Retrospective analysis of the effects of hypocalcemia in severely injured trauma patients

BACKGROUND

It has been suggested that the Lethal Triad be modified to include hypocalcemia, coined as the Lethal Diamond. Hypocalcemia in trauma has been attributed to multiple mechanisms, but new evidence suggests that traumatic injury may result in the development of hypoCa independent of blood transfusion. We hypothesize that hypocalcemia is associated with increased blood product requirements and mortality.

METHODS

A retrospective study of 1,981 severely injured adult trauma patients from 2016 to 2019. Ionized calcium (iCa) levels were obtained on arrival and subjects were categorized by a threshold iCa level of 1.00 mmol/L and compared. Univariable and multivariable logistic regression analysis was performed.

RESULTS

The hypocalcemia (iCa <1.00 mmol/L) group had increased rate of overall (p = 0.001), 4-hr (p = 0.007), and 24-hr (p = 0.003) mortality. There was no difference in prehospital transfusion volume between groups (p = 0.25). Hypocalcemia was associated with increased blood product requirements at 4 h (p <0.001), 24 h (p <0.001), and overall hospital length of stay (p <0.001). Logistic regression analysis showed increased odds of 4-hour mortality (OR 0.077 [95 % CI 0.011, 0.523], p = 0.009) and 24-hour mortality (OR 0.121 [95 % CI 0.019, 0.758], p = 0.024) for every mmol/L increase in iCa.

CONCLUSIONS

This study shows the association of hypoCa and traumatic injury. Severe hypoCa was associated with increased odds of early and overall mortality and increased blood product requirements. These results support the need for future prospective trials assessing the role of hypocalcemia in trauma.

[The Place of Groin, Colson and McGregor Flaps in the Acute Care of Deep Burns to the Hand Dorsum : A Series of 6 Cases In Lille's Burn Centre]

The acute management of deep burns to the dorsum of the hand and fingers represents a challenge for the reconstructive surgeon. The exposure of osteo-tendinous structures often requires flap coverage, in a context where loco-regional or free flaps are not always feasible. The aims of reconstruction are to preserve a maximum of digital length, provide supple tissue, obtain protective sensitivity, and achieve a functional hand at 1 year. We report here on a series of 8 deep burns to the dorsum of the hand. Six hands were covered by Colson abdominal flap-graft and two by pedicled inguinal flap. Four out of 6 patients were reviewed in consultation, 1 patient was lost to follow-up, and 1 patient died. Clinical evaluation was performed by a surgeon other than the operator. Functional results are highly variable. Coverage time varies according to lesion depth and patient severity. Flap weaning took place at an average of 30 days. DASH scores ranged from 17.5 to 93/100, with average to poor total active motion (TAM) scores. The aesthetic result was satisfactory, with a Vancouver score of 4.5/13 on average, and an overall patient opinion of 3.75/10 on the POSAS scale. For deep burns to the dorsum of the hand and fingers, local flaps are rarely possible, and loco-regional flaps are not feasible in cases of associated upper limb damage. For medium to large surface areas, pedicled inguinal flaps and pocketing are two reliable techniques. Nevertheless, they require relative immobilization of the upper limb, which leads to stiffness. The question of digital pinning in the intrinsic or straight position remains unresolved, and does not appear to prevent secondary deformities. There is also a learning curve for these two flaps, even though they are reputed to be easy to lift. McGregor's flap or pocketing can be weighed against free flaps. However, the operating time is long, the surgical technique is complex, and vascular damage is common in the burn patient population. Although there have been enormous technical advances since their descriptions, the pedicled inguinal flap and pocketing remain alternatives to be considered in the acute management of deep burns to the dorsum of the hand. In this presentation, we propose a surgical management algorithm to situate these two techniques in the plastic surgeon's therapeutic armament.

The effects of hypocalcemia in severely injured pediatric trauma patients

INTRODUCTION

The role of calcium is ubiquitous in human physiology. Emerging evidence suggests that the lethal triad be revised to include hypocalcemia (hypoCa) and thus be known as the lethal diamond . There are data showing that traumatic injury may result in hypoCa independent from the mechanism of calcium chelation by citrate-based blood preservatives. Minimal literature exists analyzing the role of hypoCa in pediatric trauma patients. We hypothesize that there is an independent association of hypoCa with increased blood product requirements and mortality.

METHODS

A retrospective cohort study of severely injured pediatric trauma patients was conducted. Trauma registry data were collected from January 2016 to August 2021. Ionized calcium (iCa) levels were obtained from arrival blood draws. Subjects were categorized into two groups by a threshold iCa level of 1.00 mmol/L and compared. Shock Index Pediatric Adjusted scores were used to adjust for age-specific differences in vital signs.

RESULTS

A total of 142 patients were compared, of which 46.5% were hypocalcemic (iCa <1.00 mmol/L). Patients were well matched in terms of demographics and injury severity. The hypocalcemic group had lower systolic blood pressure and a higher percentage of Shock Index Pediatric Adjusted-positive patients. Weight-adjusted transfusion volumes were significantly higher in the hypocalcemic group at both the 4-hour and 24-hour time points without a difference in prehospital transfusion requirements. There was no observed difference in early or in-hospital mortality.

CONCLUSION

This study contributes to the body of literature regarding the association between hypoCa and traumatic injury in the pediatric population. Hypocalcemia was associated with increased blood product requirements without a difference in prehospital transfusion requirements, suggesting a possible independent association. Further prospective studies are needed to better understand this relationship.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

The impact of prehospital whole blood on hemorrhaging trauma patients: A multi-center retrospective study

BACKGROUND

Whole blood (WB) use has become increasingly common in trauma centers across the United States for both in-hospital and prehospital resuscitation. We hypothesize that prehospital WB (pWB) use in trauma patients with suspected hemorrhage will result in improved hemodynamic status and reduced in-hospital blood product requirements.

