Shank vessel injuries: the forgotten vascular injuries

INTRODUCTION

Vascular injuries in branch vessels of the popliteal artery, such as the tibioperoneal trunk, and shank vessels, such as anterior, posterior tibial, and peroneal vessels, occur in both blunt and penetrating trauma. Their management has evolved significantly in the past few decades. While their incidence is variable, limb loss and morbidity remain significant.

MATERIAL AND METHODS

Physical examination, along with measuring an Ankle-Brachial Index (ABI), is still sometimes all that is required for diagnosis and can expeditiously triage those that require urgent operation. Despite our technological advancements and newer algorithms for lower extremity vascular trauma, operative intervention and exposure still remain difficult and pose a great challenge for surgeons that normally do not operate on this area.

CONCLUSIONS

Shank vessel injuries still comprise a significant proportion of combat and civilian vascular injuries, and modern advances have led to a dramatic decrease in amputation rates.

Subclavian vessel injuries: difficult anatomy and difficult territory

INTRODUCTION

Thoracic and thoracic related vascular injuries represent complex challenges to the trauma surgeon. Subclavian vessel injuries, in particular, are uncommon and highly lethal. Regardless of the mechanism, such injuries can result in significant morbidity and mortality.

MATERIALS AND METHODS

Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience.

CONCLUSIONS

These injuries are associated with significant morbidity and mortality. Patients who survive transport are subject to potentially debilitating injury and possibly death. Management of these injuries varies, depending on hemodynamic stability, mechanism of injury, and associated injuries. Despite significant advancements, mortality due to subclavian vessel injury remains high.

Operative exposure and management of axillary vessel injuries

INTRODUCTION

Axillary vessel injuries are uncommon and challenging injuries encountered by trauma surgeons. Proximity of this vessel to other adjacent veins including the axillary vein, brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of associated injuries.

MATERIALS AND METHODS

Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience.

CONCLUSIONS

Although uncommon, axillary arterial injuries can result in significant morbidity, limb loss and mortality. Early diagnosis and timely repair of the artery leads to good outcomes.

Intradural spinal arachnoid cyst. Case report

An intradural spinal arachnoid cyst presenting with spinal cord compression is discussed. This case illustrates the value of magnetic resonance imaging in the diagnosis and follow-up of intradural spinal arachnoid cysts.

Enhanced responsiveness of endothelium in the growing/motile state to tumor necrosis factor/cachectin

Some in vivo observations have suggested that growing or perturbed endothelium, such as that which occurs during angiogenesis, is more sensitive to the action of cytokines (TNF/cachectin, TNF, or IL-1) than normal quiescent endothelial cells. This led us to examine the responsiveness of endothelium to TNF as a function of the growth/motile state of the cell. TNF-induced modulation of endothelial cell surface coagulant function was half-maximal at a concentration of approximately 0.1 nM in subconfluent cultures, whereas 1-2 nM was required for the same effect in postconfluent cultures. Perturbation of endothelial cell shape/cytoskeleton was similarly more sensitive to TNF in subconfluent cultures. Consistent with these results, radioligand binding studies demonstrated high affinity TNF binding sites, Kd approximately 0.1 nM on subconfluent cultures, whereas only lower affinity sites (Kd approximately 1.8 nM) were detected on postconfluent cultures. The mechanisms underlying this change in the affinity of endothelium for TNF were studied in four settings. Crosslinking experiments with 125I-TNF and endothelium showed additional bands corresponding to Mr approximately 66,000 and approximately 84,000 with subconfluent cultures that were not observed with postconfluent cultures. Experiments with X-irradiated endothelium, whose growth but not motility was blocked, indicated that proliferation was not required for induction of high affinity TNF sites. Postconfluent endothelium, triggered to enter the proliferative cycle by microbutuble poisons, expressed high affinity TNF binding sites together with changes in cell shape/cytoskeleton well before their entry into S phase. Using wounded postconfluent monolayers, cells that migrated into the wound and those close to the wound edge displayed enhanced TNF binding and modulation of coagulant properties. These results suggest a model for targetting TNF action within the vasculature; regulation of high affinity endothelial cell binding sites can direct TNF to activated cells in particular parts of the vascular tree.

Immunoreactive beta-casomorphin-8 in cerebrospinal fluid from pregnant and lactating women: correlation with plasma levels

