Outcomes in trauma patients undergoing veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome.

BACKGROUND: The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) remains controversial in trauma patients with acute respiratory distress syndrome (ARDS). Here, we aimed to investigate the therapeutic benefits of VV ECMO and the factors affecting patient outcomes. METHODS: From 2017 to 2019, 21/1938 trauma patients (median age: 47 years; 18 men) at a level I trauma center received VV ECMO for post-traumatic ARDS. Demographic, injury-specific, ECMO, and outcome data were prospectively collected and retrospectively reviewed to analyze the factors affecting hospital mortality and ECMO results. RESULTS: 19 patients (90.5%) were successfully weaned off ECMO; 16 patients (76.2%) survived to discharge. In univariate analysis, there was a significant difference in survival between the groups with a Trauma and Injury Severity Score (TRISS) ⩾0.5 and TRISS <0.5 (p = 0.05). The area under the receiver operating characteristic curve (AUC) for both TRISS and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) scores for death was 0.78. In those who failed ECMO weaning, the AUCs of the TRISS and RESP scores were 0.90 and 0.80, respectively. CONCLUSIONS: In patients with ARDS caused by severe trauma and supported by VV ECMO, survival is associated with TRISS; TRISS and RESP scores may be predictive of mortality and failure in ECMO weaning.

Life-threatening massive empyema: A novel complication of intrathoracic omental herniation.

Intrathoracic omental herniation (ITOH) is the herniation of the omentum through the esophageal hiatus without herniation of the stomach. It is a rare disease and serious complications due to ITOH have not been reported in the literature. Here, we reported the case of 47-year old man who presented to the emergency department with dyspnea and chest pain. Enhanced computed tomography (CT) demonstrated a large retrocardiac mass and ITOH was suspected. During the observation period in the emergency department, the patient's condition rapidly deteriorated. Follow-up CT showed large parapneumonic effusion and empyema. Emergency surgery was performed and the omental sac was removed. The patient's vital signs were restored and his symptoms were relieved. He was discharged on hospital day 15 without complications. Emergency physicians should be aware that severe complications of ITOH could develop and that if the patient's symptoms and vital signs worsen, emergency surgery should be considered.

Erratum: Correction of Figure in the Article: Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults.

This corrects the article on e198 in vol. 34, PMID: 31373183.

Normal Reference Plots for the Bioelectrical Impedance Vector in Healthy Korean Adults.

BACKGROUND: Accurate volume measurement is important in the management of patients with congestive heart failure or renal insufficiency. A bioimpedance analyser can estimate total body water in litres and has been widely used in clinical practice due to its non-invasiveness and ease of results interpretation. To change impedance data to volumetric data, bioimpedance analysers use equations derived from data from healthy subjects, which may not apply to patients with other conditions. Bioelectrical impedance vector analysis (BIVA) was developed to overcome the dependence on those equations by constructing vector plots using raw impedance data. BIVA requires normal reference plots for the proper interpretation of individual vectors. The aim of this study was to construct normal reference vector plots of bioelectrical impedance for Koreans. METHODS: Bioelectrical impedance measurements were collected from apparently healthy subjects screened according to a comprehensive physical examination and medical history performed by trained physicians. Reference vector contours were plotted on the RXc graph using the probability density function of the bivariate normal distribution. We further compared them with those of other ethnic groups. RESULTS: A total of 242 healthy subjects aged 22 to 83 were recruited (137 men and 105 women) between December 2015 and November 2016. The centers of the tolerance ellipses were 306.3 Ω/m and 34.9 Ω/m for men and 425.6 Ω/m and 39.7 Ω/m for women. The ellipses were wider for women than for men. The confidence ellipses for Koreans were located between those for Americans and Spaniards without overlap for both genders. CONCLUSION: This study presented gender-specific normal reference BIVA plots and corresponding tolerance and confidence ellipses on the RXc graph, which is important for the interpretation of BIA-reported volume status in patients with congestive heart failure or renal insufficiency. There were noticeable differences in reference ellipses with regard to gender and ethnic groups.

