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Introduction The Stop the Bleed course was initiated in response to the Hartford Consensus and over 1 million people have been taught basic bleeding control techniques. Our study sought to determine the extent to which this training has been utilized. Methods Surveys were sent by email to students that had taken the Stop the Bleed course through our institution in 2017 or 2018. Data were collected utilizing the REDCap system and statistical calculations were performed. Results 2505 surveys were sent with 445 (18%) responses. The mean age of respondents was 48 years of age, 343 (77%) were female, and 230 (52%) were in the medical field. There were 17 respondents (3.8%) that stated they had utilized the techniques taught in the course; 16 out of 17 put pressure on a wound, 7 packed a wound, and 6 used a tourniquet. Patients had been injured by a variety of mechanisms including gunshot wound, stabbing, accidental laceration, and motor vehicle collision. Patients had good outcomes with 3 out of 17 surviving to emergency medical services arrival without known final outcome and the remaining 14 were known to do well. Conclusion The Stop the Bleed course is important to enable bystanders to provide hemorrhage control. Our study shows that the techniques have been utilized with 17 treated patients having a good outcome and while a utilization rate of 3.8% may appear low, it is similar to the utilization rate of cardiopulmonary resuscitation instruction of 2%.

Purpose To test the hypothesis that baseline optical coherence tomography (OCT) measures predict visual field (VF) progression in a cohort of patients with suspected or established glaucoma and to compare their performance to semiquantitative optic disc measures. Design This was an observational cohort study. Methods The setting of this study was an academic institution. The study population included 171 eyes of 95 patients with good-quality baseline retinal nerve fiber layer (RNFL) and macular OCT images and disc photographs with >2 years of follow-up and ≥5 VFs. The observation procedures were baseline macular and RNFL OCT measures and cup-to-disc ratio and disc damage likelihood score. The main outcome measure was prediction of glaucomatous VF deterioration according to trend and event analyses. Results Median (interquartile range) baseline mean deviation and follow-up were -2.9 (-6.4 to -1.1) dB and 54 (44–65) months, respectively. Seventeen and 25 eyes progressed by final visit based on pointwise event analysis and trend analysis of visual field index (VFI), respectively. Thinner central corneal thickness (P = .005), female gender (P = .015), and thinner average peripapillary RNFL (P = .001) predicted VF progression on proportional hazard models. Thinner RNFL at baseline (P = .006) or thinner average ganglion cell-inner plexiform layer (P = .028) along with higher baseline VFI (P = .018 and .048, respectively) predicted VFI progression. Neither optic disc measures predicted VF progression in any of the explored models. Conclusions Baseline structural OCT measures predicted subsequent VF progression in contrast to semi-quantitative optic disc measures. OCT-based structural measures should be included in prognostic models of glaucomatous VF deterioration.

Long-term retention of trauma procedural core-competency skills and need for re-training after a 1-day cadaver-based course remains unknown. We measured and compared technical skills for trauma core competencies at mean 14 months (38 residents), 30 months (35 practicing surgeons), and 46 months (10 experts) after training to determine if skill degradation occurs with time. Technical performance during extremity vascular exposures and lower-extremity fasciotomy in fresh cadavers measured by validated individual procedure score (IPS) was the primary outcome.We performed a prospective study between May 2013 and September 2016.Practicing surgeons had lower IPS and IPS component scores (p = 0.02 to 0.001) than residents (p 0.05) and experts (p0.002) for vascular procedures. Frequencies of errors were no different among residents and experts. Practicing surgeons made more critical errors (p0.05) than experts or residents. Experts had shortest time to proximal vascular control. Fasciotomy procedural errors occurred in all participants. Cluster analysis of anatomy vs procedural steps identified tertiles of performance and wide variance (32.5% practicing surgeons, 26.5% residents vs 13% experts) for vascular procedures. Vascular control duration20 minutes (n = 21) and failure to decompress fasciotomy compartments were correlated with incorrect landmarks and skin incisions. Modeling found interval trauma skills experience, not time since training, was associated with lower IPS.Practicing surgeons with low trauma skills experience since training had lower IPS and component scores (p = 0.02 to 0.001) and more errors compared with experts and residents (p0.05). Surgeons, including experts with low interval experience performing trauma procedures, may benefit from refreshing of correct landmarks and skin incision placement identification.

Objectives Surgical residents express confidence in performing specific vascular exposures before training, but such self-reported confidence did not correlate with co-located evaluator ratings. This study reports residents' self-confidence evaluated before and after Advanced Surgical Skills for Exposure in Trauma (ASSET) cadaver-based training, and 12-18 mo later. We hypothesize that residents will better judge their own skill after ASSET than before when compared with evaluator ratings. Methods Forty PGY2-7 surgical residents performed four procedures: axillary artery (AA), brachial artery (BA), femoral artery exposure and control (FA), and lower extremity fasciotomy (FAS) at the three evaluations. Using 5-point Likert scales, surgeons self-assessed their confidence in anatomical understanding and procedure performance after each procedure and evaluators rated each surgeon accordingly. Results For all the three evaluations, residents consistently rated their anatomical understanding (p < 0.04) and surgical performance (p < 0.03) higher than evaluators for both FA and FAS. Residents rated their anatomical understanding and surgical performance higher (p < 0.005) than evaluators for BA after training and up to 18 mo later. Only for third AA evaluation were there no rating differences. Conclusions Residents overrate their anatomical understanding and performance abilities for BA, FA, and FAS even after performing the procedures and being debriefed three times in 18 mo.

