Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e3181715d66
A. Colantonio, R. Croxford, S. Farooq, A. Laporte, P. Coyte
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability in developed countries. We document trends in TBI-related hospitalizations in Ontario, Canada, between April 1992 and March 2002, focusing on relationships between inpatient hospitalization rates, age, sex, cause of injury, severity level, and in-hospital mortality. METHODS Information on all acute hospital separations in Ontario with a diagnosis of TBI was analyzed using logistic regression. RESULTS Hospitalization rates fell steeply among children and young adults but remained stable among adults aged 66 and older. The proportion of TBI hospitalizations with mild injuries decreased from 75% to 54%, whereas the proportion with moderate injuries increased from 19% to 37%. Adjusting for other risk factors, in-hospital deaths were higher for injuries because of motor vehicle crashes than those because of falls. In-hospital death rates were stable for patients with moderate or severe injuries, but increased over time among those whose injuries were classified as mild, suggesting a trend toward more serious injury within the "mild" classification. CONCLUSIONS Hospitalizations for TBI involve fewer mild injuries over time and are highest in the oldest segment of the population.
{"title":"Trends in hospitalization associated with traumatic brain injury in a publicly insured population, 1992-2002.","authors":"A. Colantonio, R. Croxford, S. Farooq, A. Laporte, P. Coyte","doi":"10.1097/TA.0b013e3181715d66","DOIUrl":"https://doi.org/10.1097/TA.0b013e3181715d66","url":null,"abstract":"BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability in developed countries. We document trends in TBI-related hospitalizations in Ontario, Canada, between April 1992 and March 2002, focusing on relationships between inpatient hospitalization rates, age, sex, cause of injury, severity level, and in-hospital mortality. METHODS Information on all acute hospital separations in Ontario with a diagnosis of TBI was analyzed using logistic regression. RESULTS Hospitalization rates fell steeply among children and young adults but remained stable among adults aged 66 and older. The proportion of TBI hospitalizations with mild injuries decreased from 75% to 54%, whereas the proportion with moderate injuries increased from 19% to 37%. Adjusting for other risk factors, in-hospital deaths were higher for injuries because of motor vehicle crashes than those because of falls. In-hospital death rates were stable for patients with moderate or severe injuries, but increased over time among those whose injuries were classified as mild, suggesting a trend toward more serious injury within the \"mild\" classification. CONCLUSIONS Hospitalizations for TBI involve fewer mild injuries over time and are highest in the oldest segment of the population.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"08 1","pages":"179-83"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86046597","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e31815ede46
R. Nirula, Gina Nirula, L. Gentilello
BACKGROUND The delivery of optimal trauma care involves identification and repair of injuries as well as rehabilitation of patients to return them to their preinjury functional status. This requires access to appropriate rehabilitation services; however, such services may be disproportionately allocated to insured individuals leaving lower income individuals without the means to achieve optimal functional status. We hypothesized that a lack of insurance is associated with a reduced likelihood of being transferred to a rehabilitation facility after trauma. METHODS A retrospective cohort analysis of blunt National Trauma Databank patients from 2000 to 2004 were assessed to identify predictors of being transferred to a rehabilitation facility at hospital discharge. The likelihood of rehabilitation transfer based on insurance status was assessed, controlling for injury severity, physiology, comorbidities, and patient demographics. RESULTS Age, gender, comorbidities, injury, presence of blood alcohol at admission, race, and insurance status were independent predictors of being transferred to a rehabilitation facility among blunt trauma patients (n = 750,468). Patients who were uninsured were 53% (OR = 0.47, 95% CI = 0.41-0.53) less likely to be transferred to a rehabilitation facility upon hospital discharge. CONCLUSION Although access to rehabilitation services after injury is a key predictor of recovery from injury, these services are much less available to uninsured patients. This may lead to significant individual and societal emotional and economic burden. The health and economic impacts of this disparity in access to care need to be investigated to determine the personal and societal impact of appropriate resource allocation to rehabilitation for the uninsured.
