The impact of augmenter of liver regeneration in blunt liver trauma: An experimental model analysis.

BACKGROUND: Traumatic liver injury is an acute event that triggers liver repair. The augmenter of liver regeneration (ALR) has been identified as a growth factor involved in this process. This study evaluates the impact of ALR on isolated liver blunt trauma and examines its relationship with various time intervals. METHODS: Forty healthy female Wistar albino rats were divided into five groups (n=8 each). Isolated blunt liver trauma was induced using a custom-designed trauma platform in all groups except for Group 1. The groups were categorized by the timing of euthanasia post-trauma: 2nd (15 minutes), 3rd (30 minutes), 4th (45 minutes), and 5th (60 minutes). Assessments included plasma ALR levels, liver tissue ALR levels (both intact and lacerated), biochemical indices, and liver histological analysis. RESULTS: Plasma ALR levels in Group 4 were higher than in Groups 1 and 2 (p<0.01). Intact liver ALR levels in Groups 3 and 4 exceeded those in Group 1 (p<0.05, p<0.01, respectively). Intact liver tissue ALR levels in Group 5 were lower than in Groups 3 and 4 (p<0.05, p<0.01, respectively). Lacerated liver tissue ALR levels in Group 5 were higher than those in Groups 2 and 3. In Group 1, the plasma ALR level was higher than the intact liver tissue ALR level (p<0.05). In Group 2, plasma ALR levels exceeded those in intact liver tissue ALR levels (p<0.01). In Group 3, plasma ALR levels surpassed both lacerated and intact liver tissue ALR levels (p<0.05, p<0.001, respectively). In Group 4, the plasma ALR level was higher than the intact liver tissue ALR level (p<0.01), and the lacerated liver tissue level was higher than the intact liver ALR level (p<0.001). Additionally, inflammation scores were higher in Groups 3, 4, and 5 compared to Group 2 (p<0.05, p<0.01, p<0.01, respectively). CONCLUSION: This study is the first to explore the role of ALR in isolated blunt liver trauma. Following blunt liver trauma, both plasma and liver tissue ALR levels change within minutes.

Distinctive Pathology Associated With Focal Stenosis of the Main Pancreatic Duct Secondary to Remote Trauma: A Long-term Complication of Seat Belt Pancreatitis.

The radiologic finding of focal stenosis of the main pancreatic duct is highly suggestive of pancreatic cancer. Even in the absence of a mass lesion, focal duct stenosis can lead to surgical resection of the affected portion of the pancreas. We present four patients with distinctive pathology associated with non-neoplastic focal stenosis of the main pancreatic duct. The pathology included stenosis of the pancreatic duct accompanied by wavy, acellular, serpentine-like fibrosis, chronic inflammation with foreign body-type giant cell reaction, and calcifications. In all cases, the pancreas toward the tail of the gland had obstructive changes including acinar drop-out and interlobular and intralobular fibrosis. Three of the four patients had a remote history of major motor vehicle accidents associated with severe abdominal trauma. These results emphasize that blunt trauma can injure the pancreas and that this injury can result in long-term complications, including focal stenosis of the main pancreatic duct. Pathologists should be aware of the distinct pathology associated with remote trauma and, when the pathology is present, should elicit the appropriate clinical history.

Traumatic testicular dislocation: A case report and literature review.

INTRODUCTION: Traumatic testicular dislocation is an uncommon complication of blunt scrotal injury and is easily overlooked because of the presence of other severe accompanying injuries. In most cases, an operation is needed for the prevention of malignant change or infertility. PATIENT CONCERNS AND DIAGNOSIS: We report a case of traumatic testicular dislocation with pelvic fracture and internal bleeding in a 27-year-old male with testis rupture after a motorcycle collision. INTERVENTIONS AND OUTCOMES: He received emergent right radical orchiectomy, and a series of operations for femoral and pelvic fractures were performed after his condition stabilized in the intensive care unit. After 1 month postsurgery, no obvious genitourinary complications were noted. CONCLUSION: We suggest scrotum examination in all trauma patients, particularly if a pelvic injury is suspected or in case of a high risk of a motorcycle collision, to avoid missing the diagnosis and prevent severe complications.

