Michael Frink

Influence of sex and age on mods and cytokines after multiple injuries.

Although salutary effects of female sex steroids have been demonstrated not only in proestrus females but also in male animals treated with estradiol in different models of trauma, it remains unknown whether sex hormones influence post-traumatic immune response in humans. We therefore investigated the effect of sex and age on organ dysfunction and clinical course in patients with multiple injuries. Polytraumatized patients (injury severity score > 16) between 16 and 65 years old admitted to the Hannover Medical School Level 1 trauma center between January 1997 and December 2001 were included. Marshall Score for multiple organ dysfunction syndrome (MODS) was calculated for at least 14 days. The length of stay in intensive care unit and the ventilator days were recorded in addition to the number of transfusions the patient received. A total of 106 males and 37 females were included in the study. Patients with MODS had increased plasma levels of IL-6, IL-8, and IL-10. Furthermore, patients with organ dysfunction had more frequent sepsis and higher mortality rates. In addition, MODS was associated with extended length of stay in the intensive care unit and increased ventilator days. Females not older than 50 years with an injury severity score greater than 25 suffered significantly less MODS and sepsis compared with age-matched males. Moreover, they had significantly lower plasma cytokines. Thus, in this prospective study, sex difference was confirmed in MODS and sepsis, with a benefit observed in females. Although the levels of sex steroids were not measured, it seems that the protective effects may be due to estrogen effects on plasma cytokines. This suggestion is based on the fact that such salutary effects were apparent predominantly in premenopausal females.

The role of MAPK in Kupffer cell toll-like receptor (TLR) 2-, TLR4-, and TLR9-mediated signaling following trauma-hemorrhage

Severe injury deranges immune function and increases the risk of sepsis and multiple organ failure. Kupffer cells play a major role in mediating posttraumatic immune responses, in part via different Toll‐like receptors (TLR). Although mitogen‐activated protein kinases (MAPK) are key elements in the TLR signaling pathway, it remains unclear whether the activation of different MAPK are TLR specific. Male C3H/HeN mice underwent midline laparotomy (i.e., soft tissue injury), hemorrhagic shock (MAP ∼35 mmu2009Hg for 90 min), and resuscitation. Kupffer cells were isolated 2 h thereafter, lysed and immunoblotted with antibodies to p38, ERK1/2, or JNK proteins. In addition, cells were preincubated with specific inhibitors of p38, ERK1/2, or JNK MAPK followed by stimulation with the TLR2 agonist, zymosan; the TLR4 agonist, LPS; or the TLR9 agonist, CpG DNA. Cytokine (TNF‐α, interleukin‐6 (IL‐6), monocyte chemoattractant protein‐1 (MCP‐1), and KC) production was determined by cytometric bead array after 24 h in culture. MAPK activity as well as TNF‐α, MCP‐1, and KC production by Kupffer cells were significantly increased following trauma‐hemorrhage. TLR4 activation by LPS stimulation increased the levels of all measured cytokines. CpG‐stimulated TLR9 signaling increased TNF‐α and IL‐6 levels; however, it had no effect on chemokine production. Selective MAPK inhibition demonstrated that chemokine production was mediated via p38 and JNK MAPK activation in TLR2, ‐4, and ‐9 signaling. In contrast, TNF‐α and IL‐6 production was differentially regulated by MAPK depending on the TLR pathway stimulated. Thus, Kupffer cell TLR signaling employs different MAPK pathways in eliciting cytokine and chemokine responses following trauma‐hemorrhage. J. Cell. Physiol. 210: 667–675, 2007.

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

IntroductionPhysician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive.MethodsTraumatized patients (Injury Severity Score; ISS ≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score.ResultsA total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n = 8,231) were transported by GEMS and 37.7% (n = 4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P < 0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P < 0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P < 0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P < 0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P < 0.001) resulting in an increased length of ICU treatment and in-hospital time (P < 0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862).Afterwards, a subgroup analysis was performed on patients transported to level I trauma centers during daytime with the intent of investigating a possible correlation between the level of the treating trauma center and posttraumatic outcome. According to this analysis, the Standardized Mortality Ratio, SMR, was significantly decreased following the Trauma Score and the Injury Severity Score (TRISS) method (HEMS: 0.647 vs. GEMS: 0.815; P = 0.002) as well as the Revised Injury Severity Classification (RISC) score (HEMS: 0.772 vs. GEMS: 0.864; P = 0.045) in the HEMS group.ConclusionsAlthough HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.

