The provision of a trauma bed in theatre recovery and its impact on trauma theatre efficiency: experience from a high-volume trauma unit.

INTRODUCTION: Inefficiencies in the trauma setting are well known and have been further exacerbated by the COVID-19 pandemic among other factors, resulting in national guidance to aid improvements in resource utilisation. This study introduced a novel surgeon-led intervention, a trauma bed in recovery, with the aim of improving trauma theatre efficiency. METHODS: This quality improvement project was conducted using a Plan Do Study Act (PDSA) methodology and comprised multiple cycles to assess theatre performance. A multidisciplinary team (MDT) approach with relevant stakeholder input enabled intervention implementation, aimed at facilitating 'golden patient' arrival in the anaesthetic room as early as possible. The primary outcome was the time at which the first patient entered the anaesthetic room, and the secondary outcome was the number of cases performed each day. RESULTS: The study period was 1 year and encompassed three PDSA cycles. The intervention achieved its primary outcome by PDSA cycle 1 and its secondary outcome by PDSA cycle 2, demonstrating statistically significantly improved results (p < 0.001). A subanalysis assessed the specific impact of the intervention, and demonstrated a significant improvement in both outcomes when the intervention was used as intended (p < 0.0005). CONCLUSIONS: A ringfenced trauma bed significantly improved theatre start times and thereby theatre efficiency. This is a simple, pragmatic intervention that benefitted the MDT trauma team while also demonstrating a sustained impact. Given that National Health Service efficiency is at the forefront of national healthcare discourse, we recommend that this intervention is implemented in other trauma units to help provide a solution to this longstanding issue.

Revascularization for claudication: Changing the natural history of a benign disease!

OBJECTIVE: The benign natural history of intermittent claudication was first documented in 1960 and has been reconfirmed in several subsequent studies. Excellent outcomes in patients with intermittent claudication can be achieved with exercise therapy and optimal medical management. Professional society guidelines have clearly stated that revascularization procedures should be performed only in patients with incapacitating claudication who have failed conservative therapy. Despite these guidelines, revascularization procedures, primarily percutaneous interventions, have been increasingly utilized in patients with claudication. Many of these patients are not even offered an attempt at medical therapy, and those who are often do not undergo a full course of treatment. Many studies document significant reintervention rates following revascularization, which are associated with increased rates of acute and chronic limb ischemia that may result in significant rates of amputation. The objectives of this study were to compare outcomes of conservative therapy to those seen in patients undergoing revascularization procedures and to determine the impact of revascularization on the natural history of claudication. METHODS: Google Scholar and PubMed were searched for manuscripts on the conservative management of claudication and for those reporting outcomes following revascularization for claudication. RESULTS: Despite early improvement in claudication symptoms following revascularization, multiple studies have demonstrated that long-term outcomes following revascularization are often no better than those obtained with conservative therapy. High reintervention rates (up to 43% for tibial atherectomies) result in high rates of both acute and chronic limb ischemia as compared with those patients undergoing medical therapy. In addition, amputation rates as high as 11% on long-term follow-up are seen in patients undergoing early revascularization. These patients also have a higher incidence of adverse cardiovascular events such as myocardial infarctions compared with patients treated medically. CONCLUSIONS: Revascularization procedures negatively impact the natural history of claudication often resulting in multiple interventions, an increase in the incidence of acute and chronic limb ischemia, and an increased risk of amputation. Accordingly, informed consent requires that all patients undergoing early revascularization must be appraised of the potential negative impact of revascularization on the natural history of claudication.

Head-torso coordination in police officers wearing loaded tactical vests during running.

