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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.

Necrotizing lung infections (NLI) are rare occurrences; however, they can be devastating if not managed appropriately. NLI represent a spectrum of disease from lung abscess to pulmonary gangrene. The most common causes of NLI are Staphylococcus aureus and Streptococcus pneumoniae (pneumococcus). The mainstay of treatment is the early and aggressive use of appropriate antibiotics. If the infection extends to the pleural space causing an effusion or an empyema, drainage of the pleural space is necessary. If drainage of the pleural space fails or if sepsis is not controlled with antibiotics, then surgical debridement or drainage is needed. These patients require a multi-disciplinary team to provide optimal critical care and often times have long-term pulmonary dysfunction. This chapter will focus on NLI and the nuances of treatment.

Background In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. Methods The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. Results The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. Conclusion Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. Level of evidence Systematic review of predominantly level II studies, level II.

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%, P < 0.001), 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.

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.

This chapter will describe the common procedures done during the resuscitation of a badly injured patient. We will strive to provide a practical approach to those who deal with injured patients in the hope that this will aid those practitioners and ultimately the patients. Emergency care also entails some immediate lifesaving operations, usually within 1 h with simultaneous resuscitation. During emergency procedures, complications can be minimized if meticulous techniques are adopted. Pleural decompression is a common procedure following major injury and can be a lifesaving procedure; although it is relatively simple, complications can occur if attention to detail is not used. Pericardial window and transdiaphragmatic pericardial window at the time of laparotomy are diagnostic and potential temporarily therapeutic procedures in patients who may have hemopericardium. A median sternotomy is the ideal incision to access the heart and the anterior mediastinal great vessels. The most rapid method of accessing the chest is via an anterolateral thoracotomy: this incision can be performed rapidly and is versatile, as it can be brought across the sternum into a clamshell thoracotomy. Obtaining hemostasis in patients who are bleeding in the pelvis following major pelvic fractures can be challenging: pelvic packing can be lifesaving. Aortic occlusion can be obtained with REBOA which can provide temporary control of hemorrhage almost anywhere in the body.

This case report describes an immunocompromised patient with a skin boil that progressed to necrotizing fasciitis. The aim of this brief report is to raise awareness regarding necrotizing soft tissue infections caused by an unusual organism, Kocuria rosea, a typically non-pathogenic organism, and outline the course of treatment currently considered to be the standard of care.

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

Background Necrotizing soft tissue infections (NSTIs) are highly morbid infections often requiring critical care and transfusion support. We explored a large 2-year experience from a regional trauma center with a dedicated soft tissue service (STS) in an attempt to identify factors in current care with potential for improving outcomes for these critically ill patients. Methods New adult (>17 years) STS admissions, 2008–2009, were identified from the Trauma Registry. Patient records were extracted and assessed via descriptive statistics, univariate analysis, and multivariable logistic regression models. Results Mortality among 253 eligible primary admissions was 8.3% overall and 10.3% for those with an admission diagnosis of NSTI. No significant differences in wound characteristics, use of VAC (vacuum-assisted closure) dressing or hyperbaric oxygen, or wound microbiology emerged between survivors and nonsurvivors. Median time to first debridement was 5 h (interquartile range, 2–21 h). Multivariable modeling indicated association of worse outcome (death or discharge to chronic/rehab care) with age >60 years [odds ratio (OR), 3.82; P < 0.001], anemia (OR, 0.98; P = 0.03), increasing number of transfusions (OR, 1.09; P < 0.001), NSTI diagnosis (OR, 2.47; P = 0.005), preexisting diabetes mellitus (OR, 3.20; P = 0.001), and low admission hemoglobin (OR, 0.80; P = 0.004). Conclusions Mortality was less than previously reported. Number of transfusions and anemia at admission emerged as risk factors for poor outcomes. Future research should focus on the effects of transfusion on NSTI outcomes, on potentially confounding factors, and on whether a restrictive transfusion strategy reduces mortality.

Elderly patients already face declining physiologic reserve and frequently have one or more comorbidities. They may face barriers to accessing medical care that result in delay in the diagnosis and treatment of their necrotizing soft tissue infection (NSTI). Sepsis, commonly seen with NSTI carries a higher mortality rate in elderly patients. Hospital complication and comorbidities also contirbute the overall higher mortality seen in the geriatric patient population. Even after discharge from the hospital, geriatric patients have more decline in social and physical functioning than younger patients. Recovery following amputation is a particular challenge for older patients and they may not regain their independence.

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.

