External Closure Research Articles

The use of mineral trioxide aggregate for treatment of children with complications of dental trauma

Jf the study was to assess the efficacy of mineral trioxide aggregate for treatment of children with complicated permanent teeth trauma. The study comprised 29 children aged 6-13 years (mean age 8.6±1.7 years) with 36 injured constant teeth, from which 30 had immature roots, 27 (75%) teeth had necrotic pulp at baseline examination, 12 (33.3%) teeth showed radiological signs of external imflammatory root resorbtion, 2 teeth were diagnosed with of the root fracture (5.6%). MTA was used for pulp regeneration procedure in 25 (69.5%) teeth, external closure of resorbtion site in 3 (8.3%) teeth, root canal filling in 4 (11.1%) teeth, apical plug creation in 4 teeth (11.1%). The patients were folowed up for 1 to 9 years. From 36 teeth only one was extracted 9 years after regenerative endodontic procedure because of cervical root fracture. In 2 teeth with external imflammatory resorbtion progession of replacement resorption took place, in 1 tooth necrosis of regenerated pulp tissue occurred 2 years after the procedure because of restoration marginal seal failure. In 25 teeth favorable outcome was registered with stabilisation of external root resorbtion, continous root growth in 24 teeth and radioluscent lesions healing in 6 teeht showing them at baseline examination. Change of external imflammator root resorbtion to replacement resorption was detected in 1 teeth from 3 with external closure of resorbtion site. Root calan filling with MTA was performed in 3 avulsed teeth with replantation delayed for more than 1 day and in 1 tooth with root fracture. All teeth were clinically asymptomatic during more than 5 years follow-up. Favorable outcome was received in all cases of apicl plug formation. MTA is highly effective for preservation of constant teeth in children with clinically complicated situations. In many cases with hopeless long-term prognosis for a teeth MTA allows stabilization of dental tissue level with the teeth being an object for guided tissue regeneration.

Консервативное лечение недержания мочи после трансуретральной резекции доброкачественной гиперплазии предстательной железы.

Introduction. Among the existing methods of surgical treatment of patients with benign prostatic hyperplasia (BPH) transurethral resection (TUR) of the prostate is the most widely used. Due to the long-term improvement of the technique, non-lethal complications are now more characteristic of this operation. These include postoperative urinary incontinence, which dramatically reduces the quality of life of patients and casts doubt on the effectiveness of the operation performed. Stress urinary incontinence, the most common type of disorder, basically has sphincter insufficiency associated with iatrogenic damage to the external closure apparatus of the bladder when it goes beyond the distal border of resection in TUR BPH. However, an equally important role in the genesis of sphincter insufficiency belongs to the inflammatory process, which always accompanies trauma to muscle structures during surgery. The aim of this prospective study was to improve outcomes in patients with urinary incontinence after TUR BPH. Materials and methods. The study involved 86 patients who underwent TUR BPH, with the leading complaint of urinary incontinence. Patients were divided into 2 groups, initially comparable in terms of the main evaluated criteria. Patients of the first (control) group (n=30) received complex antibacterial and anti-inflammatory therapy, according to indications - alpha-blockers, prostatotropic regulatory biopeptides and enzyme preparations, in the presence of a hyperactivity component – M-anticholinergics and / or a selective agonist of β3 adrenoreceptors. Patients of the second (main) group (n=56) for the purpose of long-term anti-inflammatory effects and reduce the pharmacological load additionally received the phytocomplex «Profilaprost» 1 capsule per day for 2 months. Result. In the main group of patients who received the «Profilaprost» complex, after 2.5 months from the start of therapy, we recorded an improvement in the reservoir function of the bladder. In 65% of patients, complete continence was achieved, in 20% – stabilization of incontinence at a mild degree, requiring no more than one safety pad per day, in another 10% the result can be described as not quite satisfactory – the frequency and degree of incontinence decreased, but persisted the level of symptoms was considered unacceptable by the patients and insisted on continuing treatment. And only in 5% of patients, complex therapy had no effect. A decrease in IPSS and QoL indices, an improvement in continence significantly correlated with a decrease in the degree of leukocyturia. Conclusion. The herbal-mineral complex «Profilaprost» showed good efficacy with no side effects and adverse events in the treatment of urinary incontinence after TURP.

