Expanded MutaT7 toolkit efficiently and simultaneously accesses all possible transition mutations in bacteria.

Targeted mutagenesis mediated by nucleotide base deaminase-T7 RNA polymerase fusions has recently emerged as a novel and broadly useful strategy to power genetic diversification in the context of in vivo directed evolution campaigns. Here, we expand the utility of this approach by introducing a highly active adenosine deaminase-T7 RNA polymerase fusion protein (eMutaT7A→G), resulting in higher mutation frequencies to enable more rapid directed evolution. We also assess the benefits and potential downsides of using this more active mutator. We go on to show in Escherichia coli that adenosine deaminase-bearing mutators (MutaT7A→G or eMutaT7A→G) can be employed in tandem with a cytidine deaminase-bearing mutator (MutaT7C→T) to introduce all possible transition mutations simultaneously. We illustrate the efficacy of this in vivo mutagenesis approach by exploring mutational routes to antibacterial drug resistance. This work sets the stage for general application of optimized MutaT7 tools able to induce all types of transition mutations during in vivo directed evolution campaigns across diverse organisms.

Novel Quality Measure Set: Closing the Completion Loop on Radiology Follow-up Recommendations for Noncritical Actionable Incidental Findings.

BACKGROUND: Care gaps occur when radiology follow-up recommendations are poorly communicated or not completed, resulting in missed or delayed diagnosis potentially leading to worse patient outcomes. This ACR-led initiative assembled a technical expert panel (TEP) to advise development of quality measures intended to improve communication and drive increased completion rates for radiology follow-up recommendations. MATERIALS AND METHODS: A multistakeholder TEP was assembled to advise the development of quality measures. The project scope, limited to noncritical actionable incidental findings (AIFs), encourages practices to develop and implement systems ensuring appropriate communication and follow-up to completion. RESULTS: A suite of nine measures were developed: four outcome measures include closing the loop on completion of radiology follow-up recommendations for nonemergent AIFs (with pulmonary nodule and abdominal aortic aneurysm use cases) and overall cancer diagnoses. Five process measures address communication and tracking of AIFs: inclusion of available evidence or guidelines informing the recommendation, communication of AIFs to the practice managing ongoing care, identifying when AIFs have been communicated to the patient, and employing tracking and reminder systems for AIFs. CONCLUSION: This ACR-led initiative developed a measure set intended to improve patient outcomes by ensuring that AIFs are appropriately communicated and followed up. The intent of these measures is to focus improvement on specific areas in which gaps in communication and AIF follow-up may occur, prompting systems to devote resources that will identify and implement solutions to improve patient care.

Radiation Dose Reduction in Kidney Stone CT: A Randomized, Facility-Based Intervention.

OBJECTIVE: Kidney stones are common, tend to recur, and afflict a young population. Despite evidence and recommendations, adoption of reduced-radiation dose CT (RDCT) for kidney stone CT (KSCT) is slow. We sought to design and test an intervention to improve adoption of RDCT protocols for KSCT using a randomized facility-based intervention. METHODS: Facilities contributing at least 40 KSCTs to the American College of Radiology dose index registry (DIR) during calendar year 2015 were randomized to intervention or control groups. The Dose Optimization for Stone Evaluation intervention included customized CME modules, personalized consultation, and protocol recommendations for RDCT. Dose length product (DLP) of all KSCTs was recorded at baseline (2015) and compared with 2017, 2018, and 2019. Change in mean DLP was compared between facilities that participated (intervened-on), facilities randomized to intervention that did not participate (intervened-off), and control facilities. Difference-in-difference between intervened-on and control facilities is reported before and after intervention. RESULTS: Of 314 eligible facilities, 155 were randomized to intervention and 159 to control. There were 25 intervened-on facilities, 71 intervened-off facilities, and 96 control facilities. From 2015 to 2017, there was a drop of 110 mGy ∙ cm (a 16% reduction) in the mean DLP in the intervened-on group, which was significantly lower compared with the control group (P < .05). The proportion of RDCTs increased for each year in the intervened-on group relative to the other groups for all 3 years (P < .01). DISCUSSION: The Dose Optimization for Stone Evaluation intervention resulted in a significant (P < .05) and persistent reduction in mean radiation doses for engaged facilities performing KSCTs.