BACKGROUND: The influence of load carriage in operational police officers is not well understood despite a relatively high injury rate. Assessing load related changes in head and torso coordination may provide valuable insight into plausible injury mechanisms. RESEARCH QUESTION: Do typical police tactical vest loads alter head and torso coordination during running? METHODS: Thirty-eight UK police officers ran at a self-selected pace (>2 ms-1) on a non-motorised treadmill in four vest load conditions (unloaded, and low, high and evenly distributed loads). Peak head and torso tilt, and peak vest displacement were compared between all four conditions. Timings between vest and torso change of direction were compared between the three loaded conditions. The coupling angle between the head and torso calculated using modified vector coding were compared between unloaded and each loaded conditions using Statistical Parametric Mapping. RESULTS: No significant differences were found between conditions for peak head or torso tilt alone (p > 0.05). Loading equipment low on the vest led to significantly greater mediolateral vest displacements (38 mm) away from the torso than a high (34 mm) or evenly distributed (30 mm) conditions. The vest was found to change direction vertically before the torso in the anterior-posterior direction, and then influence torso motion. The loaded conditions changed the head-torso coupling from in-phase (with head-dominancy) to anti-phase (with torso dominancy) between 55% and 77% stance. Anti-phase with a relatively stationary head and the torso rotating forward likely places a greater concentric demand on the posterior neck muscles relative to unloaded running. SIGNIFICANCE: Current tactical vest designs allow significant extra displacement of load away from the body during running, altering coordination at the head and torso.

The SWiFT trial (Study of Whole Blood in Frontline Trauma)-the clinical and cost effectiveness of pre-hospital whole blood versus standard care in patients with life-threatening traumatic haemorrhage: study protocol for a multi-centre randomised controlled trial.

BACKGROUND: Early blood transfusion improves survival in patients with life-threatening bleeding, but the optimal transfusion strategy in the pre-hospital setting has yet to be established. Although there is some evidence of benefit with the use of whole blood, there have been no randomised controlled trials exploring the clinical and cost effectiveness of pre-hospital administration of whole blood versus component therapy for trauma patients with life-threatening bleeding. The aim of this trial is to determine whether pre-hospital leukocyte-depleted whole blood transfusion is better than standard care (blood component transfusion) in reducing the proportion of participants who experience death or massive transfusion at 24 h. METHODS: This is a multi-centre, superiority, open-label, randomised controlled trial with internal pilot and within-trial cost-effectiveness analysis. Patients of any age will be eligible if they have suffered major traumatic haemorrhage and are attended by a participating air ambulance service. The primary outcome is the proportion of participants with traumatic haemorrhage who have died (all-cause mortality) or received massive transfusion in the first 24 h from randomisation. A number of secondary clinical, process, and safety endpoints will be collected and analysed. Cost (provision of whole blood, hospital, health, and wider care resource use) and outcome data will be synthesised to present incremental cost-effectiveness ratios for the trial primary outcome and cost per quality-adjusted life year at 90 days after injury. We plan to recruit 848 participants (a two-sided test with 85% power, 5% type I error, 1-1 allocation, and one interim analysis would require 602 participants-after allowing for 25% of participants in traumatic cardiac arrest and an additional 5% drop out, the sample size is 848). DISCUSSION: The SWiFT trial will recruit 848 participants across at least ten air ambulances services in the UK. It will investigate the clinical and cost-effectiveness of whole blood transfusion versus component therapy in the management of patients with life-threatening bleeding in the pre-hospital setting. TRIAL REGISTRATION: ISRCTN: 23657907; EudraCT: 2021-006876-18; IRAS Number: 300414; REC: 22/SC/0072, 21 Dec 2021.

Indications for a "Surgery-First" Approach for the Treatment of Lower Extremity Arterial Disease.

BACKGROUND: In recent years, there has been a tendency toward an "endovascular-first" approach for the treatment for femoropopliteal arterial disease. The purpose of this study is to determine if there are patients that are better served with an initial femoropopliteal bypass (FPB) rather than an endovascular attempt at revascularization. METHODS: A retrospective analysis of all patients undergoing FPB between June 2006 - December 2014 was performed. Our primary endpoint was primary graft patency, defined as patent using ultrasound or angiography without secondary intervention. Patients with <1-year follow-up were excluded. Univariate analysis of factors significant for 5-year patency was performed using χ2 tests for binary variables. A binary logistic regression analysis incorporating all factors identified as significant by univariate analysis was used to identify independent risk factors for 5-year patency. Event-free graft survival was evaluated using Kaplan-Meier models. RESULTS: We identified 241 patients undergoing FPB on 272 limbs. FPB indication was disabling claudication in 95 limbs, chronic limb-threatening ischemia (CLTI) in 148, and popliteal aneurysm in 29. In total, 134 FPB were saphenous vein grafts (SVG), 126 were prosthetic grafts, 8 were arm vein grafts, and 4 were cadaveric/xenografts. There were 97 bypasses with primary patency at 5 or more years of follow-up. Grafts patent at 5 years by Kaplan-Meier analysis were more likely to have been performed for claudication or popliteal aneurysm (63% 5-year patency) as compared with CLTI (38%, P < 0.001). Statistically significant predictors (using log rank test) of patency over time were use of SVG (P = 0.015), surgical indication of claudication or popliteal aneurysm (P < 0.001), Caucasian race (P = 0.019) and no history of COPD (P = 0.026). Multivariable regression analysis confirmed these 4 factors as significant independent predictors of 5-year patency. Of note, there was no statistical correlation between FPB configuration (above or below knee anastomosis, in-situ versus reversed saphenous vein) and 5-year patency. There were 40 FPBs in Caucasian patients without a history of COPD receiving SVG for claudication or popliteal aneurysm that had a 92% estimated 5-year patency by Kaplan-Meier survival analysis. CONCLUSIONS: Long-term primary patency that was substantial enough to consider open surgery as a first intervention was demonstrated in Caucasian patients without COPD, having good quality saphenous vein, and who underwent FPB for claudication or popliteal artery aneurysm.

