Reverse posterior interosseous flap for defects of the dorsal ulnar wrist using previously burned and recently grafted skin.

Background: In the severely burned patient, coverage of exposed bone in the dorsal ulnar wrist can be a difficult problem. This is especially challenging in patients with a high percentage total body surface area (TBSA) where donor flaps can be scarce. The use of previously burned and/or recently grafted skin as flaps is an option.

Outcomes associated with small changes in normal-range cardiac markers.

Introduction: Troponin concentrations rising above an institutional cutpoint are used to define acute myocardial necrosis, yet it is uncertain what outcomes are associated with fluctuations in troponin that do not exceed this level. We evaluate the association between troponin fluctuations below an institutional upper limit of normal and acute coronary syndrome (ACS).

Materials And Methods: This was a post hoc analysis of the Internet tracking registry of ACS (i*trACS), which describes patients presenting to emergency departments (EDs) with suspected ACS across the spectrum of risk.

Prolonged prothrombin time after recombinant activated factor VII therapy in critically bleeding trauma patients is associated with adverse outcomes.

Background: In trauma patients with significant hemorrhage, it is hypothesized that failure to normalize prothrombin time (PT) after recombinant activated factor VII (rFVIIa) treatment predicts poor clinical outcomes and potentially indicates a need for additional therapeutic interventions.

Methods: To assess the value of PT to predict outcomes after rFVIIa or placebo therapy, we performed a post hoc analysis of data from 169 severely injured, critically bleeding trauma patients who had 1-hour postdose PT measurements from two randomized clinical trials. Baseline characteristics and outcome parameters were compared between subjects with 1-hour postdose PT >or=18 seconds and PT <18 seconds.

The Kelly technique of bladder exstrophy repair: continence, cosmesis and pelvic organ prolapse outcomes.

Purpose: The Kelly technique of radical soft tissue mobilization, an alternative to osteotomy and modern staged repair, has been used extensively at our tertiary referral center for bladder exstrophy in the last 2 decades. We present what is to our knowledge the first long-term followup of the Kelly technique in 31 patients treated at our institution.

Materials And Methods: Patients admitted for bladder exstrophy at our institution since 1980 were identified and the medical charts were reviewed.

Reimplantation of obstructive megaureters with and without tailoring.

Objectives: Reimplantation of megaureters may be complicated by excessive bulk of tissue when plicated, or stenosis at the anastomosis site when excisional tapering is performed. Some urologists in our institution reimplant megaureters without tailoring, while others routinely tailor megaureters. Aiming to compare success rates, we report our experience in reimplanting obstructive megaureters with and without tailoring.

Timing of immunoreactive B-type natriuretic peptide levels and treatment delay in acute decompensated heart failure: an ADHERE (Acute Decompensated Heart Failure National Registry) analysis.

Objectives: We undertook this analysis to determine whether there is a relationship between the time to measurement of immunoreactive B-type natriuretic peptide (iBNP) and early intervention for acutely decompensated heart failure (ADHF) and whether these variables are associated with morbidity and mortality in ADHF patients.

Background: Although natriuretic peptides (NPs) can aid emergency department (ED) physicians in the diagnosis of ADHF, the relationship between the time to measurement of NP levels and time to treatment is not clear. In addition, the impact of time to treatment on clinical outcomes has not been demonstrated.

Recombinant factor VIIa reduces rebleed hemorrhage volume in a swine aortotomy model: a randomized double-blinded study.

Noncompressible hemorrhage requires hypotensive resuscitation until definitive measures can be taken to prevent rebleeding by sustaining blood pressure at subphysiological levels. Previous studies have demonstrated that a 180- or 720-microg kg(-1) dose of recombinant factor VIIa (rFVIIa) increases the MAP at which rebleeding occurs in a swine aortotomy model. The purpose of the current study was to determine the efficacy of a lower dose of 90 microg kg(-1) given prophylactically to prevent or reduce rebleeding in a prospective, randomized, blinded study using a porcine model of uncontrolled hemorrhage and resuscitation.

Selective nonoperative management of penetrating torso injury from combat fragmentation wounds.

Background: Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy.

Methods: We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital.

Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001-2004.

Background: Effective combat trauma management strategies depend upon an understanding of the epidemiology of death on the battlefield.

Methods: A panel of military medical experts reviewed photographs and autopsy and treatment records for all Special Operations Forces (SOF) who died between October 2001 and November 2004 (n = 82). Fatal wounds were classified as nonsurvivable or potentially survivable.

