Age and traumatic brain injury as prognostic factors for late-phase mortality in patients defined as polytrauma according to the New Berlin Definition: experiences from a level I trauma center

BACKGROUND

The rationale of this study was to identify independent prognostic factors influencing the late-phase survival of polytraumatized patients defined according to the New Berlin Definition.

METHODS

Retrospective data analysis on 173 consecutively polytraumatized patients treated at a level I trauma center between January 2012 and December 2015. Patients were classified into two groups: severely injured patients (ISS > 16) and polytraumatized patients (patients who met the diagnostic criteria for the New Berlin Definition).

RESULTS

Polytraumatized patients showed significantly lower late-phase and overall survival rates. The presence of traumatic brain injury (TBI) and age > 55 years had a significant influence on the late-phase survival in polytraumatized patients but not in severely injured patients. Despite the percentage of severe TBI being nearly identical in both groups, severe TBI was identified as main cause of death in polytraumatized patients. Furthermore, severe TBI remains the main cause of death in polytraumatized patients > 55 years of age, whereas younger polytraumatized patients (< 55 years of age) tend to die more often due to the acute trauma.

CONCLUSION

Our results suggest that age beyond 55 years and concomitant (severe) TBI remain as most important influencing risk factor for the late-phase survival of polytraumatized patients but not in severely injured patients.

LEVEL OF EVIDENCE

Prognostic study, level III.

The measurement of radioactive noble gases by DWD in the frame of the Global Atmospheric Watch programme of WMO

The Deutscher Wetterdienst (DWD, German Meteorological Service) is integrated into the Global Atmospheric Watch programme (GAW) of the World Meteorological Organization (WMO). According to this programme a variety of chemical compounds and radionuclides are measured at global stations. At the research platform "Schneefernerhaus" 7Be, 222Rn, and its decay products, 14C in CO2, tritium as HTO, 85Kr and 133Xe are continuously monitored by the DWD or are sampled and then measured at the central laboratory in Offenbach. The results are used as additional information for studying atmospheric mixing processes or on the other hand as information about the background level of radioactivity. As a main subject of this paper the integration and partly the optimization of sampling and measuring procedures for the detection of noble gases are described. In particular, the methods of quality assurance are discussed for Kr and Xe.

Phaeochromocytoma associated with a de novo VHL mutation as form fruste of von Hippel-Lindau disease

Phaeochromocytomas usually occur sporadically but may be associated with dominant inherited cancer syndromes such as multiple endocrine neoplasia type 2 (MEN 2), von Hippel-Lindau disease (VHL) and type 1 neurofibromatosis. We report on a boy presenting at age 8 years with an isolated benign phaeochromocytoma of the left adrenal. Three years later a second adrenal phaeochromocytoma was diagnosed on the right side and removed. His family history was negative. Genetic analysis did not show a mutation in the MEN 2 susceptible proto-oncogene rearranged during transfection; however, we found a germline missense mutation in the VHL gene (nucleotide 695 G to A transversion) which has been described only twice before in the literature. Both parents had normal (wild type) VHL copies indicating that our patient had a de novo germline VHL mutation. Careful clinical evaluation of the patient at 18 years did not reveal any other manifestations of VHL disease.

CONCLUSION

Carriers of von Hippel-Lindau germline mutations can present with a form fruste of von Hippel-Lindau disease presenting initially with unilateral phaeochromocytoma and therefore mutation analysis should be carried out.

[Nosocomial epidemiology and transmission of Clostridium difficile infection]

BACKGROUND

Clostridium difficile is of growing importance as a hospital-acquired pathogen. Pseudomembraneous colitis is the main clinical disease. Transmission and epidemiological features are not yet fully understood.

PATIENTS AND METHODS

Stool samples from 1164 individuals (571 women and 593 men) attending were examined for the presence of C. difficile. Follow-up examinations and molecular typing methods were used for the detection nosocomial transmissions. Additionally, hospital-borne environmental samples as well as staff samples were tested.

RESULTS

Incidence of C. difficile infection was 8.4%. Nearly all patients (92.9%) had antibiotics given. Using molecular typing nosocomial transmission was evident. Though, environmental samples in general had a low positivity, toilet chairs were contaminated in 15.4% and may be a potential source of transmission. Staff was positive in only one case.

CONCLUSIONS

Prevention of infections with C. difficile becomes to be a major threat for the clinical and hygienic management.

[Problems of delayed diagnosis of an uncomplicated adrenogenital syndrome (AGS) with 21-hydroxylase defect in a 7-year-old boy]

HISTORY AND CLINICAL FINDINGS

A 7.3-year-old boy was presented at out-patient clinic because of tallness and premature puberty. His height was 150.2cm (+ 4.74 standard deviation score for chronological age), body mass index 18.4 kg/m2, pubic hair stage 3 (after Tanner), testicular volume of 5.0 ml each. Bone age was accelerated by 6.5 years (SD -1.55 for height according to bone age). Expected final height was 166 cm, mean genetic target height 180 cm.

