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Roos J, Zinngrebe J, Huber-Lang M, Lupu L, Schmidt MA, Strobel H, Westhoff MA, Stifel U, Gebhard F, Wabitsch M, Mollnes TE, Debatin KM, Halbgebauer R, Fischer-Posovszky P. Trauma-associated extracellular histones mediate inflammation via a MYD88-IRAK1-ERK signaling axis and induce lytic cell death in human adipocytes. Cell Death Dis 2024; 15:285. [PMID: 38653969 PMCID: PMC11039744 DOI: 10.1038/s41419-024-06676-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024]
Abstract
Despite advances in the treatment and care of severe physical injuries, trauma remains one of the main reasons for disability-adjusted life years worldwide. Trauma patients often suffer from disturbances in energy utilization and metabolic dysfunction, including hyperglycemia and increased insulin resistance. White adipose tissue plays an essential role in the regulation of energy homeostasis and is frequently implicated in traumatic injury due to its ubiquitous body distribution but remains poorly studied. Initial triggers of the trauma response are mainly damage-associated molecular patterns (DAMPs) such as histones. We hypothesized that DAMP-induced adipose tissue inflammation contributes to metabolic dysfunction in trauma patients. Therefore, we investigated whether histone release during traumatic injury affects adipose tissue. Making use of a murine polytrauma model with hemorrhagic shock, we found increased serum levels of histones accompanied by an inflammatory response in white adipose tissue. In vitro, extracellular histones induced an inflammatory response in human adipocytes. On the molecular level, this inflammatory response was mediated via a MYD88-IRAK1-ERK signaling axis as demonstrated by pharmacological and genetic inhibition. Histones also induced lytic cell death executed independently of caspases and RIPK1 activity. Importantly, we detected increased histone levels in the bloodstream of patients after polytrauma. Such patients might benefit from a therapy consisting of activated protein C and the FDA-approved ERK inhibitor trametinib, as this combination effectively prevented histone-mediated effects on both, inflammatory gene activation and cell death in adipocytes. Preventing adipose tissue inflammation and adipocyte death in patients with polytrauma could help minimize posttraumatic metabolic dysfunction.
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Affiliation(s)
- Julian Roos
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Julia Zinngrebe
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Markus Huber-Lang
- Institute of Clinical and Experimental Trauma Immunology, University Medical Center, Ulm, Germany
| | - Ludmila Lupu
- Institute of Clinical and Experimental Trauma Immunology, University Medical Center, Ulm, Germany
| | - Miriam A Schmidt
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Hannah Strobel
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Mike-Andrew Westhoff
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Ulrich Stifel
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Florian Gebhard
- Department of Orthopedic Trauma, Hand, and Reconstructive Surgery, University Medical Center, Ulm, Germany
| | - Martin Wabitsch
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Tom Eirik Mollnes
- Department of Immunology, Oslo University Hospital and University of Oslo, Oslo, Norway
- Research Laboratory, Nordland Hospital Trust, Bodo, Norway
| | - Klaus-Michael Debatin
- Department of Pediatrics and Adolescent Medicine, University Medical Center, Ulm, Germany
| | - Rebecca Halbgebauer
- Institute of Clinical and Experimental Trauma Immunology, University Medical Center, Ulm, Germany
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Chai CZ, Ho UC, Kuo LT. Systemic Inflammation after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2023; 24:10943. [PMID: 37446118 DOI: 10.3390/ijms241310943] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/16/2023] [Accepted: 06/18/2023] [Indexed: 07/15/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is one of the most severe neurological disorders, with a high mortality rate and severe disabling functional sequelae. Systemic inflammation following hemorrhagic stroke may play an important role in mediating intracranial and extracranial tissue damage. Previous studies showed that various systemic inflammatory biomarkers might be useful in predicting clinical outcomes. Anti-inflammatory treatment might be a promising therapeutic approach for improving the prognosis of patients with aSAH. This review summarizes the complicated interactions between the nervous system and the immune system.
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Affiliation(s)
- Chang-Zhang Chai
- Department of Medical Education, National Taiwan University, School of Medicine, Taipei 100, Taiwan
| | - Ue-Cheung Ho
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei 100, Taiwan
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Dynamics of immune responses are inconsistent when trauma patients are grouped by injury severity score and clinical outcomes. Sci Rep 2023; 13:1391. [PMID: 36697474 PMCID: PMC9876923 DOI: 10.1038/s41598-023-27969-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
The injury severity score (ISS) is used in daily practice to evaluate the severity of trauma patients; however, the score is not always consistent with the prognosis. After injury, systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome (CARS) are related to the prognosis of trauma patients. We aimed to evaluate the associations between the immune response and prognosis in trauma patients. Patients who admitted to the Trauma Intensive Care Unit (ICU) were eligible. Whole blood samples were collected at admission, and then 6, 12, 24, 48 and 72 h after admission. Natural killer (NK) cells, lymphocyte subset population and cytokines release were identified using flow cytometry. We grouped patients by their ISS (≤ 25 and > 25 as very severe injury) and ICU stay (≤ 10 days as a short ICU stay and > 10 days as a long ICU stay) for evaluation. Fifty-three patients were enrolled. ICU stay but not ISS was close correlated with activity daily living (ADL) at discharge. Patients with a long ICU stay had an immediate increase in NK cells followed by lymphopenia which persisted for 48 h. Immediate activation of CD8+ T cells and then exhaustion with a higher programmed cell death-1 (PD-1) expression and suppression of CD4+ T cells with a shift to an anti-inflammatory Th2 phenotype were also observed in the patients with a long ICU stay. When the patients were grouped by ISS, the dynamics of immune responses were inconsistent to those when the patients were grouped by ICU stay. Immune responses are associated with the prognosis of trauma patients, however the currently used clinical parameters may not accurately reflect immune responses. Further investigations are needed to identify accurate predictors of prognosis in trauma patients.
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Cancer; Pathophysiology and Stress Modulation (Cancer, Therapeutic Interventions). Semin Oncol Nurs 2022; 38:151328. [PMID: 35989196 DOI: 10.1016/j.soncn.2022.151328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The purpose of this review is to describe the myriad complications of cancer and its therapies to emphasize the pathophysiological need for prehabilitation. DATA SOURCES The information presented in this review is from applicable, peer-reviewed scientific articles. CONCLUSION Cancer itself renders negative effects on the body, most notably unintentional weight loss and fatigue. Cancer treatments, especially surgical interventions, can cause detrimental short- and long-term impacts on patients, which translate to suboptimal treatment outcomes. Prehabilitation can be used to improve patient health prior to anticancer therapies to improve treatment tolerance and efficacy. IMPLICATIONS FOR NURSING PRACTICE Nurses play an important role in the treatment of patients with cancer throughout the cancer care continuum. Many nurses are already aiding their patients in cancer prehabilitation through education. By describing common impairments amenable to multimodal prehabilitation, nurses may better advocate for their patients and can become even more involved in this aspect of care.
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Galvis D, Zavala E, Walker JJ, Upton T, Lightman SL, Angelini GD, Evans J, Rogers CA, Phillips K, Gibbison B. Modelling the dynamic interaction of systemic inflammation and the hypothalamic-pituitary-adrenal (HPA) axis during and after cardiac surgery. J R Soc Interface 2022; 19:20210925. [PMID: 35472267 PMCID: PMC9042572 DOI: 10.1098/rsif.2021.0925] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Major surgery and critical illness produce a potentially life-threatening systemic inflammatory response. The hypothalamic-pituitary-adrenal (HPA) axis is one of the key physiological systems that counterbalances this systemic inflammation through changes in adrenocorticotrophic hormone (ACTH) and cortisol. These hormones normally exhibit highly correlated ultradian pulsatility with an amplitude modulated by circadian processes. However, these dynamics are disrupted by major surgery and critical illness. In this work, we characterize the inflammatory, ACTH and cortisol responses of patients undergoing cardiac surgery and show that the HPA axis response can be classified into one of three phenotypes: single-pulse, two-pulse and multiple-pulse dynamics. We develop a mathematical model of cortisol secretion and metabolism that predicts the physiological mechanisms responsible for these different phenotypes. We show that the effects of inflammatory mediators are important only in the single-pulse pattern in which normal pulsatility is lost-suggesting that this phenotype could be indicative of the greatest inflammatory response. Investigating whether and how these phenotypes are correlated with clinical outcomes will be critical to patient prognosis and designing interventions to improve recovery.
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Affiliation(s)
- Daniel Galvis
- Centre for Systems Modelling and Quantitative Biomedicine (SMQB), University of Birmingham, Edgbaston B15 2TT, UK
| | - Eder Zavala
- Centre for Systems Modelling and Quantitative Biomedicine (SMQB), University of Birmingham, Edgbaston B15 2TT, UK
| | - Jamie J Walker
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol BS1 3NY, UK.,College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter EX4 4QD, UK
| | - Thomas Upton
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol BS1 3NY, UK
| | - Stafford L Lightman
- Henry Wellcome Laboratories for Integrative Neuroscience and Endocrinology, University of Bristol, Bristol BS1 3NY, UK
| | - Gianni D Angelini
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol BS1 3NY, UK
| | - Jon Evans
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol BS2 8HW, UK
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol BS2 8HW, UK
| | - Kirsty Phillips
- Department of Pathology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK
| | - Ben Gibbison
- Department of Anaesthesia, Bristol Medical School, University of Bristol, Bristol BS2 8HW, UK
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Luo P, Zhang Y, Wang X, Wang J, Chen H, Cai L. A nomogram for predicting skin necrosis risk after open reduction and internal fixation for tibia fractures. Int Wound J 2022; 19:1551-1560. [PMID: 35037403 PMCID: PMC9493222 DOI: 10.1111/iwj.13754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/17/2021] [Accepted: 01/06/2022] [Indexed: 11/28/2022] Open
Abstract
The purpose of our study was to determine the risk factors for skin necrosis after open reduction and internal fixation (ORIF) for tibia fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from tibia fractures and had been surgically treated by ORIF in our institution between August 2015 and October 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of skin necrosis, and a nomogram model was constructed to predict the risk of skin necrosis. The predictive performance and consistency of the model were evaluated by the Hosmer‐Lemeshow (H‐L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.906 (95% confidence interval 0.88~0.94). The H‐L test revealed that the nomogram prediction model had good calibration ability (P = .467). Finally, we found a correlation between skin necrosis and limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) after ORIF for tibia fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high‐risk patients, as interventions could be taken early to reduce the incidence of skin necrosis.
