Large Trauma Research Articles

Sprayable, antimicrobial and immunoregulation hydrogel loading exosomes based on oxidized sodium alginate for efficient wound healing at skin graft donor sites and health detection

Skin grafting techniques are widely used for large burns, trauma, and various acute and chronic wounds, contributing greatly to the repair of traumatic tissue. However, donor site repair and regeneration are often neglected, resulting in infection and delayed healing. Therefore, it is crucial to reduce the rate of donor site infection and improve the speed and quality of healing. The low-oxidized sodium alginate (OSA) grafting ε-polylysine (OSA-g-EPL) prepared through the Schiff base reaction was used to load with mesenchymal stem cell exosomes (Exo), and crosslinked by Ca2+ to form a gel film (HAE) on the surface of the wound by spraying. EPL provided the hydrogel with good antimicrobial properties, and Exo promoted the polarization of the M2 macrophage, shortened the inflammatory phase of the wound and rapidly transitioned to the proliferation phase, thus accelerating the wound healing process and avoiding the transition to chronic wounds. The excellent electrical conductivity and sensing properties of the hydrogel could be used to monitor the behavioral activities of mice in real time to determine their wound recovery. Therefore, this strategy will provide a promising prospect for efficient and high-quality treatment of donor site wounds.

Does race and insurance status play a role in high-grade renal trauma in the pediatric population? - An analysis from the traumatic renal injury collaborative in kids (TRICK) consortium.

We sought to examine the potential role of race and insurance status on the presentation, management, and outcomes of high-grade renal trauma (HGRT) in a large trauma registry. A retrospective cohort study of a large, multi-center registry of high-grade pediatric renal trauma was performed. Patients < 18 years of age with HGRT (grades III, IV, and V) from 2007 to 2020 were included. Patient demographics, presenting characteristics, hospital courses, outcomes, and follow-ups were extracted and compared. A total of 341 patients were initially identified, 32 were excluded. 66.3% were Caucasian(C), 27.5% were African American(AA), and 6.2% were Other races(O). 43.7% had public insurance,49.8% had private insurance and 6.5% were self-pay. Association of Race: AA patients had a higher rate of penetrating trauma (9% AA vs. 4% C, 0% Others, p = 0.002). Those with O and AA races presented at a younger age (9.5 yo O vs. 12.5 yo AA vs. 14 yo C, p = 0.001). However, no differences were found between race groups in the hospital course or outcome. Association of Insurance status: Those with public insurance presented with higher rates of bowel injury and blood transfusion, no differences were found in hospital course or outcome. Private insurance had higher Urology follow up rates (49% Private vs. 34.6% Public vs. 35% Self pay, p = 0.041). Race and insurance status was associated with differences found on the mechanism of injury, transfusion rate and urology follow-up rate; however, they do not influence rates of surgical intervention, post-injury complications or mortality.

Therapeutic Role of Bone Marrow Mesenchymal Stem Cells (BMSCs) in Nonalcoholic Steatohepatitis (NASH) Cirrhosis

Abstract: NASH cirrhosis is a late-stage nonalcoholic fatty liver disease (NAFLD) characterized by high morbidity, high relapse rate, and high mortality, which is clinical to treat. Presently, liver transplantation is the most effective radical treatment, but it is difficult to be widely carried out due to the problems of large surgical trauma, lack of liver donors, and strong immunological rejection. Bone marrow mesenchymal stem cells (BMSCs) are a type of stem cell with characteristics of self-replication, multidirectional differentiation, and easy accessibility. The use of BMSCs for cell transplantation therapy has the advantages of fewer complications and significant efficacy, and it has become an important option for cell transplantation therapy, especially for liver diseases. In this paper, we will review the studies related to the use of BMSCs for the treatment of NASH cirrhosis in recent years.

Opportunity Cost of Surgical Management of Craniomaxillofacial Trauma: A Longitudinal Study.

