[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.

Fluorogenic Probe Using a Mislow-Evans Rearrangement for Real-Time Imaging of Hydrogen Peroxide.

Hydrogen peroxide (H2 O2 ) mediates the biology of wound healing, apoptosis, inflammation, etc. H2 O2 has been fluorometrically imaged with protein- or small-molecule-based probes. However, only protein-based probes have afforded temporal insights within seconds. Small-molecule-based electrophilic probes for H2 O2 require many minutes for a sufficient response in biological systems. Here, we report a fluorogenic probe that selectively undergoes a [2,3]-sigmatropic rearrangement (seleno-Mislow-Evans rearrangement) with H2 O2 , followed by acetal hydrolysis, to produce a green fluorescent molecule in seconds. Unlike other electrophilic probes, the current probe acts as a nucleophile. The fast kinetics enabled real-time imaging of H2 O2 produced in endothelial cells in 8 seconds (much earlier than previously shown) and H2 O2 in a zebrafish wound healing model. This work may provide a platform for endogenous H2 O2 detection in real time with chemical probes.

Population-based study of ischemic stroke risk after trauma in children and young adults.

OBJECTIVE: To quantify the incidence, timing, and risk of ischemic stroke after trauma in a population-based young cohort. METHODS: We electronically identified trauma patients (<50 years old) from a population enrolled in a Northern Californian integrated health care delivery system (1997-2011). Within this cohort, we identified cases of arterial ischemic stroke within 4 weeks of trauma and 3 controls per case. A physician panel reviewed medical records, confirmed cases, and adjudicated whether the stroke was related to trauma. We calculated the 4-week stroke incidence and estimated stroke odds ratios (OR) by injury location using logistic regression. RESULTS: From 1,308,009 trauma encounters, we confirmed 52 trauma-related ischemic strokes. The 4-week stroke incidence was 4.0 per 100,000 encounters (95% confidence interval [CI] 3.0-5.2). Trauma was multisystem in 26 (50%). In 19 (37%), the stroke occurred on the day of trauma, and all occurred within 15 days. In 7/28 cases with cerebrovascular angiography at the time of trauma, no abnormalities were detected. In unadjusted analyses, head, neck, chest, back, and abdominal injuries increased stroke risk. Only head (OR 4.1, CI 1.1-14.9) and neck (OR 5.6, CI 1.03-30.9) injuries remained associated with stroke after adjusting for demographics and trauma severity markers (multisystem trauma, motor vehicle collision, arrival by ambulance, intubation). CONCLUSIONS: Stroke risk is elevated for 2 weeks after trauma. Onset is frequently delayed, providing an opportunity for stroke prevention during this period. However, in one-quarter of stroke cases with cerebrovascular angiography at the time of trauma, no vascular abnormality was detected.

The salutary effect of an integrated system on the rate of repeat CT scanning in transferred trauma patients: Improved costs and efficiencies.

BACKGROUND: Duplication of Computed Tomography (CT) scanning in trauma patients has been a source of quality waste in healthcare and potential harm for patients. Integrated and regional health systems have been shown to promote opportunities for efficiencies, cost savings and increased safety. METHODS: This study evaluated traumatically injured patients who required transfer to a Level One Trauma Center (TC) from either within a vertically integrated healthcare system (IN) or from an out-of-network (OON) hospital. RESULTS: We found the rate of repeat CT scanning, radiology costs and total costs for day one of hospitalization to be significantly lower for trauma patients transferred from an IN hospital as compared to those patients transferred from OON hospitals. CONCLUSION: The inefficiencies and waste often associated with transferred patients can be mitigated and strategies to do so are necessary to reduce costs in the current healthcare environment.

Association of Radiologic Indicators of Frailty With 1-Year Mortality in Older Trauma Patients: Opportunistic Screening for Sarcopenia and Osteopenia.