P491 Efficacy and safety of upadacitinib for the treatment of fistulas and fissures in patients with Crohn’s disease

Abstract Background Intestinal and perianal fistulas and fissures are associated with significant morbidity and decreased quality of life in patients with Crohn’s disease (CD). We evaluated rates of fistula and fissure improvements with upadacitinib (UPA), an oral selective Janus kinase inhibitor, in patients with CD who had fistulas or fissures at baseline in phase 3 induction and maintenance trials. Methods In the U-EXCEL (NCT03345849) and U-EXCEED (NCT03345836) phase 3 induction trials, patients with moderate-to-severe CD were randomized to UPA 45 mg once daily (QD) or placebo (PBO) for 12 weeks. Patients who achieved clinical response after 12 weeks of induction were eligible for U-ENDURE (NCT03345823) and rerandomized to UPA 30 mg QD, UPA 15 mg QD, or PBO for an additional 52 weeks of maintenance treatment. Fistula activity was assessed by presence of external openings and draining upon gentle compression. Presence of perianal fissures was also assessed. The proportion of patients with external closure of fistula openings, complete resolution of draining, and ≥ 50% reduction in draining was recorded at weeks 12 and 52. Endpoints were analyzed using non-responder imputation. Results Of 1021 enrolled patients, 143 patients had fistulas (124 [86.7%] perianal; 19 [13.3%] enterocutaneous) and 54 patients had perianal fissures at baseline. The proportion of patients who achieved external closure of fistula openings was higher with UPA vs PBO at week 12 (Fig 1A) and at week 52 (Fig 2A). The proportion of patients who achieved complete resolution of draining and ≥ 50% reduction in draining was higher with UPA vs PBO at week 12 (Fig 1B and 1C) and at week 52 (Fig 2B and 2C). A higher proportion of patients achieved complete resolution of fissures with UPA vs PBO at week 12 (Fig 1D) and at week 52 (Fig 2D). At weeks 12 and 52, a higher proportion of patients with fistulas treated with UPA vs PBO achieved clinical remission and endoscopic response (Fig 1E and 2E). Rates of adverse events (AEs), serious AEs, or AEs leading to study drug discontinuation were similar in UPA groups compared with PBO during the induction and maintenance periods. Rates of abscess formation were 1.8% with UPA 45 mg and 6.8% with PBO at week 12, and 3.0% with UPA 30 mg, 6.4% with UPA 15 mg, and 2.5% with PBO at week 52. Conclusion Among patients with CD complicated with fistulas and/or fissures at baseline, UPA treatment led to higher rates of external closure of fistula openings, resolution of draining, and healing of fissures, along with clinical remission and improvements in luminal disease compared with PBO. No new safety concerns were identified.

Lock-exchange problem for Boussinesq fluids revisited: Exact shallow-water solution

An exact solution to the lock-exchange problem, which is a two-layer analogue of the classical dam-break problem, is obtained in the shallow-water (SW) approximation for two immiscible fluids with slightly different densities. The problem is solved by the method of characteristics using analytic expressions for the Riemann invariants. The obtained solution, which represents an inviscid approximation to the high-Reynolds-number limit, is, in general, discontinuous containing up to three hydraulic jumps which are due to either multivaluedness or instability of the continuous SW solution. Hydraulic jumps are resolved by applying the Rankine–Hugoniot conditions for the SW mass and generalized momentum conservation equations. The latter contains a free parameter α which defines the relative contribution of each layer to the interfacial pressure gradient. We consider a solution for α=0, which corresponds to both layers affecting the interfacial pressure gradient with equal weight coefficients. This solution is compared with the solutions resulting from the application of the classical Benjamin's front condition as well as the circulation conservation condition, which correspond to α=−1 and α→∞, respectively. The SW solution reproduces all principal features of 2D numerical solution for viscous fluids. The gravity current speed is found to agree well with experimental and numerical results when the front acquires the largest stable height which occurs at α=5−2. We show that two-layer SW equations for the mass and generalized momentum conservation can describe interfacial waves containing hydraulic jumps in a self-contained way without external closure conditions.

