Subacute Period Research Articles

Sex-Dependent Pathology in the HPA Axis at a Sub-acute Period After Experimental Traumatic Brain Injury.

Over 2.8 million traumatic brain injuries (TBIs) are reported in the United States annually, of which, over 75% are mild TBIs with diffuse axonal injury (DAI) as the primary pathology. TBI instigates a stress response that stimulates the hypothalamic-pituitary-adrenal (HPA) axis concurrently with DAI in brain regions responsible for feedback regulation. While the incidence of affective symptoms is high in both men and women, presentation is more prevalent and severe in women. Few studies have longitudinally evaluated the etiology underlying late-onset affective symptoms after mild TBI and even fewer have included females in the experimental design. In the experimental TBI model employed in this study, evidence of chronic HPA dysregulation has been reported at 2 months post-injury in male rats, with peak neuropathology in other regions of the brain at 7 days post-injury (DPI). We predicted that mechanisms leading to dysregulation of the HPA axis in male and female rats would be most evident at 7 DPI, the sub-acute time point. Young adult age-matched male and naturally cycling female Sprague Dawley rats were subjected to midline fluid percussion injury (mFPI) or sham surgery. Corticotropin releasing hormone, gliosis, and glucocorticoid receptor (GR) levels were evaluated in the hypothalamus and hippocampus, along with baseline plasma adrenocorticotropic hormone (ACTH) and adrenal gland weights. Microglial response in the paraventricular nucleus of the hypothalamus indicated mild neuroinflammation in males compared to sex-matched shams, but not females. Evidence of microglia activation in the dentate gyrus of the hippocampus was robust in both sexes compared with uninjured shams and there was evidence of a significant interaction between sex and injury regarding microglial cell count. GFAP intensity and astrocyte numbers increased as a function of injury, indicative of astrocytosis. GR protein levels were elevated 30% in the hippocampus of females in comparison to sex-matched shams. These data indicate sex-differences in sub-acute pathophysiology following DAI that precede late-onset HPA axis dysregulation. Further understanding of the etiology leading up to late-onset HPA axis dysregulation following DAI could identify targets to stabilize feedback, attenuate symptoms, and improve efficacy of rehabilitation and overall recovery.

THE PULMONARY CIRCULATION PECULIARITIES IN MEN UNDER 60 YEARS OLD WITH PULMONARY HYPERTENSION, DEVELOPED DURING MYOCARDIAL INFARCTION

Relevance. Formation of pulmonary hypertension (PH) in myocardial infarction (MI) remains poorly understood. Aim. To evaluate changes in pulmonary circulation indicators (PCI) in men under 60 years old (y.o) with PH that is developing in subacute MI period to improve understanding of developmental options and prevention. Material and methods. The study included men aged 19-60 y.o. with MI and various dynamics of mean pulmonary ar-tery pressure (MPAP), determined by echocardiography (A. Kitabatake) in the first 48 hours (1) and completion of third week (2) of MI. Patients were divided into four groups: studied (I) included 84 patients (mean age 50.4±7.1 y.o) with PH (MPAP2 25 and more mm Hg) and normal level of MPAP1. Group II included patients with a normal level of MPAP in both phases of the study (88 men, 52.1±6.6 y.o); group III – with elevated levels of MPAP at both points of study (184 men, 51.2±5.5 y.o) and IV – with increased levels of MPAP1 and normal levels of MPAP2 (94 men, 50.5±6.8 y.o). A comparative assessment of PCI in selected groups was performed. Results. In first 48 hours of MI, the minimum values of MPAP (I: 21.9±3.3; II: 20.3±2.5; III: 39.0±11.2 (mm Hg)) and total pulmonary resistance (TPR) ) (I: 380.0±171.0; II: 306.8±136.3; III: 616.0±279.8 (dyn×sec×cm-5)) were noted in group II, and the maximum - in III (p˂0.0001). When considering their dynamics at the end of the third week of MI, MPAP increased in I (39.5%; p˂0.0001), decreased in III (16.0%; p˂0.0001) and IV groups (42.9%; p˂0.0001). TPR decreased in II (12.1%), III (28.6%) and IV (54.2%) groups (p ˂0.0001). Conclusions. The study group is distinguished by unfavorable changes in PCI during observation period, in contrast to other groups, which confirms expediency of assessing dynamics of these parameters as possible marker of negative prognosis for PH.

