Coagulation dysfunction of severe burn patients: A potential cause of death.

BACKGROUND: Research on coagulation dysfunction following burns is controversial. This study aimed to describe the coagulation changes in severe burn patients by examining coagulation parameters. METHODS: Patients with third-degree total body surface area (TBSA) burns of ≥30% were enrolled between 2017 and 2020. Platelet (PLT) count and coagulation indexes (including APTT, INR, FIB, DD, and AT Ⅲ) were measured at admission and once weekly for 8 weeks, and statistical analysis was performed. The patient medical profiles were reviewed to extract demographic and clinical data, including TBSA, third-degree TBSA, and inhalation injury. The total intravenous fluids and transfusions of crystalloids, fresh frozen plasma (FFP), and red blood cells (RBC) were calculated during the forty-eight-hour period. The number of sepsis cases was recorded. RESULTS: We enrolled 104 patients , and while the overall coagulation trend fluctuated, inflection points appeared around one week and demonstrated hypercoagulability. INR was significantly higher in the non-survival group than in the survivors' group from admission to three weeks after burn (all p<0.01). From post-injury week 1 to post-injury week 3, the APTT in the non-survival group was greater than in the survival group, but the non-survival group's PLT count was lower than that in the survival group (all p<0.05). At two and three weeks after burns, the FIB levels in the non-survival group were significantly lower than those of the survival group (both p<0.01). The prevalence of inhalation injury and the proportion of sepsis cases were significantly higher in the non-survival group than in the survival group ( p ＜ 0.05, p ＜ 0.001, respectively). At the time of death, APTT, INR, and FDP levels were significantly higher in the non-survival group in the survivor group, and FIB, ATIII, and PLT were significantly lower than in the survivor group (all p<0.01). On the day of death, nine of the 12 dead patients had disseminated intravascular coagulation (DIC). CONCLUSIONS: Coagulation dysfunction was most prominent in severe burn patients 1 week after injury and presented as hypercoagulability. Large-area burn injury, large amounts of fluid resuscitation, inhalation injury, and sepsis may all contribute to coagulation dysfunction, which can further develop into DIC and even death in severe burns patients.

Clinical significance of R-TEG in severe burn patients with coagulation dysfunction.

INTRODUCTION: The aim of this study was to retrospectively analyze Thrombelastography (TEG) data of severe burn patients to provide a clinical basis for timely diagnosis and treatment of coagulation dysfunction. METHODS: The present study comprised burn patients with full thickness TBSA ≥ 60%. The patients included in the study were admitted to the Third Affiliated Hospital of Inner Mongolia Medical University between March 2019 and March 2022 and died within 10 days. Patient demographic and clinical data, including abbreviated burn severity index (ABSI) score, full thickness and overall total surface burn area (TBSA), injury cause, International Society on Thrombosis and Hemostasis (ISTH) score, were retrieved from the electronic medical record system. TEG data (including ACT, K, α, MA and LY30), platelet count (PLT), mean platelet volume (MPV) and platelet distribution width (PDW) data were obtained from the records of included patients for analysis. RESULTS: A total of 9 patients were enrolled. The average burn area was 90.0% TBSA and the full-thickness TBSA was 72.0%. The results showed that α, MA and PLT count values were significantly lower relative to those at obtained throughout admission period (all p < 0.05). PDW and MPV were significantly higher compared with the values at admission (all p < 0.05). ACT time was significantly longer from day 2 after severe burn compared with the ACT time at admission (all p < 0.05). LY30 value from day 3 after severe burn was significantly higher compared with the value at admission (p < 0.05). One patient was diagnosed with diffuse intravascular coagulation (DIC) on admission, whereas eight patients were diagnosed with DIC on the day of death. CONCLUSION: Coagulation dysfunction after severe burn is mainly characterized by procoagulant disorders and hyperfibrinolysis, which can be timely detected by TEG. Coagulation after severe burn exhibits a gradual aggravation, and can lead to death of patients.

Mechanistic studies on the role of TGF-ß1 in angiogenesis through EndMT.

