Principles of microvascular surgery in the upper extremity.

Upper extremity replantation and microsurgery can be challenging even for the experienced hand and upper extremity surgeon and requires thoughtful consideration and evaluation. This review aims to discuss the general considerations in upper extremity replantation management from the preoperative through the postoperative period.

Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries.

BACKGROUND: There is a paucity of clinical data on severe fireworks-related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to describe the relationship between fireworks type, injury patterns, and impairment. METHODS: Retrospective case series (2005-2015) of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or an operation at a Level 1 Trauma/Burn Center. Fireworks types, injury patterns (body region, injury type), operation, and permanent impairment were examined. RESULTS: Data from 294 patients 1 to 61years of age (mean 24years) were examined. The majority (90%) were male. 119 (40%) patients were admitted who did not undergo surgery, 163 (55%) patients required both admission and surgery, and 12 (5%) patients underwent outpatient surgery. The greatest proportion of injuries was related to shells/mortars (39%). There were proportionally more rocket injuries in children (44%), more homemade firework injuries in teens (34%), and more shell/mortar injuries in adults (86%). Brain, face, and hand injuries were disproportionately represented in the shells/mortars group. Seventy percent of globe-injured patients experienced partial or complete permanent vision loss. Thirty-seven percent of hand-injured patients required at least one partial or whole finger/hand amputation. The greatest proportion of eye and hand injuries resulting in permanent impairment was in the shells/mortars group, followed by homemade fireworks. Two patients died. CONCLUSIONS: Severe fireworks-related injuries from homemade fireworks and shells/mortars have specific injury patterns. Shells/mortars disproportionately cause permanent impairment from eye and hand injury.

An Infographic Assignment to Translate Knowledge of Research Evidence for the Doctoral of Physical Therapy Classroom: A Case Report.

AIMS: The purpose of this report was to describe an example of how to incorporate infographics as a group assignment in the entry-level physical therapy classroom to integrate course content and translate knowledge of research evidence. METHODS: This was a retrospective case report. Students developed their own infographics as a group assignment to present in the classroom. During course orientation and at the end of the course, students were asked to complete an optional survey about infographics. RESULTS: Fifty students completed the survey. All students (n=50) reported that they were attracted to visual information, and 74% (n=37) had used an infographic as an educational/informative tool. 74% (n=37) completed the post-intervention survey and found infographics valuable in reviewing course content. 95% (n=35) would consider using infographics as a learning and knowledge translation (KT) tool in the future. CONCLUSION: These data validated students' interest in visual information and awareness about the use of infographics as an educational/informative tool. Health care educators may use innovative KT strategies, such as infographics, in the classroom to encourage students to develop competency in KT and dissemination of information.

Management of Artery-Only Digit Replantation: A Systematic Review of the Literature.

BACKGROUND: Artery-only replantation may be necessary in circumstances when venous repair cannot be performed due to their size or vessel injury. Venous congestion of the replanted part is inevitable. A systematic review was performed to identify techniques for mitigating congestion and analyze the outcomes of those techniques. METHODS: A comprehensive literature search was performed to identify relevant articles related to artery-only replantation. An initial query identified 1286 unique articles. A total of 55 articles were included in the final review. Included studies were categorized by decongestive technique. Data from each article included the number of patients treated, level of amputation, graft use, anticoagulation or antiplatelet therapy, replant viability, and follow-up duration. Weighted averages were determined from studies that reported five or more digits. RESULTS: A total of 1498 individual digital replantations were described. Very rarely did studies report artery-only replantation proximal to the distal interphalangeal joint. An overall survival rate of 78.5 percent was found irrespective of technique but was variable based on each particular study. Studies utilizing medicinal leech therapy were more likely to report use of intravenous anticoagulation, whereas surface bleeding techniques were more likely to report use of topical or local anticoagulant. CONCLUSIONS: Lack of a vein for anastomosis should not be regarded as a contraindication to replantation. These digits instead require a method to establish reliable drainage sufficient to allow for low resistance inflow and maintain a physiologic pressure gradient across capillary beds. The surgeon should select a decongestive technique that best suits the patient and their specific injury.

