[Modern integrated approach to surgical treatment of patients with defects and deformations following high-voltage electrical injury]. / Sovremennyi kompleksnyi podkhod v khirurgicheskom lechenii patsientov s defektami i deformatsiyami v rezul'tate vysokovol'tnoi elektrotravmy.

OBJECTIVE: To develop the algorithm for correction of defects following high-voltage electrical trauma with revascularized autografts, to assess the incidence and risk factors of postoperative complications. MATERIAL AND METHODS: Surgical interventions were performed in 16 men. Autografts were selected considering localization of defect and preoperative ultrasound data on perfusion of donor and recipient areas. We applied a sample with temporary compression of the vessels and ultrasound scanning of arteries and veins (a small-sized Doppler sound indicator of blood flow velocity - MINIDOP, BIOSS). RESULTS: Nine patients underwent microsurgical transplantation of revascularized flaps. Six patients with electrical trauma of the upper extremities underwent transplantation of free skin autografts and transposition of flexor and extensor muscles of the fingers in various combinations. In 1 patient, simultaneous microsurgical graft transplantation and plasty with local tissues were carried out. Microsurgical transplantation of thoracodorsal flap was performed in 2 patients with maxillofacial defect (with preliminary deepidermization of the flap in one case). In 3 patients with traumatic amputation of the penis, 2 patients underwent phalloplasty with a thoracodorsal flap and prefabrication of a radial forearm graft at the first stage. At the next stage, urethroplasty with a prefabricated radial forearm graft was performed. In 1 patient, closure of the penis defect was carried out using scrotal flaps. CONCLUSION: An integrated surgical approach, the use of free revascularized autografts and adequate postoperative management ensure high-quality aesthetic and functional restoration, improvement of the quality of life and social adaptation of patients with defects and deformations following high-voltage electrical injury.

A Multistep Iter for Functional Reconstruction in Mangled Upper Limb: A Retrospective Analysis of Integrated Surgical and Medical Approach.

Background and objectives: Complex limb wounds with multiple tissue involvement are commonly due to high energy trauma. Tissue damage is a dynamic entity and the exact extent of the injury is rarely instantly perceptible. Hence, reconstruction frequently involves a multi-stage procedure concluding with tissue replacement. Materials and Methods: A retrospective study was conducted between 2006 and 2018 and included 179 patients with contaminated multi-tissue injuries treated with hyperbaric oxygen therapy, negative pressure therapy, physiotherapy and drug treatment associated with multiple surgical time in a multistep approach, focusing on pain levels and wound closure rates. Results: Despite the long-term response to traumatic events, a combined approach of delayed surgical reconstructive time in mangled upper limb yielded satisfactory functional outcomes. Conclusions: The complex upper limb wound with deep tissue exposure may be treated with a multi-stage procedure alternatively to immediate reconstruction. The integrated technique enables the preservation of existing healthy tissue and concurrent radical debridement, reducing the risk of infection, as well as avoiding the loss of free flaps and dehiscence due to incorrect wound estimation.

Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana.

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure. Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality. Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality. Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Can an Integrative Care Approach Improve Physical Function Trajectories after Orthopaedic Trauma? A Randomized Controlled Trial.