Purpose To test the hypotheses that: (1) structure–function (SF) relationships between visual fields (VF) and Bruch's membrane opening-based minimum rim width (BMO-MRW) measurements are superior to those for peripapillary retinal nerve fiber layer (pRNFL) in perimetric glaucoma; (2) BMO-MRW measurements may extend the utility of structural measurement across the range of glaucoma severity; and (3) to estimate the influence of Bruch's membrane opening (BMO) size on BMO-MRW measurements. Methods One hundred eight perimetric glaucoma eyes (68 patients) with good quality spectral-domain optical coherence tomography images of the optic disc and pRNFL, and reliable VF within 6 months were recruited. Relationship of global and sectoral BMO-MRW and pRNFL thickness with corresponding VF parameters and the influence of normalizing BMO-MRW (on BMO circumference, nBMO-MRW) on SF relationships were investigated. Broken-stick models were used to compare the point at which pRNFL and BMO-MRW parameters reached their measurement floor. Results The median (interquartile range) of VF mean deviation was −5.9 (−12.6 to −3.6) dB. Spearman correlation coefficients between pRNFL, BMO-MRW, and nBMO-MRW measures and corresponding VF cluster average deviations ranged between 0.55 to 0.80, 0.35 to 0.66, and 0.38 to 0.65, respectively. Bruch's membrane opening–MRW parameters demonstrated weaker SF relationships compared with pRNFL globally and in temporal, temporal-superior, and nasal-inferior sectors (P < 0.03). Normalization of BMO-MRW did not significantly influence SF relationships. Conclusions Structure–function relationships were somewhat weaker with BMO-MRW parameters compared with pRNFL in eyes with perimetric glaucoma. Bruch's membrane opening–MRW normalization did not significantly change SF relationships in this group of eyes with mild departures from average BMO size.

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique (

PURPOSE: To test the hypothesis that the fovea-Bruch’s membrane opening axis angle (FoBMO angle) influences the thickness symmetry of the macular ganglion cell/inner plexiform layer (GCIPL) across the temporal horizontal meridian in normal subjects. DESIGN: Cross-sectional diagnostic study at a tertiary academic center. METHODS: One hundred sixteen eyes of 60 normal subjects aged 40–85 years underwent spectral-domain optical coherence tomography (SD-OCT) imaging. The FoBMO angle was estimated on en face infrared SD-OCT images. Posterior Pole Algorithm images acquired with Spectralis SD-OCT were used to define vertical asymmetry as follows. The average thickness difference between the 3 most temporal superpixels above and below the horizontal meridian, the second row of superpixels from the horizontal meridian, and 3 central superpixels above and below the horizontal meridian were calculated. Factors influencing GCIPL thickness asymmetry were explored and changes in thickness asymmetry as a function of FoBMO angle were investigated. RESULTS: No demographic or clinical factors affected temporal GCIPL asymmetry (p >0.05 for all). A more (negatively) tilted FoBMO angle was associated with relatively thinner inferior compared to superior GCIPL thickness in superpixels immediately adjacent to the temporal raphe (p

Necrotizing soft tissue infection of the perineum, or Fournier's gangrene (FG), is a morbid and mortal diagnosis. Despite the severity of FG, the optimal definitive wound closure strategy is unknown, as are long-term wound outcomes. A retrospective review was performed over a 3-year period at a single trauma center. Patients were managed according to our institutional approach focusing on primary wound closure and secondary intention healing in residual wounds. Overall 168 patients were included. Complete primary wound closure was accomplished in 39.9 per cent of patients. Patients undergoing primary wound closure were primarily male (89.6 vs 64.4%, P0.001), had lower mean sequential organ failure assessment (SOFA) scores (1.70 ± 2.30 vs 2.98 ± 3.36, P = 0.004), more often had perineum-limited FG (67.2 vs 42.6%, P = 0.003), and required fewer debridements (2.40 vs 2.79, P = 0.02). On logistic regression, predictors of primary closure included gender (odds ratio 4.643, 95% confidence interval 1.885-11.437, P = 0.001) and SOFA score (odds ratio 0.834, 95% confidence interval 0.727-0.957, P = 0.01). Wound healing rates increased over time, to an 82.1 per cent wound healing rate without further intervention at greater than six months of follow-up. Wounds healed with secondary intention ranged from 70 to 9520 cm3 and primary closure ranged from 126 to 6912 cm3, whereas wounds requiring skin grafts ranged from 405 to 16,170 cm3. Complete primary wound closure is often achievable in FG patients. Using this standardized approach to FG wound management, even large wounds and wounds undergoing secondary intention healing will often close with long-term wound care and do not require flap creation or early skin grafting.

There is current need for objective measures of sciatic nerve mobility in patients with sciatic-type pain. The objective of the study was to assess the feasibility and reliability of ultrasound elastography to quantify sciatic nerve displacement and shear strain at the sciatic nerve-hamstring muscle interface during active and passive knee extension-flexion exercises performed while sitting in healthy people. Ultrasound elastography showed excellent intrarater within-session reliability for assessing sciatic nerve displacement and sciatic nerve-hamstring muscle interface shear strain during active knee extension-flexion exercises. These findings will inform similar future work conducted in patients with sciatic-type pain.

PurposeTo test the hypothesis that structural and functional measures predict contrast sensitivity (CS) outcomes in glaucomatous eyes.DesignCross-sectional prospective study.MethodsOne hundred five eyes of 65 patients who underwent macular spectral-domain optical coherence tomography imaging, 24-2 standard achromatic visual fields (VF), and CS measurement on the same day were enrolled. Association of CS at 4 spatial frequencies (3,6, 12, and 18 cycles per degree, cpd) with structural and functional outcomes was explored with correlation and regression analyses.ResultsThe median (IQR) 24-2 visual field mean deviation was-7.6 (-11.1 to-3.0). Significant correlations were found between CS at 6 cpd and ganglion cell/inner plexiform layer thickness at inferotemporal and inferonasal macular sectors (ρ= 0.222, P= .023 and ρ= 0.209, P= .032, respectively). CS at 6 cpd demonstrated higher correlations with full macular thickness measurements, the strongest of which was with the central macular thickness in the superior 6× 3-degree region (ρ= 0.311, P= .001). Contrast sensitivity at 6cpd also had the strongest correlation with mean deviation of the 4 central VF points (ρ=-0.420; P < .001). There was a significant correlation between logMAR visual acuity and contrast sensitivity at 6, 12, and 18 cpd (ρ=-0.306, ρ=-0.348 and ρ=-0.241, P < .013, respectively).ConclusionsStructural and functional measures showed a fair relationship with contrast sensitivity. This association was most prominent between full-thickness macular measures or central VF parameters and CS at 6 cpd. Contrast sensitivity was not a reliable surrogate for glaucoma severity in this cross-sectional study.

