Paediatric percutaneous bone anchored hearing aid implant failures: Comparing the experience of a tertiary centre with a systematic review of the literature and meta-analysis

BACKGROUND

Despite the proven audiological benefits of Percutaneous Bone Anchored Hearing Aids (BAHAs) in paediatric patients with conductive or mixed hearing loss, their adoption has been limited due to concerns over implant failure and associated complications. This paper conducts a systematic review and meta-analysis to assess the prevalence of implant failure in paediatric populations, combined with a case series from our tertiary referral centre.

METHODS

A comprehensive literature search identified 562 articles, from which 34 were included in the review, covering 1599 implants in 1285 patients. Our retrospective case series included consecutive patients from our tertiary referral centre who underwent percutaneous BAHA implantation from 2003-2019.

RESULTS

Meta-analysis revealed an overall implant failure rate of 11%, predominantly attributed to traumatic extrusion. Our retrospective case series comprised 104 implantations in 76 patients, with a 4.8% failure rate.

DISCUSSION

Factors contributing to the lower-than-expected failure rates in the case series likely included consistent use of 4 mm fixtures from a single manufacturer and older age at implantation. The study underscores the need for standardised reporting formats in bone conduction implants research, given the systematic review's limitations in study design heterogeneity, especially with the expected rise in the adoption of novel active devices.

Clinical Readiness: Can Providers Learn to Perform Lower Leg Fasciotomy Through a Tablet-based Augmented Reality Surgical Training Environment?

INTRODUCTION

The uses of on-demand, interactive tablet-based surgical training environments are of interest as potential resources for both the acquisition and maintenance of rarely performed, critical procedures for expeditionary surgical care. This study examined the effectiveness of a tablet-based augmented reality (AR) procedural training environment for lower leg fasciotomy with a cohort of novice surgical trainees in (1) procedural knowledge, (2) tablet-based procedural skills, (3) tablet-based procedural time, and (4) procedural performance on a cadaver. We hypothesized that engaging with the AR procedural training would increase procedural knowledge and tablet-based skills and procedural time. We hypothesized that the tablet-based AR training environment would be insufficient to acquire the ability to perform lower leg fasciotomy on a cadaver.

MATERIALS AND METHODS

This study was approved as exempt by the Institutional Review Board at USU. Surgical interns, sub-interns, and independent duty corpsman (n = 30) with no prior lower leg fasciotomy experience voluntarily participated. Tablet-based training activities included pre-training assessment, engagement with instruction, interactive procedural practice, and post-training assessment. Tablet-based knowledge assessment included 17 multiple choice questions covering concepts, reasoning, and judgment associated with the procedure. Tablet-based procedural completion and time were assessed within the training environment. Within 1 week of completing the tablet activities, participants were assessed by fellowship-trained trauma surgeons while performing cadaver-based lower leg fasciotomy. Statistical analysis included paired t-tests and effect size (Cohen's d). Statistical significance was set at P < .05.

RESULTS

Tablet-based AR procedural training significantly improved procedural knowledge (P < .001), tablet-based procedural skills (P < .001), and reduced tablet-based procedural time (P < .002). Effect sizes were very large for tablet-based procedural knowledge (d = 1.75) and skills (d = 3.2) and small (d = 0.42) for procedural time. There were no significant effects of procedural knowledge, tablet-based procedural skills, or time on cadaver-based performance. No participant was able to accurately and independently complete lower leg fasciotomy procedure on a cadaver.

CONCLUSIONS

Tablet-based AR procedural training improved procedural knowledge and tablet-based skills; however, those gains did not transfer to the ability to perform the procedure on a cadaver. The tablet's limited AR interface did not support the acquisition of requisite surgical technique, tissue handling, and decision-making in novice surgical trainees. Experienced surgeons may have different outcomes because their mature understanding of surgical constructs would allow extrapolation of abilities to other procedural contexts. Further investigation of the tablet-based training environments for surgical care is necessary before distributing such resources to support clinical readiness.

Systemic anti-inflammatory treatment of atopic dermatitis during conception, pregnancy and breastfeeding: Interdisciplinary expert consensus in Northern Europe

Treating atopic dermatitis (AD) in pregnant or breastfeeding women, and in women and men with AD aspiring to be parents is difficult and characterized by uncertainty, as evidence to inform decision-making on systemic anti-inflammatory treatment is limited. This project mapped consensus across dermatologists, obstetricians and patients in Northwestern Europe to build practical advice for managing AD with systemic anti-inflammatory treatment in men and women of reproductive age. Twenty-one individuals (sixteen dermatologists, two obstetricians and three patients) participated in a two-round Delphi process. Full consensus was reached on 32 statements, partial consensus on four statements and no consensus on four statements. Cyclosporine A was the first-choice long-term systemic AD treatment for women preconception, during pregnancy and when breastfeeding, with short-course prednisolone for flare management. No consensus was reached on second-choice systemics preconception or during pregnancy, although during breastfeeding dupilumab and azathioprine were deemed suitable. It may be appropriate to discuss continuing an existing systemic AD medication with a woman if it provides good disease control and its benefits in pregnancy outweigh its risks. Janus kinase (JAK) inhibitors, methotrexate and mycophenolate mofetil should be avoided by women during preconception, pregnancy and breastfeeding, with medication-specific washout periods advised. For men preconception: cyclosporine A, azathioprine, dupilumab and corticosteroids are appropriate; a 3-month washout prior to conception is desirable for methotrexate and mycophenolate mofetil; there was no consensus on JAK inhibitors. Patient and clinician education on appropriate (and inappropriate) AD treatments for use in pregnancy is vital. A shared-care framework for interdisciplinary management of AD patients is advocated and outlined. This consensus provides interdisciplinary clinical guidance to clinicians who care for patients with AD before, during and after pregnancy. While systemic AD medications are used uncommonly in this patient group, considerations in this article may help patients with severe refractory AD.