BACKGROUND: Orthopaedic trauma patients frequently experience mobility impairment, fear-related issues, self-care difficulties, and work-related disability []. Recovery from trauma-related injuries is dependent upon injury severity as well as psychosocial factors []. However, traditional treatments do not integrate psychosocial and early mobilization to promote improved function, and they fail to provide a satisfying patient experience. QUESTIONS/PURPOSES: We sought to determine (1) whether an early psychosocial intervention (integrative care with movement) among patients with orthopaedic trauma improved objective physical function outcomes during recovery compared with usual care, and (2) whether an integrative care approach with orthopaedic trauma patients improved patient-reported physical function outcomes during recovery compared with usual care. METHODS: Between November 2015 and February 2017, 1133 patients were admitted to one hospital as orthopaedic trauma alerts to the care of the three orthopaedic trauma surgeons involved in the study. Patients with severe or multiple orthopaedic trauma requiring one or more surgical procedures were identified by our orthopaedic trauma surgeons and approached by study staff for enrollment in the study. Patients were between 18 years and 85 years of age. We excluded individuals outside of the age range; those with diagnosis of a traumatic brain injury []; those who were unable to communicate effectively (for example, at a level where self-report measures could not be answered completely); patients currently using psychotropic medications; or those who had psychotic, suicidal, or homicidal ideations at time of study enrollment. A total of 112 orthopaedic trauma patients were randomized to treatment groups (integrative and usual care), with 13 withdrawn (n = 99; 58% men; mean age 44 years ± 17 years). Data was collected at the following time points: baseline (acute hospitalization), 6 weeks, 3 months, 6 months, and at 1 year. By 1-year follow-up, we had a 75% loss to follow-up. Because our data showed no difference in the trajectories of these outcomes during the first few months of recovery, it is highly unlikely that any differences would appear months after 6 months. Therefore, analyses are presented for the 6-month follow-up time window. Integrative care consisted of usual trauma care plus additional resources, connections to services, as well as psychosocial and movement strategies to help patients recover. Physical function was measured objectively (handgrip strength, active joint ROM, and Lower Extremity Gain Scale) and subjectively (Patient-Reported Outcomes Measurement Information System-Physical Function [PROMIS®-PF] and Tampa Scale of Kinesiophobia). Higher values for hand grip, Lower Extremity Gain Scale (score range 0-27), and PROMIS®-PF (population norm = 50) are indicative of higher functional ability. Lower Tampa Scale of Kinesiophobia (score range 11-44) scores indicate less fear of movement. Trajectories of these measures were determined across time points. RESULTS: We found no differences at 6 months follow-up between usual care and integrative care in terms of handgrip strength (right handgrip strength ß = -0.0792 [95% confidence interval -0.292 to 0.133]; p = 0.46; left handgrip strength ß = -0.133 [95% CI -0.384 to 0.119]; p = 0.30), or Lower Extremity Gain Scale score (ß = -0.0303 [95% CI -0.191 to 0.131]; p = 0.71). The only differences between usual care and integrative care in active ROM achieved by final follow-up within the involved extremity was noted in elbow flexion, with usual care group 20° ± 10° less than integrative care (t [27] = -2.06; p = 0.05). Patients treated with usual care and integrative care showed the same Tampa Scale of Kinesiophobia score trajectories (ß = 0.0155 [95% CI -0.123 to 0.154]; p = 0.83). CONCLUSION: Our early psychosocial intervention did not change the trajectory of physical function recovery compared with usual care. Although this specific intervention did not alter recovery trajectories, these interventions should not be abandoned because the greatest gains in function occur early in recovery after trauma, which is the key time in transition to home. More work is needed to identify ways to capitalize on improvements earlier within the recovery process to facilitate functional gains and combat psychosocial barriers to recovery. LEVEL OF EVIDENCE: Level II, therapeutic study.

So you need a surgeon? Need for surgeon presence as an alternative metric to predict outcomes and assess triage in the pediatric trauma population.

BACKGROUND: Injury Severity Score (ISS) is the primary metric by which triage has been evaluated in trauma activations. We compared ISS to a previously described set of criteria defined as Need for Surgical Presence (NSP). We hypothesize that NSP may serve as a way to augment ISS in predicting mortality and assessing triage in pediatric trauma patients. METHODS: A total of 19,139 pediatric trauma patients in the 2016 National Trauma Quality Improvement Program Database (excluding transfers) had complete data for mortality, mode of transport, age, injury type, ISS, and NSP factors. NSP was defined as having one or more of the following: intubation, transfusion, operation for hemorrhage control/craniotomy, vasopressors, interventional radiology, spinal cord Injury, tube thoracostomy, emergency thoracotomy, intracranial pressure monitor, or pericardiocentesis. RESULTS: Overall mortality was 1.3% and 96% of all patients suffered blunt injury. A total of 2787 (14.6%) patients had an NSP indicator compared to 2036 (10.8%) with an ISS ≥16. NSP was noninferior to ISS in predicting mortality with the AUC of 0.91 (95% CI 0.89-0.92) and 0.90 (95% CI 0.88-0.92) respectively. CONCLUSION: NSP predicts mortality in pediatric trauma patients as well as ISS, and may compliment ISS. NSP status can be assigned shortly after patient arrival. Proper assessment of over and undertriage allows for optimal resource utilization by the medical facility and ultimately benefits the hospital, physician and patient. STUDY TYPE: Retrospective national dataset study. LEVEL OF EVIDENCE: Level II.