提供最佳创伤护理包括识别和修复损伤，以及患者的康复，使其恢复到损伤前的功能状态。这需要获得适当的康复服务;然而，这些服务可能不成比例地分配给有保险的个人，使低收入个人没有办法达到最佳的功能状态。我们假设，缺乏保险与创伤后转移到康复机构的可能性降低有关。方法对2000年至2004年钝性国家创伤数据库患者进行回顾性队列分析，以确定出院后转入康复机构的预测因素。在控制损伤严重程度、生理、合并症和患者人口统计的情况下，评估基于保险状况的康复转移的可能性。结果:年龄、性别、合并症、损伤、入院时血液酒精含量、种族和保险状况是钝性创伤患者转入康复机构的独立预测因素(n = 750,468)。未投保的患者在出院后转入康复机构的可能性降低53% (OR = 0.47, 95% CI = 0.41-0.53)。结论:虽然伤后康复服务的可及性是伤后康复的关键预测指标，但无保险患者获得康复服务的机会较少。这可能会给个人和社会带来巨大的情感和经济负担。需要调查在获得护理方面的这种差异对健康和经济的影响，以确定为无保险人员的康复适当分配资源对个人和社会的影响。
{"title":"Inequity of rehabilitation services after traumatic injury.","authors":"R. Nirula, Gina Nirula, L. Gentilello","doi":"10.1097/TA.0b013e31815ede46","DOIUrl":"https://doi.org/10.1097/TA.0b013e31815ede46","url":null,"abstract":"BACKGROUND The delivery of optimal trauma care involves identification and repair of injuries as well as rehabilitation of patients to return them to their preinjury functional status. This requires access to appropriate rehabilitation services; however, such services may be disproportionately allocated to insured individuals leaving lower income individuals without the means to achieve optimal functional status. We hypothesized that a lack of insurance is associated with a reduced likelihood of being transferred to a rehabilitation facility after trauma. METHODS A retrospective cohort analysis of blunt National Trauma Databank patients from 2000 to 2004 were assessed to identify predictors of being transferred to a rehabilitation facility at hospital discharge. The likelihood of rehabilitation transfer based on insurance status was assessed, controlling for injury severity, physiology, comorbidities, and patient demographics. RESULTS Age, gender, comorbidities, injury, presence of blood alcohol at admission, race, and insurance status were independent predictors of being transferred to a rehabilitation facility among blunt trauma patients (n = 750,468). Patients who were uninsured were 53% (OR = 0.47, 95% CI = 0.41-0.53) less likely to be transferred to a rehabilitation facility upon hospital discharge. CONCLUSION Although access to rehabilitation services after injury is a key predictor of recovery from injury, these services are much less available to uninsured patients. This may lead to significant individual and societal emotional and economic burden. The health and economic impacts of this disparity in access to care need to be investigated to determine the personal and societal impact of appropriate resource allocation to rehabilitation for the uninsured.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"79 1","pages":"255-9"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72867250","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e318157dbec
T. Tokutomi, T. Miyagi, Y. Takeuchi, Takashi Karukaya, H. Katsuki, M. Shigemori
BACKGROUND From 1994, we have used therapeutic hypothermia in patients with severe traumatic brain injury (Glasgow Coma Scale scores of 5 or less). In 2000, we altered the target temperature to 35 degrees C from the former 33 degrees C, as our findings suggested that cooling to 35 degrees C is sufficient to control intracranial hypertension, and that hypothermia below 35 degrees C may predispose patients to persistent cumulative oxygen debt. We attempted to clarify whether 35 degrees C hypothermia has the same effect as 33 degrees C hypothermia in reducing intracranial hypertension and whether it is associated with fewer complications and improved outcomes. METHODS We compared intracranial pressure (ICP) and biochemical parameters in the 30 patients treated with 35 degrees C hypothermia (January 2000 to June 2005) with those in the 31 patients treated with 33 degrees C hypothermia (July 1994 to December 1999). RESULTS Patient characteristics were similar in the two groups. The mean temperature during hypothermia was 35.1 +/- 0.7 degrees C in the 35 degrees C hypothermia group and 33.4 +/- 0.8 degrees C in the 33 degrees C hypothermia group. Mean ICP was controlled under 20 mm Hg during hypothermia in both the 35 degrees C hypothermia and 33 degrees C hypothermia groups. The incidence of intracranial hypertension and low cerebral perfusion pressure did not differ between the two groups. The 35 degrees C hypothermic patients exhibited a significant improvement in the decline of serum potassium concentrations during hypothermia and in the increment of C-reactive protein after rewarming. The mortality rate and the incidence of systemic complications tended to be lower in the 35 degrees C group. CONCLUSIONS Cooling patients to 35 degrees C is safe and the ICP reduction effects of 35 degrees C hypothermia are similar to those of 33 degrees C hypothermia.
