Mark Coventry Award: Efficacy of Saline Wash Plus Antibiotics Doped Polyvinyl Alcohol (PVA) Composite (PVA-VAN/TOB-P) in a Mouse Pouch Infection Model.

BACKGROUND: The efficacy of saline irrigation for treatment of periprosthetic infection (PJI) is limited by the presence of contaminated medical devices. This study evaluated treatment efficacy of locally placed polyvinyl alcohol (PVA)/bioceramic composite doped with vancomycin (PVA-VAN-P) or vancomycin and tobramycin (PVA-VAN/TOB-P) after saline irrigation in a mouse pouch infection model. METHODS: Sutures were implanted into air pouches of BALB/cJ mice, then inoculated with Staphylococcus aureus. Mice were randomized into 6 groups (n = 6 each): (1) no bacteria; (2) bacteria without saline wash; (3) saline wash only; (4) saline wash + PVA-P; (5) saline wash + PVA-VAN-P, and (6) saline wash + PVA-VAN/TOB-P. After 7 days, pouches were washed with saline alone or with additional injection of 0.2 mL of the composites. Sacrifice occurred 14 days after the washout. Histology was performed on the pouch tissues and bacteria cultures on the washout fluid. RESULTS: Bacterial culture (optical density) showed that infection persisted after saline irrigation (0.10 ± 0.14) but was effectively eradicated by the addition of PVA-VAN-P (0.05 ± 0.09) and PVA-VAN/TOB-P (0.002 ± 0.003, P < .05). These effects were confirmed by histology. Importantly, no residues of the PVA-P were detected in either the pouch washouts or pouch tissues. CONCLUSION: PJI is common and problematic, and few innovations have changed clinical practice and/or outcome. Our data confirmed that the effect of saline irrigation was very limited in the presence of contaminated sutures. PVA-VAN/TOB-P was biodegradable, biocompatible, and effective in eradicating bacterial retention after saline irrigation. Application of PVA-VAN/TOB-P after saline irrigation could be an option for treatment of PJI and should be evaluated in future PJI animal models.

Assessing Infant Carriage Systems: Ground Reaction Force Implications for Gait of the Caregiver.

Objective To assess the acute alterations of anterior infant carriage systems on the ground reaction force experienced during over-ground walking. Background Previous research has identified the alterations in posture and gait associated with an increased anterior load (external or internal); however, the forces applied to the system due to the altered posture during over-ground walking have not been established. Method Thirteen mixed gender participants completed 45 over-ground walking trials at a self-selected pace under three loaded conditions (unloaded, semi-structured carrier 9.9 kg, and structured carrier 9.9 kg). Each trial consisted of a 15-m walkway, centered around a piezoelectric force platform sampling at 1,200 Hz. Differences were assessed between loaded and unloaded conditions and across carriers using paired samples t tests and repeated measures ANOVA. Results Additional load increased all ground reaction force parameters; however, the magnitude of force changes was influenced by carrier structure. The structured carrier displayed increased force magnitudes, a reduction in the time to vertical maximum heel contact, and an increased duration of the flat foot phase in walking gait. Conclusion Evidence suggests that the acute application of anterior infant carriers alters both kinetic and temporal measures of walking gait. Importantly, these changes appear to be governed not solely by the additional mass but also by the structure of the carrier. Application These findings indicate carrier structure should be considered by the wearer and may be used to inform policy in the recommendation of anterior infant carriage systems use by caregivers.

Ionised calcium levels in major trauma patients who received blood in the Emergency Department.

BACKGROUND: Exsanguination and coagulopathy remain one of the leading causes of preventable trauma related death. Low ionised calcium levels have been associated with hypotension and increased mortality and may inhibit clot formation. Blood product contains citrate that acts as a chelating agent. We hypothesised that trauma patients who have bled are at risk of hypocalcaemia and that receiving any amount of blood product can exacerbate this state. METHODS: A retrospective cohort analysis was performed on all trauma patients who had received early blood product in the ED of a single urban major trauma centre in the UK between 2013 and 2014. Ionised calcium levels were taken from venous blood gases from before and after blood product had been transfused. RESULTS: The study included 55 patients; 36 male (65%), age 33 (16-92) years, median injury severity score (ISS) 24 (4-50), units of blood product received 2 (1-16), overall mortality 18%. Fifty-five per cent patients were hypocalcaemic on arrival, 89% patients were hypocalcaemic after receiving any amount of blood product. There was a statistically significant difference in ionised calcium levels after receiving blood product, pretransfusion 1.11 mmol/L (95% CI 1.09 to 1.14), post-transfusion 0.98 mmol/L (95% CI 0.93 to 1.02) (p<0.001). A fall in calcium was seen after receiving just one unit and the more units of blood product received the greater the fall seen. CONCLUSIONS: Trauma patients that have sustained blood loss are at risk of hypocalcaemia. Ionised calcium levels fall significantly further even after receiving a small amount of blood product. Prompt recognition and early targeted treatment is needed from arrival.