Antibiotic management of Fournier's gangrene (FG) is without evidence-based guidelines and is based on expert opinion. The effect of duration of antibiotic therapy on outcomes in FG is unknown.A retrospective review was performed of FG patients from 2012 to 2015 at a single institution. Patients were managed by our institutional practice of complete primary wound closure as possible, with antibiotic duration according to physician judgment. Patients were stratified into multiple durations of antibiotic administration.Overall, 168 patients with FG were included. When examining multiple stratifications of antibiotic therapy of 7 days or less, 8 days to 10 days, 11 days to 14 days, or 15 days or more of antibiotics, there was no significant difference in mortality (p = 0.11), primary closure (p = 0.75), surgical site infection (SSI) (p = 0.52), or Clostridium difficile infection (p = 0.63). There were no cases of recurrent FG in any antibiotic stratification. Mortality was not increased (p = 1.00) and ability to achieve primary closure was not decreased (p = 0.08) with initial antibiotic therapy exclusive of cultured organisms.Shorter antibiotic courses for patients in whom source control is obtained and initial antibiotic selection exclusive of many resistant organisms were not associated with worse outcomes in FG.Therapeutic, level IV.

Surgical patient outcomes are related to surgeon skills.To measure resident surgeon technical and nontechnical skills for trauma core competencies before and after training and up to 18 months later and to compare resident performance with the performance of expert traumatologists.This longitudinal study performed from May 1, 2013, through February 29, 2016, at Maryland State Anatomy Board cadaver laboratories included 40 surgical residents and 10 expert traumatologists.Performance was measured during extremity vascular exposures and lower extremity fasciotomy in fresh cadavers before and after taking the Advanced Surgical Skills for Exposure in Trauma (ASSET) course.The primary outcome variable was individual procedure score (IPS), with secondary outcomes of IPSs on 5 components of technical and nontechnical skills, Global Rating Scale scores, errors, and time to complete the procedure. Two trained evaluators located in the same laboratory evaluated performance with a standardized script and mobile touch-screen data collection.Thirty-eight (95%) of 40 surgical residents (mean [SD] age, 31 [2.9] years) who were evaluated before and within 4 weeks of ASSET training completed follow-up evaluations 12 to 18 months later (mean [SD], 14 [2.7] months). The experts (mean [SD] age, 52 [10.0] years) were significantly older and had a longer (mean [SD], 46 [16.3] months) interval since taking the ASSET course (both P .001). Overall resident cohort performance improved with increased anatomy knowledge, correct procedural steps, and decreased errors from 60% to 19% after the ASSET course regardless of clinical year of training (P .001). For 21 of 40 residents (52%), correct vascular procedural steps plotted against anatomy knowledge (the 2 IPS components most improved with training) indicates the resident's performance was within 1 nearest-neighbor classifier of experts after ASSET training. Five residents had no improvement with training. The Trauma Readiness Index for experts (mean [SD], 74 [4]) was significantly different compared with the trained residents (mean [SD], 48 [7] before training vs 63 [7] after training [P = .004] and vs 64 [6] 14 months later [P = .002]). Critical errors that might lead to patient death were identified by pretraining IPS decile of less than 0.5. At follow-up, frequency of resident critical errors was no different from experts. The IPSs ranged from 31.6% to 76.9% among residents for core trauma competency procedures. Modeling revealed that interval experience, rather than time since training, affected skill retention up to 18 months later. Only 4 experts and 16 residents (40%) adequately decompressed and confirmed entry into all 4 lower extremity compartments.This study found that ASSET training improved resident procedural skills for up to 18 months. Performance was highly variable. Interval experience after training affected performance. Pretraining skill identified competency of residents vs experts. Extremity vascular and fasciotomy performance evaluations suggest the need for specific anatomical training interventions in residents with IPS deciles less than 0.5.

Background The Advanced Surgical Skills for Exposure in Trauma (ASSET) course was developed to address limited experience of residents and practicing surgeons (PS) in rapid exposure of major blood vessels for trauma. This one day, case based, scenario driven, fresh cadaver dissection course emphasizes rapid surgical exposure of the vasculature of the neck, chest, abdomen, pelvis and extremities with additional focus on fasciotomies and pelvic packing. Contained herein are the results of the first 25 courses. Methods Data collected from 25 ASSET courses conducted between September 2010 and February 2012 included self-reported comfort level (5 point Likert scale) with each of 25 specific skills before and upon completion of the course, and evaluation of the course content. Statistical analysis was accomplished using the Student t -test with α set at P Results Ninety-one surgical trainees and 123 PS were taught at 11 ASSET sites. Self-assessed comfort levels for all 25 queried skills and exposures improved significantly over baseline with P values ranging from 1.6 × 10 −7 to 3.9 × 10 −41 . Participants gained new knowledge (4.83 on 5 point scale); learned new techniques (4.83), felt better prepared to expose traumatically injured vessels (4.88), and would recommend the course to a colleague (4.92). Conclusions The ASSET course was well received and significantly improved self-reported confidence in the exposures needed to care for trauma in both surgical trainees and PS. Ongoing experience with this course will enable more comprehensive psychometric analysis and further validation of this curriculum.

