Prehospital Use of Hemostatic Bandages and Tourniquets: Translation From Military Experience to Implementation in Civilian Trauma Care

BACKGROUND

While the military use of tourniquets and hemostatic gauze is well established, few data exist regarding civilian emergency medical services (EMS) systems experience.

METHODS

A retrospective review was performed of consecutive patients with prehospital tourniquet and hemostatic gauze application in a single ground and rotor-wing rural medical transport service. Standard EMS registry data were reviewed for each case.

RESULTS

During the study period, which included 203,301 Gold Cross Ambulance and 8,987 Mayo One Transport records, 125 patients were treated with tourniquets and/or hemostatic gauze in the prehospital setting. Specifically, 77 tourniquets were used for 73 patients and 62 hemostatic dressings were applied to 52 patients. Seven patients required both interventions. Mechanisms of injury (MOIs) for tourniquet use were blunt trauma (50%), penetrating wounds (43%), and uncontrolled hemodialysis fistula bleeding (7%). Tourniquet placement was equitably distributed between upper and lower extremities, as well as proximal and distal locations. Mean tourniquet time was 27 minutes, with 98.7% success. Hemostatic bandage MOIs were blunt trauma (50%), penetrating wounds (35%), and other MOIs (15%). Hemostatic bandage application was head and neck (50%), extremities (36%), and torso (14%), with a 95% success rate. Training for both interventions was computer-based and hands-on, with maintained proficiency of %gt;95% after 2 years.

CONCLUSION

Civilian prehospital use of tourniquets and hemostatic gauze is feasible and effective at achieving hemostasis. Online and practical training programs result in proficiency of skills, which can be maintained despite infrequent use.

Risk factors for postoperative hematoma after inguinal hernia repair: an update

BACKGROUND

We recently sensed an increase in the frequency of groin hematoma after inguinal hernia repair (IHR) at our institution. The aim of this study was to provide a more updated assessment of the risk factors inherent to this complication.

METHODS

We performed a case-control study of all adult patients (age ≥ 18 y) who developed a groin hematoma after IHR at our institution between 2003 and 2015. Univariate and multivariable analyses were performed to assess for independent predictors for groin hematoma.

RESULTS

A total of 96 patients (among 6608 IHR) developed a groin hematoma, (60 were observed, 36 required intervention). The hematoma frequency increased from our previous study (1.4 % versus 0.9%, P < 0.01). Mean age was 64.6 y (range: 18-92), and 84.3% were men. There was no significant difference in the laterality, type, or technique of IHR between cases and controls. Univariate analysis (odds ratio [95% confidence interval], P) identified warfarin usage (3.5, [1.6-6.4], P < 0.01), valvular heart disease (11.6, [2.6-51.3], P < 0.01), atrial fibrillation (2.6, [1.2-5.5], P = 0.01), hypertension (2.03, [1.1-3.6], P = 0.02), recurrent hernia (3.7, [1.4-9.7], P < 0.01), and coronary artery disease (2.1, [1.0-4.4 ], P = 0.05) as significant preoperative factors. The proportion of patients on warfarin decreased since our prior report (31% versus 42%, P = 0.20). On multivariable regression, warfarin and recurrent hernia were independent predictors of hematoma development.

CONCLUSIONS

Independent risk factors for the development of groin hematoma after IHR included warfarin use and recurrent hernia. Careful consideration for anticoagulation and surgical hypervigilance remains prudent in all patients undergoing IHR and especially those with recurrence.

Early hospital readmission in the trauma population: are the risk factors different?

INTRODUCTION

Hospital readmission rates will soon impact Medicare reimbursements. While risk factors for readmission have been described for medical and elective surgical patients, little is known about their predictive value specifically in trauma patients.

PATIENTS AND METHODS

We retrospectively identified all admissions after trauma resuscitation to our urban level 1 trauma centre from 1/1/2004 to 8/31/2010. All patients discharged alive were included. Data collected included demographics, Injury Severity Score (ISS), and length of stay (LOS). We analyzed these index admissions for the development of complications that have previously been shown to be associated with readmission. Readmissions that occurred within 30 days of index admission were identified. Univariable and multivariable analyses were performed. p<0.05 was considered significant.