Single-institution retrospective financial analysis. Trauma care is consistently linked to inadequate reimbursement, posing a significant financial burden for large trauma centers. Data show that declining Medicare reimbursement rates have indirectly led to declining payment for all procedures covered by insurance. The goals of this study are to investigate the opportunity cost associated with contemporary surgical management of CMF trauma at our institution and to evaluate longitudinal financial trends. Patients with operative facial fractures between 2015 and 2022 at Duke University Medical Center were included and compared to patients undergoing general otolaryngology, plastic surgery and oral surgery operations in the same period. Procedural codes, payor type, charges billed, collections, relative value units (RVUs) and other financial data were obtained and analyzed among the 2 patient populations. Comparative analysis was performed to assess the financial trends in data reported previously from 2007-2015. The collection rate at Duke University Medical Center for operatively managed CMF fractures remains significantly lower than non-CMF counterparts. Interestingly, the collection rate gap between CMF and non-CMF surgeries has narrowed when comparing to the data from 2007-2013. This is largely due to a decrease in collection rates for non-CMF procedures from 29.61% (2007-2013) to 26.57% (2015-2022) [P = 0.0001] and an increase in collection rates for CMF procedures from 17.25% (2007-2013) to 18.05% (2015-2022) [P = 0.0001]. Despite a slight improvement of the gap in reimbursement rates for CMF and non-CMF surgeries over the last several years, trauma care continues to have a negative financial impact on health care institutions.

Blood transfusion in injured older adults: A retrospective cohort study.

We asked how increasing age interacts with transfusion and mortality among older injured adults at our large regional trauma center. Older adults are increasing proportions of acute trauma care and transfusion, but the specific interactions of increasing age with blood product use are unclear. Trauma data (age, injury severity, mechanism, etc.) were linked with transfusion service data (type, timing and numbers of units) for all acute trauma patients treated at our center 2011-2022. Subsets of patients aged ≥55 years were identified by age decade and trends assessed statistically, p < 0.01. Of 73 645 patients, 25 409 (34.5%) were aged ≥55. Within increasing 10-year age cohorts, these older patients were increasingly female (32.2%-67.2%), transferred from outside facilities (55.2%-65.9%) and injured in falls (44.4%-90.3%). Overall, patients ≥55, despite roughly equivalent injury severity, were twice as likely to be transfused (24% vs. 12.8%) as younger patients and to die during hospitalisation (7.5% vs. 2.9%). Cohort survival at all ages and levels of transfusion intensity in the first 4 h of care were more than 50%. Through age 94, numbers of red cell and whole blood units given in the first 4 h of care were a function of injury severity, not age cohort. In our trauma resuscitation practice, patients aged ≥55 years are more likely to receive blood products than younger patients, but numbers of units given in the first 4 h appear based on injury severity. Age equity in acute resuscitation is demonstrated.

Geriatric Trauma Intensive Care Unit Admission Guideline Is Associated With Reduction in Unplanned Intensive Care Unit Admissions

