Faculty Bibliography

HYPOTHESIS: Damage control laparotomy (DCL) has beneficial effects on the long-term morbidity and survival of trauma patients. DESIGN: Prospective study. SETTING: Level I trauma center. PATIENTS: Eighty-eight trauma patients who were admitted during a 3-year period (January 1, 2000, through December 31, 2003) underwent damage control laparotomy and were subsequently followed up (January 1, 2001, through December 31, 2008). INTERVENTION: Damage control laparotomy. MAIN OUTCOME MEASURES: Major and long-term complications, lengths of stay, mortality, readmissions, subsequent surgical procedures, activities of daily living, and return to work. RESULTS: On admission, the mean age and Injury Severity Score were 33 years and 34, respectively. Of the 88 patients, 66 (75%) were male; 46 patients had blunt injuries and 42 had penetrating injuries. Liver was the most common injury (63 patients), followed by bowel (34), spleen (33), major vessel (19), and pancreas (10). The mean admission pH and temperature were 7.19 and 34.4 degrees C, respectively, with 21.5 U of packed red blood cells transfused. The mean (SD) number of initial abdominal operations was 4.6 (2.5) per patient, with an overall mortality of 28% (25 patients). Intensive care unit and hospital lengths of stay were 18 (15) and 32 (20) days, respectively. Of the 63 patients who survived, 58 underwent intra-abdominal closure with polyglactin mesh. During the study, 44 intra-abdominal infections and 18 enterocutaneous fistulas were diagnosed. All 63 survivors were readmitted at least once. There were a total of 186 readmissions and 92 subsequent surgical procedures. Ventral hernia repair (66 readmissions) was the most common reason for readmission, followed by infection (41) and fistula management (29). There was 0% mortality for patients who survived the preliminary hospitalization. Of the 63 surviving patients, 51 (81%) reported that they had gone back to work and resumed normal daily activities. CONCLUSION: Although damage control laparotomy is associated with a significant complication and readmission rate, its overall benefit is indisputable.

BACKGROUND: This study is a thorough literature review of the clinical presentation and evaluation of developmental facial paralysis, with a systematic description of the various stigmata and associated anomalies. It is hoped that this approach will facilitate the differentiation of developmental facial paralysis from other causes of facial paralysis present at birth. METHODS: Forty-two cases of developmental facial paralysis were identified in a retrospective clinical review (1980 to 2010); 34 were children (80.95 percent; age, 8+/-6 years) and eight were adults (19.05 percent; age, 27+/-12 years). Thirty-one patients had simple developmental paralysis, and two patients had developmental unilateral lower lip palsy. There were nine patients with associated anomalies or craniofacial syndromes. Five of these patients had multiple cranial nerve deficits. RESULTS: Analysis of the various stigmata revealed significant correlation between the presence of developmental facial paralysis and amblyopia, hypoplastic facial nerve on imaging or surgical exploration, lower alar atresia, and skin changes (i.e., acne), but not the ear abnormalities. CONCLUSIONS: Early targeted screening and diagnosis, with prompt specialized treatment, improves the physical and emotional development of children with developmental facial paralysis and reduces the prevalence of amblyopia and other sequelae of the condition, thus facilitating reintegration among their peers. Given the dramatic presentation of this condition, accurate and reliable guidelines are necessary to facilitate early diagnosis, initiate appropriate therapy, and provide support and counseling to the family.

The purpose of this study is to clarify the confusing nomenclature and pathogenesis of Developmental Facial Paralysis, and how it can be differentiated from other causes of facial paralysis present at birth. Differentiating developmental from traumatic facial paralysis noted at birth is important for determining prognosis, but also for medicolegal reasons. Given the dramatic presentation of this condition, accurate and reliable guidelines are necessary in order to facilitate early diagnosis and initiate appropriate therapy, while providing support and counselling to the family. The 30 years experience of our center in the management of developmental facial paralysis is dependent upon a thorough understanding of facial nerve embryology, anatomy, nerve physiology, and an appreciation of well-recognized mishaps during fetal development. It is hoped that a better understanding of this condition will in the future lead to early targeted screening, accurate diagnosis and prompt treatment in this population of facially disfigured patients, which will facilitate their emotional and social rehabilitation, and their reintegration among their peers.