Leading Graduate Medical Education in the Face of Uncertainty

Leading through uncertainty poses significant challenges. The COVID-19 pandemic, the Afghanistan withdrawal, and the implementation of a new electronic medical records system led to massive shortages of health care workers throughout the Military Health System (MHS). This case describes the leadership challenges of a surgical residency program director during uncertain times.

ATP1A3 related disease manifesting as rapid onset dystonia-parkinsonism with prominent myoclonus and exaggerated startle

We report ATP1A3-associated rapid-onset dystonia-parkinsonism with an atypical presentation including myoclonus and exaggerated startle in four patients. Their prominence over parkinsonism prompted consideration of a syndromic diagnosis of myoclonus dystonia. ATP1α3 dysfunction in GABAergic neurons could explain these examination findings. The spectrum of ATP1A3-associated movement disorders includes myoclonus-dystonia.

Rare Hypermucoviscous Klebsiella pneumoniae Liver Abscess in an Active Duty Male Requiring Partial Liver Resection for Definitive Treatment

Antibiotics and drainage have largely replaced hepatic resection for the treatment of liver abscesses in the modern era; however, in cases caused by a rare strain of Klebsiella pneumoniae with a hypermucoviscous phenotype, more aggressive hepatic resection may be required. The patient is a 34-year-old male who presented to Landstuhl Regional Medical Center with a week of epigastric pain. His workup revealed a 6 cm liver abscess with growth to 10 cm in 48 hours. He underwent multiple drainage procedures at Landstuhl and then was transferred to Walter Reed where further surgical drainage was performed. Initial cultures demonstrated K. pneumoniae. He clinically improved and was able to discharge after a 2 week hospitalization. His final remaining surgical drain was removed as an outpatient, but 48 hours after removal, he was admitted to the intensive care unit in septic shock. Imaging revealed a 12 cm liver abscess, and cultures verified hypermucoviscous Klebsiella. After multidisciplinary discussion and counseling, he underwent an open right partial hepatectomy. Postoperatively he gradually recovered from his sepsis and major operation and then returned to his home in Landstuhl. This is a case of a rare hypermucoviscous variant of K. pneumoniae causing a liver abscess resistant to multiple drainage procedures, ultimately requiring open hepatic surgical resection for source control. This remains a last-resort option in the treatment of liver abscesses and should be considered early when caused by this rare strain of Klebsiella.

Use of Levetiracetam for Post-Traumatic Seizure Prophylaxis in Combat-Related Traumatic Brain Injury

INTRODUCTION

Post-traumatic seizure (PTS) prophylaxis is recommended in patients with traumatic brain injury (TBI) at high risk for PTSs, but consensus on the optimal pharmacologic therapy has not yet been established. Levetiracetam is frequently used for seizure prophylaxis in combat-related TBI, but its efficacy and safety in this patient population has not yet been described.

METHODS

A retrospective cohort of 687 consecutive casualties transferred to the CONUS from October 2010 to December 2015 was analyzed. Seventy-one patients with combat-related injuries and radiographic evidence of skull fractures or intracranial hemorrhage were included. Data collection included demographics and injury characteristics including initial Glasgow Coma Scale, computed tomography findings, interventions, and 6-month Glasgow Outcome Score.

RESULTS

All patients in this cohort were male, with an average age of 25 (median 24; Interquartile range (IQR) 4.5) and an average Injury Severity Score of 28 (median 27; IQR 15). The most common mechanism of injury was explosive blast (76%). Penetrating TBI was common (51%). Most patients (88.7%) were administered seizure prophylaxis. Of these, the majority (61/63) received levetiracetam, and the additional two were administered phenytoin. The remaining 11.3% of patients were deemed not to require seizure prophylaxis. The incidence of seizures while on prophylaxis was low (2.8%) and occurred in patients who suffered transcranial gunshot wounds and ultimately died. No serious adverse effects were attributed to levetiracetam.

CONCLUSIONS

Levetiracetam appears to be a safe and effective medication for PTS prophylaxis in combat casualties. The rate of PTSs in combat-related TBI on appropriate prophylaxis is low.

Simple signage and targeted education can lead to process improvement in acute appendicitis care

INTRODUCTION

An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration.

MATERIALS AND METHODS

Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention.

RESULTS

Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005).

CONCLUSION

This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.

