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Civilian extremity trauma with vascular injury carries a significant risk of morbidity, limb loss, and mortality. We aim to describe the trends in extremity vascular injury repair and compare outcomes between trauma and vascular surgeons.We performed a single-center retrospective review of patients 18 years or older with extremity vascular injury requiring surgical intervention between January 2009 and December 2019. Demographics, injury characteristics, operative course, and hospital course were analyzed. Descriptive statistics were used to examine management trends, and outcomes were compared for arterial repairs. Multivariate regression was used to evaluate surgeon specialty as a predictor of complications, readmission, vascular outcomes, and mortality.A total of 231 patients met our inclusion criteria; 80% were male with a median age of 29 years. The femoral vessels were most commonly injured (39.4%), followed by the popliteal vessels (26.8%). Trauma surgeons performed the majority of femoral artery repairs (82%), while vascular surgeons repaired the majority of popliteal artery injuries (84%). Both had a similar share of brachial artery repairs (36% vs. 39%, respectively). There were no differences in complications, readmission, vascular outcomes, and mortality. Median time from arrival to operating room was significantly shorter for trauma surgeons. There was a significant downward trend between 2009 and 2017 in the proportion of total and femoral vascular procedures performed by trauma surgeons. On multivariate regression, surgical specialty was not a significant predictor of need for vascular reintervention, prophylactic or delayed fasciotomies, postoperative complications, or readmissions.Traumas surgeons arrived quicker to the operating and had no difference in short-term clinical outcomes of brachial and femoral artery repairs compared with patients treated by vascular surgeons. Over the last decade, there has been a significant decline in the number of open vascular repairs done by trauma surgeons.Therapeutic/Care Management, Level IV.

Background Tracheostomy is commonly used for managing the airway of trauma patients. Complications are common and result in increased length of stays and treatment cost. The aim of this study is to evaluate whether the utilization of skin sutures or foam barrier dressings affect tracheostomy complication rates. Materials and methods This is a single-center retrospective review of patients who underwent a tracheostomy by the trauma service between January 2014 and December 2017. Collected variables included demographics, patient history, treatment variables, complications, and outcomes. Univariate and multivariate analyses were constructed to identify significant predictors for the development of complications. Results A total of 268 patients were included. The median age was 43.5 y, 221 (82.5%) patients were men, and the median BMI was 28 (IQR 24.6, 32.2). Most (87.3%) of the procedures were performed in the operating room and 82.5% were open. Skin sutures were used in 46.3% and 53.4% had a foam barrier dressing placed. Current smoking [OR 8.1 (95% CI 1.5, 43.6)] and BMI [OR 1.1 (95% CI 1.03, 1.2)] significantly increased the risk of developing pressure necrosis. Use of sutures or foam dressings was not associated with pressure necrosis, bleeding, or surgical site infection. There were no unexpected tracheostomy decannulations regardless of the use of skin sutures. Conclusions Suturing the tracheostomy or applying a foam barrier dressing was not associated with overall complications or decannulation rates. Based on our data, we suggest that skin sutures may be safely abandoned.

Background Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. Methods Trauma patients with temperatures Results 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) ( P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity ( P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia ( P = .44). Conclusion Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.

Background The incidence of underlying malignancy in appendicitis ranges between 0.5% and 1.7%. We sought to identify the subset of patients with appendicitis who are at increased risk of appendiceal malignancy. Methods Using the Eastern Association for the Surgery of Trauma Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous database, we included all patients from 28 centers undergoing immediate, delayed, or interval appendectomy between 2017 and 2018. Univariate then multivariable analyses were performed to compare patients with and without malignancy and to identify independent demographic, clinical, laboratory, and/or radiological predictors of malignancy. Akaike information criteria for regression models were used to evaluate goodness of fit. Results A total of 3,293 patients were included. The median age was 38 (27–53) years, and 46.5% were female patients. On pathology, 48 (1.5%) had an underlying malignancy (adenocarcinoma [60.4%], neuroendocrine [37.5%], and lymphoma [2.1%]). Patients with malignancy were older (56 [34.5–67] vs 37 [27–52] years, P 40 years with an appendiceal diameter >10 mm on computed tomography was 2.95% compared with 0.97% in patients ≤40 years old with appendiceal diameter ≤10 mm. The corresponding risk ratio for that population was 3.03 (95% confidence interval: 1.24–7.42; P = .02). Conclusion The combination of age >40 and an appendiceal diameter >10 mm is associated with a greater than 3-fold increased risk of malignancy in patients presenting with appendicitis.

