Current treatment procedures for civilian gunshot wounds

INTRODUCTION

This work provides an overview of the incidence of gunshot wounds during peace conditions in a civilian population and aims to assess the principles of their treatment.

METHOD

We evaluated a total of 104 patients with gunshot wounds with an average age of 38.7 years (range 1871). 84 men (80.8%) and 20 women (19.2%) were involved. The head was affected 7 times (6.7%). Out of those, penetrating injury occurred only once (1.0%). The throat was hit three times (2.9%). The chest was injured 15 times (14.4%), penetrating injury at this site was observed in 10 cases (9.6%). In five cases the lungs were affected and the heart once. Gastric injury occurred 13 times, penetration into the peritoneal cavity occurred seven times (6.7%). The intestine was injured five times, the liver three times and the gall-bladder once. Limb injury was present in 66 (63.5%) cases and in 19 of those, the injury was associated with a fracture. In 50 cases (48.1%), the patient was attacked by another person. 45 patients (43.3%) injured themselves unintentionally, five patients (4.8%) were injured in a suicidal attempt and four (3.8%) were accidentally shot by someone else. The weapons used were: pistol in 57 (54.8%) cases, air rifle in 20 cases (19.2%), a rifle in 10 cases (9.6%), two patients (1.9%) were injured with a detonator and one (1.0%) with an assault rifle. In 14 cases (13.5%), the type of firearm used was not established.

RESULTS

Surgical treatment was indicated in all cases. The first step was always a thorough wound irrigation. Single surgical treatment was performed in 48 cases (46.2%) while the other 56 patients (53.8%) required multiple surgeries. Specialized surgical procedures were performed in a total of 30 cases: seven laparotomies, five thoracotomies, five fracture stabilizations using external fixator, four amputations of limbs, two intramedullary osteosyntheses, two stabilizations with the use of Kirchner wires, two vascular surgeries, one craniotomy and one suture of a peripheral nerve. Complications of healing were not frequent: wound infection was observed in two cases (1.9%), wound dehiscence in one case (1.0%), osteomyelitis in two cases (1.9%), nonunion of the fracture (1.0 %) occurred once and in one case (1.0%), pulmonary embolism was diagnosed which was not fatal.

CONCLUSION

Consistent debridement, fasciotomy, and complete drainage of the wound are only indicated in deep gunshot wounds. A surgical revision of the abdominal cavity is indicated for all penetrating abdominal gunshot injuries. The watch-and-wait approach with surgical wound management and hospitalization is only allowed for unambiguously non-penetrating abdominal injuries. Complications of gunshot wound healing in civilian settings are not common and are most often infectious. Key words: gunshot wound - civilian settings surgical treatment.

Immunological phenotype of the murine Lrba knockout

Biallelic mutations in the human lipopolysaccharide responsive beige-like anchor (LRBA) gene lead to a primary immunodeficiency known as LRBA deficiency, characterized by a broad range of clinical manifestations including autoimmunity, organomegaly, hypogammaglobulinemia and recurrent infections. Considering the phenotypic heterogeneity in patients and the severity of the disease, our aim was to assess the role of LRBA in immune cells and to understand the underlying pathomechanisms through the study of a Lrba knockout (Lrba^-/-) mouse model. LRBA-deficient mice did not show severe clinical or immunological signs of disease, either at steady state under specific-pathogen-free conditions, after vaccination with T-dependent and T-independent antigens, or in the context of acute infections with lymphocytic choriomeningitis virus (LCMV) or Salmonella Typhimurium. Although Lrba^-/- mice were able to produce normal serum immunoglobulin M (IgM) and IgG and to mount a specific immune response after immunization, they showed elevated serum and secretory basal IgA levels. LRBA was dispensable for B- and T-cell development, as well as for in vitro B-cell proliferation, survival, isotype switching and plasmablast differentiation. Interestingly, Lrba^-/- mice displayed decreased cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) expression by regulatory T cells and activated conventional CD4⁺ and CD8⁺ T lymphocytes, reduced frequency of peritoneal B-1a cells along with diminished interleukin-10 production and increased percentages of T follicular helper cells in Peyer's patches, but without developing overt signs of autoimmunity. Our findings expand the role of LRBA in immune regulatory mechanisms previously reported in patients, and suggest a novel role in IgA production that is crucial for the protection of mucosal surfaces and gut-associated immune tolerance.

