Measurement protocols and determinants of peak oxygen consumption in adults with Down syndrome: a systematic review

This systematic review aimed to provide an overview of test protocols used to measure peak oxygen uptake (VO2peak) in adults with Down syndrome (DS) and to determine how generalisable the outcomes are for the entire population of adults with DS by describing the sample characteristics of these studies and their impact on VO2peak. A literature search (PROSPERO CRD42022309560) was performed (18 July 2023) using the following databases: PubMed, CINAHL, APA PsycINFO, Web of Science, Embase and SPORTDiscus. For articles to be included, they had to be peer-reviewed pubications, reporting VO2peak or VO2max for individuals with DS separately, with a sample of n ≥ 5 and a mean age ≥18 years. Systematic reviews and meta-analyses were excluded but their reference lists were searched for additional papers to include. Studies were evaluated for risk of bias following the guidelines of Kmet et al. The results were summarised with frequency statistics. Forty-three studies were included in this systematic review. Sample sizes of included adults with DS ranged from n = 4-226, with a total of n = 1498 adults with DS being included. Most studies (29/43) used the same standardised maximal exercise treadmill protocol to measure VO2peak in adults with DS, and 33 out of 43 studies used at least one objective criterion to determine a valid maximal effort. Participants were predominantly male, under 40 years old, and overweight or obese. Additionally, the diversity of study samples was lacking or not reported. The most widely used, standardised, maximal exercise test treadmill protocol is recommended for future use in research and practice, including objective criteria to determine valid maximal effort. The current study samples are not representative of the population of adults with DS in terms of sex, age and diverse backgrounds and therefore likely overestimate VO2peak of this population.

To close or not to close? Wound management in emergent colorectal surgery, an EAST Multicenter prospective cohort study

BACKGROUND

To determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS) and mortality in emergent colorectal surgery.

METHODS

A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, ICU admission, vasopressor use, procedure details and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates.

RESULTS

In total, 557 patients were included (SC n = 262, SLC n = 124, SO n = 171). Statistically significant differences in BMI, race/ethnicity, ASA scores, EBL, ICU admission, vasopressor therapy, procedure details, and wound class were observed across groups (Table 1). Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group (Table 2). After risk adjustment, SO was associated with increased risk of mortality (OR = 3.003, p = 0.028 in comparison to the SC group. SLC was associated with increased risk of superficial SSI (OR = 3.439, p = 0.014), after risk adjustment.

CONCLUSION

When compared to the SC group, the SO group was associated with mortality, but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery.

STUDY TYPE

Level III Therapeutic/Care Management.

Ultramassive transfusion and adjunctive therapies in a case of blood bank depletion

Background

We present the case of a patient who presents with a high velocity thoracoabdominal gunshot wound requiring ultramassive transfusion who exhausted the county blood bank requiring adjunctive therapies to balanced blood product transfusion while additional blood products could be obtained.

Summary

Thoracoabdominal gunshot wounds carry a high mortality of 14-37 % because of the risk to produce cardiopulmonary, solid organ as well as major vascular injuries (Mandal and Oparah (1989) [1]). Ultramassive transfusion (>20 units of blood product transfusion) also carries high morbidity and mortality and management has generally centered on balanced transfusion (Matthay et al. (2021) [2]).

Conclusion

Balanced blood product transfusion reduces mortality for patients requiring ultramassive transfusion but when this is not possible utilization of adjuncts to blood products may temporize resuscitation until additional blood products can be obtained.

