Biomedical subjects

Scott G Thomas

Publications and source records attributed to Scott G Thomas.

16 recordsLinked to original sources

PubMed2006

Comparison of body composition assessment methods in patients with human immunodeficiency virus-associated wasting receiving growth hormone.

CONTEXT: Bioelectrical impedance spectroscopy (BIS) and skinfold anthropometry (SKF) have been used to monitor body composition among patients with HIV wasting; however, validation of these techniques during recombinant human GH (rhGH) treatment has not been performed. OBJECTIVE: Our objective was to evaluate the degree of agreement between criterion measurements of dual-energy x-ray absorptiometry (DXA) and those of BIS and SKF in patients with HIV wasting treated with rhGH. DESIGN AND SETTING: We conducted a randomized, double-blinded, placebo-controlled, two-period crossover trial at the University of Toronto and Mount Sinai Hospital (Toronto, Canada). PATIENTS: A referred sample of 27 community-dwelling men with HIV-associated weight loss (> or =10% over preceding 12 months) despite optimal antiretroviral therapy participated in the study. INTERVENTION: Intervention was one daily injection of rhGH (6 mg) or placebo self-administered for 3 months in a crossover fashion with a 3-month washout. MAIN OUTCOME MEASURES: Fat-free mass (FFM) and fat mass (FM) were measured by BIS, SKF, and DXA before and after rhGH and placebo treatment. RESULTS: FFM(BIS) was not significantly different from FFM(DXA) after rhGH treatment (P = 0.10). Mean differences (bias +/- sd) according to Bland-Altman analysis were smaller for SKF than for BIS (P < 0.05) at all time points, yet treatment-induced change in FM was better detected with BIS than with SKF. BIS estimates of FFM and FM showed better agreement with those of DXA after rhGH treatment (1.6 +/- 4.6 kg and -2.1 +/- 3.9 kg) compared with baseline (3.8 +/- 3.5 kg and -4.1 +/- 3.6 kg) and placebo (2.7 +/- 4.4 kg and -3.1 +/- 4.6) (P < 0.05). BIS overestimated and SKF underestimated the treatment-induced changes in FFM and FM. CONCLUSIONS: SKF was more accurate than BIS when measuring body composition in patients with HIV wasting before and after rhGH treatment; nonetheless, the accuracy of BIS increased after treatment. Change in FM because of treatment was not accurately assessed with SKF.

Absorptiometry, Photon↗

PubMed2006

Improving the sensitivity of the hop index in patients with an ACL deficient knee by transforming the hop distance scores.

BACKGROUND: The one leg hop for distance is one of the most commonly employed functional tests utilized in the evaluation of the ACL deficient and reconstructed patient. While the reliability of the hop test scores has been well established, validity studies have revealed low sensitivity rates in detecting functional limitations using the hop index (the ratio or percentage of limb performance). However, the impact of the inherent limitations associated with the hop index have not been investigated to date. One specific limitation relates to the impact of the differences in the underlying hop distance scores. Therefore, this pilot study set out to determine: 1) the impact that between limb differences in hop distance has on the sensitivity of the hop index in detecting functional limitations and; 2) whether a logarithmic transformation of the underlying hop distance scores improves the sensitivity of the hop index. METHODS: A cross sectional design involving the evaluation of one leg hop for distance performance in a consecutive sample of 10 ACL deficient males with an isolated ACL tear awaiting reconstructive surgery and nine gender, age-matched controls. RESULTS: In the ACL deficient, the hop index was associated with the distance hopped on the non-injured limb (r = -0.66, p = 0.04) but not on the injured limb. Transformation (logarithmic) of the hop distance scores and re-calculation of the hop index using the transformed scores increased the sensitivity of the hop index in the detection of functional limitations from 20 to 60% and 50 to 70% using the normal limb symmetry reference norms of > or = 85% and 90% respectively. CONCLUSION: The distance hopped on the non-injured limb is a critical factor in detecting functional limitations using the hop index in patients with an ACL deficient knee. Logarithmic transformation of the hop distance scores minimizes the effect of the arithmetic differences between limbs however; the sensitivity of the hop index in detecting abnormal limb symmetry remains low.

Adult↗

PubMed2006

Maximal exercise test results in subacute stroke.

