Gene therapy for trigeminal pain in mice.

The aim of this study was to test the efficacy of a single direct injection of viral vector encoding for encephalin to induce a widespread expression of the transgene and potential analgesic effect in trigeminal behavioral pain models in mice. After direct injection of herpes simplex virus type 1 based vectors encoding for human preproenkephalin (SHPE) or the lacZ reporter gene (SHZ.1, control virus) into the trigeminal ganglia in mice, we performed an orofacial formalin test and assessed the cumulative nociceptive behavior at different time points after injection of the viral vectors. We observed an analgesic effect on nociceptive behavior that lasted up to 8 weeks after a single injection of SHPE into the trigeminal ganglia. Control virus-injected animals showed nociceptive behavior similar to naive mice. The analgesic effect of SHPE injection was reversed/attenuated by subcutaneous naloxone injections, a µ-opioid receptor antagonist. SHPE-injected mice also showed normalization in withdrawal latencies upon thermal noxious stimulation of inflamed ears after subdermal complete Freund's adjuvant injection, indicating widespread expression of the transgene. Quantitative immunohistochemistry of trigeminal ganglia showed expression of human preproenkephalin after SHPE injection. Direct injection of viral vectors proved to be useful for exploring the distinct pathophysiology of the trigeminal system and could also be an interesting addition to the pain therapists' armamentarium.

Temporary vascular shunts.

Temporary vascular shunts have been used for nearly 100 years in patients. Originally, they were used as vascular grafts that were likely to thrombose as collaterals would hopefully develop. More recently, they have been used as a device to be replaced by a permanent vascular graft during the same operation or at a reoperation. Indications for the use of shunts are a "damage control" procedure for a peripheral or truncal vascular injury, Gustilo IIIC fracture of an extremity, need for perfusion as a complex revascularization is performed, and planned replantation of a hand, forearm, or arm. They are used in approximately 8% of vascular injuries treated in urban trauma centers in the United States and have an excellent patency rate without heparinization.

Sternoclavicular joint infection: a case report.

Infection of the sternoclavicular joint (SJI) is a rare problem accounting for approximately 1 % of cases of septic arthritis. Patients typically present with symptoms of localized pain lasting a period of several weeks with or without systemic signs of fever and chills. Confirmation is made by aspirating the joint, and broad spectrum antibiotics should be tailored to treat the identified organisms. SJI can be treated conservatively with intravenous antibiotics and repeat imaging, but surgical intervention is required if patients present with an abscess, osteomyelitis or mediastinitis.

Management of penetrating injuries to carotid artery.

The diagnosis and management of penetrating injuries to the cervical carotid arteries continue to be controversial. Most patients with stab or gunshot wounds to the common or internal carotid artery in cervical zone II (sternal notch to angle of mandible) are symptomatic with external or intraoral hemorrhage, a rapidly expanding hematoma, evidence of a carotid-jugular arteriovenous fistula at an obvious site, or loss of the carotid pulse with a neurologic deficit. Immediate airway control and arterial repair are indicated in such patients. Other patients present with stab or gunshot wounds with proximity only to the carotid sheath, a stable hematoma, unknown level of a carotid-jugular arteriovenous fistula, or loss of the carotid pulse without a neurologic deficit. Diagnostic options in this latter group include duplex ultrasound, color duplex imaging, and standard arteriography, while the role of CT or MRI angiography in evaluating patients with penetrating cervical wounds is unclear at this time. Certain arterial injuries discovered on diagnostic tests are currently managed with observation, endovascular stenting (for intimal or wall irregularities), and arteriographic embolization (for small pseudoaneurysms or high carotid-jugular fistulas). Operative repairs for injuries in zone II are performed through an oblique cervical incision and include all the options used with peripheral vascular injuries. Patients with penetrating cervical wounds, preoperative neurologic deficits, and immediate transport to the trauma center should have repair rather than ligation of the injured carotid artery. When the patient is truly comatose with a Glasgow Coma Scale score < 8, an unsatisfactory neurologic outcome is likely with either arterial repair or ligation. Injuries to the extracranial internal carotid artery in cervical zone III (above the angle of the mandible) may require innovative approaches to control hemorrhage and then maintain flow to the ipsilateral cerebral cortex.