Compartment Syndrome Resulting From Improper Intraosseous Cannulation: A Case Report

Obtaining adequate vascular access is imperative for effective resuscitative, therapeutic, and diagnostic interventions. The intraosseous (IO) route is indicated when immediate vascular access is needed, and standard central or peripheral intravenous (IV) access is unattainable or would delay therapy in a critical patient. We present a rare case of improper IO line placement in the right proximal tibia of a 30-year-old female involved in a motor vehicle collision, resulting in extravasation of blood products into the surrounding tissue and development of acute compartment syndrome. Emergency Medical Services was unable to obtain IV access in a timely manner, thus a right proximal tibia 45mm IO line was placed, and a unit of whole blood was given with a high-pressure infusor in the field. At the trauma center, the patient's right lower extremity was severely tense and edematous with no palpable right lower extremity pulses and no Doppler signals. Computed tomography revealed the IO catheter extending through both the proximal and distal cortices of the right tibia. Medial and lateral fasciotomy of the right lower extremity was performed in which all four compartments of the right lower leg were released and a significant hematoma was evacuated from the superficial posterior compartment. This case highlights the importance of IO access as a life-saving intervention while also underscoring the need to educate and familiarize pre-hospital and hospital healthcare personnel in delivering IO access so as to mitigate risks and improve outcomes for critically ill patients.

Persistent pseudoaneurysm after non-operative management of a Grade 4 liver injury

A hepatic pseudoaneurysm (HPA) after blunt or penetrating liver injury is an unusual but potentially lethal complication that can develop from an injured hepatic artery branch [1-5]. Endovascular intervention with coil embolization to treat HPA is a safe and effective method and has become the standard first-line treatment, with a success rate achieving 70-100 % [13,14,15]. Infrequently the pseudoaneurysm is fed by collateral vessels and endovascular intervention may be unsuccessful. Other minimally invasive treatment options that can be considered include image guided percutaneous thrombin injection, endovascular placement of covered stents and injection of liquid agents such as fibrin glue [10,11]. We present a case of a young female who developed a post-traumatic persistent hepatic pseudoaneurysm requiring a total of nine interventions, including six endovascular interventions with angiography, three endoscopic procedures for bleeding, one percutaneous injection, and two re-admissions to the hospital. Although she avoided initial operative management, her three-month hospital course can be considered a failure of conservative management of blunt hepatic trauma due to the accrued health care costs and resources. The literature on the management of persistent pseudoaneurysm is limited. The decision to treat a persistent HPA that are found incidentally and stable in size needs further investigation.

Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial

OBJECTIVE

This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients.

METHODS

A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R).

RESULTS

Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge.

CONCLUSION

Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Brachial Artery Injury Resulting From a Dog Bite in a Pediatric Patient: A Case Report

Pediatric trauma surgeons frequently encounter severe injuries from animal bites, with dog bites being especially prevalent in children, often leading to facial injuries. This paper details the case of a six-year-old male who suffered a dog bite resulting in a rare proximal right brachial artery injury. The bite caused deep lacerations and avulsion injuries, prompting admission to the trauma center, where nonpalpable right radial and ulnar pulses and arm weakness were observed. Surgical intervention, including wound exploration and brachial artery repair using a saphenous vein graft, successfully restored vascular perfusion. This case underscores the urgency of addressing pediatric dog bite injuries through timely exploration, thorough irrigation, and antibiotic prophylaxis, while also highlighting the need for further research on preventive education and clinical guidelines for assessing vascular injuries in such cases.

A Non-Fatal Impalement Injury to the Right Thorax: A Case Report

Impalement injuries secondary to motor vehicle collisions are rare. Reviewing the systematic approach to treating these injuries can benefit the surgical community. This case report discusses the presentation and management of a 32-year-old male who was involved in a high-speed, roll-over motor vehicle collision. The car struck a chain-link fence, and the unrestrained passenger sustained a fence post impalement injury to his right thorax. He was alert and oriented when emergency services arrived. He was extricated rapidly and transported to our level-one trauma center, where he received definitive operative management. The patient survived the injury and was discharged home. This case highlights key points in the systematic approach to impalement injuries, including minimal handling of the impaled object, expedient transfer to the local trauma center, emergent operative intervention, vascular control prior to removal of the foreign object, and aggressive irrigation and debridement of the wound.

Vascular Shunt for Small Vessel Trauma in a Polytrauma Patient

A 15-year-old male patient presented with multiple gunshot injuries. The patient underwent emergency lifesaving exploratory laparotomy and subsequently needed repair of his left upper limb ulnar artery injury. A shunt helped restore blood flow to the hand in a setting of damage control surgery in an exsanguinating patient with an ulnar artery injury having a massive disruption. After resuscitation, the patient underwent definitive repair of the artery using a vein interposition graft.

