Surgical stabilization of traumatic rib fractures is associated with reduced readmissions and increased survival.

BACKGROUND: Surgical stabilization for rib fractures (SSRF) in trauma patients remains controversial, with guidelines currently suggesting the procedure for only select patient groups. How surgical stabilization for rib fractures affect hospital readmission in patients with traumatic rib fractures is unknown. We hypothesized that surgical stabilization for rib fractures would not decrease the risk of readmission. METHODS: The National Readmission Database was examined for adults with any rib fractures from 2010 to 2017. Readmission up to 90 days was examined. Patients receiving surgical stabilization for rib fractures were compared with those receiving nonoperative treatment. RESULTS: In total, 864,485 patients met criteria, with 13,701 (1.6%) receiving SSRF. For patients receiving SSRF, 338 (1.5%) were readmitted. Readmitted patients had higher Charlson Comorbidity Index and were more likely to have flail chest. On multivariate propensity score-matched analysis, SSRF (Hazard Ratio [HR]: 0.55, 95% confidence interval [CI] 0.33-0.92, P = .022) was associated with reduced readmission. Addition of surgical stabilization for rib fractures to video-assisted thoracoscopic surgery (VATS) (Odds Ratio [OR]: 0.95, 95% CI 0.52-1.73, P = .86) or thoracotomy (OR: 1.97, 95% CI 0.83-4.70, P = .13) was not associated with increased readmission. On further propensity matched analysis, VATS + SSRF when compared with SSRF alone (HR: 0.75, 95% CI 0.18-3.20, P = .696), and VATS + SSRF when compared with VATS alone (HR: 0.49, 95% CI 0.11-2.22, P = .355) was also not associated with increased readmission. SSRF on primary admission was associated with increased in-hospital survival (HR: 0.27, 95% CI 0.22-0.32, P < .001). For patients with retained hemothorax who underwent VATS, addition of SSRF did not improve survival (HR = 0.92, 95% CI 0.58-1.46, P = .72). However, for patients requiring thoracotomy for retained hemothorax, concomitant SSRF was associated with improved survival (HR = 0.14, 95% CI 0.06-0.32, P < .001). CONCLUSION: Surgical stabilization for rib fractures is associated with reduced readmission risk while also being associated with improved survival. Patients who had a thoracotomy for retained hemothorax appear to especially benefit from concomitant surgical stabilization for rib fractures.

Surgical stabilization of rib fractures is associated with improved survival but increased acute respiratory distress syndrome.

BACKGROUND: How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome. METHODS: The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs. RESULTS: There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10-0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11-0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58-3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97-2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome. CONCLUSION: The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures.

A Case of CIED-Associated Endocarditis and Septic Emboli Requiring Lead Extraction, AngioVac Suction, and Pulmonary Endarterectomy.

Cardiac Implantable Electronic Devices (CIED)-associated infective endocarditis complicated by septic emboli and acute on chronic pulmonary hypertension is rare. We present a case where pulmonary thromboendarterectomy was required for treatment. A 55 year-old man with a history of myocardial infarction and ischemic cardiomyopathy status-post ICD placement 8 years prior presented with bacteremia, infected ICD, and tricuspid valve vegetation. He underwent CIED extraction along with the use of the AngioVac suction device to remove right ventricular and atrial vegetations. However the patient had persistent valvular vegetation and bilateral sub-massive pulmonary emboli. Pulmonary angiography showed filling defects in the lobar and segmental arteries. Percutaneous attempts at embolectomy were unsuccessful and he therefore underwent a pulmonary endarterectomy surgery (PTE). This case of CIED- associated endocarditis demonstrates the importance of early aggressive treatment of such infections. Guidelines recommend compete CIED system removal when there is associated infection. The AngioVac is a novel system for removal of right-sided vegetations and thrombi; however, complications such as distal embolization can occur. PTE surgery for septic emboli is rare. However, cases of such treatment as is presented here can be successful and may be necessary should percutaneous methods fail.

Bortezomib sensitizes thyroid cancer to BRAF inhibitor in vitro and in vivo.

