Long-term outcome of alcohol withdrawal seizures

BACKGROUND AND PURPOSE

Alcohol withdrawal seizures (AWS) are a well-known complication of chronic alcohol abuse, but there is currently little knowledge of their long-term relapse rate and prognosis. The aims of this study were to identify risk factors for AWS recurrence and to study the overall outcome of patients after AWS.

METHODS

In this retrospective single-center study, we included patients who were admitted to the Emergency Department after an AWS between January 1, 2013 and August 10, 2021 and for whom an electroencephalogram (EEG) was requested. AWS relapses up until April 29, 2022 were researched. We compared history, treatment with benzodiazepines or antiseizure medications (ASMs), laboratory, EEG and computed tomography findings between patients with AWS relapse (r-AWS) and patients with no AWS relapse (nr-AWS).

RESULTS

A total of 199 patients were enrolled (mean age 53 ± 12 years; 78.9% men). AWS relapses occurred in 11% of patients, after a median time of 470.5 days. Brain computed tomography (n = 182) showed pathological findings in 35.7%. Risk factors for relapses were history of previous AWS (p = 0.013), skull fractures (p = 0.004) at the index AWS, and possibly epileptiform EEG abnormalities (p = 0.07). Benzodiazepines or other ASMs, taken before or after the index event, did not differ between the r-AWS and the nr-AWS group. The mortality rate was 2.9%/year of follow-up, which was 13 times higher compared to the general population. Risk factors for death were history of AWS (p < 0.001) and encephalopathic EEG (p = 0.043).

CONCLUSIONS

Delayed AWS relapses occur in 11% of patients and are associated with risk factors (previous AWS >24 h apart, skull fractures, and pathological EEG findings) that also increase the epilepsy risk, that is, predisposition for seizures, if not treated. Future prospective studies are mandatory to determine appropriate long-term diagnostic and therapeutic strategies, in order to reduce the risk of relapse and mortality associated with AWS.

Limited Efficacy of Empiric Antibiotics for Pediatric Facial Fractures

BACKGROUND

Controversies exist regarding the role of perioperative antibiotic use in pediatric craniomaxillofacial fracture repair.

PURPOSE

This study aims to identify factors associated with antibiotic prescribing patterns and measures the association between antibiotic exposure and postoperative infections.

STUDY DESIGN, SETTING, SAMPLE

In this retrospective cohort study, TriNetX, a research database, was used to gather data on patients under 18 years of age who underwent repair of facial fractures. The records were obtained from 2003 to 2021. Current Procedural Terminology codes for facial fracture procedures were used to identify patients.

PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE

Antibiotic use, defined as a binary categorical variable of whether or not patients received perioperative antibiotics. The secondary predictor variable was timing of antibiotic administration, categorized by pre, intra, and postoperative administration.

MAIN OUTCOME VARIABLES

Postoperative infection, determined by International Classification of Diseases, 9th and 10th Revision codes within patient charts.

COVARIATES

Covariates included demographic variables such as age, sex, race, ethnicity, geographic location, and fracture characteristics, such as number of fractures and location of fracture.

ANALYSES

χ2 analyses were used for categorical variables and two sample t tests for quantitative variables. Multivariable logistic regression was used to evaluate patient infection and antibiotic use with adjustment for covariates. P-values were 2-tailed and statistical significance was defined as P < .05.

RESULTS

This cohort included 5,413 patients of which 70.4% were male, 74.4% identified as white, and 83.3% identified as non-Hispanic or Latino. There were no differences in postoperative infections in patients who received antibiotics compared to those who did not (0.9 vs 0.5%, respectively, P = .12). Nevertheless, antibiotic prescriptions have increased over the years. After controlling for relevant covariates, antibiotic use did not decrease the odds of infection (adjusted odds ratio 1.1, 95% CI 0.53 to 2.34, P = .79). There was a significant association between the timing of antibiotic use and infection (P = .044), with increased odds of infection when antibiotics were given postoperatively (adjusted odds ratio 3.8, 95% CI 1.2 to 12.07, P = .023).

CONCLUSION AND RELEVANCE

While antibiotic prescriptions have increased over the years, this study demonstrates there is no difference in postoperative infection rates for pediatric patients prescribed antibiotics and those where were not.