Engineered red blood cells as an off-the-shelf allogeneic anti-tumor therapeutic.

Checkpoint inhibitors and T-cell therapies have highlighted the critical role of T cells in anti-cancer immunity. However, limitations associated with these treatments drive the need for alternative approaches. Here, we engineer red blood cells into artificial antigen-presenting cells (aAPCs) presenting a peptide bound to the major histocompatibility complex I, the costimulatory ligand 4-1BBL, and interleukin (IL)-12. This leads to robust, antigen-specific T-cell expansion, memory formation, additional immune activation, tumor control, and antigen spreading in tumor models in vivo. The presence of 4-1BBL and IL-12 induces minimal toxicities due to restriction to the vasculature and spleen. The allogeneic aAPC, RTX-321, comprised of human leukocyte antigen-A*02:01 presenting the human papilloma virus (HPV) peptide HPV16 E711-19, 4-1BBL, and IL-12 on the surface, activates HPV-specific T cells and promotes effector function in vitro. Thus, RTX-321 is a potential 'off-the-shelf' in vivo cellular immunotherapy for treating HPV + cancers, including cervical and head/neck cancers.

An Adaptable Platform for Directed Evolution in Human Cells.

The discovery and optimization of biomolecules that reliably function in metazoan cells is imperative for both the study of basic biology and the treatment of disease. We describe the development, characterization, and proof-of-concept application of a platform for directed evolution of diverse biomolecules of interest (BOIs) directly in human cells. The platform relies on a custom-designed adenovirus variant lacking multiple genes, including the essential DNA polymerase and protease genes, features that allow us to evolve BOIs encoded by genes as large as 7 kb while attaining the mutation rates and enforcing the selection pressure required for successful directed evolution. High mutagenesis rates are continuously attained by trans-complementation of a newly engineered, highly error-prone form of the adenoviral polymerase. Selection pressure that couples desired BOI functions to adenoviral propagation is achieved by linking the functionality of the encoded BOI to the production of adenoviral protease activity by the human cell. The dynamic range for directed evolution can be enhanced to several orders of magnitude via application of a small-molecule adenoviral protease inhibitor to modulate selection pressure during directed evolution experiments. This platform makes it possible, in principle, to evolve any biomolecule activity that can be coupled to adenoviral protease expression or activation by simply serially passaging adenoviral populations carrying the BOI. As proof-of-concept, we use the platform to evolve, directly in the human cell environment, several transcription factor variants that maintain high levels of function while gaining resistance to a small-molecule inhibitor. We anticipate that this platform will substantially expand the repertoire of biomolecules that can be reliably and robustly engineered for both research and therapeutic applications in metazoan systems.

Quantitative microinjection using fluorescence calibration of streaming microdroplets on a superhydrophobic surface.

A simple and reproducible procedure was developed to measure the volume of liquid microinjected into cells. A calibration curve of droplet fluorescence intensity versus volume was constructed by injecting a fluorescent dextran solution through a 125-150 µm diameter micropipette into an oil-filled culture dish to create a spray of varied-sized droplets. The droplets retained a spherical shape because they were in an oil medium and they settled onto a glass surface coated with a superhydrophobic surface. Fluorescent micrographs of the droplets were obtained and analyzed with Image-J software to quantify the fluorescence intensity and radius of each spherical droplet to produce the calibration curve. Subsequently, Dut-145 human prostate carcinoma cells were microinjected with the same fluorescent dextran solution and fluorescent micrographs of the cells were obtained using the identical exposure conditions used to photograph the droplets. The measured fluorescence intensity of the microinjected cells was entered into the formula for the regression line that was fit to the calibration curve allowing determination of the volume of solution injected into each cell. Thus, a mixture consisting of known concentrations of a test material of test material (macromolecules, drugs, etc.) and a fluorescent dextran, volumetric, tracer can be used to quantify the relationship between the amount of a microinjected material and subsequent effects on cells.

