Impact of Injury Mechanisms on Patterns and Management of Facial Fractures.

Mechanisms causing facial fractures have evolved over time and may be predictive of the types of injuries sustained. The objective of this study is to examine the impact of mechanisms of injury on the type and management of facial fractures at our Level 1 Trauma Center. The authors performed an Institutional Review Board-approved review of our network's trauma registry from 2006 to 2010, documenting age, sex, mechanism, Injury Severity Score, Glasgow Coma Scale, facial fracture patterns (nasal, maxillary/malar, orbital, mandible), and reconstructions. Mechanism rates were compared using a Pearson χ2 test. The database identified 23,318 patients, including 1686 patients with facial fractures and a subset of 1505 patients sustaining 2094 fractures by motor vehicle collision (MVC), fall, or assault. Nasal fractures were the most common injuries sustained by all mechanisms. MVCs were most likely to cause nasal and malar/maxillary fractures (P < 0.01). Falls were the least likely and assaults the most likely to cause mandible fractures (P < 0.001), the most common injury leading to surgical intervention (P < 0.001). Although not statistically significant, fractures sustained in MVCs were the most likely overall to undergo surgical intervention. Age, number of fractures, and alcohol level were statistically significant variables associated with operative management. Age and number of fractures sustained were associated with operative intervention. Although there is a statistically significant correlation between mechanism of injury and type of facial fracture sustained, none of the mechanisms evaluated herein are statistically associated with surgical intervention. Clinical Question/Level of Evidence: Therapeutic, III.

Robin sequence: what the multidisciplinary approach can do.

Robin sequence (RS) is a commonly encountered triad of micrognathia, glossoptosis, and airway obstruction, with or without a cleft palate. The management of airway obstruction is of paramount importance, and multiple reviews and retrospective series outline the diagnosis and treatment of RS. This article focuses on the multidisciplinary nature of RS and the specialists' contributions and thought processes regarding the management of the RS child from birth to skeletal maturity. This review demonstrates that the care of these children extends far beyond the acute airway obstruction and that thorough monitoring and appropriate intervention are required to help them achieve optimal outcomes.

Low-magnesium, trans-cleavage activity by type III, tertiary stabilized hammerhead ribozymes with stem 1 discontinuities.

BACKGROUND: Low concentrations of free magnesium in the intracellular environment can present critical limitations for hammerhead ribozymes, especially for those that are designed for intermolecular (trans) cleavage of a host or pathogen RNA. Tertiary stabilizing motifs (TSM's) from natural and artificial ribozymes with a "type I" topology have been exploited to stabilize trans-cleaving hammerheads. Ribozymes with "type II" or "type III" topologies might seem incompatible with conversion to trans-cleavage designs, because opening the loop at the end of stem 1 or stem 2 to accommodate substrate binding is expected to disrupt the TSM and eliminate tertiary stabilization. RESULTS: Stem 1, together with single-stranded segments capping or internal to this stem, contains both the substrate-binding and tertiary stabilization functions. This stem was made discontinuous within the sTRSV hammerhead ribozyme, thereby separating the two functions into discrete structural segments. The resulting ribozyme, designated "RzC," cleaved its 13 nucleotide target substrate at MgCl2 concentrations as low as 0.2 mM at 25 degrees C and 0.5 mM at 37 degrees C. Under multiple-turnover conditions, nearly thirty turnovers were observed at the highest substrate:RzC ribozyme ratios. Similar stabilization was observed for several derivatives of RzC. Catalytic activity was diminished or eliminated at sub-millimolar MgCl2 concentrations for ribozymes with weakened or deleted tertiary interactions. Eadie-Hofstee analysis revealed that the stabilized and non-stabilized ribozymes bind their substrates with equivalent affinities, suggesting that differences in observed activity are not the result of diminished binding. Some of the stabilized and non-stabilized ribozymes appear to fold into a heterogeneous collection of conformers, only a subset of which are catalytically active. CONCLUSION: Hammerhead ribozymes with the "type III" topology can be converted to a tertiary, trans-cleavage design. Separating the stabilization and substrate recognition functions of stem 1 increases cleavage activity at physiological concentrations of divalent magnesium while retaining recognition of exogenous targets. Trans-cleaving ribozymes that exploit the tertiary stabilizing motifs of all natural hammerhead topologies can therefore be used in intracellular applications.

Defining failure and its predictors in mandibular distraction for Robin sequence.

