Sympathetic skin response impairment: A good predictor of bone loss in electrical burn victims

IntroductionBurn victims are reported to have more possibility of bone loss in acute phase of injury partly due to sympathetic dysfunction and catecholamine increase beside other hypermetabolic responses. These patients are also prone to autonomic neuropathy and sympathetic skin response (SSR) impairment. We aim to investigate the correlation between SSR in the acute phase and bone mineral density (BMD) parameters in electrical burn patients and determine whether the SSR parameter in initial weeks of the event is a good predictor of bone loss in long term.Materials and methodsSixty two individuals exposed to low voltage(<1000 V) electrical current were invited to a cohort study. The SSR was recorded from their four limbs in 2–5 weeks after injury. Then, dual X-ray absorptiometry (DXA) was done to measure their BMD, T-score and Z –score, 9–12 months later. The correlation between SSR parameters in acute phase and DXA indexes was evaluated using Spearman test. A Roc curve was charted to point out a cut-off value for SSR amplitude and latency in respect to T-score to predict the subsequent bone loss.ResultAll the patients were male with a mean age of 34.09 years. Biphasic SSR parameters showed a significant correlation with lumbar BMD in a confidence interval of 99.9%. SSR amplitude threshold of 293.75 μV and latency of 2.15 s had a 100% sensitivity and 94% and 83% specificity respectively for predicting the bone loss (T-score<-1) in long term. The area under Roc curve was 0.94 and 0.99 in terms of SSR amplitude and latency.ConclusionSSR recorded in the first few weeks after electrical injury is a good predictor of bone loss in long term, so we recommend this test as a guide for screening the patients at risk for osteoporosis in electrical burn and formulating the preventive measurements.     

Transient anisocoria after a traumatic cervical spinal cord injury: A case report

Context: Autonomic dysreflexia and dysautonomia can be a common complication following spinal cord injury, especially at levels of T6 and above and can lead to complications associated with the pupil. In this case report, we review autonomic dysreflexia, the anatomy and physiology of the sympathetic nervous system of the eye, as well as review the clinical relevance in understanding autonomic and pupillary changes in response to autonomic dysfunction.

Findings: We present a patient with an incomplete C4 level injury who was found to have isolated anisocoria on two separate occasions during his acute inpatient rehabilitation stay.

Conclusion/Clinical Relevance: Anisocoria associated with abnormal sympathetic activation may be a clinical sign of dysautonomia.     

Takotsubo cardiomyopathy in a chronic spinal cord injury patient with autonomic dysreflexia: A case report

Context: Takotsubo cardiomyopathy (TC) is a transient stress-induced cardiomyopathy with left ventricular dysfunction of unknown etiology. A well accepted theory for the pathophysiology of TC is attributed to a massive catecholamine release [1]. This case report will review a chronic tetraplegia patient who was diagnosed with TC after a severe episode of autonomic dysreflexia (AD). He experiences mild episodes of AD several times a day; however, he had never experienced the severity of symptoms that was associated with this episode which led to his hospitalization. Autonomic dysreflexia is a syndrome of imbalanced sympathetic input secondary to loss of descending central sympathetic control in spinal cord injury due to noxious stimuli below the level of the injury, which occurs when the injury level is at thoracic level 6 (T6) or above [2].Findings: In this specific case, it is presumed that the massive catecholamine release associated with this severe AD episode resulted in TC. Although TC has been diagnosed after other instances of acute stress, it is unknown for it to be diagnosed after AD in a chronic setting.Clinical Relevance: The long-term effects of AD have not been well studied, and this case illustrates the importance of education to recognize and manage AD in the spinal cord patient who frequently has episodes of AD.     

Lower amputation rate after fasciotomy by straight midline incision technique for a 22,900-V electrical injury to the upper extremities

PurposeThe purpose of this study is to compare the major amputation rate following two different fasciotomy techniques, conventional versus straight midline, in patients with high-voltage arc burn injury by electric currents of 22,900 V to the upper extremities.MethodsA retrospective analysis of 230 patients (270 burned upper limbs) who underwent fasciotomy after high-voltage electrical injuries between 1996 and 2007 was performed. The patients were divided into two groups according to the fasciotomy method used. From 1996 to 2002, 158 patients (184 limbs) underwent conventional fasciotomy by Green’s volar-ulnar incision (conventional fasciotomy group). From 2003 to 2007, 72 patients (86 limbs) underwent fasciotomy using a straight midline curved incision (midline fasciotomy group). The patients were also divided into two groups based on whether the fasciotomy procedure was performed early or late. Patients who underwent fasciotomies <8 h after injury were classified as early, while those who underwent it >8 h after injury were classified as late. Major amputation rates were compared between two fasciotomy methods and analyzed following fasciotomy timing.ResultsThe midline fasciotomy group had a significantly lower major amputation rate (33.7%) than the conventional fasciotomy group (59.2%) (p < 0.001). A subsequently decreased major amputation rate of 27.8% was observed in the early fasciotomy subgroup of the midline fasciotomy group (p = 0.025).ConclusionEarly fasciotomy remarkably reduced the major amputation rate after high-voltage arc injury; in the setting of minimized vascular exposure after fasciotomy, a midline straight incision could ensure that various types of reconstructive microsurgical procedures and primary skin closures can be used to save limbs.     