Osteoplastic Thumb Reconstruction in the Immediate Setting: A Case Series.

Background: Traumatic thumb amputation can have devastating effects on residual hand function. When replantation is not possible, thumb reconstruction is often performed in a delayed manner and may require multiple stages. Furthermore, reconstruction techniques often require microsurgical skills and equipment, which are not readily available at all institutions. This case series illustrates our technique for immediate osteoplastic thumb reconstruction following traumatic amputation. Methods: This is a case series involving all patients who sustained unreplantable thumb amputations and underwent immediate osteoplastic thumb reconstruction with bone autograft and pedicled groin flap by the senior author from September 2016 through August 2018. Results: Five patients underwent immediate osteoplastic thumb reconstruction during the study period. Total operative time for the initial osteoplastic reconstruction averaged 158 minutes (range 96-290 minutes). In addition to flap division surgery, patients underwent an average of 1.2 revision procedures (range 0-2), primarily for debulking and hardware removal. Patients achieved an average gain in length of 3.3 cm compared with the maximum anticipated length with revision amputation at the time of injury, and had stable clinical outcomes for a minimum of 12 months. Conclusions: Osteoplastic thumb reconstruction is a useful technique for thumb reconstruction for select patients following traumatic thumb amputation. Advantages of this approach include shorter overall operative times and hospital length of stay, minimal donor site morbidity, and a straightforward, reproducible technique.

Electrochemical biosensors employing an internal electrode attachment site and achieving reversible, high gain detection of specific nucleic acid sequences.

Electrochemical DNA (E-DNA) sensors, which are rapid, reagentless, and readily integrated into microelectronics and microfluidics, appear to be a promising alternative to optical methods for the detection of specific nucleic acid sequences. Keeping with this, a large number of distinct E-DNA architectures have been reported to date. Most, however, suffer from one or more drawbacks, including low signal gain (the relative signal change in the presence of complementary target), signal-off behavior (target binding reduces the signaling current, leading to poor gain and raising the possibility that sensor fouling or degradation can lead to false positives), or instability (degradation of the sensor during regeneration or storage). To remedy these problems, we report here the development of a signal-on E-DNA architecture that achieves both high signal gain and good stability. This new sensor employs a commercially synthesized, asymmetric hairpin DNA as its recognition and signaling probe, the shorter arm of which is labeled with a redox reporting methylene blue at its free end. Unlike all prior E-DNA architectures, in which the recognition probe is attached via a terminal functional group to its underlying electrode, the probe employed here is affixed using a thiol group located internally, in the turn region of the hairpin. Hybridization of a target DNA to the longer arm of the hairpin displaces the shorter arm, allowing the reporter to approach the electrode surface and transfer electrons. The resulting device achieves signal increases of ∼800% at saturating target, a detection limit of just 50 pM, and ready discrimination between perfectly matched sequences and those with single nucleotide polymorphisms. Moreover, because the hairpin probe is a single, fully covalent strand of DNA, it is robust to the high stringency washes necessary to remove the target, and thus, these devices are fully reusable.

Intranasal powder live attenuated influenza vaccine is thermostable, immunogenic, and protective against homologous challenge in ferrets.

Influenza viruses cause annual seasonal epidemics and sporadic pandemics; vaccination is the most effective countermeasure. Intranasal live attenuated influenza vaccines (LAIVs) are needle-free, mimic the natural route of infection, and elicit robust immunity. However, some LAIVs require reconstitution and cold-chain requirements restrict storage and distribution of all influenza vaccines. We generated a dry-powder, thermostable LAIV (T-LAIV) using Preservation by Vaporization technology and assessed the stability, immunogenicity, and efficacy of T-LAIV alone or combined with delta inulin adjuvant (Advax™) in ferrets. Stability assays demonstrated minimal loss of T-LAIV titer when stored at 25 °C for 1 year. Vaccination of ferrets with T-LAIV alone or with delta inulin adjuvant elicited mucosal antibody and robust serum HI responses in ferrets, and was protective against homologous challenge. These results suggest that the Preservation by Vaporization-generated dry-powder vaccines could be distributed without refrigeration and administered without reconstitution or injection. Given these significant advantages for vaccine distribution and delivery, further research is warranted.

