A correlation analysis of metacarpal & phalangeal injury pattern from improvised explosive devices amongst armed force personnel.

Injuries to the hand during military combat operations, particularly from improvised explosive devices (IEDs) have a significant impact on form, function, mental health and future employment but remain underreported amidst the life and limb-threatening emergencies that garner more attention. An understanding the patterns of hand injuries encountered from IEDs is crucial to optimizing reconstruction and rehabilitation. The aim of this study was to re-evaluate hand injury sustained from IED in order to understand the clinical burden for reconstruction and direct the focus for future hand protection. We identified 484 hand injuries in 380 patients sustained as a result of IEDs among military personnel service in Afghanistan between 2006 and 2013. 53% of all surviving military personnel injured by IEDs sustain injuries to the hand. Analysis of the 103 patients who sustained injury to the metacarpal, phalanges or digital amputation revealed that the middle and ring fingers are most commonly injured. Amputation to the ring finger is strongly associated with injury to the adjacent fingers and amputations to the middle, ring and little fingers concurrently is a commonly observed pattern. The proximal phalanges of the middle and ring fingers had a strong correlation for fracture together. These findings disprove the conventional belief in an ulnar focus of injury and support the quest for a development of combat hand protection that addresses the injury pattern seen.

Hilotherapy for the management of perioperative pain and swelling in facial surgery: a systematic review and meta-analysis.

Hilotherapy is the application of cold compression at a regulated temperature through a face mask. Studies that have evaluated its efficacy have focused on postoperative oedema, pain, and the patient's comfort. However, there is no clear consensus in favour of its use, so we have made a systematic review and meta-analysis to evaluate relevant published reports. We searched PubMed, EMBASE, MEDLINE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials to identify studies. Sixty-one records were screened, six of which met the inclusion criteria and four of which were suitable for meta-analysis. All data suitable for meta-analysis were derived from studies of elective and traumatic facial skeletal surgery. Hilotherapy was associated with significant reductions in facial pain on postoperative day 2 (p<0.00001), and facial oedema on days 2 (p=0.0004) and 3 (p=0.02). Patients reported more comfort and satisfaction with hilotherapy than with cold compression (p<0.00001). The effect of hilotherapy on ecchymosis and formation of haematomas remains uncertain. Well-designed, randomised, controlled trials of its use after aesthetic facial surgery are required.

Assessment of the severity of Ebola virus disease in Sierra Leone in 2014-2015.

The current Ebola virus disease (EVD) epidemic in West Africa is unprecedented in scale, and Sierra Leone is the most severely affected country. The case fatality risk (CFR) and hospitalization fatality risk (HFR) were used to characterize the severity of infections in confirmed and probable EVD cases in Sierra Leone. Proportional hazards regression models were used to investigate factors associated with the risk of death in EVD cases. In total, there were 17 318 EVD cases reported in Sierra Leone from 23 May 2014 to 31 January 2015. Of the probable and confirmed EVD cases with a reported final outcome, a total of 2536 deaths and 886 recoveries were reported. CFR and HFR estimates were 74·2% [95% credibility interval (CrI) 72·6-75·5] and 68·9% (95% CrI 66·2-71·6), respectively. Risks of death were higher in the youngest (0-4 years) and oldest (⩾60 years) age groups, and in the calendar month of October 2014. Sex and occupational status did not significantly affect the mortality of EVD. The CFR and HFR estimates of EVD were very high in Sierra Leone.

Meta-analysis of antibiotics for simple hand injuries requiring surgery.

BACKGROUND: Simple hand trauma is very common, accounting for 1·8 million emergency department visits annually in the USA alone. Antibiotics are used widely as postinjury prophylaxis, but their efficacy is unclear. This meta-analysis assessed the effect of antibiotic prophylaxis versus placebo or no treatment on wound infection rates in hand injuries managed surgically. METHODS: Embase, MEDLINE, PubMed, Cochrane Central, ClinicalTrials.gov and the World Health Organization International Clinical Trials Portal were searched for published and unpublished studies in any language from inception to September 2015. The primary outcome was the effect of antibiotic prophylaxis on wound infection rates. Open fractures, crush injuries and bite wounds were excluded. Study quality was assessed using the Cochrane risk-of-bias tool. Data were pooled using random-effects meta-analysis, and risk ratios (RRs) and 95 per cent c.i. obtained. RESULTS: Thirteen studies (2578 patients) were included, comprising five double-blind randomized clinical trials, five prospective trials and three cohort studies. There was no significant difference in infection rate between the antibiotic and placebo/no antibiotic groups (RR 0·89, 95 per cent c.i. 0·65 to 1·23; P = 0·49). Subgroup analysis of the five double-blind randomized clinical trials (864 patients) again found no difference in infection rates (RR 0·66, 0·36 to 1·21; P = 0·18). CONCLUSION: There was moderate-quality evidence that routine use of antibiotics does not reduce the infection rate in simple hand wounds that require surgery.