The Effect of the Eastern Association for the Surgery of Trauma Guideline on Spinal Magnetic Resonance Imaging Use in Obtunded Adult Blunt Trauma Patients Over Time.

BACKGROUND: Evidence-based guidelines suggest computed tomography without magnetic resonance imaging (MRI) is sufficient to rule out clinically significant cervical spine injury in obtunded adult blunt trauma patients. This study evaluated MRI utilization over time to investigate the impact of the 2015 Eastern Association for the Surgery of Trauma guidelines suggesting cervical collar clearance with computed tomography alone in this population. We hypothesized that MRI utilization would decrease following the guidelines. MATERIALS AND METHODS: We performed a retrospective cross-sectional study of the National Trauma Data Bank from 2007 to 2018 using multivariable logistic regression of the likelihood of spinal MRI utilization. Blunt trauma patients 18 y and older with a Glasgow Coma Scale (GCS) of 8 or less, Abbreviated Injury Score head of 4 or greater, intubated for at least 72 h were included. RESULTS: The sample consisted of 76,450 patients from 567 trauma centers. Controlling for age, gender, race/ethnicity, insurance status, injury mechanism, Injury Severity Score, GCS, GCS motor, hospital teaching status and trauma center level, patients seen after 2015 had a higher odds ratio (OR) of undergoing spinal MRI relative to those seen before 2015 (OR 1.77, 95% CI 1.49-2.09; P < 0.001). Each year was associated with a significantly increased OR of undergoing spinal MRI compared to the year prior (OR 1.10, 95% CI 1.05-1.15; P < 0.001). CONCLUSIONS: Spinal MRI use has been increasing in obtunded adult blunt trauma patients including after the release of the Eastern Association for the Surgery of Trauma guidelines in 2015. Future work should identify whether this is driven by improper MRI utilization and, if so, strategies to promote guideline adherence.

Alterations of coagulation and fibrinolysis in patients with blunt splenic injury after splenic artery embolization.

BACKGROUND: Thrombotic complications following splenectomy have been documented. However, there has been sparse literature regarding thrombotic complications following splenic artery embolization (SAE).The objective of this study was to determine changes in coagulation and fibrinolysis and assess the thrombotic risk after SAE in patients with blunt splenic injury (BSI). METHODS: This study included 38 BSI patients who were hemodynamically stable on admission. SAE was performed if the splenic injury was classed as grade III or greater and had no requirement of immediate surgery. Platelet (PLT), fibrinogen (FIB), D-dimers (D-D), fibrinogen/fibrin degradation products (FDP), antithrombin III (AT III), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), hemoglobin (Hb), and hematocrit (Hct) were measured before SAE procedures and then 1d, 3d, and 7d after SAE. RESULTS: The technical success rate of SAE and the splenic salvage rate were 100%. There was no mortality. Compared with pre-SAE values, the levels of PLT, FIB, D-D, and FDP increased significantly at 3 days and 7 days after SAE (p < 0.05). However, AT III, PT, APTT, TT, Hb, and Hct showed no statistically significant difference at 1d, 3d, and 7d after SAE (p > 0.05). CONCLUSION: Alterations in PLT and hemostatic parameters might contribute to the increased risk of thrombotic complications in BSI patients undergoing SAE. Thromboembolism following SAE should be considered and thrombotic prophylaxis should be recommended.

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

BACKGROUND: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE: Retrospective diagnostic/therapeutic study, level III.

The Cutaneous Wound Innate Immunological Microenvironment.

