Search PubMed⌕ Search

Biomedical subjects

R Coimbra

Publications and source records attributed to R Coimbra.

At least 19 recordsLinked to original sources
PubMed2001

Blunt gastric injury. A multicentre experience.

A multicentre retrospective analysis of blunt gastric injuries from four trauma centres in Brazil was performed. From January 1982 to May 1996, 33 patients were found to have blunt gastric injury: 26 were male and the mean age was 26.2 years. The most frequent mechanism of injury was automobile versus pedestrian (17) followed by motor vehicle accidents (seven). Abdominal pain was the most common finding (29) and peritoneal signs were present in 14. There were 21 grade I, seven grade II, four grade III and one grade IV blunt gastric injuries. Simple suture was the treatment of choice in 24 patients, eight required no treatment, and only one patient underwent gastric resection. The liver and spleen were the most commonly associated injured organs. Two patients had isolated gastric injury. There were two gastric fistulae and both patients died. Overall morbidity and mortality was 12 (36%) and nine (27%), respectively. The ISS was higher in the non-survivor group (P=0.03) and the gastric organ injury score did not reach statistical significance when comparing survivors and non-survivors. We conclude that blunt gastric injury is uncommon and is associated with other injuries of greater magnitude, which generally influence mortality.

Abdominal Injuries↗
PubMed2001

Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center.

INTRODUCTION: We present our experience in the management of penetrating pancreatic injuries, focusing on factors related to complications and death. METHODS: Retrospective trauma registry-based analysis of 62 consecutive patients with penetrating pancreatic injuries during an 11-year period. Overall injury severity was assessed by the injury severity score (ISS) and the penetrating abdominal trauma index (PATI). Pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Complications were characterised using standardised definitions. Mortality was recorded as early (within 48 h after admission) and late (after 48 h). RESULTS: Thirty patients suffered gunshot wounds and 24 had grade I pancreatic injuries. Shotgun and gunshot wounds were more destructive than stab wounds (higher PATI, number of intraabdominal injuries and mortality). Seventeen patients died. Most deaths occurred within 1 h after admission due to massive bleeding and severe associated injuries. Only one death was potentially related to the pancreatic injury. Mortality rate also correlated with pancreatic injury grading. Sixty-one patients had associated intraabdominal injuries. Combined pancreaticoduodenal injuries were present in 13 patients, and five died. Simple drainage was the most common procedure performed. Pancreas-related complications were found in 12 out of 47 patients who survived more than 48 h; intraabdominal abscess (n=7) that was associated with colon injuries, and pancreatic fistula (n=5). CONCLUSION: An approach based on injury grade and location is advised. Routine drainage is recommended; distal resection is indicated in the presence of main duct injury, and the management of severe injuries will be tailored according to the overall physiologic status, presence of associated injuries, and duodenal viability. Morbidity and mortality is mainly due to associated injuries.

Abdominal Abscess↗
PubMed2001

Anatomic exposures for vascular injuries.

The exposure of vascular injuries is contingent on knowledge of anatomy and the limitations and boundaries for proximal and distal control of each artery. In this article, these are conveniently organized into arteries of the neck, of the chest, of the abdomen, and of the extremities. In addition, the interface between the neck and chest, and the chest and the abdomen provide particular challenges because of the need to expose two body regions frequently. The anatomy, the points of proximal and distal control, the details of exposure, and the key maneuvers required to expose particular arteries are reviewed.

Aorta↗
PubMed2001

Severe traumatic brain injury from unmotorized scooter.

The popularity and use of unmotorized, foot-propelled scooters has risen dramatically in the last few years. Increasing reports of traumatic injuries from these scooters have paralleled their commercial sales and success in this country and worldwide. We report a case of a previously healthy 48-year-old woman who suffered a severe traumatic brain injury while riding one of these scooters, resulting in a devastating neurologic outcome and permanent vegetative state. This case emphasizes the importance of public awareness regarding the potential dangers and the need for appropriate precautions and protective gear when riding these recreational devices.

Accidents↗
PubMed2001

The 15-year evolution of an urban trauma center: what does the future hold for the trauma surgeon?