Necrotising soft tissue infection in a UK metropolitan population.

INTRODUCTION: Necrotising soft tissue infection (NSTI) is a rare but life threatening diagnosis. Geographic, economic and social variances influence presentation and prognosis. As the current literature does not reflect a UK metropolitan population, we conducted a retrospective chart review to establish pertinent features relevant to our practice. METHODS: Patients with histologically confirmed diagnoses of NSTI presenting to two London teaching hospitals between January 2007 and July 2013 were included in the study. Features of presentation, surgical and medical management, microbiological findings and outcome were evaluated. RESULTS: Twenty-four patients with histologically confirmed NSTI were included. Two age clusters were identified, with means of 46 years (standard deviation [SD]: 10 years) and 80 years (SD: 6 years). Pain, erythema and sepsis were common findings. Hypertension, hypercholesterolaemia and type II diabetes mellitus were common co-morbidities. A third of younger patients had human immunodeficiency virus or hepatitis C, with a quarter dependent on drugs and/or alcohol. The mean Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score was 5.8 (SD: 3.3). The lower extremities, groin and perineum were common sites of infection. Fourteen patients required inotropic support and seventeen required transfusions. The median number of surgical procedures was 5 (range: 1-17). Group A Streptococcus was the most frequently identified pathogen. Five patients died. Being elderly, female sex and failure to use clindamycin as a first-line antibiotic were associated with significantly higher mortality. CONCLUSIONS: In contrast to other recent series, group A streptococcal monomicrobial NSTI remains the most common presentation in our population. Survival is anticipated in young patients, regardless of premorbid status. Elderly patients have a poor prognosis. The negative predictive value of the LRINEC score is questioned. Use of clindamycin as a first-line antibiotic is supported.

Systematic review of molecular mechanism of action of negative-pressure wound therapy.

BACKGROUND: Negative-pressure wound therapy (NPWT) promotes angiogenesis and granulation, in part by strain-induced production of growth factors and cytokines. As their expression profiles are being unravelled, it is pertinent to consider the mode of action of NPWT at the molecular level. METHODS: MEDLINE (January 1997 to present), Embase (January 1997 to present), PubMed (no time limit), the Cochrane Database of Systematic Reviews and the Cochrane Controlled Trials Register were searched for articles that evaluated the influence of NPWT on growth factor expression quantitatively. RESULTS: Sixteen studies met the inclusion criteria. Tumour necrosis factor expression was reduced in acute and chronic wounds, whereas expression of interleukin (IL) 1ß was reduced in acute wounds only. Systemic IL-10 and local IL-8 expression were increased by NPWT. Expression of vascular endothelial growth factor, fibroblast growth factor 2, transforming growth factor ß and platelet-derived growth factor was increased, consistent with mechanoreceptor and chemoreceptor transduction in response to stress and hypoxia. Matrix metalloproteinase-1, -2, -9 and -13 expression was reduced but there was no effect on their enzymatic inhibitor, tissue inhibitor of metalloproteinase 1. CONCLUSION: Cytokine and growth factor expression profiles under NPWT suggest that promotion of wound healing occurs by modulation of cytokines to an anti-inflammatory profile, and mechanoreceptor and chemoreceptor-mediated cell signalling, culminating in angiogenesis, extracellular matrix remodelling and deposition of granulation tissue. This provides a molecular basis for understanding NPWT.

Pretibial lacerations: experience from a lower limb trauma centre and systematic review.

