Injuries to the equine distal limb are common and often involve synovial, tendinous and/or ligamentous structures. Historically, lacerations involving the equine digital flexor tendons carried a poor prognosis for return to athletic function due to contamination of the site at presentation, involvement of multiple anatomic structures and the need for immediate weight bearing after surgery. The need for weight bearing after surgery places strain on the tenorrhaphy site that exceeds the strength of the repair itself. Extrapolation of complex, stronger tenorrhaphy patterns from human literature and applying them to equine patients has been challenging. Human tenorrhaphy techniques initially focused on strong repairs, which are able to match or exceed the strength of tendon itself. Adhesion formation is problematic in human flexor tenorrhaphies, as most injuries occur to tendons surrounded by synovial structures. Human literature now focuses on using repairs that provide initial strength, minimal damage to intrinsic tendon architecture, and allow for early mobilization. This treatment protocol has greatly improved the functional outcome of human tenorrhaphies. Recent studies have evaluated the strength of complex tenorrhaphy patterns in equine superficial digital flexor tendons, using modifications of the Savage technique. The newly evaluated patterns are stronger than previously tested and commonly used techniques, such as the three-loop pulley (3LP). A review of tendon vasculature across species and healing characteristics of tendons highlights the importance of intrinsic tendon vasculature in the healing process. Using tenorrhaphy techniques that preserve this vasculature may improve the clinical outcome in these cases. Only one study has previously evaluated the effect of tenorrhaphy patterns on intrinsic tendon vasculature in equine superficial digital flexor tendon. This study compared perfusion of intrinsic tendon vasculature of equine superficial digital flexor tendon (SDFT) after 3LP and six-strand Savage (SSS) tenorrhaphies. We hypothesized that the SSS technique would significantly decrease vascular perfusion compared to the 3LP technique. Under general anesthesia, eight pairs of forelimb SDFTs were transected and either SSS or 3LP tenorrhaphy was performed on each forelimb. The horses were heparinized, euthanatized, and forelimbs perfused with barium sulfate solution then fixed with formalin under tension. The tendons were transected every 5mm and microangiographic images were obtained using a Faxitron X-ray cabinet with computed radiography imaging. Microvascular analysis of sections proximal to the tenorrhaphy, throughout the tenorrhaphy and distal to the tenorrhaphy was completed using Image J software and a custom macro. A significant reduction in the number of perfused vessels was seen in the SSS compared to the 3LP at two locations within the tenorrhaphy (p=0.004 and 0.039). The SSS technique took on average 4.7 ± 0.9 times longer to place. The SSS technique causes a reduction in tendon perfusion compared to the 3LP, which may limit its clinical use. Further research is required to elucidate the clinical significance of this difference. / Master of Science

Flexor tendon lacerations in horses are traumatic injuries that can be career ending and life threatening. In the horse, a tendon repair must withstand the strains placed on the tenorrhaphy by immediate weight bearing and locomotion post-operatively. Despite the use of external coaptation, such strains can lead to significant gap formation, construct failure, longer healing time and poor quality of the healed tendon. Similar to equine surgery, gap formation and construct failure are common concerns in human medicine, with early return to post-operative physiotherapy challenging the primary repair. Early return to exercise and decreased gap formation has been shown to reduce adhesion formation. Based on these concerns, the ideal tenorrhaphy suture pattern for equines would provide: 1) high ultimate failure load, 2) resistance to gap formation, 3) minimal alteration in blood supply, and 4) minimal adhesion formation. Historically, various suture patterns and materials have been evaluated for human and equine flexor tendon repair. Results of equine studies suggest the three-loop pulley pattern (3LP) compares favorably to other patterns and is recommended for primary tenorrhaphy. However, this pattern still experiences significant gap formation and can result in failure. As a result, a technique which decreases the problems inherent in the 3LP is warranted for tenorrhaphy of equine flexor tendons. A review of the human literature highlights certain characteristics of the tenorrhaphy that may improve results including core purchase length and suture loop characteristics. Optimization of these tenorrhaphy characteristics can increase tenorrhaphy performance and patient outcome. The six-strand Savage technique (SSS) is a pattern routinely used in human hand surgery for tendon repair, and possesses high ultimate failure load and resistance to gap formation that may be beneficial for application in equine tendon repair. This study compared a novel tenorrhaphy pattern for horses, the SSS, with the currently recommended pattern, the 3LP, in an in vitro model. We hypothesize the SSS will fail at a higher ultimate load, resist pull through, and resist gap formation better than the 3LP. All testing used cadaveric equine superficial digital flexor tendons from horses euthanized for reasons other than musculoskeletal injury. All testing was approved by the IACUC. The two techniques were applied to cadaveric equine superficial digital flexor tendons. The same investigator performed all repairs (EE). Biomechanical properties were determined in a blinded, randomized pair design. Ultimate failure load, mode of failure and load required to form a 3mm gap were recorded on an Instron Electropuls materials testing system. Gap formation was determined using synchronized high-speed video analysis. Results are reported as mean + standard deviation. Statistical comparisons were made using Student's T test, with significance set at p<0.05. The tenorrhaphies were tested for their ultimate failure load and failure mode. The mean failure load for the SSS construct (421.1 ± 47.6) was significantly greater than that for the 3LP repaired tendons (193.7 ± 43.0). Failure mode was suture breakage for the SSS constructs (13/13) and suture pull through for the 3LP constructs (13/13). The maximum load to create a 3mm gap in the SSS repair (102.0N ± 22.4) was not significantly different from the 3LP repair (109.9N ± 16.0). The results of the current study demonstrate that the SSS tenorrhaphy has a higher ultimate failure load and resistance to pull through than the 3LP. The biomechanical properties of the SSS technique show promise as a more desirable repair for equine flexor tendons. However, in vivo testing of the effects of the pattern on live tissue and in a cyclic loading environment is necessary before clinical application of the pattern is recommended. / Master of Science

