Eastern Association for the Surgery of Trauma (EAST) vs Western Trauma Association (WTA): How a Level 1 Trauma Center Splits the Difference in Resuscitative Thoracotomy.

Background Resuscitative thoracotomy (RT) is performed in severe trauma cases as a final lifesaving effort. Prominent, yet differing, practice management guidelines exist from Eastern Association for the Surgery of Trauma (EAST) and Western Trauma Association (WTA). This study evaluates all RTs performed from 2012 to 2019 at an urban Level 1 trauma center for management guideline indication and subsequent outcomes. Methods Our trauma registry was queried to identify RT cases from 2012 to 2019. Data was collected on patient demographics, prehospital presentation, cardiopulmonary resuscitation (CPR) requirements, and resuscitation provided. Survival to the operating room, intensive care unit, and overall were recorded. Information was compared with regard to EAST and WTA criteria. Results Eighty-seven patients who underwent RTs were included. WTA guidelines were met in 78/87 (89.7%) of cases, comparatively EAST guidelines were met in every case. Within the EAST criteria, conditional and strong recommendations were met in 70/87 (80.4%) and 17/87 (19.5%) of cases, respectively. In nine cases (10.3%) indications were discordant, each meeting conditional indication by EAST and no indication by WTA. All patients that survived to the operating room (OR), ICU admission, and overall met EAST criteria. Conclusion All RTs performed at our Level 1 trauma center met indications provided by EAST criteria. WTA guidelines were not applicable in nine salvaging encounters due to the protracted duration of CPR before proceeding to RT. Furthermore, more patients that survived to OR and ICU admission met EAST guidelines suggesting an improved potential for patient survivability. As increased data is derived, management guidelines will likely be re-established for optimized patient outcomes.

Warfarin, not direct oral anticoagulants or antiplatelet therapy, is associated with increased bleeding risk in emergency general surgery patients: Implications in this new era of novel anticoagulants: An EAST multicenter study.

INTRODUCTION: This study aimed to assess perioperative bleeding complications and in-hospital mortality in patients requiring emergency general surgery presenting with a history of antiplatelet (AP) versus direct oral anticoagulant (DOAC) versus warfarin use. METHODS: A prospective observational study across 21 centers between 2019 and 2022 was conducted. Inclusion criteria were age 18 years or older, and DOAC, warfarin, or AP use within 24 hours of an emergency general surgery procedure. Outcomes included perioperative bleeding and in-hospital mortality. The study was conducted using analysis of variance, χ 2 , and multivariable regression models. RESULTS: Of the 413 patients, 221 (53.5%) reported AP use, 152 (36.8%) DOAC use, and 40 (9.7%) warfarin use. The most common indications for surgery were obstruction (23% [AP], 45% [DOAC], and 28% [warfarin]), intestinal ischemia (13%, 17%, and 23%), and diverticulitis/peptic ulcers (7%, 7%, and 15%). Compared with DOAC use, warfarin use was associated with significantly higher perioperative bleeding complication (odds ratio [OR], 4.4 [95% confidence interval (CI), 2.0-9.9]). There was no significant difference in perioperative bleeding complication between DOAC and AP use (OR, 0.7 [95% CI, 0.4-1.1]). Compared with DOAC use, there was no significant difference in mortality between warfarin use (OR, 0.7 [95% CI, 0.2-2.5]) or AP use (OR, 0.5 [95% CI, 0.2-1.2]). After adjusting for confounders, warfarin use (OR, 6.3 [95% CI, 2.8-13.9]), medical history, and operative indication were associated with an increase in perioperative bleeding complications. However, warfarin was not independently associated with risk of mortality (OR, 1.3 [95% CI, 0.39-4.7]), whereas intraoperative vasopressor use (OR, 4.7 [95% CI, 1.7-12.8]), medical history, and postoperative bleeding (OR, 5.5 [95% CI, 2.4-12.8]) were. CONCLUSION: Despite ongoing concerns about the increase in DOAC use and lack of readily available reversal agents, this study suggests that warfarin, rather than DOACs, is associated with higher perioperative bleeding complications. However, that risk does not result in an increase in mortality, suggesting that perioperative decisions should be dictated by patient disease and comorbidities rather than type of AP or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

