Preliminary analysis of the care of injured patients in 33 British hospitals: first report of the United Kingdom major trauma outcome study.

OBJECTIVE--To measure the effectiveness of management of major trauma in the United Kingdom. DESIGN--Review of the care of all seriously injured patients seen over two years. SETTING--33 hospitals which receive patients who have sustained major trauma. SUBJECTS--14,648 injured patients admitted for more than three days, transferred or admitted into an intensive care bed, or dying from their injuries. MAIN OUTCOME MEASURE--Death or survival in hospital within three months of the injury. RESULTS--21% of seriously injured patients (1299) took longer than one hour to reach hospital. Time before arrival at hospital was not related to severity of injury. A senior house officer was in charge of initial hospital resuscitation in 57% (826/1445) of patients with an injury severity score > or = 16. More senior staff were commonly responsible for definitive operations, but only 46% (165/355) of patients judged to require early operation arrived in theatre within two hours. Mortality for 6111 patients sustaining blunt trauma and treated in the 14 busiest hospitals was significantly higher (actual 408, predicted 295.6, p < 0.001) than in a comparable North American dataset. Large differences in the 14 hospitals assessed could not be explained by variations in case load or facilities. In contrast, the outcome of the 4.1% (597) of patients with penetrating injuries was better than that of a comparable group in the United States. Analysis of the 415 penetrating injuries with complete data showed that 15 patients died (19.3 predicted; p = 0.04). CONCLUSIONS--The initial management of major trauma in the United Kingdom remains unsatisfactory. There are delays in providing experienced staff and timely operations. Mortality varies inexplicably between hospitals and, for blunt trauma, is generally higher than in the United States.     

Rehabilitation of severely injured children.

Injury is the leading cause of death and disability in childhood. Ideal systems of care integrate comprehensive management of acutely injured children with rehabilitation. We review the nature of childhood injury, its disabling consequences, and the best ways to manage the care of children with serious injuries.     

Extremity hyperinsulinemia stimulates muscle protein synthesis in severely injured patients

Insulin has a well-recognized anabolic effect on muscle protein, yet critically ill, severely injured patients are often considered "resistant" to the action of insulin. The purpose of this study was to assess the in vivo effects of hyperinsulinemia on human skeletal muscle in severely injured patients. To accomplish this goal, 14 patients with burns encompassing >40% of their body surface area underwent metabolic evaluation utilizing isotopic dilution of phenylalanine, femoral artery and vein blood sampling, and sequential muscle biopsies of the leg. After baseline metabolic measurements were taken, insulin was infused into the femoral artery at 0.45 mIU.min(-1).100 ml leg volume(-1) to create a local hyperinsulinemia but with minimal systemic perturbations. Insulin administration increased femoral venous concentration of insulin (P < 0.01) but with only a 4% (insignificant) decrease in the arterial glucose concentration and a 7% (insignificant) decrease in the arterial concentration of phenylalanine. Extremity hyperinsulinemia significantly increased leg blood flow (P < 0.05) and the rate of muscle protein synthesis (P < 0.05). Neither the rate of muscle protein breakdown nor the rate of transmembrane transport of phenylalanine was significantly altered with extremity hyperinsulinemia. In conclusion, this study demonstrates that insulin directly stimulates muscle protein synthesis in severely injured patients.     

Surveillance of AIDS in the United Kingdom.

The surveillance of cases of the acquired immune deficiency syndrome (AIDS) in the United Kingdom is described and a preliminary analysis made of the 1012 cases that were reported to the end of August 1987. Homosexuals were the largest risk group. For the first time it is possible to present cases by the date of diagnosis and by the regional health authority of residence. The rate of increase of new cases shows no sign of slowing down. One third of patients with AIDS lived in a different regional health authority from that in which their disease had been diagnosed. The geographical distribution varied with the risk group. The commonest presenting clinical feature at diagnosis was Pneumocystis carinii pneumonia. Kaposi''s sarcoma was considerably more common among homosexuals than among people in other groups at risk.     

Negative selection of patients for dialysis and transplantation in the United Kingdom.

In order to understand why the United Kingdom ranks low in the treatment of end stage renal failure a questionnaire investigating knowledge of current acceptance practice for dialysis and transplantation was sent to various groups of doctors throughout the country. The questionnaire comprised 16 case histories of patients with established end stage renal failure and associated social and medical problems. In each case the responding doctor was asked to indicate whether the patient would be suitable for treatment by dialysis or transplantation or both. The questionnaire was sent to a randomly selected sample of general practitioners and non-renal consultant physicians and their responses compared with those of all the nephrologists identified in the United Kingdom. The mean number of cases rejected by both general practitioners and non-renal consultant physicians was significantly higher than the number rejected by nephrologists. The findings suggest that underreferral of patients to dialysis and transplant units contributes to the current low acceptance rate of new patients into treatment programmes in the United Kingdom.