Better be prepared: the spectrum of neuropsychiatric impairment among Libyan war victims transferred to Germany for trauma rehabilitation.

BACKGROUND: The current Libyan civil war has originated many casualties, imposing medical challenges. War injuries are complex, requiring specialized knowledge and interdisciplinary assessment for adequate patient and intercultural management. METHODS: This retrospective study analyzed records of 78 Libyan patients admitted from July 2016 to November 2017 to neurological and trauma surgical departments of Krankenhaus Nordwest, Frankfurt, Germany. Issues of system preparation of the hospital, demographics, injury patterns and therapies were analyzed. The chi-squared test was used to analyze differences in injury patterns in explosion and gunshot injuries. RESULTS: Seventy-seven of seventy-eight patients were male (mean age 30.6 years). The patients received primary and secondary treatment in Tunisia (n = 39), Libya (n = 36) and Turkey (n = 23). Forty-eight patients had gunshot injuries, 37 explosion injuries, 11 both. Preparation for management of injuries included hygienic and isolation protocols, organization of interpreters and intercultural training. Patients presented with a broad variety of neurological, psychiatric and trauma surgical injuries. Fifty-six patients had sensory, 47 motor deficits. Nine reported headache, 5 vertigo, 13 visual impairment, 28 psychiatric symptoms. Eighteen patients had central nervous damage, 50 peripheral nervous damage. Central nervous damage was significantly more common in gunshot than explosion injuries (p = 0.015). Peripheral nervous damage was more common in explosion than gunshot injuries (p < 0.1). Fifty-one patients had polytrauma and 49 suffered from fractures. Therapy included surgical interventions (n = 56) and physiotherapy. Structured rehabilitation programs were often indicated. CONCLUSION: Specialized knowledge about war injuries and their management including hospital preparation and planning regarding infrastructure may be required anytime. Injuries include a broad variety of neurological, psychiatric and trauma surgical injuries. Therefore, an interdisciplinary approach is crucial.

High Prevalence of Multidrug-Resistant Bacteria in Libyan War Casualties Admitted to a Tertiary Care Hospital, Germany.

The ongoing Libyan conflict constantly causes victims among the military and civilian population. Cross-border transfer of patients represents a high risk of introducing multidrug-resistant organisms (MDROs), for example, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, and carbapenem-resistant gram-negative organisms (CROs), into the country of destination. This study assessed the MDRO status in Libyan war casualties (n = 67) admitted to Northwest Medical Centre in Frankfurt/Main, Germany, from August 2016 till January 2017. Identified multidrug-resistant nonfermenters and Enterobacteriaceae were subjected to molecular detection of ß-lactamases and further mechanisms of resistance. All isolates were typed by enzymatic macrorestriction and subsequent pulsed-field gel electrophoresis. MDROs were found in 40 (60%) patients, including 25 (37%) positive for at least one CRO and 11 (16%) patients with MRSA. A total of 37 isolates of Klebsiella pneumoniae, Acinetobacter baumannii, Escherichia coli, Enterobacter cloacae, and Serratia marcescens produced carbapenemases: NDM (n = 17), OXA-48 (n = 15), and OXA-23 (n = 9) in addition to other ß-lactamases (with blaCTX-M-group-1 being most frequent) and plasmid-mediated quinolone resistance genes (qnrB, aac(6')Ib-cr). Bacterial strain typing revealed the presence of various clones. This high MDRO rate in Libyan war casualties demands awareness, appropriate screening, and containment measures for medical institutions involved in medical care to avoid patient-to-patient transmission.

Carbon-Fibre-Reinforced PEEK radiolucent intramedullary nail for humeral shaft fracture fixation: technical features and a pilot clinical study.

PURPOSE: This prospective pilot study investigated the safety and efficacy of a novel radiolucent intramedullary nail (IMN) made of Carbon-Fibre-Reinforced Polyaryl-Ether-Ether-Ketone (CFR-PEEK) for humeral shaft fracture fixation. STUDY DESIGN: A prospective, single-arm, four-centre study. PATIENTS AND METHODS: A total of 46 patients with 46 humeral fractures classified as 12 A-B were treated with a novel CFR-PEEK IMN and followed for 12 months. RESULTS: Most of the patients (65%) were female; the mean age was 65 ± 17 years. The average operating time was 66.75 ± 19.84 minutes and X-ray exposure was 104.11 ± 98.01 seconds. All patients postoperatively reported selflimiting shoulder pain and three patients developed iatrogenic transient radial palsy. Two patients required repositioning of the implant. No implant-related complications were observed. Radiological consolidation was achieved in all 43 patients who completed the 12-month follow-up. CONCLUSIONS: The CFR-PEEK IMN is user-friendly and safe. Its bone-matching elastic modulus seems to contribute to its clinical efficacy. This, together with compatibility with modern imaging techniques, can be considered a further evolution of IMN designed to stabilise humeral shaft fractures.

