Psychological Impacts of Retained Bullets From the Perspective of Survivors.

INTRODUCTION: Despite a high prevalence of retained bullet fragments (RBFs) after firearm related injury (FRI) there is limited data on the full spectrum of their consequences, particularly the psychological impacts on those injured. Further, the experiences of FRI survivors with RBFs are missing from existing literature. The objective of this study was to explore the psychological impacts of RBFs on individuals who have experienced recent FRI. METHODS: Adult (18-65 years) survivors of FRI with radiographically confirmed RBFs were purposively selected from an urban Level 1 trauma center in Atlanta, Georgia, to participate in an in-depth interview. Interviews were conducted between March 2019 and February 2020. Thematic analysis was used to identify a range of psychological effects from RBFs. RESULTS: Interviews from 24 FRI survivors were analyzed: the majority of participants were Black males (N = 22, 92%) with a mean age of 32 years whose FRI occurred ∼8.6 months prior to data collection. The psychological effects of RBFs were grouped into four categories: physical health (eg, pain, limited mobility), emotional well-being (eg, anger, fear), social isolation, and occupational welfare (eg, disability leading to inability to work). A range of coping mechanisms were also identified. CONCLUSION: Survivors of FRI with RBFs experience a range of psychological impacts that are far-reaching and affect daily activities, mobility, pain and emotional wellbeing. Study results indicate a need for enhanced resources to support those with RBFs. Further, changes to clinical protocols are warranted on removal of RBFs and communication about the effects of leaving RBFs in situ.

Quantitative muscle MRI displays clinically relevant myostructural abnormalities in long-term ICU-survivors: a case-control study.

BACKGROUND: Long-term data on ICU-survivors reveal persisting sequalae and a reduced quality-of-life even after years. Major complaints are neuromuscular dysfunction due to Intensive care unit acquired weakness (ICUAW). Quantitative MRI (qMRI) protocols can quantify muscle alterations in contrast to standard qualitative MRI-protocols. METHODS: Using qMRI, the aim of this study was to analyse persisting myostructural abnormalities in former ICU patients compared to controls and relate them to clinical assessments. The study was conducted as a cohort/case-control study. Nine former ICU-patients and matched controls were recruited (7 males; 54.8y ± 16.9; controls: 54.3y ± 11.1). MRI scans were performed on a 3T-MRI including a mDTI, T2 mapping and a mDixonquant sequence. Water T2 times, fat-fraction and mean values of the eigenvalue (λ1), mean diffusivity (MD), radial diffusivity (RD) and fractional anisotropy (FA) were obtained for six thigh and seven calf muscles bilaterally. Clinical assessment included strength testing, electrophysiologic studies and a questionnaire on quality-of-life (QoL). Study groups were compared using a multivariate general linear model. qMRI parameters were correlated to clinical assessments and QoL questionnaire using Pearson´s correlation. RESULTS: qMRI parameters were significantly higher in the patients for fat-fraction (p < 0.001), water T2 time (p < 0.001), FA (p = 0.047), MD (p < 0.001) and RD (p < 0.001). Thighs and calves showed a different pattern with significantly higher water T2 times only in the calves. Correlation analysis showed a significant negative correlation of muscle strength (MRC sum score) with FA and T2-time. The results were related to impairment seen in QoL-questionnaires, clinical testing and electrophysiologic studies. CONCLUSION: qMRI parameters show chronic next to active muscle degeneration in ICU survivors even years after ICU therapy with ongoing clinical relevance. Therefore, qMRI opens new doors to characterize and monitor muscle changes of patients with ICUAW. Further, better understanding on the underlying mechanisms of the persisting complaints could contribute the development of personalized rehabilitation programs.

Characterizing injury patterns and outcomes in hospitalized trauma patients with non-English Language Preferences.