Application fields for the new Object Management Group (OMG) Standards Case Management Model and Notation (CMMN) and Decision Management Notation (DMN) in the perioperative field

PURPOSE

Medical processes can be modeled using different methods and notations. Currently used modeling systems like Business Process Model and Notation (BPMN) are not capable of describing the highly flexible and variable medical processes in sufficient detail.

METHODS

We combined two modeling systems, Business Process Management (BPM) and Adaptive Case Management (ACM), to be able to model non-deterministic medical processes. We used the new Standards Case Management Model and Notation (CMMN) and Decision Management Notation (DMN).

RESULTS

First, we explain how CMMN, DMN and BPMN could be used to model non-deterministic medical processes. We applied this methodology to model 79 cataract operations provided by University Hospital Leipzig, Germany, and four cataract operations provided by University Eye Hospital Tuebingen, Germany. Our model consists of 85 tasks and about 20 decisions in BPMN. We were able to expand the system with more complex situations that might appear during an intervention.

CONCLUSION

An effective modeling of the cataract intervention is possible using the combination of BPM and ACM. The combination gives the possibility to depict complex processes with complex decisions. This combination allows a significant advantage for modeling perioperative processes.

Evidence for a functional role of calsequestrin 2 in mouse atrium

AIM

Several genetically modified mice models were studied so far to investigate the role of cardiac calsequestrin (CSQ2) for the contractile function of the ventricle and for the occurrence of ventricular tachycardia. Using a CSQ2 knockout mouse, we wanted to study also the atrial function of CSQ2.

METHODS

The influence of CSQ2 on atrial function and, for comparison, ventricular function was studied in isolated cardiac preparations and by echocardiography as well as electrocardiography in mice with deletion of CSQ2.

RESULTS

Using deletion of exon 1, we have successfully generated a constitutive knockout mouse of the calsequestrin 2 gene (CSQ2^-/- ). CSQ2 protein was absent in the heart (atrium, ventricle), but also in oesophagus and skeletal muscle of homozygous knockout mice. In 6-month-old CSQ2^-/- mice, relative left atrial weight was increased, whereas relative heart weight was unchanged. The staircase phenomena in paced left atrial preparations on force of contraction and the post-rest potentiation were different between wild type and CSQ2^-/- indicative for a decreased sarcoplasmic Ca²⁺ load and supporting an important role of CSQ2 also in the atrium. The incidence of arrhythmias was increased in CSQ2^-/- . In 2-year-old CSQ2^-/- mice, cardiac hypertrophy and heart failure were noted possibly as a result of chronically increased cytosolic Ca²⁺ levels.

CONCLUSION

These data suggest a functional role of CSQ2 not only in the ventricle but also in the atrium of mammalian hearts. Loss of CSQ2 function can cause not only arrhythmias, but also cardiac hypertrophy and heart failure.

Should ALPPS be Used for Liver Resection in Intermediate-Stage HCC?

BACKGROUND

Extended liver resections in patients with hepatocellular carcinoma (HCC) are problematic due to hepatitis, fibrosis, and cirrhosis. Associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has been promoted as a novel method to induce hypertrophy for patients with extensive colorectal liver metastases, but outcomes in HCC have not been well investigated.

METHODS

All patients registered in the international ALPPS Registry ( www.alpps.org ) from 2010 to 2015 were studied. Hypertrophy of the future liver remnant, perioperative morbidity and mortality, age, overall survival, and other parameters were compared between patients with HCC and patients with colorectal liver metastases (CRLM).

RESULTS

The study compared 35 patients with HCC and 225 patients with CRLM. The majority of patients undergoing ALPPS for HCC fall into the intermediate-stage category of the Barcelona clinic algorithm. In this study, hypertrophy was rapid and extensive for the HCC patients, albeit lower than for the CRLM patients (47 vs. 76 %; p < 0.002). Hypertrophy showed a linear negative correlation with the degrees of fibrosis. The 90-day mortality for ALPPS used to treat HCC was almost fivefold higher than for CRLM (31 vs. 7 %; p < 0.001). Multivariate analysis showed that patients older than 61 years had a significantly reduced overall survival (p < 0.004).

CONCLUSION

The ALPPS approach induces a considerable hypertrophic response in HCC patients and allows resection of intermediate-stage HCC, albeit at the cost of a 31 % perioperative mortality rate. The use of ALPPS for HCC remains prohibitive for most patients and should be performed only for a highly selected patient population younger than 60 years with low-grade fibrosis.

