managed surgically and 31% nonsurgically. Mortality was higher for nonsurgical therapy in both ISS groups. In the surgically treated groups, length of hospitalization increased as delay to surgery increased. In patients with an ISS > or = 15, repair at 2-4 days was associated with the lowest mortality and shortest hospitalization, while a trend to higher mortality and longer hospitalization was noted with repair within 1 day. CONCLUSION: 31% of patients were treated nonsurgically with higher associated mortality. These results support "early" surgical fixation, which can shorten hospital stay without increasing mortality regardless of overall injury severity. The trend toward higher mortality in severely injured patients operated on within 1 day of admission suggests that this group warrants further study and individualized management.

Adolescent↗
PubMed1993

The association of helmet use with the outcome of motorcycle crash injury when controlling for crash/injury severity.

Many studies have reported that helmet use by motorcycle riders significantly decreases their risk of head injury, death, and disability in the event of a crash. However, these studies have not controlled for crash severity and thus do not conclusively show the value of helmet use by motorcycle riders. Using data from a statewide trauma registry, the present study examines the association of helmet use with various outcomes of motorcycle crashes, controlling for overall crash severity as measured by a modified Injury Severity Score. The results show that in crashes where the overall degree of injury was comparable, the risk of head injury in hospitalized motorcyclists was nearly twice as high for unhelmeted riders as it was for helmeted riders, thus confirming the protective effects of helmet use. However, there were no significant differences in various measurements of resource utilization, including days in hospital, hospital charges, and need for post-hospital rehabilitation. A higher incidence of extremity injuries among the helmeted riders may account for their failure to demonstrate consistently lower resource utilization, despite lower rates of head injury.

Accidents, Traffic↗
PubMed1993

Comparison of APACHE II, Trauma Score, and Injury Severity Score as predictors of outcome in critically injured trauma patients.

Trauma Score (TS), APACHE II score, and Injury Severity Score (ISS) have been utilized to quantitate severity of illness in various groups of patients. The purpose of this study was to compare the relationship of the APACHE II score, TS, and "computer-derived" ISS with outcome in critically injured trauma patients. Data were recorded prospectively in a computer database for 428 consecutive trauma admissions. Stepwise discriminate analysis was utilized to determine the best predictor of both intensive care unit (ICU) and hospital outcome. Forty-two patients died in the ICU (10%), and another 18 patients died after leaving the ICU (4%), for a total mortality rate of 14%. The mean p value and partial R2 value obtained from stepwise discriminant analysis of the relationships between APACHE II score, TS, and ISS to ICU and hospital survival are shown. APACHE II score was the best predictor of both ICU and hospital outcome in these critically ill trauma patients. However, when combining all three measures (APACHE II score, TS, and ISS), only a portion of the variance in outcome is explained by the scores (R2 < 0.05). We conclude that scoring systems for outcome prediction should be utilized only as an adjunct to clinical assessment in the evaluation of the severity of illness and mortality risk in critically ill trauma patients.

Female↗
PubMed1993

The cost of not wearing seat belts. A comparison of outcome in 3396 patients.

Data from the North Carolina Trauma Registry were analyzed to determine the effect of seat belt usage on outcome in motor vehicle accidents. Of 6237 persons involved in motor vehicle accidents, data on seat belt usage were available for 3396. Of these, 1916 were not and 1480 were wearing seat belts. The mean hospital charge in belted patients was $10,500 +/- $18,200; and in unbelted patients, $15,250 +/- $26,300 (p < 0.001). The total hospital charges were $23 million for the 1508 patients not wearing seat belts. If the unbelted patients had outcomes similar to belted patients, the charges resulting from caring for the 1508 patients would have been $15.8 million, a potential savings of $7.2 million. There were 135 deaths among the unbelted patients (7.0%) and 47 deaths among the belted patients (3.2%) (p < 0.001). A similar projection of belted outcome for unbelted patients suggests that seat belt usage could have reduced the unbelted mortality rate by over one half. Patients wearing seat belts also had significantly shorter hospital stays, fewer days in the intensive care unit, and fewer days on the ventilator (p < 0.001). Seat belt usage is associated with a significant decrease in mortality rate, hospital charges, length of stay, intensive care unit stay, and ventilator requirements. Seat belts could have saved at least 74 lives and 7.2 million dollars during the period from October 1, 1987 to July 1, 1989 in patients seen in the seven trauma centers in North Carolina.

Accidents, Traffic↗
PubMed1993

An analysis of the association of trauma centers with per capita hospitalizations and death rates from injury.

