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Background: Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room., Case Report: We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Power tools are essential for productivity but carry significant injury risks. Addressing power tool injuries across diverse age groups is vital, as existing research predominantly focuses on specific occupational or non-occupational groups, leaving a gap in understanding various age cohorts within the diverse American population. This study aims to comprehend power tool injury epidemiology, raising awareness about the importance of targeted safety measures for enhancing public health., Methods: Using a ten-year retrospective approach, this study analyzed National Electronic Injury Surveillance System (NEISS) data from US hospital emergency departments (2013-2022). Demographic and temporal trends were examined, and associations between injury occurrence and categorical variables, including injured body parts, gender, and race, were explored., Results: In 2013, power tool injuries were highest in the "51-60″ age group (23.70 %), followed by "41-50″ (17.31 %) and "61-70″ (19.38 %). Injury rates varied across age groups over the years. Notably, the "41-50″ age group showed a significant decrease in injuries over time (χ² = 17.12, p < .05), indicating a notable temporal trend. Hand injuries were predominant (39.08 %), followed by finger (19.19 %), lower arm (11.25 %), upper arm (8.79 %), and face (4.04 %). Lacerations constituted the most frequent injury type (60.89 %), alongside fractures, amputations, foreign body insertions, and contusions/abrasions. Significant associations emerged between injury occurrence and gender (χ² = 6.19, p < .001), as well as race (χ² = 7.42, p < .001). Males accounted for the majority of injuries (95.97 %), while white individuals constituted the largest proportion (91.84 %). Females and domestic settings exhibited increasing proportions of power tool injuries., Conclusions: The higher incidence among middle-aged individuals in domestic settings, coupled with evolving gender dynamics, underscores the need for targeted safety measures. Our findings contribute crucial novel insights, emphasizing tailored preventive strategies to enhance safety outcomes in the multifaceted landscape of power tool use., Competing Interests: Declaration of competing interest None., (Published by Elsevier Ltd.)

Pelvic floor dysfunction (PFD) is common to be associated with pregnancy and birth. To date, no research has been done to understand whether the perineal massage and warm compresses technique has an impact on pelvic floor dysfunction. To assess the impact of perineal massage and warm compresses technique during the second stage of labor in pelvic floor dysfunction at 3 and 6 months postpartum. Of the 800 women recruited to randomised controlled trial to prevent perineal trauma, 496 were included in the study, with 242 (48.8%) assigned to the Perineal Massage and Warm Compresses (PeMWaC) group and 254 (51.2%) to the control group (hands-on). Used the Pelvic Floor Distress Inventory-20 (PFDI-20). The questionnaire is divided into three subscales: Urinary (UDI), Colorectal-Anal (CRADI), and Pelvic Organ Prolapse Distress Inventory (POPDI). The PeMWaC group had a significantly higher frequency of intact perineum (p < 0.001) and low-severity vaginal tears (tears without any other degree of perineal trauma) (p = 0.031) compared to the control group, while the control group had significantly more patients who suffered high-severity vaginal/perineal trauma (second degree perineal tears) (p = 0.031) and patients without spontaneous perineal trauma or vaginal tears who underwent episiotomy (p < 0.001). In addition, at 3 months postpartum, women in the control group had a higher Urinary Distress Inventory (UDI) score and global score, compared to the PeMWaC group, and after controlling for confounding variables, the perineal massage and warm compresses technique was associated with lower UDI scores at 3 months postpartum compared to control group. At 6 months postpartum, there were no differences in the UDI or global scores, indicating general recovery from perineal trauma. In addition to reducing perineal trauma during birth, the perineal massage and warm compresses technique was associated with a lower prevalence of early PFD symptoms, mainly urinary distress, at 3 months.Trial registration http://www.ClinicalTrials.gov NCT05854888, retrospectively registered., (© 2023. The Author(s), under exclusive licence to Society for Reproductive Investigation.)