Intravenous Infiltration Resulting in Compartment Syndrome: A Systematic Review.

OBJECTIVE: To determine characteristics of patients who develop compartment syndrome (CS) from IV infiltration requiring surgical intervention. METHODS: A systematic review was conducted of available English literature from 1990 to date. Key terms were entered into a MEDLINE search in addition to searching grey literature and references of included manuscripts. Inclusion criteria were cases of CS requiring surgical intervention from IV infiltration. Exclusions were cases associated with phenytoin because of the unclear mechanism leading to injury (purple glove syndrome). Cases were reviewed for demographics, clinical information, and outcomes. RESULTS: Literature search resulted in 32 manuscripts meeting inclusion with 51 cases. Age ranged from 3 days to 81 years (19.6% age <1 year [10/51], 21.6% age 1-18 years [11/51], and 58.8% age >18 years [30/51]). IV sites were reported in 43 cases: hand 46.5%, forearm 46.5%, foot 4.7%, and leg 2.3% ([20/43], [20/43], [2/43], [1/43]). Of the 42 cases reporting patient mental status, 76.2% (32/42) had impaired mental state or limited communication including young age defined as younger than 3 years. Common associated agents were contrast 36.2%, IV fluid 34%, and mannitol 8.5% ([18/47], [16/47], [4/47]). One patient required hand amputation, 5 had persistent deficits, 36 had no long-term deficits, and 9 cases did not report patient outcomes. CONCLUSION: Compartment syndrome affects patients of all ages with a significant number of patients being pediatric and specifically younger than 1 year. Patients at highest risk of developing CS requiring surgery from IV infiltration are likely to have barriers to communication.

Transportable, Chemical Genetic Methodology for the Small Molecule-Mediated Inhibition of Heat Shock Factor 1.

Proteostasis in the cytosol is governed by the heat shock response. The master regulator of the heat shock response, heat shock factor 1 (HSF1), and key chaperones whose levels are HSF1-regulated have emerged as high-profile targets for therapeutic applications ranging from protein misfolding-related disorders to cancer. Nonetheless, a generally applicable methodology to selectively and potently inhibit endogenous HSF1 in a small molecule-dependent manner in disease model systems remains elusive. Also problematic, the administration of even highly selective chaperone inhibitors often has the side effect of activating HSF1 and thereby inducing a compensatory heat shock response. Herein, we report a ligand-regulatable, dominant negative version of HSF1 that addresses these issues. Our approach, which required engineering a new dominant negative HSF1 variant, permits dosable inhibition of endogenous HSF1 with a selective small molecule in cell-based model systems of interest. The methodology allows us to uncouple the pleiotropic effects of chaperone inhibitors and environmental toxins from the concomitantly induced compensatory heat shock response. Integration of our method with techniques to activate HSF1 enables the creation of cell lines in which the cytosolic proteostasis network can be up- or down-regulated by orthogonal small molecules. Selective, small molecule-mediated inhibition of HSF1 has distinctive implications for the proteostasis of both chaperone-dependent globular proteins and aggregation-prone intrinsically disordered proteins. Altogether, this work provides critical methods for continued exploration of the biological roles of HSF1 and the therapeutic potential of heat shock response modulation.

The student's dilemma, liver edition: incorporating the sonographer's language into clinical anatomy education.

Anatomy students are often confused by multiple names ascribed to the same structure by different clinical disciplines. Increasingly, sonography is being incorporated into clinical anatomical education, but ultrasound textbooks often use names unfamiliar to the anatomist. Confusion is worsened when ultrasound names ascribed to the same structure actually refer to different structures. Consider the sonographic main lobar fissure (MLF). The sonographic MLF is a hyper-echoic landmark used by sonographers of the right upper quadrant. Found in approximately 70% of people, there is little consensus on what the sonographic MLF is anatomically. This structure appears to be related to the main portal fissure (aka principal plane of the liver or principal hepatic fissure), initially described by anatomists and surgeons as in intrahepatic division along the middle hepatic vein which in essence divides the territories of the left and right hepatic arteries and biliary systems. By exploring the relationship between the main portal fissure and the sonographic MLF in cadaveric livers ex vivo, the data suggest the sonographic MLF is actually an extrahepatic structure that parallels the rim of the main portal fissure. The authors recommend that this structure be renamed the "sonographic cystic pedicle," which includes the cystic duct and ensheathing fat and blood vessels. In the context of the redefined underlying anatomy, the absence of the sonographic cystic pedicle due to anatomic variation may serve an important clinical role in predicting complications from difficult laparoscopic cholecystectomies and is deserving of future study.

