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Biomedical subjects

T H Rainer

Publications and source records attributed to T H Rainer.

34 records · Page 2Linked to original sources
PubMed2000

Plasma DNA as a prognostic marker in trauma patients.

BACKGROUND: Recently, much interest has developed in the potential use of plasma DNA as a diagnostic and monitoring tool. We hypothesized that plasma DNA is increased in patients with trauma and may be prognostic in such patients. METHODS: We studied 84 patients who had sustained an acute blunt traumatic injury. We measured plasma DNA by a real-time quantitative PCR assay for the beta-globin gene. Blood samples were collected at a median time of 60 min following injury. Blood samples were also obtained from 27 control subjects. RESULTS: The median plasma DNA concentrations in the control, minor/moderate trauma (Injury Severity Score <16; n = 47), and major trauma (Injury Severity Score > or =16; n = 37) groups were 3154 kilogenome-equivalents/L, 13 818 kilogenome-equivalents/L, and 181 303 kilogenome-equivalents/L, respectively. Plasma DNA concentrations in patients with adverse outcomes, including acute lung injury, acute respiratory distress syndrome, and death, had 11. 6- to 12-fold higher plasma DNA concentrations than those who did not develop these complications. At a cutoff of 232 719 kilogenome-equivalents/L, the sensitivities of plasma DNA analysis for the prediction of acute lung injury, acute respiratory distress syndrome, and death were 100% (95% confidence interval, 100-100%), 100% (95% confidence interval, 100-100%), and 78% (95% confidence interval, 40-97%), respectively. The respective specificities were 81% (95% confidence interval, 71-89%), 80% (95% confidence interval, 70-88%), and 82% (95% confidence interval, 71-90%). CONCLUSIONS: Plasma DNA is increased after trauma and may be a potentially valuable prognostic marker for these patients.

Biomarkers↗
PubMed2000

Emergency medicine-the specialty.

The perception of emergency medicine as a defined specialty may vary widely in different locations around the world. While no single emergency medical system can fulfil the needs of all countries, there are three main models of delivery: the European model, the Anglo-American model, and the neglect model. This article reviews aspects of emergency medical systems around the world and compares the European and Anglo-American models of emergency care. The current state of emergency medicine in Hong Kong is also presented, including challenges facing the specialty as we enter the 21st century.

Asia↗
PubMed1999

Do peripheral blood counts have any prognostic value following trauma?

BACKGROUND: Both lymphocytosis and lymphopenia have been observed following trauma and each has been claimed to predict mortality. An understanding of the early temporal changes in leucocyte counts may help to explain why such discrepancies have been found. The purpose of this study was to determine the early serial changes in peripheral leucocyte counts following injury. METHODS: A whole blood cell counter was used to measure serial total leucocyte, granulocyte, lymphocyte and monocyte counts from 20 patients in the first 3 h following blunt injury. Four to six peripheral blood samples were taken from each subject and grouped into 20 min intervals. RESULTS: Granulocytosis, lymphocytosis and monocytosis were evident within 40 min of injury. A biphasic granulocyte and monocyte response was observed in the first 3 h following trauma. Lymphocytes showed a linear resolution towards normal (regression coefficient -0.022; p < 0.01) with some individuals developing a lymphopenia. No correlation with injury severity was observed. CONCLUSION: Rapid mobilisation and subsequent redistribution of leucocytes occurs early following injury. Temporal changes will affect any predictive value of circulating leucocytes and studies must be precise with respect to blood sampling time.

Adolescent↗
PubMed1999

Derivation of a prediction rule for post-traumatic acute lung injury.