Sport Concussion Assessment Tool Symptom Inventory: Healthy and Acute Postconcussion Symptom Factor Structures.

Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors. The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items. Case series. High school and college. A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes. Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted. A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive-fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine-fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive-ocular (eg, difficulty remembering and balance problems) symptom factors. The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acutely concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor.

Sport Concussion Assessment Tool Symptom Inventory: Healthy and Acute Postconcussion Symptom Factor Structures.

Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors. The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items. Case series. High school and college. A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes. Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted. A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive ocular (eg, difficulty remembering and balance problems) symptom factors. The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acute concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor.

Echocardiographic Findings in Pediatric Multisystem Inflammatory Syndrome Associated With COVID-19 in the United States

BackgroundCenters from Europe and United States have reported an exceedingly high number of children with a severe inflammatory syndrome in the setting of coronavirus disease 2019, which has been termed multisystem inflammatory syndrome in children (MIS-C). ObjectivesThis study aimed to analyze echocardiographic manifestations in MIS-C. MethodsA total of 28 MIS-C, 20 healthy control subjects and 20 classic Kawasaki disease (KD) patients were retrospectively reviewed. The study reviewed echocardiographic parameters in the acute phase of the MIS-C and KD groups, and during the subacute period in the MIS-C group (interval 5.2 ± 3 days). ResultsOnly 1 case in the MIS-C group (4%) manifested coronary artery dilatation (z score = 3.15) in the acute phase, showing resolution during early follow-up. Left ventricular (LV) systolic and diastolic function measured by deformation parameters were worse in patients with MIS-C compared with KD. Moreover, MIS-C patients with myocardial injury were more affected than those without myocardial injury with respect to all functional parameters. The strongest parameters to predict myocardial injury in MIS-C were global longitudinal strain, global circumferential strain, peak left atrial strain, and peak longitudinal strain of right ventricular free wall (odds ratios: 1.45 [95% confidence interval (CI): 1.08 to 1.95], 1.39 [95% CI: 1.04 to 1.88], 0.84 [95% CI: 0.73 to 0.96], and 1.59 [95% CI: 1.09 to 2.34], respectively). The preserved LV ejection fraction (EF) group in MIS-C showed diastolic dysfunction. During the subacute period, LVEF returned to normal (median from 54% to 64%; p < 0.001) but diastolic dysfunction persisted. ConclusionsUnlike classic KD, coronary arteries may be spared in early MIS-C; however, myocardial injury is common. Even preserved EF patients showed subtle changes in myocardial deformation, suggesting subclinical myocardial injury. During an abbreviated follow-up, there was good recovery of systolic function but persistence of diastolic dysfunction and no coronary aneurysms.

Pelvic MRI in spinal cord injury patients: incidence of muscle signal change and early heterotopic ossification

Prospective observational study. To evaluate pelvic MRI muscle signal changes and their association with early heterotopic ossification (HO) in patients with spinal cord injuries. National Spinal Injuries Unit, Stoke Mandeville, UK. Forty patients were imaged with at least two interval magnetic resonance (MR) studies of the pelvis in the first 6 months following a spinal cord injury. Scans were reviewed and scored for heterotopic ossification, muscle signal change and extent of muscle involvement. Muscle signal change was present in 28 (70%) on the initial MRI and 31 (77%) by the second study. Six patients developed MR changes of prodromal or immature heterotopic ossification (15%). No restricted diffusion was demonstrated and no patient developed mature HO. Patients developing MR changes of early HO were more likely to have grade 3 muscle changes. Increased T2 muscle signal is common following cord injury, is frequently progressive in the subacute period and is associated with complete injury and early MR signs of heterotopic ossification.