Spleen volume and clinical disease manifestations of severe Plasmodium falciparum malaria in African children.

BACKGROUND: Plasmodium falciparum malaria is common in African children. Severe disease manifestations include severe malarial anemia (SMA) and cerebral malaria (CM). In vitro studies suggest that splenic sequestration is associated with SMA and protective against CM. We sought to characterize the relationship between ultrasonographically derived spleen volume (SV), clinical manifestations and outcome. METHODS: We conducted a prospective observational study of severe malaria and SV in children aged 3 months to 12 years in Eastern Uganda. An SV normogram was generated from 186 healthy controls and adjusted for total body surface area (TBSA). Children with severe P. falciparum malaria were classified according to disease phenotype, and SV z-scores were compared for cases and controls to assess the degree of spleen enlargement. RESULTS: One hundred and four children with severe malaria, median age 19.2 months, were enrolled; 54 were classified as having SMA and 15 with CM. Mortality was 27% in the CM group vs 1.9% in the SMA group. TBSA-adjusted SV z-scores were lower in children with CM compared to SMA (1.98 [95% CI 1.38-2.57] vs 2.73 [95% CI 2.41-3.04]; p=0.028). Mean SV z-scores were lower in children who died (1.20 [95% CI 0.14-2.25]) compared to survivors (2.58 [95% CI 2.35-2.81]); p=0.004. CONCLUSIONS: SV is lower in CM compared to SMA. Severe malaria with no increase in SV z-score may be associated with mortality.

Protein kinase A-phosphorylated KV1 channels in PSD95 signaling complex contribute to the resting membrane potential and diameter of cerebral arteries.

RATIONALE: Postsynaptic density-95 (PSD95) is a scaffolding protein that associates with voltage-gated, Shaker-type K(+) (KV1) channels and promotes the expression of KV1 channels in vascular smooth muscle cells of the cerebral (cVSMCs) circulation. However, the physiological role of PSD95 in mediating molecular signaling in cVSMCs is unknown. OBJECTIVE: We explored whether a specific interaction between PSD95 and KV1 channels enables protein kinase A phosphorylation of KV1 channels in cVSMCs to promote vasodilation. METHODS AND RESULTS: Rat cerebral arteries were used for analyses. A membrane-permeable peptide (KV1-C peptide) corresponding to the postsynaptic density-95, discs large, zonula occludens-1 binding motif in the C terminus of KV1.2α was designed as a dominant-negative peptide to disrupt the association of KV1 channels with PSD95. Application of KV1-C peptide to cannulated, pressurized cerebral arteries rapidly induced vasoconstriction and depolarized cVSMCs. These events corresponded to reduced coimmunoprecipitation of the PSD95 and KV1 proteins without altering surface expression. Middle cerebral arterioles imaged in situ through cranial window also constricted rapidly in response to local application of KV1-C peptide. Patch-clamp recordings confirmed that KV1-C peptide attenuates KV1 channel blocker (5-(4-phenylalkoxypsoralen))-sensitive current in cVSMCs. Western blots using a phospho-protein kinase A substrate antibody revealed that cerebral arteries exposed to KV1-C peptide showed markedly less phosphorylation of KV1.2α subunits. Finally, phosphatase inhibitors blunted both KV1-C peptide-mediated and protein kinase A inhibitor peptide-mediated vasoconstriction. CONCLUSIONS: These findings provide initial evidence that protein kinase A phosphorylation of KV1 channels is enabled by a dynamic association with PSD95 in cerebral arteries and suggest that a disruption of such association may compromise cerebral vasodilation and blood flow.

