Management of self-inflicted gunshot wounds to the face: retrospective review from a single tertiary care trauma centre.

There are limited published data about the surgical management of self-inflicted facial gunshot wounds. The aim of this retrospective study was to review our management of subjects who initially survive such a wound and were admitted to a tertiary care trauma centre between 2002 and 2012. Only subjects with definitive evidence of a self-inflicted facial gunshot wound and who were admitted alive were included. Data collected included personal and clinical details, characteristics of the gunshot wound, and medical and surgical management. Types of operations and their duration were recorded, and primary reconstruction was divided into early (within the first 48hours after presentation) or delayed (longer than 48hours). Determinants of infection were assessed with univariate analysis. Seventy-six subjects (65 male and 11 female, mean (range) age 44 (18-83) years) were included in the study. Twenty-five patients needed an early surgical airway and five needed emergency intervention to control haemorrhage. Forty-five patients had primary reconstructions (28 early and 17 delayed) and 12 who were treated by delayed repair had a submental entry site to the wound. There were no significant differences in infection rates between those who had early, compared with those who had late, reconstructions. Early primary reconstruction can be successful for patients with self-inflicted facial gunshot wounds, particularly when the entry point of the bullet is in the upper and midface area. Delayed primary reconstruction was more common when the bullet entered the lower face.

The Prevalence of Malformations of Cortical Development in a Pediatric Hereditary Hemorrhagic Telangiectasia Population.

BACKGROUND AND PURPOSE: Brain AVM, cerebral abscess, and ischemic stroke are among the well known neurologic manifestations of hereditary hemorrhagic telangiectasia. However, recently reported data suggest an additional association with malformations of cortical development. The purpose of this study was to determine the prevalence of malformations of cortical development in a population of pediatric patients with hereditary hemorrhagic telangiectasia. MATERIALS AND METHODS: A retrospective review of brain MRIs from 116 pediatric patients was performed. Each patient was referred from our institution's Hereditary Hemorrhagic Telangiectasia Clinic. Each MRI included a 3D sequence, most frequently MPRAGE. The 3D sequence was evaluated by a neuroradiology fellow, with specific attention to the presence or absence of malformations of cortical development. Positive studies were subsequently reviewed by 2 attending neuroradiologists, who rendered a final diagnosis. RESULTS: Fourteen of 116 (12.1%) patients were found to have a malformation of cortical development. Among these 14, there were 12 cases of polymicrogyria and 2 cases of bifrontal periventricular nodular heterotopia. CONCLUSIONS: Pediatric patients with hereditary hemorrhagic telangiectasia have a relatively high prevalence of malformations of cortical development, typically perisylvian polymicrogyria.

Plain abdominal radiographs in patients with Crohn's disease: radiological findings and diagnostic value.

AIM: To determine the diagnostic yield and clinical value of plain film of the abdomen (PFA) in Crohn's disease (CD) patients and to determine whether performance of PFA yields definitive diagnostic information or whether additional imaging examinations are required. MATERIALS AND METHODS: One hundred and seventy-seven CD patients underwent 643 PFAs during the period September 1992 to August 2008. Two radiologists blinded to the clinical details independently evaluated individual PFAs and/or their reports for abnormal findings using the following criteria: normal, small bowel (SB) findings; colonic findings, acute CD complications, extra-colonic findings; global assessment/impression. The results of additional imaging studies performed within 5 days of PFA were recorded and findings were analysed. RESULTS: A mean of 3.6 (range 1-22) PFAs was performed per patient during the study period. Almost 70% of films were normal (n = 449). SB abnormalities were detected in 21.8% (n = 140) PFAs; most commonly dilated loops (18.8%, n = 121) and mucosal oedema (5%, n = 32). Colonic abnormalities were present in 11.4% (n = 73); most commonly mucosal oedema (7.5%, n = 48) and dilated loops (5%, n = 32). Four cases of pneumoperitoneum were detected. There was no case of toxic megacolon. There was one case in which intra-abdominal abscess/collection was suspected and two cases of obstruction/ileus. Extracolonic findings (renal calculi, sacro-iliitis, etc.) were identified in 7.5% (n = 48). PFAs were followed by additional abdominal imaging within 5 days of PFA in 273/643 (42.5%) of cases. CONCLUSION: Despite the high rates of utilization of PFA in CD patients, there is a low incidence of abnormal findings (32.5%). Many of the findings are non-specific and clinically irrelevant and PFA is frequently followed by additional abdominal imaging examinations.

The spectrum of functional gastrointestinal disorders in a tertiary referral clinic in Ireland.

