C-spine clearance in poly-trauma patients: A narrative review

The incidence of cervical spine injury in patients with polytrauma is 3.7%. Early identification and management of cervical spine injuries in these patients play a crucial role in preventing secondary cervical spine and cord injuries. C-spine clearance assumes a pivotal role in reducing the morbidity and mortality associated with cervical spine injury. Despite the availability of various validated management algorithms and protocols for C-spine clearance, there are several controversies regarding C-spine clearance, such as the ideal protocol and imaging modality, clearance of obtunded patients and management of patients that lie out of the described protocols and rules. The current article aims to provide a comprehensive review of the relevant literature and address the prevalent controversies.     

Current updates in management of extremity injuries in polytrauma

Injury-related morbidity and mortality have been one of the most common causes of loss in productivity across all geographic distributions. It remains to be a global concern despite a continual improvement in regional and national safety policies. The establishment of trauma care systems and advancements in diagnostics and management have improved the overall survival of severely injured. A better understanding of the physiopathological and immunological responses to injury led to a significant shift in trauma care from “Early Total Care” to “Damage Control Orthopedics.” While most of these algorithms were tailored to the philosophy of “life before limb,” the impact of improper fracture management on disability and societal loss is increasingly being recognized. Recently, “Early Appropriate Care” of extremities has gained importance; however, its implementation is influenced by regional health care policies, available resources, and expertise and varies between low and high-income countries. A review of the literature was performed using PubMed, Embase, Web of Science, and Scopus databases on articles published from 1990 to 2020 using the Mesh terms “Polytrauma,” “Multiple Trauma,” and “Fractures.” This review aims to consolidate on guidelines and available evidence in the management of extremity injuries in a polytraumatized patient to achieve better clinical outcomes of these severely injured.     

磷酸肌醇3激酶/蛋白激酶B信号通路在丁苯酞保护心肌缺血再灌注损伤中作用机制的实验研究

目的观察丁苯酞预处理对心肌缺血再灌注损伤的保护作用以及磷酸肌醇3激酶(PI3K)/蛋白激酶B(Akt)通路在此过程中的作用。方法将大鼠心肌细胞(H9C2)随机分为假手术组(Sham组)、缺血再灌注组(I/R组)、丁苯酞预处理组(I/R+NBP组)。通过氧气剥夺以及无糖培养基的更换模拟6 h缺血4 h复灌心肌缺血模型。通过细胞计数检测试剂盒(CCK-8)检测不同药物浓度细胞活性,探索丁苯酞的最佳药物浓度;比色法检测各组乳酸脱氢酶(LDH)以及丙二醛(MDA)含量;蛋白质印迹法(Western blot)检测PI3K、磷酸化蛋白激酶B(p-Akt)和Akt的蛋白表达水平;定量聚合酶链反应(qPCR)技术检测白细胞介素-1β(IL-1β)和肿瘤坏死因子-α(TNF-α)在核糖核酸(mRNA)水平的表达。多组之间比较采用单因素方差分析,两组之间比较采用t检验。结果丁苯酞的最佳用药浓度为100μmol/L;I/R组MDA、LDH的表达量高于Sham组[(172.03±14.99)nmol/L比(38.98±6.49)nmol/L、(195.04±14.50)%比(100.00±0.00)%,t=14.106、11.354,P<0.05];I/R组IL-1β、TNF-α的表达量高于Sham组(22.36±2.71比1.00±0.00、6.20±0.31比1.00±0.00,t=13.660、28.874,P<0.05);I/R组PI3K、p-Akt的表达量也高于Sham组(0.61±0.34比0.34±0.01、0.95±0.04比0.36±0.04,t=13.487、18.392,P<0.05),差异有统计学意义。I/R+NBP组MDA、LDH的表达量低于I/R组[(56.98±4.79)nmol/L比(172.03±14.99)nmol/L、(140.34±4.44)%比(195.04±14.50)%,t=12.661、7.890,P<0.05];I/R+NBP组IL-1β、TNF-α的表达量低于I/R组(6.66±0.60比22.36±2.71、1.76±0.11比6.20±0.31,t=9.798、23.352,P<0.05),差异有统计学意义;I/R+NBP组PI3K、p-Akt的表达量高于I/R组(1.00±0.05比0.61±0.34、1.27±0.04比0.95±0.04,t=11.440、10.432,P<0.05),差异有统计学意义。结论丁苯酞可以通过减少细胞损伤、抑制氧化及炎性反应进而减轻心肌缺血再灌注损伤,该过程可能有PI3K/Akt通路的参与。     