METHODS

The institutional trauma registries of two academic level I trauma centers were queried for all patients from 2015-2019 who underwent transfusion upon arrival to the trauma bay. Patients who were dead on arrival or had isolated head injuries were excluded. Demographics, injury and shock characteristics, transfusion requirements, including massive transfusion protocol (MTP) (>10 U in 24 hours) and rapid transfusion (CAT3+) and outcomes were compared between pWB and non-pWB patients. Significantly different demographic, injury characteristics and pWB were included in univariate followed by stepwise logistic regression analysis to determine the relationship with shock index (SI). Our primary objective was to determine the relationship between pWB and improved hemodynamics or reduction in blood product utilization.

RESULTS

A total of 171 pWB and 1391 non-pWB patients met inclusion criteria. Prehospital WB patients had a lower median Injury Severity Score (17 vs. 21, p < 0.001) but higher prehospital SI showing greater physiologic disarray. Prehospital WB was associated with improvement in SI (-0.04 vs. 0.05, p = 0.002). Mortality and (LOS) were similar. Prehospital WB patients received fewer packed red blood cells, fresh frozen plasma, and platelets units across their LOS but total units and volumes were similar. Prehospital WB patients had fewer MTPs (22.6% vs. 32.4%, p = 0.01) despite a similar requirement of CAT3+ transfusion upon arrival.

CONCLUSION

Prehospital WB administration is associated with a greater improvement in SI and a reduction in MTP. This study is limited by its lack of power to detect a mortality difference. Prospective randomized controlled trials will be required to determine the true impact of pWB on trauma patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Risk factors for massive transfusion in obstetrical hemorrhage and consideration of a whole blood program

BACKGROUND

Postpartum hemorrhage (PPH) is one of the leading causes of obstetric complications. The goal of this study was to identify risk factors for obstetric (OB) massive transfusion (MT) and determine the feasibility of developing a low-titer group O RhD-positive whole blood (LTO + WB) protocol for OB hemorrhage.

STUDY DESIGN AND METHODS

A retrospective study of OB patients who received transfusion within 24 h. MT patients were those who received >3 U of pRBC within 1 h or > 10 U in 24 h. Patient demographics, OB history, comorbidities, blood type, antibody status, and known risk factors for PPH and maternal-fetal outcomes were compared. Logistic regression was used for univariate and multivariate analyses.

RESULTS

Of the 610 transfused OB patients, 12.0% (n = 73) required MT. Groups were well matched for body mass index (BMI), maternal comorbidities, and history of spontaneous vaginal deliveries. The incidence of the previous cesarean section was higher in the MT group. Exactly 93.9% of patients were RhD-positive and 3.77% of all patients possessed an antibody on pretransfusion testing. Patients with MT had a longer length of stay (LOS), higher rate of intensive care unit (ICU) admission, fetal death, and hysterectomy. Multivariate analysis found age >35, PPH, placenta percreta, accreta, and increta to be significant (p < .05) risk factors for MT.

DISCUSSION

Patients over 35 years and those with abnormal placentation are at increased risk of requiring MT. With a time to delivery of 2 days, potential MT patients can be identified early, and with a 94% rate of RhD-positive+, they are eligible to receive low-titer O whole blood (LTOWB) providing hemostatic resuscitation with reduced donor exposure.

309 A FRAILTY CENSUS OF INPATIENTS AGED 65 AND OVER ADMITTED TO A MODEL 4 HOSPITAL

Background

Frailty is a risk factor for in-hospital mortality, long hospital stay and functional decline at discharge. Profiling the prevalence and level of frailty within the acute hospital setting is vital to ensure evidence-based practice and service development within the construct of frailty.

Methods

All patients aged ≥65 years and admitted to a medical or surgical inpatient setting, were screened over a 12-hour period (08:00-20:00) using validated frailty and co-morbidity scales. Age and Gender Demographics, Clinical Frailty Scale (CFS), Charlson Co-morbidity Index (CHI) and admitting specialty (Medical/Surgical) were collected. The data was fully anonymised and ethical approval was granted. Descriptive statistics were used to profile the cohort and Chi-squared tests applied for comparisons.

Results

Within a sample of 413 patients, 291(70%) were ≥65yrs. Of this cohort, 202(70%) were ≥75yrs. 207(71%) utilised in-patient medical services and 121(41%) surgical services while 37(12%) used both. The mean CFS was 6 indicating moderate frailty levels and the mean CCI score was 4 denoting moderate co-morbidity. Overall: 195(67%) had moderate-severe frailty (CSF ≥6) while 218 (75%) had moderate-severe co-morbidity (CCI Mod 3-4, Severe ≥5). Associations with age &gt;75 and frailty (p=0.001) and medical service usage and frailty (p=0.004) were established. No significant differences were observed across genders for CFS (p=0.110) and CCI (p=0.465).

Conclusion

There is a high prevalence of frailty and co-morbidity within the admitted patient cohort ≥65yrs. Overcrowding across the hospital system and higher levels of frailty and comorbidity will contribute to increased lengths of stay and the need for specialist intervention, particularly for those ≥75yrs who represented 70% of patients screened. With an increased focus on the integration of care for older adults across care transitions, there is a clear need for expansion of frailty-based services and staff training in frailty care across the hospital and community setting.

299 OLDER PERSONS’ EXPERIENCES AND PERSPECTIVES OF COMPREHENSIVE GERIATRIC ASSESSMENT

Background

There is an abundance of evidence to demonstrate the positive impacts of Comprehensive Geriatric Assessment (CGA) on clinical and process outcomes for older adults across settings of care. However, it is unclear how older adults themselves view CGA and their experiences of the care process. The aim of this qualitative evidence synthesis is to explore the experiences and perspectives of older adults of CGA.

Methods

A comprehensive literature search was completed across MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text. Qualitative or mixed methods studies that included qualitative data on the perspectives and experiences of older adults of CGA were included. The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Findings were synthesised using thematic analysis

Results

Nine studies were included in the synthesis, including studies where CGA was completed in hospital, outpatient assessment unit and home settings. Divergent experiences of CGA were reported. Older adults reported experiences of being respected and listened to during CGA and attention paid to all their issues and priorities. Good communication by healthcare providers was central to these positive experiences (theme 1). In contrast, experiences of being unclear about the aim of CGA or perceived benefits of CGA, feeling that the outcome of CGA did not align with their priorities (theme 2) and not feeling involved in decision making during CGA (theme 3) were also commonly reported.