The Study of Properties of an Axial Flux Switching Permanent Magnet Alternator with Open Magnetic Cores

Abstract The article studies magnetic field distribution in the alternator inductors with an axial arrangement of open magnetic cores (OMC) and an external closure of the magnetic flux. The study compares the efficiency of magnetic flux utilization for four models with different modifications of the geometry of the magnetic circuit of inductors. The analysis of the density distribution of magnetic flux in OMC is carried out by 3D modelling of the magnetic field using EMWorks software. Based on the experimental study of the properties of the base model, the influence of the configuration of the magnetic circuit of the inductor on the efficiency of the alternator is shown. The results are presented in the form of tables and diagrams characterising changes in magnetic fluxes and electromotive force (EMF) in relative units. The results provide the grounds for assessing the potential and possible limits of optimization with respect to the size of air gaps and dimensions of the magnetic flux toggle switches. The study indicates that the proposed alternator can be adapted for various load requirements and optimized for various applications, such as charging power banks and powering bicycle electronics. The study also demonstrates that for such generators, OMC can be manufactured using a waste-free strip production technology.

Axial Flux Switching Permanent Magnet Alternator with External Magnetic Cores

Abstract The article introduces the results of studying the magnetic field distribution in the alternator inductor with an axial arrangement of open magnetic cores (OMC) and external closure of magnetic fluxes. The study compares the efficiency of using magnetic fluxes from permanent magnets (PM) on the example of two model variants of inductors with OMC developed by the authors. The analysis of the density distribution of magnetic fluxes in OMC was carried out by 3D modelling of the magnetic field using EMWorks software. It has been shown that such generators can be manufactured using a waste-free technology for strip of OMC. This technology significantly reduces the production costs of OMC. By modelling the distribution of magnetic fluxes in the OMC of the inductor, the results of experimental studies and analysis of the created device show that the capacity of generator can be varied by changing its dimensions and the number of the toggle switches on the rotor. This allows the alternator to be adapted to the load requirements – power banks and bicycle electronics.

"I Trust in Staff's Creativity"-The Impact of COVID-19 Lockdowns on Physical Activity Promotion in Nursing Homes Through the Lenses of Organizational Sociology.

Objectives: The health-enhancing benefits or regular physical activity (PA) reach into old age. With the emergence of the coronavirus disease of 2019 (COVID-19) pandemic and the associated national lockdowns and restrictions, nursing home residents were restrained from being physically active. In our study, we aimed to assess the impact of the COVID-19-related restrictions on PA promotion in nursing homes from an organizational-sociological lens.Methods: We collected data in eight nursing homes in Germany. Data collection included (i) semistructured interviews focusing on COVID-19-related restrictions and their effects on nursing homes from the home administrators' perspectives; (ii) open-ended surveys with nursing home staff and relatives focusing on daily routines and contact restrictions; and (iii) collection of documents such as care concepts, mission statements, and weekly activity plans. We analyzed all data with a reflexive thematic analysis approach.Results: We identified three stages of COVID-19-related changes in nursing homes that impacted PA promotion, as follows: (1) external closure and search for emergency control, (2) organizational adaptations to create a livable daily life in the internal environment, and (3) slow reintegration of interactions with the external organizational environment. Document analysis revealed that PA promotion was not part of decision programs or internal staff work descriptions. Rather, PA promotion was delegated to external service providers. The assignment of PA promotion to external providers was not structurally anchored in decision programs, which makes PA promotion not sustainable, particularly during unforeseen events that limit access to the organization. During the pandemic, executive staff believed in internal staff to buffer competencies with regard to PA promotion. Thus, executive staff often considered PA promotion relevant, even during the pandemic, but thought that PA promotion is a task that can be fulfilled by unqualified but motivated internal staff.Conclusion: While our study participants showed a high level of coping-capacity belief, it remains unclear which long-term impacts of COVID-19 on PA promotion in nursing homes are to be expected. At the practice level, executive staff in nursing homes that aim to promote PA within their organization should become aware that PA promotion needs to be incorporated into organizational structures to be implemented and continued in challenging times such as in a pandemic.

