A method for identifying the learning curve for the surgical stabilization of rib fractures.

BACKGROUND: Surgical stabilization of rib fractures (SSRF) is an accepted efficacious treatment modality for patients with severe chest wall injuries. Despite increased adoption of SSRF, surgical learning curves are unknown. We hypothesized intraoperative duration could define individual SSRF learning curves. METHODS: Consecutive SSRF operations between January 2017 and December 2021 at a single institution were reviewed. Operative time, as measured from incision until skin closure, was evaluated by cumulative sum methodology using a range of acceptable "missteps" to determine the learning curves. Misstep was defined by extrapolation of accumulated operative time data. RESULTS: Eighty-three patients underwent SSRF by three surgeons during this retrospective review. Average operative times ranged from 135 minutes for two plates to 247 minutes for seven plates. Using polynomial regression of average operative times, 75 minutes for general procedural requirements plus 35 minutes per plate were derived as the anticipated operative times per procedure. Cumulative sum analyses using 5%, 10%, 15%, and 20% incident rates for not meeting expected operative times, or "missteps" were used. An institutional learning curve between 15 and 55 SSRF operations was identified assuming a 90% performance rate. An individual learning curve of 15 to 20 operations assuming a 90% performance rate was observed. After this period, operative times stabilized or decreased for surgeons A, B, and C. CONCLUSION: The institutional and individual surgeon learning curves for SSRF appears to steadily improve after 15 to 20 operations using operative time as a surrogate for performance. The implementation of SSRF programs by trauma/acute care surgeons is feasible with an attainable learning curve. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

"Early results after initiation of a rib fixation programme: A propensity score matched analysis".

INTRODUCTION: Chest wall injuries are very common in blunt trauma and development of treatment protocols can significantly improve outcomes. Surgical stabilisation of rib fractures (SSRF) is an adjunct for the most severe chest injuries and can be used as a part of a comprehensive approach to chest injuries care. We hypothesized that implementation of a SSRF programme program would result in improved short-term outcomes. MATERIALS AND METHODS: The characteristics of the initial group of SSRF patients (Early-SSRF) were used to identify matching factors. Patients prior to SSRF protocol underwent a propensity score match, followed by screening for operative indications and contraindications. After exclusions, a non-operative (Non-Op) cohort was defined (n=36) resulting in an approximately 1:1 match. An overall operative cohort, inclusive of Early-SSRF and all subsequent operative patients, was defined (All- SSRF). A before-and-after analysis using chi-squared, Students T-tests, and Mann-Whitney U-tests were used to assess significance at the level of 0.05. RESULTS: Early-SSRF (n=22) and All-SSRF (n=45) were compared to Non-Op (n=36). The selection process resulted in well matched groups, and equally well-balanced operative indications between the groups. The Early-SSRF group demonstrated shortened duration of mechanical ventilation and a decreased frequency of being discharged a long-term acute care hospital. The All-SSRF group again demonstrated markedly shorter duration of mechanical ventilation compared to Non-Op (median 6 days vs 16 days, p < 0.01), more decrease discharge to a long-term acute care hospital (9% vs. 36%, p=0.01), and reduced risk for tracheostomy (8.9% vs. 33.3% respectively, p<0.01) CONCLUSION: The introduction of an operative rib fixation to a comprehensive chest wall injury protocol can produce improvements in clinical outcomes that decrease time on the ventilator and tracheostomy rates, and result in more patients being discharged to home. Creation and implementation of a chest wall injury protocol to include SSRF requires a multidisciplinary approach and thoughtful patient selection.

The Association Between Pulmonary Contusion Severity and Respiratory Failure.