Conclusion

Findings indicate that CGA is a process by which older adults can felt respected and paid attention to. However, scope exists to further improve older adults’ experiences of CGA. Enhanced healthcare provider communication and facilitation of older adult involvement in decision-making are priority areas for improvement. Further research should focus on exploring other stakeholder groups experiences of CGA including caregivers and healthcare professionals.

303 SCREENING INSTRUMENTS TO PREDICT ADVERSE OUTCOMES FOR UNDIFFERENTIATED OLDER ADULTS ATTENDING THE EMERGENCY DEPARTMENT: RESULTS OF SOAED PROSPECTIVE COHORT STUDY

Background

Frailty screening facilitates the stratification of older adults at most risk of adverse events for urgent assessment and subsequent intervention in the acute or community setting. We assessed the validity of the ISAR (Identification of Seniors at Risk), Rockwood Clinical Frailty Scale (CFS), PRISMA-7 and InterRAI-ED at predicting adverse outcomes at 30 days and six months among older adults presenting to the ED.

Methods

A prospective cohort study of consecutive older adults (≥65 years) who presented to the ED at a University Hospital was conducted. The ISAR, CFS, PRISMA-7 and InterRAI-ED were performed by an experienced ED research nurse. Blinded follow-up telephone interviews were completed at 30 days and six months to assess the incidence of mortality, ED re-attendance, hospital readmission, functional decline and nursing home admission. The sensitivity and specificity of the screening tools were calculated using 2×2 tables.

Results

419 patients were recruited with 49% female and a mean age of 76.9 years (SD 7.15). The prevalence of frailty varied across the screening tools (ISAR, 47% vs InterRAI-ED, 63%). At 30-days, mortality rate was 5.4%, ED re-attendance 16.9%, hospital readmission 13.6%, functional decline 47.1% and nursing home admission 7.3%. Older adults who screened positive for frailty demonstrated an increased risk of all adverse outcomes at 30 days and 6 months, regardless of frailty screening tool administered. All tools had a relatively high sensitivity but low specificity. The ISAR was the only tool which was statistically significant at predicting all outcomes at 30 days.

Conclusion

The ISAR, CFS, PRISMA-7 and InterRAI-ED demonstrated modest validity at predicting adverse outcomes at 30 days and 6 months. We would recommend the implementation of one of these frailty screening tools in Irish EDs to support clinicians in identifying older adults most likely to benefit from specialised geriatric assessment and intervention in the hospital or community setting.

319 CAN INDEX BARTHEL SCORE AT EMERGENCY DEPARTMENT PRESENTATION PREDICT ADVERSE OUTCOMES AMONG OLDER ADULTS AT 30 DAYS AND 6 MONTHS?

Background

Frailty is acknowledged as a significant syndrome particularly in the older population. Monitoring frailty in late life aetiology and recognising the value of frailty as a marker of risk for adverse health outcomes is vital and ensures the identification of opportunities for intervention with this cohort in clinical practice. The aim of this prospective cohort study is to examine if an index Barthel Score at Emergency Department presentation predicts adverse outcomes among older adults at 30 days and 6 months.

Methods

Six-hundred and fifty older adults (≥65 years) attending a university model 4 hospital ED were recruited. Baseline evaluation included the Barthel Index. Adverse outcomes (hospital readmission or death) were recorded by a research nurse at 30 days and 6 months, blinded to Barthel score. Descriptive statistics were used to profile the population and report the incidence of adverse outcomes.

Results

At 30 days, 61 older adults had either being admitted to hospital (n=28) or died (n=33) and at 180 days a further 72 had been admitted (n=43) or died (n=29). A total of 29% (n=189) of the population had a Barthel score of ≤15 indicating moderate dependency. Of this cohort, 70% had an adverse outcome-readmitted or died within 180 days.

Conclusion

It may be worth looking at introducing the Barthel Index as a routine measure of activity for older adults presenting to the ED. This tool demonstrates an increased risk of adverse outcomes among older adults who present with moderate dependency. Early intervention either in the hospital or community setting with this ‘at risk’ cohort may serve to reduce adverse outcomes among this group.

265 A PHYSIOTHERAPY-LED TRANSITION TO HOME INTERVENTION FOR OLDER ADULTS FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: A PILOT FEASIBILITY RANDOMISED-CONTROLLED TRIAL

Background

Older adults frequently attend the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. A presentation to an ED can be viewed as an opportunity to assess those at risk of adverse outcomes and initiate a care plan in those deemed as ‘high risk'. Our aim was to evaluate the feasibility of a physiotherapy led integrated care intervention for older adults discharged from the ED (ED-PLUS).

Methods

Older adults presenting to the ED with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED-PLUS (Trial registration: NCT04983602). ED-PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient’s own home. Feasibility (recruitment and retention rates) and acceptability of the programme were assessed quantitatively and qualitatively. Functional decline was examined post-intervention using the Barthel Index. All outcomes were assessed by a research nurse blinded to group allocation.

Results

29 participants were recruited, indicating 97% of our recruitment target. 90% of participants completed the ED-PLUS intervention. All participants expressed positive feedback about the intervention. The incidence of functional decline at 6 weeks was 10% in the ED-PLUS group versus 70-89% in the usual care and CGA-only groups.

Conclusion

High adherence and retention rates were observed among participants and preliminary findings indicate a lower incidence of functional decline in the ED-PLUS group. Recruitment challenges existed in the context of COVID-19. Data collection is ongoing for six-month outcomes.

[Gynécomastia. Management of diagnosis and therapy. Apropos of 148 cases]

Gynecomastia is the most frequently breast lesion in males. 148 patients (mean age 24,7 years) operated in our department were reviewed with a mean follow-up of five years. Gynecomastia occurred most frequently during puberty (77,7 %), was bilateral (86,5%) and idiopathic (89,9%). The size of the enlargement was evaluated according to Simon's-classification based on breast-volume and skin-redundancy. 17 (11,5%) stage 1, 77 (52%) stage 2A, 32 (21,6%) stage 2B, 22 (14,9%) stage 3. Clinical examination and mammography determined the consistency of gynecomastia: adipose or firm. 4 different surgical managements were used: 17 (11,5%) subcutaneous mastectomies, 4 (2,7%) liposuctions, 110 (74,3%) liposuctions associated with subcutaneous mastectomy, 17 (11,5%) total mastectomy. All techniques gave good morphologic results. Nonetheless, the authors recommend the combination «liposuction and subcutaneous mastectomy», as this technique presents many advantages: small intraoperative blood loss, good skin redraping, short hospital stay, complete histologic examination of the material removed.

