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Issue #11: July 26th, 2023

Updated: Sep 25, 2024

Bright star, would I were stedfast as thou art—

Not in lone splendour hung aloft the night

And watching, with eternal lids apart,

Like nature’s patient, sleepless Eremite,

The moving waters at their priestlike task

Of pure ablution round earth’s human shores,

Or gazing on the new soft-fallen mask

Of snow upon the mountains and the moors—

No—yet still stedfast, still unchangeable,

Pillow’d upon my fair love’s ripening breast,

To feel for ever its soft fall and swell,

Awake for ever in a sweet unrest,

Still, still to hear her tender-taken breath,

And so live ever—or else swoon to death.




The gut microbiome is one of the great frontiers of the human body; however, its role within the digestive tract has yet to be fully discovered. In times of stress, such as sepsis or shock, the diversity of the gut microbiome is significantly reduced in what is referred to as the “pathobiome.” This has many effects on the immune system and the ability of the small bowel to recover from trauma. A previous study had shown this to be the case for individuals recovering from multicompartmental traumatic injury. Other studies have shown females had quicker return of microbial diversity in the setting of sepsis in animal models. In this study, the authors investigated sex as a biological variable and its impact on outcomes and prognosis.

This is a randomized, preclinical animal study where 48 nine to eleven week old Sprague-Dawley rats (24 males; 24 proestrous females) were split evenly into 3 different groups : Naïve, Polytrauma (PT), Polytrauma with Chronic Stress (PT/CS). Those in the PT and PT/CS groups were subject to a number of injury models to reflect common clinical scenarios of polytrauma involving multicompartmental injuries and chronic restraint stress was applied via a nose cone with loud alarms for 2 hours daily. Statistical analysis was achieved by calculating a Chao1 index and a Shannon Index representing microbiome diversity for each group. Lipopolysaccharide-Binding Protein and plasma Occludin were measured to assess intestinal permeability from blood and fecal samples. Results show a Shannon index of 2.9 +/- 0.4 in males and 3.4 +/- 0.4 in females (p=0.03) on Day 0. This was shown to have been eliminated by Day 2 with no significant differences seen in rats in the PT and PT/CS groups. Overall, male rats had elevated levels of Terminal Ileum Injury scores in the PT/CS group: males had a score of 8.8 +/- 1.8, and females had scores of 4.1 +/-1.7 (p=0.0002). Plasma occludin levels were found to be elevated at Day 2 in PT and PT/CS compared to Naïve (PT: 34.4+/-16.2, PT/CS: 25.42+/-12.8, Naïve: 7.6+/-1.3, p=0.03). Subgroup analysis showed elevated plasma Occludin in males compared to females in the PT group (PT Males: 45 +/-13.9, PT Females: 23.7 +/- 10.4, p=0.004). Multicompartmental injury males had dominant amounts of Ruminococcus and Roseburia, as well as Lacnospiraceae and Muribaculaceae in PT/CS patients and PT/CS females had elevated levels Bifidobacterium (p<0.01). A number of conclusions can be made about the effects of multicompartmental trauma: trauma results in decreased microbial diversity, males have increased rates of terminal ileum damage, males may have increased intestinal permeability, and different microbial profiles develop based on biologic sex. This study points towards sex as being an important biological variable to be considered in cases of severe trauma and critical illness.