IntroductionGeriatric trauma patients experience disproportionate adverse outcomes compared to younger patients with similar injuries and represent an important target for quality improvement. Our institution created a Geriatric Trauma Intensive Care Unit (ICU) Admission Guideline to identify high-risk patients and elevate their initial level of care. The goal of implementation was reducing unplanned ICU admissions (UIAs), a recognized surrogate marker for adverse outcomes. MethodsThe Geriatric Trauma ICU Admission Guideline was implemented on July 1, 2020, at a large academic level-1 trauma center. Using trauma registry data, we retrospectively analyzed geriatric patients who met the criteria for ICU admission 2 y preimplementation and postimplementation. The main outcome was UIAs in the target geriatric population. Secondary outcomes included hospital length of stay, ICU length of stay, ventilator days, mortality, and 30-d readmissions. Characteristics between groups were compared with t-test, Mann-Whitney U test, or chi-square test. Risk-adjusted logistic and negative binomial regressions were used for the categorical and continuous outcomes, respectively. ResultsA total of 1075 patients were identified with 476 in the preimplementation and 599 in the postimplementation group. The groups were similar across most demographic and physiologic characteristics, with the exception of a higher incidence of hypertension in the preimplementation group (77.7% versus 71.6%, P = 0.02) and COVID in the postimplementation group (3.8% versus 0.4%, P < 0.001). While mechanism of injury was similar, there was a higher incidence of traumatic brain injury in the preimplementation group (35.1% versus 26.2%, P = 0.002). In the postimplementation group, there was a higher incidence ≥3 rib fractures (68% versus 61.3%, P = 0.02) and an expected increase in initial ICU level of care (69.5% versus 37.1%, P < 0.001). The odds of a UIA after guideline implementation were reduced by half (adjusted odds ratio 0.52, 95% confidence interval 0.3-0.92). There was not a significant difference in the secondary outcomes of mortality, 30-d readmission, hospital-free days, ICU-free days, or ventilator-free days. ConclusionsImplementation of the Geriatric Trauma ICU Admission Guideline was associated with a reduction in UIAs by half in the target population. There was not a significant change in hospital-free days, ICU-free days, ventilator-free days, mortality, 30-d readmission, or venous thromboembolism. Further research is needed to better refine admission guidelines, examine the association of preventative admission on delirium, and determination of criteria that would allow safe, earlier downgrade.

Tracheostomy tube changes by speech-language pathologists: a service review of an expanded scope of practice

Background/Aims Patients in acute care who have received a tracheotomy require efficient management to adequately progress through the acute care setting. This progression is predicated on efficient tracheostomy weaning through tracheostomy downsizing, capping and decannulation. The objective of this retrospective study was to review the outcomes of tracheostomy tube changes by speech-language pathologists. Methods A retrospective cohort analysis was performed of adult patients who received a tracheostomy tube change during their acute care hospitalisation by speech-language pathologists during a 6-month span in 2022. A total of 38 consecutive referrals undergoing an initial tracheostomy tube change had their electronic medical records reviewed. Success was defined as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement with no adverse events. Complications were recorded at the time of the tracheostomy tube change. Results Speech-language pathologists performed 38 (100%) initial tracheostomy tube changes successfully at the bedside without complications. The primary referral services were trauma and neurology. The primary diagnoses were polytrauma with a traumatic brain injury and multiple trauma without a traumatic brain injury or spinal cord injury. The mean Glasgow Coma Scale score and number of intubations were 12.4 and 1.4 respectively. A total of 34 (89%) tracheostomy tube changes resulted in the downsizing of the tracheostomy tube, while the remainder of tracheostomy tube changes (n=4; 11%) maintained the same size but were cuffless. All the tracheostomy tube changes were completed without complications, and all patients were noted as stable after 24 hours. Conclusions The procedural success corroborates the data reported by an earlier study in the literature and further validates the efficacy of a competent and experienced speech-language pathologists' ability to perform low-risk tracheostomy tube changes in the acute setting. This study demonstrates real world data from a single large trauma centre of tracheostomy tube changes performed by speech-language pathologists. Such data better defines the emerging role expansion of speech-language pathologists in the acute care setting. Implications for practice This study has the potential to expand the discussion around speech-language pathologists changing tracheostomy tubes in the acute care setting for a low-risk cohort. The authors have outlined the requisite training that may serve as a resource for speech-language pathologists to develop procedural competency.

Do Postoperative Surgeon Phone Calls Improve Outcomes Following Mandibular Fracture Repair?

