[Tetanus: an immunopreventable disease]. / Tétanos: una enfermedad inmunoprevenible.

Tetanus is an infectious disease caused by a ubiquitous bacterium Clostridium tetani, that synthesizes and releasesa potent neurotoxin under anaerobic conditions, which is responsible for the clinical manifestations. As it is found in soil contaminated with animal and human excreta, it is difficult to eradicate but it may be prevented by immunization. Immunization rate has decreased in the last years, especially during the COVID-19 pandemic. We report two cases of tetanus, attended during 2022. A 39-year-old man whose entry route was a gunshot wound and he was discharged from the intensive care unit (ICU) and a second case of an 83-year-old woman with unknown entry point, who died during her ICU stay. The cases reported highlight that it is a life-threatening disease, its diagnosis is mainly clinical and it should be in the algorithm of differential diagnoses. We emphasize about the prompt treatment administration or consultation to a specialized healthcare center. The importance of this presentation is to show the severity of the disease, whose assessment is mainly clinical and should not escape the algorithm of differential diagnoses, emphasizing that treatment should be instituted early or when in doubt consult a specialized center. In addition to this, it is important to check theimmunization rate in our country, especially during thepandemic, becauseit is a vaccine-preventable disease.

El tétanos es causado por el Clostridium tetani, una bacteria ubicua que frente a condiciones de anaerobiosis puede sintetizar y liberar sus toxinas, responsables del cuadro clínico. Dado que es una bacteria que se encuentra en el suelo y en el tracto gastrointestinal de muchas especies, se trata de una enfermedad no erradicable pero si controlable a través de la inmunización para la prevención. Las tasas de inmunización han disminuido en los últimos años, evento que se ha acentuado durante la COVID-19. Se presentan a continuación dos casos clínicos ingresados durante el año 2022. El primero es un hombre de 39 años cuya puerta de entrada fue una herida de arma de fuego conevolución favorable y el segundo caso se trata de una mujer de 83 años sin puerta de entrada clara quien falleció durante su internación en terapia intensiva. La importancia de esta presentación es mostrar la gravedad de la enfermedad, cuyavaloración es principalmente clínica y no debe escapar al algoritmo de diagnósticos diferenciales, acentuando que se debe instaurar el tratamiento de forma precoz o frente a la duda consultar con un centro especializado. Asímismo, es importante revisar las tasas de inmunización en nuestro país y los cambios que se presentaron durante la pandemia, teniendo en cuenta, como se ha expuesto previamente, se trata de una enfermedad inmunoprevenible.

In Vivo Fitness Adaptations of Colistin-Resistant Acinetobacter baumannii Isolates to Oxidative Stress.

The loss of fitness in colistin-resistant (CR) Acinetobacter baumannii was investigated using longitudinal isolates from the same patient. Early CR isolates were outcompeted by late CR isolates for growth in broth and survival in the lungs of mice. Fitness loss was associated with an increased susceptibility to oxidative stress since early CR strains had reduced in vitro survival in the presence of hydrogen peroxide and decreased catalase activity compared to that of late CR and colistin-susceptible (CS) strains.

[CHARACTERISTICS OF ANTIBIOTICORESISTANCE OF MICROFLORA IN A COMBAT (THE GUN-SHOT ANO THE MINE-EXPLOSION) WOUNDS OF THE EXTREMITIES].

Abstract Results of bacteriological investigations of a gun-shot and a mine-explosion woundings of the extremities were analyzed in Military-Medical Clinical Centres (MMCC) of Kyiv, Lviv and Vinnytsya. Spectrum of the allotted microorganisms and profile of their antibioticoresistance were disclosed. The patterns of resistance were determined in accordance to offering of international experts of European Committee on Antimicrobial Susceptibility Testing (EUCAST). Dominating microflora in a Chief MMCC (Kyiv) and MMCC of a Western Region (Lviv) were various species of the Enterobacteriaceae and P. aeruginosa families, while in MMCC of a Central Region (Vinnytsya)--a gramm-negative non-fermentative bacilli of the Acinetobacter genus and Pseudomonas genus. The majority (79.5%) of isolates were characterized by polyresistance for antibiotics. Maximal quantity of strains with a widened spectrum of resistance was revealed in 2 - 3 weeks after a wounding--in 71.4 and 96.9% accordingly.

