Benny Dahl

Plasma concentration of Gc-globulin is associated with organ dysfunction and sepsis after injury.

ObjectiveClinical and experimental studies suggest that the proteins of the extracellular actin scavenger system have a role in the pathophysiological processes taking place in critically ill and injured patients. Circulating levels of Gc-globulin and gelsolin are reduced shortly after severe trauma, and admission levels of Gc-globulin are associated with survival. Herein, we sought to measure the association between admission levels of Gc-globulin and postinjury organ dysfunction and infection. We also wanted to describe the serial changes in Gc-globulin in these severely injured patients. DesignProspective cohort. SettingIntensive care unit at a county hospital that serves as a level one trauma center. PatientsNinety-eight consecutive trauma victims admitted to the intensive care unit for >24 hrs during a 4-month period. Measurements and Main ResultsCirculating levels of Gc-globulin were measured by using immunonephelometry. All patients were evaluated daily to obtain the necessary data for assessment of organ dysfunction and sepsis. The median Gc-globulin concentration at admission was 127 mg/L in patients who developed severe multiple organ dysfunction compared with 184 mg/L in patients who did not (p = .001). The admission level of Gc-globulin was comparable to known risk factors such as age and injury severity score, regarding development of organ dysfunction. Plasma concentrations of Gc-globulin remained significantly lower in patients who developed respiratory failure and sepsis, compared with patients who did not develop these complications (p = .02 and p = .015, respectively). ConclusionsAdmission plasma concentration of Gc-globulin is lower in patients who develop organ dysfunction and sepsis after traumatic injury. These data, combined with the work of others, support the hypothesis that actin release and depletion of the extracellular actin scavenger system proteins are associated with, and may contribute in part to, the complications of sepsis and organ dysfunction, particularly respiratory failure and thrombocytopenia.

Plasma gelsolin is reduced in trauma patients

Tissue injury results in the release of the intracellular protein actin which is cleared from the circulation by the plasma proteins gelsolin and Gc-globulin, constituting the Extracellular Actin Scavenger System (EASS). Experimental studies have shown that excessive amounts of actin in the circulation can lead to a condition resembling multiple organ dysfunction syndrome (MODS), and we have previously demonstrated that the level of Gc-globulin is decreased after severe trauma. The purpose of the present study was to determine whether the plasma levels of gelsolin were altered in the early phase after trauma. Twenty-three consecutive trauma patients were studied. Plasma samples were assayed for gelsolin by immunonephelometry with polyclonal rabbit antihuman gelsolin prepared in our own laboratory. The median time from injury until the time the first blood sample was taken was 52 min (range 20-110) and the median Injury Severity Score (ISS) was 20 (range 4-50). The gelsolin level on admission was reduced significantly in the trauma patients compared with normal controls. The median level was 51 mg/L (7-967) vs. 207 mg/L (151-621), P < 0.0001. There was no correlation between admission levels of gelsolin and ISS or survival. This study illustrates that the plasma concentration of gelsolin is significantly diminished immediately after traumatic injury. Further studies are necessary to establish a role for gelsolin or EASS in the development of MODS in trauma patients. The level of serum or plasma gelsolin can be determined rapidly and accurately using a nephelometric assay.

Serum Gc-globulin in the early course of multiple trauma

OBJECTIVES In patients with multiple trauma, actin released from damaged cells may cause severe circulatory disturbance due to thrombi formation. The aim of this study was to evaluate serum concentrations of the actin scavenger, Gc-globulin, in relation to the severity of injury and outcome. DESIGN Prospective, longitudinal, observational study. SETTING Trauma center at a university hospital. PATIENTS Twelve patients with multiple trauma, consecutively included, according to defined criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Serum Gc-globulin concentrations were measured at the time of admission and daily thereafter for 1 wk or until death. In all patients, the Gc-globulin concentration was significantly low (p < .0001), and the proportion of Gc-globulin bound to actin was already increased compared with normal values (p < .0001) by the time of hospital arrival. There was an inverse correlation between the mean concentration of serum Gc-globulin in the first week after trauma and the Injury Severity Score (r = -0.72, p < .05). Surviving patients had a significantly (p < .05) higher concentration of serum Gc-globulin in the first week after trauma compared with nonsurvivors. CONCLUSIONS Serum concentrations of Gc-globulin were significantly low in trauma patients. The reduction took place within 60 mins after injury. Because the normal half-life of Gc-globulin is almost 48 hrs, our observations suggest a marked consumption of Gc-globulin immediately after the trauma. This finding could be the first clinical evidence that Gc-globulin plays a role in the systemic inflammatory response syndrome after trauma. This result is supported by the finding that lack of Gc-globulin was related to nonsurvival and the severity of the trauma.

