Incidence of delayed intracranial hypertension in children with isolated sagittal synostosis following open calvarial vault reconstruction.

PURPOSE: Delayed intracranial hypertension (DIH) occurs most frequently in children with syndromic or multi-suture synostosis after surgical correction. The rarity of DIH in children with isolated non-syndromic sagittal synostosis (ISS) warrants follow-up evaluation by large craniofacial centers until skeletal maturity. This study reports the incidence of DIH in children following open repair for ISS by our center's craniofacial team. METHODS: A single-center retrospective study of patients who underwent open calvarial vault remodeling (CVR) for ISS at our institution between November 2000 and November 2012 was performed. Syndromic and multi-suture synostosis patients were excluded. Demographic and follow-up data were extracted from the medical record for analysis until July 2017. RESULTS: One hundred five patients with ISS were identified who had undergone CVR in the aforementioned timeframe. Average age at initial surgery was 11.7 ± 15.32 months. Mean follow-up in our craniofacial clinic was 4.94 ± 3.53 years, with 69 patients (65.7%) having follow-up in craniofacial clinic ≥ 3 years and 74 (70.5%) having follow-up ≥ 3 years in any clinic at our institution. Four patients (3.8%) had intracranial pressure (ICP) monitors placed for symptoms concerning for DIH, one of which (0.95%) had confirmed DIH and underwent a second surgical procedure at 7.4 years of age. The patient presented late initially, having his first operation at 1.56 years of age. CONCLUSION: One patient out of 105 (0.95%) developed DIH, confirmed by ICP monitoring, and required reoperation. The occurrence of DIH, albeit rare, remains an important topic to include in parental discussions and mandates long-term follow-up in this population.

Comparison of Geriatric Trauma Outcomes When Admitted to a Medical or Surgical Service After a Fall.

BACKGROUND: Blunt trauma in the geriatric population is fraught with poor outcomes, with injury severity and comorbidities impacting morbidity and mortality. METHODS: We retrospectively reviewed 2172 patients aged ≥65 y who fell, requiring hospital admission between January 2012 and December 2016. There were 403 patients in the surgical arm (SA) and 1769 patients in the medical arm (MA). Ground-level falls were the only mechanism of injury included. We excluded all ICU admissions and deaths within 24 h. RESULTS: There were 5 deaths (1.24%) in the SA and 16 deaths (0.90%) in the MA (P = 0.57). The mean trauma injury severity score survival probability prediction in the SA was 96.9% versus 97.1% in the MA. MA patients had more comorbidities overall than SA patients. There was no difference in mortality between the SA and MA groups in multiple logistic regression models that accounted for trauma injury severity scores (TRISS) and comorbidities. Unadjusted hospital length of stay was 1 d shorter (median; 95% CI -1.4 to -0.6) in the SA and 0.5 d shorter (median; 95% CI -0.8 to -0.1) when adjusted for TRISS and comorbidities using multiple quantile regression. Finally, patients in the SA were 2.1 (95% CI 1.7 to 2.6) times more likely to be discharged home compared with patients in the MA, and this remained significant (OR 1.9; 95% CI 1.5 to 2.5) with simultaneous adjustment for TRISS and comorbidities using multiple logistic regression. CONCLUSIONS: Geriatric blunt trauma patients admitted to surgical services after mechanical falls have no difference in survival, a shorter median length of stay, and increased likelihood of being discharged home compared with patients admitted to medical services.

Outcomes After Open Reduction With Internal Fixation of Mandible Fractures.

INTRODUCTION/HYPOTHESIS: Mandible fractures contribute substantially to morbidity after blunt trauma. Controversy exists surrounding the appropriate timing of surgical intervention and benefit from routine postreduction imaging. METHODS: The authors retrospectively reviewed 146 patients who sustained traumatic mandible fractures at a level 2 trauma center over a 5-year period, between January 2012 and December 2016. The authors excluded all patients who did not undergo surgery, underwent operative closed reduction only, sustained other significant maxillofacial injuries, penetrating mechanisms, and other major injuries based on injury severity scores (ISS) over 15. There were 51 patients meeting inclusion criteria. The authors reviewed admission face computed tomography (CT) scans and Panorex x-rays. Patients were divided into early (<72 hours) and late (>72 hours) open reduction with internal fixation (ORIF) groups. The authors reviewed demographics, mechanism of injury, postreduction imaging, and ISS. All statistical analyses were performed using Stata 15. RESULTS: There were 39 males (76%) and 12 females (24%) in the authors' study, with a mean age of 32 years. Twenty-eight patients (55%) underwent early ORIF and 23 patients (45%) underwent late ORIF, with no mortalities. There was no statistically significant difference in ISS between the 2 groups (P = 0.081). Preoperative face CT scans were performed in 49 patients (96%) and Panorex in 2 patients (4%). Eight patients (16%) had both modalities, with CT face identifying fractures in 5 patients not seen on Panorex, resulting in a change in operative approach. Postreduction imaging was obtained in 33 patients (65%), of whom 26 were Panorex X-rays. These demonstrated adequate reduction in 31 patients (94%) and did not change management in any instance. Complications occurred in 19 patients (37%), of whom there were 11 with uncontrolled pain after 1 week, 6 abscesses, 5 nonunions/malunions, 2 hardware extrusions, and 1 incisional dehiscence. A positive urine drug screen predicted uncontrolled pain (P < 0.05). There was no statistically significant difference in complications between the 2 groups. CONCLUSION: The authors' data suggest that CT scans of the face are superior to panoramic radiographs in traumatic mandible fracture evaluation, with no apparent benefit from routine postreduction imaging in detecting complications. Open reduction with internal fixation remains an effective treatment with favorable outcomes, and operative delays > 72 hours do not appear to increase complication rates.

