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Physical inactivity is a modifiable risk factor (similar to dyslipidemia and hypertension) for a variety of chronic diseases, including cancer and cardiovascular disease. Exercise provides a clear health benefit, which serves in the primary and secondary prevention of these disease processes (the most important being a reduction in cardiovascular disease and premature death). The physiologic mechanisms for such a benefit occur at both a cellular and multisystem level. Prolonged periods of occupational or leisure-time sitting have adverse health effects independent of exercise performed before or after. Almost any form of physical activity (PA) is beneficial, whether part of a regular exercise program or as a series of intermittent, incidental, non-purposeful, lifestyle-embedded activity (causing non-exercise activity thermogenesis or NEAT). The health benefits of exercise appear to be dose-dependent. Physicians should recommend near daily exercise which includes at various times strength training, stretching, and aerobic activity in addition to emphasizing adjustments that allow for reduced sitting and increased activity during daily routines. Patients should understand that for optimal health, exercise is no longer optional.

STATEMENT OF THE PROBLEM Penetrating wounds of the neck are common in the civilian trauma population. Risk of significant injury to vital structures in the neck is dependent on the penetrating object. For gunshot wounds, approximately 50% (higher with high velocity weapons) of victims have significant injuries, whereas this risk may be only 10% to 20% with stab wounds. The management of injuries to the neck that penetrate the platysma is dependent on the anatomic level of injury. The neck has been divided into threes zones. Zone I, including the thoracic inlet, up to the level of the cricothyroid membrane, is treated as an upper thoracic injury. Zone III, above the angle of the mandible, is treated as a head injury. Zone II, between zones I and III, is the area of controversy. Because of the density of vital structures in this zone, multiple injuries are common and can affect length of stay. Mortality, particularly for major vascular injuries may reach 50%. Delayed complications such as pseudoaneurysms or arteriovenous fistulae can affect long-term outcomes. Appropriate and timely management of these injuries is critical. For the patients with hard signs of significant injury, including active hemorrhage, expanding hematoma, bruit, pulse deficit, subcutaneous emphysema, hoarseness, stridor, respiratory distress, or hemiparesis, immediate operative management may be indicated. Controversy arises over management of the patient without significant symptoms. The management of these patients has been evolving from an era of mandatory exploration to an era of more selective management. Mandatory exploration, while seemingly safe and conservative, led to many nontherapeutic operations. This fact, along with advances in technology, such as high resolution computed tomography (CT), may eliminate the need to explore the neck to determine whether there are injuries. Also during the time that technology had been advancing, many reports have documented the safety of selective management of neck injuries that penetrate the platysma. This experience has demonstrated that physical examination may be reliable and that not all injuries to vital structures in the neck need surgical intervention for repair. This guideline was therefore initiated to examine the specific roles of mandatory exploration versus selective management based on physical examination and current imaging technologies for penetrating neck trauma.

Ultrasound guided vascular access has been well-characterized as a safe and effective technique for internal jugular and femoral vein catheterization. However, there is limited experience with the use of ultrasound to access the infraclavicular subclavian vein. Multiple ultrasound techniques do exist to identify the subclavian vein, but real time access is limited by vessel identification in a single planar view. To overcome this limitation, a novel technique of ultrasound guided infraclavicular subclavian vein catheterization using a real time multiplanar approach has been developed. The initial experience with this approach is described. A single surgeon used combined oblique, transverse, and longitudinal views along with Doppler color flow images to both define the infraclavicular anatomy and to obtain subclavian vein access in 42 adult patients (20 M/22 F and 22 L/20 R) with a mean body mass index of 29.2 (range = 18.9-55.4). Chest x-ray was obtained to confirm position and to rule out pneumothorax. Subclavian vein cannulation was achieved in 100 per cent of patients; subsequent catheterization was successful in 92.9 per cent. The number of attempts required for cannulation averaged 1.3 (range = 1-5), and decreased after a five patient learning curve. No patient developed a pneumothorax, hematoma, or cannula malposition. Ultrasound guided multiplanar infraclavicular subclavian vein access appears to be a safe and effective adjunct for central line placement.

