Search

Objective: To evaluate whether early age of first exposure to contact sports (AFE-CS) is associated with worse long-term brain health outcomes., Design: A cross-sectional, survey study of older men with a history of contact sport participation was completed., Setting: Tertiary care facility., Participants: A cohort of community-dwelling older men dichotomized by using AFE-CS (<12 years vs ≥12 years)., Interventions: Independent variables included a dichotomized group of AFE-CS (<12 years vs ≥12 years)., Main Outcome Measures: Brain health outcomes measured by depression, anxiety, cognitive difficulties, and neurobehavioral symptoms. Endorsements of general health problems, motor symptoms, and psychiatric history were also collected. Age of first exposure groups was compared using t tests, χ 2 tests, and multivariable linear regressions, which included the following covariates: age, number of prior concussions, and total years of contact sport., Results: Of 69 men aged 70.5 ± 8.0 years, approximately one-third of the sample (34.8%) reported AFE-CS before age 12 years. That group had more years of contact sports (10.8 ± 9.2 years) compared with those with AFE-CS ≥12 (5.6 ± 4.5 years; P = 0.02). No differences were found after univariate testing between AFE-CS groups on all outcomes ( P -values >0.05). Multivariable models suggest that AFE-CS is not a predictor of depression or anxiety. Those in the AFE-CS <12 group had fewer cognitive difficulties ( P = 0.03) and fewer neurobehavioral symptoms ( P = 0.03)., Conclusions: Those with AFE-CS <12 to contact sports did not have worse long-term brain health outcomes compared with those with AFE-CS ≥12. Individuals with AFE-CS <12 had significantly lower British Columbia Cognitive Complaints Inventory and Neurobehavioral Symptom Inventory scores compared with those with AFE-CS ≥12., Clinical Relevance: The benefits of earlier AFE-CS may outweigh the risks of head strikes and result in comparable long-term brain health outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The purpose of this study is to examine and characterize patterns of injury to the upper extremity caused by fireworks in a nationally representative sample of emergency department patients from 2011 to 2020., Methods: The National Electronic Injury Surveillance System was queried for upper-extremity injuries caused by fireworks between 2011 and 2020., Results: One thousand two hundred fifty-one injuries were identified from the database representing 47,235 national cases that presented to emergency departments in the United States. Case frequency was stable during the period until 2020, which was nearly 70% higher than the previous 9-y average. Patients were generally young and male, with most cases in the 10-29-y age group and males over three times as likely to be injured as females. The most common injury was burn, and the week of July 4th accounted for 53% of cases alone. Diagnosis was also significantly associated with device type., Conclusions: These data can be used to target prevention measures and campaigns to specific patient populations most at risk of injury, specifically young males. They may also be used to highlight the impact of policy changes on availability of fireworks, the need for public health education coinciding with injury incidence peaks, and secondary pandemic effects., (Published by Elsevier Inc.)

Introduction: Repeat sport-related concussion (SRC) is anecdotally associated with prolonged recovery. Few studies have examined repeat concussion within the same athlete. We sought to explore differences in symptom burden and recovery outcomes in an individual athlete's initial and repeat SRC., Methods: A retrospective within-subject cohort study of athletes aged 12-23 years diagnosed with two separate SRCs from 11/2017-10/2020 was conducted. Primary outcomes were initial symptom severity and time-to-symptom-resolution. Secondary outcomes included return-to-learn (RTL) and return-to-play (RTP) duration., Results: Of 868 athletes seen, 47 athletes presented with repeat concussions. Median time between concussions was 244 days (IQR 136-395). Comparing initial to repeat concussion, no differences were observed in time-to-clinic (4.3 ± 7.3vs.3.7 ± 4.6 days, p  = 0.56) or initial PCSS (26.2 ± 25.3 vs. 30.5 ± 24.1, p  = 0.32). While a difference was observed in time-to-symptom resolution between initial/repeat concussion (21.2 ± 16.3 vs. 41.7 ± 86.0 days, p  = 0.30), this did not reach statistical significance. No significant differences were observed in time-to-RTL (17.8 ± 60.6 vs. 6.0 ± 8.3 days, p  = 0.26) and RTP (33.2 ± 44.1 vs. 29.4 ± 39.1 days, p  = 0.75). Repeat concussion was not associated with symptom resolution on univariate (HR 1.64, 95% CI 0.96-2.78, p  = 0.07) and multivariable (HR 0.85, 95% CI 0.49-1.46, p  = 0.55) Cox regression., Conclusion: No significant differences in symptom duration and RTP/RTL were seen between initial/repeat concussion.

Pyomyositis is an acute bacterial infection of the skeletal muscle that is commonly associated with localized abscess formation. It is estimated that pyomyositis accounts for up to 4% of all hospital admissions throughout Asia, tropical Africa, Oceania and the Caribbean Islands. However, there has been an increasing emergence of pyomyositis in temperate climates and high-income countries. Staphylococcus aureus is the most common organism implicated. Management requires a high index of clinical suspicion, prompt diagnosis and early management to prevent sequalae that can be fatal if left untreated. We describe an interesting case of pyomyositis in an otherwise fit and immunocompetent individual causing mediastinitis; a rare sequalae of the disease. Percutaneous drainage of his left pectoral abscess and a prolonged course of antibiotics provided complete clinical and radiological resolution of the disease despite mediastinal extension. Here we discuss aetiology, associations, pathophysiology and epidemiology of pyomyositis with associated sequalae of the disease., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2022.)

