Regional Anesthesia in Upper-Limb Surgery.

BACKGROUND: Local and regional anesthesia is associated with numerous clinical and institutional advantages relative to general anesthesia. As anesthesiologists and surgeons increasingly integrate local and regional anesthesia into their clinical practice, an understanding of the principles, evolution, and trends underpinning modern anesthetic techniques continues to be relevant. METHODS: A review of the literature in databases Medline, PubMed, and EMBASE identified recent developments, ongoing trends, and historical milestones in upper-limb regional anesthesia. RESULTS: Advances in regional anesthetic techniques in the last century have led to reduced postoperative pain, improved safety, and improved outcomes in upper-limb surgery. The development of ultrasound-guided techniques, as well as pharmacological advances in local anesthetic drugs and adjuncts, has further advanced the role of regional anesthesia. Wide-awake local anesthesia with no tourniquet has allowed certain procedures to be performed on select patients in outpatient and low-resource settings. CONCLUSIONS: This review provides an overview of local and regional anesthesia in the upper-limb from its historical origins to its contemporary applications in upper-limb surgery, particularly during the COVID-19 pandemic.

Iatrogenic Femur Fracture Following Medial Femoral Condyle Flap Harvest.

A case of iatrogenic femoral fracture after harvest of a medial femoral condyle flap is presented. The procedure was performed for a recalcitrant nonunion of the clavicle that required a flap of 6 × 1 × 1 cm. The patient suffered a supracondylar fracture at the proximal extent of the flap harvest site 3 weeks after surgery, requiring surgical fixation of the femur.

Citizen science for water quality monitoring: Data implications of citizen perspectives.

Citizen science, where citizens play an active role in the scientific process, is increasingly used to expand the reach and scope of scientific research while also achieving engagement and educational goals. Despite the emergence of studies exploring data outcomes of citizen science, the process and experience of engaging with citizens and citizen-lead groups through participatory science is less explored. This includes how citizen perspectives alter data outcomes, a critical upshot given prevalent mistrust of citizen versus scientist data. This study uses a citizen science campaign investigating watershed impacts on water quality to interrogate the nature and implications of citizen involvement in producing scientifically and societally relevant data. Data representing scientific outcomes are presented alongside a series of vignettes that offer context regarding how, why, and where citizens engaged with the project. From these vignettes, six specific lessons are examined towards understanding how integration of citizen participation alters data outcomes relative to 'professional' science. In particular, elements of participant social identity (e.g., their motivation for participation), and contextual knowledge (e.g., of the research program itself) can shape participation and resulting data outcomes. Such scientific outcomes are particularly relevant given continued concerns regarding the quality of citizen data, which could hinder scientific acceptance of citizen sciences. Importantly, the potential for meaningful engagement with citizen and participants within citizen groups - given significant capacity within the community - represents a substantial and under-realized opportunity.

Population-based study shows that resuscitating apparently stillborn extremely preterm babies is associated with poor outcomes.

AIM: This population-based study determined the delivery room management and outcomes of extremely preterm infants born with Apgar scores of 0. METHODS: We linked birth, neonatal intensive care unit (NICU) and death records for babies who were born between 22 + 0 and 27 + 6 weeks of gestation with a one-minute Apgar score of 0, in New South Wales, Australia, between 1998 and 2011. RESULTS: We classified 2173/2262 (96%) of infants with a one-minute Apgar score of 0 as stillborn. Resuscitation was provided for 48/89 (54%) live births and 40/2173 (2%) stillbirths. Cardiac massage was given to 44 infants, including three 22-week stillborn babies. Of the 13 live births admitted to an NICU, 11 survived to hospital discharge. Most (98%) of the 2212 deaths occurred on the first day of life. One baby who was classified as stillborn lived for 51 days. Resuscitation increased the mean (95% confidence interval) duration of survival from 1 (0-2) to 45 (0-104) hours (p < 0.001). No infant with a five-minute Apgar score of 0 survived. CONCLUSION: Clinicians resuscitated extremely preterm infants without a detectable heartbeat, even at 22 weeks of gestation. No infant survived without resuscitation or if their heartbeat was not regained by five minutes.

Non-prescription drug-associated out-of-hospital cardiac arrest: Changes in incidence over time and the odds of receiving resuscitation.