Complications of open reduction and internal fixation (ORIF) of mandibular fractures are influenced by several patient factors. A postoperative surgeon phone call could modify these factors through education and reinforcement of instructions, but its effect has not been studied. The purpose of this study was to measure and compare the frequencies of postoperative inflammatory complications (POICs) following ORIF of mandibular fractures in patients who did and did not receive a postoperative surgeon phone call. The authors conducted an ambispective cohort study consisting of patients with mandibular fractures treated with ORIF at a large urban trauma hospital with the prospective cohort from January 1, 2021 to March 31, 2022 and a retrospective cohort from April 1, 2020 to December 31, 2020. Prisoners and patients with gunshot wounds were excluded. The primary predictor variable was the surgeon call group. After January 2021, a postoperative call was implemented 1-3days following fracture repair to review instructions, such as nonchew diet and oral hygiene, and provide education, such as reviewing expectations. Prior to January 2021, patients were not called. This resulted in 3 categories: Not Called, Called and Answered, and No Answer. The primary outcome variable was POICs, defined as the occurrence of exposed or infected hardware, abscess formation, recurrent swelling/pain, nonunion, osteomyelitis, or fistula formation. Demographic variables, injury-related variables, and treatment-related variables were also measured. Statistical analysis was performed using Fisher's exact and Wilcoxon rank-sum tests, as well as multivariable logistic regression. A P value was considered significant if<.05. Of the 178 patients in the study, 137 (77%) were male and the average age was 39.9±12.6years. Sixty-five patients (36.5%) were not called. Of the patients called, 79 (44.4%) answered and 34 (19.1%) did not answer. POICs occurred in 9.2% of the Not Called group and 8.9% of the Called and Answered group (P=.99). In the No Answer group, 29.4% had POICs, which was higher than the other 2 groups (P=.01). A surgeon phone call was not associated with complication rates; however, patients in the No Answer group were significantly more likely to experience a POIC.

Characteristics of fatal and non-fatal drownings at a Texas level-1 paediatric trauma centre

BackgroundDrowning is a leading cause of death for young children and knowing what puts a child at risk helps efforts across the spectrum of prevention. The purpose of this study...

Influencing factors for delayed diagnosed injuries in multiple trauma patients – introducing the ‘Risk for Delayed Diagnoses Score’ (RIDD-Score)

PurposeDelayed diagnosed injuries (DDI) in severely injured patients are an essential problem faced by emergency staff. Aim of the current study was to analyse incidence and type of DDI in a large trauma cohort. Furthermore, factors predicting DDI were investigated to create a score to identify patients at risk for DDI.MethodsMultiply injured patients admitted between 2011 and 2020 and documented in the TraumaRegister DGU® were analysed. Primary admitted patients with severe injuries and/or intensive care who survived at least 24 h were included. The prevalence, type and severity of DDI were described. Through multivariate logistic regression analysis, risk factors for DDI were identified. Results were used to create a ‘Risk for Delayed Diagnoses’ (RIDD) score.ResultsOf 99,754 multiply injured patients, 9,175 (9.2%) had 13,226 injuries first diagnosed on ICU. Most common DDI were head injuries (35.8%), extremity injuries (33.3%) and thoracic injuries (19.7%). Patients with DDI had a higher ISS, were more frequently unconscious, in shock, required more blood transfusions, and stayed longer on ICU and in hospital. Multivariate analysis identified seven factors indicating a higher risk for DDI (OR from 1.2 to 1.9). The sum of these factors gives the RIDD score, which expresses the individual risk for a DDI ranging from 3.6% (0 points) to 24.8% (6 + points).ConclusionDDI are present in a sounding number of trauma patients. The reported results highlight the importance of a highly suspicious and thorough physical examination in the trauma room. The introduced RIDD score might help to identify patients at high risk for DDI. A tertiary survey should be implemented to minimise delayed diagnosed or even missed injuries.