Background: Second-degree perineal tears are common and can vary widely in the extent of tissue trauma. Therefore, a better understanding of perineal pain based on tissue trauma severity in second-degree tears is needed., Aim: The primary aim of this study was to assess differences in perineal pain according to the severity of perineal tears, with a focus on subcategories of second-degree tears, during the first three months postpartum. The secondary aim was to assess the use of pain medication and breastfeeding patterns according to the severity of the second-degree tears., Methods: In this observational cohort study, nulli- and multiparous women with singleton pregnancies were included during pregnancy. After birth, perineal tears were classified using the latest international classification system. In addition, second-degree tears were subcategorised according to percentage of damage to the perineum (<50 %=2A,>50 % but less than entire perineum=2B, affecting entire perineum, anal sphincter not involved=2C). Perineal pain, use of pain medication and breastfeeding patterns were assessed during a phone interview seven to ten days postpartum and through an electronic questionnaire three months postpartum., Findings: Out of 880 vaginal births, 852 participants completed the phone interview and 715 answered the electronic questionnaire. During the first three months postpartum, women with 2C-tears reported statistically significantly higher pain scores and more frequent use of pain medication compared to women with 2A-tears. There was no statistically significant difference between the number of participants not breastfeeding between second-degree tear subcategories., Conclusion: Women with 2C-tears reported higher perineal pain scores and more use of pain medication compared to those with less severe tears during three months postpartum., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Coronary obstruction (CO) is a potentially life-threatening complication of transcatheter aortic valve replacement (TAVR). Chimney stenting or leaflet laceration with transcatheter electrosurgery (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction [BASILICA]) are 2 techniques developed to prevent CO., Objectives: The aim of the present study was to compare periprocedural and 1-year outcomes of chimney and BASILICA in TAVR patients at high risk of CO., Methods: This multicenter observational registry enrolled consecutive TAVR patients at high risk of CO, undergoing either preventive chimney stenting or BASILICA. Clinical success was defined as successful performance of the chimney or BASILICA technique without clinically relevant ostial CO. The primary endpoint was major adverse cardiovascular events, a composite of death, myocardial infarction, stroke, or unplanned target lesion coronary revascularization at 1 year., Results: A total of 168 patients were included: 71 (42.3%) received chimney stenting, and 97 (57.7%) underwent BASILICA. Patients undergoing BASILICA had higher preprocedural risk of CO, as indicated by lower sinotubular junction height (18.2 ± 4.8 mm vs 14.8 ± 3.4 mm; P < 0.001) and diameter (28.2 ± 4.5 vs 26.8 ± 3.4; P = 0.029). Rates of periprocedural complications were similar between the 2 groups. Clinical success was 97.2% and 96.9% in chimney and BASILICA, respectively (P = 0.92). At 1-year follow-up, the cumulative incidence of major adverse cardiovascular events was 18.7% (95% CI: 11%-30.6%) in the chimney group and 19.9% (95% CI: 12.1%-31.5%) in the BASILICA group (log-rank P = 0.848), whereas chimney was associated with a numerically higher cardiovascular mortality than BASILICA (6.7% vs 1.3%; log-rank P = 0.168)., Conclusions: Chimney stenting and BASILICA effectively prevent TAVR-induced acute CO. Both techniques seem to have comparable acceptable periprocedural and 1-year outcomes., Competing Interests: Funding Support and Author Disclosures Dr Mangieri serves as a proctor for Kardia; has received speaker fees from Boston Scientific, Abbott Vascular, and Edwards Lifesciences; and has received institutional grants from Boston Scientific and Abbott Vascular. Dr Montorfano has received consultant fees from Abbott, Boston, Kardia, and Medtronic. Dr Latib is a consultant and serves on advisory boards for Boston Scientific, Edwards Lifesciences, Medtronic, Abbott, and Philips. Dr Van Mieghem has received research grants from Abbott Vascular, Biotronik, Boston Scientific, Edwards Lifesciences, Medtronic, Daiichi-Sankyo, AstraZeneca, and Pie Medical; and has received advisory board/consultancy fees from Anteris, JenaValve, Amgen, Materialise, Siemens, Abbott Vascular, Biotronik, Boston Scientific, Medtronic, and Daiichi-Sankyo. Prof Abdel-Wahab declares that his hospital receives speaker honoraria and/or consultancy fees on his behalf from Boston Scientific, Medtronic, and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Degenerative meniscus tears can cause discomfort in some patients, and when medical treatments fail to provide relief, arthroscopy may be considered before resorting to knee prosthesis. However, the benefits of arthroscopy over nonsurgical treatments in patients over 60 years old are limited, and the evidence regarding its overall efficiency and drawbacks remains scarce. Furthermore, there has been no investigation into whether those patients treated with partial meniscectomy, undergo the knee operation at an earlier stage of osteoarthritis., Methods: This study focused on data from a single Belgian hospital, involving patients over 60 years old with internal meniscal tears. The participants were categorized into two groups based on the treatment they received: arthroscopic partial meniscectomy (APM) or conservative management. The primary outcome assessed was the occurrence of knee arthroplasty within a five year period. Secondary outcomes included evaluating the ICRS cartilage grade and the time taken until total knee arthroplasty (TKA)., Results: A total of 194 patients with internal meniscal tears were included in the study. At the 5-year mark, the overall rate of knee arthroplasty was found to be 16.5%, with 11.9% of cases occurring within two years. After the 5-year follow-up, it was observed that 19.2% (24 patients) of the APM group and 11.6% (8 patients) of the conservative management group underwent knee arthroplasty. Notably, patients over 70 years old who underwent APM had a higher risk of eventually requiring TKA compared to those who received conservative management. Additionally, patients who underwent meniscectomy and later underwent TKA showed less wear in the internal compartment of the knee compared to patients in the conservative treatment group who underwent TKA., Conclusion: The study suggests that patients who underwent arthroscopy faced a similar risk of knee arthroplasty compared to those who underwent conservative management, excepted for patients over 70 years old. Despite this similar risk of arthroplasty for the whole population, they exhibited lower osteoarthritis severity when compared to the conservative group., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery., Material and Methods: We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia)., Results: We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy., Conclusions: We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position., (© 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Objectives: Caring for pediatric lacerations in the emergency department (ED) is typically painful because of irrigation and suturing. To improve this painful experience, we aimed to increase the use of a topical anesthetic, Eutectic Mixture of Local Anesthetics (EMLA) on eligible pediatric lacerations with an attainable, sustainable, and measurable goal of 60%. The baseline rate of applying topical anesthetic to eligible lacerations was 23% in our ED. We aimed to increase the use of topical anesthetics on eligible pediatric lacerations to a measurable goal of 60% within 3 months of implementing our intervention., Methods: We conducted a prospective, single-center, interrupted time series, ED quality improvement project from November 2019 to July 2020. A multidisciplinary team of physicians and nurses performed a cause-and-effect analysis identifying 2 key drivers: early placement of EMLA and physician buy-in on which we built our Plan, Do, Study, and Act (PDSA) cycles. We collected data on number of eligible patients receiving EMLA, as well as patient and physician feedback via phone calls within 2 days after encounter. Balancing measures included ED length of stay (LOS), patient and physician satisfaction with EMLA, and adverse effects of EMLA., Results: We needed 3 PDSA cycles to reach our goal of 60% in 3 months, which was also maintained for 5 months. The PDSA cycles used educational interventions, direct provider feedback about noncompliance, and patient satisfaction results obtained via phone calls. Balancing measures were minimally impacted: 75% good patient satisfaction, no adverse events but an increase in LOS of patients who received EMLA compared with those who did not (1.79 ± 0.66 vs 1.41 ± 0.83 hours, P < 0.001). The main reasons for dissatisfaction for physicians were the increased LOS and the preference for procedural sedation or intranasal medications., Conclusions: With a few simple interventions, our aim of applying EMLA to 60% of eligible pediatric lacerations was attained and maintained., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications., Recent Findings: There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing., Summary: Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: In recent years, pelvic-abdominal dynamics has become a research topic in the field of pelvic floor dysfunction (PFD), and the relationship between diastasis of the rectus abdominis (DRA) and stress urinary incontinence (SUI) has been controversial. The study is helpful to further strengthen perinatal education, accurately identify the risk factors of SUI and DRA, and improve the quality of life of puerperae., Objective: This study aimed to investigate the association of SUI and DRA in women with PFD as measured by vaginal palpation or pelvic floor biofeedback machine testing., Study Design: A total of 301 patients diagnosed with female PFD who were 6-8 weeks postpartum at The Fifth People's Hospital of Zhuhai between May 2018 and April 2021 were enrolled. The prevalence rates and potential influencing factors of SUI and DRA were analyzed., Results: A total of 29.5% (89 of 301) of the patients were diagnosed with SUI, and 31.9% (96 of 301) were diagnosed with DRA. Binary logistic regression showed that a history of delivery ( P = 0.012; odds ratio [OR], 1.982) and vaginal delivery with perineal lacerations or episiotomy ( P = 0.016; OR, 2.187) were risk factors for SUI. High birth weight (weight>4.0 kg, P < 0.001; OR, 14.507) was a risk factor for DRA., Conclusions: A history of delivery and vaginal delivery with perineal lacerations or episiotomy increased the risk of SUI, and high birth weight was an independent risk factor for DRA. Early intervention, including exercise therapy, manual therapy, and neuromuscular electrical stimulation, may be important for patients with PFD having these risk factors., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Pelvic floor pain and dyspareunia are both important entities of postpartum pelvic pain, often concomitant and associated with perineal tears during vaginal delivery. The association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia has not been fully established. We aimed to determine the prevalence of postpartum anal sphincter defects using three-dimensional endoanal ultrasonography (3D-EAUS) and evaluate their association with symptoms of pelvic floor pain and dyspareunia., Material and Methods: This prospective cohort study followed 239 primiparas from birth to 12 months post delivery. Anal sphincters were assessed with 3D-EAUS 3 months postpartum, and self-reported pelvic floor function data were obtained using a web-based questionnaire distributed 1 year after delivery. Descriptive statistics were compared between the patients with and without sonographic defects, and the association between sonographic sphincter defects and outcomes were analyzed using logistic regression., Results: At 3 months postpartum, 48/239 (20%) patients had anal sphincter defects on 3D-EAUS, of which 43 (18%) were not clinically diagnosed with obstetric anal sphincter injury at the time of delivery. Patients with sonographic defects had higher fetal weight than those without defects, and a perineum <2 cm before the suture was a risk factor for defects (odds ratio [OR], 6.9). Patients with sonographic defects had a higher frequency of dyspareunia (OR, 2.4), and pelvic floor pain (OR, 2.3) than those without defects., Conclusions: Our results suggest an association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia. A perineal height <2 cm, measured by bidigital palpation immediately postdelivery, was a risk factor for sonographic anal sphincter defect. We suggest offering pelvic floor sonography around 3 months postpartum to high- risk women to optimize diagnosis and treatment of perineal tears and include perineum <2 cm prior to primary repair as a proposed indication for postpartum follow-up sonography., (© 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: Leaflet thrombosis after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) may be caused by blood flow stagnation in the native and neosinus regions. To date, aortic leaflet laceration has been used to mitigate coronary obstruction following TAVR; however, its influence on the fluid mechanics of the native and neosinus regions is poorly understood. This in vitro study compared the flow velocities and flow patterns in the setting of SAVR vs TAVR with and without aortic leaflet lacerations., Methods: Two valves, (23-mm Perimount and 26-mm SAPIEN 3; Edwards Lifesciences) were studied in a validated mock flow loop under physiologic conditions. Neosinus and native sinus fluid mechanics were quantified using particle image velocimetry in the left and noncoronary cusp, with an increasing number of aortic leaflets lacerated or removed., Results: Across all conditions, SAVR had the highest average sinus and neosinus velocities, and this value was used as a reference to compare against the TAVR conditions. With an increasing number of leaflets lacerated or removed with TAVR, the average sinus and neosinus velocities increased from 25% to 70% of SAVR flow (100%). Diastolic velocities were substantially augmented by leaflet laceration. Also, the shorter frame of the SAVR led to higher flow velocities compared with the longer frame of the TAVR, even after complete leaflet removal., Conclusions: Leaflet laceration augmented TAVR native and neosinus flow fields, approaching that of SAVR. These findings may have potential clinical implications for the use of single or multiple leaflet lacerations to reduce leaflet thrombosis and thus potentially improve TAVR durability., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

