Transthorakale Echokardiographie bei thorakaler Messerstichverletzung

Penetrating chest trauma involving the heart is usually known with a high mortality rate. Neither the absence of hemodynamic depression nor ECG changes exclude a potential fatal injury to the heart. We report on the diagnosis and definitive treatment of a stab wound injury with transected coronary artery, concomittant ventricular penetration, and pulmonary injury.A 37-year-old female was admitted to our emergency room with multiple left-sided gashes (cheek, neck, upper extremity) and a single stab wound in the left thorax. At the scene of the accident the patient's hemodynamic condition was stable with no signs of shock or shortness of breath. Auscultation revealed regular respiratory sound on both lung sides. Hospital transfer by ground was uneventful. Chest X-ray showed left pleural effusion with no signs of pneumothorax. ECG demonstrated regular sinus rhythm without repolarization changes or low voltage. Transthoracic echocardiography revealed pericardial effusion with a swinging heart. The patient was electively intubated in the emergency room and transferred to the operating room for pericardial paracentesis. Median sternotomy was necessary due to extensive bleeding in the drain. Examination of the heart showed a laceration of the left coronary artery (LAD), left ventricle, and upper lobe of the left lung. Cardiopulmonary bypass was instituted and the LAD was ligated proximal to the penetration. The left internal thoracic artery was used for coronary revascularization of the LAD. Postoperative ECG and creatine kinase evaluations excluded myocardial ischemia. The patient was discharged from hospital at POD 10 fully recovered. Transthoracic echocardiography in the emergency room is the diagnostic tool of choice to exclude/confirm a potential cardiac injury. In the case of pericardial effusion, paracentesis sometimes followed by thoracotomy should be performed. The importance of rapid diagnosis and intervention should be emphasized to reduce mortality due to cardiac tamponade or acute myocardial infarction as illustrated by this case.     

The role of supplemental translaminar screws in anterior lumbar interbody fixation: a biomechanical study

The immediate stabilization provided by anterior interbody cage fixation is often questioned. Therefore, the role of supplementary posterior fixation, particularly minimally invasive techniques such as translaminar screws, is relevant. The purpose of this biomechanical study was to determine the immediate three-dimensional flexibility of the lumbar spine, using six human cadaveric functional spinal units, in four different conditions: (1) intact, (2) fixed with translaminar screws (TLS), (3) instrumented with anterior interbody cage insertion with the BAK system and (4) instrumented with BAK cage with additional TLS fixation. Flexibility was determined in each testing condition by measuring the vertebral motions under applied pure moments (i.e. flexion-extension, bilateral axial rotation, bilateral lateral bending) in an unconstrained manner. Anterior fixation with the BAK alone provided significant stability in flexion and lateral bending. Additional posterior TLS significantly reduced the motion in extension and axial rotation. TLS fixation alone resulted in smaller rotations than BAK fixation in all loading directions. Based on these results, it seems that interbody cage fixation with the BAK system stabilizes the spine in some, but not all, loading directions. The problematic loading directions of extension and axial rotation can be substantially stabilized by using translaminar screw fixation. However, one should emphasize that the degree of stability needed to achieve solid fusion is not known. Received: 14 August 1997 Revised: 28 May 1998 Accepted: 9 June 1998     

Insulin dose-response characteristics for suppression of glycerol release and conversion to glucose in humans

To compare the dose-response characteristics for suppression of lipolysis and suppression of glucose production by insulin, 13 normal nonobese individuals were infused with insulin at rates of 0.1, 0.2, 0.4, 0.8, and 1.6 mU X kg-1 X min-1 while normoglycemia was maintained with the glucose clamp technique. Glucose appearance and glycerol appearance (taken as index of lipolysis) were measured isotopically with simultaneous infusions of 3-[3H]glucose and U-[14C]glycerol. Baseline glucose and glycerol rates of appearance were 14 +/- 0.5 and 1.7 +/- 0.2 mumol X kg-1 X min-1, respectively. Approximately 3% of plasma glucose originated from glycerol, and this accounted for approximately 50% of glycerol disposal. During the insulin infusions, arterial insulin (basal, 9.8 +/- 0.6 microU/ml) increased to 14 +/- 0.5, 20 +/- 0.5, 31 +/- 1, 58 +/- 2, and 104 +/- 6 microU/ml; calculated portal venous insulin (basal, 24 +/- 2 microU/ml) increased to 26 +/- 1, 32 +/- 3, 70 +/- 4, and 115 +/- 6 microU/ml. The rate of glucose appearance was suppressed 100%, whereas the rate of appearance of glycerol was maximally suppressed only 85%. Nevertheless, the insulin concentration that produced half-maximal suppression of glucose appearance was twice as great as that required for half-maximal suppression of glycerol appearance (26 +/- 2 vs. 13 +/- 2 microU/ml, P less than .001). Insulin decreased both the absolute rate of glycerol conversion to plasma glucose and the percent of glycerol disposal appearing in plasma glucose (both P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Offene Reposition und Osteosynthese mit primärer subtalarer Arthrodese bei intraartikulärer Kalkaneusfraktur

