[Hyperbaric oxygen therapy in trauma surgery].
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Evidence-Based Medicine↗
Biomedical subjects
W Mutschler
Publications and source records attributed to W Mutschler.
[Hyperbaric oxygen therapy in trauma surgery].
Hyperbaric oxygenation is achieved when a patient breathes 100 percent oxygen in an environment of elevated atmospheric pressure. Physiologically, this produces a directly proportional increase in the plasma volume fraction of transported oxygen which is readily available for cellular metabolism. A number of beneficial biochemical, cellular and physiologic effects result which account for the use of hyperbaric oxygen as an adjunctive therapy in the treatment of clostridial myonecrosis, crush injuries, compromised flaps, osteoradionecrosis and chronic problem wounds. Indications, modes of treatment, contraindications, side effects, costs and experimental and clinical results are presented. Overall, these data demonstrate that hyperbaric oxygen is no longer "a therapy in search of diseases". However, more randomized controlled clinical trials are necessary to demonstrate its efficacy.
Contraindications↗
[Pathological fracture in osteofibrous dysplasia].
Osteofibrous dysplasia Campanacci is a rare tumor-like lesion mostly presented in the meta-epiphyseal region of the tibia. Different options exist about the treatment modalities. The rare case of a 4 1/2-year-old girl suffering from a pathologic fracture of the tibia shaft due to a osteofibrous dysplasia is presented. The fracture was stabilized by intramedullary nailing using elastic titanium rods. During this procedure a biopsy of the lesion confirmed the radiological suspected diagnosis of an osteofibrous dysplasia. The implant was removed after ten months when fracture and lesion were healed. The treatment options and the differential diagnoses are discussed by review of the literature.
Bone Cysts↗
[Introduction of a new mobile C-arm/CT combination equipment (ISO-C-3D). Initial results of 3-D sectional imaging].
Preclinical evaluation of a new mobile C-arm image amplifier with an option for three-dimensional computed tomography (CT) imaging (prototype Iso-C3D) with respect to high-contrast resolution and possible clinical applications. Cadaveric specimens (n = 30) of different joints of the lower and upper extremities and specimens of the spinal column were examined with the Iso-C3D and evaluated for image quality. In addition, using a high-contrast phantom (Catphan, Phantom Laboratory, Salem, N.Y., USA) and a fracture model of the femoral bone, measurements of high-contrast resolution were performed in comparison to spiral CT. With the exception of the shoulder, all joint regions including the entire spinal column could be examined. Adequate image quality could be achieved in smaller joints such as the wrist, elbow, ankle, and knee, whereas a remarkably decreased image quality was found when imaging the hip as well as the lumbar and thoracic spine. Images of the phantom study and high-contrast fracture model showed a high-contrast resolution comparable to helical CT (9 Lp/cm in xy-axis). In smaller joints, the image quality of the mobile C-arm CT imaging system (Iso-C3D) is comparable to that of helical CT. Image quality in examinations of the hip and lumbar and thoracic spine seems to be sufficient for intraoperative control studies of osteosynthesis. Problems still occur in shoulder examinations.
Arthrography↗
[3-D imaging with a mobile surgical image enhancement equipment (ISO-C-3D). Initial examples of fracture diagnosis of peripheral joints in comparison with spiral CT and conventional radiography].
To analyze a prototype mobile C-arm image amplifier (Iso-C3D) in the evaluation of different joint fractures of the upper and lower limbs using multiplanar reconstruction (MPR). Different cadaver joint specimens (n = 14) were examined with a prototype (Iso-C3D, Siemens AG, Erlangen, Germany), plain radiographs (CR), and spiral computed tomography (CT). The motorized C-arm provides fluoroscopic images during a 190 degrees orbital rotation computing a 119-mm data cube. These three-dimensional data sets yielded MPR images, which were evaluated by two readers for the detection and extent of fracture lines. Initial data show that fractures were easily depicted and correctly classified on MPR images with the Iso-C3D and that there was no difference between the Iso-C and CT in the detection of fractures. The preliminary results suggest a remarkably good detection of joint fractures with the Iso-C3D. Studies in an adequate number of patients are required to elucidate whether these promising results can also be obtained in a clinical setting.