OBJECTIVE: This study aims to investigate the mechanism of transforming growth factor-ß1 (TGF-ß1) in promoting angiogenesis through endothelial-to-mesenchymal transition (EndMT). METHODS: The mesenchymal transition of human umbilical vein endothelial cells (HUVECs) was induced by TGF-ß1. The angiogenesis, migration, and proliferation of HUVECs undergoing EndMT were examined by tube formation assay, scratch assay, Transwell assay, and CCK-8 assay. RESULTS: The outcomes revealed that EndMT promoted angiogenesis, migration, and proliferation of HUVECs and the secretion of the vascular endothelial growth factor (VEGF) of HUVECs. Phosphorylated AKT (p-AKT) increased in EndMT by inhibiting the mitigation of angiogenesis. CONCLUSION: EndMT induces angiogenesis by promoting the secretion of VEGF, and p-AKT participates in this regulation.

[Involvement of PI 3 K/Akt/mTOR Signaling in Protective Effects of Moxibustion for Premature Ovarian Failure in Rats].

OBJECTIVE: To study the protective effect of moxibustion for tripterygium-induced premature ovarian failure (POF) and its underlying mechanisms in rats. METHODS: Forty-five female SD rats were randomly divided into normal control, POF model and moxibustion groups (n＝15/group). The POF model was induced by intragastric administration of Triptolide (40 mg/kg), once daily for 6 weeks. From the 4th week after modeling, moxibustion was given at "Guanyuan" (CV 4) and bilateral "Sanyinjiao" (SP 6) for 10 min, once daily for 3 weeks. Pathological changes of ovary tissues were determined by hematoxylin-eosin (HE) staining. The serum estradiol (E2), luteinizing hormone (LH), follicle-stimulating hormone (FSH), interleukin-6 (IL-6) and interleukin-1 ß (IL-1 ß) contents were measured by enzyme-linked immunosorbent assay (ELISA). The expression levels of phosphatidyl inositol 3- kinase (PI 3 K), protein kinase B (Akt) and mammalian target of rapamycin (mTOR) proteins of the ovarian tissue were detected by Western blot. RESULTS: After modeling, HE staining showed that the numbers of ovarian follicles and follicular granulocytes and corpora luteum layers were decreased, and the number of corpora atretica was increased in the model group. The content of serum E2 was markedly decreased and those of serum LH, FSH, IL-6 and IL-1 ß were markedly increased in the model group (P<0.01), and the expression levels of ovarian p-PI 3 K, p-Akt and p-mTOR were markedly increased after modeling relevant to the control group (P<0.01). Following moxibustion, the pathological damage of ovarian tissue was improved, the contents of serum LH, FSH, IL-6, IL-1 ß, and the levels of p-PI 3 K, p-Akt and p-mTOR proteins in the ovarian tissue were significantly decreased (P<0.05, P<0.01), and the content of serum E2 was markedly increased (P<0.05) in comparison with the model group. CONCLUSION: Moxibustion can improve POF in POF rats, which may be related to its actions in inhibiting PI 3 K/Akt/mTOR signaling, down-regulating serum IL-6, IL-1 ß, and regulating serum hormones.

[Early effectiveness of total hip arthroplasty in treating protrusion acetabuli].

OBJECTIVE: To evaluate the method and the early effectiveness of total hip arthroplasty in the treatment of protrusion acetabuli. METHODS: Between January 2006 and February 2010, 16 cases (16 hips) of protrusion acetabuli were treated, including 6 males and 10 females with an average age of 56.5 years (range, 39-72 years). The median disease duration was 6.4 years (range, 1 year and 6 months to 35 years). Involved hips included 7 left hips and 9 right hips; 3 patients had primary protrusion acetabuli and 13 patients had secondary protrusion acetabuli. The preoperative Harris score was 49.5 +/- 5.5. According to Dunlop et al. classification criterion, there were 3 cases of mild, 9 cases of moderate, and 4 cases of severe. All patients received total hip arthroplasty with bone graft and cementless prosthesis for recovery of femoral offset and acetabular center of rotation. RESULTS: All incisions healed by first intention without complication of infection, deep venous thrombosis, or nerve injury. All patients were followed up 12-62 months with an average of 37 months. The Harris score at last follow-up was 90.5 +/- 4.5, showing significant difference (t = 49.578, P = 0.000) when compared with preoperative score. The X-ray films showed that no prosthesis loosening or subsidence was observed, and bone graft healed with no sign of re-protrusion. CONCLUSION: In treatment of protrusion acetabuli, total hip arthroplasty with bone graft and cementless prosthesis can recover the femoral offset and acetabular center of rotation and provide satisfactory early effectiveness.

