Cutaneous Impact Location Predicts Intracranial Injury Among the Elderly Population with Traumatic Brain Injury.

Background: Traumatic brain injury (TBI) is one of the most common trauma-related diagnoses among the elderly population treated in emergency departments (ED). Identification of patients with increased or decreased risk of intracranial bleeding is of clinical importance. The objective of this study was to evaluate the implication of cutaneous impact location (CIL) on the prevalence of intracranial injury after suspected or confirmed TBI irrespective of its severity. Methods: This was a retrospective, single-center, descriptive observational study of geriatric patients aged 65 years and older treated for suspected or confirmed TBI in a trauma surgery ED. The primary outcome of the study was the assessment of a CIL of the injury and its association with the prevalence of intracranial lesions found on a head computed tomography scan. Results: Among 381 patients included in the analysis, the CIL of interest (temporo-parietal and occipital impacts) was present among 178 (46.7%) cases. Thirty-six (9.5%) patients were diagnosed with intracranial bleeding. The prevalence of intracranial bleeding was higher in the CIL of interest group compared with other locations outside (12.9% vs 6.4%; p = 0.030). CIL of interest was a predictor of intracranial bleeding (p = 0.033; OR: 2.17; 95% CI: 1.06 to 4.42). Conclusion: The CIL of head injury is a predictor of intracranial lesions among geriatric patients with traumatic brain injury. Physicians should be aware of this association when assessing elderly patients with head injuries. More studies are needed to develop a clinical management tool incorporating CIL to guide the diagnosis of TBI in this population.

Ischemic Tolerance-A Way to Reduce the Extent of Ischemia-Reperfusion Damage.

Individual tissues have significantly different resistance to ischemia-reperfusion damage. There is still no adequate treatment for the consequences of ischemia-reperfusion damage. By utilizing ischemic tolerance, it is possible to achieve a significant reduction in the extent of the cell damage due to ischemia-reperfusion injury. Since ischemia-reperfusion damage usually occurs unexpectedly, the use of preconditioning is extremely limited. In contrast, postconditioning has wider possibilities for use in practice. In both cases, the activation of ischemic tolerance can also be achieved by the application of sublethal stress on a remote organ. Despite very encouraging and successful results in animal experiments, the clinical results have been disappointing so far. To avoid the factors that prevent the activation of ischemic tolerance, the solution has been to use blood plasma containing tolerance effectors. This plasma is taken from healthy donors in which, after exposure to two sublethal stresses within 48 h, effectors of ischemic tolerance occur in the plasma. Application of this activated plasma to recipient animals after the end of lethal ischemia prevents cell death and significantly reduces the consequences of ischemia-reperfusion damage. Until there is a clear chemical identification of the end products of ischemic tolerance, the simplest way of enhancing ischemic tolerance will be the preparation of activated plasma from young healthy donors with the possibility of its immediate use in recipients during the initial treatment.

Area of the plateau depression and higher age predict post-operative subsidence in split-depression lateral tibial fracture.

INTRODUCTION: The aim of this study was to determine factors that affect post-operative subsidence in split-depression lateral plateau tibial fracture (OTA/AO 41B3.1) which was treated with raft construct through a locking plate. PATIENTS AND METHODS: The retrospective study evaluated all split-depression lateral plateau tibial fracture cases treated with raft construct through a locking plate between 01/2015 and 04/2020 with a minimum of 12-month follow-up. Data on the patients' age, sex, time from injury to surgery, type of plate, and use of subchondral bone defect filler were retrieved from the hospital database. The measurements of total plateau area (TPA), depressed lateral plateau area (DPA), and maximal plateau depression (MPD) were performed on the patients' pre-operative CT scans. The percentage of DPA to TPA (%DPA) was calculated. Post-operative radiographs were used for the evaluation of plateau subsidence. A subsidence greater than 2 mm was considered a failure. RESULTS: There were 41 consecutive cases of split-depression lateral plateau tibial fracture in the reviewed period. Five cases were excluded, three of them were lost to follow up, 1 patient had no pre-operative CT scan and 1 had a history of cancer. A failure was identified in 11 (31%) cases. Patients in the failure group were older (61.0 vs 50.7 years, p = 0.01), and had a higher incidence of fractures extending into intercondylar eminence (100% vs 56%, p = 0.02). Multiple logistic regression identified DPA (OR = 3.6; 95%CI 1.4-9.5, p < 0.01) and age (OR = 1.2; 95% CI 1.0-1.4, p = 0.02) as predictive factors for plateau subsidence. DPA cut-off value for predicting subsidence greater than 2 mm was 5.8 cm2 [Area Under the ROC Curve 0.89 (95% CI 0.74-0.97), sensitivity 91%, specificity 80%, p < 0.01)]. CONCLUSION: Age and depressed lateral plateau area (DPA) in split-depression lateral plateau tibial fracture treated with raft construct through a locking plate are risk factors for post-operative subsidence greater than 2 mm.