BACKGROUND: Pretibial lacerations are an important and neglected problem among the elderly. Poor management leads to prolonged hospitalisation and terminal decline. This study summarises our experience and evidence from the literature to ascertain an evidence-based rationale for referral and management. METHODS: Our data were obtained from review of a prospectively gathered database. Additionally, Pubmed, Embase, Medline, and the Cochrane Database of Systematic Reviews were searched through July 2013, with eligible studies evaluated using standard methodology. RESULTS: Seventy-three pretibial lacerations in 73 patients (63 females) were identified. Mean age was 78 ± 14, 1SD. Sixty patients were managed operatively with a mean length of stay of 11 ± 7 days, 1SD when uncomplicated by medical co-morbidity. Seven deaths occurred (4 in-hospital; 2 treated surgically and 2 treated conservatively) and 3 deaths occurred within 3 months of discharge; a death rate more than twice that of matched controls. Donor site "over-grafting" was performed in 19 cases and resulted in accelerated donor site healing (11 ± 9 days, 1SD vs. 29 ± 42 days, 1SD; P < 0.001). Negative pressure wound therapy delayed discharge (21 ± 23 days, 1SD vs. 15 ± 14 days, 1SD; P = 0.028). Microbiological sampling is unhelpful. Bed rest is unnecessary. "De-fatting" the flap is unproven. CONCLUSION: Admissions expose the elderly to physical/functional decline and death. Our findings support a change of practice, minimising admissions for minor (Dunkin type I/II) injuries and rapid, protocol-driven surgical intervention and discharge for Dunkin type III/IV injuries with avoidance of negative pressure wound therapy in all but selected cases.

Cochrane corner: bone morphogenetic protein (BMP) for fracture healing in adults.

BACKGROUND: Delay in fracture healing is a complex clinical and economic issue for patients and health services. OBJECTIVES: To assess the incremental effectiveness and costs of bone morphogenetic protein on fracture healing in fractures and nonunions compared with standards of care. SEARCH STRATEGY: We searched The Cochrane Library (2008, Issue 4), MEDLINE, and other major health and health economics databases (to October 2008). SELECTION CRITERIA: Randomized controlled trials (RCTs) and full or partial economic evaluations of bone morphogenetic protein for fracture healing in skeletally mature adults. DATA COLLECTION AND ANALYSIS: All clinical and economic data were extracted by one author and checked by another.

Anticipating the species jump: surveillance for emerging viral threats.

Zoonotic disease surveillance is typically triggered after animal pathogens have already infected humans. Are there ways to identify high-risk viruses before they emerge in humans? If so, then how and where can identifications be made and by what methods? These were the fundamental questions driving a workshop to examine the future of predictive surveillance for viruses that might jump from animals to infect humans. Virologists, ecologists and computational biologists from academia, federal government and non-governmental organizations discussed opportunities as well as obstacles to the prediction of species jumps using genetic and ecological data from viruses and their hosts, vectors and reservoirs. This workshop marked an important first step towards envisioning both scientific and organizational frameworks for this future capability. Canine parvoviruses as well as seasonal H3N2 and pandemic H1N1 influenza viruses are discussed as exemplars that suggest what to look for in anticipating species jumps. To answer the question of where to look, prospects for discovering emerging viruses among wildlife, bats, rodents, arthropod vectors and occupationally exposed humans are discussed. Finally, opportunities and obstacles are identified and accompanied by suggestions for how to look for species jumps. Taken together, these findings constitute the beginnings of a conceptual framework for achieving a virus surveillance capability that could predict future species jumps.

The microbiological basis for a revised antibiotic regimen in high-energy tibial fractures: preventing deep infections by nosocomial organisms.

BACKGROUND: Deep surgical site infections (SSI's) complicate Gustilo IIIB tibial fractures in 8-13% of cases. Antibiotic prophylaxis typically covers environmental contaminants. However, nosocomial organisms are usually implicated in deep infection. We used the microbiological profile of infected Gustilo IIIB tibial fractures to define a new, dynamic prophylactic regimen which recognises the need for prophylaxis against nosocomial organisms at the time of definitive closure. METHODS: The microbiological profiles of Gustilo IIIB tibial fractures presenting over a 2-year period from January 2006 to December 2007 were reviewed. The environmental contaminants were compared with the organisms isolated from deep SSI's and correlated with the prophylactic antibiotic regimen used. RESULTS: Fifty-two patients were included. Nine developed a deep tissue infection. The pathogens implicated included resistant Enterococci, Pseudomonas, Enterobacter and MRSA. Standard antibiotic prophylaxis provided cover for these combinations in only one of nine cases. This would have improved to eight of nine cases with the use of teicoplanin and gentamicin, given as a one-time dose during definitive soft-tissue closure. Specimens taken from wound debridement were neither sensitive nor specific for the subsequent development of deep infection and did not predict the organisms responsible. CONCLUSIONS: Following high-energy open fracture, a single prophylactic antibiotic regimen directed against environmental wound contaminants does not provide cover for the organisms responsible for deepest SSI's and may have depopulated the niche, promoting nosocomial contamination prior to definitive closure. We advocate a dynamic prophylactic strategy, tailoring a second wave of prophylaxis against nosocomial organisms at the time of definitive wound closure, and at the same time avoiding the potential complications of prolonged antibiotic use.