[Is it legitimate to propose surgery of the breast area before the end of puberty?]

Breast surgery is usually recommended for women who have completed puberty. Indeed, during adolescence the breast is constantly changing, the patient's weight is often unstable, the risk of inflammatory scars (hypertrophic or keloid) is higher and disturbances of areolar sensitivity can affect the patient's quality of sexual life. In addition, the risk of infection is not negligible, especially during an acne outbreak. In case of early implant placement, iterative changes should be planned. Finally, the result obtained is not always stable but above all the lack of psychological maturity and the legal need to obtain the agreement of both parents are obstacles to early surgery. However, the authors argue for the possibility of surgical correction of the breast around puberty, in particular because of the very clear positive psychological impact. Other arguments are also detailed: to ensure a breast reconstruction in successive stages started early, to limit the repercussions of hypertrophy, to correct thoracic or skin anomalies. These indications are illustrated by numerous clinical cases demonstrating the need for customized surgery on a case-by-case basis.

1081 A COMPARISON OF THE ISAR TOOL AND THE CLINICAL FRAILTY SCALE TO PREDICT MORTALITY AND ED REATTENDANCE IN A COHORT OF ED ATTENDER

Background

Frailty Screening is one method by which we can risk stratify older adults to urgent assessment in the Emergency Department. The ISAR (Identification of Seniors at Risk) and Rockwood Clinical Frailty Scale are two frailty screening tools. We assessed the validity of these tools at predicting adverse outcomes for older adults presenting to the Emergency Department.

Method

This was a prospective cohort study. Patients over 65 were recruited, baseline.

demographics were obtained and a research nurse assessed them using both the Clinical Frailty Scale and ISAR. Patients were assessed by telephone interviews at one month and six months. The outcome measures assessed were mortality, ED re-attendance, hospital readmission, functional decline and institutionalisation.

Results

419 patients were recruited. 53.3% (223) were male with a median age of 76 (IQR = 10). The median ISAR and CFS score was 2,5 respectively at baseline. The mortality rate was 5.4% and rate of ED re-attendance was 16.9% at one month. The relative risk of ED re-admission with an ISAR score &gt;/= 2 more was 1.84 (1.12, 3.02) and CFS &gt; 4 was 1.85 (1.08, 3.16). The ISAR tool &gt;/= 2, had a sensitivity of 74.29 (95% CI = 62.44, 83.99) and specificity of 41.18 (95% CI = 35.90, 46.61) when used as a diagnostic tool for ED re-admission at one month. The CFS &gt; 4 had a sensitivity of 71.43 (95% CI = 57.79, 82.70) and specificity of 45.23 (95% CI = 39.33, 51.23) for the same outcome.

Conclusion

The ISAR tool &gt;/= 2 was the more sensitive at predicting ED reattendance at one month in comparison to the Clinical Frailty Scale. We would advocate using this tool in the ED setting to highlight those at greatest risk of adverse outcomes and those most likely to benefit from Comprehensive Geriatric Assessment.

240 A COMPARISON OF THE ISAR AND THE CLINICAL FRAILTY SCALE TO PREDICT MORTALITY AND ED RE-ATTENDANCE IN OLDER ED ATTENDERS

Background

Frailty Screening is one method by which we can risk stratify older adults to urgent assessment in the Emergency Department. The ISAR (Identification of Seniors at Risk) and Rockwood Clinical Frailty Scale (CFS) are two frailty screening tools. We assessed the validity of these tools at predicting adverse outcomes for older adults presenting to the Emergency Department.

Methods

This was a prospective cohort study. Patients over 65 were recruited, baseline demographics were obtained and a research nurse assessed them using both the CFS and ISAR. Patients were assessed by telephone interviews at one month and six months. The outcome measures assessed were mortality, ED re-attendance, hospital readmission, functional decline and institutionalisation.

Results

419 patients were recruited. 53.3% (223) were male with a median age of 76 (IQR = 10). At baseline, the median ISAR was 2 and CFS was 5. The mortality rate was 5.4% and the rate of ED re-attendance was 16.9% at one month. The relative risk of ED re-admission with an ISAR score ≥ 2 was 1.84 (1.12, 3.02) and CFS &gt; 4 was 1.85 (1.08, 3.16). The ISAR tool ≥2 had a sensitivity of 74% (95% CI = 62.44, 83.99) and specificity of 41% (95% CI = 35.90, 46.61) when used as a diagnostic tool for ED re-admission at one month. The CFS &gt; 4 had a sensitivity of 71% (95% CI = 57.79, 82.70) and specificity of 45% (95% CI = 39.33, 51.23) for ED re-attendance.

Conclusion

The ISAR tool ≥2 was more sensitive at predicting ED reattendance at one month in comparison to the CFS. We advocate to use this tool in the ED setting to highlight those at greatest risk of adverse outcomes and those most likely to benefit from Comprehensive Geriatric Assessment.

Prehospital whole blood reduces early mortality in patients with hemorrhagic shock

BACKGROUND

Low titer O+ whole blood (LTOWB) is being increasingly used for resuscitation of hemorrhagic shock in military and civilian settings. The objective of this study was to identify the impact of prehospital LTOWB on survival for patients in shock receiving prehospital LTOWB transfusion.

STUDY DESIGN AND METHODS

A single institutional trauma registry was queried for patients undergoing prehospital transfusion between 2015 and 2019. Patients were stratified based on prehospital LTOWB transfusion (PHT) or no prehospital transfusion (NT). Outcomes measured included emergency department (ED), 6-h and hospital mortality, change in shock index (SI), and incidence of massive transfusion. Statistical analyses were performed.