Update on the roles of angiography and embolisation in pelvic fracture

Trauma accounts for approximately 1 in 10 deaths worldwide. The presence of a pelvic fracture increases this mortality risk. Successful management depends on accurate diagnostic staging and control of fracture-related haemorrhage. From the standpoint of the trauma surgeon, this necessitates thorough compression and stabilisation of the fracture using external compression, combined with retroperitoneal or preperitoneal packing. However, vascular injury in many parts of the body can preferentially and effectively be treated on an emergency basis with angiographic procedures, using superselective embolisation in combination with other interventional techniques. The option of combining open surgery and angiographic methods should be kept in mind, but there are no uniform guidelines. In the literature, numerous studies and reports have documented the feasibility of interventional radiological procedures in trauma cases with pelvic fracture. Thus all level I trauma centres should be able to provide this service on a 24h basis.

No difference in clinical outcome after posterolateral lumbar fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease using pedicle screw instrumentation: a comparative study of 112 patients with 4 years of follow-up

Abstract. We compared the clinical outcome after spinal fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease of the lumbar spine, using multiple logistic regression analysis. A questionnaire describing medication, pain, vocational status and patient satisfaction was mailed to all the patients at a median interval of 4 years after their operation. Fusion was evaluated on plain radiographs at a minimum of 12 months after surgery, and patients were classified as fused or not fused. The overall satisfaction rate was 70%. The results of the present study showed no difference in the outcome after spinal fusion between the two groups of patients. The factors that significantly increased the likelihood of an optimal result – defined as patient satisfaction, return to work, and reduced medication – were male gender, being in work prior to surgery, and being a non-smoker. Since spinal fusion is an expensive treatment with potentially serious risks, and leaves one-third of the patients with an unsatisfactory result, we believe that more studies focusing on the indications for surgery should be performed.

Nonorganic pain drawings are associated with low psychological scores on the preoperative SF-36 questionnaire in patients with chronic low back pain

Abstract The Short Form 36 questionnaire (SF-36) measures general health and well-being. Within the last 5 years it has been used increasingly to characterise patients in the medical literature. Relatively few studies have used the SF-36 on patients with chronic low back pain undergoing preoperative evaluation, but results suggest that it may be predictive of surgical outcome. Pain drawings are a routine part of evaluation prior to spinal surgery in several centres, since their classification of organic or nonorganic has been shown in some studies to correlate well with psychological characteristics predicting poor outcome. The purpose of the present study was to assess possible correlations between nonorganic pain drawings and the psychological scales in the SF-36. We included 128 patients in the study, all of them referred from other hospitals. Previous spinal surgery had been undergone by 25%, and 59% required daily medication because of low back pain. All patients completed pain drawings using predefined symbols These pain drawings were scored dichotomously as organic or nonorganic based on a brief description of a typical nonorganic characteristics. Patients also completed the Danish version of the SF-36 questionnaire. Statistical analysis was performed using logistic regression analysis. The pain drawing classification was used as the dependent variable and scores on the eight scales of the SF-36 as independent variables. P values of <0.05 were considered significant. The mean scores of the patient population on all eight scales were significantly lower than Danish norms. The only scales that correlated with the presence of nonorganic pain drawings were emotional role (RE) and mental health (MH), both measuring psychological health. The odds ratio (OR) of receiving a nonorganic pain drawing was 22 (95% confidence interval, or CI, 7–65) if the scores on RE and MH were more than 2 standard deviations (SD) below the Danish norm. This is the first study providing evidence that pain drawing ratings are influenced by the psychological scales of the SF-36. The clinical relevance of this observation regarding prediction of outcome after spinal surgery should be assessed in future studies.

Admission level of Gc-globulin predicts outcome after multiple trauma

BACKGROUND Actin is the dominating protein in mammalian cells. Release of excessive amounts of actin into the circulation may result in a condition resembling multiple organ failure. The purpose of this study was to determine if admission levels of Gc-globulin can predict survival after multiple trauma. Also, we wanted to compare the predictive ability of Gc-globulin with that of the TRISS-Like scoring system. METHODS Fifty-seven patients with a median ISS 18 (16-75) were included. All patients had a blood sample taken median 42 min after the injury (19-110 min). Serum Gc-globulin was measured by rocket immunoelectrophoresis. RESULTS On admission, all patients had significantly reduced levels of Gc-globulin compared with normal controls. Gc-globulin was significantly higher in the group of survivors (n = 41), compared with non-survivors (n = 16). Median 237 mg/l vs. 188 mg/l (P < 0.01). The predictive ability of Gc-globulin regarding death was similar to that of TRISS-Like with positive predictive values of 69%, a negative predictive value of 84%, a sensitivity of 56% and a specificity of 90%. CONCLUSIONS The predictive value of Gc-globulin regarding survival was similar to that of an established scoring system. Gc-globulin, alone or in combination with other parameters, may serve as a routine tool for early identification of patients at risk after severe injury, increasing the possibility of early intervention.

