浸入式金属自显影技术检测游离锌离子在人脑外伤、急性脑缺血、癫痫后神经元中的异常聚集

目的 研究游离锌离子在脑外伤、急性脑缺血和癫痫患者神经元中的分布,为探讨锌离子是否参与上述疾病的神经元损伤提供形态学证据. 方法 于南京军区南京总医院神经外科手术台上直接采集3例脑缺血标本、3例癫痫标本、5例脑外伤标本和5例相对正常新鲜皮层标本,应用浸入式金属自显影方法检测标本中的锌离子分布,应用HE染色观察神经元形态学变化.结果 脑外伤、急性脑缺血和癫痫患者皮层神经元内聚集了大量的锌离子,阳性反应产物主要位于含锌神经元的胞体和轴突终末,胶质细胞中未见明显着色.在正常皮层未见阳性反应产物沉积.进一步的HE染色提示这些富含锌的神经元呈明显损伤样外观. 结论 锌离子可能在脑外伤、急性脑缺血和癫痫的神经元损伤中起重要作用,参与这些疾病的病理生理过程.     

Evaluation of Probability of Survival Using Trauma and Injury Severity Score Method in Severe Neurotrauma Patients

Objective

Despite several limitations, the Trauma Injury Severity Score (TRISS) is normally used to evaluate trauma systems. The aim of this study was to evaluate the preventable trauma death rate using the TRISS method in severe trauma patients with traumatic brain injury using our emergency department data.

Methods

The use of the TRISS formula has been suggested to consider definitively preventable death (DP); the deaths occurred with a probability of survival (Ps) higher than 0.50 and possible preventable death (PP); the deaths occurred with a Ps between 0.50 and 0.25. Deaths in patients with a calculated Ps of less than 0.25 is considered as no-preventable death (NP). A retrospective case review of deaths attributed to mechanical trauma occurring between January 1, 2011 and December 31, 2011 was conducted.

Results

A total of 565 consecutive severe trauma patients with ISS>15 or Revised Trauma Score<7 were admitted in our institute. We excluded a total of 24 patients from our analysis : 22 patients younger than 15 years, and 2 patients with burned injury. Of these, 221 patients with head injury were analyzed in the final study. One hundred eighty-two patients were in DP, 13 in PP and 24 in NP. The calculated predicted mortality rates were 11.13%, 59.04%, and 90.09%. The actual mortality rates were 12.64%, 61.547%, and 91.67%, respectively.

Conclusion

Although it needs to make some improvements, the present study showed that TRISS performed well in predicting survival of traumatic brain injured patients. Also, TRISS is relatively exact and acceptable compared with actual data, as a simple and time-saving method.     

Destination healthcare facility of patients with suspected traumatic brain injury in Scotland: Analysis of pre-hospital data

Background

Traumatic brain injury is common. Guidelines from the Brain Trauma Foundation and the Scottish Intercollegiate Guidelines Network recommend that patients with suspected severe traumatic brain injury should be treated in centres with neurosurgical expertise. Scotland does not have a framework for the delivery of trauma care. The aim of this study was to examine the demographic characteristics of incidents involving patients who have suffered a suspected traumatic brain injury, and to evaluate the level of the destination healthcare facility which patients are currently taken to.

Methods

Retrospective analysis of prospectively collected Scottish Ambulance Service data on incidents involving traumatic injury, between Nov 2008 and Oct 2010. Two groups of casualties were analysed: those who had a Glasgow coma scale of less than 14 (GCS < 14), and those who had a Glasgow coma scale of less than 9 (GCS < 9).

Results

126,934 incidents were identified and analysed. 3890 (3.1%) patients had a GCS of less than 14, and 657 (0.5% of total) had a GCS of less than 9. Almost one-third of incidents involving patients with either a GCS < 14 or GCS < 9 occurred in the greater Glasgow health board area. The Lothian health board region had the second-highest number of patients with either a GCS < 14 or GCS < 9. Only 13.8% of patients with a GCS < 14, and 16.7% of those with a GCS < 9, were taken to a hospital with a neurosurgical service.