Influence of mRNA expression of epiregulin and amphiregulin on outcome of patients with metastatic colorectal cancer treated with 5-FU/LV plus irinotecan or irinotecan plus oxaliplatin as first-line treatment (FIRE 1-trial)

Our aim was to investigate the impact of EREG and AREG mRNA expression (by RT-qPCR) in patients with metastatic colorectal cancer (mCRC). In addition, epidermal growth factor receptor (EGFR) expression (by immunohistochemistry) as well as RAS-and PIK3CA-mutations (by pyrosequencing) were assessed. Tumors of 208 mCRC patients receiving 5-fluorouracil/leucovorin plus irinotecan (FUFIRI) or irinotecan plus oxaliplatin (mIROX) within the FIRE-1 trial were analyzed for mutations. Molecular characteristics were correlated with response, progression-free survival (PFS), overall survival (OS). mRNA expression was evaluated using ROC-analysis in 192 tumors (AREG high n = 31 vs. low n = 161; EREG high n = 89 vs. low n = 103). High versus low AREG expression was associated with PFS of 10.0 versus 8.0 months (HR = 0.62, 95% CI: 0.402-0.940, p = 0.03) and OS of 24.6 versus 18.7 months (HR = 0.72, 95% CI: 0.476-1.078, p = 0.11). High versus low EREG expression correlated with prolonged PFS (9.4 vs. 6.8 months, HR = 0.62, 95% CI: 0.460-0.846, p = 0.002) and OS (25.8 vs. 15.5 months, HR = 0.48, 95% CI: 0.351-0.657, p < 0.001). The positive prognostic effect of high EREG expression was confirmed in a multivariate analysis and was neither affected by EGFR expression nor by mutations of RAS- and PIK3CA-genes. EREG expression appears as an independent prognostic marker in patients with mCRC receiving first-line irinotecan-based chemotherapy.

Gain dynamics in Raman fiber lasers and passive pump-to-Stokes RIN suppression

We report on theoretical and experimental investigations of gain dynamics in Raman fiber lasers in the frequency range of 1 Hz-1 MHz. An analytical solution of the problem is due to the nonlinear nature of the Raman effect not feasible. Thus, we used a numerical simulation to gain general insights. Experimentally and numerically obtained results for a Raman fiber laser emitting at 1180 nm show good qualitative agreement. We also present a potential physical interpretation of the observed dynamical properties. In addition, we report on an experimental proof-of-principle of a passive pump-to-Stokes RIN suppression scheme for the main Stokes order in cascaded Raman fiber lasers utilizing an additional parasitic Stokes order. Again, results from numerical and experimental studies of a cascaded Raman fiber laser at 1180 nm and 1240 nm show good agreement and confirm the passive pump-to-Stokes RIN suppression at 1180 nm. The dependencies between the resonator design and the parameters of the noise suppression are investigated. In addition, it is shown that the scheme can also be applied to cascaded Raman fiber lasers with more then two Stokes shifts. This opens the possibility to design for example low-noise Raman fiber lasers at 1480 nm to pump low-noise Er(3+) doped fiber amplifiers.

Gain dynamics in Er(3+):Yb(+) co-doped fiber amplifiers

Understanding the gain dynamics of fiber amplifiers is essential for the implementation and active stabilization of low noise amplifiers or for coherent beam combining schemes. The gain dynamics of purely Er³⁺ or Yb³⁺ doped fiber amplifiers are well studied, whereas no analysis for co-doped systems, especially for Er³⁺:Yb³⁺ co-doped fiber amplifiers has been performed, so far. Here, we analyze for the first time the gain dynamics of Er³⁺:Yb³⁺ co-doped fiber amplifiers theoretically and experimentally. It is shown that due to the energy transfer between the Yb³⁺ and Er³⁺ ions a full analytical solution is not possible. Thus, we used numerical simulations to gain further insights. Comparison of experimental and numerical results shows good qualitative agreement. In addition, we were able to determine the Yb³⁺-Er³⁺ transfer function of the energy transfer experimentally.

[Perspective of patients undergoing surgery for secondary peritonitis]

INTRODUCTION

Peritonitis is a life-threatening disease with high mortality and morbidity. The prognosis depends on patient factors, the nature of the disease, and on diagnostic and therapeutic methods. The goal of our study was to perform a retrospective analysis of a group of patients with secondary peritonitis and to compare patients with non-stercoral peritonitis and those with stercoral peritonitis, and finally, to determine the prognostic value of the MPI prognostic index.

METHODS

We analysed 124 patients who had undergone surgery for secondary peritonitis during the years 2012-2013. We divided the patients into two groups. Group A comprised patients with non-stercoral peritonitis and group B consisted of patients with stercoral peritonitis. We compared the two groups and predicted the peritonitis outcome using the Mannheim Peritonitis Index (MPI).