BACKGROUND Many patients experiencing acute coronary syndrome (ACS) present in cardiac arrest. Mechanical chest compressions are a common tool in cardiopulmonary resuscitation (CPR) and have their benefits as well as disadvantages and reported complications. In recent years, veno-arterial extracorporeal oxygenation membrane (VA-ECMO) has proven to be a promising tool in these circumstances and is now considered part of the treatment algorithm in emergent and refractory cases. The combination of mechanical compressions and the ECMO lead to "new" complicated situations in the patients. We discuss such a patient, who required emergent surgery due to complications from his resuscitation, while under ECMO. CASE REPORT A 56-year-old man, with medical history of cardiovascular risk factors, presented to our facility due to ST segment elevation myocardial infarction. During his catheterization, he went into cardiac arrest and needed cardiopulmonary resuscitation (CPR) using a LUCAS3™ device. Because no rhythm was restored, he was promptly placed on VA-ECMO support with immediate, albeit transient, stabilization. After transportation to our Intensive Care Unit (ICU), he quickly deteriorated again hemodynamically and after imaging workup it was discovered he had a major laceration to his liver and was rushed emergently to the operating room where he underwent partial hepatectomy, while on full anticoagulation due to the ECMO support. CONCLUSIONS Complications from mechanical CPR are common, including liver laceration. Patients who are placed on ECMO following such measures should be carefully evaluated for such complications as they might affect the treatment and prognosis.

