Base deficit correlates with mortality in pediatric abusive head trauma

Background/purpose

Children suffering from abusive head trauma (AHT) have worse outcomes compared to non-AHT, but the reasons for this are unclear. We hypothesized that delayed medical care associated with AHT causes prolonged pre-hospital hypotension and hypoxia as measured by admission base deficit (BD), and that this would correlate with outcome.

Methods

We performed a 10-year retrospective chart review of children admitted for AHT at two academic level-I trauma centers. Statistics were performed using Student's t test, chi-square analysis, and multivariate logistic regression, and considered significant at p < 0.05.

Results

Four-hundred twelve children with AHT were identified, and admission BD was drawn for 148/412 (36%) children, including 104 survivors and 44 non-survivors. Non-survivors had significantly higher BD compared to survivors (12.6 ± 1.6 versus 5.3 ± 0.6, p < 0.001). Non-survivors were more likely to be intubated pre-hospital and get cardiopulmonary resuscitation (CPR) (p < 0.001). Mortality increased with rising BD, according to CPR status. There was no difference in patterns of brain injury between survivors and non-survivors (p > 0.05).

Conclusions

BD correlates with mortality in children suffering severe AHT. Non-survivors are also more likely to be intubated pre-hospital and require CPR, with no difference in pattern of brain injury, suggesting that secondary injury is a major determinant of outcome in severe AHT.     

Obesity and outcomes following burns in the pediatric population

Purpose

While obesity is associated with increased mortality and decreased functional outcomes in adult burn patients, the ramifications of larger than average body size in the pediatric burn population are less well understood. The present study examines whether obesity was associated with poor outcomes following pediatric burn injuries.

Methods

Thermal injury data for patients ≤ 18 years of age admitted to a Level III burn center over ten years (n = 536) was analyzed. Obesity was defined as ≥ 95th percentile of weight for height according to the WHO growth charts (< 2 years of age) or BMI for age according to the CDC growth charts (2–18 years of age). Outcomes were compared between thermally injured obese (n = 154) and non-obese (n = 382) children. All data was collected in accordance with IRB regulations.

Results

Obese and non-obese thermally-injured children did not differ in TBSA, percentage of full thickness burn, or overall mortality. However, these groups were significantly different with respect to age (obese = 7.16 ± 0.46 years, non-obese = 9.38 ± 0.32 years, p < 0.001) and days requiring mechanical ventilation (obese = 4.89 ± 1.3 days, non-obese = 2.67 ± 0.49 days, p < 0.05). For thermally injured children admitted to the BICU without inhalation injury (n = 175); the obese (n = 46) and non-obese (n = 129) did not differ significantly with respect to age, TBSA, percentage of full thickness burn or other outcome measures. However, significant differences between these groups were noted for ICU LOS (obese = 18.59 ± 5.18 days, non-obese = 9.51 ± 1.82 days, p < 0.05) and number of days requiring mechanical ventilation (obese = 11.65 ± 3.91 days, non-obese = 3.92 ± 0.85 days, p < 0.05).

Conclusion

These data show thermally-injured obese pediatric patients required longer and more intensive medical support in the form of BICU care and respiratory intervention. Counter to findings in adult populations, differences in mortality were not observed. Collectively, these findings suggest obesity as a risk factor for increased morbidity in the pediatric burn population.     

Infant car safety seats and risk of head injury

Background/Purpose

We observed a high incidence of traumatic brain injuries (TBI) in properly restrained infants involved in higher speed motor vehicle crashes (MVCs). We hypothesized that car safety seats are inadequately protecting infants from TBI.

Methods

We retrospectively queried scene crash data from our State Department of Transportation (2007–2011) and State Department of Public Health data (2000–2011) regarding infants who presented to a trauma center after MVC.

Results

Department of Transportation data revealed 94% of infants in MVCs were properly restrained (782/833) with average speed of 44.6 miles/h when there was concern for injury. Department of Public Health data showed only 67/119 (56.3%) of infants who presented to a trauma center after MVC were properly restrained. Properly restrained infants were 12.7 times less likely to present to a trauma center after an MVC (OR = 12.7, CI 95% 5.6–28.8, p < 0.001). TBI was diagnosed in 73/119 (61.3%) infants; 42/73 (57.5%) properly restrained, and 31/73 (42.5%) improperly/unrestrained (p = 0.34). Average head abbreviated injury scale was similar for properly restrained (3.2 ± 0.2) and improperly/unrestrained infants (3.5 ± 0.2, p = 0.37).