Potential therapeutic use of relaxin in accelerating closure of cranial bone defects in mice

Bone fractures are associated with considerable morbidity and increased mortality. A major limitation to healing is lack of bone blood flow, which is impaired by physical disruption of intraskeletal and/or periosteal vasculature by the fracture. Thus, pharmacological interventions are needed to improve osseous blood flow, thereby accelerating bone fracture closure. Relaxin is secreted by the ovary and circulates in rodents and humans during pregnancy. Because relaxin might benefit bone fracture healing by stimulating angiogenesis, vasculogenesis (and potentially osteogenesis) through mobilization and activation of bone marrow progenitor cells, and by increasing blood flow via vasodilation, we investigated whether relaxin administration would accelerate closure of a calvarial defect in mice. Whether administered systemically by osmotic pump or locally by collagen scaffolds for ~2 week period after lesioning, relaxin did not accelerate bone healing. Despite implementing relaxin doses that reached plasma concentrations spanning the physiological to supraphysiological range, testing the closure of two different sizes of calvarial lesions, allowing for different intervals of time from instigation of cranial lesion to euthanasia, and investigating mice of different ages, we did not observe a significant benefit of relaxin in bone lesion healing. Nor did we observe stimulation of blood vessel formation in the bone lesion by the hormone. An incidental finding was that relaxin appeared to enhance trabecular bone growth in an uninjured control bone (femur). Although the results of this study were not supportive of a therapeutic benefit for relaxin on calvarial defect closure, future investigation is needed employing different animal species and experimental models of bone fracture.

Effects of combined menaquinone-4 and PTH1-34 treatment on osetogenesis and angiogenesis in calvarial defect in osteopenic rats

PURPOSE

The aim of this study was to evaluate the effect of combining human parathyroid hormone (1-34) (PTH_1-34; PTH) and menaquinone-4 (MK-4) on calvarial bone defect repair in osteopenic rats.

METHODS

Fourteen week olds were subject to craniotomy for the establishment of osteopenic animal models fed through a chronically low-protein diet. After that, critical calvarial defect model was established and all rats were randomly divided into four groups: sham, MK-4, PTH, and PTH + MK-4. The animals received MK-4 (30 mg/kg/day), PTH_1-34 (60 μg/kg, three times a week), or PTH_1-34 (60 μg/kg, three times a week) plus MK-4 (30 mg/kg/day) for 8 weeks, respectively. Serum γ-carboxylated osteocalcin (Gla-OC) levels, histological and immunofluorescent labeling were employed to evaluate the bone formation and mineralization in calvarial bone defect. In addition, Microfil perfusion, immunohistochemical, and micro-CT suggested enhanced angiogenesis and bone formation in calvarial bone healing.

RESULTS

In this study, treatment with either PTH_1-34 or MK-4 promoted bone formation and vascular formation in calvarial bone defects compared with the sham group. In addition, combined treatment of PTH_1-34 plus MK-4 increased serum level of Gla-OC, improved vascular number and vascular density, and enhanced bone formation in calvarial bone defect in osteopenic conditions as compared with monotherapy.

CONCLUSIONS

In summary, this study indicated that PTH_1-34 plus MK-4 combination therapy accelerated bone formation and angiogenesis in calvarial bone defects in presence of osteopenia.

Use of an anionic collagen matrix made from bovine intestinal serosa for in vivo repair of cranial defects

Polymeric biomaterials composed of extracellular matrix components possess osteoconductive capacity that is essential for bone healing. The presence of collagen and the ability to undergo physicochemical modifications render these materials a suitable alternative in bone regenerative therapies. The objective of this study was to evaluate the osteogenic capacity of collagen-based matrices (native and anionic after alkaline hydrolysis) made from bovine intestinal serosa (MBIS). Twenty-five animals underwent surgery to create a cranial defect to be filled with native and anionic collagen matrixes, mmineralized and non mineralized. The animals were killed painlessly 6 weeks after surgery and samples of the wound area were submitted to routine histology and morphometric analysis. In the surgical area there was new bone formation projecting from the margins to the center of the defect. More marked bone neoformation occurred in the anionic matrices groups in such a way that permitted union of the opposite margins of the bone defect. The newly formed bone matrix exhibited good optical density of type I collagen fibers. Immunoexpression of osteocalcin by osteocytes was observed in the newly formed bone. Morphometric analysis showed a greater bone volume in the groups receiving the anionic matrices compared to the native membranes. Mineralization of the biomaterial did not increase its osteoregenerative capacity. In conclusion, the anionic matrix exhibits osteoregenerative capacity and is suitable for bone reconstruction therapies.