Factors Affecting Postoperative Lung Expansion in Patients with Pyogenic Empyema.

BACKGROUND: In patients with parapneumonic empyema, decortication is usually preferred to ensure functional lung re-expansion. However, there could be patients exhibiting incomplete postoperative lung expansion and inadequate drainage despite decortication. Therefore, we evaluated factors affecting postoperative lung expansion in patients undergoing decortication. METHODS: A total of 221 patients with pyogenic empyema who underwent video-assisted thoracoscopic surgery (VATS) between January and October 2016 in our hospital were reviewed in terms of surgical success. The following factors were evaluated: age; the time between identification of a localized effusion and surgical referral; chest tube drainage durations; any underlying morbidity preoperative blood culture data; and the thickness of the visceral pleura. RESULTS: Several factors that significantly prolonged the postoperative time to lung expansion were evident in patients with diabetes mellitus (DM) and bacteremia; postoperative chest tube drainage was significantly longer in those with DM (p = 0.009) and bacteremia (p = 0.01); and postoperative hospitalization time was significantly longer in patients with bacteremia (p = 0.01). The thickness of the visceral pleura was strongly correlated with postoperative chest tube drainage duration and postoperative hospitalization time (Pearson correlation coefficient, r = 0.245, p = 0.00). CONCLUSIONS: In patients with DM, bacteremia, or thickened pleura, the time to lung expansion after operation was longer. Therefore, stricter pre- and post-operative control of blood-sugar levels and adequate antibiotics are required to facilitate postoperative lung re-expansion. In patients with thickened pleurae, prolonged chest tube placement is unavoidable.

The influence of side branch stenosis on fractional flow reserve assessment of the main branch in a swine model.

OBJECTIVES: The aim of this study was to explore the effect of one stenosis in a daughter artery on the fractional flow reserve (FFR) of another stenosis parallels in side branch. BACKGROUND: The impact of one stenosis on the FFR of another parallel stenosis has not been evaluated. METHODS: The proximal segments of the left anterior descending (LAD) and left circumflex (LCX) arteries were exposed and encircled with a Teflon pledget complex in seven swine (55-70 kg). Five degrees of stenosis (to approximate angiographic diameter stenoses of 0%, 25%, 50%, 75%, and 100%) were made by tightening the pledgets. FFR was evaluated simultaneously in the LAD and the LCX with two pressure wires in each coronary artery. A mixed-effects linear model was used to evaluate the association between the FFR values. RESULTS: A total of 115 paired FFR values were obtained. The FFR of the LAD and LCX were not significantly associated with each other (F = 0.237 and P = 0.627 for the LCX FFR to predict the LAD FFR; F = 0.541 and P = 0.463 for the LAD FFR to predict the LCX FFR). CONCLUSIONS: The individual FFR values of each parallel stenosis in the LAD and the LCX were not significantly influenced by each other. This relationship was independent of the mean aortic pressure and heart rate. © 2016 Wiley Periodicals, Inc.

Hybrid Repair for Anastomotic Pseudoaneurysm on the Innominate Artery Following Blunt Chest Trauma.

A 55-year-old male with a previous open surgical repair of a traumatic right subclavian artery rupture was admitted following a fall with a rupture of the bifurcation of the innominate artery. The right common carotid artery was debranched from the left common carotid artery using a ringed 8 mm vascular graft. Simultaneously, a 16 × 80 mm vascular stent graft was inserted from the origin of the innominate artery to the mid portion of the subclavian artery, successfully covering the rupture site.

Role of extracorporeal life support for traumatic hemopericardium: A single level I trauma center review.

