Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe.

INTRODUCTION: Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. METHODS: Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. RESULTS: The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. CONCLUSIONS: Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Slippery Antifouling Polymer Coatings Fabricated Entirely from Biodegradable and Biocompatible Components.

We report the design of slippery liquid-infused porous surfaces (SLIPS) fabricated from building blocks that are biodegradable, edible, or generally regarded to be biocompatible. Our approach involves infusion of lubricating oils, including food oils, into nanofiber-based mats fabricated by electrospinning or blow spinning of poly(ε-caprolactone), a hydrophobic biodegradable polymer used widely in medical implants and drug delivery devices. This approach leads to durable and biodegradable SLIPS that prevent fouling by liquids and other materials, including microbial pathogens, on objects of arbitrary shape, size, and topography. This degradable polymer approach also provides practical means to design "controlled-release" SLIPS that release molecular cargo at rates that can be manipulated by the properties of the infused oils (e.g., viscosity or chemical structure). Together, our results provide new designs and introduce useful properties and behaviors to antifouling SLIPS, address important issues related to biocompatibility and environmental persistence, and thus advance new potential applications, including the use of slippery materials for food packaging, industrial and marine coatings, and biomedical implants.

Validation of the adapted clavien dindo in trauma (ACDiT) scale to grade management related complications at a level I trauma center.

Objectives: Complications during trauma management are the main factor responsible for the overall increase in treatment cost. There are very few grading systems to measure the burden of complications in trauma patients. A prospective study was conducted using the Adapted Clavien Dindo in Trauma (ACDiT) scale, with the primary aim of validating it at our center. As a secondary aim, it was also wanted to measure the mortality burden among our admitted patients. Material and Methods: The study was conducted at a dedicated trauma center. All patients with acute injuries, who were admitted, were included. An initial treatment plan was made within 24 hours of admission. Any deviation from this was recorded and graded according to the ACDiT. The grading was correlated with hospital-free days and ICU-free days within 30 days. Results: A total of 505 patients were included in this study, with a mean age of 31 years. The most common mechanism of injury was road traffic injury, with a median ISS and NISS of 13 and 14, respectively. Two hundred and forty-eight out of 505 patients had some grade of complication as determined by the ACDiT scale. Hospital-free days (13.5 vs. 25; p <0.001) were significantly lower in patients with complications than those without complications, and so were ICU-free days (29 vs. 30; p <0.001). Significant differences were also observed when comparing mean hospital free and ICU free days across various ACDiT grades. Overall mortality of the population was 8.3 %, the majority of whom were hypotensive on arrival and required ICU care. Conclusion: We successfully validated the ACDiT scale at our center. We recommend using this scale to objectively measure in-hospital complications and improve trauma management quality. ACDiT scale should be one of the data points in any trauma database/registry.

Slippery nanoemulsion-infused porous surfaces (SNIPS): anti-fouling coatings that can host and sustain the release of water-soluble agents.

We report the design of 'slippery' nanoemulsion-infused porous surfaces (SNIPS). These materials are strongly anti-fouling to a broad range of substances, including microorganisms. Infusion with water-in-oil nanoemulsions also endows these slippery coatings with the ability to host and control or sustain the release of water-soluble agents, including polymers, peptides, and nucleic acids, opening the door to new applications of liquid-infused materials.

Fabrication of Slippery Liquid-Infused Coatings in Flexible Narrow-Bore Tubing.

We report a layer-by-layer suction-and-flow approach that enables the fabrication of polymer-based "slippery" liquid-infused porous surfaces (SLIPS) in the confined luminal spaces of flexible, narrow-bore tubing. These SLIPS-coated tubes can prevent or strongly reduce surface fouling after prolonged contact, storage, or flow of a broad range of complex fluids and viscoelastic materials, including many that are relevant in the contexts of medical devices (e.g., blood and urine), food processing (beverages and fluids), and other commercial and industrial applications. The robust and mechanically compliant nature of the nanoporous coating used to host the lubricating oil phase allows these coated tubes to be bent, flexed, and coiled repeatedly without affecting their inherent slippery and antifouling behaviors. Our results also show that SLIPS-coated tubes can prevent the formation of bacterial biofilms after prolonged and repeated flow-based exposure to the human pathogen Staphylococcus aureus and that the anti-biofouling properties of these coated tubes can be further improved or prolonged by coupling this approach with strategies that permit the sustained release of broad-spectrum antimicrobial agents. The suction-and-flow approach used here enables the application of slippery coatings in the confined luminal spaces of narrow-bore tubing that are difficult to access using several other methods for the fabrication of liquid-infused coatings and can be applied to tubing of arbitrary length and diameter. We anticipate that the materials and approaches reported here will prove useful for reducing or preventing biofouling, process fouling, and the clogging or occlusion of tubing in a wide range of consumer, industrial, and healthcare-oriented applications.