Genome-wide analysis of transcriptomic divergence between laboratory colony and field Anopheles gambiae mosquitoes of the M and S molecular forms.

Our knowledge of Anopheles gambiae molecular biology has mainly been based on studies using inbred laboratory strains. Differences in the environmental exposure of these and natural field mosquitoes have inevitably led to physiological divergences. We have used global transcript abundance analyses to probe into this divergence, and identified transcript abundance patterns of genes that provide insight on specific adaptations of caged and field mosquitoes. We also compared the gene transcript abundance profiles of field mosquitoes belonging to the two morphologically indistinguishable but reproductively isolated sympatric molecular forms, M and S, from two different locations in the Yaoundé area of Cameroon. This analysis suggested that environmental exposure has a greater influence on the transcriptome than does the mosquito's molecular form-specific genetic background.

Commensal ecology, urban landscapes, and their influence on the genetic characteristics of city-dwelling Norway rats (Rattus norvegicus).

Movement of individuals promotes colonization of new areas, gene flow among local populations, and has implications for the spread of infectious agents and the control of pest species. Wild Norway rats (Rattus norvegicus) are common in highly urbanized areas but surprisingly little is known of their population structure. We sampled individuals from 11 locations within Baltimore, Maryland, to characterize the genetic structure and extent of gene flow between areas within the city. Clustering methods and a neighbour-joining tree based on pairwise genetic distances supported an east-west division in the inner city, and a third cluster comprised of historically more recent sites. Most individuals (approximately 95%) were assigned to their area of capture, indicating strong site fidelity. Moreover, the axial dispersal distance of rats (62 m) fell within typical alley length. Several rats were assigned to areas 2-11.5 km away, indicating some, albeit infrequent, long-distance movement within the city. Although individual movement appears to be limited (30-150 m), locations up to 1.7 km are comprised of relatives. Moderate F(ST), differentiation between identified clusters, and high allelic diversity indicate that regular gene flow, either via recruitment or migration, has prevented isolation. Therefore, ecology of commensal rodents in urban areas and life-history characteristics of Norway rats likely counteract many expected effects of isolation or founder events. An understanding of levels of connectivity of rat populations inhabiting urban areas provides information about the spatial scale at which populations of rats may spread disease, invade new areas, or be eradicated from an existing area without reinvasion.

Improving lower limb salvage following fractures with vascular injury: a systematic review and new management algorithm.

BACKGROUND: Lower limb fractures with vascular injuries are associated with a high rate of secondary amputation. Reducing ischaemic time is vital for limb salvage. However, the optimal sequence of surgical management remains unclear. We aimed to review the literature to establish an evidence-based management algorithm. METHODS: All identifiable English language or translated literature related to the surgical sequence of lower limb fractures with vascular injuries was reviewed. RESULTS: A total of 101 cases described in 10 publications (median age: 31; range: 2.5-76) were suitable for analysis. The mean MESS was 4.2. The limb-salvage rate with an ischaemic time of less than 6h was 87%, falling to 61% when ischaemic time exceeded 6h. A preoperative angiography caused a significant delay. The rate of re-vascularisation within 6h improved from 46% (33 of 71) to 90% (27 of 30) with the use of a shunt (p=0.04), with a mean ischaemic time of 3.8h (+/-1.7h, 1 standard deviation (SD)) versus 7.6h (+/-3.8h, 1SD) in those re-vascularised using grafts (p<0.001). The amputation rate of 27% was reduced to 13% by using shunts. CONCLUSION: Early recognition of vascular injury is vital. Formal angiograms are unnecessary and cause crucial delays. A vascular shunt can significantly reduce ischaemic time, enabling unhurried assessment of the feasibility of limb salvage, debridement of demonstrably non-viable tissue and safe skeletal fixation prior to definitive vascular and soft-tissue repair.

Atrophy of the intrinsic musculature of the hands associated with the use of botulinum toxin-A injections for hyperhidrosis: a case report and review of the literature.

Botulinum toxin type A (BTX-A) has been used therapeutically for the treatment of spastic disorders for many years. More recently, the therapeutic utility of BTX-A in the treatment of hyperhidrosis has been recognised. While studies have reported on the efficacy of BTX-A in managing hyperhidrosis, long term data are required in order for the treatment implications to be fully appreciated. We report on a case of severe atrophy of the intrinsic muscles of the hands in a patient treated with intra-palmar BTX-A (Dysport, Speywood, UK) injections for hyperhidrosis. To our knowledge this has not been described in the literature before.