INTRODUCTION: Patients with Non-English Language Preferences (NELP) experience challenges navigating the US healthcare system which can lead to disparate outcomes. This study sought to investigate injury patterns and outcomes in hospitalized trauma patients with NELP. METHODS: A retrospective review was performed at a trauma center from January 2019-December 2020. An institutional database of all emergency department video consultations for interpreter services was cross-referenced with the trauma registry and comparisons were made between NELP and English-preferred (EP) speaking patients. RESULTS: During the study, 257 NELP patients were hospitalized after traumatic injury. Twenty-two percent had work related injuries compared to only 3.0% in the EP cohort (p < 0.001). When propensity score matched, there were no significant differences in ICU and hospital length of stay or mortality between NELP and EP patients. DISCUSSION: Trauma patients are linguistically diverse and understanding their injury patterns and outcomes is crucial for guiding culturally and linguistically appropriate injury prevention.

Presentation, clinical course and complications in trauma patients with concomitant COVID-19 infection.

BACKGROUND: This study investigated the impact of COVID-19 infection on hospitalized trauma patients. METHODS: A retrospective review of hospitalized trauma patients at a level I trauma center was performed from March-December 2020. Data pertaining to patient demographics, presentation and hospital course was compared between COVID positive and negative trauma patients. RESULTS: There were 4,912 patients and 179 (3.64%) were COVID-19 positive. Demographics and clinical presentation did not differ significantly between those with and without concomitant COVID-19. However, COVID positive trauma patients had higher rates of acute kidney injury (p = 0.016), sepsis (p = 0.016), unplanned intubation (p = 0.002) and unplanned return to the ICU (p = 0.01). The COVID positive cohort also had longer hospital stays (p < 0.01) with no significant difference in mortality. CONCLUSIONS: In the setting of an ongoing pandemic, awareness of the complications COVID positive trauma patients are predisposed to is important for providers.

Systematic Review on Pain-Related Outcome Domains After Sternotomy: A First Step Toward the Development of a Core Outcome Set.

OBJECTIVES: Pain after surgery has a major impact on acute and long-term recovery and quality of life, but its management is often insufficient. To enhance the quality of research and to allow for better comparability between studies, it is important to harmonize outcomes for assessing the efficacy and effectiveness of pain management interventions after surgery. As a first step in developing a core outcome set, this study aimed to systematically search for outcome domains assessed in research regarding acute pain management after sternotomy as an example of a typically painful surgical procedure. METHODS: A systematic literature review was performed using MEDLINE, Embase, and CENTRAL. Eligibility criteria consisted of randomized controlled trials and observational trials targeting pain management after sternotomy in adults in the acute postoperative setting (≤2 weeks). After duplicate removal and title and abstract screening by 2 independent reviewers, study characteristics and outcome domains were identified, which were extracted from full texts and summarized qualitatively. RESULTS: Of 1350 studies retrieved by database searching, 156 studies were included for full-text extraction. A total of 80 different outcome domains were identified: pain intensity, analgesic consumption, physiological function, and adverse events were the most frequent ones. Outcome domains were often not explicitly reported, and the combination of domains and assessment tools was heterogeneous. The choice of outcomes is commonly made within clinicians; patients' perspectives are not considered. CONCLUSIONS: The wide variety of commonly applied outcome domains, the nonexplicit wording, and the heterogeneous combination of the domains indicating treatment benefit demonstrate the need for harmonization of outcomes assessing perioperative pain management after surgery.

[Anesthesia management in microsurgical reconstructions]. / Anästhesiologisches Management bei mikrochirurgischen Rekonstruktionen.

Microsurgical procedures for construction of anastomoses present new challenges for anesthetists in the perioperative setting. Despite their increasing importance, so far no perioperative management guidelines for these patients existed. Anesthetists can influence the success of surgery (e. g. successful perfusion of a flap) via an optimal preoperative, intraoperative and postoperative approach. Patients should be carefully evaluated preoperatively for increased risks to avoid poor postoperative outcomes. Perioperatively, the choice of anesthetic procedure as well as the management of fluid infusion, blood glucose, temperature and blood transfusion are of great importance. Adequate analgesia as well as strict control should be performed as soon as possible postoperatively, preferably in a surveillance unit to detect and treat any complications as early as possible.