Moving into the red - a near infra-red optical probe for analysis of human neutrophil elastase in activated neutrophils and neutrophil extracellular traps

Neutrophils are the first immune cells recruited for defence against invading pathogens; however, their dysregulated activation and subsequent release of the enzyme human neutrophil elastase is associated with several, inflammation-based, diseases. Herein, we describe a FRET-based, tri-branched (one quencher, three fluorophores) near infrared probe that provides an intense OFF/ON amplified fluorescence signal for specific detection of human neutrophil elastase. The probe allowed selective detection of activated neutrophils and labelling of neutrophil extracellular traps.

Military experience in the management of pelvic fractures from OIF/OEF

INTRODUCTION

Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures.

METHODS

We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined.

RESULTS

Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy.

CONCLUSIONS

Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.

Protocols for single-cell RNA-seq and spatial gene expression integration and interactive visualization

There is a wealth of software that utilizes single-cell RNA-seq (scRNA-seq) data to deconvolve spatial transcriptomic spots, which currently are not yet at single-cell resolution. Here we provide protocols for implementing Seurat and Giotto packages to elucidate cell-type distribution in our example human ureter scRNA-seq dataset. We also describe how to create a stand-alone interactive web application using Seurat libraries to visualize and share our results. For complete details on the use and execution of this protocol, please refer to Fink et al. (2022).1.

Content validity test of a safety checklist for simulated participants in simulation-based education in the United Kingdom: a methodological study

PURPOSE

Simulation training is an ever-growing means of healthcare education and often involves simulated participants (SPs), commonly known as actors. Simulation-based education (SBE) can sometimes endanger SPs, and as such we have created a safety checklist for them to follow. This study describes how we developed the checklist through a quality improvement project, and then evaluated feedback responses to assess whether SPs felt our checklist was safe.

METHODS

The checklist was provided to SPs working in an acute trust simulation service when delivering multidisciplinary SBE over 4 months. Using multiple plan–do–study–act cycles, the checklist was refined by reflecting on SP feedback to ensure that the standards of the safe simulation were met. We collected 21 responses from September to December 2021 after SPs completed an SBE event.

RESULTS

The responses showed that 100% of SPs felt safe during SBE when using our checklist. The average “confidence in safety” rating before using the checklist was 6.8/10, which increased significantly to 9.2/10 after using the checklist (P<0.0005). The checklist was refined throughout the 4 months and implemented in adult and pediatric SBE as a standard operating procedure.

CONCLUSION

We recommend using our safety checklist as a standard operating procedure to improve the confidence and safety of SPs during safe and effective simulations.

Single-cell and spatial mapping Identify cell types and signaling Networks in the human ureter

Tissue engineering offers a promising treatment strategy for ureteral strictures, but its success requires an in-depth understanding of the architecture, cellular heterogeneity, and signaling pathways underlying tissue regeneration. Here, we define and spatially map cell populations within the human ureter using single-cell RNA sequencing, spatial gene expression, and immunofluorescence approaches. We focus on the stromal and urothelial cell populations to enumerate the distinct cell types composing the human ureter and infer potential cell-cell communication networks underpinning the bi-directional crosstalk between these compartments. Furthermore, we analyze and experimentally validate the importance of the sonic hedgehog (SHH) signaling pathway in adult progenitor cell maintenance. The SHH-expressing basal cells support organoid generation in vitro and accurately predict the differentiation trajectory from basal progenitor cells to terminally differentiated umbrella cells. Our results highlight the essential processes involved in adult ureter tissue homeostasis and provide a blueprint for guiding ureter tissue engineering.

Restoration of marine ecosystems: Understanding possible futures for optimal outcomes

Accelerating declines in the extent, quality and functioning of the world's marine ecosystems have generated an upsurge in focus on practical solutions, with ecosystem restoration becoming an increasingly attractive mitigation strategy for systems as diverse as coral reefs, mangroves and tidal flats. While restoration is popular because it promises positive outcomes and a return to something approaching unimpacted condition and functioning, it involves substantial public and private investment, both for the initial restoration activity and for on-going maintenance of the restored asset. This investment often affords one big chance to get things right before irretrievable damage is done. As a result, precise, well considered and accountable decision-making is needed to determine the specific focus for restoration, the scale of restoration, the location for deploying restoration activities, and indeed whether or not restoration is necessary or even possible. We explore the environmental/ecological considerations and constraints governing optimal decisions about the nature, location and prioritisation of restoration activities in marine ecosystems, and in particular the constraints on achieving understanding of possible futures and the likelihood of achieving them. We conclude that action must be informed by a context-specific understanding of the historical situation, the current situation, the constraints on change, the range of potential outcome scenarios, and the potential futures envisioned.

Filaggrin mutations in relation to skin barrier and atopic dermatitis in early infancy

BACKGROUND

Loss-of-function mutations in the skin barrier gene filaggrin (FLG) increase the risk of atopic dermatitis (AD), but their role in skin barrier function, dry skin and eczema in infancy is unclear.

OBJECTIVES

To determine the role of FLG mutations for impaired skin barrier function, dry skin, eczema and AD at three months of age and through infancy.

METHODS

FLG mutations were analyzed in 1836 infants in the Scandinavian population-based PreventADALL study. Transepidermal water loss (TEWL), dry skin, eczema and AD were assessed at three, six and 12 months of age.

