Microsurgical Reconstruction of the Columella.

BACKGROUND: Traditionally, the columella can be difficult to reconstruct because of its unique contours, paucity of adjacent soft tissues, and tenuous vascularity. When local or regional tissues are unavailable, microsurgical transfer can provide a means for reconstruction. In this retrospective review, the authors report their experience with microsurgical reconstruction of the columella. METHODS: Seventeen patients were enrolled in this study and divided into two groups: group 1, isolated columella defects; and group 2, defects of the columella and portions of adjacent soft tissues. RESULTS: There were 10 patients in group 1. Their average age was 41.2 years. Average follow-up was 10.1 years. Causes of the columellar defects included trauma, complication of nasal reconstruction, and complication of rhinoplasty. The first dorsal metacarpal artery flap was used in seven cases, and the radial forearm flap was used in five. Two flap losses were salvaged with a second free flap. The average number of surgical revisions was 1.5. In group 2, there were seven patients with an average follow-up of 10.1 years. Causes of the columella defects included cocaine injury, carcinoma, and complication of rhinoplasty. The average number of surgical revisions was 3.3. The radial forearm flap was used in all cases. There were no flap losses. All 17 cases in this series were brought to a successful conclusion. CONCLUSIONS: The authors' experience shows that microsurgical reconstruction of the columella provides a reliable and aesthetic means for reconstruction. This technique avoids the facial disfigurement and visible scarring that often accompany use of local flaps. In addition, microsurgical flaps can be preformed "off site," which may provide certain advantages in selected cases. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

COVID-19 infection presenting with acute epiglottitis.

In this case report, we present a novel presentation of acute epiglottitis in a patient with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) who presented to the emergency room in extremis and respiratory failure requiring emergent cricothyrotomy. Epiglottitis has become less common since the introduction and widespread use of the Haemophilus influenzae type B (Hib) vaccine. This reduction in cases has shifted demographics of the disease from the pediatric population towards adults with comorbid conditions. Interestingly there is a high degree of overlap between many of the comorbidities between epiglottitis and COVID-19. The novel severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), also referred to as coronavirus disease 19 (COVID-19), has been reported to affect the gastrointestinal tract and neural tissue and has been implicated in necrotizing encephalitis. We report the first known case of the novel SARS-CoV-2 virus presenting with acute epiglottitis.

A novel beta-oxa polyunsaturated fatty acid downregulates the activation of the IkappaB kinase/nuclear factor kappaB pathway, inhibits expression of endothelial cell adhesion molecules, and depresses inflammation.

Several novel polyunsaturated fatty acids (PUFAs) that contain either an oxygen or sulfur atom in the beta-position were found to exhibit more selective antiinflammatory properties than their natural PUFA counterparts. One of these, beta-oxa-23:4n-6, unlike natural PUFAs, lacked ability to stimulate oxygen radical production in neutrophils but caused marked inhibition of agonist-induced upregulation of leukocyte adhesion to cultured human umbilical vein endothelial cells (HUVEC) and E-selectin, intercellular adhesion molecule-1, and vascular cell adhesion molecule-1 expression. In addition, beta-oxa-23:4n-6 inhibited acute and chronic inflammatory responses in mice as well as the upregulation of adhesion molecule expression in arterial endothelium. This action of beta-oxa-23:4n-6 required a functional 12- but not 5-lipoxygenase or cyclooxygenases, consistent with its metabolism via the 12-lipoxygenase pathway. Whereas beta-oxa-23:4n-6 did not affect the activation of mitogen-activated protein kinases by tumor necrosis factor, activation of the IkappaB kinase/nuclear factor kappaB pathway was selectively inhibited. These novel PUFAs could form the basis for a potential new class of pharmaceuticals for treating inflammatory diseases, including atherosclerosis.

Rapid resolution of severe subcutaneous emphysema with simple percutaneous angiocatheter decompression.

Subcutaneous emphysema (SE) is often seen as a sequela of chest tube placement, cardiothoracic surgery, trauma, pneumothorax, infection or malignancy. In most cases SE is self-limited and requires no intervention. Rarely, air can rapidly dissect into subcutaneous tissue planes leading to respiratory distress, patient discomfort and airway compromise. This is a case of a 75-year-old woman that developed massive SE and impending respiratory failure with rapid progression of air into her subcutaneous tissue. In an effort to rapidly stabilize the patient we placed multiple percutaneous angiocatheters into the subfascial space with complete resolution in <24 h. This technique was an excellent temporizing measure and found to be superior to previously described techniques involving large open 'blow hole' incisions or large bore drains. Placement of angiocatheter needles for the decompression of subcutaneous air is a well-tolerated, readily accessibility, low cost and simple procedure for the treatment of SE.

