Systematic review of groin incision surgical site infection preventative measures in vascular surgery.

OBJECTIVE: Groin surgical site infections (SSIs) after open revascularization can lead to devastating consequences in patients. As a result, prevention has been crucial in minimizing the rate of SSIs. This review aims to evaluate the current body of literature regarding prevention ,techniques including prophylactic flaps, incision technique, topical antibiotic use, closed-incision negative pressure wound therapy, and adhesive drapes. METHODS: This review was conducted and reported in accordance with the PRISMA statement. A systematic review was conducted using the Google Scholar, PubMed, and Cochrane Review databases regarding the five prevention topics. The authors identified 1371 potential studies with 33 studies selected and analyzed after systematic review regarding the five preventative topics. RESULTS: The primary outcome of interest was how the rate of SSI was affected with each preventative technique. As a result, the recommendations are as follows. We suggest prophylactic flaps be considered in high-risk surgical patients undergoing open arterial exposure of the groin (Grade 2C). We suggest consideration of transverse incisions for open arterial exposure of the groin as a means of SSI prevention (Grade 2C). Given the lack of data regarding topical antibiotics no recommendation can be made regarding its use, we suggest closed-incision negative pressure wound therapy be used in groin surgical incisions at high risk for SSI (Grade 2B). Given the paucity of data regarding adhesive drapes, such as Ioban, no recommendation can be made regarding its use. CONCLUSIONS: This review highlights the effects of various preventative techniques and their potential benefit in the prevention of SSI in the groin. However, there is a glaring deficit in the available data, emphasizing the need for additional robust studies to better delineate their effectiveness and implementation into surgical practice. The use of endovascular techniques continues to increase, thus limiting the number of open arterial procedures and the potential for further studies to be conducted. To provide the high-quality studies needed to better evaluate these prevention techniques, large multi-institutional collaboration will likely be necessary to provide the appropriate number of patients to evaluate true effectiveness.

The Influence of Transdiagnostic Vulnerability Factors on PTSD Symptom Clusters in a Veteran Sample.

BACKGROUND: There is continuing debate as to the latent structure underpinning posttraumatic stress disorder symptomatology. The transdiagnostic vulnerability factors of negative affect, anxiety sensitivity (and subcomponents) and intolerance of uncertainty have previously demonstrated the ability to explain symptom clusters in a range of anxiety and depressive disorders, and may give further understanding of PTSD symptomatology. METHOD: Within an Australian Defence Force veteran population, structural equation modeling is utilized to assess whether a hierarchical Original Model containing negative affect as the general cognitive factor, anxiety sensitivity and intolerance of uncertainty as mid-level factors, can explain variability among posttraumatic stress disorder symptom clusters as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A further hierarchical Anxiety Sensitivity Extended model consisting of the general cognitive factor of negative affect and the three sub-factors of anxiety sensitivity as mid-level factors was also tested upon PTSD symptom clusters. RESULTS: Both the hierarchical Original and Anxiety Sensitivity Extended models fit the data well. Within both models, negative affect consistently showed significant direct effects upon the posttraumatic stress disorder symptom clusters. In the Original Model, anxiety sensitivity served as a significant mediator of negative affect for several symptom clusters, while intolerance of uncertainty was non-significant both as a direct effect and as a mediator of negative affect. In the Anxiety Sensitivity Extended Model, the cognitive concerns sub-factor of anxiety sensitivity served as a significant mediator of negative affect for several symptom clusters, while the social and physical concerns sub-factors did not have significant direct or mediating effects. CONCLUSIONS: This study demonstrates a transdiagnostic hierarchical model significantly explains the severity of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition posttraumatic stress disorder symptom constructs within a subclinical population. Negative affect and anxiety sensitivity can each be targeted with specific interventions, suggesting new avenues to augment current gold standard psychotherapeutic interventions.

Electrochemical Metal Recycling: Recovery of Palladium from Solution and In Situ Fabrication of Palladium-Carbon Catalysts via Impact Electrochemistry.

