Increased serum levels of procollagen type III peptide in severely injured patients

Objectives: To determine the serum concentrations of procollagen type in peptide in severely injured patients with different outcomes and to evaluate the relationship between serum procollagen type III peptide concentrations, sources of increased posttraumatic fibrotic activity (wounds, lung, liver, kidney), and decreased elimination of procollagen type III peptide (liver). Design: Prospective study. Setting: Surgical ICU, university hospital. Patients: Fifty-seven patients (mean injury severity score: 38.5 points, range 13 to 75 points), between 16 and 70 yrs of age, treated in our institution within 6 hrs after the accident. Measurements: Serial measurements were started on admission and continued on a 6-hr basis. After 48 hrs, the monitoring interval was extended to 24 hrs until recovery (but at least until day 14) or death. At each point of evaluation, pulmonary and circulatory function parameters and chest radiographs (once a day) were evaluated, the results were recorded, and blood samples were drawn to determine procollagen type III peptide, total bilirubin, creatinine, [gamma]-glutamyl transferase, polymorphonuclear elastase, and other parameters. Statistic evaluation was done with the Wilcoxon test, Spearman rank correlation, and a multiple regression model. Results: Mean procollagen type m peptide serum concentrations (+/- sd) were significantly different in patients who died (8.0 +/- 3.8 U/mL) compared with those patients who survived with organ failure (2.7 +/- 1.3 U/mL) or without complications (1.4 +/- 0.5 U/mL), respectively. Significant correlations of procollagen type HI peptide concentrations with the serum bilirubin concentrations (r = .7), days with need of mechanical ventilation (r = .64), Pao2/Fio2 ratio (r = -.6), polymorphonuclear elastase (r = .6), serum creatinine concentrations (r = .55), and injury severity score (r = .33) were observed. There was a tendency toward higher serum procollagen type III peptide concentrations in patients with severe skeletal injuries. Conclusions: Serum procollagen type III peptide concentrations in severely injured patients may be considerably increased in correlation with injury severity and outcome. Procollagen type III peptide serum concentrations seem to reflect the sum of increased collagen formation from wound healing and fibrogenesis of mediator-related organ damage (especially lung) and decreased procollagen type HI peptide excretion due to impaired liver function. Further data are necessary to evaluate the role of hepatic elimination in these patients

Inflammatory mediators, infection, sepsis, and multiorgan failure after severe trauma

The relation of (multiple) organ failure (OF) to the release of inflammatory mediators and the incidence of infection and sepsis was studied prospectively in 100 patients with multiple trauma (injury severity score=37). Sixteen patients died of OF, 47 patients survived OF, and 37 patients had no OF. Fifteen (24%) of the patients with OF showed no signs of infection. In patients with early onset of OF (n=45), infection followed with a lag of 2 or more days. In 16 (44%) of these patients, infection led to a deterioration in organ function. With late onset of OF (n=18), infection preceded OF in nine patients. Polymorphonuclear leukocyte—elastase, neopterin, C-reactive protein, lactate, antithrombin III, and phospholipase A discriminated significantly among the three outcome groups. Of all factors, only polymorphonuclear leukocyte—elastase showed a difference between patients with and without infection or sepsis, respectively. These data indicate that infection might not play a crucial role in the pathogenesis of posttraumatic OF in a substantial portion of patients with trauma. Early OF, especially, seems to be mainly influenced by the direct sequelae of tissue damage and shock (eg, the release of inflammatory mediators). Since infection and sepsis did not lead to an augmented release of mediators in patients with trauma, the role of both entities remains unclear

Effektivität stationärer Rehabilitation hinsichtlich arbeitsplatzbezogener Belastungen und Ressourcen bei Patienten mit Depression und Anpassungsstörungen