Diagnosis and management of surgical disease at Ethiopian health centres: cross-sectional survey of resources and barriers to care.

OBJECTIVES: The aim of this study was to characterise the resources and challenges for surgical care and referrals at health centres (HCs) in South Wollo Zone, Ethiopia. SETTING: Eight primary HCs in South Wollo Zone, Ethiopia. PARTICIPANTS: Eight health officers and nurses staffing eight HCs completed a survey. DESIGN: The study was a survey-based, cross-sectional assessment of HCs in South Wollo Zone, Ethiopia and data were collected over a 30-day period from November 2014 to January 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Survey assessed human and material resources, diagnostic capabilities and challenges and patient-reported barriers to care. RESULTS: Eight HCs had an average of 18 providers each, the majority of which were nurses (62.2%) and health officers (20.7%). HCs had intermittent availability of clean water, nasogastric tubes, rectal tubes and suturing materials, none of them had any form of imaging. A total of 168 surgical patients were seen at the 8 HCs; 58% were referred for surgery. Most common diagnoses were trauma/burns (42%) and need for caesarean section (9%). Of those who did not receive surgery, 32 patients reported specific barriers to obtaining care (91.4%). The most common specific barriers were patients not being decision makers to have surgery, lack of family/social support and inability to afford hospital fees. CONCLUSIONS: HCs in South Wollo Zone, Ethiopia are well-staffed with nurses and health officers, however they face a number of diagnostic and treatment challenges due to lack of material resources. Many patients requiring surgery receive initial diagnosis and care at HCs; sociocultural and financial factors commonly prohibit these patients from receiving surgery. Further study is needed to determine how such delays may impact patient outcomes. Improving material resources at HCs and exploring community and family perceptions of surgery may enable more streamlined access to surgical care and prevent delays.

Tratamento para queloides: revisão de literatura / Treatment of keloids: a literature review

Introdução: Queloides surgem de resposta excessiva à lesão da derme, resultando em proliferação de fibroblastos, produção exagerada de colágeno e comprometimento da pele sadia adjacente. O diagnóstico é clínico e muitos métodos conservadores e cirúrgicos já foram utilizados para tratamento. Porém, dados da eficácia desses tratamentos são limitados e não há consenso na literatura quanto a melhor técnica a ser empregada, permanecendo uma lacuna que necessita ser preenchida, a fim de que seus usos sejam indicados com maior confiabilidade, em um modelo de medicina baseada em evidências. Métodos: Revisão não sistemática da literatura sobre "queloides" nas bases de dados PubMed, Scielo, MEDLINE, UptoDate e livros-texto das áreas de Dermatologia e Cirurgia Dermatológica. Revisão de Literatura: Foram enumeradas e abordadas as principais informações sobre técnicas cirúrgicas e adjuvantes empregadas para essas lesões, que são: excisão, injeções intralesionais, crioterapia, laserterapia, revestimento com gel de silicone, radioterapia e pressoterapia. Torna-se relevante o levantamento dessas informações, tendo em vista que, além de poder causar dor, prurido e restrição de movimento, o principal motivo da procura de assistência médica para queloide é devido ao aspecto cosmético/estético, e as taxas de reincidência e falha terapêutica ainda são altas, sendo necessário conscientizar o paciente sobre o procedimento e seus efeitos. Conclusão: São muitos os tratamentos disponíveis para o queloide, sejam cirúrgicos ou não, todavia não há consenso sobre uma abordagem universalmente aceita. São necessários mais estudos, com a finalidade de definir a melhor conduta e atingir melhores resultados, visto a qualidade mediana das evidências apresentadas nos estudos.