Utility of transmanubrial osteomuscular sparing approach and its modification in vascular surgery: a case series study of surgeries related to subclavian artery

BackgroundThe operative field in subclavian vessel surgery is limited by thoracic inlet and outlet structures. Although endovascular therapy for the subclavian artery could be an option, open repair management is occasionally required in cases of large aneurysms, infectious vasculopathy, and trauma. The transmanubrial osteomuscular sparing approach, commonly used in thoracic surgery area to resect superior sulcus tumors, is a simple and safe procedure providing an excellent view of the operative field. Herein, we present three cases that underwent open repair of the subclavian artery using the transmanubrial osteomuscular sparing approach, and we also highlight the utility of the technique along with the procedural details.Case presentationCase 1: A 54-year-old man presented with a true aneurysm of the proximal portion of the right subclavian artery. The aneurysm measured 50 × 80 mm and compressed the right lung and trachea. We performed an aneurysm resection and a right subclavian artery reconstruction via the transmanubrial osteomuscular sparing approach under cardiopulmonary bypass support.Case 2: A 72-year-old man who presented with an abscess that formed around the left subclavian artery due to an unremoved guidewire during thoracic endovascular aortic repair for an aortic arch aneurysm in another hospital. After the antibiotics administration, debridement and axillary-axillary bypass were performed, and the guidewire was removed via a transmanubrial osteomuscular sparing approach with a use of cardiopulmonary bypass.Case 3: A 60-year-old man presented with misplacement of an indwelling dialysis catheter inserted for acute renal failure and hyperkalemia. The catheter was placed through the right neck, but had penetrated the right internal jugular vein and was misplaced from the right subclavian artery into the proximal aortic arch. Emergently, we removed the catheter using the transmanubrial osteomuscular sparing approach.ConclusionsThe transmanubrial osteomuscular sparing approach to the subclavian artery provides an excellent view and a wide surgical field, even in different pathological situations. This is a simple, safe, and highly useful procedure and could be the standard approach for subclavian artery surgeries.

Dislocations deteriorate postoperative functional outcomes in supination-external rotation ankle fractures

PurposeTo assess the relationship between dislocation and functional outcomes in supination-external rotation (SER) ankle fractures. MethodsA retrospective case series study was performed on patients with ankle fractures treated surgically at a large trauma center from January 2015 to December 2021. The inclusion criteria were young and middle-aged patients of 18–65 years with SER ankle fractures that can be classified by Lauge-Hansen classification and underwent surgery at our trauma center. Exclusion criteria were serious life-threatening diseases, open fractures, fractures delayed for more than 3 weeks, fracture sites ≥2, etc. Then patients were divided into dislocation and no-dislocation groups. Patient demographics, injury characteristics, surgery-related outcomes, and postoperative functional outcomes were collected and analyzed. The functional outcomes of SER ankle fractures were assessed postoperatively at 1-year face-to-face follow-up using the foot and ankle outcome score (FAOS) and American orthopedic foot and ankle society score and by 2 experienced orthopedic physicians. Relevant data were analyzed using SPSS version 22.0 by Chi-square or t-test. ResultsDuring the study period, there were 371 ankle fractures. Among them, 190 (51.2%) were SER patterns with 69 (36.3%) combined with dislocations. Compared with the no-dislocation group, the dislocation group showed no statistically significant differences in gender, age composition, fracture type, preoperative complications with diabetes, smoking history, preoperative waiting time, operation time, and length of hospital stay (all p > 0.05), but a significantly higher Lauge-Hansen injury grade (p < 0.001) and syndesmotic screw fixation rate (p = 0.033). Moreover, the functional recovery was poorer, revealing a significantly lower FAOS in the sport/rec scale (p < 0.001). Subgroup analysis showed that among SER IV ankle fracture patients, FAOS was much lower in pain (p = 0.042) and sport/rec scales (p < 0.001) for those with dislocations. American orthopedic foot and ankle society score revealed no significant difference between dislocation and no-dislocation patients. ConclusionDislocation in SER ankle fractures suggests more severe injury and negatively affects functional recovery, mainly manifested as more pain and poorer motor function, especially in SER IV ankle cases.