Effektivität stationärer Rehabilitation hinsichtlich arbeitsplatzbezogenen Belastungen und Ressourcen bei Patienten mit Depression und Anpassungsstörung Einleitung: Arbeitsplatzbezogene Störungen nehmen ein immer breiteres Feld in der psychosomatischen Medizin ein. Da bei vielen Patienten mit beruflichen Problemlagen entweder eine depressive Episode oder eine Anpassungsstörung vorliegt, stellt sich die Frage, inwiefern sich das Outcome dieser beiden Diagnosegruppen in der psychosomatischen Rehabilitation unterscheidet. Des Weiteren werden oftmals potentielle Ressourcen außer Acht gelassen und viel mehr nach Belastungen gesucht. Daher stellte sich uns die Frage, welche Veränderungen sich im Verlauf der psychosomatischen Rehabilitation hinsichtlich der Ressourcen der Patienten, gemessen an einem neunen Selbstbeurteilungsinstrument, der Burnout-Screening-Skala III, abbilden lassen. Methoden: Untersucht wurden 100 konsekutive Patienten einer Schwerpunktstation zu arbeitsplatzbezogenen Störungen (71w/29m; Alter± 8,73 Jahre) in der psychosomatischen Rehabilitation. Hiervon erfüllten 73 die Kriterien einer depressiven Störung und 23 die Kriterien einer Anpassungsstörung. Die klinische Diagnose wurde mit einem strukturierten Interview, dem Mini-DIPS (Margraf 1994) und dem SKID I (Wittchen et al. 1997) gesichert. Zur Erfassung der psychischen Symptomatik wurden der Health-49 (Rabung et al.2009), der BDI-II (Hautzinger et al. 2009), das AVEM (Schaarschmidt & Fischer 2003) sowie die Burnout-Screening-Skalen (Hagemann & Geuenich 2009) zur Erfassung arbeitsplatzbezogener Belastungen (BOSS I), Beschwerden (BOSS II) und Ressourcen (BOSS III) bei Aufnahme (T0), Entlassung (T1) und nach 6 Monaten (T2) eingesetzt. In der 6-Monats-Katamnese wurde zusätzlich der sozialmedizinische Status erhoben. Ergebnisse: Patienten mit Anpassungsstörungen waren zu Therapiebeginn und nach der stationären Rehabilitation auf allen symptombezogenen Skalen geringer belastet als Patienten mit einer depressiven Störung. Beide Gruppen konnten trotz des unterschiedlichen Ausgangsniveaus in etwa gleichem Maße von der Therapie profitieren mit Effektstärken d zwischen .79 und 1.25 bei Patienten mit Anpassungsstörungen und d zwischen .79 und 1.16 bei Pateinten mit depressiven Störungen. Bezüglich der Arbeitsfähigkeit unterschieden sich die beiden Diagnosegruppen zu keinem Zeitpunkt signifikant, der Anteil der Arbeitsfähigen stieg in der Gesamtstichprobe von 50% zum Aufnahmezeitpunkt (T0) auf 90% zum Zeitpunkt der 6-Monatskatamnese (T2) an. Von T0 zu T1 beschrieben die Rehabilitanden im BOSS III signifikant mehr Ressourcen bezogen auf die eigene Person, dieser Effekt blieb in der Katamnese nach 6 Monaten (T2) stabil. Diskussion: Hinsichtlich der Unterschiede im Therapie-Outcome zwischen Patienten mit einer Anpassungsstörung, die eine Kausalität in ihrer Ätiopathogenese aufweist und Patienten mit einer depressiven Störung, die sowohl Ursache als auch Folge einer Arbeitsplatzproblematik sein oder auch unabhängig hiervon bestehen kann, stellte sich heraus, dass beide Diagnosegruppen gleich gut vom der psychosomatischen Rehabilitation profitieren können, sowohl hinsichtlich der psychometrisch erfassten Belastung, als auch hinsichtlich der Arbeitsfähigkeit. Das Therapie-Outcome bezogen auf persönliche Verhaltens- und Erlebensmerkmale des AVEM zeigt, dass sowohl eine hohe Depressivität, als auch eine starke klinische Beschwerdesymptomatik mit einer reduzierten Lebenszufriedenheit einhergehen. Dagegen scheinen beruflicher Ehrgeiz und die subjektive Bedeutsamkeit der Arbeit eine untergeordnete Rolle zu spielen. Selbstwirksamkeit, die durchaus in der psychosomatischen Rehabilitation erlernt werden kann, stellt möglicherweise eine Strategie dar, um Depressivität zu lindern und um persönliche Ziele zu verwirklichen. Die Ressourcenausprägung der Patienten erfährt den höchsten Zuwachs während und nach der Rehabilitation im Bereich der Eigenen Person selbst. Zukünftige Studien könnten sich damit befassen, ob Patienten mit Anpassungsstörung in der psychosomatischen Rehabilitation spezifischere Belastungen haben und ob sie die gleiche Behandlung benötigen wie Patienten mit einer depressiven StörungIntroduction: Workplace-related disorders gain in importance in psychosomatic medicine. But most of the patients with job strain have either a depressive disorder or an adjustment disorder. So there is the question whether patients with adjustment disorders differ from patients with depressions regarding the results of the therapy. In addition resources of the patients are often disregarded. Stresses and strain are getting focused. Therefore we observed if there are changes during psychosomatic rehabilitation regarding to the resources of the patients, measured by a new questionnaire, which is called Burnout-Screening-Scale (BOSS). Methods: 100 patients in psychosomatic rehabilitation, treated on a special station for workplace related strain (71 female/29 male; age 49,84±8,73 years), attended this study. 73 achieved the criteria of a depressive disorder, 23 of an adjustment disorder. The diagnosis was checked by a structured clinical interview, Mini-DIPS (Margraf, 1994) and SKID I (Wittchen et al. 1997). To measure psychiatric symptoms we used Health-49 (Rabung et al. 2009), BDI-II (Hautzinger et al. 2009), AVEM (Schaarschmidt & Fischer 2003) and Burnout-Screening-Scales I-III (BOSS I-III) (Hagemann & Geuenich 2009), which detect job strain, somatic disorders and resources, at admission of rehabilitation (T0), at discharge (T1) and six month after discharge (T2). Six month after discharge we also checked social medical status. Results: Patients with adjustment disorders showed at T0 and T1 less strain than patients with depressive disorder. Both groups could benefit from the psychosomatic rehabilitation in the same degree despite of the different base levels (effect sizes d between .79 and 1.25 for patients with adjustment disorders and d between .79 and 1.16 for patients with depressions). Relating to the inability of work both groups didn`t differ at any time. Those who were inability to work decreased from 45 % at T0 to 9,5 % at T2. There are also significant more resources regarding the own person measured by BOSS III from T0 to T1. This effect stays stable six month after discharge at T2. Discussion: Patients with adjustment disorder have as expected less psychopathology strain at T0 and T1 than patients with depressive disorders. Regarding the state of employment both groups are similar strained and both groups benefit equal and lasting from the psychosomatic rehabilitation. The results of the therapy regarding items of AVEM show, that high level of depression as well as high clinical strain lead to less life satisfaction. In contrast job ambition and subjective significance of the job seem to be less important. Self-efficiency, which can be learned during psychosomatic rehabilitation, may be a strategy to manage depression and to reach personal targets. Resources grow the most in the range of the own person. Future studies should research whether patients in psychosomatic rehabilitation with adjustment disorder have more specific strains and whether they need the same treatment in rehabilitation as patients with depressive disorders

