Journal of Clinical Medicine

Editorial

Jump to: Research, Review

5 pages, 151 KiB

Open AccessEditorial

New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient

by Frank Hildebrand and Klemens Horst

J. Clin. Med. 2020, 9(11), 3468; https://doi.org/10.3390/jcm9113468 - 28 Oct 2020

Cited by 1 | Viewed by 1282

Abstract

Severe trauma remains a leading cause of death, especially in the younger population [...] Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

Research

Jump to: Editorial, Review

14 pages, 1072 KiB

Open AccessArticle

Is ROTEM Diagnostic in Trauma Care Associated with Lower Mortality Rates in Bleeding Patients?—A Retrospective Analysis of 7461 Patients Derived from the TraumaRegister DGU^®

by Katrin Riehl, Rolf Lefering, Marc Maegele, Michael Caspers, Filippo Migliorini, Hanno Schenker, Frank Hildebrand, Matthias Fröhlich and Arne Driessen

J. Clin. Med. 2022, 11(20), 6150; https://doi.org/10.3390/jcm11206150 - 19 Oct 2022

Cited by 6 | Viewed by 2505

Abstract

Introduction: Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM^®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of [...] Read more.

Introduction: Death from uncontrolled trauma haemorrhage and subsequent trauma-induced coagulopathy (TIC) is potentially preventable. Point-of-care devices such as rotational thromboelastometry (ROTEM^®) are advocated to detect haemostatic derangements more rapidly than conventional laboratory diagnostics. Regarding reductions in RBC transfusion, the use of ROTEM has been described as being efficient and associated with positive outcomes in several studies. Objective: The effect of ROTEM use was assessed on three different outcome variables: (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality in severely injured patients. Methods and Material: A retrospective analysis of a large data set of severely injured patients collected into the TraumaRegister DGU^® between 2009 and 2016 was conducted. The data of 7461 patients corresponded to the inclusion criteria and were subdivided into ROTEM-using and ROTEM-non-using groups. Both groups were analysed regarding (i) administration of haemostatics, (ii) rate of RBC transfusions and (iii) mortality. Results: A lower mortality rate in ROTEM-using groups was observed (p = 0.043). Furthermore, more patients received haemostatic medication when ROTEM was used. In ROTEM-using groups, there was a statistically relevant higher application of massive transfusion. Conclusions: In this retrospective study, the use of ROTEM was associated with reduced mortality and an increased application of haemostatics and RBC transfusions. Prospective evidence is needed for further evidence-based recommendations. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

13 pages, 680 KiB

Open AccessArticle

Traumatic Hip Dislocations in Major Trauma Patients: Epidemiology, Injury Mechanisms, and Concomitant Injuries

by Christian D. Weber, Rolf Lefering, Richard M. Sellei, Klemens Horst, Filippo Migliorini, Frank Hildebrand and TraumaRegister DGU

J. Clin. Med. 2022, 11(3), 472; https://doi.org/10.3390/jcm11030472 - 18 Jan 2022

Cited by 8 | Viewed by 2269

Abstract

Introduction: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and [...] Read more.

Introduction: Traumatic hip dislocations (THDs) are severe injuries associated with considerable morbidity. Delayed recognition of fracture dislocations and neurovascular deficits have been proposed to cause deleterious long-term clinical outcomes. Therefore, in this study, we aimed to identify characteristics of epidemiology, injury mechanisms, and associated injuries to identify patients at risk. Methods: For this study based on the TraumaRegister DGU^® (January 2002–December 2017), the inclusion criterion was an Injury Severity Score (ISS) ≥9 points. Exclusion criteria were an isolated head injury and early transfer to another hospital. The THD group was compared to a control group without hip dislocation. The ISS and New ISS were used for injury severity and the Abbreviated Injury Scale for associated injuries classification. Univariate and logistic regression analyses were performed. Results: The final study cohort comprised n = 170,934 major trauma patients. We identified 1359 individuals (0.8%) with THD; 12 patients had sustained bilateral hip dislocations. Patients with THD were predominantly male (79.5%, mean age 43 years, mean ISS 22.4 points). Aortic injuries (2.1% vs. 0.9%, p ≤ 0.001) were observed more frequently in the THD group. Among the predictors for THDs were specific injury mechanisms, including motor vehicle accidents (odds ratio (OR) 2.98, 95% confidence interval (CI) 2.57–3.45, p ≤ 0.001), motorcycle accidents (OR 1.99, 95% CI 1.66–2.39, p ≤ 0.001), and suicide attempts (OR 1.36, 95% CI 1.06–1.75, p = 0.016). Despite a lower rate of head injuries and a comparable level of care measured by trauma center admission, both intensive care unit and total hospital stay were prolonged in patients with THD. Conclusions: Since early diagnosis, as well as timely and sufficient treatment, of THDs are of high relevance for long-term outcomes of severely injured individuals, knowledge of patients at risk for this injury pattern is of utmost importance. THDs are frequently related to high-energy mechanisms and associated with severe concomitant injuries in major trauma patients. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

13 pages, 1704 KiB

Open AccessArticle

The Role of Ribonuclease 1 and Ribonuclease Inhibitor 1 in Acute Kidney Injury after Open and Endovascular Thoracoabdominal Aortic Aneurysm Repair

by Elisabeth Zechendorf, Alexander Gombert, Tanja Bülow, Nadine Frank, Christian Beckers, Arne Peine, Drosos Kotelis, Michael J. Jacobs, Gernot Marx and Lukas Martin

J. Clin. Med. 2020, 9(10), 3292; https://doi.org/10.3390/jcm9103292 - 14 Oct 2020

Cited by 5 | Viewed by 2031

Abstract

Acute kidney injury (AKI) is one of the most common post-operative complications and is closely associated with increased mortality after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Ribonuclease (RNase) 1 belongs to the group of antimicrobial peptides elevated in septic patients and [...] Read more.

Acute kidney injury (AKI) is one of the most common post-operative complications and is closely associated with increased mortality after open and endovascular thoracoabdominal aortic aneurysm (TAAA) repair. Ribonuclease (RNase) 1 belongs to the group of antimicrobial peptides elevated in septic patients and indicates the prediction of two or more organ failures. The role of RNase 1 and its antagonist RNase inhibitor 1 (RNH1) after TAAA repair is unknown. In this study, we analyzed RNase 1 and RNH1 serum levels in patients undergoing open (n = 14) or endovascular (n = 19) TAAA repair to determine their association with post-operative AKI and in-hospital mortality. Increased RNH1 serum levels after open TAAA repair as compared with endovascular TAAA repair immediately after surgery and 12, 48, and 72 h after surgery (all p < 0.05) were observed. Additionally, elevated RNase 1 and RNH1 serum levels 12, 24, and 48 h after surgery were shown to be significantly associated with AKI (all p < 0.05). RNH1 serum levels before and RNase 1 serum levels 12 h after TAAA repair were significantly correlated with in-hospital mortality (both p < 0.05). On the basis of these findings, RNase 1 and RNH1 may be therapeutically relevant and may represent biomarkers for post-operative AKI and in-hospital mortality. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

8 pages, 211 KiB

Open AccessArticle

Impact of Chest Trauma and Overweight on Mortality and Outcome in Severely Injured Patients

by Thurid Eckhardt, Klemens Horst, Philipp Störmann, Felix Bläsius, Martijn Hofman, Christian Herren, Philipp Kobbe, Frank Hildebrand and Hagen Andruszkow

J. Clin. Med. 2020, 9(9), 2752; https://doi.org/10.3390/jcm9092752 - 26 Aug 2020

Cited by 5 | Viewed by 2157

Abstract

The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an [...] Read more.