Ankle Injuries↗
[Comparative study of the quality of C-arm based 3D imaging of the talus].
Malposition of extraosseous or intra-articular screws, e.g., in osteosyntheses of joint fractures or in the vicinity of joints, frequently remains undiscovered in intraoperative fluoroscopy and is only recognized on postoperative computed tomography (CT) scans. The aim of the study, therefore, was to assess the value of a new mobile C-arm three-dimensional imaging device in comparison with fluoroscopy, conventional radiographs, and CT scans using an extremity model. Screws were inserted ventrally in four anatomic lower leg specimens without talus fractures parallel to the longitudinal axis to simulate surgical management of fractures of the talus. The specimens supplied were examined with fluorscopy, conventional radiography, spiral CT, and the new three-dimensional imaging with the SIREMOBIL Iso-C3D. These four modalities were evaluated by ten radiologists and ten trauma surgeons and were compared regarding subjective image quality and position of the screws. The quality of information acquired with the SIREMOBIL Iso-C3D was equal to that of the CT examinations, although image quality was considered inferior to fluoroscopy, conventional radiography, and CT (p < 0.001). In contrast to the previous procedure with intraoperative fluoroscopy and subsequent postoperative X-ray control, the results obtained with the SIREMOBIL IsoC3D were superior. The SIREMOBIL Iso-C3D is useful for the intraoperative diagnosis of small joints with few artifacts producing osteosynthesis material, i.e., for recognizing the position of screws in the region of glenoid surfaces.
Bone Screws↗
Early cellular brain damage and systemic inflammatory response after cardiopulmonary resuscitation or isolated severe head trauma: a comparative pilot study on common pathomechanisms.
Severe neurological deficits are common characteristics of patients surviving cardiopulmonary resuscitation (CPR) or isolated severe head trauma (SHT). For comparative evaluation of underlying pathomechanisms, 22 patients with out-of-hospital cardiac arrest and successful CPR as well as 10 patients with SHT were included in our prospective study. Circulating S-100B was determined as an indicator of cellular brain damage. Interleukin-8 (IL-8), soluble E-selectin (sE-selectin) and polymorphonuclear (PMN-) elastase were measured as markers of systemic inflammation following whole body ischaemia and reperfusion injury. Venous blood samples were drawn on scene (median time 11.0 min after starting basic life support) and in the intensive care unit (median time 12.5 h thereafter) in CPR patients and at admission to hospital (median time 43.8 min after trauma) and approx. 12 h later in SHT patients. Biochemical parameters in these samples were compared with specimens taken from 20 healthy volunteers. Initial median S-100B levels of the CPR and SHT patients were both significantly increased compared with the controls. Twelve hours later, significant falls in S-100B revealed no differences between the two patient groups, but did not reach control values. Median IL-8 and sE-selectin levels entry to the study were elevated in both patient groups compared with controls and showed further rises within the following 12 h. Finally, increased initial median levels of PMN-elastase revealed significant differences between the patient groups and between patients and controls. Twelve hours later, median PMN-elastase values were equally elevated in the CPR and SHT subjects. Our preliminary data suggest similar pathomechanisms occurring after both CPR and SHT. Both clinical entities seem to be associated with early transient cellular brain damage as shown by prolonged rapidly increasing and subsequent fall in S-100B serum levels. In contrast, the prolonged elevation of circulating IL-8, sE-selectin and PMN-elastase may indicate a very similar systemic inflammatory response by endothelial cells and neutrophils initiated by ischaemia and reperfusion injury in both conditions. Further studies should be carried out to determine the cause and the prognostic value of these biochemical parameters in relation to long-term neurological outcome.
Aged↗
[Radiological diagnosis in polytrauma: interdisciplinary management].