The Masquelet technique of induced membrane for healing of bone defects. A review of 8 cases.

BACKGROUND Segmental defects of long bones are notoriously difficult to treat. This study evaluates eight cases in which the Masquelet technique of induced membranes was used. The primary purpose was to assess the results compared to other types of bone reconstruction and share our tips and tricks to improve the outcome. METHOD Retrospective study based on patient records and radiographs. Eight patients operated between 2011 and 2014 were included. Three had infected non-unions. Outcome measures were time-to full weight-bearing, time to radiographic consolidation, need for secondary bone grafting procedures and occurrence of complications. RESULTS Time to full weight bearing seemed shorter in patients treated with nails. In two cases only partial radiographic consolidation was noted at the latest follow up visit. One patient needed secondary bone grafting and two limbs were malaligned. There were no amputations, no persistent infections, and no implant failures. DISCUSSION The induced membrane technique is a useful tool to substitute bone loss yet consolidation time is somewhat unpredictable and prolonged non-weight bearing is required. CONCLUSION Nailing seems to improve outcome compared to plating. It shortens treatment time, reduces the amount of bone graft needed, aligns the bone and should be considered when feasible. Further larger scale studies are welcome to throw more light into the efficacy and effectiveness of this technique.

Clinical outcome after spinal fusion with a rigid versus a semi-rigid pedicle screw system

Several biomechanical studies have evaluated the quality of fusion obtained with a rigid versus a semi-rigid pedicle screw implant. Some studies indicate that increased rigidity of the implant system results in an increased strength of the fusion mass. Other reports have underlined the risk of stress shielding due to rigid implant systems. Based on these findings some authors have recommended the use of a semi-rigid system. There are, however, few studies focusing on any possible difference in clinical outcome between the two different types of implant systems. Questionnaires were sent to 89 patients who had undergone primary spinal fusion with either a rigid or a semi-rigid pedicle-screw-based implant system. In every case the diagnosis was spondylolisthesis or degenerative lumbar disease. The questionnnaires were analysed using forward stepwise logistic regression analysis. Eighty (90%) of the questionnaires were returned. There was a mean follow-up of 4 years (range 2–8 years). It was not possible to demonstrate any difference in clinical outcome between patients undergoing lumbar fusion with a rigid implant system and those given a semi-rigid system. The overall patient satisfaction rate was 69%, with no difference between the two types of implant. No difference in clinical outcome between the two types of implant was found. Considering the fact that the primary goal of spinal fusion procedure is to obtain a solid fusion mass, biomechanical tests favour the used of a rigid pedicle screw system. This fact combined with the fact that early mobilisation is possible with rigid implants justifies the use of rigid implant systems, although no difference in clinical outcome could be demonstrated in this study.

How does extracerebral trauma affect the clinical value of S100B measurements

Background Protein S100B has proven to be a useful biomarker for cerebral damage. The predictive ability of S100B may, however, be affected by extracerebral injuries. The aim of this study was to investigate serum levels of S100B in patients with either isolated head injury (IHI), multi trauma with head injury (MTHI), or no head injury (NHI). The primary aim was to assess if a significant difference in serum levels of S100B could be found between IHI and MTHI patients. Methods Patients (233) were primarily admitted to the trauma centre. Serum samples were drawn on admission and 6 h after trauma and then stored at −80°C until analysed. Variables included Abbreviated Injury Scale (AIS) for head trauma, Injury Severity Score (ISS) and 30-day survival. Results Two patients could not be classified. IHI occurred in 28, MTHI in 102 and NHI was found in 101. The median S100B concentrations on arrival were 0.47, 1.68 and 0.49 μg/l, respectively (p<0.0001). The corresponding values at 6 h were 0.14, 0.31 and 0.15 μg/l, respectively (p<0.0001). S100B was significantly higher in patients with MTHI than in patients with IHI at both time points (p values 0.0005 and 0.01). There was no significant difference in S100B between patients having IHI and patients with NHI (p=0.81 and p=0.67). Conclusions High serum levels of S100B were found early after trauma. The highest concentrations of S100B were found in patients with multi trauma. This suggests that S100B serum concentrations are significantly affected by extracerebral injuries.