The morbidity and mortality of severely injured patients are commonly affected by multiple factors. Especially, severe chest trauma has been shown to be a significant factor in considering outcome. Contemporaneously, weight-associated endocrinological, haematological, and metabolic deviations from the norm seem to have an impact on the posttraumatic course. Therefore, the aim of this study was to determine the influence of body weight on severely injured patients by emphasizing chest trauma. A total of 338 severely injured patients were included. Multivariate regression analyses were performed on patients with severe chest trauma (AIS ≥ 3) and patients with minor chest trauma (AIS < 3). The influence of body weight on in-hospital mortality was evaluated. Of all the patients, 70.4% were male, the median age was 52 years (IQR 36–68), the overall Injury Severity Score (ISS) was 24 points (IQR 17–29), and a median BMI of 25.1 points (IQR 23–28) was determined. In general, chest trauma was associated with prolonged ventilation, prolonged ICU treatment, and increased mortality. For overweight patients with severe chest trauma, an independent survival benefit was found (OR 0.158; p = 0.037). Overweight seems to have an impact on the mortality of severely injured patients with combined chest trauma. Potentially, a nutritive advantage or still-unknown immunological aspects in these patients affecting the intensive treatment course could be argued. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

9 pages, 590 KiB

Open AccessArticle

Increased First Pass Success with C-MAC Videolaryngoscopy in Prehospital Endotracheal Intubation—A Randomized Controlled Trial

by Christian Macke, Felix Gralla, Marcel Winkelmann, Jan-Dierk Clausen, Marco Haertle, Christian Krettek and Mohamed Omar

J. Clin. Med. 2020, 9(9), 2719; https://doi.org/10.3390/jcm9092719 - 22 Aug 2020

Cited by 26 | Viewed by 3991

Abstract

Endotracheal intubation (ETI) with direct view laryngoscopy (DL) is the gold standard for airway management. Videolaryngoscopy (VL) can improve glottis visualization, thus facilitating ETI. The aim of this monocentric, randomized, prospective study on a physician staffed German air ambulance is to compare DL [...] Read more.

Endotracheal intubation (ETI) with direct view laryngoscopy (DL) is the gold standard for airway management. Videolaryngoscopy (VL) can improve glottis visualization, thus facilitating ETI. The aim of this monocentric, randomized, prospective study on a physician staffed German air ambulance is to compare DL and VL for ETI in terms of number of attempts and time as well as visualization of the glottis in a prehospital setting in a physician-based rescue system in adult patients. A power analysis was performed à priori. We used consecutive on-scene randomization with a sealed envelope system for the DL and VL-group. Successful ETI with first pass success was significantly more frequent with VL than DL and three seconds faster. The percentage of glottis opening and the Cormack & Lehane classification were significantly better with VL than DL. Regarding improved first pass success in ETI with the VL, we would recommend the use of VL for prehospital airway management in physician-based rescue systems. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

14 pages, 2557 KiB

Open AccessArticle

Safety, Effect and Feasibility of Percutaneous SI-Screw with and without Augmentation—A 15-Year Retrospective Analysis on over 640 Screws

by René Hartensuer, Moritz F. Lodde, Jonas Keller, Maria Eveslage, Josef Stolberg-Stolberg, Oliver Riesenbeck and Michael J. Raschke

J. Clin. Med. 2020, 9(8), 2660; https://doi.org/10.3390/jcm9082660 - 17 Aug 2020

Cited by 24 | Viewed by 2921

Abstract

Background: Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem [...] Read more.

Background: Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem to be contradictory. Methods: The present single center retrospective cohort study investigated percutaneous SI-screw fixation and augmentation over 15 years. Groups were compared concerning the general epidemiological data, mobilization, complication rates, duration of stay, and safety of SI-screw insertion. Multivariable analyses were performed using logistic regression. Results: Between 2005 and March 2020, 448 patients with 642 inserted SI-screws were identified. Iatrogenic neurological impairment was documented in 2.47% and correlated with screw misplacement. There was an increased complication risk in patients with AO type C over patients with AO type B and in FFP II over FFP III/IV patients. Cement-augmented FFP patients showed a 25% reduced stay in hospital and a reduced complication risk. Cement-associated complications were seen in 22% without correlation to neurologic impairment. Conclusions: The present study confirms the safety and usability of percutaneous SI-screw fixation, despite specific risks. Cement augmentation seems to reduce the complication risk in FFP patients and shorten hospital stay for some reasons, without increased specific complications or correlated neurological impairment. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

10 pages, 890 KiB

Open AccessArticle

Modified Split-Scan Computed Tomography (CT) Diagnostics of Severely Injured Patients: First Results from a Level I Trauma Center Using a Dedicated Head-and-Neck CT-Angiogram for the Detection of Cervical Artery Dissections

by Daniel Popp, Claudius Thiedemann, Wolf Bäumler, Antonio Ernstberger, Volker Alt and Andreas Schicho

J. Clin. Med. 2020, 9(8), 2568; https://doi.org/10.3390/jcm9082568 - 8 Aug 2020

Cited by 5 | Viewed by 2746

Abstract

Introduction: Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have [...] Read more.

Introduction: Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured. Materials and Methods: A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD). Results: Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5–9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A). Conclusion: A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

10 pages, 1828 KiB

Open AccessArticle

Load-Bearing Detection with Insole-Force Sensors Provides New Treatment Insights in Fragility Fractures of the Pelvis

by Daniel Pfeufer, Christopher A. Becker, Leon Faust, Alexander M. Keppler, Marissa Stagg, Christian Kammerlander, Wolfgang Böcker and Carl Neuerburg

J. Clin. Med. 2020, 9(8), 2551; https://doi.org/10.3390/jcm9082551 - 6 Aug 2020

Cited by 10 | Viewed by 3862

Abstract

Background: Due to an aging society, more and more surgeons are confronted with fragility fractures of the pelvis (FFPs). The aim of treatment of such patients should be the quickest possible mobilization with full weight-bearing. Up to now however, there are no data [...] Read more.

Background: Due to an aging society, more and more surgeons are confronted with fragility fractures of the pelvis (FFPs). The aim of treatment of such patients should be the quickest possible mobilization with full weight-bearing. Up to now however, there are no data on loading of the lower extremities in patients suffering FFPs. We hypothesized to find differences in loading of the lower limbs. Methods: 22 patients with a mean age of 84.1 years were included. During gait analysis with insole-force sensors, loading on the lower extremities was recorded during early mobilization after index fracture. Results: Especially the average peak force showed differences in loading, as the affected limb was loaded significantly less {59.78% (SD ± 16.15%) of the bodyweight vs. 73.22% (SD ± 14.84%) (p = <0.001, effect size r = 0.58)}. Furthermore, differences in loading in between the fracture patterns of FFPs were observed. Conclusion: This study shows that it is possible to reliably detect the extremity load, with the help of an insole device, in patients presenting with fragility fractures of the pelvis. There is great potential to improve the choice and time of treatment with insole-force sensors in FFPs in future. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

13 pages, 777 KiB

Open AccessArticle

Evidence of Prolonged Monitoring of Trauma Patients Admitted via Trauma Resuscitation Unit without Primary Proof of Severe Injuries

by Martin Heinrich, Matthias Lany, Lydia Anastasopoulou, Christoph Biehl, Gabor Szalay, Florian Brenck and Christian Heiss

J. Clin. Med. 2020, 9(8), 2516; https://doi.org/10.3390/jcm9082516 - 4 Aug 2020

Cited by 1 | Viewed by 2256

Abstract

Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. Methods: All trauma patients in a period of eight months in a Level I trauma center were followed. [...] Read more.

Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. Methods: All trauma patients in a period of eight months in a Level I trauma center were followed. Retrospective analysis was performed only in patients ≥18 years with primary TRU admission, Abbreviated Injury Scale (AIS) ≤ 1, Maximum Abbreviated Injury Scale (MAIS) ≤ 1 and Injury Severity Score (ISS) ≤3 after treatment completion and ≥24 h monitoring in the units. Cochran’s Q-test was used for the statistical evaluation of AIS and ISS changes in units. Results: One hundred and twelve patients were enrolled in the study. Twenty-one patients (18.75%) reported new complaints after treatment completion in the TRU. AIS rose from the Intermediate Care Unit (IMC) to Normal Care Unit (NCU) 6.2% and ISS 6.9%. MAIS did not increase >2, and no intervention was necessary for any patient. No correlation was found between computed tomography (CT) diagnostics in TRU and AIS change. Conclusions: The data suggest that AIS, MAIS and ISS did not increase significantly in patients without a severe injury during inpatient treatment, regardless of the type of CT diagnostics performed in the TRU, suggesting that monitoring of these patients may be unnecessary. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

11 pages, 1474 KiB

Open AccessArticle

Isolated Pubic Ramus Fractures Are Serious Adverse Events for Elderly Persons: An Observational Study on 138 Patients with Fragility Fractures of the Pelvis Type I (FFP Type I)

by Pol Maria Rommens, Johannes Christof Hopf, Michiel Herteleer, Benjamin Devlieger, Alexander Hofmann and Daniel Wagner

J. Clin. Med. 2020, 9(8), 2498; https://doi.org/10.3390/jcm9082498 - 3 Aug 2020

Cited by 28 | Viewed by 5034

Abstract

Background: Fractures of the pubic ramus without involvement of the posterior pelvic ring represent a minority of fragility fractures of the pelvis (FFP). The natural history of patients suffering this FFP Type I has not been described so far. Material and methods: All [...] Read more.

Background: Fractures of the pubic ramus without involvement of the posterior pelvic ring represent a minority of fragility fractures of the pelvis (FFP). The natural history of patients suffering this FFP Type I has not been described so far. Material and methods: All patients, who were admitted with isolated pubic ramus fractures between 2007 and mid-2018, have been reviewed. Epidemiologic data, comorbidities, in-hospital complications, and one-year mortality were recorded. Of all surviving patients, living condition before the fracture and at follow-up was noted. Mobility was scored with the Parker Mobility Score, quality of life with the European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), subjective sensation of pain with the Numeric Rating Scale (NRS). Results: A consecutive series of 138 patients was included in the study. There were 117 women (84.8%) and 21 men (15.2%). Mean age was 80.6 years (SD 8.6 years). 89.1% of patients presented with comorbidities, 81.2% of them had cardiovascular diseases. Five patients (4%) died during hospital-stay. Median in-hospital stay was eight days (2–45 days). There were in-hospital complications in 16.5%, urinary tract infections, and pneumonia being the most frequent. One-year mortality was 16.7%. Reference values for the normal population of the same age are 5.9% for men and 4.0% for women. One-year mortality rate was 22.2% in the patient group of 80 years or above and 8.8% in the patient group below the age of 80. The rate of surviving patients living at home with or without assistance dropped from 80.5% to 65.3%. The median EQ-5D-Index Value was 0.62 (0.04–1; IQR 0.5–0.78). Reference value for the normal population is 0.78. Average PMS was 4 and NRS 3. Within a two-year period, additional fragility fractures occurred in 21.2% and antiresorptive medication was taken by only 45.2% of patients. Conclusion. Pubic ramus fractures without involvement of the posterior pelvis (FFP Type I) are serious adverse events for elderly persons. During follow-up, there is an excess mortality, a loss of independence, a restricted mobility, and a decreased quality of life. Pubic ramus fractures are indicators for the need to optimize the patient’s general condition. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

9 pages, 409 KiB

Open AccessArticle

Retrospective Analysis of the Clinical Outcome in a Matched Case-Control Cohort of Polytrauma Patients Following an Osteosynthetic Flail Chest Stabilization

by Marcel Niemann, Frank Graef, Serafeim Tsitsilonis, Ulrich Stöckle and Sven Märdian

J. Clin. Med. 2020, 9(8), 2379; https://doi.org/10.3390/jcm9082379 - 26 Jul 2020

Cited by 2 | Viewed by 1955

Abstract

Background: In polytrauma (PT) patients, osseous thoracic injuries are commonly observed. One of the most severe injuries is the flail chest where the rib cage is broken in such a way that leads to a partial functional detachment of the thoracic wall. Especially [...] Read more.

Background: In polytrauma (PT) patients, osseous thoracic injuries are commonly observed. One of the most severe injuries is the flail chest where the rib cage is broken in such a way that leads to a partial functional detachment of the thoracic wall. Especially in PT patients, the integrity of the respiratory system and especially, of the respiratory muscles is essential to prevent respiratory failure. Besides conservative treatment options, flail chest injuries may be surgically stabilized. However, this treatment option is rarely carried out and evidence on the outcome of surgically treated flail chest patients is rare. Objective: This study intends to investigate the clinical outcome of PT patients with the diagnosis of a flail chest who received an osteosynthetic stabilization for that compared to the same group of patients without an operative treatment. The between-groups outcome was compared regarding the duration of the total hospital and the intensive care unit (ICU) stay, the total of the invasive ventilation days, the incidence of pneumonia, and the dosage of the pain medication at the hospital discharge. Methods: A retrospective analysis was conducted including all PT patients who received an osteosynthetic stabilization of a flail chest. Furthermore, another cohort of PT patients and the diagnosis of a flail chest but without operative treatment was determined. Both groups were case-control matched for the Injury Severity Score (ISS) and age. Further statistical analysis was performed using the Wilcoxon signed-rank test and the McNemar’s test. Results: Out of eleven operatively and 59 conservatively treated patients, eleven patients per group were matched. Further analysis revealed no significant differences in the normal ward treatment duration (5.64 ± 6.62 and 6.20 ± 5.85 days), the invasive ventilation duration (was 6.25 ± 7.17 and 7.10 ± 6.14 days), the morphine equivalent dosage of the oral analgesia (61.36 ± 67.23 mg and 39.67 ± 65.65 mg), and the pneumonia incidence (36.4 and 54.5%) when conservatively and operatively treated patients were compared, respectively. However, surgically treated patients had a longer ICU (25.18 ± 14.48 and 15.27 ± 12.10 days, Z = −2.308, p = 0.021) and a longer total hospital treatment duration (30.10 ± 13.01 and 20.91 ± 10.34 days, Z = −2.807, p = 0.005) when compared to conservatively treated patients. Conclusion: In the present study cohort, there was no outcome difference between conservatively and operatively treated patients with the diagnosis of a flail chest regarding the normal ward treatment duration, the invasive ventilation duration, the morphine equivalent dosage of the oral analgesia, and the pneumonia incidence while ICU treatment duration and hospital treatment duration was longer in operatively treated patients. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

14 pages, 1477 KiB

Open AccessArticle

Reduced Recovery Capacity After Major Trauma in the Elderly: Results of a Prospective Multicenter Registry-Based Cohort Study

by Viola Freigang, Karolina Müller, Antonio Ernstberger, Marlene Kaltenstadler, Lisa Bode, Christian Pfeifer, Volker Alt and Florian Baumann

J. Clin. Med. 2020, 9(8), 2356; https://doi.org/10.3390/jcm9082356 - 23 Jul 2020

Cited by 9 | Viewed by 2494

Abstract

Aims: Considering the worldwide trend of an increased lifetime, geriatric trauma is moving into focus. Trauma is a leading cause of hospitalization, leading to disability and mortality. The purpose of this study was to compare the global health-related quality of life (HRQoL) of [...] Read more.