Learning Pattern of Two-Dimensional, Three-Dimensional, and Ultra-High-Definition Endovision System on Standardized Phantom Tasks: An Ex Vivo Randomized Study.

Introduction: Three-dimensional (3D), high-definition (HD), and ultra-high-definition (4K HD) are recent additions over regular HD technology for laparoscopic surgery. The aim of this study was to evaluate the learning pattern of these systems on standardized phantom tasks. Methodology: Forty-five stereo-enabled resident doctors were randomly assigned into three groups. They performed three validated tasks, precision touch on flat surface, precision touch on uneven surface, surgical knot on rubber tube using either two-dimensional (2D) HD, 3D HD, or 4K HD Endovision systems. Each task was repeated 20 times. Data from four consecutive repetitions were pooled to make five blocks. Split group analysis by comparing the consecutive blocks in execution time and errors were made to see the learning pattern. A significant difference was accepted as continuous learning while no significant difference was accepted as learning stabilization. Result: Operating time was stabilized in two tasks after third block in 2D HD, one task after fourth block in 4K HD. There was continuous learning in all tasks with 3D HD. The 3D HD group was significantly faster than 2D HD and 4K HD in most of the tasks on fifth block. The error scores were similar between the consecutive blocks in 4K HD. It was stabilized after second block in 2D HD group and third block on 3D HD. Conclusion: The 3D HD Endovision system has more potential of faster execution of a task, but need more practice to reach similar safety profile. The 4K HD reached the safety plateau with minimal repetitions.

Liquid Crystal-Infused Porous Polymer Surfaces: A "Slippery" Soft Material Platform for the Naked-Eye Detection and Discrimination of Amphiphilic Species.

We report the design and characterization of liquid crystal (LC)-infused porous polymer membranes that can detect and report on the presence of natural and synthetic amphiphiles in aqueous solution. We demonstrate that thermotropic LCs can be infused into nanoporous polymer membranes to yield LC-infused surfaces that exhibit slippery behaviors in contact with a range of aqueous fluids. In contrast to conventional liquid-infused surfaces (LIS) or slippery liquid-infused porous surfaces (SLIPS) prepared using isotropic oils, aqueous solutions slide over the surfaces of these LC-infused materials at speeds that depend strongly upon the composition of the fluid, including the presence, concentration, or structure of a dissolved surfactant. In general, the sliding times of aqueous droplets on these LC-infused surfaces increase significantly (e.g., from times on the order of seconds to times on the order of minutes) with increasing amphiphile concentration, allowing sliding times to be used to estimate the concentration of the amphiphile. Additional experiments revealed other intrinsic and extrinsic variables or parameters that can be used to further manipulate droplet sliding times and discriminate among amphiphiles of similar structure. Our results are consistent with a physical picture that involves reversible changes in the interfacial orientation of anisotropic LCs mediated by the interfacial adsorption of amphiphiles. These materials thus permit facile "naked-eye" detection and discrimination of amphiphiles in aqueous samples using equipment no more sophisticated than a stopwatch. We demonstrate the potential utility of these LC-infused surfaces for the unaided, naked-eye detection and monitoring of amphiphilic biotoxins in small droplets of fluid extracted directly from cultures of two common bacterial pathogens (Pseudomonas aeruginosa and Staphylococcus aureus). The ability to translate molecular interactions at aqueous/LC interfaces into large and readily observed changes in the sliding times of small aqueous droplets on surfaces could open the door to new applications for antifouling, liquid-infused materials in the context of environmental sensing and other fundamental and applied areas.

Massive parietal defect with multiple enteroatmospheric fistulae after thermal injury abdomen in a metal industry accident: Case report of a rare survivor.