Bone regeneration induced by an in situ gel-forming poloxamine, bone morphogenetic protein-2 system

The aim of this study was to confirm previously shown, in vitro osteogenic induction by the Tetronics T908 and T1307 in a critical-size, rat calvaria defect. In vivo, the osteogenic activity of the hydrogels was comparable to in vitro, but less pronounced. However, similar to in vitro, the system was strongly potentiated by incorporating 6.5 microg of bone morphogenetic protein-2 in solution or pre-encapsulated in poly(lactic-co-glycolic) acid microspheres. These two systems extended the in vivo release of bone morphogenetic protein-2, determined with 125I- bone morphogenetic protein-2, for one and two additional weeks, respectively, time enough to fill approximately 40% and 90% of the defect with well-organized bone. Furthermore, the structural characteristics of Tetronic hydrogels together with their biocompatibility, injectability, and adaptability to multiple defect sizes and shapes suggest their role as new, potential bone morphogenetic protein-2 delivery, low-cost scaffolds for minor as well as critical bone defects.

Injectable gel with synthetic collagen-binding peptide for enhanced osteogenesis in vitro and in vivo

A synthetic peptide denoted as collagen-binding motif (CBM) was identified from osteopontin (OPN), a multisubunit extracellular matrix (ECM) protein, by enzymatic digestion with chymotrypsin. The aim of this study was to examine the feasibility of identified CBM peptide as an active component of gel type scaffold material in osteogenesis. The binding of CBM peptide to collagen was specific and presented high affinity. Cell adhesion and growth on CBM peptide-immobilized gel were significantly increased as compared with those on gel with control peptide or without peptide. The CBM peptide-immobilized gel increased osteoblastic differentiation, followed by marked bone formation in the rabbit calvarial defect sites at 4 weeks. Taken together, the injectable gel with synthetic CBM peptide has a potential to induce osteogenesis in vitro and in vivo, suggesting its clinical application in bone regeneration procedure.

Skull Bone Regeneration in Nonhuman Primates by Controlled Release of Bone Morphogenetic Protein-2 from a Biodegradable Hydrogel

The objective of this study was to investigate the feasibility of biodegradable gelatin hydrogels as the controlled-release carrier of bone morphogenetic protein-2 (BMP-2) to enhance bone regeneration at a skull defect of nonhuman primates. Hydrogels with 3 different water contents were prepared through glutaraldehyde crosslinking of gelatin with an isoelectric point of 9.0 under varied reaction conditions. A critical-sized defect (6 mm in diameter) was prepared at the skull bone of skeletally mature cynomolgus monkeys, and gelatin hydrogels incorporating various doses of BMP-2 were applied to the defects. When the bone regeneration was evaluated by soft radiography and bone mineral density (BMD) examinations, the gelatin hydrogel incorporating BMP-2 exhibited significantly higher osteoinduction activity than did an insoluble bone matrix that incorporated BMP-2 (one of the best osteoinduction systems), although the activity depended on the water content of hydrogels. BMD enhancement was highest for the gelatin hydrogel that had a water content of 97.8 wt% among all types of hydrogels. Moreover, the gelatin hydrogel enabled BMP-2 to induce the bone regeneration in nonhuman primates even at low doses. We conclude that the controlled release of BMP-2 for a certain time period was essential to inducing the osteoinductive potential of BMP-2.

