Spiral computed tomography in the diagnosis of gunshot wounds of the abdomen and pelvis

Spiral computed tomography (SCT) in combination with SCT angiography with the rapidity and low-invasiveness of the study yields necessary information and minimizes the number of diagnostic measures in severely wounded patients, by substantially reducing the preoperative period of their examination. The assessment of findings, the processing of data, and the construction of additional repairs do not require the presence of the patient and may be made in later periods. If required, repeated studies make it possible to evaluate the time course of postoperative changes, to identify complications of wound disease at the right time, and to optimize surgical treatment policy. Thus, SCT for fighting gunshot abdominal injury may significantly amplify and, in many cases, substantiate for the existing radiation diagnostic techniques.     

核因子-κB 在腹部火器伤肠管穿透后肺组织细胞凋亡中的作用*

目的:探讨腹部火器伤肠管穿透后核因子-κB在肺组织细胞凋亡中的作用,了解腹部火器伤肠管穿透后继发性肺损伤机制。方法:健康长白仔猪42头随机等分为对照组和伤后1h、2h、4h、8h、12h和24h组,实验组建立腹部火器伤肠管穿透模型后,用免疫组化图像分析法测定各组肺组织内NF-κB活性,同时用TUNEL测定肺组织细胞凋亡变化情况。结果:伤后各组肺组织内NF-κB活性明显高于对照组,并于伤后8h出现高峰。肺组织细胞凋亡指数伤后显著增高(P<0.05),并与NF-κB活性变化基本一致。结论:腹部火器伤肠管穿透后肺组织内NF-κB活性增强,肺细胞凋亡增多,从而继发导致肺损伤。     

NF-κB在腹部肠管火器伤后肝组织中的表达及意义

目的:探讨NF-κB在腹部火器伤肠管穿透后肝组织中的变化及意义。方法:42头健康长白仔猪随机等分为对照组和伤后1h、2h、4h、8h、12h和24h组,实验组建立腹部肠管火器伤模型后,用免疫组化图像分析法测定各组肝内NF-κB的表达,同时测定血清中ALT、AST水平,光镜下观察各组肝脏组织学变化。结果:实验组肝内NF-κB活性明显高于对照组,并于伤后1h和8h出现2个高峰(P<0.05)。实验组出现逐渐加重的肝细胞水肿、变性、坏死,血清ALT、AST水平在伤后明显升高,并于伤后2h和12h出现2个高峰(P<0.05)。结论:NF-κB的活化在腹部火器伤肠管穿透后继发性肝损伤中扮演着重要角色。     

核因子-KB在腹部火器伤肠管穿透后肺组织细胞凋亡中的作用

目的：探讨腹部火器伤肠管穿透后核因子-κB在肺组织细胞凋亡中的作用,了解腹部火器伤肠管穿透后继发性肺损伤机制。方法：健康长白仔猪42头随机等分为对照组和伤后1h、2h、4h、8h、12h和24h组,实验组建立腹部火器伤肠管穿透模型后,用免疫组化图像分析法测定各组肺组织内NF-κB活性,同时用TUNEL测定肺组织细胞凋亡变化情况。结果：伤后各组肺组织内NF-κB活性明显高于对照组,并于伤后8h出现高峰。肺组织细胞凋亡指数伤后显著增高（P〈0.05）,并与NF-κB活性变化基本一致。结论：腹部火器伤肠管穿透后肺组织内NF-κB活性增强,肺细胞凋亡增多,从而继发导致肺损伤     

高寒环境实验兔骨骼肌火器伤组织病理学观察

目的:探讨高寒低温干燥自然条件下,火器伤病理组织学变化特点,为临床救治及预防冻-火器复合伤提供依据。方法:对一组实验兔,在-18℃～-22℃低温干燥自然条件下,用5.62 mm小口径手枪,距0.5cm射击双后肢,制做冻-火器复合伤模型;观察骨骼肌火器伤病理组织学改变及超微结构特征。结果:高寒低温干燥自然条件下冻-火器复合伤的病理改变,挫伤区组织以坏死为主,震动区以变性为主。提示高寒低温环境肌组织火器伤病理改变是火器与高寒低温共同引起损伤,高寒条件加剧损伤程度;而在创伤肌组织震荡区中,仍保存较多的肌性修复功能,呈现以肌巨细胞增生性为主的修复过程。结论:高寒干燥自然条件下早期脱离高寒环境,可以较好地减轻或预防冻-火器复合伤的程度。     

