Hsin-Chin Shih

Prognostic factors for mortality following falls from height

AIMnTo identify the potential prognostic factors for mortality after falls from height.nnnMETHODnA retrospective clinical observational study included victims of fall of >6m from October 2000 to December 2007. Variables studied comprised each casualtys age, gender, height of fall, Glasgow Coma Scale (GCS) score, Abbreviated Injury Scale scores, Injury Severity Score, heart rate, Mean Arterial Pressure (MAP), White Blood Cell (WBC) count, haemoglobin, serum glucose, Creatine Kinase and duration of hospital stay. The relationships between these variables and outcomes were evaluated.nnnRESULTSnAmong the 66 patients studied the mortality rate was 22.7%, i.e. 7 out-of-hospital and 8 in-hospital deaths. In univariate analysis, Glasgow Coma Score < or =14, Injury Severity Score > or =16, head/neck Abbreviated Injury Scale score > or =4, chest Abbreviated Injury Scale score > or =4, heart rate > or =100 or < or =50 beats/min, Mean Arterial Pressure < or =60 and serum glucose > or =140 mg/dl were significantly related to mortality. In multivariate analysis, head/neck Abbreviated Injury Scale score > or =4 was independently correlated with mortality.nnnCONCLUSIONSnSevere head injury (head/neck Abbreviated Injury Scale score > or =4) is a significant factor for mortality following falls from >6 m.

Usefulness of triggering receptor expressed on myeloid cells-1 in differentiating between typical and atypical community-acquired pneumonia.

OBJECTIVESnThe purpose of this study is to investigate the clinical use of inflammatory marker triggering receptor expressed on myeloid cells (TREM)-1 at admission for differentiating between typical and atypical bacterial community-acquired pneumonia (CAP).nnnMETHODSnA prospective, noninterventional study of patients with CAP hospitalized through the emergency department was performed. Surface expression of TREM-1 was analyzed using flow cytometry on peripheral blood cells, and soluble TREM-1 (sTREM-1) concentration was determined in plasma.nnnRESULTSnEighty-eight patients with clinical suspicion of CAP were eligible. The causative pathogen was identified in 39 patients (44.3%). After excluding 4 mixed pneumonia cases, 21 typical and 14 atypical bacterial infections were enrolled. Patients with typical bacterial CAP demonstrated increased TREM-1 surface expression on monocytes and neutrophils. Median plasma sTREM-1 levels at admission were 65.2 pg/mL (range, 17.6-138.1 pg/mL) in patients with typical CAP and 25.9 pg/mL (range, 11.5-54.8 pg/mL) in patients with atypical CAP (P < .001). Soluble TREM-1 had good discriminative value to differentiate typical from atypical pathogens with an area under the receiver operating characteristic curve of 0.87 (95% confidence interval, 0.75-0.98). At a cutoff level of 44.2 pg/mL, sTREM-1 yielded a sensitivity of 81%, a specificity of 79%, a positive likelihood ratio of 3.79, and a negative likelihood ratio of 0.24.nnnCONCLUSIONSnIn newly admitted patients with CAP, determination of the TREM-1 levels may provide useful additional diagnostic information on the bacterial etiology.

Magnolol Attenuates the Lung Injury in Hypertonic Saline Treatment from Mesenteric Ischemia Reperfusion through Diminishing iNOS

BACKGROUNDnHypertonic saline (HTS) administration can decrease the inflammation following ischemia reperfusion. Magnolol is a potent antioxidant. The present study investigated whether combined treatment of magnolol and HTS could provide further protection in mesenteric ischemia reperfusion injury.nnnMETHODSnMale C3H/HeOuJ mice were randomly segregated into the following groups: sham-operated (sham), vehicle treatment and mesenteric ischemia reperfusion (MSIR) (vehicle-treated), magnolol treatment and MSIR (magnolol-treated), HTS treatment and MSIR (HTS-treated), as well as co-administration of magnolol plus HTS and MSIR (combined-treated). In MSIR, mice were subjected to mesenteric ischemia for 60 min followed by reperfusion for 30 min. Lung injury was evaluated by lung edema (water ratio) and myeloperoxide (MPO) activity; RNA expression of inducible nitric oxide synthetase (iNOS), TNF-α, and IL-6 were assayed by real time RT-PCR. The formation of peroxynitrite in plasma was assayed by the peroxynitrite-dependent oxidation of dihydrorhodamine 123 (DHR 123) to rhodamine.nnnRESULTSnCompared with those in the sham-treated group, lung edema and MPO activity, expressions of iNOS, TNF-α and IL-6, and plasma peroxynitrite were significantly increased in the vehicle-treated group. Significant attenuations of these parameters were found in the magnolol-treated or HTS-treated animals. Combined treatment of magnolol and HTS further suppressed the lung edema, iNOS, and TNF-α expressions, and plasma peroxynitrite, compared with the results of a single treatment of magnolol or HTS.nnnCONCLUSIONSnCompared with single-agent use, co-administration of magnolol and HTS further decreases iNOS expression and plasma peroxynitrite as well as the degree of lung injury from MISR. These results may provide another treatment measure for post-injury immunomodulation.