Reagentless measurement of aminoglycoside antibiotics in blood serum via an electrochemical, ribonucleic acid aptamer-based biosensor.

Biosensors built using ribonucleic acid (RNA) aptamers show promise as tools for point-of-care medical diagnostics, but they remain vulnerable to nuclease degradation when deployed in clinical samples. To explore methods for protecting RNA-based biosensors from such degradation we have constructed and characterized an electrochemical, aptamer-based sensor for the detection of aminoglycosidic antibiotics. We find that while this sensor achieves low micromolar detection limits and subminute equilibration times when challenged in buffer, it deteriorates rapidly when immersed directly in blood serum. In order to circumvent this problem, we have developed and tested sensors employing modified versions of the same aptamer. Our first effort to this end entailed the methylation of all of the 2'-hydroxyl groups outside of the aptamer's antibiotic binding pocket. However, while devices employing this modified aptamer are as sensitive as those employing an unmodified parent, the modification fails to confer greater stability when the sensor is challenged directly in blood serum. As a second potentially naive alternative, we replaced the RNA bases in the aptamer with their more degradation-resistant deoxyribonucleic acid (DNA) equivalents. Surprisingly and unlike control DNA-stem loops employing other sequences, this DNA aptamer retains the ability to bind aminoglycosides, albeit with poorer affinity than the parent RNA aptamer. Unfortunately, however, while sensors fabricated using this DNA aptamer are stable in blood serum, its lower affinity pushes their detection limits above the therapeutically relevant range. Finally, we find that ultrafiltration through a low-molecular-weight-cutoff spin column rapidly and efficiently removes the relevant nucleases from serum samples spiked with gentamicin, allowing the convenient detection of this aminoglycoside at clinically relevant concentrations using the original RNA-based sensor.

Management of Finger Joint Dislocation and Fracture-Dislocations in Athletes.

Although finger joint dislocations are generally thought of as benign by many athletes and assumed to be a sprain, these injuries represent a spectrum that includes disabling fracture-dislocations. Failure to recognize certain dislocations or fracture-dislocations may result in permanent deformity and loss of motion. Simple dislocations are frequently amenable to early return to play with protection; however, more complex injuries may require specialized splinting or surgery. Delay in diagnosis of unstable proximal interphalangeal fracture-dislocations may require reconstruction or fusion. Early diagnosis and appropriate treatment are essential to ensure optimal functional results.

Free T4 immunoassays are flawed during pregnancy.

OBJECTIVE: The purpose of this study was to evaluate the diagnostic accuracies of 2 free thyroxine immunoassays during pregnancy. STUDY DESIGN: Serum was collected from healthy, thyroid peroxidase antibody-negative women during each trimester and nonpregnant controls. Thyrotropin, total T4 (TT4), free T4 index (FT4I), and 2 different FT4 immunoassays were studied. RESULTS: As expected, TT4 was elevated in all 3 trimesters compared to controls (P < .001). FT4I was elevated in the 1st trimester as compared with controls (P < .05) and returned to the nonpregnant range in the 2nd and 3rd trimesters. In contrast, 1st trimester FT4 immunoassay values were either comparable or lower than controls and by the 2nd and 3rd trimesters had decreased to approximately 65% of controls. CONCLUSION: Neither FT4 immunoassay accurately reflects established free T4 changes during pregnancy. TT4 and the FT4I retained an appropriate inverse relationship with TSH throughout pregnancy and appear to provide a more reliable free T4 estimate.

Coupling among Microbial Communities, Biogeochemistry, and Mineralogy across Biogeochemical Facies.

