The Ca2+ -binding protein sorcin stimulates transcriptional activity of the unfolded protein response mediator ATF6.

Sorcin is a calcium-binding protein involved in maintaining endoplasmic reticulum (ER) Ca2+ stores. We have previously shown that overexpressing sorcin under the rat insulin promoter was protective against high-fat diet-induced pancreatic beta-cell dysfunction in vivo. Activating transcription factor 6 (ATF6) is a key mediator of the unfolded protein response (UPR) that provides cellular protection during the progression of ER stress. Here, using nonexcitable HEK293 cells, we show that sorcin overexpression increased ATF6 signalling, whereas sorcin knock out caused a reduction in ATF6 transcriptional activity and increased ER stress. Altogether, our data suggest that sorcin downregulation during lipotoxic stress may prevent full ATF6 activation and a normal UPR during the progression of obesity and insulin resistance.

Explosive-driven double-blast exposure: molecular, histopathological, and behavioral consequences.

Traumatic brain injury generated by blast may induce long-term neurological and psychiatric sequelae. We aimed to identify molecular, histopathological, and behavioral changes in rats 2 weeks after explosive-driven double-blast exposure. Rats received two 30-psi (~ 207-kPa) blasts 24 h apart or were handled identically without blast. All rats were behaviorally assessed over 2 weeks. At Day 15, rats were euthanized, and brains removed. Brains were dissected into frontal cortex, hippocampus, cerebellum, and brainstem. Western blotting was performed to measure levels of total-Tau, phosphorylated-Tau (pTau), amyloid precursor protein (APP), GFAP, Iba1, αII-spectrin, and spectrin breakdown products (SBDP). Kinases and phosphatases, correlated with tau phosphorylation were also measured. Immunohistochemistry for pTau, APP, GFAP, and Iba1 was performed. pTau protein level was greater in the hippocampus, cerebellum, and brainstem and APP protein level was greater in cerebellum of blast vs control rats (p < 0.05). GFAP, Iba1, αII-spectrin, and SBDP remained unchanged. No immunohistochemical or neurobehavioral changes were observed. The dissociation between increased pTau and APP in different regions in the absence of neurobehavioral changes 2 weeks after double blast exposure is a relevant finding, consistent with human data showing that battlefield blasts might be associated with molecular changes before signs of neurological and psychiatric disorders manifest.

Neuronal and glial changes in the brain resulting from explosive blast in an experimental model.

Mild traumatic brain injury (mTBI) is the signature injury in warfighters exposed to explosive blasts. The pathology underlying mTBI is poorly understood, as this condition is rarely fatal and thus postmortem brains are difficult to obtain for neuropathological studies. Here we report on studies of an experimental model with a gyrencephalic brain that is exposed to single and multiple explosive blast pressure waves. To determine injuries to the brain resulting from the primary blast, experimental conditions were controlled to eliminate any secondary or tertiary injury from blasts. We found small but significant levels of neuronal loss in the hippocampus, a brain area that is important for cognitive functions. Furthermore, neuronal loss increased with multiple blasts and the degree of neuronal injury worsened with time post-blast. This is consistent with our findings in the blast-exposed human brain based on magnetic resonance spectroscopic imaging. The studies on this experimental model thus confirm what has been presumed to be the case with the warfighter, namely that exposure to multiple blasts causes increased brain injury. Additionally, as in other studies of both explosive blast as well as closed head mTBI, we found astrocyte activation. Activated microglia were also prominent in white matter tracts, particularly in animals exposed to multiple blasts and at long post-blast intervals, even though injured axons (i.e. ß-APP positive) were not found in these areas. Microglial activation appears to be a delayed response, though whether they may contribute to inflammation related injury mechanism at even longer post-blast times than we tested here, remains to be explored. Petechial hemorrhages or other gross signs of vascular injury were not observed in our study. These findings confirm the development of neuropathological changes due to blast exposure. The activation of astrocytes and microglia, cell types potentially involved in inflammatory processes, suggest an important area for future study.

