U-shaped association of uric acid to overall-cause mortality and its impact on clinical management of hyperuricemia

Serum uric acid (SUA) is significantly elevated in obesity, gout, type 2 diabetes mellitus, and the metabolic syndrome and appears to contribute to the renal, cardiovascular and pulmonary comorbidities that are associated with these disorders. Most previous studies have focused on the pathophysiologic effects of high levels of uric acid (hyperuricemia). More recently, research has also shifted to the impact of hypouricemia, with multiple studies showing the potentially damaging effects that can be caused by abnormally low levels of SUA. Along with these observations, recent inconclusive data from human studies evaluating the treatment of hyperuricemia with xanthine oxidoreductase (XOR) inhibitors have added to the debate about the causal role of UA in human disease processes. SUA, which is largely derived from hepatic degradation of purines, appears to exert both systemic pro-inflammatory effects that contribute to disease and protective antioxidant properties. XOR, which catalyzes the terminal two steps of purine degradation, is the major source of both reactive oxygen species (O2.-, H2O2) and UA. This review will summarize the evidence that both elevated and low SUA may be risk factors for renal, cardiovascular and pulmonary comorbidities. It will also discuss the mechanisms through which modulation of either XOR activity or SUA may contribute to vascular redox hemostasis. We will address future research studies to better account for the differential effects of high versus low SUA in the hope that this will identify new evidence-based approaches for the management of hyperuricemia.

High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction

A 17-year experience from 1977 to 1993 with gunshot, shotgun, and high-energy avulsive facial injuries emphasizes the superiority and safety of "ballistic wound" surgical management: (1) immediate stabilization in anatomic position of existing bone, (2) primary closure of existing soft tissue, (3) periodic "second look" serial debridement procedures, and (4) definitive early reconstruction of soft-tissue and bony defects. The series contains 250 gunshot wounds, 53 close-range shotgun wounds, and 15 high-energy avulsive facial injuries. Four general patterns of involvement are noted for both gunshot and shotgun wounds and three for avulsive facial injuries. The treatment algorithm begins with identifying zones of injury and loss for both soft and hard tissue. Gunshot wounds are best classified by the location of the exit wound; shotgun and avulsive facial wounds are classified according to the zone of soft-tissue and bone loss. Treatment, prognosis, and complications vary according to four patterns of gunshot wounds and four patterns of shotgun wounds. Avulsive wounds have not been recommended previously for ballistic wound surgical management. The appropriate management of high-energy avulsive and ballistic facial injuries is best approached by an aggressive treatment program emphasizing initial primary repair of existing tissue, serial conservative debridement, and early definitive reconstruction.

Palatal fractures: classification, patterns, and treatment with rigid internal fixation

A classification of palatal fracture types is developed from patterns observed on CT scans, and success with open reduction techniques is correlated with fracture pattern. The six palatal fracture types are as follows: I, anterior and posterolateral alveolar; II, sagittal; III, parasagittal; IV, para-alveolar; V, complex; and VI, transverse. Associated fractures were LeFort I (100 percent), LeFort II and III (55 percent), mandible (48 percent), and dental (55 percent). Large segment, sagittally oriented palatal fractures could be stabilized with rigid internal fixation. Complete rigid fixation of the palate consists of (1) roof of mouth, (2) pyriform or alveolar, and (3) four LeFort I buttress stabilization. Comminuted palatal fractures were managed by standard LeFort I and alveolar buttress fixation, palatal splinting, and intermaxillary, fixation. If complete rigid fixation was employed in the palate in type II, III, and IV fractures, a palatal splint was avoided in 60 percent of these cases. Rigid internal fixation is therefore concluded to facilitate the treatment of certain types of palatal fractures by reduced length of intermaxillary fixation and avoidance of palatal splinting.

Le Fort fractures without mobility

The Le Fort fracture without maxillary mobility constitutes 9 percent of maxillary fractures observed over a 3-year period. A high Le Fort (level II or III) injury exists as a one- or two-piece incomplete fracture. The degree of fracture is insufficient to permit mobility of the maxillary alveolus. Frequently, an obvious unilateral zygomatic fracture is present. Physical findings consist of bilateral eyelid ecchymosis and malocclusion. The occlusal disturbance may consist of either crossbite, open bite, maxillary rotation, or lack of proper dental intercuspation. On CT scan, fractures are best demonstrated in the posterior and medial maxillary walls at the Le Fort I level; they are most obvious unilaterally with contralateral fractures that may be subtle. Bilateral maxillary sinus fluid is consistently present on CT. Treatment usually consists of observation and traction elastics but may require mobilization of the fragments followed by open reduction and rigid fixation.

Inferior alveolar nerve grafting: an approach without intermaxillary fixation

Although most commonly seen with dental extractions, inferior alveolar nerve injury is occasionally seen with orthognathic surgery and facial trauma. Nerve grafting can be performed by lateral corticotomy without the use of maxillomandibular fixation. A case is reported with this technique and recovery of sensibility documented with quantitative sensory testing.

Modified Transconjunctival Approach to the Lower Eyelid: Technical Details for Predictable Results

The transconjunctival approach to the lower orbit is well described in the literature and has been used for both cosmetic and reconstructive purposes. When properly performed, it allows access to the orbital floor and inferior orbital rim with minimal lower lid morbidity and an inconspicuous scar. Many variations of this approach have been described and these can lead to confusion and uncertainty regarding the surgical technique including when and how to best utilize this approach in the traumatized eyelid. Residents and less experienced attendings employing this approach often fail to fully understand the technical and anatomic details that can make this a very fast and simple way to gain complete access to the inferior, medial, and lateral orbit while minimizing complications such as postoperative lid malposition and canthal deformities. We describe our method for transconjunctival access to the inferior orbital rim and orbital floor with specific attention to several precise surgical aspects that make this a fast and reliable technique with low morbidity and predictable architecture of closure.

Negative pressure wound therapy in the setting of acute abdominal evisceration secondary to major thoracoabdominal burns

Negative pressure wound therapy has allowed for improved management of critical ill patients who requiring abdominal exploration by minimizing operation length, expediting resuscitation, and avoiding unnecessary resections. The use of this vital resource is often limited in burn patients with involvement of the thoracoabdominal wall due to difficulty with maintaining a seal necessary for the negative pressure. This report highlights the case of a 57-year-old patient who sustained significant thoracoabdominal burns and suffered an acute evisceration of small bowel following a debridement. The patient required an emergent return to the operating room and temporary abdominal closure in order to allow for a second look laparotomy. We detail the use of ostomy/barrier rings in order to establish a seal necessary for the negative pressure wound therapy. This novel technique has the potential to expand the use of temporary abdominal closure using negative pressure wound therapy in clinically injured burn patients.

Correction to: IAMSE Meeting Report: Student Plenary at the 24th Annual Conference of the International Association of Medical Science Educators

[This corrects the article DOI: 10.1007/s40670-020-01087-9.].