Evaluating helicopter emergency medical missions: a reliability study of the HEMS benefit and NACA scores.

BACKGROUND: The benefits of the Helicopter Emergency Medical Service (HEMS) and dispatch accuracy are continuously debated, and a widely accepted score to measure the benefits of the mission is lacking. The HEMS Benefit Score (HBS) has been used in Finnish helicopter emergency medical services, but studies are lacking. The National Advisory Committee for Aeronautics (NACA) score is widely used to measure the severity of illness or injury in the pre-hospital setting, but it has many critics due to its subjectivity. We investigated the inter-rater and rater-against-reference reliability of these scores. METHODS: Twenty-five fictional HEMS missions were created by an expert panel. A total of 22 pre-hospital physicians were recruited to participate in the study from two different HEMS bases. The participants received written instructions on the use of the scores. Intraclass correlation coefficients (ICCs) and mean differences between rater-against-reference values were calculated. RESULTS: A total of 17 physicians participated in the study. The ICC was 0.70 (95% CI 0.57-0.83) for the HBS and 0.65 (95% CI 0.51-0.79) for the NACA score. Mean differences between references and raters were -0.09 (SD 0.72) for the HBS and 0.28 (SD 0.61) for the NACA score, indicating that raters scored some lower NACA values than reference values formed by an expert panel. CONCLUSION: The HBS and NACA score had substantial inter-rater reliability. In addition, the rater-against-reference values were acceptable, though large differences were observed between individual raters and references in some clinical cases.

Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study.

BACKGROUND: Finland has the fourth highest injury mortality rate in the European Union. To better understand the causes of the high injury rate, and prevent these fatal injuries, studies are needed. Therefore, we set out to complete an analysis of the epidemiology of fatal trauma, and any contributory role for alcohol, long suspected to promote fatal injuries. As a study area, we chose the four northernmost counties of Finland; their mix of remote rural areas and urban centres allowed us to correlate mortality rates with 'rurality'. METHODS: The Causes of Death Register was consulted to identify deaths from external causes over a 5-year time period. Data were retrieved from death certificates, autopsy reports and medical records. The municipalities studied were classified as either rural or urban. RESULTS: Of 2915 deaths categorized as occurring from external causes during our study period, 1959 were eligible for inclusion in our study. The annual crude mortality rate was 54 per 100,000 inhabitants; this rate was higher in rural vs. urban municipalities (65 vs. 45 per 100,000 inhabitants/year). Additionally, a greater number of pre-hospital deaths from accidental high-energy trauma occurred in rural areas (78 vs. 69%). 42% of all pre-hospital deaths occurred under the influence of alcohol. CONCLUSION: The crude mortality rate for fatal injuries was high overall as compared to other studies, and elevated in rural areas, where pre-hospital deaths were more common. Almost half of pre-hospital deaths occurred under the influence of alcohol.

Farm exposures are associated with lower percentage of circulating myeloid dendritic cell subtype 2 at age 6.

BACKGROUND: Early life farm exposures have been shown to decrease the risk of allergic diseases. Dendritic cells (DCs) may mediate asthma-protective effect of farm exposures as they play an important role in the development of immunity and tolerance. Our aim was to investigate whether the numbers and phenotypes of circulating DCs at age 6 are associated with farming, asthma, and atopy in a selected sample of French and Finnish children from the PASTURE study. METHODS: We studied 82 farm and 86 nonfarm children with and without asthma. Using flow cytometry, BDCA1+ CD11c+ myeloid DC1s (mDC1), BDCA3+(high) mDC2s and BDCA2+ plasmacytoid DCs (pDCs) were identified and expressions of CD86, immunoglobulin-like transcript 3 (ILT3) and ILT4 were analyzed. Questionnaires were used to assess prenatal and lifetime patterns of farm exposures and to define asthma. Atopic sensitization was defined by specific IgE measurements. RESULTS: The percentage of mDC2 cells was lower in farm children (0.033 ± 0.001) than in nonfarm children (0.042 ± 0.001; P = 0.008). Similar associations were found between mDC2 percentage and prenatal (P = 0.02) and lifetime exposure to farm milk (P = 0.03) and stables (P = 0.003), but these associations were not independent from farming. Asthma was positively associated with ILT4 + mDCs (P = 0.04) and negatively with CD86 + pDCs (P = 0.048) but only in nonfarm children. CONCLUSIONS: Inverse association between farm exposure and mDC2 percentage suggest that this DC subset may play a role in farm-related immunoregulation.