Objective: Adolescents sustaining sport-related concussion often experience difficulties with the return-to-learn (RTL) process. Whereas the initial symptom burden has predicted prolonged RTL, no studies have established a relationship between acute cognitive symptoms and RTL duration. The authors sought to evaluate the relationship between initial cognitive symptoms and RTL duration., Methods: A retrospective single-institution cohort study of adolescent athletes aged 12-23 years who were evaluated within 5 days of a diagnosed sport-related concussion between November 2017 and October 2020 was conducted. Athletes missing cognitive symptom ratings and RTL data were excluded. The primary exposure variable was the Cognitive Symptom Ratio (CSR), defined as total cognitive symptom cluster score divided by total Post-Concussion Symptom Scale (PCSS) score from the initial clinic visit. Primary and secondary outcomes were time to RTL and total length of care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of CSR on RTL duration., Results: Of 653 athletes evaluated within 5 days of injury, 346 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (interquartile range [IQR] 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of difficulty concentrating (n = 212, 61.3%). The median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, a higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = 0.004). When initial PCSS score was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = 0.367). When dichotomized based on frequency distribution, a higher proportion of patients with low CSR achieved RTL by 7 days postinjury (82.2% vs 69.9%, p = 0.007), a difference not seen at 14 days (92.2% vs 87.3%, p = 0.133)., Conclusions: An acute ratio of cognitive symptoms may predict patients at increased risk for prolonged RTL and those with normal PCSS scores who may experience difficulties once resuming school activities.

Background: Both the Canadian Cardiovascular Society (CCS) and the Canadian Association of Emergency Physicians (CAEP) have published documents to guide atrial fibrillation (AF) management. In 2021, the CAEP updated its AF checklist. Prior to this update, the recommendations of the 2 organizations differed in several key areas, including the suggested cardioversion timeframe, the factors determining cardioversion eligibility, and anticoagulant initiation after cardioversion. Whether emergency physicians (EPs) are aware of, or adhering to, one, both, or neither of these documents is unknown., Methods: We assessed document awareness, adherence, and EP practice using a piloted questionnaire administered to EPs at 5 emergency departments in 3 provinces., Results: Of 166 survey recipients, 123 (74.1%) responded. The majority (64.7%) worked at an academic site, 38.8% identified as female, and median years in practice was 10.0. Most (93.1%) were aware of at least one of the documents; 45.7% were aware of both. Reported awareness was higher for the CCS (77.6%) vs the CAEP (61.2%) guidelines. Respondents varied in their adherence, with 40.5% using parts of both documents. Considerable practice variability occurred when recommendations conflicted. Despite its use not being recommended by either organization, half of respondents (50.0%) reported using the CHA 2 DS 2 -VASc score as their stroke-risk assessment tool., Conclusions: Although most surveyed EPs were aware of at least one organization's AF documents, many reported using parts of both. When recommendations conflicted, EPs were divided in their decision-making. These findings emphasize the need to improve consensus between organizations and further improve knowledge translation., (© 2022 The Authors.)

Background: The heart has an intrinsic ability to regenerate, orchestrated by progenitor or stem cells. However, the relative complexity of non-resident cardiac progenitor cell (CPC) therapy makes modulation of resident CPCs a more attractive treatment target. Thiamine analogues improve resident CPC function in pre-clinical models. In this double blinded randomised controlled trial (identifier: ACTRN12614000755639), we examined whether thiamine would improve CPC function in humans., Methods and Results: High dose oral thiamine (one gram twice daily) or matching placebo was administered 3-5 days prior to coronary artery bypass surgery (CABG). Right atrial appendages were collected at the time of CABG, and CPCs isolated. There was no difference in the primary outcome (proliferation ability of CPCs) between treatment groups. Older age was not associated with decreased proliferation ability. In exploratory analyses, isolated CPCs in the thiamine group showed an increase in the proportion of CD34 - /CD105 + (endoglin) cells, but no difference in CD34 - /CD90 + or CD34 + cells. Thiamine increased maximum force developed by isolated trabeculae, with no difference in relaxation time or beta-adrenergic responsiveness., Conclusion: Thiamine does not improve proliferation ability of CPC in patients undergoing CABG, but increases the proportion of CD34 - /CD105 + cells. Having not met its primary endpoint, this study provides the impetus to re-examine CPC biology prior to any clinical outcome-based trial examining potential beneficial cardiovascular effects of thiamine., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Long-chain acylcarnitines (LCACs) are known to directly alter cardiac contractility and electrophysiology. However, the acute effect of LCACs on human cardiac function is unknown. We aimed to determine the effect of LCAC 18:1, which has been associated with cardiovascular disease, on the contractility and arrhythmia susceptibility of human atrial myocardium. Additionally, we aimed to assess how LCAC 18:1 alters Ca 2+ influx and spontaneous Ca 2+ release in vitro. Human right atrial trabeculae ( n = 32) stimulated at 1 Hz were treated with LCAC 18:1 at a range of concentrations (1-25 µM) for a 45-min period. Exposure to the LCAC induced a dose-dependent positive inotropic effect on myocardial contractility (maximal 1.5-fold increase vs. control). At the 25 µM dose ( n = 8), this was paralleled by an enhanced propensity for spontaneous contractions (50% increase). Furthermore, all LCAC 18:1 effects on myocardial function were reversed following LCAC 18:1 washout. In fluo-4-AM-loaded HEK293 cells, LCAC 18:1 dose dependently increased cytosolic Ca 2+ influx relative to vehicle controls and the short-chain acylcarnitine C3. In HEK293 cells expressing ryanodine receptor (RyR2), this increased Ca 2+ influx was linked to an increased propensity for RyR2-mediated spontaneous Ca 2+ release events. Our study is the first to show that LCAC 18:1 directly and acutely alters human myocardial function and in vitro Ca 2+ handling. The metabolite promotes proarrhythmic muscle contractions and increases contractility. The exploratory findings in vitro suggest that LCAC 18:1 increases proarrhythmic RyR2-mediated spontaneous Ca 2+ release propensity. The direct effects of metabolites on human myocardial function are essential to understand cardiometabolic dysfunction. NEW & NOTEWORTHY For the first time, the fatty acid metabolite, long-chain acylcarnitine 18:1, is shown to acutely increase the arrhythmia susceptibility and contractility of human atrial myocardium. In vitro, this was linked to an influx of Ca 2+ and an enhanced propensity for spontaneous RyR2-mediated Ca 2+ release.

