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Biomedical subjects

D Rixen

Publications and source records attributed to D Rixen.

At least 19 recordsLinked to original sources
PubMed2006

[Has anything changed in the quality of continuing education in orthopaedic/trauma surgery? Evaluation 1 year after implementation of a new code of practice for resident training in orthopaedic/trauma surgery in Bavaria].

OBJECTIVE: It was the aim of this study to evaluate any changes in the quality of orthopaedic/trauma training 1 year after implementation of the new code of practice for resident training in Bavarian clinics. METHODS: A questionnaire was prepared by the Educational Committee and the Junges Forum of the German Trauma Society and sent to all 120 instructors (and their medical staff) for resident training in Bavaria for general surgery, trauma surgery as well as orthopaedic/trauma surgery on July 26 2005. RESULTS: While 56% of the chairmen claimed to perform a structured, curricular training, only 18% of the residents could verify this. In a similar manner, the majority of chairmen were satisfied with the new code of practice for resident training, while the majority of residents and attendings were not. CONCLUSION: One year after implementation of a new code of practice for resident training in Bavaria, surgical training structures are not well established. There is a large discrepancy in the evaluation of training quality between chairmen and residents. It is therefore imperative to develop recommendations for structuring orthopaedic/trauma training.

Education, Medical, Graduate↗
PubMed2005

[Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients. A systematic literature review].

OBJECTIVE: Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof. METHODS: Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system). RESULTS: The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment. CONCLUSION: Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.

Clinical Trials as Topic↗
PubMed2004

[Is implant removal after percutaneous iliosacral screw fixation of unstable posterior pelvic ring disruptions indicated?].

The aim of this study was to examine the indication for implant removal (IR) after percutaneous iliosacral screw fixation of unstable posterior pelvic ring disruptions by systematic literature analysis and clinical follow-up examination. Retrospective identification revealed 27 operatively stabilized patients [12 females, mean age: 35 years, ISS 22 points (range: 14-37)] between January 1996 and July 2001. Patient characteristics, AO classification, Hannover fracture scale pelvis, ISS, and DGU pelvis score points were analyzed. All cases showed a C-type lesion (C1:67%, C2:33%). A total of 21 patients were seen at follow-up, 12 with and 9 without IR. In ten cases with IR, clinical outcome improved after surgery according to the DGU pelvis score ( p=0.001, Wilcoxon's test). These mostly young patients also showed a better outcome compared with those cases without IR. Due to the good clinical results, implant removal seems to be beneficial for selected individual patients, especially when pain is present.

Adolescent↗
PubMed2001

[Predicting the outcome in severe injuries: an analysis of 2069 patients from the trauma register of the German Society of Traumatology (DGU)].

UNLABELLED: On hospital admission numerous variables are documented from multiple trauma patients. The value of these variables to predict outcome are discussed controversially. The aim was the ability to initially determine the probability of death of multiple trauma patients. Thus, a multivariate probability model was developed based on data obtained from the trauma registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU). PATIENTS AND METHODS: On hospital admission the DGU trauma registry collects more than 30 variables prospectively. In the first step of analysis those variables were selected, that were assumed to be clinical predictors for outcome from literature. In a second step a univariate analysis of these variables was performed. For all primary variables with univariate significance in outcome prediction a multivariate logistic regression was performed in the third step and a multivariate prognostic model was developed. RESULTS: 2069 patients from 20 hospitals were prospectively included in the trauma registry from 01.01.1993-31.12.1997 (age 39 +/- 19 years; 70.0% males; ISS 22 +/- 13; 18.6% lethality). From more than 30 initially documented variables, the age, the GCS, the ISS, the base excess (BE) and the prothrombin time were the most important prognostic factors to predict the probability of death (P(death)). The following prognostic model was developed: P(death) = 1/1 + e(-[k + beta 1(age) + beta 2(GCS) + beta 3(ISS) + beta 4(BE) + beta 5(prothrombin time)]) where: k = -0.1551, beta 1 = 0.0438 with p < 0.0001, beta 2 = -0.2067 with p < 0.0001, beta 3 = 0.0252 with p = 0.0071, beta 4 = -0.0840 with p < 0.0001 and beta 5 = -0.0359 with p < 0.0001. Each of the five variables contributed significantly to the multifactorial model. CONCLUSIONS: These data show that the age, GCS, ISS, base excess and prothrombin time are potentially important predictors to initially identify multiple trauma patients with a high risk of lethality. With the base excess and prothrombin time value, as only variables of this multifactorial model that can be therapeutically influenced, it might be possible to better guide early and aggressive therapy.