The effectiveness of physiotherapy interventions on fecal incontinence and quality of life following colorectal surgery: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: To investigate the effectiveness of physiotherapy interventions compared to control conditions on fecal incontinence (FI) and quality of life (QoL) following colorectal surgery. METHODS: Electronic searches in English-language (Scopus, Web of Science, Embase, AMED, CENTRAL, CINAHL, MEDLINE, Ovid, and PEDro) and Chinese-language (CNKI, Wanfang Data) databases were conducted. Trials comparing physiotherapy interventions against control conditions and assessing FI and QoL outcomes were included in the review. RESULTS: Ten trials were included. Meta-analysis revealed statistically significant improvements in lifestyle (0.54; 95% CI 0.03, 1.05; p = 0.04), coping behavior (MD 1.136; 95% CI 0.24, 2.04; p = 0.01), and embarrassment (0.417; 95% CI 0.14, 0.70; p = 0.00) components of QoL among individuals receiving pelvic floor muscle training (PFMT) compared with those receiving usual care (UC). Meta-analysis showed biofeedback to be significantly more effective than UC in enhancing anal resting pressure (ARP; 9.551; 95% CI 2.60, 16.51; p = 0.007), maximum squeeze pressure (MSP; 25.29; 95% CI 4.08, 48.50; p = 0.02), and rectal resting pressure (RRP; 0.51; 95% CI 0.10, 0.9; p = 0.02). Meta-analysis also found PFMT combined with biofeedback to be significantly more effective than PFMT alone for ARP (3.00; 95% CI 0.40, 5.60; p = 0.02), MSP (9.35, 95% CI 0.17, 18.53; p = 0.05), and RRP (1.54; 95% CI 0.60, 2.47; p = 0.00). CONCLUSIONS: PFMT combined with biofeedback was more effective than PFMT alone, but both interventions delivered alone were superior to UC. Future studies remain necessary to optimize and standardize the PFMT parameters for improving QoL among individuals who experience FI following CRC surgery. REVIEW REGISTRATION: This systematic review is registered in the PROSPERO registry (Ref: CRD42022337084).

Anticoagulation in emergency general surgery: Who bleeds more? The EAST multicenter trials ACES study.

BACKGROUND: While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs versus warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs). METHODS: This was a prospective observational trial, conducted between 2019 and 2022, across 21 centers. Inclusion criteria were 18 years or older, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, χ 2 , and multivariable regression models were used to conduct the analysis. RESULTS: Of the 413 patients enrolled in the study, 261 (63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs. 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (odds ratio [OR], 4.3; p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR, 4.27; p = 0.016), nonocclusive mesenteric ischemia (OR, 3.13; p = 0.001), and diverticulitis (OR, 3.72; p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR, 4.87; p < 0.001), and intraoperative vasopressors (OR, 4.35; p = 0.003) were associated with increased in-hospital mortality. CONCLUSION: Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

More than Means to an End: Assessing Surgical Provider Familiarity with Palliative Care.

BACKGROUND: As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers' endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers' understanding of the scope of palliative medicine is necessary to direct further training and development efforts. METHOD: A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network. RESULTS: 30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions (P = .009). CONCLUSIONS: Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.

Laparoscopic Cholecystectomy in the Time of Coronavirus: A Level-1 Trauma Center's Experience.

INTRODUCTION: Laparoscopic cholecystectomy (LC), one of the most common surgical procedures performed in the U.S., offers a window into the effects of the COVID-19 pandemic on routine surgical care. The purpose of our study was to analyze the effects of the COVID-19 pandemic at a Level-1 trauma center on the performance rate of non-elective LC over time. METHODS: A retrospective chart review from July 2019 to December 2020 identified all non-elective LC cases performed at a level-1 trauma center. Patients were categorized into 4 temporal phases along the course of the pandemic based on statewide incidence data on COVID-19: pre-pandemic, peak 1, recovery, and peak 2. We compared the phases based on demographic information and outcomes. RESULTS: In total, 176 patients were reviewed. The performance rate in cases/day varied as follows: pre-pandemic .61, 1st peak .34, recovery .44, and 2nd peak .53. The complication rate was highest in the 2nd peak (16%) (P < .05). Compared to the pre-pandemic period, the intra-pandemic period had a higher incidence of complicated gallbladder disease (P < .05). In the non-elderly subgroup, complicated gallbladder disease was significantly more prevalent in the intra-pandemic period compared to the pre-pandemic period (25% vs 10%, P < .05). CONCLUSIONS: Our data suggests a learning curve throughout the course of the pandemic, reflecting a stepwise increase in the performance rate of LC. The higher incidence of complicated gallbladder disease in the intra-pandemic period may imply patient hesitancy to seek routine surgical care, especially among younger patients.

