Pectin based biologic Velcro effectively seals traumatic solid organ and small bowel injuries.

INTRODUCTION: Injuries to the liver and small bowel are common in multiple injuries. While there are currently a variety of accepted damage-control techniques to expeditiously manage such injuries, morbidity and mortality remain high. Pectin polymers have previously been shown to effectively seal visceral organ injuries ex vivo through physiochemical entanglement with the glycocalyx. We sought to compare the standard of care for the management of penetrating liver and small bowel injuries with a pectin-based bioadhesive patch in a live animal model. METHODS: Fifteen adult male swine underwent a laparotomy with standardized laceration to the liver. Animals were randomized to one of three treatment arms: packing with laparotomy pads (n = 5), suture repair (n = 5), or pectin patch repair (n = 5). Following 2 hours of observation, fluid was evacuated from the abdominal cavity and weighed. Next, a full-thickness small bowel injury was created, and animals were randomized to either a sutured repair (n = 7) or pectin patch repair (n = 8). The segment of bowel was then pressurized with saline, and the burst pressure was recorded. RESULTS: All animals survived the protocol to completion. There were no clinically significant differences between groups regarding baseline vitals or laboratory studies. On one-way analysis of variance, there was a statistically significant difference between groups regarding blood loss after liver repair (26 mL suture vs. 33 mL pectin vs. 142 mL packing, p < 0.01). On post hoc analysis, there was no statistically significant difference between suture and pectin ( p = 0.9). After repair, small bowel burst pressures were similar between pectin and suture repair (234 vs. 224 mm Hg, p = 0.7). CONCLUSION: Pectin-based bioadhesive patches performed similarly to the standard of care for the management of liver lacerations and full-thickness bowel injuries. Further testing is warranted to assess the biodurability of a pectin patch repair, as it may offer a simple option to effectively temporize traumatic intra-abdominal injuries.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019.

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. U.S. burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from five large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained second-degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by secondhand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in the initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognize electronic cigarette use as a public health problem with the potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on an outpatient basis have good outcomes.

Extending the golden hour for Zone 1 resuscitative endovascular balloon occlusion of the aorta: Improved survival and reperfusion injury with intermittent versus continuous resuscitative endovascular balloon occlusion of the aorta of the aorta in a porcine severe truncal hemorrhage model.

BACKGROUND: Noncompressible hemorrhage can be controlled using resuscitative endovascular balloon occlusion of the aorta (REBOA). Prolonged ischemia limits REBOA application during Zone 1 deployment. Intermittent inflation/deflation may effectively mitigate this problem. METHODS: A lethal abdominal vascular injury was created in 28 swines. Animals were randomized to controls (n = 7), 60 minutes full REBOA (FR, n = 5), time-based intermittent REBOA (iRT, n = 7), and pressure-based REBOA (iRP, n = 9). Intermittent groups had an initial inflation for 15 minutes, followed by 10-minute inflation: 3-minute deflation cycles (iRT), or an inflate/deflate schedule based on mean arterial pressure (MAP) less than 40 mm Hg (iRP). Experiments were concluded after 120 minutes or death (MAP < 20 mm Hg). RESULTS: Intermittent REBOA animals all survived to 120 minutes versus 15 minutes for controls and 63 minutes for FR (p < 0.001). After 60 minutes, FR animals were more hypotensive (MAP 20 mm Hg vs. 80 mm Hg [iRP] and 100 mm Hg [iRT]; p < 0.001), had lower cardiac output (1.06 mL/min vs. 5.1 L/min [iRP] and 8.2 L/min [iRT]; p < 0.001), higher lactate (12.5 mg/dL vs. 8.5 mg/dL [iRP], p = 0.02), and decreased clot firmness on rotational thromboelastometry than iRP/T (64 mm vs. 69 mm [iRP] and 69 mm [iRT], p = 0.04). Acidosis was worse in iRT versus iRP at 120 minutes (pH 7.28 vs. pH 7.12; p = 0.02), improved lactate (11.9 mg/dL vs. 16.3 mg/dL; p = 0.04), and decreased whole blood resuscitation (452 mL vs. 646 mL, p = 0.05). Blood loss (clot weight) was higher in controls (2.0 kg) versus iRT and iRP (1.16 kg and 1.23 kg; p < 0.01) and not different from FR (0.87 kg; p = 0.10). CONCLUSION: Intermittent REBOA can maintain supraceliac hemorrhage control while decreasing distal ischemia in a swine model. Prolonged survival times, decreased acidosis, and lower resuscitation requirements indicate that this technique could potentially extend Zone 1 REBOA deployment times. Schedules based on MAP may be superior to time-based regimens.