Isolated volar dislocation of the distal radioulnar joint: a case series and systematic review.

INTRODUCTION: Isolated volar dislocations of the distal radioulnar joint are reported as rare. We observed three such cases over a 12-month period. Literature to date consists of multiple case reports and case series with no structured reviews. There is debate as to incidence, mechanism, investigation, treatment and prognosis. METHODS: A case series and formal systematic review was performed. This included an analysis of the demographics, mechanism, presentation, investigation, treatment and outcome of the cases identified from the wider published series. FINDINGS: In total 99 cases of this injury were identified from 59 papers, with a further 9 cases having an associated ulna styloid fracture. CONCLUSIONS: This is a rare injury, representing up to 0.02% of all bony injuries, which is diagnosed late in 36% of cases. Inability to obtain a true lateral radiograph may contribute to the diagnosis being missed. Computed tomography scans are useful in suspected cases without radiographic confirmation. Acute cases are successfully treated with closed reduction in 78% of cases; however associated soft tissue injuries may need to be surgically addressed. Delayed presentation is more likely to require open surgery and preoperative MRI scans are indicated to aid surgical planning. Chronic instability rarely occurs and may need treatment with reconstruction or salvage. A good, subjective, result is reported in the majority of patients.

Incidence of venous thromboembolism in patients with sickle cell disease undergoing noncardiovascular surgery.

OBJECTIVE: Patients with sickle cell disease (SCD) will have a baseline hypercoagulable state and an increased risk of venous thromboembolism (VTE). Few data are available regarding the efficacy of standard prophylaxis in preventing VTE after noncardiovascular surgery for patients with SCD. Our objective was to investigate the incidence of VTE in patients with SCD who had undergone noncardiovascular surgery. METHODS: We performed a retrospective medical record review of 352 patients with SCD who had undergone noncardiovascular surgery from August 2009 to August 2019 at Beaumont Hospitals. An equal number of control patients without SCD were propensity matched for age, sex, race, body mass index, and specific surgery. The data collected included demographics, comorbidities, VTE prophylaxis used, occurrence of deep vein thrombosis (DVT) and pulmonary embolism (PE), hospital length of stay, and 30-day mortality. RESULTS: We found no differences in age, race, sex, ethnicity, operative time, or hospital length of stay between the SCD and propensity-matched control patients. DVT prophylaxis was used more frequently for the SCD patients than for the controls (96.0% vs 88.6%; P < .001). Four SCD patients (1.1%) had developed DVT vs five control patients (1.4%; P > .999). One patient in each group had developed PE (0.3%; P > .999). No difference was found in 30-day mortality between the SCD group and the control group (1 [0.3%] vs 3 [0.9%]; P = .312). Of those with a diagnosis of VTE ≤30 days postoperatively, no differences were present in age, sex, race, BMI, or procedure type. DVT had been diagnosed significantly later in the SCD patients than in the controls (median, postoperative day 12 vs 5; P = .014). None of the five SCD patients with VTE was a smoker compared with four of the six non-SCD patients with VTE, who were current or former tobacco users (P = .061). All the patients who had developed VTE had received DVT prophylaxis at surgery. CONCLUSIONS: We found no differences in the perioperative rates of DVT, PE, or mortality between the SCD patients and matched control patients after noncardiovascular surgery. Vigilant attention to routine VTE prophylaxis seemed to effectively reduce the VTE risk for these hypercoagulable patients. SCD patients might need VTE prophylaxis for a longer period postoperatively compared with those without SCD.