Introduction: Keloids are characterized by an abnormal response to dermal trauma, resulting in fibroblast proliferation, excessive collagen production, and impairment of adjacent healthy tissue. The diagnosis is clinical, and many conservative and surgical methods can be used as treatments. However, data on the efficacy of these treatments are limited, and there is no consensus regarding the best treatment option. This gap needs to be filled by developing comprehensive evidence-based therapies. Methods: A non-systematic literature review of keloid scars was carried out using PubMed, Scielo, MEDLINE, UptoDate, and dermatology and dermatological surgery textbooks. Literature review: The search retrieved relevant information on surgical and adjuvant therapies used for keloids, including excision, intralesional injections, cryotherapy, laser therapy, silicone gel sheeting, radiation therapy, and pressure therapy. These data are crucial because, in addition to complaints of pain, itching, and restriction of movement, the main reason for seeking treatment for keloids is for cosmetic and aesthetic improvement, and the rates of recurrence and treatment failure are high, emphasizing the importance of creating awareness regarding the available procedures and their effectiveness. Conclusion: Many surgical and adjuvant therapies for keloids are available. Nonetheless, there is no consensus on a universally accepted treatment. Therefore, additional high-quality studies are needed to identify the most effective therapeutic approaches to achieve better results.

Appropriate Prophylactic Antibiotic Use in Clean Wound Surgery Under Local Anesthesia.

BACKGROUND: Although guidelines to prevent surgical site infections (SSIs) were published more than a decade ago, prophylactic antibiotics are still used subjectively in clinical practice. In this study, we evaluated the safety of single-dose preoperative intravenous antibiotics without postoperative antibiotics in the field of clean wound surgery performed under local anesthesia. We also surveyed the present clinical conditions for prophylactic antibiotic use in the plastic surgery departments of training hospitals in Korea. METHODS: A total of 360 consecutive patients who underwent clean wound surgery under local anesthesia in an outpatient clinic from March 2018 to October 2018 were reviewed. In the study group, a single surgeon administered first-generation cephalosporins intravenously within 1 hour of skin incision and did not prescribe additional antibiotics. In the control group, 2 other surgeons prescribed oral first-generation cephalosporins postoperatively for 2 to 3 days without preoperative antibiotics. A telephone survey about perioperative antibiotic regimens was conducted at the departments of plastic surgery in training hospitals. RESULTS: There were 128 patients in the study group and 232 patients in the control group. There were no significant differences between the 2 groups regarding SSIs and other surgical complications. A total of 41 training hospitals answered the survey and every hospital had protocols of prescribing postoperative oral antibiotics routinely at the time of discharge with a mean duration of 3.9 days. Only 11 hospitals (26.8%) prescribed parenteral antibiotics before surgery as well as postoperative oral antibiotics. CONCLUSION: Intravenous injection of single-dose first-generation cephalosporins 1 hour before surgery without postoperative antibiotics did not increase the incidence of SSIs compared with the usual practice of giving only postoperative antibiotics prescription for 2 to 3 days in cases of clean wound surgery performed under local anesthesia. Proper antibiotic prophylaxis should be performed by surgeons in training hospitals without hesitation.

Medical-grade Honey as an Alternative to Surgery: A Case Series.

INTRODUCTION: Modern wound management continues to present new challenges. Many patients elect to forego operative debridement secondary to high risk, fear, cost concerns, and personal ideologies on healing. Although operative debridement has long been a tenet of proper wound care, alternative innovative approaches to wound management must be considered. OBJECTIVE: This case series describes the successful outcomes of 12 patients with dissimilar wounds who were managed with medical-grade honey (active Leptospermum honey [ALH]) as an alternative to surgery. MATERIALS AND METHODS: A case series was identified from clinical experience, chart review, and photographic documentation of all patients evaluated by the acute wound care service. To be included, patients had to decline the recommendation of operative debridement or skin grafting, utilize ALH as an alternative to surgery, and have regular follow-up visits. RESULTS: Twelve patients with complex wounds were identified and included in this case series. Five patients were considered high risk for surgery due to comorbidities. Seven patients were at low risk for surgery but desired to avoid operative procedures. The use of ALH facilitated autolytic debridement and healing without surgery or hospital readmission. CONCLUSIONS: The properties of ALH include autolytic debridement, bacterial growth inhibition, anti-inflammatory mediation, and cytokine release, making it a viable option for wound management for patients with contraindications to surgery. However, surgical debridement should remain a tenet of wound care in appropriate patients.

Machaon: the first trauma surgeon in Western history?