The effective removal of proinflammatory cytokines by continuous hemofiltration with a polymethylmethacrylate membrane following severe burn injury: Report of three cases

(Received for publication on Mar. 11, 1998; accepted on Nov. 6, 1998)     

Bladder inhibition or excitation by electrical perianal stimulation in a cat model of chronic spinal cord injury

OBJECTIVE

To test the hypothesis that perianal electrical stimulation (PES) in chronic spinal cord‐injured (SCI) cats could induce frequency‐dependent inhibitory or excitatory reflex bladder responses.

MATERIALS AND METHODS

The experiments were conducted ≥4–5 weeks after spinal cord transection at the T9‐T10 level. PES was applied via a pair of hook electrodes to the perianal skin area in three awake female cats with chronic SCI. A double‐lumen balloon catheter was inserted through the urethra into the bladder to monitor bladder pressure and infuse saline (2–4 mL/min).

RESULTS

Under isovolumetric conditions PES at 3–10 Hz significantly inhibited large‐amplitude reflex bladder activity induced by bladder distension above the micturition volume threshold. However, PES at 20–50 Hz induced large‐amplitude bladder contractions when the bladder volume was below the micturition volume threshold. Inhibitory PES (7 Hz) significantly increased the mean (sem ) bladder capacity by 40 (10)% when it was applied continuously during cystometrography. The optimum excitatory PES (30 Hz) induced large‐amplitude (>25 cmH₂O), long‐duration (>20 s) bladder contractions at a wide range of bladder volumes (10–90% of bladder capacity).

CONCLUSIONS

This study showed that activation of pudendal afferent fibres by PES could induce frequency‐dependent reflex bladder responses in awake cats with chronic SCI, indicating that a possible noninvasive treatment based on PES could be developed to restore both continence and micturition function for patients with SCI.     

Mitochondria-initiated apoptosis triggered by oxidative injury play a role in total parenteral nutrition-associated liver dysfunction in infant rabbit model

Purpose

The aim of the study was to investigate oxidative injury and apoptosis as the mechanisms underlying total parenteral nutrition (TPN)-associated liver dysfunction.

Methods

Twenty New Zealand rabbits (2 weeks old) were divided into 2 groups as follows: 10 in the control group (maternal feed) and 10 in the TPN group. The rabbits in the TPN group received continuous PN infusion through a silastic catheter inserted in the right jugular vein.

Results

After 10 days of treatment, the serum levels of total bilirubin and bile acid were significantly higher in the TPN group than in the control group (P < .01, respectively). The light microscopic findings in the TPN rabbits included inflammatory cell infiltration and hepatic steatosis. Electron microscopy showed change in the cytosolic vacuoles and rare microvilli in the microbile duct. Moreover, 10 days of treatment resulted in an inhibition of the superoxide dismutase (SOD) activity in hepatocytes, an increase of the malondialdehyde level, a significant increase in cytochrome c release from the mitochondria, a significant increase in caspase 3 activity, and increased apoptosis (P < .01, individually).

Conclusions

Oxidative damage may be one of the essential mechanisms of TPN-associated liver dysfunction. Moreover, mitochondria-initiated apoptosis triggered by oxidative damage may play an important role in this process.     

Predicting complicated outcomes in spinal cord injury patients with urinary tract infection: Development and internal validation of a risk model

Context/objective: Patients with chronic SCI hospitalized for UTI can have significant morbidity. It is unclear whether SIRS criteria, SOFA score, or quick SOFA score can be used to predict complicated outcome.

Design: Retrospective cohort study. A risk prediction model was developed and internally validated using bootstrapping methodology.

Setting: Urban, academic hospital in St. Louis, Missouri.

Participants: 402 hospitalizations for UTI between October 1, 2010 and September 30, 2015, arising from 164 patients with chronic SCI, were included in the final analysis.

Outcome/measures: An a priori composite complicated outcome defined as: 30-day hospital mortality, length of hospital stay >4 days, intensive care unit (ICU) admission, and hospital revisit within 30 days of discharge.