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Affiliation(s)
- Peng Luo
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yingying Zhang
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xingyu Wang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianshun Wang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hua Chen
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Leyi Cai
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
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Qi J, Xie Q, Li Z, Sun C. A Nomogram to Better Predict the In-Hospital Mortality of Trauma Patients with Sepsis in the Intensive Care Unit. Int J Clin Pract 2022; 2022:4134138. [PMID: 36134327 PMCID: PMC9481405 DOI: 10.1155/2022/4134138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/08/2022] [Accepted: 07/14/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Trauma has a high incidence and mortality worldwide, and sepsis is one of the main causes of mortality in trauma patients. Therefore, it is essential to identify the risk factors of in-hospital mortality for trauma patients with sepsis. METHODS Data were extracted from the Medical Information Mart for Intensive Care III database and divided into a training set and internal validation set, and another Chinese dataset was used as external validation set. Then, risk factors were estimated using univariate and multivariate logistic regression analyses in the training set. Finally, a nomogram was created to predict the probability of in-hospital mortality for trauma patients with sepsis. RESULTS A total of 503 patients were enrolled in our study (335 in the training set and 168 in the validation set). Multivariate logistic regression analysis revealed that age (1.047 [1.025-1.071]), respiratory rate (1.258 [1.135-1.394]), PTT (1.026 [1.008-1.044]), ventilation (6.703 [1.528-29.408]), and vasopressor use (3.682 [1.502-9.025]) were independent factors associated with in-hospital mortality. The nomogram for trauma-related sepsis predicted in-hospital mortality with AUC values of 0.8939 in the training set, 0.8200 in the internal validation set, and 0.7779 in the external validation set. CONCLUSIONS The new nomogram has a well predicted value for in-hospital mortality for patients with trauma and sepsis in intensive care units.
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Affiliation(s)
- Jing Qi
- Department of Emergency, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Qin Xie
- Department of Emergency, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhenzhou Li
- Department of Emergency, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Chuanzheng Sun
- Department of Emergency, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
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IL-1β primed mesenchymal stromal cells moderate hemorrhagic shock-induced organ injuries. Stem Cell Res Ther 2021; 12:438. [PMID: 34353366 PMCID: PMC8340459 DOI: 10.1186/s13287-021-02505-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 07/08/2021] [Indexed: 12/20/2022] Open
Abstract
Background Organ damages following hemorrhagic shock (HS) have been partly attributed to an immunological dysfunction. The current challenge in the management of HS patients is to prevent organ injury-induced morbidity and mortality which currently has not etiological treatment available. Mesenchymal stromal cells (MSC) are used in clinical cell therapy for immunomodulation and tissue repair. In vitro priming is often used to improve the immunomodulation efficiency of MSC before administration. Objective Assess the effect of naive MSC (MSCn) or interleukin (IL)-1β primed (MSCp) treatment in a context of HS-induced organ injury. Methods Rats underwent fixed pressure HS and were treated with allogenic MSCn or MSCp. Liver and kidney injuries were evaluated 6h later by histological and biochemical analysis. Whole blood was collected to measure leukocytes phenotypes. Then, in vitro characterization of MSCn or MSCp was carried out. Results Plasma creatinine, blood urea nitrogen, and cystatin C were decrease by MSCp infusion as well as kidney injury molecule (KIM)-1 on histological kidney sections. Transaminases, GGT, and liver histology were normalized by MSCp. Systemic cytokines (IL-1α, IL-6, and IL-10) as well as CD80, 86, and PD-1/PDL-1 axis were decreased by MSCp on monocytes and granulocytes. In vitro, MSCp showed higher level of secreted immunomodulatory molecules than MSCn. Conclusion An early administration of MSCp moderates HS-induced kidney and liver injury. IL-1β priming improves MSC efficiency by promoting their immunomodulatory activity. These data provide proof of concept that MSCp could be a therapeutic tool to prevent the appearance of organs injury following HS. Supplementary Information The online version contains supplementary material available at 10.1186/s13287-021-02505-4.
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Club Cell Protein 16 Attenuates CD16 brightCD62 dim Immunosuppressive Neutrophils in Damaged Tissue upon Posttraumatic Sepsis-Induced Lung Injury. J Immunol Res 2021; 2021:6647753. [PMID: 33575362 PMCID: PMC7861919 DOI: 10.1155/2021/6647753] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/24/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Background Recently, identification of immunosuppressive polymorphonuclear leukocytes (PMNL) that were traditionally described as proinflammatory cells emerged in the field of posttraumatic immunity. To understand their local and remote distribution after trauma, PMNL-subsets and the impact of immunomodulatory Club Cell protein (CC)16 that correlates with pulmonary complications were assessed. Methods C57BL/6N mice were divided into three groups, receiving isolated blunt chest trauma (TxT), undergoing TxT followed by cecal ligation and puncture (CLP, TxT + CLP) after 24 h, or sham undergoing analgosedation (n = 18/group). Further, each group was subdivided into three groups receiving either no treatment (ctrl) or intratracheal neutralization of CC16 by application of anti-CC16-antibody or application of an unspecific IgG control antibody (n = 6/group). Treatment was set at the time point after TxT. Analyses followed 6 h post-CLP. PMNL were characterized via expression of CD11b, CD16, CD45, CD62L, and Ly6G by flow cytometry in bone marrow (BM), blood, spleen, lung, liver, and bronchoalveolar and peritoneal lavage fluid (BALF and PL). Apoptosis was assessed by activated (cleaved) caspase-3. Results from untreated ctrl and IgG-treated mice were statistically comparable between all corresponding sham, TxT, and TxT + CLP groups. Results Immature (CD16dimCD62Lbright) PMNL increased significantly in BM, circulation, and spleen after TxT vs. sham and were significantly attenuated in the lungs, BALF, PL, and liver. Classical-shaped (CD16brightCD62Lbright) PMNL increased after TxT vs. sham in peripheral tissue and were significantly attenuated in circulation, proposing a trauma-induced migration of mature or peripheral differentiation of circulating immature PMNL. Immunosuppressive (CD16brightCD62Ldim) PMNL decreased significantly in the lungs and spleen, while they systemically increased after TxT vs. sham. CLP in the TxT + CLP group reduced immunosuppressive PMNL in PL and increased their circulatory rate vs. isolated TxT, showing local reduction in affected tissue and their increase in nonaffected tissue. CC16 neutralization enhanced the fraction of immunosuppressive PMNL following TxT vs. sham and decreased caspase-3 in the lungs post-CLP in the TxT + CLP group, while apoptotic cells in the liver diminished post-TxT. Posttraumatic CC16 neutralization promotes the subset of immunosuppressive PMNL and antagonizes their posttraumatic distribution. Conclusion Since CC16 affects both the distribution of PMNL subsets and apoptosis in tissues after trauma, it may constitute as a novel target to beneficially shape the posttraumatic tissue microenvironment and homeostasis to improving outcomes.
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Taghavi S, Ramirez S, Duchesne J, Tatum D. Preinjury Use of Marijuana and Outcomes in Trauma Patients. J Surg Res 2020; 257:42-49. [PMID: 32818783 DOI: 10.1016/j.jss.2020.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/11/2020] [Accepted: 07/11/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recent studies have examined the effects of marijuana in various populations; however, there has been limited research on the effect of marijuana use in severely injured trauma patients. We hypothesized that preinjury use of marijuana would be associated with improved outcomes in severely injured trauma patients. METHODS All adult (18+ y) level I and level II trauma activations who presented to two large regional trauma centers between 2014 and 2018 were reviewed. Delta-9-tetrahydrocannabinol (THC)- indicated absence of drugs confirmed by testing and as THC + confirmed THC without another drug present. RESULTS Of the 4849 patients included, 1373 (28.3%) were THC+. The THC + cohort was younger, had more males, and was more likely to be injured by penetrating mechanism (P < 0.001 for all) than THC-. THC + patients had shorter median length of stay (LOS) (P < 0.001) and intensive care unit LOS (P < 0.001). Mortality rate was lower in the THC + group (4.3% versus 7.6%, P < 0.001), but not in multivariate analysis. THC + patients with traumatic brain injury had shorter hospital LOS (P = 0.025) and shorter ventilator days (P = 0.033) than THC- patients. In patients with Injury Severity Score ≥16, THC + patients had significantly lower intensive care unit LOS (P = 0.009) and mortality (19.3% versus 25.0% P = 0.038) than drug-negative patients. CONCLUSIONS Although preinjury use of marijuana does not improve survival in trauma patients, it may provide some improvement in outcomes in patients with traumatic brain injury and those that are more severely injured (Injury Severity Score ≥16). The mechanism behind this finding needs further evaluation.
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Affiliation(s)
- Sharven Taghavi
- Department of Surgery, Division of Trauma & Critical Care, Tulane University School of Medicine, New Orleans, Louisiana
| | - Saul Ramirez
- Trauma Specialist Program, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana; Dartmouth College Geisel School of Medicine, Hanover, New Hampshire
| | - Juan Duchesne
- Department of Surgery, Division of Trauma & Critical Care, Tulane University School of Medicine, New Orleans, Louisiana
| | - Danielle Tatum
- Trauma Specialist Program, Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana.