猪腹部火器伤肠管穿透伤后继发性肺脏损伤的变化

目的:探讨腹部火器伤肠管穿透后继发性肺脏损伤及内毒素的变化规律。方法:健康长白仔猪42头随机分为对照组以及伤后1h、2h、4h、8h、12h和24h组.实验组建立腹部火器伤肠管穿透模型后,分别用显色基质鲎试剂法检测伤后1h、2h、4h、8h、12h和24h组各组动物血清中内毒素水平,并与对照组比较,观察实验组各时间点肺脏组织病理学及超微结构的变化。结果:伤后各组血浆内毒素水平用明显高于对照组(P<0.01)。伤后4h、8h、12h、24h组光镜下出现逐渐加重的肺组织内炎性细胞浸润,肺泡壁增厚,肺泡间质血管扩张充血;电镜下创伤组出现逐渐加重的线粒体肿胀、溶解;对照组光、电镜下未见明显的损伤性变化。结论:腹部火器伤肠管穿透后内毒素血症可能在继发性肺损伤中起重要作用,肺部损伤随着伤后时间的延长而逐渐加重。     

Craniocerebral gunshot wound in a baby chimpanzee – an uncommon experience of neurosurgical treatment conducted in the Guinean forest

An orphan female chimpanzee was wounded by a left craniocerebral gunshot complicated with a right hemiparesis. Local treatment and long‐term antibiotherapy failed to lead to healing. A neurosurgical procedure was planned and achieved. She fully recovered, and 2 years after the procedure, there is no evidence of infection.     

Fracture management of civilian gunshot wounds to the hand

Civilian gunshot wounds to the hand are typically caused by low-velocity weapons, which create a localized pattern of soft-tissue and bone injury that usually allows for early definitive treatment. A retrospective chart review of 72 patients treated for 98 gunshot wound fractures at an urban level I trauma center was conducted to evaluate the results of limited debridement and early definitive fracture fixation of urban gunshot wound fractures of the hand. The incidence of hand fractures, means of fracture fixation, number of operations, occurrence of infection, and level of patient compliance were determined. Twenty-nine fractures were managed definitively with reduction and splinting in the emergency department or intensive care unit. Sixty-eight fractures were treated surgically, at a mean of 2 days after injury. Eleven patients required more than one operation. The overall infection rate was 8 percent and was not influenced by the fracture fixation method. All infections were superficial and resolved with antibiotics alone. Thirty-nine percent of patients were lost to follow-up after hospital discharge and 85 percent of patients were lost to follow-up before documented fracture healing. Twenty-six percent of patients were lost to follow-up with a removable fixation device in place. Limited debridement and early definitive fracture fixation are associated with low rates of complications for typical civilian handgun wound fractures. Cases with extensive injury or contamination do require a staged approach to treatment. Poor patient compliance in the urban trauma setting should be expected and may affect the management plan.     

口腔颌面部爆炸伤的研究现状

口腔颌面部爆炸伤是指由致伤物爆炸所造成的口腔颌面部组织损伤,两种主要致伤因素是冲击波和高速破片,较一般火器伤而言,爆炸伤的致伤机制及致伤特点都有不同之处。对爆炸伤害的物理机制和病理生理反应方面研究有助于改进防护及改善治疗策略。本文在简述口腔颌面部爆炸伤的致伤因素和损伤特点的基础上,着重综述了动物模型和有限元模型的研究方法及结果,旨在为以后的模型研究提供思路和参考。     