Adolescent↗
PubMed2001

Base deficit development and its prognostic significance in posttrauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft für unfallchirurgie.

This prospective, multi-center, observational study of 2069 multiple trauma patients evaluated the prognostic significance of the posttrauma base deficit (BD) on hospital and intensive care unit (ICU) admission to hemodynamic changes, volume and transfusion requirements, lactate and coagulation, as well as mortality. Furthermore, the importance of the BD development throughout a patient's course of critical illness from the time of injury to ICU admission is analyzed as a prognostic factor for fatal outcome. The data were obtained by the trauma registry of the 'Deutsche Gesellschaft für Unfallchirurgie.' The patients were subdivided into five categories of increasing BD values on hospital and ICU admission: Category I, BD < or = -2; Category II, -2 < BD < or = 2; Category III, 2 < BD < or = 6; Category IV, 6 < BD < or = 10; and Category V, BD > 10. A statistical analysis was performed by means of the ANOVA and chi-square tests. In 1264 (61.1%) of 2069 multiple trauma patients (age 39 +/- 19 years, 70.0% males, injury severity score 22 +/- 13, 18.6% mortality), the BD was documented on hospital and in 1536 (74.2%) patients on ICU admission. At both points in time, an increase in the BD category was associated with a significant decrease in systolic blood pressure and prothrombin time as well as increases in heart rate, lactate level and mortality (P < 0.0001). Also transfusion requirements (Category I: 4.5 +/- 7.7 and Category V: 13.7 +/- 13.0 packed red blood cells) increased significantly on hospital admission (P < 0.0001) with a worsening in the BD category. Mortality increased significantly (P < 0.0001) with a worsening of BD from hospital to ICU admission (from a mortality of 13% in patients with a hospital and an ICU admission BD of <6 to 45% in patients with a hospital and an ICU admission BD of >6). These data show that the base deficit is an early available important indicator to identify trauma patients with hemodynamic instability, high transfusion requirements, metabolic and coagulatory decompensation, as well as a high probability of death. The base deficit development may help to guide an early and aggressive therapy for the trauma/hemorrhage induced tissue hypoxia.

Acidosis↗
PubMed2001

A pig hemorrhagic shock model: oxygen debt and metabolic acidemia as indicators of severity.

"Uncontrolled bleeding," "a controlled prefixed bleeding volume," or "controlled decrements in blood pressure" are traditional models of experimental hemorrhagic shock. They are influenced by compensatory mechanisms and do not adequately reflect the severity of the cellular insult as a major target for therapeutic strategies. The aim of this study was to develop an animal model that uses oxygen debt (OD) and metabolic acidemia as indicators of hemorrhage severity. Twenty-five female pigs (mean weight: 23.8 kg) were anesthesized and randomized to 1 of 5 groups of increasing OD (<50 through >120 mL/kg). The predetermined OD was accrued by hemorrhage uniformly over 60 min and followed by retransfusion. The animals were allowed to recover under anesthesia for 200 min and were then observed for 3 days. The extent of metabolic derangements were quantified by arterial base excess (BE) and plasma lactate (LAC) measurements. OD, BE, and LAC were shown to be superior as predictors of outcome in comparison with traditional variables ("bleeding volume," "blood pressure," "cardiac output") in correlation and regression. Of the analyzed predictors of outcome, BE and LAC showed the highest correlation to levels of OD (r = -0.78, 0.8 respectively; P < 0.0001), and regression models were developed. The LD50 for OD was 95.0 mL/kg, for BE -15.3 mmol/L and for LAC 7.7 mmol/L. By using the developed regression models, it is possible to estimate accurately the actual level of OD from BE and LAC values obtained during hemorrhagic shock. OD, BE, and LAC appear to be optimal indicators of severity for a pig hemorrhagic shock model.