Myth or Fact: Can organ transplants from donors with primary brain tumors transmit cancer to recipients? This study debunks a commonly displayed case in TV Dramas such as The Good Doctor and Grey’s Anatomy. A cohort study in England and Scotland aimed to study the risk of cancer transmission associated with organ transplants from donors with primary brain tumors who were deceased. The study involved 887 transplants from a total of 282 donors with primary brain tumors, out of which 262 transplants were from donors with high-grade tumors and 494 from those with previous surgical interventions or radiation therapy. The study obtained data through the UK Transplant Registry, and analyzed the data of deceased donors and recipients between the years 2000 and 2016, and were followed up for cancer transmission rates until 2020. The results showed that, over a span of 3-9 years, a total of 83 post transplant malignancies occurred in 79 transplant recipients, however, none of the tumors were determined to have the matching histological type and staging of the donor’s brain tumors. The 10 year post transplant survival rates was 65% (95% CI: 59%-71%), 69% (95% CI: 60%-76%), 73% (95% CI: 59%-83%), and 46% (95% CI: 29%-61%) for kidney, liver, heart and lung transplants respectively. The study determined that there is no difference in survival or cancer transmission rates compared to matched controls. This study analyzed various comorbidities, time of cancer diagnosis, lifestyle risk factors, and differences in recipient ages. Certainly, the population size of the study and the long term follow-up of these patients is impressive. However, as the study admits, the risk of cancer transmission should always be considered and weighed to determine mortality benefit in the recipient. Although further research with more controlled confounding variables in single organ transplants would give more reliable results, this is an impressive study which may lead to more investigations in the possibility of expanding transplantation from a wider range of donors.


Is antibiotic treatment actually the best method to prevent a bacterial infection? This masked, randomized controlled pilot trial aimed to uncover whether further research into the administration of local gentamicin into open tibial fractures would reduce the risk of fracture-related infection and other postoperative complications. Open tibial fractures are a common traumatic injury among elderly and victims of high-impact motor vehicle accidents. Despite current standards in immediate systemic antibiotic administration for open tibial fractures, the incidence of fracture-related infection proves to be a difficult complication to prevent, often leading to an increase in patient dissatisfaction, longer hospital stays, and a decrease in patient quality of life. Evidence of an effective method in reducing fracture-related infection in surgical management of open tibial fractures are conflicted. Intravenous antibiotics have been shown to increase systemic toxicity in the patient, leading to poor wound healing. This study suggests that the local use of antibiotics like gentamicin deserves some time in the spotlight because of the decreased chances of systemic toxicity, biofilm formation and, arguably the most important factor, antibiotic resistance. This double-blinded pilot study included 100 patients with open tibial shaft fractures from motor vehicle accidents (85% of participants), and falls (5% of participants) who were treated with systemic ceftriaxone upon admission followed by irrigation and debridement and internal or external fixation of the fracture. The participants were administered a local injection of 80mg aqueous gentamicin diluted in 40ml of saline, or a local injection of 40ml of normal saline, the control agent. The researchers hoped to gain evidence of efficacy of local gentamicin administration and collect data on incidence of fracture related infection at multiple follow-up appointments. The rate of fracture related infection was 15% in the control group treated with saline and 24% in the gentamicin group (95% CI; 0.87-2.25; hazard ratio 1.40). Other complications like re-operation due to nonunion were also measured at follow-up appointments, and 1.8% of patients in the saline group were taken back to the operating room, compared to 6.6% of patients in the gentamicin group. Laboratory or physical findings suggestive of fracture related infection were seen in 9% of the saline group and 6.6% of the gentamicin group. As a first of its kind, this study proves that further research in this treatment modality for infection prophylaxis is both possible and necessary. Further investigation into the effects of local antibiotic administration for reducing infections during management of open fractures is needed to explore feasible alternatives to decrease post-reduction complications


Passing the Olympic torch of surgical skills. Training for open procedures in trauma surgeries are limited in clinical practice as modern practices trend towards endovascular and non-operative management in addition to resident duty hour restrictions enforced by accrediting bodies in the United States and Europe. As a result, proficiency for open trauma procedures are difficult to achieve for trainee surgeons. Trauma skills training courses have been developed to bridge the learning gap, but their training efficacy has not been validated. It remains unknown whether these courses actually translate into improving performance in the real-world operating room. In this article, the authors explore the efficacy of the available courses based on their content and published literature. A systematic review was conducted with the sole focus on papers emphasizing trauma surgery skills education. Course reports were judged for the level of evidence for efficacy based on Kirkpatrick’s framework which includes level 1 “reactions'' for self-reported feedback, level 2 “learning” for objective assessment of the knowledge, level 3 “behaviors” for objective skills evaluation, and level 4 “results” for improving patient outcomes. Thirty-two studies met the criteria and were included. There were no prospective controlled trials. The highest level of evidence achieved was Kirkpatrick’s level 3 by the ASSET training course only. ATLS and the Trauma Course (Italy) fulfilled some Level 3 criteria whereas others only satisfied Level 1 or 2. Because the course content available is widely varied, the study suggests that the standardization of the training course content can be beneficial to improve trauma patient outcomes by providing better training for surgery trainees. There is also a need for faculty to investigate the efficacy of their training content on trauma outcomes with more research. Reliable training for acute trauma can be beneficial for both surgery trainees and patient outcome, and it is evident that there are still gaps for improvement for the surgery training model.