Influence of transcutaneous spinal stimulation on human LTP-like pain amplification. A randomized, double-blind study in volunteers.

OBJECTIVE: Transcutaneous spinal direct current stimulation (tsDCS) has been proven to affect nociceptive signal processing. We designed a randomized, double-blind, cross-over study to investigate whether tsDCS applied before or after inducing long-term potentiation-(LTP)-like hyperalgesia may decrease nociceptive sensitivity. METHODS: In healthy volunteers, tsDCS (2.5mA, 15min) was applied to the thoracic spine prior (n=14) or immediately following (n=12) electrical high-frequency stimulation (HFS) to the thigh, inducing hyperalgesia. Mechanical and electrical perception were assessed before HFS stimulation and at three time points following HFS stimulation (all within 90min of HFS). Subjects took part in three separate sessions to test effects of anodal, cathodal, or sham tsDCS. RESULTS: Within 60minHFS led to unilateral changes on the conditioned side: mechanical pain thresholds tended to decrease and electrical detection thresholds significantly decreased (p<0.001); pain ratings measured using the numerical rating scale (NRS) increased for electrical stimuli (p<0.01) and two categories of mechanical stimuli ("Light(8-64mN)": p=ns; "Heavy(128-512mN)": p<0.01). Irrespective of stimulation order or polarity, tsDCS could not influence nociceptive sensitivity. CONCLUSION: Hyperalgesia was adequately induced, but tsDCS had no effect on HFS-induced sensitization. SIGNIFICANCE: While tsDCS has been shown to affect pain measures, our results suggest irrespective of time of stimulation or polarity that tsDCS may be less effective in modulating pain in a sensitized state in healthy subjects.

Adding muscle where you need it: non-uniform hypertrophy patterns in elite sprinters.

Sprint runners achieve much higher gait velocities and accelerations than average humans, due in part to large forces generated by their lower limb muscles. Various factors have been explored in the past to understand sprint biomechanics, but the distribution of muscle volumes in the lower limb has not been investigated in elite sprinters. In this study, we used non-Cartesian MRI to determine muscle sizes in vivo in a group of 15 NCAA Division I sprinters. Normalizing muscle sizes by body size, we compared sprinter muscles to non-sprinter muscles, calculated Z-scores to determine non-uniformly large muscles in sprinters, assessed bilateral symmetry, and assessed gender differences in sprinters' muscles. While limb musculature per height-mass was 22% greater in sprinters than in non-sprinters, individual muscles were not all uniformly larger. Hip- and knee-crossing muscles were significantly larger among sprinters (mean difference: 30%, range: 19-54%) but only one ankle-crossing muscle was significantly larger (tibialis posterior, 28%). Population-wide asymmetry was not significant in the sprint population but individual muscle asymmetries exceeded 15%. Gender differences in normalized muscle sizes were not significant. The results of this study suggest that non-uniform hypertrophy patterns, particularly large hip and knee flexors and extensors, are advantageous for fast sprinting.

Transcutaneous spinal DC stimulation reduces pain sensitivity in humans.

Non-invasive approaches to pain management are needed to manage patient pain escalation and to providing sufficient pain relief. Here, we evaluate the potential of transcutaneous spinal direct current stimulation (tsDCS) to modulate pain sensitivity to electrical stimuli and mechanical pinpricks in 24 healthy subjects in a sham-controlled, single-blind study. Pain ratings to mechanical pinpricks and electrical stimuli were recorded prior to and at three time points (0, 30, and 60min) following 15min of anodal tsDCS (2.5mA, "active" electrode centered over the T11 spinous process, return electrode on the left posterior shoulder). Pain ratings to the pinpricks of the highest forces tested (128, 256, 512mN) were reduced at 30min and 60min following anodal tsDCS. These findings demonstrate that pain sensitivity in healthy subjects can be suppressed by anodal tsDCS and suggest that tsDCS may provide a non-invasive tool to manage mechanically-induced pain.

[Possibilities for use of Scheimpflug technology in cataract surgery]. / Einsatzmöglichkeiten der Scheimpflug-Technologie in der Kataraktchirurgie.