Aims: Considering the worldwide trend of an increased lifetime, geriatric trauma is moving into focus. Trauma is a leading cause of hospitalization, leading to disability and mortality. The purpose of this study was to compare the global health-related quality of life (HRQoL) of geriatric patients with adult patients after major trauma. Methods: This multicenter prospective registry-based observational study compares HRQoL of patients aged ≥65 years who sustained major trauma (Injury Severity Score (ISS) ≥ 16) with patients <65 years of age within the trauma registry of the German Trauma Society (DGU). The global HRQoL was measured at 6, 12, and 24 months post trauma using the EQ-5D-3L score. Results: We identified 405 patients meeting the inclusion criteria with a mean ISS of 25.6. Even though the geriatric patients group (≥65 years, n = 77) had a lower ISS (m = 24, SD = 8) than patients aged <65 years (n = 328), they reported more difficulties in each EQ dimension compared to patients <65 years. Contrary to patients < 65, the EQ-5D Index of the geriatric patients did not improve at 12 and 24 months after trauma. Conclusions: We found a limited HRQoL in both groups after major trauma. The group of patients ≥65 showed no improvement in HRQoL from 6 to 24 months after trauma. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

8 pages, 508 KiB

Open AccessArticle

Is the Additional Effort for an Intraoperative CT Scan Justified for Distal Radius Fracture Fixations? A Comparative Clinical Feasibility Study

by Sascha Halvachizadeh, Till Berk, Alexander Pieringer, Emanuael Ried, Florian Hess, Roman Pfeifer, Hans-Christoph Pape and Florin Allemann

J. Clin. Med. 2020, 9(7), 2254; https://doi.org/10.3390/jcm9072254 - 16 Jul 2020

Cited by 9 | Viewed by 2044

Abstract

Introduction: It is currently unclear whether the additional effort to perform an intraoperative computed tomography (CT) scan is justified for articular distal radius fractures (DRFs). The purpose of this study was to assess radiological, functional, and clinical outcomes after surgical treatment of distal [...] Read more.

Introduction: It is currently unclear whether the additional effort to perform an intraoperative computed tomography (CT) scan is justified for articular distal radius fractures (DRFs). The purpose of this study was to assess radiological, functional, and clinical outcomes after surgical treatment of distal radius fractures when using conventional fluoroscopy vs. intraoperative CT scans. Methods: Inclusion criteria: Surgical treatment of DRF between 1 January 2011 and 31 December 2011, age 18 and above. Group distribution: intraoperative conventional fluoroscopy (Group Conv) or intraoperative CT scans (Group CT). Exclusion criteria: Use of different image intensifier devices or incomplete data. DRF classification according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification. Outcome variables included requirement of revision surgeries, duration of surgery, absorbed radiation dose, and requirement of additional CT scans during hospitalization. Results: A total of 187 patients were included (Group Conv n = 96 (51.3%), Group CT n = 91 (48.7%)). AO Classification: Type A fractures n = 40 (50%) in Group Conv vs. n = 16 (17.6%) in Group CT, p < 0.001; Type B: 10 (10.4%) vs. 11 (12.1%), not significant (n.s.); Type C: 38 (39.6%) vs. 64 (70.3%), p < 0.001. In Group Conv, four (4.2%) patients required revision surgeries within 6 months, but in Group CT no revision surgery was required. The CT scan led to an intraoperative screw exchange/reposition in 23 (25.3%) cases. The duration of the initial surgery (81.7 ± 46.4 min vs. 90.1 ± 43.6 min, n.s.) was comparable. The radiation dose was significantly higher in Group CT (6.9 ± 1.3 vs. 2.8 ± 7.8 mGy, p < 0.001). In Group Conv, 11 (11.5%) patients required additional CT scans during hospitalization. Conclusion: The usage of intraoperative CT was associated with improved reduction and more adequate positioning of screws postoperatively with comparable durations of surgery. Despite increased efforts by utilizing the intraoperative CT scan, the decrease in reoperations may justify its use. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

10 pages, 446 KiB

Open AccessArticle

High Prevalence of Sarcopenia in Older Trauma Patients: A Pilot Study

by Robert C. Stassen, Kostan W. Reisinger, Moaath Al-Ali, Martijn Poeze, Jan A. Ten Bosch and Taco J. Blokhuis

J. Clin. Med. 2020, 9(7), 2046; https://doi.org/10.3390/jcm9072046 - 29 Jun 2020

Cited by 10 | Viewed by 2087

Abstract

Sarcopenia is related to adverse outcomes in various populations. However, little is known about the prevalence of sarcopenia in polytrauma patients. Identifying the number of patients at risk of adverse outcome will increase awareness to prevent further loss of muscle mass. We utilized [...] Read more.

Sarcopenia is related to adverse outcomes in various populations. However, little is known about the prevalence of sarcopenia in polytrauma patients. Identifying the number of patients at risk of adverse outcome will increase awareness to prevent further loss of muscle mass. We utilized data from a regional prospective trauma registry of all polytrauma patients presented between 2015 and 2019 at a single level-I trauma center. Subjects were screened for availability of computed tomography (CT)-abdomen and height in order to calculate skeletal mass index, which was used to estimate sarcopenia. Additional parameters regarding clinical outcome were assessed. Univariate analysis was performed to identify parameters related adverse outcome and, if identified, entered in a multivariate regression analysis. Prevalence of sarcopenia was 33.5% in the total population but was even higher in older age groups (range 60–79 years), reaching 82 % in patients over 80 years old. Sarcopenia was related to 30-day or in-hospital mortality (p = 0.032), as well as age (p < 0.0001), injury severity score (p = 0.026), and Charlson comorbidity index (p = 0.001). Log rank analysis identified sarcopenia as an independent predictor of 30-day mortality (p = 0.032). In conclusion, we observed a high prevalence of sarcopenia among polytrauma patients, further increasing in older patients. In addition, sarcopenia was identified as a predictor for 30-day mortality, underlining the clinical significance of identification of low muscle mass on a CT scan that is already routinely obtained in most trauma patients. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Graphical abstract

11 pages, 263 KiB

Open AccessArticle

Effects of Four-Week Rehabilitation Program on Hemostasis Disorders in Patients with Spinal Cord Injury

by Magdalena Mackiewicz-Milewska, Małgorzata Cisowska-Adamiak, Danuta Rość, Iwona Głowacka-Mrotek and Iwona Świątkiewicz

J. Clin. Med. 2020, 9(6), 1836; https://doi.org/10.3390/jcm9061836 - 12 Jun 2020

Cited by 4 | Viewed by 2231

Abstract

Background: Patients with spinal cord injury (SCI) exhibit hemostasis disorders. This study aims at assessing the effects of a 4-week rehabilitation program on hemostasis disorders in patients with SCI. Methods: Seventy-eight in-patients undergoing a 4-week rehabilitation were divided into three groups based on [...] Read more.