Interaction between Mesenchymal Stem Cells and the Immune System in Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is an autoimmune disease that causes damage to joints. This review focuses on the possibility of influencing the disease through immunomodulation by mesenchymal stem cells (MSCs). There is an occurrence of rheumatoid factor and RA-specific autoantibodies to citrullinated proteins in most patients. Citrulline proteins have been identified in the joints of RA patients, and are considered to be the most suitable candidates for the stimulation of anti-citrulline protein antibodies production. Fibroblast-like proliferating active synoviocytes actively promote inflammation and destruction in the RA joint, in association with pro-inflammatory cells. The inflammatory process may be suppressed by MSCs, which are a population of adherent cells with the following characteristic phenotype: CD105+, CD73+, CD90+, CD45-, CD34- and HLA DR-. Following the stimulation process, MSCs are capable of immunomodulatory action through the release of bioactive molecules, as well as direct contact with the cells of the immune system. Furthermore, MSCs show the ability to suppress natural killer cell activation and dendritic cells maturation, inhibit T cell proliferation and function, and induce T regulatory cell formation. MSCs produce factors that suppress inflammatory processes, such as PGE2, TGF-ß, HLA-G5, IDO, and IL-10. These properties suggest that MSCs may affect and suppress the excessive inflammation that occurs in RA. The effect of MSCs on rheumatoid arthritis has been proven to be a suitable alternative treatment thanks to successful experiments and clinical studies.

A new comprehensive Classification Scheme for ECU Tendon Problems at the Wrist.

Based on a systematic review of the literature, description of previous classification schemes and new anatomical knowledge, a new comprehensive classification scheme for ECU tendon problems at the wrist is described.

Scope Assessment of Soft Tissue Injury within Polytrauma for Needs of Fortis System Injury Classification.

BACKGROUND: The paper points out the importance of quantifying the extent and nature of organ and tissue injury within the assessment of severity of damage to health caused by effect of blunt or combined force. OBJECTIVE: This study aims to determine the value of mechanical violence that caused the injury using the Fortis system based on the detected range of injured soft tissue and the localization of the sites affected by said violence. MATERIAL AND METHODS: In this experimental study the authors carried out measurements and calculations in 10 pedestrians, who died of polytrauma in an accident. The morphometric Ellipse v.2.0.7.1.software was used for the purpose (Vidito Kosice, Slovak Republic). RESULTS: The internal organ injuries were successfully evaluated in a planographic manner on serial sections with the following calculation of total extent of tissue damage (TETD). It turned out that if TETD is more than 40%, it will be possible to evaluate an injury as severe or life-threatening. CONCLUSION: The above classification and localization of pedestrian injuries facilitate calculations in simulation programs to determine how the movement of a pedestrian´s body during and after the collision occurred based on the unrepeatability of movement parameters; besides, contacts with a vehicle help determine the input data to calculate the collision. Based on the submitted case reports and performed measurements and calculations, the presented method of the extent classification of soft tissue damage is evaluated to be useful to standardize the injury parameters and assess polytrauma as a result of disproportionate force.

Reversed Z-effect and Z-effect phenomena in femoral neck fracture treated with a dynamic locking plate fixation: Case report.

The aim of this case report is to present an unusual mechanism of failure of a dynamic locking plate (DLP), previously reported in dual lag screw proximal femoral nails. A 78-year-old female patient experienced a displaced right femoral neck fracture (FNF) which was managed with DLP. At the postoperative sixth-week appointment, her hip radiographs showed that two of three telescoping screws had slid within the telescrew barrel, and one screw was fully extended and cutting through the femoral head. At the third-month checkup, radiographs revealed an unhealed FNF and 12 mm sliding on all three telescoping screws. At the final 11th-month follow-up, two screws were completely collapsed and the previously nonpenetrating screw was partially extended and cutting through the femoral head. Femoral neck shortening and femoral neck nonunion were noticed as well. In conclusion, the postoperative course of the case supports the hypothesis of a specific pattern of DLP failure resembling reversed Z- and Z-effects found in dual lag screw proximal femoral nails.