Conclusion

Car safety seats prevent injuries. However, TBI is similar among properly restrained and improperly/unrestrained infants involved in higher speed MVCs who present to a trauma center.     

Cervical spine computed tomography utilization in pediatric trauma patients

Background

Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).

Methods

Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.

Results

5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p < 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p < 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.

Conclusions

Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.     

National trends in pediatric blunt spleen and liver injury management and potential benefits of an abbreviated bed rest protocol

Purpose

Recent reports suggest that an abbreviated bed rest protocol (ABRP) may safely reduce length of stay (LOS) and resource utilization in pediatric blunt spleen and liver injury (BSLI) patients. This study evaluates national temporal trends in BLSI management and estimates national reduction in LOS using an ABRP.

Methods

Pediatric patients (< 18 years old) sustaining BLSI were identified in the Kids’ Inpatient Database from 2000 to 2009. Yearly rates of injury and operative intervention were examined and stratified by type of injury. APSA guidelines and the reported ABRP were applied based on abbreviated injury score (AIS) and compared with actual LOS.

Results

22,153 patients were identified. Over the study period, operative rates for spleen and liver injuries and overall mortality significantly declined: LOS = 3.1 days (± 1.6) and 2.7 days (± 1.9) for spleen and liver, respectively. If APSA guidelines were followed, the rates were LOS = 3.7 days (± 1.1) and 3.4 days (± 0.7), respectively. Application of the ABRP would result in LOS = 1.3 days (± 0.5) for all BSLI patients. An ABRP could potentially save 1.7 hospital days/patient or 36,964 patient hospital days nationally.

Conclusion

Our study confirms a significant national decrease in operative intervention and overall mortality in patients with BSLI. Additionally, it appears that a shorter observation period than the APSA guidelines is being utilized. The implementation of ABRP holds potential in further reducing LOS and resource utilization.     

Facteurs prédictifs de défaillance d’organes chez les patients admis en réanimation pour hémorragie digestive aiguë

Introduction

Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU.

Design

Retrospective and observational

Methods and measurements

Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization.

Results

During this period study, 441 consecutive patients with a mean age of 67 ± 15 years were included. The median ICU length of stay was of 4 (3–7) days and 116 (26% [IC95%: 22–30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR = 3.5 [IC95%: 1.9–6.7], P < 0.001) and an increase in troponin at the admission above the 99th percentile (OR = 3.1 [IC95%: 1.8–5.5], P < 0.001).

Conclusion

Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.     

The effect of colchicine and low-dose methotrexate on intestinal ischemia/reperfusion injury in an experimental model

Aim

Intestinal ischemia/reperfusion (I/R) injury is a serious clinical condition. Colchicine and low-dose methotrexate have anti-inflammatory features. An experimental model was conducted to investigate the effect of colchicine and methotrexate on intestinal I/R injury.

Methods

Twenty-four rats were included. Only laparotomy was done in control group (CG, n = 6). In experimental groups, superior mesenteric artery was occluded. After 1 h ischemia, reperfusion (1 h) was started by de-occlusion. 30 min before reperfusion, saline in sham group (SG, n:6), colchicine (1 mg/kg) in colchicine group (CNG, n:6), and methotrexate (0.1 mg/kg) in methotrexate group (MTXG, n:6) were infused intraperitoneally. Small intestines were harvested for evaluation of intestinal mucosal injury (Chiu score) and oxidative stress markers (nitric oxide: NO, malondialdehyde: MDA, superoxide dismutase: SOD).

Results

Biochemically, MDA levels were significantly low in CG compared to SG, CNG, and MTXG (p < 0.05). NO levels were significantly low and SOD levels were significantly high in CG compared to MTXG (p < 0.05). Histopathologically, Chiu score was significantly low in CG compared to SG, CNG, and MTXG (p < 0.05), and significantly high in MTXG compared to SG and CNG (p < 0.05).

Conclusion

The present experimental model caused I/R injury in rat intestines. Contrary to literature, it was found that methotrexate worsens and colchicine does not attenuate intestinal I/R injury.     

Prenatal MRI fetal lung volumes and percent liver herniation predict pulmonary morbidity in congenital diaphragmatic hernia (CDH)

Purpose

The purpose of this study was to determine whether prenatal imaging parameters are predictive of postnatal CDH-associated pulmonary morbidity.