RESULTS

We identified 10,306 index admissions, with 447 (4.3%) early (within 30 days) readmissions. Mean ISS was 11.1 (SD 10.4). On multivariable analysis, African-American race (OR 1.3, p=0.009), pre-existing chronic obstructive pulmonary disease (COPD) (OR 1.5, p=0.02), and diabetes mellitus (OR 1.8, p<0.001) were associated with readmission, along with higher ISS (OR 1.01, p<0.001), ICU admission (OR 2.1, p<0.001), and increased LOS (OR 1.01, p<0.001). Among many in-hospital complications examined, only the development of surgical site infection (SSI) (OR 1.9, p=0.02) was associated with increased risk of readmission.

CONCLUSIONS

Trauma patients have a low risk of readmission. In contrast to elective surgical patients, the only modifiable risk factor for readmission in our trauma population was SSI. Other risk factors may present clinicians with opportunities for targeted interventions, such as proactive follow up or early phone contact. With future changes to health care policy, clinicians may have even greater motivation to prevent readmission.

The incidence of serious eye injury in Scotland: a prospective study

PURPOSE

Ocular trauma remains an important cause of visual morbidity worldwide. A previous population-based study in Scotland reported a 1-year cumulative incidence of 8.14 per 100 000 population. The purpose of this study was to identify any change in the incidence and pattern of serious ocular trauma in Scotland.

METHODS

This study was a 1-year prospective observational study using the British Ophthalmological Surveillance Unit reporting scheme among Scottish ophthalmologists. Serious ocular trauma was defined as requiring hospital admission. Data were collected using two questionnaires for each patient 1 year apart.

RESULTS

The response rate from ophthalmologists was 77.1%. There were 102 patients reported with complete data giving an incidence of 1.96 per 100 000 population, four times less than in 1992. In patients younger than 65 years, the age-adjusted incidence ratio (males/females) indicated a ninefold higher risk of trauma in males. In 25 patients (27.2%), the injured eye was blind (final visual acuities (FVA) <6/60), 24 being attributable to the eye injury. Standardised morbidity ratios suggested a threefold decrease in risk of poor visual outcome in 2009 compared with 1992.

CONCLUSIONS

The incidence of serious ocular trauma has fallen; this study has shown hospital admission for serious eye injury in Scotland has decreased fourfold in 17 years. Young adult males continue to be at highest risk, which needs to be specifically addressed in future health-prevention strategies. This study also observed a reduction in visual loss from serious ocular injuries, although the reasons for this require further exploration.

The perioperative management of patients with left ventricular assist devices undergoing noncardiac surgery

OBJECTIVE

To describe the perioperative management of patients with left ventricular assist devices (LVADs) who require general anesthesia while undergoing noncardiac surgery (NCS) at a single, large tertiary referral center.

PATIENTS AND METHODS

Electronic medical records from September 2, 2005, through May 31, 2012, were retrospectively reviewed to evaluate the perioperative management and outcomes in LVAD patients undergoing NCS. Patients were included only if they required a general anesthetic and had previously been discharged from the hospital after initial LVAD implantation.

RESULTS

Thirty-three patients with LVADs underwent general anesthesia for 67 noncardiac operations. The mean ± SD time from LVAD implantation to NCS was 317 ± 349 days. All but 1 patient had axial flow LVADs. Anticoagulation or antiplatelet agents were present within 7 days before NCS in 49 procedures (73%) and reversed in 32 of 49 (65%). No perioperative thrombotic complications related to anticoagulation or antiplatelet reversal were noted. Red blood cell, fresh frozen plasma, and platelet transfusions were administered during 10, 6, and 4 operations, respectively. The only intraoperative complication was surgical bleeding. Postoperative complications were present in 12 patients after NCS and were mainly composed of bleeding. Three patients died within 30 days of NCS, with the causes of death not attributed to NCS.

