FlatWire Sternal Closure System technique for median sternotomy closure.

Sternal closure after median sternotomy traditionally uses a stainless steel wire cerclage. Sternal wires are placed through or around the sternum, and the wire ends are twisted together to bring the sternum back together. Complications of this technique include sternal instability, dehiscence, non-union, and increased pain. Compared to traditional wire cerclage, the Figure 8 FlatWire Sternal Closure System has been demonstrated to be stronger and significantly reduce sternal cut-through and postoperative pain. There was no significant difference in hospital length of stay or mean hospitalization cost. Operative time was slightly longer in the FlatWire group, but this difference has been attributed to the learning curve of mastering the FlatWire technique. This article and supplemental video will demonstrate the technique of FlatWire Sternal Closure System. Briefly, the FlatWire is placed around the sternum, and the FlatWire end is fed through the security box. Once all of the wires are placed, the Figure 8 tensioning device is used to tighten each wire through the security box to the appropriate tensile force. Next, the FlatWires are rotated 90 degrees to hold the sternal position temporarily. Once sternal approximation is achieved, each FlatWire is twisted 120 degrees, and any excess length of the FlatWire is clipped.

Nanoelectrochemical quantification of single-cell metabolism.

At the most fundamental level, the behavior of tissue is governed by the activity of its single cells. A detailed examination of single-cell biology is necessary in order to gain a deeper understanding of disease progression. While single-cell genomics and transcriptomics are mature due to robust amplification strategies, the metabolome is difficult to quantify. Nanoelectrochemical techniques stand poised to quantify single-cell metabolism as a result of the fabrication of nanoelectrodes, which allow one to make intracellular electrochemical measurements. This article is concerned with intracellular nanoelectrochemistry, focusing on the sensitive and selective quantification of various metabolites within a single, living cell. We will review the strong literature behind this field, discuss the potential deleterious effects of passing charge inside cells, and provide future outlooks for this promising avenue of inquiry. We also present a mathematical relationship based on Faraday's Law and bulk electrolysis theory to examine the consumption of analyte within a cell due to passing charge at the nanotip.Graphical abstract.

Novel Modification of HeartMate 3 Implantation.

We have modified the HeartMate 3 (Abbott, Abbott Park, IL) implantation technique to better suit our patient population. This modification optimizes the placement of the HeartMate 3 sewing cuff and allows passage of the suture transmurally from endocardium to epicardium in a "cut then sew" technique. We believe this affords a superior seal and protection from tearing friable myocardium.

Does routine uniportal thoracoscopy during rib fixation identify more injuries and impact outcomes?

BACKGROUND: Flail chest and severely displaced rib fractures due to blunt trauma can be associated with intrathoracic injuries. At our institution, two thoracic surgeons perform all surgical stabilization of rib fractures (SSRF): one performs routine uniportal thoracoscopy (R-VATS) at the time of SSRF and the other for only select cases (S-VATS). In this pilot study, we hypothesized that R-VATS at the time of SSRF identifies and addresses intrathoracic injuries not seen on imaging and may impact patient outcomes. METHODS: A retrospective review of all patients who underwent SSRF from 2013-2019 at our institution was performed for severely displaced rib fractures or flail chest. Data collected included demographics, imaging results, treatment strategy, and operative findings. RESULTS: Ninety-nine patients underwent SSRF. Uniportal thoracoscopy was performed on 69% of these patients. When thoracoscopy was performed, 31 additional injuries were identified. R-VATS identified 23 additional intrathoracic findings at time of thoracoscopy not seen on CT scan compared to 8 findings in the S-VATS group (P=0.367). At 3 months follow-up, one empyema and one diaphragmatic hernia required reoperation-neither of which underwent thoracoscopy at time of SSRF. There were no differences in LOS, operative times, and overall mortality between the SSRF/thoracoscopy and SSRF only groups. CONCLUSIONS: R-VATS at the time of SSRF did not identify a statistically significant greater number of occult intrathoracic injuries compared to S-VATS. R-VATS was not associated with increased operative time, LOS, and mortality. Further study is needed to determine if there is benefit to R-VATS in patients meeting requirements for rib fracture repair.

Supplementing dams with both arachidonic and docosahexaenoic acid has beneficial effects on growth and immune development.

