Etiology of musculoskeletal injuries in amateur breakdancers

AIM

The aim of this study was to assess the incidence of musculoskeletal injuries in breakdancers and investigate the association with training habits.

METHODS

Forty-six males and sixteen females completed a questionnaire regarding their training and competition habits (frequency, warm-up and stretching, strength training, protective equipment, move types and supervision) and the musculoskeletal injuries sustained as a result of breakdancing in the previous 12 months. The effects of training habits and sex on injury rates were analyzed by a Mann-Whitney Test and a Kruskal-Wallis Test, while a stepwise linear regression analysis assessed the link between injury rates and quantitative risk factors.

RESULTS

The injury rate was 4.02 injuries per 1000 h, with no significant difference between males and females (P>0.05). The main injuries affected were the knee (23.4%) and wrist (15.3%), and females were characterized by a significantly greater number of finger injuries and a lower number of shoulder injuries that males (P<0.05). In addition, of all the factors evaluated, only the amount of time spent performing breakdance training showed a significant association with injury rate (P<0.05).

CONCLUSION

These results suggest that interventions should focus on protecting specific body parts and improving training quality and recovery.

[Local antibiotic administration in osteomyelitis treatment--a comparative study with two different carrier substances]

Two antibiotic carriers (collagen sponge/PMMA-beads--loaded with gentamicin) for the treatment of osteomyelitis of long bones are compared in a randomised prospective study of 20 patients in respect of efficacy, safety and biocompatibility. In addition, the concentration of gentamicin in serum, urine and wound exudate was measured. This revealed marked differences. Gentamicin was released rapidly from the collagen sponge, leading to high levels in wound exudate and urine within the first 48 hours, with measurable but non-toxic concentrations in the serum. The liberation of gentamicin from the PMMA beads was much slower. This resulted in low steady levels in wound exudate and urine, and no detectable concentrations in the serum. The clinical outcome showed no differences between both methods of application. In 80% of the collagen sponge group and in 90% of the PMMA-beads group the osteomyelitis was completely allayed with disappearance of all infectious parameters. The number of re-operations was significantly higher in the PMMA group. It is recommended to use collagen sponges for the local treatment of osteomyelitis in cases that can probably be eradicated in a single surgical procedure, whereas PMMA beads should be applied in larger defects requiring a space-occupying function for further reconstructive operations.

Leukotriene generation in patients with multiple injuries

We determined the generation and metabolism of lipoxygenase products in isolated granulocyte fractions of patients with multiple trauma (n = 9) and compared the results with those of healthy volunteers (n = 8). The supernatants of stimulated cells were analyzed by high-performance liquid chromatography. During the first week after injury a significantly reduced capacity to generate LTB4 and an increased metabolism of LTB4 into omega-oxidated products (20-OH-LTB4 and 20-COOH-LTB4) were observed after stimulation of the granulocytes with Ca ionophore. The depressed leukotriene production could be partly abrogated by the addition of arachidonic acid. These findings are comparable with alterations previously described in severely burned patients with postburn sepsis. Additionally, an elevated production of LTC4 by peripheral granulocyte fractions was observed in two patients suffering from adult respiratory distress syndrome (ARDS) as well as an increased number of eosinophils during the time of lung dysfunction. Analysis of bronchoalveolar lavage in patients with multiple trauma (11 patients with ARDS and 11 patients without ARDS) by a specific radio-immunoassay confirmed an elevated production of cysteinyl-leukotrienes.(ABSTRACT TRUNCATED AT 250 WORDS)

Generation of anaphylatoxin C3a in plasma and bronchoalveolar lavage fluid in trauma patients at risk for the adult respiratory distress syndrome

OBJECTIVE

To determine the generation of anaphylatoxin C3a in plasma and bronchoalveolar lavage fluid in trauma patients at risk for the adult respiratory distress syndrome (ARDS).

DESIGN

Prospective study.

SETTING

ICU in a university hospital.

PATIENTS

Severely traumatized patients at risk for the ARDS (n = 25).

INTERVENTION

EDTA plasma samples and bronchoalveolar lavage fluid were obtained.

