Interleukin-1 mediates increased plasma levels of eicosanoids and cytokines in patients with sepsis syndrome.

The purpose of this was to study evaluate the effects of interleukin-1 (IL-1) inhibition by human recombinant IL-1 receptor antagonist (IL-1ra) on plasma prostaglandin, leukotriene, and cytokine levels in sepsis syndrome. As part of a multisite, prospective, randomized, double-blind, placebo-controlled clinical trial, 19 septic patients received IL-1ra in a 100 mg bolus followed by 2.0 mg/kg/h i.v. for 72 h (n = 10) or placebo (n = 9). Plasma thromboxane B2 (TXB2), prostaglandin 6-keto-F1 alpha (PGI), leukotriene B4 (LTB4), leukotrienes C4D4E4 (LTC4D4E4), IL-1 beta, IL-6, and tumor necrosis factor alpha (TNF) were measured by ELISA before study drug infusion (baseline) and at 24, 48, 72, and 96 h after the beginning of the study drug infusion. Differences between placebo and IL-1-ra for plasma LTB4 and TNF were not significant. Plasma TXB2, PGI, LTC4D4E4, and IL-6, expressed as % baseline, were significantly lower in patients receiving IL-1ra than in the placebo group (p < .05), while plasma IL-1 was increased significantly. IL-1 may be a necessary mediator of increased circulating PGI, TXB2, LTC4D4E4, and IL-6 levels in patients with sepsis syndrome. Plasma IL-1 is increased with infusion of IL-1ra. The clinical significance of IL-1 in modifying circulating eicosanoid and cytokine concentrations in clinical sepsis is not clear from the data.

Three-dimensional computerized tomographic demonstration of bilateral atlantoaxial rotatory dislocation in an adult: report of a case and review of the literature.

A rare case of bilateral atlantoaxial rotatory dislocation (Fielding type V) in an adult is presented. The diagnosis was rapidly made by computed axial tomography. Prior reports of this entity have not clearly defined the pathoanatomy, which in our case was confirmed by three-dimensional tomographic reconstruction. We offer a clarification of the anatomic lesion and a discussion of this injury, which may make recognition and treatment of future cases easier.

Complications of anticoagulation for pulmonary embolism in low risk trauma patients.

Trauma patients are at significant risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). Anticoagulation is standard therapy for DVT/PE, but may cause severe complications. We reviewed the course of 70 trauma ICU patients treated over a 28-month period. Thirty-six patients (51.4 percent) were treated by continuous IV heparin and/or oral warfarin. Of these, 13 patients (36 percent) developed complications requiring termination of anticoagulation. These included recurrent PE (four), subdural hematomas (three), hemothorax (two), heparin-induced thrombocytopenia (one), hemorrhagic pericardial effusion (one), retroperitoneal hematoma (one), and sudden unexplained drop in hemoglobin and shock (one). All patients with subdural hematomas had no prior evidence of head injury on brain computed tomography. All patients with recurrent PE received adequate anticoagulation therapy. Age > 55 was associated with increased risk of complications (8 of 13; p = .02:chi 2). Thirty-four other patients (48.6 percent) received inferior vena caval filters with no related complications or deaths. Anticoagulation for DVT/PE should be used selectively in trauma patients and avoided in elderly patients. Such patients should undergo early caval filter placement.

Bacterial translocation occurs in humans after traumatic injury: evidence using immunofluorescence.

UNLABELLED: We evaluated the occurrence of bacterial translocation (BT) in humans after traumatic injury. Twenty trauma patients (18 with blunt trauma) requiring celiotomy and without hollow viscus injury were studied. After surgical hemostasis and repair, portal venous blood (PVB) was sampled for culture. Additionally, a mesenteric lymph node (MLN) was harvested for culture and indirect immunofluorescence analysis using, first, mouse monoclonal antibody to E. coli beta-galactosidase, then goat anti-mouse immunoglobulin G (IgG). Injury Severity Score (ISS), Trauma Score (TS), and period of hemorrhagic shock (HS; systolic BP < 90 mm Hg with blood loss > 500 mL) were recorded before specimens were obtained. RESULTS: Fifteen patients initially had HS (mean period of 60 minutes). Mean TS and ISS were 10 and 29, respectively. Seven patients did not have HS (mean TS and ISS, 10 and 13). Three patients received antibiotics preoperatively. Portal venous blood culture produced positive results in only three patients (two with HS) and culture of the MLN specimen was positive in one. However E. coli beta-galactosidase was detected within the cytoplasm of macrophages in all MLNs. One patient developed multiple organ failure. CONCLUSION: Bacterial translocation occurs in humans following traumatic injury and may be independent of HS. Culture techniques may not detect BT since organisms may have been phagocytized by macrophages. The clinical significance of BT in trauma patients remains unclear.

Blunt traumatic bladder rupture: the role of retrograde cystogram.

STUDY OBJECTIVE: We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture. DESIGN: All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively. SETTING: Level I trauma center, university hospital. TYPE OF PARTICIPANTS: All patients with acute blunt abdominal trauma admitted to this Level I trauma center. INTERVENTIONS: The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome. MEASUREMENTS AND MAIN RESULTS: Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. Twenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. CONCLUSION: Significant (more than 50 RBCs/high-power field) hematuria is the principal indication for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality.

Serum amylase determination and blunt abdominal trauma.

To determine the value of serum amylase sampling as an indicator of intra-abdominal injury, the records of 940 consecutive victims of blunt trauma were retrospectively reviewed. The sensitivity, specificity, and predictive value were poor in the determination of intra-abdominal injury, whether accompanied by craniofacial injury or not. It was concluded that routine serum amylase determination is of no value in the clinical management of the patient suffering blunt injury.

Blunt aortic trauma following deceleration in a seven year old.

Aortic injury following deceleration is an uncommon clinical entity in the pediatric population. Flexibility of the thoracic cage and marked tissue elasticity have been hypothesized as critical factors. Unfortunately, the scarcity of this phenomenon can lead to a lowered suspicion. We describe a case of blunt aortic injury following deceleration to raise the index of suspicion for this injury in the pediatric population.