In industrial foundries, raw metal is heated almost up to its melting point and then passed through the rolling mill to mould it into a desired shape. Contact with hot machinery or the hot metal can cause severe deep burns. When such thermal injury involves the abdominal wall, complex bowel injury can occur, leading to life-threatening abdominal sepsis. We report successful management of a patient with abdominal wall defect and multiple open fistulae. Severe thermal injury of the anterior abdominal wall may be associated with latent bowel injuries and abdominal compartment syndrome. A low threshold for surgery and re-look surgery may prevent complications.

Evolution from sinusoidal to collinear A-type antiferromagnetic spin-ordered magnetic phase transition in Tb1-xPrxMnO3solid solution.

The present study reports on the structural and magnetic phase transitions in Pr-doped polycrystalline Tb0.6Pr0.4MnO3, using high-resolution neutron powder diffraction (NPD) collected at SINQ spallation source, to emphasize the suppression of the sinusoidal magnetic structure of pure TbMnO3and the evolution to a collinear A-type antiferromagnetic ordering. The phase purity, Jahn-Teller distortion, and one-electron bandwidth for egorbital of Mn3+cation have been calculated for polycrystalline Tb0.6Pr0.4MnO3,in comparison to the parent materials TbMnO3and PrMnO3, through the Rietveld refinement study from x-ray diffraction data at room temperature, which reveals the GdFeO3type orthorhombic structure of Tb0.6Pr0.4MnO3havingPnmaspace group symmetry. The temperature-dependent zero field-cooled and field-cooled dc magnetization study at low temperature down to 5 K reveals a variation in the magnetic phase transition due to the effect of Pr3+substitution at the Tb3+site, which gives the signature of the antiferromagnetic nature of the sample, with a weak ferromagnetic component at low temperature-induced by an external magnetic field. The field-dependent magnetization study at low temperatures gives the weak coercivity having the order of 2 kOe, which is expected due to the canted-spin arrangement or ferromagnetic nature of Terbium ordering. The NPD data for Tb0.6Pr0.4MnO3confirms that the nuclear structure of the synthesized sample maintains its orthorhombic symmetry down to 1.5 K. Also, the magnetic structures have been solved at 50 K, 25 K, and 1.5 K through the NPD study, which shows an A-type antiferromagnetic spin arrangement having the magnetic space groupPn'ma'.

Magnitude and outcomes of complex perineal injury - A retrospective analysis of five years' data from a Level 1 trauma centre.

Complex perineal injuries pose a major diagnostic and therapeutic challenge to trauma surgeons. A retrospective review of the hospital records of 29 patients with complex perineal injury following blunt trauma was done. Demographic profile, management and outcomes were collected. Quality of life analysis was conducted for patients with complex perineal injuries who were discharged. The most predominant mode of injury was a road crash: being a pedestrian run over by a heavy motor vehicle. Pelvic fracture was seen in 20, anorectal involvement in 22 and urogenital injuries in 14. Urgent surgical debridement was done in all patients, faecal diversion in 27 and urinary diversion in 14. There were nine deaths, three from haemorrhage, and the remainder from sepsis and multi-organ dysfunction. Complex perineal injury remains a major cause of morbidity and mortality in trauma patients. There is a need to ensure adequate rehabilitation services for such patients.

Traumatic Arterio-Enteric Fistula-A Report of 2 Cases With Review of Literature.

BACKGROUND: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. CASE DESCRIPTION: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. CONCLUSION: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two.

Complex open sternal fracture with impingement of the pericardium.

The incidence of sternal fracture ranges from 3 to 8%. In more than half, they are associated with other organ trauma such as blunt cardiac injuries, rib, scapular or vertebral fractures. Hence, the presence of sternal fracture is considered a marker for significant transmission of energy. The management of isolated sternal fractures is usually non-operative with surgery reserved for displaced fractures or in cases of respiratory insufficiency. However, management may become challenging when they are associated with other significant trauma. We discuss a case of sternal fracture complicated by the presence of blunt cardiac injury, open pneumothorax, rib fractures, anterior flail chest and empyema.

Comparison of two-dimensional high-definition, ultra high-definition and three-dimensional endovision systems: an ex-vivo randomised study.