Objective: To develop pragmatic recommendations for starting, building and sustaining a program of research in emergency medicine (EM) in Canada at sites with limited infrastructure and/or prior research experience., Methods: At the direction of the Canadian Association of Emergency Physicians (CAEP) academic section, we assembled an expert panel of 10 EM researchers with experience building programs of research. Using a modified Delphi approach, our panel developed initial recommendations for (1) starting, (2) building, and (3) sustaining a program of research in EM. These recommendations were peer-reviewed by emergency physicians and researchers from each of the panelist's home institutions and tested for face and construct validity, as well as ease of comprehension. The recommendations were then iteratively revised based on feedback and suggestions from peer review and amended again after being presented at the 2020 CAEP academic symposium., Results: Our panel created 15 pragmatic recommendations for those intending to start (formal research training, find mentors, local support, develop a niche, start small), build (funding, build a team, collaborate, publish, expect failure) and sustain (become a mentor, obtain leadership roles, lead national studies, gain influence, prioritize wellness) a program of EM research in centers without an established research culture. Additionally, we suggest four recommendations for department leads aiming to foster a program of research within their departments., Conclusion: These recommendations serve as guidance for centres wanting to establish a program of research in EM.

The release of Ca 2+ by ryanodine receptor (RyR2) channels is critical for cardiac function. However, abnormal RyR2 activity has been linked to the development of arrhythmias, including increased spontaneous Ca 2+ release in human atrial fibrillation (AF). Clustering properties of RyR2 have been suggested to alter the activity of the channel, with remodeling of RyR2 clusters identified in pre-clinical models of AF and heart failure. Whether such remodeling occurs in human cardiac disease remains unclear. This study aimed to investigate the nanoscale organization of RyR2 clusters in AF patients - the first known study to examine this potential remodeling in diseased human cardiomyocytes. Right atrial appendage from cardiac surgery patients with paroxysmal or persistent AF, or without AF (non-AF) were examined using super-resolution (dSTORM) imaging. Significant atrial dilation and cardiomyocyte hypertrophy was observed in persistent AF patients compared to non-AF, with these two parameters significantly correlated. Interestingly, the clustering properties of RyR2 were remarkably unaltered in the AF patients. No significant differences were identified in cluster size (mean ∼18 RyR2 channels), density or channel packing within clusters between patient groups. The spatial organization of clusters throughout the cardiomyocyte was also unchanged across the groups. RyR2 clustering properties did not significantly correlate with patient characteristics. In this first study to examine nanoscale RyR2 organization in human cardiac disease, these findings indicate that RyR2 cluster remodeling is not an underlying mechanism contributing to altered channel function and subsequent arrhythmogenesis in human AF., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Munro, van Hout, Aitken-Buck, Sugunesegran, Bhagwat, Davis, Lamberts, Coffey, Soeller and Jones.)

Diabetes is associated with cardiac metabolic disturbances and increased heart failure risk. Plasma fructose levels are elevated in diabetic patients. A direct role for fructose involvement in diabetic heart pathology has not been investigated. The goals of this study were to clinically evaluate links between myocardial fructose and sorbitol (a polyol pathway fructose precursor) levels with evidence of cardiac dysfunction, and to experimentally assess the cardiomyocyte mechanisms involved in mediating the metabolic effects of elevated fructose. Fructose and sorbitol levels were increased in right atrial appendage tissues of type 2 diabetic patients (2.8- and 1.5-fold increase respectively). Elevated cardiac fructose levels were confirmed in type 2 diabetic rats. Diastolic dysfunction (increased E/e', echocardiography) was significantly correlated with cardiac sorbitol levels. Elevated myocardial mRNA expression of the fructose-specific transporter, Glut5 (43% increase), and the key fructose-metabolizing enzyme, Fructokinase-A (50% increase) was observed in type 2 diabetic rats (Zucker diabetic fatty rat). In neonatal rat ventricular myocytes, fructose increased glycolytic capacity and cytosolic lipid inclusions (28% increase in lipid droplets/cell). This study provides the first evidence that elevated myocardial fructose and sorbitol are associated with diastolic dysfunction in diabetic patients. Experimental evidence suggests that fructose promotes the formation of cardiomyocyte cytosolic lipid inclusions, and may contribute to lipotoxicity in the diabetic heart.

Introduction: One in nine (11.7%) people in Saskatchewan identify as First Nations. It is known that First Nations people have a higher burden of cardiovascular disease, but not whether outcomes of out of hospital cardiac arrest are different., Methods/methodology: We reviewed pre-hospital and inpatient records of patients with out of hospital cardiac arrest between January 1st, 2015 and December 31st, 2017. The population consisted of patients aged 18 years or older with out of hospital cardiac arrest of presumed cardiac origin occurring in the catchment area of Saskatoon's emergency medical services (EMS). Variables of interest included age, gender, First Nations status, EMS response times, bystander cardiopulmonary resuscitation (CPR), and shockable rhythm. Outcomes of interest included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge., Results: In all, 372 patients sustained out of hospital cardiac arrest, of which 27 were status First Nations. There were no differences between First Nations and non-First Nations patients in terms of shockable rhythms (24% vs 26%; p = 0.80), ROSC (42% vs 41%; p = 0.87), survival to hospital admission (27% vs 33%; p = 0.53), and survival to hospital discharge (15% vs 12%; p = 0.54). First Nations patients with out of hospital cardiac arrest were significantly younger (mean age 46 vs. 65 years; p < 0.0001) and had shorter EMS response times (median times 5.3 vs. 6.2 min; p = 0.01) when compared to non-First Nations patients., Conclusions: In Saskatoon, First Nations patients with out of hospital cardiac arrest appear to have similar survival rates when compared with non-First Nations patients. However, First Nations patients sustaining out of hospital cardiac arrest were significantly younger than their non-First Nations counterparts. This highlights a significant public health issue.