Inversion Models for the Retrieval of Total and Tropospheric NO2 Columns

Inversion models for retrieving the total and tropospheric nitrogen dioxide ( NO 2 ) columns from spaceborne remote sensing data are presented. For total column retrieval, we propose the so-called differential radiance models with internal and external closure and solve the underlying nonlinear equations by using the method of Tikhonov regularization and the iteratively regularized Gauss–Newton method. For tropospheric column retrieval, we design a nonlinear and a linear model by using the results of the total column retrieval and the value of the stratospheric NO 2 column delivered by a stratosphere–troposphere separation method. We also analyze the fundamentals of the commonly used differential optical absorption spectroscopy (DOAS) model and outline its relationship to the proposed inversion models. By a numerical analysis, we analyze the accuracy of the inversion models to retrieve total and tropospheric NO 2 columns.

Soft tissue response to dental implant closure caps made of either polyetheretherketone (PEEK) or titanium

Polyetheretherketone (PEEK) is a popular synthetic thermoplastic polymer for medical applications, but its clinical use suffers from several limitations. Therefore, the aim was to compare the soft tissue response to dental implant closure caps made of PEEK or titanium as evaluated by the occurrence of multinucleated giant cells (MNGCs). Forty-two implants were placed in the maxilla of seven miniature pigs. While commercially pure titanium (Ti) implants had a Ti closure cap, ceramic implants made of either zirconia (Zr) or alumina-toughened zirconia (Zr+Al) received a PEEK closure cap. Histomorphometry was performed to evaluate the number of small and large MNGCs being in contact with the PEEK or the Ti in different compartments of the implant systems. No histological signs of inflammation were noticed, and MNGCs were observed on both PEEK and Ti closure caps and on all three implant types. Significantly higher numbers of MNGCs were found on closure caps made of PEEK than on closure caps made of Ti on the external closure cap surface facing both soft (p=0.0008 for PEEK on Zr and p=0.0016 for PEEK on Zr+Al) and hard tissues (p=0.016 for PEEK on Zr and p=0.003 for PEEK on Zr+Al) as well as in the internal closure cap surface (p=0.014 for PEEK on Zr and p=0.0088 for PEEK on Zr+Al). No statistically significant differences in the number of MNGCs were observed on the three implant types. Significantly more MNGCs were in contact with PEEK than with Ti closure caps.

Foreign Bodies in the Female Reproductive Tract

Purpose:Most imaged foreign bodies of the female reproductive tract are intentionally placed, either by a medical professional or the patient herself. In many cases, these are reported as incidental findings, but occasionally studies are ordered specifically to locate wayward devices or assess for complications related to them. This requires radiologists to be able to correctly identify a wide range of foreign bodies, recognize their expected location, and assess for any associated complications. The purpose of this article is to familiarize the reader with a variety of foreign bodies and their usual positions in the female reproductive tract as well as their associated complications, if any. Methods: A search was performed of our institutional database, Montage, to find examples of frequently encountered foreign bodies of the external genitalia, vagina, cervix, uterus, and fallopian tubes in their expected positions. Further searches were made to illustrate common complications related to each. Results: Imaging of foreign bodies including external genital piercings, tampons, menstrual cups, pessaries, contraceptive rings, brachytherapy applicators, intra uterine contraceptive devices, and internal and external tubal closure devices were compiled across multiple modalities including x-ray, CT, MRI, and ultrasound. Complications including migration, perforation, and infection were reviewed. Conclusion: Foreign bodies of the female reproductive tract are ubiquitous and should be readily recognized by radiologists. Comprehensive evaluation includes assessment for correct location and device-related complications.