RESULTS

A total of 538 patients met inclusion criteria. Patients undergoing PHT had worse shock physiology (median SI 1.25 vs. 0.95, p < .001) with greater reversal of shock upon arrival (-0.28 vs. -0.002, p < .001). In a propensity-matched group of 214 patients with prehospital shock, 58 patients underwent PHT and 156 did not. Demographics were similar between the groups. Mean improvement in SI between scene and ED was greatest for patients in the PHT group with a lower trauma bay mortality (0% vs. 7%, p = .04). No survival benefit for patients in prehospital cardiac arrest receiving LTOWB was found (p > .05).

DISCUSSION

This study demonstrated that trauma patients who received prehospital LTOWB transfusion had a greater improvement in SI and a reduction in early mortality. Patient with prehospital cardiac arrest did not have an improvement in survival. These findings support LTOWB use in the prehospital setting. Further multi-institutional prospective studies are needed.

The interest of "ortho-plastic" collaboration in management of complex limb injury

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

The Impact of a Breast Cancer Diagnosis on Women´s Work Status

Background: Many women diagnosed with breast cancer are of working age at the time of diagnosis, so the impact of a diagnosis and treatment regimen on their lives can cause financial stress-partly by impacting on their ability to continue in paid employment. The financial fallout from not working, changes in employment status and the hidden costs associated with cancer treatment can add to financial toxicity. Aim: Our aim was to identify changes in work status after a diagnosis of breast cancer. Our secondary aim was to determine if there was a correlation between different treatment modalities and work status at 12 month follow-up. Finally, we wanted to consider the role of treatment and change in work status on the financial stress experienced by patients after their diagnosis and treatment. Methods: An audit of the medical record of women who present to Western Health with a diagnosis of early breast cancer and consequently attended the nurse led breast cancer survivorship clinic (SC) between October 2015 and October 2016 was performed to identify employment status at diagnosis and at review in SC 12 months later. Results: 114 patients attended the SC in a 1 year period- 2 were males and both retired at diagnosis. The records of 111 women were reviewed. 46 of the 84 women < 65 years, were in paid employment at diagnosis. 38 of these 46 women were working in some capacity at 12 month review though only 28 were working the same, having decreased hours since diagnosis. 17 of the 111 (15%) women reported financial stress at the 12 month review. 9 of the 19 (42%) women with changed work status reported financial stress. 2 of the 28 (7%) women working the same hours reported financial stress. 14 of the 19 (74%) women who had changed work status had chemotherapy. 65% of those who reported financial stress (11/17) had chemotherapy as part of their treatment. 10/19 (53%) had changed or stop working since axillary dissection. Conclusion: Our data suggest that 83% of women returned to work in some capacity- most at the same level, and these women were unlikely to report financial stress. Women who returned to work at reduced hours, increased hours, or did not return to work at all were more likely to report significant financial concerns at one year postdiagnosis. Health care professionals as part of ongoing care should be aware of the financial impact a cancer diagnosis and its treatments, and should aim to refer appropriately.

Assessment of the comparability of CLSI, EUCAST and Stokes antimicrobial susceptibility profiles for Escherichia coli uropathogenic isolates

BACKGROUND

As many clinical laboratories convert between Stokes, Clinical and Laboratory Standards Institute (CLSI) and European Committee for Antimicrobial Susceptibility Testing (EUCAST) methods, the problem of comparing differently derived sets of antimicrobial susceptibility testing (AST) data with each other arises, owing to a scarcity of knowledge of inter-method comparability. The purpose of the current study was to determine the comparability of CLSI, EUCAST and Stokes AST methods for determining susceptibility of uropathogenic Escherichia coli to ampicillin, amoxicillin-clavulanate, trimethoprim, cephradine/cephalexin, ciprofloxacin and nitrofurantoin.

METHODS

A total of 100 E. coli isolates were obtained from boric acid urine samples from patients attending GP surgeries. For EUCAST and CLSI, the Kirby-Bauer disc diffusion method was used and results interpreted using the respective breakpoint guidelines. For the Stokes method, direct susceptibility testing was performed on the urine samples.

RESULTS

The lowest levels of agreement were for amoxicillin-clavulanate (60%) and ciprofloxacin (89%) between the three AST methods, when using 2017 interpretive guidelines for CLSI and EUCAST. A comparison of EUCAST and CLSI without Stokes showed 82% agreement for amoxicillin-clavulanate and 94% agreement for ciprofloxacin. Discrepancies were compounded by varying breakpoint susceptibility guidelines issued during the period 2011-2017, and through the inclusion of a definition of intermediate susceptibility in some cases.

CONCLUSIONS

Our data indicate that the discrepancies generated through using different AST methods and different interpretive guidelines may result in confusion and inaccuracy when prescribing treatment for urinary tract infection.

Quantifying alcohol-related emergency admissions in a UK tertiary referral hospital: a cross-sectional study of chronic alcohol dependency and acute alcohol intoxication

OBJECTIVES

Alcohol is responsible for a proportion of emergency admissions to hospital, with acute alcohol intoxication and chronic alcohol dependency (CAD) implicated. This study aims to quantify the proportion of hospital admissions through our emergency department (ED) which were thought by the admitting doctor to be (largely or partially) a result of alcohol consumption.

SETTING

ED of a UK tertiary referral hospital.

PARTICIPANTS

All ED admissions occurring over 14 weeks from 1 September to 8 December 2012. Data obtained for 5497 of 5746 admissions (95.67%).

PRIMARY OUTCOME MEASURES

Proportion of emergency admissions related to alcohol as defined by the admitting ED clinician.

SECONDARY OUTCOME MEASURES

Proportion of emergency admissions due to alcohol diagnosed with acute alcohol intoxication or CAD according to ICD-10 criteria.

RESULTS

1152 (21.0%, 95% CI 19.9% to 22.0%) of emergency admissions were thought to be due to alcohol. 74.6% of patients admitted due to alcohol had CAD, and significantly greater than the 26.4% with 'Severe' or 'Very Severe' acute alcohol intoxication (p<0.001). Admissions due to alcohol differed to admissions not due to alcohol being on average younger (45 vs 56 years, p<0.001) more often male (73.4% vs 45.1% males, p<0.001) and more likely to have a diagnosis synonymous with alcohol or related to recreational drug use, pancreatitis, deliberate self-harm, head injury, gastritis, suicidal ideation, upper gastrointestinal bleeds or seizures (p<0.001). An increase in admissions due to alcohol on Saturdays reflects a surge in admissions with acute alcohol intoxication above the weekly average (p=0.003).

