Physical function and pain after surgical or conservative management of multiple rib fractures - a follow-up study.

BACKGROUND: There is scarce knowledge of physical function and pain due to multiple rib fractures following trauma. The purpose of this follow-up was to assess respiratory and physical function, pain, range of movement and kinesiophobia in patients with multiple rib fractures who had undergone stabilizing surgery and compare with conservatively managed patients. METHODS: A consecutive series of 31 patients with multiple rib fractures who had undergone stabilizing surgery were assessed >1 year after the trauma concerning respiratory and physical function, pain, range of movement in the shoulders and thorax, shoulder function and kinesiophobia. For comparison, 30 patients who were treated conservatively were evaluated with the same outcome measures. RESULTS: The results concerning pain, lung function, shoulder function and level of physical activity were similar in the two groups. The patients who had undergone surgery had a significantly larger range of motion in the thorax (p < 0.01) and less deterioration in two items in Disability Rating Index (sitting and standing bent over a sink) (p < 0.05). DISCUSSION: It is questionable whether the control group is representative since the majority of patients were invited but refused to participate in the follow-up. In addition, this study is too small to make a definitive conclusion if surgery is better than conservative treatment. But we see some indications, such as a tendency for decreased pain, better thoracic range of motion and physical function which would indicate that surgery is preferable. If operation technique could improve in the future with a less invasive approach, it would presumably decrease post-operative pain and the benefit of surgery would be greater than the morbidity of surgery. CONCLUSIONS: Patients undergoing surgery have a similar long-term recovery to those who are treated conservatively except for a better range of motion in the thorax and fewer limitations in physical function. Surgery seems to be beneficial for some patients, the question remains which patients. TRIAL REGISTRATION: FoU i Sverige (R&D in Sweden), No 106121.

Surgical treatment of multiple rib fractures and flail chest in trauma: a one-year follow-up study.

BACKGROUND: Multiple rib fractures and unstable thoracic cage injuries are common in blunt trauma. Surgical management of rib fractures has received increasing attention in recent years and the aim of this 1-year, prospective study was to assess the long-term effects of surgery. METHODS: Fifty-four trauma patients with median Injury Severity Score 20 (9-66) and median New Injury Severity Score 34 (16-66) who presented with multiple rib fractures and flail chest, and underwent surgical stabilization with plate fixation were recruited. Patients responded to a standardized questionnaire concerning pain, local discomfort, breathlessness and use of analgesics and health-related quality of life (EQ-5D-3 L) questionnaire at 6 weeks, 3 months, 6 months and 1 year. Lung function, breathing movements, range of motion and physical function were measured at 3 months, 6 months and 1 year. RESULTS: Symptoms associated with pain, breathlessness and use of analgesics significantly decreased from 6 weeks to 1 year following surgery. After 1 year, 13 % of patients complained of pain at rest, 47 % had local discomfort and 9 % used analgesics. The EQ-5D-3 L index increased from 0.78 to 0.93 and perceived overall health state increased from 60 to 90 % (p < 0.0001) after 6 weeks to 1 year. Lung function improved significantly with predicted Forced vital capacity and Peak expiratory flow increasing from 86 to 106 % (p = 0.0002) and 81 to 110 % (p < 0.0001), respectively, from 3 months to 1 year after surgery. Breathing movements and range of motion tended to improve over time. Physical function improved significantly over time and the median Disability rating index was 0 after 1 year. CONCLUSIONS: Patients with multiple rib fractures and flail chest show a gradual improvement in symptoms associated with pain, quality of life, mobility, disability and lung function over 1 year post surgery. Therefore, the final outcome of surgery cannot be assessed before 1 year post-operatively.

[58 people with bullet wounds in Gothenburg during 18 months. This demonstrates the need for preparedness and competence within trauma care]. / 58 personer skottskadade i Göteborg under 18 månader - Visar på behovet av beredskap och kompetens inom traumasjukvården.

