An increase in heart rate variability can be an index for end point of resuscitation in trauma patients.

PURPOSE: The measurement of heart rate variability (HRV) is a non-invasive method to analyze the balance of the autonomic nervous system. The aim of this study was to compare the changes of HRV and base deficit (BD) during the treatment of trauma patients. METHODS: Forty-three trauma patients with a low injury severity scores (ISS < 24) and negative base excess on admission were included in this study. Based on the BD changes, patients were divided into three groups: 'end pointed' group (n = 13), patients' BDs instantly cleared after primary hydration; 'needs further resuscitation' group (n = 21), patients' BDs did not reach the end point and thus required further hydration or packed red blood cells transfusion; and 'hydration minimal change' group (n = 9), patients' BDs lower than 2.5 mmol/L at the onset of admission and thereafter had minimal change (near normal range). The changes in HRV during fluid resuscitation were detected and compared to BD changes in their arterial blood gases. All data were analysed using the SPSS software Version 15.0. Repeated measures ANOVA was used to determine the changes in HRV, heart rate, blood pressure, and BD among groups. RESULTS: A significant reverse correlation was found between the BD ratio and the HRV ratio (r = -0.562; p = 0.01). The HRV of patients with aggravated BDs after fluid resuscitation was decreased. There was an increase in HRV at the time of BD clearance. A decrease in HRV after primary crystalloid hydration bore a significant connection with the need for an ICU (p = 0.021) and transfusion of packed red blood cells (p < 0.001). CONCLUSION: Increase in HRV may be a new non-invasive index for the end point of resuscitation in trauma patients.

A new brace for maintaining the neck in a suitable position following tracheal reconstruction.

Segmental resection and end-to-end anastomosis is the treatment of choice for patients suffering from tracheal stenosis for whom conservative management is not planned. A complication of this procedure is tension-induced anastomotic failure. To prevent this complication, maintaining the neck in full flexion by means of a suture between the chin and upper chest is a traditional approach. We have designed a new brace (Shiraz brace) that securely supports the neck in this position and decreases the bothersome use of the suture alone.

Implementation of Upper Extremity Trauma Registry: A Pilot Study.

Background: Hand traumas are common in young men and their complications can have negative effects on their occupation and economic activities. On the other hand, most of the hand injuries are related to occupation accidents and thus necessitates preventive measures. The goal of a clinical registry is assisting epidemiologic surveys, quality improvement preventions. Methods: This article explains the first phase of implementing a registry for upper extremity trauma. This phase includes recording of demographic data of patients. A questionnaire was designed. Contents include patients' characteristics, pattern of injury and past medical history in a minimal data set checklist. This questionnaire was filled in the emergency room by general practitioners. For 2 months the data were collected in paper based manner, then problems and obstacles were evaluated and corrected. During this period a web based software was designed. The registry was then ran for another 4 months using web based software. Results: From 6.11.2019 to 5.3.2020, 1675 patients were recorded in the registry. Random check of recorded data suggests that accuracy of records was about 95.5%. Most of the missing data was related to associated injuries and job experience. Some mechanisms of injury seems to be related to Iran community and thus warrants special attention for preventive activities. Conclusion: With a special registry personnel and supervision of plastic surgery faculties, an accurate record of data of upper extremity trauma is possible. The patterns of injury were remarkable and can be used for investigations and policy making for prevention.

Epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran: a community-based survey.

OBJECTIVE: To determine the epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran. METHODS: This cross-sectional study was conducted in Fars Province of Iran during a 29-month period from March 2009 to July 2011. The data were from the Fars Forensic Medicine Registry. In 4 923 recorded road traffic accident fatalities, 971 deaths were due to pedestrian accidents. The demographic and accident-related information were analyzed by SPSS version 11.5. P value less than 0.05 was considered significant. RESULTS: The mean age of decedents was (47.2+/-26.2) years, ranging from 6 months to 103 years old. Males accounted for 69.8% of all deaths. Fatal accidents were most common in September; 56.1% of the fatal injuries occurred on intracity roads and 33.1% on extracity roads. Fatal head injuries were present in 60.54% of cases. Evaluation of the injury site and the cause of death found that they were significantly associated with age, interval between injury and death. Besides, the type of roads played an important role in mortality. CONCLUSION: Although the clinical management of trauma patients has been improved in our country in the recent decade, decreasing the burden of injuries needs coordination among trauma system organizations.