Necrotizing soft tissue infection caused by bowel perforation is uncommon. Failure to diagnose and treat it in a timely manner adds to the already significant associated mortality and morbidity. As with necrotizing soft tissue infections resulting from other causes, the initial presentation can be subtle. Laboratory studies and imaging may supplement clinical judgement to improve diagnostic accuracy. Once diagnosed antibiotics are promptly administered and urgent surgery performed. Prolonged resuscitation should not delay surgery. Spread to the gluteal region and thigh can occur. Evaluation with careful examination, imaging, and/or exploration might be required. Extensive debridements are the rule rather than the exception. Multiple procedures aimed at source control, removal of dead and infected tissue followed by wound stabilization are necessary. Long intensive care unit and hospital stays are standard. Post discharge rehabilitative services are required in all but a few patients. With comprehensive care that includes nutritional and physical therapy acceptable outcomes can be achieved.

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.

A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure.The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held.OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II).OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

DOI: 10.1167/tvst.5.4.5 Article Local Variability of Macular Thickness Measurements With SD-OCT and Influencing Factors Arezoo Miraftabi 1,2 , Navid Amini 1 , Jeff Gornbein 1 , Sharon Henry 1 , Pablo Romero 1 , 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, CA, USA Eye Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran Correspondence: Kouros Nouri- Mahdavi, MD MSc, 100 Stein Plaza, Los Angeles, CA 90095, USA. e-mail: nouri-mahdavi@jsei.ucla.edu Received: 25 September 2015 Accepted: 9 May 2016 Published: 19 July 2016 Keywords: SD-OCT; macular imag- ing; glaucoma; variability Citation: Miraftabi A, Amini N, Gornbein J, et al. Local variability of macular thickness measurements with SD-OCT and influencing fac- tors. Trans Vis Sci Tech. 2016;5(4):5, doi:10.1167/tvst.5.4.5 Purpose: To compare the intrasession variability of spectral-domain optical coherence tomography (SD-OCT)-derived local macular thickness measures and explore influencing factors. Methods: One hundred two glaucomatous eyes (102 patients) and 21 healthy eyes (21 subjects) with three good quality macular images during the same session were enrolled. Thickness measurements were calculated for 38 superpixels for the inner plexiform (IPL), ganglion cell (GCL), or retinal nerve fiber layers (mRNFL), GC/IPL, ganglion cell complex, and full macular thickness. Spatial distribution and magnitude of measurement errors (ME; differences between the 3 individual superpixel values and their mean) and association between MEs and thickness, age, axial length, and image quality were explored. Results: MEs had a normal distribution with mostly random noise along with a small fraction of outliers (1.2%–6.6%; highest variability in mRNFL and on the nasal border) based on M-estimation. Boundaries of 95% prediction intervals for variability reached a maximum of 3 lm for all layers and diagnostic groups after exclusion of outliers. Correlation between proportion of outliers and thickness measures varied among various parameters. Age, axial length, or image quality did not influence MEs (P . 0.05 for both groups). Conclusions: Local variability of macular SD-OCT measurements is low and uniform across the macula. The relationship between superpixel thickness and outlier proportion varied as a function of the parameter of interest. Translational Relevance: Given the low and uniform variability within and across eyes, definition of an individualized ‘variability space’ seems unnecessary. The variability measurements from this study could be used for designing algorithms for detection of glaucoma progression. Introduction Glaucoma is characterized by progressive loss of retinal ganglion cells (RGCs). With the advent of spectral-domain optical coherence tomography (SD- OCT), there has been increased interest in measuring RGC loss or thinning of the inner retina in the macula. 1–5 Approximately 50% of the RGCs are located within 4.5 mm (168) of the foveal center. 6 The central macula is the only part of the retina where the RGC layer is more than one cell thick; the peak RGC density occurs approximately 750 to 1100 lm from the center of the fovea. 6 Regional inner retinal thickness measurements such as ganglion cell/inner plexiform layer (GC/IPL) thickness perform as well as regional retinal nerve fiber layer (RNFL) thickness measures for detection of early glaucoma. 3,4,7 Hood et al. 8 demonstrated that GC/IPL thinning could be demonstrated in a group of patients with preperimet- ric glaucoma, although other studies have not found macular thickness to perform as well as RNFL thickness for detection of glaucoma in such pa- tients. 5,9 The role of macular SD-OCT imaging for detec- tion of glaucoma progression is yet to be fully elucidated. Early results have indicated its potential use. 10–12 Reproducibility of any structural outcome measure is one of the main determinants of how TVST j 2016 j Vol. 5 j No. 4 j Article 5 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.