Screening of biochemical and molecular mechanisms of secondary injury and repair in the brain after experimental blast-induced traumatic brain injury in rats.

Abstract Explosive blast-induced traumatic brain injury (TBI) is the signature insult in modern combat casualty care and has been linked to post-traumatic stress disorder, memory loss, and chronic traumatic encephalopathy. In this article we report on blast-induced mild TBI (mTBI) characterized by fiber-tract degeneration and axonal injury revealed by cupric silver staining in adult male rats after head-only exposure to 35 psi in a helium-driven shock tube with head restraint. We now explore pathways of secondary injury and repair using biochemical/molecular strategies. Injury produced ∼25% mortality from apnea. Shams received identical anesthesia exposure. Rats were sacrificed at 2 or 24 h, and brain was sampled in the hippocampus and prefrontal cortex. Hippocampal samples were used to assess gene array (RatRef-12 Expression BeadChip; Illumina, Inc., San Diego, CA) and oxidative stress (OS; ascorbate, glutathione, low-molecular-weight thiols [LMWT], protein thiols, and 4-hydroxynonenal [HNE]). Cortical samples were used to assess neuroinflammation (cytokines, chemokines, and growth factors; Luminex Corporation, Austin, TX) and purines (adenosine triphosphate [ATP], adenosine diphosphate, adenosine, inosine, 2'-AMP [adenosine monophosphate], and 5'-AMP). Gene array revealed marked increases in astrocyte and neuroinflammatory markers at 24 h (glial fibrillary acidic protein, vimentin, and complement component 1) with expression patterns bioinformatically consistent with those noted in Alzheimer's disease and long-term potentiation. Ascorbate, LMWT, and protein thiols were reduced at 2 and 24 h; by 24 h, HNE was increased. At 2 h, multiple cytokines and chemokines (interleukin [IL]-1α, IL-6, IL-10, and macrophage inflammatory protein 1 alpha [MIP-1α]) were increased; by 24 h, only MIP-1α remained elevated. ATP was not depleted, and adenosine correlated with 2'-cyclic AMP (cAMP), and not 5'-cAMP. Our data reveal (1) gene-array alterations similar to disorders of memory processing and a marked astrocyte response, (2) OS, (3) neuroinflammation with a sustained chemokine response, and (4) adenosine production despite lack of energy failure-possibly resulting from metabolism of 2'-3'-cAMP. A robust biochemical/molecular response occurs after blast-induced mTBI, with the body protected from blast and the head constrained to limit motion.

Characteristics of an explosive blast-induced brain injury in an experimental model.

Mild traumatic brain injury resulting from exposure to an explosive blast is associated with significant neurobehavioral outcomes in soldiers. Little is known about the neuropathologic consequences of such an insult to the human brain. This study is an attempt to understand the effects of an explosive blast in a large animal gyrencephalic brain blast injury model. Anesthetized Yorkshire swine were exposed to measured explosive blast levels in 3 operationally relevant scenarios: simulated free field (blast tube), high-mobility multipurpose wheeled vehicle surrogate, and building (4-walled structure). Histologic changes in exposed animals up to 2 weeks after blast were compared to a group of naive and sham controls. The overall pathologic changes in all 3 blast scenarios were limited, with very little neuronal injury, fiber tract demyelination, or intracranial hemorrhage observed. However, there were 2 distinct neuropathologic changes observed: increased astrocyte activation and proliferation and periventricular axonal injury detected with ß-amyloid precursor protein immunohistochemistry. We postulate that the increased astrogliosis observed may have a longer-term potential for the exacerbation of brain injury and that the pattern of periventricular axonal injury may be related to a potential for cognitive and mood disorders.

Blast exposure in rats with body shielding is characterized primarily by diffuse axonal injury.