Recycling of critical materials, regeneration of waste, and responsible catalyst manufacture have been repeatedly documented as essential for a sustainable future with respect to the environment and energy production. Electrochemical methods have become increasingly recognized as capable of achieving these goals, and "impact" electrochemistry, with the advantages associated with dynamic nanoelectrodes, has recently emerged as a prime candidate for the recovery of metals from solution. In this report, the nanoimpact technique is used to generate carbon-supported palladium catalysts from low-concentration palladium(II) chloride solutions (i.e., a waste stream mimic) as a proof of concept. Subsequently, the catalytic properties of this material in both synthesis (Suzuki coupling reaction) and electrocatalysis (hydrogen evolution) are demonstrated. Transient reductive impact signals are shown and analyzed at potentials negative of +0.4 V (vs SCE) corresponding to the onset of palladium deposition in traditional voltammetry. Direct evidence of Pd modification was obtained through characterization by environmental scanning electron microscopy/energy-dispersive X-ray spectroscopy, inductively coupled plasma mass spectrometry, X-ray photoelectron spectroscopy, transmission electron microscopy, and thermogravimetric analysis of impacted particles. This showed the formation of deposits of Pd0 partially covering the 50 nm carbon black particles with approximately 14% Pd (wt %) under the conditions used. This material was then used to demonstrate the conversion of iodobenzene into its biphenyl product (confirmed through nuclear magnetic resonance) and the successful production of hydrogen as an electrocatalyst under acidic conditions (under cyclic voltammetry).

"Janus" Calixarenes: Double-Sided Molecular Linkers for Facile, Multianchor Point, Multifunctional, Surface Modification.

We herein report the synthesis of novel "Janus" calix[4]arenes bearing four "molecular tethering" functional groups on either the upper or lower rims of the calixarene. These enable facile multipoint covalent attachment to electrode surfaces with monolayer coverage. The other rim of the calixarenes bear either four azide or four ethynyl functional groups, which are easily modified by the copper(I)-catalyzed azide-alkyne cycloaddition reaction (CuAAC), either pre- or postsurface modification, enabling these conical, nanocavity reactor sites to be decorated with a wide range of substrates to impart desired chemical properties. Redox active species decorating the peripheral rim are shown to be electrically connected by the calixarene to the electrode surface in either "up" or "down" orientations of the calixarene.

Contrast enhanced ultrasound for traumatic spinal cord injury: an overview of current and future applications.

STUDY DESIGN: Systematic review. OBJECTIVE: Contrast-enhanced ultrasound (CEUS) is an imaging modality that has only recently seen neurosurgical application. CEUS uses inert microbubbles to intraoperatively visualize vasculature and perfusion of the brain and spinal cord in real time. Observation and augmentation of spinal cord perfusion is vital component of the management of traumatic spinal cord injury, yet there are limited imaging modalities to evaluate spinal cord perfusion. CEUS provides an intraoperative imaging tool to evaluate spinal cord perfusion in real time. The objective of this review is to evaluate the current literature on the various applications and benefits of CEUS in traumatic spinal cord injury. SETTING: South Carolina, USA. METHODS: This review was written according to the PRISMA 2020 guidelines. RESULTS: 143 articles were found in our literature search, with 46 of them being unique. After excluding articles for relevance to CEUS and spinal cord injury, we were left with 10 papers. Studies in animal models have shown CEUS to be an effective non-invasive imaging modality that can detect perfusion changes of injured spinal cords in real time. CONCLUSION: This imaging modality can provide object perfusion data of the nidus of injury, surrounding penumbra and healthy neural tissue in a traumatized spinal cord. Investigation in its use in humans is ongoing and remains promising to be an effective diagnostic and prognostic tool for those suffering from spinal cord injury.

Caring for the country: fatigue, sleep and mental health in Australian rural paramedic shiftworkers.

This study investigated sleep quality, fatigue, mental health and physical activity in rural paramedic shiftworkers. Although limited, previous studies have associated high fatigue levels and poorer health in this sector with shiftwork rostering and occupational demands. A modified version of the Standard Shiftwork Index was completed by 150 paramedics (117 male and 31 females) from rural Victoria. Single sample t tests found significantly higher levels of fatigue, depression, anxiety, and stress, and significantly poorer sleep quality than reference samples. Paramedics also reported less physical activity than community samples. By regression analysis, sleep quality explained the greatest amount of variance in fatigue scores, followed by depression and age. No gender differences in levels of depression or fatigue were found. Consistent with an earlier study of metropolitan paramedics based on the same methodology, findings suggest rural ambulance paramedic shiftworkers are at particular risk for increased levels of fatigue and depression (regardless of age or gender) and poor quality sleep. Organisational intervention was suggested.