BACKGROUND: Pulmonary contusions (PCs) have historically been viewed as a serious complicating factor in thoracic injury. Recently, there has been conflicting evidence regarding the influence of PCs on outcomes; however, many studies do not stratify contusions by severity and may miss clinical associations. We sought to identify if contusion severity is associated with worse outcomes. METHODS: A previously published chest wall injury database at an urban Level I trauma center was retrospectively reviewed. All severely injured subjects (defined as Injury Severity Score [ISS] ≥ 15) with moderate to severe thoracic injury (defined as a chest wall Abbreviated Injury Scale [AIS] ≥ 3) who required mechanical ventilation for > 24 h were stratified by contusion severity. Moderate to severe contusions were defined as AIS contusion ≥ 3 and Blunt Pulmonary Contusion 18 (BPC18) score ≥ 3. RESULTS: Over 5 y, 3,836 patients presented with chest wall injuries, of which 1,176 (30.6%) had concomitant contusions. When screened for inclusion criteria, 339 subjects with contusions and 211 subjects without contusions (no-PC) were identified. Of these, 234 had moderate to severe contusions defined by AIS contusion ≥ 3 (PC-A) and 230 had moderate to severe contusions by BPC18 ≥ 3 (PC-B). Compared to no-PC, both PC-A and PC-B groups had significantly lower mortality (17.9% and 17.4%, respectively, vs 28.9%); however, PC-A and PC-B groups had longer durations of mechanical ventilation (6 and 7 d, respectively, vs 5 d), longer ICU length of stay (10 and 10 vs 8 d), and longer overall hospital length of stay (15 and 15 vs 13 d). CONCLUSIONS: In severely injured polytrauma patients, PCs are seen with more severe chest injuries. Furthermore, moderate to severe contusions are associated with longer durations of mechanical ventilation, ICU length of stay, and hospital length of stay. Despite practice pattern changes, contusions appear to contribute significantly to the clinical course of the blunt chest wall injured patients.

Does chest wall Organ Injury Scale (OIS) or Abbreviated Injury Scale (AIS) predict outcomes? An analysis of 16,000 consecutive rib fractures.

BACKGROUND: Chest wall injuries have serious clinical consequences. It is presumed a higher severity of injury correlates with worse outcomes. The 2 most common chest wall injury severity scores, the Organ Injury Scale and the Abbreviated Injury Scale, are based on expert opinion with unknown clinical endpoints. Our aim was to determine if either the Organ Injury Scale or the Abbreviated Injury Scale are associated with clinical outcomes. METHODS: A single institution, 4-year retrospective study of all patients with rib or sternal fractures was conducted. All patients were assessed for both Organ Injury Scale and Abbreviated Injury Scale scores. Outcomes assessed included mortality, complications, tracheostomy, and readmissions. Receiver operating characteristic areas under the curve were calculated to measure discriminatory accuracy of scoring systems for outcomes in chest wall injury. RESULTS: Overall, 3,033 patients presented with a total of 16,055 rib fractures. The median chest wall scores were 2 for Organ Injury Scale and 3 for Abbreviated Injury Scale. Abbreviated Injury Scale scores for the same patients were greater than the Organ Injury Scale in 48.7%, equivalent in 46.7%, and lower in 4.6%. The receiver operating characteristic areas under the curve for in-hospital outcomes were weakly predictive for the Organ Injury Scale over the Abbreviated Injury Scale. The receiver operating characteristic areas under the curve for readmissions were very weakly predictive for the Abbreviated Injury Scale over the Organ Injury Scale. CONCLUSION: There is a very weak association between chest wall Organ Injury Scale score and in-hospital outcomes. The Abbreviated Injury Scale score outperformed the Organ Injury Scale, only being weakly predictive of readmission. Chest wall injury scoring systems may need revision for future outcomes-based research and practice improvements.

Readmission rates and associated factors following rib cage injury.

