Review of gunshot wounds in Dayton, Ohio. Demographics, anatomic areas, results, and costs

A retrospective review of 210 admissions for gunshot wounds was performed to evaluate the frequency that various anatomic areas were injured, complication rates, results of treatment, and costs. Seventy-two percent of patients had a single anatomic site involved. The complication rate was 13% and the death rate was 10.9%. A good result was obtained in 72%, but 12.4% had long-term disabilities. The average length of stay was 11 days with an average cost of +5,682 per patient. Application of today's prospective payment under diagnosis-related groups suggests this system of payment may adversely affect the delivery of trauma care in this country.     

Enteric bacteriology, absorption, morphology and emptying after ileal pouch-anal anastomosis

The aim was to determine whether changes in enteric bacteriology, absorption, morphology, and emptying occur after ileal pouch-anal anastomosis for ulcerative colitis, and to relate any changes to the clinical result. Twenty patients were studied 26 +/- 2 months (mean +/- s.e.m.) after operation. Eight patients had a good result, six a poor result, and six a history of recurrent pouch ileitis. Anaerobic and aerobic overgrowth occurred in the jejunum of patients with a poor result, but not in those with a good result or with pouch ileitis. In contrast, ileal pouch bacterial overgrowth occurred in all patients regardless of the clinical result. Patients with jejunal overgrowth had increased 24 h stool volume and stool nitrogen, but other patients did not. The larger the stool volume, the greater the anaerobic overgrowth. Pouch biopsies showed chronic inflammation in all patients, while 45 per cent had colonic metaplasia. Neither the inflammation nor the metaplasia correlated with the clinical result, nor did the clinical result correlate with the efficiency of pouch emptying. In conclusion, jejunal bacterial overgrowth after ileal pouch-anal anastomosis was associated with an increased stool output, azotorrhoea, and a poor clinical result. A distinguishing bacterial, absorptive, morphological, or emptying abnormality was not found in patients with a history of recurrent pouch ileitis.     

Glutaraldehyde-cross-linked meniscal allografts: clinical, gross, and histological results

Osteoarthritic changes in the knee are often a late result of total meniscectomy. In cases of total resection, availability of a prosthetic meniscus might limit development of these changes. The objective of this research was to evaluate a glutaraldehyde-cross-linked medial meniscus as a morphologically and biologically compatible prosthesis in a canine model. Medial and lateral menisci were harvested from donor dogs, frozen in saline, and cross-linked with glutaraldehyde. Five host animals were selected and matched with donors. Glutaraldehyde-cross-linked medial menisci were implanted bilaterally in the stifle joints and one glutaraldehyde cross-linked lateral meniscus was implanted subcutaneously. Clinical results showed asymptomatic limb and joint usage during the 12 postoperative weeks. Gross and histological evaluations indicated acceptable biocompatibility. The subcutaneous implants were encapsulated with a thin fibrous tissue capsule that was only mildly inflamed. Within the joints, the anterior attachment and periphery were maintained in position by their sutures; however, there was dehiscence of the posterior suture in all cases. The articulating surfaces of the implants were intact. There was an initial loss in the quantity of proteoglycans following glutaraldehyde treatment, with significant recovery after implantation into the joints. There were significant degenerative changes (loss of proteoglycans and fibrillation) in the articular cartilage on the femoral condyle and tibial plateau most likely a result of the posterior attachment failure. It was concluded that glutaraldehyde-cross-linked meniscal allografts showed an acceptable degree of histocompatibility. However, failure of the posterior attachment interfered with testing the efficacy of the prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Selection bias, survival, and brachytherapy for glioma.

Interstitial irradiation is a promising treatment for malignant glioma. Longer than expected survival periods following treatment of recurrent tumor have led to the use of brachytherapy as an adjuvant treatment. The impact of patient selection on survival data was studied among candidates for this therapy. Consecutive, conventionally treated adults with newly diagnosed supratentorial tumors were identified retrospectively at a center where experience with glioma is population-based. Based on imaging and performance status, two surgeons and a radiation oncologist designated each patient as either eligible or ineligible for adjuvant brachytherapy. The survival and prognostic factors in the eligible and ineligible groups were analyzed. Overall, the patients eligible for brachytherapy (32% of the series) lived significantly longer than the ineligible patients (16.57 vs. 9.30 months), were younger, and had larger resections and better function. For glioblastoma, 40% of patients were eligible, and lived much longer than those who were ineligible (13.90 vs. 5.80 months). It is concluded that better outcome following adjuvant brachytherapy for glioma is at least in part the result of patient selection. Randomized trials of comparably selected patients will be necessary to demonstrate conclusively that longer survival is also a result of treatment.     