CONCLUSIONS

Alcohol was thought to be implicated in 21% of emergency admissions in this cohort. CAD is responsible for a significantly greater proportion of admissions due to alcohol than acute intoxication. Interventions designed to reduce alcohol-related admissions must incorporate measures to tackle CAD.

Current management options for the small renal mass in a solitary kidney

The widespread use of cross-sectional imaging has resulted in an increase in the frequency of incidentally identified small renal masses (SRMs). With high cancer-specific survival rates following radical nephrectomy, there is an increasing patient cohort at risk of developing a metachronous contralateral tumour. Nephron-sparing surgery (NSS) has been shown to reduce progression of chronic kidney disease, being the impetus to utilize NSS for the management of SRMs in an anatomical or functional solitary kidney. At present, open partial nephrectomy is the gold standard treatment for an SRM in a solitary kidney; however, there are a number of other minimally invasive options, including laparoscopic partial nephrectomy, and in situ ablative procedures. In addition, variables such as warm and cold ischaemia and renal vascular clamping have been shown to affect outcomes. In this review, we summarize contemporary management options focusing specifically on oncological and functional outcomes.

The effect of temperature and humidity on the permeability of film dressings

The moisture vapour permeability of a dressing can make an important contribution to its overall fluid handling capacity. Despite the fact that this parameter is often quoted in scientific literature and manufacturers' promotional material, it is a concept that is not generally well understood. In particular, the effect of changing environmental conditions upon experimentally determined permeability values for particular dressings is rarely acknowledged. The present study was undertaken to derive and validate a method that could be used to predict the permeability of a self-adhesive semipermeable film dressing under specific conditions of temperature and humidity using a single set of data generated in the laboratory. A calculator that facilitates this process is also described.

Clinical signs and symptoms of oropharyngeal aspiration and dysphagia in children

The diagnostic value of various signs and symptoms (clinical markers) in predicting oropharyngeal aspiration (OPA) or swallowing dysfunction has not been established in children. The present retrospective study was undertaken to: 1) identify specific clinical markers associated with radiographic evidence of OPA, isolated laryngeal penetration (ILP) and post-swallow residue (PSR); 2) determine the sensitivity and specificity of clinical markers associated with OPA; and 3) determine the influence of age and neurological impairment on clinical markers of OPA. In total, 11 clinical markers of dysphagia were compared with the videofluoroscopic swallow study (VFSS) results (OPA, ILP and PSR) in 150 children on diets of thin fluid and purée consistencies. Chi-squared and logistic regression were used to analyse the association between clinical markers and VFSS-identified swallowing dysfunction. In children with OPA, wet voice (odds ratio (OR) 8.90, 95% confidence interval (CI) 2.87-27.62), wet breathing (OR 3.35, 95% CI 1.09-10.28) and cough (OR 3.30, 95% CI 1.17-9.27) were significantly associated with thin fluid OPA. Predictive values included: wet voice (sensitivity 0.67; specificity 0.92); wet breathing (sensitivity 0.33; specificity 0.83); and cough (sensitivity 0.67; specificity 0.53). No clinical markers were significantly associated with OPA, ILP or PSR on the purée consistency. Cough was significantly associated with PSR on thin fluids (OR 3.59, 95% CI 1.22-10.55). Differences were found for age. Wet voice, wet breathing and cough were good clinical markers for children with oropharyngeal aspiration on thin fluid but not on purée. Age and neurological status influenced the significance of these clinical markers.

Characterization of two New York City Jewish populations at six short tandem repeat loci

The Hasidic and non-Hasidic Jewish communities of New York City represent two subpopulations with long-documented histories of restrictive marriage patterns and a high degree of endogamy. As part of a continuing study into their genetic structure, allele frequencies were determined for the six tetrameric short tandem repeat (STR) loci: FESFPS, F13AO1, vWA, CSF1PO, TPOX, and THO1. All loci were tested for Hardy-Weinberg equilibrium (HWE) by three tests: chi-square analysis, Monte Carlo chi-square analysis. and the exact test. The non-Hasidic population failed to meet HWE at the F13A01, FESFPS, and CSF1PO loci by all three tests. The Hasidic population also failed to meet HWE at the same loci by some of the tests. Comparison of the Hasidic to the non-Hasidic population using an R x C contingency table demonstrated a similarity at only the vWA locus. Significant differences exist when comparing the two Jewish populations to a reference Caucasian population.

Geographical differences in primary therapy for early-stage breast cancer

BACKGROUND

Breast-conserving surgery may not be uniformly available to all women. We evaluated geographical differences across Connecticut in the proportions of cases with early stage breast cancer treated by partial mastectomy (PM). We also looked at geographical variation in PM with axillary lymph node dissection (AND) and PM with adjuvant radiotherapy (RAD).

METHODS

The Connecticut Tumor Registry identified 9106 cases of early disease for 1991 to 1995. Latitude-longitude coordinates for place of residence at diagnosis and initial form of therapy were available for 8795 records. A spatial scan statistic was used to detect geographical differences in treatment rates across the state.

RESULTS

A total of 57.7% of early breast cancer cases were treated by PM. Women living around New Haven were less likely than others to be treated in that manner (relative risk [RR] = .86; P = .0001), whereas those living around Norwalk were more likely (RR = 1.26; P = .0001). PM with AND, relative to PM alone, was reported less often for cases from a large area of southwestern Connecticut (RR = .89; P = .0001), but more often for those in north central Connecticut (RR = 1.13; P = .0001). PM with RAD, relative to PM alone, was less common for cases around Danbury (RR = .40; P = .0001) but more common among cases around Hartford (RR = 1.14; P = .0001).

CONCLUSIONS

Geographical analysis is a way for physicians and health officials to identify groups of women who may not yet benefit from preferred surgical procedures.