Utilising the New Technology Add-on Payment (NTAP): Improving Medicare-insured patients’ access to innovative therapeutics

Andexanet alfa (Andexxa) is the first reversal agent for direct factor Xa inhibitors. It qualified as a new, novel therapeutic for the New Technology Add-on Payment (NTAP) reimbursement from the Centers for Medicare and Medicaid Services (CMS) in October 2018. This paper is the first analysis of a healthcare system (HCS) reporting its implementation and utilisation of the NTAP for a new therapeutic. The number of patients treated with Andexxa at the level 1 trauma centre of southern New Jersey, Cooper University Hospital (CUH) was analysed. This paper highlights the successful implementation of Andexxa as a treatment option for (non)traumatic intracranial haemorrhage and acute, nongastrointestinal haemorrhage requiring surgical management at CUH. This paper looked at how well CUH obtained the Andexxa NTAP from CMS for Medicare patients. During the 4-year reimbursement period, CUH treated a total of 88 patients with Andexxa, of which 53 were Medicare patients treated before the expiry of the Andexxa NTAP. The study found that CUH received NTAP for 81 per cent of Andexxa-treated Medicare patients and that CUH received the maximal NTAP amount of US$18,281.25 for 43 per cent of those same patients. The paper discusses how a large trauma centre implemented and received the NTAP for Andexxa and evaluates the effect of cost on reimbursement amounts during the Andexxa NTAP period. Finally, this paper should help healthcare providers, stakeholders and administrators better understand the process through which to obtain NTAP reimbursements from CMS and improve their HCS with new, innovative therapies for their patients.

Retraction Note: Review of a large trauma registry in Addis Ababa, Ethiopia: Insights into prehospital care and provider training for trauma quality improvement

Retraction Note: Review of a large trauma registry in Addis Ababa, Ethiopia: Insights into prehospital care and provider training for trauma quality improvement

Review of a large trauma registry in Addis Ababa, Ethiopia: insights into prehospital care and provider training for trauma quality improvement

BackgroundInjury is a major cause of death and disability in Ethiopia. ALERT Hospital, one of only three designated trauma centers in the country, has employed a basic trauma registry since...

Incidence and Management of Acute Pain in Trauma Patients in a Large Trauma Center

Objective: Trauma is a major cause of acute and intense pain. Inadequate pain control can lead to chronic pain that lessens the quality of life of the patients. The main objective of the present study was to identify the incidence of moderate to severe pain in trauma patients. Moreover, the incidence of neuropathic pain and the factors affecting the pain severity were also identified. Materials and Methods: A prospective descriptive study was conducted in 150 trauma-related patients admitted to the trauma ward at Siriraj Hospital. The patients’ demographic data, pain score at hospital arrival, admission, and every four hours until discharged, time to first analgesia, and type of analgesia were recorded. Neuropathic pain was evaluated by clinical diagnosis together with the scores from the DN4 and painDETECT questionnaires. The information was analyzed using descriptive study statistics. Results: One hundred fifty patients were analyzed. The incidences of moderate to severe pain on arrival at the trauma unit and at admission were 72.7% and 65.3%, respectively. The incidence of neuropathic pain was 15.3%. Neuropathic pain and multiple injuries were not significantly related to pain severity. In response to pain management, 71 patients (47.3%) had an improved pain score, and the median (IQR) pain score decreased from 7 (3 to 10) to 5 (2 to 8) (p&lt;0.001). Among all the patients, 46.0% were treated with multimodal analgesia. The time to first analgesia for the severe pain patients was four hours (2.0 to 7.0) after arrival and two hours (0.8 to 6.0) after admission. Conclusion: Most of the trauma patients experienced moderate to severe pain irrespective of the degree of their injuries. Neuropathic pain was found in the acute phase of traumatic pain. Pain management remains a problem that needs more attention and better pain management strategies are needed in trauma settings.