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Hokari M, Uchida K, Shimbo D, Gekka M, Asaoka K, Itamoto K. Acute systematic inflammatory response syndrome and serum biomarkers predict outcomes after subarachnoid hemorrhage. J Clin Neurosci 2020; 78:108-113. [PMID: 32600972 DOI: 10.1016/j.jocn.2020.05.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/06/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
Abstract
Subarachnoid hemorrhage (SAH) can trigger immune activation sufficient to induce systematic inflammatory response syndrome (SIRS). Serum inflammatory biomarkers and SIRS can predict a poor outcome. The relationship between surgical stress and inflammatory response is well known but described in few reports in the neurosurgical population. We aimed to ascertain whether postoperative SIRS and initial serum biomarkers were associated with outcomes and evaluate whether the postoperative SIRS score differed between those with clipping and coil embolization. We evaluated 87 patients hospitalized within 24 h from onset of nontraumatic SAH. Serum biomarkers, such as levels of C-reactive protein (CRP), white blood cells (WBC), and D-dimer, as well as stress index (SI: blood sugar/K ratio) were obtained at admission. SIRS scores 3 days after admission were derived by adding the number of variables meeting the standard criteria (heart rate [HR] >90, respiratory rate [RR] >20, temperature >38 °C or <36 °C, and WBC count <4000 or >12,000). Clinical variables were compared according to whether they were associated with poor outcomes. Coil embolization was performed in 30 patients and clipping in 57. WBC, SI, D-dimer levels, and SIRS scores were significantly higher in patients with poor-grade SAH and were associated with poor outcomes. SIRS scores were significantly higher with clipping than with coil embolization among patients with good-grade SAH without intracerebral hemorrhage. Acute SIRS and serum biomarkers predict outcomes after SAH. Moreover, our study suggests the influence of surgical invasion via clipping on SIRS after SAH.
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Affiliation(s)
- Masaaki Hokari
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-Ku, Sapporo, Hokkaido 006-0811, Japan.
| | - Kazuki Uchida
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-Ku, Sapporo, Hokkaido 006-0811, Japan.
| | - Daisuke Shimbo
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-Ku, Sapporo, Hokkaido 006-0811, Japan
| | - Masayuki Gekka
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-Ku, Sapporo, Hokkaido 006-0811, Japan
| | - Katsuyuki Asaoka
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-Ku, Sapporo, Hokkaido 006-0811, Japan.
| | - Koji Itamoto
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-Ku, Sapporo, Hokkaido 006-0811, Japan.
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Izumo T, Morofuji Y, Hayashi K, Ryu N, Matsuo T. Surgical Treatment of Ruptured Anterior Circulation Aneurysms: Comparative Analysis of Modified Mini-Pterional and Standard Pterional Craniotomies. Neurol India 2019; 67:1248-1253. [PMID: 31744952 DOI: 10.4103/0028-3886.271261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Minimally invasive surgical techniques for cerebral aneurysms have been developed. Aims To compare the efficacy and safety of modified mini-pterional (mMPT) and standard pterional (PT) craniotomies for ruptured anterior circulation aneurysms. Materials and Methods A total of 45 patients with ruptured anterior circulation aneurysms underwent surgical clipping; for 21 patients PT was used and for 24 patients mMPT was used. Initial clinical demographics and outcomes were retrospectively compared. A systemic inflammatory response syndrome (SIRS) score was derived by summing the number of variables meeting standard criteria for SIRS. Results The two groups were comparable with initial clinical demographics. Total operative time was significantly shorter in the mMPT (166.6 minutes, P = 0.001) compared with the PT (235 minutes). The rate of permanent operative morbidity were similar in both groups (P = 0.92). The mean SIRS score at 24 hours after the completion of the operation was significantly lower for patients in the mMPT group (0.96, P = 0.01) as compared to the patients in the PT group (1.81). The rate of postoperative symptomatic vasospasm was significantly lower in patients operated through the mMPT (8.3%, P = 0.03) than the PT (38.1%). Good outcome at discharge was more frequently seen in the mMPT (91.7%) than in the PT (70%), but this difference was not statistically significant (P = 0.11). Conclusion The mMPT craniotomy is a safe and less invasive approach for ruptured anterior circulation aneurysms, leading to a significant lower rate of postoperative symptomatic vasospasm and a marginally significant improvement in clinical outcomes.
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Affiliation(s)
- Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kentaro Hayashi
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Nobutoshi Ryu
- Department of Neurosurgery, Juzenkai Hospital, Nagasaki, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Tekin YK. Are Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios Associated with Mortality in Pediatric Trauma Patients? A Retrospective Study. Rambam Maimonides Med J 2019; 10:RMMJ.10376. [PMID: 31675303 PMCID: PMC6824831 DOI: 10.5041/rmmj.10376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There are very limited data on the prognostic capacity of the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) for the systemic inflammatory response in pediatric trauma (PT) patients. The purpose of this study was to evaluate the prognostic ability of NLR and PLR on mortality in pediatric trauma patients. METHODS This study looked at 358 PT patients who were admitted to the Cumhuriyet University Hospital's Emergency Department between January 2010 and June 2018. The NLR and PLR were calculated by dividing the blood neutrophil count and blood platelet count, respectively, by the lymphocyte count, at the time of admission. After performing a stepwise logistic regression analysis to determine the predictive factors on the mortality risk of post-traumatic systemic inflammatory response syndrome (SIRS), receiver operating characteristic (ROC) curve analysis was used to define the optimum cut-off values of the NLR and the PLR parameters for survival. RESULTS The NLR, and PLR values were significantly higher in survivors than in non-survivors (NLR, 6.2±5.7 versus 2.6±2.5, P<0.001; PLR, 145.3±85.0 versus 46.2±25.2, P<0.001 ). The NLR (odds ratio [OR], 3.21; P=0.048), PLR (OR, 0.90; P=0.032), blood glucose (OR, 1.02; P=0.024), and Injury Severity Score (ISS) (OR, 1.28; P=0.011) were independent predictors of the mortality risk in PT patients. The area under the curve in the ROC curve analysis was 0.764 with a cut-off of 2.77 (sensitivity 70%, specificity 77%) for the NLR; and 0.928 with a cut-off of 61.83 (sensitivity 90%, specificity 85%) for the PLR. CONCLUSION Acquiring the NLR and PLR at the time of admission could be a useful predictor for mortality in PT patients.
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Jacome T, Tatum D. Systemic Inflammatory Response Syndrome (SIRS) Score Independently Predicts Poor Outcome in Isolated Traumatic Brain Injury. Neurocrit Care 2019; 28:110-116. [PMID: 28547319 DOI: 10.1007/s12028-017-0410-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Systemic inflammatory response syndrome (SIRS) is frequently observed after various types of acute cerebral injury and has been linked to clinical deterioration in non-traumatic brain injury (TBI). SIRS scores have also been shown to be predictive of length of stay and mortality in trauma patients. We aimed to determine the prognostic utility of SIRS present at admission in trauma patients with isolated TBI. METHODS This was a 5-year retrospective cohort study of adults (≥18 years) with isolated TBI admitted to a Level II trauma center. The prognostic value of SIRS, total SIRS scores, and each SIRS criterion was examined by Χ 2 and logistic regression analyses. RESULTS Of the 330 patients identified, 50 (15.2%) met SIRS criteria. SIRS was significantly associated with poor outcome (P < 0.001). Relative risk of poor outcome was 2.7 times higher in patients with a SIRS score of 2 on admission (P = 0.007) and increased significantly to 6.5 times in patients with a SIRS score of 3 (P = 0.002). Logistic regression demonstrated SIRS and each criterion to be significant independent prognostic factors (SIRS, P = 0.030; body temperature, P = 0.006; tachypnea, P = 0.022, tachycardia P = 0.023). CONCLUSION SIRS at admission is an independent predictor of poor outcome in isolated TBI patients. These data demonstrate SIRS to be an important clinical tool that may be used in facilitating prognostication, particularly in elderly trauma patients. Future prospective studies aimed at therapeutic interventions to mitigate SIRS in TBI patients are warranted. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Tomas Jacome
- Trauma Specialist Program, Our Lady of the Lake Regional Medical Center, 5000 Hennessey Blvd., Baton Rouge, LA, 70808, USA
| | - Danielle Tatum
- Trauma Specialist Program, Our Lady of the Lake Regional Medical Center, 5000 Hennessey Blvd., Baton Rouge, LA, 70808, USA.
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15
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Manson J, Hoffman R, Chen S, Ramadan MH, Billiar TR. Innate-Like Lymphocytes Are Immediate Participants in the Hyper-Acute Immune Response to Trauma and Hemorrhagic Shock. Front Immunol 2019; 10:1501. [PMID: 31354702 PMCID: PMC6638190 DOI: 10.3389/fimmu.2019.01501] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 06/17/2019] [Indexed: 02/03/2023] Open
Abstract
Adverse outcomes following severe traumatic injury are frequently attributed to a state of immunological dysfunction acquired during treatment and recovery. Recent genomic evidence however, suggests that the trajectory toward development of multiple organ dysfunction syndrome (MODS) is already in play at admission (<2 h following injury). Improved understanding of the molecular events during the hyper-acute immunological response to trauma, <2 h following injury, may reveal opportunities to ameliorate organ injury and expedite recovery. Lymphocytes have not previously been considered key participants in this early response; however, two observations in human trauma patients namely, raised populations of circulating NKT and NK cells during the hyper-acute phase and persistent lymphopenia beyond 48 h show association with the development of MODS during recovery. These highlight the need for greater understanding of lymphocyte function in the hyper-acute phase of inflammation. An exploratory study was therefore conducted in a well-established murine model of trauma and hemorrhagic shock (T&HS) to investigate (1) the development of lymphopenia in the murine model and (2) the phenotypic and functional changes of three innate-like lymphocyte subsets, NK1.1+ CD3–, NK1.1+ CD3+, γδTCR+ CD3+ cells, focusing on the first 6 h following injury. Rapid changes in phenotype and function were demonstrated in these cells within blood and spleen, but responses in lung tissue lagged behind. This study describes the immediacy of the innate-like lymphocyte response to trauma in different body compartments and considers new lines for further investigation to develop our understanding of MODS pathogenesis.