Plasma coadministration improves resuscitation with tranexamic acid or prothrombin complex in a porcine hemorrhagic shock model.

BACKGROUND: Traumatic coagulopathy has now been well characterized and carries high rates of mortality owing to bleeding. A 'factor-based' resuscitation strategy using procoagulant drugs and factor concentrates in lieu of plasma is being used by some, but with little evidentiary support. We sought to evaluate and compare resuscitation strategies using combinations of tranexamic acid (TXA), prothrombin complex concentrate (PCC), and fresh frozen plasma (FFP). METHODS: Sixty adult swine underwent 35% blood volume hemorrhage combined with a truncal ischemia-reperfusion injury to produce uniform shock and coagulopathy. Animals were randomized to control (n = 12), a single-agent group (TXA, n = 10; PCC, n = 8; or FFP, n = 6) or combination groups (TXA-FFP, n = 10; PCC-FFP, n = 8; TXA-PCC, n = 6). Resuscitation was continued to 6 hours. Key outcomes included hemodynamics, laboratory values, and rotational thromboelastometry. Results were compared between all groups, with additional comparisons between FFP and non-FFP groups. RESULTS: All 60 animals survived to 6 hours. Shock was seen in all animals, with hypotension (mean arterial pressure, 44 mm Hg), tachycardia (heart rate, 145), acidosis (pH 7.18; lactate, 11), anemia (hematocrit, 17), and coagulopathy (fibrinogen, 107). There were clear differences between groups for mean pH (p = 0.02), international normalized ratio (p < 0.01), clotting time (CT; p < 0.01), lactate (p = 0.01), creatinine (p < 0.01), and fibrinogen (p = 0.02). Fresh frozen plasma groups had significantly improved resuscitation and clotting parameters (Figures), with lower lactate at 6.5 versus 8.4 (p = 0.04), and increased fibrinogen at 126 versus 95 (p < 0.01). Rotational thromboelastometry also demonstrated shortened CT at 60 seconds in the FFP group vs 65 seconds in the non-FFP group (p = 0.04). CONCLUSION: When used to correct traumatic coagulopathy, combinations of FFP with TXA or PCC were superior in improving acidosis, coagulopathy, and CT than when these agents are given alone or in combination without plasma. Further validation of pure factor-based strategies is needed.

No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model.

BACKGROUND: The acute coagulopathy of trauma is often accompanied by hyperfibrinolysis. Tranexamic acid (TXA) can reverse this phenomenon, and, when given early, decreases mortality from bleeding. Establishing intravenous (IV) access can be difficult in trauma and intraosseous (IO) access is often preferred for drug administration. Currently, there are no data on the efficacy of IO administered TXA. Our objectives were to compare serum concentrations of TXA when given IV and IO and to compare the efficacy of IO administered TXA to IV at reversing hyperfibrinolysis. METHODS: Using a porcine hemorrhage and ischemia-reperfusion model, 18 swine underwent hemorrhagic shock followed by a tissue plasminogen activator infusion to induce hyperfibrinolysis. Animals then received an IV or tibial IO infusion of TXA over 10 minutes. Blood was then analyzed using rotational thromboelastometry to monitor reversal of hyperfibrinolysis. Serum was analyzed for drug concentrations. RESULTS: After hemorrhage and ischemia-reperfusion, there were no significant differences in mean arterial pressure (48 vs. 49.5), lactate (11.1 vs. 10.8), and pH (7.20 vs. 7.22) between groups. Intraosseous TXA corrected the lysis index at 30 minutes in EX-TEM and IN-TEM, like IV infusion. Peak serum levels of TXA after IV and IO administration show concentrations of 160.9 µg/mL and 132.57 µg/mL respectively (p = 0.053). Peak levels occurred at the completion of infusion. Drug levels were tracked for four hours. At the end of monitoring, plasma concentrations of TXA were equivalent. CONCLUSION: Intraosseous administration of TXA is as effective as IV in reversing hyperfibrinolysis in a porcine model of hemorrhagic shock. Intraosseous administration was associated with a similar peak levels, pharmacokinetics, and clearance. Intraosseous administration of TXA can be considered in hemorrhagic shock when IV access cannot be established.