Surgical Residents as Certified Bilingual Speakers: A Quality Improvement Initiative

BACKGROUND

The objective of this quality improvement initiative was to identify general surgery residents proficient in a non-English language and have each attempt the Clinician Cultural and Linguistic Assessment (CCLA) to become qualified bilingual staff speakers.

METHODS

General surgery house staff were asked to self-identify as proficient in a language other than English. Fees for the certification examination were waived, and each resident was excused from clinical duties to complete the exam. McNemar's test was used for statistical analysis.

RESULTS

All residents responded to the initial survey, with 18/65 reporting a non-English language proficiency. Of the 12 residents who sat for the CCLA exam, 9 (75.0%) passed, with 5 certifying in the most commonly spoken non-English languages at this institution. The number of certified residents increased from 1 to 10 (1.5 % to 15.4%, p = 0.004).

CONCLUSION

Language barriers result in health care disparities for patients with limited English proficiency. This reproducible quality improvement initiative significantly increased the number of qualified bilingual speakers, while 25.0% of self-described proficient speakers did not demonstrate adequate language proficiency. These newly certified providers allow for increased language concordant care, which may be associated with improved outcomes.

Surgery After an Initial Episode of Uncomplicated Diverticulitis: Does Time to Resection Matter?

BACKGROUND

The aim of this study was to determine whether time to surgery after an initial episode of uncomplicated diverticulitis is associated with undergoing an emergent versus an elective resection.

METHODS

In this retrospective, administrative claims database study, we identified patients at least 18 y old in the 2005-2011 California State Inpatient Database who had an initial episode of uncomplicated diverticulitis and then underwent a bowel resection within 2 y. After characterizing the distribution in time to surgery among all patients, we used a multivariable logistic regression to determine whether time to surgery was associated with undergoing an emergent resection. Next, we assessed differences in three outcomes between elective and emergent resections: at least one of eight postoperative complications, extended length of stay (defined as the top decile of hospitalizations), and 30-d inpatient readmissions. Analyses adjusted for time between initial hospitalization and resection, number of inpatient hospitalizations for diverticulitis before the resection, clinical factors, and hospital clustering.

RESULTS

We identified 4478 patients with an initial episode of uncomplicated diverticulitis followed by a bowel resection within the subsequent 2 y. One-fifth (21.1%) underwent an emergent resection. The median time from the initial episode to resection was 3.8 mo (IQR: 2.3-8.1 mo) for elective resections and 5.1 mo (IQR: 2.3-12.4 mo) for emergent resections. The adjusted odds of undergoing an emergent relative to an elective resection increased by 7% (aOR 1.07 [1.02-1.11]) for every 3 passing mo. Emergent resections were associated with greater adjusted odds of complications (adjusted odds ratio [aOR] 1.75 [95%-CI 1.43-2.15]), extended LOS (aOR 4.52 [3.31-6.17]), and 30-d readmissions (aOR 1.49 [1.09-2.04]).

CONCLUSIONS

Among patients who experienced an initial episode of uncomplicated diverticulitis and eventually underwent a resection, the odds of having an emergent relative to elective surgery increased with every 3 passing mo. These findings may inform the management of uncomplicated diverticulitis for high-risk patients eventually needing surgery.

RAS Mutations, and RET/PTC and PAX8/PPAR-gamma Chromosomal Rearrangements Are Also Prevalent in Benign Thyroid Lesions: Implications Thereof and A Systematic Review

BACKGROUND

Molecular markers associated with thyroid malignancy are increasingly being used as differential diagnostic tools for thyroid nodules. However, little has been reported recently regarding the prevalence of these markers in benign lesions. The literature was systematically reviewed to examine studies that reported on the prevalence of these markers in benign thyroid lesions.