128. Subacute and chronic preoperative opioid use associated with reoperations in single-level ACDF patients without myelopathy

BACKGROUND CONTEXT Recent literature has demonstrated that preoperative opioid use is associated with both worse postoperative outcomes and increased postoperative opioid dependence after anterior cervical discectomy and fusion (ACDF). However, no studies have demonstrated a relationship between acute, subacute, and chronic preoperative opioid use and reoperation on the cervical spine. This information would be valuable for counseling patients for preoperative opioid cessation. PURPOSE To demonstrate an association between preoperative use of five different opioid medications on reoperation after ACDF in patients without myelopathy. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE This study included 445 patients undergoing single-level ACDF without myelopathy. OUTCOME MEASURES Reoperation on the cervical spine within 5 years postoperatively. METHODS Preoperative use of five opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release (ER) oxycodone) were assessed and categorized as acute (within 3 months), subacute (acute use and use between 3-6 months), and chronic (subacute use and use prior to 6 months). Multivariate regression was used to determine the relative association of each medication on reoperations during the acute, subacute, and chronic periods. All patients were followed for 5 years postoperatively. RESULTS The most commonly used preoperative opioid was hydrocodone (50.3% acute use, 24.7% chronic use), followed by oxycodone (19.6% acute use, 6.7% chronic use), and tramadol (14.4% acute use, 5.4% chronic use). Hydromorphone and ER-oxycodone were only used in 1.8% and 0.4% of patients, respectively, and were excluded from further analyses. A total of 42 patients (9.4%) underwent reoperation within 5 years. At 5 years postoperatively patients who had acute, subacute, and chronic preoperative use of hydrocodone had reoperation rates of 9.4%, 14.8%, and 15.5%, respectively, compared to 4.7% in opioid naive patients (P 0.05). CONCLUSIONS Both subacute and chronic use of common opioid medications are associated with increased reoperations after single-level ACDF in non-myelopathic patients. While the reasons for this are unclear, chronic mu-receptor agonism is known to result in opioid-induced hyperalgesia. This may make identification of pain generators difficult in non-myelopathic patients or lead to chronic postoperative pain. This information is also critical when counseling patients on preoperative opioid cessation. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Management of upper extremity war injuries in the subacute period: A review of 62 cases

ObjectiveIn this study, we aimed to describe the relationship between the localization of rarely seen upper extremity war injuries and their complications in the subacute period, and define our preferences for surgery and antibiotic use. MethodsPatients with an upper extremity war injury who presented to our institution between 2015 and 2018 were retrospectively evaluated. Data regarding demographics, time between injury and presentation, location of injury, type of damage, complications, treatment methods, infection rates and antibiotic use were recorded. Tissue defects, fracture fixation, neurovascular damage, infection development and treatment approaches were analyzed. ResultsSixty-two male patients with isolated upper extremity injuries (mean age: 31.66 ± 8.28 years) were included in the study. The average time between trauma and hospitalization was 14 days. The mean hematocrit (Hct) level at presentation was 36.3 ± 6.8%. Patients had been followed up for an average period of 95.6 ± 32.1 days. Twenty-nine patients (46.8%) had nerve injury, eight (12.9%) had arterial injury that required repair, and 23 had infection (37.1%), of which five developed osteomyelitis. Infection was polymicrobial in nine cases and monobacterial in 14. A positive correlation was found between the presence of fracture and nerve injury (p = 0.013). The frequency of nerve injuries due to gunshot wounds was higher in the mid-section and lower part of the arms and in the proximal forearm when compared to other regions (p = 0.011). The infection rates were significantly higher in patients with fractures (p = 0.033). The mean hematocrit (Hct) level at presentation of the patients with infection (32.1 ± 6.3%) was significantly lower than that of those who did not have infection (38.8 ± 5.9%) (p<0.001). ConclusionUpper extremity war injuries require case-specific solutions. Microbiological samples should be taken prior to empirical antibiotic treatment for infection management and rational antibiotic use principles should be applied according to the culture and antibiogram results. The holistic and ambiguous character of nerve injuries often requires early exploration and combined reconstructive interventions. Arterial injuries can be overlooked by physical examination alone and thus routine angiography should be performed. Completion of the bone and soft tissue reconstructions in the same session using a holistic approach minimizes the possible risks.