The skin represents the first line of defense and innate immune protection against pathogens. Skin normally provides a physical barrier to prevent infection by pathogens; however, wounds, microinjuries, and minor barrier impediments can present open avenues for invasion through the skin. Accordingly, wound repair and protection from invading pathogens are essential processes in successful skin barrier regeneration. To repair and protect wounds, skin promotes the development of a specific and complex immunological microenvironment within and surrounding the disrupted tissue. This immune microenvironment includes both innate and adaptive processes, including immune cell recruitment to the wound and secretion of extracellular factors that can act directly to promote wound closure and wound antimicrobial defense. Recent work has shown that this immune microenvironment also varies according to the specific context of the wound: the microbiome, neuroimmune signaling, environmental effects, and age play roles in altering the innate immune response to wounding. This review will focus on the role of these factors in shaping the cutaneous microenvironment and how this ultimately impacts the immune response to wounding.

KSHV enhances mesenchymal stem cell homing and promotes KS-like pathogenesis.

Kaposi's sarcoma (KS) tends to occur in injured or inflamed sites of the body, which is described as the "Koebner phenomenon". KS is also unique in its extraordinary angio-hyperplastic inflammatory phenotype. Recently, evidence has accrued indicating that KS may derive from KSHV-infected mesenchymal stem cells (MSCs), which possess enhanced migration and homing ability. Inspired by these findings, we hypothesized that KS may arise from KSHV-infected MSCs that chemotactically migrate to preexisting inflammatory or injured sites. Here we report that KSHV infection of human MSCs significantly up-regulated expression of several chemokine receptors and enhanced cell migration ability in vitro. Furthermore, using a wound mouse model, we demonstrated that KSHV infection dramatically promotes MSCs migrating and settling in the wound sites. In addition, two mice in the KSHV-infected group showed purpura and tumors with KS-like features. Taken together, KSHV-enhanced MSC migration ability and inflammatory microenvironment play crucial roles in KS development.

Aortic Remodeling and Clinical Outcomes Following Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury.

BACKGROUND: There is currently limited data assessing the long-term consequences of thoracic endovascular aortic repair (TEVAR) in otherwise healthy aortic segments remote from the site of endograft coverage. The aim of this study is to retrospectively evaluate aortic remodeling and long-term outcomes of blunt thoracic aortic injury (BTAI) patients treated with TEVAR. Our hypothesis is that significant changes to the aorta proximal to the graft-covered segment are suspected following TEVAR. METHODS: An institutional review board-approved retrospective review of patients who underwent TEVAR for BTAI at a level I trauma center from 2004 to 2018 was performed. Forty-six patients were identified and of these, 32 patients with high-resolution computed tomographic angiography imaging follow-up were included in the study. Computed tomographic angiography measurements of aortic dimensions and branch vessels proximal, distal, and adjacent to the stent grafted segment were recorded preprocedure and postprocedure and analyzed. Primary device-related outcomes such as birdbeaking, mural thrombus, stent migration, and persistent endoleak were assessed. Patient outcomes including mortality, graft-related morbidity, and need for secondary interventions were also analyzed. RESULTS: Mean follow-up of the selected patients in the study was 1.52 y (range, 0.06-8.0 y). Following TEVAR, the ascending aortic length increased significantly (mean 5.7 ± 4.6 mm, P < 0.001). The mean diameters of the ascending aorta (1.5 ± 1.5, P < 0.001 mm), the midaortic arch (1.3 ± 1.7 mm, P < 0.001), and proximal and the distal endograft landing zones (1.9 ± 2.1 mm and 2.2 ± 1.6 mm, respectively, P < 0.001) also increased significantly following TEVAR. Clinically relevant device-related outcomes occurred with the presence of endograft infolding and subsequent development of endograft mural thrombus (P < 0.001). The need for secondary intervention following TEVAR for BTAI was associated with endograft mural thrombus (P < 0.05). CONCLUSIONS: TEVAR for BTAI causes significant geometric changes in the aorta proximal to the stented grafted segment of the aorta. Direct consequences of the graft at the stented segment includes mural thrombus development within the endograft which was associated with the need for secondary intervention. Although clinical significance is yet to be determined, post-TEVAR changes in aortic architecture warrant continued aortic surveillance following BTAI.

Rhabdomyolysis associated acute renal failure - Report of two fatal cases and a brief review of literature.

