Citations

Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. Setting: Fourteen level-1 trauma centers across the United States. Patients: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. Intervention: Delay definitive fixation and flap coverage in tibial type III fractures. Main Outcome Measurements: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). Conclusion: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

We previously reported that augmented skeletal muscle vasodilation during mild hypoxic forearm exercise includes beta‐adrenergic mechanisms. Furthermore, hypoxic vasodilation at rest is known to include beta‐adrenergic mediated nitric oxide (NO) production. Therefore, we tested the hypothesis that NO contributes to augmented vasodilation with hypoxic exercise. Twelve subjects (6M/6F; 26 ± 2 years) breathed hypoxic gas to titrate arterial O 2 saturation to 80% while remaining normocapnic via a rebreath system. Subjects performed incremental forearm exercise (10% and 20% of maximum) during saline infusion (control) and NO synthase inhibition ( N G ‐monomethyl‐L‐arginine; L‐NMMA) under normoxic and hypoxic conditions. Forearm vascular conductance (FVC; ml/min/100mmHg) was calculated from blood flow (ml/min) and blood pressure (mmHg). During the control condition, the rise in FVC (Δfrom normoxic baseline) due to hypoxic exercise was 211 ± 23 and 367 ± 34 (10% and 20% respectively). Infusion of L‐NMMA during hypoxic exercise attenuated ΔFVC at 10% (174 ± 20; P < 0.001) and 20% (317 ± 32; P < 0.01) compared to control condition. Our data indicate that NO contributes to the augmented vasodilation observed during hypoxic exercise. Supported by NIH HL‐46493 (MJJ) and AR‐55819 (DPC) and by CTSA RR‐024150.

The augmented skeletal muscle vasodilation during hypoxic exercise is due, in part, to an intensity dependent contribution of beta‐receptor activation. We tested the hypothesis that an adenosine mediated vasodilation increases with hypoxic exercise intensity. Subjects (N=10) breathed hypoxic gas to titrate arterial O 2 saturation to 80% while remaining normocapnic (re‐breath system). Consecutive bouts of forearm exercise (10% and 20% of maximum) were performed under normoxia and hypoxia during phentolamine (alpha‐receptor antagonist) alone and the combination of phentolamine / aminophyline (adenosine receptor antagonist). Exogenous adenosine administered before and after aminophyline established effective receptor blockade. Forearm vascular conductance (FVC; ml/100mmHg/min) was calculated from blood flow (ml/min) and blood pressure (mmHg). During hypoxic exercise, the rise in FVC (Δ from baseline) during phentolamine was 314±30 and 470±37 (10% and 20% respectively). ΔFVC was similar at both 10% (349±45; P=0.3) and 20% (536±47; P=0.2) exercise during hypoxia with combined phentolamine / aminophyline. This occurred despite significant reduction in ΔFVC to exogenous adenosine following phentolamine / aminophyline (P<0.03). Our data suggests that in the absence of overlying vasoconstriction, adenosine does not contribute to the augmented hypoxic exercise hyperemia in humans.

Evidence suggests that increased sympathetic tone but no change of blood pressure (BP) via lower body negative pressure (LBNP) reduces indices of aortic wave reflection in young adults. The aim of this study was to examine whether aging affects central artery hemodynamics and indices of wave reflection during LBNP. In 12 young (27 ± 2 years, 5F/7M) and 10 older (70 ± 2 years 5F/5M) subjects, noninvasive aortic pressure waveforms were synthesized from high‐fidelity radial pressure waveforms via applanation tonometry before and during 10 minutes of LBNP (‐20mmHg). Aortic BP and indices of aortic wave reflection (i.e. Augmentation index; AIx) were calculated from the generated aortic pressure waveform. Aortic systolic BP decreased during LBNP in the young (110 ± 3 vs. 106 ± 3 mmHg, P<0.05), but not the older adults (139 ± 3 vs. 136 ± 3 mmHg, P=0.15). Aortic diastolic BP did not change in either group (P=0.56). Since heart rate (HR) changed in the young (P<0.05) but not in the older adults (P=0.33) during LBNP, we used the AIx normalized to a HR of 75bpm as an index of wave reflection. AIx@75bpm decreased in young adults (‐6 ± 3 vs. ‐13 ± 3%, P<0.001), whereas no change was observed in older adults (26 ± 3 vs. 25 ± 3%, P=0.39). Our data suggest that reductions in aortic systolic blood pressure and wave reflection during lower body negative pressure are attenuated in older compared to young adults. Funded by NIH HL‐105467