Fatal motorcycle accidents in Fars Province, Iran: a community-based survey.

OBJECTIVE: To identify the main characteristics of victims of motorcycle accidents in Fars Province, Iran. METHODS: This cross-sectional study was conducted in Fars Province which has the fourth largest population of all 31 provinces in Iran from March 2009 to June 2010. We included data from all 542 recorded cases of fatalities due to motor vehicle accidents. Data were recorded from the forensic medicine registry consisting of demographic and accident-related information. Demographic information consisted of name, age, sex, status of fatal victim (motorcycle driver vs passenger) and educational level. RESULTS: Of the 2 345 autopsy records from the forensic medicine archives, 542 (23.1%) gave the cause of death as motor vehicle accidents. Mean age of these victims was (31.4+/-6.5) years, and the male to female ratio was 28. Head injury was the most common cause of death in these victims, and overall they tended to have a low level of education. Motorcycle accidents frequently involved younger age groups (15-35 years), and head trauma related with non-use of a helmet was the most common cause of death. CONCLUSIONS: Head injury is frequent among victims in the province we studied. This situation may be related to the victims' low socioeconomic status and little education regarding traffic laws leading to speeding and disregard of these laws along with their weak enforcement.

Heart Rate Variability May Predict the Severity of Appendicitis: A Cross-Sectional Study.

Objective: To evaluate the role of heart rate variability (HRV) in predicting pre-operative severity of appendicitis. Methods: In this cross-sectional study, 171 cases of acute appendicitis who underwent appendectomy were enrolled. Pre-anesthetic pulse rate of included patients were documented while the severity of appendicitis was determined by intra-operative evidences reported by two independent surgeons. Demographic characteristics, laboratory variables, and Alvarado criteria were recorded. Results: The mean age of patients was 28.75±4.21 years; 54% were men. HRV negatively associated the severity of appendix inflammation. A positive association was found between HRV and omental wrapping and Alvarado score (p<0.01). The receiver operating characteristic (ROC) curve analysis demonstrated that HRV could differentiate simple and complicated appendicitis with a sensitivity of 78.5% and specificity of 97.2%. Conclusion: The present findings revealed that HRV may predict the pre-operative severity of appendicitis and help differentiate simple and complicated appendicitis.

Isolated Congenital Absence of Right Lower Lateral Cartilage and Reconstruction with Septal Cartilage: A Case Report and Review of Literature.

Congenital anomalies of the nose are rare but may be associated with syndromes affecting craniofacial structures. Herein, we report a case of a congenital absence of lower lateral cartilage seen during an open rhinoplasty in a 23-yr-old lady with no underlying health conditions. Medical and surgical history were unremarkable and there were no evidences conducted of any previous traumatic facial injuries. During physical examination, a significant nostril asymmetry was noted to be present. In addition, cotton test showed no evidence of obstruction. The absence of lower lateral cartilage on the right side was noted during the degloving stage of the open rhinoplasty. Absence of lower lateral cartilage poses a technical challenge in surgery and in order to reconstruct this structure, cartilage can be harvested from concha, lower lateral cartilage, septum and cartilaginous dorsal hump during an open approach rhinoplasty.

Use of heart rate variability to predict hospital length of stay for COVID-19 patients: A prospective observational study.