The effects of elevated intraabdominal pressure, hypercarbia, and positioning on the hemodynamic responses to laparoscopic colectomy in pigs

BACKGROUND

This study investigated three factors postulated to be sources of physiological stress in laparoscopic surgery: hypercarbia, elevated intraabdominal pressure, and the steep Trendelenburg position. Our research was designed to define the effects of each of these potential stressors on hemodynamic responses observed during laparoscopic colectomy in pigs.

METHODS

Twenty-four pigs were randomized into the following four groups, based on the method for obtaining surgical exposure while a colectomy or laparoscopic-assisted colectomy was performed: Open surgery (n = 6), CO2 pneumoperitoneum (n = 6), Helium pneumoperitoneum (n = 6), and abdominal wall Lifter (n = 6). The animals were paralyzed with minute ventilation adjusted. All animals underwent extensive pulmonary and hemodynamic monitoring with measurements of the following parameters: RR, Vt, minute ventilation, O2, sat, ETCO2, PVR, HR, MAP, CO, PAP, CVP, PCWP, SV, LVSWI, DO2, and VO2. The laparoscopic pigs were placed in the steep Trendelenburg position during surgery.

RESULTS

The effect of a CO pneumoperitoneum was to increase PaCO2 PVR and cause an acidemia that could not be prevented by an increase in minute ventilation. Elevated intraabdominal pressure decreased UO. Both pneumoperitoneum groups had a fourfold increase in IVCP, a measure of intraabdominal pressure. Some of this increase was due to placement into the Trendelenburg position; IVCP increased to a lesser degree in the Lifter group. The steep Trendelenburg position caused significant increases in PAP, CVP, and PCWP; however, a contributory effect of elevated intraabdominal pressure cannot be ruled out. None of these procedures had any significant effect on the HR or MAP. There was a significant increase in CO in the CO2 and Lifter groups; however, when CO was controlled for HR effects, there was no significant effect on SV from any of these different procedures. LVSWI, DO2, and VO2 were not affected by any of the different exposure methods.

CONCLUSIONS

The effects of laparoscopic surgery and open surgery on hemodynamic responses are minimal, and no one method is superior to another when performed in pigs that are healthy, hydrated, and hyperventilated to keep ETCO2 < 40. However, since elderly and sick patients have a lower threshold for physiologic decompensation, we can infer that the small hemodynamic changes noted in this study might become significant factors when surgery is performed on compromised patients. The finding that an abdominal wall lifting device causes the fewest metabolic and hemodynamic effects makes its use an important consideration when performing laparoscopic surgery in patients with cardiopulmonary compromise, hemodynamic instability, or any preexisting renal insufficiency.

A prospective comparison of laparoscopic exposure techniques for rectal mobilization and sigmoid resection

BACKGROUND

We determined the efficacy of a pneumoperitoneum and a gasless abdominal wall lifting device in providing exposure for low rectal mobilization and sigmoid resection in a swine model. The results of these laparoscopic techniques were compared with those obtained using standard open surgical methods.

STUDY DESIGN

We conducted a prospective randomized nonblinded trial. Twenty-four adult female pigs were randomized into three groups depending on exposure technique: group 1, open (n = 6); group 2, carbon dioxide (n = 6) or helium (n = 6) pneumoperitoneum; and group 3, a mechanical abdominal wall lifting device (n = 6). A low rectal mobilization and sigmoid resection with a double-stapled, circular, end-to-end anastomosis was performed in all pigs. In group 2, a laparoscopic-assisted approach was used. Parameters assessed included length of operation, length of the colonic specimen, number of lymph nodes per specimen, and extent of anterior and posterior rectal mobilization (centimeters from the anal verge).

RESULTS

Operative times were significantly shorter for group 1 than for group 2; no significant differences were found between the two laparoscopic subgroups. No significant difference was found in length of the colonic specimen or in number of lymph nodes harvested for each group. Extent of anterior and posterior rectal mobilization was also not significantly different for the three groups. Although mean mobilization lengths for each group were not significantly different, the range of values was broader in the laparoscopic groups.

CONCLUSIONS

A comparable mobilization and bowel resection can be performed laparoscopically, regardless of the exposure technique used. Gasless laparoscopy may prove useful in patients in whom pneumoperitoneum is contraindicated; it will not replace pneumoperitoneum as the only method for obtaining laparoscopic exposure because of the ease of use and frank superiority of the pneumoperitoneum in most circumstances. Abdominal wall lifting devices seem to be a reasonable alternative to pneumoperitoneum for sigmoid resection and rectal mobilization.

Smoking prevalence among perinatal women: the role of socioeconomic status, race, and ethnicity

Baseline data were collected as part of an intervention project designed to reduce substance abuse among pregnant and postpartum women in Waterbury. Personal interviews, including questions on smoking behavior were conducted with a sample of 503 perinatal women. African American and Hispanic women represented respectively 11.8% and 10.2% of the population. Twenty-six percent of respondents reported they smoked cigarettes during pregnancy which exceeds the nationally comparable rate of 19.1%. Socioeconomic status was a stronger predictor of smoking status than other sociodemographic variables. Logistic regression analysis showed that lower socioeconomic status women were 3.7 times (P < .001) more likely to smoke during pregnancy than their higher status counterparts. Hispanics were 70% (P < .01) less likely to smoke than Whites and there were no significant differences between respondents based on race, marital status, age, or source of prenatal care. The authors conclude that smoking during pregnancy continues to be a major problem requiring multifaceted interventions and attention to underlying structural factors.