BACKGROUND: Safer cars, decreased violence, and nonoperative management have changed the trauma patient's nature. We evaluated changes in a Level I trauma center over 15 years and considered their effect on trauma surgeons. METHODS: From January 1985 through August 1999, 16,799 trauma registry patients were analyzed for mechanism of injury, Injury Severity Score, and procedures. RESULTS: Mean Injury Severity Score decreased from 15.9 to 10.7 and length of stay fell from 8.0 days to 5.9 days. There were significant decreases in penetrating trauma admissions and percentage of patients with Abbreviated Injury Scale score > 3 for head, chest, and abdomen. Frequency of craniotomy, thoracotomy, and laparotomy dropped dramatically. CONCLUSION: Significant decreases in injury severity, penetrating violence, and operations have occurred over 15 years. These changes will have profound effects on the practice of trauma surgeons and on surgical education.

Abdominal Injuries↗
PubMed2000

The role of associated injuries on outcome of blunt trauma patients sustaining pelvic fractures.

In order to identify the prognostic factors and to evaluate the impact of associated injuries in the outcome of patients with pelvic fractures, a retrospective review of the medical records of patients admitted with a pelvic fracture during a 42-month period was carried out. Demographic data, the mechanism of injury, the physiologic status on admission, associated injuries, pelvic fracture classification, complications and mortality were analysed. One hundred and three patients were included in the study. Fifty-nine were male, and the mean age was 34. The mean Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.1 and 20, respectively. Pedestrian vs vehicle (59%), was the most frequent mechanism of injury. Twenty patients died (19%) most frequently due to "shock". Complications developed in 37 patients (36%), pneumonia being the most frequent. Age greater than 40 years (p=0.02), "shock" upon admission (p=0.002), a Glasgow Coma Scale (GCS)<9, Head AIS>2 (p<0. 001), Chest AIS>2 (p=0.007), and abdominal AIS>2 (p=0.03) all correlated with increased mortality. No correlation between pelvic fracture classification or fracture stability with mortality was observed. The outcome of patients with pelvic fractures due to blunt trauma correlates with the severity of associated injuries and physiological derangement on admission rather than with characteristics of or the type of fracture.

Accidents, Traffic↗
PubMed2000

Traumatic brain injury: patterns of failure of nonoperative management.

OBJECTIVE: The circumstances of failure for nonoperative management of blunt traumatic brain injury have been poorly defined. In this study, all trauma patients identified over a 12-year period with progression of neurologic injury requiring craniotomy were retrospectively reviewed. METHODS: Data collected included demographic information, mechanism of injury, field and admission vital signs, and Glasgow Coma Scale score, medications, associated injuries, and coagulopathy. Head computed tomographic scans were reviewed, and anatomic findings were correlated with clinical changes (change in mental status or elevation of intracranial pressure) that led to subsequent CT scan and craniotomy. RESULTS: Of 20,100 patients, there were 852 who had computed tomographic scans with acute intracranial injuries on admission; 462 patients were managed nonoperatively. Fifty-seven patients had progression of neurologic injury (34 < 24 hours = early; 23 > 24 hours = late) that required surgery. CONCLUSION: Of the variables investigated, only anatomic location of injury was found to be predictive of early failure of nonoperative management. Frontal intraparenchymal hematomas are particularly prone to early failure. Clinical examination and intracranial pressure monitoring are equally important in detecting failure and should be an integral part of nonoperative management.

Adult↗
PubMed2000

Hypertonic saline and pentoxifylline prevent lung injury and bacterial translocation after hemorrhagic shock.

Previous reports have shown beneficial effects of pentoxifylline (PTX) and hypertonic saline (HS) in the treatment of hemorrhagic shock. We compared the effects of these solutions to those of conventional lactated Ringer's (LR) treatment on bacterial translocation (BT), lung injury and total and differential cell count in the bronchoalveolar lavage fluid (BAL) after hemorrhagic shock. Rats (280-330 g) were bled to a MAP of 35 mmHg for 1 h and then randomized into 4 groups: LR (3x shed blood); HS (7,5% NaCl, 4 mL/kg); LR+PTX (25 mg/kg) and SHAM (no shock, no treatment). Additionally, total shed blood was reinfused. At 24 h lung injury was analyzed by a pathologist blinded to the groups, and a score was calculated. BT was determined by microbiological cultures of mesenteric lymph node complex. BAL was performed on a separate set of animals that received the same treatments. Lung score was significantly higher in LR group (11.5+/-1.4) as compared to HS (6.8+/-0.9), and PTX treated animals (7.2+/-0.9). The percentage of neutrophils in the BAL of LR animals (15.8%) was also significantly higher as compared with HS (5.25%) and PTX groups (9.72%). BT was noted in 50% of rats for LR group, 30% for PTX, 10% for HS and 0% for sham group. HS and PTX reduced BT and lung injury after hemorrhage. Attenuation of lung injury could be the result of less neutrophil infiltration into the lungs of HS and PTX treated animals. LR resuscitation caused pronounced lung injury and BT.