The adipocytokine resistin is released from epicardial adipose tissue (EAT). Plasma resistin and EAT deposition are independently associated with atrial fibrillation. The EAT secretome enhances arrhythmia susceptibility and inotropy of human myocardium. Therefore, we aimed to determine the effect of resistin on the function of human myocardium and how resistin contributes to the proarrhythmic effect of EAT. EAT biopsies were obtained from 25 cardiac surgery patients. Resistin levels were measured by ELISA in 24-h EAT culture media ( n = 8). The secretome resistin concentrations increased over the culture period to a maximal level of 5.9 ± 1.2 ng/mL. Coculture with β-adrenergic agonists isoproterenol ( n = 4) and BRL37344 ( n = 13) had no effect on EAT resistin release. Addition of resistin (7, 12, 20 ng/mL) did not significantly increase the spontaneous contraction propensity of human atrial trabeculae ( n = 10) when given alone or in combination with isoproterenol. Resistin dose-dependently increased trabecula-developed force (maximal 2.9-fold increase, P < 0.0001), as well as the maximal rates of contraction (2.6-fold increase, P = 0.002) and relaxation (1.8-fold increase, P = 0.007). Additionally, the postrest potentiation capacity of human trabeculae was reduced at all resistin doses, suggesting that the inotropic effect induced by resistin might be due to altered sarcoplasmic reticulum Ca 2+ handling. EAT resistin release is not modulated by common arrhythmia triggers. Furthermore, exogenous resistin does not promote arrhythmic behavior in human atrial trabeculae. Resistin does, however, induce an acute dose-dependent positive inotropic and lusitropic effect.

Epicardial adipose tissue (EAT) deposition has a strong clinical association with atrial arrhythmias; however, whether a direct functional interaction exists between EAT and the myocardium to induce atrial arrhythmias is unknown. Therefore, we aimed to determine whether human EAT can be an acute trigger for arrhythmias in human atrial myocardium. Human trabeculae were obtained from right atrial appendages of patients who have had cardiac surgery ( n = 89). The propensity of spontaneous contractions (SCs) in the trabeculae (proxy for arrhythmias) was determined under physiological conditions and during known triggers of SCs (high Ca 2+ , β-adrenergic stimulation). To determine whether EAT could trigger SCs, trabeculae were exposed to superfusate of fresh human EAT, and medium of 24 h-cultured human EAT treated with β 1/2 (isoproterenol) or β 3 (BRL37344) adrenergic agonists. Without exposure to EAT, high Ca 2+ and β 1/2 -adrenergic stimulation acutely triggered SCs in, respectively, 47% and 55% of the trabeculae that previously were not spontaneously active. Acute β 3 -adrenergic stimulation did not trigger SCs. Exposure of trabeculae to either superfusate of fresh human EAT or untreated medium of 24 h-cultured human EAT did not induce SCs; however, specific β 3 -adrenergic stimulation of EAT did trigger SCs in the trabeculae, either when applied to fresh (31%) or cultured (50%) EAT. Additionally, fresh EAT increased trabecular contraction and relaxation, whereas media of cultured EAT only increased function when treated with the β 3 -adrenergic agonist. An acute functional interaction between human EAT and human atrial myocardium exists that increases the propensity for atrial arrhythmias, which depends on β 3 -adrenergic rather than β 1/2 -adrenergic stimulation of EAT.

Competing Interests: None

Objectives: Performing an extended Focused Assessment with Sonography in Trauma (eFAST) exam is common practice in the initial assessment of trauma patients. The objective of this study was to systematically review the published literature on diagnostic accuracy of all components of the eFAST exam., Methods: We searched Medline and Embase from inception through October 2018, for diagnostic studies examining the sensitivity and specificity of the eFAST exam. After removal of duplicates, 767 records remained for screening, of which 119 underwent full text review. Meta-DiSc™ software was used to create pooled sensitivities and specificities for included studies. Study quality was assessed using the Quality in Prognostic Studies (QUADAS-2) tool., Results: Seventy-five studies representing 24,350 patients satisfied our selection criteria. Studies were published between 1989 and 2017. Pooled sensitivities and specificities were calculated for the detection of pneumothorax (69% and 99% respectively), pericardial effusion (91% and 94% respectively), and intra-abdominal free fluid (74% and 98% respectively). Sub-group analysis was completed for detection of intra-abdominal free fluid in hypotensive (sensitivity 74% and specificity 95%), adult normotensive (sensitivity 76% and specificity 98%) and pediatric patients (sensitivity 71% and specificity 95%)., Conclusions: Our systematic review and meta-analysis suggests that e-FAST is a useful bedside tool for ruling in pneumothorax, pericardial effusion, and intra-abdominal free fluid in the trauma setting. Its usefulness as a rule-out tool is not supported by these results.