Importance: Assessment of physical frailty in older trauma patients admitted to the intensive care unit is often not feasible using traditional frailty assessment instruments. The use of opportunistic computed tomography (CT) scans to assess sarcopenia and osteopenia as indicators of underlying frailty may provide complementary prognostic information on long-term outcomes. Objective: To determine whether sarcopenia and/or osteopenia are associated with 1-year mortality in an older trauma patient population. Design, Setting, and Participants: A retrospective cohort constructed from a state trauma registry was linked to the statewide death registry and Comprehensive Hospital Abstract Reporting System for readmission data analyses. Admission abdominopelvic CT scans from patients 65 years and older admitted to the intensive care unit of a single level I trauma center between January 2011 and May 2014 were analyzed to identify patients with sarcopenia and/or osteopenia. Patients with a head Injury Severity Score of 3 or greater, an out-of-state address, or inadequate CT imaging or who died within 24 hours of admission were excluded. Exposures: Sarcopenia and/or osteopenia, assessed via total cross-sectional muscle area and bone density at the L3 vertebral level, compared with a group with no sarcopenia or osteopenia. Main Outcomes and Measures: One-year all-cause mortality. Secondary outcomes included 30-day all-cause mortality, 30-day readmission, hospital length of stay, hospital cost, and discharge disposition. Results: Of the 450 patients included in the study, 269 (59.8%) were male and 394 (87.6%) were white. The cohort was split into 4 groups: 74 were retrospectively diagnosed with both sarcopenia and osteopenia, 167 with sarcopenia only, 48 with osteopenia only, and 161 with no radiologic indicators. Among the 408 who survived to discharge, sarcopenia and osteopenia were associated with higher risks of 1-year mortality alone and in combination. After adjustment, the hazard ratio was 9.4 (95% CI, 1.2-75.4; P = .03) for sarcopenia and osteopenia, 10.3 (95% CI, 1.3-78.8; P = .03) for sarcopenia, and 11.9 (95% CI, 1.3-107.4; P = .03) for osteopenia. Conclusions and Relevance: More than half of older trauma patients in this study had sarcopenia, osteopenia, or both. Each factor was independently associated with increased 1-year mortality. Given the prevalent use of abdominopelvic CT in trauma centers, opportunistic screening for radiologic indicators of frailty provides an additional tool for early identification of older trauma patients at high risk for poor outcomes, with the potential for targeted interventions.

Orthobiologic Interventions Using Ultrasound Guidance.

The application of regenerative therapies for the treatment of musculoskeletal conditions has emerged over the last decade with recent acceleration. These include prolotherapy, platelet-rich plasma, and mesenchymal stem cell therapy. These strategies augment the body's innate physiology to heal pathologic processes. This article presents an overview of platelet-rich plasma and mesenchymal stem cell therapy for the treatment of musculoskeletal injuries. A brief literature review is included, as are techniques for the use of ultrasound guidance to assist with these procedures.

Protecting trauma patients from duplicated computed tomography scans: the relevance of integrated care systems.

BACKGROUND: Duplicated computed tomography (CT) scans in transferred trauma patients have been described in university-based trauma systems. This study compares CT utilization between a university-based nonintegrated system (NIS) and a vertically integrated regional healthcare system (IS). METHODS: Trauma patients transferred to 2 Level I trauma centers were prospectively identified at the time of transfer. Imaging obtained before and subsequent to transfer and the reason for CT imaging at the Level I center were captured by real-time reporting. RESULTS: Four hundred eighty-one patients were reviewed (207 at NIS and 274 at IS). Ninety-nine patients (48%) at NIS and 45 (16%) at IS underwent duplicate scanning of at least one body region. Inadequate scan quality and incomplete imaging were the most common reason category reported at NIS (54%) and IS (78%). CONCLUSIONS: Fewer patients received duplicated scans within the vertically IS as compared with a traditional university-based referral system. Our findings suggest that the adoption of features of a vertically IS, particularly improved transferability of radiographic studies, may improve patient care in other system types.

Lymphangiography: forgotten tool or rising star in the diagnosis and therapy of postoperative lymphatic vessel leakage.

