Delayed recovery and late development of complex regional pain syndrome in patients with an isolated fracture of the distal radius: prediction of a regional inflammatory response by early signs.

We studied prospectively the regional inflammatory response to a unilateral distal radial fracture in 114 patients at eight to nine weeks after injury and again at one year. Our aim was to identify patients at risk for a delayed recovery and particularly those likely to develop complex regional pain syndrome. In order to quantify clinically the inflammatory response, a regional inflammatory score was developed. In addition, blood samples were collected from the antecubital veins of both arms for comparative biochemical and blood-gas analysis. The severity of the inflammatory response was related to the type of treatment (Kruskal-Wallis test, p = 0.002). A highly significantly-positive correlation was found between the regional inflammatory score and the length of time to full recovery (r(2) = 0.92, p = 0.01, linear regession). A regional inflammatory score of 5 points with a sensitivity of 100% but a specificity of only 16% also identified patients at risk of complex regional pain syndrome. None of the biochemical parameters studied correlated with regional inflammatory score or predicted the development of complex regional pain syndrome. Our study suggests that patients with a distal radial fracture and a regional inflammatory score of 5 points or more at eight to nine weeks after injury should be considered for specific anti-inflammatory treatment.

Subareolar breast abscesses: characteristics and results of surgical treatment.

Our objective was to describe the characteristics of subareolar breast abscesses and to analyze the results of surgical treatment in relation to the prevention of recurrences. Almost 70% of patients smoked more than 10 cigarettes a day. The recurrence rate after excision of the lactiferous ducts was 28% and after management without excision of the lactiferous ducts was 79% (p < 0.001). Gram-positive bacteria were isolated more frequently in primary subareolar breast abscesses (not significant). Anaerobic microorganisms were more frequently cultured in recurring subareolar breast abscesses (p = 0.02). Definitive treatment of subareolar breast abscesses should consist of excision of the affected lactiferous ducts.

Pentoxifylline does not improve outcome in a murine model for the multiple-organ dysfunction syndrome.

OBJECTIVE: To investigate the effects of pentoxifylline (PTX) administration in a murine model for the multiple-organ dysfunction syndrome (MODS). DESIGN AND SETTING: Prospective double-blind randomized animal study in a university research laboratory. INTERVENTIONS AND MEASUREMENTS: Sixty C57BL/6 mice were given an aseptic intraperitoneal injection of lipopolysaccharide followed after 6 days by zymosan (day 0) at a dose of either 0.9 or 1.0 mg/g body weight. Starting on day 0 mice were administered PTX at a dose of 80 mg/kg body weight or saline per os every 8 h. On day 17 surviving animals were killed, and their liver, lungs, spleen, and kidneys were collected. RESULTS: Mortality, course of body temperature, body weight, and macroscopic lung damage were similar between zymosan-treated groups. Administration of PTX did not significantly alter survival, body temperature, body weight, or macroscopic lung damage. In addition, there were no significant differences in organ weights between mice that received PTX and mice that received PBS. Although PTX inhibited the lipopolysaccharide-induced increase in tumor necrosis factor alpha and interleukin 6 expression (but not interleukin 1beta expression) at both mRNA and protein level in a murine macrophage cell line, tumor necrosis factor alpha mRNA expression in the livers of PTX-treated mice was not significantly inhibited. CONCLUSIONS: The results reported here do not support the hypothesis that PTX improves outcome in zymosan-induced multiple-organ dysfunction in mice.

Increased expression of matrix metalloproteinases in the murine zymosan-induced multiple organ dysfunction syndrome.