Homer's epics, the Iliad and the Odyssey, written between 800-700 BC, offer valuable information about what medical practice meant at that time. Descriptions of injuries and care given can be found among the 26,000 verses of these poems. During the Trojan War many warriors possessed empirical knowledge of wound care. However, Machaon and his brother Podalirius were the chief medical officers of the Greek army as it besieged Troy. Machaon was acting mainly as a trauma surgeon, while Podalirius was a physician. The original texts of the Iliad and Odyssey, as well as relevant literature and references, were methodically studied for extraction of adequate information about the life and work of Machaon. He provided medical care to injured soldiers and officers, and performed small operations. He treated the wound of King Menelaus of Sparta, the co-chief of the Greek army and many others. He was also a talented warrior, participating in many battles around the walls of Troy. When he was injured, the Greeks rallied around him so that he would not be taken or killed by the enemy. Since he had the knowledge and the ability to save lives, his life was considered equal to that of many men. Future generations would worship him as god protector of surgery. Machaon's techniques and skills can be considered to constitute the origins of modern surgery and trauma management at the dawn of western civilisation.

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

Ascitis quilosa postraumática tratada con nutrición parenteral total y octreótido / Post-trauma Chylous Ascites Treated with Total Parenteral Nutrition and Octreotide

La ascitis quilosa es la acumulación de quilo en la cavidad peritoneal por ruptura u obstrucción de los conductos linfáticos abdominales. Aunque es infrecuente, se describe mayor probabilidad de aparición después de traumas abdominales. Se presenta un paciente masculino de 46 años que sufre herida por arma blanca tóracoabdominal por lo que requirió tratamiento quirúrgico de urgencia. Luego de varias cirugías se constató la presencia de líquido abdominal blanquecino, con triglicéridos elevados. Se confirmó la ascitis quilosa, que se reabsorbió en 45 días con nutrición parenteral y octreótido(AU)

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity due to rupture or obstruction of the abdominal lymph ducts. Although it is rare, greater probability is described for its onset after abdominal traumas. The case is presented of a 46-year-old male patient who suffers from a thorax-abdomen knife wound and therefore required emergency surgical treatment. After several surgeries, the presence of whitish abdominal liquid was detected, with elevated triglycerides. Chylous ascites was confirmed, which was reabsorbed in 45 days with parenteral nutrition and octreotide(AU)

[Cost and Revenue Relationship in Orthopaedic and Trauma Surgery Patients in Relation to Body Mass Index]. / Kosten-Erlös-Verhältnis orthopädisch-unfallchirurgischer Patienten in Abhängigkeit vom Body-Mass-Index.

BACKGROUND: Growing numbers of patients in orthopaedic and trauma surgery are obese. The risks involved are e.g. surgical complications, higher costs for longer hospital stays or special operating tables. It is a moot point whether revenues in the German DRG system cover the individual costs in relation to patients' body mass index (BMI) and in which area of hospital care potentially higher costs occur. MATERIAL AND METHODS: Data related to BMI, individual costs and revenues were extracted from the hospital information system for 13,833 patients of a large hospital who were operated in 2007 to 2010 on their upper or lower extremities. We analysed differences in cost revenue relations dependent on patients' BMI and surgical site, and differences in the distribution of hospital cost areas in relation to patients' BMI by t and U tests. RESULTS: Individual costs of morbidly obese (BMI ≥ 40) and underweight patients (BMI < 18.5) significantly (p < 0.05) exceeded individual DRG revenues. Significantly higher cost revenue relations were detected for all operations on the lower and upper extremities except for ankle joint surgeries in which arthroscopical procedures predominate. Most of the incremental costs resulted from higher spending for nursing care, medication and special appliances. Costs for doctors and medical ancillary staff did not increase in relation to patients' BMI. CONCLUSION: To avoid BMI related patient discrimination, supplementary fees to cover extra costs for morbidly obese or underweight patients with upper or lower extremities operations should raise DRG revenues. Moreover, hospitals should be organisationally prepared for these patients.

[A Nationwide Survey of Undergraduate Training in Orthopaedics and Trauma Surgery]. / Statuserhebung der studentischen Lehre in Orthopädie und Unfallchirurgie.