Intramural hematoma of the thoracic aorta: A single-institution, 12-year experience.

OBJECTIVE: The natural history and management of intramural hematoma (IMH) has varied significantly worldwide. From the present retrospective analysis of our institutional database, we have reported the long-term results from medical and surgical management of types A and B IMH. METHODS: Computed tomography reports completed at our tertiary care hospital from July 2007 to July 2020 were used to identify patients with IMH with a thickness of ≥7 mm. Those with IMH directly related to trauma, previous aortic surgery, penetrating atheromatous ulcer, dissection flap, or an iatrogenic source and those who had never received any treatment of IMH at presentation were excluded. RESULTS: A total of 54 patients with IMH had met the inclusion and exclusion criteria. Of the 54 patients, 24 had presented with Stanford type A. Of these 24 patients, 10 had initially undergone surgery and 14 had initially received medical treatment. Two patients in the medical group had subsequently undergone surgery. In addition, 30 patients had presented with type B IMH and had initially received medical treatment, with 3 eventually requiring surgical intervention. In-hospital survival was 90% for type A IMH treated surgically, 93% for type A IMH treated medically, and 97% for type B IMH treated medically. At the last follow-up imaging study of the medically treated patients, 36% of those with type A IMH and 31% of those with type B IMH had experienced complete resolution of IMH at 3.7 and 31.5 months respectively, without surgical intervention. The development of an aortic aneurysm at the site of a previous IMH had occurred in 18% (2 of 11) and 12% (3 of 26) of the type A medical and type B medical cohorts. The overall rate of aortic aneurysm formation in the region of IMH or in another segment was 50%. No difference was found in long-term survival between the three cohorts at a mean follow-up of 22.8 months. CONCLUSIONS: A role appears to exist for medical treatment with anti-impulse therapy for appropriately selected patients with type A IMH. These patients must be followed up closely clinically and radiographically for signs of deterioration in the short- and long-term phases of their care. They can achieve long-term survival similar to that of surgically treated type A IMH and medically treated type B IMH patients using this algorithm. However, they might require late surgical intervention, especially for aneurysmal disease.

Long-term outcomes and interventions of postoperative type 1a endoleak following elective endovascular aortic aneurysm repair.

OBJECTIVE: This study evaluated the incidence and long-term outcomes of postoperative type 1a endoleak (PT1a) following endovascular aortic aneurysm repair (EVAR). METHODS: A retrospective review of consecutive aortoiliac EVARs performed at a single institution from June 2006 to June 2012 was conducted. Patients with PT1a were identified by postoperative imaging and compared with those who did not develop a PT1a. Late outcomes were also studied of a subset of patients with PT1a who had persistent intraoperative type 1a endoleak (iT1a) on completion angiogram during EVAR that had resolved on initial follow-up imaging. RESULTS: Three hundred eighty-nine patients underwent EVAR with median follow-up of 87 months (interquartile range, 64-111 months). The incidence of PT1a was 8.2% (n = 32) with a median follow-up of 74 months (interquartile range, 52-138 months). Compared with the total cohort, those who developed PT1a were statistically more likely to be female (32% vs 17%; P = .03) and have a higher all-cause mortality (71% vs 40%; P < .01) and aneurysm-related mortality (15.6% vs 1.7%; P < .01). Median time to presentation was 52 months. Of the 32 patients with PT1a, five (15.6%) presented with aortic rupture, of which three underwent extension cuff placement, one had open graft explant, and one declined intervention. Six patients in total (18.7%) declined intervention; five of these died of nonaneurysmal causes and one remains alive. Of the 26 patients with PT1a who had intervention, 21 (80.7%) showed resolution of PT1a, and five (19.2%) had recurrence. For patients with recurrent PT1a, two had resulting aneurysm-related mortality, two endoleaks resolved after relining with an endograft, and one patient declined intervention but remains alive. Patients with PT1a who had intervention with resolution showed no significant difference in median survival estimates (140.0 months) compared with the remaining EVAR cohort (120.0 months; P = .80). Within the PT1a cohort, 6 (18.7%) had also experienced iT1a with a mean time to presentation of the late PT1a of 45 months. iT1a was associated with a significantly increased likelihood of developing a PT1a (P < .01) and decreased median survival (P < .01), but there was no known aneurysm-related mortality. CONCLUSIONS: Development of PT1a following elective EVAR is associated with increased all-cause and aneurysm-related mortality and presents an average of 52 months postoperatively. This underscores the importance of long-term surveillance. Patients with PT1a who had a successful intervention showed no significant difference in median survival. Those with iT1a had a higher risk for PT1a compared with the EVAR cohort overall and had decreased median survival, without increased aneurysm-related mortality.