The Role of MIP-1α in the Development of Systemic Inflammatory Response and Organ Injury following Trauma Hemorrhage

Although MIP-1α is an important chemokine in the recruitment of inflammatory cells, it remains unknown whether MIP-1α plays any role in the development of systemic inflammatory response following trauma-hemorrhage (T-H). C57BL/6J wild type (WT) and MIP-1α-deficient (KO) mice were used either as control, subjected to sham operation (cannulation or laparotomy only or cannulation plus laparotomy) or T-H (midline laparotomy, mean blood pressure 35 ± 5 mmHg for 90 min, followed by resuscitation) and sacrificed 2 h thereafter. A marked increase in serum α-glutathione transferase, TNF-α, IL-6, IL-10, MCP-1, and MIP-1α and Kupffer cell cytokine production was observed in WT T-H mice compared with shams or control. In addition lung and liver tissue edema and neutrophil infiltration (myeloperoxidase (MPO) content) was also increased following T-H in WT animals. These inflammatory markers were markedly attenuated in the MIP-1α KO mice following T-H. Furthermore, compared with 2 h, MPO activities at 24 and 48 h after T-H declined steadily in both WT and KO mice. However, normalization of MPO activities to sham levels within 24 h was seen in KO mice but not in WT mice. Thus, MIP-1α plays an important role in mediating the acute inflammatory response following T-H. In the absence of MIP-1α, acute inflammatory responses were attenuated; rapidly recovered and less remote organ injury was noted following T-H. Thus, interventions that reduce MIP-1α levels following T-H should be useful in decreasing the deleterious inflammatory consequence of trauma.

Metabolic modulators following trauma sepsis: sex hormones.

Background:The development of metabolic perturbations following severe trauma/sepsis leading to decreased energy production, hyperglycemia, and lipolysis is often rapid. Gender is increasingly recognized as a major factor in the outcome of patients suffering from trauma/sepsis. Moreover, sex hormones influence energy, glucose, and lipid metabolism. Metabolic modulators, such as peroxisome proliferator-activated receptor-&ggr; coactivator-1 and peroxisome proliferator-activated receptor-&agr;, which are required for mitochondrial energy production and fatty acid oxidation, are regulated by the estrogen receptor-&bgr; and consequently contribute to cardioprotection following trauma hemorrhage. Additionally, sex steroids regulate inflammatory cytokines that cause hypermetabolism/catabolism via acute phase response, leading to increased morbidity and mortality. Measurements:This article examines the following: (1) the evidence for gender differences; (2) energy, glucose, and lipid metabolism and the acute phase protein response; (3) the mechanisms by which gender/sex hormones affect the metabolic modulators; and (4) the tissue-specific effect of sex hormone receptors and the effect of genomic and nongenomic pathways of sex hormones following trauma. Results and Conclusions:The available information indicates that sex steroids not only modulate the immune/cardiovascular responses but also influence various metabolic processes following trauma. Thus, alteration or modulation of the prevailing hormone milieu at the time of injury appears to be a novel therapeutic adjunct for improving outcome after injury.

Keratinocyte-derived chemokine plays a critical role in the induction of systemic inflammation and tissue damage after trauma-hemorrhage

Neutrophil infiltration is a crucial step in the development of organ dysfunction after trauma. We have previously shown that keratinocyte-derived chemokine (KC), a chemoattractant for neutrophils, is up-regulated after trauma-hemorrhage. To determine the role of KC after trauma-hemorrhage, the effect of a KC-neutralizing antibody on the posttraumatic inflammatory response was examined. One hour before surgery, male C3H/HeN mice were treated with an anti-KC antibody or isotype control. Animals were subjected to sham operation or trauma-hemorrhage and resuscitated with Ringer lactate thereafter. They were killed 2 h later, and Kupffer cells were isolated. Plasma levels, Kupffer cell production, and lung and liver content of TNF-α, IL-6, IL-10, monocyte chemoattractant protein 1, macrophage inflammatory protein 1α, and KC were determined by BD cytometric bead arrays. Myeloperoxidase content in lung and liver were measured as a parameter for neutrophil infiltration, and wet-to-dry weight ratios of these organs were also determined. Hepatocyte damage was assessed by measuring α-gluthathione S-transferase concentration. Administration of the anti-KC antibody before trauma-hemorrhage prevented increases in KC plasma levels, which was accompanied by amelioration of neutrophil infiltration and edema formation in lung and liver after trauma-hemorrhage. No effect on other cytokines in plasma or Kupffer cell release was observed. These results suggest that KC plays a pivotal role in neutrophil infiltration and organ damage after trauma-hemorrhage and resuscitation.