Impact Electrochemistry of MoS2: Electrocatalysis and Hydrogen Generation at Low Overpotentials.

MoS2 materials have been extensively studied as hydrogen evolution reaction (HER) catalysts. In this study nanoparticulate MoS2 is explored as a HER catalyst through impact voltammetry. The onset potential was found to be -0.10 V (vs RHE) at pH 2, which was confirmed to be due to HER by scale-up of the impact experiment to generate and collect a sufficient volume of the gas to enable its identification as hydrogen via gas chromatography. This is in contrast to electrodeposited MoS2, which was found to be stable in pH 2 sulfuric acid solution with an onset potential of -0.29 V (vs RHE), in good agreement with literature. XPS was used to categorize the materials and confirm the chemical composition of both nanoparticles and electrodeposits, with XRD used to analyze the crystal structure of the nanoparticles. The early onset of HER was postulated from kinetic analysis to be due to the presence of nanoplatelets of about 1-3 trilayers participating in the impact reactions, and AFM imaging confirmed the presence of these platelets.

Black macular patches on parietal peritoneum and other extraintestinal sites from intraperitoneal spillage and spread of India ink from preoperative endoscopic tattooing: an endoscopic, surgical, gross pathologic, and microscopic study.

BACKGROUND: Three cases, including one case report and two clinical images, have been reported of extraintestinal or peritoneal black maculae detected at laparoscopy after colonoscopic tattooing, presumably from intraperitoneal spillage of India ink during tattooing. AIMS: Report three cases of inadvertent extraintestinal tattooing from endoscopic tattooing of intestinal lesions, provide histologic evidence for the presumed pathophysiology, and promulgate recommendations to prevent this complication. METHODS: Three patients underwent endoscopic tattooing of intestinal lesions using India ink, surgery for lesion removal, and pathologic analysis. RESULTS: Three patients had black macular patches or streaks identified intraoperatively at extraintestinal sites after endoscopic tattooing of intestinal lesions with India ink: (1) black patches on peritoneum 7 days after colonoscopic tattooing of cecal cancer, (2) black streaks on band connecting cecum to peritoneum 13 days after colonoscopic tattooing of cecal cancer, and (3) blackish band on jejunal mesentery 28 days after tattooing presumptive bleeding jejunal lesion. Pigmentation was detected at both injection and extraintestinal sites in all patients by (1) surgery, (2) gross pathology, and (3) microscopic examination demonstrating intracellular black pigmentation within mesothelial cells and macrophages. Special histologic stains were consistent with a carbon-based pigment, and inconsistent with iron or melanin as the pigment. The proposed mechanism is intraperitoneal India ink spillage from deep intestinal injection, as supported by histologic findings of subserosal pigment accumulation. An alternative histologic mechanism is migration of pigment-laden macrophages via lymphovascular channels. CONCLUSIONS: Endoscopic injection of India ink using standard sclerotherapy needles can inadvertently tattoo extraintestinal sites in addition to tattooing the primary lesion. Despite its striking appearance, this intraoperative, gross, and microscopic finding is likely not pathologically significant, given its proposed pathophysiology. Surgical recognition of this entity is important, however, to prevent misinterpretation of findings as peritoneal melanoma, endometrial implants, infarcted mesentery, or tattooed cancer. This complication may be prevented by proper tattooing technique.

Surface modification of polymeric biomaterials: utilization of cyclodextrins for blood compatibility improvement.

A novel modified polymeric biomaterial surface using cyclodextrins (CDs) for improved blood compatibility was studied. Plasticized poly(vinyl chloride) (PVC-P) was selected for modification and polyethylene was used as a reference material. The modification was achieved by polymer blending. Fibrinogen and albumin adsorption were utilized as indices for the assessment of the blood compatibility. Surface characterization confirmed that CDs were able to accumulate at the PVC surface and alter the surface properties. The combination of other hydrophilic polymers such as poly(ethylene oxide) (PEO) and PEO/poly(propylene oxide) (PPO) copolymers, such as Pluronic F68 (F68), with CDs were also investigated. These modified materials have a remarkable protein-resistant surface. The combination of B-cyclodextrin (B-CD)/PEO and B-CD/F68 in certain feeding ratio are synergistic in producing enhanced blood compatibility.