Radiation dose index of renal colic protocol CT studies in the United States: a report from the American College of Radiology National Radiology Data Registry.

PURPOSE: To determine radiation dose indexes for computed tomography (CT) performed with renal colic protocols in the United States, including frequency of reduced-dose technique usage and any institutional-level factors associated with high or low dose indexes. MATERIALS AND METHODS: The Dose Imaging Registry (DIR) collects deidentified CT data, including examination type and dose indexes, for CT performed at participating institutions; thus, the DIR portion of the study was exempt from institutional review board approval and was HIPAA compliant. CT dose indexes were examined at the institutional level for CT performed with a renal colic protocol at institutions that contributed at least 10 studies to the registry as of January 2013. Additionally, patients undergoing CT for renal colic at a single institution (with institutional review board approval and informed consent from prospective subjects and waiver of consent from retrospective subjects) were studied to examine individual renal colic CT dose index patterns and explore relationships between patient habitus, demographics, and dose indexes. Descriptive statistics were used to analyze dose indexes, and linear regression and Spearman correlations were used to examine relationships between dose indexes and institutional factors. RESULTS: There were 49 903 renal colic protocol CT examinations conducted at 93 institutions between May 2011 and January 2013. Mean age ± standard deviation was 49 years ± 18, and 53.9% of patients were female. Institutions contributed a median of 268 (interquartile range, 77-699) CT studies. Overall mean institutional dose-length product (DLP) was 746 mGy ⋅ cm (effective dose, 11.2 mSv), with a range of 307-1497 mGy ⋅ cm (effective dose, 4.6-22.5 mSv) for mean DLPs. Only 2% of studies were conducted with a DLP of 200 mGy ⋅ cm or lower (a "reduced dose") (effective dose, 3 mSv), and only 10% of institutions kept DLP at 400 mGy ⋅ cm (effective dose, 6 mSv) or less in at least 50% of patients. CONCLUSION: Reduced-dose renal protocol CT is used infrequently in the United States. Mean dose index is higher than reported previously, and institutional variation is substantial.

Photoacoustic and photothermal detection of circulating tumor cells, bacteria and nanoparticles in cerebrospinal fluid in vivo and ex vivo.

Circulating cells, bacteria, proteins, microparticles, and DNA in cerebrospinal fluid (CSF) are excellent biomarkers of many diseases, including cancer and infections. However, the sensitivity of existing methods is limited in their ability to detect rare CSF biomarkers at the treatable, early-stage of diseases. Here, we introduce novel CSF tests based on in vivo photoacoustic flow cytometry (PAFC) and ex vivo photothermal scanning cytometry. In the CSF of tumor-bearing mice, we molecularly detected in vivo circulating tumor cells (CTCs) before the development of breast cancer brain metastasis with 20-times higher sensitivity than with current assays. For the first time, we demonstrated assessing three pathways (i.e., blood, lymphatic, and CSF) of CTC dissemination, tracking nanoparticles in CSF in vivo and their imaging ex vivo. In label-free CSF samples, we counted leukocytes, erythrocytes, melanoma cells, and bacteria and imaged intracellular cytochromes, hemoglobin, melanin, and carotenoids, respectively. Taking into account the safety of PAFC, its translation for use in humans is expected to improve disease diagnosis beyond conventional detection limits.

Evaluation of pulmonary embolism in the emergency department and consistency with a national quality measure: quantifying the opportunity for improvement.