CONCLUSION

Patients with LVAD safely underwent NCS in a multidisciplinary setting that included preoperative optimization by cardiologists familiar with LVADs when feasible. Anticoagulation or antiplatelet agents were present preoperatively in most patients with LVADs and were safely reversed when necessary for NCS. The relatively high occurrence of postoperative bleeding is consistent with previous series.

Engineering nanocages with polyglutamate domains for coupling to hydroxyapatite biomaterials and allograft bone

Hydroxyapatite (HA) is the principal constituent of bone mineral, and synthetic HA is widely used as a biomaterial for bone repair. Previous work has shown that polyglutamate domains bind selectively to HA and that these domains can be utilized to couple bioactive peptides onto many different HA-containing materials. In the current study we have adapted this technology to engineer polyglutamate domains into cargo-loaded nanocage structures derived from the P22 bacteriophage. P22 nanocages have demonstrated significant potential as a drug delivery system due to their stability, large capacity for loading with a diversity of proteins and other types of cargo, and ability to resist degradation by proteases. Site-directed mutagenesis was used to modify the primary coding sequence of the P22 coat protein to incorporate glutamate-rich regions. Relative to wild-type P22, the polyglutamate-modified nanocages (E2-P22) exhibited increased binding to ceramic HA disks, particulate HA and allograft bone. Furthermore, E2-P22 binding was HA selective, as evidenced by negligible binding of the nanocages to non-HA materials including polystyrene, agarose, and polycaprolactone (PCL). Taken together these results establish a new mechanism for the directed coupling of nanocage drug delivery systems to a variety of HA-containing materials commonly used in diverse bone therapies.

Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses

INTRODUCTION

Although rapid response systems (RRS) have been shown to decrease the incidence of cardiac arrest (CA), there are no studies evaluating optimal staffing. We hypothesize that there are no outcome differences between ICU physician and senior resident led events.

METHODS

A retrospective study of the RRS database at a single, academic hospital was performed from July 1, 2006 to May 31, 2010. Surgical patients and those in the ICU were excluded. Daytime (D) was defined as 7 am-5 pm Monday through Friday, and weekends were defined as 5 pm on Friday to 6:59 am on Monday. The nurse to patient ratio is constant during all shifts. An ICU physician leads daytime events on weekdays whereas night/weekend (NW) events are led by residents. NW events were compared against D events using chi square or Fischer's exact test. Significance was defined as p<0.05.

RESULTS

A total of 1404 events were reviewed with 534 (38%) D and 870 (62%) NW events. Respiratory and staff concerns were more likely during NW compared to D (50% vs. 39% and 46% vs. 34%, p<0.001, respectively). Following RRS activation, no difference was noted between D and NW periods in the incidence of progression to CA, transfer to ICU, or hospital mortality. Invasive procedures were more common in the NW period.

CONCLUSION

Resident-led RRS may have similar outcomes to attending intensivist led events. Prospective studies are needed to determine the ideal team composition.

Site-directed coordination chemistry with P22 virus-like particles

Protein cage nanoparticles (PCNs) are attractive platforms for developing functional nanomaterials using biomimetic approaches for functionalization and cargo encapsulation. Many strategies have been employed to direct the loading of molecular cargos inside a wide range of PCN architectures. Here we demonstrate the exploitation of a metal-ligand coordination bond with respect to the direct packing of guest molecules on the interior interface of a virus-like PCN derived from Salmonella typhimurium bacteriophage P22. The incorporation of these guest species was assessed using mass spectrometry, multiangle laser light scattering, and analytical ultracentrifugation. In addition to small-molecule encapsulation, this approach was also effective for the directed synthesis of a large macromolecular coordination polymer packed inside of the P22 capsid and initiated on the interior surface. A wide range of metals and ligands with different thermodynamic affinities and kinetic stabilities are potentially available for this approach, highlighting the potential for metal-ligand coordination chemistry to direct the site-specific incorporation of cargo molecules for a variety of applications.