The presence of a radiologist within the admitting area of an emergency department and his capability as a member of the trauma team have a major impact on the role of diagnostic radiology in trauma care. The knowledge of clinical decision criteria, algorithms, and standards of patient care are essential for the acceptance within a trauma team. We present an interdisciplinary management concept of diagnostic radiology for trauma patients, which comprises basic diagnosis, organ diagnosis, radiological ABC, and algorithms of early clinical care. It is the result of a prospective study comprising over 2000 documented multiple injured patients. The radiologist on a trauma team should support trauma surgery and anesthesia in diagnostic and clinical work-up. The radiological ABC provides a structured approach for diagnostic imaging in all steps of the early clinical care of the multiple injured patient. Radiological ABC requires a reevaluation in cases of equivocal findings or difficulties in the clinical course. Direct communication of radiological findings with the trauma team enables quick clinical decisions. In addition, the radiologist can priority-oriented influence the therapy by using interventional procedures. The clinical radiologist is an active member of the interdisciplinary trauma team, not only providing diagnostic imaging but also participating in clinical decisions.
Diagnostic Imaging↗
Elevated serum levels of S-100B reflect the extent of brain injury in alcohol intoxicated patients after mild head trauma.
Elevated systemic levels of S-100B are proposed as a potential indicator of brain damage in identifying high-risk patients after mild head trauma (MHT). Although incidence of alcohol intoxication is high in these patients, the influence of alcohol intoxication on S-100B levels is unclear. Therefore, the aim of our study was to investigate serum concentrations of S-100B in intoxicated (group 1) and sober (group 2) patients after MHT in comparison with those of mild (group 3) or severely intoxicated (group 4) individuals without trauma. S-100B was significantly increased in MHT patients exhibiting posttraumatic lesions in initial cranial computed tomography scan. Alcohol intoxication did not elevate S-100B levels in group 3 or 4 subjects. Our data indicate for the first time that alcohol intoxication does not influence the diagnostic value of S-100B measurements in patients after MHT.
Alcohol Drinking↗
[Surgical treatment of injuries of the thoracolumbar transition. 2: Operation and roentgenologic findings].
The authors report on a prospective multicenter study with regard to the operative treatment of acute fractures and dislocations of the thoracolumbar spine (T10-L2). The study should analyze the operative methods currently used and determine the results in a large representative collective. This investigation was realized by the working group "spine" of the German Trauma Society. Between September 1994 and December 1996, 682 patients treated in 18 different traumatology centers in Germany and Austria were included. Part 2 describes the details of the operative methods and measured data in standard radiographs and CT scans of the spine. Of the patients, 448 (65.7%) were treated with posterior, 197 (28.9%) with combined posterior-anterior, and 37 (5.4%) with anterior surgery alone. In 72% of the posterior operations, the instrumentation was combined with transpedicular bone grafting. The combined procedures were performed as one-stage operations in 38.1%. A significantly longer average operative time (4:14 h) was noted in combined cases compared to the posterior (P < 0.001) or anterior (P < 0.05) procedures. The average blood loss was comparable in both posterior and anterior groups. During combined surgery the blood loss was significantly higher (P < 0.001; P < 0.05). The longest intraoperative fluoroscopy time (average 4:08 min) was noticed in posterior surgery with a significant difference compared to the anterior group. In almost every case a "Fixateur interne" (eight different types of internal fixators) was used for posterior stabilization. For anterior instrumentation, fixed angle implants (plate or rod systems) were mainly preferred (n = 22) compared to non-fixed angle plate systems (n = 12). A decompression of the spinal canal (indirect by reduction or direct by surgical means) was performed in 70.8% of the neurologically intact patients (Frankel/ASIA E) and in 82.6% of those with neurologic deficit (Frankel/ASIA grade A-D). An intraoperative myelography was added in 22% of all patients. The authors found a significant correlation between the amount of canal compromise in preoperative CT scans and the neurologic deficit in Frankel/ASIA grades. The wedge angle and sagittal index measured on lateral radiographs improved from -17.0 degrees and 0.63 (preoperative) to -6.3 degrees and 0.86 (postoperative). A significantly (P < 0.01) stronger deformity was noted preoperatively in the combined group compared to the posterior one. The segmental kyphosis angle improved by 11.3 degrees (8.8 degrees with inclusion of the two adjacent intervertebral disc spaces). A significantly better operative correction of the kyphotic deformity was found in the combined group. In 101 (14.8%) patients, intra- or postoperative complications were noticed, 41 (6.0%) required reoperation. There was no significant difference between the three treatment groups. Of the 2264 pedicle screws, 139 (6.1%) were found to be misplaced. This number included all screws, which were judged to be not placed in an optimal direction or location. In seven (1.0%) patients the false placement of screws was judged as a complication, four (0.6%) of them required revision. The multicenter study determines the actual incidence of thoracolumbar fractures and dislocations with associated injuries and describes the current standard of operative treatment. The efforts and prospects of different surgical methods could be demonstrated considering certain related risks. The follow-up of the population is still in progress and the late results remain for future publication.