The Global Evolution of Travel Visa Regimes.

The Global Evolution of Travel Visa Regimes.

THE VULKAN TECHNIQUE: A NOVEL OSTOMY-CLOSURE TECHNIQUE THAT REDUCES COMPLICATIONS AND OPERATIVE TIMES.

ABSTRACTBackground: Ostomy reversals remain at high risk for surgical complications. Indeed, surgical-side infections due to bacterial contamination of the stoma lead to revision surgery and prolonged hospital stay. Aim: To describe the novel vulkan technique of ostomy reversal that aims to reduce operative times, surgical complications, and readmission rates. Methods: Ostomy closure was performed using the vulkan technique in all patients. This technique consists of external intestinal closure, circular skin incision and adhesiolysis, re-anastomosis, and closure of the subcutaneous tissue in three layers, while leaving a small secondary wound through which exudative fluid can be drained. The medical records of enterostomy patients were retrospectively reviewed from our hospital database. Results: The vulkan technique was successfully performed in 35 patients mainly by resident surgeons with <5 years of experience (n=22; 62.8%). The ileostomy and colostomy closure times were 53 min (interquartile range [IQR], 41-68 min; n=22) and 136 min (IQR: 88-188 min; n=13; p<0.001), respectively. The median hospital stay was seven days (IQR: 5−14.5 days); the length of hospital stay did not differ between ileostomy and colostomy groups. Major surgical complications occurred only in patients who underwent colostomy closure following the Hartmann procedure (n=2); grade≥IIIb according Clavien-Dindo classification. Conclusion: The vulkan technique was successfully applied in all patients with very low rates of surgical-site infections. Off note, residents with limited surgical experience mainly performed the procedure while operating time was less than one hour.

Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate.

In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4-0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

Measuring the Europeanization of Everyday Life: Three New Indices and an Empirical Application

ABSTRACTThis article seeks to conceptually clarify the measurement of Europeanization from a transactional perspective. Following Karl Deutsch, we regard cross-border practices and sense of community as constitutive for an emerging European society. But we critically reassess how this approach has been put into empirical practice by contemporary scholars. Typically, too much attention is paid to absolute Europeanization, and too little to relative Europeanization. In order to properly investigate the European society as situated between the nation-state and the world society, we argue that Europeanization involves both national openness (the salience of Europe compared to the nation-state) and external closure (the salience of Europe compared to the world). Three indices are suggested to capture relative Europeanization and its major components. Recent Eurobarometer and European Values Study data on practices and attitudes of EU citizens is used to illustrate our approach empirically. The results demonstrate that external closure adds a new layer of information for understanding everyday life Europeanization. We also find a bifurcation between practices for which Europe is the more relevant reference frame (as compared to the world) and attitudes for which it is not.

Intraluminal Negative Pressure Wound Therapy for Optimizing Pharyngeal Reconstruction