RESULTS

Filaggrin mutations were observed in 166 (9%) infants. At three months, carrying FLG mutations was not associated with impaired skin barrier function (TEWL > 11.3 g/m² /h) or dry skin, but with eczema (OR(95%CI): 2.76 (1.81, 4.23), p < 0.001). At six months, mutation carriers had significantly higher TEWL than non-mutation carriers (mean (95%CI) 9.68 (8.69, 10.68) vs. 8.24 (7.97, 8.15), p < 0.01) and at three and six months an increased risk of dry skin on truncus (OR: 1.87 (1.25, 2.80), p = 0.002; 2.44 (1.51, 3.95), p < 0.001) or extensor limb surfaces (1.52 (1.04, 2.22), p = 0.028; 1.74 (1.17, 2.57), p = 0.005). FLG mutations were associated with eczema and AD in infancy.

CONCLUSION

Filaggrin mutations were not associated with impaired skin barrier function or dry skin in general at three months of age, but increased the risk for eczema, as well as for dry skin on truncus and extensors at three and six months.

NSQIP Based Predictors of False Negative and Indeterminate Ultrasounds in Adults With Appendicitis

BACKGROUND

It has been well established that ultrasound (US) is the initial screening tool for children with suspected acute appendicitis. However, computed tomography (CT) has become the standard screening modality for adults presenting with abdominal pain. A recent review of National Surgical Quality Improvement Program (NSQIP) data revealed US is being utilized as a screening modality in adults. We aimed to assess the diagnostic performance of US in evaluating adults with acute appendicitis.

STUDY DESIGN

The American College of Surgeons NSQIP and NSQIP Procedure Targeted Data Files were accessed and examined for all patients in 2016 and 2017 who received an US and underwent an appendectomy. The US results were then correlated to the pathology in order to determine the diagnostic performance. Additionally, we identified predictors for indeterminate and false negative US results.

RESULTS

Our study included 3607 appendectomy patients of which 1135 (30%) had an indeterminate US, 683 (18%) had an US not consistent with appendicitis, and 1789 (49%) had an US consistent with appendicitis. Sensitivity and Specificity were 74.3% and 53.0%, respectively. Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were 95.9% and 12.2%, respectively. On regression analysis, clinically relevant predictors for false negative and indeterminate studies included age, sex, and BMI.

CONCLUSIONS

Ultrasound is an effective initial imaging modality for acute appendicitis in the adult population. Females, age >30 y, and elevated BMI were more likely to have indeterminate or false negative results. These patients may benefit from CT as their initial screening test.

Water height modifies forelimb kinematics of horses during water treadmill exercise

Although equine water treadmills (WTs) are increasingly being used for the rehabilitation of equine athletes, the immediate- and short-term effects of this type of exercise on limb movement in the WT and overground are unknown. Therefore, the objective of this study was to evaluate the effects of WT exercise on equine forelimb kinematics on land and under various WT conditions before and after a prolonged period of WT conditioning. External markers were used to collect 2D kinematic data (joint extension, flexion, range of motion (ROM), elevation; stride mechanics) at 120 frames/s. Thirteen mixed breed, English performance horses were filmed under three test conditions: (1) horses walked on sand; (2) horses walked on a WT (water heights: dry, carpus, stifle); (3) horses walked on sand immediately following a WT session. Walking speeds during testing varied between horses, ranging from 1.3-1.5 m/s, but were held constant for each individual horse for all tests on both days. Testing occurred on days 1 and 10, with horses being trained on the WT for days 2 through 8 (28 min/day). Comparisons were made using linear mixed effects models. Carpal ROM and elbow ROM were greater when horses were walked in water, compared to without water (dry treadmill) and overground (P<0.0001 for all). This increased ROM was achieved primarily via an increase in joint flexion. With the addition of water, stride length increased and stride frequency decreased, accompanied by an increased percentage duration of swing phase. No effects of conditioning on gait mechanics were observed overground. Therefore, WT exercise may be meaningful for physical rehabilitation through increased joint flexion and ROM observed.

Association between atopic dermatitis and autoimmune diseases: a population-based case-control study

Background

Atopic dermatitis (AD) is a common chronic skin disorder and is well known to be associated with other atopic conditions. There is increasing evidence for an association also with nonatopic conditions, including autoimmune diseases, but data are limited about several autoimmune diagnoses.

Objectives

To investigate the association between AD and autoimmune diseases.

Methods

This case–control study used Swedish national healthcare registers. The source population comprised the entire Swedish population aged ≥ 15 years from 1968 to 2016. Cases, including all those with an inpatient diagnosis of AD (from 1968) and/or a specialist outpatient diagnosis of AD (from 2001), were matched by sex and age to healthy controls (104 832 cases of AD, 1 022 435 controls).