INVESTIGATIONS

Basal serum concentration of 17-hydroxyprogesterone was 142.1 ng/ml (normal: < 1.9) and testosterone of 93 ng/dl (normal: < 11). 24-hour urine showed an increased excretion of pregnantriol of 8280 micrograms/d (normal < 500). Gonadotropine-releasing hormone test (GnRH), blood collected at 0 and 30 min, showed an increased rise of the serum LH concentration of 0.6 to 8.2 mU/ml (normal < 0.3 and < 3.6, respectively) and a normal FSH increase of 1.3 to 3.2 mU/ml (normal < 1.3 and < 4.0, respectively). The diagnosis of adrenogenital syndrome (AGS) with 21-hydroxylase defect was confirmed by molecular genetic testing.

TREATMENT AND COURSE

The boy was treated with hydrocortisone (average dose 18.3 mg/m2 body surface area). Because of the premature puberty and the poor growth endprognosis treatment with the GnRH agonist Decapeptyl Depot, 3.75 mg every 4 weeks i.m., was started.

CONCLUSION

The correct diagnosis should have been made in the neonatal period on the basis of the family history (15-year-old brother with AGS) and at the latest on correct interpretation of the clinical signs during early childhood.

Healing response to non-surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological, and immunologic results

The aim of the present study was to monitor clinical, microbiological, medical, and immunological effects of non-surgical periodontal therapy in diabetics and healthy controls. 20 IDDM (insulin dependent, n = 7) or NIDDM (non-insulin dependent, n = 13) diabetic patients (median duration 11.5 years, range of HbA1C: 4.4-10.6%) with moderate to advanced periodontal disease and 20 matched healthy control patients, were subjected to supragingival pretreatment and subsequent subgingival therapy. Periodontal examinations (API, PBI, BOP, PPD, PAL), microbiological examinations (culture), medical routine examinations, and immunological examinations (oxidative burst response of PMNs to TNF-alpha and FMLP) were performed at baseline, 2 weeks after supragingival, and 4 months after subgingival therapy. 4 months after completion of non-surgical therapy, the following compared to baseline significant (p < or = 0.05) changes (delta) of clinical parameters (median) were found in diabetic patients versus control patients: deltaAPI (30.4% versus 36.3%), deltaPBI (22.9% versus 24.2%), deltaBOP (39.5% versus 46.9%). The median % per patient of pockets with PPD > or = 4 mm decreased from 41.9% to 28.3% in diabetics, and from 41.6% to 31.8% in controls. Microbiologically, similar reductions of periopathogenic bacteria were found in diabetics and controls. Neither periodontal data nor the oxidative burst response of PMNs showed any significant difference (p > 0.05) between diabetics and control patients. In this study, periodontal therapy had no significant influence on medical data of diabetics. In conclusion, this study indicates that metabolically well-controlled diabetics might respond to non-surgical periodontal therapy as well as healthy control patients.

In vivo comparison of different algorithms for the artificial beta-cell

Using an extracorporeal artificial beta-cell in chronically diabetic dogs, the effects of four different mathematical models of glucose-controlled insulin dosage were compared: the Biostator algorithm (quadratic equation), Toronto algorithm (hyperbolic tangent function), Karlsburg algorithm (modified first-order derivative controller), and Ilmenau algorithm (second-order linear difference equation). The constants of all formulas implemented for the artificial beta-cell were obtained by regression analysis of paired blood glucose and plasma insulin data from normal control animals. Thus, they were biologically equivalent for all formulas. The patterns of blood glucose, insulin doses, and plasma insulin before, during, and after an intravenous glucose infusion test performed during the glucose-controlled insulin infusion showed no significant differences between the experimental groups subjected to the different algorithms. However, in no case were really normal blood glucose response curves restored by the artificial beta-cell. This might be due, first, to the fact that the algorithm parameters were not adapted to the actual individual insulin responsiveness, second, to the unphysiological peripheral venous route of insulin administration, and, third, to the lack of appropriate adaptation of the animals to normoglycemia.

[The effect of indomethacin on basal and stimulated plasma renin activity in normal subjects (author's transl)]

The influence of indomethacin, a potent inhibitor of prostaglandin synthesis, on basal and stimulated plasma renin activities in normal human subjects was determined. Stimulation of the renin activity was achieved by orthostasis or by furosemide. Indomethacin led to a considerable decrease of both basal and stimulated plasma renin activity in chronic and acute experiments. Our experiments provide no evidence that major changes in the sodium balance are responsible for the effects observed. It is concluded that some antagonistic function of the renin angiotensin system and prostaglandins seems probable. These antagonistic actions might play a role in the regulation of the kidney circulation or the arterial blood pressure.

The effect of indomethacin on plasma renin activity in man under normal conditions and after stimulation of the renin angiotensin system

1) The influence of oral indomethacin on basal and stimulated plasma renin activity in normal human subjects was determined. 2) Indomethacin lowers the basal plasma renin activity in man. 3) The response of the plasma renin activity after indomethacin to physiological and pharmacological stimuli is maintained at a lower level. 4) There is no evidence from our experiments that major changes in the sodium balance are responsible for the effects observed.