Predictors of mortality in nonagenarians undergoing abdominal aortic aneurysm repair: Analysis of the National Surgical Quality Improvement Program dataset.

BACKGROUND: The present study used the American College of Surgeons National Surgical Quality Improvement Program dataset to identify the predictors of 30-day mortality for nonagenarians undergoing endovascular aortic aneurysm repair (EVAR) or open surgical repair (OSR). METHODS: Patients aged >90 years who had undergone abdominal aortic aneurysm repair from 2005 to 2017 were identified using procedure codes. Those with operative times <15 minutes were excluded. The demographics, preoperative comorbidities, and postoperative complications of those who had died by 30 days were compared with those of the patients alive at 30 days. RESULTS: A total of 1356 nonagenarians met the criteria: 1229 (90.6%) had undergone EVAR and 127 (9.4%) had undergone OSR. The overall 30-day mortality was 10.4%. The patients who had died within 30 days were significantly more likely to have undergone OSR than EVAR (40.9% vs 7.2%; P < .001). They also had a greater incidence of dependent functional status (22.0% for those who had died vs 8.1% for those alive at 30 days; P < .001), American Society of Anesthesiology (ASA) classification of ≥4 (81.2% vs 18.8%; P < .001), perioperative blood transfusion (59.6% vs 20.3%; P < .001), postoperative pneumonia (12.1% vs 2.9%; P = .001), mechanical ventilation >48 hours (22.7% vs 2.6%; P < .001), and acute renal failure (12.1% vs 0.5%; P < .001). The EVAR group had a 30-day mortality rate of 2.6% in 1008 elective cases and 28.6% in 221 emergent cases. The OSR group had a 30-day mortality rate of 19.1% in 47 elective cases and 53.7% in 80 emergent cases. In the EVAR cohort, the 30-day mortality group had had a significantly greater incidence of dependent functional status (17% for those who had died vs 8% for those alive at 30 days; P = .004), ASA classification of ≥4 (76.4% vs 40.3%; P < .001), perioperative blood transfusion (57% vs 19%; P < .001), emergency surgery (71% vs 14%; P < .001), and longer operative times (150 vs 128 minutes; P = .001). CONCLUSIONS: Nonagenarians had an incrementally increased, but acceptable, risk of 30-day mortality with EVAR in elective and emergent cases compared with that reported for octogenarians and cohorts of patients not selected for age. We found greater mortality for patients with dependent status, a higher ASA classification, emergent repair, and OSR. These preoperative risk factors could help identify the best surgical candidates. Given these results, consideration for EVAR or OSR might be reasonable for highly selected patients, especially for elective patients with a larger abdominal aortic aneurysm diameter for whom the risk of rupture is higher.

Hypochloraemia following admission to hospital with heart failure is common and associated with an increased risk of readmission or death: a report from OPERA-HF.

AIMS: Hypochloraemia is common in patients hospitalized with heart failure (HF) and associated with a high risk of adverse outcomes during admission and following discharge. We assessed the significance of changes in serum chloride concentrations in relation to serum sodium and bicarbonate concentrations during admission in a cohort of 1002 consecutive patients admitted with HF and enrolled into an observational study based at a single tertiary centre in the UK. METHODS AND RESULTS: Hypochloraemia (<96 mmol/L), hyponatraemia (<135 mmol/L), and metabolic alkalosis (bicarbonate >32 mmol/L) were defined by local laboratory reference ranges. Outcomes assessed were all-cause mortality, all-cause mortality or all-cause readmission, and all-cause mortality or HF readmission. Cox regression and Kaplan-Meier curves were used to investigate associations with outcome. During a median follow-up of 856 days (interquartile range 272-1416), discharge hypochloraemia, regardless of serum sodium, or bicarbonate levels was associated with greater all-cause mortality [hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.15-1.79; P = 0.001], all-cause mortality or all-cause readmission (HR 1.26, 95% CI 1.04-1.53; P = 0.02), and all-cause mortality or HF readmission (HR 1.41, 95% CI 1.14-1.74; P = 0.002) after multivariable adjustment. Patients with concurrent hypochloraemia and natraemia had lower haemoglobin and haematocrit, suggesting congestion; those with hypochloraemia and normal sodium levels had more metabolic alkalosis, suggesting decongestion. CONCLUSION: Hypochloraemia is common at discharge after a hospitalization for HF and is associated with worse outcome subsequently. It is an easily measured clinical variables that is associated with morbidity or mortality of any cause.