Background Massive transfusion protocols (MTP) aid in the efficient delivery of blood components to rapidly exsanguinating patients. Unfortunately, clinical gestalt and currently available clinical scoring systems lack the optimal accuracy to prevent blood product wastage (through over-activation), as well as individual patient morbidity and mortality (through under-activation). In order to help refine the MTP activation criteria and protocols, we surveyed clinicians on acceptable over- and under-activation rates for massive transfusions. Methods We surveyed Canadian content experts in their respective fields, using a snowball survey technique. Respondents were categorized into two groups: Group 1 was comprised of trauma and acute care specialists (TACS), while Group 2 was comprised of clinical and laboratory medicine specialists (CLMS). Between-group differences were examined using Fisher's exact test and the likelihood ratio. Statistical significance was set at p < 0.05. Results We received responses from 35 clinicians in the TACS group and 10 clinicians in the CLMS group. About half (45.7%) of respondents in the TACS group considered an MTP overactivation rate of 5% - 10% acceptable (vs. 60% of the CLMS group; not significant (NS)). Approximately one-third (34.2%) of the respondents in the TACS group considered an MTP under-activation rate of less than 5% acceptable, whereas the majority (60%) of respondents in the CLMS group considered an under-activation rate of less than 5% acceptable (NS). A significantly greater proportion of respondents in the TACS group felt that an anticipated need for > 20 units of packed red blood cells within the next 24 hours was an acceptable criterion for MTP activation. Respondents in the CLMS group were more likely to consider "poor communication" as a reason for blood component wastage. Conclusion Similarities in acceptable MTP over- and under-activation rates were noted across specialties. Collaboration between involved parties is necessary for MTP protocol development to improve patient outcomes and reduce blood wastage., Competing Interests: The authors have declared that no competing interests exist.

Objectives: The objective of this study was to systematically review the published literature for risk factors associated with adverse outcomes in older adults sustaining blunt chest trauma., Methods: EMBASE and MEDLINE were searched from inception until March 2017 for prognostic factors associated with adverse outcomes in older adults sustaining blunt chest trauma using a pre-specified search strategy. References were independently screened for inclusion by two reviewers. Study quality was assessed using the Quality in Prognostic Studies tool. Where appropriate, descriptive statistics were used to evaluate study characteristics and predictors of adverse outcomes., Results: Thirteen cohort studies representing 79,313 patients satisfied our selection criteria. Overall, 26 prognostic factors were examined across studies and were reported for morbidity (8 studies), length of stay (7 studies), mortality (6 studies), and loss of independence (1 study). No studies examined patient quality of life or emergency department recidivism. Prognostic factors associated with morbidity and mortality included age, number of rib fractures, and injury severity score. Although age and rib fractures were found to be associated with adverse outcomes in more than 3 studies, meta-analysis was not performed due to heterogeneity amongst included studies in how these variables were measured., Conclusions: While blunt chest wall trauma in older adults is relatively common, the literature on prognostic factors for adverse outcomes in this patient population remains inadequate due to a paucity of high quality studies and lack of consistent reporting standards.

Background: Antibiotics play an important role in the treatment of many surgical diseases that affect older adults, and the potential for inappropriate use of these drugs is high. Our objective was to describe antibiotic use among older adults admitted to an acute care surgery service at a tertiary care teaching hospital., Methods: Detailed data regarding diagnosis, comorbidities, surgery and antibiotic use were retrospectively collected for patients 70 years and older admitted to an acute care surgery service. We evaluated antibiotic use (perioperative prophylaxis and treatment) for appropriateness based on published guidelines., Results: During the study period 453 patients were admitted to the acute care surgery service, and 229 underwent surgery. The most common diagnoses were small bowel obstruction (27.2%) and acute cholecystitis (11.0%). In total 251 nonelective abdominal operations were performed, and perioperative antibiotic prophylaxis was appropriate in 49.5% of cases. The most common prophylaxis errors were incorrect timing (15.5%) and incorrect dose (12.4%). Overall 206 patients received treatment with antibiotics for their underlying disease process, and 44.2% received appropriate first-line drug therapy. The most common therapeutic errors were administration of second- or third-line antibiotics without indication (37.9%) and use of antibiotics when not indicated (12.1%). There was considerable variation in the duration of treatment for patients with the same diagnoses., Conclusion: Inappropriate antibiotic use was common among older patients admitted to an acute care surgery service. Quality improvement initiatives are needed to ensure patients receive optimal care in this complex hospital environment.

Objective: Critics have raised concerns regarding the validity of maintenance of certification (MOC) programs. We sought to examine the quality of the randomized controlled trials (RCTs) selected for the lifelong learning and self-assessment (LLS) component of the American Board of Emergency Medicine (ABEM) MOC program., Methods: We systematically reviewed the ABEM LLS reading lists from 2004 to 2017 to identify RCTs with dichotomous outcomes and superiority designs. A fragility index (FI) was calculated using Fisher's exact test for all statistically significant dichotomous outcomes. Bivariate correlation was performed to examine associations between the FI and RCT study characteristics. Each included study was evaluated with the Cochrane Collaboration risk-of-bias (ROB) tool., Results: Thirteen superiority RCTs with dichotomous outcomes were included in the 2004-2017 LLS reading lists. Ten had a statistically significant outcome, and the majority were robust and at low ROB. The median trial size was 511 patients (interquartile range [IQR] = 251-1,517), and the median FI was 10 (IQR = 7-18); i.e., if 10 patients in the treatment arm had not had events, the results would not have been statistically significant., Conclusions: The majority of RCTs included in the LLS are robust and at low ROB.

