Factors associated with changes in creatine phosphokinase (CPK) in trauma patients submitted to the "Red Wave", with evolution to rhabdomyolysis / Fatores associados à variação da creatina fosfoquinase (CPK) em pacientes vítimas de trauma, submetidos à "Onda Vermelha", com evolução à rabdomiólise

ABSTRACT Objective: to identify and analyze factors associated with plasma creatine phosphokinase (CPK) levels in trauma victims with progression to rhabdomyolysis. Methods: we conducted a prospective, longitudinal study, with 50 patients submitted to the "Red Wave" protocol, with evolution to rhabdomyolysis after hospital admission. We studied the variables age, gender, trauma scores, mechanism and outcome, CPK at admission and final, intervals of days between laboratory evaluations, surgery and complications. We stratified CPK values in <500U/L, ≥500 - <1000 U/L, and ≥1000U/L, with calculation of the difference between the initial and final values. Results: at admission, 83% of patients (n=39) had CPK≥1000U/L, with predominance of blunt trauma and thoracic injury (p<0.05), as well as orthopedic fracture, acute renal failure and gastrointestinal bleeding, CPK being lower in those without acute renal injury, with a trend towards statistical significance. There were no differences in final CPK stratification. Factors that were independently associated with the greater CPK variation were, positively, hospitalization time greater than one week and compartment syndrome, and negatively, acute renal injury. Conclusion: the CPK level of 1000U/L remains the lower limit, with importance for early intervention in worsening conditions such as digestive hemorrhage, acute renal injury and compartment syndrome, which implied greater absolute differences between initial and final CPK, in addition to blunt trauma, thoracic injury and orthopedic fracture.

RESUMO Objetivo: identificar e analisar fatores associados à variação dos níveis plasmáticos de creatina fosfoquinase (CPK) em vítimas de trauma com evolução à rabdomiólise. Métodos: estudo longitudinal prospectivo, com 50 pacientes que seguiram para o protocolo "Onda Vermelha", com evolução à rabdomiólise, após admissão hospitalar. Foram estudadas as variáveis: idade, sexo, escores, mecanismo e desfecho de trauma, CPK na admissão e final, intervalos de dias entre as avaliações laboratoriais, realização de cirurgia e complicações. Os valores da CPK foram estratificados em <500U/L; ≥500 - <1000 U/L; ≥1000U/L, com cálculo da diferença entre os valores inicial e final. Resultados: à admissão, 83% dos pacientes (n=39) apresentavam CPK≥1000U/L, com predomínio de trauma contuso e lesão torácica (p<0,05), além de fratura ortopédica, lesão renal aguda e hemorragia digestiva, sendo que a CPK era menor naqueles sem lesão renal aguda, com tendência à significância estatística. Não houve diferenças na estratificação por CPK final. Fatores que se revelaram independentemente associados à maior variação da CPK foram, positivamente, o tempo de internação superior a uma semana e síndrome compartimental, e negativamente, lesão renal aguda. Conclusão: como achado, nível de CPK de 1000U/L permanece como limite inferior, com importância à intervenção precoce em condições de agravamento do quadro, como hemorragia digestiva, lesão renal aguda e síndrome compartimental, que implicaram maiores diferenças absolutas entre CPK inicial e final, além do trauma contuso, lesão torácica e fratura ortopédica.

The analysis on the expression of gasotransmitters in early trauma patients

Summary Objective: Nitric oxide (NO), carbon monoxide (CO) and hydrogen sulfide (H2S) were endogenously-generated molecules gas. They owned important biological activity and participated in many pathophysiological processes. This study aimed to examine the levels of three gasotransmitters in the early phase of trauma patients. Method: Blood samples were collected from 60 trauma patients and ten healthy volunteers. Concentration of serum iNOS and HO-1 were analyzed by enzyme linked immunosorbent assay and plasma H2S was determined by colorimetric method. Meanwhile, the occurrence of multiple organ dysfunction syndrome (MODS) was also monitored. Results: The levels of iNOS, HO-1 and endogenous H2S in the patients group were significantly different from the healthy control group, and the difference was more obvious with the increase of ISS score. iNOS levels were positively correlated with ISS scores and blood lactic acid values, and HO-1 and endogenous H2S were negatively correlated with ISS scores and blood lactic acid values. Of 60 trauma patients, eight (13.33%) developed MODS. The level of iNOS in the MODS group was higher than that in non-MODS group, while HO-1 and H2S were significant lower in the MODS group. Conclusion: The three gasotransmitters participated in systemic inflammatory responses during early trauma and could be used as important indicators for trauma severity. Their measurements were meaningful for evaluating the severity and prognosis of trauma.