从1994年开始，我们对严重创伤性脑损伤患者(格拉斯哥昏迷评分为5分或以下)使用低温治疗。在2000年，我们将目标温度从之前的33摄氏度改为35摄氏度，因为我们的研究结果表明，冷却到35摄氏度足以控制颅内高压，而低于35摄氏度的低温可能使患者易于持续累积氧债。我们试图澄清35℃低温是否与33℃低温在降低颅内高压方面具有相同的效果，以及它是否与更少的并发症和改善的预后有关。方法比较30例(2000年1月~ 2005年6月)35℃低温治疗患者与31例(1994年7月~ 1999年12月)33℃低温治疗患者的颅内压(ICP)及生化指标。结果两组患者特征相似。35℃低温组平均体温为35.1 +/- 0.7℃，33℃低温组平均体温为33.4 +/- 0.8℃。35℃和33℃低温组的平均颅内压均控制在20 mm Hg以下。颅内高压和低脑灌注压的发生率在两组间无差异。35℃低温组患者在降低体温过程中血清钾浓度下降和复温后C反应蛋白升高的情况均有显著改善。35℃组死亡率和全身并发症发生率较低。结论将患者降温至35℃是安全的，35℃与33℃降低颅内压的效果相似。
{"title":"Effect of 35 degrees C hypothermia on intracranial pressure and clinical outcome in patients with severe traumatic brain injury.","authors":"T. Tokutomi, T. Miyagi, Y. Takeuchi, Takashi Karukaya, H. Katsuki, M. Shigemori","doi":"10.1097/TA.0b013e318157dbec","DOIUrl":"https://doi.org/10.1097/TA.0b013e318157dbec","url":null,"abstract":"BACKGROUND From 1994, we have used therapeutic hypothermia in patients with severe traumatic brain injury (Glasgow Coma Scale scores of 5 or less). In 2000, we altered the target temperature to 35 degrees C from the former 33 degrees C, as our findings suggested that cooling to 35 degrees C is sufficient to control intracranial hypertension, and that hypothermia below 35 degrees C may predispose patients to persistent cumulative oxygen debt. We attempted to clarify whether 35 degrees C hypothermia has the same effect as 33 degrees C hypothermia in reducing intracranial hypertension and whether it is associated with fewer complications and improved outcomes. METHODS We compared intracranial pressure (ICP) and biochemical parameters in the 30 patients treated with 35 degrees C hypothermia (January 2000 to June 2005) with those in the 31 patients treated with 33 degrees C hypothermia (July 1994 to December 1999). RESULTS Patient characteristics were similar in the two groups. The mean temperature during hypothermia was 35.1 +/- 0.7 degrees C in the 35 degrees C hypothermia group and 33.4 +/- 0.8 degrees C in the 33 degrees C hypothermia group. Mean ICP was controlled under 20 mm Hg during hypothermia in both the 35 degrees C hypothermia and 33 degrees C hypothermia groups. The incidence of intracranial hypertension and low cerebral perfusion pressure did not differ between the two groups. The 35 degrees C hypothermic patients exhibited a significant improvement in the decline of serum potassium concentrations during hypothermia and in the increment of C-reactive protein after rewarming. The mortality rate and the incidence of systemic complications tended to be lower in the 35 degrees C group. CONCLUSIONS Cooling patients to 35 degrees C is safe and the ICP reduction effects of 35 degrees C hypothermia are similar to those of 33 degrees C hypothermia.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"69 1","pages":"166-73"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83825406","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e3181929ce3
C. Lucas
{"title":"34th William Fitts Jr oration: the parathyroid response to acute hemorrhage, sepsis, and multiple organ failure.","authors":"C. Lucas","doi":"10.1097/TA.0b013e3181929ce3","DOIUrl":"https://doi.org/10.1097/TA.0b013e3181929ce3","url":null,"abstract":"","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"74 1","pages":"92-7"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83976529","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e31817f2c57
S. Nichols, M. McCarthy, A. P. Ekeh, R. Woods, M. Walusimbi, J. Saxe
BACKGROUND Cervical near-hangings are not rare, but have received little attention in the trauma literature. Increasing numbers of patients received from our local jail and detention centers prompted this study. METHODS Seventeen-year review of a level I Trauma Center Registry identified 67 patients with cervical strangulation for study. Data were analyzed using the Mann-Whitney test to evaluate continuous predictors, and Fisher's exact test for categorical predictors. RESULTS Ten of 67 patients died (14.9% mortality). Patients having a lower Glasgow Coma Score (GCS) at the scene (3.5 +/- 1.3 vs. 8.3 +/- 5.0; p = 0.001) and lower GCS in the emergency department (ED) (3.0 +/- 0.0 vs. 9.0 +/- 5.3; p < 0.001) were more likely to die. Injuries consisted predominantly of neck abrasions and anoxic brain injuries (83% mortality). Laryngeal fractures and carotid arterial injuries were detected. No cervical spine fractures were seen, but subluxations were identified. Forty-two percent of the patients were in detention centers when the near-hanging incident occurred. CONCLUSIONS Cervical near-hangings are referred to the Trauma Service for evaluation. Scene or ED GCS of 3 does not preclude neurologically intact survival, although mortality is high. In our study, the most useful prognostic factors were the need for airway control by intubation or cricothyrotomy, cardiopulmonary resuscitation, lower scene and ED GCS, and cerebral edema on CT Scan. Optimal evaluation includes head and neck CT and CT angiography of the neck. We plan to share these results with local authorities and encourage improvement in risk identification, with earlier involvement of mental health personnel.