Empleo de ácido tranexámico en el herido de combate, experiencia de la sanidad militar española. Serie de casos y revisión de la literatura / Use of tranexamic acid in combat casualties. Experience of the Spanish medical corps. Clinical series and literature review

Objetivo. Describir la experiencia obtenida con el ácido tranexámico (ATX) durante la atención a bajas de combate en el hospital militar español desplegado en Herat (Afganistán) y analizar la bibliografía relacionada en el ámbito militar. Material y métodos. Con la aprobación de las instituciones militares pertinentes, se analizó la administración de ATX en bajas de combate entre marzo y mayo de 2014. De los 745 pacientes atendidos, 10 fueron por arma de fuego/artefacto explosivo (bajas de combate). El método estadístico empleado fue el descriptivo. Para variables categóricas se emplearon frecuencias absolutas y relativas en tanto por ciento (%). Como índices de la tendencia central, la media aritmética y la desviación estándar o la mediana y el rango intercuartílico. Los datos se obtuvieron del registro militar de pacientes atendidos en el hospital militar español de Herat. Resultados. En nuestra serie de datos, todos los pacientes recibieron ATX antes de las 3 primeras horas tras el ataque. La dosis empleada más prevalente fue un gramo iv (intravenoso). La hemorragia fue controlada en el 100% de los casos. Todos los pacientes sobrevivieron y en ninguno se objetivaron efectos secundarios. Estos datos coinciden con lo recomendado en las guías de atención a la baja de combate seguidas por sanidades militares de otros países de nuestro entorno. Conclusión. Todas las bajas en combate fueron tratadas con ATX durante las 3 primeras horas. La dosis más prevalente fue de un gramo iv. La hemorragia fue controlada en la totalidad de los casos. Todos los pacientes sobrevivieron sin efectos secundarios (AU)

Objective. To describe the experience with tranexamic acid (TXA) during the care of combat causalities treated in the Spanish military hospital based in Herat (Afghanistan) and to perform an analysis of the literature related to the military setting. Material and methods. With the approval of the appropriate military institutions, an analysis was performed on the use of TXA in combat casualties treated between March and May 2014. Of the 745 patients seen, 10 were due to a firearm/explosive device (combat casualties). A descriptive analysis was performed on the data collected. Absolute and relative frequencies (%) were used for the categorical variables. For central tendency measurements, the arithmetic mean and standard deviation or the median and interquartile range was calculated. The data were obtained from the military records of patients treated in the Herat military hospital. Results. All the patients in this series received TXA within the first 3 hours after the attack. The most frequent dose used was one gram i.v, with bleeding was controlled in 100% of cases. All the patients survived and none of them had secondary effects. These data agree with that recommended in the combat casualties treatment guide followed by military health in other countries in this setting. Conclusion. All combat casualties were treated with TXA within the first 3 hours. The most frequent dose used was one gram iv and bleeding was controlled in all cases. All the patients survived with no adverse effects being observed (AU)

Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures.

BACKGROUND: Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma. MATERIALS AND METHODS: A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70 %) respondents worked at a Level-1 trauma center, 176 (80 %) had received fellowship education in orthopaedic trauma and 104 (47 %) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC). RESULTS: One hundred eighty-six respondents (86 %) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50 %) and pelvic fractures with visceral injury (10/16, 63 %). Most surgeons (167, 76 %) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70 %) do not base their antibiotic choice on the classification system. Few institutions (58, 26 %) have protocols guiding antibiotic use for LVBF. CONCLUSIONS: Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.

[COMPLEX OF THE TREATMENT MEASURES IN A SYSTEM OF THE MEDICAL CARE DELIVERY TO WOUNDED PERSONS WITH THE GUN-SHOT AND MINE-EXPLOSIVE INJURIES OF THE FOOT].

Complex of the treatment measures, conducted in 302 wounded persons, suffering the gun-shot and mine-explosive injuries of the foot in 2014 - 2015 yrs, was analyzed. Primary surgical processing of the wound was conducted in all injured persons, secondary surgical processing--in 64.6%, the foot bones osteosynthesis--in 13.9%, primary immobilization, using improvised tire--in 77.8%, secondary immobilization, using the plaster splint--in 48.1%, llizarov's spokes--in 35.2%, Ilizarov's apparatus--in 18.5%, the rods apparatuses of external fixation--in 16.7%. For improvement of functioning of a modern system for the treatment-evacuation provision it is necessary, to reduce the quantity of levels of the medical help provision maximally.