BACKGROUND: Rhabdomyolysis is a potentially fatal condition which occurs due to skeletal muscle injury and classically presents with myalgia and red-brown coloured urine. Presence of excess myoglobin in the glomerular filtrate forms myoglobin casts which causes severe obstruction and necrosis of the tubules leading to acute renal failure. METHODS: We report two fatal cases of rhabdomyolysis associated acute renal failure. The first victim died in police custody and the second victim died due to severe physical exertion. RESULTS: In both the cases, creatine kinase levels were elevated and myoglobin was detected in urine in the second case. Myoglobin immunohistochemistry detected the presence of myoglobin cast in the glomerular tubules of kidney in both the cases. CONCLUSIONS: Myoglobin immunohistochemistry of renal tissues, serum creatine kinase, urine myoglobin analysis and muscle histopathology are the laboratory tests that should be considered at autopsy where rhabdomyolysis is suspected.

A minimally invasive incision and loop drainage technique for the treatment of lower limb Morel-Lavallée lesions: Nose ring drainage technique.

Morel-Lavallée lesions (MLLs) are shearing injuries resulting in separation of the skin and subcutaneous tissue from the underlying fascia. They are closed internal degloving injuries. Classical sites of the lesions are around the greater trochanter, pelvis, thigh, knee joint, and on the head, in decreasing order of frequency. This injury is often delayed or misdiagnosed when patients present with soft tissue injury alone or when more obvious injuries distract from its presence in polytrauma patients. There is currently no universally accepted treatment for these lesions. Conservative management often fails and requires surgical intervention. The purpose of this manuscript is to show that nose ring drainage, a minimally invasive incision and loop drainage technique for the treatment of lower limb Morel-Lavallée lesions, is effective and economical.

Contributing factors in the development of acute lung injury in a murine double hit model.

OBJECTIVES: Blunt chest (thoracic) trauma (TxT) is known to contribute to the development of secondary pulmonary complications. Of these, acute lung injury (ALI) is common especially in multiply injured patients and might not only be due to the direct trauma itself, but seems to be caused by ongoing and multifactorial inflammatory changes. Nevertheless, the exact mechanisms and contributing factors of the development of ALI following blunt chest trauma are still elusive. METHODS: 60 CL57BL/6N mice sustained either blunt chest trauma combined with laparotomy without further interventions or a double hit (DH) including TxT and cecal ligation puncture (CLP) after 24 h to induce ALI. Animals were killed either 6 or 24 h after the second procedure. Pulmonary expression of inflammatory mediators cxcl1, cxcl5, IL-1ß and IL-6, neutrophil infiltration and lung tissue damage using the Lung Injury Score (LIS) were determined. RESULTS: Next to a moderate increase in other inflammatory mediators, a significant increase in CXCL1, neutrophil infiltration and lung injury was observed early after TxT, which returned to baseline levels after 24 h. DH induced significantly increased gene expression of cxcl1, cxcl5, IL-1ß and IL-6 after 6 h, which was followed by the postponed significant increase in the protein expression after 24 h compared to controls. Neutrophil infiltration was significantly enhanced 24 h after DH compared to all other groups, and exerted a slight decline after 24 h. LIS has shown a significant increase after both 6 and 24 h compared to both control groups as well the late TxT group. CONCLUSION: Early observed lung injury with moderate inflammatory changes after blunt chest trauma recovered quickly, and therefore, may be caused by mechanical lung injury. In contrast, lung injury in the ALI group did not undergo recovery and is closely associated with significant changes of inflammatory mediators. This model may be used for further examinations of contributing factors and therapeutic strategies to prevent ALI.

Investigation of Bosentan's Effects on Pulmonary Contusion Created by Blunt Thoracic Trauma in Rats.