Gunshot wounds to the ureter: a 40-year experience at Grady Memorial Hospital.

PURPOSE: Because of the morbidity associated with missed ureteral injuries, a high index of suspicion must be present to diagnose this type of injury. We reviewed our 40 years of trauma experience at Grady Memorial Hospital. MATERIALS AND METHODS: We retrospectively reviewed the records of 118 patients with ureteral injuries secondary to a gunshot wound to the ureter from 1960 to 1999. All cases were reviewed for the mechanism of injury, location, initial urinalysis, imaging modalities, associated injuries, operative procedures and complications. RESULTS: Our population consisted of patients 14 to 71 years old, of whom 66 had right ureteral, 51 had left ureteral and 1 had bilateral injury. Urinalysis revealed no evidence of blood in the urine in 15% of the patients in whom the test was performed. Excretory urography had a false-negative rate of 33%. The injury was located at the proximal, mid and distal ureter in 43, 38 and 37 cases, respectively. Multiple surgical approaches were used depending on the location and severity of the defect. Only 1 patient had an isolated ureteral injury, while the remainder had associated injuries. Complications were present in 24 cases. CONCLUSIONS: To our knowledge this series of ureteral injuries is the largest reported to date. Because preoperative urinalysis and imaging studies are unreliable for ruling out injury, a high index of suspicion must be present. Furthermore, a predefined trauma protocol, as defined in our algorithm, decreases the number of missed ureteral injuries that may potentially complicate the outcome of an already critical case.

Results with abdominal vascular trauma in the modern era.

This is a report of a 10-year experience (1989-1998) with 300 consecutive patients found to have an injury to a named abdominal vessel at the time of an exploratory laparotomy for trauma. An abdominal gunshot wound was the mechanism of injury in 78 per cent of patients, and injury to more than one named abdominal vessel was present in 42 per cent. The abdominal aorta, inferior vena cava, and external iliac artery and vein were the most commonly injured vessels. When management for the five most commonly injured arteries was grouped, exsanguination before attempts at repair occurred in 11 to 15 per cent of patients and the mean survival in the remainder was 46 per cent. When management for the five most commonly injured veins was grouped, exsanguination before attempts at repair occurred in 5 per cent of patients and the mean survival in the remainder was 64 per cent. A number of administrative and medical changes in the management of patients with abdominal trauma occurred from 1992 through 1994. Despite significantly increased Injury Severity Scores for patients treated from 1993 through 1998 as compared with those treated from 1989 through 1992 survival rates for patients with injuries to the abdominal aorta and inferior vena cava were unchanged. Survival rates for injuries to the external iliac artery and vein increased significantly. The local changes in management should be considered for prospective studies in other urban trauma centers.

Surgeon-performed ultrasound in the critical care setting: its use as an extension of the physical examination to detect pleural effusion.

BACKGROUND: Critically ill surgical patients are often difficult to assess for complications because of their altered sensorium, multiple monitoring devices, and immobility. Surgeon-performed ultrasound may enhance the physical examination of these patients and provide for an early detection of select complications. We hypothesized that a focused thoracic ultrasound examination could reliably detect a pleural effusion and the results could be used in the decision matrix for patient care. METHODS: Serial focused thoracic ultrasound examinations were performed by a surgeon and a medical student on critically ill patients. The medical student learned select facets of the physical examination and then demonstrated how ultrasound imaging could enhance these findings. Ultrasound images were recorded on hard copy and videotape, with the results available to the surgical intensive care unit and surgery teams. The images were reviewed and compared with the chest radiograph readings. RESULTS: Forty-seven patients underwent 140 ultrasound examinations. There were 85 true-negative, 46 true-positive, 9 false-negative, and zero false-positive examination results, yielding an 83.6% sensitivity, 100% specificity, and 94% accuracy. Of the 46 true-positive results, thoracentesis was performed or a thoracostomy tube was placed in 5 patients. Nine false-negative ultrasound examinations occurred in six patients, five of whom had their effusions detected on computed tomographic scans. CONCLUSION: A focused thoracic ultrasound examination reliably detects pleural effusions in critically ill patients, and the results can be used successfully in the decision matrix for patient care.