A survey of rodent-borne pathogens carried by wild-caught Norway rats: a potential threat to laboratory rodent colonies.

Unintentional infection of laboratory rodents can compromise scientific research as well as the health of the animals and animal handlers. The source of contamination often is unknown, but may be introduced by wild rats from surrounding environments. To determine whether rats in Baltimore, Maryland, USA carry infectious agents commonly found in laboratory rodent colonies, we live-trapped 162 rats during 2005 to 2006 and screened them for a panel of viruses, bacteria and parasites. Antibodies against rat coronavirus/sialodacryoadenitis virus (91.7%), Mycoplasma pulmonis (72.9%), cilia-associated respiratory bacillus (52.1%), rat parvovirus/rat minute virus (29.2%), Kilham rat virus (10.4%), Toolan's H-1 virus (10.4%), Sendai virus (4.2%) and Theiler's mouse encephalomyelitis virus (4.2%), were detected in wild-caught Norway rats. Antibodies against reovirus and pneumonia virus of mice were not detected in wild Norway rats. Endoparasites, including Nippostrongylus braziliensis (71.6%), Rodentolepis nana or Hymenolepis diminuta (34.4%), Hetarakis spumosa (24.1%) and Trichuris muris (14.8%), as well as ectoparasites (14.8%), were identified in wild-caught rats. The risk of pathogen transmission from wild-caught rats to laboratory colonies needs to be mitigated by minimizing exposures rather than assuming wild animals represent a minimal hazard.

Nasal tip necrosis--an unusual presentation of rheumatoid vasculitis.

We describe an unusual case of cutaneous necrosis of the nasal tip presenting to a facial reconstructive surgeon. The patient had developed this painless necrosis over a period of about 10 days. Her past medical history included rheumatoid arthritis. She described an exacerbation of her arthritic symptoms in the weeks preceding the development of the nasal tip necrosis. Her rheumatoid arthritis had been managed with corticosteroid and immunosuppressive therapy for more than 3 years. She had not previously experienced extra-articular manifestations (EAMs). A biopsy was taken and histological analysis identified a lymphocytic vasculitis. She was referred to her rheumatologist, and surgical management of her necrotic nasal tip commenced.

A survey of zoonotic pathogens carried by Norway rats in Baltimore, Maryland, USA.

Norway rats (Rattus norvegicus) carry several zoonotic pathogens and because rats and humans live in close proximity in urban environments, there exists potential for transmission. To identify zoonotic agents carried by rats in Baltimore, Maryland, USA, we live-trapped 201 rats during 2005-2006 and screened them for a panel of viruses, bacteria, and parasites. Antibodies against Seoul virus (57.7%), hepatitis E virus (HEV, 73.5%), Leptospira interrogans (65.3%), Bartonella elizabethae (34.1%), and Rickettsia typhi (7.0%) were detected in Norway rats. Endoparasites, including Calodium hepatica (87.9%) and Hymenolepis sp. (34.4%), and ectoparasites (13.9%, primarily Laelaps echidninus) also were present. The risk of human exposure to these pathogens is a significant public health concern. Because these pathogens cause non-specific and often self-limiting symptoms in humans, infection in human populations is probably underdiagnosed.

Modeling the spread of annual influenza epidemics in the U.S.: the potential role of air travel.

The role of air travel in the global spread of influenza has been the subject of a significant body of research, but this question has yet to be explored within the U.S. The goal of this research is to explore whether knowledge of U.S. air travel patterns and volumes leads to better forecasting of epidemics. We report the results of a series of simulations for the 1998-1999 through 2000-2001 influenza seasons using a standard compartmental model coupled with air transportation data. These preliminary results suggest that air travel may play an important role in the spread of annual influenza within the U.S., particularly in cities with large air travel volumes.

Forecasting the geographical spread of smallpox cases by air travel.

Instituting air travel restrictions to slow the geographical spread of smallpox cases would have significant consequences and present serious logistical concerns. Public health decision makers must weigh the potential benefits of such restrictions against their negative impact. The goal of this research is to provide a basic analytical framework to explore some of the issues surrounding the use of air travel restrictions as a part of an overall containment strategy. We report preliminary results of a compartmental model for the inter-city spread of smallpox cases resulting from US domestic air travel. Although air traffic can be halted within hours as was shown following the terrorist attacks of 11 September 2001, these results suggest that the consequences of halting domestic air travel may not be outweighed by public health benefits.