Remote ischemic postconditioning as well as blood plasma from double-conditioned donor ameliorate reperfusion syndrome in skeletal muscle.

The aim of this study was to verify the possibility of preparation and effectiveness of the use of blood plasma containing an effector of ischemic tolerance activated by applying two sublethal stresses to a donor. As sublethal stresses, two periods of 20-minute hindlimb ischemia were used with a two-day interval between them. Active plasma was isolated six hours after the second hindlimb ischemia. The effectiveness of active plasma as well as remote postconditioning was tested after three hours of tourniquet-induced ischemia on the gastrocnemius muscle. The wet/dry ratio of gastrocnemius muscle (degree of tissue oedema), nitroblue tetrazolium reduction (tissue necrosis), and CatWalk test (hind limb functionality) were evaluated 24 h after the end of ischemia. Three hours of ischemia increased muscle oedema and necrosis in comparison to control by 26.72% (p < 0.001) and 41.58% (p < 0.001) respectively. Remote ischemic postconditioning as well as injection of conditioned blood plasma significantly prevented these changes, even when they were applied one or three hours after the end of ischemia. Equally effective double-conditioned plasma appears to have better prospects in life-threatening situations such as stroke and myocardial infarction.

Factors influencing femoral neck fracture healing after internal fixation with dynamic locking plate.

INTRODUCTION: The purpose of this study was to determine factors that affect the early failure of femoral neck fracture healing after internal fixation with a dynamic locking plate implant. PATIENTS AND METHODS: Retrospective analysis of all cases of femoral neck fracture (FNF) primarily treated with dynamic locking plate implant from 04/2014 to 04/2017 with a minimum of 6 month follow-up. For the purpose of the study age, sex and time from admission to surgery were retrieved from the hospital medical database. Patient's pre- and postoperative hip radiographs were reviewed by the authors. Radiographically detected fracture healing failure (non-union and screw cut-out) was recorded. RESULTS: For the period of the study, there were 77 consecutive FNF (76 patients) treated with the dynamic locking plate implant. Eight (10%) patients were lost to follow-up, 13 (17%) patients died within 6 months after surgery. Healing failure was identified in 23 (41%) of remaining 56 cases. Three of four (75% failure rate) failures were observed in cases with fair-quality reduction and two of two (100% failure rate) failures were noticed in the case of none telescoping screw located within subchondral bone. Multiple logistic regression showed an increased risk of fracture failure in cases with at least one completely collapsed telescoping screw (OR = 73.2; 95% CI 9.4-568.5, p < 0.01), while telescoping screws' location around centre of the femoral head reduces the risk of failure (OR = 14.7; 95% CI 1.6-135.1, p = 0.02). CONCLUSION: In our group of patients, fracture healing failure of the FNF treated with dynamic locking plate reached 41%. This high failure rate was associated with poor fracture reduction, not subchondrally and centrally placed telescoping screws and in the case of complete collapse on at least one of the telescoping screws.

Redistribution of acute traumatic infratentorial subdural hematoma to the spinal subdural space.

Spinal subdural hematoma is a rare and potentionally life-threatening condition associated with trauma and other pathological conditions. In this paper we report the autopsy findings of a 64 year old male who was repeatedly hospitalized with traumatic head injuries in the past. In this case spinal subdural hematoma was diagnosed post-mortem and later comfirmed by ante-mortem CT scan revaluation. Keywords: intracranial subdural hematoma - recurrent spinal subdural hematoma - diffuse axonal injury - autopsy findings.

Rare Presentation of Left Lower Lobe Pulmonary Artery Dissection.