Glaucoma Macular SD-OCT Outcome Measures: Comparison of Local Structure-Function Relationships and Dynamic Range Arezoo Miraftabi, 1,2 Navid Amini, 1 Esteban Morales, 1 Sharon Henry, 1 Fei Yu, 1,3 Abdolmonem Afifi, 3 Anne L. Coleman, 1 Joseph Caprioli, 1 and Kouros Nouri-Mahdavi 1 Glaucoma Division, Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, United States 2 Eye Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran Department of Biostatistics, Jonathan and Karin Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California, United States Correspondence: Kouros Nouri- Mahdavi, 100 Stein Plaza, Los An- geles, CA, 90095, USA; nouri-mahdavi@jsei.ucla.edu. Submitted: March 28, 2016 Accepted: July 14, 2016 Citation: Miraftabi A, Amini N, Morales E, et al. Macular SD-OCT outcome measures: comparison of local struc- ture-function relationships and dy- namic range. Invest Ophthalmol Vis Sci. 2016;57:4815–4823. DOI:10.1167/iovs.16-19648 P URPOSE . We tested the hypothesis that the macular ganglion cell layer (GCL) thickness demonstrates a stronger structure-function (SF) relationship and extends the useful range of macular measurements compared with combined macular inner layer or full thickness. M ETHODS . Ninety-eight glaucomatous eyes and eight normal eyes with macular spectral domain optical coherence tomography (SD-OCT) volume scans and 10-2 visual fields were enrolled. Inner plexiform layer (IPL), GCL, macular retinal nerve fiber layer (mRNFL), ganglion cell-inner plexiform layer (GCIPL), ganglion cell complex (GCC), and full thickness (FT) measurements were calculated for 8 3 8 arrays of 38 superpixels. Main outcome measures were local structure- function relationships between macular superpixels and corresponding sensitivities on 10-2 fields after adjusting for ganglion cell displacement, dynamic range of measurements, and the change point (total deviation value where macular parameters reached measurement floor). R ESULTS . Median (interquartile range [IQR]) mean deviation was 7.2 (11.6 to 3.2) dB in glaucoma eyes. Strength of SF relationships was highest for GCIPL, GCL, GCC, and IPL (q ¼ 0.635, 0.627, 0.621, and 0.577, respectively; P 0.046 for comparisons against GCIPL). Highest SF correlations coincided with the peak of GCL thickness, where the dynamic range was widest for FT (81.1 lm), followed by GCC (65.7 lm), GCIPL (54.9 lm), GCL (35.2 lm), mRNFL (27.5 lm), and IPL (20.9 lm). Change points were similar for all macular parameters (7.8 to 8.9 dB). C ONCLUSIONS . GCIPL, GCL, and GCC demonstrated comparable SF relationships while FT, GCC, and GCIPL had the widest dynamic range. Measurement of GCL did not extend the range of useful structural measurements. Measuring GCL does not provide any advantage for detection of progression with current SD-OCT technology. Keywords: macular imaging, SD-OCT, dynamic range, structure-function dentification of glaucoma progression is a pivotal task in day- to-day management of glaucoma, to which various structural and functional measures have been applied. The advent of spectral-domain optical coherence tomography (SD-OCT) has provided the glaucoma research community with a powerful tool for detecting early glaucoma or its progression. Many reports have highlighted the potential role of retinal nerve fiber layer (RNFL), 1,2 although more research is needed to better understand its limitations and the appropriate circumstances for its application. Some recent investigations have demon- strated the utility and added value of macular SD-OCT imaging for detecting glaucoma, but its role remains less well defined with respect to progression. 3–10 Thanks to development of segmentation algorithms applied to SD-OCT imaging, various inner macular parameters are now available to investigators and clinicians. 3,11,12 These include single layer measurements such as ganglion cell (GCL), inner plexiform (IPL), or retinal nerve fiber layer, combination of inner retinal layers such as the ganglion cell-inner plexiform layer (GCIPL) and the ganglion cell complex (GCC), which includes the combined I thickness of the GCIPL and macular RNFL (mRNFL), or the full retinal thickness. The comparative utility of these various thickness parameters for detection of glaucoma progression is unknown. To this aim, the strength of the corresponding structure-function relationships and the comparative dynamic range of these parameters need to be compared. Another issue of interest is the point of change on structure-function plots at which each parameter reaches its measurement floor. We hypothesized that the macular GCL has a stronger correlation with central visual field sensitivities and may extend the range of useful structural measurements compared with other individual or combined inner retinal layers and may be a better outcome measure for detection of glaucoma progression. To this aim, this study was carried out to compare: (1) localized structure-function relationships between GCL and other macular thickness measurements, (2) the dynamic range of macular structural parameters, and (3) the change point for these parameters (i.e., the approximate threshold sensitivity beyond which the structural measures do not provide much additional information). iovs.arvojournals.org j ISSN: 1552-5783 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Glaucoma is a chronic optic neuropathy characterized by slow loss of the retinal ganglion cells (RGC) and their axons. Early damage to RGC axons is considered to occur at the level of the lamina cribrosa (LC), a multilayered connective tissue structure through which all the RGC axons pass when leaving the eye to form the optic nerve.1 Hence, studying the anatomy of the optic nerve head (ONH) and the peripapillary area is important for studying the mechanisms by which glaucoma damages these structures. Historically, the inner edge of the sclera, called the border tissue of Elschnig, has been presumed to form the clinical optic disc margin or outer boundary of the anterior neural canal. The complex relationships of the tissues bordering the neural canal now is better understood thanks to availability of in vivo imaging of the peripapillary region with spectral domain optical coherence tomography (SD-OCT). Strouthidis et al.2 recently proposed that the appearance of the clinical disc margin depended mainly on the colocation of the inner edge of the Bruch's membrane (BM) and the border tissue of Elschnig (BTE). The direction of the BTE has been shown to vary around the ONH and internally oblique, externally oblique, and nonoblique configurations have been well defined.3,4 The termination of the BM around the optic nerve forms the BM opening (BMO), which defines the anterior most boundary of the neural canal and commonly is the narrowest part of the neural canal. In monkeys, the clinical disc margin consistently localizes to BMO,3,5 while based on findings by Reis et al.,6 this is not the case in humans. In human eyes, BM overhang (i.e., extension of BM beyond the BTE) is common. The BMO area may better predict the number of ganglion cell axons in individual eyes or indicate the best location for centering SD-OCT's disc/retinal nerve fiber layer (RNFL) measurement cube,7 although it is likely that the narrowest region of the neural canal determines the axonal complement of a given eye. In addition, it has been demonstrated that neuroretinal rim area measurements based on the minimum distance between the inner edge of BMO and the internal limiting membrane (minimum rim width [MRW]) are superior to those based on clinical disc margin (horizontal rim width).8 Also, MRW measurements have been found to perform better or at least as well as peripapillary RNFL thickness measurements for discriminating glaucoma from normal eyes and demonstrate similar structure–function relationships compared to RNFL.8,9 To date, most clinical disc area measurements are based on identification of the clinical disc margin by experienced observers either on optic disc photographs or on images obtained with scanning laser ophthalmoscopy (such as the Heidelberg Retina Tomograph [HRT]). Some of the current SD-OCT machines have an automated algorithm for locating the inner edge of the BMO. Whether the relationship between the BMO and the clinical disc margin (CDM) is a function of the size of the optic disc is unknown; likewise, it is unclear whether BMO area can change over time in glaucoma. This study was performed to test the hypothesis that the anatomical relationship of the CDM and BMO is a function of the BMO area (BMOA). We also tested the hypothesis that the relationship between the clinical disc margin and BMO was different between glaucoma and normal eyes with less mismatch in glaucoma eyes.