背景宫颈近悬垂并不罕见，但在创伤文献中很少受到关注。越来越多的病人从我们当地的监狱和拘留中心收到促使这项研究。方法:对17年来一级创伤中心登记的67例颈部勒死患者进行回顾性研究。使用Mann-Whitney检验评估连续预测因子，使用Fisher精确检验评估分类预测因子。结果67例患者死亡10例，死亡率14.9%。现场格拉斯哥昏迷评分(GCS)较低的患者(3.5 +/- 1.3 vs. 8.3 +/- 5.0;p = 0.001)，急诊科(ED)的GCS较低(3.0 +/- 0.0 vs. 9.0 +/- 5.3;P < 0.001)更容易死亡。损伤主要包括颈部擦伤和缺氧脑损伤(死亡率83%)。发现喉部骨折及颈动脉损伤。未见颈椎骨折，但发现半脱位。几乎被吊死的事件发生时，42%的病人在拘留中心。结论颈部近悬垂应提交创伤科评估。Scene或ED GCS为3并不排除神经完整存活，尽管死亡率很高。在我们的研究中，最有用的预后因素是是否需要通过插管或环甲环切开术来控制气道，心肺复苏，下场景和ED GCS，以及CT扫描上的脑水肿。最佳评价包括头颈部CT和颈部CT血管造影。我们计划与地方当局分享这些结果，并鼓励在精神卫生人员早期参与的情况下改进风险识别。
{"title":"Outcome of cervical near-hanging injuries.","authors":"S. Nichols, M. McCarthy, A. P. Ekeh, R. Woods, M. Walusimbi, J. Saxe","doi":"10.1097/TA.0b013e31817f2c57","DOIUrl":"https://doi.org/10.1097/TA.0b013e31817f2c57","url":null,"abstract":"BACKGROUND Cervical near-hangings are not rare, but have received little attention in the trauma literature. Increasing numbers of patients received from our local jail and detention centers prompted this study. METHODS Seventeen-year review of a level I Trauma Center Registry identified 67 patients with cervical strangulation for study. Data were analyzed using the Mann-Whitney test to evaluate continuous predictors, and Fisher's exact test for categorical predictors. RESULTS Ten of 67 patients died (14.9% mortality). Patients having a lower Glasgow Coma Score (GCS) at the scene (3.5 +/- 1.3 vs. 8.3 +/- 5.0; p = 0.001) and lower GCS in the emergency department (ED) (3.0 +/- 0.0 vs. 9.0 +/- 5.3; p < 0.001) were more likely to die. Injuries consisted predominantly of neck abrasions and anoxic brain injuries (83% mortality). Laryngeal fractures and carotid arterial injuries were detected. No cervical spine fractures were seen, but subluxations were identified. Forty-two percent of the patients were in detention centers when the near-hanging incident occurred. CONCLUSIONS Cervical near-hangings are referred to the Trauma Service for evaluation. Scene or ED GCS of 3 does not preclude neurologically intact survival, although mortality is high. In our study, the most useful prognostic factors were the need for airway control by intubation or cricothyrotomy, cardiopulmonary resuscitation, lower scene and ED GCS, and cerebral edema on CT Scan. Optimal evaluation includes head and neck CT and CT angiography of the neck. We plan to share these results with local authorities and encourage improvement in risk identification, with earlier involvement of mental health personnel.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"71 1","pages":"174-8"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90807729","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e318181e555
T. Lv, Xiao-kun Shen, Yi Shi, Yong Song
BACKGROUND Acute lung injury (ALI) and acute respiratory distress syndrome in patients with hemorrhagic shock (HS) or resuscitation is associated with the expression of TLR4. However, the role of TLR4 in ALI induced by unresuscitated HS remains obscure. METHODS The lung pathologic change was observed by hematoxylin and eosin staining. Interleukin-1beta and tumor necrosis factor-alpha were analyzed by enzyme-linked immunosorbent assay. Polymorphonuclear leukocyte sequestration and lung leak were analyzed by pulmonary myeloperoxidase activity and Evans blue dye. The expressions of TLR4 mRNA and protein were analyzed by reverse transcription-polymerase chain reaction and Western blot, respectively. TLR4 distribution was analyzed by immunohistochemistry. RESULTS Lung neutrophil accumulation and microvascular permeability were significantly increased after unresuscitated HS, meanwhile, lung interleukin-1beta and tumor necrosis factor-alpha were gradually augmented. TLR4 mRNA, TLR4 distribution and TLR4 protein were also significantly increased in TLR4 wt mice, however, no above-mentioned changes appeared in TLR4 mutant mice. CONCLUSIONS TLR4 is strongly associated with the pathogenesis of ALI induced by unresuscitated HS, which may serve as a useful therapeutic target.
