Implementation and adoption of advanced care planning in the elderly trauma patient.

Background: Geriatric trauma has high morbidity and mortality, often requiring extensive hospital stays and interventions. The number of geriatric trauma patients is also increasing significantly and accounts for a large proportion of trauma care. Specific geriatric trauma protocols exist to improve care for this complex patient population, who often have various comorbidities, pre-existing medications, and extensive injury within a trauma perspective. These guidelines for geriatric trauma care often suggest early advanced care planning (ACP) discussions and documentation to guide patient and family-centered care. Methods: A provincial ACP program was implemented in April of 2012, which has since been used by our level 1 trauma center. We applied a before and after study design to assess the documentation of goals of care in elderly trauma patients following implementation of the standardized provincial ACP tool on April 1, 2012. Results: Documentation of ACP in elderly major trauma patients following the implementation of this tool increased significantly from 16 to 35%. Additionally, secondary outcomes demonstrated that many more patients received goals of care documentation within 24 h of admission, and 93% of patients had goals of care documented prior to intensive care unit (ICU) admission. The number of trauma patients that were admitted to the ICU also decreased from 17 to 5%. Conclusion: Early advanced care planning is crucial for geriatric trauma patients to improve patient and family-centered care. Here, we have outlined our approach with modest improvements in goals of care documentation for our geriatric population at a level 1 trauma center. We also outline the benefits and drawbacks of this approach and identify the areas for improvement to support improved patient-centered care for the injured geriatric patient. Here, we have provided a framework for others to implement and further develop.

The secondary and recurrent abdominal compartment syndrome.

INTRODUCTION: The Secondary Abdominal Compartment Syndrome (SACS) refers to cases of the ACS that do not originate from the abdomino-pelvic region. With greater awareness of the physiologic consequences of raised intra-abdominal hypertension (IAH), cases of the SACS are being increasingly described. The prior treatment or the presence of a partially open abdomen does not preclude the ACS if the abdomen and viscera continue to swell or the clinician is not vigilant in monitoring intra-abdominal pressure (lAP). Such recurrent cases (RACS) have been defined as those which redevelop following the previous medical or surgical treatment of primary or SACS. Although there has been a diverse range of etiologies implicated, these cases seem to be linked by the common occurrence of severe shock requiring aggressive fluid resuscitation. The aim of this paper is to thus to review the historical background, awareness, definitions, pathophysiological implications and treatment options for SACS and RACS. METHODS: This review will focus on the available literature regarding SACS and RACS. A Medline and Pubmed search was performed using the keywords; secondary abdominal compartment syndrome AND secondary AND tertiary AND recurrent AND abdominal compartment syndrome AND intra-abdominal pressureAND intra-abdominal hypertension. Bibliographies of recovered papers were hand-searched for other appropriate references. The resulting references were included in the current review on the basis of relevance and scientific merit RESULTS: There has been remarkably little specific study of these entities outside of specific groups such as those injured by thermal or traumatic injury. The epidemiology, risk factors for, treatment of and most importantly, strategies for prevention all remain scientifically unknown and therefore based on opinion. Notable, although small, studies suggest that specific resuscitation practices may avert these conditions. CONCLUSIONS: ACS can occur in any patient who is critically ill and subject to visceral and somatic swelling, regardless of whether the inciting pathology is extra-abdominal. The ACS may also reoccur with recurrent shock and swelling even if previous therapies had partially addressed IAH. Therefore IAP measurements should be considered a routine monitoring for the critically ill, especially those subjected to shock and requiring a subsequent resuscitation. Much further study is required to understand the differences in etiology, diagnosis, pathophysiology, and treatment for all cases of the ACS.

The secondary and recurrent abdominal compartment syndrome.