RESULTS

The complete sample of 124 patients consisted of 70 men and 54 women. The average age of the patients was 63 years and the average length of hospitalization was 18 days. In total, 18 patients (15%) died during their hospitalization. The average MPI score was 19, which correlates to an 18% mortality rate prediction. In group A, which consisted of 68 patients with non-stercoral peritonitis, the average age was 59 years and the average length of hospitalization was 12 days. Two patients (3%) from this group died during hospitalization. The average MPI score was 9, which correlates to a 9% mortality rate prediction. In group B, which consisted of 56 patients with stercoral peritonitis, the average age was 67 years and the average length of hospitalization was 25 days. 16 patients (29%) from this group died during hospitalization. The average MPI score was 29, which correlates to a 31% mortality rate prediction.

CONCLUSIONS

The outcome of our comparison between the two groups is that group A with non-stercoral peritonitis had a significantly lower mortality, lower number of complications and a shorter length of hospitalization. Both basic clinical data and sophisticated scoring systems can be used for mortality prediction in peritonitis. The Mannheim Peritonitis Index, a simple scoring system, proved to be useful in our study.

Overexpression of protein phosphatase 2A in a murine model of chronic myocardial infarction leads to increased adverse remodeling but restores the regulation of β-catenin by glycogen synthase kinase 3β

BACKGROUND/OBJECTIVES

Increased activity of cardiac protein phosphatases is an important feature in human heart failure. Several different protein phosphatases (PP) are involved in the regulation of excitation-contraction-coupling of the myocardium. Protein phosphatase 2A (PP2A) is a serine/threonine phosphatase consisting of a dimeric core enzyme and tissue-specific subunits. In this study we used transgenic mice overexpressing PP2A to further investigate the role of PP2A in cardiac remodeling after myocardial infarction.

METHODS AND RESULTS

Adult male CD-1 mice overexpressing the catalytic subunit α of PP2A (αMHC-PP2A; TG) underwent chronic LAD-ligation or sham surgery, respectively; wildtype littermates (WT) were used as controls. Cardiac function was determined by echocardiography before and 28 days after LAD-ligation. 28 days after MI, the animals were sacrificed and cardiac remodeling was analyzed in histological sections and by Western blots. PP2A overexpression leads to dilated cardiomyopathy in mice, and increased cardiomyocyte hypertrophy and fibrosis of the remote myocardium can be seen after myocardial infarction. However, we found an improved survival of TG in the subacute phase after MI in comparison to WT. On the molecular level, TG shows reduced expression of SERCA and CaMKII alpha both under basal condition as well 28 days after MI. Additionally, the regulation of the Akt/GSK3β/β-catenin pathway is severely disturbed in TG at baseline where a significant activation of Akt is found that coincides with the typical phosphorylation of GSK3β. However, this does not lead to the accumulation of β-catenin - on the contrary: phosphorylation-induced degradation of β-catenin is significantly enhanced.

CONCLUSION

Transgenic overexpression of myocardial PP2A causes adverse remodeling which coincides with a disruption of the classical Akt/GSK3/β-catenin pathway under baseline conditions that is restored to normal values in chronic myocardial infarction. Even so overall survival of TG after myocardial infarction was not constrained and survival after day 2 post MI was improved.

Reward processing in obesity, substance addiction and non-substance addiction

Similarities and differences between obesity and addiction are a prominent topic of ongoing research. We conducted an activation likelihood estimation meta-analysis on 87 studies in order to map the functional magnetic resonance imaging (fMRI) response to reward in participants with obesity, substance addiction and non-substance (or behavioural) addiction, and to identify commonalities and differences between them. Our study confirms the existence of alterations during reward processing in obesity, non-substance addiction and substance addiction. Specifically, participants with obesity or with addictions differed from controls in several brain regions including prefrontal areas, subcortical structures and sensory areas. Additionally, participants with obesity and substance addictions exhibited similar blood-oxygen-level-dependent fMRI hyperactivity in the amygdala and striatum when processing either general rewarding stimuli or the problematic stimuli (food and drug-related stimuli, respectively). We propose that these similarities may be associated with an enhanced focus on reward--especially with regard to food or drug-related stimuli--in obesity and substance addiction. Ultimately, this enhancement of reward processes may facilitate the presence of compulsive-like behaviour in some individuals or under some specific circumstances. We hope that increasing knowledge about the neurobehavioural correlates of obesity and addictions will lead to practical strategies that target the high prevalence of these central public health challenges.