Animals↗
PubMed2000

[Severe craniocerebral trauma in multiple trauma. An assessment of the interaction of local and systemic mediator responses].

Isolated severe head trauma (SHT) or SHT in combination with multiple injuries are important factors for the prognosis of morbidity and mortality in patients suffering from the consequences of accidents. The prognosis mainly depends on the presence of primary mechanic brain injury and the development of secondary brain damage. Causes for the development of secondary brain damage are the intracranial space demand after traumatic injury and edema formation which may result in iscemia, as well as inflammatory processes. Both isolated SHT and polytrauma with or without brain damage may result in a systemic inflammatory response syndrome (SIRS) due to the synthesis of cytokines and other inflammatory mediators which may cause a single or multiple organ failure (MOF). Often the organism is able to survive isolated traumatic injuries and functional disturbances, but in combination or cumulation they may be lethal. The hypermetabolism after SHT is often regarded as an interaction between the central nervous system and the whole organism by the activation of the neuroendocrine axis. In contrast to the consequences of SHT for the whole organism, multiple injuries after polytrauma may affect brain functions, such as the shock dependent disturbance of the brain perfusion accompanied by brain hypoxia which may lead to an aggravated prognosis. Moreover, coagulation, metabolism and fracture healing are influenced by the onset of SIRS as well. Our knowledge about the bidirectional inflammatory interaction between brain and whole organism is still limited. In this context, the effects of secondary surgical interventions which may additionally, stress a traumatized body have to be considered and are the subject for actual clinical discussions and experimental studies. This article tries to summarize some important aspects on this topic.

Brain Injuries↗
PubMed2000

Metabolic correlates of oxygen debt predict posttrauma early acute respiratory distress syndrome and the related cytokine response.

BACKGROUND: The purpose of this study was to quantify the relationship between negative base excess (base deficit) and lactate as correlates of oxygen debt and the probability of the early acute respiratory distress syndrome (ARDS) response and with regard to the mediator and metabolic response characteristic of this disease. METHODS: Eighty patients with multiple trauma were studied (514 samples) during their intensive care unit courses (Injury Severity Score 27.6+/-8.8, 36% deaths). Simultaneous samples of arterial base excess and lactate as correlates of oxygen debt, and enzyme-linked immunosorbent assay-measured mixed venous cytokines were obtained daily. At each sample period, the patient was categorized as having ARDS or non-ARDS. RESULTS: Twenty-nine patients (36%; 19 deaths) developed ARDS over the period studied: 17 in postinjury days 1 to 4 (EARLY ARDS) and 12 in postinjury days 5 or later (LATE ARDS). Patients subsequently developing ARDS had evidence of ischemic acidosis on or within the first 24 hours after hospital admission (lower base excess -7.1 mmol/L and higher lactate 5.2 mmol/L in ARDS versus base excess -3.8 mmol/L and lactate 3.6 mmol/L in non-ARDS; p < 0.05). Patients with EARLY ARDS showed even lower (p < 0.05) initial 24 hour mean base excess and higher lactate (base excess -9.1 mmol/L and lactate 6.4 mmol/L) compared with LATE ARDS (base excess -4.3 mmol/L and lactate 3.3 mmol/L). In EARLY ARDS, this degree of ischemic acidosis was followed by a greater mean IL-6 response in the postinjury days 1 to 4 (323 pg/mL) compared with the LATE ARDS response (141 pg/mL) (p < 0.05) or compared with the non-ARDS IL-6 response (67 pg/mL; p < 0.001). In addition, in EARLY ARDS, mean IL-8 levels in postinjury days 1 to 4 (264 pg/mL) were higher than in LATE ARDS (168 pg/mL) (p < 0.05) and the mean IL-1 response in postinjury days 1 to 4 of EARLY ARDS (65 pg/mL) was greater than non-ARDS (32 pg/mL) (p < 0.05). Derivation of probability curves suggests a critical threshold of base excess -6.6 mmol/L or greater for an increased risk of EARLY ARDS. CONCLUSION: These data suggest that the maximum posttrauma oxygen debt (quantified by the ischemia correlates of negative base excess and lactate) is a critical primary determinant of the later fulminant autoinflammatory EARLY ARDS response mediated by the host's endogenous cytokine mediators.