Yes / Dog bite injuries are a common cause of patient presentation to NHS emergency departments (EDs) and minor injuries units, and are generally associated with a low level of acuity, despite an inherent capacity for significant soft tissue damage to be inflicted by canine jaws capable of exerting terrific bite forces. Anatomical sites for injury correlate to victim age, with hand and wrist injuries predominating in the adult population. The most common complication is infection secondary to inoculation of oral flora, with the hands being particularly vulnerable due to their anatomy. Injuries to structures such as tendons can be discreet, and retained foreign bodies can easily be overlooked. Wound care has a propensity to attract a disproportionately high level of malpractice actions, and approaches to the management of dog bite injuries have largely been empirical, which may render the practitioner particularly exposed. In response to increasing pressures on healthcare systems, paramedics with extended scopes of practice, including wound care and suturing, are being utilised to assess, manage, treat, and either refer or discharge patients with apparently minor injuries, in strategies aimed at reducing hospital admissions. This article adopts a case study format to examine and evaluate treatment modalities and the current evidence base informing best practice in terms of dog bite injuries from the perspective of a paramedic practitioner, with critical reflection on the decision making process and complexities of such episodes of care in the pre-hospital setting.

No description available.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote / Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote / Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

Introdução: A laceração obstétrica do esfíncter anal (LOEA) está associado com incontinência anal. A episiotomia foi proposta como uma forma de proteção do esfíncter anal no parto, especialmente a episiotomia mediolateral; entretanto, diversos estudos mostraram que o uso de rotina da episiotomia não reduz o risco de LOEA. Objetivo: Este estudo tem por objetivo analisar se a redução na taxa de episiotomia em hospital escola no Brasil foi associada a um aumento na incidência de lacerações obstétricas do esfíncter anal, além de fatores associados a elas. Métodos: Estudo observacional, transversal e retrospectivo, realizado no Hospital de Clínicas de Porto Alegre, Rio Grande do Sul, Brasil. Foram incluídos todos os partos vaginais de gestações únicas, apresentação cefálica, a partir de 34 semanas de idade gestacional, realizados em 2011-2012 (uso liberal da episiotomia) e 2015-2016 (uso restrito da episiotomia), e comparados em relação a taxa de episiotomia mediolateral e de LOEA. Resultados: foram analisados 4268 partos (2043 no período de 2011-2012, 2225 de 2015-2016), foram analisados 2043 partos. A taxa de episiotomia reduziu de 59.4% para 44.2% (p≤0.0001). No período 2011-2012, ocorreram 10 lacerações obstétricas do esfíncter anal em 2043 partos (0.48%), enquanto que no período 2015-2016, ocorreram 31 lacerações em 2225 partos (1.39%). Houve interação quando comparado os dois períodos em relação a realização de episiotomia e a ocorrência de LOEA (p≤0.0001). A episiotomia foi fortemente associada a não ocorrência de LOEA em 2011-2012 (59.5%), enquanto que não ter episiotomia foi associado ao grupo com (67.7%) e sem LOEA (55.7%) em 2015-2016. Fatores associados a LOEA foram indução do parto e distócia de ombro. Conclusão: Houve um aumento na taxa de lacerações do esfíncter anal com a diminuição da taxa de episiotomia. A episiotomia de rotina foi prote / Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery, especially mediolateral episiotomy; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study, conducted at Hospital de Clínicas, Porto Alegre, Rio Grande do Sul, Brazil. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015- 2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p≤0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p≤0.0001). Episiotomy was strongly related to 2011-2012 group with no OAST (59.5%), while not having an episiotomy was related to both OAST (67.7%) and no OAST (55.7%) group in 2015-2016. Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with a decrease in the rate of episiotomy. Routine episiotomy was protective.