Shave Excision of Common Acquired Melanocytic Nevi: Cosmetic Outcome, Recurrences, and Complications

Background. Surgical treatment of benign melanocytic lesions demands the application of simple and effective surgical techniques with the possibility of performing a histopathologic examination with an acceptable cosmetic outcome. However, recurrence rates and the cosmetic result should be taken into account because the main reason for these lesions to be removed is the patient's cosmetic improvement. The present study evaluates the results obtained by shave excision of benign pigmented lesions in terms of cosmetic outcome, recurrence rates, and complications from both a subjective and an objective point of view.
Discussion. An acceptable cosmetic result, along with a low rate of recurrence, should be the aim of the surgical treatment of benign melanocytic lesions. The results obtained in this series allow us to provide more detailed and accurate information regarding the outcome and complications expected.
Material and Methods. Shave excision of common acquired melanocytic nevi was performed. The patients were reviewed 3 months after surgery to evaluate the objective and subjective cosmetic results, recurrences, and postsurgical complications.
Results. Over a 12-week period, 204 common acquired melanocytic nevi were shaved. Objective evaluation revealed excellent results in one-third (32.8%) of the lesions excised, with a poor result in 8.3%. The likelihood of having an imperceptible scar was significantly greater in lesions excised from the face (p < .05). Ninety-eight percent of patients (  n = 192  ) declared that "the scar looked better than the original mole." Clinical and dermatoscopic recurrences were observed in 40 scars (19.6%).     

Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization

BACKGROUND: Radial head fractures often occur in association with other elbow fractures and soft-tissue injuries. Radial head replacement is indicated for irreparable radial head fractures associated with elbow instability. The purpose of this study was to analyze the results after treatment of such injuries with a titanium radial head prosthesis, repair of torn collateral ligaments, and early mobilization of the elbow. METHODS: Sixteen patients with sixteen Mason type-III radial head fractures and collateral ligament injury were treated with use of a titanium radial head prosthesis over a five-year period at the Royal Adelaide Hospital and Modbury Public Hospital in South Australia. The surgery was performed acutely in ten patients and was delayed an average of thirty-seven days (range, fifteen to seventy-nine days) in six. All patients were followed clinically and radiographically for a mean of 2.8 years (range, 1.2 to 4.3 years). RESULTS: Eight patients had an excellent result; five, a good result; and three, a fair result, according to the Mayo Elbow Performance Score. The three fair results occurred in patients with delayed surgery. The mean flexion contracture was 15 degrees (range, 0 degrees to 42 degrees ), with an average loss of 10 degrees (range, 0 degrees to 25 degrees ) of full flexion compared with that of the contralateral elbow. Both pronation and supination decreased an average of 12 degrees (range, 0 degrees to 45 degrees ) compared with that of the contralateral forearm. CONCLUSIONS: The results of treatment of Mason type-III radial head fractures with a monoblock titanium radial head prosthesis and soft-tissue reconstruction are satisfactory. Early mobilization of the elbow is important for the restoration of elbow range of motion and function.     

Indikationen, Komplikationen und Ergebnisse der Ellenbogenarthroskopie

Background

Loose bodies, osteoarthritis, radiohumeral epicondylitis, unclear movement restrictions and appearance after radial head fracture are pathologies in the region of the elbow which have been known for a long time. Nevertheless, the elbow joint has long been regarded as unsuitable for endoscopic examinations because of its relatively complex anatomy and proximity to neurovascular structures. However, arthroscopy is now also gaining increasing importance for examinations in this region. The aim of this study was to evaluate the clinical outcome and patient satisfaction after arthroscopic surgery of the elbow joint in comparison with the international literature, as well as a correlation analysis of the recently developed patient-rated elbow evaluation (PREE) score with the QuickDASH questionnaire.

Methods

Out of 55 patients who underwent elbow arthroscopy in the period from 2005 to 2010, 53 were included in the study and were interviewed by telephone. The data collection was performed using the Morrey elbow score, the QuickDASH questionnaire and the PREE score.