Purpose: Shoulder function limitation duration after a full-thickness rotator cuff tendon (RCT) tear may influence post-repair healing and outcomes. A suture anchor was developed to improve footprint repair fixation and healing through biological fluid delivery and scaffold augmentation. The primary multicenter study objective was to evaluate RCT repair failure rate based on 6-month MRI examination, and device survival at 1-year follow-up. The secondary objective was to compare the clinical outcomes of subjects with shorter- and longer-term shoulder function limitation duration., Methods: Seventy-one subjects (46 men) with moderate-to-large RCT tears (1.5-4 cm), at a median 61 years of age (range = 40-76), participated in this study. Pre-repair RCT tear location/size and 6-month healing status were confirmed by an independent radiologist. Subjects with shorter- (Group 1: 17.8 ± 21 days, n = 37) and longer-term (Group 2: 185.4 ± 89 days, n = 34) shoulder function limitation durations were also compared over 1 year for active mobility, strength, American Shoulder and Elbow Surgeon's Shoulder Score (ASES score), Veterans RAND 12 Item Health Survey (VR-12), and visual analog scale (VAS) pain and instability scores., Results: Three of the 52 subjects [5.8%] who underwent 6-month MRI experienced a re-tear at the original RCT footprint repair site. By the 1-year follow-up, overall anchor survival was 97%. Although Group 2 displayed lower ASES and VR-12 scores pre-repair (ASES = 40.1 ± 17 vs. 47.9 ± 17; VR-12 physical health (PH) = 37.2 ± 9 vs. 41.4 ± 8) (p ≤ 0.048), at 3-month post-RCT repair (ASES = 61.3 ± 19 vs. 71.3 ± 20; VR-12 PH = 40.8 ± 8 vs. 46.8 ± 9) (p ≤ 0.038), and at 6-month post-RCT repair (ASES = 77.4 ± 18 vs. 87.8 ± 13; VR-12 PH = 48.9 ± 11 vs. 54.0 ± 9) (p ≤ 0.045), by 1-year post-RCT repair, groups did not differ (n.s.). Between-groups VR-12 mental health score differences were not evident at any time period (n.s.). Shoulder pain and instability VAS scores also did not differ (n.s.), displaying comparable improvement between groups from pre-RCT repair to 1-year post-RCT repair. Groups had comparable active shoulder mobility and strength recovery at each follow-up (n.s.)., Conclusion: At 6-month post-RCT repair, only 3/52 of patients [5.8%] had a footprint re-tear, and at 1-year follow-up, overall anchor survival was 97%. Use of this scaffold anchor was associated with excellent early clinical outcomes regardless of shoulder function impairment duration., Level of Evidence: II., (© 2023. The Author(s) under exclusive licence to European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Objective: This study aimed to systematically determine and compare the incidence of anal incontinence between those with different grades of obstetric anal sphincter injury., Data Sources: Ovid MEDLINE, Embase, and the Cochrane Library were searched from January 2000 to April 2021., Study Eligibility Criteria: Observational studies investigating the incidence of anal incontinence following an obstetric anal sphincter injury that was graded using the Sultan classification were eligible for inclusion. To allow comparison between individual tear grades (3a, 3b, 3c, fourth), a network meta-analysis was performed using Stata (version 15.1)., Methods: For binary outcomes, odds ratios with corresponding 95% confidence intervals were reported. Obstetric anal sphincter injury grades were ranked from the best clinical outcome to the worst clinical outcome. The percentage chance of each grade taking each rank with regards to outcome was calculated. Study quality and risk of bias was assessed using the relevant tool from the Joanna Briggs Institute., Results: Of the 696 studies identified, 10 were eligible for inclusion and were included in the network meta-analysis (n=2467 women). The mean incidence of anal incontinence among those with 3a tears was 22.4% (range, 6.1%-51.2%), 24.9% (range, 6.9%-46.7%) among those with 3b tears, 26.8% (range, 0%-55.6%) among those with 3c tears, and 28.6% (0%-71.4%) among those with fourth-degree tears. Anal incontinence incidence was found to be significantly higher among those with 3c (odds ratio, 1.79; 95% confidence interval, 1.09-2.94) and fourth-degree tears (odds ratio, 2.37; 95% confidence interval, 1.40-4.02) than among those with 3a tears. In addition, anal incontinence incidence was significantly higher among those with fourth-degree tears (odds ratio, 1.89; 95% confidence interval, 1.10-3.22) than among those with 3b tears. Those with 3a tears had the highest probability of having the best clinical outcome; those with 3b; second-, 3c; third- and fourth-degree tears had the highest probability of having the worst clinical outcome. Overall, all studies had a high or unclear risk of bias across 1 or more assessed element., Conclusion: This was a network meta-analysis comparing the incidence of anal incontinence among those with different grades of obstetric anal sphincter injury. Increasing tear-grade severity is associated with worse clinical outcomes. This study provides useful, clinically applicable information that can assist clinicians in the counseling of women following an obstetric anal sphincter injury. In addition, it highlights the importance of accurately diagnosing the obstetric anal sphincter injury grade and subsequently performing the appropriate repair., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: We aimed to explore the risk factors and countermeasures of stress urinary incontinence (SUI) after mesh implantation for patients with pelvic organ prolapse (POP)., Methods: A total of 224 POP patients undergoing mesh implantation from January 2018 to December 2021 were divided into group A (n = 68, postoperative new-onset SUI) and group B (n = 156, without postoperative new-onset SUI). Their clinical data were collected, and the treatment outcomes were analyzed. The independent risk factors for postoperative new-onset SUI were determined through multivariate logistic regression analysis. A risk-scoring model was established and assessed. The patients with postoperative new-onset SUI were divided into low-, moderate- and high-risk groups using this model., Results: Mesh implantation significantly improved the pelvic floor muscle strength and function of patients. Multivariate logistic regression analysis revealed that age ≥50 years old, gravidity ≥3 times, parity ≥3 times, history of macrosomia delivery, history of chronic respiratory diseases, vaginal delivery, and perineal laceration were independent risk factors for postoperative new-onset SUI, and pelvic floor muscle training by biofeedback electrical stimulation was a protective factor ( p < 0.05). The risk-scoring model was safe, reliable and practical, with high discrimination, accuracy and efficiency., Conclusions: Age ≥50 years old, gravidity ≥3 times, parity ≥3 times, history of macrosomia delivery, history of chronic respiratory diseases, vaginal delivery, and perineal laceration are independent risk factors for postoperative new-onset SUI, and pelvic floor muscle training by biofeedback electrical stimulation is a protective factor. Therefore, POP patients with new-onset SUI following mesh implantation should receive more pelvic floor muscle training., Competing Interests: The authors declare no conflict of interest., (© 2023 The Author(s).)