Background: Postoperative complications have been identified as an important and potentially preventable cause of increased hospital costs. While older adults are at increased risk of experiencing complications and other adverse events, very little research has specifically examined how these events impact inpatient costs. We sought to examine the association between postoperative complications, hospital mortality and loss of independence and direct inpatient health care costs in patients 70 years or older who underwent nonelective abdominal surgery., Methods: We prospectively enrolled consecutive patients 70 years or older who underwent nonelective abdominal surgery between July 1, 2011, and Sept. 30, 2012. Detailed patient-level data were collected regarding demographics, diagnosis, treatment and outcomes. Patient-level resource tracking was used to calculate direct hospital costs (2012 $CDN). We examined the association between complications, hospital mortality and loss of independence cost using multiple linear regression., Results: During the study period 212 patients underwent surgery. Overall, 51.9% of patients experienced a nonfatal complication (32.5% minor and 19.4% major), 6.6% died in hospital and 22.6% experienced a loss of independence. On multivariate analysis nonfatal complications (p < 0.001), hospital mortality (p = 0.021) and loss of independence at discharge (p < 0.001) were independently associated with health care costs. These adverse events respectively accounted for 30%, 4% and 10% of the total costs of hospital care., Conclusion: Adverse events were common after abdominal surgery in older adults and accounted for 44% of overall costs. This represents a substantial opportunity for better patient outcomes and cost savings with quality improvement strategies tailored to the needs of this high-risk surgical population.

Objective: To describe the change in residential status at discharge and 6 months after hospitalization among older adults who have undergone nonelective abdominal surgery and to identify risk factors associated with discharge to institution., Background: Surgery in older adults may lead to a loss of independence that prevents them from returning to their preadmission residential status. Understanding the impact of surgery on residential status and risk factors for institutionalization is important for patient counseling, discharge planning, and resource allocation., Methods: Community-dwelling patients aged 70 years and older who underwent nonelective abdominal surgery over a 15-month period were prospectively enrolled. Residential status before admission, at discharge, and 6 months after admission was assessed. Multiple logistic regression was used to identify factors associated with discharge to institution., Results: Of the 197 patients who underwent surgery and survived to discharge, 30% were living alone before admission and 70% were living with others. At discharge, 72% of patients returned to their preadmission residential status and 22% were institutionalized. Six months after hospitalization, 55% of institutionalized patients had returned to community-living, and 79% of all patients had returned to their preadmission residential status. Change in residential status was associated with decreased quality of life. Increasing American Society of Anesthesiologists score, frailty, surgery for malignancy, and postoperative complications were associated with discharge to institution., Conclusions: The majority of older patients, including those who were discharged to an institution, returned to their preadmission residential status 6 months after nonelective abdominal surgery.

Background: The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults., Methods: We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected., Results: Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant., Conclusion: These data suggest that some elderly patients with SBO may be waiting too long for surgery.

Nitric oxide (NO) and Ca(2+) are two of the many intracellular signal transduction pathways mediating the control of growth hormone (GH) secretion from somatotropes by neuroendocrine factors. We have previously shown that the NO donor sodium nitroprusside (SNP) elicits Ca(2+) signals in identified goldfish somatotropes. In this study, we examined the relationships between NO- and Ca(2+)-dependent signal transduction mechanisms in GH secretion from primary cultures of dispersed goldfish pituitary cells. Morphologically identified goldfish somatotropes stained positively for an NO-sensitive dye indicating they may be a source of NO production. In 2h static incubation experiments, GH release responses to the NO donor S-nitroso-N-acetyl-d,l-penicillamine (SNAP) were attenuated by CoCl2, nifedipine, verapamil, TMB-8, BHQ, and KN62. In column perifusion experiments, the ability of SNP to induce GH release was impaired in the presence of TMB-8, BHQ, caffeine, and thapsigargin, but not ryanodine. Caffeine-elicited GH secretion was not affected by the NO scavenger PTIO. These results suggest that NO-stimulated GH release is dependent on extracellular Ca(2+) availability and voltage-sensitive Ca(2+) channels, as well as intracellular Ca(2+) store(s) that possess BHQ- and/or thapsigargin-inhibited sarcoplasmic/endoplasmic reticulum Ca(2+)-ATPases, as well as TMB-8- and/or caffeine-sensitive, but not ryanodine-sensitive, Ca(2+)-release channels. Calmodulin kinase-II also likely participates in NO-elicited GH secretion but caffeine-induced GH release is not upstream of NO production. These findings provide insights into how NO actions many integrate with Ca(2+)-dependent signalling mechanisms in goldfish somatotropes and how such interactions may participate in the GH-releasing actions of regulators that utilize both NO- and Ca(2+)-dependent transduction pathways., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The mitral annulus can be rendered hostile by several uncommon clinical situations such as infective endocarditis, calcification, or previous valve surgery. These can all lead to difficulties seating a prosthesis or annuloplasty ring. The posterior mitral annulus or anteriorly the intervalvar fibrous body can be affected. These situations continue to pose a formidable technical challenge to the cardiac surgeon in the operating room. We review the evidence around solutions for these problems with the intent of giving surgeons an overview of techniques to address these issues., (Copyright © 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: In the United States, 37.5 % of adults (78 million) are obese. The direct medical costs of treating obesity-related disease account for more than 6 % of the national health expenditure. Robotic bariatric surgery is becoming more common, but it is unclear whether robotic procedures result in lower complication rates. Additionally, some evidence is conflicting regarding the costs of robotic Roux-en-Y gastric bypass (RYGB) compared with those of laparoscopic RYGB. This study aimed to compare complication rates, operative characteristics, and expected costs between robotic and laparoscopic RYGB., Methods: A systematic review of the literature was performed with searches of five databases and grey literature, hand searches, and reference and forward citation searches. Studies comparing robotic versus laparoscopic RYGB involving patients ages 18-65 years who met the National Institutes of Health (NIH) criteria for bariatric surgery were included in the study if they reported overall or major complication rates. Outcomes were pooled using random-effects metaanalysis. A decision-tree economic analysis was performed to calculate expected costs associated with each technique., Results: The systematic search strategy returned 1,374 potentially relevant studies. The inclusion criteria were met by 10 of these studies, which included results from 2,557 patients. The overall major and minor complications did not differ significantly between the robotic and laparoscopic groups. The rates for anastomotic leak, bleeding, stricture, and reoperation did not differ significantly. An economic analysis found that the expected costs for robotic RYGB ($15,447) were higher than for laparoscopic RYGB ($11,956). Sensitivity analyses produced similar results., Conclusion: The complication rates did not differ significantly between robotic and laparoscopic RYGB, but the expected costs were greater for robotic RYGB. Further cost effectiveness analyses are recommended before adoption of a robotic approach to RYGB.