Complex wounds present a challenge to both the surgeon and patient in operative management, long-term care, cosmetic outcome, and effects on lifestyle, self-image, and general health. Each patient with complex wounds usually manifests multiple risk factors for their development. This article focuses on complex wounds involved with traumatic and orthopedic blunt or penetrating injuries, particularly in the extremities, as well as massive soft tissue infections including necrotizing fasciitis, gas gangrene, and Fournier gangrene. The principles of management of complex wounds involve assessing the patient's clinical status and the wound itself, appropriate timing of intervention, providing antibiotic therapy when necessary, and planning and executing surgical therapy, including the establishment of a clean wound bed and closure/reconstructive strategies.

Necrotizing soft tissue infections (NSTI) represent a rare but devastating disease for which the systemic manifestations have been poorly characterized. In an effort to define an optimal endpoint for clinical trials in this condition, the objective of this study was to establish the pattern of organ dysfunction over time and determine the correlation between organ dysfunction and clinical outcome in patients with NSTI.We conducted a multicenter, retrospective clinical study of patients with NSTI presenting to 12 academic medical centers in the U.S. during 2013. Patients with a diagnosis of NSTI confirmed by surgical findings were included. Organ dysfunction was assessed using a modified Sequential Organ Failure Assessment (SOFA) score (mSOFA: excluding liver) on admission and on hospital days 1, 2, 3, 7, 10, and 14. The presence of organ dysfunction on admission and resolution of organ dysfunction were correlated with clinical parameters, including intensive care unit (ICU)-free days (of 28 d), ventilator-free days, number of debridements, and mortality rate. The incidence of acute kidney injury (AKI) and recovery also were assessed.There were 198 patients enrolled, of whom 62% were male, the mean age was 51 years, and 40% had monomicrobial infections. The mean mSOFA score on admission was 2.4 ± 3.0, with 49% of the patients having a score ≥2 and 35% a score of ≥3. Patients typically demonstrated worsening of the mSOFA score over the first 24 h followed by gradual resolution. An mSOFA ≥3 at admission was associated with a significant decrease in ventilator-free days (mean 20.1 vs. 25.6 days; p 0.001); ICU-free days (15.2 vs. 23.1, p 0.001); more debridements (mean 2.3 vs. 2.0; p = 0.11); a higher mortality rate (15.9% vs. 3.1%; p = 0.003); and a higher rate of AKI (59.4 vs. 35.9%; p 0.001). The persistence of organ dysfunction (mSOFA1) among survivors at day 14 was associated with fewer ICU-free days (17.8 vs. 23.6; p 0.001) and ventilator-free days (23.6 vs. 27; p = 0.001) and a lower recovery rate from AKI (38.7% vs. 81.3%; p 0.001).Early development of systemic organ dysfunction in patients with NSTI is associated with higher morbidity and mortality rates. Failure of the resolution of organ dysfunction by day 14 forecasts a poor outcome. The mSOFA score may be a useful marker for patient selection for inclusion in interventional trials, and the resolution of organ dysfunction by day 14 may be an important clinical endpoint.

Tracheostomy is one of the most common procedures performed in trauma patients in the intensive care unit (ICU). Few studies have evaluated the incidence of surgical site infections (SSIs) specifically in a trauma population. Our objective was to compare the incidence of SSI after open versus percutaneous tracheostomy and to discern whether there were any differences in outcome.A prospective single-institution study was conducted on 640 patients admitted to the ICU over eight years who underwent tracheostomy. Age, gender, race, admission Injury Severity Score (ISS) and Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mechanism of injury were obtained. The majority of patients were male (56.1%) and white (62.5%) with a mean age of 43.2 ± 20.2 years, ISS of 30.7 ± 13.2 points, and APACHE score of 13.3 ± 6.3 points. The majority of patients were admitted for blunt trauma (85.1%). The outcome was measured by hospital (HLOS) and ICU (ILOS) lengths of stay, duration of mechanical ventilation, infection rate, and mortality rate.A total of 330 open and 310 percutaneous tracheostomies were performed. A total of 36 SSIs (5.3%) were found. Patients who underwent percutaneous tracheostomy had a statistically significantly lower rate of SSI (3.4%) than the open surgery group (7%) (p=0.04). There was no difference in HLOS, ILOS, ventilator days, or mortality rate.To our knowledge, this is the largest study of the benefit of percutaneous tracheostomy in a critically injured trauma population. The risk of SSI is significantly lower after percutaneous than open tracheostomy.