{"title":"TLR4 is essential in acute lung injury induced by unresuscitated hemorrhagic shock.","authors":"T. Lv, Xiao-kun Shen, Yi Shi, Yong Song","doi":"10.1097/TA.0b013e318181e555","DOIUrl":"https://doi.org/10.1097/TA.0b013e318181e555","url":null,"abstract":"BACKGROUND Acute lung injury (ALI) and acute respiratory distress syndrome in patients with hemorrhagic shock (HS) or resuscitation is associated with the expression of TLR4. However, the role of TLR4 in ALI induced by unresuscitated HS remains obscure. METHODS The lung pathologic change was observed by hematoxylin and eosin staining. Interleukin-1beta and tumor necrosis factor-alpha were analyzed by enzyme-linked immunosorbent assay. Polymorphonuclear leukocyte sequestration and lung leak were analyzed by pulmonary myeloperoxidase activity and Evans blue dye. The expressions of TLR4 mRNA and protein were analyzed by reverse transcription-polymerase chain reaction and Western blot, respectively. TLR4 distribution was analyzed by immunohistochemistry. RESULTS Lung neutrophil accumulation and microvascular permeability were significantly increased after unresuscitated HS, meanwhile, lung interleukin-1beta and tumor necrosis factor-alpha were gradually augmented. TLR4 mRNA, TLR4 distribution and TLR4 protein were also significantly increased in TLR4 wt mice, however, no above-mentioned changes appeared in TLR4 mutant mice. CONCLUSIONS TLR4 is strongly associated with the pathogenesis of ALI induced by unresuscitated HS, which may serve as a useful therapeutic target.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"57 1","pages":"124-31"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89422657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e318191bb1f
Todd W. Costantini, W. Loomis, James G. Putnam, Lauren Kroll, B. Eliceiri, A. Baird, V. Bansal, R. Coimbra
BACKGROUND Burn injury can result in loss of intestinal barrier function, leading to systemic inflammatory response syndrome and multiorgan failure. Myosin light chain kinase (MLCK), a tight junction protein involved in the regulation of barrier function, increases intestinal epithelial permeability when activated. Prior studies have shown that tumor necrosis factor (TNF)-alpha activates MLCK, in part through a nuclear factor (NF)-kappa B-dependent pathway. We have previously shown that pentoxifylline (PTX) decreases both TNF-alpha synthesis and NF-kappaB activation in models of shock. Therefore, we postulate that PTX will attenuate activation of the tight junction protein MLCK, which may decrease intestinal tight junction permeability after severe burn. METHODS Male balb/c mice undergoing a severe burn were randomized to resuscitation with normal saline (NS) or NS + PTX (12.5 mg/kg). Intestinal TNF-alpha levels were evaluated using enzyme linked immunosorbent assay. Gut extracts were obtained to assess MLCK, phosphorylated IKK, IkappaB-alpha, and NF-kappaB p65 levels by immunoblotting. RESULTS Burn injury increased intestinal MLCK protein levels threefold in animals resuscitated with NS, whereas those receiving PTX had MLCK levels similar to control (p < 0.01). Treatment with PTX attenuated burn-induced intestinal permeability. PTX decreased cytoplasmic IKK, IkappaB-alpha phosphorylation, and nuclear NF-kappaB p65 translocation to sham levels (p < 0.05 vs. NS). CONCLUSION Treatment with PTX attenuates activation of the tight junction protein MLCK, likely through its ability to decrease local TNF-alpha synthesis and NF-kappaB activation after burn. PTX may have therapeutic utility by decreasing intestinal barrier breakdown after burn.