Physical properties of sediments are commonly used to define subsurface lithofacies and these same physical properties influence subsurface microbial communities. This suggests an (unexploited) opportunity to use the spatial distribution of facies to predict spatial variation in biogeochemically relevant microbial attributes. Here, we characterize three biogeochemical facies-oxidized, reduced, and transition-within one lithofacies and elucidate relationships among facies features and microbial community biomass, richness, and composition. Consistent with previous observations of biogeochemical hotspots at environmental transition zones, we find elevated biomass within a biogeochemical facies that occurred at the transition between oxidized and reduced biogeochemical facies. Microbial richness-the number of microbial taxa-was lower within the reduced facies and was well-explained by a combination of pH and mineralogy. Null modeling revealed that microbial community composition was influenced by ecological selection imposed by redox state and mineralogy, possibly due to effects on nutrient availability or transport. As an illustrative case, we predict microbial biomass concentration across a three-dimensional spatial domain by coupling the spatial distribution of subsurface biogeochemical facies with biomass-facies relationships revealed here. We expect that merging such an approach with hydro-biogeochemical models will provide important constraints on simulated dynamics, thereby reducing uncertainty in model predictions.

Economics and Health Reform: Academic Research and Public Policy.

Two prior studies, conducted in 1966 and in 1979, examined the role of economic research in health policy development. Both concluded that health economics had not been an important contributor to policy. Passage of the Affordable Care Act offers an opportunity to reassess this question. We find that the evolution of health economics research has given it an increasingly important role in policy. Research in the field has followed three related paths over the past century-institutionalist research that described problems; theoretical research, which proposed relationships that might extend beyond existing institutions; and empirical assessments of structural parameters identified in the theoretical research. These three strands operating in concert allowed economic research to be used to predict the fiscal and coverage consequences of alternative policy paths. This ability made economic research a powerful policy force. Key conclusions of health economics research are clearly evident in the Affordable Care Act.

Extended Component Separation for Repair of High Ventral Hernia in Pediatric Omphalocele.

Abdominal wall reconstruction ideally involves maintenance of domain by restoration of competent fascia and innervated muscle. Component separation allows closure of ventral hernias, but the technique is limited for high abdominal defects in the epigastric region. We describe an extended component separation that facilitated mobilization of the rectus abdominis muscle along its costal insertion to close an upper midline defect in a child with giant omphalocele, who had already undergone previous traditional component separation.

3D imaging of microbial biofilms: integration of synchrotron imaging and an interactive visualization interface.

Understanding the structure of microbial biofilms and other complex microbial communities is now possible through x-ray microtomography imaging. Feature detection and image processing for this type of data focuses on efficiently identifying and segmenting biofilm biomass in the datasets. These datasets are very large and segmentation often requires manual interventions due to low contrast between objects and high noise levels. New software is required for the effectual interpretation and analysis of such data. This work specifies the evolution and ability to analyze and visualize high resolution x-ray microtomography datasets. Major functionalities include read/write with multiple popular file formats, down-sampling large datasets to generate quick-views on low-power computers, image processing, and generating high quality output images and videos. These capabilities have been wrapped into a new interactive software toolkit, BiofilmViewer. A major focus of our work is to facilitate data transfer and to utilize the capabilities of existing powerful visualization and analytical tools including MATLAB, ImageJ, Paraview, Chimera, Vaa3D, Cell Profiler, Icy, BioImageXD, and Drishti.

Vulnerability of larval and juvenile white sturgeon to barotrauma: can they handle the pressure?

Techniques were developed to determine which life stages of fish are vulnerable to barotrauma from expansion of internal gases during decompression. Eggs, larvae, and juvenile hatchery-reared white sturgeon (Acipenser transmontanus; up to 91 days post hatch; d.p.h.) were decompressed to assess vulnerability to barotrauma and identify initial swim bladder inflation. Barotrauma-related injury and mortality were first observed 9 d.p.h., on the same day as initial exogenous feeding. However, barotrauma-related injury did not occur again until swim bladder inflation 75 d.p.h. (visible at necropsy and on radiographs). Swim bladder inflation was not consistent among individuals, with only 44% being inflated 91 d.p.h. Additionally, swim bladder inflation did not appear to be size dependent among fish ranging in total length from 61 to 153 mm at 91 d.p.h. The use of a combination of decompression tests and radiography was validated as a method to determine initial swim bladder inflation and vulnerability to barotrauma. Extending these techniques to other species and life-history stages would help to determine the susceptibility of fish to hydro turbine passage and aid in fish conservation.