Nonoperative management is presently considered the treatment modality of choice in over 50% of adult patients sustaining blunt hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma centers could validate the currently reported high success rate, low morbidity, and virtually nonexistent mortality associated with this approach. Thirteen level I trauma centers accrued 404 adult patients sustaining blunt hepatic injuries managed nonoperatively over the last 5 years. Seventy-two percent of the injuries resulted from motor vehicle crashes. The mean injury severity score for the entire group was 20.2 (range, 4-75), and the American Association for the Surgery of Trauma-computerized axial tomography scan grading was as follows: grade I, 19% (n = 76); grade II, 31% (n = 124); grade III, 36% (n = 146); grade IV, 10% (n = 42); and grade V, 4% (n = 16). There were 27 deaths (7%) in the series, with 59% directly related to head trauma. Only two deaths (0.4%) could be attributed to hepatic injury. Twenty-one (5%) complications were documented, with the most common being hemorrhage, occurring in 14 (3.5%). Only 3 (0.7%) of these 14 patients required surgical intervention, 6 were treated by transfusions alone (0.5 to 5 U), 4 underwent angio-embolization, and 1 was further observed. Other complications included 2 bilomas and 3 perihepatic abscesses (all drained percutaneously). Two small bowel injuries were initially missed (0.5%), and diagnosed 2 and 3 days after admission. Overall, 6 patients required operative intervention: 3 for hemorrhage, 2 for missed enteric injuries, and 1 for persistent sepsis after unsuccessful percutaneous drainage. Average length of stay was 13 days. Nonoperative management of blunt hepatic injuries is clearly the treatment modality of choice in hemodynamically stable patients, irrespective of grade of injury or degree of hemoperitoneum. Current data would suggest that 50 to 80% (47% in this series) of all adult patients with blunt hepatic injuries are candidates for this form of therapy. Exactly 98.5% of patients analyzed in this study successfully avoided operative intervention. Bleeding complications are infrequently encountered (3.5%) and can often be managed nonoperatively. Although grades IV and V injuries composed 14% of the series, they represented 66.6% of the patients requiring operative intervention and thus merit constant re-evaluation and close observation in critical care units. The optimal time for follow-up computerized axial tomography scanning seems to be within 7 to 10 days after injury.

We tested the hypothesis that the macular ganglion cell layer (GCL) thickness demonstrates a stronger structure-function (SF) relationship and extends the useful range of macular measurements compared with combined macular inner layer or full thickness.Ninety-eight glaucomatous eyes and eight normal eyes with macular spectral domain optical coherence tomography (SD-OCT) volume scans and 10-2 visual fields were enrolled. Inner plexiform layer (IPL), GCL, macular retinal nerve fiber layer (mRNFL), ganglion cell-inner plexiform layer (GCIPL), ganglion cell complex (GCC), and full thickness (FT) measurements were calculated for 8 × 8 arrays of 3° superpixels. Main outcome measures were local structure-function relationships between macular superpixels and corresponding sensitivities on 10-2 fields after adjusting for ganglion cell displacement, dynamic range of measurements, and the change point (total deviation value where macular parameters reached measurement floor).Median (interquartile range [IQR]) mean deviation was -7.2 (-11.6 to -3.2) dB in glaucoma eyes. Strength of SF relationships was highest for GCIPL, GCL, GCC, and IPL (ρ = 0.635, 0.627, 0.621, and 0.577, respectively; P ≤ 0.046 for comparisons against GCIPL). Highest SF correlations coincided with the peak of GCL thickness, where the dynamic range was widest for FT (81.1 μm), followed by GCC (65.7 μm), GCIPL (54.9 μm), GCL (35.2 μm), mRNFL (27.5 μm), and IPL (20.9 μm). Change points were similar for all macular parameters (-7.8 to -8.9 dB).GCIPL, GCL, and GCC demonstrated comparable SF relationships while FT, GCC, and GCIPL had the widest dynamic range. Measurement of GCL did not extend the range of useful structural measurements. Measuring GCL does not provide any advantage for detection of progression with current SD-OCT technology.

Previous reports cite optimization of O2 delivery (DO2) to 660 mL/min/m2, O2 consumption (VO2) to 170 mL/min/m2, and cardiac index (CI) of 4.5 L/min as predicting survival. We prospectively evaluated 76 consecutive patients with multiple trauma admitted directly to the ICU from the operating room or emergency department. Patients had serum lactate levels and oxygen transport measured on ICU admission and at 8, 16, 24, 36, and 48 hours. Patients were analyzed with respect to survival (S) versus nonsurvival (NS), lactate clearance to normal (< or = 2 mmol/L) by 24 and 48 hours, hemodynamic optimization as defined above, as well as Injury Severity Score (ISS), ICU stay (LOS), and admission blood pressure. All patients achieved non-flow-dependent VO2. There was no difference in CI, DO2, VO2, or ISS when S was compared with NS. All 27 patients whose lactate level normalized in 24 hours survived. If lactate levels cleared to normal between 24 and 48 hours, the survival rate was 75%. Only 3 of the 22 patients who did not clear their lactate level to normal by 48 hours survived. Ten of the 25 nonsurvivors (40%) achieved the above arbitrary optimization criteria. Fifteen of the survivors never achieved any of these criteria. Optimization alone does not predict survival. However, the time needed to normalize serum lactate levels is an important prognostic factor for survival in severely injured patients.

Background Destruction of chest wall musculature from trauma, empyema, or local infection limits closure options, especially with muscle flaps. While the vacuum-assisted closure system (VAC; KCI International, San Antonio, TX) has been used for wounds in other anatomic locations, we have found no series for chest wounds. Methods This is a retrospective review of trauma registry data from the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine from 2000 to 2003. Results Seventeen patients were identified and divided into two groups. Group I consisted of seven patients with primary chest wall processes: four necrotizing soft-tissue infections and three with thoracic trauma resulting in significant loss of chest wall musculature. Group II consisted of ten patients with empyema and varying levels of chest wall extension. Six were postpneumonic and four postoperative. Wound size averaged 16 × 7 cm (range, 7 × 3 cm to 21 × 11 cm). The VAC duration averaged nine days (range, 3 to 21 days) and changed every two to three days. Fourteen wounds were culture positive; nine staphylococcus aureus , two alpha hemolytic streptococcus , and one each with enterococcus , Citrobacter, and anaerobes. Eight were polymicrobial. There were no deaths. All wounds healed without rotational muscle flaps. Ten underwent delayed primary closure, four split-thickness skin graft, and three healed by secondary intention. There was one significant complication: a wound infection after delayed primary closure which required reoperation. Conclusions Closure of complex chest wall wounds can present significant technical challenges. The VAC system is a simple, useful, and novel alternative to conventional wound care even with large, infected wounds.

