Posttraumatic complications and inflammatory mediators

In a series of 71 patients with trauma, we measured weekly the blood levels of a number of complement proteins and activation products. We also measured the following: leukocytes, platelets, granulocyte enzyme elastase, alpha 1-antitrypsin, total protein, albumin, haptoglobin, and fibronectin. The intensity of complement activation and the blood levels of elastase correlated with the following factors: injury severity (especially the severity of limb injury), development of adult respiratory distress syndrome, development and severity of multiple organ failure, and probability of a fatal outcome. The plasma elastase level seemed to be the best predictor of adult respiratory distress syndrome and the best correlate of injury severity and multiple organ failure severity. Our findings support the hypothesis that posttraumatic activation of the complement system leads to activation of granulocytes, followed by microvascular injury and finally by organ failure.     

Intrauterine spermatic cord torsion in the newborn: sonographic and pathologic correlation

In five newborn patients with spermatic cord torsion, sonography demonstrated an enlarged and globular testis, hydrocele, and skin thickening. In four of these patients the testicular parenchyma was heterogeneous. Peripheral hypoechoic areas were seen in two of the four patients; the other two had a central hypoechoic region and a peripheral echogenic rim. The testis in the fifth patient was diffusely hyperechoic. Duplex Doppler sonography performed in two patients failed to demonstrate any signal in the spermatic cord in either the abnormal or contralateral hemiscrotum. Scintigraphic findings were positive for testicular torsion in two patients and equivocal in three patients. Surgery was performed 2-12 days after sonography and established the diagnosis of spermatic cord torsion. Pathologic examination demonstrated hemorrhagic infarction of the entire testis as well as scattered calcifications. The authors conclude that a solid globular testicular mass seen during the neonatal period is suggestive of intrauterine spermatic cord torsion.     

Long-term disability following high-voltage electric hand injuries

Fifty-eight patients who sustained high-voltage electric hand injuries over a ten-year period were reviewed to determine the incidence of long-term disability. Patients were divided into two groups, depending on whether or not they had sustained a current or noncurrent injury. Follow-up ranged between three months and nine years, with an average of 29.5 months. In Group A' (current group), 34 patients had 52 hand injuries. In this group, 21 patients required operative intervention to relieve vascular or neurologic compression. Thirty percent of explored limbs were subsequently amputated. Of the remaining extremities, 42% had normal function while 58% had diminished or greatly diminished function. There were 24 patients in Group B (noncurrent group) with 35 hand injuries. Function was diminished in 23%, greatly diminished in 14%, and absent in 3% of cases. The amputation rate and the residual functional deficit in Group A concurs with those of previously reported series. Although there is a significant inevitable morbidity after noncurrent injuries, many patients may benefit from nerve/muscle conduction studies and physical therapy.     

Drug-induced linear immunoglobulin A bullous disease that clinically mimics toxic epidermal necrolysis

Drug-induced linear immunoglobulin A bullous disease is a subepidermal blistering disorder that most commonly occurs after exposure to vancomycin. It can clinically mimic toxic epidermolytic necrolysis. We describe an 87-year-old white woman in whom linear immunoglobulin A bullous disease developed while she was taking vancomycin and phenytoin. A few days after the linear immunoglobulin A bullous disease developed, both medications were discontinued. No new bullae developed, and the eruption completely resolved within 2 weeks. The patient was treated with only topical therapy.     

Cytokines and acute phase response in delirium

OBJECTIVE: This study aimed to examine the expression patterns of pro- and anti-inflammatory cytokines in elderly patients with and without delirium who were acutely admitted to the hospital. METHODS: All consecutive patients aged 65 years and older, who were acutely admitted to the Department of Internal Medicine of the Academic Medical Center, Amsterdam, a tertiary university teaching hospital, were invited. Members of the geriatric consultation team completed a multidisciplinary evaluation for all study participants within 48 h after admission, including cognitive and functional examination by validated measures of delirium, memory, and executive function. C-reactive protein and cytokines (IL-1beta, IL-6, TNF-alpha, IL-8, and IL-10) were determined within 3 days after admission. RESULTS: In total, 185 patients were included; mean age was 79 years; 42% were male; and 34.6% developed delirium within 48 h after admission. Compared to patients without delirium, patients with delirium were older and had experienced preexistent cognitive impairment more often. In patients with delirium, significantly more IL-6 levels (53% vs. 31%) and IL-8 levels (45% vs. 22%) were above the detection limit as compared with patients who did not have delirium. After adjusting for infection, age, and cognitive impairment, these differences were still significant. CONCLUSIONS: Proinflammatory cytokines may contribute to the pathogenesis of delirium in acutely admitted elderly patients.     

Avian influenza virus: Of virus and bird ecology

The recent introductions of highly pathogenic avian influenza (HPAI) H5N1 virus in wild birds and its subsequent spread throughout Asia, the Middle East, Africa and Europe has put a focus on the role of wild birds in the geographical spread of HPAI H5N1 virus. Large-scale surveillance programs are ongoing to determine a potential role of wild birds in H5N1 virus spread and to serve as sentinel systems for introductions into new geographical regions. The unprecedented scale and coverage of these surveillance programs offer a unique opportunity to expand our current knowledge on the ecology of LPAI in wild migratory birds. We provide an update on the current knowledge on the relation between host and virus ecology.     

Muscle necrosis in the extremities: evaluation with Tc-99m pyrophosphate scanning--a retrospective review

A retrospective review was done of 34 extremities studied between 1981 and 1985 with technetium-99m pyrophosphate scanning; 22 were subsequently amputated. Results of detailed pathologic examination or immediate postoperative examination of the resected extremity were available in 16 cases. In these cases, scanning had allowed correct prediction of the level of amputation and of the specific areas of muscle infarction in 13 cases. In the one case in which amputation was performed for infection rather than muscle necrosis, the lack of necrosis was correctly predicted with the scan. The limited results of this study indicate that the Tc-99m pyrophosphate scan allows the location of necrotic muscle to be predicted accurately and may therefore be a useful adjunct in determining the best level for ultimate amputation. Special caution is required in those cases in which muscle necrosis is due to acute causes (e.g., traumatic thrombosis) rather than chronic vascular disease.