Mild traumatic brain injury and anxiety sequelae: a review of the literature

There is scattered but significant psychological and neuropsychological evidence to suggest that mild traumatic brain injury (mild TBI) plays a notable role in the emergence and expression of anxiety. Conversely, there is also empirical evidence to indicate that anxiety may exert a pronounced impact on the prognosis and course of recovery of an individual who has sustained a mild TBI. Although the relationship between mild TBI and anxiety remains unclear, the present body of research attempts to elucidate a number of aspects regarding this topic. Overall, the mild TBI research is rife with inconsistencies concerning prevalence rates, the magnitude and implications of this issue and, in the case of PTSD, even whether certain diagnoses can exist at all. This review obviates the need for greater consistencies across studies, especially between varying disciplines, and calls for a shift from studies overly focused on categorical classification to those concerned with dimensional conceptualization.     

Histologic Findings One Year After Positive Crossmatch or ABO Blood Group Incompatible Living Donor Kidney Transplantation

Recent protocols have allowed successful positive crossmatch (+XM) and ABO incompatible (ABOI) kidney transplantation, although their long-term outcome is not clear. To begin to assess this issue we compared protocol biopsies performed 12 months posttransplant in 37 +XM, 24 ABOI and 198 conventional allografts. Although the majority in all three groups had only minimal histologic changes, transplant glomerulopathy (TG) was significantly increased in +XM (22% vs. 13% ABOI vs. 8% conventional, p = 0.015), and correlated with prior humoral rejection (HR) by multivariate analysis (odds ratio 17.5, p < or = 0.0001). Patients with a prior history of HR also had a significant increase in interstitial fibrosis (No HR 54% vs. HR 86%, p = 0.045). In the absence of HR no difference in histologic changes was seen between groups, although all three groups had a demonstrable mild increase in interstitial fibrosis from biopsies performed at the time of transplant. Thus, although HR is associated with an increase in TG, in its absence allograft histology is similar in +XM, ABOI and conventional allografts 1 year posttransplant.     

Interval laparoscopic appendectomy in children

BACKGROUND: Conservative management of advanced complicated appendicitis in children is becoming more common. Formation of an appendiceal mass or abscess may mitigate against urgent appendectomy during the acute stage, and conservative treatment followed by interval appendectomy has been advocated. We present our experience of interval laparoscopic appendectomy in our institution. MATERIALS AND METHODS: All children who were offered interval laparoscopic appendectomy between January 2000 and December 2004 were included. Retrospective case note analysis was performed and data collected included demographics, duration of symptoms, method of diagnosis, days of antibiotics, length of interval, operative time, length of hospital stay (conservative treatment and interval laparoscopic appendectomy), analgesia requirements, complications, and histology. RESULTS: Thirty-six children, median age 8 years (range, 1-15 years) diagnosed with appendiceal mass or abscess were offered interval laparoscopic appendectomy by two surgeons in our institution: one patient declined interval laparoscopic appendectomy. Median antibiotic treatment was 10 days (range, 3-23 days). Median length of stay for conservative treatment was 6 days (range, 1-27 days). Five children required percutaneous drainage. For the 35 children who had interval laparoscopic appendectomy, the median interval was 93 days (range, 34-156 days) and median operative time was 55 minutes (range, 25-120 minutes). Median length of stay for interval laparoscopic appendectomy was 1 day (range, 1-3 days). There were no complications following interval laparoscopic appendectomy. CONCLUSION: Interval laparoscopic appendectomy can be safely performed in children, is associated with a short hospital stay and minimal morbidity, analgesia, and scarring following conservative management of appendiceal mass or abscess. Interval laparoscopic appendectomy eliminates the risk of recurrent appendicitis and serves to excise undiagnosed carcinoid tumors. In future it may be possible to perform interval laparoscopic appendectomy as a day-case procedure in selected patients.     