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Affiliation(s)
- Joanna Manson
- Department of Surgery, F1281 Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA, United States.,Barts Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Rosemary Hoffman
- Department of Surgery, F1281 Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA, United States
| | - Shuhua Chen
- Department of Surgery, F1281 Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mostafa H Ramadan
- Department of Surgery, F1281 Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA, United States
| | - Timothy R Billiar
- Department of Surgery, F1281 Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA, United States
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16
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Can systemic inflammatory response syndrome score at admission predict clinical outcome in patients with severe burns? Burns 2019; 45:860-868. [DOI: 10.1016/j.burns.2018.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/18/2018] [Accepted: 11/29/2018] [Indexed: 01/05/2023]
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17
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Eguia E, Cobb AN, Baker MS, Joyce C, Gilbert E, Gonzalez R, Afshar M, Churpek MM. Risk factors for infection and evaluation of Sepsis-3 in patients with trauma. Am J Surg 2019; 218:851-857. [PMID: 30885453 DOI: 10.1016/j.amjsurg.2019.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/01/2019] [Accepted: 03/06/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND We aim to examine the risk factors associated with infection in trauma patients and the Sepsis-3 definition. METHODS This was a retrospective cohort study of adult trauma patients admitted to a Level I trauma center between January 2014 and January 2016. RESULTS A total of 1499 trauma patients met inclusion criteria and 15% (n = 232) had an infection. Only 19.8% (n = 46) of infected patients met criteria for Sepsis-3, with the majority (43%) of infected cases having a Sequential Organ Failure Assessment (SOFA) score greater on admission compared to the time of suspected infection. In-hospital death was 7% vs 9% (p = 0.65) between Sepsis-3 and infected patients, respectively. Risk factors associated with infection were female sex, admission SOFA score, Elixhauser score, and severe injury (P < 0.05). CONCLUSION Patients with trauma often arrive with organ dysfunction, which adds complexity and inaccuracy to the operational definition of Sepsis-3 using changes in SOFA scores. Injury severity score, comorbidities, SOFA score, and sex are risk factors associated with developing an infection after trauma.
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Affiliation(s)
- Emanuel Eguia
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA.
| | - Adrienne N Cobb
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA
| | - Marshall S Baker
- Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA
| | - Cara Joyce
- Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA
| | - Emily Gilbert
- Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Richard Gonzalez
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Surgery, Acute Care Surgery Division, Loyola University Chicago, Maywood, IL, USA
| | - Majid Afshar
- Loyola University Chicago Burn Shock Trauma Research Institute, Maywood, IL, USA; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL, USA; Division of Pulmonary and Critical Care Medicine, Loyola University Chicago, Maywood, IL, USA
| | - Matthew M Churpek
- Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
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18
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Chang BP. Can hospitalization be hazardous to your health? A nosocomial based stress model for hospitalization. Gen Hosp Psychiatry 2019; 60:83-89. [PMID: 31376645 PMCID: PMC6791742 DOI: 10.1016/j.genhosppsych.2019.07.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/17/2019] [Accepted: 07/25/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Hospitalization places patients at elevated risk for the development of "nosocomial" or hospital acquired complications, ranging from multidrug resistant infections to delirium and physical deconditioning. Adverse nosocomial psychological effects of hospitalization may also exist. This paper introduces a nosocomial based stress model, conceptualizing hospitalization as a unique period of biopsychosocial vulnerability, due to physiologic effects of acute illness and psychosocial variables of the hospital experience. METHOD A research synthesis and narrative review was performed to evaluate evidence supporting this model, integrating existing knowledge of the psychological and physiological effects of acute life threatening events, with known sequelae associated with hospitalization. RESULT Psychosocial factors during hospitalization may act as independent predictors of recovery following hospitalization, moderating variables impacting ongoing physiologic changes due to acute illness, and/or dynamic bidirectional elements, influencing medical and psychological outcomes in the near and long-term setting. CONCLUSION The Nosocomial Stress model provides a novel framework to understanding the biopsychosocial interactions between the psychological and physiologic processes associated with illness and hospitalization. Based on this model, a research agenda is proposed to assess the contributions of acute illness, the hospital experience, and their interactions on the recovery of patients following hospitalization.
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19
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Hsieh CH, Chen YC, Hsu SY, Hsieh HY, Chien PC. Defining polytrauma by abbreviated injury scale ≥ 3 for a least two body regions is insufficient in terms of short-term outcome: A cross-sectional study at a level I trauma center. Biomed J 2018; 41:321-327. [PMID: 30580796 PMCID: PMC6306305 DOI: 10.1016/j.bj.2018.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022] Open
Abstract
Background Patients with polytrauma are expected to have a higher risk of mortality than the summation of expected mortality for their individual injuries. This study was designed to investigate the outcome of polytrauma patients, diagnosed by abbreviated injury scale (AIS) ≥ 3 for at least two body regions, at a level I trauma center. Methods Detailed data of 694 polytrauma patients and 2104 non-polytrauma patients with an overall Injury Severity Score (ISS) ≥ 16 and hospitalized between January 1, 2009, and December 31, 2014 for treatment of all traumatic injuries, were retrieved from the Trauma Registry System. Two-sided Fisher exact or Pearson chi-square tests were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann–Whitney U-test was used to compare non-normally distributed data. Propensity-score matching in a 1:1 ratio was performed using NCSS software with logistic regression to evaluate the effect of polytrauma on in-hospital mortality. Results There was no significant difference in short-term mortality between polytrauma and non-polytrauma patients, regardless of whether the comparison was made among the total patients (11.4% vs. 11.0%, respectively; p = 0.795) or among the selected propensity score-matched groups of patients following controlled covariates including sex, age, systolic blood pressure, co-morbidities, Glasgow Coma Scale scores, injury region based on AIS. Conclusions Polytrauma defined by AIS ≥3 for at least two body regions failed to recognize a significant difference in short-term mortality among trauma patients.
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Affiliation(s)
- Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| | - Yi-Chun Chen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Shiun-Yuan Hsu
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
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20
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Dharap SB, Ekhande SV. An observational study of incidence, risk factors & outcome of systemic inflammatory response & organ dysfunction following major trauma. Indian J Med Res 2018; 146:346-353. [PMID: 29355141 PMCID: PMC5793469 DOI: 10.4103/ijmr.ijmr_1538_15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background & objectives: Trauma is known to lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), which is often a cause of late deaths after injury. SIRS and MODS have been objectively measured using scoring systems. This prospective observational study was carried out in a tertiary care hospital in India to evaluate SIRS and MODS following trauma in terms of their incidence, the associated risk factors and the effect on the outcome. Methods: All adult patients with major life- and limb-threatening trauma were included. Patients who died within 24 h, those with severe head injury, known comorbidity, immunocompromised state, on immunosuppressants or pregnancy were excluded. SIRS and MODS scores were recorded after initial management (baseline score), on days 3 and 6 of admission. SIRS was defined as SIRS score of ≥2 and MODS was defined as MODS score of ≥1. Results: Two hundred patients were enrolled. SIRS was noted in 156 patients (78%). MODS was noted in 145 (72.5%) patients. Overall mortality was 39 (19.5%). Both SIRS and MODS scores were significantly associated with age >60 yr, blunt injury, (lower) revised trauma score hypotension on admission and (higher) injury severity score, but not with gender, pre-hospital time or operative treatment. Interpretation & conclusions: Both SIRS and MODS scores were associated with longer Intensive Care Unit (ICU) stay, more ICU interventions and higher mortality. Incidence of MODS was significantly higher in patients with SIRS. Both scores showed rising trend with time in non-survivors and a decreasing trend in survivors. The serial assessment of scores can help prognosticate outcome and also allocate appropriate critical care resources to patients with rising scores.
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Affiliation(s)
- Satish Balkrishna Dharap
- Department of Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Sanket Vishnu Ekhande
- Department of Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
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21
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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22
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Wulff A, Haarbrandt B, Tute E, Marschollek M, Beerbaum P, Jack T. An interoperable clinical decision-support system for early detection of SIRS in pediatric intensive care using openEHR. Artif Intell Med 2018; 89:10-23. [PMID: 29753616 DOI: 10.1016/j.artmed.2018.04.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clinical decision-support systems (CDSS) are designed to solve knowledge-intensive tasks for supporting decision-making processes. Although many approaches for designing CDSS have been proposed, due to high implementation costs, as well as the lack of interoperability features, current solutions are not well-established across different institutions. Recently, the use of standardized formalisms for knowledge representation as terminologies as well as the integration of semantically enriched clinical information models, as openEHR Archetypes, and their reuse within CDSS are theoretically considered as key factors for reusable CDSS. OBJECTIVE We aim at developing and evaluating an openEHR based approach to achieve interoperability in CDSS by designing and implementing an exemplary system for automated systemic inflammatory response syndrome (SIRS) detection in pediatric intensive care. METHODS We designed an interoperable concept, which enables an easy integration of the CDSS across different institutions, by using openEHR Archetypes, terminology bindings and the Archetype Query Language (AQL). The practicability of the approach was tested by (1) implementing a prototype, which is based on an openEHR based data repository of the Hannover Medical School (HaMSTR), and (2) conducting a first pilot study. RESULTS We successfully designed and implemented a CDSS with interoperable knowledge bases and interfaces by reusing internationally agreed-upon Archetypes, incorporating LOINC terminology and creating AQL queries, which allowed retrieving dynamic facts in a standardized and unambiguous form. The technical capabilities of the system were evaluated by testing the prototype on 16 randomly selected patients with 129 days of stay, and comparing the results with the assessment of clinical experts (leading to a sensitivity of 1.00, a specificity of 0.94 and a Cohen's kappa of 0.92). CONCLUSIONS We found the use of openEHR Archetypes and AQL a feasible approach to bridge the interoperability gap between local infrastructures and CDSS. The designed concept was successfully transferred into a clinically evaluated openEHR based CDSS. To the authors' knowledge, this is the first openEHR based CDSS, which is technically reliable and capable in a real context, and facilitates clinical decision-support for a complex task. Further activities will comprise enrichments of the knowledge base, the reasoning processes and cross-institutional evaluations.