Adolescent↗
Double traumatic abdominal wall hernia and colon laceration due to a pelvic fracture.
A traumatic abdominal wall hernia was observed in association with a colonic laceration due to a pelvic fracture. The presence of this specific combination of injuries is a rare clinical entity. CT evaluation with intravenous and bowel contrast media identified the traumatic abdominal wall hernia and the bowel entrapment.
Abscess↗
[Implementation of a quality management system for the curriculum in emergency medicine education].
Medical teaching, training and education in basic and advanced life support were improved by basic quality management procedures. 3rd year medical students (n = 276) of two consequent semesters were questionnaired about their acute emergency medicine curriculum. While Group A (n = 134) received a standard course, the new course for group B (n = 142) was reorganised on the basis of the results of group A. Interventive educational measures were an increased number of models provided for exercising the students skills, and an extension of megacode training possibilities. Participation of students in course design improved the overall performance in respect of knowledge, skills and decision-making (p < 0.05). Curriculum acceptance and intrinsic motivation of students however were not positively influenced by practical training compared to traditional knowledge transfer.
Curriculum↗
Altered calcium regulation and function of human neutrophils during multiple trauma.
Altered intracellular Ca2+ concentration is a pivotal regulatory mechanism of leukocyte function. Since polymorphonuclear neutrophils (PMN) are involved in traumatic organ dysfunction, we prospectively investigated Ca2+ regulation and function of circulating PMN multiple trauma patients (Group A: ISS < 27; Group B: ISS > or = 27). Circulating PMN were isolated during 12 days, followed by determination of formyl-methionyl-leucyl-phenylalanine (fMLP)-induced PMN-superoxide production (PMN-SOP) by SOD-inhibitable ferricytochrome C reduction, and PMN cytosolic Ca2+ concentration ([Ca2+]i) by fluorescent fura2/AM (340/380 ratio). PMN-SOP was significantly higher in Group B (mean ISS: 39.9 +/- 2; n = 21) at day of admission than in controls and Group A (mean ISS: 18.2 +/- 1; n = 22) (P< 0.05). In Group B, the significant rise of basal [Ca2+]i between Day 2 and Day 4 was associated with significant lower PMN-SOP during that period (P < 0.05). The fMLP-induced [Ca2+]i response was supranormal in both groups. PMN-elastase concentrations were substantially higher in Group B compared with Group A until Day 4. Circulating IL-6, IL-8, and soluble TNF-receptor (55 kD) were significantly increased in Group B compared with Group A at the day of trauma (P < 0.05). Severe trauma is characterized by a biphasic pattern of neutrophil priming characterized by early increase and secondary suppression. The association of depressed neutrophil superoxide production (deactivation) and elevated basal [Ca2+]i suggests Ca2+-mediated disturbance of neutrophil NADPH-oxidase metabolism.
Adult↗
Incidence of cancer among commercial airline pilots.
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Circadian Rhythm↗
Overexpression of matrix metalloproteinase 2 predicts unfavorable outcome in early-stage non-small cell lung cancer.