Subspecialties: Cardiothoracics/Vascular


Blunt Traumatic thoracic aortic injury (BTAI) is the second-leading cause of death among trauma patients. Although the Society of Vascular Surgery guidelines recommend the use of endovascular repair over open surgical repair for traumatic TAI, the potential benefit and long-term durability and efficiency of this less invasive treatment remain uncertain. In this retrospective cohort study, researchers compared patients undergoing open repair (OR), TEVAR, or medical management for BTAI. Outcomes assessed were injury details, operative complications, and long term outcomes. Amongst 42 patients the overall mortality was 7.5%. The data also demonstrated that the in-hospital survival rate was higher in patients receiving TEVAR than in those receiving OR (15.8% vs 5.6%, respectively). Interestingly, patients undergoing open repair were statistically significantly younger and thus demonstrated smaller aortic diameters (22.3 vs 24.0 mm with p=<0.001) than those undergoing TEVAR. Specifically this study is unique in how it pinpointed age as a significant influence on whether to opt for OR or TEVAR: younger patients being ideal for OR and older patients being ideal for TEVAR.


Subspecialties: Orthopedics


Distal tibial fractures (DTFs) are primarily treated with intramedullary nailing (IMN), locked plating, or external fixation depending on various factors including fracture site, fracture extent, and soft tissue damage. Each approach has differing complication patterns, and malalignment is most common with IMN. The traditional approach to IMN for DTF is via a hyper-flexed infrapatellar (HFIP) approach in which the knee is maintained in a hyperflexion position and the intramedullary canal is accessed via a patellar tendon splitting or sparing method. During canal preparation, knee flexion and extension are needed for proper visualization and implant placement. This extremity manipulation could contribute to the malalignment and/or reduction loss commonly seen with IMN for DTF. The surgeons in this study developed a novel approach to IMN for DTF: a semi-extended infrapatellar (SEIP) approach. In contrast to HFIP, the SEIP approach maintains the knee in approximately 30° flexion throughout the surgery eliminating extremity manipulation. In this randomized clinical trial, researchers aimed to assess the malalignment rates between the SEIP and HFIP approaches for IMN of DTFs. 88 patients with extra articular fractures (OTA 43-A) and with nondisplaced intraarticular fracture lines (OTA 43-C1 and C2) were enrolled with 45 undergoing traditional HFIP IMN and 43 undergoing SEIP IMN. Post-surgical management was identical for each treatment group. They were followed clinically and radiographically every 4 weeks until union occurred. Alignment was assessed by coronal and sagittal plane radiographs of the entire knee, tibia, and ankle. Satisfactory radiographic alignment was described as < 5° in either plane. Malalignment occurred in 9 patients (20.0%) in the HFIP treatment group and 2 patients (4.7%) in the SEIP group (p-value = 0.030). The adjusted relative risk of SEIP versus HEIP was 0.16 (95% CI 0.00 to 0.58). Secondary outcomes found reduced intraoperative fluoroscopy duration and surgery time. This study provides evidence that the SEIP IMN approach is a worthy option for DTF management. However, due to the small sample size, lack of variability in IMN type used, and lack of rotational malalignment monitoring, additional research is needed to confirm the superiority of this approach to the traditional HFIP IMN technique.