Red-Light (670 nm) Therapy Reduces Mechanical Sensitivity and Neuronal Cell Death, and Alters Glial Responses after Spinal Cord Injury in Rats.

Individuals with spinal cord injury (SCI) often develop debilitating neuropathic pain, which may be driven by neuronal damage and neuroinflammation. We have previously demonstrated that treatment using 670 nm (red) light irradiation alters microglia/macrophage responses and alleviates mechanical hypersensitivity at 7 days post-injury (dpi). Here, we investigated the effect of red light on the development of mechanical hypersensitivity, neuronal markers, and glial response in the subacute stage (days 1-7) following SCI. Wistar rats were subjected to a mild hemi-contusion SCI at vertebra T10 or to sham surgery followed by daily red-light treatment (30 min/day; 670 nm LED; 35 mW/cm2) or sham treatment. Mechanical sensitivity of the rat dorsum was assessed from 1 dpi and repeated every second day. Spinal cords were collected at 1, 3, 5, and 7 dpi for analysis of myelination, neurofilament protein NF200 expression, neuronal cell death, reactive astrocytes (glial fibrillary acidic protein [GFAP]+ cells), interleukin 1 β (IL-1β) expression, and inducible nitric oxide synthase (iNOS) production in IBA1+ microglia/macrophages. Red-light treatment significantly reduced the cumulative mechanical sensitivity and the hypersensitivity incidence following SCI. This effect was accompanied by significantly reduced neuronal cell death, reduced astrocyte activation, and reduced iNOS expression in IBA1+ cells at the level of the injury. However, myelin and NF200 immunoreactivity and IL-1β expression in GFAP+ and IBA1+ cells were not altered by red-light treatment. Thus, red-light therapy may represent a useful non-pharmacological approach for treating pain during the subacute period after SCI by decreasing neuronal loss and modulating the inflammatory glial response.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

What's Important: What I Learned as My Spouse's "Recovery Partner" Following Rotator Cuff Surgery.

Investigation of Bowel Function with Anorectal Manometry in a Rat Spinal Cord Contusion Model.

Bowel dysfunction after chronic spinal cord injury (SCI) is a common source of morbidity and rehospitalization. Typical complications include constipation, fecal impaction, incontinence, abdominal distention, autonomic dysreflexia, and the necessity of interventions (i.e., suppositories, digital stimulation) to defecate. Numerous surveys have confirmed that the remediation of bowel complications is more highly valued for quality of life than improvements in walking. Much of what is known about bowel function after SCI for diagnosis and research in humans has been gained using anorectal manometry (ARM) procedures. However, ARM has been underutilized in pre-clinical animal work. Therefore, a novel combination of outcome measures was examined in the current study that incorporates functional output of the bowel (weekly fecal measurements), weight gain (pre-injury to terminal weight), and terminal ARM measurement with external anal sphincter electromyography under urethane anesthesia. The results indicate higher fecal output after contusion during the sub-acute period (4-7 days) post-injury, changes in the composition of the feces, and functionally obstructive responses in a specific section of the rectum (increased baseline pressure, increased frequency of contraction, and reduced ability to trigger a giant contraction to a distension stimulus). These results demonstrate significant bowel dysfunction in the rodent SCI contusion model that is consistent with data from human research. Thus, the combined measurement protocol enables the detection of changes and can be used, with minimal cost, to assess effectiveness of therapeutic interventions on bowel complications.

Serial Diffusion Kurtosis Magnetic Resonance Imaging Study during Acute, Subacute, and Recovery Periods after Sport-Related Concussion.