OBJECTIVES: To establish the feasibility and reliability of graded maximal exercise testing, suitability of standard indexes of maximum oxygen consumption (Vo(2)max), and evidence of trial-to-trial practice effects in subacute stroke. DESIGN: Descriptive, cross-sectional study. SETTING: Rehabilitation hospital. PARTICIPANTS: Consecutive sample of 35 participants (mean age, 65.7+/-2.6 y; mean days poststroke, 17.6+/-2.2 d). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Graded maximal exercise test using semirecumbent cycle ergometry. A subset (n=20) performed repeated tests to determine test-retest reliability and presence of practice effects. RESULTS: Thirty-one (89%) participants completed the exercise test without symptomatic responses (mean peak level of oxygen consumed [Vo(2)peak], 10.7 mL.kg(-1).min(-1); peak work rate, 39 W). Twelve (34%), 15 (44%), and 3 (9%) participants achieved oxygen consumption per unit time (Vo(2)) plateau, respiratory exchange ratio, and heart rate criteria, respectively. Although test-retest correlations were high (intraclass correlation coefficient range, .67-.87), higher Vo(2)peak (1.0 mL.kg(-1).min(-1), P=.04) and work rate (7.3 W, P=.01) were observed with repeated testing, with no associated increase in reaching standard criteria for Vo(2)max. CONCLUSIONS: This work has important implications for developing guidelines for measuring aerobic capacity early after stroke. Although maximal exercise testing using semirecumbent cycle ergometry is feasible, standard Vo(2)max criteria are not consistently appropriate. At least 1 practice trial is recommended before the actual evaluation is performed.

Adult↗

PubMed2005

Anabolic growth hormone action improves submaximal measures of physical performance in patients with HIV-associated wasting.

Growth hormone (GH) treatment reverses the muscle loss allegedly responsible for diminished aerobic capacity and increased fatigue in patients with HIV-associated wasting. This study examined whether submaximal measures of physical performance can be used as objective measures of the functional impact of GH treatment-induced anabolism. We randomized 27 HIV-positive men [mean (SD) age, 43.9 (7.2) yr; body mass, 71.9 (10.4) kg; BMI, 23.1 (2.8) kg/m2] with unintentional weight loss despite antiretroviral therapy to receive GH (6 mg) or placebo in a double-blinded, placebo-controlled, cross-over trial with a 3-mo washout. Lean body mass (LBM), maximum oxygen uptake (Vo2 peak), ventilatory threshold (VeT), 6-min walk test (6MWT) distance and work, profile of mood states (POMS) fatigue and vigor scores, and Nottingham health profile (NHP) energy and physical mobility scores were measured. LBM significantly increased after 3 mo of GH treatment vs. placebo (means +/- SE, 3.7 +/- 0.6 vs. 0.3 +/- 0.4 kg; P < 0.001). VeT significantly improved (17.6 +/- 3.7 vs. -5.9 +/- 2.5%; P < 0.001), but Vo2 peak did not change significantly. 6MWT distance improved (24.9 +/- 9.7 vs. 19.9 +/- 11.6 m; P > 0.05) and 6MWT work increased significantly more after 3 mo of GH treatment (33.3 +/- 8.8 vs. 16.5 +/- 7.5 kJ; P < 0.05). POMS scores of fatigue and vigor and the NHP score of energy improved, yet the changes were not statistically significant. GH treatment improved VeT linearly to the increase in LBM (r =0.43, P = 0.037) and 6MWT work (r = 0.51, P = 0.008), and the increase in 6MWT work correlated with increase in LBM (r = 0.45, P = 0.024). Improvement in 6MWT work above the median (27.3 kJ) showed a decrease in fatigue (r = -0.62, P = 0.024). We concluded that GH treatment-induced LBM gains in HIV-associated wasting were functionally relevant, as determined by effort-independent submaximal measures of cardiopulmonary exercise testing.

Adult↗

PubMed2005

Circulating and synovial levels of IGF-I, cytokines, physical function and anthropometry differ in women awaiting total knee arthroplasty when compared to men.

PURPOSE: Determine if gender differences in osteoarthritis relate to cytokine and growth factor levels. METHODS: Cross-sectional comparison of serum and synovial concentrations of cytokines (IL-1alphabeta, TNF-alpha, IL-6), growth factors (IGF-I, TGF-beta, IRAP), physical performance and perceived function in total knee arthroplasty candidates (TKAC) (n=17) and healthy controls (n=21) was done. RESULTS: Serum IGF-I values were reduced in female (TKAC 137.6+/-7.2; Controls 160.2+/-26.2) but not male TKAC (TKAC 182.6+/-18.4; Controls 184.0+/-18.4) (p<0.05).). Serum and synovial levels of cytokines and growth factors did not differ significantly by group or gender. Physical performance testing (SPW, TUG) revealed significant group and gender differences (p=0.001) with women demonstrating greater functional impairment. DISCUSSION: A systemic, not local component to OA pathophysiology may exist for female TKAC. Male TKAC were less impaired, and their IGF-I levels differ little from Control values.