Animals↗
PubMed1999

Immune dysfunction in trauma.

This article documents that all immunomodulation strategies for patients sustaining traumatic injury are still under intense investigation. Although we can speculate that combination strategies may be more beneficial than single-agent immunomodulation approaches, comprehensive clinical studies are required to determine efficacious immune therapy for trauma patients. The only strategy available to clinicians caring for trauma patients is immunonutrition, and this should be strongly considered as a rational approach to improve immune function and reduce septic complications in critically ill or injured patients.

Adjuvants, Immunologic↗
PubMed1998

Hypertonic saline resuscitation diminishes lung injury by suppressing neutrophil activation after hemorrhagic shock.

UNLABELLED: Hypertonic saline (HS) resuscitation after hemorrhage and sepsis has been shown to markedly reduce the development of lung injury in animals, compared with traditional resuscitation with lactated Ringer's (LR). These experiments examined the effect of HS on lung injury after hemorrhage without sepsis. The effects of HS and LR resuscitation on neutrophil trafficking, neutrophil adhesion, and neutrophil oxidative burst were studied. METHODS: BALB/c mice were hemorrhaged to a mean arterial pressure of 40 torr for 1 h. Animals were resuscitated with shed blood and either 4 mL/kg of 7.5% HS or LR in twice the volume of the shed blood. Lung histology was examined 24 h after hemorrhage. Lung myeloperoxidase content and bronchoalveolar lavage fluid neutrophil counts were obtained. Peripheral blood smears were obtained to determine the neutrophil percentage. Peripheral blood neutrophil CD11b expression and neutrophil H2O2 production were assayed by flow cytometry. RESULTS: HS animals had less lung injury than LR animals. The mean myeloperoxidase activity in HS versus LR animals was 1.79+/-1.33 U/100 mg versus 3.0+/-1.33 U/100 mg, respectively. The percentage of neutrophils in the bronchoalveolar lavage fluid of HS animals (3.8%+/-.8) was significantly less than that of LR animals (10.8%+/-2.1). This corresponded to a significantly higher peripheral blood neutrophil count in HS animals compared with LR animals, 41% vs. 20%, respectively. There was no difference in neutrophil expression of the CD11b integrin between the HS and LR groups. The neutrophils of LR animals had basal H2O2 production that was 107% greater than that of controls; HS suppressed this hemorrhage-induced activation by > 60%. HS resuscitation after hemorrhagic shock protects against the development of lung injury. This protection is due, in part, to suppression of the hemorrhage-induced neutrophil oxidative burst. HS resuscitation offers immunomodulatory potential after hemorrhagic shock.

Animals↗
PubMed1997

Hypertonic saline resuscitation decreases susceptibility to sepsis after hemorrhagic shock.

BACKGROUND: We hypothesized that improvements in cellular immune function after hypertonic saline (HTS) resuscitation will alter the outcome of sepsis after hemorrhage. METHODS: To test this hypothesis, a two-hit model was used. Hemorrhage was induced in BALB/c mice by catheterizing the femoral artery and bleeding until a mean arterial pressure = 35 mm Hg was reached and maintained for 1 hour. Resuscitation was performed with HTS (NaCl 7.5%, 4 mL/kg) or lactated Ringer's (LR, twice the shed blood volume), plus the shed blood. Cecal ligation and puncture (CLP) was performed 24 hours after hemorrhage. Mortality was assessed for 72 hours, comparing HTS (n = 14) and LR (n = 13) resuscitation. Another set of animals (n = 10 in each group at each time point) were killed at 2 and 24 hours after blood collection. Liver and blood were cultured for the presence of bacteria, and lung and liver samples were scored on a scale from 0 (normal) to 4 (most severe) in a blind fashion by a pathologist. RESULTS: Mortality 72 hours after CLP was 14.3% in HTS and 76.9% in LR treated animals (p < 0.002). At 24 hours after CLP, 44% of HTS, but 77% of LR treated animals had > 1,000 colony forming units/mL of blood. Positive liver cultures (> 100,000 colony forming units/g) also showed the same trend (HTS = 30%, LR = 60%). Autopsies revealed a better containment of the infection (abscess formation) in the HTS group. At 2 hours, lung scores were 1.2 +/- 0.25 and 2.6 +/- 0.31 for HTS and LR, respectively (p < 0.002). At 24 hours, HTS treated animals showed marked improvement of lung injury, while the scores in the LR group remained high. A significant difference was also observed regarding liver injury. At 2 hours, scores were 0.4 +/- 0.22 and 2.3 +/- 0.16 for HTS and LR, respectively (p < 0.002). At 24 hours, HTS treated animals showed normal hepatic architecture, although mild injury was still observed in the LR group. CONCLUSION: HTS resuscitation leads to increased survival after hemorrhage and CLP. Marked improvements were observed in lung and liver injury compared with isotonic resuscitation. The better containment of the infection observed with HTS resuscitation corresponds to a marked decreased in bacteremia. HTS resuscitation stands as an alternative resuscitation regimen with immunomodulatory potential.