BACKGROUND: Two-dimensional high-definition (2D HD) endovision system is preferred for laparoscopic surgery. Recently, new generation three-dimensional (3D) HD and ultra-HD (4K) endovision systems are introduced to improve the safety and efficacy of laparoscopic surgery. There is limited evidence on superiority of one technology over the others. This experimental trial was designed to evaluate 2D HD, 3D HD and 4K HD endovision systems in performance of standardized tasks. METHODS: This was a randomized, cross-over experimental study. Twenty-one surgical residents who were exposed to laparoscopic surgery were enrolled. Participants were randomly assigned into three groups. Each group performed standardised tasks i.e. peg transfer, precision cutting, navigating in space and intra-corporeal suturing using 2D HD, 4K HD and 3D HD endovision systems on a box trainer. Procedures were recorded as 2D HD videos and analysed later. Participant's perceived workload was assessed using Surg-TLX questionnaire. Primary endpoints were execution time in seconds and error score. Secondary endpoint was workload assessment. RESULTS: The 3D HD had shorter execution time compared to 2D HD and 4K HD in all tasks except precision cutting (p = 0.004, 0.03, 0.001, 0.001 and p = 0.002, 0.191, 0.006, 0.005 in peg transfer, precision cutting, navigating in space and intra-corporeal suturing respectively). The 4K HD was significantly faster than 2D HD only in navigating in space task (p = 0.002). The error score between 3D HD and 4K HD were comparable in all tasks. The 2D HD had significantly more error scores compared to 4K HD, 3D HD in peg transfer task (p = 0.005, 0.014, respectively). 3D HD had significantly less workload than 2D HD and 4K HD in most of the dimensions of Surg-TLX CONCLUSIONS: 3D HD endovision system in comparison to 2D HD and 4K HD, may lead to faster execution without compromising safety of a task and is associated with less workload.

Early hospital discharge following non-operative management of blunt liver and splenic trauma: A pilot randomized controlled trial.

BACKGROUND: Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial. MATERIALS AND METHODS: After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge. RESULTS: Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits. CONCLUSION: Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist.

Innocuous wound with occult central vascular injury: A case report.

Penetrating trauma is one of the most common cause of occult vascular injury, especially in low velocity penetrating injury. This is usually in pretext of an innocuous looking small external wound. It is important for clinician to have high index of suspicion for such types of injuries, as the clinical examination with presenting signs and symptoms may be deceptive. Radiological evaluation is of paramount importance and essential to rule out any occult vascular insult. Conventional open surgical exploration is the gold standard for vascular injuries in neck. Minimal invasive endovascular stenting has selective role based on zone of neck, mechanism of injury, hemodynamic stability, neurological status and resource availability at treating centre. Early diagnosis and referral to an appropriate higher centre, preferably a trauma centre with expertise in handling major vascular injuries, improve the outcome. We present a case report of small innocuous looking external wound harbouring major central vessel injury underneath following low-velocity penetrating injury.

Management of Complex Traumatic Renal Artery-Inferior Vena Cava Fistula: A Case Report and Review of the Literature.

BACKGROUND: Renal artery-inferior vena cava (IVC) fistula is usually caused by penetrating injury to the back. However, it is a very rarely reported entity with only 20 cases reported in the literature. They may present acutely with hemodynamic instability or chronically as congestive heart failure. A thorough examination and adequate imaging are required to avoid missing such injuries. CASE PRESENTATION: A 28-year-old gentleman presented after sustaining stab injury to the back. The stab had penetrated the renal artery and IVC, leading to arteriovenous fistula. He was managed surgically, as he went into hemorrhagic shock, with a successful outcome. The case is also unique as an accessory renal artery was also involved in the fistula. CONCLUSION: Early identification and management of renal artery-IVC fistula is important to ensure a successful outcome. Such fistulas can be managed by either endovascular approach or surgical approach. The decision of approach depends on the level of expertise available and hemodynamic status of the patient.

Compartment syndrome of the non-injured limb.

Compartment syndrome is a common limb-threatening entity in trauma. However, the occurrence of the same in the non-injured limb is rare. It seems to be multifactorial in origin, with abnormal positioning being the most common cause. We present such a case of well-leg compartment syndrome which was treated by an urgent fasciotomy. We emphasise on the fact that the diagnosis of compartment syndrome is clinical and the management remains the same irrespective of whether the limb has sustained an injury or not.