瞬时感受器电位离子通道香草素受体4在睾丸缺血再灌注损伤中对GC-1细胞增殖及凋亡的作用及其机制

目的探讨瞬时感受器电位离子通道香草素受体4(TRPV4)在睾丸缺血再灌注损伤(IRI)中对GC-1细胞增殖和凋亡的作用及其机制。方法建立睾丸GC-1细胞缺氧复氧模型,采用蛋白质印迹法(Western blot)检测不同复氧损伤时间点TRPV4的表达变化;分别采用噻唑蓝(MTT)实验、流式细胞术检测转染TRPV4对GC-1细胞增殖和凋亡的影响;采用Western blot法检测睾丸组织中转染TRPV4对GC-1细胞中半胱氨酰天冬氨酸特异性蛋白酶(Caspase)-3和细胞色素C(Cyt-C)表达的影响,组间比较采用t检验,多组间比较采用单因素方差分析。结果对照组及缺氧复氧组(0、6、12、24、48和72 h)TRPV4的蛋白表达水平分别为0.19±0.02、0.35±0.03、0.42±0.04、0.46±0.04、0.62±0.05、0.54±0.05、0.45±0.04。缺氧复氧组TRPV4表达显著高于未缺氧GC-1细胞的对照组,并在复氧24 h达到峰值(F=6.898,P<0.05),差异有统计学意义;缺氧复氧组中细胞增殖水平明显低于对照组(52.32±4.58比100.00±7.63,t=-9.280,P<0.05),差异有统计学意义,细胞凋亡水平高于对照组(15.60±1.72比4.08±0.87,t=10.352,P<0.05),差异有统计学意义;过表达TRPV4组中细胞增殖水平低于其对照组(23.65±3.98比51.35±4.67,t=-7.820,P<0.05),差异有统计学意义,细胞凋亡水平高于其对照组(26.93±2.15比14.62±1.68),t=7.814,P<0.05),差异有统计学意义;沉默TRPV4组中细胞增殖水平高于其对照组(72.49±6.21比53.18±5.14,t=4.150,P<0.05),差异有统计学意义,细胞凋亡水平低于其对照组(9.71±1.25比15.07±1.64,t=-4.502,P<0.05),差异有统计学意义。缺氧复氧组中Caspase-3和Cyt-C表达水平高于对照组(0.70±0.06比0.20±0.02,t=13.693,P<0.05;0.74±0.07比0.26±0.03,t=10.917,P<0.05),差异有统计学意义;过表达TRPV4组中Caspase-3和Cyt-C表达水平高于其对照组(1.25±0.11比0.69±0.07,t=7.439,P<0.05;1.38±0.14比0.72±0.07,t=7.303,P<0.05),差异有统计学意义;沉默TRPV4组中Caspase-3和Cyt-C表达水平低于其对照组(0.46±0.05比0.68±0.06,t=-4.879,P<0.05;0.45±0.05比0.72±0.06,t=-5.988,P<0.05),差异有统计学意义。结论TRPV4在GC-1细胞中高表达,其可能通过改变GC-1细胞的增殖和凋亡能力,从而影响睾丸IRI的发生发展。     