Results

Overall, 94?% of patients had a satisfactory result in the Morrey elbow score by which 81?% achieved an excellent result. In the PREE score a range from a minimum of 47?% up to a maximum of 100?% of the optimum value was achieved by the patients. The median in the PREE score was 94?% of the optimal result to be achieved and in the QuickDASH score 92?%. The range of results was between 41?% and 100?%. Validating the PREE score and the QuickDASH a high correlation (r?=?0.90) was found in the overall results. The subgroups pain and function showed moderate to high correlations (r?=?0.83 and r?=?0.74, respectively).     

Diagnostic, percutaneous peritoneal lavage in blunt abdominal trauma: rationale, technique and results

The records of 90 consecutive adult patients, who presented after blunt abdominal trauma and who underwent diagnostic, percutaneous peritoneal lavage over a 3 year period, were reviewed. Lavage effluents were considered positive, negative or equivocal. An equivocal result was one where the tubing contained blood stained fluid, but it was still possible to see newsprint through the tubing. Fifty-one lavages were positive, 24 negative and 15 equivocal. All 51 patients with a positive effluent and three of the patients with an equivocal effluent had a laparotomy and in all but one case a significant injury was found. There were no false negative results. In a single patient the transverse colon was perforated during the insertion of the lavage catheter. Diagnostic, percutaneous peritoneal lavage is a simple, safe, rapidly performed, accurate technique designed to detect intraperitoneal blood and the results of this review suggest that it has a role to play in the decision-making process when assessing adult patients who have suffered blunt abdominal trauma.     

Experience with latrogenic pediatric vascular injuries. Incidence, etiology, management, and results

During a 32-month period, 79 extremities in 76 children (age 1 day-13 years, mean = 31 months) were evaluated with regard to iatrogenic vascular injuries. Prospectively, 42 children were studied pre- and post-cardiac catheterization. Ten of these children sustained vascular injuries (incidence = 24%). Thirty-four additional children were referred because of 35 iatrogenic vascular injuries as a result of transfemoral cardiac catheterization (n = 20), umbilical artery catheterization (n = 10), or recent surgery (n = 5). All 45 injuries were evaluated by lower extremity segmental Doppler pressure measurements in addition to routine physical examination at the time of injury and at frequent follow-up. An ankle/brachial pressure index (ABI) less than 0.9 was considered abnormal. Selected children (ABI less than 0.9 for greater than 30 days) underwent orthoroentgenograms to assess limb growth. The average ABI immediately following injury was 0.34 +/- 0.33. Thirty-four injuries were treated nonoperatively. Twelve injuries were excluded from further study due to death (n = 7) or being lost to follow-yp (n = 5). A return of ABI to normal was seen from 1 day to 2 years in 93% of children treated with heparin (n = 14) compared to 63% of children who were simply observed (n = 8) (p less than 0.10). The initial severity of ischemia did not correlate with the subsequent rate of improvement. Only patients with absent femoral pulses were selected for operative intervention, which consisted of aortic thrombectomy (n = 2), femorofemoral bypass (n = 2), femoral artery patch angioplasty (n = 1), or femoral artery thrombectomy (n = 7) with no mortality. Nine patients had immediate return of a normal ABI after surgery. A delayed return of ABI to normal occurred in the other two. Nine per cent of surgically treated children and 23% of nonsurgically treated children developed leg length discrepancies (0.5-3.0 cm) as a result of ischemia lasting greater than 30 days. Overall, 91% of the children in this series eventually regained normal circulation following injury and no child lost a limb. This study indicates that iatrogenic pediatric vascular injuries are common and can result in significant limb growth impairment. Immediate operative intervention is highly successful when the injury is proximal to the common femoral artery bifurcation and avoids the prolonged ischemia seen with nonoperative therapy. For more distal occlusions, heparin therapy provides better results than simple observation. Although therapeutic intervention for these injuries is generally successful, a limb length discrepancy rate of 14% mandates that indications for invasive vascular monitoring and diagnostic procedures be strict.     

Observations of pressure waves in stomach, jejunal, and colonic loops used to replace the esophagus.

The motility characteristics of the stomach, upper jejunum, and right colon were studied in 25 patients in whom these organs were used to replace the resected esophagus. The pattern of motility in all three replacement organs generally was similar to that recorded in normal individuals by other workers. But the stomach replacement showed a greater percentage of Type 1 waves, and Type II contractions were weaker. Activity in the jejunal replacements was much reduced. A propagated pressure wave was observed on swallowing water in the jejunal replacements. The nature of this wave needs further elucidation. The functional result was good, except in patients with a weak or without an upper esophageal sphincter. Patients experienced no pain during the test and no side effects were observed.     