Adolescent↗
PubMed1999

Combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy.

A case of combined abdominal wall paresis and incisional hernia after laparoscopic cholecystectomy is reported. The paresis possibly occurred by a lesion of the N. intercostalis when extending the incision for stone extraction. Possibly the paresis was a predisposing factor for the development of an incisional hernia. The causes of abdominal wall paresis are explored with a review of the literature. In spite of minimal trauma to the anterior abdominal wall in laparoscopic procedures, the risk of iatrogenic lesions remains.

Abdominal Muscles↗
PubMed1998

Neutrophil adhesion to histamine stimulated cultured endothelial cells is primarily mediated via activation of phospholipase C and nitric oxide synthase isozymes.

OBJECTIVE AND DESIGN: In order to understand the underlying mechanism of histamine stimulated inflammatory responses, histamine receptor subtypes and signal transduction pathways by which histamine mediates the stimulation of neutrophil adhesion to endothelial cells has been studied in vitro. MATERIAL: Human neutrophils and human umbilical vein endothelial cells. TREATMENT: Confluent human endothelial cell layer were incubated with histamine (1 mM), H1, H2 or H3 receptor agonists: fluorophenylhistamine (10 microM), amthamine (10 microm), methylhistamine (10 microM), respectively. Ten minutes prior to histamine (1 mM) stimulation H1, H2 or H3 receptor antagonists (dimethindene, 100 microM; famotidine, 1OO microM, thioperamid 100 microM, respectively) were added. Histamine stimulated signal transduction pathways were inhibited by adding phospholipase C inhibitor 2-nitro-4-carboxyphenyl N,N-diphenylcarbamat (200 microM), adenylate cyclase inhibitor 9-(2 tetrahydrofuryl)adenine (80 microM), nitric oxide synthase isozymes inhibitor S-ethylisothiourea (1 microM) or guanylate cyclase inhibitor (LY 83583; 10 microM). Neutrophil adhesion was monitored at 30, 60, 90, 120, 150, 180 and 210 min. METHODS: Neutrophil adhesion to endothelial cells was quantified by analysing alkaline phosphatase activity. RESULTS: Histamine stimulation of endothelial cells resulted in a biphasic time and concentration dependent pattern of neutrophil adhesion. This pattern of neutrophil adhesion was mimicked by stimulation of endothelial cells with H1 or H2 agonists. Stimulation of endothelial cells with an H3 agonist had no effect on neutrophil binding. Inhibition of phospholipase C (PLC), nitric oxide synthase isozymes (NOS) or guanylate cyclase (GC) resulted in a significant decrease of neutrophil binding to histamine or agonist stimulated endothelial cells. An increase of neutrophil binding to unstimulated or to agonist stimulated endothelial cells was observed during inhibition of adenylate cyclase. CONCLUSIONS: Our results suggest that histamine stimulated neutrophil adhesion is due to H1 and H2 receptor mediated activation of PLC, NOS and GC. Increase of cAMP concentration seems to mediate an inhibitory effect on PMN adhesion to endothelial cells.

