As multiple trauma is ubiquitous, affects predominantly young people and is attended by a high mortality, it seemed a fruitful area for study in an effort to reduce morbidity and mortality. One of the main problems in trauma research has been accurate description of the severity of injury and associating severity with subsequent outcome. While a number of scoring systems have been proposed the Injury Severity Score has been the most widely adopted and validated. The Injury Severity score was adopted with a number of other systems of scoring infection and other complications in a retrospective study of multiple trauma patients admitted to an Intensive Therapy Unit. This study revealed an unexpected increased in mortality in the latter two years of the study period which was not associated with an increase in injury severity as assessed by the ISS nor by any other change in patient characteristics which might explain this finding. Eventually it was noted that the introduction of a hypnotic drug etomidate for use in sedation of ventilated patients seemed to be associated with the increased mortality. Clinical evidence suggested that etomidate might inhibit adrenocortical function and an experimental study indeed confirmed that etomidate had a direct effect on adrenal steroidogenesis such that cortisol and aldosterone production were completely suppressed. Following analysis of the retrospective clinical study etomidate was withdrawn from use in our unit. Analysis of mortality rates both for trauma patients and the general patient population indicated a reversion to the rate which pertained prior to introduction of etomidate. The results of retrospective and prospective clinical studies strongly implied that the administration of etomidate was associated with an increased mortality among trauma patients. The experimental study based on clinical observations clearly demonstrated that etomidate infusion was a potent inhibitor of adrenal steroidogenesis. It seems highly likely that the detrimental effect of etomidate was mediated by its direct inhibitory effect on the production of cortisol and aldosterone by the adrenal gland. Subsequent clinical and experimental studies from other authors tend to confirm these findings.

Bibliographische Zusammenfassung 82 Seiten gesamt, 54 Seiten Textteil, 108 Literaturangaben, 20 Abbildungen, 5 Tabellen, 4 Anlagen Referat: Ziel der vorliegenden Arbeit war die Betrachtung der Krankenhausmortalität und deren Risikofaktoren sowie des 3-Jahres-Überlebens bei invasiv beatmeten Patienten der internistischen Intensivstation (ITS). Es wurden 250 erwachsene Patienten des Universitätsklinikums Leipzig mit Aufnahme im Jahr 2007 in diese Studie eingeschlossen. Erfasst wurde eine große Anzahl an Patientendaten: Erkrankungen, der Aufnahmegrund, die Aufenthaltsdauer, Informationen zur Intubation/Tracheotomie und zur Beatmung, das hämodynamische Monitoring, erweiterte invasive Maßnahmen, der APACHE-Score sowie Informationen zum Tod (APACHE= Acute Physiology and Chronic Health Evaluation). Eine Krankenhausmortalität von 49,6 % konnte ermittelt werden - eine relativ hohe Mortalität verglichen mit anderen Studien. Das Vorliegen eines Tumorleidens, einer Niereninsuffizienz oder einer Reanimation im Verlauf wurden als Risikofaktoren, im Krankenhaus zu versterben, erkannt. Die unterschiedliche Mortalität thematisch ähnlicher Studien könnten u.a. durch die unterschiedlichen Ein- und Ausschlusskriterien erklärt werden. In der Regel ist die Mortalität auf internistischen höher als auf chirurgischen ITS. Die Notwendigkeit zur invasiven Beatmung weist auf einen kritischen Gesundheitszustand hin, der häufiger zum Tode führt. Eine Aussage über das genaue Mortalitätsrisiko jedes einzelnen Patienten ist nicht möglich. Grenzentscheidungen zwischen Leben und Tod müssen im Hinblick auf die Gesamtsituation getroffen werden. Der Gesundheitszustand sowie der Patientenwille sollten bei der Entscheidung eine ausschlaggebende Rolle spielen. Die ermittelten Risikofaktoren können während dieses Prozesses als Hilfsmittel bei der Entscheidungsfindung herangezogen werden.

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Very little research has studied the common challenge in adulthood of coming to terms with the eventual mortality of one’s parents as they age and experience illness. The present work begins to explore this emotional adjustment and draws on Attachment Theory and the study of how people cope with their own mortality (Terror Management Theory) to develop hypotheses about potential responses of the adult child. Feelings of vigilance and thoughts or behavioural predispositions toward proximity-seeking, disengagement, and control are considered. I hypothesized specific differences in these responses based on the tendency for those high in attachment anxiety to ‘hyperactivate’ attachment-related thoughts and for those high in attachment avoidance to ‘deactivate’ these thoughts. Study 1 used self-report measures in a community sample of adults for whom a parent had experienced a significant illness. Participants high in either attachment anxiety or attachment avoidance were less likely to seek proximity to ill parents than those low on these attachment dimensions. Those high in attachment avoidance were also less likely to experience feelings of vigilance for signs of illness in their parents and to want to assert control over their parents’ health care relative to those who were low in attachment avoidance. These findings were consistent with hypotheses based on attachment avoidance but opposite to hypotheses based on attachment anxiety. Variation in responses to an ill parent was also found depending on the age of participants and their parents, the severity of the parents’ illness and their health care behaviours, and whether the adult served as a caregiver for their parent. Using a word-completion task, Study 2 assessed whether themes of proximity, disengagement, and control were cognitively accessible following imaginal induction of a parents’ mortality, participants’ own mortality, or an experience of physical pain. The pattern of results did not support hypothesized differences in reaction times based on dimensions of attachment anxiety and avoidance. Predicted differences based on which induction was completed were also not found. Self-report responses replicated findings from Study 1 such that participants high in attachment anxiety were less likely to want to seek proximity to ill parents when thinking about their mortality than those low in attachment anxiety, and that those high in attachment avoidance were less likely to feel vigilant and to want to seek proximity or to assert control over their parent relative to those who scored low on measures of attachment avoidance. The manner in which adults respond to being confronted with their parents’ mortality has significant implications for their own emotional well-being as well as for the emotional and physical well-being of their parent. Given that adults often become caregivers for their ill and aging parents, this area of study warrants further research.

Thesis (B.A.(Hons.))--University of Adelaide, 1977.

Thesis (Ph. D.)--University of Melbourne, 1995. / Typescript. Includes bibliographical references (leaves 284-300).

Diss. (sammanfattning) Umeå : Umeå universitet, 2006. / Härtill 4 uppsatser.

Thesis (M.A. in Security Studies (Homeland Security and Defense))--Naval Postgraduate School, June 2009. / Thesis Advisor(s): Richter, Anke. "June 2009." Description based on title screen as viewed on July 13, 2009. Author(s) subject terms: Critical mortality, triage accuracy, definitive care, damage control, regional preparedness, standard of care, mass casualty event, trauma medicine, rationing, Spain, Israel, United Kingdom, Tactical Combat Casualty Care, TCCC. Includes bibliographical references (p. 73-78). Also available in print.