Inhibition of Plasma Kallikrein with Aprotinin in porcine endotoxin Shock

Activation of the contact phase of coagulation has been implicated in the pathogenesis of septic shock. We wanted to determine if inhibition of plasma kallikrein can prevent arterial hypotension and liberation of kinins from kininogen, induced by an infusion of bacterial lipopolysaccharide (LPS) in anesthetized, ventilated 20-kg pigs. The LPS was given IV in a dose of 5 [mu]g/kg/h for 8 hours. The plasma kallikrein inhibitor aprotinin, 537 [mu]mol, was given IV during 8 hours, resulting in plasma levels above 10 [mu]mol/L. Ten animals (SA) received LPS and aprotinin and ten randomized controls (SC) received LPS and saline. Kinin-containing kininogen was determined on the basis of the amount of kinin releasable in plasma samples by incubation with trypsin. Kininogen decreased to 58% +/- 4% of the baseline value without any difference between groups. This may indicate participation of other processes than degradation by plasma kallikrein in the decrease of kininogen. Arterial blood pressure was higher at 7 hours in the SA animals than in the SC group (101% +/- 11% vs. 68% +/- 8%; mean +/- SEM; p = 0.026). Fibrin monomer and C3adesArg plasma levels were attenuated by aprotinin treatment. These findings underscore the important role of the contact system in LPS shock