Conclusions

Many patients who may harbour a traumatic brain injury are taken to a facility which may not be equipped or staffed to deal with such injuries. This mismatch needs to be addressed. However, the care of patients with head injuries is only one aspect of trauma care. The UK has long lagged behind North America in terms of the quality of trauma care provided, although the provision of trauma care in England is currently undergoing major changes. Scotland should consider the development of a similar service delivery framework.     

Increased risk of pneumonia among ventilated patients with traumatic brain injury: every day counts!

Background

Patients with traumatic brain injury (TBI) frequently require mechanical ventilation (MV). The objective of this study was to examine the association between time spent on MV and the development of pneumonia among patients with TBI.

Materials and methods

Patients older than 18 y with head abbreviated injury scale (AIS) scores coded 1–6 requiring MV in the National Trauma Data Bank 2007–2010 data set were included. The study was limited to hospitals reporting pneumonia cases. AIS scores were calculated using ICDMAP-90 software. Patients with injuries in any other region with AIS score >3, significant burns, or a hospital length of stay >30 d were excluded. A generalized linear model was used to determine the approximate relative risk of developing all-cause pneumonia (aspiration pneumonia, ventilator-associated pneumonia [VAP], and infectious pneumonia identified by the International Classification of Disease, Ninth Revision, diagnosis code) for each day of MV, controlling for age, gender, Glasgow coma scale motor score, comorbidity (Charlson comorbidity index) score, insurance status, and injury type and severity.

Results

Among the 24,525 patients with TBI who required MV included in this study, 1593 (6.5%) developed all-cause pneumonia. After controlling for demographic and injury factors, each additional day on the ventilator was associated with a 7% increase in the risk of pneumonia (risk ratio 1.07, 95% confidence interval 1.07–1.08).

Conclusions

Patients who have sustained TBIs and require MV are at higher risk for VAP than individuals extubated earlier; therefore, shortening MV exposure will likely reduce the risk of VAP. As patients with TBI frequently require MV because of neurologic impairment, it is key to develop aggressive strategies to expedite ventilator independence.     

Expression of intestinal CD40 after experimental traumatic brain injury in rats

Background

Nuclear factor kappa B (NF-κB) has been shown to be activated in the intestine after traumatic brain injury (TBI), and results in gastrointestinal mucosal injury. In addition, CD40 has a major role in the activation of NF-κB and is up-regulated in inflammatory bowel disease. However, we found no study in the literature investigating the intestinal expression of CD40 after TBI. Hence, we designed the current study to explore the intestinal expression pattern of CD40 after TBI in rats. We hypothesized that CD40 could mediate inflammation and ultimately contribute to acute intestinal mucosal injury after TBI.

Methods

We randomly divided rats into control and TBI groups at 3, 6, 12, 24, and 72 h, respectively. We assessed the expression of CD40 by quantitative real-time polymerase chain reaction, Western blotting, and immunohistochemical study, and detected the levels of tumor necrosis factor-α (TNF-α), intracellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) by enzyme-linked immunosorbent assay.

Results

The mRNA and protein levels of -CD40 increased by 3 and 6 h, peaked at 6 and 12 h, and remained elevated until 24 and 72 h post-injury, respectively. Levels of TNF-α, VCAM-1, and ICAM-1 also markedly increased in jejunum tissue after TBI. Interestingly, there was a positive relationship between the expression of CD40 and that of TNF-α, VCAM-1, and ICAM-1.

Conclusions

CD40 could be markedly elevated in intestine after TBI in rats, and it might have an important role in the pathogenesis of acute intestinal mucosal injury mediated by inflammatory response.     

参附注射液治疗外伤性蛛网膜下腔出血后凝血相关因子的变化及其临床意义

目的 探讨参附注射液治疗外伤性蛛网膜下腔出血后患者血液中凝血相关因子的变化规律及其意义. 方法 选取本院收治的外伤性蛛网膜下腔出血患者65例,随机分为治疗组33例与对照组32例,对照组给予常规治疗,治疗组在对照组的基础上加用参附注射液静脉滴注,每日2次,连续用药14天.动态监测患者部分凝血活酶时间(APTT)、凝血酶原时间(PT)、D-二聚体并进行统计学处理. 结果 参附注射液治疗外伤性蛛网膜下腔出血患者的部分凝血活酶时间延长(APTT)、凝血酶原时间(PT)延长、D-二聚体下降. 结论 外伤性蛛网膜下腔出血早期应用参附注射液治疗,可以有效预防外伤性蛛网膜下腔出血患者的血管痉挛,预防颅脑损伤后微血栓的形成,降低脑梗塞风险,改善患者的预后.     