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Affiliation(s)
- Antje Wulff
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany.
| | - Birger Haarbrandt
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Erik Tute
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany
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23
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Thakkar RK, Diltz Z, Drews JD, Wheeler KK, Shi J, Devine R, Fabia R, Hall M. Abnormal lymphocyte response after pediatric thermal injury is associated with adverse outcomes. J Surg Res 2018; 228:221-227. [PMID: 29907215 DOI: 10.1016/j.jss.2018.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/07/2018] [Accepted: 03/15/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Burns are a leading cause of morbidity in children, with infections representing the most common group of complications. Severe thermal injuries are associated with a profound inflammatory response, but the utility of laboratory values to predict infections in pediatric burn patients is poorly understood. MATERIALS AND METHODS Our institutional burn database was queried for patients aged 18 y and younger with at least 10% total body surface area burns. Demographics, mechanism, laboratory results, and outcomes were extracted from the medical record. Patients were classified as having an abnormal or normal total white blood cell count, neutrophil percentage, and lymphocyte percentage using the first complete blood count drawn 72 or more hours postinjury. Outcomes were compared between groups. RESULTS White blood cell data were available for 90 patients, 84 of whom had neutrophil and lymphocyte percentages. Abnormal lymphocyte percentage 72 h or more after burn injury was associated with a significant increase in infections (67.9% versus 32.3%, P = 0.003), length of stay (33.1 versus 18.8 d, P = 0.02), intensive care unit length of stay (13.1 versus 3.7 days, P = 0.01), and ventilator days (5.8 versus 2.3, P = 0.02). It was also an independent predictor of infection (odds ratio 7.2, 95% confidence interval 2.1-24.5). CONCLUSIONS Abnormal lymphocyte percentage at or after 72 h after burn injury is associated with adverse outcomes, including increased infectious risk.
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Affiliation(s)
- Rajan K Thakkar
- The Ohio State University College of Medicine, Columbus, Ohio; Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatric Surgery, Burn Center, Nationwide Children's Hospital, Columbus, Ohio; Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio.
| | - Zachary Diltz
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Drews
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Krista K Wheeler
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Junxin Shi
- Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Racheal Devine
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Renata Fabia
- The Ohio State University College of Medicine, Columbus, Ohio; Department of Pediatric Surgery, Burn Center, Nationwide Children's Hospital, Columbus, Ohio; Center for Pediatric Trauma Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Mark Hall
- The Ohio State University College of Medicine, Columbus, Ohio; Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, Ohio
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24
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Wang YC, Liu QX, Liu T, Xu XE, Gao W, Bai XJ, Li ZF. Caspase-1-dependent pyroptosis of peripheral blood mononuclear cells predicts the development of sepsis in severe trauma patients: A prospective observational study. Medicine (Baltimore) 2018; 97:e9859. [PMID: 29465571 PMCID: PMC5841964 DOI: 10.1097/md.0000000000009859] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Pyroptosis plays a pivotal role in sepsis and septic shock in animal studies. However, its clinical significance in pathological conditions has not been well elucidated. This study aimed to evaluate the correlation between the percentage of pyroptotic peripheral blood mononuclear cells (PBMCs) and the clinical index and to investigate the relationship between PBMCs pyroptosis and the development of sepsis in trauma patients.This prospective study was conducted from October 2016 to May 2017 in a comprehensive trauma center. Sixty trauma patients and 10 healthy controls were enrolled. Peripheral blood samples were collected from the patients within 24 hours after injury. The percentages of pyroptotic and apoptotic PBMCs were measured using flow cytometry, and plasma levels of cytokines were evaluated using flow cytometric analysis with a human inflammation 13-plex panel.Trauma patients who developed sepsis had higher percentages of pyroptotic and apoptotic PBMCs at admission. Patients who developed sepsis (n = 33) had higher interleukin (IL)-6, IL-18, and monocyte chemotactic protein-1 (MCP-1) concentrations at admission than patients (n = 27) who did not develop sepsis. The percentage of PBMCs pyroptosis was significantly correlated with injury severity score (ISS), acute physiology and chronic health evaluation (APACHE) II score, IL-10, IL-18, and MCP-1 levels in trauma patients. PBMCs pyroptosis is a better biomarker in predicting the development of sepsis after trauma.This study indicates that the percentage of pyroptotic PBMCs increases during the early phase of trauma and that this increase is significantly correlated with the severity and state of inflammation in trauma patients. PBMCs pyroptosis is a potential marker for predicting the development of sepsis after trauma.
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Dieleman J, Peelen L, Coulson T, Tran L, Reid C, Smith J, Myles P, Pilcher D. Age and other perioperative risk factors for postoperative systemic inflammatory response syndrome after cardiac surgery. Br J Anaesth 2017; 119:637-644. [DOI: 10.1093/bja/aex239] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 02/05/2023] Open
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Guo J, Yan W, Yang Y, Wang Z, Tian F. Monitoring of vascular endothelial growth factor and its soluble receptor levels in early trauma. J Trauma Acute Care Surg 2017; 82:766-770. [PMID: 28099389 DOI: 10.1097/ta.0000000000001373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This clinical observation study aimed to investigate the relationship between the serum levels of vascular endothelial growth factor (VEGF) and its soluble receptors with the severity and the occurrence of late acute respiratory distress syndrome (ARDS) in early trauma. METHODS Sixty patients with multiple injuries were divided into three groups according to the Injury Severity Score (ISS) and the serum levels of VEGF, soluble VEGF receptor 1 (sVEGFR1), and sVEGFR2, were measured. Ten healthy people were recruited as controls. The incidence of late ARDS was also monitored, and its relationship to the above measures analyzed. RESULTS VEGF was not associated with ISS (p > 0.05); sVEGFR1 was positively associated with ISS (r = 0.459, p < 0.0001); however, sVEGFR2 was negatively associated with ISS (r = 0.510, p < 0.0001). The serum VEGF levels between the ARDS group and the non-ARDS group showed no significant difference (p > 0.05). sVEGFR1 in the ARDS group was significantly higher than that in the non-ARDS group (p < 0.0001), and sVEGFR2 in the ARDS group was significantly lower than that in the non-ARDS group (p < 0.0001). CONCLUSION In conclusion, the increasing of sVEGFR1 and the decreasing of sVEGFR2 in early trauma might be closely related to the occurrence of late ARDS. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Jianying Guo
- From the Department of Critical Care Medicine (J.G., Z.W.), the Third Hospital of Hebei Medical University, Shijiazhuang, China; Department of Intensive Care Unit (W.Y.), the First Hospital of Baoding, Baoding, Hebei, China; Department of Severe Medicine (Y.Y.), Xingtai People's Hospital, Xingtai, Hebei, China; and Department of Respiratory (F.T.), the Third Hospital of Hebei Medical University, Shijiazhuang, China
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Ibrahim DA, Swenson A, Sassoon A, Fernando ND. Classifications In Brief: The Tscherne Classification of Soft Tissue Injury. Clin Orthop Relat Res 2017; 475:560-564. [PMID: 27417853 PMCID: PMC5213932 DOI: 10.1007/s11999-016-4980-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/07/2016] [Indexed: 01/31/2023]
Affiliation(s)
- David A. Ibrahim
- Department of Orthopaedics and Sports Medicine, University of Washington, 10330 Meridian Avenue N, Suite 270, Seattle, WA 98133 USA
| | - Alan Swenson
- Department of Orthopaedics and Sports Medicine, University of Washington, 10330 Meridian Avenue N, Suite 270, Seattle, WA 98133 USA
| | - Adam Sassoon
- Department of Orthopaedics and Sports Medicine, University of Washington, 10330 Meridian Avenue N, Suite 270, Seattle, WA 98133 USA
| | - Navin D. Fernando
- Department of Orthopaedics and Sports Medicine, University of Washington, 10330 Meridian Avenue N, Suite 270, Seattle, WA 98133 USA
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Segura-Sampedro JJ, Morales-Soriano R, González-Argente X, Borges M. Should we assume the new definition of sepsis in the surgical field? Cir Esp 2017; 95:415-416. [PMID: 28126207 DOI: 10.1016/j.ciresp.2016.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/17/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Juan José Segura-Sampedro
- Departmento de Cirugía General y Digestiva, Hospital Universitario Son Espases, Grupo de investigación de Enfermedad Oncológica Peritoneal en el Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, España.
| | - Rafael Morales-Soriano
- Departmento de Cirugía General y Digestiva, Hospital Universitario Son Espases, Grupo de investigación de Enfermedad Oncológica Peritoneal en el Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, España
| | - Xavier González-Argente
- Departmento de Cirugía General y Digestiva, Hospital Universitario Son Espases, Grupo de investigación de Enfermedad Oncológica Peritoneal en el Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, España
| | - Marcio Borges
- Unidad de Sepsis, Hospital Son Llatzer, Palma de Mallorca, España
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An Integrated Clinico-transcriptomic Approach Identifies a Central Role of the Heme Degradation Pathway for Septic Complications after Trauma. Ann Surg 2016; 264:1125-1134. [DOI: 10.1097/sla.0000000000001553] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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The prognostic value of neutrophil-to-lymphocyte ratio on mortality in critically ill trauma patients. J Trauma Acute Care Surg 2016; 81:882-888. [DOI: 10.1097/ta.0000000000000980] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Song BH, Hyun SY, Kim JJ, Cho JS, Ma DS, Kim HK, Lee G. A Comparison of the Effectiveness of Before and After the Regional Trauma Center’s Establishment. JOURNAL OF TRAUMA AND INJURY 2016. [DOI: 10.20408/jti.2016.29.3.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Bo Hyung Song
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Sung Youl Hyun
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin Joo Kim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jin Seong Cho
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Dae Sung Ma
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Ha Kyung Kim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Geun Lee
- Department of Emergency Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Abstract
The best time to operate on a fracture is governed in part by the nature of the fracture itself. It is also influenced by the premorbid condition of the patient and by the degree that associated injuries have disrupted normal processes. It is likely that some patients have a period of increased physiological risk for intervention, during which a second insult will result in further harm. The picture is not yet fully clear but relates to variations in the inflammatory response to trauma. One consistent lesson appears to resonate throughout the published literature. The most predictable risk factor for iatrogenic physiological disturbance is transfer to the operating theatre before adequate resuscitation of the patient has taken place.