The influence of transportation mode on mortality in polytraumatized patients. An analysis based on the German Trauma Registry

ZusammenfassungHintergrundNach mehr als 30xa0Jahren Erfahrung mit Rettungshubschraubern in Deutschland ist die Studienlage bezüglich Zeitvorteil und Letalität im Vergleich zu bodengebundenen Rettungsmitteln nach wie vor umstritten. Ziel dieser Studie war es, den Einfluss des Transportmittels auf Prähospitalintervall und Letalität bei polytraumatisierten Patienten anhand des Traumaregisters der Deutschen Gesellschaft für Unfallchirurgie zu evaluieren.Material und MethodenEs wurden 17.200 prospektiv multizentrisch erhobene Patientendatensätze von 1993–2003 aus dem Traumaregister berücksichtigt. Patienten, die ohne Arztbegleitung ins Krankenhaus eingeliefert wurden, wurden ebenso ausgeschlossen wie Patienten mit einem „Injury Severity Score“ (ISS)<16. Die Daten der eingeschlossenen Patienten wurden hinsichtlich der Prähospitalzeit und Einflusses des Transportmittels auf die Letalität ausgewertet.ErgebnisseVon den 7534 eingeschlossenen Patienten wurden 3870 mittels Rettungshubschrauber (RTH) und 3664 mittels bodengebundener Rettungsmittel (NEF) ins Krankenhaus transportiert. Der Anteil männlicher Patienten in der RTH-Gruppe betrug 74,9%, in der NEF-Gruppe 71,3%. Der mittlere ISS war in der RTH-Gruppe geringfügig höher (31,4 vs. 30,7; p<0,01). Das Alter der Patienten war ebenfalls in beiden Gruppen unterschiedlich (RTH: 39,2; NEF 41,3; p<0,01). Das NEF war durchschnittlich 14:33xa0min nach dem Unfall vor Ort, während der RTH 18:18xa0min benötigte (p<0,01). Die RTH-Gruppe verweilte länger am Unfallort als die NEF-Gruppe (RTH: 26:26xa0min; NEF: 22:29xa0min; p<0,01). Beim bodengebunden Transport wurden die Patienten in ca. 60% der Fälle intubiert, bei der Luftrettung lag die Intubationsrate bei ca. 80%. Die Gesamtletalität des Kollektivs betrug 30,9%. Dabei zeigte sich bei der Analyse der Überlebenswahrscheinlichkeit nach der TRISS-Methode ein spezifischer Vorteil für den Transport mittels RTH. In einer multivariaten Analyse konnte bei intubierten Patienten mit einem ISS≤60 ebenfalls ein Überlebensvorteil bei der Luftrettung nachgewiesen werden (NEF: 40,1%; RTH 34,9%; p<0,01).SchlussfolgerungDie beiden untersuchten Kollektive zeigten nur geringe Unterschiede bezüglich Alter und Verletzungsschwere. Die Zeit zwischen Unfallgeschehen und Ankunft war bei der RTH-Gruppe länger. Das RTH-Team verbrachte einen längeren Zeitraum am Unfallort und führte häufiger Interventionen durch. Bei der Analyse der Letalität zeigten sich Vorteile für den nicht bodengebundenen Transport polytraumatisierter Patienten.AbstractBackgroundThirty years after its introduction in Germany, the benefits of the helicopter emergency medical service (HEMS) compared to ground ambulances (GA) still remain unclear. The aim of this study was to evaluate the influence of helicopter transport on rescue time and mortality based on the data of the German Trauma Registry.MethodsData from patients with multiple injuries were documented prospectively between 1993 and 2003 in different trauma centers in Germany, Switzerland, Austria and The Netherlands. From these data, patients with an injury severity score (ISS) <16 were excluded. Patients who were transported to the hospital without a physician were also excluded. The data from included patients were evaluated for time to hospital and influence of transportation service on mortality.ResultsA total of 7,534 patients with multiple injuries were included. Of these, 3,870 patients were transported by HEMS and 3,664 reached the hospital by GA. There were 74.9% male patients in the HEMS group, and 71.3% male patients in the GA group. The mean ISS was higher in the HEMS group (31.4 vs 30.7; P<0.01); patients transported by GA were older (HEMS: 39.2; NEF:41.3; P<0.01). The GA arrived on the scene after 14.33xa0min, the HEMS after 18.18xa0min (P<0.01). Time at the scene was longer in the HEMS group (HEMS: 26:26xa0min; NEF: 22:29xa0min; P<0.01). Intubation rate in the HEMS group was about 80%, while patients transported by GA were intubated in 60% of cases. The overall mortality was 30.9%. Evaluation of the TRISS prediction of survival showed a benefit for patients transported with HEMS. In a multivariate analysis, intubated patients with ISS≤60 had a lower mortality rate if transported with HEMS (NEF: 40.1%; HEMS 34.9%; P<0.01).ConclusionsOnly minor differences in age and ISS were found between the groups. The time between the accident and arrival of the physician was longer in the HEMS group. The HEMS group also remained on the scene for longer, but had a higher rate of intervention. According to our analysis of the German Trauma Registry, patients with multiple injuries benefit from HEMS transportation.