BACKGROUND: Traumatic hemopericardium may lead to cardiac tamponade, arrhythmia, arrest, or death and requires emergency surgery. We reviewed cases of traumatic hemopericardium in our center and the role of extracorporeal life support in these cases. METHODS: From November 2011 to January 2022, 28 patients with significant hemopericardium and suspected cardiac injury were enrolled. In our center, surgery is the primary treatment of choice; however, if the patient is in an unstable condition, extracorporeal life support is administered in the emergency room prior to surgery. RESULTS: Preoperative extracorporeal life support was applied to 10 patients (36 %). Two patients (20 %) were converted from extracorporeal life support to cardiopulmonary bypass during operation. After surgery, 2 patients (20 %) needed postoperative extracorporeal membrane oxygenation support. Overall, 21 patients (75 %) survived; of these, 6 (29 %) received extracorporeal life support. Meanwhile, 7 patients (25 %) died; of these, 4 patients (57 %) received extracorporeal life support. CONCLUSION: Resuscitation method is the most crucial survival strategy in patients with severe chest trauma. Extracorporeal life support in cases of traumatic hemopericardium may be beneficial and efficient in stabilizing patients prior to surgery.

Presynaptic structural and functional plasticity are coupled by convergent Rap1 signaling.

Dynamic presynaptic actin remodeling drives structural and functional plasticity at synapses, but the underlying mechanisms remain largely unknown. Previous work has shown that actin regulation via Rac1 guanine exchange factor (GEF) Vav signaling restrains synaptic growth via bone morphogenetic protein (BMP)-induced receptor macropinocytosis and mediates synaptic potentiation via mobilization of reserve pool vesicles in presynaptic boutons. Here, we find that Gef26/PDZ-GEF and small GTPase Rap1 signaling couples the BMP-induced activation of Abelson kinase to this Vav-mediated macropinocytosis. Moreover, we find that adenylate cyclase Rutabaga (Rut) signaling via exchange protein activated by cAMP (Epac) drives the mobilization of reserve pool vesicles during post-tetanic potentiation (PTP). We discover that Rap1 couples activation of Rut-cAMP-Epac signaling to Vav-mediated synaptic potentiation. These findings indicate that Rap1 acts as an essential, convergent node for Abelson kinase and cAMP signaling to mediate BMP-induced structural plasticity and activity-induced functional plasticity via Vav-dependent regulation of the presynaptic actin cytoskeleton.

Impact of insertion into the left internal jugular vein in chemoport-associated infections: a retrospective single-center study of 1690 cases.

We analyzed chemoport insertion procedures to evaluate infectious morbidity and factors causing infection. This single-center retrospective study included 1690 cases of chemoport implantation between January 2017 and December 2020. Overall, chemoports were inserted in 1582 patients. The average duration of chemoport use was 481 days (range 1-1794, median 309). Infections occurred in 80 cases (4.7%), with 0.098 per 1000 catheter-days. Among the 80 cases in which chemoports were removed because of suspected infection, bacteria were identified in 48 (60%). Significantly more cases of left internal jugular vein punctures were noted in the infected group (15 [18.8%] vs. 147 [9.1%]; p = 0.004). Pulmonary embolism was significantly different between the infection groups (3 [3.8%] vs. 19 (1.2%), p = 0.048). The hazard ratio was 2.259 (95% confidence interval [CI] 1.288-3.962) for the left internal jugular vein, 3.393 (95% CI 1.069-10.765) for pulmonary embolism, and 0.488 (95% CI 0.244-0.977) for chronic obstructive pulmonary disease. Using the right internal jugular vein rather than the left internal jugular vein when performing chemoport insertion might reduce subsequent infections.

Predictive factors for size change of aorta in patients with acute blunt traumatic aortic injury.