Since the advent of computed tomography, numbers and expertise in Lymphangiography (LAG) have markedly dropped. The intention of our study was to demonstrate the persisting diagnostic and therapeutic impact of LAG on the postoperative patient with known or suspected lymphatic vessel leakage. Between May 1, 1999, and April 30, 2006, we investigated pedal lipiodol-LAGs (18 monopedal, 2 bipedal) on 22 patients (16 male, 6 female) with known or suspected postoperative chylothorax, chylaskos, lymphocele, or lymphatic fistula. Ages varied from 26 to 81 years. The spectrum of operative procedures was broad: 6 thoracic, 5 abdominal, and 11 peripheral operations were performed. In 20 patients who underwent mono- or bipedal LAG for lymphatic vessel injury, we were able to demonstrate the specific site of leakage in 15 cases (75%) and found signs of extravasation in 5 patients (25%). Furthermore, in 11 patients (55%) we were able to avoid surgery because of closure of the leak after LAG. As the conservative therapeutic approach usually takes 2-3 weeks to reveal its therapeutic effects, 73.3% (11/15) of the patients who were not reoperated before this hallmark was passed did not need any further operation. Our study clearly demonstrates that even in the decades of modern cross-sectional imaging, classic LAG is a powerful and highly reliable tool to visualize and even assist occlusion of the postoperatively damaged lymphatic vessel and may thereby avoid the need for reoperation.

Altered central micro-opioid receptor binding after psychological trauma.

BACKGROUND: Functional neuroimaging studies have detected abnormal limbic and paralimbic activation to emotional probes in posttraumatic stress disorder (PTSD), but few studies have examined neurochemical mechanisms that underlie functional alterations in regional cerebral blood flow. The mu-opioid neurotransmitter system, implicated in responses to stress and suppression of pain, is distributed in and is thought to regulate the function of brain regions that are implicated in affective processing. METHODS: Here we examined the micro-opioid system with positron emission tomography and the micro-opioid receptor-selective radiotracer [11C] carfentanil in 16 male patients with PTSD and two non-PTSD male control groups, with (n = 14) and without combat exposure (n = 15). Differences in micro-opioid receptor binding potential (BP2) were detected within discrete limbic and paralimbic regions. RESULTS: Relative to healthy controls, both trauma-exposed groups had lower micro-opioid receptor BP2 in extended amygdala, nucleus accumbens, and dorsal frontal and insular cortex but had higher BP2 in the orbitofrontal cortex. PTSD patients exhibited reduced BP2 in anterior cingulate cortex compared with both control groups. Micro-opioid receptor BP2 in combat-exposed subjects without PTSD was lower in the amygdala but higher in the orbitofrontal cortex compared with both PTSD patients and healthy controls. CONCLUSIONS: These findings differentiate the general response of the micro-opioid system to trauma from more specific changes associated with PTSD.

Treatment of high-pressure water gun injection injury of the foot with adjunctive hyperbaric oxygen: a case report.

High-pressure injection injuries are reported often in the hand and occasionally in the foot. Injection with water and air causes minimal tissue damage but nevertheless requires irrigation, minimal debridement, administration of antibiotics, and concern for development of compartment syndrome. The outcome for patients injected with water and air should be excellent. Adjunctive hyperbaric oxygen causes immediate resolution of subcutaneous emphysema, edema, and pain for more rapid rehabilitation.

Hernia of Morgagni in a trauma patient.

A case is presented of a patient with a congenital hernia of Morgagni that was diagnosed after a motorcycle accident. These may be confused with a traumatic diaphragmatic hernia. The lateral chest film is helpful in the differential diagnosis. The barium enema is usually diagnostic.

Radionuclide evaluation of renal function.

The renal scintillation camera study and the excretory urogram should be considered to be complementary studies. The renal scintillation camera study provides an accurate evaluation of changes in total, differential, and segmental renal function but affords only a gross assessment of anatomic changes. The excretory urogram provides superior information about renal anatomic changes but only inferior information about functional changes of the kidney. The advantages of a renal scintillation camera study with regard to the patient are that it is done in a state of normal hydration, it requires no bowel preparation, it is not associated with allergic reactions, it provides a low radiation exposure, and it is a noninvasive procedure for differential renal function which requires no ureteral catheters.

Lumbosacral nerve root avulsion: report of a case and review of the literature.

The 14th myelographically demonstrated case of lumbosacral nerve root avulsion is presented with a summary of the previously reported cases. In most cases lumbosacral nerve root avulsion is associated with pelvic fractures and sacroiliac dislocation, which cause a stretching force to be applied to the nerves of the lumbar and sacral plexuses, and in turn to the nerve roots intradurally. This force causes nerve root avulsion in the intradural course of the nerve root. The myelographic defect is a pseudomeningocele or diverticulum-like outpouching created by the tearing of the arachnoid covering of the nerve roots. Myelography clearly indicates nerve root avulsion and surgical exploration is not indicated.