Methods

The records of all neonates with CDH treated from 2004 to 2012 were reviewed. Patients requiring supplemental oxygen at 30 days of life (DOL) were classified as having chronic lung disease (CLD). Fetal MRI-measured observed/expected total fetal lung volume (O/E-TFLV) and percent liver herniation (%LH) were recorded. Receiver operating characteristic (ROC) curves and multivariate regression were applied to assess the prognostic value of O/E-TFLV and %LH for development of CLD.

Results

Of 172 neonates with CDH, 108 had fetal MRIs, and survival was 76%. 82% (89/108) were alive at DOL 30, 46 (52%) of whom had CLD. Neonates with CLD had lower mean O/E-TFLV (30vs.42%; p = 0.001) and higher %LH (21.3 ± 2.8 vs.7.1 ± 1.8%; p < 0.001) compared to neonates without CLD. Using ROC analysis, the best cutoffs in predicting CLD were an O/E-TFLV < 35% (AUC = 0.74; p < 0.001) and %LH > 20% (AUC =0.78; p < 0.001). On logistic regression, O/E-TFLV < 35% and a %LH > 20% were highly associated with indicators of long-term pulmonary sequelae. On multivariate analysis, %LH was the strongest predictor of CLD in patients with CDH (OR: 10.96, 95%CI: 2.5–48.9, p = 0.002).

Conclusion

Prenatal measurement of O/E-TFLV and %LH is predictive of CDH pulmonary morbidity and can aid in establishing parental expectations of postnatal outcomes.     

Association of head,thoracic and abdominal trauma with delayed diagnosis of co-existing injuries in critical trauma patients

Background

Management of critically injured patients is usually complicated and challenging. A structured team approach with comprehensive survey is warranted. However, delayed diagnosis of co-existing injuries that are less severe or occult might still occur, despite a standard thorough approach coupled with advances in image intervention. Clinicians are easily distracted or occupied by the more obvious or threatening conditions. We hypothesised that the major area of injured body regions might contribute to this unwanted condition.

Methods

A retrospective study of all trauma patients admitted to our surgical intensive care units (ICU) was performed to survey the incidence of delayed diagnosis of injury (DDI) and the association between main body region injured and possibility of DDI. Demographic data and main body regions injured were compared and statistically analysed between patients with and without DDI.

Results

During the two-year study period, a total 976 trauma patients admitted to our surgical ICU were included in this study. The incidence of DDI was 12.1% (118/976). Patients with DDI had higher percentages of thoracic, abdominal, and pelvic injuries (30.5%, 16.1%, and 7.6% respectively) than the non-DDI group (14.7%, 7.5%, and 3.0% respectively) (p < 0.001, 0.003, and 0.024 respectively). A logistic regression model demonstrated that head (odds ratio = 1.99; 95%CI = 1.20–3.31), thoracic (odds ratio = 2.44; 95%CI = 1.55–3.86), and abdominal injuries (odds ratio = 2.38; 95%CI = 1.28–4.42) were independently associated with increasing DDI in patients admitted to the surgical ICU.

Discussion

In conclusion, critical trauma patients admitted to the surgical ICU with these categories of injuries were more likely to have DDI. Clinicians should pay more attention to patients admitted due to injuries in these regions. More detailed and dedicated secondary and tertiary surveys should be given, with more frequent and careful re-evaluation.     

Antithrombin III administration in neonates with congenital diaphragmatic hernia during the first three days of extracorporeal membrane oxygenation

Purpose

To evaluate the effect of Antithrombin III (ATIII) on blood product requirement in neonates receiving extracorporeal membrane oxygenation (ECMO).

Methods

A retrospective case control study of neonates presenting with or without congenital diaphragmatic hernia (CDH) requiring ECMO between 2006 and 2010 was performed. Patient demographics, laboratory data, and information on blood products administered were compared in patients treated before (n = 37) and after (n = 38) a protocol for antithrombin-III (ATIII) administration was implemented.