Blast-induced traumatic brain injury (TBI) is the signature insult in combat casualty care. Survival with neurological damage from otherwise lethal blast exposures has become possible with body armor use. We characterized the neuropathologic alterations produced by a single blast exposure in rats using a helium-driven shock tube to generate a nominal exposure of 35 pounds per square inch (PSI) (positive phase duration ∼ 4 msec). Using an IACUC-approved protocol, isoflurane-anesthetized rats were placed in a steel wedge (to shield the body) 7 feet inside the end of the tube. The left side faced the blast wave (with head-only exposure); the wedge apex focused a Mach stem onto the rat's head. The insult produced ∼ 25% mortality (due to impact apnea). Surviving and sham rats were perfusion-fixed at 24 h, 72 h, or 2 weeks post-blast. Neuropathologic evaluations were performed utilizing hematoxylin and eosin, amino cupric silver, and a variety of immunohistochemical stains for amyloid precursor protein (APP), glial fibrillary acidic protein (GFAP), ionized calcium-binding adapter molecule 1 (Iba1), ED1, and rat IgG. Multifocal axonal degeneration, as evidenced by staining with amino cupric silver, was present in all blast-exposed rats at all time points. Deep cerebellar and brainstem white matter tracts were most heavily stained with amino cupric silver, with the morphologic staining patterns suggesting a process of diffuse axonal injury. Silver-stained sections revealed mild multifocal neuronal death at 24 h and 72 h. GFAP, ED1, and Iba1 staining were not prominently increased, although small numbers of reactive microglia were seen within areas of neuronal death. Increased blood-brain barrier permeability (as measured by IgG staining) was seen at 24 h and primarily affected the contralateral cortex. Axonal injury was the most prominent feature during the initial 2 weeks following blast exposure, although degeneration of other neuronal processes was also present. Strikingly, silver staining revealed otherwise undetected abnormalities, and therefore represents a recommended outcome measure in future studies of blast TBI.

Prehospital hypotension in blunt trauma: identifying the "crump factor".

BACKGROUND: Trauma activation for prehospital hypotension in blunt trauma is controversial. Some patients subsequently arrive at the trauma center normotensive, but they can still have life-threatening injuries. Admission base deficit (BD)≤-6 correlates with injury severity, transfusion requirement, and mortality. Can admission BD be used to discriminate those severely injured patients who arrive normotensive but "crump," (i.e., become hypotensive again) in the Emergency Department? The purpose is to determine whether admission BD<-6 discriminates patients at risk for future bouts of unexpected hypotension during evaluation. METHODS: Retrospective chart review was performed on all blunt trauma admissions at a Level I trauma center from August 2002 through July 2007. Hypotension was defined as a systolic blood pressure≤90 mm Hg. Patients who were hypotensive in the field but normotensive upon arrival in the emergency department (ED) were included. Age, gender, injury severe score, arterial blood gas analysis, results of focused abdominal sonogram for trauma (FAST), computed tomography, intravenous fluid administration, blood transfusions, and the presence of repeat bouts of hypotension were noted. Patients were stratified by BD≤-6 or ≥-5. Statistical analysis was performed using paired t test, χ, and logistic regression analysis with significance attributed to p<0.05. RESULTS: During the 5-year period, 231 blunt trauma patients had hypotension in the field with subsequent normotension on admission to the ED. Of these, 189 patients had admission BD data recorded. Patients with a BD≤-6 were significantly more likely to have repeat hypotension (78% vs. 30%, p<0.001). Overall mortality was 13% (24 of 189), but patients with repeat hypotension had greater mortality (24% vs. 5%, p<0.003). CONCLUSION: Blunt trauma patients with repeat episodes of hypotension have significantly greater mortality. Patients with transient field hypotension and a BD≤-6 are more than twice as likely to have repeat hypotension (crump). This study reinforces the need for early arterial blood gases and trauma team involvement in the evaluation of these patients. Patients with BD≤-6 should have early invasive monitoring, liberal use of repeat FAST exams, and careful resuscitation before computed tomography scanning. Surgeons should have a low threshold for taking such patients to the operating room.