Abdominal vascular injuries: injuries to the aorta.

This article discusses injuries to the abdominal aorta at its supra- and infrarenal positions, focusing on the surgical approaches to abdominal aorta injuries and renal vascular pedicles. The controversy regarding the use of bioprosthetic materials and the coLlective experience with these injuries as reported in the literature are reviewed. Primary renal artery repair versus nephrectomy also is examined.

Skin only or silo closure in the critically ill patient with an open abdomen.

BACKGROUND: The morbidity and mortality of various open abdominal techniques remains unclear. METHODS: A retrospective review was made of all trauma or general surgery patients who underwent an open abdominal closure from January 1997 to December 2000, at a large urban acute care hospital. Data are mean +/- SD. RESULTS: From 1997 to 2000, 181 patients (aged 39.8 +/- 16.5 years) had an open abdomen for abdominal infection, planned reexploration, abdominal compartment syndrome, inability to reapproximate fascia, or as part of a "damage control" procedure. Twenty-three patients went on to develop an abdominal compartment syndrome. Gastrointestinal fistulas occurred in 26 patients, and 9 patients had a dehiscence. The overall mortality was 44.7%. Of the survivors, 52% went on to fascial closure, requiring 1 to 7 additional abdominal operations. CONCLUSIONS: The morbidity of the open abdomen varies with the particular indication. Gastrointestinal fistulas are the most common acute complication and an abdominal wall hernia, the most common chronic complication.

Transmediastinal gunshot wounds: a prospective study.

OBJECTIVE: To evaluate admission systolic blood pressure (SBP) in the emergency center (EC) as a means by which patients with transmediastinal gunshot wounds (TM-GSWs) can be triaged to the operating room versus further diagnostic evaluation. METHODS: A prospective case series presenting concurrent data collected for 68 consecutive patients with TM-GSWs admitted to one urban trauma center over a 4.5-year period. For purposes of analysis, patients were assigned to the following groups based on SBP in the EC: group I, SBP > 100 mm Hg; group II, SBP from 60 to 100 mm Hg; group III, SBP < 60 mm Hg. RESULTS: The management and outcomes of 68 patients with a mean age of 29 years were evaluated. For patients in group I (n = 20), TM-GSW was diagnosed by findings on x-ray film for 15 patients (75%), at physical examination for 4 patients (20%), and at operation for 1 patient (5%). Indications for immediate operation were found in five patients (25%), whereas further diagnostic evaluation prompted operation for three additional patients. Only one patient developed persistent hypotension from neurogenic shock. There were two deaths from late complications. In patients in group II (n = 16), TM-GSW was diagnosed by findings on x-ray film for 9 patients (56%), at physical examination for 5 patients (31%), and at operation for 2 patients (13%). Six patients with persistent hypotension had indications for immediate operation, whereas further diagnostic evaluation in the remaining patients, who became hemodynamically normal during resuscitation, prompted operation in an additional two patients. There were two intraoperative deaths. For the patients in group III (n = 32), six patients with signs of life underwent immediate operation with one intraoperative death, seventeen patients required EC thoracotomy with 100% mortality, and nine patients were pronounced dead in the EC without an attempt at operation. CONCLUSION: The diagnosis of TM-GSW for patients in groups I and II is confirmed by finding at physical examination and on chest x-ray films in 90% of cases. In the absence of obvious bleeding, patients with TM-GSWs and SBP > 100 mm Hg may safely undergo further diagnostic evaluation. Sixty percent of such patients did not require an operation. All patients with TM-GSWs and SBP < 60 mm Hg (group III) require immediate operation. For patients with TM-GSWs, SBP from 60 to 100 mm Hg (group II), and without obvious bleeding, it is the response to resuscitation and the results of further diagnostic evaluation that determine the need for operation. Fifty percent of such patients did not require operation.

Penetrating cardiac trauma at an urban trauma center: a 22-year perspective.