{"title":"Pentoxifylline modulates intestinal tight junction signaling after burn injury: effects on myosin light chain kinase.","authors":"Todd W. Costantini, W. Loomis, James G. Putnam, Lauren Kroll, B. Eliceiri, A. Baird, V. Bansal, R. Coimbra","doi":"10.1097/TA.0b013e318191bb1f","DOIUrl":"https://doi.org/10.1097/TA.0b013e318191bb1f","url":null,"abstract":"BACKGROUND Burn injury can result in loss of intestinal barrier function, leading to systemic inflammatory response syndrome and multiorgan failure. Myosin light chain kinase (MLCK), a tight junction protein involved in the regulation of barrier function, increases intestinal epithelial permeability when activated. Prior studies have shown that tumor necrosis factor (TNF)-alpha activates MLCK, in part through a nuclear factor (NF)-kappa B-dependent pathway. We have previously shown that pentoxifylline (PTX) decreases both TNF-alpha synthesis and NF-kappaB activation in models of shock. Therefore, we postulate that PTX will attenuate activation of the tight junction protein MLCK, which may decrease intestinal tight junction permeability after severe burn. METHODS Male balb/c mice undergoing a severe burn were randomized to resuscitation with normal saline (NS) or NS + PTX (12.5 mg/kg). Intestinal TNF-alpha levels were evaluated using enzyme linked immunosorbent assay. Gut extracts were obtained to assess MLCK, phosphorylated IKK, IkappaB-alpha, and NF-kappaB p65 levels by immunoblotting. RESULTS Burn injury increased intestinal MLCK protein levels threefold in animals resuscitated with NS, whereas those receiving PTX had MLCK levels similar to control (p < 0.01). Treatment with PTX attenuated burn-induced intestinal permeability. PTX decreased cytoplasmic IKK, IkappaB-alpha phosphorylation, and nuclear NF-kappaB p65 translocation to sham levels (p < 0.05 vs. NS). CONCLUSION Treatment with PTX attenuates activation of the tight junction protein MLCK, likely through its ability to decrease local TNF-alpha synthesis and NF-kappaB activation after burn. PTX may have therapeutic utility by decreasing intestinal barrier breakdown after burn.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"43 8 1","pages":"17-24; discussion 24-5"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85824354","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e318194560b
F. Carinci, L. Arduin, F. Pagliaro, I. Zollino, G. Brunelli, R. Cenzi
BACKGROUND Mandibular fractures (MF) are a daily problem in maxillofacial surgery. A staging system for classifying MF is of paramount importance to plan surgery, to define prognosis, and to exchange information among trauma centers. In this article, a classification for MF is proposed. METHODS The mandible is divided into six sites (symphysis, body, angle, ramus, coronoid, and condyle) and the mandibular nerve divides the alveolar process (i.e., the upper part containing teeth) from the basal bone (placed caudally with respect to the nerve). MF can be summarized using three abbreviations: A = alveolar, B = basal, and C = complete. Consequently, MFs are staged as follows: F in situ = a greenstick fracture; F1 = a single mobile fragment of alveolar or basal bone; F2 = double mobile fractures of the alveolar or basal portion or a single complete separation of the mandibular arch continuity; F3 = a complete double separation of the mandibular arch continuity; F4 = triple or more mandibular arch fragments. To evaluate the suitability of the proposed classification, a retrospective study on a series of 128 patients (and 205 MFs) was performed. Age, gender, stage, clinical diagnosis at admission, type of surgery, and outcome were considered. RESULTS A good correlation between the proposed classification and the studied variables was detected. CONCLUSIONS The new classification is a simple and precise method for staging MF. It can summarize MFs and be used in daily practice. It is our understanding, however, that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.
{"title":"Scoring mandibular fractures: a tool for staging diagnosis, planning treatment, and predicting prognosis.","authors":"F. Carinci, L. Arduin, F. Pagliaro, I. Zollino, G. Brunelli, R. Cenzi","doi":"10.1097/TA.0b013e318194560b","DOIUrl":"https://doi.org/10.1097/TA.0b013e318194560b","url":null,"abstract":"BACKGROUND Mandibular fractures (MF) are a daily problem in maxillofacial surgery. A staging system for classifying MF is of paramount importance to plan surgery, to define prognosis, and to exchange information among trauma centers. In this article, a classification for MF is proposed. METHODS The mandible is divided into six sites (symphysis, body, angle, ramus, coronoid, and condyle) and the mandibular nerve divides the alveolar process (i.e., the upper part containing teeth) from the basal bone (placed caudally with respect to the nerve). MF can be summarized using three abbreviations: A = alveolar, B = basal, and C = complete. Consequently, MFs are staged as follows: F in situ = a greenstick fracture; F1 = a single mobile fragment of alveolar or basal bone; F2 = double mobile fractures of the alveolar or basal portion or a single complete separation of the mandibular arch continuity; F3 = a complete double separation of the mandibular arch continuity; F4 = triple or more mandibular arch fragments. To evaluate the suitability of the proposed classification, a retrospective study on a series of 128 patients (and 205 MFs) was performed. Age, gender, stage, clinical diagnosis at admission, type of surgery, and outcome were considered. RESULTS A good correlation between the proposed classification and the studied variables was detected. CONCLUSIONS The new classification is a simple and precise method for staging MF. It can summarize MFs and be used in daily practice. It is our understanding, however, that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"317 1","pages":"215-9"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80136906","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e31816073e3
Jason M Schauer, L. Engle, David T Maugher, R. Cherry
BACKGROUND A number of conflicting studies have been conducted to analyze the relationship between the timing of tracheostomy and mortality, intensive care unit (ICU) length of stay (LOS), hospital LOS, and the incidence of pneumonia. In contrast to previous studies, this relationship was investigated in the context of expected survival based on probability of survival (Ps) greater than 25%. METHODS Trauma patients were screened using a statewide registry during a 5-year period (January 2001 to December 2005). Burn patients, transfer patients, permanent tracheostomies, and patients who underwent multiple surgical airways were excluded from the study. Data were collected on patient demographics, Trauma and Injury Severity Score, days to tracheostomy, mortality, ICU LOS, total ventilator days, pneumonia, and hospital LOS. STATISTICAL ANALYSES log-linear modeling, chi2, p < 0.05. RESULTS A total of 125,533 trauma patients were analyzed. Out of these, 82,148 patients met inclusion criteria and had complete data for analysis. There were 6,880 patients intubated at the scene, during transport, or at admission to the emergency department, with 685 receiving a temporary tracheostomy. There was a significantly higher mortality rate (48.9%) associated with patients with low Ps (<0.25) receiving early tracheostomy (ET), <4 days. Among high-Ps patients, the ET group demonstrated reduced ICU LOS, total ventilator days, pneumonia, and hospital LOS (p < 0.05). CONCLUSION ET in patients with low Ps may not be beneficial given the substantially high mortality rate before post injury day 4. However, ET in high-Ps patients reduces ICU and hospital LOS, total ventilator days, and the incidence of pneumonia. This suggests an increased benefit in ET to trauma patients with high Ps.