A 48-year-old male patient presented with inner skin retraction after a sports accident involving the knee. In a multi-ligament injury it must be assumed that knee dislocation has occurred. Inner skin retraction after knee distortion can result from an intra-articular dislocation of the ruptured medial collateral ligament. Prompt reduction and exclusion of concomitant neurovascular injuries is thus obligatory. After surgical reconstruction of the medial collateral ligament, instability was no longer apparent 3 months postoperatively., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Objective: The aim of the study is to determine characteristic features of open globe injuries caused by firecrackers among pediatric population., Methods: In this retrospective cross-sectional chart review, medical records of children with ocular trauma who were hospitalized in Isfahan, Iran, during 2013-2017 were reviewed. We analyzed the collected data before and after propensity score (PS) matching., Results: Of 396 pediatric patients with open globe injury, 22 injuries (5.9%) were caused by firecrackers. Hyphema, iris prolapse, and lens rupture were noted in 15 (68.18%), 10 (45.45%), and 2 (9.09) eyes, respectively. None of patients had endophthalmitis. The mean age of patients in firecracker group was higher and significant (11.86 ± 4.05 in firecracker vs 7.80 ± 4.68 in nonfirecracker, P < 0.001). Furthermore, most boys were in firecracker group (95.5%, P = 0.005). Patients in firecracker group resided more in urban areas (86.4%, P = 0.054) and had more intraocular foreign body (IOFB) in the eyes (40.9%, P < 0.001). After PS matching, patients in firecracker group had higher IOFB ( P = 0.008). In logistic regression models, patients with corneal lacerations had lower odds for long-time admission (≥4 days) than patients with both corneal and scleral lacerations in crude model (odds ratio, 0.35; 95% confidence interval, 0.17-0.69) and adjusted model (odds ratio, 0.37; 95% CI, 0.18 to 0.74). After PS matching, there was no significant association between risk factors and outcomes., Conclusions: The present study showed several differences between the pediatric open globe injuries caused by firecrackers and other mechanisms of injuries, including the age, sex, living place, presence of IOFB, and length of hospital stay., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: This case involved a 67-year-old female who was admitted for general anesthesia for a mitral clip procedure. Following anesthesia induction, the patient underwent an uneventful orotracheal intubation. Shortly afterwards she developed an ongoing respiratory failure, accompanied by neck and chest subcutaneous emphysema. Upon workup, she was found to have a 6 cm long tracheal laceration on the posterior side. Emergency repair surgery was performed using an extracorporeal membrane oxygenator (ECMO). The patient passed away 11 days later from sepsis. The aim of this case report is to increase awareness of this rare intubation complication, and explore the best approach to prevent, diagnose and treat tracheal injuries during endotracheal intubation.

Background: Explosions can produce blast waves, high-speed medium, thermal radiation, and chemical spatter, leading to complex and compound eye injuries. However, few studies have comprehensively investigated the clinical features of different eye injury types or possible risk factors for poor prognosis., Methods: We retrospectively reviewed all consecutive records of explosive eye injuries (1449 eyes in 1115 inpatients) in 14 tertiary referral hospitals in China over 12 years (between January 2008 and December 2019). Data on demographics, eye injury types, ocular findings, treatments, and factors affecting visual prognosis were extracted from a standardized database of eye injuries and statistically analyzed., Results: Mechanical ocular trauma accounted for 94.00% of explosion-related eye injuries, among which intraocular foreign bodies (IOFBs) resulted in 55.17% of open globe injuries (OGIs) and contusion caused 60.22% of close globe injuries (CGIs). Proliferative vitreous retinopathy (PVR) was more common in perforating (47.06%) and IOFB (26.84%) than in penetrating (8.79%) injuries, and more common with laceration (24.25%) than rupture (9.22%, P < 0.01). However, no difference was observed between rupture and contusion. Ultimately, 9.59% of eyes were removed and the final vision was ≤ 4/200 in 45.82% of patients. Poor presenting vision [odds ratio (OR) = 5.789], full-thickness laceration of the eyeball ≥ 5 mm (OR = 3.665), vitreous hemorrhage (OR = 3.474), IOFB (OR = 3.510), non-mechanical eye injury (NMEI, OR = 2.622, P < 0.001), rupture (OR = 2.362), traumatic optic neuropathy (OR = 2.102), retinal detachment (RD, OR = 2.033), endophthalmitis (OR = 3.281, P < 0.01), contusion (OR = 1.679), ciliary body detachment (OR = 6.592), zone III OGI (OR = 1.940), and PVR (OR = 1.615, P < 0.05) were significant negative predictors for poor visual outcomes., Conclusions: Explosion ocular trauma has complex mechanisms, with multiple eyes involved and poor prognosis. In lethal level I explosion injuries, eyeball rupture is a serious condition, whereas contusion is more likely to improve. In level II injuries, IOFBs are more harmful than penetrating injuries, and level IV represents burn-related eye injuries. PVR is more associated with penetrating mechanisms than with OGI. Identifying the risk predictors for visual prognosis can guide clinicians in the evaluation and treatment of ocular blast injuries., (© 2023. The Author(s).)

Background: The aim of the present study was to evaluate the complications associated with conventional methods of cast removal and to compare them with the complications associated with a novel method involving the use of externally guided aids for skin protection., Methods: Two hundred and eight cooperative patients ≥5 years of age who had no experience with cast removal were included in the study. Patients were selected arbitrarily and were divided into 2 groups. In Group 1 (106 patients [115 casts]; 60% male; average age, 20 years), conventional protection methods were used. In Group 2 (102 patients [108 casts]; 62% male; average age, 26 years), tong-shaped, externally guided, steel plate aids were used for skin protection. After the insertion of the protective part between the skin and the cast materials, the outer portion of the aid guided the operator to stay in a safe cutting line. The cast removal procedures in each group were documented, and skin injuries, burns, patient anxiety, operator anxiety, and processing time were noted., Results: In Group 1, the skin mark/scratch rate was 18%, the full-thickness skin laceration rate was 0.9%, the burn sensation rate was 22%, and the rate of first/second-degree burns was 2.5%. Anxiety was classified as moderate by 57% of the patients and as severe by 8%. Moderate anxiety was reported by 20% of the cast operators. In Group 2, only 6% of the patients experienced moderate anxiety and the removal time was reduced by >25%. When the groups were compared with regard to severe complications such as skin laceration (resulting in bleeding), visible burn, and severe anxiety, the former 2 complications were eliminated in Group 2 but the difference between the groups was statistically significant in the last category only (p = 0.325, p = 0.247, p = 0.007, respectively)., Conclusions: Eliminating saw blade-to-skin contact with a tong-like, externally guided flexible steel aid provides a high level of safety, decreases removal time by 5 to 10 minutes (depending on cast length), and makes cast removal a better experience for both patients and operators., Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article ( http://links.lww.com/JBJS/H252 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Orbital wall fractures are often associated with concomitant ocular injury. In some cases, detection and treatment of such injuries requires ophthalmology evaluation. Study Objective: To identify a change in ocular management as a result of ophthalmology evaluation in patients with orbital wall fractures. Materials and Methods: Retrospective cohort, patients >18 years of age with orbital wall fracture, and prompt evaluation by an ophthalmologist from 2012 to 2020 in a tertiary Level 1 trauma center. Results: Fifty percent of patients had a moderate and/or severe ocular injury. Ophthalmology evaluation led to an ocular management change in 27% of patients. Patients with eyelid laceration, extra-ocular motion (EOM) abnormality, and pupillary defect were more likely to have a change in management. There was no delay of surgical bony fracture management. Conclusion: In patients with midface trauma including orbital wall fractures those with eyelid laceration, EOM abnormality, and pupillary defect were likely to undergo ocular management change as a result of ophthalmology consultation.