Sport-related concussion (SRC) is common in contact sports, but there remains a lack of reliable, unbiased biomarkers of brain injury and recovery. Although the symptoms of SRC generally resolve over a period of days to weeks, the lack of a biomarker impairs detection and return-to-play decisions. To this date, the pathophysiological recovery profile and relationships between brain changes and symptoms remained unclear. In the current study, diffusion kurtosis imaging (DKI) was used to monitor the effects of SRC on the brain and the trajectory of recovery in concussed American football players (n = 96) at <48 h, and 8, 15, and 45 days post-injury, who were compared with a matched group of uninjured players (n = 82). The concussed group reported significantly higher symptoms within 48 h after injury than controls, which resolved by the 8-day follow-up. The concussed group also demonstrated poorer performance on balance testing at <48 h and 8 days than controls. There were no significant differences between the groups in the Standardized Assessment of Concussion (SAC), a cognitive screening measure. DKI data were acquired with 3 mm isotropic resolution, and analyzed using tract-based spatial statistics (TBSS). Additionally, voxel- and region of interest-based analyses were also conducted. At <48 h, the concussed group showed significantly higher axial kurtosis than the control group. These differences increased in extent and magnitude at 8 days, then receded at 15 days, and returned to the normal levels by 45 days. Kurtosis fractional anisotropy (FA) exhibited a delayed response, with a consistent increase by days 15 and 45. The results indicate that changes detected in the acute period appear to be prolonged compared with clinical recovery, but additional brain changes not observable acutely appear to progress. Although further studies are needed to understand the pathological features of DKI changes after SRC, these findings highlight a potential disparity between clinical symptoms and pathophysiological recovery after SRC.

Functional preservation and enhanced capacity for visual restoration in subacute occipital stroke.

Stroke damage to the primary visual cortex (V1) causes a loss of vision known as hemianopia or cortically-induced blindness. While perimetric visual field improvements can occur spontaneously in the first few months post-stroke, by 6 months post-stroke, the deficit is considered chronic and permanent. Despite evidence from sensorimotor stroke showing that early injury responses heighten neuroplastic potential, to date, visual rehabilitation research has focused on patients with chronic cortically-induced blindness. Consequently, little is known about the functional properties of the post-stroke visual system in the subacute period, nor do we know if these properties can be harnessed to enhance visual recovery. Here, for the first time, we show that 'conscious' visual discrimination abilities are often preserved inside subacute, perimetrically-defined blind fields, but they disappear by ∼6 months post-stroke. Complementing this discovery, we now show that training initiated subacutely can recover global motion discrimination and integration, as well as luminance detection perimetry, just as it does in chronic cortically-induced blindness. However, subacute recovery was attained six times faster; it also generalized to deeper, untrained regions of the blind field, and to other (untrained) aspects of motion perception, preventing their degradation upon reaching the chronic period. In contrast, untrained subacutes exhibited spontaneous improvements in luminance detection perimetry, but spontaneous recovery of motion discriminations was never observed. Thus, in cortically-induced blindness, the early post-stroke period appears characterized by gradual-rather than sudden-loss of visual processing. Subacute training stops this degradation, and is far more efficient at eliciting recovery than identical training in the chronic period. Finally, spontaneous visual improvements in subacutes were restricted to luminance detection; discrimination abilities only recovered following deliberate training. Our findings suggest that after V1 damage, rather than waiting for vision to stabilize, early training interventions may be key to maximize the system's potential for recovery.

Chip-based serum proteomics approach to reveal the potential protein markers in the sub-acute stroke patients receiving the treatment of Ginkgo Diterpene Lactone Meglumine Injection