Streptococcus milleri infections of the pleural space: operative management predominates

BACKGROUND: Management of patients with thoracic empyema ranges from tube thoracostomy drainage, with or without fibrinolytics, to operative intervention, with the optimal intervention remaining uncertain. Streptococcus milleri, typically a benign bacterium colonizing the oropharynx, has recently been reported as a potential pathogen in pneumonia and pleural space disease. Our initial experience indicated this infection, when in the pleural space, was particularly tenacious and often required major operative intervention to eradicate. Therefore, we hypothesized that patients with S milleri pleural space infections often require operative intervention as definitive treatment. METHODS: We reviewed all patients from June 17, 1999 to April 15, 2005 with S milleri infections at our level I academic trauma/acute care surgery department at a safety-net hospital. S milleri infections were diagnosed by thoracentesis, bronchoalveolar lavage, tube thoracostomy fluid, or intraoperative culture. RESULTS: Over the 70-month period evaluated, of 697 patients with S milleri infections, 39 patients had S milleri infections of the pleural space; 26 (67%) patients underwent operative intervention. The majority (72%) were men with a mean age of 46 (range 22 to 63); the underlying etiology in those patients requiring operation was pneumonia (26 patients; 67%), trauma (9 patients; 23%), postoperative infection (2 patients), foreign body ingestion (1 patient), and malignancy (1 patient). The vast majority of patients in the operative group were treated preoperatively with tube thoracostomy (88%) and antibiotics (96%). The average duration of chest tube drainage prior to operation was 4.4 days (95% confidence interval [CI] 2.6 to 6.2) and antibiotic treatment was 6.0 days (95% CI 3.8 to 8.2). Thirteen patients (50%) underwent video-assisted thoracoscopic surgery (VATS) and 13 patients required thoracotomy. VATS was performed more often when operative intervention occurred early (average hospital day 6.2) compared to initial thoracotomy or conversion from VATS to thoracotomy (average hospital day 9.8). Hospital length of stay was less in the operative group (average 24 days; 95% CI 17 to 31) than in the nonoperative group (34 days; 95% CI 19 to 49), discharge to home was greater in the operative group (77% vs. 16%), and mortality was less in operative group (0% vs. 23%). CONCLUSIONS: Despite attempts at nonoperative management, the majority of patients with a S milleri pleural space infection require operative intervention for definitive therapy. Patients diagnosed with S milleri empyema should be considered for early operative intervention due to the unrelenting nature of their infection. Operative treatment is associated with a shorter hospital length of stay, increased discharge to home, and decreased mortality.     

Hypercoagulability following blunt solid abdominal organ injury: when to initiate anticoagulation

Background

The optimal time to initiate venous thromboembolism pharmacoprophylaxis after blunt abdominal solid organ injury is unknown.

Methods

Postinjury coagulation status was characterized using thromboelastography (TEG) in trauma patients with blunt abdominal solid organ injuries; TEG was divided into 12-hour intervals up to 72 hours.

Results

Forty-two of 304 patients (13.8%) identified underwent multiple postinjury thromboelastographic studies. Age (P = .45), gender (P = .45), and solid organ injury grade (P = .71) were similar between TEG and non-TEG patients. TEG patients had higher Injury Severity Scores compared with non-TEG patients (33.2 vs 18.3, respectively, P < .01). Among the TEG patients, the shear elastic modulus strength and maximum amplitude values began in the normal range within the first 12-hour interval after injury, increased linearly, and crossed into the hypercoagulable range at 48 hours (15.1 ± 1.9 Kd/cs and 57.6 ± 1.6 mm, respectively; P < .01, analysis of variance).

Conclusions

Patients sustaining blunt abdominal solid organ injuries transition to a hypercoagulable state approximately 48 hours after injury. In the absence of contraindications, pharmacoprophylaxis should be considered before this time for effective venous thromboembolism prevention.     

Prospective assessment of fibrinolysis in morbid obesity: tissue plasminogen activator resistance improves after bariatric surgery

BackgroundMorbid obesity is associated with an increased risk of thrombotic events, which has been attributed to increased thrombotic activity. Multiple mechanisms have been proposed to explain this increased risk, including an inflammatory state with upregulation of procoagulant and antifibrinolytic proteins. We therefore hypothesize that patients with morbid obesity are hypercoagulable and will revert to normal after bariatric surgery.ObjectivesTo evaluate changes in the hypercoagulable state after bariatric surgery.SettingUniversity Hospital, Bariatric Center of Excellence, United States.MethodsThromboelastography (TEG) data were collected on 72 subjects with morbid obesity, with 36 who had 6 months of follow-up after bariatric surgery. TEG data of 75 healthy subjects (HS) without obesity, recent trauma or surgery, acute infection, or chronic conditions (e.g., liver, cardiovascular, or kidney disease; cancer; diabetes; autoimmune or inflammatory disorders; and disorders of coagulation) were used for comparison. TEG was performed alone and with the addition of 75 and 150 ng/mL tissue plasminogen activator (tPA) to quantify fibrinolysis resistance (tPA-challenged TEG).ResultsThe bariatric surgery cohort had a median age of 40.5 years, a median body mass index of 44.6 kg/m², and 90% female patients. Median body mass index reduced significantly 6 months post surgery but remained elevated compared with the HS group (31.4 versus 25.4 kg/m², P < .0001). At 6 months post surgery, subjects had longer reaction time (mean difference, 1.3; P = .02), lower maximum amplitude (–2.4, P = .01), and increased fibrinolysis with low-dose (3.1, P < .0001) and high-dose tPA-challenged TEG (9, P < .0001). Compared with HS, the postsurgery TEG values were still more likely to be abnormal (all P < .05).ConclusionsPatients with morbid obesity form stronger clots more rapidly and are more resistant to fibrinolysis than subjects without obesity. Bariatric surgery significantly improved the hypercoagulable profile and fibrinolysis resistance of morbid obesity.     