OBJECTIVE: We aimed to investigate the changes in aorta size, the factors affecting size changes in patients with acute blunt traumatic aortic injury and to evaluate the adequacy of the current 120% thoracic endovascular aortic repair graft oversizing policy. DESIGN AND METHODS: This retrospective review study was conducted using the prospectively collected medical records of 45 patients (mean age: 53.5 years, male: 39 patients) with blunt traumatic aortic injury treated at a level 1 trauma center between 2012 and 2021. Aortic diameter was measured by computed tomography angiographic images at four different levels [ascending aorta (A), isthmus (B), descending thoracic aorta (C), and infrarenal aorta (D)] on arrival and follow-up (median time interval, 13 days). Associated factors including patient characteristics and hemodynamic parameters on arrival and follow-up were collected to determine their influence on changes in the aorta. RESULTS: The mean diameter of all four aortic levels increased on follow-up computed tomography compared to initial computed tomography (A: + 11.77%, B: + 10.19%, C: + 7.71%, D: + 12.04%). Patient age and injury severity score influenced changes in the diameter of the ascending aorta (P < 0.05). Patient age and blunt traumatic aortic injury grade were significantly associated with changes in the infrarenal aortic diameter (P < 0.05). Three cases of type 1 endoleak were observed at follow-up but all were spontaneously resolved without further intervention at next computed tomography follow-up. CONCLUSIONS: In patients with acute blunt traumatic aortic injury, aortic diameter is significantly smaller by about 10% under shock and is not considered a basis for oversizing the currently implemented 120% thoracic endovascular aortic repair graft sizing. However, in young patients under the age of 40, the change is significantly large and subsequent computed tomography follow-up is required.

Health Provider's Feedback on Physical Activity Surveillance Using Wearable Device-Smartphone Application for Adults with Metabolic Syndrome; a 12-Week Randomized Control Study.

Purpose: Research on whether wearable device interventions can effectively prevent metabolic syndrome remains insufficient. This study aimed to evaluate the effect of feedback on clinical indicators in patients with metabolic syndrome on activities measured using wearable devices, such as smartphone apps. Methods: Patients with metabolic syndrome were recruited and prescribed to live for 12 weeks using a wrist-wearable device (B.BAND, B Life Inc., Korea). A block randomization method was used to distribute participants between the intervention (n=35) and control groups (n=32). In the intervention group, an experienced study coordinator provided feedback on physical activity to individuals through telephonic counseling every other week. Results: The mean number of steps in the control group was 8892.86 (4473.53), and those in the intervention group was 10,129.31 (4224.11). After 12 weeks, metabolic syndrome was resolved. Notably, there were statistically significant differences in the metabolic composition among the participants who completed the intervention. The mean number of metabolic disorder components per person remained at 3 in the control group, and decreased from 4 to 3 in the intervention group. Additionally, waist circumference, systolic and diastolic blood pressure, and triglyceride levels were significantly reduced, while HDL-cholesterol levels were significantly increased in the intervention group. Conclusion: Overall, 12 weeks of telephonic counseling intervention using wearable device-based physical activity confirmation improved the damaged metabolic components of patients with metabolic syndrome. Telephonic intervention can help increase physical activity and reduce waist circumference, which is a typical clinical indicator of metabolic syndrome.

Acute limb ischemia after minimally invasive cardiac surgery using the ProGlide: A case series.

BACKGROUND: We report two cases of acute femoral artery occlusion following the use of ProGlide in minimally invasive cardiac surgery and insertion of large-bore catheters through the common femoral artery. This will add to the existing body of literature by highlighting the possible complications associated with the use of ProGlide and reiterate that the use of the sono-guided ProGlide skill will reduce the incidence of these complications. CASE SUMMARY: A 78-year-old man underwent minimally invasive cardiac surgery for severe aortic valve stenosis. After the operation, the puncture site of the common femoral artery was closed using ProGlide. The next morning, after regaining consciousness, he complained of pain, motor weakness (grade 2), and coldness in the right lower extremity. A 65-year-old man underwent minimally invasive cardiac surgery for a large secundum atrial septal defect (5 cm × 5 cm). After the operation, the puncture site of the common femoral artery was closed using ProGlide. After extubation, the patient complained of paresthesia of the right thigh. Both the patients underwent emergency surgery for acute occlusion of the common femoral artery. CONCLUSION: If the sono-guided ProGlide skill is used, complications can be prevented, and ProGlide can be safely used.