Approaches to Repair of Penetrating Injuries of the Proximal, Mid, and Distal Esophagus.

INTRODUCTION: Traumatic esophageal injuries represent less than 10% of traumatic injuries. Penetrating injuries represent an even smaller but more lethal percent. Esophageal injuries can be cervical, thoracic, or abdominal with decreasing frequency. Cervical and thoracic esophageal injuries represent >80% of these injuries and are more morbid. Morbidity and mortality are increased with delayed identification. Although diagnosis can be hard, management is similar despite location. CASES: We present 3 cases of esophageal injuries to the cervical, thoracic, and abdominal esophageal segments with descriptions on diagnosis, repair, and management differences. DISCUSSION: Despite low incidence of penetrating esophageal injuries, morbidity and mortality are extremely high, especially with associated injuries. Early identification and treatment is paramount. Anatomical knowledge is necessary for successful surgical management. Primary repair in 2 layers should be attempted whenever possible including musical closure with absorbable suture. Flaps, diversions, wide drainage, and feeding tube access should always be key surgical considerations. Flaps can include sternocleidomastoid muscle for cervical injuries, intercostal muscle, diaphragm, and pericardium for thoracic injuries and "Thal" gastric flaps for gastroesophageal junction and abdominal injuries. Successful identification and management can lead to increased survival.

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

BACKGROUND: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time. METHODS: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate. RESULTS: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs. CONCLUSION: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice. LEVEL OF EVIDENCE: Retrospective diagnostic/therapeutic study, level III.

Partial swing golf shots: scaled from full swing or independent technique?

During practice and competition, golfers are required to use submaximal effort to hit the ball a given distance, i.e., perform a partial shot. While the full golf swing has undergone extensive research, little has addressed partial shots and the biomechanical modifications golfers employ. This study investigates the biomechanical changes between full and partial swings, and determines if the partial swing is a scaled version of the full swing. Using a repeated measures design, 13 male golfers completed a minimum of 10 swings in the full and partial swing conditions, whilst club, ball, kinematic, and kinetic parameters were recorded. Large and statistically significant reductions in body motion (centre of pressure ellipse: 33.0%, p = 0.004, d = 2.26), combined with moderate reductions in lateral shift (25.5%, p = 0.004, d = 0.33) and smaller reductions in trunk rotation (arm to vertical at top of backswing: 14.1%, p = 0.002, d = 2.58) indicate golfers favour larger reductions in proximal measures, combined with diminished reductions as variables moved distally. Furthermore, the partial swing was not found to be a scaled version of the full swing implying a new approach to coaching practices might be considered.

Career success implications of political skill.

The authors investigated the individual characteristic of political skill and its relation to 5 different career-related outcomes (total compensation, promotions, career satisfaction, life satisfaction, and perceived external job mobility). They examined data obtained from a sample of 191 employees working a wide range of occupations. The results reveal that political skill is associated with 4 of the 5 outcomes. In addition, they examined the 4 dimensions of political skill and found that the networking ability dimension dominates the relations with the examined outcomes. The authors discuss practical implications, limitations, and directions for future research.

Validity of the diagnosis of pneumonia in hospitalised patients with COPD.

RATIONALE: Exacerbations of chronic obstructive pulmonary disease (COPD) and pneumonia are two of the most common reasons for acute hospital admissions. Acute exacerbations and pneumonia present with similar symptoms in COPD patients, representing a diagnostic challenge with a significant impact on patient outcomes. The objectives of this study were to compare the prevalence of radiographic consolidation with the discharge diagnoses of hospitalised COPD patients. METHODS: COPD patients admitted to three UK hospitals over a 3-year period were identified. Participants were included if they were admitted with an acute respiratory illness, COPD was confirmed by spirometry and a chest radiograph was performed within 24 h of admission. Pneumonia was defined as consolidation on chest radiograph reviewed by two independent observers. RESULTS: There were 941 admissions in 621 patients included in the final analysis. In 235 admissions, consolidation was present on chest radiography and there were 706 admissions without consolidation. Of the 235 admissions with consolidation, only 42.9% had a discharge diagnosis of pneumonia; 90.7% of patients without consolidation had a discharge diagnosis of COPD exacerbation. The presence of consolidation was associated with increased rate of high-dependency care admission, increased mortality and prolonged length of stay. Inhaled corticosteroid use was associated with recurrent pneumonia. CONCLUSIONS: Pneumonia is underdiagnosed in patients with COPD. Radiographic consolidation is associated with worse outcomes and prolonged length of stay. Incorrect diagnosis could result in inappropriate use of inhaled corticosteroids. Future guidelines should specifically address the diagnosis and management of pneumonia in COPD.