INTRODUCTION: Bosentan is an endothelin-1 receptor antagonist with anti-inflammatory, antioxidant, and antiproliferative effects. We aimed to evaluate its effects on lung tissue in a pulmonary contusion (PC) model. MATERIALS AND METHODS: The rats were randomly divided into five groups: PC3: PC evaluated on the 3rd day (n = 8), PC-B3: PC enteral bosentan 100 mg/kg/day, for 3 days (n = 8), PC7: PC evaluated on the 7th day (n = 7), PC-B7: PC 7 days bosentan 100 mg/kg/day, for 7 days (n = 8), C: control (n = 6). Unilateral lung contusion was created by dropping a metal weight onto the chest. The rats were sacrificed on the 3rd or the 7th days. The lung tissue was evaluated histopathologically for alveolar edema, congestion, and leukocyte infiltration, biochemically for malondialdehyde (MDA), superoxide dismutase (SOD), and nitric oxide (NO) levels, and immunohistochemically for inducible nitric oxide synthase (iNOS), endothelial nitric oxide synthase (eNOS), and apoptosis scores. RESULTS: Alveolar edema, congestion, and leukocyte infiltration scores were increased in all groups compared with the control group (p < 0.05) and decreased in bosentan-treated groups compared with the relevant nontreated groups (p < 0.05). Fibrosis was observed only in PC7 and PC-B7 groups. Bosentan did not have any effect on fibrosis development. iNOS and eNOS levels were higher in all groups compared with the control (p < 0.05) without a difference in the nontreated versus treated groups (p > 0.05). Bosentan treatment caused decreased MDA and increased SOD levels in comparison to the nontreated groups (p < 0.05). Tissue NO levels did not show any significant difference among groups. PC groups had higher levels of apoptosis compared with the control group (p < 0.05). The degree of apoptosis decreased in bosentan-treated groups compared with the nontreated groups (p < 0.05). CONCLUSION: PC causes progressive lung tissue damage. Bosentan reduced leukocyte infiltration and alveolar edema and congestion caused by PC. It also decreased MDA levels and increased SOD levels. Bosentan prevents tissue damage by inhibiting acute inflammatory response and reduces oxidative stress secondary to inflammation. It has therapeutic effects on apoptosis.

Degloving injury to groin, scrotum and penis due to low-velocity handlebar injury.

Bicycles are a common cause of blunt abdominal trauma causing 5%-14% of injuries. However, impalement or shear injuries from low-velocity mechanism of injury are rare. We report a case of a 14-year-old boy presenting with an extensive left groin injury sustained while cycling one-handed along the pavement at walking pace. The laceration ran for 12-14 cm from the left groin across the pubis to the right and 10 cm inferiorly into the perineum. This inverted the left scrotum and partially degloved the penis. The corpus cavernosa and tunica vaginalis were exposed up to the level of the superficial inguinal ring. Literature on handlebar-impalement injuries is sparse and the majority of penile degloving injuries described in the literature result from alternative mechanisms. This unusual case demonstrates the potential forces involved, and potential damage resulting from handlebar injuries even at low velocity.

First report of traumatic scleral rupture after penetrating keratoplasty.

Globe rupture is a major postoperative complication after penetrating keratoplasty (PK). Because the corneal wound is never comparable with that of healthy corneal tissue, globe rupture following blunt trauma occurs at the corneal graft-host junction. In this study, we report a case of scleral rupture that arose from blunt trauma occurring after PK. A 60-year-old female presented with loss of vision, redness and pain in the left eye, which was the consequence of blunt trauma, was our case in this study. Slit-lamp examination revealed ecchymosis on the eyelids, diffuse subconjunctival hemorrhage and total hyphema. The donor cornea was intact. The right eye showed PK, the cornea was transparent, and the sclera was blue. A 2 mm rupture behind the limbus extending from 3 o'clock to 9 o'clock in the upper half of the sclera was observed during exploratory surgery. She did not report any coexisting medical conditions except for systemic hypertension. The differential diagnosis of the bluish discoloration of her sclera was investigated. In detailed anamnesis, the patient reported that she had been treated for severe allergic eye disease during childhood. Vernal keratoconjunctivitis complication was diagnosed. It should be kept in mind that closed scleral perforation may occur in the patient with PK and blue sclera due to blunt trauma.