Background The appropriate duration of antibiotic therapy for surgical site infection (SSI) prevention in traumatic mandibular fracture repair is unknown, and practices vary significantly. The objective of this study was to characterize antibiotic duration and outcomes after surgical repair of traumatic mandibular fracture. Methods A single-center, retrospective analysis of all adult patients who underwent surgical fixation of a mandible fracture between January 2014 and December 2016 was performed. Operative service was categorized between otolaryngology (ear, nose, and throat surgery), plastic and reconstructive surgery, and oral and maxillofacial services. Primary outcomes were SSI and operative complications (including osteomyelitis, nonunion, malocclusion, and hardware infections). Differences in antibiotic prescription pattern were analyzed using analysis of variance test and Pearson chi-squared test. Results A total of 75 patients were included in the study with 33 (44.0%), 26 (34.7%), and 16 (21.3%) managed by plastic and reconstructive surgery, ear, nose, and throat surgery, and oral and maxillofacial services, respectively. Median age was 30.0 y. Median injury severity score was 4.0. There was no significant difference in hospital length of stay (P = 0.44), intensive care unit length of stay (P = 0.53), or postoperative complications (P = 0.15). None of our patients developed an SSI or postantibiotics complications. Although the total inpatient duration of antibiotics was not significantly different among services (P = 0.37), there were significant differences in outpatient duration of antibiotics (P = 0.007) and total duration of antibiotics (P = 0.003). Conclusions Duration of antibiotics is not associated with postoperative SSI or antibiotics-related complications. The wide variation in prescribing practices and lack of any clear benefit for prolonged antibiotics provides an opportunity to explore the benefits of a standardized short course of antibiotics. Level of evidence Therapeutic study, III.

Appendicitis usually manifests as either uncomplicated or complicated disease. Uncomplicated appendicitis is generally treated with an appendectomy without further antibiotic therapy. In contrast, complicated appendicitis can be treated in a myriad of ways. Nonoperative treatment has been proven to be effective but has variable failure rates. Operative management typically involves resection with postoperative antibiotics. The duration of antibiotic therapy is a topic of interest. Past studies have shown that a shorter duration of antibiotics (3-5 days) are equally as effective in treating intra-abdominal contamination. In the fall 2015, our practice pattern for antibiotic duration for acute complicated appendicitis changed to reflect this finding. The purpose of this study is to retrospectively review this change in practice.The aim of this study was to determine if a shorter duration of antibiotics for acute complicated appendicitis is as effective as a traditional longer duration of antibiotics with a historical cohort. We also aim to determine if the duration of stay improved with the shorter duration of antibiotics.Appendicitis cases documented after September 2015 until the present were identified. Study inclusion criteria included patients aged ≥18 and patients undergoing an appendectomy (open or laparoscopic). Exclusion criteria included patients age18, appendicitis cases not undergoing an operation, pregnant, or immunocompromised patients. Patient demographics, operation performed, pathology reports, antibiotic duration, duration of stay, infectious and postoperative complications, and 30-day readmission rates were collected through chart review. A sample of our treatment group prior to September 2015 was also obtained in a similar technique.The durations of stay between cohorts were not different; both were about 6.1 days. The duration of antibiotics was less in the post-2015 group (5.5 days vs 4.1 days, P = .005). The 30-day readmission rate was significantly less in the post-2015 group (16% vs 2%; P.017). Neither in hospital infectious complications nor types of complications were statistically significantly different between groups.This study shows that adherence to short duration antibiotic treatment appears to be effective in decreasing the 30-day readmission rate without increasing in hospital infectious complications. Short duration of antibiotics did not, however, decrease the duration of hospital stay.

BACKGROUNDAs more pneumothoraxes (PTX) are being identified on chest computed tomography (CT), the empiric trigger for tube thoracostomy (TT) versus observation remains unclear. We hypothesized that PTX measuring 35 mm or less on chest CT can be safely observed in both penetrating and blunt trauma m

Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury.Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed.During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred.The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient.Prognostic/Epidemiologic, level III.