Background: Patients with spinal cord injury (SCI) exhibit hemostasis disorders. This study aims at assessing the effects of a 4-week rehabilitation program on hemostasis disorders in patients with SCI. Methods: Seventy-eight in-patients undergoing a 4-week rehabilitation were divided into three groups based on time elapsed since SCI: I (3 weeks–3 months), II (3–6 months), and III (>6 months). Tissue factor (TF), tissue factor pathway inhibitor (TFPI), thrombin–antithrombin complex (TAT) and D-dimer levels, antithrombin activity (AT), and platelet count (PLT) were measured on admission and after rehabilitation. Results: Rehabilitation resulted in an increase in TF in group III (p < 0.050), and decrease in TFPI (p < 0.022) and PLT (p < 0.042) in group II as well as AT in group I (p < 0.009). Compared to control group without SCI, TF, TFPI, and TAT were significantly higher in all SCI groups both before and after rehabilitation. All SCI groups had elevated D-dimer, which decreased after rehabilitation in the whole study group (p < 0.001) and group I (p < 0.001). Conclusion: No decrease in activation of TF-dependent coagulation was observed after a 4-week rehabilitation regardless of time elapsed since SCI. However, D-dimer levels decreased significantly, which may indicate reduction of high fibrinolytic potential, especially when rehabilitation was done <3 months after SCI. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

13 pages, 1814 KiB

Open AccessArticle

Early Spinal Injury Stabilization in Multiple-Injured Patients: Do All Patients Benefit?

by Philipp Kobbe, Patrick Krug, Hagen Andruszkow, Miguel Pishnamaz, Martijn Hofman, Klemens Horst, Carolin Meyer, Max Joseph Scheyerer, Christoph Faymonville, Gregor Stein, Frank Hildebrand and Christian Herren

J. Clin. Med. 2020, 9(6), 1760; https://doi.org/10.3390/jcm9061760 - 5 Jun 2020

Cited by 9 | Viewed by 2610

Abstract

Background: Thoracolumbar spine fractures in multiple-injured patients are a common injury pattern. The appropriate timing for the surgical stabilization of vertebral fractures is still controversial. The purpose of this study was to analyse the impact of the timing of spinal surgery in multiple-injured [...] Read more.

Background: Thoracolumbar spine fractures in multiple-injured patients are a common injury pattern. The appropriate timing for the surgical stabilization of vertebral fractures is still controversial. The purpose of this study was to analyse the impact of the timing of spinal surgery in multiple-injured patients both in general and in respect to spinal injury severity. Methods: A retrospective analysis of multiple-injured patients with an associated spinal trauma within the thoracic or lumbar spine (injury severity score (ISS) >16, age >16 years) was performed from January 2012 to December 2016 in two Level I trauma centres. Demographic data, circumstances of the accident, and ISS, as well as time to spinal surgery were documented. The evaluated outcome parameters were length of stay in the intensive care unit (ICU) (iLOS) and length of stay (LOS) in the hospital, duration of mechanical ventilation, onset of sepsis, and multiple organ dysfunction syndrome (MODS), as well as mortality. Statistical analysis was performed using SPSS. Results: A total of 113 multiple-injured patients with spinal stabilization and a complete dataset were included in the study. Of these, 71 multiple-injured patients (63%) presented with an AOSpine A-type spinal injury, whereas 42 (37%) had an AOSpine B-/C-type spinal injury. Forty-nine multiple-injured patients (43.4%) were surgically treated for their spinal injury within 24 h after trauma, and showed a significantly reduced length of stay in the ICU (7.31 vs. 14.56 days; p < 0.001) and hospital stay (23.85 vs. 33.95 days; p = 0.048), as well as a significantly reduced prevalence of sepsis compared to those surgically treated later than 24 h (3 vs. 7; p = 0.023). These adverse effects were even more pronounced in the case where cutoffs were increased to either 72 h or 96 h. Independent risk factors for a delay in spinal surgery were a higher ISS (p = 0.036), a thoracic spine injury (p = 0.001), an AOSpine A-type spinal injury (p = 0.048), and an intact neurological status (p < 0.001). In multiple-injured patients with AOSpine A-type spinal injuries, an increased time to spinal surgery was only an independent risk factor for an increased LOS; however, in multiple-injured patients with B-/C-type spinal injuries, an increased time to spinal surgery was an independent risk factor for increased iLOS, LOS, and the development of sepsis. Conclusion: Our data support the concept of early spinal stabilization in multiple-injured patients with AOSpine B-/C-type injuries, especially of the thoracic spine. However, in multiple-injured patients with AOSpine A-type injuries, the beneficial impact of early spinal stabilization has been overemphasized in former studies, and the benefit should be weighed out against the risk of patients’ deterioration during early spinal stabilization. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

13 pages, 947 KiB

Open AccessArticle

Severe Traumatic Brain Injury (TBI) Modulates the Kinetic Profile of the Inflammatory Response of Markers for Neuronal Damage

by Cora Rebecca Schindler, Thomas Lustenberger, Mathias Woschek, Philipp Störmann, Dirk Henrich, Peter Radermacher and Ingo Marzi

J. Clin. Med. 2020, 9(6), 1667; https://doi.org/10.3390/jcm9061667 - 1 Jun 2020

Cited by 24 | Viewed by 3332

Abstract

The inflammatory response plays an important role in the pathophysiology of multiple injuries. This study examines the effects of severe trauma and inflammatory response on markers of neuronal damage. A retrospective analysis of prospectively collected data in 445 trauma patients (Injury Severity Score [...] Read more.

The inflammatory response plays an important role in the pathophysiology of multiple injuries. This study examines the effects of severe trauma and inflammatory response on markers of neuronal damage. A retrospective analysis of prospectively collected data in 445 trauma patients (Injury Severity Score (ISS) ≥ 16) is provided. Levels of neuronal biomarkers (calcium-binding Protein B (S100b), Enolase2 (NSE), glial fibrillary acidic protein (GFAP)) and Interleukins (IL-6, IL-10) in severely injured patients (with polytrauma (PT)) without traumatic brain injury (TBI) or with severe TBI (PT+TBI) and patients with isolated TBI (isTBI) were measured upon arrival until day 5. S100b, NSE, GFAP levels showed a time-dependent decrease in all cohorts. Their expression was higher after multiple injuries (p = 0.038) comparing isTBI. Positive correlation of marker level after concomitant TBI and isTBI (p = 0.001) was noted, while marker expression after PT appears to be independent. Highest levels of IL-6 and -10 were associated to PT und lowest to isTBI (p < 0.001). In all groups pro-inflammatory response (IL-6/-10 ratio) peaked on day 2 and at a lower level on day 4. Severe TBI modulates kinetic profile of inflammatory response by reducing interleukin expression following trauma. Potential markers for neuronal damage have a limited diagnostic value after severe trauma because undifferentiated increase. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

11 pages, 660 KiB

Open AccessArticle

Which Risk Factors Predict Knee Ligament Injuries in Severely Injured Patients?—Results from an International Multicenter Analysis

by Christian D. Weber, Lucian B. Solomon, Rolf Lefering, Klemens Horst, Philipp Kobbe, Frank Hildebrand and TraumaRegister DGU

J. Clin. Med. 2020, 9(5), 1437; https://doi.org/10.3390/jcm9051437 - 12 May 2020

Cited by 5 | Viewed by 2949

Abstract

Introduction: Ligament injuries around the knee joint and knee dislocations are rare but potentially complex injuries associated with high-energy trauma. Concomitant neurovascular injuries further affect their long-term clinical outcomes. In contrast to isolated ligamentous knee injuries, epidemiologic data and knowledge on predicting knee [...] Read more.