From 1 January 2013 to 30 June 2014, 58 patients sustained gunshot wounds in the city of Gothenburg. 57 were males and the median age was 26 years. The majority of injuries were musculoskeletal. Ten patients died, of these 4 patients suffered single gunshot wounds to the head, while 6 patients had wounds to mediastinal structures and large abdominal vessels. 90 % of patients presented out-of-hours. The total length of stay for the 47 patients admitted was 316 days. Direct health care costs were calculated to 6.2 MSEK.

Deficiency of filamin A in endothelial cells impairs left ventricular remodelling after myocardial infarction.

AIMS: Actin-binding protein filamin A (FLNA) regulates signal transduction important for cell locomotion, but the role of FLNA after myocardial infarction (MI) has not been explored. The main purpose of this study was to determine the impact of endothelial deletion of FLNA on post-MI remodelling of the left ventricle (LV). METHODS AND RESULTS: We found that FLNA is expressed in human and mouse endothelial cells (ECs) during MI. To determine the biological significance of endothelial expression of FLNA, we used mice that are deficient for endothelial FLNA by cross-breeding adult mice expressing floxed Flna (Flna(o/fl)) with mice expressing Cre under the vascular endothelial-specific cadherin promoter (VECadCre+). Male Flna(o/fl) and Flna(o/fl)/VECadCre+ mice were subjected to permanent coronary artery ligation to induce MI. Flna(o/fl)/VECadCre+ mice that were deficient for endothelial FLNA exhibited larger and thinner LV with impaired cardiac function as well as elevated plasma levels of NT-proBNP and decreased secretion of VEGF-A. The number of capillary structures within the infarcted areas was reduced in Flna(o/fl)/VECadCre+ hearts. ECs silenced for Flna mRNA expression exhibited impaired tubular formation and migration, secreted less VEGF-A, and produced lower levels of phosphorylated AKT and ERK1/2 as well as active RAC1. CONCLUSION: Deletion of FLNA in ECs aggravated MI-induced LV dysfunction and cardiac failure as a result of defective endothelial response and increased scar formation by impaired endothelial function and signalling.

Blood biomarkers for brain injury in concussed professional ice hockey players.

IMPORTANCE: Lack of objective biomarkers for brain damage hampers acute diagnosis and clinical decision making about return to play after sports-related concussion. OBJECTIVES: To determine whether sports-related concussion is associated with elevated levels of blood biochemical markers of injury to the central nervous system and to assess whether plasma levels of these biomarkers predict return to play in professional ice hockey players with sports-related concussion. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective cohort study involving all 12 teams of the top professional ice hockey league in Sweden, the Swedish Hockey League. Two hundred eighty-eight professional ice hockey players from 12 teams contesting during the 2012-2013 season consented to participate. All players underwent clinical preseason baseline testing regarding concussion assessment measures. Forty-seven players from 2 of the 12 ice hockey teams underwent blood sampling prior to the start of the season. Thirty-five players had a concussion from September 13, 2012, to January 31, 2013; of these players, 28 underwent repeated blood sampling at 1, 12, 36, and 144 hours and when the players returned to play. MAIN OUTCOMES AND MEASURES: Total tau, S-100 calcium-binding protein B, and neuron-specific enolase concentrations in plasma and serum were measured. RESULTS: Concussed players had increased levels of the axonal injury biomarker total tau(median, 10.0 pg/mL; range, 2.0-102 pg/mL) compared with preseason values (median, 4.5pg/mL; range, 0.06-22.7 pg/mL) (P < .001). The levels of the astroglial injury biomarker S-100 calcium-binding protein B were also increased in players with sports-related concussion(median, 0.075 µg/L; range, 0.037-0.24 µg/L) compared with preseason values (median,0.045 µg/L; range, 0.005-0.45 µg/L) (P < .001). The highest biomarker concentrations of total tau and S-100 calcium-binding protein B were measured immediately after a concussion, and they decreased during rehabilitation. No significant changes were detected in the levels of neuron-specific enolase from preseason values (median, 6.5 µg/L; range,3.45-18.0 µg/L) to postconcussion values (median, 6.1 µg/L; range, 3.6-12.8 µg/L) (P = .10). CONCLUSIONS AND RELEVANCE: Sports-related concussion in professional ice hockey players is associated with acute axonal and astroglial injury. This can be monitored using blood biomarkers, which may be developed into clinical tools to guide sport physicians in the medical counseling of athletes in return-to-play decisions.