Development of a multiplex quantitative PCR signature to predict progression in non-muscle-invasive bladder cancer

In bladder cancer, clinical grade and stage fail to capture outcome. We developed a clinically applicable quantitative PCR (QPCR) gene signature to predict progression in non-muscle-invasive bladder cancer. Comparative metaprofiling of 12 DNA microarray data sets (comprising 631 samples and 241,298 probe sets) identified 96 genes, which showed differential expression in seven clinical outcome categories, or were identified as outliers, historic markers, or housekeeping genes. QPCR was done to determine mRNA expression from 96 bladder tumors. Fifty-seven genes differentiated T2 from non-T2 tumors (P < 0.05). Principal components analysis and Cox regression models were used to predict probability of T2 progression for non-T2 patients, placing them into high- and low-risk groups based on their gene expression. At 2 years, high-risk patients exhibited greater T2 progression (45% for high-risk patients versus 12% for low-risk patients; P = 0.003, log-rank test). This difference remained significant within T1 tumors (61% for high-risk patients versus 22% for low-risk patients; P = 0.02) and Ta tumors (29% for high-risk patients versus 0% for low-risk patients; P = 0.03). The best multivariate Cox model included stage and gender, and this signature provided predictive improvement over both (P = 0.002, likelihood ratio test). Immunohistochemistry was done for two genes in the signature not previously described in bladder cancer, ACTN1 and CDC25B, corroborating their up-regulation at the protein level with disease progression. Thus, we identified a 57-gene QPCR panel to help predict progression of non-muscle-invasive bladder cancers and delineate a systematic, generalizable approach to converting microarray data into a multiplex assay for cancer progression.

Single-center North American experience with wolf Piezolith 3000 in management of urinary calculi

OBJECTIVES

To review our experience with the newest generation piezoelectric lithotripter, the Piezolith 3000, in adult patients undergoing extracorporeal shock wave lithotripsy for solitary urinary calculi.

METHODS

We identified 139 shock wave lithotripsy procedures that had used the Piezolith 3000 from February 2005 to July 2007. All procedures were performed under intravenous sedation. Retrospective chart review was used to obtain the pertinent information. Stone-free status was defined as the absence of any fragments, and success as the absence of stone fragments >4 mm, on follow-up imaging after a single treatment.

RESULTS

The stone-free and success rate 1 month after a single shock wave lithotripsy session was 45% and 64%, respectively. Only stone size correlated with the overall success rate (P = .004). The overall complication rate was 15% and included a 5.8% major complication rate requiring intervention or admission. The median time in the procedure room was 33 minutes. The adjunctive procedure rate was 1.4%, and the secondary retreatment rate was 10%.

CONCLUSIONS

The Piezolith 3000 provides modest, but acceptable, single-treatment stone-free and success rates, with a reasonable safety profile, and offers rapid and convenient lithotripsy requiring only intravenous sedation.

Periocular basal cell carcinoma: 5-year outcome following Slow Mohs surgery with formalin-fixed paraffin-embedded sections and delayed closure

AIM

The aim of the study was to determine the 5-year outcome of periocular basal cell carcinoma (BCC) managed by Mohs surgery using formalin-fixed, paraffin-embedded sections (Slow Mohs).

METHODS

This was a prospective, non-comparative, interventional case series of all patients with periocular BCC treated by Slow Mohs in Newcastle upon Tyne, UK, between 1985 and 1999. Data collected included demographic information, indication for Slow Mohs, tumour site, histology, recurrence rate after 5 years and cosmetic outcome.

RESULTS

Of 287 BCCs in 278 patients, 5-year follow-up data were available for 173 (60.2%). Recurrence following Slow Mohs occurred in one patient: 0.34% of total and 0.58% of those with 5-year follow-up. The main indication for Slow Mohs was most frequently due to the tumour site. Cosmetic outcome was deemed excellent in 56%, good in 18%, adequate in 8%, unknown in 14% and revision advised in only 4%.

CONCLUSION

The low 5-year recurrence rate (0.58%) reported in this prospective series confirms the importance of margin-controlled removal of recurrent, poorly defined or critically sited BCCs, and illustrates that Slow Mohs is equivalent to standard Mohs. While delayed closure does not appear to compromise cosmetic outcome, this technique offers a histologically superior and cheaper alternative to frozen-section Mohs surgery.