BACKGROUND: Multiple jurisdictions reported a significant increase in out-of-hospital cardiac arrest (OHCA) incidence over the past decade, however the reasons for this remain unclear. We investigated how drug-associated OHCA (DA-OHCA) contributed to overall OHCA incidence, and whether the likelihood of treatment by emergency medical services (EMS) was associated with DA-OHCA classification. METHODS: Using a large provincial cardiac arrest registry, we included consecutive, non-traumatic adult OHCA from 2016-2022. We classified as drug-associated if there were historical accounts of non-prescription drug use within the preceding 24 hours or evidence of paraphernalia at the scene. We examined year-by-year trends in OHCA and DA-OHCA incidence. We also investigated the association between DA-OHCA and odds of EMS treatment using an adjusted logistic regression model. RESULTS: Of 33,365 EMS-assessed cases, 1,985/18,591 (11%) of EMS-treated OHCA and 887/9,200 (9.6%) of EMS-untreated OHCA were DA-OHCA. Of EMS-treated DA-OHCA, the median age was 40 years (IQR 31-51), 1,059 (53%) had a known history of non-prescription drug use, and 570 (29%) were public-location. From 2016 to 2022, EMS-treated OHCA incidence increased from 60 to 79 per 100,000 person-years; EMS-treated DA-OHCA incidence increased from 3.7 to 9.1 per 100,000 person-years. The proportion of overall OHCA classified as DA-OHCA increased from 6.1% to 11.5%. DA-OHCA was associated with greater odds of EMS treatment (AOR 1.34; 95%CI 1.13-1.58). CONCLUSION: Although EMS-treated DA-OHCA incidence increased by nearly three-fold, it comprised a minority of the overall OHCA increase during the study period. DA-OHCA was associated with an increased likelihood of EMS treatment.

The burn injury transfer feedback form: A 16 year Australian statewide review of burn inter-hospital transfer.

INTRODUCTION: Modern burn care is centralised, and studies show that early, prompt referral to dedicated burn services improve clinical outcomes. We describe the use of a novel clinical instrument, the burn injury Transfer Feedback Form, to support and educate referring clinicians about the early assessment and management of burn injuries. Since 2005, Transfer Feedback Forms have been completed for all burn-injured patients with inter-hospital transfer to a specialised burn unit in the state of New South Wales (NSW), Australia. The aim of this study was to review physiological, procedural, and system or process issues in the care of both adult and paediatric burn-injured patients needing retrieval and transfer in NSW as identified by the Transfer Feedback Form. Secondary objectives were to determine any significant differences in these parameters between metropolitan and regional or remote referring institutions, and if any improvements occurred in these parameters over time. METHODS: This was a retrospective analysis of all patients who were transferred to a burn unit in NSW between July 2005 and July 2021 using their prospectively completed Transfer Feedback Forms. Patients were divided into metropolitan and non-metropolitan referral sources based on geographic location. Clinical issues or deficiencies identified during each patient transfer were then classified into various groups. To determine if transfer-related clinical concerns had changed with time, two distinct periods before and after 2015, when the NSW Trauma App was introduced, were analysed. We compared trends in frequency of transfer-related concerns before and after App introduction by using interrupted time series analysis. RESULTS: A total of 3233 patients had Feedback Forms submitted during the 16-year period. We included 929 children (28.7%) and 2304 adults (71.3%). Transfer-related clinical issues were identified in 904 adults (39.0%) and 484 children (52.0%). In both adult and paediatric patients, the most common transfer-related clinical deficiency was in relation to burn size estimation with 525 patients (43.7%) and 207 patients (30.6%), respectively. Between the time periods analysed, the number of issues arising during inter-hospital transfer fell significantly for both adults (from 46.1% to 26.1%; p < 0.05) and children (from 55.3% to 40.7%; p < 0.05). Segmented regression analysis demonstrated a significant break in the rate of transfer-related clinical issues in 2014 (p < 0.05) and 2015 (p < 0.01) for adults. Accurate body surface area estimations also increased significantly by 53% and 50% for adults and children (p < 0.05 for both), respectively, after 2015. CONCLUSION: Our analysis indicates that the early care of burn-injured patients undergoing inter-hospital transfer is associated with clinical, technical, and logistical challenges. However, introduction of the burn injury Transfer Feedback Form has been associated with improvements in early burn care by referring centres both temporally and geographically. Smartphone-based applications such as the NSW Trauma App have also probably contributed to these findings. Adopting these simple, inexpensive strategies into burn care systems will augment inter-hospital transfer of burn-injured patients, and improve clinical outcomes.

Temporal trends in burn size estimation and the impact of the NSW Trauma App on estimation accuracy.