Introduction: Ligament injuries around the knee joint and knee dislocations are rare but potentially complex injuries associated with high-energy trauma. Concomitant neurovascular injuries further affect their long-term clinical outcomes. In contrast to isolated ligamentous knee injuries, epidemiologic data and knowledge on predicting knee injuries in severely injured patients is still limited. Methods: The TraumaRegister DGU^® (TR-DGU) was queried (01/2009–12/2016). Inclusion criteria for selection from the database: maximum abbreviated injury severity ≥ 3 points (MAIS 3+). Participating countries: Germany, Austria, and Switzerland. The two main groups included a “control” and a “knee injury” group. The injury severity score (ISS) and new ISS (NISS) were used for injury severity classification, and the abbreviated injury scale (AIS) was used to classify the severity of the knee injury. Logistic regression analysis was performed to evaluate various risk factors for knee injuries. Results: The study cohort included 139,462 severely injured trauma patients. We identified 4411 individuals (3.2%) with a ligament injury around the knee joint (“knee injury” group) and 1153 patients with a knee dislocation (0.8%). The risk for associated injuries of the peroneal nerve and popliteal artery were significantly increased in dislocated knees when compared to controls (peroneal nerve from 0.4% to 6.7%, popliteal artery from 0.3% to 6.9%, respectively). Among the predictors for knee injuries were specific mechanisms of injury: e.g., pedestrian struck (Odds ratio [OR] 3.2, 95% confidence interval [CI]: 2.69–3.74 p ≤ 0.001), motorcycle (OR 3.0, 95% CI: 2.58–3.48, p ≤ 0.001), and motor vehicle accidents (OR 2.2, 95% CI: 1.86–2.51, p ≤ 0.001) and associated skeletal injuries, e.g., patella (OR 2.3, 95% CI: 1.99–2.62, p ≤ 0.001), tibia (OR 1.9, 95% CI: 1.75–2.05, p ≤ 0.001), and femur (OR 1.8, 95% CI: 1.64–1.89, p ≤ 0.001), but neither male sex nor general injury severity (ISS). Conclusion: Ligament injuries and knee dislocations are associated with high-risk mechanisms and concomitant skeletal injuries of the lower extremity, but are not predicted by general injury severity or sex. Despite comparable ISS, knee injuries prolong the hospital length of stay. Delayed or missed diagnosis of knee injuries can be prevented by comprehensive clinical evaluation after fracture fixation and a high index of suspicion is advised, especially in the presence of the above mentioned risk factors. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

11 pages, 1248 KiB

Open AccessArticle

Clinical Utility of Extracorporeal Shock Wave Therapy on Hypertrophic Scars of the Hand Caused by Burn Injury: A Prospective, Randomized, Double-Blinded Study

by So Young Joo, Seung Yeol Lee, Yoon Soo Cho and Cheong Hoon Seo

J. Clin. Med. 2020, 9(5), 1376; https://doi.org/10.3390/jcm9051376 - 7 May 2020

Cited by 11 | Viewed by 3744

Abstract

Postburn hypertrophic scarring is a common complication in burn injuries to the hands, often associated with impaired hand function. We evaluated the effects of extracorporeal shock wave therapy (ESWT), compared to a sham stimulation therapy, on hypertrophic scars of the hand caused by [...] Read more.

Postburn hypertrophic scarring is a common complication in burn injuries to the hands, often associated with impaired hand function. We evaluated the effects of extracorporeal shock wave therapy (ESWT), compared to a sham stimulation therapy, on hypertrophic scars of the hand caused by burn injury and investigated its effects on hand function. This was a double-blinded, randomized, controlled trial of 48 patients with a burn to their dominant right hand. The parameters of ESWT were as follows: energy flux density, 0.05–0.30 mJ/mm²; frequency, 4 Hz; 1000 to 2000 impulses per treatment; four treatments, once a week for four weeks. The outcomes measured were as follows: a 10-point visual analogue scale pain score; Vancouver scar scale for scar vascularity, height, pliability and pigmentation; ultrasound measurement of scar thickness; Jebsen−Taylor hand function test; grip strength; Perdue pegboard test; and the Michigan hand outcomes questionnaire. The change in the score from baseline to post-treatment was compared between the two groups. ESWT improved the pain score (p = 0.001), scar thickness (p = 0.018), scar vascularity (p = 0.0015), and improved hand function (simulated card-turning, p = 0.02; picking up small objects, p = 0.004). The other measured outcomes were not different between the two groups. ESWT is effective in decreasing pain, suppressing hypertrophic scarring, and improving hand function. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

15 pages, 1154 KiB

Open AccessArticle

Post-Traumatic Sepsis Is Associated with Increased C5a and Decreased TAFI Levels

by Jan Tilmann Vollrath, Ingo Marzi, Anna Herminghaus, Thomas Lustenberger and Borna Relja

J. Clin. Med. 2020, 9(4), 1230; https://doi.org/10.3390/jcm9041230 - 24 Apr 2020

Cited by 15 | Viewed by 3082

Abstract

Background: Sepsis frequently occurs after major trauma and is closely associated with dysregulations in the inflammatory/complement and coagulation system. Thrombin-activatable fibrinolysis inhibitor (TAFI) plays a dual role as an anti-fibrinolytic and anti-inflammatory factor by downregulating complement anaphylatoxin C5a. The purpose of this study [...] Read more.

Background: Sepsis frequently occurs after major trauma and is closely associated with dysregulations in the inflammatory/complement and coagulation system. Thrombin-activatable fibrinolysis inhibitor (TAFI) plays a dual role as an anti-fibrinolytic and anti-inflammatory factor by downregulating complement anaphylatoxin C5a. The purpose of this study was to investigate the association between TAFI and C5a levels and the development of post-traumatic sepsis. Furthermore, the predictive potential of both TAFI and C5a to indicate sepsis occurrence in polytraumatized patients was assessed. Methods: Upon admission to the emergency department (ED) and daily for the subsequent ten days, circulating levels of TAFI and C5a were determined in 48 severely injured trauma patients (injury severity score (ISS) ≥ 16). Frequency matching according to the ISS in septic vs. non-septic patients was performed. Trauma and physiologic characteristics, as well as outcomes, were assessed. Statistical correlation analyses and cut-off values for predicting sepsis were calculated. Results: Fourteen patients developed sepsis, while 34 patients did not show any signs of sepsis (no sepsis). Overall injury severity, as well as demographic parameters, were comparable between both groups (ISS: 25.78 ± 2.36 no sepsis vs. 23.46 ± 2.79 sepsis). Septic patients had significantly increased C5a levels (21.62 ± 3.14 vs. 13.40 ± 1.29 ng/mL; p < 0.05) and reduced TAFI levels upon admission to the ED (40,951 ± 5637 vs. 61,865 ± 4370 ng/mL; p < 0.05) compared to the no sepsis group. Negative correlations between TAFI and C5a (p = 0.0104) and TAFI and lactate (p = 0.0423) and positive correlations between C5a and lactate (p = 0.0173), as well as C5a and the respiratory rate (p = 0.0266), were found. In addition, correlation analyses of both TAFI and C5a with the sequential (sepsis-related) organ failure assessment (SOFA) score have confirmed their potential as early sepsis biomarkers. Cut-off values for predicting sepsis were 54,857 ng/mL for TAFI with an area under the curve (AUC) of 0.7550 (p = 0.032) and 17 ng/mL for C5a with an AUC of 0.7286 (p = 0.034). Conclusion: The development of sepsis is associated with early decreased TAFI and increased C5a levels after major trauma. Both elevated C5a and decreased TAFI may serve as promising predictive factors for the development of sepsis after polytrauma. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

15 pages, 1534 KiB

Open AccessArticle

Regulatory T Cells Modulate CD4 Proliferation after Severe Trauma via IL-10

by Ramona Sturm, Lara Xanthopoulos, David Heftrig, Elsie Oppermann, Teodora Vrdoljak, Ildiko Rita Dunay, Ingo Marzi and Borna Relja

J. Clin. Med. 2020, 9(4), 1052; https://doi.org/10.3390/jcm9041052 - 8 Apr 2020

Cited by 9 | Viewed by 3075

Abstract

Objective: Severely injured patients frequently develop an immunological imbalance following the traumatic insult, which might result in infectious complications evoked by a persisting immunosuppression. Regulatory T cells (Tregs) maintain the immune homeostasis by suppressing proinflammatory responses, however, their functionality after trauma is unclear. [...] Read more.