Ethnopharmacological relevanceGinkgo biloba L. is a kind of traditional Chinese medicinal material with a long history. Its main active ingredients, ginkgolides, can be used for the treatment of stroke and other cardio-cerebrovascular diseases. Ginkgo Diterpene Lactone Meglumine Injection (GDLI), a modernized TCM, has attracted much attention because of its neuroprotective and anti-inflammatory properties.Aim of the study: To uncover the effects of GDLI on ischemic stroke patients, as well as the underlying biomarkers involved in sub-acute stroke. Materials and methodsWe used a state-of-the-art targeted proteomics chip to investigate the association between numerous serum proteins (1101 proteins) and the sub-acute phase post-ischemic stroke. Then, the relative proteins of anti-apoptosis, anticoagulant, and neuroprotection of GDLI were verified in animal models. ResultsCompared with the serum from healthy volunteers, we identified 15 up-regulated proteins and 26 down-regulated proteins (FC ≥ 1.5) involved in inflammatory response, immune response, and nervous system development in the sub-acute ischemic stroke. The pro-inflammatory proteins, such as IL17, MSP-R, G–CSF–R, TLR3, MIP-3β, TNFRSF19, and TNFRSF12, were significantly increased in serum, illustrating that the chronic inflammatory state was evident in the sub-acute stage of ischemic stroke. However, the common pro-inflammatory proteins, such as IL-1β, IL-6, IL-8, TNF-α, IFN-γ, and IL-10, known to be up-regulated in acute stroke, had close or lightly lower levels than healthy humans (FC ≥ 1.5, P > 0.05). And some cytokines (IL3, CCL13, TNFRSF3, IL10 R beta, HLA-A, IL-1 F8/FIL1 eta, TNFRSF8, CCL18) were also markedly down-regulated in the sub-acute phase of stroke. These proteins are highly associated with the onset of stroke-induced immunosuppression and post-stroke infection. Moreover, we noticed that Ginkgo Diterpene Lactone Meglumine Injection (GDLI) treatment for 14 days was helpful to the recovery of patients in the subacute period. After the treatment of GDLI, it was observed that several inflammatory cytokines (i.e. IL-17 and IL-28A), chemokine (i.e. CCL14), and Coagulation Factor III were reduced. Meanwhile, the anti-inflammatory cytokines (IL-10 R alpha, GREMLIN, and Activin C) and neurotrophic factors (Neurturin and IGFBP2) were found to be up-regulated in stroke patients through self-control observation. Finally, we identified the IGFBP2 as a novel marker in the animal models. ConclusionsIn summary, the potential markers in sub-acute stroke patients were highly different from known protein markers in the acute phase of ischemic stroke. The serum protein IGFBP2 could be novel biomarkers for the treatment of GDLI in sub-acute stroke patients. Our present findings provide an innovative insight into the novel treatment of GDLI in ischemic stroke therapy.

Subacute reconstruction using flap transfer for complex defects of the upper extremity

BackgroundDespite advances in microsurgical techniques of flap transfer, complex upper extremity trauma reconstruction remains a challenge for surgeons. This study aimed to present the outcomes in using flaps in the subacute reconstruction of complex upper extremity injuries.MethodsFrom July 2013 to December 2016, 35 patients ranging in age from 23 to 69 years with complicated upper extremity traumatic injuries were treated using flap reconstruction in subacute period. The number and causes of injury were 12 machine crush injuries, 18 machine strangulation injuries, two chainsaw accidents, two traffic accidents, and one incident of heavy bruising. Thirty-five patients underwent flap procedures, including 24 anterolateral thigh flaps (68.57%), five latissimus dorsi flaps (14.29%), and six lateral arm flaps (17.14%). Flap sizes ranged from 3 × 4 to 42 × 16 cm2. The mean time of flap reconstruction was 14 days (range 5–29). During postoperative follow-up, flap appearance, sensory recovery, scarring and satisfaction were assessed.ResultsThe overall flap survival rate was 94.3%.Two flaps developed partial necrosis, both of which were later treated with skin grafting. Traumatic wound infections occurred in three patients. All upper limb injuries were completely covered. The follow-up periods ranged from 18 to 62 months with an average of 2.9 months. All skin flap textures were soft with varying degrees of pigmentation. Flap sensory recovery was S1 in three cases, S2 in eight cases, S3 in 15 cases, and S4 in nine cases. There were no donor site complications other than three cases with scar hyperplasia.ConclusionsThe severe upper limb soft tissue defects still achieved satisfactory function and appearance with negligible complications and low amputation rates during the subacute period.