Is surgical airway necessary for airway management in deep neck infections and Ludwig angina?

BACKGROUND: Deep neck infections are potentially life-threatening conditions because of airway compromise. Management requires early recognition, antibiotics, surgical drainage, and effective airway control. The Surgical Education and Self-Assessment Program 12 states that awake tracheostomy is the treatment of choice for these patients. HYPOTHESIS: With advanced airway control techniques such as retrograde intubation, GlideScope, and fiberoptic intubation, surgical airway is not required. DESIGN: A retrospective analysis of all deep neck abscesses treated from December 1999 to July 2006 was performed. METHODS: All patients who underwent urgent or emergent surgery for Ludwig angina and submental, submandibular, sublingual, and parapharyngeal abscesses (Current Procedural Terminology codes 41015, 41016, 41017, 42320, and 42725) were included in our review. Charts were studied for age, presence of true Ludwig angina, presence of airway compromise, airway management, morbidity/mortality, and the requirement for surgical airway. RESULTS: Of 29 patients, 6 (20%) had symptoms consistent with true Ludwig angina. Nineteen (65.5%) had evidence of airway compromise. Eight (42%) of these 19 patients required advanced airway control techniques. No patient required a surgical airway, and no mortality resulted from airway compromise. Advance airway control techniques were required more often in patients with airway compromise (P < .05). CONCLUSION: Treatment of Ludwig angina and deep neck abscesses requires good clinical judgment. Patients with deep neck infections and symptoms of airway compromise may be safely managed with advanced airway control techniques.

Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study.

BACKGROUND: We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents. DESIGN: Retrospective review. SETTING: Seventeen general surgery training programs in the western United States. PARTICIPANTS: Six hundred seven residents who graduated in 2000-2007. MAIN OUTCOME MEASURES: First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research. RESULTS: The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]). CONCLUSIONS: Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

An introductory characterization of a combat-casualty-care relevant swine model of closed head injury resulting from exposure to explosive blast.

Explosive blast has been extensively used as a tactical weapon in Operation Iraqi Freedom (OIF) and more recently in Operation Enduring Freedom(OEF). The polytraumatic nature of blast injuries is evidence of their effectiveness,and brain injury is a frequent and debilitating form of this trauma. In-theater clinical observations of brain-injured casualties have shown that edema, intracranial hemorrhage, and vasospasm are the most salient pathophysiological characteristics of blast injury to the brain. Unfortunately, little is known about exactly how an explosion produces these sequelae as well as others that are less well documented. Consequently, the principal objective of the current report is to present a swine model of explosive blast injury to the brain. This model was developed during Phase I of the DARPA (Defense Advanced Research Projects Agency) PREVENT (Preventing Violent Explosive Neurotrauma) blast research program. A second objective is to present data that illustrate the capabilities of this model to study the proximal biomechanical causes and the resulting pathophysiological, biochemical,neuropathological, and neurological consequences of explosive blast injury to the swine brain. In the concluding section of this article, the advantages and limitations of the model are considered, explosive and air-overpressure models are compared, and the physical properties of an explosion are identified that potentially contributed to the in-theater closed head injuries resulting from explosions of improvised explosive devices (IEDs).

Observation for nonoperative management of the spleen: how long is long enough?

BACKGROUND: Nonoperative management of splenic injury is common with reported success rates between 83% and 97%. However, there are no specific protocols for nonoperative observation published in the literature. The purpose of this study is to analyze the safety and effectiveness of our institutional guideline for observation of patients managed nonoperatively for splenic injury. METHODS: A retrospective registry and chart review was conducted for all patients with splenic injury who were admitted for nonoperative management (NOM). Our guideline for observation is admission with bed rest, serial hemoglobins every 6 hour, and discharge when hemoglobin is stable. Data collected for this study was age, gender, Injury Severity Score, grade of splenic injury, length of stay, NOM failures while in hospital and readmissions after discharge for nonoperative failure. RESULTS: From August 2002 through June 2007, 449 patients were admitted for NOM of splenic injury. Sixteen (4%) patients failed NOM and went to the operating room for splenectomy. CONCLUSIONS: NOM of blunt splenic injuries had a 96% success rate following our protocol. The guideline successfully identified all the patients failing NOM during the inpatient observation period with the exception of one patient that was noncompliant to protocol. This guideline for observation is safe and effective.