Results

AD was significantly associated with one or more autoimmune diseases compared with controls – adjusted odds ratio (aOR) 1·97, 95% confidence interval (CI) 1·93–2·01 – and this association was significantly stronger in the presence of multiple autoimmune diseases compared with only one. The association was strongest for autoimmune disorders involving the skin (aOR 3·10, 95% CI 3·02–3·18), the gastrointestinal tract (aOR 1·75, 95% CI 1·69–1·82) or connective tissue (aOR 1·50, 95% CI 1·42–1·58). In the overall analysis, men with AD had a stronger association with rheumatoid arthritis and coeliac disease than did women with AD. In subanalyses, the findings remained stable in multivariable analyses after adjustment for smoking and parental autoimmune disease.

Conclusions

This large population‐based study indicates significant autoimmune comorbidity of adults with AD, especially between AD and autoimmune dermatological, gastrointestinal and rheumatological diseases. Having multiple autoimmune diseases resulted in a stronger association with AD than having only one autoimmune disease.

What is already known about this topic?

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases.

Some studies have shown that AD is associated with some autoimmune diseases, such as Crohn disease, ulcerative colitis, coeliac disease, alopecia areata and vitiligo, but data are limited for several major autoimmune diagnoses.

What does this study add?

In this study, AD was associated with several autoimmune diseases, especially those involving the skin, the gastrointestinal tract or connective tissue.

The association was stronger for individuals with multiple autoimmune comorbidities.

Linked Comment: J.I. Silverberg. Br J Dermatol 2021; 185:243–244.

Plain language summary available online

Development of Resilience Among Rheumatoid Arthritis Patients: A Qualitative Study

OBJECTIVE

Resilience, the ability to recover from and adapt successfully to stressful situations, is a valuable resource for patients who live with chronic conditions. This qualitative study examines the development of resilience among rheumatoid arthritis (RA) patients. We aimed to describe the resilience development process and to describe strategies used by patients to cultivate resilience.

METHODS

Our approach combined ethnographic data collection and narrative analysis methods. Semistructured interviews were conducted with adult RA patients in the US. Interviewees were asked to discuss their experiences with diagnosis, living with RA, coping with challenges, treatment, and health care providers. The interviews were audiorecorded, transcribed, and analyzed to describe the stages of resilience development and to identify patients' strategies for building/maintaining resilience.

RESULTS

Eighteen patients were interviewed, ages 27-80 years and with RA duration of 5-41 years. Patient responses to challenging situations were grouped into 3 stages: 1) lacking capacity to handle the situation, 2) struggling but growing in capacity to handle the situation, and 3) attaining mastery. Patients used 10 strategies to cultivate resilience: perseverance, exchanging social support, pursuing valued activities, flexibility, positive reframing, acceptance, humor, avoiding threatening thoughts, equanimity, and maintaining a sense of control.

CONCLUSION

RA patients acquire resilience in a dynamic process of learning in response to new challenges. Patients use a combination of behavioral and emotion management strategies to cultivate resilience. Awareness of these strategies may benefit patients, health care providers, and researchers developing behavioral interventions and social support programs in the context of RA and other chronic diseases.

Damage Control Resuscitation Protocol and the Management of Open Abdomens in Trauma Patients

Although the use of damage control laparotomy (DCL) is well established, the effect of damage control resuscitation (DCR) on the management of open abdomens is relatively poorly studied. The aim of the present study was to determine the predictors for failure to achieve primary fascial closure (PFC) after DCL in the setting of a massive transfusion (MT) and DCR. This is a retrospective review over a 12-year period of all patients that underwent MT and DCL. Patients who achieved PFC were compared with those who did not (NPFC). Student's t tests were used to compare the two groups. A multiple logistic regression model was performed to identify independent risk factors for failure to attain PFC. Of 174 patients, 101 achieved PFC. Mean (6 standard deviation) age was 35.6 ± 14.9 years for PFC and 36.3 ± 14.0 years for NPFC ( P = 0.75). Admission Glasgow Coma Scale score was 11.4 ± 4.6 for PFC and 10.6 ± 5.0 for NPFC ( P = 0.25). Initial lactate (7.3 ± 3.8 vs 7.7 ± 4.1, P = 0.50), hemoglobin (11.3 ± 1.9 vs 11.0 ± 2.2, P = 0.43), systolic blood pressure (108 ± 44 vs 107 ± 35, P = 0.82), Injury Severity Score (34 ± 14 vs 36 ± 15, P = 0.32), and abdominal Abbreviated Injury Score (3.6 ± 1.1 vs 3.9 ± 1.0, P = 0.13) were similar between the two groups. There was no difference in total blood products administered at 24 hours (46 ± 26 vs 49 ± 29 units, P = 0.45). Logistic regression identified increasing volume of crystalloid at 24 hours (odds ratio, 0.86; 95% confidence interval, 0.74 to 0.99; P = 0.047), earlier operative year (2.1; 1.52 to 2.91; P < 0.001), and increased number of procedures (0.32, 0.18 to 0.58; P < 0.001) as independent predictors for failure to obtain PFC. Injury severity is not associated with failure to achieve PFC, whereas administration of large-volume crystalloid resuscitation, increasing number procedures, and earlier year of DCL are independent predictors for failure to achieve PFC. Application of DCR to DCL techniques results in an improvement in ability to achieve PFC.