This prospective study was performed to assess the impact of matrix metalloproteinase (MMP) 2 expression on the clinical course of patients with operable non-small cell lung cancer (NSCLC). Specimens of 193 consecutive patients with completely resected NSCLC were examined for MMP-2 expression by immunohistochemical staining with a polyclonal antibody. Homogeneous immunostaining of cancer cells was considered positive and heterogeneous, or no staining was considered negative concerning overexpression of MMP-2. Four specimens were excluded from further analyses because of unspecific staining. The median follow-up period was 71.5 months (range, 12-120 months). Overexpression of MMP-2 was observed in 64 (33.9%) of 189 patients and did not correlate with clinicopathoiogical parameters. In patients without lymph node involvement (pN0 stage) MMP-2 overexpression was an independent prognostic parameter for unfavorable outcome: Log-rank analysis showed a significant association of MMP-2 overexpression with shortened cancer-related survival (P = 0.04) and disease-free survival (P = 0.03). Multivariate regression analysis confirmed MMP-2 overexpression as predictor of shortened cancer-related survival in NSCLC without lymph node involvement (P = 0.005, relative risk, 2.6). The present study revealed that MMP-2 overexpression predicts a poor prognosis in early-stage NSCLC. Therefore, it might be worth investigating the role of MMP inhibitors as adjuvant therapeutic agents in NSCLC.
Adult↗
First clinical experience with an endoscopic retroperitoneal approach for anterior fusion of lumbar spine fractures from levels T12 to L5.
BACKGROUND: Recent experience indicates that unstable spine fractures should be stabilized dorsoventrally. To avoid the high morbidity associated with the common anterior approach-i.e., thoraco-phreno-lumbotomy-we developed a technique that allows the anterior fusion of lumbar spine fractures using an endoscopic retroperitoneal (lumboscopic) approach. METHODS: Lumboscopic anterior fusion was performed a few days after the initial dorsal stabilization. The retroperitoneal space was accessed endoscopically via a suprailic incision and enlarged using a balloon spacer and CO(2) insufflation. The peritoneum and the kidney were gently pushed ventrally. Mobilization of the psoas muscle dorsally then allowed exposure of the fractured spine bodies. Via two additional trocars placed opposite the fractured level, the damaged disc and bone were removed, and anterior spondylodesis was performed with an iliac crest bone block and a titanium plate. RESULTS: The technique was applied successfully in 12 patients with fractures of L1 (n = 6), L2 (n = 4), L3 (n = 1), and L4 (n = 1) as a mono- or bisegmental fusion, requiring instrumentation from T12 to L5. No major complications (including neurological problems) were encountered. Blood loss was minimal. None of the patients required conversion to open surgery. Patients were mobilized early, starting regularly at the second postoperative day. CONCLUSIONS: Lumboscopic instrumentation of the lumbar spine is a safe, minimally invasive method for the treatment of spine fractures. The patients benefit from reduced pain, low morbidity, and excellent cosmetic results.
Adult↗
Monoclonal antibody to tumor necrosis factor-alpha modulates hepatocellular Ca2+ homeostasis during hemorrhagic shock in the rat.
Tumor necrosis factor-alpha (TNF-alpha) is a key mediator of shock-induced cellular and humoral inflammatory cascades. The present study investigated the role of TNF-alpha in oxidative membrane injury and altered hepatocyte Ca2+ regulation, both of which are critical steps in cellular dysfunction during ischemia/reperfusion events. Hemorrhagic shock was induced by bleeding male Sprague-Dawley rats (200-250 g, n=6/group) to a mean arterial blood pressure of 40 mmHg for 60 min. Rats were resuscitated with 60% of shed blood and twice the shed blood volume as Ringers' lactate. At the end of hemorrhage and 60 min after resuscitation, hepatocytes were isolated by liver collagenase perfusion. Hepatocyte Ca2+ uptake (Ca2+up) and Ca2+ membrane flux (Ca2+flux) were determined by 45Ca2+ incubation techniques. Hepatocyte reduced/oxidized glutathione and lipid peroxidation were determined fluorometrically. Both hemorrhage and hemorrhage/resuscitation significantly increased hepatocyte Ca2+up and Ca2+flux. The monoclonal chimeric mouse gamma1 TNF-alpha antibody (TN3gamma1.19.12; 20 mg/kg b.w.) given with resuscitation significantly decreased hepatocyte Ca2+up and Ca2+flux and prevented hepatocyte lipid peroxidation. These findings suggest that oxidative membrane injury could be the result of TNF-alpha modulation of hepatocellular Ca2+ regulation during hemorrhage/resuscitation.
Animals↗