Baclofen dosage after traumatic spinal cord injury: a multi-decade retrospective analysis.

OBJECTIVES: To perform an analysis of oral baclofen dosage in patients with traumatic spinal cord injuries over time and to ascertain the clinical determinants of long-term baclofen dosage trends. STUDY DESIGN: Retrospective cohort study of patient records from the PM&R units at the Johns Hopkins Bayview Medical Center and the Johns Hopkins Hospital. SUBJECTS: A total of 115 PM&R patients suffering spinal cord injury due to trauma leading to either complete or incomplete paralysis. The modes of injury included were motor vehicle accidents (MVA) (n=39), gunshot wounds (GSW) (n=55), falls (n=17), diving (n=2), workplace (n=1) and swimming (n=1) accidents. The location of injury in the spinal cord was categorized into either cervical (n=52), thoracic (n=59), lumbar (n=2), or unspecified (n=2). RESULTS: From time of injury, an aggregate of all dosage assignments for each patient demonstrated a significant yearly increase in baclofen dosage (1.26 mg/year, p<0.01). Baclofen dosage for MVA cases were seen to rise at 4.99 mg/year (p<0.0001). Kaplan-Meier analysis revealed that GSW patients received their first baclofen dosage earlier than MVA patients (log-rank p<0.05, unadjusted). CONCLUSIONS: We observed a marginal increase in baclofen dosage over nearly 25 years in a single provider's patient database and observed different timings of first dose between two causes of traumatic SCI. These results provide an estimate of baclofen dosage trends over time after spinal cord injury and may be useful for patient counseling or as a method to assess costs of providing SCI patient care.

Craniocerebral gunshot wound in a baby chimpanzee--an uncommon experience of neurosurgical treatment conducted in the Guinean forest.

An orphan female chimpanzee was wounded by a left craniocerebral gunshot complicated with a right hemiparesis. Local treatment and long-term antibiotherapy failed to lead to healing. A neurosurgical procedure was planned and achieved. She fully recovered, and 2 years after the procedure, there is no evidence of infection.

Antibiotics in the treatment of low-velocity gunshot-induced fractures: a systematic literature review.

BACKGROUND: Low-velocity gunshots are often associated with extremity fractures. There is no consensus, however, on the use of antibiotics for these injuries. QUESTIONS/PURPOSES: We performed a literature review to answer the following questions: (1) Are antibiotics needed for the treatment of these fractures? (2) Is gram-negative coverage necessary? (3) How long should antibiotics be administered? And (4) which is the optimal administration route? METHODS: We conducted a MEDLINE(®) search and found only two relevant prospective, randomized studies. Further searches identified all case series with information on the use of antibiotics in gunshot fractures. In total, 33 studies provided enough data to answer the study questions. An assessment of the quality of the identified studies was performed. Twenty-three studies met at least ½ of the quality items of the assessment tool. RESULTS: Antibiotics did not significantly reduce the infection rate for fractures treated nonoperatively (1.7% with antibiotics versus 5.1% without) with the numbers available. There was no significant difference in infection rates when gram-negative coverage was added, either in nonoperatively treated fractures (1.7% versus 2.8%) or in operatively treated fractures (0% versus 2.5%). Duration of antibiotic administration did not significantly affect the infection rate. No difference was found between intravenous and oral antibiotic administration for nonoperatively treated fractures. CONCLUSIONS: This literature review could not demonstrate a significant benefit with the use of antibiotics for low-velocity gunshot fractures treated nonoperatively; however, the statistical power for these comparisons was low in the available literature, which is insufficiently strong to recommend a treatment. Gram-negative coverage did not alter the infection rates in gunshot fractures, nor did longer duration of antibiotic administration. For fractures treated nonoperatively, oral antibiotics are as efficacious as intravenous antibiotics.

Civilian gunshot injuries of the spinal cord: a systematic review of the current literature.