METHODS

Appropriate studies published between January 1, 2000, and April 30, 2015, and cataloged in PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for by combining different keywords for "thyroid tumor" with both general and specific keywords for "molecular marker" by using "AND" as the Boolean operator. All studies meeting criteria that reported the prevalence of RAS mutations, and RET/PTC and PAX8/PPAR-gamma chromosomal rearrangements in benign thyroid lesions were included for study.

RESULTS

A total of 64 articles (including 8162 patients, of whom 42.5% had benign lesions) that met all the study criteria were systematically reviewed and abstracted. Among 35 studies examining RAS mutations, the reported prevalence of RAS mutation in benign lesions ranged from 0% to 48%. In 38 studies examining RET/PTC rearrangements, the prevalence in benign lesions ranged from 0% to 68%. PAX8/PPAR-gamma rearrangements were examined in 27 studies, with the prevalence in benign lesions ranging from 0% to 55%.

CONCLUSION

The presence of these biomarkers and the tremendous variation in reports of their prevalence in benign lesions suggests the need for caution when including these markers in diagnostic decisions. Further understanding of the importance of these markers, as well as newly discovered markers of thyroid malignancy, may be required in order to avoid overtreatment of patients with benign thyroid tumors.

Cocaine-associated hemoperitoneum following atraumatic splenic rupture: a case report and literature review

Introduction

Splenic hematoma or rupture of the spleen is rare in the absence of trauma. This case report with a brief review of the literature is intended to raise awareness of splenic bleeding as an etiology of abdominal pain; it highlights the importance of a detailed social history.

Presentation of case

This report of an otherwise healthy 42-year old man details hemoperitoneum with splenic rupture as a cause for hemorrhage following cocaine use. The patient was managed non-operatively in the surgical intensive care unit. He did not require transfusion and was discharged home on hospital day four with close follow-up.

Discussion

While splenic pathology associated with cocaine use has been described, this case illustrates a novel report of cocaine-associated splenic hemorrhage. A plausible mechanism is transient vasospasm with subsequent bleeding into the infarcted area.

Conclusion

Although uncommon, atraumatic splenic rupture should be recognized early because it is potentially fatal. This case is the first to describe hemoperitoneum of splenic etiology following cocaine use.

Detection of Alzheimer’s and Parkinson’s disease from exhaled breath using nanomaterial-based sensors

Aim: To study the feasibility of a novel method in nanomedicine that is based on breath testing for identifying Alzheimer’s disease (AD) and Parkinson’s disease (PD), as representative examples of neurodegenerative conditions. Patients & methods: Alveolar breath was collected from 57 volunteers (AD patients, PD patients and healthy controls) and analyzed using combinations of nanomaterial-based sensors (organically functionalized carbon nanotubes and gold nanoparticles). Discriminant factor analysis was applied to detect statistically significant differences between study groups and classification success was estimated using cross-validation. The pattern identification was supported by chemical analysis of the breath samples using gas chromatography combined with mass spectrometry. Results: The combinations of sensors could clearly distinguish AD from healthy states, PD from healthy states, and AD from PD states, with a classification accuracy of 85, 78 and 84%, respectively. Gas chromatography combined with mass spectrometry analysis showed statistically significant differences in the average abundance of several volatile organic compounds in the breath of AD, PD and healthy subjects, thus supporting the breath prints observed with the sensors. Conclusion: The breath prints that were identified with combinations of nanomaterial-based sensors have future potential as cost-effective, fast and reliable biomarkers for AD and PD.