Results: Mean age of patients was 46.4?±?12.3 years; 83.6% of patient-visits involved males. The primary outcome occurred in 278 (69.2%) hospitalizations. In multivariate analysis, male sex was protective (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.18-0.99; P?=?0.048) while Gram-positive urine culture (OR 3.07; 95% CI, 1.05-9.01; P?=?0.041), urine culture with no growth (OR, 1.69; 95% CI, 1.02-2.80; P?=?0.041), and greater SOFA score (for one-point increments, OR, 1.41; 95% CI, 1.18-1.69; P?<?0.001) were predictive for complicated outcome. SIRS criteria and qSOFA score were not associated with complicated outcome. Our risk prediction model demonstrated good overall performance (Brier score, 0.19), fair discriminatory power (c-index, 0.72), and good calibration during internal validation.

Conclusion: Clinical variables present on hospital admission with UTI may help identify SCI patients at risk for complicated outcomes and inform future clinical decision-making.     

5-羟色胺1A受体激动剂改善脊髓损伤大鼠排尿功能障碍的实验研究

目的 研究5-羟色胺-1A(5-HTlA)受体激动剂对慢性脊髓损伤(spinal cord injury,SCI)大鼠排尿障碍的改善作用. 方法 雌性SD大鼠14只,体质量175 ～ 200 g.随机分为2组:实验组7只显微镜下大鼠T10棘突水平行脊髓离断建立脊髓损伤模型,正常对照组7只.8周后乌拉坦(1.3 g/kg)麻醉下,2组大鼠颈静脉和膀胱内置管,连接压力感受器,记录膀胱最大容量、残余尿量、排尿量和尿道外括约肌的肌电活动.静脉注入5-HTI A/7受体激动剂8-羟基-丙胺-四氢萘(8-OH-DPAT,0.03 ～1.00 mg/kg),得出剂量—效应曲线后再给予5HTIA受体抑制剂WAY-100635 (0.3g/kg).观察比较2组大鼠用药前后尿动力学指标的变化. 结果 随着8-OH-DPAT剂量增加,SCI大鼠膀胱容量从(33.2 ±8.3)ml降至(22.8±2.4) ml,排尿量从(0.14±0.08)ml增至(0.38 ±0.09) ml,残余尿量从(3.68±1.36)ml降至(1.84±0.21)ml,而膀胱最高压力从(27.1±3.6)mm Hg(1 mm Hg=0.133 kPa)降至(22.8±2.4) mm Hg,用药前后差异均有统计学意义(P＜0.05).对照组大鼠用药前后排尿情况变化差异无统计学意义.肌电图显示8-OH-DPAT引起SCI大鼠尿道外括约肌强直收缩中出现阶段性的松弛,正常对照组大鼠作用无明显改变. 结论 8-OH-DPAT可以剂量依赖性地部分恢复SCI大鼠的尿道外括约肌协调性松弛,从而降低膀胱容量,增加排尿量,减少残尿量,增加排尿效率,改善排尿障碍.     

The preventative role of growth hormone on acute liver injury induced by cardiopulmonary bypass in a rat model

Objective: Cardiopulmonary bypass (CPB)-induced acute liver injury is a life-threatening complication after cardiac surgery and is thought to be associated with inflammatory response and acute-phase response (APR). Recombinant human growth hormone (rhGH) can modulate the APR and inflammatory response. Here, we tested the protective effect of GH on CPB-induced liver injury in the rat. Methods: Adult male Sprague–Dawley rats (group G, received 2.5 mg/kg of rhGH intramuscularly at 8 a.m. every 24 h for 3 days and just before the initiation of CPB; group C served as control) underwent CPB (120 min, 120 ml/kg per minute, 34 °C) and were killed 3 h after the termination of CPB. Results: Administration of rhGH markedly increased serum insulin-like growth factor (IGF)-I and IGF-I-binding protein (IGFBP)-3 compared with group C. Group G showed significantly lower serum concentrations of alanine aminotransferase and total bilirubin after CPB termination. Those receiving rhGH demonstrated a significant increase in serum prealbumin and serum transferrin and a marked decrease in serum amyloid A and serum C-reactive protein compared with group C. rhGH significantly decreased serum tumor necrosis factor- (TNF-) and interleukin-1β (IL-1β), whereas no changes were found for serum IL-6 and IL-10 compared with group C. rhGH significantly increased total liver protein content, hepatocyte proliferation, and decreased hepatocyte apoptosis versus group C. Conclusions: These results suggest that GH administration in rats seems to play a preventative role in acute liver injury associated with CPB via the decrease in acute-phase proteins, proinflammatory cytokines TNF- and IL-1β, and hepatocyte apoptosis, which is associated with increase in constitutive hepatic proteins, total liver protein content, and hepatocyte proliferation.