Reduced cerebral blood flow and reactivity may explain age‐related changes in cognitive function. We examined cerebrovascular reactivity, and the potential role of prostaglandins, in young and old healthy humans. Middle cerebral artery velocity (MCAv) responses to stepped hypercapnia were measured in young (26±2y; 6M/5F) and old (66±2y, 3M/4F) adults before (PRE) and 90 min after (POST) oral indomethacin (1.2mg/kg). To account for any changes in blood pressure, cerebrovascular conductance index (CVCi) was calculated as the MCAv divided by mean arterial pressure. Cerebrovascular reactivity slopes were calculated using linear regression between either MCA velocity or CVCi and end‐tidal CO 2 . There were no differences between young and old adults in height, weight, BMI, or brachial blood pressures. Young adults demonstrated greater MCAv (53.7±6.7 vs. 32.0±3.3), MCAv reactivity (1.62±0.21 vs. 0.94±0.10), and CVCi (0.66±0.08 vs. 0.39±0.04) compared with old adults at PRE (P<0.05 for all). In both young and old adults, MCAv, MCAv reactivity, CVCi, and CVCi reactivity decreased between PRE and POST measurements. Furthermore, any age‐related differences in these cerebrovascular variables were abolished by indomethacin. These results suggest that cerebral blood flow and cerebrovascular reactivity is attenuated in aging adults and that this reduction may be mediated by prostaglandins. NIH: AG16574‐11PP2

Hypoxia during exercise augments vasodilation and blood flow to ensure adequate delivery of O 2 to active muscles. However, the impact of hyperoxia on skeletal muscle blood flow during exercise is poorly understood. Therefore, we tested the hypothesis that the hyperemic response to exercise with hyperbaric hyperoxia would be blunted compared to exercise during normoxia. Seven subjects (6M/1F; 26 ± 2 years) performed forearm exercise (20% of maximum) under normoxic and hyperoxic conditions. Forearm blood flow (FBF; ml/min) was measured using Doppler ultrasound. Forearm vascular conductance (FVC; ml/min/100mmHg) was calculated from FBF and blood pressure (mmHg; brachial arterial catheter). Studies were performed in a hyperbaric chamber with the subjects supine at 1 ATA (sea level) and 2.8 ATA while breathing normoxic (21% O 2 , 1 ATA; F I O 2 ≈ 150 mmHg), hyperbaric normoxic (7% O 2 , 2.8 ATA, F I O 2 ≈ 150 mmHg) and hyperoxic (7% O 2 , 2.8 ATA, F I O 2 ≈ 2100 mmHg) gas. The change in FBF and FVC (Δ from rest) during exercise under normoxia and hyperbaric normoxia did not differ (P > 0.05). However, the ΔFBF and ΔFVC during exercise under hyperoxia were attenuated by ~18–29% compared to both normoxic conditions (P ≤ 0.01). Our data suggest that exercise hyperemia in skeletal muscle is highly dependent on oxygen availability during hyperoxia as well as hypoxia. NIH HL46493 (MJJ), AR55819 (DPC) and RR‐024150.

We tested the hypothesis that local inhibition of NOS would 1) alter the kinetics of vasodilation during dynamic forearm (FA) exercise and 2) prolong the time to reach steady state (SS). Subjects (n=22) performed rhythmic FA exercise (20% of maximum) during saline infusion (control) and NOS inhibition (L‐NMMA). Additionally, a subset of subjects performed a third trial of FA exercise during combined inhibition of either 1) NOS and adenosine (aminophylline; n=9), or 2) NOS and prostaglandins (Ketorolac; n=8). Forearm vascular conductance (FVC; ml/min/100mmHg) was calculated from blood flow (ml/min) and blood pressure (mmHg). Vasodilator kinetics were assessed by calculating the slope of the FVC response for every duty cycle between baseline and SS exercise as well as the number of duty cycles (1s contraction/2s relaxation) to reach SS. NOS inhibition reduced the kinetics of vasodilation during dynamic FA exercise (8.5 ± 0.6 vs. 11.1 ± 0.8 FVC/duty cycle; P < 0.001 vs. control) and increased the time to reach SS (25.1 ± 1 vs. 32 ± 1 duty cycles; P < 0.001 vs. control). The kinetics of vasodilation were reduced further with combined inhibition of NOS and adenosine (6.2 ± 0.8 vs. 7.5 ± 0.6 FVC/duty cycle; P < 0.05 vs. L‐NMMA alone), but not with combined inhibition of NOS and prostaglandins. Our data indicate that NOS inhibition blunts the kinetics of vasodilation during dynamic FA exercise and prolongs the time to reach SS.