BACKGROUND: There remains a lack of knowledge about readmission characteristics after sustaining rib fractures. We aimed to determine rates, characteristics, and predictive/protective factors associated with unexpected reevaluation and readmission after rib cage injury. METHODS: A retrospective review was performed based on trauma patients evaluated at an urban Level I trauma center from January 2014 to December 2016. Adult patients sustaining blunt trauma with more than one rib fracture or a sternomanubrial fracture were defined as having moderate to severe rib cage injury. Exclusion criteria included penetrating injury, death during initial hospitalization, and only one rib fracture. Reevaluation was defined as presenting at a hospital within 90 days of discharge urgently or emergently. Demographics, injury characteristics, comorbidities, complications, imaging, and readmission data were collected. Univariate and multivariate analysis was performed with a significance of p less than 0.05. RESULTS: During the study period, 11,667 patients underwent trauma evaluation, of which 1,717 patients were found to have a moderate to severe rib cage injury. Within 90 days, 397 (23.1%) of patients underwent reevaluation, while 177 (10.3%) required readmission. One hundred forty-two (8.3%) patients were reevaluated specifically for chest-related complaints, and 55 (3.2%) required readmission. On univariate analysis, Injury Severity Score greater than 15, hospital length of stay longer than 7 days, intensive care unit (ICU) length of stay longer than 3 days, a worsened chest x-ray at discharge, a psychiatric comorbidity, a smoking comorbidity, deep vein thrombosis, unplanned readmission to the ICU, and unplanned intubation were higher in the overall reevaluation cohort. On multivariate analysis, age of 15 years to 35 years, Risk Assessment Profile score greater than 8, hypertension, psychiatric comorbidity, current smoker, and unplanned return to the ICU on index admission were predictive of reevaluation of overall reevaluation. CONCLUSION: Moderate to severe rib cage injury is associated with high rates of reevaluation and readmission. Younger patients who smoke and required a return to the ICU are at greater risk for readmission. LEVEL OF EVIDENCE: Level IV, Prognostic and Epidemiologic.

Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis.

BACKGROUND: Recombinant factor VIIa (rFVIIa) has been used off-label as an adjunct in the reversal of warfarin therapy and management of hemorrhage after trauma. Only a handful of these reports are rigorous studies, from which results regarding safety and effectiveness have been mixed. There remains no clear consensus as to the role of rFVIIa in traumatic brain injury (TBI). METHODS: Eleven level 1 trauma centers provided clinical data and head CT scans of patients with a Glasgow Coma Scale (GCS) score of ≤13 and radiographic evidence of TBI. A propensity score (PS) to receive rFVIIa in those surviving ≥2 days was calculated for each patient based on patient demographics, comorbidities, physiology, Injury Severity Score, admission GCS score, and treatment center. Patients receiving rFVIIa within 24 hours of admission were matched to patients who did not receive rFVIIa for outcomes assessment. Subgroup analysis evaluated patients with primary head injury with PS matching. RESULTS: There were 4284 patient observations; 129 received rFVIIa. Groups were comparable after matching. No differences in mortality or morbidity were found. Improvement in GCS score from admission to discharge was less among those receiving rFVIIa (5.5 vs. 2.4; P value 0.001); however, there was no difference in average GCS score at discharge. No significant differences in outcomes were identified in patients with isolated TBI receiving rFVIIa. DISCUSSION: rFVIIa in early management of TBI is not associated with a decreased risk of mortality or morbidity, and may negatively impact recovery and functional status at discharge in the severely injured patient with polytrauma. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Therapeutic/care management.

Safety and efficacy of brain injury guidelines at a Level III trauma center.

BACKGROUND: Patients with mild to moderate traumatic brain injury (TBI) are often primarily managed by emergency medicine and trauma/acute care physicians. The Brain Injury Guidelines (BIG) were developed at an American College of Surgeons-accredited Level 1 trauma center to triage mild to moderate TBI patients and help identify patients who warrant neurosurgical consultation. The BIG have not been validated at a Level III trauma center. We hypothesized that BIG criteria can be safely adapted to an American College of Surgeons-accredited Level III trauma center to guide transfers to a higher echelon of care. METHODS: We reviewed the trauma registry at a Level III trauma center to identify TBI patients who presented with an Abbreviated Injury Severity-Head score greater than zero. Demographic data, injury details, and clinical outcomes were abstracted with primary outcome measures of worsening on second computed tomography of the head, neurosurgical intervention, transfer to a Level I trauma center, and in-hospital mortality. Patients were classified using the BIG criteria. After validating the BIG in our cohort, we reclassified patients using updated BIG criteria. Updated criteria included mechanism of injury, reclassification of anticoagulation or antiplatelet use, and replacement of the neurologic examination component with stratification by admission Glasgow Coma Scale (GCS) score. RESULTS: From July 2013 to June 2016, 332 TBI patients were identified: 115 BIG-1, 25 BIG-2, and 192 BIG-3. Patients requiring neurosurgical intervention (n = 30) or who died (n = 29) were BIG-3 with one exception. Patients with GCS score of less than 12 had worse outcomes than those with a GCS score of 12 or greater, regardless of BIG classification. Anticoagulant or antiplatelet use was not associated with worsened outcomes in patients not meeting other BIG-3 criteria. The updated BIG resulted in more patients in BIG-1 (n = 109) and BIG-2 (n = 100) without negatively affecting outcomes. CONCLUSION: The BIG can be applied in the Level III trauma center setting. Updated BIG criteria can aid triage of mild to moderate TBI patients to a Level I trauma center and may reduce secondary overtriage. LEVEL OF EVIDENCE: Care management, level IV.