[Effectiveness of traumatic dislocation of knee joint combined with multiple ligament injuries treated by stages].

OBJECTIVE: To observe the effectiveness of traumatic dislocation of the knee joint combined with multiple ligament injuries treated by stages. METHODS: Between june 2005 and November 2008, 13 cases of traumatic dislocation of the knee joint combined with multiple ligament injuries were treated by stages, including 9 males and 4 females with an average age of 30.7 years (range, 18-54 years). The dislocations were left knee in 3 cases and right knee in 10 cases. The causes of injury were sports injury in 8 cases, traffic accident injury in 2 cases, falling from height injury in 2 cases, and sprain injury in 1 case. The average time from injury to hospitalization was 9 hours (range, 6 hours to 2 days). Anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), and medial collateral ligament (MCL) were involved in 8 cases; ACL, PCL, and lateral collateral ligament (LCL) in 3 cases; and ACL, PCL, MCL, and LCL in 2 cases. The valgus stress testing results of 10 knees were ++ to +++; the varus stress testing results of 5 knees were ++ to +++; all knees showed positive in the anterior or the posterior drawer test and ++ to +++ in Lachman test. The nerve, vessel, MCL, LCL, PCL, meniscus were repaired in the first operation. The functional exercise of knee joint was done after fixation for 3-4 weeks. During the second operation, the ACL was reconstructed under arthroscopy after the range of motion (ROM) of knee joint was good with anterior instability of knee within 4-6 months. RESULTS: All wounds healed by first intention after two operations; no complications of infection and compartment syndrome occurred. All cases were followed up 12-60 months with an average of 36 months. Joint effusion of knee occurred in 2 cases at 4 weeks after the first operation and was cured after removal of fluid. At 3 months after the second operation, the results of valgus stress testing and Lachman test were ++ in 1 case, respectively; the results of valgus stress testing, varus stress testing, and Lachman test were + in 1 case, respectively; and others showed negative results. After 12 months of the second operation, the mean flexion of the knee was 123.4 degrees (range, 100-135 degrees), and the mean extension of the knee was 2.3 degrees (range, 0-4 degrees). According to Lysholm evaluation system, 9 patients got excellent results, 2 good, and 2 fair; the excellent and good rate was 84.6%. CONCLUSION: It is an effective method in the treatment of traumatic dislocation of the knee joint combined with multiple ligament injuries by stages.

[Treatment of Schatzker V/VI tibial plateau fracture involved posteromedial condyle through combined approach].

OBJECTIVE: To observe the clinical results of treatment of Schatzker V/VI tibial plateau fracture involved posteromedial condyle through combined posteromedial and anterolateral approach and fixed with two or three plates. METHODS: From April 2005 to April 2008, 18 cases of tibial plateau fracture involved posteromedial condyle were treated, including 14 males and 4 females with an average age of 38.5 years old (range, 18-62 years old). According to Schatzker classification, there were 12 cases of type V and 6 cases of type VI. The posteromedial condyle were involved in 13 cases and bilateral posterior condyle in 5 cases. All patients were given posteromedial fragment and medial condyle fracture reduction through posteromedial approach firstly, and then lateral condyle fracture reduction through anterolateral approach, and injury of meniscus and cruciate ligaments were treated at the same time. Three plates (lateral, medial, posterior) were used in 10 cases and two plates (lateral, posteromedial) in 8 cases. RESULTS: All wounds achieved healing by first intention without complications such as infection, flap necrosis, osteofascial compartment syndrome, chronic osteomyelitis, nonunion. All patients were followed up for 12 to 48 months with an average of 24.4 months. The mean flexion of the knee was 118.4 degrees (range, 100-130 degrees) 1 year after operation. According to Iowa evaluation system, 12 patients got excellent results, 4 good, and 2 fair; the excellent and good rate was 88.9%. CONCLUSION: Combined posteromedial and anterolateral approach and fixed with two or three plates is effective in treatment of the Schatzker V/VI tibial plateau fracture involved posteromedial condyle. Anatomical reduction and rigid internal fixation of the posteromedial fragment are critical to successful operation.