Clonal variation in interferon response determines the outcome of oncolytic virotherapy in mouse CT26 colon carcinoma model.

In our earlier studies, Semliki Forest virus vector VA7 completely eliminated type I interferon (IFN-I)-unresponsive human U87-luc glioma xenografts, whereas interferon-responsive mouse gliomas proved refractory. Here, we describe in two clones of CT26 murine colon carcinoma, opposed patterns of IFN-I responsiveness and sensitivity to VA7. Both CT26WT and CT26LacZ clones secreted biologically active interferon in vitro upon virus infection but only CT26WT cells were protected. Focal infection of CT26WT cultures was self-limiting but could be rescued using IFN-I pathway inhibitor Ruxolitinib or antibody against IFNß. Whole transcriptome sequencing (RNA-Seq) and protein expression analysis revealed that CT26WT cells constitutively expressed 56 different genes associated with pattern recognition and IFN-I signaling pathways, spanning two reported anti-RNA virus gene signatures and 22 genes with reported anti-alphaviral activity. Whereas CT26WT tumors were strictly virus-resistant in vivo, infection of CT26LacZ tumors resulted in complete tumor eradication in both immunocompetent and severe combined immune deficient mice. In double-flank transplantation experiments, CT26WT tumors grew despite successful eradication of CT26LacZ tumors from the contralateral flank. Tumor growth progressed uninhibited also when CT26LacZ inoculums contained only a small fraction of CT26WT cells, demonstrating dominance of IFN responsiveness when heterogeneous tumors are targeted with interferon-sensitive oncolytic viruses.

Pre-hospital airway management by non-physicians in Northern Finland -- a cross-sectional survey.

BACKGROUND: Airway management is an important skill in pre-hospital emergency medicine. The most optimal method depends on the resources and experience of the emergency medical service (EMS) providers. We wanted to study the frequency of occurrence, equipment used, problems experienced and maintenance of skills in pre-hospital airway management by non-physicians. METHODS: A structured questionnaire consisting of 30 questions was distributed to 383 EMS providers in three hospital districts (population 597,521 and area 147,467 km(2) ) in Northern Finland. RESULTS: The questionnaire was answered by 226 EMS providers and 58.5% (224/383) were included in the final analyses. In all, 82.6% (185/224) of the EMS providers were allowed to perform endotracheal intubation (ETI) and 44.2% (99/224) could perform ETI using sedative agents. The annual mean frequency of using a supraglottic airway device (SAD) was 1.0 (range 0-20, n = 224), for ETI it was 2.0 (range 0-16, n = 185) and for bag-valve-mask ventilation it was 4.3 (range 0-30, n = 223). The mean frequency of drug-assisted ETI was 1.1 (range 0-13, n = 99). Unsuccessful ETI had been experienced by 65.7% (119/181) of the EMS providers. Airway management had been practised in an operating room by 25.9% (56/216) and with a manikin by 81.3% (182/224) of the EMS providers during the past 12 months. CONCLUSION: Advanced airway management procedures are uncommon for most EMS providers in Northern Finland. Procedures, training in and maintenance of airway management skills should be re-evaluated.

Development of renal failure during the initial 24 h of intensive care unit stay correlates with hospital mortality in trauma patients.

BACKGROUND: Although multiple organ failure is the leading late cause of death, there is controversy about the impact of acute organ dysfunction and failure on trauma survival. METHODS: Consecutive adult trauma admissions between January 2000 and June 2003, excluding isolated head traumas and burns, were analysed for parameters of organ function during the first 24 h following intensive care unit (ICU) admission using the Sequential Organ Failure Assessment (SOFA) scoring system. A national prospectively collected ICU data registry was used for analysis, including data from 22 ICUs in university and central hospitals in Finland. RESULTS: The study population consisted of 1044 eligible trauma admissions; 32% of the cases were treated at university hospital level, the rest being secondary referral central hospital admissions. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15 (SD8), ICU mortality was 5.6% and a further 1.6% of patients died during their post-ICU hospital stay. Forty-five per cent of the patients were categorized as having multiple traumas. In univariate analysis, APACHE II > or = 25 [odds ratio (OR), 35; 95% confidence interval (CI), 18-66] and renal failure (OR, 29.5; 95% CI, 14-63) produced the highest ORs for ICU mortality. In the APACHE II-, sex- and age-adjusted logistic regression model, renal failure was a significant risk factor for both ICU and hospital mortality (OR, 11.8; 95% CI, 3.9-35.4; OR, 8.2; 95% CI, 2.9-23.2, respectively). CONCLUSION: The development of renal failure during the initial 24 h of ICU stay remained an independent risk factor for mortality in trauma patients requiring intensive care treatment even after adjusting for the APACHE II score, age and sex.