The in vitro adsorption of cytokines by polymer-pyrolysed carbon.

This study investigated a range of phenol-formaldehyde-aniline-based pyrolysed carbon matrices and their component materials, for their ability to adsorb a range of inflammatory cytokines crucial to the progression of sepsis. The efficiency of adsorption of the target molecules from human plasma was assessed and compared to that of Adsorba 300C, a commercially available cellulose-coated activated charcoal. Results indicate that a number of the primary carbon/resin materials demonstrate efficient adsorption of the cytokines studied here (TNF, IL-6 and IL-8), comparable to other adsorbents under clinical investigation. Our findings also illustrate that these adsorbent capabilities are retained when the primary particles are combined to form a pyrolysed carbon matrix. This capability will enable the engineering of the carbon matrix porosity allowing a blend of carbonised particle combinations to be tailored for maximum adsorption of inflammatory cytokines. The present findings support further investigation of this carbon material as a combined carbon-based filtration/adsorbent device for direct blood purification.

Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide.

This manuscript reports recommendations of the National Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force. This task force was convened by 6 major emergency medicine organizations to develop a standardized curriculum for fourth year medical students. The structure of the curriculum is based on clerkship curricula from other specialties such as internal medicine and pediatrics. The report contains a historical context, global and targeted needs assessment, goals and objectives, recommended educational strategies, implementation guidelines, and suggestions on feedback and evaluation.

Metal-free electrocatalytic hydrogen oxidation using frustrated Lewis pairs and carbon-based Lewis acids.

Whilst hydrogen is a potentially clean fuel for energy storage and utilisation technologies, its conversion to electricity comes at a high energetic cost. This demands the use of rare and expensive precious metal electrocatalysts. Electrochemical-frustrated Lewis pairs offer a metal-free, CO tolerant pathway to the electrocatalysis of hydrogen oxidation. They function by combining the hydrogen-activating ability of frustrated Lewis pairs (FLPs) with electrochemical oxidation of the resultant hydride. Here we present an electrochemical-FLP approach that utilises two different Lewis acids - a carbon-based N-methylacridinium cation that possesses excellent electrochemical attributes, and a borane that exhibits fast hydrogen cleavage kinetics and functions as a "hydride shuttle". This synergistic interaction provides a system that is electrocatalytic with respect to the carbon-based Lewis acid, decreases the required potential for hydrogen oxidation by 1 V, and can be recycled multiple times.

Novel B(Ar')2(Ar'') hetero-tri(aryl)boranes: a systematic study of Lewis acidity.

A series of homo- and hetero-tri(aryl)boranes incorporating pentafluorophenyl, 3,5-bis(trifluoromethyl)phenyl, and pentachlorophenyl groups, four of which are novel species, have been studied as the acidic component of frustrated Lewis pairs for the heterolytic cleavage of H2. Under mild conditions eight of these will cleave H2; the rate of cleavage depending on both the electrophilicity of the borane and the steric bulk around the boron atom. Electrochemical studies allow comparisons of the electrophilicity with spectroscopic measurements of Lewis acidity for different series of boranes. Discrepancies in the correlation between these two types of measurements, combined with structural characterisation of each borane, reveal that the twist of the aryl rings with respect to the boron-centred trigonal plane is significant from both a steric and electronic perspective, and is an important consideration in the design of tri(aryl)boranes as Lewis acids.

Assessing the in vitro biocompatibility of a novel carbon device for the treatment of sepsis.

The aim of the present study was to conduct a preliminary investigation into the blood biocompatibility of a novel, uncoated carbon for use in a filtration/adsorption device for the treatment of sepsis. Carbon well prototypes were manufactured from phenol-formaldehyde-aniline-based pyrolysed carbons using monolithic polymer technology. Inflammatory blood cell and plasma protein mediation of the inflammatory response were evaluated using the novel carbon prototypes and compared with dialyser membrane and tissue culture plate controls. Assays determining monocyte and granulocyte adhesion, platelet adhesion and activation, granulocyte activation and complement activation were performed. Preliminary findings suggest an adsorptive but passivating carbon surface. Moderate levels of monocyte and granulocytes adhesion were seen in conjunction with adsorption of plasma proteins to the carbon surface. Activation of granulocyte and adherent platelets was not detected and the complement cascade was not activated by the carbons, indicating a surface compatible with blood contact. The results support the further development of the proposed carbon-based device for the treatment of sepsis.