BACKGROUND: Several studies demonstrated that burn size calculations by referring clinicians are poor. The purpose of this study was to determine if inaccuracies in burn size estimation have improved with time within the same population, and whether widespread roll-out of a smartphone-based TBSA calculator (in the form of the NSW Trauma App) had an impact on accuracy. METHODS: A review of all burn-injured adult patients transferred to Burn Units from August 2015, following the roll out of the NSW Trauma App, to January 2021 was performed. The TBSA determined by the referring centre was compared with the TBSA calculated by the Burn Unit. This was compared to historical data from the same population between January 2009 and August 2013. RESULTS: There were 767 adult burn-injured patients transferred to a Burn Unit between 2015 and 2021. The median overall TBSA was 7%. There were 290 patients (37.9%) who had equivalent TBSA calculations by the referring hospital and the Burn Unit. This was a significant improvement compared to the preceding time period (P < 0.005). Overestimation by the referring hospital occurred in 364 cases (47.5%), which was significantly reduced compared to 2009 - 2013 (P < 0.001). Unlike the earlier time period where changes in estimation accuracy were seen in relation to increasing time after the burn injury, burn size estimation accuracy remained relatively consistent in the contemporary time period with no significant change observed (P = 0.86). CONCLUSIONS: This cumulative, longitudinal study of nearly 1500 adult burn-injured patients over 13 years demonstrates improvements in burn size estimation by referring clinicians over time. It is the largest cohort of patients analysed with respect to burn size estimation and is the first to demonstrate improvements in accuracy of TBSA in association with a smartphone-based app. Adopting this simple strategy into burn retrieval systems will augment early assessment of these injuries and improve outcomes.

Revisiting misfolding propensity of serum amyloid A1: Special focus on the signal peptide region.

AA amyloidosis is the result of overproduction and aberrant processing of acute-phase serum amyloid A1 (SAA1) by hepatocytes. Proteolytic cleavage of SAA1 is believed to play a central role in AA amyloid formation. The SAA1 protein undergoes a cleavage of 18 residues consisting of the signal peptide at the N-terminal region. To better understand the mechanism behind systemic amyloidosis in the SAA1 protein, we studied the misfolding propensity of the signal peptide region. We first examined the signal peptide amino acid SAA derived from different animal species. A library of 16 peptides was designed to evaluate the propensity of aggregation. The amyloidogenic potential of each SAA1 signal peptide homolog was assessed using in silico Tango program, thioflavin T (ThT) fluorescence, transmission electron microscopy (TEM), and seeding with misfolded human SAA1 signal peptide. After 7 days of incubation, most of the SAA1 signal peptide fragments had the propensity to form fibrils at a concentration of 100 µM in 50 mM Tris buffer at 37 °C by TEM. All peptides were able to generate fibrils at a higher concentration, i.e 500 µM in 25 mM Tris buffer with 50% HFIP, by ThT. All SAA1 signal synthetic peptides designed from the different animal species had the propensity to misfold and form fibrils, particularly in species with low occurrence of systemic amyloidosis. The human SAA1 signal peptide region was capable to seed the SAA1 1-25 and 32-47 peptide regions. Characterizing fibrillar conformations are relevant for seeding intact and/or fragmented SAA, which may contribute, to the mechanism of protein misfolding. This research signifies the importance of the signal peptide region and its possible contribution to the misfolding of aggregation-prone proteins.

Rationale for withholding professional resuscitation in emergency medical system-attended out-of-hospital cardiac arrest.

BACKGROUND: Half of out-of-hospital cardiac arrests (OHCA) are deemed inappropriate for resuscitation by emergency medical services (EMS). We investigated patient characteristics and reasons for non-treatment of OHCAs, and determined the proportion involving illicit drug use. METHODS: We reviewed consecutive EMS-untreated OHCA from the British Columbia Cardiac Arrest Registry (2019-2020). We abstracted patient characteristics and categorized reasons for EMS non-treatment: (1) prolonged interval from the OHCA to EMS arrival ("non-recent OHCA") with or without signs of "obvious death"; (2) do-not-resuscitate (DNR) order; (3) terminal disease; (4) verbal directive; and (5) unspecified. We abstracted clinical details regarding a history of, or evidence at the scene of, illicit drug use. RESULTS: Of 13 331 cases, 5959 (45%) were not treated by EMS. The median age was 67 (IQR 54-81) and 1903 (32%) were female. EMS withheld resuscitation due to: non-recent OHCA, with and without signs of "obvious death" in 4749 (80%) and 108 (1.8%), respectively; DNR order in 952 (16%); terminal disease in 77 (1.3%); family directive in 41 (0.69%); and unspecified in 32 (0.54%). Overall and among those with non-recent OHCA, 695/5959 (12%) and 691/4857 (14%) had either a history of or evidence of recent illicit drug use, respectively. CONCLUSION: A prolonged interval from the OHCA until EMS assessment was the predominant reason for withholding treatment. Innovative solutions to decrease this interval may increase the proportion of OHCA that are treated by EMS and overall outcomes. Targeted interventions for illicit-drug use-related OHCAs may add additional benefit.