IL-10 is highly expressed in the cryptorchid cryptepididymal epithelium: a probable mechanism preventing immune responses against autoantigenic spermatozoa in the epididymal tubule.

The expression of several immunoregulatory adhesion proteins and cytokines was studied in the normal epididymis, cryptorchid cryptepididymis, the epididymis of oestrogen-treated mice and the epididymis of non-obese diabetic (NOD) mice at the protein level to see which of these immunoregulatory proteins may be involved in lymphocyte regulation in the normal or pathological epididymis and if cytokine balance in this organ is on the cellular or humoral side. The aim of the study was to characterize the immunological microenvironment of the epididymis to explain the survival of the autoantigenic spermatozoa in this site. In the 6-week-old BALB/c or NOD mouse epididymis there were some CD18 and CD44 expressing cells in the interstitial tissue. There were no differences between these strains in the expression of the studied antigens, except that some CD4 positive cells were present in the interstitial tissue of BALB/c mice. In the cryptorchid cryptepididymis CD4, CD8, CD18, CD44, CD54 and CD106 expressing cells were occasionally present in the connective tissue surrounding the epididymal tubule. In the epididymis of the oestrogen-treated mice these antigens were not expressed. In the cryptorchid cryptepididymis the epithelial cells expressed IL-10 highly and the myoid peritubular cells IL-6. The present results suggest that the epididymal epithelial IL-10 suppressing TH0, TH1 and TH2 immune responses may be involved in the protection of autoantigenic spermatozoa from immune destruction.

Two percent lidocaine spinal anaesthesia compared with sevoflurane anaesthesia in ambulatory knee surgery - cost-effectiveness, home readiness and recovery profiles.

A total of 60 patients scheduled for elective knee arthroscopy were randomized to receive spinal anaesthesia (SA) with 2% lidocaine (n=30) or general anaesthesia with sevoflurane (SE) (n=30). SA and SE were compared in terms of the total costs of anaesthesia. The time to reach home readiness and the total time spent in the recovery unit (RU) were assessed. The early postoperative period and recovery at 24 h and 1 week were evaluated in terms of the incidence of pain, sedation, nausea and general satisfaction with the method of anaesthesia and postoperative instructions. The total costs of anaesthetic materials in the operation theatre (OT) and anaesthetic materials and personnel costs until home readiness was achieved in the RU were 160.7 FIM (1 FIM=0.17 EUR) for SA and 171.0 FIM for SE (not significant). The corresponding sums were 197.2 FIM for SA and 224.4 FIM for SE (P=0.001) when the total stay in RU was considered. The time to reach home readiness was 140.8 min (S.D. 52) in the SA group and 96.4 min (S.D. 62) in the SE group (P=0.02). There were no differences in the total RU time (224.0 min (S.D. 67) for SA and 218.0 min (S.D. 59) for SE). The level of postoperative pain was generally low, as all the SA patients and 86.7% of the SE patients had VAS<4 2 h postoperatively. Six SA patients (20.0%) had postoperative headache and two of them also had headache in the supine position. There were no headaches in the SE group (P=0.024). None of the patients in the SA group and six SE patients (20.0%) had nausea (needed treatment) in the RU (P=0.024). Four patients (13.3%) in the SE group and 1 patient (3.3%) in the SA group had nausea during the first 24 h postoperatively. All the patients were alert 60 min postoperatively with no difference between the groups and they were very satisfied during the first 24 h. All patients would have liked to have a similar operation done on an ambulatory basis. 93.3% said they would choose the same kind of anaesthesia. 91.7% were satisfied with the first week.General anaesthesia with SE is more cost-effective than SA with 2% lidocaine in ambulatory knee surgery if a short RU time is needed. The patients do generally well, but the incidence of postspinal headache with SA, adequate postoperative pain treatment and the possibility to have nausea with SE must be kept in mind.

Cytokines in the BALB/c mouse testis in various conditions.

