A Nationwide Analysis of Gunshot Wounds of the Head and Neck: Morbidity, Mortality, and Cost.

BACKGROUND: Gun violence in the United States rose continuously from 2010 to 2022, spiking during the pandemic, and peaking in 2021 at 48,830 deaths (14.8 per 100,000). Previous reports investigated health and financial burden associated with gunshot wounds (GSWs) during 2004 to 2013; however estimates related specifically to head and neck (H&N) injuries have been lacking. This population-based study aims to examine incidence, morbidity, mortality, and health resource utilization of H&N injuries utilizing the Nationwide Inpatient Sample database. METHODS: A population-based study was undertaken using the National (Nationwide) Inpatient Sample (NIS) database (2015Q4-2017Q4). The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to create a composite variable (inclusive of brain, eye, facial nerve, and facial fractures) resulting from GSW to the H&N. Incidence per 100,000 hospitalizations and case fatality rates were calculated to determine the health burden of H&N injuries. Length of hospital stay, and inflation- adjusted hospital charges were compared among H&N and non-H&N injuries. Χ 2 (classical and bootstrapped) and Mann-Whitney tests were used to compare groups. RESULTS: Of 101,300 injuries caused by firearms, 16,140 injuries (15.9%) involved H&N region. The average incidence of H&N injuries was 20.1 cases per 100,000 hospitalizations, with intentional injuries having the highest case fatality rates of 32.4%. Patients with H&N injuries had extreme loss of function (33.4% versus 18.3%, P <0.001) and extreme likelihood of mortality (27.0% versus 11.3%, P <0.001) than non-H&N injuries. Statistically significant differences in the median length of stay (4.8 d versus 3.7 d; P <0.001) and median inflation-adjusted hospital charges ($80,743 versus $58,946, P <0.001) were found among H&N and non-H&N injuries. CONCLUSIONS: Injuries due to GSW remain an inordinate health care and financial burden, with trauma to the H&N carrying an especially high cost in dollars, morbidity, and mortality.

Genomic Analysis of Thrombophilia Variants in the General Population for the Creation of an Effective Preoperative Screening Tool.

BACKGROUND: The loss of a free flap in reconstructive microsurgery is a devastating complication in both the intraoperative and postoperative setting. Previous research has identified a variety of genetic polymorphisms that induce a hypercoagulable state and predispose patients to clot formation and subsequent free flap loss. We aim to review the risks of performing microsurgery on patients who are genetically predisposed to hypercoagulability, as well as identify options, for preoperative screening of inherited thrombophilia. METHODS: A thorough literature review was conducted with an online database. A total of 30 studies were reviewed to identify genetic polymorphisms that cause inherited thrombophilia. Through manual review of the literature, a table was created that included thrombotic risk factors and their associated genetic polymorphisms. If the information was available, prevalence for each thrombotic risk was also reported. RESULTS: Overall, 18 thrombotic risk factors that contribute to hereditary thrombophilia were identified and linked with specific genes and/or genetic polymorphisms. In studies that did not look at particular ethnic groups, 13 unique thrombotic risk factors were identified. In studies that examined specific ethnic groups exclusively, 12 thrombotic risk factors were identified and related to their respective gene or group of genes. Five of the 18 thrombotic risk factors identified were associated with increased risks of both venous and arterial thrombosis. The remainder of the thrombotic risk factors was associated with increased risk of venous thrombosis exclusively. CONCLUSION: The use of genetic screening tests for hereditary thrombophilia in the preoperative setting can serve as an effective preventative measure against postoperative thrombosis. Further exploration of thrombotic risk factors and their related genetic polymorphisms are important steps in reducing postoperative free flap loss.

Ahead of the Curve: Tracking Progress in Novice Microsurgeons.