A feasibility study of 60 consecutive patients operated for unstable thoracic cage.

BACKGROUND: About 10% of adult patients in high-energy trauma sustain multiple rib fractures. Some of these patients suffer from flail chest leading to respiratory insufficiency. During last years interest and results for operative treatment has improved. The literature today all show positive results for surgical versus conservative treatment, specifically with regard to time spent in mechanical ventilator, complication rates and length of hospital stay. METHODS: Between September 2010 and July 2012, 60 patients with flail chest or multiple rib-fractures resulting in unstable thoracic cage were operated. 16 women and 44 men with an age between 19-86 years (mean 57). We used modern fracture techniques with plates and intramedullary splint. Thoracotomy was performed and lung lacerations were debrided (11/60). Time spent in ventilator, complications and other adverse effects was studied. The operated cohort was compared to results from six previous years, when none was operated for that diagnose (153 patients). RESULTS: There is a significant correlation between Injury Severity Score (ISS) and time spent in ventilator both for patients operated and not operated (p< 0,01). The mean time in ventilator was 9,01 days for not operated patients compared to 2,7 for the operated (p<0,0001). No clear pneumonias were found. We had two deaths during the acute period. The infection rate was low. CONCLUSIONS: Open reduction and internal fixation is a safe method to treat the unstable thoracic cage with multiple rib fractures and flail chest. Complication are few. The treatment time in mechanical ventilator is significant decreased. The operative treatment is probably cost effective and can be recommended. Knowledge in thoracic surgery and modern fracture surgery is needed. This is a therapeutic consecutive, level III, cohort study with historical controls.

Targeting filamin A reduces K-RAS-induced lung adenocarcinomas and endothelial response to tumor growth in mice.

BACKGROUND: Many human cancer cells express filamin A (FLNA), an actin-binding structural protein that interacts with a diverse set of cell signaling proteins, but little is known about the biological importance of FLNA in tumor development. FLNA is also expressed in endothelial cells, which may be important for tumor angiogenesis. In this study, we defined the impact of targeting Flna in cancer and endothelial cells on the development of tumors in vivo and on the proliferation of fibroblasts in vitro. METHODS: First, we used a Cre-adenovirus to simultaneously activate the expression of oncogenic K-RAS and inactivate the expression of Flna in the lung and in fibroblasts. Second, we subcutaneously injected mouse fibrosarcoma cells into mice lacking Flna in endothelial cells. RESULTS: Knockout of Flna significantly reduced K-RAS-induced lung tumor formation and the proliferation of oncogenic K-RAS-expressing fibroblasts, and attenuated the activation of the downstream signaling molecules ERK and AKT. Genetic deletion of endothelial FLNA in mice did not impact cardiovascular development; however, knockout of Flna in endothelial cells reduced subcutaneous fibrosarcoma growth and vascularity within tumors. CONCLUSIONS: We conclude that FLNA is important for lung tumor growth and that endothelial Flna impacts local tumor growth. The data shed new light on the biological importance of FLNA and suggest that targeting this protein might be useful in cancer therapeutics.

Afferent intussuscepted antireflux nipple valve complications in the Kock pouch for continent urinary diversion Early results with a modified technique.

OBJECTIVES: To analyse the risk of afferent nipple valve stenosis and its consequences and management in patients with a Kock pouch for continent urinary diversion and to study the early results after using an alternative antireflux technique. MATERIAL AND METHODS: Sixty patients consecutively operated on with a conventional Kock reservoir for continent cutaneous urinary diversion between 1988 and 2001 were analysed with regard to the occurrence of afferent nipple valve stenosis and its clinical characteristics. Sixteen patients operated on for continent urinary diversion during the period 2002-04 had the antireflux valve constructed according to the serous-lined extramural ileal valve technique. RESULTS: Eight patients with a conventional Kock pouch developed true afferent nipple valve stenosis and the risk approached 30% after 15 years. Dilatation and stenting were usually successful. CONCLUSIONS: The high risk of afferent nipple valve stenosis when using the intussuscepted nipple valve in the construction of a Kock reservoir for continent cutaneous urinary diversion calls for an alternative method for anastomosing the ureters to the reservoir. Our early results with the combined Kock/T-pouch are promising.