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Affiliation(s)
- MP Revell
- SpR Trauma & Orthopaedics, West Midlands, UK
| | - KM Porter
- Consultant Trauma & Orthopaedic Surgeon, Selly Oak Hospital, Birmingham, UK
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Abstract
Management of non-compressible torso hemorrhage (NCTH) remains a challenge despite continued advancements in trauma resuscitation. Resuscitative thoracotomy with aortic cross-clamping and recent advances in endovascular aortic occlusion, including resuscitative endovascular occlusion of the aorta, have finite durations of therapy due to the inherent physiologic stressors that accompany complete occlusion. Here, we attempt to illuminate the current state of aortic occlusion for trauma resuscitation including explanation of the deleterious consequences of complete occlusion, potential methods and limitations of existing technology to overcome these consequences, and a description of innovative methods to improve the resuscitation of NCTH. By explaining the complexity and potential deleterious effects of resuscitation augmented with aortic occlusion, our goal is to provide practitioners with a real-world perspective on current endovascular technology and to encourage the continued innovation required to overcome existing obstacles.
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Affiliation(s)
- Rachel Russo
- Department of Surgery, UC Davis Medical Center, 2315 Stockton Blvd. Sacramento, California 94535
| | - Lucas P. Neff
- Department of Surgery, UC Davis Medical Center, 2315 Stockton Blvd. Sacramento, California 94535
- Department of General Surgery, David Grant USAF Medical Center, Travis Air Force Base, California 94533
- Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814
| | - M. Austin Johnson
- Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd. Sacramento, CA 95917
| | - Timothy K. Williams
- Department of Vascular and Endovascular Surgery, David Grant USAF Medical Center, Travis Air Force Base, California 94533
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Manson J, Cole E, De'Ath HD, Vulliamy P, Meier U, Pennington D, Brohi K. Early changes within the lymphocyte population are associated with the development of multiple organ dysfunction syndrome in trauma patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:176. [PMID: 27268230 PMCID: PMC4895987 DOI: 10.1186/s13054-016-1341-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 05/12/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early survival following severe injury has been improved with refined resuscitation strategies. Multiple organ dysfunction syndrome (MODS) is common among this fragile group of patients leading to prolonged hospital stay and late mortality. MODS after trauma is widely attributed to dysregulated inflammation but the precise mechanics of this response and its influence on organ injury are incompletely understood. This study was conducted to investigate the relationship between early lymphocyte responses and the development of MODS during admission. METHODS During a 24-month period, trauma patients were recruited from an urban major trauma centre to an ongoing, observational cohort study. Admission blood samples were obtained within 2 h of injury and before in-hospital intervention, including blood transfusion. The study population was predominantly male with a blunt mechanism of injury. Lymphocyte subset populations including T helper, cytotoxic T cells, NK cells and γδ T cells were identified using flow cytometry. Early cytokine release and lymphocyte count during the first 7 days of admission were also examined. RESULTS This study demonstrated that trauma patients who developed MODS had an increased population of NK dim cells (MODS vs no MODS: 22 % vs 13 %, p < 0.01) and reduced γδ-low T cells (MODS vs no MODS: 0.02 (0.01-0.03) vs 0.09 (0.06-0.12) × 10^9/L, p < 0.01) at admission. Critically injured patients who developed MODS (n = 27) had higher interferon gamma (IFN-γ) concentrations at admission, compared with patients of matched injury severity and shock (n = 60) who did not develop MODS (MODS vs no MODS: 4.1 (1.8-9.0) vs 1.0 (0.6-1.8) pg/ml, p = 0.01). Lymphopenia was observed within 24 h of injury and was persistent in those who developed MODS. Patients with a lymphocyte count of 0.5 × 10(9)/L or less at 48 h, had a 45 % mortality rate. CONCLUSIONS This study provides evidence of lymphocyte activation within 2 h of injury, as demonstrated by increased NK dim cells, reduced γδ-low T lymphocytes and high blood IFN-γ concentration. These changes are associated with the development of MODS and lymphopenia. The study reveals new opportunities for investigation to characterise the cellular response to trauma and examine its influence on recovery.
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Affiliation(s)
- Joanna Manson
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK.
| | - Elaine Cole
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Henry D De'Ath
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Paul Vulliamy
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Ute Meier
- Centre for Neuroscience, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Dan Pennington
- Centre for Immunobiology, Blizard Institute, QMUL, London, E1 2AT, UK
| | - Karim Brohi
- Barts Centre for Trauma Sciences, Blizard Institute, QMUL, London, E1 2AT, UK
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Rodríguez A, Martín-Loeches I, Yébenes JC. New definition of sepsis and septic shock: What does it give us? Med Intensiva 2016; 41:38-40. [PMID: 27255771 DOI: 10.1016/j.medin.2016.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 03/23/2016] [Accepted: 03/29/2016] [Indexed: 01/31/2023]
Affiliation(s)
- A Rodríguez
- Servicio de Medicina Intensiva, Hospital Universitario de Tarragona Joan XXIII/URV/IISPV/CIBERES, Tarragona, Spain.
| | - I Martín-Loeches
- Multidisciplinary Intensive Care Research Organization (MICRO), Department of Anaesthesia and Critical Care, St James's University Hospital, Trinity Centre for Health Sciences, Dublin, Ireland
| | - J C Yébenes
- Servicio de Medicina Intensiva, Hospital Universitario de Mataró, Mataró, Spain
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Sasse M, Dziuba F, Jack T, Köditz H, Kaussen T, Bertram H, Beerbaum P, Boehne M. In-line Filtration Decreases Systemic Inflammatory Response Syndrome, Renal and Hematologic Dysfunction in Pediatric Cardiac Intensive Care Patients. Pediatr Cardiol 2015; 36:1270-8. [PMID: 25845941 PMCID: PMC4495711 DOI: 10.1007/s00246-015-1157-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/24/2015] [Indexed: 11/25/2022]
Abstract
Cardiac surgery with cardiopulmonary bypass (CPB) frequently leads to systemic inflammatory response syndrome (SIRS) with concomitant organ malfunction. Infused particles may exacerbate inflammatory syndromes since they activate the coagulation cascade and alter inflammatory response or microvascular perfusion. In a randomized, controlled, prospective trial, we have previously shown that particle-retentive in-line filtration prevented major complications in critically ill children. Now, we investigated the effect of in-line filtration on major complications in the subgroup of cardiac patients. Children admitted to tertiary pediatric intensive care unit were randomized to either control or filter group obtaining in-line filtration throughout complete infusion therapy. Risk differences and 95 % confidence intervals (CI) of several complications such as SIRS, sepsis, mortality, various organ failure and dysfunction were compared between both groups using the Wald method. 305 children (n = 150 control, n = 155 filter group) with cardiac diseases were finally analyzed. The majority was admitted after cardiac surgery with CPB. Risk of SIRS (-11.3 %; 95 % CI -21.8 to -0.5 %), renal (-10.0 %; 95 % CI -17.0 to -3.0 %) and hematologic (-8.1 %; 95 % CI -14.2 to -0.2 %) dysfunction were significantly decreased within the filter group. No risk differences were demonstrated for occurrence of sepsis, any other organ failure or dysfunctions between both groups. Infused particles might aggravate a systemic hypercoagulability and inflammation with subsequent organ malfunction in pediatric cardiac intensive care patients. Particle-retentive in-line filtration might be effective in preventing SIRS and maintaining renal and hematologic function. In-line filtration offers a novel therapeutic option to decrease morbidity in cardiac intensive care.
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Affiliation(s)
- Michael Sasse
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Friederike Dziuba
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Harald Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Torsten Kaussen
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Harald Bertram
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Martin Boehne
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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Baek JH, Kim MS, Lee JC, Lee JH. Systemic inflammation response syndrome score predicts the mortality in multiple trauma patients. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:523-8. [PMID: 25551073 PMCID: PMC4279832 DOI: 10.5090/kjtcs.2014.47.6.523] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 09/13/2014] [Accepted: 09/15/2014] [Indexed: 11/19/2022]
Abstract
Background Numerous statistical models have been developed to accurately predict outcomes in multiple trauma patients. However, such trauma scoring systems reflect the patient’s physiological condition, which can only be determined to a limited extent, and are difficult to use when performing a rapid initial assessment. We studied the predictive ability of the systemic inflammatory response syndrome (SIRS) score compared to other scoring systems. Methods We retrospectively reviewed 229 patients with multiple trauma combined with chest injury from January 2006 to June 2011. A SIRS score was calculated for patients based on their presentation to the emergency room. The patients were divided into two groups: those with an SIRS score of two points or above and those with an SIRS score of one or zero. Then, the outcomes between the two groups were compared. Furthermore, the ability of the SIRS score and other injury severity scoring systems to predict mortality was compared. Results Hospital death occurred in 12 patients (5.2%). There were no significant differences in the general characteristics of patients, but the trauma severity scores were significantly different between the two groups. The SIRS scores, number of complications, and mortality rate were significantly higher in those with a SIRS score of two or above (p<0.001). In the multivariant analysis, the SIRS score was the only independent factor related to mortality. Conclusion The SIRS score is easily calculated on admission and may accurately predict mortality in patients with multiple traumas.