Bone regeneration using hyaluronic acid-based hydrogel with bone morphogenic protein-2 and human mesenchymal stem cells

Acrylated hyaluronic acid (HA) was used as a scaffold for bone morphogenic protein-2 (BMP-2) and human mesenchymal stem cells (hMSCs) for rat calvarial defect regeneration. HA was acrylated by two-step reactions: (1) introduction of an amine group using adipic acid dihydrazide (ADH); (2) acrylation by N-acryloxysuccinimide. Tetrathiolated poly(ethylene) glycol (PEG-SH(4)) was used as a cross-linker by a Michael-type addition reaction and the hydrogel was formed within 10min under physiological conditions. This hydrogel is degraded completely by 100U/ml hyaluronidase in vitro. hMSCs and/or BMP-2 was added during gelation. Cellular viability in vitro was increased up to 55% in the hydrogels with BMP-2 compared with the control. For in vivo calvarial defect regeneration, five different samples (i.e., control, hydrogel, hydrogel with BMP-2, hydrogel with MSCs, and hydrogel with BMP-2 and MSCs) were implanted for 4 weeks. The histological results demonstrated that the hydrogels with BMP-2 and MSCs had the highest expression of osteocalcin and mature bone formation with vascular markers, such as CD31 and vascular endothelial growth factors, compared with the other samples. This study demonstrated that HA base hydrogel can be used for cell and growth factor carriers for tissue regeneration.

[Traumatic lesion of the optic nerve head by flying fish: a case report]

BACKGROUND

Traumatic lesion to the optic nerve often leads to severe and persistent functional loss.

HISTORY AND SIGNS

A male patient was transferred to our hospital from the University Eye Clinic of Guadeloupe 5 days after ocular injury caused by a flying fish. Visual function was light perception. The anterior part of the eye and retina were unremarkable. A computer tomography disclosed a fracture of the sphenoid sinus, with a little bone fragment (DD: foreign body) located close to the optic nerve.

THERAPY AND OUTCOME

Therapy had been started with Aminopenicillin combined with clavulan acid (Augmentin) i. v., 500 ml methylprednisolone (Solumedrol) i. v., lysine-acetyl salicylate (Aspegic) and topical application of dexamethasone combined with neomycin/polymyxin B (Maxitrol). We continued this therapy and intensified it by adding nimodipine (Nimotop) 30 1-1-1 and acetazolamide retard (Diamox sustet) 1-0-1. Unfortunately visual function did not recover under therapy.

CONCLUSIONS

Traumatic lesions of the optic nerve head, especially when due to axial or tangential forces, can lead to severe and irreversible functional loss. Severe traumatic lesions, even bone fractures induced by flying fish are not a seldom encounter in the Caribbean Sea.

Les polysaccharides microbiens d’origine marine et leur potentiel en thérapeutique humaine

Bacterial polysaccharides offer fascinating potential applications for the pharmaceutical industry. Although many known marine bacteria produce exopolysaccharides (EPS), continuation in looking for new polysaccharide-producing micro-organisms is promising. Marine bacteria, isolated from deep-sea hydrothermal vents, have demonstrated their ability to produce in aerobic conditions, unusual EPS. With the aim of discovering biological activities, EPS presenting different structural features were studied. An EPS secreted by Vibrio diabolicus was evaluated on the restoration of bone integrity in experimental model and was demonstrated to be a strong bone-healing material. Another EPS produced by Alteromonas infernus was modified in order to obtain new heparin-like compounds. Unlike the native EPS, the resulting EPS presented anticoagulant properties as heparin. These EPS could provide biochemical entities with suitable functions for obtaining new drugs. They present original structural feature that can be modified to design compounds and improve their specificity.

Cervical epidural haematoma with clivus fracture: case report

Clivus fractures are rare and severe entities, usually associated with vascular or cranial nerve lesions and frequently diagnosed postmortem. Cervical epidural haematomas can be traumatic or spontaneous, manifested in acute or chronic form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits. The authors report the case of a female patient, 8 years old, victim of trampling in public way by a high velocity motorized vehicle, admitted in Glasgow 7, anisocoric pupils (left pupil midriatic), whose radiological investigation showed a transverse fracture of the clivus, cervical epidural haematoma and diffuse axonal injury. The patient was submitted to intracranial pressure monitorization, sedation and conservative treatment with dexamethasone, with good outcome. The authors also present a literature review.