INTRODUCTION: Robin sequence (RS) is defined as the triad of micrognathia, glossoptosis and airway obstruction. A popular surgical treatment is mandibular distraction osteogenesis (MDO). In this study, it is demonstrated that the associated variables change, dependent on the manner in which failure is defined. These multiple failure outcomes are used to construct a scoring system to predict MDO failure. METHODS: A retrospective database of neonatal MDO patients was constructed. Failure outcomes studied included tracheostomy; a decrease in the apnea-hypopnea index (AHI) but an AHI >20; and death. A combination of bivariate and regression analysis was used to produce significantly associated variables and a scoring system. RESULTS: Statistical analysis demonstrated the association of gastroesophageal reflux; age >30 days; neurologic anomaly; airway anomalies, other than laryngomalacia; an intact palate; and pre-operative intubation on the outcome variables studied. Multiple scoring systems were produced with reasonable sensitivity, specificity, and positive and negative predictive value. CONCLUSIONS: When reporting surgical outcomes of MDO in the setting of RS, it is important to consider the AHI as well as avoidance of tracheostomy as an outcome variable. Incomplete amelioration of AHI accounts for half of the patients with a problem after MDO. The predictive scores presented will be used and validated on a larger, prospectively collected dataset.

Mandibular Distraction Osteogenesis in Low-Weight Neonates with Robin Sequence: Is It Safe?

BACKGROUND: The aim of this study was to evaluate the efficacy, safety profile, and complications associated with mandibular distraction osteogenesis performed in infants weighing less than 4 kg with Robin sequence. METHODS: An 11-year retrospective review of all infants (younger than 6 months) with mandibular distraction osteogenesis-treated Robin sequence was performed. Patients weighing less than 4 kg (experimental) and 4 kg or more (control) who underwent mandibular distraction osteogenesis were compared. Demographics, medical comorbidities, improvement in apnea/hypopnea index, need for tracheostomy, repeated distraction, and complications were evaluated. RESULTS: One hundred twenty-one patients underwent mandibular distraction osteogenesis. Eighty-one patients weighed less than 4 kg and 40 weighed 4 kg or more. The mean follow-up was 2.8 years in patients weighing less than 4 kg and 3.0 years in the control group. Mean age and weight at the time of distraction were 23 days and 3.1 kg, respectively, in the study group; and 2.7 years and 11 kg, respectively, in the control group. There was no significant difference in success of mandibular distraction osteogenesis to treat airway obstruction in the group weighing less than 4 kg compared with the control group (92.6 percent versus 88.9 percent; p = 0.49). The most common complication in each group was surgical-site infection (9.9 percent and 20.0 percent; p = 0.15). Overall complication rates were similar between the two groups (17.3 percent versus 25.0 percent; p = 0.34). The rates of repeated distraction were similar between the two groups (6.3 percent and 13.5 percent; p = 0.28). CONCLUSIONS: Mandibular distraction osteogenesis is a safe and effective treatment modality for infants weighing less than 4 kg with severe airway obstruction. The efficacy, safety, and complication profiles are not significantly different from those of larger patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Epidemiology and cause-specific outcomes of facial fracture in hospitalized children.

PURPOSE: Facial fractures in the pediatric population have a significant impact on public health. Although some demographic data exists regarding the overall epidemiology of facial fractures, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma. MATERIAL AND METHODS: The Kids' Inpatient Database 2000-2009 was utilized to analyze pediatric facial fractures. A total of 21,533 patients were identified. Associations of patient characteristics with outcomes of interest were assessed. RESULTS: The top three etiologies were motor vehicle accident (MVA), intentional trauma (IT), and falls. There was a decrease in the incidence of facial fractures due to MVAs and an increase in injuries due to IT and falls. Concomitant injuries were present in 58.8% and the mortality rate was 2%. The rate of concomitant injuries increased during study period. Age was significantly associated with concomitant injury, mortality, and LOS. CONCLUSION: The increasing rate of IT and falls with concomitant injury warrants special consideration to reduce undiagnosed accompanying injuries. Further programs should be put in place to protect children younger than 5 years of age, who have increased risk of concomitant injury and mortality following intentional trauma.

Spring-assisted cranial vault expansion in the setting of multisutural craniosynostosis and anomalous venous drainage: case report.