Although overall survival rate for patients with thyroid cancer (TC) is high, there is an alarming 10-year recurrence rate of up to 30% conferring a ~50% survival among these high-risk patients. The BRAFV600E mutation is estimated to be present in over 50% of papillary thyroid cancer (PTC) cases besides being associated with carcinogenesis and poor prognosis. We assessed the status of NF-κB, Ki-67, cyclin D1 and BRAFV600E in TC tissues and TC cell lines using immunohistochemistry and Western blot analysis. Concurrently, we evaluated the outcomes of combined targeting of the proteasome pathway in addition to selective BRAF inhibitors in cases of PTC. In this study, BRAFV600E-bearing TC cells were treated with BRAFV600E inhibitor, Vemurafenib alone or in combination with the proteasome inhibitor, Bortezomib. The combination of both drugs showed synergistic effects as evidenced by cell growth inhibition (P < 0.05), increased G2-phase cell cycle arrest and induced apoptosis (P < 0.05). In our TC xenograft model, the combination of Vemurafenib and Bortezomib significantly reduced tumor size (P < 0.05) and expression of the markers of cell growth and proliferation, Ki-67 and cyclin D1 (P < 0.001), when compared to monotherapy. Further analysis demonstrated that treatment with Bortezomib sensitized TC cells to Vemurafenib via mitochondrial dysregulation and apoptosis of TC cells, as evidenced by the increase in the expression of p53, Noxa protein, the loss of mitochondrial membrane potential, cytochrome c release and Poly (ADP-ribose) polymerase cleavage. Our results demonstrate a strong clinical potential for the combination of the Bortezomib and the BRAF inhibitor Vemurafenib as an efficient therapeutic approach for the treatment of TC.

Assessment of the quality and content of national and international guidelines on hypertensive disorders of pregnancy using the AGREE II instrument.

OBJECTIVES: High-quality evidence-based clinical practice guidelines can guide diagnosis and treatment to optimise outcomes. The purpose of this study was to evaluate the quality and content of national and international guidelines on hypertensive disorders of pregnancy. DATA SOURCES: The MEDLINE database, the National Guideline Clearinghouse and several international databases were searched for appropriate guidelines from the past 10 years. STUDY APPRAISAL AND SYNTHESIS METHODS: Six guidelines met inclusion and exclusion criteria and were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. RESULTS: A total of 695 records were identified and screened by two authors. Disorder definitions, classifications, preventive measures and treatment recommendations were evaluated and compared among guidelines. AGREE II results varied widely across domains and categories. Only two guidelines received consistently high ratings across domains and few demonstrated a high level of methodological rigour. Recommendations regarding classification and treatment were similar across guidelines, while assessment of preventive measures varied widely. CONCLUSIONS: Clinical practice guidelines for hypertensive disorders of pregnancy vary significantly in quality and with respect to assessment of preventive measures.

Novel biomarkers for heart failure.

Heart failure (HF) has proven to be a major burden on the health system. The continuing prevalence of the condition and its rising associated costs and care, has amplified the need for earlier diagnosis, better risk stratification and cost-effective treatment to cut rates of hospitalization. Biomarkers seem poised to undertake such tasks, with biomarker management of patients with HF quickly evolving over the past several years. Biomarker guided diagnosis and treatment has become vital, especially during the acute setting in which the majority of patients with HF, were initially present. An adequate assessment of risk requires a multi-marker approach to a given HF patient. Established markers including brain natriuretic peptide and NT-proBNP are a significant clinical aid to physicians, though their utility is limited. In the past few years, momentous effort has been put into the discovery of new biomarkers. These endeavors have led to the emergence of several capable and promising biomarkers for HF management including troponins, mid-regional pro-adrenomedullin, GDF-15, C-reactive protein, Galectin-3, IL-6, ST-2, neutrophil gelatinase-associated lipocalin, copeptin and procalcitonin. This review will offer an insight into the novel biomarkers considered as the cutting-edge in the diagnosis and management of HF.

Heart failure biomarkers.

Biomarker testing in patients with heart failure (HF) is rapidly expanding. With high-quality research indicating its diagnostic and prognostic capabilities, biomarkers are excellent adjuncts to manage patients with HF. Their superiority lies mainly in their reflection of ongoing pathophysiological events at a cellular level. Monitoring biomarker levels has been shown to provide incremental information on the progression of disease, thus allowing to better tailor treatment and management. Several biomarkers have gained attention in the past decade and continuing research demonstrates the specificity of each biomarker to be used on its own or in combination to improve diagnostic accuracy. This review will provide an insight into the role of such biomarkers, which are widely studied in the setting of HF so as to delineate their role in diagnosing, prognosticating, and titrating HF therapy.

Diversification of de-agrarianization? Income diversification, labor, and processes of agrarian change in southern and northern Malawi, mid-1930s to mid-1950s.

This article investigates the links between market-oriented activities and subsistence production among peasant farmers in the Thyolo and Mzimba districts in Malawi from the mid-1930s to the mid-1950s. The two districts were chosen because of their differences in terms of land-labor ratios, quality of soils, and structure of market engagement. Exploring the different paths of agrarian change in these two districts demonstrates that they were dependent on the structure of market engagement and its effects on the supply and flexibility of labor. African agricultural history is best understood when agricultural systems are viewed in connection to the overall economic activities of rural households. More simply put, the dynamics of agrarian change in rural Africa cannot be understood without linking such changes to the wider economy and their impact on local labor processes.