The purpose of this study was to derive an early, highly sensitive and specific prediction rule for the development of post-traumatic acute lung injury (ALI). In a prospective, non-interventional study a convenience sample of 92 adults admitted to the resuscitation room following blunt trauma was studied in order to derive this prediction rule. The study was conducted in the emergency department of a university hospital in the New Territories of Hong Kong. One emergency physician assessed each patient for 25 variables, which might predict post-traumatic ALI, and the primary outcome measure was the presence or absence of ALI 48 h post-injury. Eleven variables associated with ALI were entered into a classification and regression tree (CART) in order to derive models predictive of ALI. Two models were developed and used to derive the decision rule. Acute lung injury was likely if either: (1) the patient had an ISS > 27 and a haematocrit < 0.37, or (2) the patient had a haematocrit < 0.36 and a total leucocyte count > 15. The first guideline had a classification rate of 96.7% (95% confidence interval (CI), 90.8-99.3%), a sensitivity of 100% (CI 65.2-100%) and a specificity of 96.5% (CI 90.0-99.3%). The second guideline had a classification rate of 96.7% (CI 90.8-99.3%), a sensitivity of 85.7% (CI 42.1-99.6%) and a specificity of 97.7% (CI 91.8-99.7%). Practical highly sensitive and specific prediction guidelines for post-traumatic acute lung injury have been derived and now require prospective validation.

Adult↗
PubMed1999

Adrenaline upregulates monocyte L-selectin in vitro.

OBJECTIVE: Although surface adhesion molecules mediate leucocyte-endothelial interactions at sites of inflammation, relatively little is known of the factors which increase the expression of L-selectin in circulating leucocytes. The expression of leucocyte L-selectin increases during acute stress events such as injury and is temporally related to an early neuroendocrine response. This study investigates whether adrenaline increases the expression of L-selectin on monocytes, neutrophils and lymphocytes in vitro and whether these effects are mediated via beta-adrenoceptors. METHODS: A total of 20 ml of blood was withdrawn from 28 healthy volunteers (21 males) with a mean age of 29 years (range 23-67 years). Adrenaline at physiological doses mimicking trauma (0-200 nmol/l) was added to whole blood prior to immunofluorescent staining and analysis by flow cytometry. Propranolol (50 microl of 2 x 10(-5) M) was also added to separate tubes prior to incubation with adrenaline. Saline (40 microl 0.9% solution) was used as a control. Expression is described firstly as percentage of cells expressing L-selectin and secondly as average intensity (mean channel fluorescence, mcf) per cell expressing CD62L. Summary measures were used to analyse the data. RESULTS: A significant increase in both the percentage of monocytes expressing L-selectin and mean channel fluorescence of L-selectin was evident with adrenaline in vitro (P < 0.0001). Maximal increases occurred at 100 nmol/l adrenaline when a 9% increase in the percentage of monocytes expressing L-selectin and a 23% increase in mean channel fluorescence were observed. These effects were both blocked by propranolol (P < 0.0001). No significant differences were observed for neutrophils or lymphocytes except for a slight increase in the percent neutrophils expressing L-selectin, and a small decreasing trend in percent lymphocytes expressing L-selectin. CONCLUSIONS: Adrenaline upregulates the surface expression of L-selectin on monocytes in vitro, an effect which is partially mediated by beta-adrenoceptors. As monocytes initiate early aspects of the inflammatory response, these findings suggest that beta-blockade may have an inhibitory role for certain aspects of leucocyte trafficking.

Adult↗
PubMed1999

Systemic hormonal, electrolyte, and substrate changes after non-thermal limb injury in children.

Relatively little is known regarding the hormonal changes after injury in children. Adult protocols are often applied to children, although the latter often have different physiological responses to trauma. Twenty children with an angulated displaced fracture of the radius and/or ulna (injury severity score 9) were studied prospectively for changes in adrenaline, noradrenaline, cortisol, angiotensin II, arginine vasopressin, urea, electrolytes, and glucose. Two blood samples were taken: one an arrival at the accident and emergency department and one preoperatively several hours later. There were marked increases in adrenaline, noradrenaline, cortisol, and arginine vasopressin above the normal range. Five (25%) cases demonstrated greater early increases in adrenaline than those reported for adult injuries of similar severity. Early hypokalaemia in four cases had corrected towards normal within a few hours, without potassium supplementation.