Causes of death in US Special Operations Forces in the global war on terrorism: 2001-2004.

Introduction: Effective combat trauma management strategies depend on an understanding of the epidemiology of death on the battlefield, resulting in evidence-based equipment, training, and research requirements.

Methods: All Special Operations Forces (SOF) fatalities (combat and noncombat) in Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) from October 2001 until November 2004 were reviewed. All available autopsy and treatment records and photographs were used.

The clinical and laboratory response to recombinant factor VIIA in trauma and surgical patients with acquired coagulopathy.

Objective: In bleeding patients who are coagulopathic, the clinical response to administration of recombinant factor VIIa (rFVIIa) relates to the changes in prothrombin time (PT).

Design: Retrospective review of all surgical and trauma patients who were coagulopathic and received factor VIIa at the authors' institution over the past 27 months.

Setting: Academic tertiary referral facility and level I trauma center.

Morbidity from rib fractures increases after age 45.

Background: Recent studies have demonstrated increased morbidity in elderly patients with rib fractures after blunt trauma. As a first step in creating a multidisciplinary rib fracture clinical pathway, we sought to determine the relationship between increasing age, number of rib fractures, and adverse outcomes in blunt chest trauma patients, without major abdominal or brain injury.

Study Design: We performed a retrospective cohort study involving all blunt patients greater than 15 years old with rib fractures, excluding those with Abbreviated Injury Scores (AIS) greater than 2 for abdomen and head, admitted to an urban Level I trauma center during 20 months.

Renal allograft survival in patients with congenital obstruction of the posterior urethra.

In an attempt to clarify the influence of dysfunctional bladders on renal allograft outcome, graft survival was studied retrospectively in patients with congenital posterior urethral obstruction (posterior urethral valves). Using the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), 25 index patients were compared to all other transplant recipients of the same age range. Three instances of abnormal bladder function leading to graft function deterioration were found, therefore we would recommend investigation of bladder function in all boys with congenital urethral obstruction prior to renal transplant, and as part of the work-up of graft failure, where the cause is otherwise not obvious.

The negative influence of delayed renal allograft function on longer-term graft survival in a pediatric population.

The influence of delayed graft function on renal allograft survival has been studied in a review of 322 renal transplants performed at one pediatric institution. The appearance of the first radionuclide renal scan was used to indicate early function in patients receiving their first cadaveric allograft. Patients whose first radionuclide renal scan showed both good renal perfusion and good function (n = 52) were compared with those whose scans demonstrated good perfusion but no function (n = 32).

Internal ureteric stenting following pyeloplasty reduces length of hospital stay in children.

The advent of totally internal ureteric stents has the potential to reduce hospital stay in paediatric pyeloplasty. Traditionally, discharge from hospital has followed removal of an external trans-anastomotic drain, usually 5 days to a week post-operatively. The use of totally internal catheters negates the need for nursing supervision by removing external attachments that a paediatric patient might inadvertently dislodge.

The management of renal transplant artery stenosis in children by percutaneous transluminal angioplasty.

Between 1967 and 1989 in this unit 262 children (age at transplantation 9 months to 17 years, mean 9.6 years) had 345 renal transplants performed. Transplant artery stenosis (TAS) was found in 30 (8.

Continence in bladder exstrophy: determinants of success.

We evaluated 19 female and 18 male patients with bladder exstrophy, who had completed staged reconstruction, had required no further surgery and underwent urodynamic studies. Of the male population 61% were continent based on a significantly higher urethral continence length (25.8 +/- 6.

The appropriateness evaluation protocol: application in an Australian children's hospital.

Objective: The study was undertaken to evaluate the use of the Paediatric Evaluation Protocol (PAEP) in the Princess Margaret Hospital for Children, Western Australia. A random sample of 557 patient records was reviewed using the United States Paediatric Appropriateness Evaluation Protocol (AEP).

Results: Thirteen per cent of admissions and 10% of days of stay may have been medically inappropriate in the year of study.

Selective use of splenectomy after liver transplantation in children.

In a series of 106 pediatric liver transplantations, five patients were identified with recurrent rejection who could not tolerate the addition of azathioprine (Aza) to their immunosuppressive therapy because of leukopenia. Splenectomy was performed posttransplantation to allow the use of Aza. The number and severity of rejection episodes were compared before and after splenectomy in these patients.