Novel "anchor modification" of polymeric biomaterial surfaces by the utilization of cyclodextrin inclusion complex supramolecules.

In this article, a novel approach for the surface modification of polymeric biomaterials by the utilization of supramolecules was studied. The supramolecules selected were cyclodextrin inclusion complexes (CICs). The biomaterial selected for surface modification was plasticized poly (vinyl chloride) (PVC-P). Results indicate that when the CICs were blended into PVC-P, they tend to migrate and "anchor" on the surface to achieve a remarkable protein-resistant surface, with improved blood compatibility. In comparison with a physical mixture of cyclodextrins and a "guest" molecule, such as poly(ethylene oxide) (PEO)-poly(propylene oxide) (PPO)-PEO and PPO-PEO-PPO for PVC-P modification, CICs modified PVC-P are more consistent in processing and achieve reproducible surface characteristics. Based on this study, a novel "anchor modification" was proposed regarding CICs modified surface. This "anchor modification" is likely to reduce plasticizer extraction from PVC-P and also can be utilized for the modification of polymers other than PVC-P.

Case files of the University of Massachusetts fellowship in medical toxicology: lethal dose of opioids contained in an elastomeric capsule labeled as vancomycin.

UNLABELLED: A 67 year-old male presented to the emergency department with alteration in mental status. On arrival he had vital signs: pulse 110, BP 173/83, respiratory rate 4, oxygen saturation 57% and temperature 36.1 degrees Celsius. His past medical history included hypertension, vitamin B12 deficiency, hyperlipidemia, and recurrent cellulitis treated with vancomycin. The patient had no response to noxious stimuli, pinpoint pupils, and agonal respirations. Secondary to his wife's vehement denial that he had access to or history of using any narcotics, he was intubated after 2.2mg IV naloxone failed to reverse respiratory depression. Thirty minutes before presentation, however, he had received an intravenous infusion of vancomycin administered by his wife at home. The vancomycin, obtained from a home infusion medication supply company, was contained in one of five sealed elastomeric capsules delivered earlier that day. A qualitative comprehensive toxicology screen of urine for 1043 substances identified morphine, codeine, naloxone, lidocaine and caffeine. The original elastomeric container was not available for testing, but another container from the same delivery was submitted for testing to the state forensic laboratory. This intact container was labeled as Vancomycin 1g in 240mL of normal saline. The forensic laboratory confirmed that the alkaloidal contents of the elastomeric capsule were 10% codeine, 4.4% 6-monoacetyl morphine, and 84% morphine. No vancomycin was identified in the infusion bottles. The case was referred to the local police department and the state department of health drug control board. The home infusion company was also immediately notified to prevent similar occurrence. CONCLUSION: We are reporting the first known case of opioid overdose from an adulterated elastomeric capsule that was labeled as containing an antimicrobial agent.

Blood interactions with plasticised poly (vinyl chloride): influence of surface modification.

Surface modification of plasticised poly (vinyl chloride) (PVC), with di-(2-ethylhexyl) phthalate (DEHP) as plasticiser, for the improvement of blood compatibility in potential clinical use such as cardiopulmonary bypass was achieved by heparinisation. The influence of surface modification on blood compatibility was assessed in terms of the influence on fibrinogen and factor XII adsorption in vitro, and the generation of thrombin-antithrombin III complex (TAT) and the complement component C3a, in vitro and ex vivo. Electron spectroscopy for chemical analysis (ESCA) was used to characterise the heparinised surface in order to correlate the surface properties with the blood response. Results indicate that at the plasticised PVC surface there is a higher content of heparin than that of the PVC and the DEHP content is lower than that present at the surface of standard plasticised PVC. The blood compatibility assessment confirms the importance of surface modification for the improvement of blood compatibility.