Matrix metalloproteinases (MMPs) have been implicated as mediators of tissue damage in several inflammatory diseases. Since the multiple organ dysfunction syndrome (MODS) is thought to result from systemic inflammation, overactivation of MMPs could contribute to the organ damage observed. The expression and activity of several MMPs were studied in a murine model for MODS. Sixty mice were given an aseptic intraperitoneal injection of lipopolysaccharide, followed, after 6 days, by zymosan. At days 2, 5, 8, 12, and 16 after the injection of zymosan, the liver, lungs, spleen, and kidneys were collected from groups of mice for either RNA extraction, gelatinase zymography and collagenase (MMP-1 and -13) assays (six mice per time point), or immunohistochemistry (three mice per time point). A group of nine mice did not receive zymosan and acted as controls. The expression of MMP-2 mRNA in zymosan-treated mice was strongly up-regulated in liver tissue only. For MMP-9, this was the case in all organs examined. Quantitative gelatin zymography demonstrated the near complete absence of any gelatinase activity in tissues from control mice. However, in the liver, lungs, and especially the spleen of zymosan-treated animals, significantly increased activity of proform and active MMP-2 and -9 was observed with time. Overall, MMP-1 and -13 activities were very low in all samples from the liver and lungs. In the spleen, however, high levels of MMP-1 and -13 were observed in zymosan-treated animals. Immunohistochemical staining for MMP-2 was detected in the liver and spleen, but not in lung and kidney tissue of zymosan-treated animals. Staining for MMP-9 could be detected in liver, lung, and spleen tissues of zymosan-treated mice. For both MMPs, staining appeared to be limited to phagocytes. In conclusion, the data suggest a role for MMPs, especially MMP-9, in the pathogenesis of MODS.

Capillary blood gas analysis in complex regional pain syndrome: a pilot study.

BACKGROUND: The pathophysiology of complex regional pain syndrome type 1 (CRPS 1) is still a matter of debate. An inflammatory reaction may cause the syndrome. Increasing evidence points to a role for impairment of oxygen metabolism in the affected limb. METHODS: In this pilot study (16 patients) we performed capillary blood gas analysis in extremities with acute CRPS 1, in order to assess oxygen saturation and lactate concentrations. Comparison was made with the unaffected limb for capillary blood pH, pO(2), SaO(2), and lactate and glucose concentrations. RESULTS: No statistically significant differences could be found. CONCLUSIONS: Capillary blood gas analysis is not useful to detect changes in oxygen saturation and lactate concentrations in CRPS 1.

[One hundred years of the Association of Surgeons in the Netherlands. V. Traumatology]. / Honderd jaar Nederlandse Vereniging voor Heelkunde. V. Traumatologie.

Traumatology in the Netherlands gained considerable momentum during the last years of the twentieth century. This breakthrough was due to the creation of ten trauma care centres, each with its own 'mobile medical team'. Additionally, four of these centres dispose of a helicopter for rapid transport of this team. Furthermore, within the field of medical education and training, new courses on advanced trauma and life support (ATLS) and advanced pediatric life support (APLS), for example, not only offer more practical knowledge, but also provide a 'common language' for all those involved in the medical and organisational aspects of trauma care. Surgical treatment of trauma injuries is becoming increasingly oriented towards minimally invasive techniques. Assessment of the quality of care provided requires a broad and reliable registration system for injuries.

A multiantioxidant supplementation reduces damage from ischaemia reperfusion in patients after lower torso ischaemia. A randomised trial.

BACKGROUND: open repair of intra-abdominal aortic aneurysm (AAA) is associated with lower torso ischaemia and reperfusion. OBJECTIVE: to examine the effect of antioxidants on the activation and sequestration of white blood cells and muscle injury during AAA repair. METHOD: forty-two patients undergoing elective infrarenal aneurysm repair, were randomised to either standard therapy (22 patients) or standard therapy with additional multiantioxidant supplementation (20 patients). Vitamin E and C, Allopurinol, N-acetylcysteine and mannitol was administered perioperatively. White blood cell count (WBC), serum creatine kinase, aspartateaminotransferase, lactate and lipofuscine were measured. RESULTS: WBC remained higher after reperfusion in the antioxidant group (p = 0.008). CK, ASAT and lipofuscine levels were significantly lower after reperfusion in the antioxidant group (p = 0.02, p = 0.018, p = 0.017). CONCLUSION: multi-antioxidant supplementation was associated with a reduction in serum CK and ASAT after AAA repair. This is likely due to a reduction in oxidative stress and a decreased leucocyte sequestration and activation.