Prospective economic evaluation alongside the non-invasive ventilation trial.

OBJECTIVE: To determine the cost-effectiveness of nasal continuous positive pressure (nCPAP) compared with nasal intermittent positive pressure ventilation (NIPPV) in the context of the reported randomized clinical trial. STUDY DESIGN: Using patient-level data from the clinical trial, we undertook a prospectively planned economic evaluation. We measured costs, from a third-party payer perspective in all patients, and from a societal perspective in a subgroup with a time horizon through the earlier of discharge, death or 44 weeks post-menstrual age. RESULTS: From the third-party payer perspective, the mean cost of hospitalization per infant was statistically similar, $143 745 in the NIPPV group compared to $140 403 in the nCPAP group. Cost-effectiveness evaluation revealed a 61% probability that NIPPV is more expensive and less effective than nCPAP. Similar results were found in subgroup analysis from a societal perspective. CONCLUSION: In addition to being clinically equivalent, economic evaluation confirms that NIPPV, as employed in this trial, is also not economically favorable.

A practical approach to the use of prone therapy in acute respiratory distress syndrome.

In this article we propose a practical approach to the use of prone therapy for acute respiratory distress syndrome (ARDS). We have attempted to provide information to improve the understanding and implementation of prone therapy based on the literature available and our own experience. We review the basic physiology behind ARDS and the theoretical mechanism by which prone therapy can be of benefit. The findings of the most significant studies regarding prone therapy in ARDS as they pertain to its implementation are summarized. Also provided is a discussion of the nuances of utilizing prone therapy, including potential pitfalls, complications, and contraindications. The specific considerations of prone therapy in open abdomens and traumatic brain injuries are discussed as well. Finally, we supply suggested protocols for the implementation of prone therapy discussing criteria for initiation and cessation of therapy as well as addressing issues such as the use of neuromuscular blockade and nutritional supplementation.

Decompressive craniectomy or medical management for refractory intracranial hypertension: an AAST-MIT propensity score analysis.

BACKGROUND: Moderate/severe traumatic brain injury (TBI) management involves minimizing cerebral edema to maintain brain oxygen delivery. While medical therapy (MT) consisting of diuresis, hyperosmolar therapy, ventriculostomy, and barbiturate coma is the standard of care, decompressive craniectomy (DC) for refractory intracranial hypertension (ICH) has gained renewed interest. Since TBI treatment guidelines consider DC a second-tier intervention after MT failure, we sought to determine if early DC (<48 hours) was associated with improved survival in patients with refractory ICH. METHODS: Eleven Level 1 trauma centers provided clinical data and head computed tomographic scans for patients with a Glasgow Coma Scale (GCS) score of 13 or less and radiographic evidence of TBI excluding deaths within 48 hours. Computed tomographic scans were graded according to the Marshall classification. A propensity score to receive DC (regardless of whether DC was performed) was calculated for each patient based on patient characteristics, physiology, injury severity, GCS, severity of intracranial injury, and treatment center. Patients who actually received a DC were matched to patients with similar propensity scores who received MT for analysis. Outcomes were compared between early (<48 hours of injury) primary or secondary DC and matched controls and then between early primary DC only and matched controls. RESULTS: There were 2,602 patients who met the inclusion criteria ,of whom 264 (10.1%) received DC (either primary or secondary to another cranial procedure) and 109 (5%) had a DC that was primary. Variables associated with performing a DC included sex, race, intracranial pressure monitor placement, in-house trauma attending, traumatic subarachnoid hemorrhage, midline shift, and basal cistern compression. There was no survival benefit with early primary DC compared with the controls (relative risk, 1.07; 95% confidence interval, 0.67-1.73; p = 0.77), and resource use was higher. CONCLUSION: Early DC does not seem to significantly improve mortality in patients with refractory ICH compared with MT. Neurosurgeons should pause before entertaining this resource-demanding form of therapy. LEVEL OF EVIDENCE: Therapeutic care/management, level III.