War injuries of colon and rectum--results after 10 years

The aim of our study is to evaluate results of treating war injuries of colon and rectum, after 10 years. During the war in Croatia, 21 wounded, with colon (19) and rectum (2) injuries, were treated in the Department of Surgery at Nova Gradiska General Hospital from August 1991 to April 1992. Bullet wounds accounted for 57% of the injuries. All patients had other associated injuries. Primary repair and proximal derivation was possible in 2 cases (9.5%), while primary resection with intraperitoneal anastomosis was performed in 3 (14.3%) patients. In 2 (9.5%) patients sustained intraperitoneal and extraperitoneal rectal penetrating injury rectum was resected and closed performing temporary sigmoidostomy. When multiple perforations or crush injury of the colon were found, in 8 (38.1%) injured persons resection of the involved segment was combined with proximal end colostomy and aboral mucous fistula. Exteriorization of injured segment of the colon and creating colostomy incorporating the injured colon as the stoma was performed in 6 (28.5%) wounded patients. Four of the wounded (19.0%) died two of them during the operative procedure due to hemorrhagic shock. One injured died after eight days due to pulmonary embolism, and one patient died after thirty days due to sepsis. Reoperation was necessary in two (9.5%) injured due to bowel obstruction four days following initial surgery because of adhesions. Three (14.3%) of the injured had wound infection, one of them died 30 days after injury due to sepsis, and two (9.5%) consequently developed ventral hernia that was operated after 4 and 5 years respectively. Four (19.0%) of the injured are still occasionally experiencing occasional abdominal pain.     

Microcirculatory changes in the tissues surrounding a gunshot wound

An examination was carried out of microcirculation disorders as the main link of the pathogenetic process in the tissues surrounding a gunshot wound. Microcirculatory disorders were assessed in rabbits (924) with the help of radionuclide method (tissue radiometry and scannography) and the method of vital contact microscopy in gunshot wounds of posterior extremity soft tissues. After the injury the formation of four zones of tissue damage was revealed, with different character of microcirculatory changes in wound process dynamics. The obtained data may serve as the basis for working out zonal disorder classification and local treatment of gunshot wounds.     

Immediate and long-term management of gunshot wounds to the lower face

The steadily increasing level of urban violence and attempted suicides in the recent past has resulted in large numbers of gunshot injuries to the face from small-caliber weapons. Our experience with 35 consecutive cases of civilian gunshot wounds involving primarily the lower face is presented. Initial management included securing of the airway, control of bleeding, and treatment of coexisting injuries. After clinical and radiologic evaluation and conservative debridement of all devitalized tissues, the mandibular fractures were reduced and stabilized appropriately. Large bony defects were treated by stabilization of the mandibular segments followed by secondary bone grafting. Intraoral soft tissues were then repaired with local mucosal flaps or tongue flaps when necessary. Finally, the soft tissues were repaired by primary closure or local flaps. Distant flaps were used only as a secondary procedure. Our results are presented, the differences between civilian and military injuries are discussed, and the principles of gunshot ballistics are described. We conclude that most of these wounds can be treated in a relatively conservative manner immediately after the injury with good functional and cosmetic results.     

汶川地震伤员627例伤情分析及现场和后续救治回顾思考

目的：探讨地震现场和后续救护更加合理的组织方法,为未来重大灾害救助提供更好的方法。方法：回顾分析＂汶川地震＂入住院绵阳404医院627例伤员的伤情,总结分析救治重点及关键问题,探讨地震救护组织、后续救治重点及有效组织形式。结果：收治的627例伤员中四肢伤36.2%（227/627）,头面伤21.1%（132/627）,多发伤10.7%（67/627）,胸部伤7.7%（48/627）,挤压伤6.7%（42/627）,椎骨骨折5.6%（35/627）,骨盆骨折4.1%（26/627）。快速分拣和高效ICU病房救治对于提高后续救治成功率十分关键。结论：现场挖掘救援队联合适宜装备的医疗救援队才是最有效的现场救援;强有力的ICU病房救治可降低死亡率;血液透析和呼吸机十分关键。具有地域特点的灾害救助预案构建十分必要。     

