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Owusu Sekyere E, Hardcastle TC, Sathiram R, Tlou B. Overview of lower urinary tract symptoms post-trauma intensive care unit admission. AFRICAN JOURNAL OF UROLOGY 2020. [DOI: 10.1186/s12301-020-00027-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The study was undertaken to assess the incidence of lower urinary tract symptoms (LUTS) after short-term indwelling urethral catheter (IUC) in polytrauma patients admitted to a level one trauma unit using core lower urinary tract symptom score (CLSS). Data of patients admitted between January 2013 and December 2015 and meeting the study criteria were retrieved from the hospital informatics system. Chart review was done, and patients were subsequently interviewed telephonically.
Results
Ninety-four respondents comprising of 81.9% males and 18.1% females out of the 221 eligible patients were contacted. The most common LUTS reported was urethral pain, and 90% had mild to moderate symptoms. No severe LUTS were identified. There was a positive correlation between the duration of IUC and LUTS, but there was no statistically significant association between age and LUTS in our study population.
Conclusion
Short-term duration of IUC in the trauma ICU patient is associated with predominantly mild irritative LUTS which are mostly self-limiting and may not need further investigations and management. CLSS was found to be a useful screening tool. Further studies are needed to confirm findings in our study.
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Dharap SB, Ekhande SV. An observational study of incidence, risk factors & outcome of systemic inflammatory response & organ dysfunction following major trauma. Indian J Med Res 2018; 146:346-353. [PMID: 29355141 PMCID: PMC5793469 DOI: 10.4103/ijmr.ijmr_1538_15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background & objectives: Trauma is known to lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), which is often a cause of late deaths after injury. SIRS and MODS have been objectively measured using scoring systems. This prospective observational study was carried out in a tertiary care hospital in India to evaluate SIRS and MODS following trauma in terms of their incidence, the associated risk factors and the effect on the outcome. Methods: All adult patients with major life- and limb-threatening trauma were included. Patients who died within 24 h, those with severe head injury, known comorbidity, immunocompromised state, on immunosuppressants or pregnancy were excluded. SIRS and MODS scores were recorded after initial management (baseline score), on days 3 and 6 of admission. SIRS was defined as SIRS score of ≥2 and MODS was defined as MODS score of ≥1. Results: Two hundred patients were enrolled. SIRS was noted in 156 patients (78%). MODS was noted in 145 (72.5%) patients. Overall mortality was 39 (19.5%). Both SIRS and MODS scores were significantly associated with age >60 yr, blunt injury, (lower) revised trauma score hypotension on admission and (higher) injury severity score, but not with gender, pre-hospital time or operative treatment. Interpretation & conclusions: Both SIRS and MODS scores were associated with longer Intensive Care Unit (ICU) stay, more ICU interventions and higher mortality. Incidence of MODS was significantly higher in patients with SIRS. Both scores showed rising trend with time in non-survivors and a decreasing trend in survivors. The serial assessment of scores can help prognosticate outcome and also allocate appropriate critical care resources to patients with rising scores.