Pharyngocutaneous fistula formation after pharyngeal reconstruction is one of the most common and challenging problems to manage. Despite many advances in management, the published success rates indicate a role for any adjuvant therapy that could potentially decrease this complication. To describe the use of intraluminal negative pressure dressings (NPDs) in pharyngeal reconstruction. Retrospective case series at a tertiary care academic hospital. Twelve laryngectomy patients underwent pharyngeal reconstruction augmented by placement of an intrapharyngeal NPD in combination with the introduction of vascularized tissue from August 2011 to May 2012. All patients had potential risk factors for compromised wound healing defined as previous radiation therapy, hypothyroidism, diabetes mellitus, compromised nutrition, or established pharyngocutaneous fistula. An NPD was placed in an intraluminal position spanning the length of the pharyngeal defect as part of the reconstructive procedure. The negative pressure sponge was attached to a standard nasogastric tube to which negative pressure was applied. External closure of the pharynx was then achieved with regional or free tissue transfer. Pharyngeal closure rates, timing until return to oral diet, identification of wound healing risk factors, and adverse events related to use of the device. Eleven of 12 patients (92%) achieved pharyngeal closure with reconstruction using negative pressure wound therapy. All patients had at least 1 potential risk factor for compromised wound healing, with 11 of 12 (92%) having 2 or more. Seven patients had an established pharyngocutaneous fistula, and 5 patients underwent primary reconstruction after laryngopharyngectomy. In 6 of these 7 patients undergoing fistula repair, pharyngeal closure was achieved, and they resumed an oral diet at 1 week postoperatively. The other had successful leak repair initially, but 1 week later developed a separate area of wound breakdown and a second fistula. All 5 patients in whom an intraluminal NPD was placed at the time of initial vacularized tissue reconstruction were able to resume an oral diet by 3 weeks postoperatively, with 3 of them eating by mouth at 1 week postoperatively. No serious adverse events could be attributed to the use of intraluminal NPDs. Intraluminal negative pressure wound therapy is feasible and safe. Future research should be conducted to determine its potential in optimizing pharyngeal reconstruction in high-risk patients.

Microfluidic wound bandage: Localized oxygen modulation of collagen maturation

AbstractRestoring tissue oxygenation has the potential to improve poorly healing wounds with impaired microvasculature. Compared with more established wound therapy using hyperbaric oxygen chambers, topical oxygen therapy has lower cost and better patient comfort, although topical devices have provided inconsistent results. To provide controlled topical oxygen while minimizing moisture loss, a major issue for topical oxygen, we have devised a novel wound bandage based on microfluidic diffusion delivery of oxygen. In addition to modulating oxygen from 0 to 100% in 60 seconds rise time, the microfluidic oxygen bandage provides a conformal seal around the wound. When 100% oxygen is delivered, it penetrates wound tissues as measured in agar phantom and in vivo wounds. Using this microfluidic bandage, we applied the oxygen modulation to 8 mm excisional wounds prepared on diabetic mice. Treatment with the microfluidic bandage demonstrated improved collagen maturity in the wound bed, although only marginal differences were observed in total collagen, microvasculature, and external closure rates. Our results show that proper topical oxygen can improve wound parameters underneath the surface. Because of the ease of fabrication, the oxygen bandage represents an economical yet practical method for oxygen wound research.

Application of Platysma-Based Transpositional Flap for Through-and-Through Facial Defect When the Facial Artery Circulation Is Blocked or Compromised

A novel use of site-limited platysma-based transpositional flap is demonstrated and discussed for the reconstruction of facial defects. Between January 1985 and January 2001, 342 patients were operated on for advanced oral-oropharyngeal and orofacial cancers. In 6 cases, a platysma-based transpositional flap was used for external closure of facial through-and-through defects. Internally, the saved oral mucosa was used in 4 patients and fasciocutaneous forearm free flaps in 2 patients. The facial artery was blocked in all cases. The postoperative course was uneventful except in 1 case, when partial loss of the flap was observed intraorally. The externally used transpositional platysma-based flap showed cosmetic and functional advantages: its consistency, color, and texture were similar to those of the original facial tissues, the area of operation was the same, and the donor site was closed primarily. The site-limited platysma-based myocutaneous transpositional flap is usable and safe even in those cases in which circulation of the facial artery is damaged or local vascular compromise has occurred and the facial through-and-through defect is extended. The facial reconstruction described is one of several applicable reconstructive methods that may be chosen for special facial defects. The method is not applicable when the neck is radically operated on (radical neck dissection) and/or irradiated. No similar use of platysma-based transpositional flaps has been reported thus far.