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Affiliation(s)
- Jong Hyun Baek
- Department of Thoracic and Cardiovascular Surgery, Yeungnam University College of Medicine
| | - Myeong Su Kim
- Department of Thoracic and Cardiovascular Surgery, Yeungnam University College of Medicine
| | - Jung Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Yeungnam University College of Medicine
| | - Jang Hoon Lee
- Department of Thoracic and Cardiovascular Surgery, Yeungnam University College of Medicine
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Paffrath T, Lefering R, Flohé S. How to define severely injured patients? -- an Injury Severity Score (ISS) based approach alone is not sufficient. Injury 2014; 45 Suppl 3:S64-9. [PMID: 25284238 DOI: 10.1016/j.injury.2014.08.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Multiple injured patients, polytrauma or severely injured patients are terms used as synonyms in international literature describing injured patients with a high risk of mortality and cost consuming therapeutic demands. In order to advance the definition of these terms, we analysed a large trauma registry. In detail, we compared critically ill trauma patients first specified on a pure anatomical base according to the ISS or NISS, second in the original "polytrauma definition" with two body regions affected and finally all of them combined with a physiological component. PATIENTS AND METHODS Records that were collected in the TraumaRegister DGU(®) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) between 1993 and 2011 (92,479 patients) were considered for this study. All patients with primary admission from scene with a minimum hospital stay of 48 h and an Injury Severity Score (ISS)≥ 16 were included. Pre-hospital and early admission data were used to determine physiological risk factors and calculate individual risk of death using the Revised Injury Severity Classification (RISC). RESULTS 45,350 patients met inclusion criteria. The overall hospital mortality rate was 20.4%. The predicted mortality according to the RISC-Score was 21.6%. 36,897 patients (81.4%) had injuries in several body regions. The prevalence of the five physiological risk factors varied between 17% (high age) and 34% (unconsciousness). There were 17,617 patients (38.8%) without any risk factor present on admission, while 30.6% (n=13,890) of the patients had one and 30.5% (n=13,843) had two or more factors present. Patients with ISS ≥ 16 but no physiological risk factor present had a very low mortality rate of 3.1% (542 of 17,617). With an increasing number of physiological factors there was an almost linear increase in mortality up to an 86% rate in patients with all five factors present. The 'polytrauma' definition of Butcher and colleagues with AIS ≥ 3 in at least two different body regions would apply to only 56.2% of patients in the present group with ISS ≥ 16. The mortality in this subgroup is only marginally higher (21.8%; 5559 of 25,494) than in the group of patients with only one severely affected body region (18.5%; 3675 of 19,875). CONCLUSIONS In our opinion the principle of sharpening an anatomically based definition by a defined physiological problem will help to specify the really critically ill trauma patients.
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Affiliation(s)
- Thomas Paffrath
- Department of Orthopaedic and Trauma Surgery, University Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany; Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Sascha Flohé
- Department of Trauma and Hand Surgery, University Hospital Duesseldorf, Duesseldorf, Germany; Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany
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Kesani AK, Urquhart JC, Bedard N, Leelapattana P, Siddiqi F, Gurr KR, Bailey CS. Systemic inflammatory response syndrome in patients with spinal cord injury: does its presence at admission affect patient outcomes? Clinical article. J Neurosurg Spine 2014; 21:296-302. [PMID: 24836657 DOI: 10.3171/2014.3.spine13784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object in this study was to determine whether the presence of systemic inflammatory response syndrome (SIRS) in patients with traumatic spinal cord injury (SCI) on admission is related to subsequent clinical outcome in terms of length of stay (LOS), complications, and mortality. METHODS The authors retrospectively reviewed the charts of 193 patients with acute traumatic SCI who had been hospitalized at their institution between 2006 and 2012. Patients were excluded from analysis if they had insufficient SIRS data, a cauda equina injury, a previous SCI, a preexisting neurological condition, or a condition on admission that prevented appropriate neurological assessment. Complications were counted only once per patient and were considered minor if they were severe enough to warrant treatment and major if they were life threatening. Demographics, injury characteristics, and outcomes were compared between individuals who had 2 or more SIRS criteria (SIRS+) and those who had 0 or 1 SIRS criterion (SIRS-) at admission. Multivariate logistic regression (enter method) was used to determine the relative contribution of SIRS+ at admission in predicting the outcomes of mortality, LOS in the intensive care unit (ICU), hospital LOS, and at least one major complication during the acute hospitalization. The American Spinal Injury Association Impairment Scale grade and patient age were included as covariates. RESULTS Ninety-three patients were eligible for analysis. At admission 47.3% of patients had 2 or more SIRS criteria. The SIRS+ patients had higher Injury Severity Scores (24.3 ±10.6 vs. 30.2 ±11.3) and a higher frequency of both at least one major complication during acute hospitalization (26.5% vs. 50.0%) and a fracture-dislocation pattern of injury (26.5% vs. 59.1%) than the SIRS- patients (p < 0.05 for each comparison). The SIRS+ patients had a longer median hospital stay (14 vs 18 days) and longer median ICU stay (0 vs. 5 days). However, mortality was not different between the groups. Having SIRS on admission predicted an ICU LOS > 10 days, hospital LOS > 25 days, and at least one complication during the acute hospitalization. CONCLUSIONS A protocol to identify SCI patients with SIRS at admission may be beneficial with respect to preventing adverse outcomes and decreasing hospital costs.
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Affiliation(s)
- Anil K Kesani
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine, University of Western Ontario; and Orthopaedic Spine Program, Victoria Hospital, London Health Sciences Centre, London, Ontario, Canada
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Inoue Y, Onodera M, Fujita Y, Fujino Y, Kikuchi S, Endo S. Factors associated with severe effects following acute glufosinate poisoning. Clin Toxicol (Phila) 2013; 51:846-9. [PMID: 24044532 DOI: 10.3109/15563650.2013.841180] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT In acute glufosinate poisoning, sudden respiratory arrest and convulsion can occur after a latent period of 4-60 h. There is still no factor that accurately predicts the occurrence of these symptoms. OBJECTIVE To elucidate the predictors of severe effects following acute glufosinate poisoning. MATERIALS AND METHODS This study is a retrospective observational case series. The subjects were 16 patients who had acute glufosinate poisoning. They were divided into a group with respiratory arrest or convulsion during hospitalization (severe group) and a group without (non-severe group). The following characteristics (or predictors) were compared between the groups: age, sex, calculated amount of glufosinate (volume of ingested poison (glufosinate-containing herbicide) × glufosinate concentration of the product), time duration from poison ingestion to arrival at our hospital, use of gastric lavage, use of whole bowel irrigation, Glasgow Coma Scale, laboratory parameters, PaO₂/FiO₂ ratio (P/F ratio), shock index, and presence or absence of systemic inflammatory response syndrome (SIRS) on arrival. RESULTS The P/F ratio was significantly lower in the severe group than in the non-severe group (median, 287.5 vs. 409.0; P = 0.049). The receiver operating characteristic (ROC) curve was plotted for the predictor of increasing severity based on the P/F ratio. The area under the curve was 0.714, and the optimal cutoff point for increasing severity was 374.0. The sensitivity was 75.0%, specificity of 71.4%, and accuracy of 75.0%. The shock index was significantly higher (median, 0.52 vs. 0.41; P = 0.031). Significantly more patients had SIRS in the severe group than in the non-severe group (P = 0.015). Logistic regression analysis was performed with a backward elimination procedure. SIRS was selected as the independent predictor of increasing severity (odds ratio, 29.810; 95% confidence interval, 1.011-878.952; P = 0.049). DISCUSSION AND CONCLUSION Severe effects following acute glufosinate poisoning were associated with two positive SIRS criteria. A low P/F ratio may be useful for predicting the occurrence of respiratory complications.
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Affiliation(s)
- Y Inoue
- Department of Emergency Medicine, Iwate Medical University, School of Medicine , Morioka, Iwate , Japan
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The Systemic Inflammatory Response Syndrome in Patients With ST-Segment Elevation Myocardial Infarction*. Crit Care Med 2013; 41:2080-7. [DOI: 10.1097/ccm.0b013e31828a67b2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Garcia DDFV, de Sá RRC, de Oliveira Bernini C, Rasslan S. Preliminary Results of a Prospective Study on Severe Lower Limb Trauma: Analysis of Laboratory Tests as Predictors of Amputation. ACTA ACUST UNITED AC 2013. [DOI: 10.5005/jp-journals-10030-1059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ABSTRACT
The decision of either preserving a member or primary amputation (PA) in severe extremity trauma, especially in the presence of fractures, vascular injuries or serious injuries of soft tissues has always been a challenge for the trauma surgeon. The initial assessment with objective criteria like indexes, such as the Mangled Extremity Severity Score (MESS) or the PSI, can aid in the differentiation of members that can be saved or should be amputated primarily. We report on the design and preliminary results of our ongoing prospective study analyzing laboratory test as predictors of amputation in severe lower limb trauma.
Materials and methods
All patients treated in our emergency department with severe lower limb trauma and open fractures (classified as Gustilo III) were included in this study. We collected blood for laboratory test of all patients at admission. All injured limb were photographed for posterior analysis and MESS classification.
Results
From March 15, 2012, to June 10, 2012, n = 20 patients were included in our study. PA was performed in eight (40%) and preserving procedures (PP) in 12 (60%). Mean age was 30 in PP group and 40.5 in PA. Mean systolic pressure at the emergency room was 130 mm Hg in PP and 107 mm Hg in PA. MESS index was calculated for all patients and the means were 5 for the PP group and 8 for the PA group. Laboratory test of the two groups were compared and statistically analyzed. Acidosis, arterial lactate levels and hemoglobin levels at admission had a statistical difference between the two groups: pH = 7.36 PP vs 7.18 PA (p = 0.001); lactate: PP = 25 vs PA = 63 (p < 0.001); hemoglobin: PP = 13.6 vs PA = 7.85 (p = 0.03).
Conclusion
Laboratory results of tests collected during initial assessment of patients with severe lower limb trauma are different between those submitted to PA or a PP.
How to cite this article
Garcia DFV, de Sá RRC, Bernini CO, Rasslan S . Preliminary Results of a Prospective Study on Severe Lower Limb Trauma: Analysis of Laboratory Tests as Predictors of Amputation. Panam J Trauma Critical Care Emerg Surg 2013;2(1):58-61.
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Abstract
Injury is a major cause of critical illness worldwide. Severely injured patients often require mechanical ventilation not only to manage primary respiratory failure but also as adjunct to manage other conditions. Injury induces fundamental changes in multiple organ systems which directly impact ventilator management; these changes are not shared by patients without concomitant tissue injury. In this article, we review the physiologic changes after injury and discuss the impact of injury on ventilator strategies and management. We also explore the special considerations in patients with traumatic brain injury, thermal injury, blast injury or bronchopleural fistula.