Three- versus four-factor prothrombin complex concentrates for "factor-based" resuscitation in a porcine hemorrhagic shock model.

BACKGROUND: Bleeding is a leading cause of preventable death after severe injury. Prothrombin complex concentrates (PCC) treat inborn coagulation disorders and reverse oral anticoagulants, but are proposed for use in "factor-based" resuscitation strategies. Few studies exist for this indication in acidosis, or that compare 3-factor PCC (3PCC) versus 4-factor PCC (4PCC) products. We aimed to assess and compare their safety and efficacy in a porcine model of severe hemorrhagic shock and coagulopathy. METHODS: Twenty-five adult Yorkshire swine underwent 35% volume hemorrhage, ischemia-reperfusion injury, and protocolized crystalloid resuscitation. Seventeen animals were randomized at 4 hours after model creation to receive a 45-IU/kg dose of either 3PCC or 4PCC. An additional eight animals received autologous plasma transfusion before 4PCC to better characterize response to PCC. Individual factor levels were drawn at 4 hours and 6 hours. RESULTS: The model created significant acidosis with mean pH of 7.21 and lactate of 9.6 mmol/L. After PCC, 66.7% of 3PCC animals and 25% of 4PCC animals (regardless of plasma administration) developed consumptive coagulopathy. The animals that developed consumptive coagulopathy had manifested the "lethal triad" with lower temperatures (36.3°C vs. 37.8°C), increased acidosis (pH, 7.14 vs. 7.27; base excess, -12.1 vs. -6.5 mEq/L), and worse coagulopathy (prothrombin time, 17.1 vs. 14.6 seconds; fibrinogen, 87.9 vs. 124.1 mg/dL) (all p < 0.05). In the absence of a consumptive coagulopathy, 3PCC and 4PCC improved individual clotting factors with transient improvement of prothrombin time, but there was significant depletion of fibrinogen and platelets with no lasting improvement of coagulopathy. CONCLUSION: PCC failed to correct coagulopathy and was associated with fibrinogen and platelet depletion. Of greater concern, PCC administration resulted in consumptive coagulopathy in the more severely ill animals. The incidence of consumptive coagulopathy was markedly increased with 3PCC versus 4PCC, and these products should be used with caution in this setting.

Resuscitative endovascular balloon occlusion of the aorta for major abdominal venous injury in a porcine hemorrhagic shock model.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rescue maneuver for unstable patients with noncompressible hemorrhage below the diaphragm. The efficacy of REBOA in the setting a major abdominal venous injury is unknown. Our objective was to examine the use of REBOA in a large animal model of major abdominal venous injury and characterize any impact on the hemodynamics, rate and volume of hemorrhage, and survival. METHODS: Ten swine (35-55 kg) underwent a controlled and validated hemorrhage and ischemia/reperfusion injury protocol to produce shock physiology. Animals were randomly assigned to a control arm (N = 5) or a treatment (REBOA) arm (N = 5). An injury was then created in the common iliac vein. Bleeding was allowed for 60 seconds and the balloon was then inflated in the REBOA arm. Hemodynamics were recorded for 45 minutes or until death. Blood loss was verified post-mortem and bleeding rate calculated. RESULTS: All animals demonstrated shock physiology at the time of randomization. There were no differences between control versus REBOA animals in baseline mean arterial pressure (42 vs. 50), pH (7.29 vs. 7.26), lactate (6.19 vs. 6.26), or INR (1.2 vs. 1.3, all p = NS). REBOA animals demonstrated immediate improvements in mean arterial pressure (50.6 vs. 97.2, p = 0.04). The mean survival time was 4.1 minutes for controls (100% died) versus 40.1 minutes for REBOA (p < 0.01). There was no difference in total blood loss (mean 630 mL for both). The rate of bleeding was significantly lower in the REBOA animals (control 197 mL/min vs. REBOA 14 mL/min, p = 0.02). CONCLUSION: In the setting of an abdominal venous injury, REBOA improved hemodynamics and lengthened survival time. Blood loss was similar between groups but the rate of bleeding was markedly decreased with REBOA. REBOA appears effective for central venous injuries and provides a sustained period of stabilization and window for surgical intervention.