背景:为了分析气管切开术时机与死亡率、重症监护病房(ICU)住院时间(LOS)、医院住院时间(LOS)和肺炎发病率之间的关系，已经进行了许多相互矛盾的研究。与以往的研究相反，在基于生存概率(Ps)大于25%的预期生存的背景下，研究了这种关系。方法在5年期间(2001年1月至2005年12月)，使用全州范围内的注册表对患者进行筛查。烧伤患者、转移患者、永久性气管切开术患者和接受多个手术气道的患者被排除在研究之外。收集的数据包括患者人口统计学、创伤和损伤严重程度评分、气管切开术天数、死亡率、ICU LOS、呼吸机总天数、肺炎和医院LOS。统计分析:对数线性模型，ch2, p < 0.05。结果共对125,533例创伤患者进行了tsa分析。其中，82148例患者符合纳入标准，有完整的数据供分析。有6880名患者在现场、运输过程中或急诊入院时插管，其中685人接受了临时气管切开术。低p值(<0.25)患者早期接受气管切开术(ET) <4天，死亡率(48.9%)显著增高。在高ps患者中，ET组显示ICU LOS、呼吸机总天数、肺炎和医院LOS降低(p < 0.05)。结论:考虑到损伤后第4天之前的高死亡率，低p患者的et可能不是有益的。然而，高p患者的ET降低了ICU和医院的LOS、呼吸机总天数和肺炎的发病率。这表明ET对高Ps的创伤患者有更大的益处。
{"title":"Does acuity matter?--Optimal timing of tracheostomy stratified by injury severity.","authors":"Jason M Schauer, L. Engle, David T Maugher, R. Cherry","doi":"10.1097/TA.0b013e31816073e3","DOIUrl":"https://doi.org/10.1097/TA.0b013e31816073e3","url":null,"abstract":"BACKGROUND A number of conflicting studies have been conducted to analyze the relationship between the timing of tracheostomy and mortality, intensive care unit (ICU) length of stay (LOS), hospital LOS, and the incidence of pneumonia. In contrast to previous studies, this relationship was investigated in the context of expected survival based on probability of survival (Ps) greater than 25%. METHODS Trauma patients were screened using a statewide registry during a 5-year period (January 2001 to December 2005). Burn patients, transfer patients, permanent tracheostomies, and patients who underwent multiple surgical airways were excluded from the study. Data were collected on patient demographics, Trauma and Injury Severity Score, days to tracheostomy, mortality, ICU LOS, total ventilator days, pneumonia, and hospital LOS. STATISTICAL ANALYSES log-linear modeling, chi2, p < 0.05. RESULTS A total of 125,533 trauma patients were analyzed. Out of these, 82,148 patients met inclusion criteria and had complete data for analysis. There were 6,880 patients intubated at the scene, during transport, or at admission to the emergency department, with 685 receiving a temporary tracheostomy. There was a significantly higher mortality rate (48.9%) associated with patients with low Ps (<0.25) receiving early tracheostomy (ET), <4 days. Among high-Ps patients, the ET group demonstrated reduced ICU LOS, total ventilator days, pneumonia, and hospital LOS (p < 0.05). CONCLUSION ET in patients with low Ps may not be beneficial given the substantially high mortality rate before post injury day 4. However, ET in high-Ps patients reduces ICU and hospital LOS, total ventilator days, and the incidence of pneumonia. This suggests an increased benefit in ET to trauma patients with high Ps.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"22 1","pages":"220-5"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81431958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2009-01-01DOI: 10.1097/TA.0b013e318191bdd6
M. Eckert, J. Perry, Vance Y. Sohn, Joren B. Keylock, J. Munaretto, A. Beekley, Matthew J. Martin
BACKGROUND Complex duodenal injury remains a challenging problem for the trauma surgeon. Although primary repair of small injuries is often possible, extensive damage requires complex enteric reconstruction and drainage procedures. We sought to determine the efficacy of a bioprosthetic repair for large duodenal wounds in a porcine model. METHODS A 60% circumferential wall defect in the second portion of the duodenum was created in eight female Yorkshire swine (38 kg +/- 5 kg). After 30 minutes of peritoneal soilage, a bioprosthetic repair using 1.5 mm porcine acellular dermal matrix was performed. Animals were recovered and resumed a normal diet on day 3. Repeat abdominal exploration and anastomotic bursting pressure strength was performed at 1-, 2-, 3-, and 6-week intervals. Pathologic analysis of all specimens was performed. RESULTS All animals tolerated a normal diet postoperatively, with progressive weight gain and normal bowel function. On re-exploration, no animal had evidence of duodenal stenosis, proximal dilation, or abscess formation. Pathologic analysis demonstrated progressive in-growth of native bowel tissue, with almost complete incorporation at 6 weeks. Mean bursting pressure (202 mm Hg +/- 60 mm Hg) occurred at native bowel, not patch repair site, in three of eight animals. CONCLUSION Bioprosthetic repair of enteric wall defects, even in proximity to upper intestinal secretions, allows successful recovery of bowel function and injury repair without extensive anatomic reconstruction. This technique may provide a more conservative approach to the treatment of complex duodenal injuries after trauma.