Cardiac rehabilitation in a heart failure patient after left ventricular assist device insertion and subsequent heart transplantation: A case report.

BACKGROUND: Insertion of a left ventricular assist device (LVAD) and heart transplantation (HT) improve the survival of patients with heart failure. In addition, cardiac rehabilitation (CR) further increases the functional capacity. This case report describes a successful case of CR after LVAD insertion and subsequent HT. CASE SUMMARY: In the present case, during the LVAD insertion period, peak oxygen consumption (VO2) increased by 12.16% after CR. HT was performed 7 mo after the LVAD insertion, and the patient participated in phases I and II CR. The peak VO2 increased from 17.24 to 22.29 mL/kg/min. This improvement was more significant than that reported in previous studies on CR after LVAD insertion or HT. The patient's quality of life also improved. The total average score of the short form-36 questionnaire increased from 29.5 points at admission to 53.3 points 9 mo after HT. CONCLUSION: A tailored CR program after LVAD insertion or HT may improve the patients' quality of life and increase survival.

Open repair versus thoracic endovascular aortic repair for treating traumatic aortic injury.

BACKGROUND/OBJECTIVE: Blunt traumatic aortic injury (BTAI) is rare and fatal. Treatment has evolved with advances in imaging and the emergence of thoracic endovascular aortic repair (TEVAR). This study reports a single-center, 5-year experience of TEVAR and open repair for BTAI. METHODS: Patients with BTAI treated at a level I trauma center from 2014 to 2019 were retrospectively reviewed with patient charts and successive computed tomography angiography images. Patients were grouped according to treatment modality: open repair, TEVAR, or medical management, chosen based on patients' characteristics and injury severity. Groups were compared in terms of preoperative demographics, injury characteristics, operative variables, short-term, and long-term outcomes. RESULTS: Forty-two patients were included in the study: 16 (38%) underwent open repair, 17 (40.4%) underwent TEVAR, seven (16.6%) were managed medically, and two (4.7%) died during triage. The median age was 49 years (interquartile range [IQR], 38-57.5 years), and 92.5% were male; the median Injury Severity Score was 33 (IQR, 29-41). Overall mortality was 7.5%. The median hospital stay was 33 days (IQR, 19.5-58.5). Patients undergoing open repair were significantly younger (43 vs. 55 years; p = 0.002) and had a smaller aortic diameter (22.3 vs. 24.0 mm; p=<0.001) than those undergoing TEVAR. No BTAI-related late mortality or reintervention was observed during follow-ups. CONCLUSION: This study demonstrated excellent outcomes with multidisciplinary team efforts and appropriate application of treatment modality. TEVAR is ideal for older or severely injured patients; open repair is an important alternative for young patients or patients with unsuitable aortic anatomy.

Diagnostic significance of calf circumference in sarcopenia of healthy korean adult males.

This study aimed to determine the relationship between sarcopenia and physical function, and the best method of diagnosing sarcopenia in healthy adults. Early prevention of sarcopenia is important; however, no studies have been conducted in healthy and relatively young adults. In addition, it remains unclear whether calf circumference is associated with sarcopenia-defined variables. A total of 85 healthy male participants were enrolled, and the mean standard deviation age of the participants was 59.76 (8.12) years. Abdominal computed tomography (CT) was performed to measure muscle areas. All subjects were divided into sarcopenia and non-sarcopenia groups based on skeletal muscle mass index using computed tomography. Sarcopenia showed a tendency to be related to lower grip strength, five times sit-to-stand and timed up and go tests for physical function. This result shows that overweight and obesity in the sarcopenia group had fully adjusted odds ratios of 0.026 (95% CI: 0.002-0.317) and 0.008 (95% CI: 0.001-0.096), respectively. Calf circumference was higher specificity (71.43 and 64.86) better than bioelectrical impedance analysis-based skeletal mass index and had a similar sensitivity (72.09 and 82.35). In conclusion, calf circumference suggests the need to consider its use as a tool for assessing muscle mass in the diagnosis of sarcopenia.