BACKGROUND: The purpose of this study was to evaluate learning curves for an existing microsurgical training model. We compared efficiency and amount of training needed to achieve proficiency between novice microsurgeons without operative experience versus those who had completed a surgical internship. METHODS: Ten novice microsurgeons anastomosed a silastic tube model. Time to perform each anastomosis, luminal diameter, and number of errors were recorded. RESULTS: First year residents improved up to a brief plateau at 10 repetitions, followed by continued improvement. Second year residents improved up to a plateau at 10 repetitions with no further improvement thereafter. There was no significant difference in luminal area or errors between groups. CONCLUSION: Residents with no operative experience can benefit from early exposure to microsurgical training. These interns continue to improve with additional repetitions while second year residents achieve proficiency with fewer repetitions.

Objective evaluation of skill acquisition in novice microsurgeons.

INTRODUCTION: Medical training is increasingly focused on patient safety, limiting the ability to practice technical skills in the operative arena. Alternative methods of training residents must be designed and implemented. METHODS: Three expert microsurgeons were solicited to develop two drills to help residents acquire the basic subset of skills in microsurgery. The first drill was performance of five consecutive simple interrupted sutures on a rubber glove. Expert proficiency was considered a drill time of two standard deviations from expert mean. The drill was performed up to 10 times until completion of the task at expert proficiency. The second drill was performance of an anastomosis on silastic tubing. Residents performed the drill sequentially until performing two consecutive drills at expert proficiency. RESULTS: Eight residents with no microsurgical experience volunteered. Six of the eight residents were able to perform the rubber glove drill at expert proficiency within 10 attempts, with an average of 5.3. All of the residents were able to perform two consecutive silastic tubing drills at expert proficiency within nine attempts, with an average of 5.4. CONCLUSION: Residents were able to acquire a basic subset of microsurgical skills within a reasonable time period using these drills.

Distraction osteogenesis of the palate: an experimental model.

Although most cleft palates can be closed with conventional mucoperiosteal flap techniques, the occasional wide cleft or difficult fistula has few options for an early 1-stage reconstruction. Distraction osteogenesis (DO) has the potential to close the palate with both hard and soft tissues as well as mitigating the possibility of future oronasal fistula. A right unilateral 5-mm cleft was surgically created in 15 New Zealand white rabbits. In group 1 (N = 5), no further repair was performed (NR); in group 2 (N = 5), mucoperiosteal flaps were used to close the cleft for a soft-tissue-only repair (STR); in group 3 (N = 5), a unilateral osteotomy in the palate on the noncleft side allowed distraction of the palatal shelf across the cleft until closed (DO). Clinical examination, Micro-computed tomography bone density, direct cephalometry, and histology were evaluated at 8 weeks after the completion of distraction. Bone mineral density (BMD; mg/mL) data were obtained from micro-computed tomography scans of both the cleft and noncleft sides for each rabbit, and a ratio was obtained [(BMDc/BMDnc) x100]; NR = 1.38, STR = 44.27, DO = 88.36, P = 0.007. Facial measurements revealed no growth disturbances as a result of DO. Histologic evaluation revealed increased organization of new bone in DO group compared with NR and STR. Clinically, DO group rabbits did not show any increase in feeding disturbances, infection, or wound healing. The success of membranous facial bone distraction has been applied to a new model for palatal repair with the potential to ameliorate the problems associated with soft-tissue-only repair.

A nitric oxide scavenger protects against pulmonary inflammation following hemorrhagic shock.