Prediction of venous thromboembolism using clinical and serum biomarker data from a military cohort of trauma patients

INTRODUCTION

Venous thromboembolism (VTE) is a frequent complication of trauma associated with high mortality and morbidity. Clinicians lack appropriate tools for stratifying trauma patients for VTE, thus have yet to be able to predict when to intervene. We aimed to compare random forest (RF) and logistic regression (LR) predictive modelling for VTE using (1) clinical measures alone, (2) serum biomarkers alone and (3) clinical measures plus serum biomarkers.

METHODS

Data were collected from 73 military casualties with at least one extremity wound and prospectively enrolled in an observational study between 2007 and 2012. Clinical and serum cytokine data were collected. Modelling was performed with RF and LR based on the presence or absence of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). For comparison, LR was also performed on the final variables from the RF model. Sensitivity/specificity and area under the curve (AUC) were reported.

RESULTS

Of the 73 patients (median Injury Severity Score=16), nine (12.3%) developed VTE, four (5.5%) with DVT, four (5.5%) with PE, and one (1.4%) with both DVT and PE. In all sets of predictive models, RF outperformed LR. The best RF model generated with clinical and serum biomarkers included five variables (interleukin-15, monokine induced by gamma, vascular endothelial growth factor, total blood products at resuscitation and presence of soft tissue injury) and had an AUC of 0.946, sensitivity of 0.992 and specificity of 0.838.

CONCLUSIONS

VTE may be predicted by clinical and molecular biomarkers in trauma patients. This will allow the development of clinical decision support tools which can help inform the management of high-risk patients for VTE.

Successful implementation of an appendectomy process improvement protocol

Background

A key component of a process improvement program is the institution of hospital-specific protocols to address certain disparities and streamline patient care. In that regard, we evaluated the implementation of an outpatient laparoscopic appendectomy (OLA) protocol at a tertiary military hospital. We hypothesized that OLA would reduce length of stay (LOS) without increasing complications.

Methods

In August 2016, our institution implemented an OLA protocol-defined as discharge within 24 hours of surgery. Exclusion criteria included age <18 years old, grade 4 or 5 appendicitis, immunosuppression, current pregnancy, and no supervision during the first 24 hours postdischarge. To determine OLA's effect on LOS, analysis of variance was used to perform a comparison between the years 2014 and 2017. Successful outpatient appendectomies were recorded preprotocol and postprotocol, as well as readmission complications.

Results

In 2017, the first full year of protocol implementation, 44 of 59 (75%) patients met the inclusion criteria, and all but 2 (42 of 44, 95%) stayed for less than 24 hours. Of the two outliers, one developed acute on chronic kidney disease and one had a slow return of bowel function following grade 3 appendicitis. Complications were low across all years (one per year). In 2017, the readmission was for percutaneous drainage of an abscess. Overall, protocol implementation produced a significant decrease in LOS.

Discussion

OLA protocol decreased LOS at a military hospital and should be expanded to other department of defense (DoD) facilities. Further research is needed to identify cost benefit to the military health system.

Level of evidence

III.

Prevention of Deep Venous Thromboembolism

The nature of many combat wounds puts patients at a high risk of developing deep venous thrombosis (DVT) and pulmonary embolism (PE), which fall under the broader disease category of venous thromboembolism (VTE). In addition to the hypercoagulable state induced by trauma, massive injuries to the extremities, prolonged immobility, and long fixed wing transport times to higher echelons of care are unique risk factors for venous thromboembolism in the combat-injured patient. These risk factors mandate aggressive prophylaxis for DVT and PE that can effectively be achieved by the use of lower extremity sequential compression devices and low dose unfractionated heparin or low molecular weight heparin. In addition, inferior vena cava filters are often used for PE prophylaxis when chemical DVT prophylaxis fails or is contraindicated. The following Department of Defense (DoD) Joint Trauma System (JTS) Clinical Practice Guideline (CPG) discusses the current recommendations for the prevention of DVT and PE including the use of inferior vena cava filters (IVCFs).

Comparison of a Radiant Patient Warming Device with Forced Air Warming during Laparoscopic Cholecystectomy

The importance of maintaining a patient's core body temperature during anaesthesia to reduce the incidence of postoperative complications has been well documented. The standard practice of this institution is the use of a forced air device for intraoperative warming. The purpose of this study was to compare this standard with an alternative warming device using a radiant heat source which only heated the face.

This prospective, randomized controlled trial compared the efficacy of two methods of intraoperative warming: the BairHugger™ (Augustine Medical, U.S.A.) forced air device and the SunTouch™ (Fisher & Paykel Healthcare, N.Z.) radiant warmer during laparoscopic cholecystectomy in 42 female patients. Oesophageal core temperatures were recorded automatically on to computer during operations using standardised anaesthesia, intravenous infusions and draping.

The study failed to show any statistical or clinical difference between the two patient groups in terms of mean core temperature both intraoperatively (P=0.42) and in the recovery period (P=0.54). Mean start to end core temperature differences were marginly lower in the radiant group (0.08°C) but not statistically or clinically significantly different.

Given some of the drawbacks with forced air systems, such as the expense of the single use blanket, this new radiant warming device offers an alternative method of active warming with advantages in terms of cost and possible application to a wide variety of surgical procedures.