The purpose of this study was to describe differences in demographics, injury pattern, transfusion needs, and outcome of pelvic fractures in older versus younger patients.This was a retrospective registry review of all patients with pelvic fractures admitted directly from the scene between January 1998 and December 1999.We cared for 234 patients with pelvic fractures during the study period. Mean age was 37.2 years, 51% were men, and mean Injury Severity Score (ISS) was 19. Overall mortality was 9%. Eighty-three percent were under the age of 55 years and 17% were older than 55 years. Severe pelvic fractures (AP3, LC3) were more common in young patients (p0.05). Admitting systolic blood pressure was lower and heart rate higher, although ISS was not different between the two age groups. Older patients were 2.8 times as likely to undergo transfusion (p0.005), and those undergoing transfusion required more blood (median, 7.5 units vs. 5 units). Older patients underwent angiography more frequently and were significantly more likely to die in the hospital even after adjusting for ISS (p0.005). This was most marked with ISS 15 to 25. Lateral compression (LC) fractures occurred 4.6 times more frequently in older patients than anteroposterior (AP) compression, and 8.2 times more frequently in those older patients undergoing transfusion as compared with AP compression. Ninety-eight percent of LC fractures in older patients were minor (LC1,2). However, older patients with LC fractures were nearly four times as likely to require blood compared with younger patients.In older patients, pelvic fractures are more likely to produce hemorrhage and require angiography. Fracture patterns differ in older patients, with LC fractures occurring more frequently, and commonly causing significant blood loss. The outcome of older patients with pelvic fractures is significantly worse than younger patients, particularly with higher injury severity. Recognition of these differences should help clinicians to identify patients at high risk for bleeding and death early, and to refine diagnostic and resuscitation strategies.

PURPOSE To determine factors affecting the disc-fovea angle (DFA), and to test the hypotheses that adjusting for DFA improves limits of retinal nerve fiber layer (RNFL) variability in normal subjects or enhances performance of RNFL measures for glaucoma detection. METHODS Disc-fovea angle was measured on scanning laser ophthalmoscope fundus images from 170 eyes (110 normal and glaucoma subjects). The DFA measurements were repeated in 24 eyes. The relationship between DFA and various anatomic variables was explored. Main outcome measures were changes in 95% RNFL prediction limits or glaucoma discrimination after adjusting for DFA. We also explored the angle between temporal raphe and horizontal meridian in 19 eyes with nasal field defects limited to one hemifield. RESULTS Average mean deviation and DFA were -0.1 (±1.2) dB and -6.6° (±3.4°) and -4.1 (±3.3) dB and -7.9° (±3.9°) in the control and glaucoma groups, respectively (P < 0.001 and = 0.029). The average difference between DFA repeat measurements was 2.0° (±1.8°). Predictors for DFA were female sex (P = 0.004), smaller disc area (P = 0.006), and glaucoma diagnosis (P = 0.019). The absolute change in sectoral RNFL thickness was 6.1 (±3.9) and 4.6 (±3.1) μm in control and glaucoma subjects, respectively. Retinal nerve fiber layer prediction limits improved in 5, 9, and 10 o'clock sectors (P < 0.02). Discrimination ability for the best-performing RNFL sector did not improve (P = 0.936). The average angle between temporal raphe and horizontal meridian was 0.8° (±0.8°). CONCLUSIONS Disc-fovea angle measurements demonstrated fair intersession repeatability. While adjusting for DFA improved RNFL prediction limits in some sectors, it did not enhance glaucoma detection.

Objective : To review a series of patients who sustained internal carotid artery (ICA) gunshot wounds. Design, Materials, and Methods : We retrospectively studied the demographics and clinical presentation, angiographic findings, methods of treatment, and outcome of 38 consecutive patients who had ICA injury identified by angiography. Results : Thirty-four of 38 patients were symptomatic with neck hematomas (32 patients), active hemorrhage (12 patients), and/or neurologic deficit (10 patients). Angiography showed active bleeding in 22 patients and occlusion in 16 patients. Twelve patients were treated operatively by ligation (seven patients), repair (four patients), or intracranial/extracranial bypass (one patient). Twenty-six patients were managed nonoperatively either by angioplasty (one patient), embolotherapy (17 patients), or observation alone (eight patients). Percutaneous balloon catheters were also used in three patients for vascular control of the ICA before operative repair or as a method of assessing intracranial collateral circulation. The mortality of 18.4% was largely related to strokes. Conclusions : Penetration of the ICA is a very severe injury with a high mortality. The major cause of death in this series was related to neurologic damage associated with carotid injury and shock. However, neurologic deficit among the survivors was uncommon and often resulted from emboli. Interventional radiology can play an important role in the management of these wounds and often obviates the need for operative exploration.

Objective : The inability to normalize lactate predicts death after trauma, but lactate may not be immediately available in every center. We postulated that, in a normal acid-base environment, lactate would correlate with the anion gap and the base excess of an arterial blood gas. Methods : We studied 52 consecutive, invasively monitored patients with trauma admitted directly to the intensive care unit (ICU) from the emergency department or operating room in our level I center to determine whether base excess and anion gap could predict lactate. Lactate, base excess, and anion gap were recorded upon admission to the ICU and 8, 16, 24, 36, and 48 hours after admission. Correlation coefficients (r 2 ) were calculated for the total patients, the 43 survivors, and the nine nonsurvivors. Results : Serum lactate was significantly higher in nonsurvivors at 16 hours after post ICU admission (4.0 ± 1.69 vs. 2.84 ± 1.49, p < 0.05), and this trend persisted ; the greatest difference was seen at 48 hours after admission (2.92 ± 1.47 vs. 1.76 ± 0.57, p < 0.001). There were no differences in base excess or anion gap between survivors and nonsurvivors. We found no consistent correlation between lactate versus anion gap, lactate versus base excess, or anion gap versus base excess. Conclusions : There is no correlation between lactate, base excess, and anion gap after initial resuscitation. Neither anion gap nor base excess was capable of predicting lactate ; therefore, lactate must be directly measured. The lack of correlation of anion gap with base excess or lactate suggests the presence of unmeasured anions, an impairment in acid-base regulation after injury and resuscitation, or both.