Multi-institutional review of characteristics and management of gunshot wounds to the spine

BACKGROUND CONTEXTGunshot wounds (GSWs) to the vertebral column represent an important cause of morbidity and mortality in the United States, constituting approximately 20% of all spinal injuries. The management of these injuries is an understudied and controversial topic, given its heterogeneity and lack of follow-up data. PURPOSETo characterize the management and follow-up of GSWs to the spine. STUDY DESIGN/SETTINGA multi-institutional retrospective review of the experience of two urban Level 1 trauma centers. PATIENT SAMPLEPatients with GSWs to the spine between 2010–2021. OUTCOME MEASURESMeasures included work status, follow-up healthcare utilization, and pain management were collected. METHODSCharts were reviewed for demographics, injury characteristics, surgery and medical management, and follow-up. Statistical analysis included T-tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables. All statistics were performed on SPSS v24 (IBM, Armonk, NY). RESULTSA total of 271 patients were included for analysis. The average age was 28 years old, 82.7% of patients were black, 90% were male, and 76.4% had Medicare/Medicaid. The thoracic spine (35%) was most commonly injured followed by lumbar (33.9%) and cervical (25.6%). Cervical GSW was associated with higher mortality (p<.001); 8.7% of patients developed subsequent osteomyelitis/discitis, 71.3% received prophylactic antibiotics, and 56.1% of cervical GSW had a confirmed vertebral or carotid artery injury. ASIA scores at presentation were most commonly A (26.9%), D (20.7%), or E (19.6%), followed by C (7.4%) and B (6.6%). 18.8% of patients were unable to be assessed at presentation. ASIA score declined in only 2 patients, while 15.5% improved over their hospital stay. Those who improved were more likely to have ASIA B injury (p<.001). Overall, 9.2% of patients underwent spinal surgery. Of these, 33% presented as ASIA A, 21% as ASIA B, 29% as ASIA C, and 13% as ASIA D. Surgery was not associated with an improvement in ASIA score. CONCLUSIONSGiven the ubiquitous and heterogeneous experience with GSWs to the spine, rigorous attempts should be made to define this population and its clinical and surgical outcomes. Here, we present an analysis of 11 years of patients presenting to two large trauma centers to elucidate patterns in presentation, management, and follow-up. We highlight that GSWs to the cervical spine are most often seen in young black male patients. They were associated with high mortality and high rates of injury to vertebral arteries and that surgical intervention did not alter rates of discitis/osteomyelitis or propensity for neurologic recovery; moreover, there was no incidence of delayed spinal instability in the study population.

Surgical management and outcomes following atypical subtrochanteric femoral fractures − results from a matched-pair analysis of the registry for geriatric trauma of the German Trauma Society

Background and objectivesThe outcomes of patients with atypical subtrochanteric fractures (ASFs) remain unclear. Data from a large international geriatric trauma registry were analysed to examine the outcome of patients with ASFs compared to patients with typical osteoporotic subtrochanteric fractures (TSFs).Materials and methodsData from the Registry for Geriatric Trauma of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie [DGU]) (ATR-DGU) were analysed. All patients treated surgically for ASFs or TSFs were included in this analysis. Across both fracture types, a paired matching approach was conducted, where statistical twins were formed based on background characteristics sex, age, American Society of Anesthesiologists (ASA) score and walking ability. In-house mortality and mortality rates at the 120-day follow-up, as well as mobility at 7 and 120 days, the reoperation rate, hospital discharge management, the hospital readmission rate at the 120-day follow-up, health-related quality of life, type of surgical treatment and anti-osteoporotic therapy at 7 and 120 days, were assessed as outcome measures using a multivariate logistic regression analysis.ResultsAmongst the 1,800 included patients, 1,781 had TSFs and 19 had ASFs. Logistic regression analysis revealed that patients with ASFs were more often treated with closed intramedullary nailing (RR = 3.59, p < 0.001) and had a higher probability of vitamin D supplementation as osteoporosis therapy at 120 days (RR = 0.88, p < 0.002). Patients with ASFs were also more likely to live at home after surgery (RR = 1.43, p < 0.001), and they also tended to continue living at home more often than patients with TSFs (RR = 1.33, p < 0.001). Accordingly, patients with TSFs had a higher relative risk of losing their self-sufficient living status, as indicated by increased rates of patients living at home preoperatively and being discharged to nursing homes (RR = 0.19, p < 0.001) or other hospitals (RR = 0.00, p < 0.001) postoperatively.ConclusionsSurgical treatment of ASFs was marked by more frequent use of closed intramedullary fracture reduction. Furthermore, patients with ASFs were more likely to be discharged home and died significantly less often in the given timeframe. The rate of perioperative complications, as indicated by nonsignificant reoperation rates, as well as patient walking abilities during the follow-up period, remained unaffected.