Treating the burnt auricle using Biobrane.

Auricle burns remain a challenge for surgeons who must navigate the common and morbid complication of chondritis through often complex and painful dressing regimes. Our technique involving the application of Biobrane promotes healing, is individualized, single application and conducive to topical antimicrobial application. We find it is a simple and effective approach to treating the burnt auricle.

Hybrid-virtual simulations for Canadian medical students during the COVID-19 pandemic.

Given the efficacy of simulations as a medical education tool, the inability to provide them during the COVID-19 pandemic may be detrimental to pre-clinical medical student learning. We developed hybrid simulations, where remote learner participants could direct an in-person assistant. This offered a learning opportunity that was more realistic than fully virtual simulations and abided by public health guidelines. Hybrid simulations provided an opportunity for medical students to practice real-time clinical decision making in a remote, high-fidelity, simulated environment. This approach could be adapted for rural healthcare students and professionals to participate in simulations without a local simulation centre.

BACKGROUND: Compte tenu de l'efficacité des simulations en tant qu'outil d'éducation médicale, l'impossibilité d'en proposer pendant la pandémie de la COVID-19 pourrait nuire à l'apprentissage préclinique des étudiants en médecine. Nous avons conçu des simulations hybrides, où les apprenants peuvent diriger à distance un assistant qui intervient en personne. Ces simulations permettent un apprentissage plus réaliste que celles qui sont entièrement virtuelles tout en respectant les directives en matière de santé publique. Les simulations hybrides ont permis aux étudiants en médecine de s'exercer à distance à la prise de décision clinique en temps réel dans un environnement simulé de haute fidélité. Cette approche pourrait être adaptée pour permettre aux étudiants et aux professionnels de la santé en milieu rural, qui ne disposent pas d'un centre de simulation local, de néanmoins participer à des simulations.

Transforming Disruption Into Innovation: A Partnership Between the COVID-19 Medical Student Response Team and the University of British Columbia.

The COVID-19 pandemic caused substantial disruptions in medical education. The University of British Columbia (UBC) MD Undergraduate Program (MDUP) is the sixth-largest medical school in North America. MDUP students and faculty developed a joint response to these disruptions to address the curriculum and public health challenges that the pandemic posed. After clinical activities were suspended in March 2020, third- and fourth-year MDUP students formed a COVID-19 Medical Student Response Team (MSRT) to support frontline physicians, public health agencies, and community members affected by the pandemic. A nimble organizational structure was developed across 4 UBC campuses to ensure a rapid response to meet physician and community needs. Support from the faculty ensured the activities were safe for the public, patients, and students and facilitated the provision of curricular credit for volunteer activities meeting academic criteria. As of June 19, 2020, more than 700 medical students had signed up to participate in 68 projects. The majority of students participated in projects supporting the health care system, including performing contact tracing, staffing public COVID-19 call centers, distributing personal protective equipment, and creating educational multimedia products. Many initiatives have been integrated into the MDUP curriculum as scholarly activities or paraclinical electives for which academic credit is awarded. This was made possible by the inherent flexibility of the MDUP curriculum and a strong existing partnership between students and faculty. Through this process, medical students were able to develop fundamental leadership, advocacy, communication, and collaboration skills, essential competencies for graduating physicians. In developing a transparent, accountable, and inclusive organization, students were able to effectively meet community needs during a crisis and create a sustainable and democratic structure capable of responding to future emergencies. Open dialogue between the MSRT and the faculty allowed for collaborative problem solving and the opportunity to transform disruption into academic innovation.

Pancreatoduodenectomy With Arterial Resection for Locally Advanced Pancreatic Cancer of the Head: A Systematic Review.

The development of increasingly effective chemotherapy regimens and increasing tumor necrosis is allowing radical pancreatectomy to be re-evaluated. This systematic review examines the outcome of patients with locally advanced cancer of the pancreatic head after pancreatectomy with arterial resection. Electronic searches were performed on PubMed and Medline databases between January 2000 and December 2018. The end points were to determine the safety and overall survival after arterial resection in pancreatectomy. Thirteen studies with 467 patients were included. Celiac, hepatic, mesenteric, and splenic arteries were resected across all studies. The median overall morbidity was 52% (range, 37%-100%) and with major complications occurring in a median of 25% (range, 12%-54%) of patients. The median 90-day mortality was 5% (range, 0%-17%). R0 was achieved in 66% (range, 43%-100%) and R1 in 31% (range, 0%-74%). The median survival was 17 (range, 7-29) months with a 1- and 3-year survival of 59% (range, 16%-92%) and 17% (range, 0%-13%), respectively. Pancreatectomy with arterial resection may be safely performed in high-volume centers with acceptable survival results in highly selected patients. Pooling of data through a multi-institutional registry will allow a more accurate assessment of the safety and efficacy of this treatment strategy.