Importance of diversity, equity, and inclusion in the community practice setting.

Vascular surgeons of all backgrounds play an important role in providing high quality vascular surgical care in their communities. In America, with our diverse population and communities, patients presenting with vascular disease are very common and could pattern the community demographic. Often faced with the challenges of community hospital politics and demand, the vascular surgical workforce has continued to be active members in their communities, focusing on their strengths to lead vascular surgery healthcare in an environment of high patient demand. Having a varied vascular surgery workforce provides all patients afflicted by vascular disease a comfortable opportunity for compassionate and empathic vascular care. This is a significant strength of vascular care when diversity, equity, and inclusion are supported by the leadership.

Fit-testing of respiratory protective equipment in the UK during the initial response to the COVID-19 pandemic.

BACKGROUND: Public Health England guidance stipulates the use of filtering facepiece (FFP3) masks for healthcare workers engaged in aerosol-generating procedures. Mask fit-testing of respiratory protective equipment is essential to protect healthcare workers from aerosolized particles. AIM: To analyse the outcome of mask fit-testing across National Health Service (NHS) hospitals in the UK during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. METHODS: Using the Freedom of Information Act, 137 NHS hospitals were approached on May 26th, 2020 by an independent researcher to provide data on the outcome of fit-testing at each site. FINDINGS: Ninety-six hospitals responded to the request between May 26th, 2020 to October 29th, 2020. There was a total of 86 mask types used across 56 hospitals, 13 of which were used in at least 10% of these hospitals; the most frequently used was the FFP3M1863, used by 92.86% of hospitals. Overall fit-testing pass rates were provided by 32 hospitals with mean pass rate of 80.74%. The most successful masks, in terms of fit-test failure rates, were the Alpha Solway 3030V and the Alpha Solway S-3V (both reporting mean fit-test failures of 2%). Male- and female-specific pass and failure rates were provided by seven hospitals. Across the seven hospitals, 20.1% of men tested failed the fit-test for all masks used, whereas 19.9% of women tested failed the fit-test for all masks used. Failure rates were significantly higher in staff from Black, Asian, and Minority Ethnic (BAME) backgrounds 644/2507 (25.69%) across four hospitals. CONCLUSION: Twenty percent of healthcare workers tested during the first response to the pandemic failed fit-testing for masks. A small sample revealed that this was most prominent in staff from BAME backgrounds.

The association of hand and wrist injuries with other injuries in multiple trauma patients. A retrospective study in a UK Major Trauma Centre.

BACKGROUND: Approximately 20,000 major trauma cases occur in England every year. However, the association with concomitant upper limb injuries is unknown. This study aims to determine the incidence, injury pattern and association of hand and wrist injuries with other body injuries and the Injury Severity Score (ISS) in multiply injured trauma patients. METHODS: Single centre retrospective study was performed at a level-one UK Major Trauma Centre (MTC). Trauma Audit and Research Network (TARN) eligible multiply injured trauma patients that were admitted to the hospital between January 2014 and December 2018 were analysed. TARN is the national trauma registry. Eligible patients were: a trauma patient of any age who was admitted for 72 h or more, or was admitted to intensive care, or died at the hospital, was transferred into the hospital for specialist care, was transferred to another hospital for specialist care or for an intensive care bed and whose isolated injuries met a set of criteria. Data extracted included: age, gender, mode of arrival, location of injuries including: hand and/or wrist and mechanism of injury. We performed a logistic regression analysis to assess the association between hand/wrist injury to ISS score of 15 points or above/below and to the presentation of other injuries. RESULTS: 107 patients were analysed. Hand and wrist injuries were the second most common injury (26.2%), after thoracic injuries. Distal radial injuries were found in 5.6%, carpal/carpometacarpal in 6.5%, concurrent distal radius and carpometacarpal in 0.9%, phalangeal injuries in 4.7%, tendon injuries in 0.9% and concurrent hand and wrist injuries in 7.5% cases. There was a significant association between hand or wrist injuries and lower limb injuries (Odds Ratio (OR): 3.84; 95% confidence intervals (CI): 1.09 to 13.50; p = 0.04) and pelvic injuries (OR: 4.78; 95% CI: 1.31 to 17.44; p = 0.02). There was no statistical association between hand and wrist injuries and ISS score (OR: 0.80; 95% CI: 0.11 to 5.79; p = 0.82). CONCLUSIONS: Hand and wrist injuries are prevalent in trauma patients admitted to MTCs. They should not be under-estimated but routinely screened for in multiply injured patients particularly those with a pelvic or lower limb injury.