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Affiliation(s)
- Satish Balkrishna Dharap
- Department of Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
| | - Sanket Vishnu Ekhande
- Department of Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India
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Guo J, Yan W, Yang Y, Wang Z, Tian F. Monitoring of vascular endothelial growth factor and its soluble receptor levels in early trauma. J Trauma Acute Care Surg 2017; 82:766-770. [PMID: 28099389 DOI: 10.1097/ta.0000000000001373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This clinical observation study aimed to investigate the relationship between the serum levels of vascular endothelial growth factor (VEGF) and its soluble receptors with the severity and the occurrence of late acute respiratory distress syndrome (ARDS) in early trauma. METHODS Sixty patients with multiple injuries were divided into three groups according to the Injury Severity Score (ISS) and the serum levels of VEGF, soluble VEGF receptor 1 (sVEGFR1), and sVEGFR2, were measured. Ten healthy people were recruited as controls. The incidence of late ARDS was also monitored, and its relationship to the above measures analyzed. RESULTS VEGF was not associated with ISS (p > 0.05); sVEGFR1 was positively associated with ISS (r = 0.459, p < 0.0001); however, sVEGFR2 was negatively associated with ISS (r = 0.510, p < 0.0001). The serum VEGF levels between the ARDS group and the non-ARDS group showed no significant difference (p > 0.05). sVEGFR1 in the ARDS group was significantly higher than that in the non-ARDS group (p < 0.0001), and sVEGFR2 in the ARDS group was significantly lower than that in the non-ARDS group (p < 0.0001). CONCLUSION In conclusion, the increasing of sVEGFR1 and the decreasing of sVEGFR2 in early trauma might be closely related to the occurrence of late ARDS. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Jianying Guo
- From the Department of Critical Care Medicine (J.G., Z.W.), the Third Hospital of Hebei Medical University, Shijiazhuang, China; Department of Intensive Care Unit (W.Y.), the First Hospital of Baoding, Baoding, Hebei, China; Department of Severe Medicine (Y.Y.), Xingtai People's Hospital, Xingtai, Hebei, China; and Department of Respiratory (F.T.), the Third Hospital of Hebei Medical University, Shijiazhuang, China
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Conway Morris A, Datta D, Shankar-Hari M, Weir CJ, Rennie J, Antonelli J, Rossi AG, Warner N, Keenan J, Wang A, Brown KA, Lewis S, Mare T, Simpson AJ, Hulme G, Dimmick I, Walsh TS. Predictive value of cell-surface markers in infections in critically ill patients: protocol for an observational study (ImmuNe FailurE in Critical Therapy (INFECT) Study). BMJ Open 2016; 6:e011326. [PMID: 27431901 PMCID: PMC4964235 DOI: 10.1136/bmjopen-2016-011326] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Critically ill patients are at high risk of nosocomial infections, with between 20% and 40% of patients admitted to the intensive care unit (ICU) acquiring infections. These infections result in increased antibiotic use, and are associated with morbidity and mortality. Although critical illness is classically associated with hyperinflammation, the high rates of nosocomial infection argue for an importance of effect of impaired immunity. Our group recently demonstrated that a combination of 3 measures of immune cell function (namely neutrophil CD88, monocyte HLA-DR and % regulatory T cells) identified a patient population with a 2.4-5-fold greater risk for susceptibility to nosocomial infections. METHODS AND ANALYSIS This is a prospective, observational study to determine whether previously identified markers of susceptibility to nosocomial infection can be validated in a multicentre population, as well as testing several novel markers which may improve the risk of nosocomial infection prediction. Blood samples from critically ill patients (those admitted to the ICU for at least 48 hours and requiring mechanical ventilation alone or support of 2 or more organ systems) are taken and undergo whole blood staining for a range of immune cell surface markers. These samples undergo analysis on a standardised flow cytometry platform. Patients are followed up to determine whether they develop nosocomial infection. Infections need to meet strict prespecified criteria based on international guidelines; where these criteria are not met, an adjudication panel of experienced intensivists is asked to rule on the presence of infection. Secondary outcomes will be death from severe infection (sepsis) and change in organ failure. ETHICS AND DISSEMINATION Ethical approval including the involvement of adults lacking capacity has been obtained from respective English and Scottish Ethics Committees. Results will be disseminated through presentations at scientific meetings and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02186522; Pre-results.
