Intracapsular neck of femur fractures secondary to civilian gunshot injuries: an inter- and intra-observer agreement study on classification and treatment using the AO/OTA classification.

PURPOSE: Numerous classification systems have been developed for neck of femur fractures, but none have been tested for reliability in gunshot injuries. Our primary objective was to assess the inter-observer and intra-observer reliability of the AO/OTA classification system when applied to intracapsular neck of femur fractures secondary to low-velocity civilian gunshots wounds (GSWs). Our secondary objective was to test the reliability of the AO/OTA classification system in guiding surgeon treatment choices for these fractures. PATIENTS AND METHODS: Eighteen reviewers (six orthopaedic traumatologists, six general orthopaedic surgeons and six junior orthopaedic fellows) were given a set of 25 plain radiographs and CT scans of femur neck fractures secondary to GSW. For each clinical case, all reviewers selected a classification as well as treatment option from a list of given options. Inter-observer reliability was measured at the initial classification. The exercise was repeated 10-12 weeks later by the same 18 reviewers to test intra-observer reliability. RESULTS: The Fleiss kappa values indicate only slight agreement amongst raters, across all experience levels, for both injury classification and treatment. Intra-observer agreement was fair across all experience levels for both injury classification and treatment. CONCLUSION: The AO/OTA classification showed only slight reliability in classification of gunshot fractures of the femur neck. With only fair reliability, it also failed to guide surgical treatment thus rendering its routine use in daily clinical practice of questionable value.

Resection and reconstruction in high-grade pancreatic head injuries.

This study by Chui et al adds further important evidence in the treatment of high-grade pancreatic injuries and endorses the concept of the model of pancreatic trauma care designed to optimize treatment, minimize morbidity and enhance survival in patients with complex pancreatic injuries. Although the authors have demonstrated favorable outcomes based on their limited experience of 5 patients who underwent a pancreaticoduodenectomy (PD), including 2 patients who were "unstable" and did not have damage control surgery (DCS), we would caution against the general recommendations promoting index PD without DCS in "unstable" grade 5 pancreatic head injuries.

Late video-assisted thoracoscopic surgery versus thoracostomy tube reinsertion for retained hemothorax after penetrating trauma, a prospective randomized control study.

BACKGROUND: Early video-assisted thoracoscopic surgery (VATS) is the recommended treatment of choice for retained hemothorax (RH). A prospective single-center randomized control study was conducted to compare outcomes between VATS and thoracostomy tube (TT) reinsertion for patients with RH after penetrating trauma in a resource constrained unit. Our hypothesis was that patients with a RH receiving VATS instead of TT reinsertion would have a shorter hospital stay and lesser complications. MATERIALS AND METHODS: From January 2014 to November 2019, stable patients with thoracic penetrating trauma complicated with retained hemothoraces were randomized to either VATS or TT reinsertion. The outcomes were length of hospital stay (LOS) and complications. RESULTS: Out of the 77 patients assessed for eligibility, 65 patients were randomized and 62 analyzed: 30 in the VATS arm and 32 in the TT reinsertion arm. Demographics and mechanisms of injury were comparable between the two arms. Length of hospital stay was: preprocedure: VATS 6.8 (+/-2.8) days and TT 6.6 (+/- 2.4) days (p = 0.932) and postprocedure: VATS 5.1 (+/-2.3) days, TT 7.1 (+/-6.3) days (p = 0.459), total LOS VATS 12 (+/- 3.9) days, and TT 14.4 (+/-7) days (p = 0.224). The TT arm had 15 complications compared to the VATS arm of four (p = 0.004). There were two additional procedures in the VATS arm and 10 in the TT arm (p = 0.014). CONCLUSION: VATS proved to be the better treatment modality for RH with fewer complications and less need of additional procedures, while the LOS between the two groups was not statistically different.

Safety, Feasibility, and Acceptability of a Multisite Individualized Exercise Intervention for People with Multiple Myeloma.

