Reconstruction of composite leg defects post-war injury

Background: In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap. Methods: Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage. Results: There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing. Conclusion: A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions. © 2019, SICOT aisbl

The role of the dorsolateral funiculi in the pain relieving effect of spinal cord stimulation: a study in a rat model of neuropathic pain

Activation of the dorsal columns is relayed to supraspinal centers, involved in pain modulation, probably via the descending fibers in the dorsolateral funiculi (DLF). The present study examines the role of the DLF in the attenuation of pain-related signs by spinal cord stimulation (SCS). Several groups of rats were subjected to nerve injury and to chronic bilateral DLF lesions at C5–7 level. In each animal, two sets of miniature electrodes were implanted, a caudal system placed in the dorsal epidural space at low thoracic level and another implanted over the dorsal column nuclei, rostral to the lesions. Stimulation (50 Hz, 0.2 ms; 70 % of motor threshold) was applied for 5 min via either of the electrodes. Behavioral tests were used to assess the effects of SCS on the nerve injury-induced mechanical and cold hypersensitivity and heat hyperalgesia. Prior to application of SCS, antagonists to either of GABAA or B, 5-HT1 or 1–2 or α/β-adrenergic receptors were injected i.p. Both stimulations produced comparable decreases (80–90 % of the control) of neuropathic manifestations in rats with intact spinal cords. DLF lesions attenuated the effects of both types of stimulation by about 50 %. Pretreatment with receptor antagonists differentially counteracted the effects of rostral and caudal stimulation; the inhibition with rostral stimulation generally being more prominently influenced. These results provide further support to the notion of important involvement of brainstem pain modulating centers in the effects of SCS. A major component of the inhibitory spinal–supraspinal–spinal loop is mediated by fibers running in the DLF. © 2014, Springer-Verlag Berlin Heidelberg

Designing the digital organization

Abstract Increasingly, organizations are assessing their opportunities, developing and delivering products and services, and interacting with customers and other stakeholders digitally. Mobile computing, social media, and big data are the drivers of the future workplace, and these and other digitally based technologies are having large economic and social impacts, including increased competition and collaboration, the disruption of many industries, and pressure being put on organizations to develop new capabilities and transform their cultures. In this article, we provide a conceptual framework for the design of effective digital organizations. Our framework is predicated on the current state of digitization across diverse sectors of the global economy. In the digital world, all activities and transactions leave digital marks, and all actors, things, and places can be reached and affected digitally. As a result, we can design for self-organization rather than using hierarchical mechanisms for control and coordination. Such designs require the strategic and cultural alignment of digital technologies within the organization and externally with stakeholders. We propose that “actor-oriented” principles are at the heart of designing digital organizations and that, if properly applied, can result in a workplace where organization members are highly engaged and productive

Bystander modulation of chemokine receptor expression on peripheral blood T lymphocytes mediated by glatiramer therapy

Background: Glatiramer acetate therapy is thought to be effective for multiple sclerosis (MS) by promoting TH2 cytokine deviation, possibly in the brain, but the exact mechanism and site of action are incompletely understood. Determining the site of action and effect of glatiramer on cell trafficking is of major importance in designing rational combination therapy clinical trials. Objective: To determine whether glatiramer therapy will also act in the peripheral blood through bystander modulation of chemokine receptor (CKR) expression and cytokine production on T lymphocytes. Design: Before-and-after trial. Setting: A university MS specialty center. Patients: Ten patients with relapsing-remitting MS. Interventions: Treatment with glatiramer for 12 months and serial phlebotomy. Main Outcome Measures: Cytokine production, CKR expression, and cell migration. Results: The glatiramer-reactive T cells were TH2 cytokine biased, consistent with previous studies. We found a significant reduction in the expression of the TH1 inflammation associated with the CKRs CXCR3, CXCR6, and CCR5 on glatiramer- and myelin-reactive T cells generated from patients with MS receiving glatiramer therapy vs baseline. Conversely, expression of the lymph node-homing CKR, CCR7, was markedly enhanced on the glatiramer-reactive T cells derived from patients with MS undergoing glatiramer therapy. There was a reduction in the percentage of CD4+ glatiramer-reactive T cells and an increase in the number of CD8+ glatiramer-reactive T cells. Conclusions: Glatiramer may suppress autoreactive CD4+ effector memory T cells and enhance CD8+ regulatory responses, and bystander modulation of CKRs may occur in the periphery. ©2005 American Medical Association. All rights reserved.Link_to_subscribed_fulltex