The Role of Reduced Polyamine Synthesis in Ischemic Stroke

Our aim was to determine the levels of arginine decarboxylase (ADC), ornithine decarboxylase (ODC) and agmatine, ornithine, nitric oxide (NO) and arginase activity in the acute and subacute phases of acute ischemic stroke (AIS), by revealing the possible role of these levels in neuroinflammation and neurogenesis that are postulated to begin after AIS. 35 patients diagnosed with AIS and 35 controls were included in the study. ADC, ODC, agmatinase and NO levels were determined by ELISA kits. Arginase activity and ornithine levels were measured spectrophotometrically. There was no statistically significant difference between the levels of agmatinase, ornithine and arginase activity on days 1 and 7 in the AIS group and the levels measured in the control group (p > 0.05). High ADC and low ODC and NO values were found in the patients compared to the controls in both acute and subacute periods (p < 0.05). It was shown that polyamine synthesis decreased in both acute and subacute periods after AIS; and this was due to the decrease in ODC levels, the rate-regulating step of the major pathway. This reduction may be associated with both the inadequate stimulation of neurogenesis and the immune system with reduced NO synthesis. polyamine synthesis enzymes, ornithine, ornitine decarboxylase, nitric oxide, arginine decarboxylase, agmatine, agmatinase, arginase activity, neuroinflammation, neurogenesis, immune system, acute ischemic stroke.

Acute, subacute and chronic sequelae of horses accidentally exposed to monensin-contaminated feed.

Monensin is highly toxic to horses and inadvertent ingestion can result in cardiac injury and death. To describe sequelae of monensin ingestion and to determine clinical predictors of outcome. Observational clinical study. Physical examination, electrocardiogram and echocardiography were performed on 76 horses accidentally exposed to monensin-contaminated feed. Four horses were examined within 14days of exposure (acute period), 29 horses were examined between 15 and 45dayspost-exposure (subacute period) and 70 horses were examined 4-10months after exposure (chronic period). Follow-up information was obtained for 56 horses by telephone interviews approximately 16months after exposure. Cardiac abnormalities were detected in 4/4, 19/29 and 31/70 horses during the acute, subacute and chronic periods, respectively. Sixteen months post-exposure, 34 of the 64 horses (53%) for which the outcome was known had returned to their previous use, 13 (20%) were reported to be exercise intolerant, three (5%) were retired and 14 (22%) were dead (two deaths, 12 euthanasia). Thinning of the myocardium observed at any point in time was associated with a negative outcome. Heterogeneity of the myocardium observed in the acute/subacute period was associated with a negative outcome while subjective contractile intraventricular dyssynchrony, cardiac chamber dilation, decreased fractional shortening and multiple premature ventricular complexes observed in the chronic period were associated with a negative outcome. Some horses with significant changes associated with a negative outcome in the chronic phase still returned to their previous work. No control group and only 27 horses were examined more than once. Clinical outcome of horses exposed to sublethal doses of monensin is highly variable. The presence of heterogeneity and thinning of the myocardium shortly after intoxication were associated with a negative outcome.

Feasibility of Telephone Follow-Up after Critical Care Discharge.

Background: Critical care has evolved from a primary focus on short-term survival, with greater attention being placed on longer-term health care outcomes. It is not known how best to implement follow-up after critical care discharge. Study aims were to (1) assess the uptake and feasibility of telephone follow-up after a critical care stay and (2) profile overall physical status and recovery during the sub-acute recovery period using a telephone follow-up assessment. Methods: Adults who had been admitted to critical care units of St. James’s Hospital, Dublin, for >72 h were followed up by telephone 3–9 months post discharge from critical care. The telephone assessment consisted of a battery of questionnaires (including the SF-36 questionnaire and the Clinical Frailty Scale) and examined quality of life, frailty, employment status, and feasibility of telephone follow-up. Results: Sixty five percent (n = 91) of eligible participants were reachable by telephone. Of these, 80% (n = 73) participated in data collection. Only 7% (n = 5) expressed a preference for face-to-face hospital-based follow-up as opposed to telephone follow-up. For the SF-36, scores were lower in a number of physical health domains as compared to population norms. Frailty increased in 43.2% (n = 32) of participants compared to pre-admission status. Two-thirds (n = 48) reported being >70% physically recovered. Conclusion: Results showed that telephone follow-up is a useful contact method for a typically hard-to-reach population. Deficits in physical health and frailty were noted in the sub-acute period after discharge from critical care.