Total hip arthroplasty (THA) has conventionally used the capsular repair method, which is often followed by complications including but not limited to high-risk dislocations. Due to the risk of dislocation post-reconstruction, prospective studies are observing the use of mesh in THA to improve stability, provide more favorable patient outcomes, and reduce complications. The randomized controlled study presented compares the use of mesh in reconstructive versus traditional capsular repair in maintaining capsular integrity, reducing the occurrence of dislocation after primary THA, and to evaluate the efficacy of mesh in capsule anatomical reconstruction. A total of 124 patients with high-risk dislocation THA were randomly assigned to either conventional capsular repair or mesh reconstruction group. Capsular integrity was primarily evaluated post-operatively with magnetic resonance imaging (MRI), the Harris hip score (HHP), and subsequent dislocation. A total of 106 patients were compliant with follow-ups and MRI results demonstrated that success rates of capsule repair was 98% (50 hips) in the mesh group and 67% (37 hips) in the conventional capsule repair group (P<0.001). Additionally, no dislocations (0%, 0 hips) occurred in the mesh group and three dislocations (3 hips, 5%) occurred in the conventional repair group (P=0.244). Thus, mesh reconstruction showed a higher rate of posterior capsule integrity and a reduced rate of high-risk dislocation in patients with a prior THA. Although mesh provides promise for more favorable results post-reconstruction, the use of mesh slightly increases operation time and the cost of the procedure. Steps are being made in the right direction to help eradicate risk of dislocation after reconstruction, but subsequent studies should be performed with larger sample sizes to better reflect the population and to further evaluate the kinesthetic properties of the mesh itself.



Subspecialties: Neurosurgery


Cerebral vasospasm is a relatively well-researched topic with regards to subarachnoid hemorrhage (SAH); however, when it comes to traumatic intracranial hemorrhage (tICH), the literature is less abundant. A wide range has been offered for the potential incidence of posttraumatic vasospasm (PTV) from 5% to 63%. However, there are no routine guidelines for assessment of PTV as it is typically only investigated in the setting of specific clinical indications. Therefore, asymptomatic patients may go underdiagnosed and undertreated leading to increased morbidity.

Researchers employed the use of the National Inpatient Sample database to elucidate the incidence, risk factors, and clinical associations of PTV. Inclusion criteria consisted of patients diagnosed with tICH who subsequently underwent diagnostic angiography. Multivariable logistic regression analysis was performed using demographics, comorbid conditions, and other clinically relevant variables to uncover associations.

The database included 5880 patients with diagnosed tICH, 375 of which developed PTV, establishing an incidence of 6.4%. Covariates most strongly associated with PTV development included: intraventricular hemorrhage (OR 6.27, 95% CI 3.49–11.26), SAH (OR 2.46, 95% CI 1.45–4.12), obesity (OR 2.34, 95% CI 1.65–3.37), acute anemia (OR 11.47, 95% CI 3.04–43.2), acute elevated blood pressure (OR 3.23, 95% CI 2.15–4.87), fever (OR 2.09, 95% CI 1.34–3.27), and cocaine use (OR 3.62, 95% CI 1.97–6.63). In the patients with PTV, associated clinical outcomes included a lower likelihood of routine discharge (OR 0.60, 95% CI 0.45–0.78) and extended hospital stay (OR 3.53, 95% CI 2.78–4.48), but no relation to mortality was seen (p>0.05).

While retrospective research has inherent limitations with limited effects on surgical practice, establishing the incidence and baseline associations of demographics, comorbidities, and clinical factors relating to PTV is a critical step as it should lead to future investigation. This study provides clues as to where efforts should be focused to identify, treat, and mitigate effects of PTV.


In a neurosurgeon's approach to treatment of life-threatening acute subdural hematomas, a question has to be asked; craniotomy, or decompressive craniectomy? A craniotomy removes a bone flap to reach the brain and overlying blood clot, and place the bone back where it came. A decompressive craniectomy, on the other hand, will also removed a bone flap, but close up the surgical site without replacing the bone flap, in theory to avoid increased intracranial pressure. But, does such a drastic measure such as leaving a patient’s brain without its protective encasing lead to equally drastic improvements in that patient’s overall outcome?