BACKGROUND: As the COVID-19 pandemic continues, determining hospital demands has become a vital priority. Heart rate variability (HRV) has been linked to both the presence of viral infection and its severity. We investigate the possibility of using HRV parameters in comparison to other clinical parameters for predicting the hospital length of stay (LOS) for COVID-19 patients. METHODS: This was a population-based cohort study. Measurements were performed in a specialized hospital for respiratory disease, dedicated to COVID-19. Patients were polymerase chain reaction positive for COVID-19 and on their 1st day of admission. Heart period, respiratory sinus arrhythmia (RSA), low frequency (LF) HRV, and vagal efficiency were calculated from electrocardiogram signals. This study investigated the correlation of HRV, demographic, and laboratory parameters with hospital LOS. RESULTS: Forty-one participants were recruited, with a significant relationship, observed between hospital LOS and some demographic and clinical parameters such as lymphocyte count, age, and oxygen saturation of arterial blood. There was a negative relationship between LF and hospital LOS (r = -0.53, 95% confidence interval: -0.73, -0.24). Higher vagal efficiency predicted shorter hospital LOS in patients younger than 40 years of age (19.27% shorter hospital LOS was associated with a one SD higher value of VE, P = 0.007). CONCLUSION: HRV measurement is a non-invasive, inexpensive, and scalable procedure that produces several metrics, some of which are useful for predicting hospital LOS and managing treatment resources during COVID-19 pandemic.

The Role of Recombinant Fibroblast Growth Factor 1 in Enhancing the Angiogenesis in Random Cutaneous Flaps in Animal Model of Rat.

BACKGROUND: Randomized skin flaps have been used as a basic treatment modality for covering skin defects for a long time but they have always been in the risk of an inherent ischemia. Fibroblast growth factor 1 is a known angiogenic factor in in vitro studies which has shown conflicting results in in vivo investigation. We aimed to determine the effect of recombinant fibroblast growth factor on the angiogenesis rate of random cutaneous flap in animal model of rats. METHODS: This experimental study was conducted on 24 adult male rats randomized to 2 groups. In the first group FGF1 was injected subdermally in equally divided doses and distances of random flap surface in days 1, 3 and 5. In second group, normal saline was injected as control. Flap surgery was done on day 21 after first injection. The extent of necrosis and angiogenesis (mean vessel density) were assessed in day 14 after surgery. RESULTS: The mean percentage of clinically apparent necrosis was 35.2% (±10.5) in intervention (FGF1) group and 38.1% (±8.7) in control (normal saline), respectively. Mean vessel density was 86.20±5.6/mm2 in control group and 90.17±5.5/mm2 in intervention group, which showed no statistically significant difference. CONCLUSION: Mean vessel density and mean percentage of clinically apparent necrosis area were similar in 2 groups of rats with random cutaneous flaps receiving FGF1 or normal saline.

Results of a Campaign for Motorcycle Helmets Advocacy in a City in Southwest of Iran; A Population-Based Intervention Study.

OBJECTIVE: We conducted a triple phase project for motorcycle helmets advocacy in Darab, a city in southwest Iran. The aim of this study was to evaluate the effect of the project on decreasing the hazards of motorcycle accidents. METHODS: Using a questionnaire, data for ICU admission rates, hospital costs for patients who required ICU admission, rate of helmet usage, mortality and the duration of ICU care for patients admitted to Darab hospital due to motorcycle accidents in Winter 2015 (before conducting the project) and Winter 2016 (after conducting the project) were gathered and compared. This feature was also separately done for patients younger than 17 years. RESULTS: The rate of wearing helmets increased significantly in winter 2016 (from 3.4 % to 33%). Also ICU admission rate due to head trauma was significantly decreased after the project was done (from 14.5 % to 4%). However, hospital costs for patients required ICU admission were increased in winter 2016. This increase, though not significant, seems to be due to an increase in health service expenses in the year 2016 as compared with the year 2015. The mortality rate was not significantly changed between the two mentioned years results. For patients younger than 17 years, no ICU admissions were needed in winter 2016. CONCLUSION: Even a short period of intervention can have positive effects on increasing the safety of motorcycle drivers.

Evaluation of Patients' Satisfaction and Functional Outcome of Dorsal Hand Unit Reconstruction in Burn Patients in Shiraz, Southern Iran.