Aged↗

PubMed2004

Acute and chronic effects of hormone replacement therapy on the cardiovascular system in healthy postmenopausal women.

Previous studies have shown that conjugated estrogens and continuous medroxyprogesterone increases heart disease risk in healthy women. Little is known about the effects of the natural ovarian hormones estradiol and progesterone on cardiovascular function at rest and exercise. The purpose of this study was to investigate the short- and longer-term effects of a cyclic format of hormone replacement therapy (HRT) (1 mg estradiol daily with cyclic micronized progesterone, 200 mg for 10 d/month) on cardiovascular function at rest and during exercise in healthy, postmenopausal women. A double-blind, cross-over study was conducted in 31 patients. Peak oxygen uptake and ventilatory threshold in addition to submaximal cardiac output were determined. Peripheral measures of resting and peak ischemic blood flows were also determined. Measurements were made at baseline, after 4 h of estrogen/placebo exposure, and subsequently after 1, 2, and 3 months. The sequence of data collection was repeated after 6-wk washout. Oral estradiol with cyclic micronized progesterone increases peak ischemic peripheral blood flow chronically but fails to improve exercise tolerance and peak oxygen uptake. Similarly, submaximal central cardiovascular function is unaffected by HRT. This suggests that estradiol has a beneficial effect on peripheral blood flow, but this benefit offers little advantage in terms of peak exercise performance after 3 months of HRT.

Cardiac Output↗

PubMed2004

Growth hormone treatment improves peripheral muscle oxygen extraction-utilization during exercise in patients with human immunodeficiency virus-associated wasting: a randomized controlled trial.

The arteriovenous oxygen difference (a-vO(2) difference), a measure of peripheral muscle oxygen extraction-utilization during exercise, is reduced in antiretroviral-treated patients with human immunodeficiency virus (HIV), thus causing a shift in the cardiac output-oxygen consumption (Q-VO(2)) relationship. We investigated the impact of recombinant human GH (rhGH) treatment on a-vO(2) difference and the Q-VO(2) relationship during submaximal exercise by randomizing 12 HIV-infected patients (mean +/- sem: age, 43.3 +/- 1.5 yr; body mass, 69.5 +/- 2.9 kg; body mass index, 22.4 +/- 0.9 kg/m(2); maximum oxygen consumption, 33.6 +/- 1.5 ml/kg x min), with documented unintentional weight loss (>or=10% within the preceding 12 months) despite antiretroviral therapy, to receive 3 months of rhGH (6 mg/d) in a double-blind, placebo-controlled, cross-over trial. We assessed Q (determined noninvasively using CO(2) rebreathing), and subsequently a-vO(2) difference, from Q-VO(2) relationships. At study entry, the mean slope (8.1 +/- 1.0 liters/min x 1-liter increase in VO(2)) and intercept (3.1 +/- 1.3 liters/min), generated from each patient's Q-VO(2) relationship, were greater and lower, respectively, than those reported for healthy individuals (6.0 and 4.0, respectively), thereby indicating a deficit in the a-vO(2) difference. After 3 months of rhGH treatment, the slope decreased to 7.0, and the intercept increased to 3.5. After 1 month of rhGH treatment, the a-vO(2) difference (at a VO(2) of 1250 ml/min) significantly (P < 0.05) increased (17.1 +/- 8.9%) from baseline (9.92 +/- 0.51 ml/dl) and remained elevated (10.39 +/- 0.48 ml/dl) after 3 months of treatment. No significant changes were seen with placebo. Therefore, treatment with rhGH leads to an improvement in peripheral muscle oxygen extraction-utilization and the Q-VO(2) relationship during exercise in patients with HIV-associated wasting despite antiretroviral therapy.

Adult↗

PubMed2003

Short-term aerobic training and circulatory function in women: age and hormone-replacement therapy.