Advanced trauma life support, 8th edition, the evidence for change.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Prone ventilation in trauma or surgical patients with acute lung injury and adult respiratory distress syndrome: is it beneficial?

BACKGROUND: To compare the effectiveness of supine versus prone kinetic therapy in mechanically ventilated trauma and surgical patients with acute lung injury (ALI) and adult respiratory distress syndrome (ARDS). METHODS: A retrospective review of all patients with ALI/ARDS who were placed on either a supine (roto-rest) or prone (roto-prone) oscillating bed was performed. Data obtained included age, revised trauma score (RTS), base deficit, Injury Severity Score (ISS), head Abbreviated Injury Scale score (AIS), chest (AIS), PaO2/FiO2 ratio, FiO2 requirement, central venous pressure (CVP), days on the bed, ventilator days, use of pressors, complications, mortality, and pulmonary-associated mortality. Data are expressed as mean+/-SE with significance attributed to p<0.05. RESULTS: From March 1, 2004 through May 31, 2006, 4,507 trauma patients were admitted and 221 were identified in the trauma registry as having ALI or ARDS. Of these, 53 met inclusion criteria. Additionally, 8 general surgery patients met inclusion criteria. Of these 61 patients, 44 patients were positioned supine, 13 were placed prone, and 4 patients that were initially placed supine were changed to prone positioning. There was no difference between the groups in age, CVP, ISS, RTS, base deficit, head AIS score, chest AIS score, abdominal AIS score, or probability of survival. The PaO2/FiO2 ratios were not different at study entry (149 vs. 153, p=NS), and both groups showed improvement in PaO2/FiO2 ratios. However, the prone group had better PaO2/FiO2 ratios than the supine group by day 5 (243 vs. 200, p=0.066). The prone group had fewer days on the ventilator (13.6 vs. 24.2, p=0.12), and shorter hospital lengths of stay (22 days vs. 40 days, p=0.08). There were four patients who failed to improve with supine kinetic therapy that were changed to prone kinetic therapy. These patients had significant improvements in PaO2/FiO2 ratio, and significantly lower FiO2 requirements. There were 18 deaths (7 pulmonary related) in the supine group and 1 death in the prone group (p < 0.01 by chi test). CONCLUSIONS: ALI/ARDS patients who received prone kinetic therapy had greater improvement in PaO2/FiO2 ratio, lower mortality, and less pulmonary-related mortality than did supine positioned patients. The use of a prone-oscillating bed appears advantageous for trauma and surgical patients with ALI/ARDS and a prospective, randomized trial is warranted.

Aggressive traffic enforcement: a simple and effective injury prevention program.

PURPOSE: To investigate whether an aggressive traffic violation enforcement program could reduce motor vehicle crashes (MVCs), injury collisions, fatalities, and fatalities related to speed, and decrease injury severity in crash victims treated at the trauma center. METHODS: A vigorous enforcement program was established within Fresno, Calif, city boundaries using increased traffic patrol officers. Data on citations, collisions, fatal collisions, and fatalities related to speed, as well as injury severity from the trauma registry, were collected for the year before program onset (2002), during the first year (2003), and after full implementation (2004). U.S. Census Bureau information was used for population. Statistical analysis was performed using Fisher's exact test and independent samples t test with significance attributed to p < 0.05. RESULTS: There were significant increases in citations issued, with marked decreases in motor vehicle crashes, injury collisions, fatalities, and fatalities related to speed. There was a decrease in admissions from MVCs, a significant decrease in the number of patients with moderate injury severity (Injury Severity Score of 10-16; p < 0.01), a decrease in hospital length of stay for all MVC victims, and a decrease in hospital charges for MVC patients. These changes were not seen in the area of Fresno County outside the area of increased enforcement. CONCLUSIONS: Aggressive traffic enforcement decreased MVCs, crash fatalities, and fatalities related to speed, and it decreased injury severity. This is a simple, easily implemented injury prevention program with immediate benefit.