INTRODUCTION: High rates of disease- and treatment-related symptoms, such as bone lesions, in people with multiple myeloma (MM) create uncertainty on the safety and feasibility of exercise. This study determined the safety, feasibility, and acceptability of an individualized exercise medicine program for people with MM at any disease stage. METHODS: A multisite, randomized waitlist-controlled trial was conducted of an individualized, high-intensity aerobic, resistance, and impact-loading exercise program. The exercise sessions were supervised twice weekly by accredited exercise physiologists, with one additional unsupervised session per week, for 12 wk. Safety was determined by number of adverse and serious adverse events. Feasibility outcome measures were study eligibility, recruitment, adherence, and attrition. Acceptability was determined by qualitative interviews and subjective levels of enjoyment. RESULTS: Of 203 people with MM screened, 88% were eligible, with 34% accepting participation (60 people) and 20% attrition for the between-group analysis, meeting a priori criteria (≥25% and <25%, respectively). No adverse or serious adverse events attributed to testing and/or exercise training were reported. Attendance at supervised exercise sessions was 98%, with 45% completion of the home-based exercise sessions. Adherence rates were 35%, 63%, and 34% for the aerobic, resistance, and impact-loading protocols, with 55%, 80%, and 37% of participants meeting a priori criteria (75% of protocol). Acceptability of the exercise program was high (mean, 82%; 95% confidence interval, 78%-87%) and highly supported by qualitative responses. CONCLUSIONS: An individualized, high-intensity aerobic, resistance, and impact-loading exercise medicine program is safe and acceptable, and feasible by some measures for people with MM. Adherence to the prescribed exercise protocols was limited by comorbidities and disease symptoms. Strategies to improve unsupervised exercise completion are warranted in this population.

Penetrating renal injuries: an observational study of non-operative management and the impact of opening Gerota's fascia.

BACKGROUND: Non-operative management has become increasingly popular in the treatment of renal trauma. While data are robust in blunt mechanisms, the role of non-operative management in penetrating trauma is less clear. Additionally, there is a paucity of data comparing gunshot and stab wounds. METHODS: A retrospective review of patients admitted to a high-volume level 1 trauma center (Groote Schuur Hospital, Cape Town) with penetrating abdominal trauma was performed. Patients with renal injuries were identified and compared based on mechanism [gunshot (GSW) vs. stab] and management strategy (operative vs. non-operative). Primary outcomes of interest were mortality and failure of non-operative management. Secondary outcomes of interest were nephrectomy rates, Clavien-Dindo complication rate, hospital length of stay, and overall morbidity rate. RESULTS: A total of 150 patients with renal injuries were identified (82 GSW, 68 stab). Overall, 55.2% of patients required emergent/urgent laparotomy. GSWs were more likely to cause grade V injury and concurrent intra-abdominal injuries (p > 0.05). The success rate of non-operative management was 91.6% (89.9% GSW, 92.8% stab, p = 0.64). The absence of hematuria on point of care testing demonstrated a negative predictive value of 98.4% (95% CI 96.8-99.2%). All but 1 patient who failed non-operative management had associated intra-abdominal injuries requiring surgical intervention. Opening of Gerota's fascia resulted in nephrectomy in 55.6% of cases. There were no statistically significant risk factors for failure of non-operative management identified on univariate logistic regression. CONCLUSIONS: NOM of penetrating renal injuries can be safely and effectively instituted in both gunshot and stab wounds with a very low number of patients progressing to laparotomy. Most patients fail NOM for associated injuries. During laparotomy, the opening of Gerota's fascia may lead to increased risk of nephrectomy. Ongoing study with larger populations is required to develop effective predictive models of patients who will fail NOM.

An Individualized Exercise Intervention for People with Multiple Myeloma-Study Protocol of a Randomized Waitlist-Controlled Trial.

People with multiple myeloma (MM) are second only to people with lung cancer for the poorest reported health-related quality of life (HRQoL) of all cancer types. Whether exercise can improve HRQoL in MM, where bone pain and lesions are common, requires investigation. This trial aims to evaluate the efficacy of an exercise intervention compared with control on HRQoL in people with MM. Following baseline testing, people with MM (n = 60) will be randomized to an exercise (EX) or waitlist control (WT) group. EX will complete 12-weeks of supervised (24 sessions) and unsupervised (12 sessions) individualized, modular multimodal exercise training. From weeks 12-52, EX continue unsupervised training thrice weekly, with one optional supervised group-based session weekly from weeks 12-24. The WT will be asked to maintain their current activity levels for the first 12-weeks, before completing the same protocol as EX for the following 52 weeks. Primary (patient-reported HRQoL) and secondary (bone health and pain, fatigue, cardiorespiratory fitness, muscle strength, body composition, disease response, and blood biomarkers) outcomes will be assessed at baseline, 12-, 24- and 52-weeks. Adverse events, attendance, and adherence will be recorded and cost-effectiveness analysis performed. The findings will inform whether exercise should be included as part of standard myeloma care to improve the health of this unique population.

Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center.