The majority of the academic discourse surrounding Dostoevsky and his epic, The Brothers Karamazov, has been directed toward the philosophic and religious implications of his characters. Largely overlooked, however, is the theme of laceration. In the greater scope of laceration stands the topic of self-laceration. Self-laceration refers to the practice of causing harm to the self in a premeditated and specifically emotionally destructive fashion. The cause of this experience is varied and expressed in as many ways as there are individuals. The struggle in the Russian psyche between viewing the world as fatalistic or as more of an existential experience finds resolution through self-laceration. By consciously choosing actions that will lead to an abject state, the characters take fate into their own hands. This thesis will explore the themes of self-laceration in a number of characters’ narratives and demonstrate that by utilizing emotional self-destruction they find a modicum of control.

Articular cartilage is the translucent, heterogeneous three-component biological load processing gel that overlays the end of the articulating bones of mammalian joints. Normally, healthy intact articular cartilage performs two biomechanical functions very effectively. These are (i) redistribution of stresses due to loads acting on the joint; (ii) act as a near-frictionless interface between contacting bone ends. These principal functions are enabled by its highly elastic properties. Under normal physiological conditions, these essential biomechanical functions are provided over the lifetime of a mammalian joint with little or no degenerative changes. However, certain levels of physiological and traumatic loads and degenerative processes induced by activities such as running, walking, extreme sport, and aging can alter the composition and structure of the tissue, leading to changes in its biomechanical properties. This, inturn, influences its functional characteristics. The most common degenerative change in articular cartilage is osteoarthritis and the management and treatment of this disease is pivotal to all research targeted toward articular cartilage. Several scientific groups around the world have developed models of articular cartilage to predict its fundamental and functional responses to load and altered biochemical conditions through both in vivo and in vitro studies. The most predominant of these models are the biphasic and triphasic models, which are based on the conceptualisation of articular cartilage as a dispersed mixture of its three main components namely collagen fibrils proteoglycan aggregates and water. The triphasic model is an extension of the biphasic model and incorporates swelling as a separate identifiable component of the tissue's biomechanical response. While these models are capable of predicting the elastic and viscoelastic behaviour and certain aspects of the swelling characteristics of articular cartilage, they are incapable of accounting for its short-term responses where the fluid component is the main carrier of the applied pressure. The hydrostatic and swelling components of the fluid content determine the manner of stress-sharing and hence transient load processing within the matrix as stress is transmitted to the underlying structure. Furthermore, the understanding of the nature of this stress-sharing between fluid and solid components of the tissue is fundamental to the comprehension of the nature of degeneration and its biomechanical consequence in the function of the articulating joint. The inability of the biphasic and triphasic theories to predict, in accordance with experimental results, the transient behaviour of the loaded matrix fluid requires a more representative model. This imperative therefore forms the basis for the research work presented in this thesis. In this thesis, a new mathematical model of articular cartilage load carriage is presented which can predict the transient load-induced responses. The model is based on a continuum framework invoking the principle of mechanical consolidation of fluid-saturated, swollen porous elastic materials. The cartilage matrix is conceptualised as a heterogeneous anisotropic fluid-saturated porous material in which its solid component responds to load as a hyperelastic material and whose interaction with the swelling component produces a partially distributed time-varying permeability. In accordance with the principle of consolidation, a phenomenological approach is adopted for developing both analogue/engineering models and mathematical models for the tissue. The models are then used to predict both bulk matrix responses and the properties of the hypothetical layers of the tissue when subjected to physiological loading conditions. Ultimately, the generalized mathematical model is used to analyse the effect of superficial layer laceration on the stress-processing or stress-sharing characteristic of normal healthy articular cartilage. Finally, predicted results are shown to compare with experimental data demonstrating that the new models for swelling deformation, the hyperelastic law for solid skeletal structure and the distributed, time-dependent permeability are representative of the articular cartilage.

Percutaneous dilatational tracheostomy (PDT) has become an appropriate alternative to conventional surgical tracheostomy. It is now performed worldwide by a diverse array of physician specialists. Although adverse events are relatively uncommon, serious complications can arise from this bedside procedure. We report a patient who suffered life-threatening hemorrhage from a common carotid artery laceration and pseudo-aneurysm formation in the innominate artery following an elective PDT procedure.