MEASUREMENTS AND MAIN RESULTS

Complement proteins C3, C4, C5, and the inhibitors C1-inhibitor, Factor H, and Factor I were quantitated in EDTA-plasma samples obtained every 6 hrs during the first 48 hrs after ICU admission and every morning from days 4 to 14 after injury. In bronchoalveolar lavage fluid, the complement activation production of C3a-desArg was quantitated and the volume of epithelial lining fluid was calculated. All patients showed a decrease of the complement proteins C3, C4, C5 and of the inhibitors C1-inhibitor, Factor H, and Factor I during the first 24 hrs, indicating complement consumption. Patients developing ARDS (n = 11) showed significantly higher C3 concentrations and a higher C3a/C3 ratio in the first few hours after multitrauma. Follow-up bronchoalveolar lavages demonstrated highly increased amounts of C3a in epithelial lining fluid during the first 24 hrs, mainly in ARDS patients and, to a lesser degree, in non-ARDS patients. To determine the origin of C3a in bronchoalveolar lavages, the ratio of C3a in epithelial lining fluid and plasma was calculated.

CONCLUSION

The C3a of epithelial lining fluid to plasma ratio was extremely high in patients developing ARDS, but even the non-ARDS group had a ratio greater than 1, indicating that a substantial local complement activation occurs in the lung.

The role of the kininogens as cysteine proteinase inhibitors in local and systemic inflammation

The contribution of the kininogens and cystatin C to the functional inhibitory capacity for cysteine proteinases of blood plasma and inflammatory secretions was estimated from ex vivo experiments. 98.5% of the inhibitory capacity of blood plasma for cathepsin L (4-5 microM) is provided by the kininogens ensuring a complete control of this enzyme even at a lowered kininogen concentration. Control of cathepsin B activity by the kininogens is incomplete and depends critically on the active concentration of cystatin C (70 nM in normal plasma), which is reduced in blood plasma of polytraumatized and septic patients and very low in epithelial lining fluid of the shock lung.

[Alveolo-capillary permeability following multiple trauma--monitoring by bronchoalveolar lavage]

In trauma patients (ISS greater than 40 points) bronchoalveolar lavage (BAL) as well as the first clinical measurements was performed within the first 6 hours after admission to hospital. Thereafter BAL was carried out once per day, using 100 ml NaCl 0.9% (10 x 10 ml). BAL-protein-concentrations (i.e. albumin) were converted to epithelial lining fluid (ELF) according to Rennard, using urea as an internal standard. The limitations of this method were taken into account. The alveolo-capillary permeability (ACP) was described by the quotient of the protein concentrations in ELF and plasma. Progressive lung failure (ARDS) was defined using the criteria given by Murray. Lung contusion was an exclusion criteria. The study period was 14 days. This study evaluated data from 12 patients (m: 10, f: 2; age 30.4 (17-52); ISS 63.4). Five patients developed a progressive lung failure ("+ARDS"--age 32.2; ISS 71.5), 7 patient suffered no pulmonary failure during intensive care ("-ARDS")--age 29.5; ISS 59.2). No patient died in the course of the study. An increased ACP for albumin (combined endothelial-epithelial disturbance) was detectable for both +ARDS- und -ARDS-patients after the 6th hour, reaching a maximum around the 24th hour. +ARDS-patients showed a significant higher ACP. Further, beginning from the 48th hour to the 4th day, the ACP value for -ARDS-patients again dropped to a physiologic range. The degree of the increased ACP depends on the size of the marker protein, but it is independent of pulmonary hemodynamics. It is of value for the prediction of ARDS within 24 hours and for monitoring of pulmonary damage in posttraumatic course.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum CD14 levels in polytraumatized and severely burned patients

Recently it has been demonstrated that the CD14 molecule which is expressed on monocytes and macrophages serves as a receptor for lipopolysaccharide (LPS) bound to LPS-binding protein (LBP) and thus mediates LPS-induced tumour necrosis factor (TNF) production. Here we report that CD14 is found as a soluble (s) molecule in serum. In healthy volunteers sCD14 levels (mean +/- s.e.m.) were 3.7 +/- 0.05 micrograms/ml (n = 30, 25-50 years of age) as determined by ELISA (detection limit 20 ng/ml serum) using two monoclonal antibodies in a sandwich technique. In polytraumatized patients (n = 16) significantly decreased levels (1.7 +/- 0.3) were detected immediately after the trauma, which increased to 4.9 +/- 0.3 micrograms/ml within the first 6 days post trauma. sCD14 remained elevated during the first 14 days post trauma in patients with the most severe injuries (injury severity score greater than 45 points), whereas a return to normal levels was observed in patients with an injury score of less than 45 points. In addition, the levels of the high-density lipoproteins that partially inactivate free endotoxin are significantly decreased post trauma. No correlation between parameters of inflammation (C3a and neopterin levels, leucocyte counts, amount of band cells), liver function and sCD14 levels was established. Comparable to polytraumatized patients, increased sCD14 serum levels were observed in five patients with burn trauma (burned area greater than 35%) within the second week post trauma when clinical signs of septicaemia were evident.

