Civilian gunshot wounds to the hand are typically caused by low-velocity weapons, which create a localized pattern of soft-tissue and bone injury that usually allows for early definitive treatment. A retrospective chart review of 72 patients treated for 98 gunshot wound fractures at an urban level I trauma center was conducted to evaluate the results of limited debridement and early definitive fracture fixation of urban gunshot wound fractures of the hand. The incidence of hand fractures, means of fracture fixation, number of operations, occurrence of infection, and level of patient compliance were determined. Twenty-nine fractures were managed definitively with reduction and splinting in the emergency department or intensive care unit. Sixty-eight fractures were treated surgically, at a mean of 2 days after injury. Eleven patients required more than one operation. The overall infection rate was 8 percent and was not influenced by the fracture fixation method. All infections were superficial and resolved with antibiotics alone. Thirty-nine percent of patients were lost to follow-up after hospital discharge and 85 percent of patients were lost to follow-up before documented fracture healing. Twenty-six percent of patients were lost to follow-up with a removable fixation device in place. Limited debridement and early definitive fracture fixation are associated with low rates of complications for typical civilian handgun wound fractures. Cases with extensive injury or contamination do require a staged approach to treatment. Poor patient compliance in the urban trauma setting should be expected and may affect the management plan.
The Hedgehog (Hh) signaling pathway plays an integral role in the patterning and development of diverse structures in the vertebrate embryo. Aberrations in Hh signaling are associated with a range of developmental defects including failure of interhemispheric division of the embryonic forebrain as well as midline facial dysmorphia including cleft lip/palate and cyclopia, collectively termed holoprosencephaly (HPE). Postnatally, Hh signaling has been postulated to play a pivotal role in healing and repair processes and inappropriate Hh pathway activation has been implicated in several types of cancers. The Veratrum alkaloid cyclopamine is a potent inhibitor of Hh signaling and causes HPE-like defects in diverse species including sheep, hamster, mouse, and zebra fish. Using murine cell-based assays, we have determined that a number of dietary alkaloids similar in structure to cyclopamine also inhibit Hh signaling but with significantly lower potency. We found that these dietary compounds act additively through a mechanism similar to cyclopamine, downstream of Ptc1 and upstream of Gli1. Using an embryonic zebra fish developmental assay, we found that while cyclopamine exposure caused HPE-like defects, exposure to one of these dietary compounds, solanidine, did not.
Diagnosis of peripheral neuropathies is based upon patterns of functional deficits and electrodiagnostic testing. However, anatomic variations can lead to confounding patterns of physical and electrodiagnostic findings. Authors present a case of ulnar nerve compression due to a rare combination of anatomic variations, aberrant branching pattern, and FCU insertion at the wrist, which posed a diagnostic and therapeutic dilemma. The literature related to isolated distal ulnar motor neuropathy and anatomic variations of the ulnar nerve and adjacent structures is also reviewed. This case demonstrates how anatomic variations can complicate the interpretation of clinical and electrodiagnostic findings and underscores the importance of thorough exploration of the nerve in consideration for possible variations.
Poor patency is cited as a reason to not perform radial artery reconstruction after the harvest of the radial forearm flap. The need for a long vein graft and the presence of a patent ulnar artery are offered as explanations for thrombosis of the reconstruction in this setting. Similar arguments have been made regarding radial artery reconstruction in the trauma setting. In this study, the patency rate for patients undergoing radial forearm flap harvest with immediate reconstruction with reversed interposition vein grafting was evaluated. The mean follow-up time was 24 months, and all seven patients had patent reconstructions. Ultrasound examination revealed slightly larger diameters of the vein grafts compared with native arteries. No areas of stenosis were detected. No complications resulted from harvest of the vein. From these data, we conclude that radial artery reconstruction can be performed with the expectation of patency.
Complex wounds surrounding the knee and proximal tibia pose a significant challenge for the reconstructive surgeon. Most of these defects can be managed using local or regional flaps alone. However, large defects with a wide zone of injury frequently require microvascular tissue transfers to aid in soft tissue coverage and closure of large cavities. We describe a unique recipient vessel for microvascular anastomosis for free flap reconstruction involving the knee and proximal tibia through anatomic and clinical studies.
Low-dose computed tomography (CT) lung cancer screening is recommended by the US Preventive Services Task Force for high lung cancer-risk populations. In this study, we investigated an important factor affecting the CT dose-the scan length, for this CT exam. A neural network model based on the BUNET^framework was established to segment the lung region in the CT scout images. It was trained initially with 247 chest X-ray images and then with 40 CT scout images. The mean Intersection over Union (IOU) and Dice coefficient were reported to be 0.954 and 0.976, respectively. Lung scan boundaries were determined from this segmentation and compared with the boundaries marked by an expert for 150 validation images, resulting an average 4.7% difference. Seven hundred seventy CT low-dose lung screening exams were retrospectively analyzed with the validated model. The average Bdesired^scan length was 252 mm with a standard deviation of 28 mm. The average Bover-range^was 58.5 mm or 24%. The upper boundary (superior) on average had an Bover-range^of 17 mm, and the lower boundary (inferior) on average had an Bover-range^of 41 mm. Further analysis of this data showed that the extent of Bover-range^was independent of acquisition date, acquisition time, acquisition station, and patient age, but dependent on technologist and patient weight. We concluded that this machine learning method could effectively support quality control on the scan length for CT low-dose screening scans, enabling the eliminations of unnecessary patient dose.
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