Patients with multisutural craniosynostosis can develop anomalous venous connections between the intracranial sinuses and cutaneous venous system through enlarged emissary veins. Cranial vault remodeling in this subset of patients carries the risk of massive intraoperative blood loss and/or occlusion of collateral draining veins leading to intracranial venous hypertension and raised intracranial pressure, increasing the morbidity of cranial expansion. The authors report the use of spring-mediated expansion as a technique for cranial reconstruction in which the collateral intracranial venous drainage system can be preserved. A patient with bilateral lambdoid, sagittal, and unicoronal synostosis presented for cranial reconstruction. A tracheostomy and ventriculoperitoneal shunt were placed prior to intervention. At the time of reconstruction, a Luckenschadel skull abnormality and Chiari malformation Type I were present. A preoperative CT venogram demonstrated large collateral superficial occipital veins, small bilateral internal jugular veins, and hypoplastic jugular foramina. Collateral flow from the transverse and sigmoid sinuses through large occipital emissary veins was seen. Spring-mediated cranial vault expansion was performed with care to preserve the large collateral veins at the occipital midline. Four springs were placed at each lambdoid and the posterior and anterior sagittal sutures following 1-cm strip suturectomies. Removal of the springs was performed 2 months postoperatively. Cranial vault expansion was performed without disturbing the aberrant intracranial/extracranial venous collateral system. Estimated blood loss was 150 ml. A CT scan obtained 3 months postoperatively showed resolution of the Luckenschadel deformity and a 40% volumetric increase in the skull compared with the preoperative CT. Patients with anomalous venous drainage patterns and multisutural synostosis can undergo spring-mediated cranial vault expansion while preserving the major emissary veins draining the intracranial sinuses. Risks of blood loss, intracranial venous hypertension, and increased intracranial pressure may be decreased compared with traditional techniques of repair.

High-frequency oscillatory ventilators in burn patients: experience of Riley Hospital for Children.

The objective of the study is to review a single institution's experience with high-frequency oscillatory ventilation (HFOV) and compare patient characteristics, outcomes, and complications with other reported studies of HFOV use in burn patients with acute respiratory distress syndrome and respiratory failure. This study is a retrospective chart review of the burn patients treated with HFOV in Pediatric Burn Unit at Riley Hospital for Children from October 1996 to April 2007. Patient data were collected, including demographics, percentage of TBSA burn, percentage of full-thickness burn, mechanisms of burn, settings on conventional mechanical ventilation and HFOV, and blood gas data before initiation of HFOV and at 1, 3, 6, 12, 24, 72 (3 days), 120 (5 days), 168 (7 days), 240 (10 days), and 336 hours (14 days). Length of stay, mortality, and complications were also included. HFOV was used 24 times in 21 patients between October 1996 and April 2007 with a mean age of 10 ± 11 years. At initiation of HFOV, the PaO2/FiO2 and oxygenation index values were 109 ± 26 and 36 ± 12, respectively. At stop, the PaO2/FiO2 improved to 166 ± 24 with an average increase from before HFOV of 57 ± 39 (P < .002). At 5 days of HFOV, oxygenation index improved to 14.1 ± 1.7 (P < .02) but did not significantly improve at discontinuation of HFOV at 28.8 ± 6.2 (P = .11). The mortality rate during admission to the burn unit was 29%. Barotrauma occurred in 38% of patients during HFOV. Severe hypercapnea was present briefly in 49% of patients, and this was refractory to standard treatment in 19%. In our experience, HFOV in severe burn patients has significant, early, and sustained improvement in oxygenation. Earlier institution of HFOV seems to significantly lower rates of barotraumas.

Evolutionary landscapes for the acquisition of new ligand recognition by RNA aptamers.

The evolution of ligand specificity underlies many important problems in biology, from the appearance of drug resistant pathogens to the re-engineering of substrate specificity in enzymes. In studying biomolecules, however, the contributions of macromolecular sequence to binding specificity can be obscured by other selection pressures critical to bioactivity. Evolution of ligand specificity in vitro--unconstrained by confounding biological factors--is addressed here using variants of three flavin-binding RNA aptamers. Mutagenized pools based on the three aptamers were combined and allowed to compete during in vitro selection for GMP-binding activity. The sequences of the resulting selection isolates were diverse, even though most were derived from the same flavin-binding parent. Individual GMP aptamers differed from the parental flavin aptamers by 7 to 26 mutations (20 to 57% overall change). Acquisition of GMP recognition coincided with the loss of FAD (flavin-adenine dinucleotide) recognition in all isolates, despite the absence of a counter-selection to remove FAD-binding RNAs. To examine more precisely the proximity of these two activities within a defined sequence space, the complete set of all intermediate sequences between an FAD-binding aptamer and a GMP-binding aptamer were synthesized and assayed for activity. For this set of sequences, we observe a portion of a neutral network for FAD-binding function separated from GMP-binding function by a distance of three mutations. Furthermore, enzymatic probing of these aptamers revealed gross structural remodeling of the RNA coincident with the switch in ligand recognition. The capacity for neutral drift along an FAD-binding network in such close approach to RNAs with GMP-binding activity illustrates the degree of phenotypic buffering available to a set of closely related RNA sequences--defined as the set's functional tolerance for point mutations--and supports neutral evolutionary theory by demonstrating the facility with which a new phenotype becomes accessible as that buffering threshold is crossed.