Background. Pulmonary arterial dissection with chronic pulmonary arterial hypertension as its major cause is a very rare but life-threatening condition. In most cases the main pulmonary trunk is the affected site usually without involvement of its branches. Segmental or lobar pulmonary artery dissection is extremely rare. Case Presentation. We report a unique case of left lower lobe pulmonary artery dissection in a 70-year-old male, with confirmed chronic pulmonary hypertension. To confirm dissection MDCT pulmonary angiography was used. Multiplanar reformation (MPR) images in sagittal, coronal, oblique sagittal, and curved projections were generated. This case report presents morphologic CT features of rare chronic left lobar pulmonary artery dissection associated with chronic pulmonary hypertension at a place of localised pulmonary artery calcification. CT pulmonary angiography excluded signs of thromboembolism and potential motion or flow artefacts. Conclusion. To the best of our knowledge, no case of lower lobe pulmonary artery dissection with flap calcification has been reported yet. CT imaging of the chest is a key diagnostic tool that is able to detect an intimal flap and a false lumen within the pulmonary arterial tree and is preferred in differential diagnosis of rare complications of sustained pulmonary arterial hypertension.

Prenatal three-dimensional sonographic findings associated with fetal defecation. Case Report.

Routine ultrasonography examination may miss fetal defecation and if seen it can be a source of misinterpretation which can lead to a wrong diagnose and management of pregnancy. We report two rare cases of fetal defecation in the second trimester and we describe 3D sonographic findings associated with this condition.

Delayed remote ischemic postconditioning protects against transient cerebral ischemia/reperfusion as well as kainate-induced injury in rats.

To test the appropriateness of using delayed remote ischemic postconditioning against damage caused to the hippocampus by ischemia or apoptosis inducing intoxication, we chose 10-min normothermic ischemia induced by four-vessel occlusion or kainate injection (8 mg/kg i.p.) in rats. Ischemia alone caused the number of degenerated CA1 neurons after 7 days lasting reperfusion to be significantly (p<0.001) increased by 72.77%. Delayed remote ischemic postconditioning lasting 20 min was able to prevent massive increase in the neurodegeneration. The group with 10 min of ischemia and postconditioning after 2 days of reperfusion had only 15.87% increase in the number of apoptotic neurons. Seven days after kainic acid injection the number of surviving neurons was 42.8% (p<0.001), but the portion of surviving pyramidal cells in the postconditioning group is more than 98%. Our data show that remote postconditioning, performed with 20 min of tourniquet ischemia applied to the hind limb, is a simple method able to effectively stop the onset of neurodegeneration and prevent occurrence of massive muscle cell necrosis, even when used 2 days after the end of the adverse event. Surviving neurons retained a substantial part of their learning and memory ability.

Obturator artery injury after hip fracture surgery.

We present the case of a 55-year-old woman who sustained a left femoral neck fracture which was managed by insertion of a dynamic hip screw. Six hours after surgery, distension appeared in the left lower quadrant of her abdomen associated with a decline in haemoglobin concentration and clinical signs of ongoing bleeding. Computed tomography showed a left retroperitoneal mass without concomitant extravasation of contrast material. Exploratory laparotomy revealed a damaged left obturator artery with a large haematoma in its vicinity. After arterial ligation and retroperitoneal space decompression her postoperative course was uneventful. Reviewing intraoperative C arm images a 0.8 cm protrusion of the threaded guide wire was identified as the cause of obturator artery damage.

Local transcutaneous cooling of the spinal cord in the rat: effects on long-term outcomes after compression spinal cord injury.

This study tested efficiency of a novel thermoelectric cooler for local transcutaneous spinal cord cooling. Spinal cord compression was made by epidural balloon inflation at T8-T9 level of the spinal cord. Experimental animals (n=20) were divided into two groups. In the hypothermic group, local cooling started 25 min after spinal cord injury and lasted for 1 h with paravertebral temperature maintained at 28.5 degrees C (+/-0.3). Normothermic group underwent identical procedures, but their temperature was maintained normothermic. The assessment of neurologic recovery was performed once a week during a 4 weeks survival period. After 4 weeks animals were sacrificed and the extent of the spinal cord lesion morphometrically evaluated. There were no statistically significant intergroup differences in BBB scores and preserved volumes of the spinal cord tissue. In consecutive cross-sectional areas, hypothermic animals had significantly more preserved white matter at the cranial periphery of the lesion. It was concluded that mild posttraumatic hypothermia (31.8 degrees C) had some protective effect on tissue loss after spinal cord injury but this effect was not associated with functional improvement.