BACKGROUND: Musculoskeletal conditions are the most frequent cause of long-term pain and disability. Scientifically funded, structured training would be highly desirable for all medical students and of great economic relevance for the health care system. The present article portrays the status quo of undergraduate training in orthopaedics and trauma surgery, with a comparison to the status quo of 2008. MATERIAL AND METHODS: A 51-item questionnaire was sent to all heads of the departments of orthopaedics or trauma surgery at the 37 medical faculties in Germany. RESULTS: A return rate of 81.1% from orthopaedics and 73% from trauma surgery was attained. The organisation of undergraduate training in orthopaedics and trauma surgery is completely separated in 34.4% of hospitals. The corresponding figure in 2008 was 64%. The amount of training in lectures and practical training rarely changed during this period. CONCLUSION: Even closer collaboration between lecturers in orthopaedics and trauma surgery would be desirable. This would reflect the importance of the disciplines, as well as politico-economic relevance of musculoskeletal injuries and diseases, and would encourage the sharing of resources.

Patient Perceptions of the Use of Medical Marijuana in the Treatment of Pain After Musculoskeletal Trauma: A Survey of Patients at 2 Trauma Centers in Massachusetts.

OBJECTIVE: To evaluate musculoskeletal trauma patients' beliefs regarding the usefulness of marijuana as a valid medical treatment for postinjury and postoperative pain and anxiety. DESIGN: Prospective survey. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: Five hundred patients in an orthopedic outpatient clinic. INTERVENTION: Survey. MAIN OUTCOME MEASUREMENTS: (1) Do patients believe that marijuana can be used as medicine? (2) Do patients believe that marijuana can help treat postinjury pain? (3) Are patients comfortable speaking with their health care providers about medical marijuana? RESULTS: The majority of patients felt that marijuana could be used to treat pain (78%, 390) and anxiety (62%, 309). Most patients (60%, 302) had used marijuana at least once previously, whereas only 14% reported using marijuana after their injury. Of those who used marijuana during their recovery, 90% (63/70) believed that it reduced symptoms of pain, and 81% (57/70) believed that it reduced the amount of opioid pain medication they used. CONCLUSIONS: The majority of patients in this study believed that medical marijuana is a valid treatment and that it does have a role in reducing postinjury and postoperative pain. Those patients who used marijuana during their recovery felt that it alleviated symptoms of pain and reduced their opioid intake. Our results help inform clinicians regarding the perceptions of patients with trauma regarding the usefulness of marijuana in treating pain and support further study into the utility of medical marijuana in this population.

[Establishment of a trauma surgical department at the Diospi Suyana missionary hospital in Curahuasi, Peru]. / Aufbau einer unfallchirurgischen Abteilung am Missionsspital Diospi Suyana in Curahuasi, Peru.

The confusingly structured and in many areas corrupt health system in Peru even today provides only a fragmentary and insufficient medical treatment especially for the indigenous population (mainly Quechua Indians). Since October 2007 the Diospi Suyana missionary hospital in Curahuasi (State of Apurímac) has provided an affordable medical treatment at a high level mainly for these indigenous people of Peru; however, so far the hospital could only insufficiently meet the traumatological needs of the region. The establishment of a surgical trauma department aims to meet those needs but is also encumbered by special problems and challenges. Some patients, for example only present at the hospital after the fractures have already incorrectly healed, sometimes many weeks or even months after the trauma either due to a long journey through the country to different hospitals where treatment was not possible or they could not pay for the treatment and sometimes because of inadequate prior treatment, for example by traditional healers. Cultural and infrastructural particularities of the country must be included in the process of choosing the right method of treatment.

Traumatic spinal cord injury.

Traumatic spinal cord injury (SCI) has devastating consequences for the physical, social and vocational well-being of patients. The demographic of SCIs is shifting such that an increasing proportion of older individuals are being affected. Pathophysiologically, the initial mechanical trauma (the primary injury) permeabilizes neurons and glia and initiates a secondary injury cascade that leads to progressive cell death and spinal cord damage over the subsequent weeks. Over time, the lesion remodels and is composed of cystic cavitations and a glial scar, both of which potently inhibit regeneration. Several animal models and complementary behavioural tests of SCI have been developed to mimic this pathological process and form the basis for the development of preclinical and translational neuroprotective and neuroregenerative strategies. Diagnosis requires a thorough patient history, standardized neurological physical examination and radiographic imaging of the spinal cord. Following diagnosis, several interventions need to be rapidly applied, including haemodynamic monitoring in the intensive care unit, early surgical decompression, blood pressure augmentation and, potentially, the administration of methylprednisolone. Managing the complications of SCI, such as bowel and bladder dysfunction, the formation of pressure sores and infections, is key to address all facets of the patient's injury experience.