A Systematic Review of Isometric Lingual Strength-Training Programs in Adults With and Without Dysphagia.

PURPOSE: This systematic review summarizes the effects of isometric lingual strength training on lingual strength and swallow function in adult populations. Furthermore, it evaluates the designs of the reviewed studies and identifies areas of future research in isometric lingual strength training for dysphagia remediation. METHOD: A comprehensive literature search of 3 databases and additional backward citation search identified 10 studies for inclusion in the review. The review reports and discusses the isometric-exercise intervention protocols, pre- and postintervention lingual-pressure data (maximum peak pressures and lingual-palatal pressures during swallowing), and oropharyngeal swallowing measures such as penetration-aspiration scales, oropharyngeal residue and duration, lingual volumes, and quality-of-life assessments. RESULTS: Studies reported gains in maximum peak lingual pressures following isometric lingual strength training for both healthy adults and select groups of individuals with dysphagia. However, due to the variability in study designs, it remains unclear whether strength gains generalize to swallow function. CONCLUSION: Although isometric lingual strength training is a promising intervention for oropharyngeal dysphagia, the current literature is too variable to confidently report specific therapeutic benefits. Future investigations should target homogenous patient populations and use randomized controlled trials to determine the efficacy of this treatment for individuals with dysphagia.

A multi-year longitudinal study of water quality parameters in four salmon-bearing and recreational streams on mount hood, Oregon.

Four streams-Clear Fork, Lost Creek, Camp Creek and Still Creek-in northwestern Oregon's Sandy River Basin were monitored for temperature, dissolved oxygen levels, and fecal bacterial concentrations in a multi-year analysis examining stream health for recreational users and anchor habitat for Pacific Salmon. Temperatures were recorded using micro -T temperature loggers at 15 locations, during 22 July - 5 September 2006, 2 July - 4 September 2007, 20 June - 7 September 2008, 23 June - 9 September 2009, and 2 July -9 September 2010. The Seven-Day Average Maximum water temperature (7-DAM) of 13°C was used as a reference value for the biological limit governing suitable salmonid spawning and egg incubation conditions. The maximum 7-DAM temperatures occurred on different dates and all streams neared or exceeded the 13°C standard at least once each summer. Dissolved oxygen levels were measured at weekly or longer intervals in 2006, 2007, 2008, and 2009. Dissolved oxygen levels fell below the 9.0 ppm standard for Clear Fork on almost half the sampling dates in 2006, 2007, and 2009. Concentrations of the bacterial genus Enterococcus were measured as an indicator of fecal contamination. Samples were collected at 15 sites along the four streams. Weekly samples were collected during a 9 week period from July - September 2007, an 11 week period from June - September 2008, and an 11 week period from June - September 2009. Enterococcus counts exceeded the federal recommended national criterion value of 61 colony forming units (CFU) per 100 mL every year in Camp Creek and occasionally elsewhere, with exceedances trending towards late summer.

Peripheral white blood cell toxicity induced by broad spectrum cyclin-dependent kinase inhibitors.

Cyclin-dependent kinases (CDKs) have been pursued for more than a decade for the treatment of cancer. CDK inhibitors are expected to slow the rate of cell division and potentially increase the apoptotic fraction of rapidly dividing cells. Although CDK activity is often increased in tumors, normal dividing tissues are also susceptible to the cytostatic and cytotoxic effects of CDK inhibitor action. Therefore the typical toxicity profile associated with cytotoxic anti-cancer therapy, bone marrow suppression and gastrointestinal toxicity, is expected with CDK inhibitors. Bone marrow toxicity and the ensuing delayed peripheral leukocyte suppression often limit the therapeutic application of cytotoxic anticancer drugs. Here we characterize an unusual bone marrow-independent acute toxicity toward leukocytes from broad spectrum CDK inhibitors in monkeys and rodents. The potential combination of both acute and delayed immunosuppression would likely further restrict the application of these particular compounds. Since the cells targeted were non-proliferating, it was assumed that the toxicity was not driven by the intended pharmacological mechanism thereby facilitating the development of a testing strategy to identify compounds with a reduced potential for acute leukocyte toxicity. This testing strategy resulted in a CDK inhibitor void of bone marrow-independent leukocyte toxicity that is currently undergoing clinical testing.