[Effects of autologous periosteum wrapping allogenic tendon graft on tendon-bone healing inside a bone tunnel in rabbits].

OBJECTIVE: To explore the situation of tendon-bone healing when allogenic tendon graft is wrapped with autologous periosteum around the tendon in rabbits. METHODS: Twenty healthy New Zealand white rabbits with the age of 4-5 months were used in the experiment, weighing 2.5-3.0 kg. One-side posterior limb was selected randomly as the test, and the contralateral limb was served as the control at the same time. The allogenic tendon graft was designed as a tendon-bone model in the proximal tibial metaphysis of rabbits. The portion of tendon in the bone tunnel was wrapped with autologous periosteal graft in which the cambium layer was facing the bone tunnel in the experimental group, while the portion of tendon in the bone tunnel was not wrapped with autologous periosteal graft in the control group. The histologic examination of the tendon-bone interface (n = 2) and the biomechanical test for maximal pullout load (n = 8) were conducted 4 and 8 weeks after operation, respectively. RESULTS: All specimens were observed with naked eyes 4 and 8 weeks after the operation. Many new bones around bone tunnel outlet were seen in the experimental group, while a few or few new bones were seen in the control group. Four weeks after operation, histological observation showed there were a lot of proliferative mesenchymal cells in the periosteal germinal layer in the experimental group and conspicuous membrane bone formation was obvious. The arrangement of massive osteoblasts around newborn bone trabecula was similar to palisade. The newborn bone trabecula was linked with the periosteum. Some loose connective tissues and few newborn bones between the tendon graft and the bone tunnel were seen in the control group, and the connection of them was loose. Eight weeks after operation, the connection between the tendon graft and the bone tunnel was tight and no gap existed in the experimental group. The number of newborn bones was large and their arrangement was relatively regular. The tidemark line was seen between the tendon graft and the bone tunnel, which was similar to normal tendon-bone interface. The proliferation of fibroblast was active in the periosteum, and there were many fibrous joints between the periosteum and the tendon graft. Partial bone formation was seen between the tendon graft and the bone tunnel in the control group, with disorderly arrangement, and there were many collagen fibrous joints between the tendon graft and the bone tunnel. Four and 8 weeks after operation, the pullout or pull and break loads of the experimental group were (35.03 +/- 1.21) N/cm and (42.36 +/- 1.31) N/cm, respectively, and those of the control group were (26.14 +/- 6.13) N/cm and (31.63 +/- 6.87) N/cm, respectively. There was significant difference between the two groups (P < 0.05). CONCLUSION: The transplantation of autologous periosteum graft wrapping around allogenic tendon graft may shorten the time of osteochondral ossification between the tendon graft and the bone tunnel, improve healing strength and promote tendon-bone healing in the bone tunnel in rabbits.

[The efficacy of biological dressing containing calcium and magnesium on the management of hydrofluoric acid burns].

