OBJECTIVE:To determine whether active negative pressure peritoneal therapy with the ABThera temporary abdominal closure device reduces systemic inflammation after abbreviated laparotomy.
...BACKGROUND:Excessive systemic inflammation after abdominal injury or intra-abdominal sepsis is associated with poor outcomes.
METHODS:We conducted a single-center, randomized controlled trial. Forty-five adults with abdominal injury (46.7%) or intra-abdominal sepsis (52.3%) were randomly allocated to the ABThera (n = 23) or Barkerʼs vacuum pack (n = 22). On study days 1, 2, 3, 7, and 28, blood and peritoneal fluid were collected. The primary endpoint was the difference in the plasma concentration of interleukin-6 (IL-6) 24 and 48 hours after temporary abdominal closure application.
RESULTS:There was a significantly lower peritoneal fluid drainage from the ABThera at 48 hours after randomization. Despite this, there was no difference in plasma concentration of IL-6 at baseline versus 24 (P = 0.52) or 48 hours (P = 0.82) between the groups. There was also no significant intergroup difference in the plasma concentrations of IL-1β, −8, −10, or −12 p70 or tumor necrosis factor α between these time points. The cumulative incidence of primary fascial closure at 90 days was similar between groups (hazard ratio, 1.6; 95% confidence interval, 0.82–3.0; P = 0.17). However, 90-day mortality was improved in the ABThera group (hazard ratio, 0.32; 95% confidence interval, 0.11–0.93; P = 0.04).
CONCLUSIONS:This trial observed a survival difference between patients randomized to the ABThera versus Barkerʼs vacuum pack that did not seem to be mediated by an improvement in peritoneal fluid drainage, fascial closure rates, or markers of systemic inflammation.
TRIAL REGISTRATION:ClinicalTrials.gov identifier NCT01355094.
Unfortunately, these positive traits have also been seeded with unintended consequences, including prolonged surgeon work hours, frustration with repeatedly changing information systems, and a ...decrease in the time available to actually care for patients at the bedside. Examples include research (university ethics review boards and processes; provincial health care research impact assessments; individual program barriers and obstacles; grant agency applications), physician reimbursement (billing documentation; time stamp confirmations; fees submission; shadow-billing), teaching (competency-based education assessments; trainee evaluations), professional development (regulatory body performance, competency assessments and renewal exams; professional surveys) and quality improvement (introduction of new technologies, processes, pathways, checklists, safety protocols, and programs; safety learning incident reviews). Associate health care providers (nurse practitioners, physician assistants, clinical associates, surgical hospitalists) not only contribute to direct patient care, but also to documentation requirements. Within surgery, many high-volume ophthalmology outpatient practices employ dictation scribes, documentation specialists, billing (public and private) experts, and other clinical specialists (e.g., optometrists) to increase throughput, enhance efficiency, and focus the surgeon/physician on direct patient care.
Abstract Background Alpine skiing and snowboarding are popular winter sports in Canada. Every year participation in these activities results in traumatic injury. The purpose of this study was to ...identify the incidence and injury patterns, as well as risk factors associated with ski and snowboarding injuries. Methods A comprehensive 10-year retrospective review of Alpine ski and snowboarding injuries from 1996 to 2006 was conducted. The Alberta Trauma Registry was used as the primary source of data. Results A total of 196 patients (56.6% skiers, 43.4% snowboarders) were identified as having major traumatic injuries (Injury Severity Score, ≥12). Forty-three patients required intensive care unit support. The majority of injuries were related to falls and collisions with natural objects. Head injuries were most common, followed by chest, spinal, and extremity trauma. Seventy-nine patients required emergency surgery. Conclusions Skiing and snowboarding represent activities with high potential for traumatic injury. Safety initiatives should be developed to target this population.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
4.
Thrombotic triad in microgravity Elahi, Mohammad M; Witt, Alexandra N; Pryzdial, Edward L G ...
Thrombosis research,
01/2024, Volume:
233
Journal Article
Peer reviewed
Thrombotic disease may be an underdiagnosed condition of prolonged exposure to microgravity and yet the underlying factors remain poorly defined. Recently, an internal jugular vein thrombosis was ...diagnosed in a low-risk female astronaut after an approximately 7-week space mission. Six of the additional 10 crew members demonstrated jugular venous flow risk factors, such as suspicious stagnation or retroversion. Fortunately, all were asymptomatic. Observations in space as well as clinical and in vitro microgravity studies on Earth, where experiments are designed to recapitulate the conditions of space, suggest effects on blood flow stasis, coagulation, and vascular function. In this article, the related literature on thrombotic disease in space is reviewed, with consideration of these elements of Virchow's triad.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Early antithrombotic therapy (AT) is the mainstay of treatment in the management of blunt cerebrovascular injury (BCVI). Despite this, optimal timing of initiation of AT in patients with BCVI in the ...presence of concomitant traumatic brain injury (TBI) or solid organ injury (SOI) remains controversial. The purpose of this study was to evaluate the impact of early initiation of AT on outcomes in patients with BCVI and TBI and/or SOI.