Delayed fixation of displaced bilateral, atraumatic, femoral neck fractures in a patient with pregnancy related osteomalacia

We present the case of a woman diagnosed with simultaneous displaced intracapsular femoral neck fractures following the birth of her second child. No traumatic event was identified. Diagnosis was delayed as the cause of her pain was thought to be non-skeletal in origin. Radiological and serological investigations were diagnostic of osteomalacia. Surgical fixation of her fractures was further delayed due to profound hypocalcaemia. Despite the delays, fixation with bilateral dynamic hip screws resulted in union with no evidence of avascular necrosis at 2 years follow-up. We believe this to be the first report of atraumatic bilateral femoral neck fractures and it shows that a good result can be achieved even in the presence of delayed fixation.     

大连地区不育流行病学调查

1989年9月至12月在大连地区进行了不育症的流行地病学调查。采用简单随机和系统随机两步抽样法获得调查样本。应用统一问卷,入户调查,并有严格的质量控制。应答率96％。对5 918对夫妇调查资料分析结果表明该地区原发不育的患病率为1.01％。农村与城市无明显差别。妇女有结核史明显增加不育的危险性。采用非配对与配对病例对照方法计算,相对危险性分别为7.97(3.14～17.9)和12.0(2.5～56.5)。本材料未发现其它因素对不育的影响。     

Anesthetic-related maternal mortality, 1954 to 1985

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.     

Lawrence of Arabia, Sir Hugh Cairns, and the origin of motorcycle helmets

When Colonel T.E. Lawrence ("Lawrence of Arabia") was fatally injured in a motorcycle accident in May 1935, one of the several doctors attending him was a young neurosurgeon, Hugh Cairns. He was moved by the tragedy in a way that was to have far-reaching consequences. At the beginning of the Second World War, he highlighted the unnecessary loss of life among army motorcycle dispatch riders as a result of head injuries. His research concluded that the adoption of crash helmets as standard by both military and civilian motorcyclists would result in considerable saving of life. It was 32 years later, however, that motorcycle crash helmets were made compulsory in the United Kingdom. As a consequence of treating T.E. Lawrence and through his research at Oxford, Sir Hugh Cairns' work largely pioneered legislation for protective headgear by motorcyclists and subsequently in the workplace and for many sports worldwide. Over subsequent decades, this has saved countless lives.     

Compression-staple fixation for fractures, non-unions, and delayed unions of the carpal scaphoid.

We used the Richards scaphoid compression staple for operative fixation in a total of twenty-five patients who had a fracture of the carpal scaphoid: sixteen whom we reported on previously and nine whom we are reporting on for the first time here. In the current series, we extended the application of the method to fresh, unstable fractures (two patients) and treated an additional seven patients who had a non-union or delayed union. The procedure was simple, and no operative complications were encountered. Both patients who had a fresh fracture had a satisfactory result. Of the other twenty-three patients, only two had a result that was not satisfactory. One patient had a persistent non-union. Three patients had doubtful radiographic evidence of a persistent non-union; however, all three had a good result clinically, and only one had moderate loss of function. Although the over-all results were good, there was some worsening of the clinical results on long-term follow-up compared with those that we reported earlier. This deterioration probably was due to secondary degenerative changes in the articular surfaces.     

Meta-analysis: peritoneal membrane transport, mortality, and technique failure in peritoneal dialysis

Peritoneal membrane solute transport in peritoneal dialysis (PD) patients is assessed by the peritoneal equilibration test, which measures the ratio of creatinine in the dialysate to plasma after a standardized 4-h dwell (D/Pc). Patients then are classified as high, high-average, low-average, or low transporters on the basis of this result. A meta-analysis of observational studies was carried out to characterize the relationship between D/Pc and mortality and technique failure in patients who are on PD. Citations were identified in Medline by using a combination of Medical Subject Heading search terms and key words related to PD, peritoneal membrane permeability/transport, and mortality and technique failure. The table of contents of relevant journals and bibliographies of relevant citations were reviewed in duplicate. Twenty studies that met study criteria were identified. Nineteen studies were pooled to generate a summary mortality relative risk of 1.15 for every 0.1 increase in the D/Pc (95% confidence interval 1.07 to 1.23; P < 001). This result equated to an increased mortality risk of 21.9, 45.7, and 77.3% in low-average, high-average, and high transporters, respectively, as compared with patients with low transport status. Meta-regression analysis showed that the proportion of patients who were on continuous cycler PD within a study was inversely proportional to the mortality risk (P = 0.05). The pooled summary relative risk for death-censored technique failure was 1.18 (95% confidence interval 0.96 to 1.46; P = 0.12) for every 0.1 increase in the D/Pc. This meta-analysis demonstrates that a higher peritoneal membrane solute transport rate is associated with a higher mortality risk and a trend to higher technique failure.     