Cell Adhesion↗
PubMed1998

Laparoscopic colorectal resection for diverticulitis.

This study evaluated outcome in patients undergoing laparoscopically assisted sigmoid resection for diverticular disease. A total of 29 consecutive patients were treated surgically for colonic diverticulitis; in 27 of these laparoscopy was performed. The review of medical records from a control group of 34 patients undergoing open resection were used for comparison. The conversion rate was 7.5%. Using the laparoscopic technique the duration of surgery was longer (165 vs. 121 min, P < 0.05), blood loss less (182 vs. 352 ml, P < 0.05), and subsequent blood transfusion less (0 vs. 61%). The incidence of complications following laparoscopic resection was lower (two anastomotic leakages, two wound infections) than in the conventional group. Convalescence in the laparoscopic group was more rapid and hospital stay shorter (7.9 vs. 14.3 days, P < 0.05). In the laparoscopic group patients expressed less pain at rest and in motion. The cost of the laparoscopically assisted procedure was less than that of conventional resection (7185 vs. 8975 DM). In this series laparoscopically assisted sigmoid resection for diverticulitis proved safe. Recovery was faster, hospital stay was shorter, and patients expressed less pain than in conventional open surgery.

Adult↗
PubMed1998

Thirty years of anti-mediator treatment in sepsis and septic shock--what have we learned?

Sepsis, the systemic response (specific and non-specific) of the body to an infection, is an increasing clinical problem. During the last 30 years, nearly 50 clinical trials involving more than 10,000 patients have failed to demonstrate improvement of patients' outcome with different "anti-mediator" strategies. The wrong conceptional approaches to interact with the complex mediator network and flaws in study design and conduct are the main reasons for this disappointing situation. We learned, however, that the systemic host response is more than persistent uncontrolled inflammation; it is also a stimulation of the counter regulatory network. Although it is important to analyse the complex picture, we have now reached a point where more sophisticated strategies for describing complexity and novel attempts for synthesis are needed. Along this line, improved study designs (decrease of "signal-to-noise ratio") are mandatory. In addition, secondary preventive strategies are emphasised.

Clinical Trials as Topic↗
PubMed1997

Plasma nitric oxide in posttrauma critical illness: a function of "sepsis" and the physiologic state severity classification quantifying the probability of death.

The time course of nitric oxide (NO) production in posttrauma critical illness was monitored, and its relationship to posttrauma "sepsis/SIRS" and physiologic patterns was described. Eighty multiple trauma patients were studied (514 samples) during their course in the intensive care unit (Injury Severity Score 27.6; 36% deaths). Plasma NO was estimated from NO3 + NO2 by the Griess test and compared with that of 10 healthy controls (HC). At each sample period, the patient was categorized as having bacteremic sepsis (BAC), sepsis syndrome (SS), or systemic inflammatory response syndrome (SIRS), and classified by Physiologic State Severity Classification (PSSC) into normal stress response (A-State), metabolic insufficiency (B-State), or respiratory insufficiency (C2-State), each quantified by their physiologic "distance" from reference state of recovering trauma patients (R-State). A severity index (L2PDEATH), based on a logistic model of state distances from R-State, quantified probability of death. Deaths showed increased NO (p < .05) over survivors or HC by day 3 posttrauma. A fall in vascular tone in deaths was related to the increased NO (p < .0001). The level of NO was higher as sepsis worsened: BAC > SS > SIRS > HC (all simultaneous, p < .05). PSSC and L2PDEATH correlated with incidence > HC and level of NO. In conclusion, the severity of posttrauma critical illness was classified by PSSC and quantified by the L2PDEATH index. These reflect progressively increased NO levels and suggest worsening sepsis status. The reduced total peripheral resistance (TPR)-to-flow relationship (vascular tone) in deaths characteristic of the more severe septic PSSC states appeared related to the increased plasma NO.

Adult↗