ICl-Mediated Functional Group Interconversion from Methyl Homopropargyl Ether to α-Iodo-γ-chloroketone.

An ICl-mediated highly chemo- and regioselective functional group interconversion from methyl homopropargyl ether to α-iodo-γ-chloro-ketone is reported. Density functional theory (DFT)-calculated reaction coordinate and potential energy surface support the high chemo-selectivity observed for the formation of α-iodo-γ-chloroketone over furan. The five-membered oxonium ring formation-ring opening mechanism is a potential template for the preparation of polyfunctionalized carbonyl compounds.

Oil-Based Mud Waste as a Filler Material in LDPE Composites: Evaluation of Mechanical Properties.

Traditionally, the drilling waste generated in oil and gas exploration operations, including spent drilling fluid, is disposed of or treated by several methods, including burial pits, landfill sites and various thermal treatments. This study investigates drilling waste valorisation and its use as filler in polymer composites. The effect of the poor particle/polymer interfacial adhesion bonding of the suspended clay in oil-based mud (OBM) slurry and the LDPE matrix is believed to be the main reason behind the poor thermo-mechanical and mechanical properties of low-density polyethylene (LDPE)/OBM slurry nanocomposites. The thermo-mechanical and mechanical performances of LDPE)/OBM slurry nanocomposites without the clay surface treatment and without using compatibilizer are evaluated and discussed. In our previous studies, it has been observed that adding thermally treated reclaimed clay from OBM waste in powder form improves both the thermal and mechanical properties of LDPE nanocomposites. However, incorporating OBM clay in slurry form in the LDPE matrix can decrease the thermal stability remarkably, which was reported recently, and thereby has increased the interest to identify the mechanical response of the composite material after adding this filler. The results show the severe deterioration of the tensile and flexural properties of the LDPE/OBM slurry composites compared to those properties of the LDPE/MMT nanocomposites in this study. It is hypothesised, based on the observation of the different test results in this study, that this deterioration in the mechanical properties of the materials was associated with the poor Van der Waals force between the polymer molecules/clay platelets and the applied force. The decohesion between the matrix and OBM slurry nanoparticles under stress conditions generated stress concentration through the void area between the matrix and nanoparticles, resulting in sample failure. Interfacial adhesion bonding appears to be a key factor influencing the mechanical properties of the manufactured nanocomposite materials.

Chelating Phosphine-N-Heterocyclic Carbene Platinum Complexes via Catalytic Asymmetric Hydrophosphination and Their Cytotoxicity Toward MKN74 and MCF7 Cancer Cell Lines.

A series of activated vinyl azoles was hydrophosphinated in the presence of a chiral palladacycle catalyst under mild conditions to give enantioenriched phosphine azoles with moderate enantioselectivities and yields. The racemic phosphine azoles were transformed into eleven novel chelating phosphine-N-heterocyclic carbene (NHC) platinum complexes. The drug efficacies of nine selected phosphine-NHC platinum(II) chlorides in two cancer cell lines (MKN74 and MCF7) were evaluated, and two were found to exhibit activities comparable to that of cisplatin.

Timing of Gastrografin administration in the management of adhesive small bowel obstruction (ASBO): Does it matter?

BACKGROUND: Gastrografin challenge is increasingly used as a diagnostic tool to predict patients who may benefit from nonoperative management in adhesive small bowel obstruction. This study explores the optimal timing of Gastrografin in the management of adhesive small bowel obstruction by comparing early versus late Gastrografin challenge. METHODS: A retrospective chart review from January 2016 to January 2018 identified patients with adhesive small bowel obstruction who underwent Gastrografin challenge. A receiver operating characteristic curve, to predict a duration of stay less than 5 days, calculated a 12-hour limit which separated early and late groups. Nonoperative and operative patients were compared separately. Our primary outcome was duration of stay. Secondary outcomes included operative requirement, time to the operating room, complication rate, and 1-year mortality. In a separate analysis, multivariable logistic regression identified independent risk factors for 1-year mortality. RESULTS: One hundred thirty-four patients were identified (58 early, 76 late). In nonoperative patients, the early group had a shorter duration of stay (3.2 days vs 5.4 days), fewer complications, and a lower complication and 1-year mortality rate (P < .05). In operative patients, the early group had a shorter preoperative duration of stay (1.8 days vs 3.9 days) (P < .05). On multivariable regression, congestive heart failure, any postoperative complication, and operative requirement were the best predictors of 1-year mortality (R2 = 0.321; P < .05). CONCLUSION: Gastrografin administration within 12 hours of adhesive small bowel obstruction diagnosis had favorable outcomes in terms of duration of stay, complications, and mortality in nonoperative patients. Moreover, in operative patients, preoperative duration of stay was shortened. Our findings suggest protocolizing early Gastrografin challenge may be an important principle in adhesive small bowel obstruction management.