OBJECTIVE: To observe the efficacy of biological dressing containing calcium and magnesia (sheep dermis absorbing calcium and magnesia and cross-link with glutaraldehyde) on the management of hydrofluoric acid burns in rats and patients. METHODS: Wistar rats were randomly divided into A ( n = 24, normal control, with isotonic saline dressing after burns), B ( n = 32, with isotonic saline dressing treatment after hydrofluoric acid burns), C ( n = 32, with wet-dressing treatment after hydrofluoric acid burns), and D ( n = 32, with biological dressing treatment after hydrofluoric acid burns) groups. The rats in the latter 3 groups were inflicted with 3 cm x 3 cm TBSA full-thickness burns, and mortality, concentration of blood calcium , histopathological observation were carried out at 4,8,24 and 72 postburn hours (PBH), with 8 rats at each time-points. In addition, 46 patients with hydrofluoric acid burns were divided into E (with wet-dressing treatment) and F (with biological dressing treatment) groups to compare the curative effect. RESULTS: The mortality in A,B,C,D groups were 0,31.2% ,15. 6% ,6. 2% , respectively. The wound in B group was deepened gradually after burns, but that in D group was slighter when compared with that in C group. The concentration of blood calcium in A group was higher than that in B, C and D groups at each time-points, and that in D groups was higher than that in B and C groups. The concentration of blood calcium in D group at 8 and 24 PBH were [(2.215 +/-0.008) ,(2.216 +/-0.008) mmol/L], which were obviously higher than those in B [(1.813 +/-0.017),(1.912 +/-0.013)mmol/L l] and C [(2.015 +/-0.006), (2.018 +/-0. 010)mmol/L] groups, (P <0. 01). The clinical outcome in E group was much better than that in F group. CONCLUSION: Biological dressing containing calcium and magnesium can be applied in the emergency management and following treatment after hydrofluoric acid burns.

[Advance of lower cervical spine pedicle screw fixation in treatment of lower cervical spine instability].

OBJECTIVE: To review the anatomic character of lower cervical pedicle, the placement and the biomechanical stability of the cervical pedicle screw fixation, the clinical application and the complication caused by fixation. METHODS: The literature concerned the cervical pedicle screw fixation in recent years were extensively reviewed. RESULTS: The cervical pedicle screw fixation can be widely used in the lower cervical spine instability according to the anatomic character of lower cervical pedicle, and the good biomechanical stability of the cervical pedicle screw fixation, and the complication can be controlled. CONCLUSION: The cervical pedicle screw fixation is an effective internal fixation for the lower cervical spine instability.

[Clinical application of interbody cage systems in the lumbar spine].

OBJECTIVE: To study the clinical value of interbody cage systems in the surgical treatment of unstable lumbar segment, and evaluate the biomechanical properties. METHODS: Ninety-seven cases were selected for operation by posterior lumbar interbody fusion with the BAK-cage or TFC device. Of the patients, 18 were diagnosed as lumbar disc degeneration disease (DDD), 37 as lumbar stenosis, 23 as spondylolisthesis, and 19 as unstable traumatic lesion. Thirty-six of them received additional posterior pedicle devices; 13 cases with severe mechanical back pain underwent anterior interbody fusion with the BAK-cage or TFC or interbod spacer, 4 of them underwent surgery once again. A new anterior Mesh-cage was used in spinal reconstruction for some patients, including 8 patients with thoracolumbar tumor, 2 with lumbar burst fracture, and 1 with osteoportic late collapse of a vertebral body. RESULTS: In the follow-up for an average of 21 months, 63 patients were available for review. The clinical results were excellent and good in 91.2% of the patients who underwent posterior interbody cage fusion; the preoperative percentage of slip was corrected in 89% of the patients with spondlyolithsis and in 100% of the patients with traumatic dislocation. The satisfactory rate was 94.6% in the patients with severe back pain who underwent anterior interbody cage fusion. The rate of union in the grafted area was 95% at the 6th month after the operation. A preliminary experience showed that the clinical effect was obvious as the Mesh-cage was used in the patients with tumor, symptoms were relieved and motion ability was greatly improved in these patients. CONCLUSION: The interbody cage implant produces immediate stabilisation on unstable spinal segments, offers a conductive biomechanical environment for interbody graft healing by distraction properties and weight bearing function, and restores the normal interbody space and spinal column lordosis with satisfactory clinical effects on such diseases as DDD, traumatic lesion, osteoporotic late collapse of a vertebral body and spinal tumors.