BACKGROUND: Since its first use in geography 100 years ago Scheimpflug photography has undergone much refinement making it a standard technique in anterior segment diagnostics and even surgical therapy. This review presents the perioperative applications of Scheimpflug photography in cataract and refractive lens surgery. OBJECTIVES: Possible perioperative applications of Scheimpflug photography in cataract surgery and refractive lens surgery. METHODS: Selective review of the literature and personal experiences. RESULTS: In recent years there have been numerous new applications for Scheimpflug photography, with its main use in preoperative diagnostics and surgical planning. There are also useful applications for intraoperative visualization and postoperative counseling. CONCLUSION: Multifunctional devices which enable a variety of further examinations besides Scheimpflug technology alone make the use of this technology possible and reasonable even in hospitals and practices without a focus on refractive surgery.

[Reliability and safety of intravitreal Ozurdex injections. The ZERO study]. / Zuverlässigkeit und Sicherheit von intravitrealen Ozurdex-Injektionen. Die ZERO-Studie.

BACKGROUND: Since July 2010 Ozurdex® is approved in Germany for treatment of macular edema from retinal vein occlusion (RVO). The objective of this observational study was a systemic summary and analysis of clinical experience regarding complications and side effects of intravitreal administration of dexamethasone. PATIENTS AND METHODS: In a retrospective, multicenter study conducted at 10 centers, 342 eyes with RVO were treated with intravitreal dexamethasone (Ozurdex®, Allergan). After treatment the patients were followed-up over a period of 8 months and intraoperative, perioperative and postoperative complications, such as elevated intraocular pressure and dislocation of implants were systematically recorded. RESULTS: No infections, endophthalmitis, perioperative hypotension, intraoperative lens injuries or retinal detachment occurred. Elevated intraocular pressure was the most common complication accounting for nearly 20 %. In 9 % of patients the intraocular pressure increased by more than 10 mmHg compared to baseline and in 6 patients to > 35 mmHg. In cases of known glaucoma intraocular pressure elevation was not significantly more frequent compared to non-glaucoma patients. In four cases a progression of lens opacity led to phacoemulsification and two implant dislocations in the anterior chamber required surgical repositioning in the vitreous cavity. In two cases a postinterventional macular hole was observed. CONCLUSIONS: In the clinical routine Ozurdex treatment has proven to be a therapy method with minimal side effects. In Ozurdex administration intraocular pressure elevation was observed as the most common side effect; however, this generally did not require surgical intervention. Caution is advised in patients with an anterior chamber lens and iridectomy. Macular holes as a rare complication might result from vitreous traction during the administration process. In summary, even in the clinical routine application of Ozurdex the complication rate was not higher than in registration studies.

[Pharmacokinetics of intravitreally administered VEGF inhibitors]. / Pharmakokinetik intravitreal applizierter VEGF-Inhibitoren.

BACKGROUND: In addition to topical, periocular and systemic administration, intravitreal injection has been established in recent years as an additional standard procedure for ophthalmological drug delivery. This route of administration is now most frequently used for the therapy of retinal diseases with vascular endothelial growth factor (VEGF) inhibitors. MATERIAL AND METHODS: A selective literature review and an analysis of own research data were carried out. RESULTS: Intravitreal administration achieves high drug concentrations in the target tissue while minimizing systemic drug exposure. Depending on properties such as molecular weight and binding capacity to the neonatal Fc receptor, intravitreally applied VEGF inhibitors can exhibit relevant differences in intraocular and systemic pharmacokinetics. Moreover, the pharmacokinetics can be affected by properties of the individual eye, such as ocular volume, vitreous liquefaction, and prior vitrectomy. CONCLUSIONS: Pharmacokinetics of intravitreally administered drugs determine both the duration of ocular effect and the degree of systemic exposure and are thus of clinical relevance with regard to the reinjection strategy and systemic safety.