Duplication of the pituitary gland associated with multiple blastogenesis defects: Duplication of the pituitary gland (DPG)-plus syndrome. Case report and review of literature.

BACKGROUND: Duplication of the pituitary gland (DPG) is a rare craniofacial developmental anomaly occurring during blastogenesis with postulated etiology such as incomplete twinning, teratogens, median cleft face syndrome or splitting of the notochord. The complex craniocaudal spectrum of blastogenesis defects associated with DPG is examined with an illustrative case. CASE DESCRIPTION: We report for the first time in the medical literature some unique associations with DPG, such as a clival encephalocele, third cerebral peduncle, duplicate odontoid process and a double tongue with independent volitional control. This patient also has the previously reported common associations such as duplicated sella, cleft palate, hypertelorism, callosal agenesis, hypothalamic enlargement, nasopharyngeal teratoma, fenestrated basilar artery and supernumerary teeth. This study also reviews 37 cases of DPG identified through MEDLINE literature search from 1880 to 2011. It provides a detailed analysis of the current case through physical examination and imaging. CONCLUSION: The authors propose that the developmental deformities associated with duplication of pituitary gland (DPG) occur as part of a developmental continuum, not as chance associations. Considering the fact that DPG is uniquely and certainly present throughout the spectrum of these blastogenesis defects, we suggest the term DPG-plus syndrome.

Scatter in cargo radiography.

As a complement to passive detection systems, radiographic inspection of cargo is an increasingly important tool for homeland security because it has the potential to detect highly attenuating objects associated with special nuclear material or surrounding shielding, in addition to screening for items such as drugs or contraband. Radiographic detection of such threat objects relies on high image contrast between regions of different density and atomic number (Z). Threat detection is affected by scatter of the interrogating beam in the cargo, the radiographic system itself, and the surrounding environment, which degrades image contrast. Here, we estimate the extent to which scatter plays a role in radiographic imaging of cargo containers. Stochastic transport simulations were performed to determine the details of the radiography equipment and surrounding environment, which are important in reproducing measured data and to investigate scatter magnitudes for typical cargo. We find that scatter plays a stronger role in cargo radiography than in typical medical imaging scenarios, even for low-density cargo, with scatter-to-primary ratios ranging from 0.14 for very low density cargo, to between 0.20 and 0.40 for typical cargo, and higher yet for dense cargo.

Effect of thyroid peroxidase antibodies on thyroid-stimulating hormone reference limits in a primarily Latina population.

The aim of the paper is to determine the prevalence of thyroid peroxidase antibodies (TPOAb) and assess its effect on the thyroid-stimulating hormone (TSH) reference range during pregnancy in a primarily Latina population. Serum samples were collected from healthy pregnant women and non-pregnant controls. TSH reference ranges were calculated when TPOAb-positive patients were either included or excluded. A total of 134 pregnant women and 107 non-pregnant controls were recruited. Positive TPOAb titres were found in 23 (17.2%) of the 134 pregnant women, and in 14 (13.1%) of the 107 non-pregnant controls. When the TPOAb-positive women were included in the TSH analysis, the upper reference limit using two different methods was consistently higher: 0-2.2 fold in the non-pregnant women, 2.01-2.78 fold in the first trimester, 3.18-4.7 fold in the second and 1.05-1.42 fold in the third. The lower TSH reference limit was not affected by the inclusion of TPOAb-positive subjects. In conclusion, inclusion of TPOAb-positive patients results in higher upper reference limits during pregnancy.