Original submitted 29 January 2012; Revised submitted 8 May 2012; Published online 15 October 2012

Image-guided near-infrared fluorescent sentinel lymph node mapping in human breast cancer

e11591

Background: Breast cancer surgery is presently performed without real-time image-guidance. We have developed a novel optical imaging system for image-guided surgery that uses invisible near-infrared (NIR) fluorescent light to highlight structures on the surgical field with high sensitivity, specificity, and contrast. We have also performed the first human clinical trial of the imaging system in women undergoing SLN mapping for breast cancer. Methods: We used a portable imaging system with an articulating arm that has 6 degrees of freedom, high power LED light source, custom optics, custom software, and sterile drape. The imaging system provided simultaneous and real-time imaging of color video and NIR fluorescence at up to 15 frames per second. N = 6 women with biopsy- confirmed breast cancer undergoing SLN mapping gave informed consent. All subjects received conventional mapping with Tc-99m sulfur colloid using a handheld gamma probe as well as NIR fluorescence-guided SLN mapping using a mixture of indocyanine green (ICG) diluted to a final concentration of 10 μM in human serum albumin (ICG:HSA). Results: The imaging system was easy to position in the operating room, with the articulating arm providing 50” horizontal reach and 70” vertical reach. Working distance to the patient was 18”. NIR fluorescence excitation was 20 mW/cm2 at 760 nm. NIR-depleted white light was 40,000 lux. A total of 1.6 ml of ICG:HSA was injected intra-tumorally and peri-tumorally and the site massaged for 5 min. 8 of 9 SLNs identified by Tc- 99m sulfur colloid were also identified by NIR fluorescence. However, NIR fluorescence identified an SLN, confirmed to have cancer in it, that was not identified by Tc-99m sulfur colloid. These differences were consistent with asynchrony in the injection techniques. Unlike the gamma-ray probe, NIR fluorescence provided high-resolution, large area optical imaging of the surgical field, and helped guide surgical resection. Conclusions: In this 6-patient pilot study, a novel NIR fluorescence optical imaging system was used for the first time, and provided real-time image-guided surgery for SLN mapping of breast cancer.

No significant financial relationships to disclose.

Subtrochanteric fracture after fixation of slipped capital femoral epiphysis: a complication of unused drill holes

Subtrochanteric fracture of the femur has been infrequently reported after in situ fixation of slipped capital femoral epiphysis, and this occurred in only 1.4% of our patients over a 10-year period. As this technique is used more frequently, however, the incidence of this complication is likely to rise. All four subtrochanteric fractures occurred through unused drill holes, and avoiding extraneous screw holes seems to be the best way to prevent postoperative subtrochanteric fracture. Once subtrochanteric fracture occurs, immediate open reduction and internal fixation with a compression hip screw device is the recommended treatment.

Bausch & Lomb CW 79 aphakic extended wear contact lens: multi-year follow-up

We undertook a follow-up case study of 126 patients (146 eyes) to determine success rate and replacement rate of the Bausch & Lomb CW 79 aphakic extended wear contact lens. One hundred eighteen eyes (81%) were successful in wearing the contact lens, and 16 eyes (11%) were reported as contact lenses dropouts. Twelve eyes (8%) elected to receive intraocular lenses (IOLs). A total of 134 lenses were replaced, yielding a replacement rate of 0.3 lenses per eye per year. The average length of follow-up for successful patients was 3.7 years.

Osteoporotic correlates of alcoholism in young males

A group of 22 white males (ages, 28 to 40 years) with histories of chronic alcohol abuse ranging from 1 to 21 years were evaluated for trabecular bone mineral density in the left femoral neck area. A group of age and weight-matched white males with no history of alcoholism served as controls. All participants completed medical history questionnaires regarding fracture history, dietary habits, medications, and physical activity. Singh femoral trabecular indices also were measured for the alcoholic participants. Analysis of bone mineral data as measured by dual photon absorptiometry revealed no statistically significant reduction in the bone mineral densities of the alcoholic group when compared to the controls. No differences were seen in the areas of the femoral neck, Ward's triangle, and greater trochanter. Duration of alcoholism also was not correlated with the degree of osteopenia. Singh index measurements of right and left femoral heads were compared and revealed no significant differences within individual patients. Left femoral Singh index values averaged 5.5 (range, 4 to 6) for the alcoholic group and were not indicative of decreased bone mineral density. It is concluded from this study that chronic alcoholism associated with heavy smoking most likely has a debilitating effect on the trabecular bone density of white males, yet clinical and radiographic evidence is not widely manifested in men under the age of 40 years.