Pelvic fracture pattern predicts the need for hemorrhage control intervention-Results of an AAST multi-institutional study.

BACKGROUND: Early identification of patients with pelvic fractures at risk of severe bleeding requiring intervention is critical. We performed a multi-institutional study to test our hypothesis that pelvic fracture patterns predict the need for a pelvic hemorrhage control intervention. METHODS: This prospective, observational, multicenter study enrolled patients with pelvic fracture due to blunt trauma. Inclusion criteria included shock on admission (systolic blood pressure <90 mm Hg or heart rate >120 beats/min and base deficit >5, and the ability to review pelvic imaging). Demographic data, open pelvic fracture, blood transfusion, pelvic hemorrhage control intervention (angioembolization, external fixator, pelvic packing, and/or REBOA [resuscitative balloon occlusion of the aorta]), and mortality were recorded. Pelvic fracture pattern was classified according to Young-Burgess in a blinded fashion. Predictors of pelvic hemorrhage control intervention and mortality were analyzed by univariate and multivariate regression analyses. RESULTS: A total of 163 patients presenting in shock were enrolled from 11 Level I trauma centers. The most common pelvic fracture pattern was lateral compression I, followed by lateral compression I, and vertical shear. Of the 12 patients with an anterior-posterior compression III fracture, 10 (83%) required a pelvic hemorrhage control intervention. Factors associated with the need for pelvic fracture hemorrhage control intervention on univariate analysis included vertical shear pelvic fracture pattern, increasing age, and transfusion of blood products. Anterior-posterior compression III fracture patterns and open pelvic fracture predicted the need for pelvic hemorrhage control intervention on multivariate analysis. Overall in-hospital mortality for patients admitted in shock with pelvic fracture was 30% and did not differ based on pelvic fracture pattern on multivariate analysis. CONCLUSION: Blunt trauma patients admitted in shock with anterior-posterior compression III fracture patterns or patients with open pelvic fracture are at greatest risk of bleeding requiring pelvic hemorrhage control intervention. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Current management of hemorrhage from severe pelvic fractures: Results of an American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: There is no consensus as to the optimal treatment paradigm for patients presenting with hemorrhage from severe pelvic fracture. This study was established to determine the methods of hemorrhage control currently being used in clinical practice. METHODS: This prospective, observational multi-center study enrolled patients with pelvic fracture from blunt trauma. Demographic data, admission vital signs, presence of shock on admission (systolic blood pressure < 90 mm Hg or heart rate > 120 beats per minute or base deficit < -5), method of hemorrhage control, transfusion requirements, and outcome were collected. RESULTS: A total of 1,339 patients with pelvic fracture were enrolled from 11 Level I trauma centers. Fifty-seven percent of the patients were male, with a mean ± SD age of 47.1 ± 21.6 years, and Injury Severity Score (ISS) of 19.2 ± 12.7. In-hospital mortality was 9.0 %. Angioembolization and external fixator placement were the most common method of hemorrhage control used. A total of 128 patients (9.6%) underwent diagnostic angiography with contrast extravasation noted in 63 patients. Therapeutic angioembolization was performed on 79 patients (5.9%). There were 178 patients (13.3%) with pelvic fracture admitted in shock with a mean ± SD ISS of 28.2 ± 14.1. In the shock group, 44 patients (24.7%) underwent angiography to diagnose a pelvic source of bleeding with contrast extravasation found in 27 patients. Thirty patients (16.9%) were treated with therapeutic angioembolization. Resuscitative endovascular balloon occlusion of the aorta was performed on five patients in shock and used by only one of the participating centers. Mortality was 32.0% for patients with pelvic fracture admitted in shock. CONCLUSION: Patients with pelvic fracture admitted in shock have high mortality. Several methods were used for hemorrhage control with significant variation across institutions. The use of resuscitative endovascular balloon occlusion of the aorta may prove to be an important adjunct in the treatment of patients with severe pelvic fracture in shock; however, it is in the early stages of evaluation and not currently used widely across trauma centers. LEVEL OF EVIDENCE: Prognostic study, level II; therapeutic study, level III.