The physiological basis of training responses in women, and particularly older women, is not well understood. Short-term aerobic training (STAT) was used to probe the effects of age and hormone-replacement therapy (HRT) on women's ability to rapidly change peak uptake ( VO(2max)), plasma volume and cardiac function. A total of 39 females participated in the STAT programme: 15 younger (Y; aged 19-29 years), 12 postmenopausal women undergoing HRT and 12 non-medicating postmenopausal (PM) women (aged 60-75 years). Training consisted of ten sessions of cycling over a 2-week period, which progressed in duration from 20 to 60 min and in intensity from 60-75% of maximum heart rate. Plasma volume (PV; as determined by Evan's Blue dye dilution), VO(2max) (cycle ergometry) and cardiac function (radionuclide ventriculography) were analysed using analysis of covariance or repeated measures ANOVA. All groups demonstrated similar increase in VO(2max) (Y, 13%; PM, 17%; HRT, 13%), but without a significant change in left-ventricular ejection fraction and diastolic function or volumes during supine exercise. PV expansion was observed among the Y group (7%; P <0.05) but not the PM group (2%; P >0.05) or women undergoing HRT (1%; P >0.05). Age and hormone-replacement status did not affect the magnitude of VO(2max) change. This study suggests that STAT improves VO(2max), independent of central adaptations.

Adult↗

PubMed2003

Women awaiting knee replacement have reduced function and growth hormone.

Women experience greater functional impairment and occurrence of osteoarthritis than men. We hypothesized that lower levels of serum insulin-like growth factor-I may contribute to gender differences in physical impairments. A cross-sectional comparison (n = 139) was done on candidates having total knee arthroplasty and healthy controls subjects of similar age (range, 55-75 years). Physical function, perceived function, and serum insulin-like growth factor levels were compared across group and gender using analysis of variance. Insulin-like growth factor-I values were markedly reduced in women overall and women having surgery had significantly reduced levels despite lean body mass correction. Values consistent with clinical hormone deficiency were observed in 21% of women and only 4% of men having arthroplasty. Physical function was markedly reduced in women, at times functioning only 33% when compared with healthy women, whereas men's limitations were not as profound. The current findings indicate that physical function is more impaired and serum insulin-like growth factor-I is markedly reduced in women awaiting arthroplasty than their male counterparts. The gender differences observed biochemically and with functional performance indicate that the pathophysiology of end stage osteoarthritis may differ between men and women.

Activities of Daily Living↗

PubMed2003

Myostatin is a skeletal muscle target of growth hormone anabolic action.

Myostatin is a cytokine that has recently been shown to selectively and potently inhibit myogenesis. To investigate the mechanisms of anabolic actions of GH on skeletal muscle growth, we examined the in vitro and in vivo effects of GH on myostatin regulation. Twelve GH-deficient hypopituitary adult subjects were treated with recombinant GH (5 micro g/kg.d) in a double-blind, placebo-controlled fashion. Body composition and physical function were assessed and skeletal muscle biopsies from the vastus lateralis performed at 6-monthly intervals during 18 months of treatment. Myostatin mRNA expression was significantly inhibited to 31 +/- 9% (P < 0.001) of control by GH but not by placebo administration (79 +/- 11%) as determined by quantitative real-time PCR normalized for the housekeeping glyceraldehyde-3-phosphate dehydrogenase gene. The inhibitory effect of GH on myostatin was sustained after 12 and 18 months of GH treatment. These effects were associated with increases in lean body mass and translated into enhanced aerobic performance as determined by maximal oxygen uptake and ventilation threshold. Parallel in vitro studies of skeletal muscle cells demonstrated significant reduction of myostatin expression by myotubes in response to GH, compared with vehicle treatment. Conversely, GH receptor antagonism resulted in up-regulation of myostatin in myoblasts. Given the potent catabolic actions of myostatin, our data suggest that myostatin represents a potential key target for GH-induced anabolism.

Adult↗

PubMed2003

Exercise training benefits growth hormone (GH)-deficient adults in the absence or presence of GH treatment.

