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Blunt traumatic thoracic aortic injuries: early or delayed repair-results of an American Association for the Surgery of Trauma prospective study
BACKGROUND: The traditional approach to stable blunt thoracic aortic injuries (TAI) is immediate repair, with delayed repair reserved for patients with major associated injuries. In recent years, there has been a trend toward delayed repair, even in low-risk patients. This study evaluates the current practices in the surgical community regarding the timing of aortic repair and its effects on outcomes. METHODS: This was a prospective, observational multicenter study sponsored by the American Association for the Surgery of Trauma. The study included patients with blunt TAI scheduled for aortic repair by open or endovascular procedure. Patients in extremis and those managed without aortic repair were excluded. The data collection included demographics, initial clinical presentation, Injury Severity Scores, type and site of aortic injury, type of aortic repair (open or endovascular repair), and time from injury to aortic repair. The study patients were divided into an early repair ( 24 hours). The outcome variables included survival, ventilator days, intensive care unit (ICU) and hospital lengths of stay, blood transfusions, and complications. The outcomes in the two groups were compared with multivariate analysis after adjusting for age, Glasgow Coma Scale, hypotension, major associated injuries, and type of aortic repair. A second multivariate analysis compared outcomes between early and delayed repair, in patients with and patients without major associated injuries. RESULTS: There were 178 patients with TAI eligible for inclusion and analysis, 109 (61.2%) of which underwent early repair and 69 (38.8%) delayed repair. The two groups had similar epidemiologic, injury severity, and type of repair characteristics. The adjusted mortality was significantly higher in the early repair group (adjusted OR [95% CI] 7.78 [1.69-35.70], adjusted p value = 0.008). The adjusted complication rate was similar in the two groups. However, delayed repair was associated with significantly longer ICU and hospital lengths of stay. Analysis of the 108 patients without major associated injuries, adjusting for age, Glasgow Coma Scale, hypotension, and type of aortic repair, showed that in early repair there was a trend toward higher mortality rate (adjusted OR 9.08 [0.88-93.78], adjusted p value = 0.064) but a significantly lower complication rate (adjusted OR 0.4 [0.18-0.96], adjusted p value 0.040) and shorter ICU stay (adjusted p value = 0.021) than the delayed repair group. A similar analysis of the 68 patients with major associated injuries, showed a strong trend toward higher mortality in the early repair group (adjusted OR 9.39 [0.93-95.18], adjusted p value = 0.058). The complication rate was similar in both groups (adjusted p value = 0.239). CONCLUSIONS: Delayed repair of stable blunt TAI is associated with improved survival, irrespective of the presence or not of major associated injuries. However, delayed repair is associated with a longer length of ICU stay and in the group of patients with no major associated injuries a significantly higher complication rate
High genetic diversity within Epimeria georgiana (Amphipoda) from the southern Scotia Arc
DNA barcoding revealed four well-supported
clades among amphipod specimens that keyed out to
Epimeria georgiana Schellenberg, 1931, three clades with
specimens from the southern Scotia Arc and one clade with
specimens from the Weddell Sea. Detailed morphological
investigations of sequenced specimens were conducted,
through light and scanning electron microscopy. High
magnification (500–2,000 fold) revealed features such as
comb-scales on the first antenna and trich bearing pits on
the fourth coxal plate to be similar for all specimens in the four clades. Consistent microstructure character differences in the Weddell Sea specimens combined with high genetic distances (COI divergence>20%) allowed the description of Epimeria angelikae, a species new to science. Specimens of E. georgiana in the other three COI clades from the Scotia Arc were morphologically indistinguishable. Representative specimens of clade A are also illustrated in detail.
Our results on the high genetic divergences in epimeriid
amphipods support the theory of the southern Scotia Arc
being a centre of Antarctic diversification