Animals↗
PubMed1997

Hypertonic saline resuscitation: a tool to modulate immune function in trauma patients?

Hypertonic saline (HS) resuscitation has recently gained attention from trauma physicians because it may benefit the immune system of trauma patients. We have found that HS augments in vitro and in vivo immune function of healthy T-cells. In addition, HS restored the function of suppressed T-cells in vitro and in vivo and reduced immunosuppression after hemorrhage, protecting mice from subsequent sepsis. These effects of HS are based on its direct influence on cellular signaling events through specific signaling pathway(s) that include protein tyrosine kinase and mitogen-activated protein kinase p38 activation. HS provides a costimulatory signal that enhances the proliferation of activated T-cells. HS may be able to substitute signals lost through blockage as a result of trauma induced suppressive factors, thereby restoring the function of suppressed T-cells. Although further work is needed to determine the optimal conditions and possible risks of HS resuscitation, the data presented in this short review of our recent work shed a favorable light on HS as a simple but effective tool to modulate cellular immune function after trauma.

Adjuvants, Immunologic↗
PubMed1996

Hypertonic saline resuscitation restores hemorrhage-induced immunosuppression by decreasing prostaglandin E2 and interleukin-4 production.

It was previously shown that hypertonic saline (HTS) enhances in vivo and in vitro cellular immune function of normal mice and reverses in vitro prostaglandin E2 (PGE2)-induced immunosuppression of normal peripheral blood mononuclear cells. Hemorrhage induces immunosuppression despite adequate isotonic fluid resuscitation. The effects of HTS resuscitation on immunosuppression following hemorrhage were studied. A mouse model of hemorrhagic shock was used. Bleeding was performed through a catheter placed in the femoral artery. Phytohemagglutinin-induced splenocyte proliferation and interleukin (IL)-1, IL-2,IL-4, IL-6, IL-10, transforming growth factor beta, and PGE2 plasma levels were measured 2 and 24 hr following hemorrhage and resuscitation with lactated Ringer's and HTS. In vivo cellular immune function was measured using a contact hypersensitivity test. Suppression of splenocyte proliferation (40%) 24 hr following hemorrhage occurred after lactated Ringer's resuscitation. HTS prevented immunosuppression. In vivo cell-mediated immune function 24 hr after hemorrhage was improved by HTS. HTS-resuscitated animals showed significantly lower levels of IL-4 and PGE2, and slightly elevated levels of proinflammatory cytokines (IL-1, IL-2, and IL-6). HTS reverses hemorrhage-induced T-cell suppression by reducing the production and/or release of IL-4 and PGE2.

Animals↗
PubMed1996

The ongoing challenge of retroperitoneal vascular injuries.