Reduced aerobic capacity is a prominent manifestation among patients with GH deficiency (GHD). Exercise training may improve the physiological capacity to undertake aerobic activity. The ability of patients with GHD to participate in and benefit from a structured program of aerobic exercise with or without replacement recombinant human GH (rhGH) was investigated. We examined the effect of aerobic training on cycle ergometers in a double-blind crossover trial. Ten patients with GHD trained for 3 months with rhGH (6 microg/kg.d) or placebo, stopped both exercise and drug for 2 months, and resumed training for another 3 months with the other agent. Peak oxygen uptake (VO(2)peak) and ventilation threshold (VeT) were measured during a progressive cycle ergometer test to fatigue or symptom-limited maximum. Serum IGF-I levels were monitored to assess compliance with GH treatment. VO(2)peak was low at the two baseline measures (B1, 19.3 +/- 5.5; B2, 19.9 +/- 6.9 ml/kg.min; normal, approximately 30 ml/kg.min) as was VeT (B1, 11.6 +/- 2.2 ml/kg.min; B2, 11.7 +/- 2.6 ml/kg.min; normal, approximately 16 ml/kg.min). Exercise training increased VeT with (8.6%) or without (9.4%) rhGH treatment. Similarly, exercise training resulted in significant reduction in submaximal heart rate in the presence (-5 +/- 4 beats per minute; P < 0.05) or absence of rhGH treatment (-4 +/- 4 beats per minute; P < 0.05). Peak oxygen uptake was not significantly affected by training with or without rhGH treatment. Our findings suggest that exercise training is a feasible intervention in GH-deficient adults that can measurably improve their submaximal responses to exercise. The beneficial effects of exercise can mimic and are not additive to the effects of GH treatment alone.

Adult↗

PubMed2003

Exercise training in women with heart disease: influence of hormone replacement therapy.

PURPOSE: To examine the central and peripheral cardiovascular effects of exercise training in postmenopausal women with CAD with and without hormone replacement therapy (HRT and N-HRT). METHODS: Thirty-eight female cardiac patients referred for cardiac rehabilitation were divided into HRT ( N= 18) or N-HRT (N = 20) groups. Peak oxygen uptake (VO2) peak and ventilatory anaerobic thresholds (AT) were determined, in addition to submaximal cardiac output (Q). Peripheral measures of resting and peak ischemic blood flows (BF) were also measured. Measurements were all repeated after 12 and 26 wk of exercise training consisting of 1 h of walking at 75-80% of the measured VO2peak at baseline (T1) for 5 d.wk(-1). RESULTS: VO2peak mL.kg(-1).min(-1) at baseline (14.9 +/- 0.4) increased by 5% after 12 wk (15.6 +/- 0.4) and significantly by 15% (17.2 +/- 0.5) after 26 wk of exercise training (P < 0.001). The HRT group was significantly younger than the N-HRT group (58 vs 65 yr; P < 0.01) and had significantly higher VO2peaks at baseline (15.7 vs 14.2 mL.kg(-1).min(-1); P < 0.05), yet either did not influence changes in other variables. At fixed submaximal work rates, there was a significant training bradycardia ( P < 0.01), but insignificant changes in Q or stroke volume regardless of HRT status. Resting and peak ischemic calf BF and vascular conductance increased significantly ( P < 0.001) at 12 and 26 wk, with no difference found according to HRT status. CONCLUSIONS: The cardiovascular responses to training in postmenopausal women with CAD appear to be consistent regardless of HRT status and dominated by peripheral adaptations.

Aged↗

PubMed2003

Systems modelling of the relationship between training and performance.

Mathematical models may provide a method of describing and predicting the effect of training on performance. The current models attempt to describe the effects of single or multiple bouts of exercise on the performance of a specific task on a given day. These models suggest that any training session increases fitness and provokes a fatigue response. Various methods of quantifying the training stimulus (training impulse, absolute work, psychophysiological rating) and physical performance (criterion scale, arbitrary units) are employed in these models. The models are empirical descriptions and do not use current knowledge regarding the specificity of training adaptations. Tests of these models with published data indicate discrepancies between the predicted and measured time course of physiological adaptations, and between the predicted and measured performance responses to training. The relationship between these models and the underlying physiology requires clarification. New functional models that incorporate specificity of training and known physiology are required to enhance our ability to guide athletic training, rehabilitation and research.

Humans↗

PubMed2003

Physical activity and its relationship to physical performance in patients with end stage knee osteoarthritis.