Objective: Postpartum urinary retention is a frequently occurring condition for which screening is not typically a standardized part of postpartum care. The aim of this study was to determine the incidence of and risk factors for postpartum urinary retention after the introduction of a universal postpartum voiding protocol., Methods: This was a single-center retrospective case-control study of women delivering in a 12-month period. Women with a documented diagnosis of postpartum urinary retention per the institution's voiding protocol were classified as cases, and a matched sample of those without urinary retention were controls. Demographic and obstetric characteristics were compared between both groups using univariate and multivariate analyses as a means to identify risk factors for postpartum urinary retention., Results: 8992 women were studied during the time period examined; 195 (2.2%) were identified to have postpartum urinary retention. On multivariate logistic regression analysis, operative vaginal delivery (aOR 2.98 95% CI 1.32-6.70) and second-degree or greater perineal laceration (aOR 2.83 CI 1.59-5.04) were significantly associated with postpartum urinary retention., Conclusions: The incidence of postpartum urinary retention with a postpartum voiding protocol in place was low. Risk factors identified for urinary retention included operative vaginal delivery and second degree or greater perineal laceration. Awareness of these risk factors and implementation of standardized voiding protocols may aid with the early identification and prevention of postpartum urinary retention.

Background: Traumatic non-obstetrical hematomas of the vulva are rare, and most reports only involve adult patients. There are no data on presentation, management, and outcomes from either conservative or surgical management in pediatric and adolescent patients. The objective of this project was to compare the etiology, treatment, and outcomes of traumatic vulvar hematomas occurring in premenarchal and postmenarchal young women., Methods: A retrospective chart review was performed on females aged 0-24 years seen at a tertiary care academic center using ICD 9 and 10 codes for traumatic vulvar hematoma from 2006-2019. Data describing their clinical presentation and course were collected. IRB approval was obtained., Results: Twenty patients, aged 3-23 years (median age of 13.5 years) were identified. All 8 premenarchal patients presented with a straddle injury, whereas only 50% of postmenarchal patients were found to have a straddle injury. Other etiologies among postmenarchal patients included consensual sexual intercourse and recent vulvar surgery. Hematoma diameter ranged from 1-3 cm in premenarchal patients and 0.4-7 cm in postmenarchal patients. Associated perineal lacerations were reported in 50% of the premenarchal girls and 8% of postmenarchal young women. Of the 8 premenarchal patients, 5 were managed conservatively, and 3 were taken to the operating room for repair of perineal lacerations; 1 patient also underwent evacuation of a 3-cm hematoma. Of the 12 postmenarchal patients, 5 had surgical intervention, 2 for pain secondary to large 7-cm hematomas and 3 for suspected vulvar abscesses, which were identified as hematomas after drainage. One patient in each group required a Foley catheter for comfort. Two postmenarchal patients required a second surgery for further wound management. One premenarchal patient with surgical treatment required a follow-up exam under anesthesia. Four patients were admitted for pain and postoperative observation, 1 of whom was premenarchal. Eleven patients were seen for follow-up, and 10 were doing well. One postmenarchal patient in the conservative management group returned to the Emergency Department with continued pain 10 days later., Conclusions: In this study that examined traumatic vulvar hematomas in premenarchal and postmenarchal young women, the only mechanism of injury in premenarchal girls was straddle injury, and surgical intervention was usually needed only for repair of perineal lacerations, not a primary hematoma. In the postmenarchal patients, surgical intervention was undertaken for larger hematomas and suspected vulvar abscesses. Our study suggests that most hematomas up to 3 cm in premenarchal patients and up to 6 cm in postmenarchal patients can be managed conservatively., Competing Interests: Declaration of Competing Interest The authors of this study have no conflicts of interest to disclose., (Copyright © 2022. Published by Elsevier Inc.)

Purpose: Over the last decade Surgical Stabilisation of Rib Fractures (SSFR) gained popularity in our hospital. With increased numbers, we noted that frequently injuries were missed during primary/secondary survey and radiological imaging that were found during the surgical procedure. With this observation, the research question was formulated: What is the value of diagnostics thoracotomy or thoracoscopy during surgical stabilisation of rib fractures?, Methods: In a single-centre, retrospective study between February 2010 and December 2019, trauma patients who underwent Surgical Stabilisation of Rib Fractures (SSFR) and an inspection thoracotomy were included. All radiological injuries were compared with intraoperative findings. Missed injuries that were discovered during the surgical procedure that were not analysed during primary/secondary survey or on radiological imaging were recorded and retrospectively analysed by an independent radiologist., Results: Fifty-one patients were included. Eight patients had additional injuries; all had a diaphragmatic rupture, one patient had an additional stomach laceration, and another patient had a significant lung laceration in need of surgical repair. On a CT scan there are 7 signs of predictive value for a diaphragmatic rupture. Only 13 out of the total of 56 diaphragm rupture CT signs were confirmed on the primary CT scans of the eight patients with diaphragmatic injuries; therefore, still 77% of signs could not be confirmed by initial radiological findings., Conclusion: With the recent shift towards surgical stabilisation of rib fractures, an inspection thoracoscopy or thoracotomy during SSFR should be considered to minimise the incidence of missed intrathoracic injuries requiring early or late surgical treatment., (© 2021. Royal Academy of Medicine in Ireland.)