Omega-3 long-chain polyunsaturated fatty acids (LCPUFAS) modulate immune cells in vitro and in vivo. This study investigated the effects of enriching the maternal diet with the n-6 and n-3 LCPUFAs, arachidonic (20:4n-6, 0.6%wt ARA) and docosahexaenoic acid (22:6n-3, 0.32%wt DHA), or 1:1 and 2:1 ratios (ARA: DHA) on total lipids in milk, total lipids, and immunophenotypes in plasma, lymph nodes, and spleen from isolated immune cells from 28d old pups. From day 15 of gestation to day 3 pp, Sprague-Dawley dams were fed a commercial chow. On day 3 pp litters were culled and pups (4 males and 2 females) randomly cross-fostered to dams who were randomized to one of the 5 experimental diets resulting in 20 male and 10 female pups/diet group. Dams fed ARA or ARA: DHA had 28-36% more 20:4n-6 in milk and feeding DHA or ARA: DHA doubled 22:6n-3 in milk lipids (P<0.05). Feeding 1:1 or 2:1 ARA: DHA resulted in greater pup weight at weaning (P<0.05). Compared to the control pups, ARA + DHA fed pups had a lower proportion of splenic CD45RA+ lymphocytes. In summary, postpartum supplementation with a combination of ARA + DHA, compared to ARA or DHA alone, resulted in a higher content of ARA and DHA in dam's milk and tissues and had positive effects on growth, accompanied by evidence of progression toward a mature immune phenotype, and suggests a need for ARA when DHA is supplemented in the early diet. Additional investigations are needed of ARA immunomodulation to better understand and estimate nutritional requirements for LCPUFAs during early development.

Changing state of pediatric injuries in South Africa: An analysis of surveillance data from a Pediatric Emergency Department from 2007 to 2011.

BACKGROUND: Pediatric injuries are associated with significant morbidity and mortality, especially in low- and middle-income countries. Data to characterize the cause and risk factors associated with childhood injuries in low- and middle-income countries are very scarce. The aim of this study is to describe the cause of pediatric injuries and their possible changes between 2007 and 2011 using hospital-based data in Cape Town, South Africa. METHODS: Data from injured children <13 years of age who presented to the Red Cross War Memorial Children's Hospital's emergency department in 2007 and 2011 were captured in Childsafe South Africa's trauma surveillance system. Poisson regression was used to assess changes in rates of injury between 2007 and 2011 in terms of demographics, geographic location of injury, type of injury mechanism, injury severity, and anatomic region of the sustained injury. RESULTS: In total, 14,915 injured children with 15,414 injuries presented to Red Cross War Memorial Children's Hospital in 2007 and 2011. The mean age was 5.01 ± 3.5 years and 60.3% were male. Common mechanisms of injury included falls (n = 6,036; 40%), road traffic injuries (n = 1,939; 13%), burns (n = 1,885; 12.6%), and assault (n = 640; 4.3%). Comparing 2011 to 2007, the incidence of road traffic injuries has decreased by 7% (P < .05) while burn injuries increased 11% (P < .05). Seventy-three percent (73%) of injuries that presented to Red Cross War Memorial Children's Hospital occurred in the Cape Flats area of Cape Town, where many informal settlements exist. CONCLUSION: These epidemiologic findings suggest that while road traffic injuries decreased and burn injuries increased at Red Cross War Memorial Children's Hospital, there is a need for data that are population-based and not hospital based. If we could describe injuries accurately within the pediatric population of a city such as Cape Town, we could in turn use this data to strengthen the need for targeted interventions to address risk factors for pediatric injuries. Despite this, hospital-based data remain a powerful tool to study injuries in low and middle-income countries.

Trauma care in India: A review of the literature.

BACKGROUND: We reviewed the published literature related to prehospital and hospital trauma care in India to identify how trauma care is defined in the literature and what factors limit the delivery of appropriate trauma care. In summarizing the evidence and recommendations regarding trauma care, this review identifies essential research and development goals to address the burden of injury in India. METHODS: A review of the literature was conducted between August 2014 and September 2014. The literature was sorted into 3 categories: prehospital care, hospital clinical care, and hospital administrative care. The characteristics of trauma care were explored using the Essential Trauma Care Project of the World Health Organization. RESULTS: A total of 38 studies were included. Prehospital care lacked care provided at the scene of the injury, timely transport to a hospital, and transport via ambulance. With regard to hospital care, we found a lack of capabilities of basic clinical care, such as airway management, insertion of chest tubes, and efforts at resuscitation. There was a lack of administrative capabilities, including trauma data systems, trauma-specific training, quality improvement, and development of designated trauma teams. CONCLUSION: The high rate of injury-related deaths and disabilities in India could be in part due to the absence of integrated and organized systems of trauma care. In the prehospital setting, a multisector approach must be implemented to address the training of emergency medical service providers and community members. Prehospital transport time can be decreased through improved communication and transport modalities. The Indian trauma care system could also be strengthened through hospital-based training programs and trauma response teams.