STUDY DESIGN: Cross-sectional observational design. OBJECTIVES: To compare physical activity levels in men and women with end-stage knee osteoarthritis to those of a comparison group and to examine the relationship between physical activity level and physical performance. BACKGROUND: Osteoarthritis of the knee is associated with significant losses in functional performance and high social costs. Although reductions in physical activity are reported, they have not been quantified or explored. METHODS AND MEASURES: Fifty-nine candidates awaiting total knee arthroplasty (TKAC group) and 79 individuals without osteoarthritis (comparison group) participated. Physical activity was assessed using the Voorrips Questionnaire. Performance measures included fast self-paced walk test, timed up-and-go test, and a timed stair performance measure. A subset of subjects completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and underwent muscular strength and endurance testing. The effects of gender and group were tested using GLM ANOVA. Pearson product moment correlations were used to examine relationships between the variables. RESULTS: All aspects of physical activity were lower (P<.001) in the TKAC group, with a moderate difference in household score (18%) and a large difference in leisure activities (63%). Unlike the comparison group, modest but significant correlations (r = 0.31-0.33, P<.03) were observed between overall physical activity and performance test scores for the TKAC group. Physical activity was not significantly related to pain reported on the WOMAC or during the performance tasks. CONCLUSIONS: The belief that pain limits the physical activity of patients with severe osteoarthritis requires further investigation. The profound differences between a comparison group and patients with end-stage osteoarthritis in physical activity have critical implications for the well-being and effective treatment of this population.

Activities of Daily Living↗

PubMed2002

Ventilation threshold as a measure of impaired physical performance in adults with growth hormone excess.

OBJECTIVE: Fatigue is a prominent symptom among patients with GH excess and acromegaly. Identifying the physiological basis of such complaints and obtaining objective measures to quantify their severity remains an ongoing challenge. We investigated whether submaximal measures of aerobic performance can be used to assess GH excess-associated fatigue objectively. DESIGN AND PATIENTS: To investigate this possibility we examined the relation between physical function and physical capacity in 12 patients with active acromegaly and persistent fatigue before and after 3 and 6 months of treatment with the long-acting somatostatin analogue octreotide (LAR(R)). MEASUREMENTS: Heart rate (HR) and rating of perceived exertion (RPE using Borg's 10-point scale) were measured during a 160-metre self-paced walk test (SPW). Maximum oxygen uptake (VO2max) and ventilation threshold (VeT: a measure of work rate when breathlessness develops) were measured during a progressive treadmill test to fatigue or symptom-limited maximum. The Profile Of Mood States questionnaire (POMS) was used to quantify subjective feelings of fatigue and vigour. Morning fasting levels of GH and IGF-I were measured using immunoassay of serum samples. RESULTS: SPW speed at a fast pace of 1.69 +/- 0.18 m/s was achieved with higher than normal HR (112 +/- 15/min; normal = 102) and RPE (2.4 +/- 1.2). Similar to GH-deficient adults, VO2max (22.6 +/- 6.4 ml.kg-1.min-1; normal approximately 30 ml.kg-1.min-1) and VeT (13.1 +/- 2.9 ml.kg-1.min-1; predicted normal approximately 16 ml.kg-1(min-1) were low. However, VeT occurred at a normal fraction of VO2max (VeT/VO2max = 0.58). VeT was significantly increased and plasma IGF-I levels reduced following 3 and 6 months of octreotide LAR(R) treatment. Reduction in circulating IGF-I levels was correlated with improvement in reported vigour (r = 0.85) and VeT (r = 0.65) (P < 0.05). CONCLUSIONS: Our findings demonstrate impairment in physical function and physical capacity consistent with the perception of increased fatigue among acromegalic patients. These objective measures of compromised physical function are similar to the changes that we have reported previously in adults with GH deficiency. Taken together, these data suggest that a narrow window for GH/IGF-I levels is required to maintain optimal physical function.

Acromegaly↗

PubMedDate not supplied

Reducing missed injuries at a level II trauma center.

The phenomenon of missed injury in trauma patients has been recognized for some time. Tertiary examination has been proposed as one strategy to decrease the incidence of missed injuries. The tertiary examination is a comprehensive reevaluation that includes a repeated head-to-toe examination and review of all laboratory and radiologic studies, completed within 24 hours of admission. The purpose of this study was to assess the statistical significance of missed injuries discovered through tertiary examinations at a level II trauma center. Over a period of 6 months, a tertiary examination was completed before discharge of admitted patients who met activation criteria. Of the 90 patients, 13 had a missed injury (incidence of 14%), which was significant. The 16 missed injuries represented only 2.7% of the total 589 injuries, which was not significant. The most commonly missed injuries were fractures of the extremities. We propose that tertiary examinations be adopted as a standard of care for patients admitted to level II trauma centers.

Diagnostic Errors↗