The use of bupivacaine in elective inguinal herniorrhaphy as a fast and safe technique for relief of postoperative pain

The intraoperative use of local anesthetic agents to decrease postoperative pain has been used in many types of procedures. Most of these techniques involve needle injection of anesthetic and result in a low but troublesome incidence of complications. In this study, we evaluated the reliability, safety, and efficacy of a technique emphasizing bathing of tissues with anesthetic rather than needle injection for relieving postoperative pain. Thirty consecutive patients undergoing outpatient elective inguinal herniorrhaphy with general anesthetic were prospectively randomized into four treatment groups. Group 1 received 0.5 per cent bupivacaine plus epinephrine 1 to 200,000; group 2, 0.5 per cent bupivacaine; group 3, normal saline solution, and group 4, no treatment. At the end of the repair, one-third of the test solution (approximately 5 milliliters) was bathed along the spermatic cord throughout its length in the inguinal canal. The external oblique aponeurosis was closed superficial to the cord structures and another one-third of the solution was instilled into the wound. Just prior to the end of skin closure the remaining solution was instilled subcutaneously. No needles were used to instill the solutions and they were not suctioned or removed from the wound. Data collection consisted of an analog type of patient questionnaire allowing subjective assessment of postoperative pain at various time intervals during the first 20 hours postoperatively. Pain medication provided was propoxyphene, 100 milligrams and acetaminophen, 650 milligrams every three hours as needed. Total doses of pain medication for the study period and the time to first pain medication requirement were obtained. Results were analyzed using analysis of variance, and Wilcoxon ranked sums test. Patients in group 1 (0.5 per cent bupivacaine with epinephrine) exhibited significantly less pain than those in groups 3 (saline solution) and 4 (control) for more than 12 hours postoperatively. Patients in group 2 (0.5 per cent bupivacaine) likewise experienced less pain than those in groups 3 and 4 through seven hours. The patients receiving saline solution were not significantly different than those in the control group throughout. Objectively, groups 1 and 2 required fewer total doses of pain medication and waited longer before requesting oral pain medication postoperatively compared with those in the control group. No complications occurred that could be attributed to the technique. The results of this study indicate that the bathing of wounds with 0.5 per cent bupivacaine with or without epinephrine 1:200,000 is a safe and effective method of decreasing postoperative pain for several hours in patients undergoing elective inguinal herniorrhaphy.(ABSTRACT TRUNCATED AT 400 WORDS)

Health promotion--a focus for hospitals

A hospital is in a unique position, both as a service provider and an employer, to provide a focus for disease prevention and health maintenance based on a greater understanding of the relationship between social and physical environment and lifestyle factors on health. Developing hospitals to become a resource for health instead of merely another link in the sick-care chain requires a substantial change in philosophy, management and practice. Reaching out into the community, establishing new and different relationships with consumers, and creating an environment conducive to healthy behaviour are only some of the changes necessary to reflect a health promotion focus. This paper discusses the experiences of establishing, developing and maintaining health promotion services at Flinders Medical Centre.

The treatment of tumors by the induction of anemia and irradiation in hyperbaric oxygen

Because increased effects have been achieved when murine tumors are irradiated after a period of hypoxia and because of anecdotal clinical experiences of an improved result after irradiation of previously anemic patients in hyperbaric oxygen, the relationship between irradiation and increased survival was investigated in seventy-two patients with advanced head and neck or cervical cancer. Anemia was achieved by means of a two-stage isovolemic venesection maintained for seventy-two hours, hemoglobin was returned to a normal level, and treatment in hyperbaric oxygen was started. Marked tumor shrinkage after the induction of anemia and before radiotherapy was seen and was probably disease, site, and hemoglobin level related. As a result, a possible new approach to cancer therapy is suggested. After completion of therapy, the 1-year disease-free survival for patients with head and neck and cervical cancer was not improved, but the 21-month survival for cervical cancer was improved. Further studies are strongly urged.

Cavernous haemangioma of the head and neck in the adult

This paper reviews a personal experience of 51 cases seen over a 30 year period. Patients were treated in either a combined Head and Neck clinic or a Combined Ophthalmology clinic and a balanced view is thus represented. A method of grading the severity of the disease is described as well as a method of assessing response. This approach has not been proposed hitherto. It is generally concluded that the preferred treatment for small lesions is excisional surgery and for larger lesions carefully planned and highly localized radiation.

Interstitial misonidazole: clinical experience in advanced mouth cancer

In an attempt to obtain full radiosensitisation and avoid dose-limiting neurotoxicity, a needle has been specially developed for the injection of misonidazole pellets into tumours. The methods of production and insertion of the pellets are described. Thirteen advanced, untreated squamous carcinomas of the mouth were injected and then irradiated to tolerance. Twelve out of 13 implanted lesions had completely regressed at the end of treatment but only six remained healed after 1 year.

A feasibility study of a new approach to clinical radiosensitisation: hypothermia and hyperbaric oxygen in combination with pharmacological vasodilatation

It is proposed that hyperbaric oxygen fails in the clinical situation due to a high proportion (greater than 33%) of hypoxic cells in human tumours. The means of overcoming this problem are reviewed. Additional to hyperbaric oxygenation, moderate hypothermia (30 degrees C) to allow redistribution of oxygen in the tumour is proposed. A system of externally controlled intravenous anaesthesia has been developed for the single-subject hyperbaric cylinder. Pharmacological vasodilatation is induced in the anaesthetised patient who is then fluid loaded and cooled. Initial single-sensitising treatments are advocated. Twenty-nine patients with advanced mouth cancer have completed a course of this treatment, of whom five of nine were free of disease after 2 years and 10 of 21 at 1 year, with three intercurrent deaths. Fifteen have experienced local failure. This approach would appear to be practical, safe and promising.

Irradiation with misonidazole and hyperbaric oxygen: final report on a randomized trial in advanced head and neck cancer

One hundred and thirty patients with locally advanced squamous carcinoma of the head and neck were treated in a prospective randomized trial to compare conventional irradiation (63.00 Gy in 30 fractions) with a combination sensitizer regimen of misonidazole and hyperbaric oxygen. The drug (2.0 gm/m2) was given with each of six fractions of 6.0 Gy in hyperbaric oxygen at 3 ATA. The results support a previous study and favor the combination at 1 year at better than the 10% level. This regimen could be useful for bulky primary or nodal disease.

Immunoreactive LRF neurosecretory pathways in mammals

Using antisera to synthetic luteinizing hormone-releasing factor (LRF) and antisera labeled with fluorescein isothiocyanate or peroxidase, it was possible in various physiological and experimental conditions to determine the topography of the LRF secretory cells in the guinea pig. The axons of these cells form a preoptico-infundibular LRF pathway, which controls the prehypophyseal gonadotropic secretion, and various "extrahypophyseal pathways". These latter suggest that LRF, in addition to its prehypophysiotropic action, may have a neuromodulator function.