BACKGROUND: The functional gastrointestinal disorders (FGIDs) are a heterogenous group of chronic conditions which cause troubling gastrointestinal symptoms. Though common and sometimes disabling, causing considerable social and economic burden, there is little recent literature on presentation or impact of FGIDs in Ireland. AIM: To describe the characteristics of patients with FGIDs at a tertiary referral clinic in Ireland. METHODS: A retrospective review of those attending a university hospital gastroenterology clinic with a special interest in FGIDs between January 1999 and July 2008 was performed. Data were mined from electronic outpatient records and clinic letters. RESULTS: A total of 1,909 patients were included. Of these patients, 41.2% (787 of 1,909) received a diagnosis of FGID. FGID patients were predominantly (70.14%) female and the average age at first presentation was 38.3 years. Of these, 76% (598 of 787) were referred from general practice; 35.8% (282 of 787) received onward referrals to other specialties. Nine hundred FGIDs were diagnosed. The most common FGID was irritable bowel syndrome (633 of 900, 70.3%). In the FGID group, 13.1% of patients (103 of 787) had more than one FGID diagnosis. Females received a definitive diagnosis of FGID faster than males; mean diagnostic latency: 5.3 versus 6.4 months (p < 0.05). Sixty-six percent (523 of 787) of FGID patients had non-gastrointestinal co-morbidities, with 315 (60.2%) of these having more than one co-morbidity. The burden of non-GI co-morbidity was significantly higher in patients with overlapping functional syndromes than in patients with single FGID (p < 0.05). CONCLUSIONS: In Ireland, FGIDs are common, represent a significant burden for the health-care system and deserve greater recognition and further research attention.

Minimization of radiation exposure due to computed tomography in inflammatory bowel disease.

Exposure to ionising radiation as a result of diagnostic imaging is increasing among patients with inflammatory bowel disease (IBD), primarily due to the more widespread use of computed tomography (CT). The potentially harmful effects of ionising radiation are a major cause for concern and radiologists, technologists and referring physicians who have a responsibility to the patient to ensure judicious use of those imaging modalities which result in exposure to ionising radiation and, when imaging is necessary, to ensure that a diagnostic quality imaging examination is acquired with lowest possible radiation exposure. This can be achieved by limiting the use of those imaging studies which involve ionising radiation to clinical situations where they are likely to change management, by implementing advances in low-dose CT technology, and, where feasible, by using alternative imaging modalities, such as ultrasonography or magnetic resonance imaging, which avoid radiation exposure.

Tracking the oxidative kinetics of carbohydrates, amino acids and fatty acids in the house sparrow using exhaled 13CO2.

Clinicians commonly measure the (13)CO(2) in exhaled breath samples following administration of a metabolic tracer (breath testing) to diagnose certain infections and metabolic disorders. We believe that breath testing can become a powerful tool to investigate novel questions about the influence of ecological and physiological factors on the oxidative fates of exogenous nutrients. Here we examined several predictions regarding the oxidative kinetics of specific carbohydrates, amino acids and fatty acids in a dietary generalist, the house sparrow (Passer domesticus). After administering postprandial birds with 20 mg of one of seven (13)C-labeled tracers, we measured rates of (13)CO(2) production every 15 min over 2 h. We found that sparrows oxidized exogenous amino acids far more rapidly than carbohydrates or fatty acids, and that different tracers belonging to the same class of physiological fuels had unique oxidative kinetics. Glycine had a mean maximum rate of oxidation (2021 nmol min(-1)) that was significantly higher than that of leucine (351 nmol min(-1)), supporting our prediction that nonessential amino acids are oxidized more rapidly than essential amino acids. Exogenous glucose and fructose were oxidized to a similar extent (5.9% of dose), but the time required to reach maximum rates of oxidation was longer for fructose. The maximum rates of oxidation were significantly higher when exogenous glucose was administered as an aqueous solution (122 nmol min(-1)), rather than as an oil suspension (93 nmol min(-1)), supporting our prediction that exogenous lipids negatively influence rates of exogenous glucose oxidation. Dietary fatty acids had the lowest maximum rates of oxidation (2-6 nmol min(-1)), and differed significantly in the extent to which each was oxidized, with 0.73%, 0.63% and 0.21% of palmitic, oleic and stearic acid tracers oxidized, respectively.

Exposure to cold but not exercise increases carbon turnover rates in specific tissues of a passerine.

