Operative and Nonoperative Management of Blunt Liver Injuries

Purpose of Review The purpose of this review is to discuss the indications for operative and nonoperative management in patients with blunt liver injuries. Recent Findings Over the past several years, research has begun to show that nonoperative management in blunt liver injuries is feasible and has favorable outcomes over immediate operations in patients who are hemodynamically stable. This includes high-grade injuries who were previously taken to the operating room, in the absence of peritoneal signs or instability, for washout and packing. This trend in management is likely multifactorial and includes improved quality of critical care medicine, advances in imaging to accurately define the injury and trend changes, and other interventional techniques such as embolization, percutaneous drainage and endoscopy. The mainstay of treatment for hemodynamically unstable patients remains operative. Summary This article will provide current recommendations for operative and nonoperative management strategies in patients with blunt liver injuries, taking into account initial clinical picture and resources available

Des stratégies afin d ́améliorer la fluidité de la lecture des élèves à l ́école primaire: une révision

La fluidez lectora es un requisito necesario para una buena competencia en lectura. Su vinculación con la comprensión lectora la ha llevado a situarse en los últimos años en uno de los componentes principales de los programas de enseñanza de la lectura. En este trabajo se realiza una revisión de algunas de las estrategias más eficaces para desarrollar esta habilidad en estudiantes de educación primaria con y sin dificultades lectoras, señalando las características y directrices de cómo llevarlas a cabo en la práctica, tanto en el aula ordinaria como en la de apoyo.Reading fluency is a necessary requirement for a good reading competence. Its connection with reading comprehension has led to become in the latest years in one of the main components in the reading teaching programs. In this article, some effective strategies to improve this skill in elementary students with and without reading difficulties are revised, pointing out its characteristics and the main ideas on how to apply them either in the normal classroom or the supportive one.La fluidité en lecture est nécessaire pour une bonne compétence en lecture. Sa relation avec la compréhension de la lecture a constitué la fluidité, ces dernières années, l'un des principaux éléments dans les programmes d'enseignement de lecture. Dans cet article nous faisons une révision des stratégies les plus efficaces pour développer cette compétence dans les élèves avec et sans difficulté de lecture de l’école primaire, mettant l’accent sur les caractéristiques de ces stratégies et les lignes principales liées à la façon de les utiliser en classe régulière ou spécialisée

Obesity Does Not Increase Mortality after Emergency Surgery

Objective. The aim of this study is to evaluate the impact of obesity on patient outcomes after emergency surgery. Methods. A list of all patients undergoing emergent general surgical procedures during the 12 months ending in July 2012 was obtained from the operating room log. A chart review was performed to obtain the following data: patient characteristics (age, gender, BMI, and preexisting comorbidities), indication for surgery, and outcomes (pulmonary embolus (PE), deep venous thrombosis (DVT), respiratory failure, ICU admission, wound infection, pneumonia, and mortality). Obesity was defined as a BMI over 25. Comparisons of outcomes between obese and nonobese patients were evaluated using Fischer’s exact test. Predictors of mortality were evaluated using logistic regression. Results. 341 patients were identified during the study period. 202 (59%) were obese. Both groups were similar in age (48 for obese versus 47 for nonobese, ). Obese patients had an increased incidence of diabetes, (27% versus 7%, ), hypertension (52% versus 34%, ), and sleep apnea (0% versus 5%, ). There was a statistically significant increased incidence of postoperative wound infection (obese 9.9% versus nonobese 4.3%, ) and ICU admission (obese 58% versus nonobese 42%, ) among the obese patients. Obesity alone was not shown to be a significant risk factor for mortality. Conclusions. A higher BMI is not an independent predictor of mortality after emergency surgery. Obese patients are at a higher risk of developing wound infections and requiring ICU admission after emergent general surgical procedure

Safety and effectiveness of propranolol in severely burned patients: systematic review and meta-analysis

Background The objective of this systematic review was to determine the effectiveness and safety of propranolol compared to placebo or usual care for improving clinical relevant outcomes in severely burned patients (TBSA \u3e20%). Methods Relevant articles from randomized controlled trials were identified by a literature search in MEDLINE, EMBASE, and CENTRAL. We included trials involving patients with a severe burn (\u3e20% of total body surface area affected). Trials were eligible if they evaluated propranolol and compared to usual care or placebo. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for the final analysis. We conducted a meta-analysis using a random-effects model. Results We included ten studies in our systematic review. These studies randomized a total of 1236 participants. There were no significant differences between propranolol and placebo with respect to mortality (RD −0.02 [95% CI −0.06 to 0.02]), sepsis (RD −0.03 [95% CI −0.09 to 0.04]), and the overall hospital stay (MD −0.37 [−4.52 to 3.78]). Propranolol-treated adults had a decrease in requirements of blood transfusions (MD −185.64 [95% CI −331.06 to −40.43]) and a decreased heart rate (MD −26.85 [95% CI −39.95 to −13.75]). Conclusions Our analysis indicates that there were no differences in mortality or sepsis in severely burned patients treated with propranolol compared with those who had usual care or placebo. However, the use of propranolol in these patients resulted in lower requirements of blood transfusion and lower values of heart rate. The evidence synthesized in this systematic review is limited to conclude that propranolol reduces the length of hospital stay among severely burned patients. Future trials should assess the impact of propranolol on clinically relevant outcomes such as mortality and adverse events