BACKGROUND: The National Quality Forum (NQF) has endorsed a performance measure designed to increase imaging efficiency for the evaluation of pulmonary embolism (PE) in the emergency department (ED). To our knowledge, no published data have examined the effect of patient-level predictors on performance. METHODS: To quantify the prevalence of avoidable imaging in ED patients with suspected PE, we performed a prospective, multicenter observational study of ED patients evaluated for PE from 2004 through 2007 at 11 US EDs. Adult patients tested for PE were enrolled, with data collected in a standardized instrument. The primary outcome was the proportion of imaging that was potentially avoidable according to the NQF measure. Avoidable imaging was defined as imaging in a patient with low pretest probability for PE, who either did not have a D-dimer test ordered or who had a negative D-dimer test result. We performed subanalyses testing alternative pretest probability cutoffs and imaging definitions on measure performance as well as a secondary analysis to identify factors associated with inappropriate imaging. χ(2) Test was used for bivariate analysis of categorical variables and multivariable logistic regression for the secondary analysis. RESULTS: We enrolled 5940 patients, of whom 4113 (69%) had low pretest probability of PE. Imaging was performed in 2238 low-risk patients (38%), of whom 811 had no D-dimer testing, and 394 had negative D-dimer test results. Imaging was avoidable, according to the NQF measure, in 1205 patients (32%; 95% CI, 31%-34%). Avoidable imaging owing to not ordering a D-dimer test was associated with age (odds ratio [OR], 1.15 per decade; 95% CI, 1.10-1.21). Avoidable imaging owing to imaging after a negative D-dimer test result was associated with inactive malignant disease (OR, 1.66; 95% CI, 1.11-2.49). CONCLUSIONS: One-third of imaging performed for suspected PE may be categorized as avoidable. Improving adherence to established diagnostic protocols is likely to result in significantly fewer patients receiving unnecessary irradiation and substantial savings.

Factors associated with positive D-dimer results in patients evaluated for pulmonary embolism.

OBJECTIVES: Available D-dimer assays have low specificity and may increase radiographic testing for pulmonary embolism (PE). To help clinicians better target testing, this study sought to quantify the effect of risk factors for a positive quantitative D-dimer in patients evaluated for PE. METHODS: This was a prospective, multicenter, observational study. Emergency department (ED) patients evaluated for PE with a quantitative D-dimer were eligible for inclusion. The main outcome of interest was a positive D-dimer. Odds ratio (ORs) and 95% confidence intervals (CIs) were determined by multivariable logistic regression. Adjusted estimates of relative risk were also calculated. RESULTS: A total of 4,346 patients had D-dimer testing, of whom 2,930 (67%) were women. A total of 2,500 (57%) were white, 1,474 (34%) were black or African American, 238 (6%) were Hispanic, and 144 (3%) were of other race or ethnicity. The mean (+/-SD) age was 48 (+/-17) years. Overall, 1,903 (44%) D-dimers were positive. Model fit was adequate (c-statistic = 0.739, Hosmer and Lemeshow p-value = 0.13). Significant positive predictors of D-dimer positive included female sex; increasing age; black (vs. white) race; cocaine use; general, limb, or neurologic immobility; hemoptysis; hemodialysis; active malignancy; rheumatoid arthritis; lupus; sickle cell disease; prior venous thromboembolism (VTE; not under treatment); pregnancy and postpartum state; and abdominal, chest, orthopedic, or other surgery. Warfarin use was protective. In contrast, several variables known to be associated with PE were not associated with positive D-dimer results: body mass index (BMI), estrogen use, family history of PE, (inactive) malignancy, thrombophilia, trauma within 4 weeks, travel, and prior VTE (under treatment). CONCLUSIONS: Many factors are associated with a positive D-dimer test. The effect of these factors on the usefulness of the test should be considered prior to ordering a D-dimer.

Clinical features from the history and physical examination that predict the presence or absence of pulmonary embolism in symptomatic emergency department patients: results of a prospective, multicenter study.