Major low-energy trauma results in non-specific immunoglobulin generation without evidence for specific autoantibody production: A prospective cohort study.

Cellular debris resulting from large trauma might overwhelm the scavenger mechanisms and lead to autoimmune reactions. We analysed whether a major well-defined trauma in humans induces laboratory signs of transient autoimmunity in the months after the insult. We included 50 patients with pertrochanteric femur fracture undergoing intramedullary nail osteosynthesis in a prospective cohort study and followed them at 3-4 days, 6 weeks, 12 weeks and 12 months postoperatively. By standard techniques, we assessed levels of total immunoglobulins, anti-nuclear antibodies (ANA), anti-cardiolipin antibodies, anti-dsDNA antibodies and anti-C1q antibodies, as well as antibodies against cytomegalovirus (CMV) as a control. Blood leukocyte differential and lymphocyte subpopulations were determined at baseline and in the first two postoperative samples. The mean age of the patients reached 80.1 years, and 23 (46%) completed all visits. Serum concentrations of total IgG, IgM and IgA increased at all follow-up time points. The ANA fluorescence light intensity units increased at 12 weeks and 12 months postoperatively (p < 0.0001), but the proportion of ANA-positive patients did not change (35%). The values of anti-C1q mildly increased at all follow-up visits, but not the ratio to total IgG. Anti-dsDNA remained negative in all patients, and anti-cardiolipin IgG/IgM antibodies did not change. Anti-CMV IgG antibodies increased significantly at all follow-up visits, without change in the ratio to total IgG. Flow cytometry showed an increased proportion of B-cells 3-4 days postoperatively. In conclusion, major musculoskeletal trauma in elderly patients induces a generalized non-specific increase in immunoglobulin production without laboratory signs for enhanced systemic autoimmunity.

Clinical application of middle descending colon-double lumen ostomy with distal stoma narrowing in the treatment of anorectal malformation

BackgroundAnorectal malformations (ARMs) are the most common congenital anomaly of the digestive tract. And colostomy should be performed as the first-stage procedure in neonates diagnosed with intermediate- or high-type ARMs. However, the most classic Pe˜na’s colostomy still has some disadvantages such as complicated operation procedure, susceptibility to infection, a greater possibility of postoperative incision dehiscence, difficulty of nursing and large surgical trauma and incision scarring when closing the stoma. We aimed to explore the effectiveness of middle descending colon-double lumen ostomy (MDCDLO) in the treatment of high and intermediate types of anorectal malformations.MethodsWe retrospectively reviewed the data of patients who underwent MDCDLO for high or intermediate types of ARMs between June 2016 and December 2021 in our hospital. The basic characteristics were recorded. All patients were followed up monthly to determine if any complication happen.ResultsThere were 17 boys and 6 girls diagnosed with high or intermediate types of ARMs in our hospital between June 2016 and December 2021. All 23 patients were cured without complications such as abdominal incision infection, stoma stenosis, incisional hernia, and urinary tract infection in the postoperative follow-up time of 6 months to 6 years except one case of proximal intestinal prolapse was restored under anesthesia.ConclusionMDCDLO offers the advantages of simplicity, efficiency, safety, mild trauma, and small scarring in the treatment of high and intermediate types of anorectal malformations.