Background: Controversy still exists on the effect that obesity has on the morbidity and mortality in severe acute pancreatitis (SAP). The primary purpose of this study was to compare the mortality rate of obese versus nonobese patients admitted to the ICU for SAP. Secondary goals were to assess the potential risk factors for abdominal compartment syndrome (ACS) and to investigate the performance of validated scoring systems to predict ACS and in-hospital mortality., Methods: A retrospective cohort of adults admitted to the ICU for SAP was stratified by their body mass index (BMI) as obese and nonobese. The rates of morbidity, mortality, and ACS were compared by univariate and multivariate regression analyses. Areas under the curve (AUC) were used to evaluate the discriminating performance of severity scores and other selected variables to predict mortality and the risk of ACS., Result: Forty-five patients satisfied the inclusion criteria and 24 (53 %) were obese with similar characteristics to nonobese patients. Among all the subjects, 11 (24 %) died and 16 (35 %) developed ACS. In-hospital mortality was significantly lower for obese patients (12.5 vs. 38 %; P = 0.046) even though they seemed to develop ACS more frequently (41 vs. 28 %; P = 0.533). At multivariable analysis, age was the most significant factor associated with in-hospital mortality (odds ratio (OR) = 1.273; 95 % confidence interval (CI) 1.052-1.541; P = 0.013) and APACHE II and Glasgow-Imrie for the development of ACS (OR = 1.143; 95 % CI 1.012-1.292; P = 0.032 and OR = 1.221; 95 % CI 1.000-1.493; P = 0.05) respectively. Good discrimination for in-hospital mortality was observed for patients' age (AUC = 0.846) and number of comorbidities (AUC = 0.801). ACS was not adequately predicted by any of the clinical severity scores (AUC = 0.548-0.661)., Conclusions: Patients' age was the most significant factor associated with mortality in patients affected by SAP. Higher APACHE II and Glasgow-Imrie scores were associated with the development of ACS, but their discrimination performance was unsatisfactory.

We surveyed 589 surgeons in Alberta, Canada, about the prevention of surgical site infections and compared their practices to the recommendations of evidence-based guidelines. Of the 247 (42%) who responded, most (156 [63%]) were not in compliance with guideline recommendations for preoperative bathing, hair removal, antimicrobial prophylaxis, or intraoperative skin preparation (although 91 [37%] state they are following guidelines).

We have investigated the biochemical and functional properties of toposome, a major protein component of sea urchin eggs and embryos. Atomic force microscopy was utilized to demonstrate that a Ca(2+)-driven change in secondary structure facilitated toposome binding to a lipid bilayer. Thermal denaturation studies showed that toposome was dependent upon calcium in a manner paralleling the effect of this cation on secondary and tertiary structure. The calcium-induced, secondary, and tertiary structural changes had no effect on the chymotryptic cleavage pattern. However, the digestion pattern of toposome bound to phosphatidyl serine liposomes did vary as a function of calcium concentration. We also investigated the interaction of this protein with various metal ions. Calcium, Mg(2+), Ba(2+), Cd(2+), Mn(2+), and Fe(3+) all bound to toposome. In addition, Cd(2+) and Mn(2+) displaced Ca(2+), prebound to toposome, while Mg(2+), Ba(2+), and Fe(3+) had no effect. Collectively, these results further enhance our understanding of the role of Ca(2+) in modulating the biological activity of toposome., (2007 Wiley-Liss, Inc.)

Background: There is little evidence that surgical mask use by physicians in the operating room (OR) reduces surgical site infections (SSIs), but masks do protect the wearer from potentially infectious splashes. Face shields offer even more protection because they cover the eyes, but they may be perceived as offering less protection to the patient than do masks. The objectives of this study were to ascertain if there were predictors to determine which OR physicians are continuing to use masks and what their reasons are for doing so, and which OR physicians would accept face shields and their reasons for doing so., Methods: We surveyed the province of Alberta's surgeons, general practice (GP) surgeons, anesthesiologists, and GP anesthetists to determine how many physicians in the OR wear surgical masks, their reasons for wearing surgical masks (ethical, legal, protection of the patient, protection of the wearer), and if they believe that face shields offer more protection to the patient or to the wearer. We also sought to examine which demographic factors affected their responses. The data were examined with chi(2) analysis to assess the relationships of age and practitioner type, and for various outcome variables. A significance level of P < .05 was accepted as statistically significant., Results: The sex of the physician did not affect his/her responses. Older physicians believe that the OR team has an ethical and legal responsibility to wear surgical masks; masks are worn to prevent the spread of disease, not because it is tradition to do so; masks protect the wearer more than do face shields; and wearing face shields alone will subject the patient to higher rates of SSIs. Surgeons are more likely than are anesthesiologists to wear surgical masks in the OR and wear a surgical mask and a face shield if the patient has risk factors for a blood borne infection., Conclusions: According to our survey, age and profession were the most important variables that affected the potential use of surgical masks and face shields. Younger OR physicians likely would be amenable to using face shields in addition to masks in the OR to protect themselves from exposure to blood or bodily fluids.