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Affiliation(s)
- Andrew Conway Morris
- University Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Deepankar Datta
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- University of Edinburgh School of Clinical Sciences, Edinburgh Critical Care Research Group, Edinburgh, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, Guy's and St Thomas’ Hospital NHS Foundation Trust, London, UK
| | - Christopher J Weir
- Edinburgh Health Services Research Unit, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Jillian Rennie
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Jean Antonelli
- Edinburgh Clinical Trials Unit, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Adriano G Rossi
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Noel Warner
- Becton Dickinson Bioscience, Franklin Lakes, New Jersey, USA
| | - Jim Keenan
- Becton Dickinson Bioscience, Franklin Lakes, New Jersey, USA
| | - Alice Wang
- Becton Dickinson Bioscience, Franklin Lakes, New Jersey, USA
| | - K Alun Brown
- Vascular Immunology Research Laboratory, Rayne Institute (King's College London), St Thomas’ Hospital, London, UK
| | - Sion Lewis
- Vascular Immunology Research Laboratory, Rayne Institute (King's College London), St Thomas’ Hospital, London, UK
| | - Tracey Mare
- Vascular Immunology Research Laboratory, Rayne Institute (King's College London), St Thomas’ Hospital, London, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Hulme
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Dimmick
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Timothy S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- University of Edinburgh School of Clinical Sciences, Edinburgh Critical Care Research Group, Edinburgh, UK
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Mondal NK, Sorensen EN, Pham SM, Koenig SC, Griffith BP, Slaughter MS, Wu ZJ. Systemic Inflammatory Response Syndrome in End-Stage Heart Failure Patients Following Continuous-Flow Left Ventricular Assist Device Implantation: Differences in Plasma Redox Status and Leukocyte Activation. Artif Organs 2015; 40:434-43. [PMID: 26416627 DOI: 10.1111/aor.12580] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The role of oxidative stress and leukocyte activation has not been elucidated in developing systemic inflammatory response syndrome (SIRS) in heart failure (HF) patients after continuous-flow left ventricular assist device (CF-LVAD) implantation. The objective of this study was to investigate the change of plasma redox status and leukocyte activation in CF-LVAD implanted HF patients with or without SIRS. We recruited 31 CF-LVAD implanted HF patients (16 SIRS and 15 non-SIRS) and 11 healthy volunteers as the control. Pre- and postimplant blood samples were collected from the HF patients. Plasma levels of oxidized low-density lipoprotein (oxLDL), malondialdehyde (MDA), total antioxidant capacity (TAC), superoxide dismutase (SOD) in erythrocyte, myeloperoxidase (MPO), and polymorphonuclear elastase (PMN-elastase) were measured. The HF patients had a preexisting condition of oxidative stress than healthy controls as evident from the higher oxLDL and MDA levels as well as depleted SOD and TAC. Leukocyte activation in terms of higher plasma MPO and PMN-elastase was also prominent in HF patients than controls. Persistent oxidative stress and reduced antioxidant status were found to be more belligerent in HF patients with SIRS after the implantation of CF-LVAD when compared with non-SIRS patients. Similar to oxidative stress, the activation of blood leukocyte was significantly highlighted in SIRS patients after implantation compared with non-SIRS. We identified that the plasma redox status and leukocyte activation became more prominent in CF-LVAD implanted HF patients who developed SIRS. Our findings suggest that plasma biomarkers of oxidative stress and leukocyte activation may be associated with the development of SIRS after CF-LVAD implant surgery.