Background . Various strategies have been introduced to minimize transfusion requirements in cardiac surgery. One strategy is the use of positive end-expiratory pressure (PEEP) postoperatively. Currently, PEEP is used in many centers to control increased mediastinal chest-tube drainage. The purpose of this study was to determine whether the prophylactic application of a PEEP of 10 cm H 2 O compared with a PEEP of 5 cm H 2 O in the immediate postoperative period reduces mediastinal chest-tube output without causing clinically significant hemodynamic compromise. Methods . We prospectively studied 84 elective coronary artery bypass grafted patients and randomized treatment groups to a PEEP of 5 or 10 cm H 2 O. Forty-four patients were assigned a PEEP of 5 cm H 2 O and 40 patients received a PEEP of 10 cm H 2 O. Results . Preoperative, intraoperative, and postoperative demographics were similar between groups. There was no statistically significant difference between the 5 cm H 2 O PEEP group and the 10 cm H 2 O PEEP group with regard to chest-tube output at 6 hours, at 24 hours, or in total output. There was no statistical difference in hemoglobin levels immediately postoperatively, at 8 hours, or at 36 hours. Conclusions . This study demonstrates that the use of postoperative PEEP levels of 10 cm H 2 O, although safe, does not reduce chest-tube output or transfusion requirements.

Blunt traumatic carotid artery dissection remains controversial in terms of diagnostic screening, reported incidence, and management. Treatment options include observation, anticoagulation and endovascular stenting, and aggressive surgical repair of the carotid artery injury. Blunt traumatic carotid artery dissections were reviewed through a retrospective study of trauma registry records. Seven patients were identified from 3342 patients over 3 years. Six patients were identified incidentally during magnetic resonance imaging (MRI) cervical spine/brain screening and one patient during angiographic evaluation for possible penetrating neck injury without MRI/magnetic resonance angiography (MRA). A total of 189 patients underwent MRI screening over this 3-year period, demonstrating a relative incidence of 3.7 per cent, contrasting with the reported incidence of 0.08 to 0.4 per cent for all trauma patients. All seven patients suffered severe head injuries (mean Glasgow Coma Score = 4.7) requiring mean intensive care unit and hospital stays of 15.6 and 23.7 days, respectively. None of the patients showed evidence of stroke with CT scanning on presentation. None of the patients demonstrated clinical focal neurologic signs or symptoms indicating carotid injury or stroke. Six patients survived their acute trauma and were discharged to rehabilitation after initiation of observation (one patient) or anticoagulation (five patients). All six patients showed neurological improvement without deterioration clinically or radiographically. In conclusion we propose early aggressive screening through MRI/MRA of severely injured patients to detect occult carotid artery dissections. Conservative medical treatment for this occult injury has been effective in this series of patients.

Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States with the majority of these injuries diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. With screening, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score ofor=16. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the screening, diagnosis, and treatment of BCVI.A computerized search of the National Library of Medicine/National Institute of Health, Medline database was performed using citations from 1965 to 2005 inclusive. Titles and abstracts were reviewed to determine relevance, and isolated case reports, small case series, editorials, letters to the editor, and review articles were eliminated. The bibliographies of the resulting full-text articles were searched for other relevant citations, and these were obtained as needed. These papers were reviewed based on the following questions: 1. What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI? 2. What is the appropriate modality for the screening and diagnosis of BCVI? 3. How should BCVI be treated? 4. If indicated, for how long should antithrombotic therapy be administered? 5. How should one monitor the response to therapy?One hundred seventy-nine articles were selected for review, and of these, 68 met inclusion criteria and are excerpted in the attached evidentiary table and used to make recommendations.The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified (see ), screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (or==8 slice) CT angiography may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population.