The oil-rich alga Schizochytrium sp. as a dietary source of docosahexaenoic acid improves shape discrimination learning associated with visual processing in a canine model of senescence.

Whole cell Schizochytrium sp. is a rich source of omega-3 long-chain polyunsaturated fatty acids (n-3 LCPUFA) including docosahexaenoic acid (DHA), an important nutrient for brain health. Aged beagle dogs experienced on a visuospatial task of working memory, variable-delay delayed-non-matching-to-position were used to assess efficacy of DHA-rich microalgae based upon DHA wt% of total phospholipids and 8-iso-PGF2α concentrations in plasma, and performance on cognitive assessments of visual object discrimination, learning, and memory consolidation after 25 weeks on fortified diet. Improved DHA status (p<0.001) and initial learning of the protocols for visual and variable contrast discrimination (p<0.05), but not long-term recall of the concurrent discrimination task were observed in animals fed the algal-fortified diet. Overall, results were consistent with dried Schizochytrium sp. as a source of n-3 LCPUFA nutrition to support DHA status in large mammals, and healthy brain function in a canine model of senescence.

Piloting a pediatric trauma course in Western Jamaica: Lessons learned and future directions.

INTRODUCTION: Pediatric injuries are a leading cause of death in low- and middle-income countries (LMICs). Despite this, there are few formal pediatric-specific trauma educational initiatives available in LMICs. While new educational tools are being developed to address this, they have not been piloted in LMICs. In Jamaica, pediatric injuries are a leading cause of hospital admission but care is limited by a lack of training in triage and stabilization. Our objective was to implement and evaluate a pediatric trauma course in Jamaica to determine the impact this may have on further course development. MATERIALS AND METHODS: A pediatric trauma course was conducted at the Cornwall Regional Hospital in Montego Bay, Jamaica sponsored by the Children's Medical Services International, a nonprofit organization. Participants took part in six didactic modules, an infant airway intubation skills session, and three clinical simulation scenarios. Participants completed a postcourse survey at the conclusion of the course. RESULTS: Twenty-five participants including surgical, pediatric, and emergency medicine residents from regional- and district-level hospitals in Jamaica participated in the course. Participants viewed the course favorably. Strengths included good review of pediatric trauma physiology, short modules, hands-on practice, and applicable clinical scenarios. Using a Likert-type rating scale of 1 to 10, with 1 being minimal and 10 being very knowledgeable, precourse knowledge was ranked as 5.9, which increased to 9.2 after the course. Using a similar scale, the precourse comfort level to run a pediatric trauma was 4.9 and increased to 8.5 following the course. DISCUSSION: Implementation of this pilot pediatric trauma course was feasible and successful through collaboration with the hosting regional hospital. The lack of formal pediatric training can be overcome by a course such as this which includes both didactics and hands-on clinical patient simulations. LEVEL OF EVIDENCE: 4.

Informing road traffic intervention choices in South Africa: the role of economic evaluations.

INTRODUCTION: Given the burden of road traffic injuries (RTIs) in South Africa, economic evaluations of prevention interventions are necessary for informing and prioritising public health planning and policy with regard to road safety. METHODS: In view of the dearth of RTI cost analysis, and in order to understand the extent to which RTI-related costs in South Africa compare with those in other low- and middle-income countries (LMICs), we reviewed published economic evaluations of RTI-related prevention in LMICs. RESULTS: Thirteen articles were identified, including cost-of-illness and cost-effectiveness studies. Although RTI-related risk factors in South Africa are well described, costing studies are limited. There is minimal information, most of which is not recent, with nothing at all on societal costs. Cost-effective interventions for RTIs in LMICs include bicycle and motorcycle helmet enforcement, traffic enforcement, and the construction of speed bumps. DISCUSSION: Policy recommendations from studies conducted in LMICs suggest a number of cost-effective interventions for consideration in South Africa. They include speed bumps for pedestrian safety, strategically positioned speed cameras, traffic enforcement such as the monitoring of seatbelt use, and breathalyzer interventions. However, interventions introduced in South Africa will need to be based either on South African cost-effectiveness data or on findings adapted from similar middle-income country settings.