Use of collagen sponge incorporating transforming growth factor-beta1 to promote bone repair in skull defects in rabbits

The objective of this study was to evaluate the potential of collagen sponge incorporating transforming growth factor-beta1 (TGF-beta1) to enhance bone repair. The collagen sponge was prepared by freeze-drying aqueous foamed collagen solution. Thermal cross-linking was performed in a vacuum at 140 degrees C for periods ranging from 1 to 48 h to prepare a number of fine collagen sponges. When collagen sponges incorporating 125I-labeled TGF-beta1 were placed in phosphate-buffered saline (PBS) solution at 37 degrees C, a small amount of TGF-beta1 was released for the first hour, but no further release was observed thereafter, irrespective of the amount of cross-linking time the sponges had received. Collagen sponges incorporating 125I-labeled TGF-beta1 or simply labeled with 125I were implanted into the skin on the backs of mice. The radioactivity of the 125I-labeled TGF-beta1 in the collagen sponges decreased with time; the amount of TGF-beta1 remaining dependent on the cross-linking time. The in vivo retention of TGF-beta1 was longer in those sponges that had been subjected to longer cross-linking times. The in vivo release profile of the TGF-beta1 was matched with the degradation profile of the sponges. Scanning electron microscopic observation revealed no difference in structure among sponges subjected to different cross-linking times. The TGF-beta1 immobilized in the sponges was probably released in vivo as a result of sponge biodegradation because TGF-beta1 release did not occur in in vitro conditions in which sponges did not degrade. We applied collagen sponges incorporating 0.1 microg of TGF-beta1 to skull defects in rabbits in stress-unloaded bone situations. Six weeks later, the skull defects were covered by newly formed bone, in marked contrast to the results obtained with a TGF-beta1 free empty collagen sponge and 0.1 microg of free TGF-beta1. We concluded that the collagen sponges were able to release biologically active TGF-beta1 and were a promising material for bone repair.

[Antibiotic prophylaxis in laterobasal fractures]

A retrospective study over 5 years evaluated the medical records of 78 patients who had suffered lateral skull base fractures. The purpose of the present study was to answer the question of whether antibiotic prophylaxis reduced the risk of meningitis. Fifty-five of 78 patients (71%) were given no antibiotics, among whom four developed meningitis. In 29% of patients treated with antibiotics, two developed meningitis. This difference was not significant. Even when cases with uncomplicated ("simple") lateral skull base fractures were separated from those with severe additional lesions related to their injuries, no significant correlation was found in the occurrence of meningitis despite the use of an antibiotic. Eight of 14 patients with initial otoliquorrheas were treated with antibiotics, with two of these 8 patients developing meningitis. None of the patients who did not receive antibiotics developed meningitis. Our findings shows that it is not advisable to treat patients who have suffered from lateral skull base fractures with prophylactic antibiotics. Instead, these patients should be examined frequently and appropriate antibiotic therapy prescribed at the first clinical symptoms of meningitis.

Insulin enhancement of in vitro wound healing in fetal rat parietal bones

PURPOSE

This study evaluated the effect of insulin on fracture in fetal rat intramembranous bone using an organ culture system in which bone mineralizes in vitro.

MATERIALS AND METHODS

Twenty-day-old fetal rat parietal bones were fractured parallel to the frontal plane and cultured in a serum-free medium with or without insulin for 4 to 12 days. They were then processed for light microscopy.

RESULTS

In the specimens not treated with insulin, bony bridges were observed in less than 10% on day 4 and 8, and only 45% on day 12. In bones treated with insulin at 10(-6) mol/L, bony bridges were observed in 73% on day 4 and 100% on day 8 and 12. No callus or cartilage formation was observed during the wound repair process, indicating that intramembranous ossification occurred.

CONCLUSION

These findings suggest that insulin has a direct effect on bone cells, which enhances the healing of fractures in intramembranous bone.