BACKGROUND: Global trend has seen management shift towards selective conservatism in penetrating abdominal trauma (PAT). The purpose of this study is to compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively. METHODS: Prospective cohort study of all patients Ùpresenting with PAT to Groote Schuur Hospital, Cape Town from 01 May 2015 to 30 April 2017. Presentation; management; and outcomes of patients were compared. Univariate predictors of delayed operative management (DOM) were explored. RESULTS: Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3 years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05). CONCLUSION: Patients with PAT in the absence of haemodynamic instability; peritonism; organ evisceration; positive radiological findings, or an unreliable clinical examination, can be managed expectantly without increased morbidity or mortality.

A Prospective Audit of 805 Consecutive Patients With Penetrating Abdominal Trauma: Evolving Beyond Injury Mechanism Dictating Management.

BACKGROUND: Global trends of penetrating abdominal trauma (PAT) have seen a shift toward a selectively conservative management strategy. However, its widespread adoption for gunshot injuries has been sluggish. The purpose of this study is to compare the injury mechanisms of gunshot (GSW) and stab wounds (SW) to the abdomen in presentation, management, and outcomes. METHODS: Prospective cohort study, set in Cape Town, South Africa, over 2 years. All patients presenting to the center with PAT during this time were included. Presentation, management, and outcomes were compared by injury mechanism, with a focus on the operative strategy (operative vs nonoperative). RESULTS: During the study period, 805 patients (SW 37.6%; GSW 62.4%) with PAT were managed. Immediate laparotomies were performed in 119 (39.3%) SW and 355 (70.7%) GSW, with a therapeutic laparotomy rate of 85.7% and 91.8% for SW and GSW, respectively. Nonoperative management (NOM) was implemented in 184 SW (60.7%) and 147 GSW (29.3%) (P < 0.001), with a 92.9% and 92.5% success rate for SW and GSW, respectively. The therapeutic laparotomy rate for the delayed laparotomies (DOM) was 69.2% for SW, and 90.9% for GSW. The accuracy of clinical assessment (with adjuncts) in determining the need for laparotomy was: GSW-92% and SW-91%. Univariate analysis revealed the mechanism not to be associated with DOM. The overall mortality rate was 7.2%, and nonfatal morbidities 22.2%. CONCLUSION: Although GSW is a more morbid and often fatal injury, the general principles of selective conservatism hold true for both GSW and SW, equally.

Physical Activity in People with Multiple Myeloma: Associated Factors and Exercise Program Preferences.

People with multiple myeloma (MM) often experience disease symptoms and treatment toxicities that can be alleviated through physical activity (PA). However, the majority of people with MM are insufficiently active. This study explored PA among people with MM, including differences by treatment stage, symptoms and demographics, and programming preferences. Overall, 126 people with MM (77% response rate) completed the survey. Pre-diagnosis, 25.4% were sufficiently active, with 12.0% remaining active after treatment. Respondents who were physically active pre-diagnosis were 46.7 times (95% confidence intervals CI: 2.03, 1072.1) more likely to meet PA guidelines following an MM diagnosis compared to people not meeting guidelines pre-diagnosis. Experiencing MM symptoms and receiving PA advice from healthcare professionals were not associated with meeting PA guidelines. People with MM were interested in exercise programs (55%) that are low-cost (77%), offered at flexible times (74%), and at locations close to home (69%), both during active treatment and remission (57%), and supervised by an exercise oncology specialist (48%). People with MM, particularly those insufficiently active prior to diagnosis, should be offered convenient, low-cost exercise programs supervised by an exercise oncology specialist to increase PA participation.

Zanubrutinib (BGB-3111) plus obinutuzumab in patients with chronic lymphocytic leukemia and follicular lymphoma.

Zanubrutinib (BGB-3111) is a next-generation Bruton tyrosine kinase inhibitor designed to be more selective with fewer off-target effects. We conducted a phase 1 study to assess the safety of its combination with obinutuzumab and evaluate early efficacy in 81 patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) or relapsed/refractory (R/R) follicular lymphoma (FL). In this phase 1b study, zanubrutinib was tolerable at 160 mg twice daily or 320 mg once daily combined with IV obinutuzumab in patients with CLL/SLL (n = 45) and FL (n = 36). Common adverse events (AEs) included upper respiratory tract infection (51%; n = 23), neutropenia (44%; n = 20), contusion (33%; n = 15), cough, diarrhea, or fatigue (27%; n = 12 each), and pyrexia (22%; n = 10) in CLL/SLL patients and upper respiratory tract infection (39%; n = 14), contusion (28%; n = 10), fatigue (25%; n = 9), and cough (22%; n = 8) in FL patients. Neutropenia was the most common grade 3/4 AE (CLL/SLL, 31% [n = 14]; FL, 14% [n = 5]). Five patients required temporary dose reductions, and 5 discontinued the study drug because of AEs. Overall response rate (ORR) was 100% (n = 20) in treatment-naïve CLL patients and 92% (n = 23) in R/R CLL patients. ORR in 36 R/R FL patients was 72% (n = 26), with 14 complete and 12 partial responses. Median follow-up was 29 months (range, 8-37) for CLL patients and 20 months (range, 2-37) for FL patients. Zanubrutinib and obinutuzumab combination therapy was generally well tolerated. This trial was registered at www.clinicaltrials.gov as #NCT02569476.