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Affiliation(s)
- Nandan K Mondal
- Department of Surgery, Artificial Organ Lab, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Erik N Sorensen
- Department of Clinical Engineering, University of Maryland Medical Center, Baltimore, MD, USA
| | - Si M Pham
- Department of Surgery, Artificial Organ Lab, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven C Koenig
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Bartley P Griffith
- Department of Surgery, Artificial Organ Lab, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Zhongjun J Wu
- Department of Surgery, Artificial Organ Lab, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, KY, USA
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Paffrath T, Lefering R, Flohé S. How to define severely injured patients? -- an Injury Severity Score (ISS) based approach alone is not sufficient. Injury 2014; 45 Suppl 3:S64-9. [PMID: 25284238 DOI: 10.1016/j.injury.2014.08.020] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Multiple injured patients, polytrauma or severely injured patients are terms used as synonyms in international literature describing injured patients with a high risk of mortality and cost consuming therapeutic demands. In order to advance the definition of these terms, we analysed a large trauma registry. In detail, we compared critically ill trauma patients first specified on a pure anatomical base according to the ISS or NISS, second in the original "polytrauma definition" with two body regions affected and finally all of them combined with a physiological component. PATIENTS AND METHODS Records that were collected in the TraumaRegister DGU(®) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) between 1993 and 2011 (92,479 patients) were considered for this study. All patients with primary admission from scene with a minimum hospital stay of 48 h and an Injury Severity Score (ISS)≥ 16 were included. Pre-hospital and early admission data were used to determine physiological risk factors and calculate individual risk of death using the Revised Injury Severity Classification (RISC). RESULTS 45,350 patients met inclusion criteria. The overall hospital mortality rate was 20.4%. The predicted mortality according to the RISC-Score was 21.6%. 36,897 patients (81.4%) had injuries in several body regions. The prevalence of the five physiological risk factors varied between 17% (high age) and 34% (unconsciousness). There were 17,617 patients (38.8%) without any risk factor present on admission, while 30.6% (n=13,890) of the patients had one and 30.5% (n=13,843) had two or more factors present. Patients with ISS ≥ 16 but no physiological risk factor present had a very low mortality rate of 3.1% (542 of 17,617). With an increasing number of physiological factors there was an almost linear increase in mortality up to an 86% rate in patients with all five factors present. The 'polytrauma' definition of Butcher and colleagues with AIS ≥ 3 in at least two different body regions would apply to only 56.2% of patients in the present group with ISS ≥ 16. The mortality in this subgroup is only marginally higher (21.8%; 5559 of 25,494) than in the group of patients with only one severely affected body region (18.5%; 3675 of 19,875). CONCLUSIONS In our opinion the principle of sharpening an anatomically based definition by a defined physiological problem will help to specify the really critically ill trauma patients.
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Affiliation(s)
- Thomas Paffrath
- Department of Orthopaedic and Trauma Surgery, University Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany; Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Sascha Flohé
- Department of Trauma and Hand Surgery, University Hospital Duesseldorf, Duesseldorf, Germany; Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany
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Zaytoun T, Mahrous AA, Dawood A, Elsammk M, El Halim AA, Attia A. Chromogranin A (CgA) as a marker of weaning in mechanically ventilated critically ill septic patients. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Kesani AK, Urquhart JC, Bedard N, Leelapattana P, Siddiqi F, Gurr KR, Bailey CS. Systemic inflammatory response syndrome in patients with spinal cord injury: does its presence at admission affect patient outcomes? Clinical article. J Neurosurg Spine 2014; 21:296-302. [PMID: 24836657 DOI: 10.3171/2014.3.spine13784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object in this study was to determine whether the presence of systemic inflammatory response syndrome (SIRS) in patients with traumatic spinal cord injury (SCI) on admission is related to subsequent clinical outcome in terms of length of stay (LOS), complications, and mortality. METHODS The authors retrospectively reviewed the charts of 193 patients with acute traumatic SCI who had been hospitalized at their institution between 2006 and 2012. Patients were excluded from analysis if they had insufficient SIRS data, a cauda equina injury, a previous SCI, a preexisting neurological condition, or a condition on admission that prevented appropriate neurological assessment. Complications were counted only once per patient and were considered minor if they were severe enough to warrant treatment and major if they were life threatening. Demographics, injury characteristics, and outcomes were compared between individuals who had 2 or more SIRS criteria (SIRS+) and those who had 0 or 1 SIRS criterion (SIRS-) at admission. Multivariate logistic regression (enter method) was used to determine the relative contribution of SIRS+ at admission in predicting the outcomes of mortality, LOS in the intensive care unit (ICU), hospital LOS, and at least one major complication during the acute hospitalization. The American Spinal Injury Association Impairment Scale grade and patient age were included as covariates. RESULTS Ninety-three patients were eligible for analysis. At admission 47.3% of patients had 2 or more SIRS criteria. The SIRS+ patients had higher Injury Severity Scores (24.3 ±10.6 vs. 30.2 ±11.3) and a higher frequency of both at least one major complication during acute hospitalization (26.5% vs. 50.0%) and a fracture-dislocation pattern of injury (26.5% vs. 59.1%) than the SIRS- patients (p < 0.05 for each comparison). The SIRS+ patients had a longer median hospital stay (14 vs 18 days) and longer median ICU stay (0 vs. 5 days). However, mortality was not different between the groups. Having SIRS on admission predicted an ICU LOS > 10 days, hospital LOS > 25 days, and at least one complication during the acute hospitalization. CONCLUSIONS A protocol to identify SCI patients with SIRS at admission may be beneficial with respect to preventing adverse outcomes and decreasing hospital costs.