创伤性脑损伤患者脑脊液中嗜中性白细胞碱性磷酸酶-1的表达及意义

目的探讨炎性体蛋白嗜中性白细胞碱性磷酸酶-1(NALP-1)在创伤性脑损伤患者脑脊液中表达水平及其与预后相关性。方法选取2017年2月至2018年9月来自首都医科大学附属北京同仁医院的120例创伤性脑损伤患者,选取同期健康体检者30例作为对照组,采用免疫印迹化学发光法检测研究对象脑脊液中炎性体蛋白NALP-1表达水平,根据格拉斯哥预后评分(GOS)将创伤性脑损伤患者分为预后良好组(GOS>3分)和预后不良组(GOS≤3分)。χ²检验和t检验分析预后良好组和预后不良组NALP-1和临床资料差异,采用多因素Logistic回归模型分析创伤性脑损伤后患者预后影响因素。结果创伤性脑损伤患者脑脊液中NALP-1表达(1.64±0.52)高于对照组(0.94±0.28,t=7.108,P<0.05),差异有统计学意义。NALP-1高表达组急性生理与慢性健康状况评分Ⅱ(APACHEⅡ)得分(26.4±5.4)分、脑挫伤比例(76.62%)、蛛网膜下腔出血比例(77.27%)高于低表达组[(22.3±4.5)分、23.38%、22.73%],差异有统计学意义(χ²/t=4.135、9.586、7.424,P<0.05)。年龄[比值比(OR):2.175,95%可信区间(CI):1.167~8.767,P<0.05]、蛛网膜下腔出血(OR:1.241,95%CI:1.101~3.794,P<0.05)、NALP-1(OR:2.841,95%CI:1.675~10.717,P<0.05)、纤维蛋白原水平(OR:1.215,95%CI:1.056~3.627,P<0.05)、APACHEⅡ得分(OR:1.615,95%CI:1.314~5.485,P<0.05)是预后不良独立影响因素,差异均有统计学意义。结论创伤性脑损伤脑脊液中NALP-1表达增加,且表达量升高与预后不良相关。     

Pulmonary contusions in patients with rib fractures: The need to better classify a common injury

BackgroundPulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion.MethodsWe identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality.ResultsAmong 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16–33%], respiratory failure 40% [95%CI: 31–50%], and intubation 46% [95%CI: 33–61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications.ConclusionsThere is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.     

Definition and epidemiology of mild traumatic brain injury

Background/objectivesThe definition of mild traumatic brain injury (mTBI), also known as concussion, has been a matter of controversy, which makes comparison between studies difficult. Incidence varies greatly from one country to another. The present article reviews definitions and epidemiology.MethodsLiterature review.ResultsAccording to the Mild TBI Committee of the American Congress of Rehabilitation Medicine, revised by the World Health Organization (WHO), mTBI is defined by a Glasgow Coma Scale score between 13 and 15 at 30 minutes post-injury, and one or more of the following symptoms: <30 min loss of consciousness; <24 hours post-traumatic amnesia (PTA); impaired mental state at time of accident (confusion, disorientation, etc.); and/or transient neurological deficit. If a focal lesion is found on computed tomography (CT) or magnetic resonance imaging (MRI), the term “complicated mild TBI” has been proposed. Incidence of mTBI is 200–300/100,000 persons per year for hospitalized patients and probably twice as high if non-hospitalized patients are included. However, a few recent population-based studies reported a much higher rate (>700/100,000). A changing pattern of epidemiology has been found in high-income countries, related to a decrease in road-accident injuries in young adults, while conversely the proportion of falls has increased with population aging.ConclusionMild TBI is a major public health concern, the epidemiology of which has greatly changed in the last twenty years.     

Symptomatic hepatothorax presenting 25 years after penetrating thoracoabdominal injury

Hepatic herniation through the diaphragm is a rare finding. It generally occurs due to a congenital diaphragmatic abnormality or blunt trauma resulting in a diaphragmatic defect. Making the diagnosis is difficult, as there are few definitive clinical signs and chest radiograph (CXR) findings may be non-specific. To our knowledge, only a single case report exists of penetrating right diaphragm injury leading to hepatic herniation.A 42-year-old man presented to the emergency department of a regional hospital with hyperglycaemia and exertional dyspnoea. He was diagnosed with diabetes mellitus type 2. He gave a history of smoking for 15 pack-years, was negative for retroviral disease and had no history of pulmonary tuberculosis. He had no significant surgical history but reported being stabbed with a knife in 1995. The point of entry was below the level of the nipple in the right anterior axillary line. At the time, he was treated with an intercostal drain and discharged home.CXR showed a right-sided chest mass. We considered a differential diagnosis of pulmonary consolidation, diaphragm eventration or hepatothorax. Computerized tomography of the chest and abdomen demonstrated apparent intrathoracic extension of the right liver lobe and partial attenuation of the superior vena cava and right atrium due to a mass effect. The upper border of the liver abutted the aortic arch. Surgical treatment options were discussed. The patient declined surgery and will be followed up as an outpatient.