Continent cutaneous urinary diversion is still a valid alternative after cystectomy for bladder carcinoma.

OBJECTIVE: We compared patient opinions concerning reservoir/bladder function as well as quality of life (QOL) after cystectomy for bladder carcinoma and continent cutaneous urinary diversion or orthotopic bladder reconstruction. MATERIAL AND METHODS: Fifteen patients with Kock reservoirs (11 females, 4 males) and 11 men with orthotopic bladders answered the European Organization for Research and Treatment of Cancer quality-of-life questionnaire-C30 as well as specially constructed questions concerning reservoir/bladder function. The glomerular filtration rate (GFR) was determined using Cr-EDTA or iohexol clearance. RESULTS: Functioning and global health/QOL scales did not differ between the two groups of operated patients or between diverted patients and gender- and age-matched groups from the general population. The majority of the patients were satisfied/very satisfied with their diversion but more patients were troubled by leakage in the orthotopic bladder group than in the Kock reservoir group. The GFR was similar in the two groups. CONCLUSION: Continent cutaneous urinary diversion is associated with fewer leakage problems than orthotopic bladder reconstruction after cystectomy for bladder carcinoma.

Prophylaxis against bone loss in Kock reservoir patients with reduced glomerular filtration rate.

OBJECTIVE: We investigated whether treatment with calcium carbonate and vitamin D3 can improve the bone mineral content of patients with ileal reservoirs for continent urinary diversion and a reduced glomerular filtration rate (GFR). MATERIAL AND METHODS: Twenty-six patients with Kock reservoirs were included in the study. Bone mineralization was determined using dual-energy X-ray absorptiometry. Kidney function was estimated from Cr-EDTA clearance and serum cystatin C concentration. Osteocalcin and parathyroid hormone in serum were also measured. Patients with reduced GFR were treated with calcium carbonate and vitamin D3 perorally. RESULTS: Bone mineral density in the femur neck and hip increased in the treatment group, as reflected by an improved T score. CONCLUSION: Patients with ileal reservoirs for continent urinary diversion and reduced kidney function should be supplemented with calcium carbonate and vitamin D3 in order to reduce the long-term risk of osteoporosis.

Luminal nitric oxide in ileal reservoirs for continent cutaneous diversion or orthotopic bladder reconstruction.

OBJECTIVES: To measure mucosal inflammation as reflected in nitric oxide (NO) production in ileal reservoirs for the storage of urine and to correlate it with the growth of bacteria as well as CRP. METHODS: Intraluminal gas NO concentrations were determined using the chemoluminescence technique in 25 patients with continent cutaneous ileal reservoirs (Kock pouch) and 12 patients with orthotopic bladders (hemi-Kock or T-pouch). NO concentrations were determined in both intestinal reservoir gas and silicon catheter balloon gas. Urinary culture and blood CRP determinations were performed. RESULTS: NO concentrations in reservoir gas were higher than in silicon catheter balloons. Bacteriuria was associated with approximately 20 times higher NO concentrations than sterile urine. NO concentrations did not differ between continent cutaneous reservoirs or orthotopic bladders when due attention was paid to variance in the rate of bacteriuria. Elevated CRP was associated with higher NO concentrations. Bacteriuria with acinetobacter, enterococci and pseudomonas appeared to cause comparatively lower NO concentrations. The inflammatory response of reservoir walls to bacteriuria did not decrease with time. CONCLUSIONS: Urine in itself causes much less intestinal wall inflammation than bacteriuria, as reflected in NO production. High CRP values are associated with high NO concentrations. The inflammatory response varies with the bacterial specimens.