Objective: Severely injured patients frequently develop an immunological imbalance following the traumatic insult, which might result in infectious complications evoked by a persisting immunosuppression. Regulatory T cells (Tregs) maintain the immune homeostasis by suppressing proinflammatory responses, however, their functionality after trauma is unclear. Here, we characterized the role of Tregs in regulating the proliferation of CD4⁺ lymphocytes in traumatized patients (TP). Methods: Peripheral blood was obtained daily from 29 severely injured TP (Injury Severity Score, ISS ≥16) for ten days following admission to the emergency department (ED). Ten healthy volunteers (HV) served as controls. The frequency and activity of Tregs were assessed by flow cytometry. Proliferation of CD4⁺ cells was analyzed either in presence or absence of Tregs, or after blocking of either IL-10 or IL-10R1. Results: The frequencies of CD4⁺CD25^high and CD4⁺CD25⁺CD127⁻ Tregs were significantly decreased immediately upon admission of TP to the ED and during the following 10 post-injury days. Compared with HV CD4⁺ T cell proliferation in TP increased significantly upon their admission and on the following days. As expected, CD4⁺CD25⁺CD127⁻ Tregs reduced the proliferation of CD4⁺ cells in HV, nevertheless, CD4⁺ proliferation in TP was increased by Tregs. Neutralization of IL-10 as well as blocking the IL-10R1 increased further CD4⁺ T cell proliferation in Tregs-depleted cultures, thereby confirming an IL-10-mediated mechanism of IL-10-regulated CD4⁺ T cell proliferation. Neutralization of IL-10 in TP decreased CD4⁺ T cell proliferation in Tregs-depleted cultures, whereas blocking of the IL-10R1 receptor had no significant effects. Conclusions: The frequency of Tregs in the CD4⁺ T lymphocyte population is reduced after trauma; however, their inductiveness is increased. The mechanisms of deregulated influence of Tregs on CD4⁺ T cell proliferation are mediated via IL-10 but not via the IL-10R1. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

13 pages, 2264 KiB

Open AccessArticle

Arthroscopy-Assisted Corrective Osteotomy, Reduction, Internal Fixation and Strut Allograft Augmentation for Tibial Plateau Malunion or Nonunion

by Jr-Yi Wang, Chun-Ying Cheng, Alvin Chao-Yu Chen and Yi-Sheng Chan

J. Clin. Med. 2020, 9(4), 973; https://doi.org/10.3390/jcm9040973 - 1 Apr 2020

Cited by 8 | Viewed by 3392

Abstract

Purpose: The purpose of this study was to present the results of arthroscopy-assisted corrective osteotomy (AACO), reduction, internal fixation, and strut allograft augmentation for tibial plateau malunion or nonunion. Methods: Fifty-eight patients, mean age 49 ± 11.9 years old, with tibial plateau malunion [...] Read more.

Purpose: The purpose of this study was to present the results of arthroscopy-assisted corrective osteotomy (AACO), reduction, internal fixation, and strut allograft augmentation for tibial plateau malunion or nonunion. Methods: Fifty-eight patients, mean age 49 ± 11.9 years old, with tibial plateau malunion (n = 44) or nonunion (n = 14), were included in this study. There were 19 Schatzker type II fractures (32.7%), 2 type III fractures (3.4%), 7 type IV fractures (12%), 20 type V fractures (34.5%), and 10 type VI fractures (17.2%). The mean follow-up period was 46.2 ± 17.6 months. Clinical and radiologic outcomes were scored by the Rasmussen system. Articular depression was measured from computed tomography. Secondary osteoarthritis was diagnosed when radiographs showed a narrowed joint space in the injured knee at follow-up. Results: Mean clinical score improved from 15.4 ± 3.9 (pre-revision) to 23.2 ± 4.5 (post-revision). Mean radiologic score improved from 7.7 ± 2.5 (pre-revision) to 12.0 ± 3.9 (post-revision). Fifty-six fractures achieved successful union. The average union time was 19.6 ± 7.5 weeks. Post-revision, 81% had good or excellent clinical results and 62% had good or excellent radiological results. Secondary osteoarthritis (OA) was noted in 91% of all injured knees, where 25.8% were mild OA, 25.8 % were moderate OA, and 38% were severe OA. There were 6 cases of deep infection (10.3%) and 1 case of wound edge necrosis (1.7%). Five cases were converted to total knee replacement after the index surgery with an average period of 13.5 months (range 8–24 months). Conclusions: Arthroscopy-assisted corrective osteotomy, reduction, internal fixation, and strut allograft augmentation can restore tibial plateau malunion/nonunion with well-documented radiographic healing and good clinical outcomes. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

9 pages, 424 KiB

Open AccessArticle

Validation of the mTICCS Score as a Useful Tool for the Early Prediction of a Massive Transfusion in Patients with a Traumatic Hemorrhage

by Klemens Horst, Rachel Lentzen, Martin Tonglet, Ümit Mert, Philipp Lichte, Christian D. Weber, Philipp Kobbe, Nicole Heussen and Frank Hildebrand

J. Clin. Med. 2020, 9(4), 945; https://doi.org/10.3390/jcm9040945 - 30 Mar 2020

Cited by 10 | Viewed by 3285

Abstract

The modified Trauma-Induced Coagulopathy Clinical Score (mTICCS) presents a new scoring system for the early detection of the need for a massive transfusion (MT). While validated in a large trauma cohort, the comparison of mTICCS to established scoring systems is missing. This study [...] Read more.

The modified Trauma-Induced Coagulopathy Clinical Score (mTICCS) presents a new scoring system for the early detection of the need for a massive transfusion (MT). While validated in a large trauma cohort, the comparison of mTICCS to established scoring systems is missing. This study therefore validated the ability of six scoring systems to stratify patients at risk for an MT at an early stage after trauma. A dataset of severely injured patients (ISS ≥ 16) derived from the database of a level I trauma center (2010–2015) was used. Scoring systems assessed were Trauma-Associated Severe Hemorrhage (TASH) score, Prince of Wales Hospital (PWH) score, Larson score, Assessment of Blood Consumption (ABC) score, Emergency Transfusion Score (ETS), and mTICCS. Demographics, diagnostic data, mechanism of injury, injury pattern (graded by AIS), and outcome (length of stay, mortality) were analyzed. Scores were calculated, and the area under the receiver operating characteristic curves (AUCs) were evaluated. From the AUCs, the cut-off point with the best relationship of sensitivity-to-specificity was used to recalculate sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). A total of 479 patients were included; of those, blunt trauma occurred in 92.3% of patients. The mean age of patients was 49 ± 22 years with a mean ISS of 25 ± 29. The overall MT rate was 8.4% (n = 40). The TASH score had the highest overall accuracy as reflected by an AUC of 0.782 followed by the mTICCS (0.776). The ETS was the most sensitive (80%), whereas the TASH score had the highest specificity (82%) and the PWH score had the lowest (51.83%). At a cut-off > 5 points, the mTICCS score showed a sensitivity of 77.5% and a specificity of 74.03%. Compared to sophisticated systems, using a higher number of weighted variables, the newly developed mTICCS presents a useful tool to predict the need for an MT in a prehospital situation. This might accelerate the diagnosis of an MT in emergency situations. However, prospective validations are needed to improve the development process and use of scoring systems in the future. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

11 pages, 1796 KiB

Open AccessArticle

Effects of Virtual Reality-Based Rehabilitation on Burned Hands: A Prospective, Randomized, Single-Blind Study

by So Young Joo, Yoon Soo Cho, Seung Yeol Lee, Hyun Seok and Cheong Hoon Seo

J. Clin. Med. 2020, 9(3), 731; https://doi.org/10.3390/jcm9030731 - 9 Mar 2020

Cited by 32 | Viewed by 7156

Abstract

Hands are the most frequent burn injury sites. Appropriate rehabilitation is essential to ensure good functional recovery. Virtual reality (VR)-based rehabilitation has proven to be beneficial for the functional recovery of the upper extremities. We investigated and compared VR-based rehabilitation with conventional rehabilitation [...] Read more.