Results

During the first three days on ECMO patients with CDH received less fresh frozen plasma (FFP) and platelets after ATIII administration was introduced (78.1 ± 19.2 ml/kg vs. 27.8 ± 6.2 ml/kg, p < 0.007 and 67.8 ± 8.6 ml/kg vs. 47.8 ± 8.4 ml/kg, p = 0.05 respectively), while FFP and platelet administration in patients without CDH was not different between the two periods. Patients both with and without CDH received less packed red blood cell (PRBC) transfusions after the ATIII protocol was introduced (230 ± 51.5 ml/kg vs. 73.8 ± 9.7 ml/kg, p < 0.002 and 173.2 ± 22.2 ml/kg vs. 66.0 ± 6.6 ml/kg, p < 0.001, respectively). Finally, cryoprecipitate administered was not different in patients with and without CDH between the two periods (13 ± 2.9 ml/kg vs. 15.9 ± 7.2 ml/kg, p = NS and 6.1 ± 1.8 ml/kg vs. 3.4 ± 0.6 ml/kg, p = NS, respectively).

Conclusions

Introduction of routine ATIII administration was associated with decreases in FFP, platelet, and PRBC exposure in neonates with CDH and decreases in PRBC transfusions in neonates without CDH during the first three days of ECMO support.     

Trauma induced hypercoagulablity in pediatric patients

Purpose

Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response.

Methods

A prospective observational study was conducted in hospitalized patients (age 8 months to 14 years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7 years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors.

Results

Forty three patients (22 trauma, median injury severity score = 9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p < 0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p = 0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p < 0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1 + 2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p < 0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults.

Conclusion

A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges.     

Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

Objective

Current APSA recommendations for blunt spleen/liver injury (BSLI) entail bedrest equal to grade of injury plus one. We reported our experience 3 years ago with a prospectively implemented abbreviated protocol, one concern of which was that more numbers would be needed to support the safety of such a protocol. We are now reporting the final experience with this protocol as we move forward with further investigation.

Methods

Following IRB approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to one night for Grade I & II injuries and two nights for Grade ≥ III.

Results

Between 11/2006 and 10/2012, 249 patients were admitted with BSLI. Mean age and weight were 10.3 ± 4.8 years and 40.1 ± 19.8 kg, respectively. Injuries included isolated spleen in 130 (52%), liver only in 107 (43%), and both in 12 (5%). One splenectomy was required for a grade V injury. Transfusions were used in 40 patients (16%), with 28 (11%) due to the injured solid organ. Bedrest for solid organ injury was applicable to 199 patients (80%), for which the mean grade of injury was 2.7 ± 1.0 and mean bedrest was 1.6 ± 0.6 days, resulting in 2.5 ± 1.9 days of hospitalization. The need for bedrest was the limiting factor for length of stay in 155 patients (62%), for which mean grade of injury was 2.5 ± 1.0 and mean bedrest was 1.6 ± 0.6 days, resulting in 1.7 ± 0.8 days of hospitalization. There were 4 deaths, 3 from brain injury and 1 from grade V liver injury. There were no patients readmitted for complications of solid organ injury.

Conclusions

These data further validate that an abbreviated protocol of one night of bedrest for grade I and II injuries and two nights for grade ≥ III can be safely employed, resulting in dramatic decreases in hospitalization compared to the current APSA recommendations.     

Inter-rater reliability of surgical reviews for AREN03B2: A COG renal tumor committee study

Purpose

The Children's Oncology Group (COG) renal tumor study (AREN03B2) requires real-time central review of radiology, pathology, and the surgical procedure to determine appropriate risk-based therapy. The purpose of this study was to determine the inter-rater reliability of the surgical reviews.

Methods

Of the first 3200 enrolled AREN03B2 patients, a sample of 100 enriched for blood vessel involvement, spill, rupture, and lymph node involvement was selected for analysis. The surgical assessment was then performed independently by two blinded surgical reviewers and compared to the original assessment, which had been completed by another of the committee surgeons. Variables assessed included surgeon-determined local tumor stage, overall disease stage, type of renal procedure performed, presence of tumor rupture, occurrence of intraoperative tumor spill, blood vessel involvement, presence of peritoneal implants, and interpretation of residual disease. Inter-rater reliability was measured using the Fleiss' Kappa statistic two-sided hypothesis tests (Kappa, p-value).

Results

Local tumor stage correlated in all 3 reviews except in one case (Kappa = 0.9775, p < 0.001). Similarly, overall disease stage had excellent correlation (0.9422, p < 0.001). There was strong correlation for type of renal procedure (0.8357, p < 0.001), presence of tumor rupture (0.6858, p < 0.001), intraoperative tumor spill (0.6493, p < 0.001), and blood vessel involvement (0.6470, p < 0.001). Variables that had lower correlation were determination of the presence of peritoneal implants (0.2753, p < 0.001) and interpretation of residual disease status (0.5310, p < 0.001).