AIM: To investigate whether testosterone, estrogens, vasectomy, experimental cryptorchidism, varicocele or aging would induce changes in the cytokine environment of the mouse testis. METHODS: In adult male BALB/c mice, testosterone implants, estradiol benzoate, vasectomy, unilateral cryptorchidism, unilateral varicocele were administered/performed. The mice were followed up for different periods of time and were then sacrificed with testes incised for examination. The control mice received the vehicle or sham-operation. RESULTS: IL-10 was present in Leydig cells of nearly every testis and IL-10 + macrophages in 39% of testes. IL-6 was found in the testes of intact adult mice, mice treated with testosterone for 70 days, cryptorchid testes and sham-operated testes. CONCLUSION: Results suggest that IL-10 might be involved in the generation of the immunologically privileged microenvironment in the testis.

One-week recovery profiles after spinal, propofol, isoflurane and desflurane anaesthesia in ambulatory knee arthroscopy.

There are comprehensive findings on the immediate recovery of patients from different types of anaesthesia, but more information is needed on how patients manage at home after ambulatory surgery. One hundred and seventy-three elective knee arthroscopy patients were randomised into four different anaesthesia groups to receive either spinal anaesthesia (SA) with 5% lidocaine or general anaesthesia (GA) with propofol infusion, isoflurane inhalation or desflurane inhalation. The patients were interviewed over the phone on the next day and asked to complete a questionnaire after 1 week. One hundred and sixty-eight patients (97%) were reached by phone. The questionnaire was returned by 163 patients (94%). After 24 h, all the patients were satisfied with the type of anaesthesia they had received, but 2% of the SA patients would have chosen GA and 4.3% of the GA patients would have chosen SA for the next operation. Based on the questionnaires returned after 1 week, 8.3% of the SA patients would have wanted to have GA, and 4.7% of the GA patients would have wanted to have SA in the future. The incidence of nausea (4.2%) and vomiting (1.8%) was very low in the whole series, with no differences between the anaesthesia groups. Headache after 24 h was experienced by 15.7% of the SA and 10.3% of the GA patients. After 1 week, SA patients reported headache upon standing in 13.5% of the cases, backache in 36.5% and lower leg pain in 59.6%. The corresponding figures for GA patients were 4.5, 9.9 and 39.6% (P<0.05). In spite of the good immediate recovery profile in the all anaesthesia groups, the fact that SA patients reported a higher incidence of headache, backache and lower leg pain after 1 week may be signs of post spinal headache and transient neurologic symptoms (TNS). For overall patient comfort, GA might be a better anaesthetic choice in ambulatory surgery.

Sperm antibodies in rat models of male hormonal contraception and vasectomy.

The presence of sperm antibodies correlates with nearly every pathological condition of the male reproductive tract. In the seasonal breeder, mink, a decrease in gonadotrophin secretion and testicular regression also induces sperm antibodies. Because the Sertoli cells and the principal cells of the epididymis (i.e. the cells mainly responsible for protection of germ cells from autoimmune destruction) are dependent on androgens, and because the androgen concentration decreases in both the testis and epididymis during male hormonal contraception, the presence of IgG class sperm antibodies in serum was studied in rats during the suppression and recovery phases of testosterone contraception and after vasectomy. Five-centimetre long testosterone implants were placed under the dorsal skin of rats under pentobarbitone anaesthesia. The control rats received empty implants. All implants were left in the rats for 27 or 53 days. The total number of testicular antigens detected by sera from the vasectomized rats increased significantly until 66 days post-operation, and then decreased to the levels of intact rats. The number of testicular antigens detected by sera from rats receiving contraceptive doses of testosterone did not increase before the testosterone capsules were removed, but at 40 days post removal of the silastic capsules, the number of antigens detected by the sera was significantly higher than in intact rats and at 77 days post removal of the silastic capsules, the number of antigens detected by the sera was significantly higher than at 27 days after starting testosterone administration. No significant changes in the number of antigens detected by the sera could be observed after the implanting of empty capsules or after their removal. Vasectomy mostly induced antibodies against testicular antigens in the molecular ratio ranges of 70-82, 25-33 and 21-24.5 kD. Antibodies against antigens in these molecular ratio ranges were not significantly induced during or after treatment with contraceptive doses of testosterone. Cell nuclei with apoptotic morphology could be observed in the seminiferous tubules of the vasectomized rats, but DNA in situ 3'-end labelling of testes could not confirm any differences between the testes of vasectomized and sham-operated rats or between testosterone-treated and empty implant-treated rats. CD3+ T cells could not be observed in the testes of any of the treatment groups. These results suggest that the immunological conditions remain stable in the testes after vasectomy and during testosterone treatment, but that the animals are more prone to develop autoantibodies after vasectomy and during recovery from treatment with exogenous testosterone.