Red-flag sepsis and SOFA identifies different patient population at risk of sepsis-related deaths on the general ward

Controversy exists regarding the best diagnostic and screening tool for sepsis outside the intensive care unit (ICU). Sequential organ failure assessment (SOFA) score has been shown to be superior to systemic inflammatory response syndrome (SIRS) criteria, however, the performance of "Red Flag sepsis criteria" has not been tested formally.The aim of the study was to investigate the ability of Red Flag sepsis criteria to identify the patients at high risk of sepsis-related death in comparison to SOFA based sepsis criteria. We also investigated the comparison of Red Flag sepsis to quick SOFA (qSOFA), SIRS, and national early warning score (NEWS) scores and factors influencing patient mortality.Patients were recruited into a 24-hour point-prevalence study on the general wards and emergency departments across all Welsh acute hospitals. Inclusion criteria were: clinical suspicion of infection and NEWS 3 or above in-line with established escalation criteria in Wales. Data on Red Flag sepsis and SOFA criteria was collected together with qSOFA and SIRS scores and 90-day mortality.459 patients were recruited over a 24-hour period. 246 were positive for Red Flag sepsis, mortality 33.7% (83/246); 241 for SOFA based sepsis criteria, mortality 39.4% (95/241); 54 for qSOFA, mortality 57.4% (31/54), and 268 for SIRS, mortality 33.6% (90/268). 55 patients were not picked up by any criteria. We found that older age was associated with death with OR (95% CI) of 1.03 (1.02-1.04); higher frailty score 1.24 (1.11-1.40); DNA-CPR order 1.74 (1.14-2.65); ceiling of care 1.55 (1.02-2.33); and SOFA score of 2 and above 1.69 (1.16-2.47).The different clinical tools captured different subsets of the at-risk population, with similar sensitivity. SOFA score 2 or above was independently associated with increased risk of death at 90 days. The sequalae of infection-related organ dysfunction cannot be reliably captured based on routine clinical and physiological parameters alone.

Sepsis-related deaths in the at-risk population on the wards: attributable fraction of mortality in a large point-prevalence study

Objective

Sepsis mortality is reported to be high worldwide, however recently the attributable fraction of mortality due to sepsis (AFsepsis) has been questioned. If improvements in treatment options are to be evaluated, it is important to know what proportion of deaths are potentially preventable or modifiable after a sepsis episode. The aim of the study was to establish the fraction of deaths directly related to the sepsis episode on the general wards and emergency departments.

Results

839 patients were recruited over the two 24-h periods in 2016 and 2017. 521 patients fulfilled SEPSIS-3 criteria. 166 patients (32.4%) with sepsis and 56 patients (17.6%) without sepsis died within 90 days. Out of the 166 sepsis deaths 12 (7.2%) could have been directly related to sepsis, 28 (16.9%) possibly related and 96 (57.8%) were not related to sepsis. Overall AFsepsis was 24.1%. Upon analysis of the 40 deaths likely to be attributable to sepsis, we found that 31 patients (77.5%) had the Clinical Frailty Score ≥ 6, 28 (70%) had existing DNA-CPR order and 17 had limitations of care orders (42.5%).

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3819-2) contains supplementary material, which is available to authorized users.

Resuscitative Endovascular Balloon Occlusion of the Aorta: A Bridge to Flight Survival

Trauma endures as the leading cause of death worldwide, and most deaths occur in the first 24 hours after initial injury as a result of hemorrhage. Historically, about 90% of battlefield deaths occur before the injured person arrives at a theater hospital, and most are due to noncompressible hemorrhage of the torso. Resuscitative endovascular balloon occlusion of the aorta is an evolving technique to quickly place a balloon into the thoracic or abdominal aorta to efficiently block blood flow to distal circulation. Maneuvers, such as resuscitative endovascular balloon occlusion of the aorta, to control endovascular hemorrhage offer a potential intervention to control noncompressible hemorrhage. This technique can be performed percutaneously or open in prehospital environments to restore hemodynamic functions and serve as a survival bridge until the patient is delivered to a treatment facility for definitive surgical hemostasis. This article describes the indications, complications, and application of resuscitative endovascular balloon occlusion of the aorta to military and civilian aeromedical transport.

Review of an emergency general surgery process improvement program at a verified military trauma center

INTRODUCTION

Decreasing combat-based admissions to our military facility have made it difficult to maintain a robust trauma process improvement (PI) program. Since emergency general surgery (EGS) and trauma patients share similarities, we merged the care of our EGS and trauma patients into one acute care surgery (ACS) team. An EGS PI program was developed based on trauma PI principles to facilitate continued identification of opportunities for improvement despite our decline in trauma admissions. Analysis of the first 18 months of combined ACS PI data is presented.

METHODS

EGS registry inclusion criteria was based on published Association for the Surgery of Trauma's recommendations. Program components and PI categories were based on our existing trauma PI program. Dedicated coordinators actively reviewed and cataloged patient care and outcomes. Deviations from standard practice patterns, unplanned interventions, and other complications were abstracted, categorized, and evaluated through levels of review similar to accepted trauma PI principles. Data for the first six quarters were collated and trends were analyzed.