Comparing carotid endarterectomy and carotid artery stenting: retrospective single-center analysis.

BACKGROUND: Extracranial cerebrovascular diseases represent approximately 20% of ischemic stroke cases. Carotid endarterectomy (CEA) was the gold standard procedure for carotid artery stenosis treatment until the introduction of carotid artery stenting (CAS) in the 1980s. While there have been several multicenter randomized trials comparing CEA and CAS, a more efficacious procedure has not been conclusively distinguished. This study reports the results of CAS versus CEA in patients with symptomatic or asymptomatic carotid stenosis and compares them with those from other studies. METHODS: This study is a single-center retrospective study and included patients who underwent CAS and CEA as elective surgery between January 2012 and December 2020. The final analysis included patient baseline characteristics, postoperative complications, and patient outcomes. RESULTS: The 235 patients included were assigned to the CAS (n=128) and CEA (n=107) groups. Within 30 days postoperatively, no significant differences were noted in myocardial infarction [n=1, 0.8% (CAS); n=1, 0.9% (CEA); P=0.899], cerebral infarction [n=4, 3.1% (CAS); n=1, 0.9% (CEA); P=0.247], and patient mortality [n=1, 0.8% (CAS); n=0, 0% (CEA); P=0.247]. CONCLUSIONS: In elective surgery, CAS and CEA had the same effect of preventing cerebral infarction with no difference in postoperative complications.

Hyperglycemia and Hypoglycemia Are Associated with In-Hospital Mortality among Patients with Coronavirus Disease 2019 Supported with Extracorporeal Membrane Oxygenation.

Metabolic abnormalities, such as preexisting diabetes or hyperglycemia or hypoglycemia during hospitalization aggravated the severity of COVID-19. We evaluated whether diabetes history, hyperglycemia before and during extracorporeal membrane oxygenation (ECMO) support, and hypoglycemia were risk factors for mortality in patients with COVID-19. This study included data on 195 patients with COVID-19, who were aged ≥19 years and were treated with ECMO. The proportion of patients with diabetes history among nonsurvivors was higher than that among survivors. Univariate Cox regression analysis showed that in-hospital mortality after ECMO support was associated with diabetes history, renal replacement therapy (RRT), and body mass index (BMI) < 18.5 kg/m2. Glucose at admission >200 mg/dL and glucose levels before ventilator >200 mg/dL were not associated with in-hospital mortality. However, glucose levels before ECMO >200 mg/dL and minimal glucose levels during hospitalization <70 mg/dL were associated with in-hospital mortality. Multivariable Cox regression analysis showed that glucose >200 mg/dL before ECMO and minimal glucose <70 mg/dL during hospitalization remained risk factors for in-hospital mortality after adjustment for age, BMI, and RRT. In conclusion, glucose >200 mg/dL before ECMO and minimal glucose level <70 mg/dL during hospitalization were risk factors for in-hospital mortality among COVID-19 patients who underwent ECMO.

Traumatic Tricuspid Regurgitation Treated by the Minimally Invasive Double Orifice Technique.

A 37-year-old man was transferred to our level I trauma center after a road traffic accident, presenting with right acetabular fracture, multiple rib fractures, epidural hemorrhage, and liver contusion. Severe traumatic tricuspid regurgitation was also discovered during the work-up for surgery. Our initial attempt at acetabular surgery failed when the patient experienced near cardiac arrest during anesthetic induction. It was hence decided that tricuspid valve repair should precede orthopedic surgery. Minimally invasive tricuspid valve repair using the double orifice technique was successfully performed. Subsequently, acetabular surgery was performed and he was discharged 35 days post-trauma without any complications.