CD106 (VCAM-1) in testicular immunoregulation.

The expression of CD18, CD49d/CD29, CD44, CD54 and CD106 was studied in the testis of normal mice at various ages, in the cryptorchid testis, in the testis of estrogen-treated mice and in the testis of non-obese diabetic (NOD) mice, using immunocytochemistry to see which of these lymphocyte and endothelial adhesion proteins may be involved in lymphocyte regulation in the testis. CD18-, CD49d/CD29-, CD44- and CD54-expressing cells were not found in the normal > 10-week-old BALB/c mouse testis. Leydig cells expressed CD106 strongly at this age. In contrast to the > 10-week-old testis, only very few interstitial cells of the 2-week-old normal mice expressed CD106. The expression of CD106 increased gradually with age so that at 6 weeks of age the expression of CD106 was moderate in the interstitial tissue. In the experimentally abdominal testis, CD106 was expressed in the interstitial tissue as strongly as in the contralateral scrotal testis. CD44- and CD18-expressing cells were occasionally present in the interstitial tissue of the abdominal testis, but not in the contralateral scrotal testis. CD54 was present in the epithelium of the ductuli efferentes. In the testis of the estrogen-treated mice, CD106 was expressed in the interstitial tissue as strongly as in the normal mice. Occasional CD44- and CD18-expressing cells were found in the testicular capsule. In the testis of adult NOD mice, CD106 was present in the interstitial tissue, but none of the other studied proteins. Immunoblotting of CD106 from the adult testis under reducing conditions demonstrated a single broad band with a M(r) of 51-65 kDa. This is a novel isoform of CD106. In a modified Stamper-Woodruff assay, lymphocytes bound to the testicular interstitial tissue. In co-incubations of native Leydig cells and lymphocytes, anti-CD106 antibodies prevented formation of Leydig cell-lymphocyte rosettes more than isotype-matched irrelevant control antibodies, suggesting that Leydig cell lymphocyte binding occurs through CD106-CD49d interactions. In lymphocyte cultures in the presence of anti-CD3, anti-CD28, the M(r) > 5 K fraction of testis extract (containing CD106 as shown by immunoblotting) and anti-CD106 or control antibody, anti-CD106 did not consistently affect T cell 3H-TdR incorporation. The present results suggest that CD106 expressed by the Leydig cells may act as an adhesion-promoting molecule or a co-stimulatory factor for T cells migrating to the testis.

Effects of intrauterine growth retardation and its subtypes on the development of the preterm infant.

The aim of this prospective study was to examine the neurological development of preterm children with asymmetric (A-SGA) or symmetric (S-SGA) intrauterine growth retardation (IUGR). Twenty-six A-SGA preterm children, 27 S-SGA preterm children and 131 appropriate for gestational age (AGA) preterm children were compared with 121 full-term AGA children. They were assessed by one author at the corrected age of 18 months +/- 2 weeks using the modified Denver Developmental Screening Test. Development was evaluated in terms of scores for fine motor and gross motor performance, for visuo-auditory perception, for speech and for social abilities. In the A-SGA group there were more children with low visuo-auditory perception scores and social abilities scores than in the control group. The S-SGA group differed from the other groups in all developmental sectors except visuo-auditory perception. Numbers of neurologically abnormal or suspect children in both SGA groups were twice the number in the control group. IUGR and sex were the only factors that correlated with slow neurological development. These results show that there will be a significant possibility of slow neurological development if a preterm baby has been subject to IUGR, especially symmetric IUGR.

The neurological condition of the newborn infant with maternal hypertension, examined at term.

The aim of this prospective study was to examine the effect of maternal hypertension on the neurological condition of the newborn infant. Of the babies born between April 1984 and March 1986, 54 preterm, 151 full-term AGA and 24 full-term SGA neonates with maternal hypertension were compared, respectively, with 128 preterm, 144 full-term AGA and 73 full-term SGA neonates without maternal hypertension. Preterms were examined at term +/- 1 week and full-term neonates at 3-5 days postpartum by the Dubowitz method (Clinics in Developmental Medicine, Vol. 79, Heinemann, London, 1981). The respective full-term groups differed mostly in regard to movement and tone, with preterm groups differing in the predominant state and in auditory orientation. The differences were clearest between preterm AGA groups. The neurological condition of the infants was affected more by pre-eclampsia than by hypertension as such. Statistical analysis was carried out with the t-test, chi2-test and stepwise discriminant analysis.