沙漠干热环境下猪腹部肠管火器伤后肝脏功能和形态的变化

目的:观察沙漠干热环境下猪腹部火器伤肠管穿透后肝脏功能和形态的变化。方法:沙漠干热环境组和常温环境组各健康长白仔猪42头随机等分为对照组和伤后1h、2h、4h、8h、12h和24h组,实验组建立腹部火器伤肠管穿透模型后,分别测定各组动物血清中AST水平,并与对照组比较。在光镜下观察各组肝脏组织学变化,电镜下观察肝脏超微结构改变。结果:伤后各组血清AST水平均高于对照组,并于伤后2h出现第1个高峰,沙漠干热环境组和常温环境组分别于伤后8h和12h出现第2个高峰。沙漠干热组和常温组分别于伤后4h和8h开始出现肝细胞的坏死和超微结构的明显变化。结论:沙漠干热环境下腹部肠管火器伤后肝脏结构和功能损伤的发生均较常温组提前,提示在沙漠干热环境下腹部火器伤更要及早对肝损伤采取相应的保护措施。     

Potentialities of spiral computed tomography in the diagnosis and treatment of traumatic injuries of the midface

The paper summarizes the results of examination of 169 patients referred to the surgeon in the period from 1 till 47 days after medial facial (MF) trauma by using spiral computed tomography (SCT) and the method of laser stereolitography (LSLG). The actual aspects of diagnosis and treatment are marked; the methods for the analysis of injuries of soft tissue structures and adjacent areas while orbit trauma are developed together with the methods for determination of degree of enophthalmos. Also discussed are the possibilities of SCT and LSLG in visualization of MF injuries and planning patient treatment.     

Staged reconstruction after gunshot wounds to the abdomen.

Immediate closure of abdominal incisions after exploration and treatment of gunshot wounds is not always feasible or advisable. Significant bowel edema after massive fluid resuscitation might preclude primary closure, whereas any attempt to close under tension might result in complications ranging from wound dehiscence, infection, and necrosis to the abdominal compartment syndrome with abdominal, cardiopulmonary, and renal complications. For these difficult cases, the open technique has been recommended. The abdomen is left open and is closed when the patient's condition permits. When immediate wound approximation is not possible, temporary coverage can be achieved with a mesh, patch, or a split-thickness skin graft and the definitive reconstruction is deferred for a more optimal time. The purpose of this retrospective study is to report the authors' experience with staged abdominal wall reconstruction after gunshot wounds. From 1989 to 1998, 1933 patients underwent exploratory laparotomy for penetrating wounds to the abdomen. Twenty-nine patients in grave condition and with multiple medical problems were comanaged by the Trauma and Plastic Surgery Services at Cook County Hospital with the following protocol: The abdomen was initially left open and exposed viscera were covered with a variety of methods, including a Gore-Tex patch (W. L. Gore and Associates, Inc., Flagstaff, Ariz.). A split-thickness graft was subsequently placed on the granulation tissue over viscera at an average of 14 days after the last laparotomy. These planned ventral hernias were definitively treated at an average of 7 months after the skin grafting procedure, primarily using the components separation technique. In 24 patients, the fascia was closed primarily without tension, while five patients required the use of synthetic mesh to restore fascial continuity. Nine patients underwent closure of a colostomy or repair of fistulas simultaneously with abdominal wall reconstruction. One patient developed a postoperative hernia, two developed superficial wound dehiscence that healed without further surgery, and one required re-exploration for a failed anastomosis after colostomy closure. All but one patient maintained a stable abdominal wall after the reconstruction. The authors concluded that staged abdominal wall reconstruction should be primarily recommended for patients with complex abdominal wounds and a compromised general condition that precludes primary closure. With this treatment protocol, patients can recover faster from their trauma surgery and the risk of perioperative complications can be reduced. After final reconstruction, the continuity, stability, and strength of the abdominal wall are maintained in the vast majority of cases with the use of autogenous tissue and without the need for alloplastic material. With close cooperation between the trauma team and the plastic surgeon and appropriate timing and planning of each stage, the success rate of the technique is high and the incidence of complications limited.     

Signal transduction in the wound response of tomato plants.