Introduction: Childbirth can sometimes be stressful or traumatic, and previous research has considered how birth complications and interventions may contribute to a negative birth experience. One of the most frequent complications during birth is trauma to the perineum. The aim of this study was to investigate whether different levels of perineal trauma were associated with differences in women's evaluation of their birth experience., Materials and Methods: As part of a longitudinal cohort study, the self-reported birth experiences of 202 primiparous women were compared based on the degree of perineal trauma they had experienced. Women who had given birth for the first time, vaginally and within the last 48   h in a large tertiary maternity unit in England were invited to take part. Data were collected from their hospital records with their consent and using the Childbirth Experience Questionnaire (CEQ), Experience of Birth Scale (EBS) and a perineal pain Visual Analogue Scale (VAS)., Results: Women with an obstetric anal sphincter injury (OASI) or episiotomy reported a more negative overall birth experience and perceived themselves as having less ability to give birth compared to those with a 1st/2nd degree sutured tear. Those with an episiotomy also reported feeling less involved in decision making processes during their birth. Significant differences remained between the OASI and 1st/2nd degree tear groups when controlling for factors known to affect birth experience, highlighting severe perineal trauma as a potential contributor to more negative birth experience., Conclusions: Perineal trauma may affect a woman's birth experience. Experiencing an episiotomy should not be overlooked as a potential contributor, especially during instrumental birth and in the absence of involved decision making. Further research is needed to disentangle the effects of episiotomy on birth experience, to explore the care needs of women with different degrees of perineal trauma and to explore how a negative birth experience may contribute to poor psychological health in the longer term.

The patient was an 82-year-old woman with localized muscle-invasive bladder cancer, who underwent robot-assisted radical cystectomy and cutaneous ureterostomy. On the 3rd day after the operation, she suddenly complained of abdominal pain. Abdominal computed tomographic scans revealed parastomal hernia. The patient underwent manual reduction of hernia, but had repeated recurrences of parastomal hernia within a few days. On the 14th day we performed a laparoscopic hernia repair. Observation of the stoma site revealed a laceration of the peritoneum and fascia, and the small intestine was prolapsed. We pulled the small intestine out and ligated the laceration with Mediflex® Suture Grasper Closure Device. After re-operation, there was no recurrence of bladder cancer and parastomal hernia, and the stoma appliances could be put on without any trouble.

Objectives: The aim of this study was to investigate the risk of coronary obstruction during redo-transcatheter aortic valve replacement (TAVR) within a previously implanted self-expanding valve in bicuspid aortic valve (BAV) versus tricuspid aortic valve (TAV) stenosis., Background: The prevalence of BAV in TAVR patients is expected to increase as the indication expands; however, no study has investigated the risk of coronary obstruction for future redo-TAVR in these patients., Methods: Computed tomography (CT) simulation analysis was performed in 86 type 0 BAV, 70 type 1 BAV, and 132 TAV patients who underwent TAVR with 1 VenusA-Valve (Venus Medtech) between January 2014 and December 2019., Results: CT-identified risk of coronary obstruction during redo-TAVR was observed in 36.1% of patients for the left coronary ostium (LCO) and 27.8% of patients for the right coronary ostium (RCO); however, the incidences were significantly lower in the type 0 BAV group than in the type 1 BAV or TAV group (for LCO: OR: 1.00 [reference] vs OR: 2.49; 95% CI: 1.24-5.01 vs OR: 2.60; 95% CI: 1.40-4.81; for RCO: OR: 1.00 [reference] vs OR: 2.14; 95% CI: 1.02-4.48 vs OR: 1.97; 95% CI: 1.02-3.80). The leaflet laceration technique may be unfeasible to improve coronary flow in 61.5% of the threatened LCOs and 58.8% of the threatened RCOs during redo-TAVR. The percentages were significantly or numerically lower in the type 0 BAV group than other groups (for LCO: 26.3% vs 62.1% vs 73.2%; P overall = 0.001; for RCO: 43.8% vs 65.2% vs 61.0%; P overall = 0.374)., Conclusions: Differences in anatomical features may impact the feasibility of future redo-TAVR. Type 0 BAV anatomy was associated with the lower incidence of CT-identified risk of coronary obstruction during redo-TAVR, and the leaflet laceration technique may be more feasible to ensure coronary flow in this population., Competing Interests: Funding Support and Author Disclosures This work was supported by the National Natural Science Foundation of China (81970325, 82102129 and 82170375); West China Hospital “1·3·5” Discipline of Excellence Project-“Percutaneous transcatheter aortic valve implantation” and “Mechanisms of aortic stenosis and the clinical applications. Drs Mao Chen and Yuan Feng are consultants of Venus MedTech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: When obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs)., Study Design: This is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair., Results: 21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear. 8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair. Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant., Conclusions: Women who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Amniotic fluid embolism (AFE) is a rare disease that can lead to profound coagulopathy and hemorrhage, especially when combined with the laceration and bleeding of other organs. Intraoperative cell salvage (ICS) has been widely used for treating obstetric hemorrhage, but it remains unclear whether ICS can be used in the treatment of AFE., Case Presentation: We report the case of a 27-year-old woman at 39 weeks' gestation who suddenly developed severe abdominal pain, convulsions, loss of consciousness, and decreased vital signs during labor. Despite an emergency cesarean section being performed, the parturient experienced sudden cardiac arrest. Fortunately, the heart rate spontaneously recovered after effective cardiopulmonary resuscitation (CPR). Further abdominal exploration revealed right hepatic laceration with active bleeding. ICS was performed and the salvaged blood was promptly transfused back to the patient. Subsequently, the patient was diagnosed with AFE based on hypotension, hypoxia, coagulopathy, and cardiac arrest. The patient was transfused with 2899 mL salvaged blood during surgery with no adverse effects. At 60- and 90-day follow-ups, no complaints of discomfort or abnormal laboratory test results were observed in the mother or the baby., Conclusion: ICS was used to rescue patient with AFE, and ICS did not worsen the condition of patients with AFE. For pregnant women who received CPR, clinicians should explore the presence of hepatic laceration which can be fatal to patients., (© 2022. The Author(s).)

Traumatic lacerations are a common reason for seeking care at the emergency departments. Clinical guidelines for treatment of traumatic lesions are not the same at all hospitals. Traumatic lacerations are often sought to be sutured within six hours which is characterized as the "golden period". However, this rule is based on an animal experiment conducted by Paul Leopold Friedrich in 1898. Several studies have confirmed that delays in wound closure rarely cause infection as summarised in this review. Wound length and depth, contamination of the wound and diabetes are found to be risk factors for wound infection.