STUDY OBJECTIVE: Prediction rules for pulmonary embolism use variables explicitly shown to estimate the probability of pulmonary embolism. However, clinicians often use variables that have not been similarly validated, yet are implicitly believed to modify probability of pulmonary embolism. The objective of this study is to measure the predictive value of 13 implicit variables. METHODS: Patients were enrolled in a prospective cohort study from 12 centers in the United States; all had an objective test for pulmonary embolism (D-dimer, computed tomographic angiography, or ventilation-perfusion scan). Clinical features including 12 predefined previously validated (explicit) variables and 13 variables not part of existing prediction rules (implicit) were prospectively recorded at presentation. The primary outcome was venous thromboembolism (pulmonary embolism or deep venous thrombosis), diagnosed by imaging up to 45 days after enrollment. Variables with adjusted odds ratios from logistic regression with 95% confidence intervals not crossing unity were considered significant. RESULTS: Seven thousand nine hundred forty patients (7.2% venous thromboembolism positive) were enrolled. Mean age was 49 years (standard deviation 17 years) and 67% were female patients. Eight of 13 implicit variables were significantly associated with venous thromboembolism; those with an adjusted odds ratio (OR) greater than 1.5 included non-cancer-related thrombophilia (OR 1.99), pleuritic chest pain (OR 1.53), and family history of venous thromboembolism (OR 1.51). Implicit variables that predicted no venous thromboembolism outcome included substernal chest pain, female sex, and smoking. Nine of 12 explicit variables predicted a positive outcome of venous thromboembolism, including patient history of pulmonary embolism or deep venous thrombosis in the past, unilateral leg swelling, recent surgery, estrogen, hypoxemia, and active malignancy. CONCLUSION: In symptomatic outpatients being considered for possible pulmonary embolism, non-cancer-related thrombophilia, pleuritic chest pain, and family history of venous thromboembolism increase probability of pulmonary embolism or deep venous thrombosis. Other variables that are part of existing pretest probability systems were validated as important predictors in this diverse sample of US emergency department patients.

Risk of thromboembolism varies, depending on category of immobility in outpatients.

STUDY OBJECTIVE: Immobility predisposes to venous thromboembolism, but this risk may vary, depending on the underlying cause of immobility. METHODS: This was a prospective, longitudinal outcome study of self-presenting emergency department (ED) patients who were from 12 hospitals and had suspected venous thromboembolism. Using explicit written criteria, clinicians recorded clinical features of each patient in the ED by using a Web-based data form. The form required one of 6 types of immobility: no immobility, general or whole-body immobility greater than 48 hours, limb (orthopedic) immobility, travel greater than 8 hours causing immobility within the previous 7 days, neurologic paralysis, or other immobility not listed above. Patients were followed for 45 days for outcome of venous thromboembolism, which required positive imaging results and clinical plan to treat. Odds ratios (ORs) were derived from logistic regression including 12 covariates. RESULTS: From 7,940 patients enrolled, 545 of 7,940 (6.9%) were diagnosed with venous thromboembolism (354 pulmonary embolism, 72 deep venous thrombosis, 119 pulmonary embolism and deep venous thrombosis). Risk of venous thromboembolism varied, depending on immobility type: limb (OR=2.24; 95% confidence interval [CI] 1.40 to 3.60), general (OR=1.76; 95% CI 1.26 to 2.44), other (OR=1.97; 95% CI 1.25 to 3.09), neurologic (OR=2.23; 95% CI 1.01 to 4.92), and travel (OR=1.19; 95% CI 0.85 to 1.67). Other significant risk factors from multivariate analysis included age greater than 50 years (OR =1.5; 95% CI 1.25 to 1.82), unilateral leg swelling (OR=2.68; 95% CI 2.13 to 3.37), previous venous thromboembolism (OR=2.99; 95% CI 2.41 to 3.71), active malignancy (OR=2.23; 95% CI 1.69 to 2.95), and recent surgery (OR=2.12; 95% CI 1.61 to 2.81). CONCLUSION: In a large cohort of symptomatic ED patients, risk of venous thromboembolism was substantially increased by presence of limb, whole-body, or neurologic immobility but not by travel greater than 8 hours. These data show the importance of clarifying the cause of immobility in risk assessment of venous thromboembolism.

Major vascular injury after laparoscopic tubal ligation.

Laparoscopy has become an established approach with diverse applications in both diagnostic and therapeutic surgical procedures. In general, the procedure is safe and effective and offers the advantage of being less invasive than conventional surgery. Complications after laparoscopy are uncommon but among them major vascular injury is potentially the most fatal, with recognition or mortality typically occurring intra-operatively or in the immediate post-operative period. We report the case of a delayed emergency department presentation of a major vascular injury after an elective laparoscopic tubal ligation. The prevalence, diagnosis, pathophysiolgy and management of major vascular injury after laparoscopic surgery is discussed.