This study included 450 patients that required immediate medical attention for a traumatic acute subdural hematoma that were randomly assigned to one of two groups; the craniotomy group (n=228) and the decompressive craniectomy group (n=222). The primary outcomes resulting from the surgeries, ranging from “death” to “good recovery” were rated with the Extended Glasgow Outcome Scale (GSOE) at 12 months post-surgery. Quality of life measures was also measured with the EQ-5D-5L questionnaire. The differences in GSOE between the two groups were analyzed after 12 months, yielding a common odds ratio of 0.85 (95% confidence interval, 0.60-1.18; p=0.32). Death rates were also compared, with the craniotomy group having a death rate of 30.2% and the decompressive craniectomy group having a death rate of 32.2%. Quality of life scores via the EQ-5D-5L were also similar. Comparing the outcomes of these two methods of treatment shows that there is no statistical advantage to either procedure when compared to the other. In theory, the decompressive craniectomy group should have shown at least some marginal benefit given its increased risks. Allowing a swollen brain room to heal, avoiding the risk of increased intracranial pressure in a post-trauma patient makes sense when thought logically. Regardless, the results of this study show that in medicine, increased risk does not always equal an increased reward.



Subspecialties: Urology


This paper reflects the importance of timely, proper and adequate assessment of patients in determining the course of treatment of kidney injury following trauma (i.e. conservative vs. surgical management) In this retrospective analysis 152 patients were utilized to describe the incidence, presentation and management of traumatic kidney injury. Out of 152 patients, the mean age was 32.8±13.7(p value=0.07), with a substantial male predominance(91.4%). Motor vehicle crashes were the major cause followed by falls. There was also an association amongst poly-trauma patients with concurrent injuries involving the chest (71%, p value=0.45), ribs (50%, p value=0.63) and spine (48%, p value= 0.20, although these were not statistically significant).

The American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) has set parameters for assessing and grading injury of patients for further management. Factors such as hemodynamic stability, response to initial resuscitation, severity and associated injuries in polytraumas all contribute to overall outcome in kidney function following initial insult. In this article initial FAST results followed by CT-scans patients were graded using AAST-OIS. Most of the patients from grade I-IV were managed conservatively (i.e. 93%). Patients with grade IV and V with vascular injuries were managed surgically (i.e. 7%, n = 23). Bilateral kidney involvement was found to be present in 10 patients (i.e. 6.6%, p value= 0.38) and 1 patient underwent a nephrectomy. Following either conservative or surgical intervention, , pneumonia was the most common complication (n=20, 13.2%, p value= 0.77) followed by sepsis (n=5, 3.3%, p value = 0.42) and acute respiratory distress syndrome or ARDS (n=4, 2.6%, p value=0.41). Complications related to renal trauma were seen among 26 patients {(17.1%, p value=0.0001), severe grade v/s minor grade (44.4% v/s 12.7% respectively)}. Massive blood transfusion was needed in 32 patients (p value=0.03, severe grade v/s minor grade was 37% v/s 13.9% respectively). The average length of hospital stay was 10 days {(p value= 0.45), with the difference between severe grade and minor grade injuries being 11 days compared to 8 days.

This paper would seem to suggest that if patients are managed conservatively then the function of glomerulus could be maintained and saved, reducing the overall morbidity which would have a direct impact on enhancing the quality of life of patients compared to patients who were managed by surgery. However, this study has several significant limitations. It is a single center study, used a single grading scale, and did not follow non-operative patients (which accounted for 93% of the study’s participants) after their hospital stay. To sum up, with proper coordination between trauma surgeons, urologist and radiologist the use of advanced techniques have paved a way for better management of traumatic kidney injured patients and have reduced the morbidity and mortality rate significantly.