BACKGROUND: Retroperitoneal vascular injury remains one of the most frequent causes of death following abdominal trauma. A risk analysis of the association between potential outcome predictors and mortality following abdominal aorta and inferior vena cava injuries was performed. METHODS: Eighty-nine patients sustaining abdominal aortic or inferior vena cava injury were concurrently evaluated for a 10-year period and retrospectively reviewed. A multiple logistic regression model evaluated the following variables:presence of shock on admission, base deficit (< -10 or > or = -10), classification by the organ injury scale (OIS), blood transfusion, crystalloid infusion, total infusion volume, associated injuries, site of injury, and presence of retroperitoneal tamponade. RESULTS: Overall mortality for all injuries was 57%. Excluding all death on arrival (DOA) patients, the mortality rate decreased to 45.7%. Death following abdominal aortic injuries was significantly associated with free bleeding in the peritoneal cavity, acidosis, and an injury in the suprarenal location (OIS > 4). For inferior vena cava injuries and combined abdominal aortic and inferior vena cava injuries, death was associated with free bleeding, the suprarenal location (OIS = 4), and the presence of shock on admission as well. CONCLUSIONS: Despite advances in transport and resuscitation, mortality of aortic and vena cava injuries remains unchanged. Shock on admission, bleeding without retroperitoneal tamponade, acidosis, and the suprarenal location each play a significant role in mortality. Immediate identification associated with a rapid surgical approach are the only factors that may improve survival of such devastating injuries.

Adolescent↗
PubMed1996

Immunosuppression after endotoxin shock: the result of multiple anti-inflammatory factors.

OBJECTIVES: Endotoxin induced suppression of cellular immune function is thought to contribute to septic complications in trauma patients. A rabbit model of endotoxemia was used to determine the relative roles of the anti-inflammatory factors interleukin-4 (IL-4), interleukin-10 (IL-10), transforming growth factor beta1 (TGFbeta1), and prostaglandin E2 (PGE2) in addition to other factors, in inducing immunosuppression. DESIGN: T-cell suppressive factors (TSF) in serum ultrafiltrates were separated and tested for the presence of the known suppressive factors PGE2, IL-4, IL-10, and TGFbeta1. MATERIAL AND METHODS: New Zealand rabbits were injected with 50 microg/kg of purified Escherichia coli lipopolysaccharide. Animals were exsanguinated after 48 hours and serum was separated by ultrafiltration (cutoff 50 kd), TSK HW-40 size exclusion chromatography, and Q-Sepharose anion exchange chromatography. TSF activities of chromatographic fractions and serum samples were measured with a mitogen induced in vitro T-cell proliferation assay. Levels of PGE2, IL-4, IL-10, and TGFbeta1 were measured with enzyme immunoassays. MEASUREMENTS AND MAIN RESULTS: Serum TSF activity, and levels of PGE2, IL-4, IL-10, and TGFbeta1 were increased after endotoxemia. Size exclusion chromatography revealed three major fractions (TSF1-3) with up to 600 times more TSF activity compared with controls. IL-4 and IL-10 were found in TSF1 and TSF3. Further separation of TSF1 by anion exchange chromatography revealed a total of eight different T-cell suppressive factors. TGFbeta1 probably remained in the retentate after ultrafiltration, while PGE2 eluted at a higher retention time. The known anti-inflammatory factors TGFbeta1, IL-10, IL-4, and PGE2 only accounted for 13% of the total serum TSF activity of 614 U/mL. CONCLUSIONS: Lipopolysaccharide shock results in the release of multiple T-cell suppressive factors in addition to known immunosuppressive factors, all of which contribute to the anti-inflammatory response.

Animals↗
PubMed1995

Factors related to the occurrence of postoperative complications following penetrating gastric injuries.

The aim of this study was to determine the relationship between diaphragmatic injury and gross contamination of the peritoneal cavity caused by gastric injuries and the occurrence of postoperative complications, especially those related to the pleural cavity. Charts of 73 patients sustaining gastric injuries due to penetrating trauma were retrospectively reviewed. There were 66 males and mean age was 28 years. Stab wounds were the most frequent mechanism of injury, occurring in 46 cases. Most of the injuries were treated using simple suture and minor debridement. Postoperative morbidity rate was 30 per cent and thoracic complications occurred in 11 patients. Twenty-six patients had diaphragmatic injuries; 54 per cent of them developed postoperative complications. Of the remaining 47 patients without diaphragmatic injuries, only eight developed complications. Of the 26 patients with diaphragmatic injuries, seven developed pleuropulmonary complications compared with 4 of 47 without diaphragmatic injury. Of sixteen patients who had gross contamination secondary to gastric injury, characterized by the presence of food or great amounts of gastric contents in the peritoneal cavity, 10 developed postoperative complications compared with 12 of 57 without gross contamination. Overall mortality rate was 11 per cent mostly due to sepsis. In conclusion, the presence of a diaphragmatic injury as well as gross contamination of the abdominal cavity are important factors related to the development of postoperative infections particularly in the pleural space.

Adolescent↗