The yolk granule is the most abundant membrane-bound organelle present in sea urchin eggs and embryos. The major protein component of this organelle, toposome, accounts for approximately 50% of the total yolk protein and has been shown to be localized to the embryonic cell surface. Extensive characterization in several laboratories has defined a role for toposome in mediating membrane-membrane interactions. The current study expands the analysis of toposome-membrane interaction by defining toposome-induced changes to the lipid bilayer. The effect of toposome on the biophysical properties of phosphatidyl serine (PS) multibilayers was investigated using deuterium nuclear magnetic resonance and perdeuterated dimyristoyl PS (DMPS-d(54)). Toposome was found to have little effect on DMPS-d(54) chain orientational order in both the gel and liquid-crystalline phases. Timescales for DMPS-d(54) reorientation were investigated using quadropole echo decay. Echo decay times were sensitive to toposome in the liquid-crystalline phase but not in the gel phase. Additional information about the perturbation of bilayer motions by toposome was obtained by analyzing its effect on the decay of Carr-Purcell-Meiboom-Gill echo trains. Collectively, these results suggest that toposome interacts peripherally with DMPS bilayers and that it increases the amplitude of lipid reorientation, possibly through local enhancement of bilayer curvature.

Emulsions often contain vegetable oils such as soybean oil. In this study, a 10% (w/w) of marine mammal oil emulsion was prepared. The effect of a group of emulsifying agents on the stability of the 10% of seal oil emulsion was examined. The emulsifying agents studied were hydrogenated castor oil coated with various polyoxyethylene derivatives. It was found that 2.5% of HCO-40 resulted in the most stable seal oil emulsion. The size of the emulsified droplets defined by their diameters was found to be around 240-270 nm. The initial zeta-potential and pH value of the emulsion were found to be around -27 mV and 3.5, respectively, which decreased over time, to about -31 mV and 2.4, respectively. This is believed to be a result of the hydrolysis of triacylglycerides into free fatty acids in the emulsion. The effect of various amounts of Crodasinic LS-30, a negatively charged surfactant, and Incroqal Behenyl TMS, a positively charged surfactant, on the emulsion was investigated. It was shown that Crodasinic LS-30 had very little effect on the particle size, zeta-potential and pH, while the effect of Incroquat Benhenyl TMS was found to be dependent upon the concentration of the surfactant used.

A method for the application of carbenes as reactive intermediates for surface modification of polymeric substrates has been developed; the efficacy of the process has been demonstrated by irreversible dyeing of polystyrene, polythene, nylon, silica, and controlled pore glass, and to a limited extent, polytetrafluoroethylene.

Objective: The present study compared two different approaches for deriving patient profiles on their ability to predict treatment outcome to a pain medicine program for migraine headache., Design/methods: Using visual analog scale measures of pain intensity and functional limitations and the Beck Depression Inventory (BDI), as a measure of depression, 235 migraine patients were classified into statistical clusters. The same patients were also classified using the Multidimensional Pain Inventory (MPI) algorithm into three subgroups: Adaptive copers (AC), characterized by lower reported levels of pain intensity, life interference, and distress, as well as higher levels of perceived life control; interpersonally distressed (ID), characterized by more intermediate levels of pain, distress, and interference, with a predominant perception of inadequate support and punishing responses from significant others; and dysfunctional (Dys), characterized by high levels of pain severity, life interference, and distress and low levels of perceived life control and activity., Results: The results of the K-cluster analysis yielded a three-cluster solution: The low impact cluster, was characterized by low pain, low functional limitations and low depression and showed significant reductions in pre-to-posttreatment pain; the moderate impact cluster displayed higher levels of pain and functional limitations and low depression and showed only slight pre-to-posttreatment pain reduction; and the high impact cluster displayed the highest levels of pain, functional limitations, and depression and showed significant increases in pre-to-posttreatment pain. Unlike the K-clustered groups, MPI subgroups failed to differentially predict treatment outcome. When the K-clustered groups were crosstabulated with the MPI subgroups, the predictive validity of the MPI subgroups was enhanced., Conclusion: This study questions the validity of the MPI subgroup classification algorithm. The results indicate that the K-clustering approach is more useful than the MPI in deriving meaningful patient clusters that differentially predict treatment outcome in a migraine population.

Using Southern blot analysis of RT-PCR products, mRNA for three different somatostatin (SS) precursors (PSS-I, -II, and -III), which encode for SS(14), goldfish brain (gb)SS(28), and [Pro(2)]SS(14), respectively, were detected in goldfish hypothalamus. PSS-I and -II mRNA, but not PSS-III mRNA, were also detected in cultured pituitary cells. We subsequently examined the effects of the mature peptides, SS(14), gbSS(28), and [Pro(2)]SS(14), on somatotrope signaling and GH secretion. The gbSS(28) was more potent than either SS(14) or [Pro(2)]SS(14) in reducing basal GH release but was the least effective in reducing basal cellular cAMP. The ability of SS(14), [Pro(2)]SS(14), and gbSS(28) to attenuate GH responses to GnRH were comparable. However, gbSS(28) was less effective than SS(14) and [Pro(2)]SS(14) in diminishing dopamine- and pituitary adenylate cyclase-activating polypeptide-stimulated GH release, as well as GH release resulting from the activation of their underlying signaling cascades. In contrast, the actions of a different 28-amino-acid SS, mammalian SS(28), were more similar to those of SS(14) and [Pro(2)]SS(14). We conclude that, in goldfish, SSs differentially couple to the intracellular cascades regulating GH secretion from pituitary somatotropes. This raises the possibility that such differences may allow for the selective regulation of various aspects of somatotrope function by different SS peptides.