[Long-term visual outcome comparison of bilateral implantation of apodised diffractive versus progressive multizonal refractive multifocal intraocular lenses after cataract extraction]. / Langzeitergebnisse nach Implantation apodisiert diffraktiver versus progressiv refraktiver Multi-Zonen-Intraokularlinsen nach Kataraktoperation.

AIM: The aim of this study was to evaluate the functional effect of bilateral implantation of apodised diffractive versus progressive multizonal refractive multifocal intraocular lenses compared to standard monofocal intraocular lenses. PATIENTS AND METHOD: 229 patients underwent cataract extraction; 66 Array SA40N (AMO, Irvine, CA, USA), 76 SA60D3 ReSTOR (Alcon, Fort Worth, TX, USA), and 87 MA60AC (Alcon, Fort Worth, TX, USA) were implanted. In this retrospective trial the main outcome measures were near, intermediate, and distance visual acuity and assessment of subjective function by questionnaire. RESULTS: Mean follow-up was 4.7 ± 1.4 years with monofocal, 6.6 ± 1.7 with Array and 4.3 ± 1.1 with ReSTOR implants. Uncorrected binocular distance visual acuity was equivalent in the three groups. Uncorrected binocular near and intermediate visual acuity and spectacle independence were significantly higher in the two multifocal groups (p < 0.001). Glare and halos were more bothersome with multifocal than monofocals implants (p < 0.05) and adverse visual symptoms at night with Array implants but equivalent between ReSTOR patients and monofocal patients. Between the two multifocal groups spectacle independence was higher and adverse visual symptoms lower in ReSTOR patients than in Array patients (p < 0.05). ReSTOR patients reported a higher overall visual satisfaction than the other groups (p < 0.001) and rated their vision at 8.8 ± 1.8. Monofocal patients reported a slightly higher satisfaction at 7.6 ± 1.7 compared to Array patients at 6.9 ± 2.6 (p = 0.05). CONCLUSION: In this long-term study the highest overall visual satisfaction could be achieved by bilateral implantation of apodised diffractive intraocular lenses.

Ultrasound compared with nerve stimulation guidance for peripheral nerve catheter placement: a meta-analysis of randomized controlled trials.

BACKGROUND: The aim of this meta-analysis was to compare the efficacy and safety of ultrasound (US) vs nerve stimulation (NS) guidance for peripheral nerve catheter placement. METHODS: This meta-analysis was performed according to the PRISMA statement and the recommendations of the Cochrane Collaboration. For dichotomous outcomes relative risks [RRs; 95% confidence intervals (CIs)] were calculated, while for continuous outcomes, mean differences (MDs; 95% CI) were calculated. All statistical analyses were performed using the Revman® statistical software (Version 5.1). RESULTS: Fifteen randomized controlled trials including 977 patients satisfied the inclusion criteria. Peripheral nerve catheters placed under US guidance showed a higher RR of 1.14 (95% CI: 1.02-1.27; P=0.02) for an overall successful block in comparison with NS. However, postoperative pain scales at movement (numeric rating scale: 0-10) were comparable between US- vs NS-guided peripheral nerve catheters 24 (MD: 0.08; 95% CI: -0.77 to 0.94; P=0.85) and 48 (MD: 1.0; 95% CI: -0.3 to 2.3; P=0.13) h after surgery. Patients receiving a US-guided peripheral nerve catheter had a lower RR of 0.13 (95% CI: 0.04-0.38; P=0.0002) for an accidental vascular puncture. CONCLUSIONS: There is evidence that US-guided peripheral nerve catheters show a higher success rate and a lower risk for an accidental vascular puncture compared with NS guidance. However, this difference resulted only in marginally lower postoperative pain scores at rest. Nevertheless, these results were influenced by heterogeneity and should be interpreted with caution.

[New options for digital photo documentation during routine examination for ophthalmologists]. / Neue Möglichkeiten der digitalen Fotodokumentation im klinischen Alltag für Augenärzte.

