J Trauma
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The management of severe traumatic brain injury (sTBI) patients with and without intact cerebral pressure autoregulation (CPA) varies markedly. Recent studies, analyzing beat-to-beat interactions between intracranial pressure (ICP) and systolic blood pressure, or transcranial Doppler velocity changes during a rapid drop in cerebral perfusion pressure (CPP), suggest that CPA is disrupted after sTBI. We use computed tomography perfusion (CTP) to guide blood pressure manipulation in sTBI and have found CPA results that differ with this literature. We present these results here and suggest modifying our basic concepts of CPA disruption. ⋯ By using direct measurement of CBF in response to a CPP challenge, we found CPA disruption to be much less common than reported in similar groups of sTBI patients. This difference reflects potentially important separate aspects of CPA. We suggest that CPA measurement using beat-to-beat interactions and transcranial Doppler measurements reflect dynamic CPA processes (dynamic autoregulation), whereas our method reflects steady-state conditions (static autoregulation). If the major disruption of CPA after sTBI involves dynamic vascular responsiveness, perhaps we need more focus on this aspect and less on static-CPP manipulation in terms of pathophysiology and treatment.
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Hemorrhagic shock and resuscitation induce immunosuppression. CD4CD25 regulatory T cells and gammadeltaT cells may affect these immunosuppressive conditions. Hypertonic saline resuscitation reduces damage to organs and apoptosis and also restores immunosuppressive condition. We investigated how hypertonic saline resuscitation affected the induction of CD4CD25 regulatory T cells and gammadeltaT cells, and their apoptosis after hemorrhagic shock and resuscitation, and its relationship to inducible nitric oxide synthase (iNOS) (nitric oxide production). ⋯ gammadelta T cells increased earlier at 24 hours, whereas CD4CD25 regulatory T cells increased later at 48 hours in spleen of wild type. Hypertonic saline was effective without the presence of iNOS, i.e., decreased gammadelta T cells at 24 hours and increased apoptosis of CD4CD25 regulatory T cells at 48 hours. CD4CD25 regulatory T cells at 48 hours without iNOS decreased compared with those of wild type. gammadelta T cells at 48 hours induced apoptosis under the condition without iNOS in spleen and thymus. iNOS worked as an accelerating factor for immunosuppressive condition, affected apoptosis, and immunoenhancing effect by hypertonic saline.
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Neglected or chronic rupture of the Achilles tendon usually needs a reconstruction procedure. Many graft sources have been reported for this procedure, such as a proximal V-Y gastrocnemius tendon flap, flexor hallucis longus tendon, fascia lata, plantaris tendon, synthetic materials, and peroneus brevis. However, how to fix the graft at the calcaneal site remains controversial. ⋯ Our technique reuses two small central incisions, thus, preserving skin integrity as much as possible to reduce wound breakdown or infection. The management of chronic or neglected Achilles tendon rupture by autogenous peroneal longus tendon with EndoButton-CL fixation at the calcaneal site is an anatomic and safe, but technically demanding technique.
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Comparative Study
Immunologic function in the elderly after injury--the neutrophil and innate immunity.
Aging is associated with a decline in immune function. This may contribute to decreased ability of an elderly patient to mount an appropriate innate inflammatory response when injured. This study examined elderly trauma patients to determine whether there was a difference in neutrophil response to injury when compared with controls. ⋯ Injury results in differences in innate immune function in the elderly when compared with controls. The clinical significance of this is uncertain and warrants further investigation.