Hemorrhagic cholecystitis in an elderly patient taking aspirin and cilostazol

Hemorrhage is a rare complication of acute cholecystitis. Patients who develop this complication often are receiving anticoagulation therapy or have a pathologic coagulopathy. We present a case of an elderly patient who developed hemorrhagic cholecystitis while taking aspirin and cilostazol, a phosphodiesterase inhibitor. The patient underwent an emergent abdominal exploration. A large, blood-filled gallbladder was found along with a large hematoma between the liver and gallbladder. We also briefly review the literature regarding hemorrhagic cholecystitis, hemorrhage into the biliary tree, and hemorrhage as a complication of aspirin and phosphodiesterase inhibitor therapy.

The role of SPINK1 in ETS rearrangement-negative prostate cancers

ETS gene fusions have been characterized in a majority of prostate cancers; however, the key molecular alterations in ETS-negative cancers are unclear. Here we used an outlier meta-analysis (meta-COPA) to identify SPINK1 outlier expression exclusively in a subset of ETS rearrangement-negative cancers ( approximately 10% of total cases). We validated the mutual exclusivity of SPINK1 expression and ETS fusion status, demonstrated that SPINK1 outlier expression can be detected noninvasively in urine, and observed that SPINK1 outlier expression is an independent predictor of biochemical recurrence after resection. We identified the aggressive 22RV1 cell line as a SPINK1 outlier expression model and demonstrate that SPINK1 knockdown in 22RV1 attenuates invasion, suggesting a functional role in ETS rearrangement-negative prostate cancers.

The discovery and application of gene fusions in prostate cancer

Chromosomal rearrangements play a causal role in haematological and mesenchymal malignancies. Importantly, the resulting gene fusions can serve as specific therapeutic targets, as exemplified by the development of imatinib (Gleevec), which specifically inhibits the BCR-ABL gene fusion product that defines chronic myeloid leukaemia. Recently, gene fusions involving the prostate-specific gene transmembrane protease, serine 2 (TMPRSS2) and members of the erythroblastosis virus E26 transforming sequence (ETS) family of transcription factors were identified in most of PSA-screened prostate cancers. In this review, we summarize the identification, characterization and detection of TMPRSS2:ETS gene fusions and their role in prostate cancer development. We also discuss the discovery of additional 5' partners that define distinct classes of ETS gene fusions based on the prostate specificity and androgen responsiveness of the 5' partner. Additionally, we also summarize conflicting reports about associations between gene fusion status and patient outcome. The specificity of ETS gene fusions in prostate cancer suggests that they may have causal roles in prostate cancer and suggest utility in prostate cancer detection, stratification and treatment.

A first-generation multiplex biomarker analysis of urine for the early detection of prostate cancer

Although prostate-specific antigen (PSA) serum level is currently the standard of care for prostate cancer screening in the United States, it lacks ideal specificity and additional biomarkers are needed to supplement or potentially replace serum PSA testing. Emerging evidence suggests that monitoring the noncoding RNA transcript PCA3 in urine may be useful in detecting prostate cancer in patients with elevated PSA levels. Here, we show that a multiplex panel of urine transcripts outperforms PCA3 transcript alone for the detection of prostate cancer. We measured the expression of seven putative prostate cancer biomarkers, including PCA3, in sedimented urine using quantitative PCR on a cohort of 234 patients presenting for biopsy or radical prostatectomy. By univariate analysis, we found that increased GOLPH2, SPINK1, and PCA3 transcript expression and TMPRSS2:ERG fusion status were significant predictors of prostate cancer. Multivariate regression analysis showed that a multiplexed model, including these biomarkers, outperformed serum PSA or PCA3 alone in detecting prostate cancer. The area under the receiver-operating characteristic curve was 0.758 for the multiplexed model versus 0.662 for PCA3 alone (P = 0.003). The sensitivity and specificity for the multiplexed model were 65.9% and 76.0%, respectively, and the positive and negative predictive values were 79.8% and 60.8%, respectively. Taken together, these results provide the framework for the development of highly optimized, multiplex urine biomarker tests for more accurate detection of prostate cancer.