Management of open tibial fractures: A 3-year regional review in Northern Ireland

Introduction: Open tibial fractures presenting to the 3 Northern Ireland trauma hospitals with over 36 months (2003–2006) were considered regarding the BAO/BAPS guidelines, which recommended joint orthopaedic/plastic management with definitive tissue coverage within 5 days. Methods: Details of Gustillo-Anderson classification, method and timing of surgery, and complications were identified retrospectively from a regional database and patient notes. Results: Of 111 patients with 115 fractures, 28 were Gustillo-Anderson grade 1, 21 were grade 2, 28 were grade 3a, 35 were grade 3b, and 3 were grade 3c. Grade 1 fractures were chiefly treated by IM nailing or cast. Most grade 2 and 3 injuries received IM nailing or external frames and primary closure within 5 days. Most grade 3b fractures were treated with external frames and tissue coverage after day 5, 46% having documented plastics referrals, and 20% receiving flaps All grade 3c fractures required amputation. Complications occurred in 42% of patients, mainly soft tissue infections (19%) and delayed union (10%) or non-union (12%). Only 42% of grade 3 injuries had documented referrals to plastics. Only 26% of patients were treated initially at the regional plastics unit (with orthpaedics on-site) but only 11% of patients required transfer for plastics input (chiefly for flaps). Conclusions: Complications were common despite most patients meeting the guidelines regarding time to definitive surgery. With increasing Gustillo-Anderson grade the number of procedures increased and method of management changed for orthopaedic and plastics procedures. Many patients with Gustillo 3 injuries had no recorded referral to plastics.

External Control of Exhalation for Cough Assistance: A Method for Patients With Glottis Dysfunction and/or Tracheostomy

Lee SC, Park JH, Kang S-W, Kim DH, Song SH. External control of exhalation for cough assistance: a method for patients with glottis dysfunction and/or tracheostomy. Objective To investigate the effectiveness of our method of assisting a cough by mimicking the functions of the glottis in patients with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube. Design Before-after trial. Setting University rehabilitation hospital. Participants Patients (N=35) with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube. Interventions Not applicable. Main Outcome Measures The unassisted peak cough flow (PCF), the assisted PCF, and the assisted PCF with the external control method mimicking glottis function by an end-inspiratory external closure of the airways. Results Of the 35 patients, 13 were tracheostomized cervical cord injury patients, 11 were neuromuscular disease (NMD) patients with glottis dysfunction only, and 11 were NMD patients with a tracheostomy and glottis dysfunction. Assisted PCF with the external control method were higher than unassisted PCF and/or assisted PCF in all patients. Assisted PCF with the external control methods were measured in all of the patients even when the unassisted PCFs and/or assisted PCFs could not be measured. For patients with measurable assisted PCFs, the assisted PCF with the external control methods were significantly higher than the assisted PCFs. Conclusions We showed the effectiveness of our method of assisting a cough by external control of the glottis in patients with bulbar muscle weakness or paralysis and/or those who had a tracheostomy tube who cannot effectively cough with the help of existing cough assistance methods.

Reconstruction of Lower Extremity Fractures with Soft Tissue Defects.

Reconstruction of osseous and soft tissue defects after high-energy lower extremity trauma remains a challenge in trauma surgery. An initial planning of the reconstruction management is crucial in the therapeutic concept of these severe injuries. In Gustilo type II and IIIa fractures with minimal contamination a primary definite osseous stabilization by internal fixation along with primary soft tissue reconstruction is preferable. A variety of local, regional, and even free microvascular flaps are available for acute wound closure in such cases. Staged reconstruction with initial external fixation and vacuum-assisted wound closure is recommended for severe contaminated wounds and extended defects. Early secondary osseous reconstruction of larger osseous defects can be performed either by distraction lengthening technique or by a free vascularized bone graft. Early secondary soft tissue reconstruction necessitates a wide therapeutic repertoire in order to plan the optimal individual strategy. With a modern therapeutic strategy limb salvage with an adequate function after reconstruction of lower extremity fractures with soft tissue defects can be achieved in the majority of patients.