OBJECTIVE: To prevent the development of painful posttraumatic degenerative joint disease by a primary one-stage procedure to treat calcaneal fractures involving obvious comminution or severe and extensive cartilage damage to the subtalar facet. INDICATIONS: Sanders type IV calcaneal fractures with severe and extensive cartilage destruction. The definitive indication for arthrodesis can only be established intraoperatively. CONTRAINDICATIONS: Severe closed IIIrd or IV nd degree soft-tissue injury according to Tscherne & Oestern. Open fractures. Vascular impairment. Diabetes mellitus. Generalized or local inactivity osteoporosis > grade I according to Kanis. Age > approximately 50 years. SURGICAL TECHNIQUE: Extended lateral approach. Osteosynthesis of the calcaneal fracture, reconstruction of axes, subtalar facet denuded of cartilage, bone graft from the anterior iliac crest, arthrodesis by screw fixation of the subtalar joint. POSTOPERATIVE MANAGEMENT: After edema has subsided, mobilization without a cast and partial loading up to 15 kg for 12 weeks. Clinical and radiologic review after 6 and 12 weeks. RESULTS: This operation is performed very rarely. Within a retrospective study including patients over a period of 14 years (1990-2004), a total of 434 patients with a calcaneal fracture were treated surgically. Primary subtalar arthrodesis was performed in only six of these patients. Healing within 4 months was achieved in all six patients. The clinical and radiologic follow-ups took place on average after 4.9 years (2.5-7.5 years). Radiologically, almost anatomic reconstruction of the axes could be achieved (Gissane and B?hler angles, talometatarsal and talocalcaneal angles, calcaneal length and width). The functional outcomes were also good to very good with an average AOFAS (American Orthopaedic Foot and Ankle Society) Score of 88 points (63-94 points) and a Hanover Score of 84 points (62-90 points).     

Behandlungsstrategien von Schussverletzungen der Extremitäten

Die Unfallchirurgie -     

The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients

OBJECTIVE: To compare the abilities and associated hypoglycemia risks of insulin glargine and human NPH insulin added to oral therapy of type 2 diabetes to achieve 7% HbA(1c). RESEARCH DESIGN AND METHODS: In a randomized, open-label, parallel, 24-week multicenter trial, 756 overweight men and women with inadequate glycemic control (HbA(1c) >7.5%) on one or two oral agents continued prestudy oral agents and received bedtime glargine or NPH once daily, titrated using a simple algorithm seeking a target fasting plasma glucose (FPG) 相似文献   

Lipolysis during fasting. Decreased suppression by insulin and increased stimulation by epinephrine.

These studies were designed to determine whether the insulin resistance of fasting extends to its antilipolytic effects and whether fasting enhances the lipolytic effects of adrenergic stimulation independent of changes in plasma hormone and substrate concentrations. Palmitate flux was determined isotopically ([1-14C]palmitate) before and during epinephrine infusion in normal volunteers after a 14-h (day 1) and an 84-h (day 4) fast. Using a pancreatic clamp, constant plasma hormone and glucose concentrations were achieved on both study days in seven subjects. Six subjects were infused with saline and served as controls. During the pancreatic clamp, palmitate flux was greater (P less than 0.01) on day 4 than day 1, despite similar plasma insulin, glucagon, growth hormone, cortisol, epinephrine, norepinephrine, and glucose concentrations. The lipolytic response to epinephrine was greater (P less than 0.05) on day 4 than day 1 in both groups of subjects. In conclusion, lipolysis during fasting is less completely suppressed by insulin and more readily stimulated by epinephrine.     

A new alpha-glucosidase inhibitor (Bay-m-1099) reduces insulin requirements with meals in insulin-dependent diabetes mellitus

Retardation of meal carbohydrate absorption by inhibition of starch degradation improves glucose tolerance in normal and diabetic humans. To determine the effects of Bay-m-1099, a new alpha-glucosidase inhibitor, on insulin requirements and prandial glucose tolerance in patients with insulin-dependent diabetes mellitus (IDDM), plasma glucose, triglyceride, and free insulin concentrations were measured after ingestion of a standard breakfast, lunch, and dinner in nine patients with IDDM in a single-blind, randomized, crossover design. A 20% reduction in insulin was given 30 minutes before the meals when the subjects received Bay-m-1099 (50 mg). This resulted in the AUC for plasma insulin to be significantly less with Bay-m-1099 (AUC, 8.2 +/- 1.3 vs. 12.8 +/- 1.6 microU/ml/min with placebo; P less than 0.01). Despite this reduction in plasma insulin levels, postprandial plasma glucose concentrations were reduced for the breakfast (73 +/- 15 vs. 112 +/- 14 mg/dl/min with placebo; P less than 0.01) and dinner (23 +/- 8 vs. 4 +/- 1 mg/dl/min with placebo; P less than 0.05) meal with Bay-m-1099. Bay-m-1099 did not affect postprandial plasma triglycerides and was well tolerated, the major side effect being flatulence (4/9) and mild diarrhea (4/9). We conclude that inhibition of intestinal alpha-glucosidases by Bay-m-1099 in IDDM reduces meal insulin requirements by at least 20% and that such an agent could be useful in the management of diabetes mellitus by reducing hyperinsulinemia.     

Glucose and ketone body kinetics in diabetic ketoacidosis

The hyperglycaemia and hyperketonaemia of diabetic ketoacidosis are initiated primarily by overproduction of these substrates; subsequent maintenance of hyperglycaemia occurs, in large part, due to impaired utilization of glucose, whereas overproduction of ketone bodies continues to be the major mechanism for maintenance of hyperketonaemia. Insulin deficiency results in increased rates of lipolysis and provides increased substrate (free fatty acids) for ketogenesis. Hyperglucagonaemia can augment ketogenesis further in the setting of insulin deficiency. It is likely that other counter-insulin hormones (growth hormone, catecholamines) also contribute to the pathogenesis of DKA, though their role is less well defined. Insulin corrects DKA largely via suppression of lipolysis (and thus ketone body production); insulin suppresses glucose production at lower levels than it does ketone body production.