[Post-traumatic alveolar changes in lung contusion]

Bronchoalveolar lavage (BAL) specimens taken from nine patients with lung contusion following multiple trauma were compared with specimens from different control groups. Early interstitial and intra-alveolar reactions are PMN degranulation, mediator release and high protein leakage. The alveolar reactions are similar in extent to the reaction found in post-traumatic ARDS.

Procoagulant activity in bronchoalveolar lavage of severely traumatized patients--relation to the development of acute respiratory distress

In a prospective study in severely traumatized patients, procoagulant activity (PCA) was determined in bronchoalveolar lavage fluids (BAL). Bronchoscopy with lavage was serially performed during the first 15 days after injury (in total 148 samples of 25 patients). PCA was measured as recalcification times in the absence or presence of excess phosphatidylethanolamine and translated into procoagulant unit equivalents using standard thromboplastin. The data were correlated to the extent of respiratory failure in the injured patients and were compared to PCA in 29 lavage samples obtained from 10 healthy control subjects. A several-fold increase in BAL PCA was noted in all trauma victims, evident already within the first 24 h after injury. A progressive rise in PCA occurred from the 4th posttraumatic day and was highly significantly more pronounced in patients developing serious respiratory failure than in those with only mild pulmonary dysfunction. Significant correlations were noted between PCA increase and alveolar protein-leakage, granulocyte-influx and surfactant alterations, however with correlation coefficients not surpassing 0.55. We conclude that a marked increase in procoagulant activity occurs in severely injured patients, which may favour alveolar fibrin deposition and is related to the development of acute respiratory failure.

Surfactant abnormalities and adult respiratory failure

Surfactant abnormalities have been implicated in the development of the acute respiratory distress syndrome in adults. Experimental studies show that surfactant inhibition by protein-leak into the alveolar space is of major importance under these circumstances. Fibrin(ogen)-surfactant-interaction appears to contribute to disturbances of surfactant function with subsequent alveolar instability and ventilation-perfusion-mismatch. In a prospective study in severely injured patients, the surfactant in serially obtained bronchoalveolar lavage fluids was investigated. An early leakage of plasma proteins into the alveolar space was noted in those patients, who developed severe ARDS. Moreover, deterioration of surfactant function was markedly more pronounced in those patients than in trauma victims who developed only mild pulmonary dysfunction. In addition to the protein-leakage, a progressive decrease of the surfactant-specific dipalmitoyl-phosphatidylcholine was noted, significantly correlated with the deterioration of surfactant function and the severity of respiratory failure. In conclusion, experimental and clinical studies show surfactant abnormalities in the adult respiratory distress syndrome. Plasma protein-leakage and progressive alteration of alveolar type II surfactant secretion appear to be of major importance.

Altered pulmonary surfactant in uncomplicated and septicemia-complicated courses of acute respiratory failure