CT of blunt splenic injuries: what the trauma team wants to know from the radiologist.

Splenic injury is commonly encountered in severe blunt abdominal trauma. Technological improvements and the increasing availability of both diagnostic computed tomography (CT) and therapeutic splenic artery embolisation (SAE) are key factors in defining the high success rate of modern-day non-operative management (NOM) for blunt splenic injuries (BSIs). The Association for Surgery for Trauma (AAST) Organ Injury Scale (OIS) is commonly used by both radiologists and clinicians to stratify injury severity, traditionally based on the degree of parenchymal disruption seen on CT, and guide management. Its recent 2018 update takes splenic vascular injuries (i.e., active bleed, pseudoaneurysm, and traumatic arteriovenous fistulae) into consideration, the presence of which will indicate at least a grade IV (i.e., high-grade) injury. This is a reflection of the paradigm shift towards spleen conservation with regular use of SAE as the current standard of treatment. Prompted by the latest AAST OIS revision, which represents a more complete and current grading system, we present the spectrum of pertinent CT findings that the diagnostic radiologist should accurately identify and convey to the multidisciplinary trauma team (including the interventional radiologist). This review divides imaging findings based on the AAST OIS definitions and categorises them into (1) parenchymal and (2) vascular injuries. Features that may help in the detection of subtle BSIs are also described. Lastly, it touches on the key changes made to the new AAST OIS, substantiated by case illustrations.

Overview of venous pathology related to repetitive vascular trauma in athletes.

BACKGROUND: Athletes are generally young, high-functioning individuals. Pathology in this cohort is associated with a decrease in function and consequently has major implications on quality of life. Venous disorders can be attributed to a combination of vascular compression with a high burden of activity. OBJECTIVE: This article promotes increased awareness of these uncommon conditions specific to the athlete by summarizing pathophysiology, clinical features, investigation, and treatment protocols for use in clinical practice. Prognostic outcomes of these management regimens are also discussed, allowing for clinicians to counsel these high-functioning individuals appropriately. With the aim of providing an overview of sport-related venous pathology, a literature review was undertaken identifying articles that were independently reviewed by the authors. RESULTS: Lower limb venous thrombosis has been identified in young, high-functioning athletes attributed to both compression-related venous trauma, associated with repetitive movements resulting in intimal damage, and blunt trauma. The diagnosis and treatment follow the same protocols as for the general population. Of note, early ambulation is advocated, with an aim to return to premorbid (noncontact) function within 6 weeks. Athletes performing high-intensity repetitive upper limb movement, such as baseball players, are predisposed to upper limb deep venous thrombosis (DVT). Diagnosis follows the same protocols as for lower extremity DVT; however, the optimal treatment strategy remains debated. Current guidelines advocate the use of anticoagulation alone. A specific subset of primary upper limb DVT is effort thrombosis, where there is compression at the level of the thoracic outlet. Thrombolysis with first rib resection is indicated in the acute setting within 14 days. In cases of complete occlusion, surgical decompression with venous reconstruction may be required. Popliteal vein entrapment syndrome is also discussed. This entity has been identified as an overuse injury associated with popliteal vein compression. Duplex ultrasound examination is indicated as a first-line investigation, with conservative noninvasive options considered as an initial management strategy. Chronic venous insufficiency or persistent symptoms may require subsequent surgical decompression. CONCLUSIONS: Key conditions including upper extremity and lower extremity venous thrombosis, venous aneurysms, Paget-Schroetter syndrome (effort thrombosis), and popliteal vein entrapment syndrome are discussed. Further studies evaluating long-term outcomes on morbidity for current treatment regimens in upper extremity DVT, effort thrombosis, venous thoracic outlet syndrome, and popliteal venous entrapment syndrome are required.

Association between computed tomographic thoracic injury scores and blood gas and acid-base balance in dogs with blunt thoracic trauma.