Predicting Carpal Bone Kinematics Using an Expanded Digital Database of Wrist Carpal Bone Anatomy and Kinematics

The wrist can be considered a 2 degrees‐of‐freedom joint with all movements reflecting the combination of flexion–extension and radial–ulnar deviation. Wrist motions are accomplished by the kinematic reduction of the 42 degrees‐of‐freedom of the individual carpal bones. While previous studies have demonstrated the minimal motion of the scaphoid and lunate as the wrist moves along the dart‐thrower's path or small relative motion between hamate‐capitate‐trapezoid, an understanding of the kinematics of the complete carpus across all wrist motions remains lacking. To address this, we assembled an open‐source database of in vivo carpal motions and developed mathematical models of the carpal kinematics as a function of wrist motion. Quadratic surfaces were trained for each of the 42‐carpal bone degrees‐of‐freedom and the goodness of fits were evaluated. Using the models, paths of wrist motion that generated minimal carpal rotations or translations were determined. Model predictions were best for flexion–extension, radial–ulnar deviation, and volar–dorsal translations for all carpal bones with R ² > 0.8, while the estimates were least effective for supination‐pronation with R ² < 0.6. The wrist path of motion's analysis indicated that the distal row of carpal bones moves rigidly together (<3° motion), along the anatomical axis of wrist motion, while the bones in the proximal row undergo minimal motion when the wrist moves in a path oblique to the main axes. The open‐source dataset along with its graphical user interface and mathematical models should facilitate clinical visualization and enable new studies of carpal kinematics and function. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2661–2670, 2019     

Ciprofloxacin for BK viremia prophylaxis in kidney transplant recipients: Results of a prospective,double‐blind,randomized, placebo‐controlled trial

In kidney transplantation, BK virus infection has historically resulted in high rates of graft dysfunction and graft loss. Unlike other opportunistic infections, no therapies have been shown to prevent BK. The purpose of the current study was to evaluate the safety and efficacy of ciprofloxacin for the prevention of BK viremia in kidney transplant recipients. Two hundred kidney transplant recipients were enrolled in a prospective, randomized, double‐blind, placebo‐controlled trial comparing a 3‐month course of ciprofloxacin (n = 133) vs placebo (n = 67) for the prevention of BK viremia. The primary endpoint of BK viremia at month 6 posttransplant occurred in 25 (18.8%) patients in the ciprofloxacin group and 5 (7.5%) in the placebo group (P = .03). Higher rates of BK viremia (23.3% vs 11.9%; P = .06) and BK nephropathy (5.8% vs 1.5%; P = .26) remained at 12 months in the ciprofloxacin group. Ciprofloxacin use was associated with a significantly higher rate of fluoroquinolone‐resistant gram‐negative infections (83.3% vs 50%; P = .04). A 3‐month course of ciprofloxacin was ineffective at preventing BK viremia in kidney transplant recipients and was associated with an increased risk of fluoroquinolone‐resistant infections. Clinical trial registration number: NCT01789203.     

Comparison of facemask and mouthpiece interfaces for multiple breath washout measurements

Background

Different interfaces (mouthpiece/nose clip vs. facemask) are used during multiple breath washout (MBW) tests in young children.

Clinical characteristics and outcomes in polyarticular septic arthritis

Objectives

Septic polyarthritis is rarer than septic monoarthritis, but associated with higher mortality. Septic polyarthritis may be difficult to distinguish clinically from noninfectious inflammatory arthritis. We describe one of the largest samples of septic polyarthritis with the aim of distinguishing septic monoarthritis from polyarthritis.