Engineering a Humanised Niche to Support Human Haematopoiesis in Mice: Novel Opportunities in Modelling Cancer.

Despite the bone marrow microenvironment being widely recognised as a key player in cancer research, the current animal models that represent a human haematopoietic system lack the contribution of the humanised marrow microenvironment. Here we describe a murine model that relies on the combination of an orthotopic humanised tissue-engineered bone construct (ohTEBC) with patient-specific bone marrow (BM) cells to create a humanised bone marrow (hBM) niche capable of supporting the engraftment of human haematopoietic cells. Results showed that this model supports the engraftment of human CD34+ cells from a healthy BM with human haematopoietic cells migrating into the mouse BM, human BM compartment, spleen and peripheral blood. We compared these results with the engraftment capacity of human CD34+ cells obtained from patients with multiple myeloma (MM). We demonstrated that CD34+ cells derived from a diseased BM had a reduced engraftment potential compared to healthy patients and that a higher cell dose is required to achieve engraftment of human haematopoietic cells in peripheral blood. Finally, we observed that hematopoietic cells obtained from the mobilised peripheral blood of patients yields a higher number of CD34+, overcoming this problem. In conclusion, this humanised mouse model has potential as a unique and patient-specific pre-clinical platform for the study of tumour-microenvironment interactions, including human bone and haematopoietic cells, and could, in the future, serve as a drug testing platform.

The gap in operative exposure in trauma surgery: quantifying the benefits of an international rotation.

BACKGROUND: International rotations with hands-on experience are commonly cited as a potential supplement to the current experience of surgical trainees in trauma; however, quantification of this experience remains unclear. METHODS: A link to an online survey was distributed by electronic mail to physicians who rotated for any period of time at the Trauma Unit of the Groote-Shuur Hospital of the University of Cape Town from January 1, 2006, to December 2016. RESULTS: Of 160 participants, 75 (47%) completed the survey. A high proportion (45%) had performed less than 25 trauma-related surgical procedures during their previous training. Most (56%) performed ≥ 10 trauma laparotomies and sternotomies/thoracotomies during their rotation, whereas 43% performed ≥ 5 vascular procedures. The level of perceived confidence in managing trauma patients increased significantly from a median of 3/10 to 7/10 (P < .05). CONCLUSION: Rotations at large-volume trauma centers abroad offer the opportunity for a hands-on operative experience and may enhance the confidence of surgical trainees. Further standardization of these opportunities may result in a larger-scale participation of graduate residents and fellows.

Maximizing the potential of trauma registries in low-income and middle-income countries.

Injury is a major global health issue, resulting in millions of deaths every year. For decades, trauma registries have been used in wealthier countries for injury surveillance and clinical governance, but their adoption has lagged in low-income and middle-income countries (LMICs). Paradoxically, LMICs face a disproportionately high burden of injury with few resources available to address this pandemic. Despite these resource constraints, several hospitals and regions in LMICs have managed to develop trauma registries to collect information related to the injury event, process of care, and outcome of the injured patient. While the implementation of these trauma registries is a positive step forward in addressing the injury burden in LMICs, numerous challenges still stand in the way of maximizing the potential of trauma registries to inform injury prevention, mitigation, and improve quality of trauma care. This paper outlines several of these challenges and identifies potential solutions that can be adopted to improve the functionality of trauma registries in resource-poor contexts. Increased recognition and support for trauma registry development and improvement in LMICs is critical to reducing the burden of injury in these settings.

An Update on Foley Catheter Balloon Tamponade for Penetrating Neck Injuries.