BACKGROUND: The principles that guide management of spinal cord injury (SCI) derive from injury resulting from blunt trauma, not gunshot wounds. Civilian gunshot-induced spinal cord injury (CGSWSCI) is a common, potentially serious cause of neurological deficit; there is disagreement about whether the same approaches used for SCI caused by blunt-force trauma should apply to gunshot-induced SCI. QUESTIONS/PURPOSES: We reviewed the literature to answer the following questions regarding presentation and outcome of gunshot wound-induced SCI: (1) Are there differences in recovery prognosis between complete SCI and other patterns of SCI in CGSWSCI. (2) Does the use of steroids improve neurological recovery? (3) Does surgery to remove the bullet affect neurological recovery in CGSWSCI? (4) Does surgery result in an increased risk of complications of treatment? METHODS: We performed a systematic literature review of articles related to civilian gunshot injuries to the spine. Information relating to incidence, pattern of neurological injury, associated injuries, treatment, neurological outcome, and associated complications was extracted. Three independent reviewers assessed the strength of evidence present in the literature by examining quality, quantity, and consistency of results. RESULTS: A total of 15 articles met the predetermined inclusion criteria. Complete SCIs are associated with the worst functional recovery regardless of treatment. Steroids do not appear to have any added benefit in terms of restoring sensory and motor function. There appears to be some neurologic benefit to surgical decompression with intracanalicular bullet retrieval in patients with an incomplete lesion and a cauda equina syndrome. Complication rates are greater in operated patients. CONCLUSIONS: These findings should be interpreted with caution because of considerable heterogeneity among the studies in the literature on gunshot-induced SCI and because of generally poor-quality study design and a high associated risk of selection bias. Supportive management should be the primary method of care, whereas surgery should be an option in case of radiographic evidence of a static compression on the spinal cord. Future studies are necessary to develop better treatment guidelines for patients with gunshot wound-associated SCI.

Life, limb or off-label recombinant VIIa use in the setting of limited blood assets: a case study.

Due to the lack of adequate controlled trials, the off-label use of recombinant factor VIIa (rFVIIa) to control hemorrhage in trauma patients remains controversial. The decision regarding when to initiate rFVIIa therapy is particularly problematic. Whereas most reports and trials have delayed use until significant bleeding has occurred, there is some evidence that coagulopathy develops early in some trauma patients, raising the possibility that early rFVIIa use may be more clinically efficacious. Herein, we report the case of a hemodynamically unstable patient with massive blood loss from multiple gunshot wounds and who had a potentially salvageable upper extremity. Rapid hemorrhage despite efforts to surgically control the bleeding resulted in virtual exhaustion of the facilities' limited blood component supply. Hemorrhage was controlled when rFVIIa was added to hypotensive resuscitation allowing salvage of the arm and significant conservation of blood products. This case raises the question as to whether earlier off-label use of this agent should be considered when amputation for hemorrhage control is being considered and/or conservation of limited blood assets is needed.

Bromelain ameliorates the wound microenvironment and improves the healing of firearm wounds.

BACKGROUND: In a previous study, we proposed a new therapy using topical bromelain as a supplement to simple wound-track incision for the debridement of firearm wounds. This enzymatic debridement greatly simplified the management of high-velocity gunshot wounds in a pig model, and bromelain was confirmed to improve wound healing. The purpose of the present study was to investigate the effect of bromelain on the microenvironment of firearm wounds. METHODS: Sixteen Chinese landrace pigs wounded by high-velocity projectiles were divided randomly into four groups: wound incision (group I), incision + bromelain (group IB), wound excision (group E), and control. Blood perfusion, oxygen partial pressure (pO(2)), and the content of tumor necrosis factor (TNF)-α and transforming growth factor (TGF)-ß in wound-track tissue were measured. Wound healing was also noted. RESULTS: The recovery of blood perfusion in tissue and pO(2) in wound tracks was significantly more rapid in group IB and group E than in group I and control. The tissue level of TNF-α was significantly lower in group IB than in group I and control 48 h and 72 h post-wounding, and was lower than in group E 48 h post-wounding. The tissue level of TGF-ß in group IB was sustained at a significantly higher level than in the other three groups. Wound healing time was also shorter in group IB. CONCLUSIONS: Enzymatic debridement using topical bromelain in incised wound tracks accelerates the recovery of blood perfusion, pO(2) in wound tissue, controls the expression of TNF-α and raises the expression of TGF-ß.