The Joint Statement from the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is intended to serve as a guide for the safe introduction and use of REBOA as a resuscitative tool for a select group of critically ill civilian trauma patients.1 Patient safety and quality care are at the forefront of these recommendations and we stand behind the statement. In no way did we intend to diminish or impair the Department of Defense physician leadership’s ability to implement combat casualty care clinical practice guidelines for REBOA implementation in deployed settings. We admire and appreciate the numerous contributions to care of the injured patient that have emerged from the years of conflict in Iraq and Afghanistan. They are a testimony to what unity of purpose, resiliency and creativity can bring in the quest …

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) provides a new tool in selected patients for the management of non-compressible torso hemorrhage.1–3 Recent improvements in technology have facilitated more rapid placement through smaller femoral access sheaths, which may reduce access-related complications.4 However, high grade evidence to guide REBOA use is limited, and there is a substantial complication risk should this approach be used inappropriately.5 To address the current state of implementation of this new therapeutic strategy, the American College of Surgeons Committee on Trauma (ACS COT) has worked in collaboration with the American College of Emergency Physicians to issue this joint policy statement which addresses the current practice relevant to patient indications, potential complications, implementation, patient management, and training of providers. We urge trauma centers to consider these factors in the adoption of this approach.

Many studies have reported that older adults with glaucoma experience mobility issues due to gait difficulties. These include walking slowly and bumping into obstacles, which increase the risk of falls in glaucoma patients. In this paper, we design and develop a shoe-integrated sensing system as well as signal processing and machine learning algorithms to objectively quantify gait patterns in glaucoma patients. The sensor platform was utilized in a randomized clinical trial involving 9 glaucoma patients and 10 age-matched healthy participants performing a series of gait tests. Sensor signals are collected wirelessly and processed on a local computer. With the captured data, we develop data analysis techniques to make a comparison between gait characteristics in older adults with or without glaucoma. Our results demonstrate that the proposed system achieved an accuracy of more than 90% in distinguishing gait patterns of those with glaucoma from healthy individuals for various gait analysis tests.

Fournier's gangrene is an aggressive, polymicrobial soft tissue infection that specifically affects the genital and perineal region. Treatment requires early recognition, broad-spectrum intravenous antibiotics, and radical surgical debridement of all infected tissues. Optimal therapy may necessitate multiple debridements that leave the patient with large tissue defects that require skin grafting for scrotal and perineal reconstruction. The presence of other surgical emergencies, such as an incarcerated inguinal hernia, in the face of Fournier's gangrene presents a rare and challenging dilemma to the general surgeon. With the widespread acceptance of tension-free repair utilizing prosthetic mesh in uncomplicated hernia surgery, outcomes have been improved. However, surgical options for hernia repair may become limited in the face of a regional necrotizing soft tissue infection, for which mesh use in an open repair after debridement of infected tissues is generally contraindicated. In this report, the authors describe three consecutive cases of incarcerated inguinal hernia in the presence of concomitant Fournier's gangrene using a laparoscopic approach and natural biomaterial mesh for abdominal wall reinforcement.

The principles for damage control were first described for the management of patients with the devastating penetrating injury to the abdomen. The same principles can be applied to injury to the pelvis and the extremities. In this article we extrapolate from the basic principles of this surgical technique and present a clinically relevant discussion of damage control in the pelvis and extremity. Although techniques for damage control continue to evolve, virtually no literature specifically addresses pelvic and extremity trauma. Thus, we are not able to present a cookbook approach to the problem. Instead, this article focuses on some general principles of care and then discusses devastating pelvic injury secondary to both blunt and penetrating trauma. We describe the current approach to the mangled extremity and discuss indications for primary amputation. The nature of pelvic and extremity injuries necessitates a multispecialty team effort in the care of these patients because fractures are usually associated with massive soft-tissue and vascular injuries. This underscores the critical role that orthopedic and plastic surgeons must play in the management of these patients. The anatomy of the pelvis makes surgical hemostasis difficult if not impossible in many cases. An expert and readily available intervention radiology service is often life-saving in these patients. However, the trauma surgeon must continue to play the leading role within this multispecialty team and make management decisions based on the patient's physiology as well as the adequacy of resuscitation. Although many patients who sustain devastating injuries to the pelvis or to an extremity die or have substantial functional disabilities, it is our opinion that rapid assessment, resuscitation, and a multidisciplinary team approach give these patients the best chance at functional survival.

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.

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.

Each decade has brought improvements in our understanding of shock. With more understanding of the underlying mechanisms, we have been able to define more clearly optimal resuscitation strategies. In the last 2 decades, however, these strategies have gone through revolutionary change. Ideas once held sacred are not only being questioned, but the foundations on which these strategies are based have been shaken. We are now being forced to rethink many issues, such as: Is hypothermia always bad? Should we limit volume resuscitation in hemorrhagic shock? Should the patient with a brain injury in shock be treated differently than other patients in shock? The answers to these and other important questions hopefully will be answered definitively in the new millennium.

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.

Perhexilene maleate ('Pexid') is a new antianginal drug not chemically related to any drug so far used in the treatment of ischaemic heart-disease. In a double-blind crossover study of 12 patients with angina pectoris perhexilene therapy caused a significant reduction in the frequency of anginal attacks and improvement in exercise tolerance. A diuretic effect was also demonstrated.