Effectiveness and safety of autologous fat grafting to the soft palate alone.

BACKGROUND: Posterior pharyngeal augmentation is an accepted method of treating velopharyngeal insufficiency (VPI). Techniques using autologous fat harvest, preparation, and grafting are well described. Based on the complications from retropharyngeal injection, we performed augmentation of the nasal surface of the palate to reduce hypernasality with decreased risks. METHODS: After Institutional Review Board approval, a chart review from 2010 to 2013 identified 46 patients with cleft palate, subjective and nasoendoscopic evidence of VPI treated with autologous fat grafting to the soft palate. Speech evaluation of velopharyngeal function was compared before and after autologous fat grafting. RESULTS: A total of 61 autologous fat grafting procedures were performed in 46 patients. The average age of the study population is 5.59 ± 2.05 years. The majority underwent a single procedure (32/46 or 69.6%), 13 of 46 patients (28.2%) had 2 fat grafting procedures and only 1 patient (2.2%) had 3 fat grafting procedures. The fat was injected primarily in the soft palate. The recorded volume of fat grafted averaged 2.4 ± 1.1 mL. Average operative time was 39 ± 12.55 minutes. There were no local or donor site complications. Four patients were lost to follow-up. Of 34 patients with adequate speech follow-up, including Pittsburgh Weighted Speech Scale (PWSS) assessment, the average preoperative score of 8.17 ± 3.59 was reduced to 5.17 ± 3.14 postoperatively. Although 26 of 34 patients (76.5%) had an improvement in their PWSS score, only 13 of 34 patients (38.23%) saw an improvement in their PWSS category. CONCLUSIONS: Autologous fat grafting to the soft palate is a safe operation with minimal risks. Speech outcomes are subjectively enhanced in the majority of patients, with a full PWSS category improvement seen in 40% of the cases. Patient selection criteria to optimize results are provided.

Downregulation of RelA (p65) by Rapamycin Inhibits Murine Adipocyte Differentiation and Reduces Fat Mass of C57BL/6J Mice despite High Fat Diet.

Rapamycin (RAPA) is a clinical immunosuppressive agent first reported in the literature in 1975 after its discovery in a soil sample from the island of Rapa Nui. Aside from the well-documented effects of RAPA on cell division and immunologic response, the literature reveals it to have negative effects on adipocyte and osteocyte differentiation as well. Understanding of the molecular effects of RAPA on cell differentiation is fragmentary in regard to these cell lineages. In this paper, we examined a potential mechanism for RAPA's effects on adipocyte differentiation in vitro and in vivo. The data point to a unique role of Rel A (p65)-a component of the NF-κB system-in mediating this event. In murine adipose derived stem cell cultures (muADSCs) from C57BL/6J mice, RAPA was found to selectively downregulate RelA/p65, mammalian target of rapamycin (mTOR), and do so in a dose-dependent manner. This implies a novel role for RelA in adipocyte biology. Intracellular lipid accumulation-as subjectively observed-was also decreased in muADSCs treated with RAPA. Mice treated with RAPA had reduced overall body weight and reduced size of both intraabdominal and subcutaneous fat pads. When treated with RAPA, mice fed a high fat diet did not develop obesity and were not different from their regular diet controls in terms of body weight. These results suggested that RAPA inhibits adipogenesis and lipogenesis of muADSCs resulting in a prevention of obesity in C57BL/6J mice. This inhibition is strong enough to negate the effects of a high fat diet and seems to act by downregulating the RelA/p65 mTOR signaling pathway-a key component of the NF-κB family.

Medical rules of engagement negative patients: the dilemma of forward surgical teams in counterinsurgency operations.