Radiation Mitigation Techniques in Kidney Stone Management.

Patients with nephrolithiasis are exposed to significant quantities of ionizing radiation with the potential to cause secondary malignancy. This risk is magnified by the high recurrence rate of nephrolithiasis. In this article, we identify the risks of ionizing radiation as they pertain to patients with nephrolithiasis. We then identify evidence-based techniques for mitigating patient radiation exposure in the preoperative, intraoperative, and postoperative settings. Key factors include limiting the use of computed tomographic imaging, appropriate modulation of fluoroscopy settings, and minimizing rates of stone recurrence.

Update on postinjury nutrition.

PURPOSE OF REVIEW: Nutritional supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma, many areas of clinical nutrition remain controversial and not well defined. The benefit of early enteral nutrition in the care of injured patients has been well established, with further benefit derived by the administration of immune-enhancing formulas supplemented with glutamine, arginine, nucleotides, and omega-3-fatty acids. A new paradigm of pharmaconutrition has been developed that separates the administration of immunomodulatory nutrients from that of nutritional support. The optimal utilization and benefit of pharmaconutrients, however, remains unclear, as does the need for full caloric provision in the early postinjury phase. RECENT FINDINGS: Nutrition studies with the greatest reduction in morbidity and mortality are those utilizing specific nutrients. The use of pharmaconutrients to modulate the inflammatory and immune response associated with critical illness seems to provide benefit to critically ill and injured patients. Additionally, studies at least suggest that trauma patients derive comparable if not additional benefit from hypocaloric feeding during the acute phase of injury. SUMMARY: Building upon previous well performed studies in trauma patients, the current focus of nutritional investigations center on the use of pharmaconutrients to modulate the inflammatory response and the use of hypocaloric feeds. These practices will be reviewed and evidence presented for their use in critically ill and injured patients.

Natural history of splenic vascular abnormalities after blunt injury: A Western Trauma Association multicenter trial.

BACKGROUND: Following blunt splenic injury, there is conflicting evidence regarding the natural history and appropriate management of patients with vascular injuries of the spleen such as pseudoaneurysms or blushes. The purpose of this study was to describe the current management and outcomes of patients with pseudoaneurysm or blush. METHODS: Data were collected on adult (aged ≥18 years) patients with blunt splenic injury and a splenic vascular injury from 17 trauma centers. Demographic, physiologic, radiographic, and injury characteristics were gathered. Management and outcomes were collected. Univariate and multivariable analyses were used to determine factors associated with splenectomy. RESULTS: Two hundred patients with a vascular abnormality on computed tomography scan were enrolled. Of those, 14.5% were managed with early splenectomy. Of the remaining patients, 59% underwent angiography and embolization (ANGIO), and 26.5% were observed. Of those who underwent ANGIO, 5.9% had a repeat ANGIO, and 6.8% had splenectomy. Of those observed, 9.4% had a delayed ANGIO, and 7.6% underwent splenectomy. There were no statistically significant differences between those observed and those who underwent ANGIO. There were 111 computed tomography scans with splenic vascular injuries available for review by an expert trauma radiologist. The concordance between the original classification of the type of vascular abnormality and the expert radiologist's interpretation was 56.3%. Based on expert review, the presence of an actively bleeding vascular injury was associated with a 40.9% risk of splenectomy. This was significantly higher than those with a nonbleeding vascular injury. CONCLUSIONS: In this series, the vast majority of patients are managed with ANGIO and usually embolization, whereas splenectomy remains a rare event. However, patients with a bleeding vascular injury of the spleen are at high risk of nonoperative failure, no matter the strategy used for management. This group may warrant closer observation or an alternative management strategy. LEVEL OF EVIDENCE: Prognostic study, level III.

Correlation of central venous and arterial blood gas measurements in mechanically ventilated trauma patients.