Multidisciplinary trauma team care in Kandahar, Afghanistan: current injury patterns and care practices.

Multidisciplinary trauma care systems have been shown to improve patient outcomes. Medical care in support of the global war on terror has provided opportunities to refine these systems. We report on the multidisciplinary trauma care system at the Role III Hospital at Kandahar Airfield, Afghanistan. We reviewed the Joint Trauma System Registry, Kandahar database from 1 October 2009 to 31 December 2010 and extracted data regarding patient demographics, clinical variables and outcomes. We also queried the operating room records from 1 January 2009 to 31 December 2010. In the study period of 1 October 2009 to 31 December 2010, 2599 patients presented to the trauma bay, with the most common source of injury being from Improvised Explosive Device (IED) blasts (915), followed by gunshot wounds (GSW) (327). Importantly, 19 patients with triple amputations as a result of injuries from IEDs were seen. 127 patients were massively transfused. The in-hospital mortality was 4.45%. From 1 January 2010 to 31 December 2010, 4106.24 operating room hours were logged to complete 1914 patient cases. The mean number of procedures per case in 2009 was 1.27, compared to 3.11 in 2010. Multinational, multidisciplinary care is required for the large number of severely injured patients seen at Kandahar Airfield. Multidisciplinary trauma care in Kandahar is effective and can be readily employed in combat hospitals in Afghanistan and serve as a model for civilian centres.

Debriding effect of bromelain on firearm wounds in pigs.

BACKGROUND: Wound excision is the standard treatment for firearm wounds. However, achieving a satisfactory curative effect is difficult because of the traumatic mechanism of high-velocity projectiles. We propose a new therapy by using topical bromelain as a supplement to wound incision for the debridement of firearm wounds. We clarified the debriding effect of bromelain on firearm wounds in pigs. METHODS: In vitro, muscle tissues around the wound track and normal muscle were incubated in bromelain solutions of different concentrations. Tissue hydrolization was estimated by measuring tissue weight and the release of total amino acids. In vivo, the hind limbs of 15 pigs were wounded with high-velocity projectiles. Five groups were classified as follows: wound excision (E), wound incision (I), bromelain (B), incision + bromelain (IB), and control (C). Debriding effectiveness was estimated using bacterial content, histopathologic examination, and wound healing time. RESULTS: In vitro, hydrolization of wound tissue was significantly more intensive than that of normal tissue. Bromelain solution (10 mg/mL) hydrolyzed wound tissue rapidly with minimal proteolysis of normal tissue. In vivo, the wound-track bacterial content of group IB was similar to that of group E and was significantly lower than that of groups I, B, and C. The wound healing time of group IB was also shorter. CONCLUSIONS: Bromelain is effective in the debridement of uncomplicated firearm wounds if used as a supplement to simple wound incision. This new therapy shows notable advantages over conventional surgical debridement as it greatly simplifies the procedures.

Celox (chitosan) for haemostasis in massive traumatic bleeding: experience in Afghanistan.

The use of Celox, a chitosan-based haemostatic agent, for the control of massive traumatic bleeding in patients arriving at a ROLE 2 (Enhanced Care) Facility in southwestern Afghanistan is described. Twenty-one soldiers with gunshot wounds were treated with successful haemostasis in 18 at the first application and in three after further applications. Celox is an effective haemostatic agent and a useful adjunct for the treatment of massive traumatic bleeding.

Prophylaxis and treatment of infections associated with penetrating traumatic injury.

Accidents or violence can result in penetrating trauma in the adult population. Contaminated penetrating foreign bodies introduced at the time of wounding cause infection, especially high velocity projectiles, which result in cavitation. Surgical debridement reduces potential infection; however, perioperative antibiotics are usually indicated owing to studies demonstrating high rates of sepsis in the pre-antibiotic era. Trauma-associated pathogens include Gram-positive, Gram-negative and anaerobic pathogens. Antibiotic resistance is increasing, and several recent panels have sought to develop guidelines for perioperative prevention and empiric treatment of infection to limit usage and reduce selective pressure for resistance. We review infections of the CNS, thorax, abdomen and extremities following penetrating trauma injury, as well as the data supporting a reasonable antimicrobial approach.