Intraoperative Pedography: A Validated Method for Static Intraoperative Biomechanical Assessment

Background: A new device was developed to perform intraoperative static pedography. The purpose of this study was to validate the introduced method by a comparison with the standard method for dynamic and static pedography. Methods: A device known as Kraftsimulator Intraoperative Pedographie® (KIOP®) was developed for intraoperative placement of standardized forces to the sole of the foot. Pedographic measurements were done with a custom-made mat that was inserted into the KIOP® (Pliance®, Novel Inc., St. Paul, MN, USA). Validation was done in two steps: (1) comparison of standard dynamic pedography walking on a platform, standard static pedography in standing on a platform, and pedography with KIOP® in supine position in 30 healthy volunteers, and (2) comparison of static pedography in standing position, pedography with KIOP® supine awake, and pedography with KIOP® supine with 30 patients under anesthesia. Individuals who had operative procedures at the knee or distal to the knee were excluded. The different measurements were compared (one-way ANOVA, t-test; significance level 0.05). Results: No significant differences were found among all measurements for the hindfoot compared to midfoot-forefoot force distribution. For the medial compared to lateral force distribution and the 10-region-mapping, significant differences were found when comparing all measurements (steps 1 and 2) and when comparing the measurements of step 1 only. No differences were found for these distributions when comparing the measurements of step 2 alone or when comparing the measurements of step 1 and 2 without the platform measurements of step 1 (dynamic walking pedography and static standing pedography). No significant differences in the force distributions were found in step 2 when comparing subjects without anesthesia, with general anesthesia, and with spinal anesthesia. Conclusions: The KIOP device allows a valid static intraoperative pedography measurement. No statistically significant force distribution differences were found between standing subjects and anesthetized subjects in the supine position.

[Voluminous bone graft harvesting of the femoral marrow cavity for autologous transplantation. An indication for the"Reamer-Irrigator-Aspirator-" (RIA-)technique].