Development and Evaluation of a Duplex Real-Time PCR Assay With a Novel Internal Standard for Precise Quantification of Plasma DNA

BACKGROUND: Circulating levels of cell-free DNA increase in many pathologic conditions. However, notable discrepancies in the quantitative analysis of cell-free DNA from a large number of laboratories have become a considerable pitfall, hampering its clinical application. METHODS: We designed a novel recombinant DNA fragment that could be applied as an internal standard in a newly developed and validated duplex real-time PCR assay for the quantitative analysis of total cell-free plasma DNA, which was tested in 5,442 healthy adults and 200 trauma patients. RESULTS: Compared with two traditional methods, this novel assay showed a lower detection limit of 0.1 ng/mL, lower intra- and inter-assay CVs, and higher accuracy in the recovery test. The median plasma DNA concentration of healthy males (20.3 ng/mL, n=3,092) was significantly higher than that of healthy females (16.1 ng/mL, n=2,350) (Mann-Whitney two-sample rank sum test, P<0.0001). The reference intervals of plasma DNA concentration were 0-45.8 ng/mL and 0-52.5 ng/mL for healthy females and males, respectively. The plasma DNA concentrations of the majority of trauma patients (96%) were higher than the upper normal cutoff values and were closely related to the corresponding injury severity scores (R²=0.916, P<0.0001). CONCLUSIONS: This duplex real-time PCR assay with a new internal standard could eliminate variation and allow for more sensitive, repeatable, accurate, and stable quantitative measurements of plasma DNA, showing promising application in clinical diagnosis.

Dexmedetomidina e S(+)-cetamina em lesão de isquemia e reperfusão no rim de rato / Dexmedetomidine and S(+)-ketamine in ischemia and reperfusion injury in the rat kidney

PURPOSE: To investigate blood creatinine and renal histology in rats anesthetized with S(+)-ketamine (keta) or dexmedetomidine (dex) and submitted to kidney ischemia/reperfusion injury (IRI). METHODS: Under intraperitoneal (ip) S(+)-ketamine, 20 male Wistar rats were divided into two groups (n=10): maintenance with iv S(+)-ketamine or dex (keta and dex groups), and submitted to right (R) nephrectomy and left (L) renal artery clamping for 45 min. Blood creatinine was measured before ischemia (T1) and 48h after reperfusion (T2), when L nephrectomy was performed. Histological analysis was performed in all kidneys. RESULTS: Blood creatinine was significantly higher at T2 in both groups, but dex group results were lower than those of keta group. Histological changes: between groups, R kidneys did not differ; there were significant high scores for vascular dilation: keta L kidneys; for vascular congestion, tubular dilation, and necrosis: L kidneys from both groups; for tubular degeneration: keta R kidneys. CONCLUSION: S(+)-ketamine plus IRI were aggressive to rat kidneys, according to histological changes, and dexmedetomidine may have not totally protected the kidneys from these injuries, despite the better results of blood creatinine.

OBJETIVO: Investigar a creatinina sanguínea e histologia renal em ratos anestesiados com S(+)-cetamina (ceta) ou dexmedetomidina (dex) e submetidos à lesão de isquemia/reperfusão renal (IR). MÉTODOS: Sob S(+)-cetamina intraperitoneal (ip), 20 ratos Wistar machos foram distribuídos em dois grupos (n=10): manutenção com S(+)-cetamina ou dexmedetomidina, iv, (grupos ceta e dex), e submetidos à nefrectomia direita (D) e clampeamento da artéria renal esquerda (E) por 45 min. A creatinina sanguínea foi dosada antes da isquemia (T1) e 48h após a reperfusão (T2), quando foi realizada nefrectomia E. Houve análise histológica de todos os rins. RESULTADOS: A creatinina foi significativamente maior em T2 em ambos os grupos, porém menor com a dexmedetomidina. Alterações histológicas: entre grupos, os rins Ds não diferiram; houve escores altos significativos para dilatação vascular: rins Es do grupo ceta; para congestão vascular, dilatação tubular, necrose: rins Es de ambos os grupos; para degeneração tubular: rins Ds do grupo ceta. CONCLUSÃO: S(+)-cetamina e IR foram agressivas histologicamente para rins de ratos e a dexmedetomidina pode não ter protegido totalmente os rins dessas lesões, apesar dos melhores resultados de creatinina.