Adolescent↗
PubMed1999

Sonography compared with radiography in revealing acute rib fracture.

OBJECTIVE: This study was undertaken to compare the sensitivities of sonography and radiography for revealing acute rib fracture. SUBJECTS AND METHODS: Chest radiography and rib sonography were performed on 50 patients with suspected rib fractures. Sonography was performed with a 9- or 12-MHz linear transducer. Fractures were identified by a disruption of the anterior margin of the rib, costochondral junction, or costal cartilage. The incidence, location, and degree of displacement of fractures revealed by radiography and sonography were compared. Sonography was performed again after 3 weeks in 37 subjects. RESULTS: At presentation, radiographs revealed eight rib fractures in six (12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all reexamined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture. CONCLUSION: Sonography reveals more fractures than does radiography and will reveal fractures in most patients presenting with suspected rib fracture. Further scientific studies are needed to clarify the appropriate role for sonography in rib fracture detection.

Adult↗
PubMed1998

Leukocyte L-selectin is up-regulated after mechanical trauma in adults.

BACKGROUND: Infection and multiple organ failure remain the principal causes of late mortality after trauma despite advances in the resuscitation of injured patients. Because a better understanding of postinjury leukocyte trafficking is essential to the development of possible therapeutic measures aimed at preventing these complications, we have performed a study of one factor in the early posttrauma endothelial adhesion behavior of monocytes, lymphocytes, and neutrophils: their cell surface expression of L-selectin (CD62L). We have also studied the plasma levels of soluble L-selectin in these patients. METHODS: Two venous blood samples were taken from each of 41 trauma patients at median times of 1 and 20 hours after injury. The study group included 16 patients with major (Injury Severity Score (ISS) > or = 16), 17 with moderate (ISS = 9-15), and 8 with minor (ISS < 9) trauma. Cell surface L-selectin was measured on leukocyte subsets by staining with specific fluorescent-labeled monoclonal antibodies to CD62L and using flow cytometry. Both the percentage of cells expressing the molecule and the mean channel fluorescence were measured. Levels of soluble L-selectin were measured in the plasma, sampled concurrently, by enzyme-linked immunosorbent assay. RESULTS: Monocytes, lymphocytes, and neutrophils all showed an early increase in cell surface L-selectin expression as measured by mean channel fluorescence (p < 0.0001, p < 0.001, and p < 0.0001, respectively), and this persisted in later samples taken at a median 20 hours after injury (p < 0.0001,p < 0.0001, and p < 0.01). Only monocytes showed an increased percentage of cells expressing the molecule in the early phase (p < 0.02), and this remained in the later phase (p < 0.001). Monocytes also showed a further significant increase in mean channel fluorescence (p < 0.02) between the two periods. No significant changes in levels of plasma soluble L-selectin were found at either stage. CONCLUSION: An increase in the expression of L-selectin on each of three leukocyte populations has been demonstrated in the early phase after trauma. This would tend to promote rolling behavior of leukocytes and increase their contact with the vascular endothelium. There were marked differences in the later responses of the three populations, which may represent differential control of their behavior.

Adolescent↗
PubMed1997

Can the full range of paramedic skills improve survival from out of hospital cardiac arrests?