Ultrasound as a tool for fluid status assessment in the trauma and critically ill patient.

Resuscitation to euvolemia in trauma as well as in the critically ill patient, continues to be a challenge. Focused cardiac ultrasound has been shown to be a reliable tool to evaluate fluid status and to guide therapy. The present manuscript reviews the evidence supporting the use of this tool and describes the clinical applications for image-based resuscitation using echocardiogram.

Trauma systems in Kenya: a qualitative analysis at the district level.

Injury is a leading cause of death and disability in low- and middle-income countries. Kenya has a particularly high burden of injuries, accounting for 88.4 deaths per 100,000 population. Despite recent attempts to prioritize injury prevention in Kenya, trauma care systems have not been assessed. We assessed perceptions of formal and informal district-level trauma systems through 25 qualitative semi-structured interviews and 16 focus group discussions with Ministry of Health officials, district hospital administrators, health care providers, police, and community members. We used the principles of theoretical analysis to identify common themes of prehospital and hospital trauma care. We found prehospital care relied primarily on "good Samaritans" and police. We described hospital care in terms of human resources, infrastructure, and definitive care. The interviewers repeatedly emphasized the lack of hospital infrastructure. We showed the need to develop prehospital care systems and strengthen hospital trauma care services.

Treatment of infections in young infants in low- and middle-income countries: a systematic review and meta-analysis of frontline health worker diagnosis and antibiotic access.

BACKGROUND: Inadequate illness recognition and access to antibiotics contribute to high case fatality from infections in young infants (<2 months) in low- and middle-income countries (LMICs). We aimed to address three questions regarding access to treatment for young infant infections in LMICs: (1) Can frontline health workers accurately diagnose possible bacterial infection (pBI)?; (2) How available and affordable are antibiotics?; (3) How often are antibiotics procured without a prescription? METHODS AND FINDINGS: We searched PubMed, Embase, WHO/Health Action International (HAI), databases, service provision assessments (SPAs), Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and grey literature with no date restriction until May 2014. Data were identified from 37 published studies, 46 HAI national surveys, and eight SPAs. For study question 1, meta-analysis showed that clinical sign-based algorithms predicted bacterial infection in young infants with high sensitivity (87%, 95% CI 82%-91%) and lower specificity (62%, 95% CI 48%-75%) (six studies, n = 14,254). Frontline health workers diagnosed pBI in young infants with an average sensitivity of 82% (95% CI 76%-88%) and specificity of 69% (95% CI 54%-83%) (eight studies, n = 11,857) compared to physicians. For question 2, first-line injectable agents (ampicillin, gentamicin, and penicillin) had low variable availability in first-level health facilities in Africa and South Asia. Oral amoxicillin and cotrimoxazole were widely available at low cost in most regions. For question 3, no studies on young infants were identified, however 25% of pediatric antibiotic purchases in LMICs were obtained without a prescription (11 studies, 95% CI 18%-34%), with lower rates among infants <1 year. Study limitations included potential selection bias and lack of neonatal-specific data. CONCLUSIONS: Trained frontline health workers may screen for pBI in young infants with relatively high sensitivity and lower specificity. Availability of first-line injectable antibiotics appears low in many health facilities in Africa and Asia. Improved data and advocacy are needed to increase the availability and appropriate utilization of antibiotics for young infant infections in LMICs. REVIEW REGISTRATION: PROSPERO International prospective register of systematic reviews (CRD42013004586). Please see later in the article for the Editors' Summary.

The cost of injury and trauma care in low- and middle-income countries: a review of economic evidence.