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries.

OBJECT: Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS: This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS: The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS: Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

The differential susceptibility of spores from virulent and attenuated Bacillus anthracis strains to aldehyde- and hypochlorite-based disinfectants.

This study compared the sensitivity of spores from virulent and attenuated Bacillus anthracis strains in suspension to inactivation by various chemical disinfectants. Spore suspensions from two virulent strains (A0256 and A0372) and two attenuated strains (Sterne and A0141) of B. anthracis were tested against two aldehyde-based disinfectants and one hypochlorite-based disinfectant. A novel statistical model was used to estimate 4-log(10) reduction times for each disinfectant/strain combination. Reduction times were compared statistically using approximate Z and χ(2) tests. Although there was no consistent correlation between virulence and increased sporicidal resistance across all three disinfectants, spores from the two virulent and two attenuated strains did display significantly different susceptibilities to different disinfectants. Significant disinfectant-strain interactions were observed for two of the three disinfectants evaluated. The comparative results suggest that the use of surrogate organisms to model the inactivation kinetics of virulent B. anthracis spores may be misleading. The accuracy of such extrapolations is disinfectant dependent and must be used with caution.

Who should we feed? Western Trauma Association multi-institutional study of enteral nutrition in the open abdomen after injury.

BACKGROUND: The open abdomen is a requisite component of a damage control operation and treatment of abdominal compartment syndrome.Enteral nutrition (EN) has proven beneficial for patients with critical injury, but its application in those with an open abdomen has not been defined. The purpose of this study was to analyze the use of EN for patients with an open abdomen after trauma and the effect of EN on fascial closure rates and nosocomial infections. METHODS: We reviewed patients with an open abdomen after injury from January 2002 to January 2009 from 11 trauma centers. RESULTS: During the 7-year study period, 597 patients required an open abdomen after trauma. Most were men (77%) sustaining blunt trauma (72%), with a mean (SD) age of 38 (0.7) years, an Injury Severity Score of 31 (0.6), an abdominal injury score of 3.8(0.1), and an Abdominal Trauma Index score of 26.8 (0.6). Of the patients, 548 (92%) had an open abdomen after a damage control operation, whereas the remainder experienced an abdominal compartment syndrome. Of the 597 patients, 230 (39%)received EN initiated before the closure of the abdomen at mean (SD) day 3.6 (1.2) after injury. EN was started with an open abdomen in one quarter of the 290 patients with bowel injuries. For the 307 patients without a bowel injury, logistic regression indicated that EN is associated with higher fascial closure rates (odds ratio [OR], 5.3; p G 0.01), decreased complication rates(OR, 0.46; p = 0.02), and decreased mortality (OR, 0.30; p = 0.01). For the 290 patients who experienced a bowel injury,regression analysis showed no significant association between EN and fascial closure rate (OR, 0.6; p = 0.2), complication rate (OR, 1.7; p = 0.19), or mortality (OR, 0.79; p = 0.69). CONCLUSION: EN in the open abdomen after injury is feasible. For patients without a bowel injury, EN in the open abdomen is associated with increased fascial closure rates, decreased complication rates, and decreased mortality. EN should be initiated in these patients once resuscitation is completed. Although EN for patients with bowel injuries did not seem to affect the outcome in this study,prospective randomized controlled trials would further clarify the role of EN in this subgroup.

IL-7R alpha versus CCR7 and CD45 as markers of virus-specific CD8+ T cell differentiation: contrasting pictures in blood and tonsillar lymphoid tissue.

In humans, circulating CD8(+) memory T cells to a nonpersistent virus (influenza) lie within CCR7(+)CD45RA(-) central memory, whereas memory to Epstein-Barr virus (EBV) latent, EBV lytic, and cytomegalovirus (CMV) antigens are progressively larger in size and are more biased toward CCR7(-)CD45RA(-) effector memory and CCR7(-)CD45RA(+) terminally differentiated compartments. We found that these populations are also distinguished by progressively lower expression of the interleukin-7 receptor (IL-7R alpha) and by lower IL-7 responsiveness; indeed, percentage IL-7R alpha -positive values showed a tight inverse correlation with population size. However, these relationships among size, differentiation phenotype, and IL-7R alpha status in blood did not hold in tonsillar tissue. In tonsil tissue, although EBV reactivities outnumbered their CMV and influenza counterparts, the distinct CCR7/CD45 isoform signatures of the different virus-specific populations were retained. Moreover, all detectable reactivities showed high levels of IL-7R alpha expression. As a discriminator between different virus-specific populations, IL-7R alpha therefore appears to be more susceptible to tissue location than the classical CCR7/CD45 markers.