The aim of this study was to assess patients' satisfaction and functional outcome of dorsal hand unit reconstruction in burn patients in Shiraz, southern Iran.From September 2013 to February 2017, 11 patients (15 hands) with hand aesthetic complaint who were unhappy with their hand appearance were included for dorsal hand unit reconstruction. Under general anesthesia and tourniquet control, the burned tissue on dorsal surface of the hands was excised and a thick partial thickness skin graft was used for coverage, whereas the fingers were fixed by sutures to the palm. After 1 year, the five-points scale was used for evaluation of patients' satisfaction regarding the five major activities considered for hand function before and after operation. The mean age of the patients was 25.8 ± 5.17 years. The skin grafts were well taken. Six (40%) and eight patients (53%) reported the result of operation as completely satisfied and satisfied, respectively. Dorsal hand unit reconstruction in patients with dorsal hand contracture and significant dorsal scar was shown to simultaneously improve the function and aesthetic outcome of the surgery.

Candida interface keratitis after deep anterior lamellar keratoplasty: clinical, microbiologic, histopathologic, and confocal microscopic reports.

PURPOSE: To report the clinical, histopathologic, microbiologic, and confocal microscopic features of Candida keratitis after deep anterior lamellar keratoplasty (DALK). METHODS: We performed clinical, confocal scan, microbiologic and histopathologic examinations on two corneas from 2 young patients who underwent DALK for keratoconus. RESULTS: The first patient presented with asymptomatic white to cream-colored interface deposits 2 months after DALK. The confocal scan disclosed clusters of hyperreflective, fine granular deposits at the region of interface, with no evidence of inflammation or hyphaelike structures. The clinical presumption of possible "epithelial downgrowth" was suggested, and because of the progression of these lesions, irrigation of the interface was considered. Finally, penetrating keratoplasty was performed because of a rupture in the Descemet membrane. Histopathologic examination of the cornea disclosed yeastlike structures within the interface area. The microbiologic results of the irrigation fluid showed Candida glabrata. The second patient presented with a symptomatic infiltration of the inferior interface close to the suture site 2.5 months after DALK. The confocal scan showed foci of inflammation with clusters of hyperreflective round-shaped structures that resembled epithelial cells. Clinically, there was a suggestion of epithelial downgrowth, and subsequently, penetrating keratoplasty was performed because of the progression of the lesion. Histopathologic examination of the cornea disclosed an acute and chronic granulomatous keratitis caused by yeastlike structures. The microbiologic results revealed infection with Candida albicans. CONCLUSIONS: These are the first reported occurrences of interface Candida keratitis after DALK and with different confocal features. The clinical and the confocal features of interface Candida keratitis may be similar to those seen in epithelial downgrowth, which may postpone correct diagnosis and treatment. Candida keratitis should be considered in cases of interface deposits after any form of lamellar keratoplasty.

Predictive Potential of Heart Rate Complexity Measurement: An Indication for Laparotomy Following Solid Organ Injury.

BACKGROUND: Nonlinear analysis of heart rate variability (HRV) has been recently used as a predictor of prognosis in trauma patients. OBJECTIVES: We applied nonlinear analysis of HRV in patients with blunt trauma and intraperitoneal bleeding to assess our ability to predict the outcome of conservative management. PATIENTS AND METHODS: An analysis of electrocardiography (ECG) from 120 patients with blunt trauma was conducted at the onset of admission to the emergency department. ECGs of 65 patients were excluded due to inadequacy of noise-free length. Of the remaining 55 patients, 47 survived (S group) and eight patients died in the hospital (Non-S group). Nineteen patients were found to have intra-abdominal bleeding, eight of which ultimately underwent laparotomy to control bleeding (Op group) and 11 underwent successful non-operative management (non-Op). Demographic data including vital signs, glasgow coma scale (GCS), arterial blood gas and injury severity scores (ISS) were recorded. Heart rate complexity (HRC) methods, including entropy, were used to analyze the ECG. RESULTS: There were no differences in age, gender, heart rate (HR) and blood pressure between the S and Non-S groups. However, approximate entropy, used as a method of HRC measurement, and GCS were significantly higher in S group, compared to the Non-S group. The base deficit and ISS were significantly higher in the Non-S group. Regarding age, sex, ISS, base deficit, vital signs and GCS, no difference was found between Op and Non-Op groups. Approximate entropy was significantly lower in the Op group, compared to the Non-Op group. CONCLUSIONS: The loss of HRC at the onset of admission may predict mortality in patients with blunt trauma. Lower entropy, in recently admitted patients with intra-abdominal bleeding, may indicate laparotomy when the vital signs are stable.