Pulse wave velocity (PWV) and sympathetic nerve activity increase with age. However, it is unknown if the age‐related increase in sympathetic activity influences PWV. We determined the effect of autonomic blockade on peripheral and central arterial stiffness in young (23 ± 4 yr) and older, postmenopausal (57 ± 3 yr) women before and during administration of trimethaphan camsylate. Arterial tonometry was used to measure carotid‐radial (peripheral) and carotid‐femoral (central) PWV. The groups did not differ in height, weight, BMI, or mean arterial pressure (MAP). At baseline, peripheral PWV did not differ between the groups. However, central PWV was significantly greater in older women compared with young women (8.2 vs. 6.1 m/s, respectively; p<0.05). Trimethaphan infusion caused a substantial drop in MAP; therefore, we corrected PWV for the change in MAP. Peripheral PWV was greater in older women compared with young women (0.12 vs. 0.08 m/s·mmHg −1 ; p<0.05). In addition, central PWV remained higher in older women during trimethaphan infusion (0.11 vs. 0.08 m/s·mmHg −1 in young; p<0.05). In conclusion, central PWV was greater in older women before and during autonomic blockade, whereas peripheral PWV was only higher in the older women after autonomic blockade. This suggests that peripheral PWV is influenced by sympathetic activity to a greater extent in young vs. older women. Funded by NIH

Acute ß‐adrenergic blockade (BB) increases aortic wave reflection in young women, however, it is unknown if this effect extends to post‐menopausal women. Thus, we examined systemic BB on aortic wave reflection in 14 post‐menopausal women (58 ± 2 yr). Non‐invasive aortic pressure waveforms were synthesized from high‐fidelity radial pressure waveforms obtained from applanation tonometry before and during systemic BB (0.25mg/kg bolus, with 0.004 mg/kg/min continuous infusion of propranolol). Aortic blood pressure, augmentation index (AIx), AIx adjusted for heart rate (AIx@75), aortic augmented pressure (AP), and wasted left ventricular energy (Ew) were calculated from the aortic pressure waveform. Heart rate (60 ± 2 vs. 51 ± 2 bpm) and mean arterial pressure (95 ± 3 vs. 91 ± 3 mmHg) were reduced with BB (P < 0.05 for both). AIx increased during BB (32 ± 2 vs. 35 ± 2%, P < 0.01), however, AIx@75 was unchanged (25 ± 2 vs. 24 ± 2%, ns). Additionally, AP (20 ± 2 vs. 20 ± 2 mmHg, ns) and Ew (4313 ± 538 vs. 4277 ± 537 dyne*cm2/sec, ns) remained unchanged during BB. When compared to our previously published study in young women, indices of aortic wave reflection were significantly less affected in post‐menopausal women in response to acute systemic BB. Taken together, our data suggest that the negative effects (i.e. increased aortic wave reflection) of non‐selective BB are less pronounced in post‐menopausal women.

Aortic wave reflection increases with age, and is influenced by numerous factors, including sympathetic nerve activity. The purpose of this study was to examine the effect of autonomic blockade using trimethaphan camsylate on indices of aortic wave reflection in young (23±4 yr) and older postmenopausal (57±3 yr) women and determine if aging alters these interactions. Arterial tonometry was used to non‐invasively measure arterial waveforms from the radial artery before and during trimethaphan infusion. Aortic augmentation index (AI x ), augmented pressure, and left ventricular wasted energy (E w ) were higher in older women compared to young women at baseline (p<0.05). Mean arterial pressure was similar between young (93±5 mmHg) and older women (91±2 mmHg) at baseline. AI x (Δ −12±5%), augmented pressure (Δ −11±4 mmHg), and E w (Δ −2364±1020 dyne·cm 2 ·sec) decreased after autonomic blockade in older women (p<0.05 for all). In addition, the age‐related differences in AI x and aortic wave reflection persisted during autonomic blockade (p<0.05). In conclusion, autonomic blockade reduces augmentation index and aortic wave reflection in older women. Our results suggest that sympathetic activity contributes to the higher aortic wave reflection observed in older women.