RESULTS

Over 18 months, 696 EGS patients met registry inclusion criteria, with 468 patients (67%) undergoing operative intervention. Over the same time, 353 trauma patients were admitted with 158 undergoing operative intervention (56.4%). Of the 696 EGS patients and 353 trauma patients, 226 (32%) and 243 (69%) PI events were identified, respectively. Common events included unplanned therapies, re-admissions, and unplanned ICU admissions. Based on analysis of all events, four new areas for improvement initiatives were identified. Results of these initiatives included implementation of a multi-disciplinary EGS PI committee, consensus protocols, and departmental and hospital-wide actions.

CONCLUSION

In an 18-month period, integration of our EGS patients into a novel, combined ACS PI program facilitated recognition of an additional 226 PI events and provided a substrate for continued improvements in patient care.

Ballistic and snake photon imaging for locating optical endomicroscopy fibres

We demonstrate determination of the location of the distal-end of a fibre-optic device deep in tissue through the imaging of ballistic and snake photons using a time resolved single-photon detector array. The fibre was imaged with centimetre resolution, within clinically relevant settings and models. This technique can overcome the limitations imposed by tissue scattering in optically determining the in vivo location of fibre-optic medical instruments.

Time-resolved spectroscopy at 19,000 lines per second using a CMOS SPAD line array enables advanced biophotonics applications

A SPAD-based line sensor fabricated in 130 nm CMOS technology capable of acquiring time-resolved fluorescence spectra (TRFS) in 8.3 milliseconds is presented. To the best of our knowledge, this is the fastest time correlated single photon counting (TCSPC) TRFS acquisition reported to date. The line sensor is an upgrade to our prior work and incorporates: i) parallelized interface from sensor to surrounding circuitry enabling high line rate to the PC (19,000 lines/s) and ii) novel time-gating architecture where detected photons in the OFF region are rejected digitally after the output stage of the SPAD. The time-gating architecture was chosen to avoid electrical transients on the SPAD high voltage supplies when gating is achieved by excess bias modulation. The time-gate has an adjustable location and time window width allowing the user to focus on time-events of interest. On-chip integrated center-of-mass (CMM) calculations provide efficient acquisition of photon arrivals and direct lifetime estimation of fluorescence decays. Furthermore, any of the SPC, TCSPC and on-chip CMM modes can be used in conjunction with the time-gating. The higher readout rate and versatile architecture greatly empower the user and will allow widespread applications across many techniques and disciplines. Here we focused on 3 examples of TRFS and time-gated Raman spectroscopy: i) kinetics of chlorophyll A fluorescence from an intact leaf; ii) kinetics of a thrombin biosensor FRET probe from quenched to fluorescence states; iii) ex vivo mouse lung tissue autofluorescence TRFS; iv) time-gated Raman spectroscopy of toluene at 3056 cm^-1 peak. To the best of our knowledge, we detect spectrally for the first time the fast rise in fluorescence lifetime of chlorophyll A in a measurement over single fluorescent transient.

Endoscopic sensing of alveolar pH

Previously unobtainable measurements of alveolar pH were obtained using an endoscope-deployable optrode. The pH sensing was achieved using functionalized gold nanoshell sensors and surface enhanced Raman spectroscopy (SERS). The optrode consisted of an asymmetric dual-core optical fiber designed for spatially separating the optical pump delivery and signal collection, in order to circumvent the unwanted Raman signal generated within the fiber. Using this approach, we demonstrate a ~100-fold increase in SERS signal-to-fiber background ratio, and demonstrate multiple site pH sensing with a measurement accuracy of ± 0.07 pH units in the respiratory acini of an ex vivo ovine lung model. We also demonstrate that alveolar pH changes in response to ventilation.

Acute skin and hair symptoms followed by severe, delayed eye complications in subjects using the synthetic opioid MT-45

BACKGROUND

The introduction of unclassified new psychoactive substances (NPS) on the recreational drugs market through open online sale ('legal highs' or 'Internet drugs') continues unabated and represents a growing health hazard. The use of NPS has resulted in numerous, severe, adverse events and fatalities, due to unintended overdose or unknown toxic side-effects.

OBJECTIVES

To try to find a possible common underlying cause for the skin-hair-eye symptoms complex observed in three men.

METHODS

From late 2013 to mid-2014, three Swedish men aged 23-34 years with a history of recreational drug use independently presented with similar and very remarkable clinical signs, requiring extensive examination and prolonged treatment.

RESULTS

Common clinical signs included hair depigmentation, hair loss, widespread folliculitis and dermatitis, painful intertriginous dermatitis, dry eyes, and elevated liver enzymes. Two of them also showed transverse white Mees' lines (leukonychia striata) on the fingernails and toenails, suggesting a temporary, drug-induced, disorganized keratinization. The clinical signs gradually disappeared over time. However, later on, two developed severe bilateral secondary cataracts requiring surgery. Because drug tests within the Swedish STRIDA project had demonstrated intake of the NPS opioid MT-45 in all patients, this was suspected to be the common causative agent.

CONCLUSIONS

These cases highlight the importance for physicians and health professionals to consider the increasing number of novel, untested recreational drugs, as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.