A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients

Background The objective of this systematic review and meta-analysis was to determine the effect of REBOA, compared to resuscitative thoracotomy, on mortality and among non-compressible torso hemorrhage trauma patients. Methods Relevant articles were identified by a literature search in MEDLINE and EMBASE. We included studies involving trauma patients suffering non-compressible torso hemorrhage. Studies were eligible if they evaluated REBOA and compared it to resuscitative thoracotomy. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. We conducted meta-analysis using random effect models. Results We included three studies in our systematic review. These studies included a total of 1276 patients. An initial analysis found that although lower in REBOA-treated patients, the odds of mortality did not differ between the compared groups (OR 0.42; 95% CI 0.17–1.03). Sensitivity analysis showed that the risk of mortality was significantly lower among patients who underwent REBOA, compared to those who underwent resuscitative thoracotomy (RT) (RR 0.81; 95% CI 0.68–0.97). Conclusion Our meta-analysis, mainly from observational data, suggests a positive effect of REBOA on mortality among non-compressible torso hemorrhage patients. However, these results deserve further investigation

Strategies to improve reading fluency in primary school´s students: a review

La fluidez lectora es un requisito necesario para una buena competencia en lectura. Su vinculación con la comprensión lectora la ha llevado a situarse en los últimos años en uno de los componentes principales de los programas de enseñanza de la lectura. En este trabajo se realiza una revisión de algunas de las estrategias más eficaces para desarrollar esta habilidad en estudiantes de educación primaria con y sin dificultades lectoras, señalando las características y directrices de cómo llevarlas a cabo en la práctica, tanto en el aula ordinaria como en la de apoyoReading fluency is a necessary requirement for a good reading competence. Its connection with reading comprehension has led to become in the latest years in one of the main components in the reading teaching programs. In this article, some effective strategies to improve this skill in elementary students with and without reading difficulties are revised, pointing out its characteristics and the main ideas on how to apply them either in the normal classroom or the supportive oneS

Efectos del entrenamiento en slackline sobre la resistencia del core y el equilibrio dinámico

Slackline challenges balance by walking on a tensioned strap, where the trunk muscles help to maintain or regain balance. This study aimed to compare a cohort of individuals who regularly practiced slackline and physically inactive individuals on core endurance (CE) and dynamic balance (DB) and to determine whether CE is associated with years of slackline practice. Nine individuals (7 men) who practiced slackline regularly (SG; age= 24.5±3.6 years) and nine physically inactive individuals (7 men) (CG; age= 23.2±3.3 years) were compared. CE was assessed with the McGill battery (trunk flexor, extensor, and side-bridge test) and the plank test. DB was measured with the modified star excursion balance test in stable and unstable conditions. The SG maintained a 36.2% and 45% longer time in left lateral bridge (p=.049) and plank (p=.031), respectively, compared to the CG. The distance achieved in the stable DB test was similar between groups, but in unstable condition was 37.8% greater (p=.016) in SG in both legs and 46.6% greater in the non-dominant leg (p=.039) compared to CG. The SG showed a correlation between years of slackline practice and flexor (r=.674; p=.046), right lateral (r=.765; p=.016) and left (r=.730; p=.026) trunk endurance. In conclusion, those who practice slackline maintain a longer time in the plank and left lateral bridge test and achieve a higher reach distance in unstable DB compared to physically inactive individuals who do not practice slackline.El slackline desafía el equilibrio al caminar sobre una cinta en tensión, donde los músculos del tronco ayudan a mantener o recuperar el equilibrio. El objetivo de este estudio fue comparar individuos que practicaban slackline e individuos inactivos fisicamente (IF) en resistencia del core (RC) y equilibrio dinámico (ED), y conocer si la RC se asocia a los años de practica de slackline. Nueve individuos (7 hombres) que practicaban slackline regularmente (GS; edad= 24.5±3.6 años) y nueve individuos IF (7 hombres) (GC; edad= 23.2±3.3 años) fueron comparados. La RC se evaluó con la bateria de McGill (prueba de flexores y extensores de tronco y puente lateral) y la prueba de la plancha. El ED se midió con la prueba de excursión de la estrella modificada en condiciones estables e inestables. El GS mantuvo un tiempo 36.2% y 45% mayor en puente lateral izquierdo (p=.049) y plancha (p=.031) respectivamente comparado con el GC. La distancia alcanzada en la prueba de ED estable fue similar entre grupos, pero en condición inestable fue 37.8% mayor (p=.016) en GS en ambas piernas y 46.6% mayor en la pierna no dominante (p=.039) comparado al GC. El GS mostró una correlación entre años de práctica de slackline y resistencia flexora (r=.674; p=.046), lateral derecha (r=.765; p=.016) e izquierda (r=.730; p=.026) de tronco. En conclusión, quienes practican slackline mantienen un tiempo mayor la prueba de la plancha y puente lateral izquierdo y logran un mayor alcance en ED inestable comparados con individuos IF que no lo practican

WSES SM (World Society of Emergency Surgery Summer Meeting) highlights: emergency surgery around the world (Brazil, Finland, USA)

Emergency surgery is performed in every hospital with a A and E unit all around the world. However it is organized in different ways with different results

Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

Background The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation (CAB), compared to those patients treated with the traditional ABC sequence. Methods This study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes. Results From 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death. Conclusion The current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted. Trial registration IRB approval number: HM20006627. Retrospective trial not registered