Randomized, Evaluator-Blind, Split-Face Comparison Study of Single Cross-linked versus Double Cross-linked Hyaluronic Acid in the Treatment of Glabellar Lines

BACKGROUND At present, various hyaluronic acids are being used to rejuvenate facial skin. There is no comparative study of single cross-linked hyaluronic acid (SCHA) versus double cross-linked hyaluronic acid (DCHA). The objective of our study is to compare the effectiveness and complications of SCHA versus DCHA in the treatment of glabellar lines.
METHODS Ten female patients were enrolled in this randomized, evaluator-blind study. One side (left vs. right) of each patient's glabellar lines was treated with SCHA and the other side was treated with DCHA. Two independent blinded observers reviewed the clinical photographs at 3, 6, 9, and 12 months after the treatment and assessed for degree of improvement as well as complications.
RESULTS The two products were equally effective in producing an optimal cosmetic result, although at 6, 9, and 12 months posttreatment, a higher proportion of patients showed over 50% improvement with DCHA than with SCHA. At 12 months posttreatment, DCHA was considered superior in 70% of patients, whereas SCHA was superior in 10% of patients.
CONCLUSIONS Both SCHA and DCHA are equally effective in producing an optimal cosmetic result. DCHA provides a more durable esthetic improvement when compared to SCHA in the treatment of glabellar lines.     

Retrograde Femurmarknagelung Indikation, operationstechnik und ergebnisse

We performed retrograde femoral nailing in 20 patients with 20 fractures of the distal femoral region. All fractures were stabilized on the day of admission after performing closed reduction. There were 15 distal femoral or supra/diacondylar fractures type A and 5 type C fractures. Four fractures were classified open (3A). Eight patients had previous surgery with implanted hip arthroplasties or dynamic hip screws. Immediate passive motion and mobilisation were begun postoperatively. All fractures healed. Follow-up was 27 months after surgery (range: 20 to 33 months). There were neither failure of the implant nor infections. In 4 patients we had loosening of interlocking screws but only 1 had to be reoperated. Two implants were chosen too long and had to be exchanged. Functional results were assessed based on the score of Leung et al. [11]. Six patients showed an excellent result, 4 a good, 3 a fair and 1 patient a poor result. We conclude retrograde interlocking femoral nailing has proven to be a minimal invasive stabilisation method for closed and open supra/diacondylar and distal femoral fractures. As there is the possibility of technical pitfalls, this technique should only be performed by well trained surgeons.     

Condylomata acuminata of the urinary bladder. Natural history, viral typing, and DNA content

Three patients with condylomata acuminata of the urinary bladder are reported. Two of the patients were immunosuppressed, and one had longstanding extensive condylomata acuminata of the external genitalia and adjacent areas. All lesions recurred at least once and were difficult to treat. The diagnosis was confirmed by in situ hybridization on archival material with human papillomavirus (HPV) DNA probes under stringent conditions. In two of the patients, probes for HPV types 6 and 11 were positive; HPV 11 only was identified in one patient. Probes for HPV types 16 and 18 and pBR322 vector controls were negative. In one patient with a strong hybridization signal, the lesion was also positive for common papillomavirus antigen. DNA content measured by cytophotometry of Feulgen-stained whole nuclei isolated from lesions in two patients revealed a markedly aneuploid DNA pattern. Whether this is a factor in the behavior of the lesions is not known at this time. Although rare, HPV infection of the urinary bladder may result in widespread condylomatosis and may mimic giant condylomas of Buschke-L?wenstein or even verrucous carcinomas, sometimes necessitating radical treatment. Nevertheless, until there is proof to the contrary, the lesions must be considered benign and should not be confused with squamous cancer of the bladder.