By definition, Forward Surgical Teams (FSTs) are located far forward in the battlespace to allow for emergent treatment of life and limb threatening trauma sustained by United States and coalition forces as well as those injured according to the medical rules of engagement (MROE). While official doctrine dictates that MROE negative patients are not entitled to care by American military medical assets, experience has shown that some FSTs do not always adhere to that doctrine during counterinsurgency (COIN) operations. Medical civic action programs (MEDCAPS) have been used in modern COIN conflicts in an attempt to gain favor with and influence the host nations? local population. However, the results have frequently been counterproductive to the intended mission. The FST, by doctrine, is not equipped to take part in traditional MEDCAPS. The focus of this paper is to explore the potential role of the FST in COIN operations. Possible roles for the FST in COIN include improving the host nation medical capabilities through education and training. Further, surgery can be a useful commodity to gain positive influence with or to trade for intelligence from key local national leaders.

Further delineation of the Kapur-Toriello syndrome.

The Kapur-Toriello syndrome (KTS) is a rare multiple congenital anomaly syndrome, with presumed autosomal recessive inheritance based on the initial report of affected siblings. Here we report on a female with multiple anomalies, including cleft lip and palate, coloboma, mental retardation with cerebral atrophy, and imperforate anus who, upon re-evaluation at 30 months, was recognized to have a columella that extended below the nares. This distinctive finding prompted the diagnosis of KTS. This is the 5th report of KTS, and the second female. Interestingly, both female cases also manifest an ano/rectal malformation, suggesting that this should be considered a component manifestation of this rare syndrome.

Safety profile of wire osteosynthesis in craniosynostosis surgery.

With the advent of resorbable systems, most surgeons have stopped using wires for craniofacial fixation. Although numerous large retrospective reports regarding craniofacial surgery have been published, no documentation exists regarding the disadvantages or complications associated with wires. We review our experience with 47 consecutive patients with bicoronal and unicoronal craniosynostosis where wire osteosynthesis alone was used. Nine patients (19.1%) developed wire-related complications, but only 5 patients (10.6%) required reoperations. No other complications were observed including growth restrictions, implant migration, or interference with radiographic imaging. These results are comparable to those reported in the literature for other fixation systems and demonstrate that wires are a safe means of fixation of the cranial vault in infancy.

Deep dopamine extravasation injury: a case report.

We report the case of a 3-month-old girl with Down's syndrome, who sustained a deep and massive extravasation of dopamine, resulting in segmented, full-thickness skin necrosis and transient brachial plexus palsy of her left upper extremity. The patient was managed conservatively, including wound care, de-bridement of necrotic tissue, secondary wound healing and intensive physical therapy. The patient showed a satisfactory outcome with complete secondary closure of her wounds and full brachial plexus recovery after 1 year of follow-up. The mechanism of action of dopamine in the deep soft tissue, the difficulties of an adequate diagnosis of a deep dopamine extravasation and alternative treatments are presented in this article.

The importance of radical intravelar veloplasty during two-flap palatoplasty.

BACKGROUND: The purpose of this study was to compare the two-flap palatoplasty technique for cleft palate repair, with and without radical intravelar veloplasty, with special emphasis on the fistula rate and speech outcome. METHODS: A retrospective, time-series cohort of 213 consecutive patients with primary two-flap palatoplasty before and after the introduction of a radical intravelar veloplasty was studied. The main outcome measures were immediate postoperative complications, oronasal fistula rate, and speech. A perceptual speech evaluation was performed by two speech pathologists and included hypernasality, nasal emission, articulation, intelligibility, and overall velopharyngeal competence. The need for secondary palate surgery for velopharyngeal insufficiency was also analyzed. RESULTS: There were no differences in postoperative complications between the two study groups. Postoperative morbidity occurred in six patients (2.8 percent) and consisted of two patients with respiratory compromise, two patients who required reoperation for bleeding, and two patients with oronasal fistula. Perceptual speech evaluation demonstrated significantly better speech outcomes (81.9 percent versus 49.5 percent, p < 0.001) and a significantly lower rate of secondary palate surgery for velopharyngeal insufficiency (29 percent versus 6.7 percent, p = 0.008) in the radical intravelar veloplasty group. The most important predictive factor of speech outcome was the addition of a radical intravelar veloplasty (odds ratio, 0.175; 95 percent confidence interval, 0.039 to 0.785). CONCLUSIONS: Despite study design limitations, such as experience bias and follow-up differences, this study demonstrates that radical intravelar veloplasty may enhance the functional results of the two-flap palatoplasty without increasing postoperative morbidity. A novel classification of the muscle repair is proposed based on the amount of muscle dissection and retropositioning.

IL-10 and IL-4 in skin allograft survival induced by T-cell depletion plus deoxyspergualin.