背景:对于创伤外科医生来说，复杂的十二指肠损伤仍然是一个具有挑战性的问题。虽然小损伤的初级修复通常是可能的，但大面积损伤需要复杂的肠道重建和引流程序。我们试图在猪模型中确定生物假体修复大十二指肠伤口的疗效。方法8头约克郡母猪(38 kg±5 kg)十二指肠第二段圆周壁缺损60%。腹膜脏污30分钟后，使用1.5毫米猪脱细胞真皮基质进行生物假体修复。第3天，动物恢复正常饮食。每隔1、2、3和6周进行重复腹部探查和吻合口破裂压力强度检查。对所有标本进行病理分析。结果所有动物术后均能耐受正常饮食，体重逐渐增加，肠道功能正常。在再次探查时，没有动物有十二指肠狭窄、近端扩张或脓肿形成的证据。病理分析显示原生肠组织进行性生长，在6周时几乎完全合并。在8只动物中，有3只动物的平均破裂压力(202 mm Hg +/- 60 mm Hg)发生在原生肠道，而不是补丁修复部位。结论生物假体修复肠壁缺损，即使靠近上肠分泌物，也可以成功恢复肠功能和修复损伤，而无需广泛的解剖重建。该技术可为创伤后复杂十二指肠损伤的治疗提供更为保守的方法。
{"title":"Bioprosthetic repair of complex duodenal injury in a porcine model.","authors":"M. Eckert, J. Perry, Vance Y. Sohn, Joren B. Keylock, J. Munaretto, A. Beekley, Matthew J. Martin","doi":"10.1097/TA.0b013e318191bdd6","DOIUrl":"https://doi.org/10.1097/TA.0b013e318191bdd6","url":null,"abstract":"BACKGROUND Complex duodenal injury remains a challenging problem for the trauma surgeon. Although primary repair of small injuries is often possible, extensive damage requires complex enteric reconstruction and drainage procedures. We sought to determine the efficacy of a bioprosthetic repair for large duodenal wounds in a porcine model. METHODS A 60% circumferential wall defect in the second portion of the duodenum was created in eight female Yorkshire swine (38 kg +/- 5 kg). After 30 minutes of peritoneal soilage, a bioprosthetic repair using 1.5 mm porcine acellular dermal matrix was performed. Animals were recovered and resumed a normal diet on day 3. Repeat abdominal exploration and anastomotic bursting pressure strength was performed at 1-, 2-, 3-, and 6-week intervals. Pathologic analysis of all specimens was performed. RESULTS All animals tolerated a normal diet postoperatively, with progressive weight gain and normal bowel function. On re-exploration, no animal had evidence of duodenal stenosis, proximal dilation, or abscess formation. Pathologic analysis demonstrated progressive in-growth of native bowel tissue, with almost complete incorporation at 6 weeks. Mean bursting pressure (202 mm Hg +/- 60 mm Hg) occurred at native bowel, not patch repair site, in three of eight animals. CONCLUSION Bioprosthetic repair of enteric wall defects, even in proximity to upper intestinal secretions, allows successful recovery of bowel function and injury repair without extensive anatomic reconstruction. This technique may provide a more conservative approach to the treatment of complex duodenal injuries after trauma.","PeriodicalId":92962,"journal":{"name":"The journal of cardiothoracic trauma","volume":"1 1","pages":"103-9"},"PeriodicalIF":0.0,"publicationDate":"2009-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88721167","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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