BACKGROUND: Many clinical investigations cannot be carried out at the examination unit or a slit lamp. Here we present three new options to obtain digital pictures in a routine clinic at a slit lamp and evaluate how user friendly they are. METHODS: A) First, a digital photo documentation is examined at a conventional slit lamp by a modified binocular ray splitter. One ray of the binocular ray splitter is connected to a digital camera, while the second ray in this patented prototype is connected to the light sources of a synchronised flash light. B) A Smartphone generated fundus images via the monocular of a microscope. Macroscopic details up to 60× at the external eye were obtained by a magnifying gadget of the iPhone. C) With a USB microscope, high resolutions pictures were generated without large technical expense directly at the job and digitally were archived over an USB connection. RESULTS: A trained ophthalmologist demonstrated an excellent documentation at a slit lamp using all 3 digital camera systems. The new ray splitter allows enhanced the image quality at the anterior and posterior segments of the eye. Also the Smartphone obtained by its autofocus and automatic exposure control stunningly high resolution images at the fundus. An attached magnifying aperture glass enables documentation with a 20-fold magnification and is already used in dermatology as the "Handyskope". The USB microscope may be used to record macroscopic details with a 200-fold magnification and resolution of 2 million pixels. It is connected to a PC desktop at the workstation and has only a limited depth resolution, requiring a precise focus. CONCLUSION: The increasing distribution of the Smartphone and significant improvement of its digital camera make its use in medicine meaningful. Low-priced attempts and mobile applications open new implications in the evaluation of ophthalmological patients.

Is intraoperative dexmedetomidine a new option for postoperative pain treatment? A meta-analysis of randomized controlled trials.

In the present meta-analysis, we assessed the efficacy and safety of intravenous administration of dexmedetomidine (DEX) compared with placebo or opioids for acute postoperative pain treatment in adults undergoing surgery. The meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and the recommendations of the Cochrane Collaboration. Randomized controlled trials investigating perioperative administration of DEX were included. For dichotomous outcomes relative risks (RR; 95% confidence intervals [CI]) and for continuous outcomes mean differences (MD; 95% CI) were calculated. Twenty-eight randomized controlled trials including 1420 patients were finally included. Patients treated with DEX reported lower postoperative pain intensity (MD1h postoperatively: -1.59U (numeric rating scale: 0 to 10) 95% CI: -2.37 to -0.82; P=.000001) and showed a lower postoperative opioid consumption (MD24h postoperatively: -17.24mg; 95% CI: -24.38 to -10.10; P=.00001) compared with placebo. Additionally, the DEX group showed a lower RR for opioid-related adverse events (e.g. RRNausea (postanesthesia care unit): 0.66; 95% CI: 0.43 to 1.02; P=.06). The most common adverse event in patients treated with DEX was intraoperative bradycardia with a RR of 2.66 (RR: 2.66; 95% CI: 1.54 to 4.58; P=.0004) compared with placebo. There is evidence that DEX administration leads to lower postoperative pain, reduced opioid consumption, and a lower risk for opioid-related adverse events. The comparison of DEX vs opioids for postoperative pain treatment is less clear due to limited data. The most common adverse event was intraoperative bradycardia after DEX administration. Therefore cautions in patients at risk are warranted, and large trials focusing on long-term outcomes after intraoperative DEX use are needed.

[Nintendo 3DS: technology, physiology and possible risks for children's eyes]. / Nintendo 3DS: Technologie, Physiologie und mögliche Risiken für Kinderaugen.

In March 2011 the new Nintendo 3DS went on sale in Switzerland and Germany. The game console features an attractive 3D display without the need of special glasses. By means of a so-called parallax barrier the depth perception can be increased or even turned off. In adults excessive use may cause symptoms such as headaches, dizziness or nausea. In children a visual impairment could be reinforced and an amblyopia could become manifest. Excessive, long hours of use especially in children could have its risks and the possible long-term effects remain unpredictable. On the other hand in the future it is likely that these kinds of 3D screens will be of considerable diagnostic value in orthoptics. The issue is likely to become a more important issue in everyday life in the future. As there is hardly any information available in the medical literature on this subject it is the aim of this article to provide an overview of the technology and physiology with the advantages and disadvantages.