Antithrombin for respiratory distress syndrome in preterm infants.

BACKGROUND: Acquired Antithrombin (AT) deficiency is a common and prognostically important finding in sick preterm infants with respiratory distress syndrome (RDS). It has been hypothesised that AT concentrate may improve clinical outcomes in preterm infants with RDS. OBJECTIVES: To determine whether the administration of AT concentrate decreases mortality in preterm infants with RDS compared with placebo or no treatment. SEARCH STRATEGY: An electronic literature search in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE in August 2006 was performed. No language restriction was applied. References from identified studies were cross-checked for possible additional studies. Experts in the field and pharmaceutical companies were contacted for unpublished data. Abstracts of the American Society of Pediatric Research and European Society of Pediatric Research meetings (1983-2005) were searched and authors of relevant studies were contacted to obtain additional information. SELECTION CRITERIA: Randomized controlled trials comparing any dose and duration of AT therapy with placebo or no treatment in preterm infants with RDS. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data from included studies regarding mortality, intraventricular hemorrhage, mechanical ventilation, and other reported events in the clinical course of the patients. Data for similar outcomes were combined where appropriate, using a fixed-effects model in MetaView 4.2 (Update Software). MAIN RESULTS: Two trials consisting of 182 preterm infants, fulfilled the inclusion criteria. Mean gestational age of patients included was 28 weeks. In one trial, patients had to be intubated and ventilated for RDS to be eligible for the study. In the other trial, RDS was not mentioned as an inclusion criteria, however the vast majority of infants in the study received surfactant. No individual trial showed a significant difference in mortality. One of the trials was stopped early because of an increase in deaths in the AT group. The pooled analysis for mortality within the first week of life showed a typical relative risk of 2.67 (95% CI 0.72-9.83) in favour of the control group. Only the trial that was stopped early followed the infants long enough to report neonatal mortality. This trial reported 7 deaths (11.5%) in the AT group and two deaths (3.3%) in the placebo group within 28 days of life. Secondary outcomes included days of mechanical ventilation and supplemental oxygen which were only reported in 1 trial. Both outcomes were in favour of the control group and statistically significant (p < 0.05). AUTHORS' CONCLUSIONS: Preterm infants with RDS are unlikely to benefit from AT treatment and may be harmed.

The sphenoid sinus natural ostium is consistently medial to the superior turbinate.

BACKGROUND: This study was performed to determine the location of the natural ostium of the sphenoid sinus relative to the intact superior turbinate. METHODS: Forty-seven cadaveric specimens were examined. Mucosa over the sphenoethmoidal recess, superior turbinate, and posterior ethmoid was left intact. The position of the sphenoid sinus natural ostium relative to the superior turbinate was identified. RESULTS: The sphenoid ostium was identified in all specimens. In all specimens, the sphenoid ostium was found to be medial to the intact superior turbinate, notwithstanding lateral deflection of the posterior few millimeters of the superior turbinate in some cases. CONCLUSION: The superior turbinate is an excellent landmark for the sphenoid sinus natural ostium. Previous observations of the ostium positioned lateral to the superior turbinate may have been caused by stripping of the superior turbinate mucosa before measurements were taken. In the intact specimen, the sphenoid ostium is reliably found medial to the superior turbinate.

Implantation of the ossified cochlea: management with the split electrode array.