OBJECTIVE: To examine the effect of full implementation of advanced skills by ambulance personnel on the outcome from out of hospital cardiac arrest. SETTING: Patients with cardiac arrest treated at the accident and emergency department of the Royal Infirmary of Edinburgh. METHODS: All cardiorespiratory arrests occurring in the community were studied over a one year period. For patients arresting before the arrival of an ambulance crew, outcome of 92 patients treated by emergency medical technicians equipped with defibrillators was compared with that of 155 treated by paramedic crews. The proportions of patients whose arrest was witnessed by lay persons and those that had bystander cardiopulmonary resuscitation (CPR) were similar in both groups. RESULTS: There was no difference in the presenting rhythm between the two groups. Eight of the 92 patients (8.7%) treated by technicians survived to discharge compared with eight of 155 (5.2%) treated by paramedics (NS). Of those in ventricular fibrillation or pulseless ventricular tachycardia, eight of 43 (18.6%) in the technician group and seven of 80 (8.8%) in the paramedic group survived to hospital discharge (NS). For patients arresting in the presence of an ambulance crew, four of 13 patients treated by technicians compared with seven of 15 by paramedics survived to hospital discharge. Only two patients surviving to hospital discharge received drug treatment before the return of spontaneous circulation. CONCLUSIONS: No improvement in survival was demonstrated with more advanced prehospital care.

Adult↗
PubMed1997

Paramedics, technicians, and survival from out of hospital cardiac arrest.

OBJECTIVE: To test the hypothesis that limited paramedic advanced life support skills afford no advantage in survival from cardiac arrest when compared with non-paramedic ambulance crews equipped with defibrillators in an urban environment; and to investigate whether separate response units delayed on scene times. METHODS: A prospective, observational study was conducted over 17 consecutive months on all adult patients brought to the accident and emergency (A&E) department of Glasgow Royal Infirmary having suffered an out of hospital cardiac arrest of cardiac aetiology. The main interventions were bystander cardiopulmonary resuscitation (CPR) and limited advance life support skills. MAIN OUTCOME MEASURES: Return of spontaneous circulation, survival to admission, and discharge. RESULTS: Of 240 patients brought to the A&E department, 19 had no clear record of whether a paramedic was or was not involved and so were excluded. There was no difference in survival between the two groups, although a trend to admission favoured non-paramedics. Paramedics spent much longer at the scene (P < 0.0001). Witnessed arrests (P = 0.01), early bystander CPR (P = 0.12), shockable rhythms (P = 0.003), and defibrillation (P < 0.0001) were associated with better survival. Intubation and at scene times were not associated with better survival. Delayed second response units did not prolong at scene times. CONCLUSIONS: The interventions of greatest benefit in out of hospital cardiac arrest are basic life support and defibrillation. Additional skills are of questionable benefit and may detract from those of greatest benefit.

Adolescent↗
PubMed1996

Adrenaline, cardiac arrest, and evidence based medicine.

In this article we review the evidence supporting the clinical application of adrenaline in cardiopulmonary arrest, and summarize the receptor effects of catecholamines and the basic principles producing perfusion during CPR. Animal and human studies show that in cardiac arrest, adrenaline has positive haemodynamic effects, increasing systemic pressures, myocardial perfusion, and cerebrally directed flow. The problems extrapolating from animal to human data are highlighted. Studies showing improvements in short term survival outcomes with high dose regimens have not been confirmed by other large prospective randomised trials. There is no evidence that high doses of adrenaline improve survival to hospital discharge. Most studies comparing adrenaline with placebo have been non-randomised and uncontrolled, with major methodological problems. Conclusions are difficult, but if anything adrenaline is associated with poorer outcomes.

Adrenergic Agonists↗
PubMed1996

Critical analysis of an accident and emergency ward.

OBJECTIVES: To describe the work, both qualitatively and quantitatively, of an accident and emergency (A&E) ward, and discuss some of the advantages and disadvantages associated with this ward. METHODS: An observational study was carried out of all patients admitted to the A&E ward of Glasgow Royal Infirmary from 1 January 1992 to 31 December 1992. Epidemiological and management data were collected for all patients admitted. RESULTS: There were 2460 admissions, of which 69% were related to trauma and 45% to head injury; 47% of the patients had consumed alcohol before admission. Accidental trauma was the commonest reason for admission (57%), followed by assault (33%). Ninety two per cent of admissions stayed for less than 3 d, but 33% of the workload was spent on a small number of patients admitted for longer than 7 d. CONCLUSIONS: This A&E ward presents a significant workload, and some of its most serious problems lie with those patients who stay longer than 72 h. The safe and effective use of the ward depends upon it being well resourced, along with the department it serves.