This is a report of a 22-year experience with penetrating cardiac trauma at a single urban Level I trauma center. We conducted a retrospective chart review supplemented by computerized patient log. Comparisons of mortality between Period 1 (1975-1985; 113 patients) and Period 2 (1986-1996; 79 patients) were by chi2 or Fisher's exact tests. Statistical significance was defined as P < or = 0.05. From 1975 to 1996, 192 patients (mean age, 32 years; 88% male) with penetrating cardiac stab wounds (68%) or gunshot wounds (32%) were treated. The most common initial clinical presentation was cardiac tamponade, and most patients (54%) were hypotensive (systolic blood pressure 30-90 mm Hg). The most common initial intervention in the emergency center was tube thoracostomy. The use of pericardiocentesis as a diagnostic and therapeutic modality in the emergency center virtually disappeared in Period 2, as compared with Period 1. Since 1994, surgeon-performed cardiac ultrasound has been performed and has correctly diagnosed hemopericardium in 12 patients (100% survival). The overall mortality for all patients during the 22-year study interval was 25 per cent and was not significantly different between Period 1 (27%) and Period 2 (22%). The mortality associated with gunshot wounds was increased compared with that of stab wounds. Similarly, mortality for patients who arrested in the emergency center was increased compared with those patients who did not arrest. We conclude: 1) cardiac tamponade is the most common presentation in patients with cardiac wounds; 2) pericardiocentesis in the emergency center has essentially disappeared; 3) surgeon-performed ultrasound of the pericardium should improve survival of future patients who are normotensive or mildly hypotensive; 4) over the last 11 years, there has been a substantial decrease in mortality in patients with stab wounds and a statistically significant decrease in arrested patients; and 5) overall mortality for penetrating cardiac trauma has not changed during the 22-year interval.

An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient.

BACKGROUND: The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected. STUDY DESIGN: An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification. RESULTS: One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery. CONCLUSIONS: Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.

The epidemic of cocaine-related juxtapyloric perforations: with a comment on the importance of testing for Helicobacter pylori.

OBJECTIVE: This is a report of 50 consecutive patients with juxtapyloric perforations after smoking "crack" cocaine (cocaine base) at one urban public hospital. SUMMARY BACKGROUND DATA: Although the exact causal relation between smoking crack cocaine and a subsequent juxtapyloric perforation has not been defined, surgical services in urban public hospitals now treat significant numbers of male addicts with such perforations. This report describes the patient set, presentation, and surgical management and suggests a possible role for Helicobacter pylori in contributing to these perforations. METHODS: A retrospective chart review was performed, supplemented by data from the patient log in the department of surgery. RESULTS: From 1994 to 1998, 50 consecutive patients (48 men, 2 women) with a mean age of 37 had epigastric pain and signs of peritonitis a median of 2 to 4 hours (but up to 48 hours) after smoking crack cocaine. A history of chronic smoking of crack as well as chronic alcohol abuse was noted in all patients; four had a prior history of presumed ulcer disease in the upper gastrointestinal tract. Free air was present on an upright abdominal x-ray in 84% of patients, and all underwent operative management. A 3- to 5-mm juxtapyloric perforation, usually in the prepyloric area, was found in all patients. Omental patch closure was used in 49 patients and falciform ligament closure in 1. Two patients underwent parietal cell vagotomy as well. In the later period of the review, antral mucosal biopsies were performed through the juxtapyloric perforation in five patients. Urease testing was positive for infection with H. pyonri in four, and these patients were prescribed appropriate antimicrobial drugs. CONCLUSIONS: Juxtapyloric perforations after the smoking of crack cocaine occur in a largely male population of drug addicts who are 8 to 10 years younger than the patient group that historically has perforations in the pyloroduodenal area. These perforations are usually 3 to 5 mm in diameter, and an antral mucosal biopsy for subsequent urease testing should be performed if the location and size of the ulcer allow this to be done safely. Omental patch closure is appropriate therapy for patients without a history of prior ulcer disease; antimicrobial therapy and omeprazole are prescribed when H. pylori is present.