Advanced laparoscopic bariatric surgery Is safe in general surgery training.

BACKGROUND: Bariatric surgery makes up an increasing percentage of general surgery training. The safety of resident involvement in these complex cases has been questioned. We evaluated patient outcomes in resident performed laparoscopic bariatric procedures. METHODS: Retrospective review of patients undergoing a laparoscopic bariatric procedure over seven years at a tertiary care single center. Procedures were primarily performed by a general surgery resident and proctored by an attending surgeon. Primary outcomes included operative volume, operative time and leak rate with perioperative outcomes evaluated as secondary outcomes. RESULTS: A total of 1649 bariatric procedures were evaluated. Operations included laparoscopic bypass (690) and laparoscopic sleeve gastrectomy (959). Average operating time was 136 min. Eighteen leaks (0.67%) were identified. Graduating residents performed an average of 89 laparoscopic bariatric cases during their training. There were no significant differences between resident levels with concern to operative time or leak rate (p 0.97 and p = 0.54). CONCLUSIONS: General surgery residents can safely perform laparoscopic bariatric surgery. When proctored by a staff surgeon, a resident's level of training does not significantly impact leak rate.

The true impact of breast magnetic resonance imaging on the management of in situ disease: more is not better.

BACKGROUND: The optimal role of breast magnetic resonance imaging (MRI) in the management of ductal carcinoma in situ (DCIS) remains controversial. We sought to better define the impact of breast MRIs when utilized during the workup of DCIS. METHODS: Patients with biopsy-proven DCIS without any additional invasive disease were prospectively enrolled in the multidisciplinary breast cancer pathway and comprised the study group. Patients who met any additional criteria for MRI screening were excluded. RESULTS: From 2008 to 2014, 93 women met the inclusion criteria. 81 patients underwent MRI as part of their workup. One patient benefited from MRI via identification of occult malignancy not previously identified. 35 MRIs identified no additional information whereas 46 had additional findings. These findings led to 23 procedures and 16 negative biopsies; recommendations for 16 radiographic studies that were normal; and influenced nodal sampling in 7 women with 1 positive metastatic focus. CONCLUSIONS: The routine use of breast MRI for women diagnosed with DCIS has limited benefit. Often, it leads to multiple procedures and studies that are clinically insignificant and delays surgical treatment.

Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air?

BACKGROUND: Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak. METHODS: Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed. RESULTS: Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6). CONCLUSIONS: The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

Treatment of presumptive idiopathic immune-mediated anemia in a Holstein heifer, using blood transfusions and corticotherapy.

An idiopathic immune-mediated anemia was diagnosed in a 1-year-old Holstein heifer. The diagnostic procedures, blood transfusions, use of an immunosuppressive dosage of dexamethasone, and favorable outcome are described, and idiopathic immune-mediated anemia in mammals is briefly reviewed.

Osteometric study of metapodial bones in sheep (Ovis aries, L. 1758).

This study, based on a sample of 215 individuals, gives detailed insight into Sheep metapodial bone main features: their variability and correlations between their various parts. This data allowed us to reveal the most relevant measurements for study of metapodial bones in sheep (GL, Bp, Dp, SD, DD, Bd, and Dd), as well as references used to split up the main population. Those references give a great help in placing any sample in relation to the breeds described in this work. The main purpose of this tool is to compare unknown populations, such as fossil ones, to present sheep breeds, in order to increase our knowledge of domesticated Sheep History, from its origins to the present day.