Background The need for extended postoperative antibiotics (Abx) for complicated (gangrenous or perforated) appendicitis (CA) remains unclear. We hypothesize that giving ≤24 h of Abx for CA is not inferior to a longer duration in preventing infectious complications after appendectomy. Methods In this post hoc analysis of a prospective multicenter study, only patients with intraoperative diagnosis of CA were included. ANOVA and Chi-squared tests were used to compare length of stay, 30-day readmission rates, surgical site infection (SSI), and intra-abdominal abscess (IAA) between patients receiving ≥96 h and ≤24 h of Abx. Results Of 751 patients with CA, 704 met inclusion criteria. Mean age was 48 (±17) y; 391 (56%) were male. A total of 185 (26%) received Abx for ≤24 h and 100 (14% of overall) received no Abx. 85 (12%) patients were lost to follow-up at 30 d postop. Twenty-seven (4%) patients developed an SSI (≤24 h = 5 (3%), ≥96 h = 22 (5%), P = 0.502) and 82 (13%) developed IAA (≤24 h = 11 (7%), ≥96 h = 71 (15%), P = 0.008) within 30d postop. Sixty-six (11%) patients underwent a secondary intervention for infection within 30 d postop. 41% of SSIs (11/27) and 60% (49/82) of IAA occurred during the index hospitalization. On the multivariate analysis, there was not any evidence of an association between the duration of Abx and an increased rate of SSI (P = 0.539), IAA (P = 0.274), emergency department visits (P = 0.509), readmission (P = 0.911), or secondary interventions (P = 0.523). Conclusions No evidence of an association between the duration of Abx (≤24 h versus ≥ 96 h) for complicated appendicitis and an increased rate of SSI was observed and ≤24 h duration was associated with shorter length of stay. Because of possible selection bias, adequately powered randomized trials are required to definitely prove noninferiority of shorter course Abx duration.

Background:. Both stenosing tenosynovitis and Dupuytren’s contracture are common conditions encountered in hand surgery. Connections between 2 diseases have been suggested in literature. The purpose of this study was to examine whether there’s an association between the 2 processes. Methods:. A retrospective chart review was performed to include all patients seen by a single surgeon between 2014 and 2017 with the diagnosis of either trigger finger or Dupuytren’s contracture in the same hand. Patients’ demographics, medical history, social and surgical histories are recorded. Univariate and multivariate analysis were conducted. Results:. A cohort of 238 patients was identified. One hundred ninety-two patients were diagnosed with trigger finger. Eighty-nine patients were diagnosed with Dupuytren’s contracture. Forty-three patients carried both diagnoses. Median age was 61.6 (56–72). Half were male (50.4%) and 66.8% reported current alcohol intake. Other factors include history of former or current tobacco use (52.9%), diabetes (23.9%), and manual labor (31.1%). In the univariate model, trigger finger, sex, and age were significantly associated with the diagnosis of Dupuytren’s contracture, and Dupuytren’s contracture and sex were significantly associated with the trigger finger diagnosis. Diabetes, manual labor, use of alcohol and tobacco were not significant. In the multivariate model, age and trigger finger were significantly associated with Dupuytren’s contracture. Conclusions:. Significant association between stenosing tenosynovitis and Dupuytren’s contracture was identified in our patient cohort. Patients with stenosing tenosynovitis may be at an increased risk of developing Dupuytren’s contracture or vice versa.

Development of novel imaging probes for cancer diagnostics remains critical for early detection of disease, yet most imaging agents are hindered by suboptimal tumor accumulation. To overcome these limitations, researchers have adapted antibodies for imaging purposes. As cancerous malignancies express atypical patterns of cell surface proteins in comparison to noncancerous tissues, novel antibody-based imaging agents can be constructed to target individual cancer cells or surrounding vasculature. Using molecular imaging techniques, these agents may be utilized for detection of malignancies and monitoring of therapeutic response. Currently, there are several imaging modalities commonly employed for molecular imaging. These imaging modalities include positron emission tomography (PET), single-photon emission computed tomography (SPECT), magnetic resonance (MR) imaging, optical imaging (fluorescence and bioluminescence), and photoacoustic (PA) imaging. While antibody-based imaging agents may be employed for a broad range of diseases, this review focuses on the molecular imaging of pancreatic cancer, as there are limited resources for imaging and treatment of pancreatic malignancies. Additionally, pancreatic cancer remains the most lethal cancer with an overall 5-year survival rate of approximately 7%, despite significant advances in the imaging and treatment of many other cancers. In this review, we discuss recent advances in molecular imaging of pancreatic cancer using antibody-based imaging agents. This task is accomplished by summarizing the current progress in each type of molecular imaging modality described above. Also, several considerations for designing and synthesizing novel antibody-based imaging agents are discussed. Lastly, the future directions of antibody-based imaging agents are discussed, emphasizing the potential applications for personalized medicine.