7X multiplexed, optofluidic detection of nucleic acids for antibiotic-resistance bacterial screening.

Rapid and accurate diagnosis of bacterial infections resistant to multiple antibiotics requires development of new bio-sensors for differentiated detection of multiple targets. This work demonstrates 7x multiplexed detection for antibiotic-resistance bacterial screening on an optofluidic platform. We utilize spectrally multiplexed multi-spot excitation for simultaneous detection of nucleic acid strands corresponding to bacterial targets and resistance genes. This is enabled by multi-mode interference (MMI) waveguides integrated in an optofluidic device. We employ a combinatorial three-color labeling scheme for the nucleic acid assays to scale up their multiplexing capability to seven different nucleic acids, representing three species and four resistance genes.

3× multiplexed detection of antibiotic resistant plasmids with single molecule sensitivity.

Bacterial pathogens resistant to antibiotics have become a serious health threat. Those species which have developed resistance against multiple drugs such as the carbapenems, are more lethal as these are last line therapy antibiotics. Current diagnostic tests for these resistance traits are based on singleplex target amplification techniques which can be time consuming and prone to errors. Here, we demonstrate a chip based optofluidic system with single molecule sensitivity for amplification-free, multiplexed detection of plasmids with genes corresponding to antibiotic resistance, within one hour. Rotating disks and microfluidic chips with functionalized polymer monoliths provided the upstream sample preparation steps to selectively extract these plasmids from blood spiked with E. coli DH5α cells. Waveguide-based spatial multiplexing using a multi-mode interference waveguide on an optofluidic chip was used for parallel detection of three different carbapenem resistance genes. These results point the way towards rapid, amplification-free, multiplex analysis of antibiotic-resistant pathogens.

Type II endoleak with an enlarging aortic sac after endovascular aneurysm repair predisposes to the development of a type IA endoleak.

OBJECTIVE: The most common endoleak after endovascular aneurysm repair is type II. Although type II endoleaks (TIIEL) are generally considered benign, there are reports that they can lead to aortic rupture. In this study, we reviewed the effect of TIIEL on sac size change to determine if sac expansion owing to a TIIEL could result in the development of a type IA endoleak (TIAEL). METHODS: After internal review board approval, all aortoiliac endovascular aneurysm repairs performed at a single institution between June 2006 and June 2012 were retrospectively reviewed. Patient demographics, comorbidities, aneurysm diameter, graft type, need for reintervention, and complications were collected. Patients with TIIEL diagnosed on follow-up imaging were categorized as those who underwent intervention for their TIIEL and those who did not. Outcomes were tabulated with attention to sac size change, development of TIAEL, rupture, and survival. RESULTS: Six hundred twenty-seven patients underwent aortoiliac stent graft placement at our institution during this time period. Patients with an operative indication other than nonruptured infrarenal abdominal aortic aneurysm and those without preoperative computed tomography angiography or follow-up data available for review were excluded. The total number of patients included was 389 with an average follow-up of 58.8 months (range, 0-194 months). Follow-up imaging diagnosed 124 patients with TIIEL (32%). Patients with TIIEL were significantly older (P < .0001) and more likely to be hypertensive (P < .05) but less likely to be smokers (P = .01). They had a significantly larger sac size increase than patients without TIIEL (9.50 vs -0.78 mm; P < .0001). Those with TIIEL were significantly more likely to develop a TIAEL than patients who did not have TIIEL (14% vs 5%; P = .004), but the rate of rupture was not significantly different (4% vs 2%; P = .33). In those with a TIIEL, the average sac size increase at which TIAEL developed was 13 mm. Patients in the TIIEL group who underwent intervention for their TIIEL survived significantly longer than patients who did not undergo intervention (140 months vs 100 months; P = .004). CONCLUSIONS: Our data suggest that there is an increased incidence of late TIAEL in patients with TIIEL compared with those without a TIIEL. Our study also demonstrates an increased overall survival in TIIEL patients who underwent intervention. Future studies are necessary to better define the association between TIIEL with enlarging sac and the development of TIAEL. However, it is reasonable to conclude that intervention for TIIEL should be undertaken at or before a cumulative sac size increase of 13 mm.