Patients with BCVI and concomitant TBI and/or SOI over 6 years were identified. Aspirin and/or clopidogrel or low-intensity heparin infusion (AT) was instituted in all patients immediately upon diagnosis of BCVI. Cessation of AT, worsening TBI, the need for delayed operative intervention, ischemic stroke, and mortality were reviewed and compared. Worsening of TBI or delayed operative intervention for SOI were compared with those of patients without BCVI treated at the same institution during the study period.
A total of 119 patients (74 with TBI, 26 with SOI, and 19 with both) were identified. Seventy-one percent were treated with heparin infusion (goal activated partial thromboplastin time, 45-60 seconds), and 29% received antiplatelet therapy alone. When compared with patients without BCVI, there was no difference in worsening of TBI (9% vs. 10% with no BCVI, p = 0.75) or need for delayed operative intervention for SOI (7% vs. 5% with no BCVI, p = 0.61). No patients required cessation of AT. A total of 11 patients (9%) experienced a BCVI-related stroke.
Initiation of early AT for patients with BCVI and concomitant TBI or SOI does not increase risk of worsening TBI or SOI above baseline. Close monitoring is required, but our results suggest that appropriate antiplatelet or heparin therapy should not be withheld in patients with BCVI and concomitant TBI or SOI. In fact, prompt treatment with either antiplatelet or heparin therapy remains the mainstay for prevention of stroke-related morbidity and mortality in these patients.
Therapeutic/care management study, level IV.
Abstract Background Remote-telementored ultrasound involves novice examiners being remotely guided by experts using informatic-technologies. However, requiring a novice to perform ultrasound is a ...cognitively demanding task exacerbated by unfamiliarity with ultrasound-machine controls. We incorporated a randomized evaluation of using remote control of the ultrasound functionality (knobology) within a study in which the images generated by distant naive examiners were viewed on an ultrasound graphic user interface (GUI) display viewed on laptop computers by mentors in different cities. Methods Fire-fighters in Edmonton (101) were remotely mentored from Calgary ( n = 65), Nanaimo ( n = 19), and Memphis ( n = 17) to examine an ultrasound phantom randomized to contain free fluid or not. Remote mentors (2 surgeons, 1 internist, and 1 ED physician) were randomly assigned to use GUI knobology control during mentoring (GUIK+/GUIK−). Results Remote-telementored ultrasound was feasible in all cases. Overall accuracy for fluid detection was 97% (confidence interval = 91 to 99%) with 3 false negatives (FNs). Positive/negative likelihood ratios were infinity/0.0625. One FN occurred with the GUIK+ and 2 without (GUIK−). There were no statistical test performance differences in either group (GUIK+ and GUIK−). Conclusions Ultrasound-naive 1st responders can be remotely mentored with high accuracy, although providing basic remote control of the knobology did not affect outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Within Canada, injuries are the leading cause of death amongst children fourteen years of age and younger, and also one of the leading causes of morbidity. Low Socio Economic Status (SES) seems to be ...a strong indicator of a higher prevalence of injuries. This study aims to identify hotspots for pediatric Traumatic Brain Injury (TBI) and examines the relationship between SES and pediatric TBI rates in greater Vancouver, British Columbia (BC), Canada.
Pediatric TBI data from the BC Trauma Registry (BCTR) was used to identify all pediatric TBI patients admitted to BC hospitals between the years 2000 and 2013. Spatial analysis was used to identify hotspots for pediatric TBI. Multivariate analysis was used to distinguish census variables that were correlated with rates of injury.
Six hundred and fifty three severe pediatric TBI injuries occurred within the BC Lower Mainland between 2000 and 2013. High rates of injury were concentrated in the East, while low rate clusters were most common in the West of the region (more affluent neighborhoods). A low level of education was the main predictor of a high rate of injury (OR = 1.13, 95% CI = 1.03-1.23, p-Value 0.009).
While there was a clear relationship between different SES indicators and pediatric TBI rates in greater Vancouver, income-based SES indicators did not serve as good predictors within this region.
Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. Open abdomen management with enhanced clearance of fluid and biomediators from the peritoneum is ...a potential therapy requiring prospective evaluation. Given the complexity of powering multi-center trials, it is essential to recruit an inception cohort sick enough to benefit from the intervention; otherwise, no effect of a potentially beneficial therapy may be apparent. An evaluation of abilities of recognized predictive systems to recognize SCIAS patients was conducted using an existing intra-abdominal sepsis (IAS) database.
All consecutive adult patients with a diffuse secondary peritonitis between 2012 and 2013 were collected from a quaternary care hospital in Finland, excluding appendicitis/cholecystitis. From this retrospectively collected database, a target population (93) of those with either ICU admission or mortality were selected. The performance metrics of the Third Consensus Definitions for Sepsis and Septic Shock based on both SOFA and quick SOFA, the World Society of Emergency Surgery Sepsis Severity Score (WSESSSS), the APACHE II score, Manheim Peritonitis Index (MPI), and the Calgary Predisposition, Infection, Response, and Organ dysfunction (CPIRO) score were all tested for their discriminant ability to identify this subgroup with SCIAS and to predict mortality.
Predictive systems with an area under-the-receiving-operating characteristic (AUC) curve > 0.8 included SOFA, Sepsis-3 definitions, APACHE II, WSESSSS, and CPIRO scores with the overall best for CPIRO. The highest identification rates were SOFA score ≥ 2 (78.4%), followed by the WSESSSS score ≥ 8 (73.1%), SOFA ≥ 3 (75.2%), and APACHE II ≥ 14 (68.8%) identification. Combining the Sepsis-3 septic-shock definition and WSESSS ≥ 8 increased detection to 80%. Including CPIRO score ≥ 3 increased this to 82.8% (Sensitivity-SN; 83% Specificity-SP; 74%. Comparatively, SOFA ≥ 4 and WSESSSS ≥ 8 with or without septic-shock had 83.9% detection (SN; 84%, SP; 75%, 25% mortality).
No one scoring system behaves perfectly, and all are largely dominated by organ dysfunction. Utilizing combinations of SOFA, CPIRO, and WSESSSS scores in addition to the Sepsis-3 septic shock definition appears to offer the widest "inclusion-criteria" to recognize patients with a high chance of mortality and ICU admission.
https://clinicaltrials.gov/ct2/show/NCT03163095; Registered on May 22, 2017.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Hemorrhage is the most preventable cause of posttraumatic death. Many cases are potentially anatomically salvageable, yet remain lethal without logistics or trained personnel to deliver diagnosis or ...resuscitative surgery in austere environments. Revolutions in technology for remote mentoring of ultrasound and surgery may enhance capabilities to utilize the skill sets of non-physicians. Thus, our research collaborative explored remote mentoring to empower non-physicians to address junctional and torso hemorrhage control in austere environments. Major studies involved using remote-telementored ultrasound (RTMUS) to identify torso and junctional exsanguination, remotely mentoring resuscitative surgery for torso hemorrhage control, understanding and mitigating physiological stress during such tasks, and the technical practicalities of conducting damage control surgery (DCS) in austere environments. Iterative projects involved randomized guiding of firefighters to identify torso (RCT) and junctional (pilot) hemorrhage using RTMUS, randomized remote mentoring of MedTechs conducting resuscitative surgery for torso exsanguination in an anatomically realistic surgical trainer ("Cut Suit") including physiological monitoring, and trained surgeons conducting a comparative randomized study for torso hemorrhage control in normal (1g) versus weightlessness (0g). This work demonstrated that firefighters could be remotely mentored to perform just-in-time torso RTMUS on a simulator. Both firefighters and mentors were confident in their abilities, the ultrasounds being 97% accurate. An ultrasound-naive firefighter in Memphis could also be remotely mentored from Hawaii to identify and subsequently tamponade an arterial junctional hemorrhage using RTMUS in a live tissue model. Thereafter, both mentored and unmentored MedTechs and trained surgeons completed resuscitative surgery for hemorrhage control on the Cut-Suit, demonstrating practicality for all involved. While remote mentoring did not decrease blood loss among MedTechs, it increased procedural confidence and decreased physiologic stress. Therefore, remote mentoring may increase the feasibility of non-physicians conducting a psychologically daunting task. Finally, DCS in weightlessness was feasible without fundamental differences from 1g. Overall, the collective evidence suggests that remote mentoring supports diagnosis, noninvasive therapy, and ultimately resuscitative surgery to potentially rescue those exsanguinating in austere environments and should be more rigorously studied.
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