OBJECTIVE: To determine the association between thoracic injuries evaluated by computed tomography (CT) and arterial blood gas and acid-base status in dogs with blunt thoracic trauma caused by motor vehicle accidents. DESIGN: Prospective observational clinical study. SETTING: University teaching hospital. ANIMALS: Thirty-one client owned traumatized dogs and 15 healthy dogs. PROCEDURES: All trauma group dogs underwent a CT scan and simultaneous arterial blood gas analysis within 24 hours, but not before 4 hours, after the traumatic incident within a 45-month enrollment period. MEASUREMENTS AND MAIN RESULTS: Thorax injuries were classified as pulmonary, pleural space, or rib cage and each of these components was scored for severity using a CT composite pulmonary, pleural, and rib score. The trauma group arterial blood gas and acid-base status were evaluated for statistical difference from the control group. The pulmonary-arterial oxygen pressure was significantly lower in the trauma group compared to the control group that was supported by significant differences in the calculated variables of arterial blood oxygenation as well. There was also a significant correlation between the composite lung score and pleural score and the variables of arterial oxygen status. The pulmonary-arterial carbon dioxide pressure was not significantly different to any of the thoracic injury variables indicating normal alveolar ventilation. Acid-base imbalances were generally mild, insignificant, and variable. CONCLUSIONS AND CLINICAL RELEVANCE: Blunt thoracic trauma causes significant pulmonary and pleural injury and the blood oxygen economy is significantly affected by this. The functional measures of arterial blood oxygenation were well correlated with thoracic CT pathology. Alveolar ventilation was mostly spared but a clinically significant ventilation perfusion mismatch was present.

Water balloon-induced orbital fracture in an aviator.

BACKGROUND: Orbital fractures are common injuries found in facial trauma. Typical etiologies of orbital fractures include motor vehicle collisions and assault. We report the case of a 32-year-old male who suffered an orbital fracture from a water balloon. Additionally, we describe the aeromedical complications that may result from this injury. Finally, we attempt to answer the question of when a patient may return to flying after sustaining such an injury through review of the literature. CASE PRESENTATION: A 32-year-old male pilot with the United States Air Force was at an outdoor event with his unit when he was struck with a water balloon launched from a sling shot into his left orbit. Shortly afterwards, he had an onset of subcutaneous emphysema and was escorted to a nearby Emergency Department. Computed tomography identified an orbital fracture with associated orbital and subcutaneous emphysema. The patient was evaluated by a plastic surgeon and was determined not to be a surgical candidate. Four weeks later, he returned to flying status. CONCLUSIONS: Water balloons are thought to be safe and harmless toys. However, when coupled with slingshots, water balloons can become formidable projectiles capable of significant orbital injury including orbital fractures. These injuries are concerning to aviators, as the most common sites for fractures of the orbit are the thin ethmoid and maxillary bones adjacent to the sinuses. At altitude, gases in the sinuses may expand and enter the orbit through these fractures, which may suddenly incapacitate the flyer. It is important for flight surgeons to identify and assess these individuals to determine suitability for flying.

Extrahepatic bile duct injury caused by a horse kicking injury.

A 35-year-old man presented to a regional hospital after being kicked by a horse in the right upper quadrant. He was transferred to our hepatobiliary unit with bile peritonitis 8 days post trauma. Laparoscopic cholecystectomy and intraoperative cholangiography were performed, demonstrating distal common bile duct (CBD) obstruction with contrast extravasation from the distal duct. The CBD was drained with a T-tube via laparotomy. On postoperative day 14, T-tube cholangiography demonstrated no extravasation of contrast from the distal CBD and minor stricturing with eventual duodenal drainage. The T-tube was clamped and 5 weeks later, the patient represented with peri-T-tube bile leakage and right upper quadrant pain. A T-tube cholangiogram confirmed a complex distal CBD stricture. Two attempts at ERCP with intent of stenting the stricture were unsuccessful. The patient underwent an end to side Roux-en-Y choledochojejunostomy and was discharged home 4 days postoperatively on simple analgesia.