INTRODUCTION: The Secondary Abdominal Compartment Syndrome (SACS) refers to cases of the ACS that do not originate from the abdominopelvic region. With greater awareness of the physiologic consequences of raised intra-abdominal hypertension (IAH), cases of the SACS are being increasingly described. The prior treatment or the presence of a partially open abdomen does not preclude the ACS if the abdomen and viscera continue to swell or the clinician is not vigilant in monitoring intra-abdominal pressure (IAP). Such recurrent cases (RACS) have been defined as those which redevelop following the previous medical or surgical treatment of primary or SACS. Although there has been a diverse range of etiologies implicated, these cases seem to be linked by the common occurrence of severe shock requiring aggressive fluid resuscitation. The aim of this paper is to thus to review the historical background, awareness, definitions, pathophysiological implications and treatment options for SACS and RACS. METHODS: This review will focus on the available literature regarding SACS and RACS. A Medline and Pubmed search was performed using the keywords; secondary abdominal compartment syndrome AND secondary AND tertiary AND recurrent AND abdominal compartment syndrome AND intra-abdominal pressure AND intra-abdominal hypertension. Bibliographies of recovered papers were hand-searched for other appropriate references. The resulting references were included in the current review on the basis of relevance and scientific merit Results: There has been remarkably little specific study of these entities outside of specific groups such as those injured by thermal or traumatic injury. The epidemiology, risk factors for, treatment of and most importantly, strategies for prevention all remain scientifically unknown and therefore based on opinion. Notable, although small, studies suggest that specific resuscitation practices may avert these conditions. CONCLUSIONS: ACS can occur in any patient who is critically ill and subject to visceral and somatic swelling, regardless of whether the inciting pathology is extra-abdominal. The ACS may also reoccur with recurrent shock and swelling even if previous therapies had partially addressed IAH. Therefore IAP measurements should be considered a routine monitoring for the critically ill, especially those subjected to shock and requiring a subsequent resuscitation. Much further study is required to understand the differences in etiology, diagnosis, pathophysiology, and treatment for all cases of the ACS.

3-Mercapto-2-methylpentan-1-ol, a new powerful aroma compound.

3-Mercapto-2-methylpentan-1-ol was first detected in a complex thermally processed flavor and finally isolated from raw onions. The chemical structure of this new compound was identified by MS and (1)H NMR measurement and synthesis of the proposed structure. Sensory evaluation at different concentrations indicated that the flavor quality is strongly dependent on concentration. At low concentration (0.5 ppb) a pleasant meat broth, sweaty, onion, and leek-like odor can be perceived. On the basis of some isolation experiments and volatiles occurring in raw onions, a formation pathway is proposed. As one intermediate 3-mercapto-2-methylpentanal, another new strong flavor compound, was suggested. The presence of this compound in raw onions was confirmed by synthesis and comparison of MS and chromatographic data.

Enantioselective syntheses and sensory properties of the 3-mercapto-2-methylpentanols.

3-Mercapto-2-methylpentanol, a new powerful flavor compound, exhibits two stereocenters giving rise to two pairs of diastereomers. To determine differences in the sensory properties, all four diastereomers and enantiomers were stereo- and enantioselectively synthesized. A highly diastereoselective aldol reaction using a chiral auxiliary was one of the key steps in the synthesis. Further derivatization yielded the enantiopure compounds. Odor thresholds in air and water were determined.

p59OASL, a 2'-5' oligoadenylate synthetase like protein: a novel human gene related to the 2'-5' oligoadenylate synthetase family.

The 2'-5' oligoadenylate synthetases form a well conserved family of interferon induced proteins, presumably present throughout the mammalian class. Using the Expressed Sequence Tag databases, we have identified a novel member of this family. This protein, which we named p59 2'-5' oligoadenylate synthetase-like protein (p59OASL), shares a highly conserved N-terminal domain with the known forms of 2'-5' oligoadenylate synthetases, but differs completely in its C-terminal part. The C-terminus of p59OASL is formed of two domains of ubiquitin-like sequences. Here we present the characterisation of a full-length cDNA clone, the genomic sequence and the expression pattern of this gene. We have addressed the evolution of the 2'-5' oligoadenylate synthetase gene family, in the light of both this new member and new 2'-5' oligoadenylate synthetase sequence data from other species, which have recently appeared in the databases.

Carpal tunnel syndrome associated with extra tunnel vascular compression of the median nerve motor branch.

We report a case of carpal tunnel syndrome associated with median nerve motor branch compression by a large superficial palmar branch of the radial artery.

Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula.

Until recently, secondary thrombosis of the deep veins of the upper extremity was rarely encountered. The expanding use of the subclavian vein as a route to the central circulation has increased its occurrence, but symptoms are uncommon. Patients on hemodialysis with a functioning arteriovenous fistula become symptomatic with venous hypertension and swelling. Treatment becomes necessary, and fistula ligation is usually recommended; however, this renders the extremity unsuitable for a future life-sustaining access. Patency of grafts in the venous system has been accomplished with a temporary arteriovenous fistula. In six patients with chronic renal failure and a functioning arteriovenous fistula, a polytetrafluoroethylene graft was used to replace or bypass the obstructed vein. Symptoms resolved, and the fistula was preserved in three of the six patients for 1 to 3 years.