[Retrospective computation of the ISS in multiple trauma patients: Potential pitfalls and limitations of findings in full body CT scans]. / Retrospektive Berechnung des ISS bei polytraumatisierten Patienten: Fehlerquellen und Anforderungen an den radiologischen Befund der Ganzkörper-CT.

INTRODUCTION: The Injury Severity Score (ISS) is a well-established anatomical scoring system for polytraumatized patients. However, any inaccuracy in the Abbreviated Injury Score (AIS) directly increases the ISS impreciseness. Using the full body computed tomography (CT) scan report, ISS computation can be associated with certain pitfalls. This study evaluates interpretation variations depending on radiological reports and indicates requirements to reliably determine the ISS. MATERIALS AND METHODS: The ISS of 81 polytraumatized patients was calculated based on the full body CT scan report. If an injury could not be attributed to a precise AIS cipher, the minimal and maximal ISS was computed. Real ISS included all conducted investigations, intraoperative findings, and final medical reports. The differences in ISS min, ISS max, and ISS real were evaluated using the Kruskal-Wallis test (p<0.05) and plotted in a linear regression analysis. RESULTS: Mean ISS min was 24.0 (± 0.7 SEM) points, mean ISS real 38.6 (±1.3 SEM) and mean ISS max was 48.3 (±1.4 SEM) points. All means were significantly different compared to one another (p<0.001). The difference between possible and real ISS showed a distinctive variation. Mean deviation was 9.7 (±0.9 SEM) points downward and 14.5 (±1.1 SEM) points upward. The difference between deviation to ISS min and ISS max was highly significant (p<0.001). CONCLUSION: Objectification of injury severity in polytraumatized patients using the ISS is an internationally well-established method in clinical and scientific settings. The full body CT scan report must meet distinct criteria and has to be written in acquaintance to the AIS scale if intended to be used for correct ISS computation.

[Lisfranc dislocation fracture: Dynamic examination under anesthesia and minimally invasive stabilization with mini-TightRope®]. / Lisfranc-Luxationsfraktur: Dynamische Narkoseuntersuchung und minimal-invasive Stabilisierung mittels Mini-TightRope®.

As Lisfranc joint injuries are rare and standard radiographic examinations can be difficult to interpret the correct diagnosis is often initially overlooked. Delayed treatment frequently results in painful and disabling arthritis, consequently, primary targeted diagnostics are essential for the functional outcome. We report on a patient with a Lisfranc fracture dislocation, with the injury severity only becoming obvious by dynamic examination with the patient under anesthesia. Due to the massive swelling we performed a minimally invasive primary stabilization using one K-wire and a mini-TightRope®.

[Posttraumatic adhesive ileus following pelvic ring fracture]. / Posttraumatischer Briden-Ileus nach Beckenringfrakturen.

We report on two cases of posttraumatic ileus after pelvic ring fracture in two patients aged 73 and 74 years, respectively. Although all conservative measures were exhausted, in both cases the ileus resulted in additional operative procedures and a significant extension of the hospital stay. Intraoperatively both patients presented with a mechanical ileus caused by adhesions which were unapparent for decades. Only the trauma-related motility disorder led to a clinical manifestation. Pathophysiological mechanisms and their implications on prophylaxis and therapy are discussed.

Impact of STAT/SOCS mRNA expression levels after major injury.

BACKGROUND: Fulminant changes in cytokine receptor signalling might provoke severe pathological alterations after multiple trauma. The aim of this study was to evaluate the posttraumatic imbalance of the innate immune system with a special focus on the STAT/SOCS family. METHODS: 20 polytraumatized patients were included. Blood samples were drawn 0 h-72 h after trauma; mRNA expression profiles of IL-10, STAT 3, SOCS 1, and SOCS 3 were quantified by qPCR. RESULTS: IL-10 mRNA expression increased significantly in the early posttraumatic period. STAT 3 mRNA expressions showed a significant maximum at 6 h after trauma. SOCS 1 levels significantly decreased 6 h-72 h after trauma. SOCS 3 levels were significantly higher in nonsurvivors 6 h after trauma. CONCLUSION: We present a serial, sequential investigation in human neutrophil granulocytes of major trauma patients evaluating mRNA expression profiles of IL-10, STAT 3, SOCS 1, and SOCS 3. Posttraumatically, immune disorder was accompanied by a significant increase of IL-10 and STAT 3 mRNA expression, whereas SOCS 1 mRNA levels decreased after injury. We could demonstrate that death after trauma was associated with higher SOCS 3 mRNA levels already at 6 h after trauma. To support our results, further investigations have to evaluate protein levels of STAT/SOCS family in terms of posttraumatic immune imbalance.

[Ethical decisions in surgery. Foundations for a principle-oriented case discussion]. / Ethische Entscheidungen in der Chirurgie. Grundlagen einer prinzipienorientierten Falldiskussion.

BACKGROUND: Due to advanced medical interventions, the multitude of beliefs in our society, and increasing economic pressure, difficult ethical decisions are also part of the surgical care of patients. QUESTION: How can health care personnel address the ethical challenges in a structured, well-founded ethical manner? MATERIALS AND METHODS: Based on the four principles of biomedical ethics beneficence, nonmaleficence, respect for autonomy, and justice, we present a model for the step-wise ethical evaluation of difficult cases. RESULTS: The principle-based model of ethical case discussions consists of five steps: 1) In the medical analysis of the case, the available management strategies are identified, including a detailed description of their benefits and risks. 2) The evaluation starts with the ethical obligations towards the patient: Which treatment strategy is in the patient's best interest? And: Which option does the patient prefer herself after appropriate disclosure? 3) Then it has to be examined whether obligations to third parties (family members, other patients, etc.) have to be taken into account. 4) In the synthesis, the individual evaluations are integrated into an overall assessment of the case; conflicting obligations have to be balanced based on good reasons. 5) A critical review of the case concludes the case discussion. The application of the model is exemplified based on a surgical case discussion. CONCLUSION: Difficult ethical decisions can be supported by structured case discussions, in which all medical disciplines and professional groups involved in the care of the patient should participate.

Concentration kinetics of serum MMP-9 and TIMP-1 after blunt multiple injuries in the early posttraumatic period.

Metalloproteinases are secreted in response to a variety of inflammatory mediators and inhibited by tissue inhibitors of matrixmetalloproteinases (TIMPs). Two members of these families, MMP-9 and TIMP-1, were differentially expressed depending on clinical parameters in a previous genomewide mRNA analysis. The aim of this paper was now to evaluate the posttraumatic serum levels and the time course of both proteins depending on distinct clinical parameters. 60 multiple traumatized patients (ISS > 16) were included. Blood samples were drawn on admission and 6 h, 12 h, 24 h, 48 h, and 72 h after trauma. Serum levels were quantified by ELISA. MMP-9 levels significantly decreased in the early posttraumatic period (P < 0.05) whereas TIMP-1 levels significantly increased in all patients (P < 0.05). MMP-9 and TIMP-1 serum concentration kinetics became manifest in an inversely proportional balance. Furthermore, MMP-9 presented a stronger decrease in patients with severe trauma and non-survivors in contrast to minor traumatized patients (ISS ≤ 33) and survivors, initially after trauma.