Screening Chest Computed Tomography is Indicated in All Patients with Abdominal Aortic Aneurysm.

BACKGROUND: This study quantifies the prevalence of thoracic aortic aneurysm (TAA) in patients with known abdominal aortic aneurysm (AAA). METHODS: A retrospective review of patients with a diagnosis of AAA from January 2007 to December 2017 within Beaumont Health was undertaken. Radiology reports of abdominal ultrasound, computed tomography (CT), and magnetic resonance imaging were reviewed to identify patients with AAA. Of these, patients with a chest CT scan performed within 180 days before or after abdominal imaging were reviewed for diagnosis of TAA. AAA was defined as aortic diameter ≥30 mm, and TAA was defined as aortic diameter ≥40 mm. RESULTS: The cohort included 218 patients with a chest CT scan performed within 180 days of initial diagnosis of AAA. The mean age at diagnosis of AAA was 74 years; 82 (37.6%) were women. There were no differences between men and women in the prevalence of diabetes mellitus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, tobacco use, and family history of aortic aneurysm. Forty concomitant AAAs and TAAs were detected, for an overall prevalence of 18.3%, with no significant difference between men and women (15% vs. 24%, P = 0.07). Women were diagnosed with AAA at an older age than men (76 vs. 73 years, P = 0.01) and had lower body mass index (23 vs. 26, P = 0.01), smaller maximum AAA diameter (36.5 vs. 40 mm, P = 0.03), and larger TAA (47 vs. 41 mm, P = 0.01). TAAs were classified by location: 47.5% (19/40), ascending; 32.5% (13/40), descending; and 20% (8/40), ascending and descending. Six patients had thoracoabdominal aortic aneurysms: 2 patients with extent II, 2 with extent III, and 2 with extent V. These patients were included in the overall analysis; excluding them resulted in a rate of concomitant AAA/TAA of 16%. No significant differences were noted in comorbidities or AAA size between the TAA/AAA and AAA only groups. CONCLUSIONS: TAAs appear to occur concomitantly with AAAs with significant frequency. Women appear to have larger TAA diameter than men, despite smaller sized AAA at diagnosis. These data support creating guidelines for obtaining a screening chest CT scan in all patients diagnosed with an AAA.

The use of psychological methodologies in cardiovascular disease interventions promoting a Mediterranean style diet: A systematic review.

AIMS: To evaluate theory-based psychological approaches that have been effective in promoting behavior change in interventions promoting a Mediterranean style diet (MD) for the reduction of cardiovascular disease (CVD) risk. DATA SYNTHESIS: A systematic review of primary research articles using PRISMA recommendations was conducted. References were retrieved using keyword searches from MEDLINE via PUBMED and included studies targeted participants at high risk for CVD. Two hundred and ninety one studies were reviewed; however, only six met the inclusionary criteria. Three articles describe the same intervention; therefore, only four were included. Included studies incorporated social cognitive theory, social learning theory, goal-system theory, social ecological theory, selfdetermination theory, and the transtheoretical model of behavior change. Overall, studies were nutrition interventions in clinical settings with participants at high risk for or with CVD. CONCLUSIONS: Results from use of the social cognitive theory and self-determination theory in increasing MD adherence for the reduction of CVD risk and events are encouraging. However, we encourage future long-term interventions focusing on dietary behavior change to provide not only an in-depth description of the psychological methodologies used but also how these methodologies were implemented in order ascertain the most effective theory for promoting dietary behavior change towards patterns of a MD.