Pulmonary surfactant, which is crucial for alveolar stability, may also be involved in endogenous defense mechanisms of the lungs. Thus, alterations in pulmonary surfactant may promote infections, including pneumonia and septicemia. Because patients who have acute respiratory failure often develop pneumonia, thus septicemia, we investigated when surfactant is altered in these patients and whether there is a specific pattern of changes in surfactant phospholipid composition associated with septicemia in these patients. To answer these questions, we determined the phospholipid content and composition in lung washings obtained from alveolar sites (by bronchoalveolar lavage) and from tracheal sites (by aspiration). Both techniques were performed serially over a period of 18 days in 30 patients who had acute respiratory failure resulting from polytrauma, 18 of whom developed septicemia caused by pneumonia. We found that in lung washings obtained from the alveolar sites from all patients, the phosphatidylglycerol content was decreased and the phosphatidylinositol content was increased as early as 6 hr after trauma and normalized during recovery of the patients. In addition, alveolar phosphatidylcholine content was decreased 24 hr after trauma. In patients who developed septicemia during the observation time, but not in patients who had uncomplicated courses of acute respiratory failure, the concentrations of alveolar phosphatidylethanolamine (normally 4.8% of total phospholipids) and alveolar phosphatidylcholine (normally 62.8%) both approached the proportions found in the trachea (phosphatidylethanolamine 33.4%, phosphatidylcholine 35.6%), suggesting that surfactant phospholipid pool size had progressively decreased. Our results indicate that in patients who have acute respiratory failure, pulmonary surfactant is altered very early, and that when septicemia complicates the course of acute respiratory failure, the surfactant phospholipid pool size decreases progressively.(ABSTRACT TRUNCATED AT 250 WORDS)

Surfactant abnormalities in patients with respiratory failure after multiple trauma

We present a prospective study, designed to evaluate surfactant abnormalities in severely injured patients during the course of post-traumatic pulmonary dysfunction. Serially obtained bronchoalveolar lavage fluids from noncontused lung areas (in total, 132 samples from 17 patients) were analyzed for alveolar phospholipid composition and surfactant function in vitro during the first 14 days after trauma. The data were compared with those of 29 lavage samples obtained from 10 healthy control subjects and correlated to severity of respiratory failure. In the traumatized patients, the total lavage phospholipid content was unchanged, but there was a progressive decrease in the relative amounts of phosphatidylcholine (%PC) and phosphatidylglycerol and an increase in phosphatidylinositol, phosphatidylethanolamine, and sphingomyelin. These alterations were paralleled by a marked decrease in the hysteresis area of the surface tension isotherm. The decrease in %PC and reduction of hysteresis area were significantly correlated. The alterations in alveolar phospholipid composition and in vitro surfactant function were more pronounced in patients with severe respiratory failure. There was a significant inverse correlation between severity of respiratory dysfunction and %PC or hysteresis area for all traumatized patients. Protein leakage into the alveolar space was significantly higher in patients with severe respiratory failure and appeared to precede surfactant abnormalities in such patients. The neutrophil content in the alveolar space was markedly increased in all patients with multiple injuries however, no significant correlation with the noted alterations in alveolar phospholipid composition or surfactant function was found. We concluded that surfactant abnormalities occur during the course of post-traumatic pulmonary dysfunction and are correlated with the severity of respiratory failure.

Distribution and function of alveolar cells in multiply injured patients with trauma-induced ARDS

To determine whether alveolar cells are involved in the pathogenesis of adult respiratory distress syndrome (ARDS), we assessed the distribution and function of alveolar cells from 30 polytraumatized patients with trauma-induced respiratory failure, 5 of whom also had lung contusion. Cells were obtained by bronchoalveolar lavage performed daily beginning on the day of trauma and continuing for 14 days. Neutrophils constituted about 60% of lavage cells in ARDS patients with lung contusion 0-2 days after polytrauma and about 50% in ARDS patients without lung contusion. In ARDS patients with lung contusion the neutrophil fraction decreased to 52% 3-6 days after trauma and to 40% 7-14 days after trauma. In patients without lung contusion the neutrophil fraction increased to 77% and then decreased to 60% at these times. Total cell counts in ARDS patients with lung contusion were more than twice as high as in patients without lung contusion 0-2 days after trauma. The difference in total cell counts decreased during days 3-6 and disappeared by day 7. In all patients morphologically altered alveolar cells were observed 4 days and more after trauma. In non-survivors significantly more altered cells were found. The chemiluminescence-response pattern of the alveolar cells was enhanced throughout the study and correlated with the neutrophil fraction (r = 0.6). The neutrophil fraction also correlated with the pulmonary vascular resistance during the first two days after trauma (r = 0.53). We conclude that alveolar cells are involved in the pathogenesis of trauma-induced ARDS and that the alveolar cell distribution is different in patients with and without lung contusion during the development of posttraumatic respiratory failure.