Heparan-like molecules induce the repair of skull defects

Heparin-binding growth factors (HBGFs) are known to stimulate bone repair when applied to bone lesions. Nevertheless, successful treatments are obtained with high protein doses since HBGFs are rapidly degraded in situ by multiple proteolytic activities associated with the inflammatory period of tissue healing. Like heparin or heparan sulfates, heparan-like molecules, named carboxymethyl-benzylamide-sulfonated dextrans (CMDBS), are known to potentiate fibroblast growth factor activities by stabilizing them against pH, thermal or proteolytic denaturations, and by enhancing their binding with cell surface receptors. We have postulated that CMDBS stimulate in vivo bone healing by interacting with endogenous HBGFs, spontaneously released in the wounded site. The effect of CMDBS on bone repair was studied in a skull defect model in rats by computer-assisted radio-morphometry and histomorphometry. Single application of CMDBS in a collagen vehicle to skull defects induced a dose-dependent increase in bone defect closure and new bone formation after 35 days. Complete bony bridging occurred in defects treated with 3 micrograms CMDBS, whereas bone formation was not observed in vehicle-treated defects which contained only dense fibrous connective tissue between the defect margins. These results indicate that heparan-like molecules, such as CMDBS, are able to induce bone regeneration of skull defects. This action is possibly mediated by potentiation of endogenous growth factor activities and/or by neutralization of proteolytic activities.

Right angular lesion and selective impairment of motion vision in left visual field

A 45-year-old right-handed man had, for more than 20 years, a depressed fracture of the right parietal bone and selective impairment of movement vision in the left visual field; an illusory overestimation of speed of moving objects and extreme sensitivity to moving stimuli. Visuo-spatial perceptions of immobile objects, and other visual functions were normal apart from slightly decreased stereoacuity. The extent of depressed fracture corresponded approximately to the right angular gyrus. Carbamazepine or phenytoin did not alter the symptoms. After the operation, his symptoms were restricted to peripheral parts of the left visual field, with transient overestimation of speed of moving objects in the right hemifield. It was suggested that the human angular gyri may be involved in the central mechanisms of movement perception, and shift of visual attention or gaze to moving stimuli in contralateral visual field, especially in its peripheral part.

Prophylactic antibiotics in traumatic wounds

There is well-documented evidence justifying, perhaps demanding, the obligatory use of early, anticipatory treatment in open fractures and in penetrating abdominal wounds, and equally convincing evidence that they are not indicated in fractures of the base of the skull with CSF leaks, in thermal injuries, or in simple lacerations. As far as penetrating chest wounds, and bites are concerned, the evidence is perhaps as yet inconclusive, but antibiotics are probably not indicated in these situations.

[Role of kinins in the pathogenesis of craniocerebral injury and the validation of corrective antiproteolytic therapy]

The role of the kinin system in the development of extra- and intracerebral complications in the acute period of severe craniocerebral trauma was studied from complex clinical and biochemical examination. The authors substantiate the expediency of applying corrective antiproteolytic therapy, in which case the predominant trend of its action--inhibition of kinin production in the vascular bed or on the tissue level--must be taken into account. The time, duration, and methods of Contrykal administration were developed.

Treatment of facial fractures in neurologically injured patients

The clinical records of 53 patients who had head injury and facial trauma were reviewed and analyzed to ascertain what affect head injury had on the repair of facial fractures. The study was designed to establish the incidence of complications and to discover what factors contributed to untoward sequela in such patients. It was found that the neurologically injured patient developed postoperative facial fracture complications, particularly in the mandible, more frequently than those facial trauma patients who were not neurologically compromised.

[Prevention of wound infection in open skull and brain injuries]

Measures aimed at the prevention of complications gain foremost importance when timely surgical treatment of a penetrating craniocerebral wound cannot be conducted. Experimental research and clinical experience have shown that the administration of 50 000--100 000 U of an antibiotic (kanamycin, monomycin, hectamycin, chloramphenicol) into the wound soon after an open penetrating injury had been inflicted to the skull and brain protects the wound from microbial contamination. This provides the possibility for postponing the plastic operation of the defect in the dura mater.

Analysis of the treatment of basilar skull fractures with and without antibiotics

The efficacy of chemoprophylaxis in the treatment of basilar skull fractures was studied in 129 patients over a 2-year period; antibiotics were found ineffective in preventing central nervous system infections, and in some cases may have proved harmful. It is suggested that a more rational approach to the treatment of basilar skull fractures includes close observation of the patient for early signs of meningitis, and if these should develop, treatment with antibiotics appropriate to the organism involved.