Carbon turnover differs between tissues within an animal, but the extent to which ecologically relevant increases in metabolism affect carbon turnover rates is largely unknown. We tested the energy expenditure and protein turnover hypotheses that predict increased carbon turnover, either in association with increased daily energy expenditure, or in concert with tissue-specific increased protein metabolism. We used stable-isotope-labeled diets to quantify the rate of carbon turnover in 12 different tissues for three groups of zebra finches (Taeniopygia guttata): cold-exposed birds kept at ambient temperatures below their thermoneutral zone, exercised birds that were flown for 2 h per day in a flight arena, and control birds that were kept at ambient temperatures within their thermoneutral zone and that were not exercised. We found that increases in metabolism associated with cold-exposure but not exercise produced measurable increases in carbon turnover rate of, on average, 2.4+/-0.3 days for pectoral muscle, gizzard, pancreas and heart, even though daily energy intake was similar for exercised and cold-exposed birds. This evidence does not support the energy expenditure hypothesis, and we invoke two physiological processes related to protein metabolism that can explain these treatment effects: organ mass increase and tissue-specific increase in activity. Such changes in carbon turnover rate associated with cold temperatures translate into substantial variation in the estimated time window for which resource use is estimated and this has important ecological relevance.

Phenotypic flexibility in digestive system structure and function in migratory birds and its ecological significance.

Birds during migration must satisfy the high energy and nutrient demands associated with repeated, intensive flight while often experiencing unpredictable variation in food supply and food quality. Solutions to such different challenges may often be physiologically incompatible. For example, increased food intake and gut size are primarily responsible for satisfying the high energy and nutrient demands associated with migration in birds. However, short-term fasting or food restriction during flight may cause partial atrophy of the gut that may limit utilization of ingested food energy and nutrients. We review the evidence available on the effects of long- and short-term changes in food quality and quantity on digestive performance in migratory birds, and the importance of digestive constraints in limiting the tempo of migration in birds. Another important physiological consequence of feeding in birds is the effect of diet on body composition dynamics during migration. Recent evidence suggests that birds utilize and replenish both protein and fat reserves during migration, and diet quality influences the rate of replenishment of both these reserves. We conclude that diet and phenotypic flexibility in both body composition and the digestive system of migratory birds are important in allowing birds to successfully overcome the often-conflicting physiological challenges of migration.

Test of a digestion optimization model: effects of costs of feeding on digestive parameters.

We tested predictions of a chemical reactor model of digestion by manipulating the short-term costs of feeding and then measuring the effect on digestive parameters. We compared residence time of digesta and extraction efficiency of glucose in cold-acclimated waxwings (Bombycilla cedrorum) feeding ad lib. and in birds whose costs of feeding were increased through the addition of intervals of time when they received no food. Such a feeding schedule simulated the ecological situation in which a frugivorous bird like a waxwing encounters food in patches and experiences nonfeeding periods as it searches for new preferred food patches. None of the results were consistent with the predictions of the optimal digestion model: extraction efficiency was independent of costs of feeding, and residence times did not increase as costs of feeding increased. This empirical evidence on the passage of digesta in waxwings suggests that movement of digesta in the guts of birds is much more complex than movement of material in an ideal chemical reactor. Tests of the optimal digestion model have involved manipulating food quality or the costs of feeding, and the conclusions are similar: compensatory modulation of retention time or digesta mixing and not rate of hydrolysis and absorption seem most important in maintaining the remarkably constant digestive efficiency.

A test for passive absorption of glucose in yellow-rumped warblers and its ecological implications.

In an earlier study, we found that yellow-rumped warblers had in vitro active uptake rates of D-glucose that were only a few percent of the glucose absorption rate achieved at the whole-animal level. Here we used a pharmacokinetic technique to test whether a substantial amount of sugar can be absorbed passively. We used yellow-rumped warblers (Dendroica coronata), known for their seasonal frugivory, freely feeding on a synthetic mash formulated with naturally occurring concentrations of D-glucose. Birds absorbed 89.8% +/- 1.0% (SE) of the D-glucose in the mash. When fed the same mash with trace-labeled 3H L-glucose, the stereoisomer that does not interact with the intestinal Na(+)-glucose cotransporter, 3H appeared in plasma, an indication that this stereoisomer of glucose was absorbed. We used 3H levels in plasma and excreta in a pharmacokinetic model to calculate L-glucose extraction efficiency (i.e., the percent absorbed). Calculated mean extraction efficiency for the passively absorbed L-glucose averaged 91% +/- 23%. Our finding of considerable passive absorption reconciles the in vitro and in vivo results for D-glucose absorption and is in concert with results from five other avian species. The passive pathway appears to provide birds with an absorptive process that can respond quickly to changing luminal concentration and that is energetically inexpensive to maintain and modulate in real time but that may bear a cost. Less discriminate passive absorption might increase vulnerability to toxins and thus constrain foraging behavior and limit the breadth of the dietary niche.