OBJECTIVES/HYPOTHESIS: To describe indications for, the surgical technique required, and the expected functional results of split electrode array cochlear implants. STUDY DESIGN: Retrospective chart review. METHODS: Data collected included etiology of deafness, radiographic findings, pre- and postoperative aided pure tone thresholds, and speech perception testing. Adult speech perception outcomes were measured using the Consonant Nucleus Consonant (CNC) monosyllable words and Hearing in Noise Test (HINT) in quiet/noise (+10 dB). The children were assessed using the Infants and Toddlers Meaningful Auditory Integration Scale. RESULTS: Five patients were implanted with a split electrode array. This included two adults and three children. Both adults had preoperative binaural aided pure tone averages worse than 50 dB and scores of 0% on both HINT quiet and CNC words. The children had undetectable preoperative aided thresholds and scored an average 4/40 on the IT-MAIS. Postimplant, the average threshold gain was 38.5 dB in the adults and 81.5 dB in the children. One adult improved to score 51%/22% on HINT quiet/noise at 6 months and 72%/30% at 12 months. The other adult continued to score 0% on HINT at 12 months but claimed substantial subjective auditory improvement after the first year of device use. The children averaged 28/40 on the IT MAIS at 6 months after implantation. Forty-two of 48 implanted electrodes were functional. CONCLUSIONS: The split electrode array is a useful alternative to traditional cochlear implants in treating deafened patients with cochlear ossification. Patients implanted with the split array show marked improvement in sound and speech perception.

Benefits of non invasive ventilation.

Mechanical ventilation of the newborn infant has increased neonatal survival. However, this increased survival has come at the expense of increased morbidity, in the form of bronchopulmonary dysplasia, and at the cost of an expensive technology. Continuous positive airway pressure (CPAP) is accepted as conferring clinical benefit in supporting the recently extubated preterm infant and in the management of apnea of prematurity. Attention is now being drawn to physiologic and clinical evidence to support CPAP use, with or without early surfactant, as a primary treatment of hyaline membrane disease. The purpose of this review is to explore these proposed benefits of non invasive ventilation and place them in the context of current clinical evidence.

Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas.

Stage at diagnosis and survival from cancer vary according to where people live, suggesting some may have delays in diagnosis. The aim of this study was to determine if time from presentation to treatment was longer for colorectal and breast cancer patients living further from cancer centres, and identify other important factors in delay. Data were collected on 1097 patients with breast and 1223 with colorectal cancer in north and northeast Scotland. Women with breast cancer who lived further from cancer centres were treated more quickly than those living closer to cancer centres (P=0.011). Multilevel modelling found that this was largely due to them receiving earlier treatment at hospitals other than cancer centres. Breast lump, change in skin contour, lymphadenopathy, more symptoms and signs, and increasing age predicted faster treatment. Screen detected cancers and private referrals were treated more quickly. For colorectal cancer, time to treatment was similar for people in rural and urban areas. Quicker treatment was associated with palpable rectal or abdominal masses, tenesmus, abdominal pain, frequent GP consultations, age between 50 and 74 years, tumours of the transverse colon, and iron medication at presentation. Delay was associated with past anxiety or depression. There was variation between general practices and treatment appeared quicker at practices with more female general practitioners.

Kakadumycins, novel antibiotics from Streptomyces sp NRRL 30566, an endophyte of Grevillea pteridifolia.

An endophytic streptomycete (NRRL 30566) is described and partially characterized from a fern-leaved grevillea (Grevillea pteridifolia) tree growing in the Northern Territory of Australia. This endophytic streptomycete produces, in culture, novel antibiotics - the kakadumycins. Methods are outlined for the production and chemical characterization of kakadumycin A and related compounds. This antibiotic is structurally related to a quinoxaline antibiotic, echinomycin. Each contains, by virtue of their amino acid compositions, alanine, serine and an unknown amino acid. Other biological, spectral and chromatographic differences between these two compounds occur and are given. Kakadumycin A has wide spectrum antibiotic activity, especially against Gram-positive bacteria, and it generally displays better bioactivity than echinomycin. For instance, against Bacillus anthracis strains, kakadumycin A has minimum inhibitory concentrations of 0.2-0.3 microg x ml(-1) in contrast to echinomycin at 1.0-1.2 microg x ml(-1). Both echinomycin and kakadumycin A have impressive activity against the malarial parasite Plasmodium falciparum with LD(50)s in the range of 7-10 ng x ml(-1). In macromolecular synthesis assays both kakadumycin A and echinomycin have similar effects on the inhibition of RNA synthesis. It appears that the endophytic Streptomyces sp. offer some promise for the discovery of novel antibiotics with pharmacological potential.