The use of extracorporeal membrane oxygenation in blunt thoracic trauma: A study of the Extracorporeal Life Support Organization database.

BACKGROUND: Reports documenting the use of extracorporeal membrane oxygenation (ECMO) after blunt thoracic trauma are scarce. We used a large, multicenter database to examine outcomes when ECMO was used in treating patients with blunt thoracic trauma. METHODS: We performed a retrospective analysis of ECMO patients in the Extracorporeal Life Support Organization database between 1998 and 2014. The diagnostic code for blunt pulmonary contusion (861.21, DRG International Classification of Diseases-9th Rev.) was used to identify patients treated with ECMO after blunt thoracic trauma. Variations of pre-ECMO respiratory support were also evaluated. The primary outcome was survival to discharge; the secondary outcome was hemorrhagic complication associated with ECMO. RESULTS: Eighty-five patients met inclusion criteria. The mean ± SEM age of the cohort was 28.9 ± 1.1 years; 71 (83.5%) were male. The mean ± SEM pre-ECMO PaO2/FIO2 ratio was 59.7 ± 3.5, and the mean ± SEM pre-ECMO length of ventilation was 94.7 ± 13.2 hours. Pre-ECMO support included inhaled nitric oxide (15 patients, 17.6%), high-frequency oscillation (10, 11.8%), and vasopressor agents (57, 67.1%). The mean ± SEM duration of ECMO was 207.4 ± 23.8 hours, and 63 patients (74.1%) were treated with venovenous ECMO. Thirty-two patients (37.6%) underwent invasive procedures before ECMO, and 12 patients (14.1%) underwent invasive procedures while on ECMO. Hemorrhagic complications occurred in 25 cases (29.4%), including 12 patients (14.1%) with surgical site bleeding and 16 (18.8%) with cannula site bleeding (6 patients had both). The rate of survival to discharge was 74.1%. Multivariate analysis showed that shorter duration of ECMO and the use of venovenous ECMO predicted survival. CONCLUSION: Outcomes after the use of ECMO in blunt thoracic trauma can be favorable. Some trauma patients are appropriate candidates for this therapy. Further study may discern which subpopulations of trauma patients will benefit most from ECMO. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Inhibition of neutrophil leukotriene B4 production by a novel synthetic N-3 polyunsaturated fatty acid analogue, beta-oxa 21:3n-3.

We recently reported the synthesis and anti-inflammatory properties of a novel long chain polyunsaturated fatty acid (PUFA) with an oxygen atom in the beta-position, beta-oxa-21:3 n-3 (Z,Z,Z)-(octadeca-9,12,15-trienyloxy) acetic acid). Our data, from studies aimed at elucidating the mechanism of its action, show that pretreatment of human neutrophils with the beta-oxa-PUFA substantially depresses the production of leukotriene B(4) (LTB(4)) in response to calcium ionophore, A23187, comparable to standard leukotriene inhibitors such as zileuton and nordihydroguaiaretic acid. Interestingly, the n-6 equivalent, beta-oxa 21:3 n-6, is also a strong inhibitor of LTB(4) production. In contrast, naturally occurring PUFA only slightly reduce, for eicosapentaenoic (20:5n-3) and docosahexaenoic (22:6n-3) acids, or increase, for arachidonic acid (20:4n-6), the formation of LTB(4). The parent beta-oxa-21:3n-3 molecule, rather than its derivatives (methyl ester, saturated, monohydroperoxy, or monohydroxy forms), is exclusively responsible for attenuation of LTB(4) formation. beta-Oxa-21:3n-3 inhibits the conversion of [(3)H]20:4n-6 to [(3)H]5-hydroxyeicosatetraenoic acid and [(3)H]LTB(4) by neutrophils in the presence of calcium ionophore and also suppresses the activity of purified 5-lipoxygenase, but not cyclooxygenase 1 and 2. Beta-oxa-21:3n-3 is taken up by neutrophils and incorporated into phospholipids and neutral lipids. In the presence of calcium ionophore, the leukocytes convert a marginal amount of beta-oxa-21:3n-3 to a 16-monohydroxy-beta-oxa-21:3n-3 derivative. After administration to rodents by gavage or i.p. injection, beta-oxa-21:3n-3 is found to be incorporated into the lipids of various tissues. Thus, beta-oxa-21:3n-3 has the potential to be used in the treatment of inflammatory diseases, which are mediated by products of the lipoxygenase pathway.