Abstract TP484: Superficial Femoral Artery Atrophy and Reduced Lower Limb Blood Flow in Subacute Stroke Survivors

Introduction: Femoral artery atrophy and reduced endothelial function in the peripheral arteries of the affected lower limb contribute to reduced hyperemic blood flow in response to muscle contractions in chronic stroke survivors. These impairments could contribute to increased muscle weakness and exacerbate neuromuscular fatigue in stroke survivors. The time-course of these changes to the peripheral vasculature post-stroke have not been examined. Hypothesis: Superficial femoral artery atrophy and reduced blood flow to the affected limb occur in the subacute stroke period. Methods: This was a prospective, observational study which enrolled subacute stroke survivors admitted to inpatient rehabilitation at a single site. Maximum voluntary contractions (MVCs) of the paretic and non-paretic knee extensor muscles were assessed using a Biodex dynamometer. The superficial femoral artery was imaged in both legs using ultrasonography and arterial diameter was measured off-line with Brachial Analyzer software. Superficial femoral artery resting and hyperemic blood flow following MVCs was also quantified using ultrasonography. Results: Twelve subacute stroke survivors were enrolled in this study (7 men, 5 women). The mean age of all study participants was 65±10 years and the mean time since stroke was 12±6 days. Superficial femoral artery diameter was smaller in the affected leg compared to the non-affected leg (5.9±0.9 mm vs. 6.3±0.9 mm, respectively; p=0.006 paired t-test). Resting blood flow to the affected leg was also lower compared to the non-affected leg (164±68 ml/min vs. 205±105 ml/min, respectively; p=0.031 paired t-test). The MVC of the knee extensor muscles of the affected leg was less than the non-affected leg (103±63 Nm vs. 152±58 Nm, respectively; p=0.027, Wilcoxon signed rank test) and hyperemic blood flow was also reduced in the affected limb (248±94 ml/min vs. 428±203 ml/min, respectively; p&lt;0.001, Wilcoxon signed rank test). There was a positive correlation between hyperemic blood flow (fold change from rest) and MVC in the affected leg (r 2 =0.47, p=0.014). Conclusions: Superficial femoral artery atrophy and reduced limb blood flow occur in stroke survivors in the first weeks post-stroke and may contribute to limb weakness.

Abstract WP195: Accelerated Repetitive Transcranial Magnetic Stimulation (rTMS) as a Treatment for Subacute Post-Stroke Depression (PSD)

Introduction: Depression affects more than 50% of stroke survivors, reducing quality of life and increasing adverse outcomes. As stroke survivorship improves, the need for innovative treatments for associated stroke morbidity such as PSD is even more urgent. Alternative therapies are necessary due to the limited efficacy of antidepressants and counseling. rTMS is well established as an effective treatment for Major Depressive Disorder (MDD) and some small trials have shown that rTMS may be effective for chronic PSD; however, no trials have looked at an accelerated rTMS protocol in the subacute stroke period for PSD. Hypothesis: An accelerated rTMS protocol will be a safe and feasible option to effectively reduce PSD symptoms within 6 months of ischemic stroke onset. Methods: Patients (N = 6) with radiographic evidence of ischemic stroke within the last 2 weeks to 6 months who had Hamilton Depression Rating Scale (HAMD-17) scores ≥ 8 were recruited for an open label study using an accelerated rTMS protocol as follows: High frequency (20 Hz) rTMS at 110% resting motor threshold (RMT) was applied to the left dorsolateral prefrontal cortex (DLPFC) during 5 sessions per day over 4 consecutive days for a total of 20 sessions. Forty trains of 2 second duration were applied with a 12 second intertrain interval for a total of 1560 pulses per session. Before and after the 4-day neurostimulation protocol, outcome measures were obtained for the HAMD, modified Rankin Scale (mRS), functional independence measures (FIM), and National Institutes of Health Stroke Scales (NIHSS). These same measures were obtained at 3-month follow up. Results: HAMD significantly decreased (Wilcoxon p = 0.03) from M=15.5 (2.81) to 4.17 (0.98) following rTMS, a difference which persisted to the 3-month follow-up (p=0.03). No statistically significant difference in FIM, mRS, or NIHSS were observed. No significant adverse events related to the treatment were observed. Conclusions: Our preliminary results indicate that an accelerated rTMS protocol is safe and feasible, and may be an effective alternative or adjunctive therapy for patients suffering from PSD. Future planned studies include a larger, randomized controlled trial in this population.