Spleen artery embolization increases the success of nonoperative management following blunt splenic injury

Background: Spleen artery embolization (SAE) may increase the success rate of nonoperative management (NOM). The present study investigated the clinical outcome after the installation of SAE in the management of blunt splenic injury. Methods: A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about the injury severity score, organ injury scale, hospitalization days, management and final outcomes were evaluated. Patients were separated into early and late groups according to the year that SAE was selectively used (2003–2004 and 2005–2008). Results: Six of eleven (55%) patients in the early group were successfully managed without surgery for blunt splenic injury, whereas all of the 38 patients (100%) in the late group were successfully managed without surgery. Eleven patients (11 of 38; 28.9%) received SAE in the late group. The rate of NOM increased from 55% in the early group to 100% in the late group (p < 0.001). Both early and late groups had similar injury severity score, length of hospitalization, blood transfusion, and complications, and there was no mortality. Conclusion: Performance of SAE for the patients with blunt splenic injury could increase the successful rate of NOM significantly and safely. An algorithm including the angioembolization might be beneficial in the management of patients with blunt spleen trauma.

Predictive indications of operation and mortality following renal trauma

Background: This study is a review of our experiences related to managing patients with renal injuries and identifying the predictive indicators of surgery and mortality. Methods: A retrospective review study was performed in our university hospital. Patients with renal injuries were enrolled. Data comparisons were performed between four patient groups (operation vs. nonoperation groups and mortality vs. survival groups, respectively). Results: Seventy‐three patients were enrolled in this study, 55 of whom (75.34%) were male. Nine patients (12.33%) were severely injured (Injury severity score (ISS) ≥ 16), and nine (12.33%) had high renal injury scores (Renal injury scale (RIS) ≥ 4). Seven patients (9.59%) had received operations, and four (5.48%) died of hemorrhagic shock and multiple organ failure. After performing multivariate analysis, patients who received operations had significantly higher ISS (≥16) and RIS (≥4) scores compared with patients who did not undergo operations. ISS ≥ 16 and Glasgow coma scale (GCS) < 8 were significantly correlated with mortality. Conclusion: In conclusion, ISS ≥ 16 and RIS ≥ 4 are predictive factors for necessitating an operation, and higher injury severity (ISS ≥ 16) and lower consciousness level (GCS < 8) scores are significantly associated with mortality after renal trauma.

The role of diagnostic algorithms in the management of blunt splenic injury

Background: Diagnostic algorithms for patients with blunt abdominal trauma have been in use since 1995. This study investigated the role of diagnostic algorithms in the management of adult patients with blunt splenic injury at our institution. Methods: A retrospective review of hospital records was performed to enroll patients with blunt injury of the spleen. Demographic data and information about injury severity, diagnostic methods, management and final outcomes were evaluated. Patients were separated into an early and late group according to the year that diagnostic algorithms were used (1990–1994 or 1995–1999). Results: One hundred and twenty‐one patients were enrolled. Initially, 71 patients had an operation (OP group), whereas 50 received non‐operative management (NOM group). Patients in the OP versus NOM group had lower blood pressure and greater transfusion volumes in the emergency room, higher grade splenic injury, and a greater rate of intra‐abdominal‐related injury. NOM failed in 7 patients (14%). Early‐versus late‐group patients were less likely to have NOM and high grade splenic injury; however, the rate of NOM failure was not different between the early and late groups. Conclusion: Diagnostic algorithms using sonograms for screening provide an initial means of selecting patients for NOM. Patients with higher grades of splenic injury can then be managed non‐operatively.

Relation of signal in mononuclear cell with endotoxin response and clinical outcome after trauma

BACKGROUNDnWe investigated the correlation of proinflammatory transcript nuclear factor κB (NF-κB) and antioxidative gene transcript nuclear factor-erythroid 2-related factor 2 (Nrf2) expressions in peripheral blood mononuclear cells (PBMCs) with the tumor necrosis factor α (TNF-α) response after endotoxin stimulation and the clinical outcome of severely injured patients.nnnMETHODSnThirty-two severe blunt trauma patients (injury severity score>16) with systemic inflammatory response syndrome were enrolled. Age- and sex-matched healthy persons were the controls. Patients blood samples were obtained at 24 and 72 hours after injury. Peripheral blood mononuclear cells were isolated, and measurements for NF-κB p65 translocation, Nrf2 and phosphorylated inhibitory κB-α expressions, and TNF-α levels were assayed after endotoxin stimulation.nnnRESULTSnIn the trauma patients, TNF-α hyporesponse, depressed NF-κB p65 translocation, and phosphorylated inhibitory κB-α expression in PBMCs were found at 24 and 72 hours after injury; the Nrf2 expressions in PBMCs were not significantly different between patients and controls. The TNF-α levels had significant correlation with the NF-κB translocation and the trend of negative correlation with Nrf2 expression. Fifteen patients had critical injury (injury severity score≥25). Patients with critical injury had a lower NF-κB signal and a lower TNF-α response than did the counter group. Twelve patients developed organ failure; their Nrf2 expressions were significantly lower than those of patients without organ failure.nnnCONCLUSIONSnThe endotoxin hyporesponse associated with NF-κB and Nrf2 signal alternations in PBMCs of injured patients develops early after injury. The hyporesponse of PBMCs with a lower TNF-α level correlates with a lower NF-κB signal and is associated with critical injury, whereas a depressed Nrf2 expression in PBMCs is associated with later organ failure in trauma patients.