We measured plasma and cerebrospinal fluid (CSF) beta-casomorphin-8, a product of beta-casein hydrolysis which has opioid activity, by RIA in women during late pregnancy and lactation and in nonpregnant nonpuerperal women. Before RIA, the samples were acidified and extracted by reverse phase silica gel chromatography, which removed most of the beta-casein. Lactating women had a significantly higher mean plasma beta-casomorphin-8 concentration (2.66 nmol/L; n = 8) than women in late pregnancy (0.82 nmol/L; n = 8) and nonpregnant women (0.32 nmol/L; n = 5). The CSF beta-casomorphin-8 concentration also was significantly higher in lactating women (mean, 0.35 nmol/L; n = 8) than during late pregnancy (0.22 nmol/L; n = 8) or in nonpregnant women (0.15 nmol/L; n = 5). A positive correlation was found between plasma and CSF beta-casomorphin-8 levels in the entire study group. The milk beta-casomorphin-8 concentration, measured in five puerperal women, averaged 19.8 nmol/L. Thus, there is a decreasing concentration gradient between milk and plasma and between plasma and CSF. Chromatographic analysis revealed mol wt heterogeneity of the RIA-active material. In CSF at least three different components were detected, two of mol wt around 900-2,000 and one of approximately 12,000. One of the low mol wt components coeluted in several chromatographic systems with synthetic beta-casomorphin-8 (mol wt, 900). Such a component was not found in milk or plasma, in which the major activity was due to larger sized peptides. The major peaks in milk were around 1,500-2,000 and 12,000 mol wt, corresponding to the larger peaks in CSF. The results suggest that fragments of the milk protein beta-casein may cross the breast parenchyma-blood barrier into plasma and subsequently penetrate the blood-brain barrier to reach the central nervous system. Thus, mammary tissue may assume endocrine function during galactopoiesis, and beta-casein could be considered a prohormone.

Calorie and nutrient intakes of elderly and young subjects measured under identical conditions

The calorie and nutrient intakes of elderly and young healthy males and females were monitored for four days at the MIT Clinical Research Center. Subjects were free to select foods for meals and snacks from among a variety of high protein and high carbohydrate foods; when necessary, fat was added to make the foods isocaloric. The elderly subjects consumed significantly fewer calories, carbohydrates, and fat than the young subjects, both absolutely and when adjusted for differences in body weight (p less than .001). Mealtime protein intake when adjusted for body weight was similar among males of both age groups and significantly greater than the intakes of both young and elderly females (p less than .001). However, young males consumed more protein from snacks than young females or older adults and thus exhibited the highest daily protein intakes. The two age groups differed significantly in their pattern of food intake from meals and snacks. Elderly adults consumed almost 85% of their total calories from meals, whereas the younger adults consumed about 72% (p less than .001) from meals. Both groups snacked mainly on carbohydrate-rich foods. The elderly subjects consumed significantly fewer snacks than the young; their daily average consumption was 2.2 and that of the young, 4.5 (p less than .001). The persistence of different patterns of food intake between young and elderly individuals when measured under identical clinical conditions suggests that age per se, in addition to age-associated lifestyle changes, may affect eating behavior.

Altered locomotor activity in neuropsychiatric patients

Movement was monitored continuously for 24-48 hours in representative neuropsychiatric patients, using a wrist-worn portable piezoelectric activity monitor with solid-state memory. Striking differences were observed in both circadian and more rapid (ultradian) rhythms between these patients and normal controls of a similar age. We found a loss of circadian rhythm following stroke, and a marked 4-hour activity rhythm in patients with dementia and brain tumor. These results may provide insights into the neural substrate of activity rhythms and may lead to better care of neuropsychiatric patients.

Role of the crystalline lens in the spatial vision loss of the elderly

This study examined the contribution of the crystalline lens to the spatial contrast sensitivity loss experienced by many healthy older adults. Spatial contrast sensitivity was measured in three groups of adults: older adults who had undergone cataract extraction and intraocular lens (IOL) insertion; older adults who were in good ocular health (agematched to the first group); and young adults also in good ocular health. Older adults had decreased contrast sensitivity at higher spatial frequencies compared to young adults, agreeing with earlier reports. In addition, both groups of older adults had similar contrast sensitivity at higher frequencies, contrary to what would be expected if the aged, noncataractous crystalline lens significantly hampered contrast transfer in the healthy older eye. Results imply that the crystalline lens is not primarily responsible for the spatial sensitivity loss of healthy older adults. Furthermore, these data indicate that for at least some IOL patients, spatial vision can be restored to a level similar to their agemates who have no history of lens opacity or ocular disease.

Near-UV radiation from the operating microscope and pseudophakic cystoid macular edema

We performed a prospective randomized study of 297 patients to determine the effect of a UV-blocking filter on the operating microscope on the angiographic incidence of cystoid macular edema in patients undergoing extracapsular surgery with implantation of a posterior chamber lens. Patients were randomly allocated preoperatively to two groups undergoing surgery with or without a UV filter in place. Of the 297 patients, 205 had angiograms readable for the presence or absence of cystoid macular edema. The incidence of aphakic cystoid macular edema in patients without the filter was 21% v 17.3% in the group with a filter. This difference was not significant. The presence of a UV-blocking filter on the operating microscope makes no difference in the angiographic incidence of cystoid macular edema or the visual outcome in these cases.

Markedly elevated creatinine phosphokinase, cotton wool spots, and pericarditis in a patient with leptospirosis

We are reporting a patient with acute leptospirosis whose creatinine phosphokinase was markedly elevated secondary to an associated myositis. In patients presenting with acute hepatitis, an elevated creatinine phosphokinase should suggest the diagnosis of leptospirosis. Our patient's course of illness was made unusual by the appearance of cotton wool spots, previously unreported in leptospirosis as well as by pericarditis in the absence of uremia. This illustrates our ever widening recognition of the clinical manifestations of leptospirosis.