Conclusion

The inter-rater reliability of the surgical review is high based on the great consistency in the 3 independent review results. This analysis provides validation and establishes precedent for real-time central surgical review to determine treatment assignment in a risk-based stratagem for multimodal cancer therapy.     

Early hospital readmission in the trauma population: Are the risk factors different?

Introduction

Hospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients.

Patients and methods

We retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p < 0.05 was considered significant.

Results

We identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p = 0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p = 0.02), and diabetes mellitus (OR 1.8, p < 0.001) were associated with readmission, along with higher ISS (OR 1.01, p < 0.001), ICU admission (OR 2.1, p < 0.001), and increased LOS (OR 1.01, p < 0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p = 0.02) was associated with increased risk of readmission.

Conclusions

Trauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.     

Estimating severity of burn in children: Pediatric Risk of Mortality (PRISM) score versus Abbreviated Burn Severity Index (ABSI)

Objective

The purpose of our study is to validate the Pediatric Risk of Mortality (PRISM) score and compare the accuracy of PRISM predicted outcomes to the Abbreviated Burn Severity Index (ABSI). We hypothesized that the PRISM score is more accurate in predicting mortality and hospital length of stay than the ABSI in children with severe burns.

Methods

All children <18 years of age admitted to a regional pediatric burn center between January 1, 2008 and July 1, 2010 were reviewed. Those with a Total Body Surface Area (TBSA) burn ≥20% who were admitted within 7 days of injury were selected for our study. Measured parameters included: demographics, burn characteristics, PRISM and ABSI scores at admission, and outcomes (mortality, hospital length of stay (LOS), ventilator days and cause of death).

Results

A total of 83 patients met criteria and had complete data sets. The mean age (±SEM) was 8.0 ± 0.6 years, mean % TBSA burn 49.9 ± 2.1%, 62.7% were male, and 45.8% had inhalation injury. Hospital LOS was 74.4 ± 7.9 days, with 31.5 ± 4.9 ventilator days. Mean PRISM score ranged from 14.2 to 16.0, with ABSI scores 7.9 to 8.5. Actual overall mortality was 18.1% compared to a PRISM predicted mortality of 19.8 ± 2.5% (p < 0.001, r = 0.570). ABSI predicted mortality varied from 10 to 20% for a score of 7.9 to 30–50% for a score of 8.5. Logistic regression showed that both PRISM (p < 0.001) and ABSI (p < 0.001) mortality predictions accurately estimated actual mortality, which remained true in a combined model. ABSI was predictive of hospital LOS (p < 0.001) and ventilator days (p < 0.001) while PRISM was not (p = 0.326 and p = 0.863).

Conclusions

Both PRISM and ABSI scores are predictive of mortality in severely burned children. Only ABSI correlates with hospital length of stay and ventilator days, and thus may also be more useful in predicting ICU resource utilization.     

Neutrophil oxidative burst capacity for peri-operative immune monitoring in trauma patients

Background

Post injury immune dysfunction can result in serious complications. Measurement of biomarkers may guide the optimal timing of surgery in clinically borderline patients and therefore prevent complications. Aim: peri-operative measurement of neutrophil oxidative burst capacity as an indicator of the immune response to major orthopaedic surgical procedures.

Methods

Prospective cohort study of trauma patients aged ≥16 yrs with pelvic, acetabular, femoral shaft or tibial shaft fractures requiring surgical intervention. Blood samples were taken immediately pre-op and at 30 min, 7, 24 and 72–96 h post-operatively. Neutrophil oxidative burst capacity was measured both with and without stimulation by formyl-methionyl-leucyl-phenylalanine (fMLP, a chemotactic factor). Clinical outcomes measured were mortality, length of stay, MOF, pneumonia, acute respiratory distress syndrome (ARDS) and sepsis.