Totally transanal LESS pull-through colectomy: a novel approach for avoiding abdominal wall incision in children with long-segment intestinal aganglionosis.

UNLABELLED: Abstract Introduction: Minimally invasive surgery in children with long-segment intestinal aganglionosis aims to reduce the number of abdominal wall incisions. Conventional laparoscopic and laparoendoscopic single-site (LESS) surgeries fulfill this goal. In children, natural orifice translumenal endoscopic surgery (NOTES™; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society for American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) has been limited because of fear of access site complications. We present a novel technique of totally transanal LESS pull-through colectomy (TLPC), avoiding abdominal wall incision, which combines LESS technology and the NOTES approach. SUBJECTS AND METHODS: Two boys and one girl (2.5 months, 6 months, and 5 years of age, respectively) with sigmoid and transverse colon aganglionosis underwent surgery. The TLPC procedure consisted of an endorectal technique with submucosal dissection starting 1 cm orally from the dentate line to above the peritoneal reflection, where the rectal muscle was divided circumferentially. After ligation of the rectal mucosa, the proximal bowel was replaced into the abdominal cavity, and a TriPort(®) (Olympus Surgical Technologies Europe, Hamburg, Germany) was introduced transanally. Mesenterial resection of the aganglionic bowel was accomplished via transanal LESS until the normoganglionic colon segment was reached and pulled down to the site of anastomosis. After removal of the port, a conventional pull-through procedure was performed. RESULTS: All children displayed normal bowel movements and were complication-free during the follow-up period of up to 7 months. CONCLUSIONS: TLPC combines the minimally invasive LESS surgery with the scarless concept of NOTES and allows resection of long-segment aganglionosis without abdominal incision. TLPC is a safe, effective, and feasible surgical procedure in children with long-segment intestinal aganglionosis.

Nested stromal epithelial tumor of liver presenting with Cushing syndrome: a rare case report.

Nested stromal and epithelial tumor of the liver is an extremely rare pediatric hepatic tumor. To the best of our knowledge, about 25 cases have been reported in the English literature so far, few of which accompanied with Cushing syndrome. Herein we report our experience with an 8-year-old boy presented with Cushing's syndrome because of ectopic ACTH production by this tumor.

Ahram mineral water-induced sulfate keratopathy: histopathologic, electron microscopic, and confocal scan features.

PURPOSE: To characterize histopathologic, electron microscopic, and confocal scan features of Ahram mineral water (AMW)-induced keratopathy in cadaver corneas. METHODS: Seven cadaver globes were examined, 5 of which were exposed to AMW from the corneal side for different durations (30 seconds and 3, 15, 30, and 60 minutes) and the other 2 were considered as control. After performing confocal scan on each cornea, we excised the corneoscleral rim and sent it for histopathologic evaluation. Scanning electron microscopic and transmission electron microscopic examinations were performed on the cornea exposed to AMW for 60 minutes. RESULTS: Depending on the time of exposure, the confocal scan features varied from intraepithelial high-contrast deposits to subepithelial bulla formation. The histopathologic features ranged from diffuse intracytoplasmic sulfur deposits to subepithelial bulla formation. Scanning electron microscopic examination disclosed rather diffuse irregular bright deposits of high sulfur content over the surface epithelium and together with focal cellular destruction and micro-hole formation in the case with 60-minute exposure. On transmission electron microscopy, electron-lucent bulky deposits were found underneath the basal epithelial cells and between their basement membrane and Bowman layer. Confocal scan of the control corneas disclosed nonspecific anterior stromal haze and Descemet folds, with no evidence of intraepithelial deposits. No pathologic finding was noted on histopathologic examination of the control corneas. CONCLUSIONS: AMW induces sulfate keratopathy of mainly anterior corneal involvement and with various histopathologic, confocal microscopic, and electron microscopic features even with short-time exposure.