Hemorrhagic shock (HS) elicits an inflammatory response characterized by increased cytokine production and recruitment of PMN which we previously found to be iNOS dependent. In this study we attempted to remove excess induced-NO by administration of the NO scavenger, NOX, with the goal of suppressing proinflammatory signaling and reducing organ damage. Rats subjected to HS (MAP = 40 mmHg for 100 min) followed by resuscitation and examined 24 h later demonstrated histological signs of lung injury including pulmonary edema as well as an 8.6-fold increase in MPO-positive PMN. These events were accompanied by a 3.9-fold increase in mRNA levels for IL-6, 3.7-fold for ICAM-1, 3.5-fold for IL-1beta, and 7.3-fold for TNFalpha compared to sham animals. Immunostaining of the lungs of shock animals demonstrated IL-6 protein localized to cells lining the luminal sides of bronchiols. These animals also demonstrated a 2-fold and 5.5-fold increase in activation of NF-kappaB and Stat3 (an IL-6 signaling intermediate), respectively. Administration of NOX (30 mg/kg/h beginning at 60 min of shock for total of 4.5 h) resulted in reduced lung injury as measured by a 46% reduction in PMN infiltration, a 20% decrease in wet-to-dry ratio, and improved arterial blood gases. NOX reduced proinflammatory signaling in the lung as demonstrated by a 62% decrease in NF-kappaB binding, 47% reduction in Stat3 binding, a reduction in mRNA expression of 48% for IL-6, 57% for ICAM-1, 67% for IL-1beta, and 64% for TNFalpha, as well as a marked reduction in the intensity of IL-6 protein staining. These data indicate that NOX prevents lung injury in this HS model, possibly through downmodulation of proinflammatory signaling and the shock-induced inflammatory response.

The modulation of hepatic injury and heat shock expression by inhibition of inducible nitric oxide synthase after hemorrhagic shock.

The role of nitric oxide (NO) in maintaining homeostasis and regulating organ function during hemorrhagic shock is complex. The inducible NO synthase (iNOS) has been hypothesized to play a critical role in the pathophysiologic consequences of severe hemorrhage. Heat shock protein (HSP) expression is increased by hemorrhage and is a marker of the magnitude of ischemic injury in the liver. HSP induction is protective against injury in animal models of inflammation and is regulated by NO in hepatocytes. To clarify the role of iNOS in hepatic injury and its relationship to HSP expression in hemorrhagic shock, NOS was inhibited with L-N-6-(1-iminoethyl) lysine (L-NIL), which is reported to be a selective inhibitor of the inducible NOS isoform. Doses of 50 microg/kg or 150 microg/kg were infused over 1 h at the end of compensated shock. Plasma ornithine carbamoyltransferase (OCT), a specific marker of liver injury, was significantly reduced after hemorrhage with low-dose L-NIL (7.1+/-1.5 IU/L) compared to saline-treated control rats (13.0+/-1.5 IU/L, P < 0.005), while high-dose L-NIL significantly increased OCT release (35.9+/-7.2 IU/L, P< 0.05 versus shock alone) despite a greater MAP after resuscitation. HSP expression (HSP-72 and HSP-32) after hemorrhage was increased by L-NIL treatment at the highest dose. We conclude that excessive NO production from iNOS contributes to shock-induced hepatic injury. Our data suggest HSP expression may reflect the degree of ischemic injury after hemorrhage.

Updating the epidemiology of cleft lip with or without cleft palate.

BACKGROUND: Much of the literature on the epidemiology of cleft lip with or without cleft palate is more than three decades old. The question arose as to whether there has been any recent change or trend in its rate of occurrence. METHODS: The number of live births with cleft lip or other congenital anomalies was solicited from national and international organizations. Data were collected for 34 states and 30 countries for the years 2002 to 2006. All data were normalized and reported per 10,000 live births. Descriptive statistics, in addition to correlation and regression, were used to analyze the data. RESULTS: Data for the 5-year period demonstrated that the overall congenital anomaly rate increased in the United States and decreased internationally. The states with the highest and lowest rates were Maryland (21.46) and West Virginia (2.59), respectively. The United States cleft lip national rate averaged 7.75. Countries with the highest and lowest rates were Japan (19.05) and South Africa (3.13), respectively. Internationally, the rate of cleft lip declined, with an average overall prevalence of 7.94. CONCLUSIONS: The average prevalence of cleft lip with or without cleft palate was 7.75 per 10,000 live births in the United States and 7.94 per 10,000 live births internationally. The trends diverged over the 5-year period, as the rate was stable in the United States and the international rate declined.