Bacterial flora of combat wounds from eastern Ukraine and time-specified changes of bacterial recovery during treatment in Ukrainian military hospital.

BACKGROUND: Microbiology of modern war wounds is unique for each military conflict. Climatic and geographical features of the theater of war, contemporary warfare as well as wound management affect the microbial flora of wounds. This study was designed to determine time-specific microbial flora of combat wounds of upper and lower extremities obtained during the war in eastern Ukraine. METHODS: The patients enrolled in study had combat wounds of upper or lower extremities which were treated in the Military Medical Clinical Center of Central Region. The wounds were swab-cultured and measured at each surgical debridement. The recovered microorganisms were identified and their antimicrobial resistance profiles were evaluated by disc diffusion method. RESULTS: Forty-nine patients with battle-field wounds were enrolled in the study from July to November 2014; all patients were male with a mean Injury Severity Score and arrival APACHE II scores of 16.2 ± 10.7 and 7.4 ± 4.2 respectively. Among 128 swab cultures, 100 swab cultures were positive. Swab cultures were obtained from 57 wounds of 49 patients. The results of the test showed that 87.7% of all positive swab cultures contained a single-organism while the rest of the swab-culture results showed polymicrobial growth. Among the isolated microorganisms 65% (76 strains) were Gram-negative rods, 22.2% (26 strains) of Gram-positive cocci, followed by Gram-positive rods (12.8%, 15 strains). We found that epidemiology of wound infection changes with the time after injury. The most common bacterial isolates cultured during the first week were Gram-positive microbes with low pathogenicity. The number of Gram-negative rods increased during the wound healing process. The incidence of Gram-positive microorganisms' growth fell after the first week and increased after third week. During wound healing, bacterial microflora of wounds changes with increasing number of Gram-negative rods with predominance of Acinetobacter species. Predominant microorganisms in positive swab-cultures after first week were nonfermentative Gram-negative bacilli (68% of swab-cultures), which in 53% of the swab-cultures belonged to the genus Acinetobacter, and in 15% to the genus Pseudomonas. The incidence of polymicrobial wound cultures increased from first week to second post-injury week. The most frequent microbial mixture were Acinetobacter baumannii with Enterobacteriaceae or other nonfermentative Gram negative rods with Enterococcus spp. We observed bacteria recovery from wounds during proliferation phase. These wounds had no pure inflammation signs and were free of devitalized tissues. CONCLUSIONS: Any wound is at some risk of becoming infected. In the event of infection, a wound fails to heal, treatment costs rise, and general wound management practices become more resource demanding. Determining the microorganisms which colonize battle wounds and cause wound infection is paramount. This information can help to treat battle wound infections or even changes infection control strategies. The fact of shifting in wound microbiology in the favor of bacteria responsible for healthcare-associated infections support to the proposition that these changes are nosocomially related [4, 14]. For Ukrainian military medicine this study is the first time-specified assessment of battle wound colonization from the World War II.

The Effect of Ozonated Olive Oil on Neovascularization in an Experimental Skin Flap Model.

OBJECTIVE: Angiogenesis is an important factor for flap viability. It has been reported that ozonated oil contributed to improved neovascularization in an acute cutaneous wound healing model. This study was undertaken to evaluate the effect of ozonated olive oil on vascular endothelial growth factor (VEGF)-mediated neovascularization of skin flaps in rats. STUDY DESIGN: A skin flap model was established in 21 rats and evaluated within 3 groups. No treatment was given to the rats in group 1. Olive oil and ozonated olive oil were topically applied (twice daily) to the flap surface for 7 days in groups 2 and 3, respectively. Immunohistochemical staining was performed to analyze the expressions of VEGF and CD34. RESULTS: The mean numbers of VEGF- and CD34-positive staining microvascular structures were 8.86 (SD, 1.35) and 10.29 (SD, 1.80) in group 1, 15.00 (SD, 1.41) and 15.57 (SD, 1.72) in group 2, and 25.14 (SD, 2.41) and 25.00 (SD, 2.16) in group 3. The VEGF and CD34 expressions in group 3 were significantly higher than those in group 2 (P < .001). Their expressions in group 2 were significantly higher than those in group 1 (P < .001). CONCLUSIONS: Both ozonated olive oil and olive oil improved neovascularization when they were topically applied on skin flaps. The effect of ozone was more prominent.