BACKGROUND: Foley catheter balloon tamponade (FCBT) for bleeding penetrating neck injuries (PNIs) is effective. This study aims to audit the technique and outcomes of FCBT. METHODS: Adult patients with PNIs requiring FCBT presenting to Groote Schuur Hospital (GSH) within a 22-month study period were prospectively captured on an approved electronic registry. Retrospective analysis included demographics, major injuries, investigations, management and outcomes. RESULTS: During the study period, 628 patients with PNI were treated at GSH. In 95 patients (15.2%), FCBT was utilised. The majority were men (98%) with an average age of 27.9 years. Most injuries were caused by stab wounds (90.5%). The majority of catheters (81.1%) were inserted prior to arrival at GSH. Computerised tomographic angiography (CTA) was done in 92.6% of patients, while eight patients (8.4%) required catheter-directed angiography. Six were performed for interventional endovascular management. Thirty-four arterial injuries were identified in 29 patients. Ongoing bleeding was noted in three patients, equating to a 97% success rate for haemorrhage control. Thirteen (13.7%) patients required neck exploration. Seventy-two (75.8%) patients without major arterial injury had removal of the catheter at 48-72 h. Two of these bled on catheter removal. A total of 36 complications were documented in 28 patients (29.5%). There was one death due to uncontrolled haemorrhage from the neck wound. CONCLUSION: This large series highlights the ease of use of FCBT with high rates of success at haemorrhage control (97%). Venous injuries and minor arterial injuries are definitively managed with this technique.

Penetrating Pharyngoesophageal Injury: Practice Patterns in the Era of Nonoperative Management - A National Trauma Data Bank Review from 2007 to 2011.

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cervical pharyngoesophageal injuries implemented by trauma surgeons in the United States. Methods: The National Trauma Data Bank datasets 2007-2011 were queried for penetrating pharyngeal and/or cervical esophageal injuries. Subjects surviving 24 hours or more were analyzed based on whether a surgical exploration was pursued and by gunshot versus stabbing mechanism. Results: In all, 1,256 patients were identified, representing 6% of all penetrating neck injuries during the study period. The majority (84%) were male, with a median age of 27 years. Injury severity was high (median score of 14). Compared to stabbing victims, gunshot patients were more likely to have associated cervical spine (24% vs. 1%, p < .01) and carotid artery injury (14% vs. 9%, p < .01). Neck exploration was performed in 49% of patients who survived at least 24 hours, with 90% occurring within the first day of admission. Of patients who underwent a delayed neck exploration, 35% required a tracheostomy and 41% required a feeding tube placement. The overall mortality was 4%. Nonoperative management was not associated with increased odds for death (adjusted odds ratio (AOR) 0.55, p = .17). Conclusions: Nonoperative management of penetrating pharyngoesophageal injuries is commonly utilized with no effect on mortality.

Selective nonoperative management of liver gunshot injuries.

PURPOSE: Nonoperative management (NOM) of gunshot liver injuries (GLI) is infrequently practiced. The aim of this study was to assess the safety of selective NOM of GLI. METHODS: A prospective, protocol-driven study, which included patients with GLI admitted to a level 1 trauma center, was conducted over a 52-month period. Stable patients without peritonism or sustained hypotension with right-sided thoracoabdominal (RTA) and right upper quadrant (RUQ), penetrating wounds with or without localized RUQ tenderness, underwent contrasted abdominal CT scan to determine the trajectory and organ injury. Patients with established liver and/or kidney injuries, without the evidence of hollow viscus injury, were observed with serial clinical examinations. Outcome parameters included the need for delayed laparotomy, complications, the length of hospital stay and survival. RESULTS: During the study period, 54 (28.3%) patients of a cohort of 191 patients with GLI were selected for NOM of hemodynamic stability, the absence of peritonism and CT imaging. The average Revised Trauma Score (RTS) and Injury Severity Score (ISS) were 7.841 and 25 (range 4-50), respectively. 21 (39%) patients had simple (Grades I and II) and 33 (61%) patients sustained complex (Grades III to V) liver injuries. Accompanying injuries included 12 (22.2%) kidney, 43 (79.6%) diaphragm, 20 (37.0%) pulmonary contusion, 38 (70.4%) hemothoraces, and 24 (44.4%) rib fractures. Three patients required delayed laparotomy resulting in an overall success of NOM of 94.4%. Complications included: liver abscess (1), biliary fistula (5), intrahepatic A-V fistula (1) and hospital-acquired pneumonia (3). The overall median hospital stay was 6 (IQR 4-11) days, with no deaths. CONCLUSION: The NOM of carefully selected patients with GLI is safe and associated with minimal morbidity.