INTRODUCTION: Injuries are a significant cause of mortality and morbidity, of which more than 90% occur in low- and middle-income countries (LMICs). Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives and to understand the costs associated with injury. The aim of this article is to describe the extent to which injury-related costing studies have been conducted in LMICs. METHODS: A review of literature was performed to explore costing data available for injury and/or trauma care in LMICs. Study quality was described using recommendations from the Community Guide's quality assessment tool for economic evaluations. RESULTS: The review identified 68 studies, of which 13 were full economic evaluations. Cost of injury varied widely with mean costs ranging from US$14 to US$17 400. In terms of injury-prevention interventions, cost per disability adjusted life year averted for injury-prevention interventions ranged from US$10.90 for speed bump installation to US$17 000 for drunk driving and breath testing campaigns in Africa. The studies varied in quality, ranging from very good to unsatisfactory. DISCUSSION: There is a lack of injury-related economic evidence from LMICs. Current costing research has considerable variability in the costs and cost descriptions of injury and associated prevention interventions. The generalizability of these studies is limited. Yet the economic burden of injury is high, suggesting significant potential for cost savings through injury prevention. A standardized approach to economic evaluation of injury in LMICs is needed to further prioritize investing in injury prevention.

Pediatric burn injuries in South Africa: a 15-year analysis of hospital data.

INTRODUCTION: Burns are a significant burden of pediatric injuries, particularly in low and middle-income countries, were more than 90% of burn-related pediatric deaths occur. This study explores pediatric burn-related injuries over a fifteen year time period in South Africa through an analysis of a pediatric trauma surveillance system. METHODS: This retrospective observational study used data collected by Childsafe South Africa from the Red Cross War Memorial Children's Hospital (RCH) trauma registry in Cape Town, South Africa between 1995 and 2009 for children less than 13 years of age who presented with burn injuries to the hospital's casualty department. Demographic data and Abbreviated Injury Scores (AISs) were first assessed, followed by an analysis of time trends using Poisson regression. Logistic regression models were used to analyse factors related to hospital admissions. RESULTS: Between 1995 and 2009, 9438 children with burn-related injuries presented to RCH, of which nearly three-quarters resulted from scalds (73%; n=7024). The mean age of the injured children was 3.1 ± 2.9 years 58% were male. 11 deaths occurred in the hospital's casualty department. 39% of injuries were minor, 56% were moderate, and 5% were severe. During the 15-year study period, moderate burn injuries increased by 3%, while minor injuries decreased by 10% (p<0.05). 49% of all children were admitted to the hospital. Hospital admissions increased by 3% (p<0.05) during the study period. CONCLUSIONS: Pediatric burn injuries are a significant contributor to the burden of child diseases in developing county hospitals. Pediatric surveillance systems, such as Childsafe South Africa's, are important to study epidemiologic changes in burn injuries. Findings suggest the need for targeted interventions to address the prevention of specific burn-related injuries.

Assessing trauma care at the district and provincial hospital levels: a case study of hospitals in Kenya.

Trauma is a major cause of death and disability worldwide, of which more than 90% occur in low- and middle-income countries. Given the magnitude of this inequality, there is a need to devise and use tools to assess the capacity of facility-based trauma care. This study used two tools, hospital flowcharts and the World Health Organization's Trauma Care Checklist, to describe trauma care capacity at two hospitals in Kenya and ways in which this capacity can be strengthened. We found these hospitals had a large volume of trauma, but due to the lack of intensive care units, specialized trauma units, and axillary services, such as orthopedics and neurosurgery, the hospitals had a limited ability to provide definitive care for injured patients in critical condition. Additionally, organizational capabilities, such as trauma registries, trauma-specific training, and quality improvement programmes were lacking. The state of trauma care at district and provincial levels in Kenya demonstrates a strong case for national and global investment in clinical and systemic interventions.

A Simulation Study of the Self-Assembly of Coarse-Grained Skin Lipids.

Computer simulations are an attractive means by which to probe the self-assembly and molecular level organization of lipids in biological membranes. In this work, we study a simple skin lipid system to demonstrate the ability of the coarse-grained models used for fatty acids, cholesterol, and water to self-assemble, thus validating the models for use in further studies of the complex lipid mixtures found in the outermost layer of the skin. Specifically, the ability of the models to predict the correct self-assembled structures from molecular dynamics simulations is compared against those seen experimentally and from all-atom simulations of preassembled bilayers. The nature of the molecular interactions and their roles in the self-assembly process is elucidated and heuristics for self-assembly established. Additionally, the coarse-grained models have been used to characterize the effect of varying cholesterol composition on bilayer properties and the mechanism of bilayer destabilization by short and long chain fatty acids in the presence of cholesterol.