Age-related differences in mechanism, cause, and location of trauma deaths.

BACKGROUND: Trauma death has traditionally been described as primarily occurring in young men exposed to penetrating trauma or road traffic accidents. The epidemiology of trauma fatalities in Europe may change as a result of the increasing proportion of elderly patients. The goal of this study was to describe age-related differences in trauma type, mechanism, cause and location of death in a well-defined European region. METHODS: We prospectively registered all trauma patients and severe burn patients in eastern Denmark over 12 consecutive months. We analyzed all trauma fatalities in our region regarding the trauma type, mechanism, cause and location of death. RESULTS: A total of 2,923 patients were registered, of which 292 (9.9%) died within 30 days. Mortality increased with age, with a mortality of 46.1% in patients older than 80 years old. Blunt trauma was the most frequent trauma type at all ages, but the trauma mechanism differed among ages, with falls constituting 46.8% of trauma deaths in the elderly. The primary cause of death was head and spine injuries across all age-groups. Death took place before arrival at the hospital in 45% of the cases, but death during primary admission became increasingly important with advanced age. CONCLUSION: Increasing age was associated with higher mortality, an increased proportion of falls and fatal head or spine injuries.

Inter- and intraobserver study of radiographic assessment of cemented total hip arthroplasties.

Radiographs are commonly used to identify loosened total hip prostheses. Interobserver and intraobserver variation was studied in an attempt to interpret 60 random pairs of radiographs with a time interval of 6 months to 12 years between the radiographs. Each of the four observers evaluated all pairs of radiographs independently, and the evaluations were repeated after 2 to 4 weeks. Each observer classified the femoral stem and the acetabular cup separately as stable or loose. Radiolucent lines of more than 2 mm were recorded. For the acetabular components, any change in inclination or migration was noted, and for the femoral components, subsidence or any change in varus or valgus of the stem was noted. There was considerable disagreement in observations of the acetabular component; agreement by all four observers was obtained in only 34 of 60 cases (57%). For the femoral component, agreement was obtained in 37 cases (62%). The observers agreed two and two (pairwise) on the acetabular component in 70 to 83% of cases and on the femoral component, in 72 to 82% of cases. Intraobserver variation was great with regard to the acetabular component, with kappa values ranging from 0.489 to 0.633. As to the femoral component, kappa values ranged from 0.737 to 0.800. Interpretation of radiographs of artificial hip arthroplasty is difficult, and comparisons between different series of implants should be made by the same person.

Outcome of infected total knee arthroplasty.

The results of 44 cases of deep infection after total knee arthroplasty were reviewed. The average age of the patients was 62 years (range, 31-81 years), and all had positive bacterial cultures from deep aspiration or tissue biopsy. Osteitis was revealed in 22 cases. One case was initially treated with antibiotics only, 27 cases were treated with surgical debridement and antibiotics, and 16 cases had immediate removal of the prosthesis. In 21 cases, failed debridement was followed by removal of the prosthesis. Revision arthroplasty was attempted in 15 of the 37 cases in which the prosthesis was removed; the infection was cured in 11 cases. A total of 25 cases that underwent removal of the prosthesis had an arthrodesis performed, and 4 ultimately underwent amputation. In no case of osteitis was the infection cured merely by debridement and antibiotics, and the index prostheses were retained mainly in cases in which osteitis did not develop.

Variation of cortical hypertrophy depending on the medullary filling material. An experimental study of canine tibial diaphysis.

In order to evaluate the mineralization of bone after polymethyl methacrylate cementation, measurements of the periosteal apposition were made histologically and measurements of the bone-mineral content were made by dual-photon absorptiometry of the tibial diaphysis in 15 adult mongrel dogs in paired studies. Six dogs were investigated 4 weeks after intramedullary reaming of both sides and obturation of the medullary cavity with bone-wax on one side. Nine dogs were reamed on both sides. The medullary cavities were filled with polymethyl methacrylate bone-cement and bone-wax, respectively. The authors found (1) an increased bone-mineral content and an increased periosteal apposition after filling with bone-wax in comparison with the reamed side and (2) a decreased bone-mineral content and a decreased periosteal apposition on the cemented side in comparison with bone-wax. These findings are interpreted as consequential upon repair processes with a high remodeling and mineralization rate after reaming or filling with bone-wax, whereas remodeling in inhibited after filling with acrylic bone-cement.

The influence of smoking on complications after primary amputations of the lower extremity.

A total of 165 primary above-the-knee (AK) and below-the-knee (BK) amputations in 137 patients were reviewed retrospectively. Of the 77 patients who smoked, 44 smoked cigarettes, 30 cheroots, and three a pipe. There were 88 nonsmokers. At the time of surgery, the smokers were on average 6.4 years younger than the nonsmokers. The review revealed no discrepancy between smokers and nonsmokers with regard to amputation level, the BK to AK ratio being 2:1. In cigarette smokers the risk of infection and reamputation was 2:5 times higher than in cheroot smokers or nonsmokers. The poor results obtained in cigarette smokers may be ascribed to the fact that this group of patients smoked during the phase of healing and that only cigarette smokers tend to inhale. Inhalation of smoke leads to high concentrations of nicotine, which compromise the cutaneous blood-flow velocity and increase the risk of the formation of microthrombi. Consequently, amputees should abstain from cigarette smoking during the phase of healing. Preferably, the habit should be broken one week before surgery, which is the requisite period for the process of coagulation and the fibrinogen level to normalize and for free radicals to be eliminated.

[Injured cyclists and bicycle passengers. A prospective study of the causes of accidents, accident patterns and consequences]. / Kvaestede cyklister og cykelpassagerer. En prospektiv undersøgelse af ulykkesårsager, skademønstre og konsekvenser.