Objectives : The aims of this study were to determine if angiographic findings can be used to predict successful nonoperative therapy of splenic injury and to determine if coil embolization of the proximal splenic artery provides effective hemostasis. Methods : Splenic injuries detected by diagnostic imaging between 1981 and 1993 at a level I trauma center were prospectively collected and retrospectively reviewed after management by protocol that used diagnostic peritoneal lavage, computed tomography (CT), angiography, transcatheter embolization, and laparotomy. Computed tomography was performed initially or after positive diagnostic peritoneal lavage. Angiography was performed urgently in stabilized patients with CT-diagnosed splenic injuries. Patients without angiographic extravasation were treated by bed rest alone ; those with angiographic extravasation underwent coil embolization of the proximal splenic artery followed by bed rest. Results : Patients (172) with blunt splenic injury are the subject of this study. Twenty-two patients were initially managed operatively because of associated injuries or disease (11 patients) or because the surgeon was unwilling to attempt nonoperative therapy (11 patients) and underwent splenectomy (17 patients) or splenorrhaphy (5 patients). One hundred fifty of 172 consecutive patients (87%) with CT-diagnosed splenic injury were stable enough to be considered for nonoperative management. Eighty-seven of the 90 patients managed by bed rest alone, and 56 of 60 patients treated by splenic artery occlusion and bed rest had a successful outcome. Overall splenic salvage was 88%. It was 97% among those managed nonoperatively, including 61 grade III and grade IV splenic injuries. Sixty percent of patients received no blood transfusions. Three of 150 patients treated nonoperatively underwent delayed splenectomy for infarction (one patient) or splenic infection (two patients). Conclusions : (1) Hemodynamically stable patients with splenic injuries of all grades and no other indications for laparotomy can often be managed nonoperatively, especially when the injury is further characterized by arteriography. (2) The absence of contrast extravasation on splenic arteriography seems to be a reliable predictor of successful nonoperative management. We suggest its use to triage CT-diagnosed splenic injuries to bed rest or intervention. (3) Coil embolization of the proximal splenic artery is an effective method of hemostasis in stabilized patients with splenic injury. It expands the number of patients who can be managed nonoperatively.

Hypothesis Damage control laparotomy (DCL) has beneficial effects on the long-term morbidity and survival of trauma patients. Design Prospective study. Setting Level I trauma center. Patients Eighty-eight trauma patients who were admitted during a 3-year period (January 1, 2000, through December 31, 2003) underwent damage control laparotomy and were subsequently followed up (January 1, 2001, through December 31, 2008). Intervention Damage control laparotomy. Main outcome measures Major and long-term complications, lengths of stay, mortality, readmissions, subsequent surgical procedures, activities of daily living, and return to work. Results On admission, the mean age and Injury Severity Score were 33 years and 34, respectively. Of the 88 patients, 66 (75%) were male; 46 patients had blunt injuries and 42 had penetrating injuries. Liver was the most common injury (63 patients), followed by bowel (34), spleen (33), major vessel (19), and pancreas (10). The mean admission pH and temperature were 7.19 and 34.4°C, respectively, with 21.5 U of packed red blood cells transfused. The mean (SD) number of initial abdominal operations was 4.6 (2.5) per patient, with an overall mortality of 28% (25 patients). Intensive care unit and hospital lengths of stay were 18 (15) and 32 (20) days, respectively. Of the 63 patients who survived, 58 underwent intra-abdominal closure with polyglactin mesh. During the study, 44 intra-abdominal infections and 18 enterocutaneous fistulas were diagnosed. All 63 survivors were readmitted at least once. There were a total of 186 readmissions and 92 subsequent surgical procedures. Ventral hernia repair (66 readmissions) was the most common reason for readmission, followed by infection (41) and fistula management (29). There was 0% mortality for patients who survived the preliminary hospitalization. Of the 63 surviving patients, 51 (81%) reported that they had gone back to work and resumed normal daily activities. Conclusion Although damage control laparotomy is associated with a significant complication and readmission rate, its overall benefit is indisputable.

Soft tissue diseases including necrotizing soft tissue infections are associated with high mortality and morbidity with hospital-acquired infection rates up to 76 per cent. Critically ill patients with soft tissue infections have increased metabolic requirements; however, the effect of early nutrition on inhospital morbidity including nosocomial infection rates remains unclear. We hypothesized that enteral nutrition within 48 hours of intensive care unit admission would be associated with fewer hospital-acquired infections. We conducted a retrospective review of patients with soft tissue infection requiring intensive care unit admission for72 hours from January 2013 through December 2014 to a high-volume, dedicated soft tissue service. Variables were compared using chi-squared, Student's t test, linear regression, and binary logistic regression analysis. Eighty-five patients met inclusion criteria; 80 per cent started enteral nutrition within 48 hours. Twenty-six per cent had a hospital-acquired infection postadmission requiring treatment. Patients started on enteral nutrition within 48 hours had fewer ventilator days (mean 5 vs 12) and shorter hospital length of stay (mean 18 vs 40 days) when adjusted for age, gender, and confounding variables present on admission. Patients receiving early nutrition also had fewer hospital-acquired infections (18 vs 59%) when adjusted for confounding factors (aOR 0.15, P = 0.045). No significant difference in mortality (13.2% early vs 5.9% late, P = 0.4) or for inhospital morbidity when evaluating percentage of goal calories or protein received or time to goal tube feed rate was found. Early enteral feeding is associated with reduced inhospital morbidity in critically ill soft tissue patients, including fewer hospital-acquired infections and ventilator days, and shorter total length of stay.