Routinely repeated computed tomography after blunt head trauma: does it benefit patients?

BACKGROUND: Computed tomography of the head (HCT) is an integral part of the diagnosis and management of the patient with head injury, but the utility of repeated HCT performed solely for routine follow-up in the patient with blunt head trauma has not been defined. In the absence of clinical indications, routinely repeated HCT, even in patients with significant brain injury, does not contribute to patient care. METHODS: Trauma registry records at a Level I trauma center from July 1, 1997, to June 30, 2002, were reviewed. Patients with severe blunt head injury (Abbreviated Injury Scale score > or = 3) admitted to the intensive care unit and who had a repeat HCT scan obtained for scheduled follow-up were included. Those patients with initial craniotomy, repeat HCT more than 72 hours after the initial HCT, or repeat HCT ordered for clinical indications were excluded. Data included were age, mechanism of injury, time to initial (HCT1) and repeat HCT (HCT2), indications for HCT2, and HCT findings. Additional data included Glasgow Coma Scale (GCS) score (admission and at HCT2); Injury Severity Score; occurrence of hypotension, coagulopathy, or elevated intracranial pressure (ICP); interventions made; and patient outcome. RESULTS: Entry criteria were met in 462 patients. Most were injured in motor vehicle crashes; the average age was 36 years and the mean initial GCS score was 9. The mean time to HCT1 was 1.3 hours and the mean time to HCT2 was 22.6 hours. HCT2 showed worsening in 85 patients (18.4%), and 16 patients had interventions in response to HCT2 (repeat HCT in 8, ICP monitoring or drainage in 6, and craniotomy in 2). No patient undergoing routine repeat HCT without other clinical findings required intervention. All patients with worsening HCT findings requiring intervention had coagulopathy, hypotension, ICP elevation, or marked decrease in GCS score. CONCLUSION: In the absence of clinical indicators or risk factors, repeat HCT after blunt head injury does not alter patient management and is unnecessary.

Are automated blood pressure measurements accurate in trauma patients?

BACKGROUND: Automated blood pressure (BP) determinations by oscillometry are reported to be as accurate as invasive monitoring for systolic pressures as low as 80 mm Hg. Automated BP devices are widely used by prehospital providers and in hospital operating rooms, emergency departments, and intensive care units, although the accuracy of automated BP has not been demonstrated in trauma patients. We hypothesized that automated BP is less accurate than manual BP in trauma patients. The purpose of this study was to determine the accuracy of automated BP versus manual BP in trauma patients. METHODS: A retrospective review of patients who met trauma activation criteria admitted to a Level I trauma center over a 30-month period was conducted. Patients were included if both manual BP and automated BP were measured within 5 minutes of admission. Additional data collected included Injury Severity Score, base deficit, and emergency department resuscitation volume. Statistical analysis was performed using paired t test, chi2, and linear regression analysis. Significance was attributed to a value of p < 0.05. RESULTS: From January 2000 through June 2002, 388 patients met inclusion criteria. Patients were grouped by manual BP levels: group 1, BP < or = 90 mm Hg (n = 92); group 2, BP 91-110 mm Hg (n = 119); and group 3, BP > or = 110 mm Hg (n = 177). The mean automated BP measurements were significantly higher than the manual measurements in groups 1 and 2 (26 and 16 mm Hg, respectively; p < 0.001). Of the 92 patients with manual BP < or = 90, 45 (49%) had automated BP > or = 100. The base deficit (-5, -3, and -2 for groups 1, 2, and 3, respectively; p < 0.01), Injury Severity Score (30, 25, and 18; p < 0.01), and volume of resuscitative fluid and blood (p < 0.001) all decreased with higher BP group. CONCLUSION: Injury severity, degree of acidosis, and resuscitation volume were more accurately reflected by manual BP. Automated BP determinations were consistently higher than manual BP, particularly in hypotensive patients. Automated BP devices should not be used for field or hospital triage decisions. Manual BP determinations should be used until systolic blood pressure is consistently > or = 110 mm Hg.