Radiology


The Art of Air: Capturing Pneumothorax on Chest X-ray




A pneumothorax is best visualized on an upright frontal chest X-ray, as air naturally rises and accumulates near the apex of the chest. In this position, a thin visceral pleural line appears as a distinct white line, running parallel to the chest wall. The space beyond the visceral pleural line is the parietal pleural space, which appears more radiolucent (i.e., darker) and lacks lung markings, indicating the presence of the pneumothorax. The mediastinum should remain unaffected unless a tension pneumothorax occurs. Additional signs may include the presence of subcutaneous emphysema adjacent to the affected side. A pneumothorax can have various origin such as primary, secondary, iatrogenic, or traumatic. Treatment options encompasses supplemental oxygen, simple aspiration, or a tube thoracostomy.







SURGEON SPOTLIGHT OF THE MONTH

R. Adams Cowley, M.D.


Sixty minutes is all that is afforded to those who are critically injured. Sixty minutes bridging the divide between life and imminent death. R. Adams Cowley, M.D., a trained thoracic surgeon and pioneer of emergency medicine and trauma resuscitation coined this concept after years of observing this one hour afforded to those most vulnerable to the mortality of severe traumatic injury. This concept known as the “Golden Hour,” greatly influenced his efforts that culminated in the establishment of the precedents that drive current emergency medicine, trauma medicine, and cardiothoracic surgery practices to date.

Dr. Cowley was born in 1917 and graduated medical school in 1944 from the University of Maryland with further training at the University of Michigan in Ann Arbor for fellowship. Dr. Cowley later served in the U. S. Army in the late 1940s in Europe, where he received extensive surgical training. Known for many groundbreaking surgical advancements, including being the first to perform open-heart surgery, inventing the Cowley surgical clamp, and development of the prototype pacemaker used by Dwight D. Eisenhower, Dr. Cowley is most recognized and celebrated for his dedication to the foundation of emergency medicine and treatment of shock trauma. During his term in the Army, Dr. Cowley pioneered the concept of the “Golden Hour,” which stressed the importance of receiving treatment for trauma within sixty minutes to improve mortality in regards to the management of shock patients in 1957. The concept of the Golden Hour was controversial at Cowley’s time because standard of practice at the time for severe trauma patients was to transport to the nearest hospital via ambulance to die. To make the milestones he needed in improving mortality for trauma patients, Dr. Cowley established the first “Shock Trauma” Center at the University of Maryland Hospital in 1959. In its early years, success rates of the Shock Trauma Center were often low due to delays in physician referral of trauma patients, often past the Golden Hour and when irreparable damage was imminent. To combat this, Dr. Cowley advocated for a more timely and streamlined patient transport system by using military helicopters to bring patients directly to the Center in 1968. By 1969, Dr. Cowley had established the first injured civilian helicopter transport system with the support of the Maryland State Police Aviation Division in addition to the first statewide coordinated EMS system of care by executive order from the Governor of Maryland by 1973. The executive order of 1973 ensured that ambulances and emergency transport were properly equipped and staffed for traumatic emergencies.


Because of the radical changes in emergency care he advocated for, Dr. Cowley was relentless in his drive to enforce the changes he proposed. Dr. Cowley persistently testified before legislatures while fighting for funding for resources needed to establish the standardization of trauma care that continue the positive acceleration of lives saved from critical injuries for years to come. The field of emergency medicine is largely established due his efforts in trauma resuscitation education for nurses, physicians, students, and providers alike.


Dr. Cowley demanded the same competence and dedication from both himself and those who worked with him. He had the vision for those critically injured to survive beyond the grim circumstance of their time, and he relentlessly fought for that vision to become a reality. Loyal to both his patients and staff, he was remembered to refuse vacations for almost fifty years so that his staff could spend their holidays with their families without compromising the meticulous oversight he needed for his critically injured patients. On October 27, 1991, Dr. R. Adams Cowley, the “Father of Trauma Medicine,” passed away at home and was later buried in Arlington National Cemetery.


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