In a one-year prospective investigation in 1985, all bicycle accidents in Denmark were registered. The circumstances of the accident were recorded. All injuries were classified in the AIS and the ISS scales. After one year, the patients were contacted and sick leave and sequelae were registered. A total of 576 patients (320 men and 256 women), were treated after bicycle accidents. Bicycle accidents were seen most frequently in the ages from 5 to 19 years. The accidents were distributed uniformly over the week and occurred most frequently in the summer. 392 of the accidents were single-accidents, and the majority had used a bicycle-track if possible. Collision with other road users and bad road conditions were responsible for 41%, and defects in the bicycle for 9%, mainly on handlebars, front fork, front wheel, gear and chain. Two were admitted dead, and 114 were admitted to hospital (20%) for median four days. Eleven per cent had sustained serious lesions (fractures or lesions of the head). 556 had an AIS-score less or equal to three and un 387 the AIS-score was one. 561 had an ISS-score less than ten, five between ten and 75 and two had 75. Eight patients could not be classified. The patients AIS score is determined as the highest score of an injured region. AIS score of 6 is fatal. The ISS score is the addition of the square of the 3 highest AIS values. ISS of 75 is fatal. AIS is thus a value of the most serious lesion and ISS is a value of how traumatized the patient is.(ABSTRACT TRUNCATED AT 250 WORDS)

[Moped accidents. A prospective study on the causes of accidents, injury patterns and sequelae]. / Knallertulykker. En prospektiv undersøgelse af ulykkesårsager, skademønster og konsekvenser.

In a one year prospective investigation, the circumstances and sequelae of 75 moped accidents were registered. The patients were aged mainly between 14 and 18 years and the accidents happened mainly in the afternoon hours. The majority of the injuries were on the head and the extremities. Twenty-one of the patients were admitted to hospital for median 4.8 days, 50 were treated as outpatients and four were dead on admission. The patients were contacted one year after the accident and one had severe sequelae and five had minor sequelae.

Epidemiology of distal forearm fractures in Danish children.

We recorded all the distal forearm fractures in inhabitants under 20 years of age in Frederiksborg County, Denmark, throughout 1985. The population at risk was 97,791 persons, and fractures occurred in 269 boys and 205 girls. The peak incidence in girls occurred at ages 10-12 (105 per 10,000) and in boys at ages 12-14 (100 per 10,000). Fractures occurred more often in the autumn than in the spring.

The influence of age and smoking on the elimination of disopyramide.

The influences of smoking and age on the elimination kinetics of disopyramide were studied in 27 subjects. Total elimination clearance of disopyramide was measured after an infusion to steady state. The total elimination clearance was significantly (P less than 0.05) decreased in elderly non-smoking patients compared with young non-smoking subjects (1.54 +/- 0.33 vs 2.12 +/- 0.67 ml kg-1 min-1) (mean +/- s.d.). Smoking more than 20 cigarettes per day significantly (P less than 0.05) increased total elimination clearance in elderly (2.02 +/- 0.35 vs 1.54 +/- 0.33 ml kg-1 min-1), while no significant induction by tobacco was observed in young healthy persons. Serum concentrations of alpha 1-acid glycoprotein, the major binding protein of disopyramide, were significantly higher (P less than 0.001) in the elderly patients. However, the volume of distribution (V) was significantly (P less than 0.001) greater in the elderly patients (2.44 +/- 0.64 vs 1.16 +/- 0.15 1 kg-1). Steady-state serum concentrations of the free drug were significantly (P less than 0.01) lower in the young volunteers (0.75 +/- 0.13 micrograms ml-1) than in the elderly (0.90 +/- 0.10 micrograms ml-1). The half-life of disopyramide was significantly shorter (P less than 0.01) in the young volunteers than in the elderly patients. No difference was observed in the relationship between the serum concentration of disopyramide and its main dealkylated metabolite in the groups studied. The results indicate that it might be advisable to reduce the dosage of disopyramide by approximately 30% in elderly non-smokers compared with young subjects.

Kinetics of disopyramide after intravenous infusion to patients with myocardial infarction and heart failure.

Total body clearance, half-life and volume of distribution of disopyramide (Norpace, Searle G.D.) was measured during a six to eight hour infusion to steady state in twenty four patients with either congestive heart failure or acute myocardial infarction and compared to eleven patients without these diseases. All patients were given a bolus injection of 150 mg disopyramide followed by a continuous infusion of 18-24 mg per hour. Serum concentration of disopyramide and its main dealkylated metabolite were determined by HPLC. The clearance in patients without myocardial infarction or congestive heart failure was 1.71 +/- 0.60 ml/min./kg (mean +/- S.D.), not significantly different from those who had either myocardial infarction, congestive heart failure or both. Half-life was 798 min. in patients without heart failure, not significantly different from the values in the other groups. The ratio between disopyramide and its metabolite varied between 3 to 10. Twenty-six % of the steady state serum concentrations of disopyramide were outside the recommended therapeutic range (2-5 micrograms/ml), but no adverse haemodynamic effects were observed in any of the patients. The suggested dosage regimen of disopyramide seems to result in a satisfactory response.

Atenolol inhibits the elimination of disopyramide.

The effect of atenolol on the total elimination of disopyramide and its main dealkylated metabolite was studied in 6 patients and 3 volunteers. During administration of 50 mg atenolol b.i.d. the clearance of disopyramide decreased significantly (p less than 0.02) from 1.90 +/- 0.71 (mean +/- SD) to 1.59 +/- 0.68 ml/kg/min, while its half-life, concentration of the metabolite, and the volume of distribution remained unchanged. The reduction in the clearance of disopyramide by atenolol might contribute to the alleged pharmacodynamic interaction between disopyramide and beta-blocking drugs.