HYPOTHESIS: Central venous blood gas (VBG) measurements of pH, PCO2, and base excess can be substituted for the same values obtained from an arterial blood gas (ABG) analysis in mechanically ventilated trauma patients, obviating the need for arterial puncture. DESIGN AND SETTING: Prospective comparison of 99 sets of VBGs and ABGs at a level 1 academic trauma center. PATIENTS: A consecutive sample of 25 trauma patients admitted to the intensive care unit who required mechanical ventilation and had both central venous and arterial catheters. MAIN OUTCOME MEASURES: Pearson correlations and Bland-Altman limits of agreement (LOAs) for pH, PCO2, and base excess values from each set of VBGs and ABGs. RESULTS: When VBG and ABG values were compared, pH had R = 0.92, P<.001, and 95% LOAs of -0.09 to 0.03; PCO2, R = 0.88, P<.001, and 95% LOAs of -2.2 to 10.9; and base excess, R = 0.96, P<.001, and 95% LOAs of -2.2 to 1.8. A receiver operating characteristic curve showed that a central venous PCO2 of 50 mm Hg had 100% sensitivity and 84% specificity for determining significant hypercarbia (arterial PCO2 > 50 mm Hg). CONCLUSIONS: Central venous and arterial PCO2, pH, and base excess values correlate well, but their LOAs represent clinically significant ranges that could affect management. Although VBGs cannot be substituted for ABGs in mechanically ventilated trauma patients during the initial phases of resuscitation, clinically reliable conclusions can be reached with VBG analysis.

Student athletes' perceptions of self.

Several factors have been found to contribute to the development of the self in adolescents, including religion, race, competence, leadership, physical appearance, and gender. The purpose of this study was to describe the development of self-perception in adolescent athletes and make comparisons with respect to gender and class level. One hundred seventy-five high school athletes were administered Harter's (1988) Self-Perception Profile for Adolescents. The data were analyzed for both the overall sample and demographic subgroups. Males had a significantly higher mean score on athletic competence than did females. Males also viewed both athletic competence and social acceptance as significantly more important than did females. These findings are discussed in the context of relevant literature on adolescents' perceptions of self.

Does human capital matter? A meta-analysis of the relationship between human capital and firm performance.

Theory at both the micro and macro level predicts that investments in superior human capital generate better firm-level performance. However, human capital takes time and money to develop or acquire, which potentially offsets its positive benefits. Indeed, extant tests appear equivocal regarding its impact. To clarify what is known, we meta-analyzed effects drawn from 66 studies of the human capital-firm performance relationship and investigated 3 moderators suggested by resource-based theory. We found that human capital relates strongly to performance, especially when the human capital in question is not readily tradable in labor markets and when researchers use operational performance measures that are not subject to profit appropriation. Our results suggest that managers should invest in programs that increase and retain firm-specific human capital.

Practice patterns and outcomes of retrievable vena cava filters in trauma patients: an AAST multicenter study.

BACKGROUND: The purpose of this study is to describe practice patterns and outcomes of posttraumatic retrievable inferior vena caval filters (R-IVCF). METHODS: A retrospective review of R-IVCFs placed during 2004 at 21 participating centers with follow up to July 1, 2005 was performed. Primary outcomes included major complications (migration, pulmonary embolism [PE], and symptomatic caval occlusion) and reasons for failure to retrieve. RESULTS: Of 446 patients (69% male, 92% blunt trauma) receiving R-IVCFs, 76% for prophylactic indications and 79% were placed by interventional radiology. Excluding 33 deaths, 152 were Gunter-Tulip (G-T), 224 Recovery (R), and 37 Optease (Opt). Placement occurred 6 +/- 8 days after admission and retrieval at 50 +/- 61 days. Follow up after discharge (5.7 +/- 4.3 months) was reported in 51%. Only 22% of R-IVCFs were retrieved. Of 115 patients in whom retrieval was attempted, retrieval failed as a result of technical issues in 15 patients (10% of G-T, 14% of R, 27% of Opt) and because of significant residual thrombus within the filter in 10 patients (6% of G-T, 4% of R, 46% Opt). The primary reason R-IVCFs were not removed was because of loss to follow up (31%), which was sixfold higher (6% to 44%, p = 0.001) when the service placing the R-IVCF was not directly responsible for follow up. Complications did not correlate with mechanism, injury severity, service placing the R-IVCF, trauma volume, use of anticoagulation, age, or sex. Three cases of migration were recorded (all among R, 1.3%), two breakthrough PE (G-T 0.6% and R 0.4%) and six symptomatic caval occlusions (G-T 0, R 1%, Opt 11%) (p < 0.05 Opt versus both G-T and R). CONCLUSION: Most R-IVCFs are not retrieved. The service placing the R-IVCF should be responsible for follow up. The Optease was associated with the greatest incidence of residual thrombus and symptomatic caval occlusion. The practice patterns of R-IVCF placement and retrieval should be re-examined.