The mechanisms mediating T-cell depletion plus 15-deoxyspergualin (DSG)-induced prolonged allograft survival or tolerance are uncertain. The purpose of this study is to evaluate the role of IL-4 and IL-10 in prolonged allograft survival induced by T-cell depletion plus DSG. MHC mismatched skin allograft transplantation was performed, using wild-type and three separate knockout (i.e., IL-4-/-, Stat6-/-, or IL-1-/ -) mice as recipients. Induction therapy consisted of T-cell depletion and or brief course of DSG. The data demonstrate that monotherapy with T-cell-depleting mAbs or DSG prolonged skin allograft survival, compared to controls, in wild-type Balb/c recipients [median survival time (MST) = 25 and 21 vs. 10 days, p < 0.007]. T-cell depletion plus DSG further augmented skin allograft survival in wild-type animals relative to monotherapy (MST = 35 days vs. 25 and 21 days, p < 0.006 vs. mAbs or DSG only), and was equally effective in IL-4-/- and Stat6-/- recipients. In contrast, combined therapy was no better than monotherapy in IL-10-/- animals (p > 0.05). Furthermore, skin allograft survival after combined therapy was shorter in IL-10-/- versus wild-type recipients (MST 20 and 41 days, respectively, p < 0.001). IL-4-mediated signaling through Stat6 is dispensable for prolonged allograft survival induced by T-cell depletion plus DSG. In contrast, IL-10 appears to be important for prolonged allograft survival induced by combined therapy in this model.

Diagnosing cutaneous leishmaniasis: the advantage of forward deployed histology in avoiding a surgical pitfall.

Military surgeons are often consulted for excisional debridement of skin lesions that fail to respond to medical therapy among soldiers who have been operating in areas of Afghanistan where cutaneous leishmaniasis is endemic. Wide surgical excision without knowledge of the primary etiology can lead to a surgical pitfall. Failure to properly treat cutaneous leishmaniasis, however, can lead to medical pitfalls of permanent disfigurement, deformity, and disability. Forward deployed surgeons should be supported by a laboratory that can confirm the presence of atypical organisms in biopsies of these lesions. With a x 100 microscope and Wright-Giemsa stains, a medical treatment facility is able to confirm cutaneous leishmaniasis, which allows for rapid transfer of soldiers for definitive antimicrobial therapy.

Enteral nutrition by a forward surgical team in Afghanistan.

OBJECTIVES: The modern practice of trauma surgery is a global physiologic approach to caring for the injured patient. Included in that approach is consideration of the traumatized patient's nutritional needs and implementing early enteral feeding. This is routine practice in the United States but logistically impractical when using commercial enteral feeding formulas in the austere environment of a Forward Operating Base in Afghanistan. METHODS: At a Forward Operating Base in southern Afghanistan, injured patients who were not expected to be taking a regular diet by 72 hours after injury are started on early enteral feedings. This is through nasogastric, gastrostomy, or jejunostomy tube, using formulas of pureed food available in the theater from local sources and supplemented with ingredients from US Army Meals-Ready-to-Eat. Preparation, nutritional calculation, and delivery are discussed. RESULTS: The injured soldiers and Afghan nationals tolerated early enteral feedings with no complications encountered related to the feeding portal, infusion, or ingredients. CONCLUSIONS: Early enteral feeding of traumatized patients in the far forward environment of southeastern Afghanistan is practical with the use of ingredients found locally in-theater.

Comorbidity trends in patients requiring sternectomy and reconstruction.

INTRODUCTION: The predisposing risk factors for sternal wound infection have been well delineated. However, the indications and comorbidity of patients who require cardiac surgery via the median sternotomy approach have changed over time and subsequently have changed the patient population presenting with sternal wound complications. These trends in cardiac surgery may require an adjustment of the plastic surgical approach and methods to optimize outcomes in the patient population. METHODS: A retrospective review was performed to identify patients who had undergone sternectomy or sternal debridement followed by flap coverage. A total of 93 cases performed between 1999 and 2004 examined to collect data about the initial presentation, operative procedure, and postoperative care of each patient. The data were then analyzed to identify population characteristics using logistic regression variables to determine univariate and adjusted (multivariable) measures of association with mortality. RESULTS: Results of the review indicated that 53% of the patients were male and 47% were female, with a median age of 62 years. Preoperative comorbidities included 64% of the patients were over age 60, 43% had diabetes, 51% had hypertension, 13% had renal insufficiency, and 6% were transplant recipients. The method of reconstruction varied, but the majority were pectoralis advancement flaps. Of the patients who underwent debridement and reconstruction, there was a 16% 30-day mortality. Among these mortalities, the distribution was 33% (5/15) male and 66% (10/15) female. CONCLUSIONS: Though the incidence of sternal wound problems is rare (about 1%-5%), there is a significant population of older, renal-insufficient, malnourished patients who present days or weeks after one would normally diagnose and treat a deep sternal wound infection who have a significant mortality rate. Appropriate identification of risk factors, preoperative management and timing for aggressive surgical treatment is required to maximize successful outcomes in this problematic patient population.