Victims of domestic violence on the trauma service: unrecognized and underreported.

BACKGROUND: Domestic violence (DV) has received increased recognition as a significant mechanism of injury. To improve awareness about DV at our institution, an educational program was presented to the departments of surgery and emergency medicine. Pre and posttests were given and improvement in knowledge was demonstrated. In addition, a screening question for DV was added to the trauma history and physical (H & P) form. This study was done to determine the long-term efficacy of these efforts in increasing recognition of DV and referral to social services in patients admitted to the trauma service. Recognition of DV and appropriate referral should be increased after education and change in H & P form. METHODS: All patients admitted to the trauma service at a Level I trauma center over a 10 month period with the mechanism of injury "assault" were reviewed. DV was determined to be present, likely, unknown, or absent based on information from the prehospital report and medical records. The DV screen question was reviewed for use and accuracy. RESULTS: During the study period, 1,550 patients were admitted to the trauma service, with assault listed as the mechanism of injury for 217 (14%). DV was confirmed or likely in 27 patients (12.4% of the assaults). Of patients with confirmed or likely DV, only 7 received appropriate referrals, with 2 generated by the nursing staff. Of the confirmed and likely DV patients, 17 (63%) were sent home without investigation of safety and only 21% of all assault victims had any social services evaluation (usually to investigate funding or placement). The DV screen was used in only 12 patients. Reasons given for failure to complete the DV screen on the H & P included examiner discomfort in asking the question, and an environment judged to be inappropriate (resuscitation area in the emergency department). CONCLUSION: DV is unrecognized and underreported. Efforts to improve recognition and reporting of DV events need to be ongoing. Screening for DV is not effectively done as part of the initial evaluation. Assessment for DV may be more appropriate as part of the tertiary survey.

Motor vehicle restraints: primary versus secondary enforcement and ethnicity.

BACKGROUND: Efforts to increase motor vehicle restraint use have been broadly based rather than focused on specific populations. Identifying specific issues, including populations with low restraint use, can help target educational campaigns. Previous studies have reported differences in restraint use by ethnicity. This study was performed to determine whether differences exist in motor vehicle restraint use by ethnicity and whether these differences are altered by the presence of primary versus secondary restraint laws. METHODS: Data were collected on motor vehicle crash victims admitted to two Level I trauma centers from October 1, 1997, through March 31, 1998; one in a state with primary restraint enforcement (motorist can be stopped for the restraint violation), the other with a secondary restraint law (restraint violation may be enforced if the motorist is stopped for another violation). Data were obtained concurrently with hospitalization and entered into computerized trauma registry databases. RESULTS: Restraint use in all motor vehicle crash victims was significantly different between the primary and secondary enforcement states (58% vs. 37%, p < 0.001). Additionally, restraint use varied markedly by ethnicity in the secondary enforcement state (Caucasian, 42%; vs. African-American, 21%, and Hispanic, 26%, p < 0.02, chi(2)). Comparison of restraint use in primary versus secondary enforcement states demonstrated significantly increased restraint use in all ethnic groups (p < 0.01). CONCLUSION: In a state with secondary enforcement laws, restraint use varied significantly with ethnicity. Restraint use was markedly increased in all ethnic groups by the presence of a primary enforcement law. Implementation and enforcement of primary restraint laws is essential to improving motor vehicle restraint use. Educational campaigns to increase restraint use need to target specific populations.