OBJECTIVE: This study used population-based data bases to assess the association of trauma centers with per capita county hospitalization and trauma death rates in the State of North Carolina. SUMMARY BACKGROUND DATA: The current study extended previous work using two North Carolina data bases to assess the association of the presence of a trauma center with per capita county trauma death rates. METHODS: Data on per capita county trauma hospitalizations and deaths were obtained from the state hospital discharge data base and the North Carolina Medical Examiner's data base. Bivariate and multivariate analysis techniques were used. The dependent variables of interest were prehospital, hospital, and total trauma death rates and hospitalization rates for injury. RESULTS: Bivariate analysis identified a number of factors associated with per capita county hospitalizations and trauma death rates. These included the per cent unemployment, racial distribution, county alcohol tax receipts, and advanced life support certified emergency medical services providers. The per capita trauma death rates were significantly lower in counties with trauma centers compared with those without trauma centers (4.0 +/- 0.5 and 5.0 +/- 1.1 deaths per 10,000 population, p = 0.0001, respectively). The per capita hospitalizations for trauma were also lower in counties with trauma centers. Multivariate modeling showed that the presence of a trauma center and advanced life support providers were the best predictors of decreased per capita county trauma death rates. CONCLUSIONS: The study showed that the presence of a trauma center and advanced life support training were the two medical system factors that were the best predictors of the per capita county prehospital and total trauma death rates. These findings are consistent with the hypothesis that trauma centers are associated with a decrease in trauma death rates.

Adolescent↗
PubMed1993

Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient.

In hypotensive blunt trauma patients with a diminished level of consciousness, it may be difficult to decide whether to proceed with immediate head CT scanning or urgent laparotomy or thoracotomy. The purpose of this study was to determine the frequency of emergency craniotomy and urgent laparotomy or thoracotomy in a group of 734 blunt trauma patients with initial hypotension (BP < 90 mm Hg systolic) admitted to the eight level I and II trauma centers in North Carolina. The mean initial systolic blood pressure was 64 +/- 26 mm Hg, and the mean Trauma Score was 8 +/- 5.8. Serious head injury (AIS head > or = 3) was present in 40% (293 of 734). Of 734 patients studied, 9.4% (69 of 734) died in the emergency department. Head CT scanning was performed on 47% (344 of 734) and produced positive results for 26% (202 of 734). Emergency craniotomy for intracranial hemorrhage was performed on 2.5% (18 of 734) (ten subdurals, three epidurals, and five other intracranial hemorrhages). Twenty-one percent (154 of 734) underwent urgent laparotomy, thoracotomy, or both. Overall hospital mortality for hypotensive blunt trauma patients was 36% (263 of 734). Although serious head injury occurs commonly (40%) in hypotensive blunt trauma patients, frequency of urgent laparotomy (21%) is 8.5 times greater than emergency craniotomy for intracranial hemorrhage (2.5%). This information may be used by trauma teams in prioritizing care for hypotensive blunt trauma patients.

Abdominal Injuries↗
PubMed1993

Injury severity grading in trauma patients: a simplified technique based upon ICD-9 coding.

UNLABELLED: The purpose of this study was to develop a simplified method of stratifying patient risk of death based on ICD-9 codes. METHODS: Data were obtained from a statewide trauma registry. A mortality risk ratio (MRR) was derived from a "training" subset by calculating a mortality rate for each ICD-9 code of interest. The independent variables of interest included TS, ISS, and MRRs (for the 1st & 2nd Dx, 1st op, & E code). RESULTS: (n = 37,100). When the 1st Dx and ISS were used as candidate variables in stepwise multivariate modeling, the MRR for the 1st Dx was the first variable to be entered into the model (1st Dx partial R2 = 0.37, ISS partial R2 = 0.02). CONCLUSION: This study shows that the 1st Dx is a better predictor of outcome than ISS. Since ICD-9 codes are more easily obtained and are better predictors of outcome, this study suggests that they may supersede the use of the ISS in injury severity scoring.

Adolescent↗
PubMed1992

Multiple resistance to sulfonylureas and imidazolinones conferred by an acetohydroxyacid synthase gene with separate mutations for selective resistance.

The acetohydroxyacid synthase (AHAS) gene from the Arabidopsis thaliana mutant line GH90 carrying the imidazolinone resistance allele imr1 was cloned. Expression of the AHAS gene under the control of the CaMV 35S promoter in transgenic tobacco resulted in selective imidazolinone resistance, confirming that the single base-pair change found near the 3' end of the coding region of this gene is responsible for imidazolinone resistance. A chimeric AHAS gene containing both the imr1 mutation and the csr1 mutation, responsible for selective resistance to sulfonylurea herbicides, was constructed. It conferred on transgenic tobacco plants resistance to both sulfonylurea and imidazolinone herbicides. The data illustrate that a multiple-resistance phenotype can be achieved in an AHAS gene through combinations of separate mutations, each of which individually confers resistance to only one class of herbicides.

Acetolactate Synthase↗
PubMed1992

The relationship between face or skull fractures and cervical spine and spinal cord injuries: a review of 13,834 patients.

A state trauma registry database containing 13,834 patients was evaluated to determine the relationship among 1,062 skull fractures, 1,329 facial fractures, 339 cervical spine injuries, and 299 spinal cord injuries. Categories studied were all trauma patients, motor vehicle crashes, automobile crashes (drivers, passengers, unknown), and belted and unbelted victims. Odds ratios calculated demonstrated that patients with skull and/or facial fractures did not have a higher likelihood of cervical spine or spinal cord injury as has been suggested. The lack of a relationship emphasizes the need for a greater vigilance for cervical spine and spinal cord injury in the group without facial or skull fractures. It appears that the pathological biomechanical forces causing each injury are a reflection of the different multiple forces associated with motor vehicle trauma.

Accidents, Traffic↗