Hands are the most frequent burn injury sites. Appropriate rehabilitation is essential to ensure good functional recovery. Virtual reality (VR)-based rehabilitation has proven to be beneficial for the functional recovery of the upper extremities. We investigated and compared VR-based rehabilitation with conventional rehabilitation (CON) in patients with burned hands. Fifty-seven patients were randomized into a VR or CON group. Each intervention was applied to the affected hand for four weeks, and clinical and functional variables were evaluated. Hand function was evaluated before intervention and four weeks after intervention using the Jebsen-Taylor hand function test (JTT), Grasp and Pinch Power Test, Purdue Pegboard test (PPT), and Michigan Hand Outcomes Questionnaire (MHQ). The JTT scores for picking up small objects and the MHQ scores for hand function, functional ADL, work, pain, aesthetics, and patient satisfaction were significantly higher in the VR group than in the CON group (p < 0.05). The results suggested that VR-based rehabilitation is likely to be as effective as conventional rehabilitation for recovering function in a burned hand. VR-based rehabilitation may be considered as a treatment option for patients with burned hands. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

13 pages, 1392 KiB

Open AccessArticle

Persistent Inflammation, Immunosuppression and Catabolism Syndrome (PICS) after Polytrauma: A Rare Syndrome with Major Consequences

by Lillian Hesselink, Ruben J. Hoepelman, Roy Spijkerman, Mark C. H. de Groot, Karlijn J. P. van Wessem, Leo Koenderman, Luke P. H. Leenen and Falco Hietbrink

J. Clin. Med. 2020, 9(1), 191; https://doi.org/10.3390/jcm9010191 - 10 Jan 2020

Cited by 30 | Viewed by 6669

Abstract

Nowadays, more trauma patients develop chronic critical illness (CCI), a state characterized by prolonged intensive care. Some of these CCI patients have disproportional difficulties to recover and suffer from recurrent infections, a syndrome described as the persistent inflammation, immunosuppression and catabolism syndrome (PICS). [...] Read more.

Nowadays, more trauma patients develop chronic critical illness (CCI), a state characterized by prolonged intensive care. Some of these CCI patients have disproportional difficulties to recover and suffer from recurrent infections, a syndrome described as the persistent inflammation, immunosuppression and catabolism syndrome (PICS). A total of 78 trauma patients with an ICU stay of ≥14 days (CCI patients) between 2007 and 2017 were retrospectively included. Within this group, PICS patients were identified through two ways: (1) their clinical course (≥3 infectious complications) and (2) by laboratory markers suggested in the literature (C-reactive protein (CRP) and lymphocytes), both in combination with evidence of increased catabolism. The incidence of PICS was 4.7 per 1000 multitrauma patients. The sensitivity and specificity of the laboratory markers was 44% and 73%, respectively. PICS patients had a longer hospital stay (median 83 vs. 40, p < 0.001) and required significantly more surgical interventions (median 13 vs. 3, p = 0.003) than other CCI patients. Thirteen PICS patients developed sepsis (72%) and 12 (67%) were readmitted at least once due to an infection. In conclusion, patients who develop PICS experience recurrent infectious complications that lead to prolonged hospitalization, many surgical procedures and frequent readmissions. Therefore, PICS forms a substantial burden on the patient and the hospital, despite its low incidence. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

Review

Jump to: Editorial, Research

11 pages, 1468 KiB

Open AccessReview

Mobile Bearing versus Fixed Bearing for Unicompartmental Arthroplasty in Monocompartmental Osteoarthritis of the Knee: A Meta-Analysis

by Filippo Migliorini, Nicola Maffulli, Francesco Cuozzo, Karen Elsner, Frank Hildebrand, Jörg Eschweiler and Arne Driessen

J. Clin. Med. 2022, 11(10), 2837; https://doi.org/10.3390/jcm11102837 - 17 May 2022

Cited by 17 | Viewed by 2477

Abstract

Introduction: Whether mobile-bearing (MB) unicompartmental knee arthroplasty (UKA) performs better than fixed-bearing (FB) implants in patients with monocompartmental osteoarthritis (OA) still remains unclear. Therefore, a meta-analysis comparing MB versus FB for UKA was conducted to investigate the possible advantages of MB versus FB [...] Read more.

Introduction: Whether mobile-bearing (MB) unicompartmental knee arthroplasty (UKA) performs better than fixed-bearing (FB) implants in patients with monocompartmental osteoarthritis (OA) still remains unclear. Therefore, a meta-analysis comparing MB versus FB for UKA was conducted to investigate the possible advantages of MB versus FB in patient-reported outcome measures (PROMs), range of motion (ROM), and complications. We hypothesised that the MB design performs better than FB. Methods: This systematic review was conducted according to the 2020 PRISMA guidelines. In December 2021, PubMed, Web of Science, Google Scholar, and Embase were accessed, with no time constraints. All the clinical investigations comparing MB versus FB bearing for UKA were accessed. Only studies published in peer-reviewed journals were considered. Studies reporting data on revision settings were excluded, as were those combining unicompartmental and total knee arthroplasty. Results: Data from 25 studies (4696 patients) were collected; 58% (2724 of 4696 patients) were women. The mean length of follow-up was 45.8 ± 43.2. The mean age of the patients was 65.0 ± 5.6 years. No difference was found in range of motion (p = 0.05), Knee Scoring System (p = 0.9), function subscale (p = 0.2), and Oxford Knee Score (p = 0.4). No difference was found in the rate of revision (p = 0.2), aseptic loosening (p = 0.9), deep infections (p = 0.99), fractures (p = 0.6), and further extension of OA to the contralateral joint compartment (p = 0.2). Conclusion: The present meta-analysis failed to identify the possible superiority of the MB implants over the FB for UKA in patients with monocompartmental knee osteoarthritis. Long observational investigations are required to evaluate possible long-term complications and implant survivorship. These results should be interpreted within the limitations of the present study. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

► Show Figures

Figure 1

20 pages, 275 KiB

Open AccessReview

Neuroendocrine Modulation of the Immune Response after Trauma and Sepsis: Does It Influence Outcome?

by Philipp Kobbe, Felix M. Bläsius, Philipp Lichte, Reiner Oberbeck and Frank Hildebrand

J. Clin. Med. 2020, 9(7), 2287; https://doi.org/10.3390/jcm9072287 - 18 Jul 2020

Cited by 5 | Viewed by 2742

Abstract

Although the treatment of multiple-injured patients has been improved during the last decades, sepsis and multiple organ failure (MOF) still remain the major cause of death. Following trauma, profound alterations of a large number of physiological systems can be observed that may potentially [...] Read more.

Although the treatment of multiple-injured patients has been improved during the last decades, sepsis and multiple organ failure (MOF) still remain the major cause of death. Following trauma, profound alterations of a large number of physiological systems can be observed that may potentially contribute to the development of sepsis and MOF. This includes alterations of the neuroendocrine and the immune system. A large number of studies focused on posttraumatic changes of the immune system, but the cause of posttraumatic immune disturbance remains to be established. However, an increasing number of data indicate that the bidirectional interaction between the neuroendocrine and the immune system may be an important mechanism involved in the development of sepsis and MOF. The aim of this article is to highlight the current knowledge of the neuroendocrine modulation of the immune system during trauma and sepsis. Full article

(This article belongs to the Special Issue New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient)

Journal Menu

Journal Browser

New Diagnostic and Therapeutic Approaches for the Care of the Severely Injured Patient

Share This Special Issue

Special Issue Editors

Special Issue Information

Keywords

Benefits of Publishing in a Special Issue

Published Papers (28 papers)

Editorial

Research

Review

Further Information

Guidelines

MDPI Initiatives

Follow MDPI