Differential gene expression after hemorrhagic shock in rat lung

Background: We investigated the differential gene expression in rat lung after hemorrhagic shock (HS). Methods: A controlled HS model in rats was used. Male Sprague‐Dawley rats were randomly segregated into 2 groups, sham and HS. Samples of lung were procured from rats 2 hours after HS and resuscitation. Commercially available gene chips for rat cDNA microarray and software packages were used for the gene expression profile study. Results: Compared with sham‐shock rats, 98 genes were upregulated in HS rat lung. Most upregulated genes were responsible for inflammation (pro‐inflammatory or anti‐inflammatory cytokines, cognate receptors, and signal transduction for inflammation), protein activation (kinase and phosphatase), oxidation (oxidative and antioxidative enzymes), and apoptosis (apoptosis and anti‐apoptosis). Eleven genes were downregulated after HS. Conclusion: HS may induce upregulation of positive and negative control genes responsible for inflammation, oxidation, protein metabolism and apoptosis, that is, a vulnerable period may develop in the host after HS. Overwhelming inflammatory response or immunosuppression may occur once a second hit, such as infection, ensues. Understanding, on a genome scale, how an organism responds to HS may facilitate the development of enhanced treatment modalities for HS.

The Benefit of Ultrasound in Deciding Between Tube Thoracostomy and Observative Management in Hemothorax Resulting from Blunt Chest Trauma

BackgroundHemothorax is most commonly resulted from a closed chest trauma, while a tube thoracostomy (TT) is usually the first procedure attempted to treat it. However, TT may lead to unexpected results and complications in some cases. The advantage of thoracic ultrasound (TUS) over a physical examination combined with chest radiograph (CXR) for diagnosing hemothorax1 has been proposed previously. However, its benefits in terms of avoiding non-therapeutic TT have not yet been confirmed. Therefore, this study is aimed to evaluate the severity of hemothorax in blunt chest trauma patients by using TUS in order to avoid non-therapeutic TT in stable cases.MethodsThe data from 46,036 consecutive patient visits to our trauma center over a four-year period were collected, and those with blunt chest trauma were identified. Patients who met any of the following criteria were excluded: transferred from another facility, with an abbreviated injury scale (AIS) score ≥ 2 for any region except the chest region, with a documented finding of tension pneumothorax or pneumothoraxxa0>10%, younger than 16xa0years old and with indications requiring any non-thoracic major operation. The decision to perform TT for those patients in the non-TUS group was made on the basis of CXR findings and clinical symptoms. The continuous data were analyzed by using the two-tailed Student’s t test, and the discrete data were analyzed by Chi-square test.ResultsA total of 84 patients met the criteria for inclusion in the final analysis, with TT having been performed on 42 (50%) of those patients. The mean volume of the drainage amount was 860xa0ml after TT. The TT drainage was less than 500xa0ml in 12 patients in the non-TUS group (40%), while none was less than 500xa0ml in the TUS group (pxa0=xa00.036, Fisher’s exact test). In terms of the positive rate of subsequent effective TT, the sensitivity of TUS was 90% and the specificity was 100%. There were 3 patients with delayed hemothorax: 2 of the 58 (3.6%) in the non-TUS group and 1 of 26 (4.5%) in the TUS group (pxa0>xa00.05, Fisher’s exact test). The hospital length of stay in the non-TUS group with non-therapeutic TT was significantly longer than in the TUS group without TT (8.2 vs. 5.4xa0days, pxa0=xa00.018). There were no other major complications or deaths in either group during the 90-day follow-up period.ConclusionIn the case of blunt trauma, TUS can rapidly and accurately evaluate hemothorax to avoid TT in patients who may not benefit much from it. As a result, the rate of non-therapeutic TT can be decreased, and the influence on shortening hospital length of stay may be further evaluated with prospective controlled study.

The impact of open to collaborative care model in cardiovascular surgical unit

Background: When compared with open care model, a closed one improves patient care in intensive care units (ICUs), mixed ICUs, surgical ICUs and trauma centers. We wanted to evaluate the benefit of a collaborative care model in highly specialized cardiovascular care unit. Methods: This study was a retrospective, observational study conducted in the cardiovascular care unit of a teaching hospital. All patients who were above 20 years old and had received cardiovascular operation were enrolled for data collection and analysis. Results: A total of 270 subjects were enrolled for analysis during the 2‐year study period. In the collaborative care model, the CVSU length of stay (p = 0.001) and CVSU‐free days (p = 0.0008) were significantly better than those in an open care model. Discussion: The collaborative care model improved postoperative outcome in the cardiovascular surgical unit for those needing prolonged ICU care.