Adult respiratory distress syndrome as a specific manifestation of a general permeability defect in trauma patients

To establish whether a general dysfunction, i.e., an increase in permeability, had occurred in 16 trauma patients (6 with adult respiratory distress syndrome [ARDS]), we measured beta 2-microglobulin (beta 2MG), myoglobin (MG), immunoglobulin G (IgG), and transferrin (TF) concentrations in bronchoalveolar lavage fluid (BAL), serum, and urine as well as extravascular lung water content (EVLW) over a period of 14 days. Our results show a positive correlation (p = 0.03) between increases of EVLW, reflecting lung edema, and beta 2MG concentrations in urine of all patients with ARDS, indicating systemically increased permeability. Generalized increase of permeability can also explain the elevation of MG urine concentrations (p = 0.03) together with an EVLW increase, and an increase of BAL protein concentrations (IgG, TF, p less than 0.01) in the early post-trauma phase during the first 48 h after admission. In contrast, commonly used kidney function tests remained unchanged over the time course of 14 days.

[Normal values of cell distribution and function in the human alveolus. Bronchoalveolar lavage as a diagnostic tool in intensive care medicine]

The cell distribution and cell function in the normal human alveolar were determined in 23 healthy subjects by obtaining the pulmonary lavage fluid from bronchoalveolar lavage. A uniform alveolar cell spectrum was found. (Alveolar macrophages 95-98%, polymorphonuclear neutrophils 2-3%, lymphocytes 0-2%.) The cell systems reacted reproducibly to a defined phagocytosis stimulation in luminol-enhanced chemoluminescence. The phospholipid lung profile, which is important for the function of the surfactant, was determined by means of high-pressure liquid chromatography. The typical inflammation mediators were not present in the humoral spectrum of the supernatant part of the lavage fluid. Albumin, transferrin, and alpha-1-antitrypsin were regularly seen in healthy adults in the bronchoalveolar lavage fluid. The results supply the basis for the interpretation of the findings in polytraumatised patients in adult respiratory distress syndrome.

Altered arachidonic acid metabolism in granulocytes of polytraumatized patients

The generation and metabolism of leukotrienes (LTs) from polymorphonuclear granulocytes of four polytraumatic patients on stimulation with the Ca-Ionophore A 23187 were studied by high performance liquid chromatography. In contrast to healthy donors the concentration of LTB4 within the supernatant of the stimulated granulocytes from these patients is reduced. The ratio of LTB4 versus the combined amounts of the biologically inactive 6-trans and 12-epi-6-trans-isomers is significantly decreased. In one patient who suffered from an Adult Respiratory Distress Syndrome (ARDS) a pronounced enhancement of LTC4 synthesis was observed.

Optic nerve trauma: clinical, electrophysiological and histological remarks

18 patients with post-traumatic visual disease of the optic nerve are presented. In the post-traumatic stage, visual evoked potentials were monitored. In amaurosis there was a high incidence of midface or frontobasal fractures. The severity of the trauma is not correlated with the severity of visual deficits. Flash evoked potential (FEP) findings were different: In most cases there was a correlation of clinical and FEP findings. In some we found false positive potentials in the acute stage. In smaller visual field deficits the alterations of FEP could not be correlated with the clinical disorders. FEP alterations depended on time. The pathophysiological mechanisms are discussed in regard to the pathological findings in 51 unselected autopsies with an investigation of the visual pathway from the intraorbital optic nerve to the visual cortex. Because of the different morphological alterations the clinical, neurological and ophthalmological examination should be followed by standard CT scanning to evaluate intracranial haematomas and by CT scanning with thin slices of the optic nerves and the soft tissue of the orbit. Visual evoked potentials (VEP) and in the unconscious patient, flash evoked potentials (FEP) do not give much more security for therapeutic decisions in comparison with former times. The histological findings do not support the hypothesis that operative decompression is successful.

[10 years of emergency medical care at the traumatology center of the university clinic in Essen]

10 years of experience with emergency treatment at a University Center sufficiently proved the necessity of an emergency physician at the site of the accident. Because of its inefficiency, the separate and individual displacement of the doctor and the emergency vehicle to the site of the accident has been abandoned in 1976. The professional qualifications of the emergency team are as important as the technical equipment. Specific attention has to be paid to the education of nursing -, ambulance personnel and doctors belonging to the team. Very early and efficient shock therapy is essential in polytrauma victims. Intubation, artificial ventilation, fluid administration (electrolyte-solution) are of utmost importance for their survival and to reduce the frequency of major complications.