Early short-term inpatient psychotherapeutic treatment versus continued outpatient psychotherapy on psychosocial outcome: a randomized controlled trial in trauma patients.

BACKGROUND: Inpatient psychotherapeutic support has been shown to reduce mental health problems in severely injured patients. However, this effect mostly disappears after discharge. The aim of this study was to compare short-term inpatient versus continued long-term outpatient psychotherapeutic support. METHODS: Patients with at least two injuries of a combined Abbreviated Injury Scale Severity Score Index≥5 were included in the study. Of 862 screened patients, 113 met all inclusion criteria. They were randomly assigned to a short-term group (n=59), where only inpatient support was given, and a long-term group (n=54), with additional outpatient sessions. The cognitive behavioral treatment was standardized by a manual. Psychological assessment for depression, anxiety, and posttraumatic stress disorder (PTSD) was performed in written form at the time of inclusion, discharge, and 6 months, 12 months, and 18 months after trauma. RESULTS: Forty-one percent (n=46) of all patients completed follow-up visits. The results show that symptoms of depression, anxiety, and PTSD disappeared more often in the long-term group than in the short-term group 1 year after trauma. Differences nearly reach significance for anxiety (p=0.051) and PTSD (p=0.059). Twenty-one percent of the short-term group patients showed at least one mental health disorder compared with no patients in the long-term group 1 year after trauma (p=0.035). CONCLUSION: Psychotherapeutic support of severely injured patients seems to be more effective in reducing depression, anxiety, and PTSD if extended further into outpatient care. This conclusion should be considered preliminary because of the small number of study patients.

Health status as an important outcome factor after hemiarthroplasty.

The goal of this study was to determine functional results of hemiarthroplasty for 3- and 4-part proximal humeral fractures in elderly patients and to analyze factors affecting the outcome. Thirty-eight consecutive shoulders were treated with hemiarthroplasty after proximal humeral fracture. Two groups of patients with different health status were classified. Group I consisted of patients with 2 or less comorbidities and a maximum of 2 medications at the time of injury. Patients in group II had 3 or more comorbidities with a minimum of 3 medications at the time of injury. The mean of the absolute Constant score in group I was 41, compared to 27 in group II (P < .05). Furthermore, compliance of the patient and regular physiotherapy proved to be important prognostic factors. If primary hemiarthroplasty is not likely to be successful with a low functional score, this surgical procedure should be reconsidered especially in patients with more than three comorbidities.

Minimally invasive intramedullary nailing of midshaft clavicular fractures using titanium elastic nails.

BACKGROUND: In up to 31% of cases, nonsurgical treatment of midshaft clavicular fractures leads to unsatisfactory results such as nonunion, brachial plexus irritation, shortening and limited function of the shoulder. To date, various implants have been developed for open reduction including intramedullary wires, screws, and plates. This study discusses elastic stable intramedullary nailing of midshaft clavicular fractures. METHODS: Between 2000 and 2005, 31 midshaft clavicular fractures were treated by intramedullary nailing with a titanium elastic nail (TEN). Subjective and clinical outcome were evaluated after an average follow-up of 26 (6-46) months. Patients were divided into three groups: patients with isolated clavicular fractures (group 1, n = 9); patients with additional injuries (group 2, n = 15), and patients with multiple injuries (group 3, n = 7). RESULTS: Nonunion was not observed. No patient sustained a refracture after TEN removal. Medial migration of the TEN in seven patients and iatrogenic perforation of the lateral cortex in one patient required secondary shortening on five occasions. Nail breakage after fracture healing was observed twice. Subjective outcome did not differ significantly between the three groups. Constant and Murley Score and the Disability of the Arm, Shoulder, and Hand Questionnaire Score showed no significant difference in the clinical outcome of the three groups. CONCLUSION: Intramedullary fixation of midshaft clavicular fractures with a TEN is a safe minimally invasive surgical technique achieving primary stability for practice. It can be seen as an alternative to plate or screw fixation or nonsurgical treatment, as it produces excellent cosmetic and functional results regardless whether patients suffered from isolated clavicular fractures, additional injuries, or multiple traumas.

Trust, social support and patient type--associations between patients perceived trust, supportive communication and patients preferences in regard to paternalism, clarification and participation of severely injured patients.