Clinical predictors of immediate intervention for isolated renal trauma.

INTRODUCTION Evidence suggests overutilization of procedural intervention for renal traumas. The objective of this study was to assess clinical factors associated with procedural intervention for patients presenting to the emergency department (ED) with isolated renal trauma. MATERIALS AND METHODS: A United States statewide trauma registry was queried for trauma patients presenting to level I or II trauma centers with isolated renal injuries (Grades I-V) from 2000-2013. Patient demographics, mechanism, American Association for the Surgery of Trauma (AAST) grade, trauma center level designation, presenting ED vital signs, Glasgow Coma Scale (GCS), intubation status, and blood product transfusion were assessed. RESULTS: Of 449,422 patients, 1383 patients (78% male, median age 29 years [range 2-92]) with isolated renal injuries had data available for analysis. Controlling for demographics, presenting vitals, GCS, trauma center level, mechanism and intubation status, level I status (OR 2.1 [1.3-3.4], p = 0.0021), white race (OR 2.5 [1.3-4.7], p < 0.005), AAST IV/V injury (OR 4.79 [3.1-6.5], p < 0.0001) and blood product administration (OR 2.7 [1.5-4.9], p = 0.0009) were independently associated with an immediate interventional radiology procedure. Independent predictors of immediate surgical intervention include level I status (OR 2.2 [1.2-4.0], p = 0.0075), penetrating mechanism of injury (OR 15.6 [8.4-28.9], p < 0.0001, AAST IV/V injury (OR 13.6 [8.7-21.1], p < 0.0001), and clinical hypotension (SBP < 95 mmHg, OR 2.1 [1.1 4.2], p = 0.03). CONCVLUSION: Level 1 trauma center designation, white race, penetrating mechanism of injury, high-grade injury, transfusion of blood products, and hypotension were all independent predictors of immediate procedural intervention following ED presentation with isolated renal trauma.

Effect of complement C1-esterase inhibitor on brain edema and inflammation after mild traumatic brain injury in an animal model.

OBJECTIVE: Traumatic brain injury (TBI) is characterized by damage to the blood-brain barrier, inflammation, and edema formation. In this pilot study, we aimed to investigate the effects of a complement inhibitor, C1-esterase inhibitor (C1 INH), on brain edema and inflammation in a rat model of mild TBI. METHODS: Thirty-six male Sprague Dawley rats were randomly assigned to control, TBI, or TBI plus C1 INH groups. TBI and TBI plus C1 INH rats received an injection of saline or 25 IU/kg C1 INH, respectively, with TBI using a weight drop model. Control rats received saline only. Rats were subsequently euthanized and their brain tissue harvested for analysis. The primary outcome was the extent of edema as assessed by the brain's water content. Secondary outcomes included enzyme-linked immunosorbent assays to determine levels of pro-inflammatory mediators. RESULTS: Tumor necrosis factor-α levels were significantly greater in TBI rats than control rats, indicating that inflammation was generated by the weight drop impact. Brain water content following TBI was significantly different between TBI rats treated with C1-INH (78.7%±0.12), untreated TBI rats (79.3%±0.12), and control rats (78.6%±0.15, P=0.001). There was a significant decrease in C3a and interleukin 2 levels among C1 INH-treated rats compared with untreated TBI rats, but no change in levels of tumor necrosis factor-α and S100ß. CONCLUSION: C1-INH inhibited the complement pathway, suggesting that C1-INH may have a therapeutic benefit in TBI. Further studies are needed to investigate the effect of C1-INH on clinical outcomes.

Chemical constituents from the thorns of Gleditsia sinensis and their cytotoxic activities.