High-performance liquid chromatography of adult human bronchoalveolar lavage: assay for phospholipid lung profile

High-performance liquid chromatography has been used to separate pulmonary phospholipids from adult human bronchoalveolar lavage. A solvent system consisting of acetonitrile-water (80:20) as solvent A and pure acetonitrile as solvent B was used with a silica column (Bio-Sil HP 10) coupled to an Si-100 Polyol precolumn. A linear gradient from 87.5 to 25% of solvent B was found to separate all biologically relevant surfactant phospholipids in the following sequence and composition: phosphatidic acid (1.1%), phosphatidylglycerol (10.6%), phosphatidylinositol (9.9%), phosphatidylethanolamine (3.6%), phosphatidylserine (4.5%), phosphatidylcholine (60.8%), sphingomyelin (8.1%) and lysophosphatidylcholine (1.6%). These results were very similar to the phospholipid pattern obtained by two-dimensional thin-layer chromatography. It is concluded that high-performance liquid chromatography is a useful and rapid method for the separation of phospholipids in biological fluids containing pulmonary surfactant.

Principles of treatment and indications for surgery in severe multiple trauma

Despite major advances, pitfalls in diagnosis and emergency treatment influence the survival chances of multitraumatized patients considerably. Diagnosis of traumatic shock cannot be made by blood pressure, pulse rate and shock index. Immediate shock therapy is indicated in all cases with severe trauma of two body regions, combined injury of one body cavity and long bone fractures and in all cases with one major thoracic or pelvic injury. In a consecutive series of 418 multitrauma patients, extremity injuries were present in 90%, severe head injuries in 65%, major thoracic trauma in 50% and abdominal or pelvic injuries in 40%. The most frequent pattern of multitrauma was long bone fractures with associated head trauma and one thoracic, abdominal or pelvic injury. Priorities of treatment are based on a 4-stage-schedule: Stage 1 includes intubation and hyperventilation for cerebral trauma, volume replacement by central venous catheter, emergency x-ray of cervical spine, chest, abdomen, pelvis and diagnostic peritoneal lavage. In 25% of admitted cases, diagnosis of abdominal hemorrhage was missed by the referring surgeon despite hemorrhagic shock, falsely attributed to cerebral trauma. At Stage 2, emergency surgery of internal and external bleeding is indicated. Wide open fractures are stabilized by external fixation. Stage 3 is concerned with stabilization of vital systems and further diagnostic evaluation, its duration varying from 2 hours to 2 days. At Stage 4, internal fixation of fractures and other non-emergency-operations are indicated. Operating time can be reduced considerably by 2 surgical teams operating simultaneously or overlapping. Early shock diagnosis, immediate intubation, ventilator treatment and the "4-stages-schedule" are considered the most successful steps in the management of multitrauma, as well as volume replacement with Fox' hypertonic saline solution and blood constituents instead of colloids. This has reduced mortality due to respiratory failure from 31% to 20%.

[Bronchoalveolar lavage as a diagnostic method in intensive therapy]

Bronchoalveolar lavage is presented as a standardised diagnostic method in the clarification of interstitial pulmonary changes in the acute respiratory distress syndrome (ARDS). Its justification is based on the fact that changes in lung biopsies are reflected by early changes in the composition of the rinse and in the ability of the cellular components to function properly, independent of the origin of the immunological processes in ARDS. Pulmonary function is not adversely affected by the procedure provided it is carried out "lege artis". We hope that it will be possible in future to achieve early detection of a developing progressive failure of pulmonary function, by employing early markers. The procedure also allows continual follow-up of the success of an initiated therapy.

[Operative methods in adenocarcinoma of the cardia]

Adenocarcinoma of the oesophagogastric transition is only incompletely resectable in 40% of cases, if resection with intrathoracic anastomosis is desired. Death-rate of thoraco-abdominal or transthoracic resection is over 40% (in the authors' own series 47%). Survival time of patients is short, some develop a recurrence at the anastomotic site. More radical and carrying a lower postoperative mortality is resection of the tumour with subtotal oesophagectomy without opening the thorax. Anastomosis with the residual stomach is made at the cervical portion of the oesophagus.