The wound response of tomato plants has been extensively studied, and provides a useful model to understand signal transduction events leading from injury to marker gene expression. The principal markers that have been used in these studies are genes encoding proteinase inhibitor (pin) proteins. Activation of pin genes occurs in the wounded leaf and in distant unwounded leaves of the plant. This paper reviews current understanding of signalling pathways in the wounded leaf, and in the systemically responding unwounded leaves. First, the nature of known elicitors and their potential roles in planta are discussed, in particular, oligogalacturonides, jasmonates and the peptide signal, systemin. Inhibitors of wound-induced proteinase inhibitor (pin) expression are also reviewed, with particular reference to phenolics, sulphydryl reagents and fusicoccin. In each section, results obtained from the bioassay are considered within the wider context of data from mutants and from transgenic plants with altered levels of putative signalling components. Following this introduction, current models for pin gene regulation are described and discussed, together with a summary for the involvement of phosphorylation-dephosphorylation in wound signalling. Finally, a new model for wound-induced pin gene expression is presented, arising from recent data from the author''s laboratory.     

Effect of pollinator-inflicted ovule damage on floral abscission in the yucca-yucca moth mutualism: the role of mechanical and chemical factors

The long-term persistence of obligate mutualisms (over 40 Mya in both fig/fig wasps and yucca/yucca moths) raises the question of how one species limits exploitation by the other species, even though there is selection pressure on individuals to maximize fitness. In the case of yuccas, moths serve as the plant's only pollinator, but eggs laid by the moths before pollination hatch into larvae that consume seeds. Previous studies have shown that flowers with high egg loads are more likely to abscise. This suggests that yucca flowers can select against moths that lay many eggs per flower through selective abscission of flowers; however, it is not known how yucca moths trigger floral abscission. We tested how the moth Tegeticula yuccasella triggers floral abscission during oviposition in Yucca filamentosa by examining the effects of ovipositor insertion and egg laying on ovule viability and floral abscission. Eggs are not laid at the site of ovipositor insertion: we used this separation to test whether wounded ovules were more closely associated with the ovipositor site or an egg's location. Using a tetrazolium stain to detect injured ovules, we determined whether the number of ovipositions affected the number of wounded ovules in naturally pollinated flowers. Two wounding experiments were used to test the effect of mechanical damage on the probability of floral abscission. The types of wounds in these experiments mimicked two types of oviposition-superficial oviposition in the ovary wall and oviposition into the locular cavity-that have been observed in species of Tegeticula. The effect of moth eggs on ovule viability was experimentally tested by culturing ovules in vitro, placing moth eggs on the ovules, and measuring changes in ovule viability with a tetrazolium stain. We found that ovules were physically wounded during natural oviposition. Ovules showed a visible wounding response in moth-pollinated flowers collected 7-12 h after oviposition. Exact location of wounded ovules relative to eggs and oviposition scars, as well as results from the artificial wounding experiments, showed that the moth ovipositor inflicts mechanical damage on the ovules. Significantly higher abscission rates were observed in artificially wounded flowers in which only 4-8% of the ovules were injured. Eggs did not affect ovule viability as measured by the tetrazolium stain. These results suggest that physical damage to ovules caused by ovipositing is sufficient to explain selective fruit abscission. Whether injury as a mechanism of selective abscission in yuccas is novel or a preadaptation will require further study.     

Angiographic yield in penetrating extremity trauma.

Indications for angiography in the evaluation of penetrating extremity trauma remain controversial. Our experience was reviewed to determine the yield of angiography in penetrating extremity trauma and to correlate clinical findings with angiographic results. During an 81-month period from 1983 through 1989, 284 extremity arteriograms were carried out in 268 patients. The angiographic yield in patients with abnormal clinical findings was 51%. The angiographic yield in patients when proximity of the injury to major vessels was the only indication was 6% (7% with gunshot wounds and 0% with stab wounds). Neurologic deficit alone as an indication for angiography accounted for 55% of the angiograms interpreted as "negative" and none of those interpreted as "positive". We conclude that the use of angiography in patients with gunshot wounds to the extremity with "proximity injuries" to major vessels should continue, its use is not warranted in extremity stab wounds when proximity is the sole indication, and abnormal neurologic findings in the absence of other findings are a poor predictor of vascular injury.