Update on prehospital emergency care of severe trauma patients

The prognosis of severe trauma patients is determined by the ability of a healthcare system to provide high intensity therapeutic treatment on the field and to transport patients as quickly as possible to the structure best suited to their condition. Direct admission to a specialized center (“trauma center”) reduces the mortality of the most severe trauma at 30 days and one year. Triage in a non-specialized hospital is a major risk of loss of chance and should be avoided whenever possible. Medical dispatching plays a major role in determining patient care. The establishment of a hospital care network is an important issue that is not formalized enough in France. The initial triage of severe trauma patients must be improved to avoid taking patients to hospitals that are not equipped to take care of them. For this purpose, the MGAP score can predict severity and help decide where to transport the patient. However, it does not help predict the need for urgent resuscitation procedures. Hemodynamic management is central to the care of hemorrhagic shock and severe head trauma. Transport helicopter with a physician on board has an important role to allow direct admission to a specialized center in geographical areas that are difficult to access.     

Effect of Intrathecal Baclofen Concentration on Spasticity Control: Case Series

Background/Objective: Intrathecal baclofen (ITB) has been shown to be an effective treatment for severe spasticity of spinal or cerebral origin. Although most patients respond well to an ITB trial, there are often difficulties in achieving and/or maintaining such effectiveness with ITB pump treatment. There are few published guidelines for dosing efficacy and no studies looking at the effect of concentration of ITB on spasticity management.

Methods: Case series of 3 adults with severe spasticity treated with ITB pump: a 44-year-old man with C7 tetraplegia using a 40-mL Medtronic SynchroMed II pump with 500-μg/mL concentration; a 35-year-old woman with traumatic brain injury with right spastic hemiplegia using a 18-mL Medtronic SynchroMed EL pump with 2,000-μg/mL concentration; and a 43-year-old woman with spastic diplegic cerebral palsy using a 40-mL Medtronic SynchroMed II pump with 2,000-μg/mL concentration.

Results: After reducing ITB concentrations in the pump, either as part of a standard protocol for dye study to assess the integrity of pump and catheter system or secondary to plateau in therapeutic efficacy, patients experienced temporary, significant reduction in spasticity based on range of motion, Modified Ashworth scores, and verbal feedback.

Conclusions: Decreasing the concentration of ITB seems to affect spasticity control. Further research in this area is needed for those patients with refractory spasticity to optimize efficacy of ITB therapy.     

Simple and effective approach for the treatment of traumatic wounds in non‐diabetic patients: a prospective open study

Infection is one of the most important obstacles in the wound‐healing process. Conventional methods used for the treatment of wound infections have their own limitations and hence, are difficult to control. If infection is not addressed well in time, it will further increase morbidity and cost of treatment. An attempt was made to develop a simple and effective treatment modality by using citric acid as the sole antimicrobial agent to control bacterial infections of traumatic wounds. A total of 259 cases of traumatic wounds infected with a variety of bacteria were investigated for culture and susceptibility, and susceptibility to citric acid. Citric acid ointment (3%) was applied to traumatic wounds to determine its efficacy in their treatment of traumatic wounds. In a culture and susceptibility study, a total of 369 aerobic bacteria and 7 fungi were isolated, with Staphylococcus aureus (30·31%) being the most common isolate and ciprofloxacin (61·43%) being the most effective agent. All the isolates were found to be inhibited by citric acid in in vitro studies (minimum inhibitory concentration – 500–2500 µg/ml). Citric acid ointment was found effective in controlling infections. Out of 259 cases, 244 (around 95%) were healed completely in 5–25 applications of 3% citric acid. As citric acid has antibacterial activity and wound‐healing property; hence it is the best alternative for the treatment of traumatic wounds. Besides these properties, citric acid has no adverse effects and it is a good dressing agent.