Due to their excellent osteoinductive, osteogenetic, and osteoconductive properties, autologous bone grafts possess biomechanical advantages over synthetic bone substitutes. Furthermore, unlike cadaveric allografts and xenografts, they carry no risk of immunogenic response or transmission of infectious diseases. However, the limited availability of autologous bone grafts requires the use of the above-mentioned bone substitutes for management of large bone defects. TheReamer-Irrigator-Aspirator- (RIA-)technique may present an alternative method for harvesting a larger volume of autologous bone graft as compared with conventional harvesting procedures. We report on intramedullary reaming by the RIA technique to obtain autologous bone graft for a nonunion of the proximal femur. The contralateral femur was reamed and the bone graft was applied to the nonunion. The patient showed clinical and radiological healing of the nonunion without donor site complications.ZusammenfassungAutologe Knochentransplantate haben aufgrund ihrer hervorragenden osteoinduktiven, osteogenetischen sowie osteokonduktiven Eigenschaften biomechanische Vorteile gegenüber künstlichen Knochenpräparaten. Auch im Vergleich zu Kadavertransplantaten oder Xenotransplantaten sind diese aufgrund fehlender immunologischer Abstoßung oder Übertragung infektiöser Erkrankungen vorteilhaft. Die limitierte Verfügbarkeit der autologen Knochenspongiosa bedingt es jedoch, bei großen Knochendefekten auf oben genannte Knochenersatzstoffe zurückzugreifen.Seit kurzem ist eine neue Technik verfügbar, welche die Gewinnung größerer Volumina an autologer Knochenspongiosa erlaubt. Wir berichten über die Verwendung der „Reamer-Irrigator-Aspirator-“ (RIA-)Technik zur Gewinnung von Knochenspongiosa bei einem Patienten mit Pseudarthrose bei großer Defektzone des proximalen Femurs. Hierzu wurde das kontralaterale Femur in gesamter Länge aufgebohrt und die gewonnene Knochenspongiosa im Bereich der Pseudarthrose angelagert. Klinisch und radiologisch zeigte sich im Verlauf eine Ausheilung der Pseudarthrose ohne Entnahmemorbidität.AbstractDue to their excellent osteoinductive, osteogenetic, and osteoconductive properties, autologous bone grafts possess biomechanical advantages over synthetic bone substitutes. Furthermore, unlike cadaveric allografts and xenografts, they carry no risk of immunogenic response or transmission of infectious diseases. However, the limited availability of autologous bone grafts requires the use of the above-mentioned bone substitutes for management of large bone defects.The“Reamer-Irrigator-Aspirator-” (RIA-)technique may present an alternative method for harvesting a larger volume of autologous bone graft as compared with conventional harvesting procedures. We report on intramedullary reaming by the RIA technique to obtain autologous bone graft for a nonunion of the proximal femur. The contralateral femur was reamed and the bone graft was applied to the nonunion. The patient showed clinical and radiological healing of the nonunion without donor site complications.

Downregulation of TLR4-dependent ATP production is critical for estrogen-mediated immunoprotection in Kupffer cells following trauma-hemorrhage.

Toll‐like receptor 4 (TLR4) mediates mitochondrial DNA (mtDNA) damage and biogenic responses. Mitochondrial transcription factor A (Tfam) is an essential regulator for mtDNA transcription and ATP production. Increased ATP levels were associated with normalization of immune function following trauma‐hemorrhage. Moreover, administration of 17β‐estradiol following trauma‐hemorrhage upregulates cardiac Tfam and ATP levels. We therefore hypothesized that the salutary effect of 17β‐estradiol on Kupffer cell function following trauma‐hemorrhage is mediated via negative regulation of TLR4, which downregulates iNOS, upregulates Tfam and mtDNA‐encoded gene cytochrome c oxidase I (mtCOI), and consequently increases cellular ATP levels. Male C3H/HeN, C3H/HeOuJ (intact TLR4), and C3H/HeJ (TLR4 mutant) mice were subjected to trauma‐hemorrhage (mean BP 35u2009±u20095 mmHg ∼90 min, then resuscitation) or sham operation. At the beginning of resuscitation, mice received 17β‐estradiol (25 µg/25 g) or vehicle intravenously and were sacrificed 2 h thereafter. Kupffer cell TLR4, iNOS, IL‐6 and TNF‐α production capacities were increased, and ATP, Tfam, and mtCOI levels were decreased following trauma‐hemorrhage. Administration of 17β‐estradiol following trauma‐hemorrhage prevented the increase in Kupffer cell TLR4, iNOS, and cytokine production. This was accompanied by normalized ATP, Tfam, and mtCOI levels. Furthermore, the decreased Kupffer cell ATP and mtCOI levels were not observed in TLR4 mutant mice following trauma‐hemorrhage. Taken together, these findings suggest that downregulation of TLR4‐dependent ATP production is critical to 17β‐estradiol‐mediated immunoprotection in Kupffer cells following trauma‐hemorrhage. J. Cell. Physiol. 211: 364–370, 2007.