Adolescent↗
PubMed1995

Evaluation of outcome following cardiac arrest in patients presenting to two Scottish emergency departments.

OBJECTIVES: To compare and contrast outcomes following cardiac arrest managed in two Accident and Emergency departments, and to identify factors which might account for such differences. DESIGN: Prospective 1-year evaluation of patients sustaining an out-of-hospital cardiac arrest. SETTING: The Accident and Emergency departments of the Edinburgh (ERI) and Glasgow (GRI) Royal Infirmaries which serve two large urban municipalities. PATIENTS: All patients sustaining a prehospital cardiac arrest and brought to ERI or GRI were included. Children (< 13 years), those declared dead on arrival at the scene, and events related to poisoning, near drowning, trauma and pregnancy were excluded. MEASUREMENTS AND MAIN RESULTS: There were 297 prehospital arrests from ERI, and 158 from GRI. Eighty-two (27.6%) were admitted as 'in-patients' to ERI and 23 (14.6%) to GRI (P < 0.01). Thirty-nine (13.1%) survived to hospital discharge from ERI; 13 (8.2%) survived to discharge from GRI (NS). The proportion of VF/VT:Asystole observed was significantly different between the two centres--162:98 from ERI, 54:73 from GRI (P < 0.001). Significantly more prehospital arrests were witnessed and received bystander CPR in those brought to ERI (P < 0.02). For the combined VF/VT/Asystole groups the ERI ambulance response times were significantly shorter (P < 0.01). However, there was no significant difference in the collapse to EMS arrival at the scene times between ERI and GRI. Two survivors from ERI had asystole as their initial observed rhythm. From GRI, one survivor had asystole, one had electromechanical dissociation and in another the initial rhythm was unknown. No survivor to discharge had severe neurological disability. CONCLUSIONS: Patients suffering out-of-hospital cardiac arrests in Edinburgh have a significantly better chance of being admitted to a ward. There is a trend favouring better survival to discharge in Edinburgh, but with the numbers investigated this does not achieve statistical significance. Amongst those factors which contribute to survival there are fewer witnessed arrests, less bystander CPR and slower ambulance response times in those brought to GRI. There is a need to investigate the environment in which patients collapse, to train the public in CPR, and to review the efficiency and resourcing of the ambulance service.

Adolescent↗
PubMed1995

Pre-hospital cardiopulmonary resuscitation and pneumoperitoneum.

A case is reported of pneumoperitoneum after prolonged ventilation of a smoke inhalation victim at the scene by a fireman using intermittent positive pressure ventilation. The clinical presentation, treatment and aetiology, when associated with cardiopulmonary resuscitation, are discussed. The need for adequate training in the use of resuscitation equipment is emphasized, especially for non-medical staff.

Emergency Medical Services↗
PubMedDate not supplied

An evaluation of paramedic activities in prehospital trauma care.

The object of the study was to identify the effect paramedics have on prehospital trauma care and evaluate their influence on outcome compared to that of ambulance technicians. A prospective review of ambulance and hospital records was conducted over 2 years from 1 August 1993 to 31 July 1995. The setting for the study was the Royal Infirmary of Edinburgh and its primary response catchment area served by the South-East Region of the Scottish Ambulance Service central control room. The study involved 1090 patients brought to hospital by ambulance who met the entry criteria for the Scottish Trauma Audit Group study. The results show that paramedics spend significantly longer at scene than the ambulance technicians; however, there was no difference in total prehospital times between the groups. Paramedics direct a significantly higher proportion of patients to the resuscitation room and significantly more of these patients go to theatre, intensive care or the mortuary. There is no reduction in mortality or length of stay in intensive care in the paramedic group. The authors conclude that paramedics deliver an improved process of care but their activities do not significantly reduce mortality or length of stay in intensive care.

Adolescent↗