The Value of Initial Ionized Calcium as a Predictor of Mortality and Triage Tool in Adult Trauma Patients

Ionized hypocalcemia is a common finding in critically ill patients, but the relationship between ionized hypocalcemia and mortality risk in trauma patients has not been well established. The aim of this study was to assess the usefulness of initial ionized calcium (iCa) in predicting mortality in the trauma population, and evaluate its superiority over the three other triage tools: base deficit, systemic inflammatory response syndrome (SIRS) score, and triage-revised trauma score (t-RTS). A proand retrospective study was performed on 255 consecutive trauma patients admitted to our Emergency Medical Center from January to December, 2005, who underwent arterial blood gas analysis. Multivariate logistic regression analysis confirmed iCa (< or =0.88 mM/L), low Glasgow coma scale score, and a large transfusion amount to be significant risk factors associated with mortality (p<0.05). The sensitivities of iCa, base deficit, SIRS score, and t-RTS were 82.9%, 76.4%, 67.1%, and 74.5%, and their specificities were 41.0%, 64.1%, 64.1%, and 87.2%, respectively. Receiver operating characteristic curve analysis determined the areas under the curves of these parameters to be 0.607+/-0.062, 0.736+/-0.056, 0.694+/-0.059, and 0.875 +/-0.043, respectively (95% confidence interval). Although initial iCa (< or =0.88 mM/L) was confirmed as a significant risk factor associated with mortality, it exhibited a poorer discriminative power for mortality prediction than other predictors, especially t-RTS.

Metabolic and stress responses of the body to trauma: produced by the laparoscopic and open cholecystectomy.

Laparoscopic cholecystectomy is regarded as gold standard therapy for symptomatic gall stone disease. This study was done to compare the metabolic and stress responses between open and lapraroscopic cholecystectomy and to evaluate their significance in postoperative recovery. Thirty patients with symptomatic gall stone disease were treated with open and laparoscopic cholecystectomy on elective basis (14 versus 16). Three samples of blood were collected from each patient to investigate serum cortisol, adrenaline, nor-adrenaline, C-reactive protein and blood glucose level. The mean age of patients was 41.86+/-10.13 blood glucose and stress hormones (cortisol, adrenaline, nor adrenaline) and C-reactive protein all were found significantly raised in the postoperative period in open cholecystectomy than laparoscopic cholecystectomy group. The postoperative recovery was also prolonged in the open group. The obvious clinical advantages of laparoscopic cholecystectomy over open cholecystectomy is mainly because of less metabolic and stress response.

Correlation between blood cAMP, cGMP levels and traumatic severity in the patients with acute trauma and its clinical significance / 华中科技大学学报（医学）（英德文版）

In order to investigate the correlation between traumatic servity and blood cAMP and cGMP levels in the patients with acute trauma and its clinical significance, 120 cases of trauma were randomly selected and divided into 4 groups (n = 30 in each group): mildly traumatic group (ISS 25). The cAMP and cGMP levels were assayed in sera, leucocytes and platelets respectively in 6 h and 24 h after trauma. The results showed that cAMP and cGMP levels were elevated significantly in sera and platelets (P < 0.05 or P < 0.01), meanwhile cGMP levels in leucocytes (P < 0.05). It was concluded that cAMP and cGMP might play an important role in traumatic stress, participate in the cellular signal transducation and promote the immune function of leucocytes and the coagulation founction of platelets. Serum cAMP and cGMP levels were upregulated correspondingly as ISS increased, and positively correlated to the traumatic severity.