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Affiliation(s)
- Anil K Kesani
- Division of Orthopaedics, Department of Surgery, Schulich School of Medicine, University of Western Ontario; and Orthopaedic Spine Program, Victoria Hospital, London Health Sciences Centre, London, Ontario, Canada
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Ning J, Mo L, Zhao H, Lu K, Wang L, Lai X, Yang B, Zhao H, Sanders RD, Ma D. Transient regional hypothermia applied to a traumatic limb attenuates distant lung injury following blast limb trauma. Crit Care Med 2014; 42:e68-78. [PMID: 24145850 DOI: 10.1097/ccm.0b013e3182a84daa] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Explosive traumatic injury to an extremity may lead to both local and distant organ injury. Regional traumatic tissue hypothermia has been reported to offer systemic protection; here we investigated the protective effects of regional limb hypothermia on local tissue trauma and the lungs. Furthermore, the optimal duration of regional traumatic limb hypothermic treatment was also evaluated. DESIGN Prospective, controlled, animal study. SETTING University research laboratory. SUBJECTS Adult male Sprague-Dawley rats. INTERVENTIONS Anesthetized rats were randomized to sham, blast limb trauma, sham and regional hypothermia for 30 minutes, and blast limb trauma and regional hypothermia for 30 minutes, 60 minutes, and 6 hours. Blast limb trauma was created using chartaceous electricity detonators. MEASUREMENTS AND MAIN RESULTS Distant lung and local tissue injury following blast limb trauma were attenuated by regional traumatic limb hypothermic treatment for 30 minutes, 60 minutes, and 6 hours reflected by reduced lung histopathological changes and water content. Regional traumatic limb hypothermic treatment for 60 minutes and 6 hours failed to further attenuate distant lung and local tissue injury compared with regional traumatic limb hypothermic treatment for 30 minutes. Inhibition of cystathionine gamma-lyase/hydrogen sulfide was reduced by regional traumatic limb hypothermic treatment for 30 minutes in blast limb trauma rats. A surrogate of neutrophil accumulation, myeloperoxidase activity, and release of tumor necrosis factor-α and interleukin-6 were also attenuated by regional traumatic limb hypothermic treatment for 30 minutes in blast limb trauma rats. Oxidative stress was alleviated by regional traumatic limb hypothermic treatment for 30 minutes evidenced by reduction of hydrogen peroxide and malondialdehyde and an increase of superoxide dismutase and glutathione in blast limb trauma rats. CONCLUSIONS Our data indicate that regional traumatic limb hypothermic treatment for 30 minutes offers both local protection for traumatic tissue and systemic protection for the lungs, which is likely associated with restoration of the cystathionine gamma-lyase/hydrogen sulfide pathway and inhibition of the inflammatory response and oxidative stress.
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Affiliation(s)
- Jiaolin Ning
- 1Department of Anesthesiology, Southwest Hospital, Third Military Medical University, Chongqing, China. 2Department of Nephrology, People's Liberation Army Chengdu Military Area Command General Hospital, Chengdu, Sichuan, China. 3Department of Hepatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China. 4State Key Laboratory of Trauma and Burns, Surgery Research Institute, Department of Traumatic Surgery, Daping Hospital, Third Military Medical University, Chongqing, China. 5Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom. 6Surgical Outcomes Research Centre, University College London Hospital & Wellcome Department of Imaging Neuroscience, University College London, London, United Kingdom
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