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Affiliation(s)
- Adrian A Maung
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT, USA
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Persistence of elevated plasma CXCL8 concentrations following red blood cell transfusion in a trauma cohort. Shock 2012; 37:373-7. [PMID: 22293598 DOI: 10.1097/shk.0b013e31824bcb72] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Red blood cell (RBC) transfusion is associated with alterations in systemic concentrations of IL-8/CXCL8 functional homologs in a murine model. Whether RBC transfusion alters systemic neutrophil chemokine concentrations in individuals sustaining traumatic injury is not known. We conducted a retrospective, single-center study of severely injured trauma patients presenting within 12 h of injury with a base deficit greater than 6 and hypotension in the field. Plasma concentrations of 25 chemokines, cytokines, and growth factors were obtained from both transfused (n = 22) and nontransfused (n = 33) groups in the first 48 h following admission. The transfused group (mean RBC units, 2.7 [SD, 1.7]) tended to be older (49.9 [SD, 21.1] vs. 40.4 [SD, 19.9] years, P = 0.10), with a higher percentage of females (40.9% vs. 18.2%, P = 0.06) and a higher Injury Severity Score (27.1 [SD, 12.7] vs. 21.4 [SD, 10.2], P = 0.07). In univariate and multivariate analyses, transfusion was associated with increased hospital and intensive care unit length of stay but not ventilator-free days. Plasma CXCL8 concentrations were higher in the transfused (84 [SD, 88] pg/mL) than the nontransfused group (31 [SD, 21] pg/mL, P = 0.003). Using a linear prediction model to calculate bioanalyte concentrations standardized for age, sex, Injury Severity Score, and admission SBP, we observed that CXCL8 concentrations diverged within 12 h following injury, with the transfused group showing persistently elevated CXCL8 concentrations by contrast to the decay observed in the nontransfused group. Other bioanalytes showed no differences across time. Red blood cell transfusion is associated with persistently elevated neutrophil chemokine CXCL8 concentrations following traumatic injury.
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Manson J, Thiemermann C, Brohi K. Trauma alarmins as activators of damage-induced inflammation. Br J Surg 2012; 99 Suppl 1:12-20. [PMID: 22441851 DOI: 10.1002/bjs.7717] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND A systemic inflammatory response syndrome (SIRS) is frequently observed after traumatic injury. The response is sterile and the activating stimulus is tissue damage. Endogenous molecules, called alarmins, are reputed to be released by injured tissues but the precise identity of these mediators is unclear. This review summarizes current preclinical and clinical evidence for trauma alarmins and their role in innate immune activation. METHODS A comprehensive literature review of putative alarmins in tissue damage after traumatic injury was conducted. RESULTS The presence of SIRS at admission is an independent predictor of mortality after trauma. The primary initiators of the human immune response are unclear. Several endogenous substances display alarmin characteristics in vitro. Preclinical studies demonstrate that blockade of certain endogenous substances can reduce adverse clinical sequelae after traumatic injury. Human evidence for trauma alarmins is extremely limited. CONCLUSION The magnitude of acute inflammation is predictive of outcome after trauma, suggesting that an early opportunity for immune modulation may exist. An understanding of the mechanisms of innate immune activation following trauma may lead to new therapeutic agents and improved patient survival.
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Affiliation(s)
- J Manson
- Trauma Sciences, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, UK.
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In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial. Intensive Care Med 2012; 38:1008-16. [PMID: 22527062 PMCID: PMC3351606 DOI: 10.1007/s00134-012-2539-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 01/12/2012] [Indexed: 11/17/2022]
Abstract
Purpose Particulate contamination due to infusion therapy carries a potential health risk for intensive care patients. Methods This single-centre, prospective, randomized controlled trial assessed the effects of filtration of intravenous fluids on the reduction of complications in critically ill children admitted to a pediatric intensive care unit (PICU). A total of 807 subjects were randomly assigned to either a control (n = 406) or filter group (n = 401), with the latter receiving in-line filtration. The primary endpoint was reduction in the rate of overall complications, which included the occurrence of systemic inflammatory response syndrome (SIRS), sepsis, organ failure (circulation, lung, liver, kidney) and thrombosis. Secondary objectives were a reduction in the length of stay on the PICU and overall hospital stay. Duration of mechanical ventilation and mortality were also analyzed. Findings Analysis demonstrated a significant reduction in the overall complication rate (n = 166 [40.9 %] vs. n = 124 [30.9 %]; P = 0.003) for the filter group. In particular, the incidence of SIRS was significantly lower (n = 123 [30.3 %] vs. n = 90 [22.4 %]; P = 0.01). Moreover the length of stay on PICU (3.89 [95 % confidence interval 2.97−4.82] vs. 2.98 [2.33−3.64]; P = 0.025) and duration of mechanical ventilation (14.0 [5.6−22.4] vs. 11.0 [7.1−14.9] h; P = 0.028) were significantly reduced. Conclusion In-line filtration is able to avert severe complications in critically ill patients. The overall complication rate during the PICU stay among the filter group was significantly reduced. In-line filtration was effective in reducing the occurrence of SIRS. We therefore conclude that in-line filtration improves the safety of intensive care therapy and represents a preventive strategy that results in a significant reduction of the length of stay in the PICU and duration of mechanical ventilation (ClinicalTrials.gov number: NCT00209768). Electronic supplementary material The online version of this article (doi:10.1007/s00134-012-2539-7) contains supplementary material, which is available to authorized users.
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Abstract
BACKGROUND Statins have many beneficial effects and may attenuate the proinflammatory and metabolic stress response to surgery and consequently reduce postoperative morbidity. OBJECTIVE This study investigated whether perioperative use of statins improved short-term outcomes after elective colectomy. DESIGN This study is a retrospective review of prospectively collected data. SETTINGS AND PATIENTS This study was conducted in consecutive patients undergoing elective colonic resection within an enhanced recovery program at a tertiary hospital (Manukau Surgery Centre, Middlemore Hospital, Auckland, New Zealand) from January 2005 to December 2010. MAIN OUTCOME MEASURES Complications, hospital stay, and readmissions were recorded for 30 days postoperatively. Postoperative functional recovery was measured by the use of the validated Surgical Recovery Score. Serum proinflammatory cytokines were measured on postoperative day 1. RESULTS There were 269 patients; 86 patients were on a statin perioperatively, whereas 183 patients had no statin. Members of the statin group were older (median age, 72 vs 69 years; p = 0.021), included more men (53% vs 40%; p = 0.049), and included a higher number of patients with an ASA score of 3 (55% vs 22%; p < 0.001). Patients on statin therapy had a significantly lower number of anastomotic leaks (1% vs 7%; p = 0.031). However, there was no significant difference in total complications or median hospital stay. The 2 groups had comparable functional recovery, and there was no significant difference in serum cytokine levels. LIMITATIONS This retrospective study did not analyze type, duration, or dose of statins given perioperatively. CONCLUSION Patients on perioperative statins had greater baseline perioperative risks compared with nonusers, but they achieved equivalent outcomes overall. Statin use was associated with reduced anastomotic leaks. Thus, perioperative statin use may reduce morbidity after elective colectomy, and this finding warrants further investigation.
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Heffernan DS, Monaghan SF, Thakkar RK, Machan JT, Cioffi WG, Ayala A. Failure to normalize lymphopenia following trauma is associated with increased mortality, independent of the leukocytosis pattern. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R12. [PMID: 22264310 PMCID: PMC3396248 DOI: 10.1186/cc11157] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 01/20/2012] [Indexed: 01/06/2023]
Abstract
Introduction Following trauma and systemic inflammatory response syndrome (SIRS), the typical response is an elevation of the total complete blood count (CBC) and a reduction of the lymphocyte count. This leukocytosis typically returns to normal within 48 hours. The persistence of a leukocytosis following trauma is associated with adverse outcomes. Although lymphocyte anergy and dysfunction following trauma is associated with increased risk for infection and sepsis, there is a paucity of data regarding the impact of a persistence of a low lymphocyte count in trauma patients. Methods This is a retrospective review of prospectively collected data from trauma patients collected over the 5 years of September 2003 to September 2008. Patients were included if the injury severity score (ISS) was >/=15, and they survived at least 3 days. Demographic data, mechanism and injury severity score, mortality, and length of stay were collected from the medical record. Laboratory values for the first 4 hospital days were collected. Leukocyte, neutrophil and lymphocyte counts were extracted from the daily complete blood count (CBC). Patients were then grouped based on response (elevation/depression) of each component of the CBC, and their return, or failure thereof, to normal. Proportional hazards regression with time-varying covariates as well as Kaplan-Meier curves were used to predict risk of death, time to death and time to healthy discharge based on fluctuations of the individual components of the CBC. Results There were 2448 patients admitted over the 5 years included in the analysis. When adjusting for age, gender and ISS the relative risk of death was elevated with a persistent leukocytosis (2.501 (95% CI = 1.477-4.235)) or failure to normalize lymphopenia (1.639 (95% CI = 10.17-2.643)) within the first 4 days following admission. Similar results were seen when Kaplan-Meier curves were created. Persistent lymphopenia was associated with shortest time to death. Paradoxically in survivors persistent lymphopenia was associated with the shortest time to discharge. Conclusions Persistently abnormal CBC responses are associated with a higher mortality following trauma. This is the first report noting that a failure to normalize lymphopenia in severely injured patients is associated with significantly higher mortality.
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Affiliation(s)
- Daithi S Heffernan
- Division of Surgical Research, Department of Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, Rhode Island, USA.
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Stein DG, Cekic MM. Progesterone and vitamin d hormone as a biologic treatment of traumatic brain injury in the aged. PM R 2011; 3:S100-10. [PMID: 21703565 DOI: 10.1016/j.pmrj.2011.03.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 03/16/2011] [Indexed: 12/22/2022]
Abstract
There is growing recognition that traumatic brain injury is a highly variable and complex systemic disorder that is refractory to therapies that target individual mechanisms. It is even more complex in elderly persons, in whom frailty, previous comorbidities, altered metabolism, and a long history of medication use are likely to complicate the secondary effects of brain trauma. Progesterone, one of the few neuroprotective agents that has shown promise for the treatment of acute brain injury, is now in national and international phase 3 multicenter trials. New findings show that vitamin D hormone (VDH) and VDH deficiency in the aging process (and across the developmental spectrum) may interact with progesterone and treatment for traumatic brain injury. In this article we review the use of progesterone and VDH as biologics-based therapies along with recent studies demonstrating that the combination of progesterone and VDH may promote better functional outcomes than either treatment independently.
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Affiliation(s)
- Donald G Stein
- Department of Emergency Medicine, Emory University School of Medicine, 1365 B Clifton Road NE, Suite 5100, Atlanta, GA 30322, USA.
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