Restoration of shoulder stability in post-traumatic plexopathy patients is very important because more distal functions depend on a stable and functioning shoulder. The purpose of this study is to present our experience with secondary surgeries in patients with devastating paralysis. Functional outcomes were analyzed in relation to age, severity score and type of reconstruction. The medical records of 55 post-traumatic plexopathy patients who underwent secondary shoulder reconstruction, by a single surgeon, between 1978 and 2006, were reviewed. 55 patients had 73 procedures, 44 for shoulder abduction and 29 for external rotation. 38 patients underwent secondary surgery to augment shoulder abduction. Trapezius advancement was performed in 14 patients, double free muscle transfer in 18, free latissimus dorsi in 4 and triceps muscle transfer in 2 patients. 26 patients had secondary procedures for enhancement of shoulder external rotation. Dynamic rerouting of latissimus dorsi and teres major was carried out in 18 patients and rotational humerus osteotomy in 11 patients. All patients had improvement of shoulder stability and function. Shoulder abduction reached 40.80 +/- 15.93 and external rotation at 24.28 +/- 17.90 degrees . Trapezius advancement yielded 41.81 +/- 9.02 degrees of abduction. Latissimus dorsi yielded stronger shoulder abduction than adductor longus. Rerouting of latissimus dorsi and teres major attained 22.33 +/- 20.31 degrees of dynamic external rotation while humerus osteotomy produced 26.87 +/- 10.32 of external rotation. Secondary procedures such as pedicle and free muscles transfers, tendon transfers, and rotational humerus osteotomy augment shoulder stability and function in patients with irreparable paralysis.

The purpose of this pilot study was to investigate the response of hypoplastic temporomandibular joints (TMJs) to mandibular distraction osteogenesis. This preliminary study describes changes in 2 male patients with unilateral craniofacial microsomia who were 5 years of age at the time of surgery. Spin echo sequence images of the TMJs without contrast media in axial, coronal, and sagittal views, along with sagittal kinematics studies, were obtained with the use of magnetic resonance imaging (MRI) at: 1 month preoperatively (T1); immediately upon removal of distraction devices (T2), and 14 months postoperatively (T3). At the same time points spiral 3D computed tomography (CT) was used to image the TMJs. Both MRI and CT data obtained were assessed by standard, qualitative interpretation. Predistraction MRI and CT data documented a hemifacial microsomia type IIb deformity with hypoplasia of the condyle and a dysfunctional TMJ on the affected side. After distraction, the MRI and CT data in both patients demonstrated no changes in the nonaffected TMJs. However, on the affected and distracted side the following changes were observed: (1) formation of a rudimentary glenoid fossa and articular eminence; (2) functional displacements of the rudimentary condyle-disk complex; (3) well-defined visualization of the temporalis and lateral pterygoid muscles; (4) increased signal intensity radio-density of the pseudodisk fibrous tissue. Thus, both patients showed improvements in the morphology and function of the TMJ as well as in the associated skeletal and soft tissue components. It was concluded that following mandibular distraction in young children, improved form and function of the TMJ complex is demonstrable using MRI. [ABSTRACT FROM AUTHOR]

Although the fields of urban planning and public health share a common origin in the efforts of reformers to tame the ravages of early industrialization in the 19th century, the 2 disciplines parted ways in the early 20th century as planners increasingly focused on the built environment while public health professionals narrowed in on biomedical causes of disease and disability. Among the unfortunate results of this divergence was a tendency to discount the public health implications of planning decisions. Given increasingly complex urban environments and grave health disparities in cities worldwide, urban planners and public health professionals have once again become convinced of the need for inclusive approaches to improve population health and achieve health equity. To make substantive progress, intersectoral collaboration utilizing ecological and systems science perspectives will be crucial as the solutions lie well beyond the control of any single authority. Grounded in the social determinants of health, and with a renewed sense of interconnectedness, dedicated and talented people in government agencies and communities who recognize that our future depends on cultivating local change and evaluating the results can come to grips with the enormous challenge that lies ahead to create more equitable, sustainable, and healthier cities worldwide.

Background : Reports after the 2005 Hurricane Katrina have documented an increase in stress reactions and environmental teratogens (arsenic, mold, alcohol). Objective : To assess the incidence of cleft pathology before and after the hurricane, and the distribution of cleft cases by gender and race. Methods : Retrospective chart review of cleft lip with or without cleft palate (CL/P) and cleft palate (CP) cases registered with the Cleft and Craniofacial Team at Children's Hospital of New Orleans, the surgical center that treated cleft cases in Greater New Orleans between 2004 and 2007. Live birth data were obtained from the Louisiana State Center for Health Statistics. Results : The incidence of cleft cases, beginning 9 months after the hurricane (i.e., June 1, 2006) was significantly higher compared with the period before the hurricane (0.80 versus 1.42; p = .008). Within racial group comparisons showed a higher incidence among African Americans versus whites (0.42 versus 1.22; p = .01). The distribution of CL/P and CP cases by gender was significant (p = .05). Conclusion : The increase in the incidence of cleft cases after the hurricane may be attributable to increased stress and teratogenic factors associated with the hurricane. The increase among African Americans may have been due to comparatively higher exposure to environmental risk factors. These findings warrant further investigation to replicate the results elsewhere in the Gulf to determine whether there is a causal relationship between environmental risk factors and increased cleft pathology.