OBJECTIVE: Trust is an important aspect of physician-patient-interaction, both in terms of compliance and patient- and physician-reported outcomes. Trust-building communication is especially important in terms of severely injured patients because of severity of their injuries and frequently associated physical and psychological consequences. Patients preferences concerning medical treatment (patient type) is also regarded to be important in terms of trust. The objective of this study was to investigate the relationships between patients perceived trust, supportive communication of physicians and patient type of severely injured patients. METHODS: Seventy-one severely injured patients, who were predominantly injured in the workplace or in traffic accidents and were treated in one of four hospitals in Northrhine-Westfalia between 2001 and 2005, completed a self-administered questionnaire. "Trust in physicians_short form" (TRIP_sf) describes different aspects, such as general trust, competence of doctors and the feeling to be in good hands. "Informational support" and "emotional support" comprise verbal and non-verbal aspects, such as clear and understandable information or devotion and empathic manner. "Patient type" measures patients preferences in regard to paternalism of physician, clarification of medical facts and participation in treatment. RESULTS: Trust is strongly correlated with informational (.628**) and emotional support (.542**) and is less correlated with patients preferences of "paternalism" (.250*)", "clarification" (.438**) and participation" (.378**). Informational and emotional support are in general not significantly correlated with type of patient, all correlations were adjusted for age, gender, marital and socioeconomic status, length of hospital stay, and severity of injury. CONCLUSIONS: Trust is significantly related to patient type but more related to doctor support: the results confirm the importance of supportive communication in terms of emotional and informational support. PRACTICE IMPLICATIONS: Medical education should integrate sound knowledge about the psychosocial aspects of physician patient interaction to enable doctors to provide effective social support and to identify and consider patients preferences.

Elastic stable intramedullary nailing of midclavicular fractures in adults: 32 patients followed for 1-5 years.

BACKGROUND: Osteosynthesis of clavicular fractures is sometimes indicated. Since plate fixation may lead to complications, we have used elastic stable intramedullary nailing and report our experience of midclavicular fractures in 32 adults. PATIENTS AND METHODS: From 2000 to 2005, we treated 32 adults (26 men), median age 40 (19-66) years, by intramedullary nailing with a titanium elastic nail (TEN). All patients were re-examined after median 27 (12-59) months. RESULTS: Nonunion was not observed. 20 clavicles healed without shortening. 12 clavicles healed with shortening of more than 5 mm. Migration of the TEN in 8 patients required secondary shortening of the nail in 5 of them. Nail breakage after fracture healing was observed twice. The nails were removed in 29 patients after a median of 6 (1.3-15) months postoperatively. No patient sustained a re-fracture after TEN removal. The mean Constant score was 95 (SD 1.9) points and the mean DASH score was 5 (SD 2.3) points. INTERPRETATION: Intramedullary stabilization of midclavicular fractures with a titanium elastic nail is a minimally invasive technique with good cosmetic and functional results. Intramedullary fixation can be seen as an alternative to plate fixation and nonoperative treatment.

Economic impact of cancellous bone grafting in trauma surgery.

INTRODUCTION: Cancellous bone grafting is currently the most frequent method for replacement of bone material. In recent years, several alternative methods came into practice. However, up to now it remains unclear whether cancellous bone grafting is cheaper as compared to these new methods. Therefore, the aim of this study was to calculate the direct costs of cancellous bone grafting. MATERIALS AND METHODS: For calculation of the direct costs operation time needed in addition to the main surgical intervention was measured and the material used recorded in a consecutive series of 50 interventions including bone grafting at the Department of Trauma Surgery at the University Hospital of Bonn Medical School. Surgical staff costs were calculated on the basis of a standard team consisting of one surgical attendant, surgical resident, surgical nurse, and nurse's service. Cost of anaesthesia was calculated on a per minute base. RESULTS: Mean additional operation time was 26.3 min (range 17-35 min). Surgical staff costs per operation minute were 2.70 Euro, costs for anaesthesiological service were 4.18 Euro/min. Material additional used consisted of sutures and sterilization costs. Material costs summed up to 32.01 Euro. The total direct costs of bone grafting were 212.95 Euro. CONCLUSION: The direct costs of harvesting cancellous bone graft and the use of bone replacement material are comparable. Due to the high complication rate at the donor site the total-cost-of-illness might be higher when using autologous bone graft.

Polylactide (LTS) causes less inflammation response than polydioxanone (PDS): a meniscus repair model in sheep.