A new aromatic glycoside (1) and a new natural product, neolignan (2), along with twenty-three known compounds (3-25), were isolated from the thorns of Gleditsia sinensis. According to the spectroscopic analyses (IR, UV, HRESIMS, NMR and ECD), the structures of isolates were elucidated. Herein, compounds 4, 6-8, 10-13, 15, 16, 18, 20, 23 were isolated from the plant of G. sinensis for the first time. Moreover, compounds 4, 6, 15 and 24 showed cytotoxic effects on human ovarian cancer (SKOV-3) cells with IC50 values of 24.83 ± 4.90, 48.86 ± 9.11, 80.13 ± 5.62, 15.38 ± 2.21 µM, respectively. [Formula: see text].

Iron-Catalyzed Transfer Hydrogenation in Aged N-Methyl-2-pyrrolidone: Reductive Ring-Opening of 3,5-Disubstituted Isoxazoles and Isoxazolines.

3,5-Disubstituted isoxazoles and isoxazolines undergo an iron-catalyzed reductive ring-opening in aged N-methyl-2-pyrrolidone (NMP). 5-Hydroxy-N-methyl-2-pyrrolidone generated in situ via a simple activation of commercial NMP acts as the hydrogen donor in the iron-catalyzed transfer hydrogenation reaction. It is the first example employing a combination of an iron catalyst and 5-hydroxy-N-methyl-2-pyrrolidone as reducing agents in a transfer hydrogenation reaction. The protocol is highly efficient for the synthesis of ß-enaminones and 1,3-diketones, providing a versatile route for the preparation of these 1,3-difunctional compounds bearing diversified substitution patterns.

Catalytic and Mechanistic Developments of the Nickel(II) Pincer Complex-Catalyzed Hydroarsination Reaction.

Synthetic challenges have significantly slowed the development of the catalytic asymmetric hydroarsination reaction despite it being a highly attractive C-As bond formation methodology. In addition, there is a poor understanding of the main reaction steps in such reactions which limit further development in the field. Herein, key intermediates of the hydroarsination reaction catalyzed by a PCP NiII -Cl pincer complex are presented upon investigating the reaction with DFT calculations, conductivity measurements, NMR spectroscopy, and catalytic screening. The novel Ni-Cl-As interaction proposed was then contrasted against known NiII -catalyzed hydrophosphination reactions to highlight dissimilarities between them even though P and As share a close group relationship. Lastly, the asymmetric hydroarsination of nitroolefins was further developed to furnish a library of chiral organoarsines in up to 99 % yield and 80 % ee under mild conditions (-20 °C to RT) between 5 to 210 mins.

Parasitic leiomyoma of the greater omentum presenting as small bowel obstruction.

Parasitic leiomyomas (PL) are rare intra-abdominal tumors usually found in young women and are considered a type of uterine leiomyomas. They are usually reported in women who underwent laparoscopic morcellation of fibroids and frequently present with symptoms such as abdominal pain and distention. Treatment usually involves en bloc removal of the mass after dividing its blood supply from the host organ. In this case report, we describe the case of a middle-aged female who developed high-grade small bowel obstruction due to compression from a large PL with blood supply from the greater omentum. The patient underwent operative resection of the PL and subsequently fared very well. Meticulous attention to blood supply and attachments of PL to host organs is necessary for safe resection.

Membrane vesicles from Pseudomonas aeruginosa activate the noncanonical inflammasome through caspase-5 in human monocytes.

Outer membrane vesicles (OMVs) are constitutively produced by Gram-negative bacteria both in vivo and in vitro. These lipid-bound structures carry a range of immunogenic components derived from the parent cell, which are transported into host target cells and activate the innate immune system. Recent advances in the field have shed light on some of the multifaceted roles of OMVs in host-pathogen interactions. In this study, we investigated the ability of OMVs from two clinically important pathogens, Pseudomonas aeruginosa and Helicobacter pylori, to activate canonical and noncanonical inflammasomes. P. aeruginosa OMVs induced inflammasome activation in mouse macrophages, as evidenced by "speck" formation, as well as the cleavage and secretion of interleukin-1ß and caspase-1. These responses were independent of AIM2 and NLRC4 canonical inflammasomes, but dependent on the noncanonical caspase-11 pathway. Moreover, P. aeruginosa OMVs alone were able to activate the inflammasome in a TLR-dependent manner, without requiring an exogenous priming signal. In contrast, H. pylori OMVs were not able to induce inflammasome activation in macrophages. Using CRISPR/Cas9 knockout THP-1 cells lacking the human caspase-11 homologs, caspase-4 and -5,we demonstrated that caspase-5 but not caspase-4 is required for inflammasome activation by P. aeruginosa OMVs in human monocytes. In contrast, free P. aeruginosa lipopolysaccharide (LPS) transfected into cells induced inflammasome responses via caspase-4. This suggests that caspase-4 and caspase-5 differentially recognize LPS depending on its physical form or route of delivery into the cell. These findings have relevance to Gram-negative infections in humans and the use of OMVs as novel vaccines.