Objective To assess the awareness and attitudes of the general public in Lebanon regarding the interactions between physicians and pharmaceutical companies. Setting Primary healthcare clinics and shopping malls in the Greater Beirut Area. Participants 263 participants completed the questionnaire, of whom 62% were female and 38% were male. Eligible participants were Arabic-speaking or English-speaking adults (age≥18 years) residing in Lebanon for at least 5 years. Primary and secondary outcome measures Awareness, attitudes and beliefs of the general public. Results 263 out of 295 invited individuals (89% completion rate) completed the questionnaire. While the majority of participants were aware of pharmaceutical company presence (or absence) in physicians9 offices (range of 71–76% across questions), smaller percentages were aware of gift-related practices of physicians (range of 26–69% across questions). 40% thought that the acceptance of small gifts or meals by physicians is wrong/unethical. The percentage of participants reporting lower trust in physicians due to their participation in various pharmaceutical company-related activities ranged from 12% to 45% (the highest percentage being for large gifts). Participants who reported receiving free medication samples were significantly more likely to consider physicians9 acceptance of small gifts as ‘not a problem’ than ‘unethical’ (OR=1.53; p=0.044). Conclusions Participants in our survey were generally more aware of pharmaceutical company presence (or absence) in physicians9 offices than of gift-related practices of physicians. While the level of trust was not affected for the majority of participants for various types of interactions, it was affected the most for accepting large gifts.

Introduction Mandibular prognathism (MP) is subject to major polygenic influence and segregates within families in autosomal dominance with variable expressivity and incomplete penetrance. We aimed to identify the inheritance pattern and genes and loci involved in the development of MP in Mediterranean families and to evaluate the dentoskeletal characteristics of affected individuals. Methods Fifty-one eastern Mediterranean families with individuals affected by MP were identified. Data and biospecimens were collected from 14 of the families, including clinical examination, lateral cephalography (on subjects with Class III malocclusion), and 5 mL blood drawn from consenting affected and nonaffected relatives. Next-generation sequencing (NGS) was performed on 8 families (7 Lebanese, 1 Lebanese/Syrian), including large numbers of affected individuals over many generations and severe conditions, with the use of whole-exome sequencing. Results Most pedigrees suggested autosomal-dominant inheritance with an equal number of affected male and female individuals. Affected individuals had macrognathic and prognathic mandibles with dentoalveolar compensation. Genetic screening did not correspond with previously reported MP-linked genes, but yielded 3 novel genes (C1orf167, NBPF8, NBPF9) on chromosome 1 potentially responsible for mandibular development and macrognathism. Conclusions In this first genetic study with the use of NGS on the largest reported number of families with MP, novel genes (C1orf167, NBPF8, NBPF9) were associated with familial MP in the eastern Mediterranean population.

Multifunctional zinc oxide (ZnO) nanoparticles (NPs) with well-integrated multimodality imaging capacities have generated increasing research interest in the past decade. However, limited progress has been made in developing ZnO NP-based multimodality tumor-imaging agents. Here we developed novel red fluorescent ZnO NPs and described the successful conjugation of 64Cu (t1/2 = 12.7 h) and TRC105, a chimeric monoclonal antibody against CD105, to these ZnO NPs via well-developed surface engineering procedures. The produced dual-modality ZnO NPs were readily applicable for positron emission tomography (PET) imaging and fluorescence imaging of the tumor vasculature. Their pharmacokinetics and tumor-targeting efficacy/specificity in mice bearing murine breast 4T1 tumor were thoroughly investigated. ZnO NPs with dual-modality imaging properties can serve as an attractive candidate for future cancer theranostics.