BACKGROUND: Incidence of meniscus injury has increased in today's active society. Arthroscopical refixation yields better results than partial meniscectomy. The best healing rates are achieved by sutures. As non-degradable sutures are permanent foreign bodies, slow absorbable materials are needed. A slow degradable suture with high concentration of polylactide acid, the so-called "long-term suture" (LTS, Panacryl), has been suggested to produce a higher inflammatory response than conventional polymer sutures [Vicryl, Dexon or polydioxanone (PDS)]. The aim of the study was to assess LTS for meniscus repair after a traumatic lesion and to evaluate immunological response, biodegradation and healing. METHODS: In 24 randomised sheep, a radial tear of the medial meniscus was sutured by either PDS or LTS. Twelve sham-operated animals served as control. Half of the sheep were killed after 6 months, the other half after 12 months. The medial and lateral meniscus, synovial membrane, articular cartilage and ascendant lymph nodes up to the kidney were examined. Joint effusion was evaluated by MRI. RESULTS: The synovial membrane was significantly thinner in the LTS group (6 months 85 +/- 10 microm, 1 year 100 +/- 28 microm) than in the PDS group (6 months 165 +/- 10 microm, 1 year 175 +/- 23 microm, P < 0.001) and the controls (6 months 150 +/- 17 microm, 12 months 192 +/- 21 microm, P < 0.001). The joint effusion was higher in the PDS than in the LTS group after 6 months, and tended to be higher in controls. In controls, effusion tended to be higher than in the LTS group. In all medial departments, osteoarthritis evolved much more intensely than in the lateral knee departments (P < 0.01). Bilateral lymph nodes from the groin up to the kidneys were larger (crosscut area) after 6 months in the controls (2.28 +/- 0.7 mm(2)) and PDS treated animals (2.3 +/- 0.7 mm(2)) than in the LTS group (1.3 +/- 0.3 mm(2), P < 0.001). After 1 year, node size differed significantly between controls and animals from the LTS group (1.98 +/- 0.4 mm(2) vs. 1.5 +/- 0.2 mm(2), P < 0.05), and between animals from the PDS and the LTS group (2.5 +/- 0.1 mm(2) vs. 1.5 +/- 0.2 mm(2), P < 0.001). CONCLUSION: The polylactide thread LTS causes less immunological reaction and synovitis than a polydioxanone suture (PDS). CLINICAL RELEVANCE: LTS may serve as an alternative to PDS for repair of slow healing structures such as tendons and menisci.

Cytokines and chemokines in serum and urine as early predictors to identify septic patients on intensive care unit.

The aim of this prospective cohort study was to address the feasibility of measuring cytokines in serum and urine as early predictor tests for the identification of septic Intensive Care Unit (ICU) patients. The study group consisted of 10 septic and 5 non-septic patients at the onset of sepsis according to modified definitions by the American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM). Serum and urine samples were taken from septic patients at the onset of sepsis and from non-septic patients, every 12 h for 3 days and thereafter every 24 h until day 10. Levels of TNF-alpha, IL-1beta, IL-6, IL-10, IL-18, IFN-gamma, MCP-1, and PCT (procalcitonin) were measured by ELISA. Apart from serum IL-18 and PCT levels, which were elevated in septic patients (p<0.05), levels of all other cytokines and chemokines in the serum of septic patients did not exceed those of the control group. In urine, in contrast with TNF-alpha, IL-1beta, IL-6, IL-10, IFN-gamma, and MCP-1 in which no differences between the two groups were observed, a distinct trend of elevated IL-18 levels was observed only in the septic group. Whereas elevated serum IL-18 and PCT are clear candidate markers for sepsis criteria, the present data indicating elevated urine IL-18 levels albeit from a limited number of septic patients is an interesting observation. The profile of inflammatory mediators in serum and urine from septic patients herein warrants further investigations in a larger group of patients at the onset of sepsis driven by different infectious foci.

Lipopolysaccharides from different bacterial sources elicit disparate cytokine responses in whole blood assays.

The stimulatory effects of different purified lipopolysaccharide (LPS) preparations from E. coli, S. typhosa, P. aeruginosa, and K. pneumoniae on cytokine and chemokine production were measured in whole blood assays by ELISA. Incubation of 0.5 ml whole blood with 10 ng/ml E. coli and S. typhosa resulted in a time-dependent production of TNF-alpha, IL-1beta, IFN-gamma, IL-10 and MCP-1. K. pneumoniae, however, showed preferential effects on IL-1beta, IL-10 and MCP-1 production with less potent effects on TNF-alpha and IFN-gamma. LPS derived from P. aeruginosa showed a similar potency to other LPS preparations on MCP-1 production, yet completely failed to elicit the production of other cytokines. To further investigate potencies of the different LPS preparations, mediator production was determined following stimulation with agonist concentrations of 0.1 ng and 1000 ng per ml over a 24 h time period. Dose-response curves were obtained with LPS derived from E. coli, S. typhosa and K. pneumoniae on all mediators apart from IL-1beta and MCP-1. Most strikingly though, was the ability of LPS derived from P. aeruginosa to selectively elicit a significant dose-response effect on MCP-1 production, despite its very weak stimulatory effects on all other cytokines. These data imply that the bacterial origin of different LPS preparations can exhibit disparate effects on inflammatory mediator production. Furthermore, the potent, selective dose-response effect of P. aeruginosa LPS on MCP-1 production could help to explain the preponderance of a relentless inflammatory cellular infiltrate in diseases such as cystic fibrosis (CF).