Abdominal compartment syndrome due to spontaneous rectus sheath hematoma with extension into the retroperitoneal space.

Rectus sheath hematoma (RSH) is an increasingly common clinical condition in our hospitals due to the increasing use of anticoagulant therapies for various purposes among our patients. Treatment of spontaneous RSH is generally conservative. For continued bleeding, interventional radiologic identification and subsequent embolization is an effective option. Surgery usually involves significant morbidity and is considered a technique of last resort. In this case report, we describe the case of middle aged female who developed abdominal compartment syndrome (ACS) from a large RSH that had extended into the retroperitoneum. The patient underwent abdominal decompression with removal of the hematoma and subsequently fared very well. Patients with large RSHs extending into the retroperitoneum should undergo constant monitoring of their abdominal pressures for early detection and treatment of potentially deadly condition of ACS.

Nickel catalyzed enantioselective hydroarsination of nitrostyrene.

A catalytic asymmetric hydroarsination reaction of an activated alkene viz. (E)-nitrostyrene was developed using chiral PCP Pt-, Pd- and Ni-pincer complexes as catalysts. The corresponding chiral tertiary arsine adduct was obtained in ees of up to 80% under mild reaction conditions using the PCP Ni-Cl pincer catalyst. The arsine adduct was furnished with catalyst loadings of 1-5 mol% and the reaction duration ranging from <5 min to 180 min. The subsequent coordination of the hydroarsination product to gold(i) chloride allowed for the confirmation of the stereochemistry of the arsine adduct via crystallographic analysis.

Stapled versus hand-sewn: A prospective emergency surgery study. An American Association for the Surgery of Trauma multi-institutional study.

BACKGROUND: Data from the trauma patient population suggests handsewn (HS) anastomoses are superior to stapled (ST). A recent retrospective study in emergency general surgery (EGS) patients had similar findings. The aim of the current study was to evaluate HS and ST anastomoses in EGS patients undergoing urgent/emergent operations. METHODS: The study was sponsored by the American Association for the Surgery of Trauma Multi-Institutional Studies Committee. Patients undergoing urgent/emergent bowel resection for EGS pathology were prospectively enrolled from July 22, 2013 to December 31, 2015. Patients were grouped by HS/ST anastomoses, and variables were collected. The primary outcome was anastomotic failure. Similar to other studies, anastomotic failure was evaluated at the anastomosis level. Multivariable logistic regression was performed controlling for age and risk factors for anastomotic failure. RESULTS: Fifteen institutions enrolled a total of 595 patients with 649 anastomoses (253 HS and 396 ST). Mean age was 61 years, 51% were men, 7% overall mortality. Age and sex were the same between groups. The overall anastomotic failure rate was 12.5%. The HS group had higher lactate, lower albumin, and were more likely to be on vasopressors. Hospital and intensive care unit days, as well as mortality, were greater in the HS group. Anastomotic failure rates and operative time were equivalent for HS and ST. On multivariate regression, the presence of contamination at initial resection (odds ratio, 1.965; 95% confidence interval, 1.183-3.264) and the patient being managed with open abdomen (odds ratio, 2.529; 95% confidence interval, 1.492-4.286) were independently associated with anastomotic failure, while the type of anastomosis was not. CONCLUSION: EGS patients requiring bowel resection and anastomosis are at high risk for anastomotic failure. The current study illustrates an apparent bias among acute care surgeons to perform HS techniques in higher-risk patients. Despite the individualized application of technique for differing patient populations, the risk of anastomotic failure was equivalent when comparing HS and ST anastomoses. LEVEL OF EVIDENCE: Therapeutic study, level II.