Atraumatic splenic rupture (ASR) is a rare but fatal complication of malignant lymphoma. However, only one case of intravascular large B-cell lymphoma (IVLBCL)-related ASR (IVLBCL-ASR) has previously been reported, and the mechanism of IVLBCL-ASR is unknown. We present the case of a 78-year-old man who died unexpectedly and was diagnosed with IVLBCL-ASR pathologically by autopsy. A massive intraperitoneal hemorrhage and four lacerations on the splenic surface were discovered during the autopsy. CD20-positive lymphoma cells that infiltrated into small vessels were highly concentrated in the center of the spleen and were only slightly distributed in the lacerations on the splenic surface. Therefore, increased intrasplenic pressure due to lymphoma cell proliferation was identified as the cause of ASR. The patient had undergone 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) for tongue cancer evaluation 3 months earlier, and positive uptake was found in the right adrenal gland, where lymphoma cell infiltration was confirmed by the autopsy. Our findings suggest that clinicians should be aware that the advanced stage of IVLBCL can cause fatal ASR via increased intrasplenic pressure. Therefore, early diagnosis and early treatment intervention are desirable to prevent the onset of IVLBCL-ASR, and 18 F-FDG PET/CT is useful for the early diagnosis of IVLBCL.

Importance: A review of the injury patterns, treatment strategies, and responding physicians' experience during the Port of Beirut blast may help guide future ophthalmic disaster response plans., Objective: To present the ophthalmic injuries and difficulties encountered as a result of the Port of Beirut blast on August 4, 2020., Design, Setting, and Participants: A retrospective medical record review of all patients who presented to the emergency department and 13 ophthalmology outpatient clinics at the American University of Beirut Medical Center for treatment of ophthalmic injuries sustained from the explosion in Port of Beirut, Beirut, Lebanon, from August 4 to the end of November 2020. Patients were identified from emergency records, outpatient records, and operative reports., Main Outcomes and Measures: Types of ocular injuries, final best-corrected visual acuity, and need for surgical intervention were evaluated. Visual acuity was measured with correction based on noncycloplegic refraction using the Snellen medical record., Exposures: Ocular or ocular adnexal injuries sustained from the Port of Beirut explosion., Results: A total of 39 blast survivors with ocular injuries were included in this study. Twenty-two patients presented with ocular injuries on the day of the blast, and 17 patients presented within the following 3 months to the ophthalmology clinics for a total of 48 eyes of 39 patients were treated secondary to the blast. Thirty-five patients (89.6%) were adults, and 24 (61.5%) were female. A total of 21 patients (53.8%) required surgical intervention, more than half of which were urgently requested on the same day of presentation (14 [35.9%]). Most eye injuries were caused by debris and shrapnel from shattered glass leading to surface injury (26 [54.2%]), eyelid lacerations (20 [41.6%]), orbital fractures (14 [29.2%]), brow lacerations (10 [20.8%]), hyphema (9 [18.8%]), open globe injuries (10 [20.8%]), and other global injuries. Only 7 injured eyes (14.5%) had a final best-corrected visual acuity of less than 20/200, including all 4 open globe injuries with primary no light perception (8.3%) requiring enucleation or evisceration., Conclusions and Relevance: In the aftermath of the Port of Beirut explosion, a review of the ophthalmic injuries showed a predominance of shrapnel-based injuries, many of which had a delayed presentation owing to the strain placed on health care services. Reverting to basic approaches was necessary in the context of a malfunctioning electronic medical record system.

Open pelvic fractures are rare but represent a serious clinical problem with high mortality rates. Acute mortality is often associated with haemorrhage and delayed mortality is most often associated with sepsis and multiple organ failure. An aggressive multidisciplinary approach is of paramount importance to prevent catastrophe. It involves emergency resuscitation, stabilization of unstable fracture with an external fixator, and faecal diversion for rectal injury. Here, a case of open pelvic fracture with rectal laceration has been presented.

Aims: To undertake an integrative literature review to identify, analyse and synthesize current literature on the Kennedy terminal ulcer (KTU) and other unavoidable skin injuries that appear at the end of life regardless of the healthcare context in which they occur., Methods: Integrative review following the Whittemore and Knafl methodology. The search was carried out in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus. It was limited to articles in English, French, Portuguese and Spanish. As there is little scientific production on the subject, no restrictions were applied regarding publication date., Results: Only 17 articles met the inclusion criteria. These articles were reviewed and analysed. Four relevant issues emerged: Skin failure, SCALE, Kennedy Terminal Ulcer, Trombley-Brennan: different names for the same problem; the defining characteristics and physiopathology of KTU; the differences between KTU and other injuries; and the care approach for KTU and other unavoidable injuries at the end of life., Conclusions: We identified gaps regarding the physiopathology of KTU since the current knowledge is based only on hypotheses. There is also a large gap in the knowledge about care approaches, perhaps because care plans are not recorded. Despite this, it is clear that the main objective in this situation at the end of life would be to prioritize patient comfort and quality of life., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Background: Catamenial pneumothorax is generally uncommon, with an incidence of less than 3-6% in women with spontaneous pneumothorax. As few cases of catamenial pneumothorax with diaphragmatic defect and liver herniation have been reported, this case report may be useful for understanding the cause and treatment. This case highlights the importance of the approach for liver hernia in patients with catamenial pneumothorax and endometriosis., Case Presentation: We report a case of catamenial pneumothorax in a 43-year-old woman with diaphragmatic partial liver hernia who was treated with thoracoscopic surgery. She was diagnosed with a right pneumothorax at menstruation onset. Chest computed tomography showed a nodule protruding above the right diaphragm. We performed thoracoscopic surgery to treat the persistent air leak and biopsied the nodule on the right diaphragm. There were blueberry spots on the diaphragm; the nodule was found to be the herniated liver. The diaphragmatic defect was sutured. Histological examination of the tissue near the partial prolapsed liver revealed endometrial tissue., Conclusions: It is speculated that ectopic endometrial tissue in the diaphragm will periodically necrose to become a diaphragmatic tear, which is a pathway for air to enter the thoracic cavity and eventually a herniated liver. Thoracoscopic surgery should be considered in patients with catamenial pneumothorax when a diaphragmatic lesion is suspected.

Background: The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory., Objective: This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries., Study Design: Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components., Results: The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204)., Conclusion: The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)