Results

100 consecutive orthopaedic trauma patients were enrolled over a 16 month period. 78% were male, with a mean age of 42 ± 18 years and an average ISS of 19 ± 13. Neutrophil oxidative burst capacity was significantly elevated at 7 h (p = 0.006) and 24 h (p = 0.022) post operatively. Patients who developed infective complications (pneumonia and sepsis) had higher levels of oxidative burst capacity pre-operatively (pneumonia: 1.52 ± 0.93 v 0.99 ± 0.66 p = 0.032, sepsis: 1.39 ± 0.86 v 0.97 ± 0.56 p = 0.024) and at 24 h post op (pneumonia: 2.72 ± 2.38 v 1.12 ± 0.63 p = <0.001, sepsis: 2.16 ± 2.09 v 1.10 ± 0.54 p = <0.001). When analysed by operation type, no statistical difference was seen between major and minor operations. No correlation was found between length of stay, length of ICU stay, ISS or age and neutrophil oxidative burst capacity at any time point.

Conclusions

Neutrophil oxidative burst capacity response to orthopaedic trauma surgery is associated with the infective post injury complications. There was no correlation between magnitude of injury or operation and oxidative burst capacity. These results are promising for the development of tools for prediction of post-operative complications and guidance for optimal timing for surgical intervention.     

Ureterovesical junction obstruction causes increment in smooth muscle contractility,and cholinergic and adrenergic activity in distal ureter of rabbits

Background/Purpose

The controversy in management of primary obstructed megaureter necessitates further elucidation of the underlying pathophysiology. We evaluated smooth muscle contractility, and cholinergic, adrenergic and serotonergic activity of rabbit distal ureters after ureterovesical junction (UVJ) obstruction.

Methods

Sham (SH) operation, partial obstruction (PO) and complete obstruction (CO) of the right UVJ were performed in rabbits. Three weeks later, distal ureters were isolated; spontaneous contractions (SC), contractile responses to electrical field stimulation (EFS), high KCl, carbachol, phenylephrine and serotonin were recorded.

Results

SC amplitudes increased in CO compared to PO and SH (p < 0.001). SC frequency was higher in CO (p < 0.05). EFS-induced contraction amplitudes were greater in CO than other groups (p < 0.05). High KCl-induced contractions were greater in CO (p < 0.001) and PO (p < 0.01). Carbachol-induced contractility was enhanced in CO and PO (p < 0.05). Contractile response to phenylephrine was greater in CO than other groups (p < 0.05). Serotonin induced contractile responses in CO and PO, greater in CO (p < 0.05). UVJ obstruction also increased spontaneous contractility in contralateral PO and CO ureters.

Conclusions

UVJ obstruction increased spontaneous and neurotransmitter-induced contractions in an obstruction grade-dependent manner. Obstruction also altered contractility of the contralateral ureters. Our findings may serve to provide further understanding of the pathophysiology of megaureter.     

Outcome of penetrating intracranial injuries in a military setting

Background

Penetrating intracranial injuries are common in the deployed military medical environment. Early assessment of prognosis includes initial conscious level. There has been no previous identification of different outcomes depending on mechanism of penetrating injury. The aim of this study was to define outcome from penetrating head injury in our population, and to compare outcome between gunshot wound (GSW) and blast fragment injury, in order to detect a difference in survival.

Methods

A retrospective database review was undertaken using the UK Joint Theatre Trauma Registry (JTTR) between the dates 2003 and 2011 to identify all cases of penetrating head injury. Data collected included mechanism of injury, first recorded GCS, injury severity score (ISS), abbreviated injury scale (AIS) head score, concomitant extracranial injury, surgical intervention, hospital length of stay, and survival.

Results

813 patients sustained a penetrating head injury, of whom 625 were injured by blast fragmentation and 188 were injured by GSW; overall 336 patients (41.3%) died. There was a significant difference between survival from GSW (41.5%) and blast fragment (63.8%; p < 0.001). In addition, the GCS in patients injured by GSW was significantly lower than that in patients injured by blast fragment. 157 cases sustained isolated head injury (79 GSW, 78 blast). The difference in injury severity between these groups was marked; median AIS was higher in the GSW group, survival lower (42% vs. 88%; p < 0.001) and distribution of GCS categories less favourable (p < 0.001). 338 of 343 patients (98.5%) with a best recorded GCS > 5, survived to discharge.

Conclusion

Most patients who present following penetrating intracranial injury, who have a GCS > 5, survive to discharge. There is a significant difference in survival to hospital discharge following penetrating injury caused by blast fragment compared to those caused by GSW, partly attributable to a difference in injury severity. This is the first study to specifically highlight and define this difference.