Overall Splenectomy Rates Stable Despite Increasing Usage of Angiography in the Management of High-grade Blunt Splenic Injury

Objective: The purpose of this study was to understand the contemporary trends of splenectomy in blunt splenic injury (BSI) and to determine if angiography and embolization (ANGIO) may be impacting the splenectomy rate. Background: The approach to BSI has shifted to increasing use of nonoperative management, with a greater reliance on ANGIO. However, the impact ANGIO has on splenic salvage remains unclear with little contemporary data. Methods: The National Trauma Data Bank was used to identify patients 18 years and older with high-grade BSI (Abbreviated Injury Scale >II) treated at Level I or II trauma centers between 2008 and 2014. Primary outcomes included yearly rates of splenectomy, which was defined as early if performed within 6 hours of ED admission and delayed if greater than 6 hours, ANGIO, and mortality. Trends were studied over time with hierarchical regression models. Results: There were 53,689 patients who had high-grade BSI over the study period. There was no significant difference in the adjusted rate of overall splenectomy over time (24.3% in 2008, 24.3% in 2014, P value = 0.20). The use of ANGIO rapidly increased from 5.3% in 2008 to 13.5% in 2014 (P value < 0.001). Mortality was similar overtime (8.7% in 2008, 9.0% in 2014, P value = 0.33). Conclusion: Over the last 7 years, the rate of angiography has been steadily rising while the overall rate of splenectomy has been stable. The lack of improved overall splenic salvage, despite increased ANGIO, calls into question the role of ANGIO in splenic salvage on high-grade BSI at a national level

Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries

Purpose The utility of measuring the pediatric adjusted shock index (SIPA) at admission for predicting severity of blunt injury in pediatric patients has been previously reported. However, the utility of following SIPA after admission is not well described. Methods The trauma registry from a level-one pediatric trauma center was queried from January 1, 2010 to December 31, 2015. Patients were included if they were between 4 and 16 years old at the time of admission, sustained a blunt injury with an Injury Severity Score ≥ 15, and were admitted less than 12 h after their injury (n = 286). Each patient's SIPA was then calculated at 0, 12, 24, 36, and 48 h after admission and then categorized as elevated or normal at each time frame based upon previously reported values. Trends in outcome variables as a function of time from admission for patients with an abnormal SIPA to normalize as well as patients with a normal admission SIPA to abnormal were analyzed. Results In patients with a normal SIPA at arrival, 18.4% of patients who developed an elevated SIPA at 12 h after admission died, whereas 2.4% of patients who maintained a normal SIPA throughout the first 48 h of admission died (p < 0.01). Among patients with an elevated SIPA at arrival, increased length of time to normalize SIPA correlated with increased length of stay (LOS) and intensive care unit (ICU) LOS. Similarly, elevation of SIPA after arrival in patients with a normal initial SIPA correlated to increased LOS and ICU LOS. Conclusions Patients with a normal SIPA at time of arrival who then have an elevated SIPA in the first 24 h of admission are at increased risk for morbidity and mortality compared to those whose SIPA remains normal throughout the first 48 h of admission. Similarly, time to normalize an elevated admission SIPA appears to directly correlate with LOS, ICU LOS, and other markers of morbidity across a mixed blunt trauma population. Whether trending SIPA early in the hospital course serves only as a marker for injury severity or if it has utility as a resuscitation metric has not yet been determined

EAES and SAGES 2018 consensus conference on acute diverticulitis management:evidence-based recommendations for clinical practice

Background Acute diverticulitis (AD) presents a unique diagnostic and therapeutic challenge for general surgeons. This collaborative project between EAES and SAGES aimed to summarize recent evidence and draw statements of recommendation to guide our members on comprehensive AD management. Methods Systematic reviews of the literature were conducted across six AD topics by an international steering group including experts from both societies. Topics encompassed the epidemiology, diagnosis, management of non-complicated and complicated AD as well as emergency and elective operative AD management. Consensus statements and recommendations were generated, and the quality of the evidence and recommendation strength rated with the GRADE system. Modified Delphi methodology was used to reach consensus among experts prior to surveying the EAES and SAGES membership on the recommendations and likelihood to impact their practice. Results were presented at both EAES and SAGES annual meetings with live re-voting carried out for recommendations with < 70% agreement. Results A total of 51 consensus statements and 41 recommendations across all six topics were agreed upon by the experts and submitted for members’ online voting. Based on 1004 complete surveys and over 300 live votes at the SAGES and EAES Diverticulitis Consensus Conference (DCC), consensus was achieved for 97.6% (40/41) of recommendations with 92% (38/41) agreement on the likelihood that these recommendations would change practice if not already applied. Areas of persistent disagreement included the selective use of imaging to guide AD diagnosis, recommendations against antibiotics in non-complicated AD, and routine colonic evaluation after resolution of non-complicated diverticulitis. Conclusion This joint EAES and SAGES consensus conference updates clinicians on the current evidence and provides a set of recommendations that can guide clinical AD management practice

Phase formation during liquid phase sintering of ZnO ceramics

ZnO doped with Bi$_2$O$_3$ and Sb$_2$O$_3$ (ZBS), is the basic system for ceramic varistors. Phase formation during sintering of ZBS was measured in situ, using 1 mm thick samples and synchrotron X-rays. Sintering shrinkage was measured in different atmospheres by an optical method. Thermodynamic calculations were performed to explain phase formation, composition, stability of additive oxides and influence of the oxygen fugacity on sintering. Sb$_2$O$_4$, pyrochlore, trirutile and spinel were formed at temperatures of 500–800 °C. The oxidation of antimony was controlled by the oxygen partial pressure and affected both, phase formation and sintering kinetics, in the ZBS system

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important

Iron-Carbon interaction at High Pressures and Temperatures

International audienceWe have performed experiments in the Fe–C system at 2200–3400 K and 25–70 GPa using a multianvil press and laser-heated diamond anvil cell in order to constrain the stability of Fe3C. Iron carbide was observed experimentally as a stable phase using both experimental methods and independently confirmed by thermodynamic calculations. Our results imply that pure iron and carbon cannot coexist in a stable equilibrium at high pressure and high temperature. The high reactivity between metallic iron and the diamond requires a careful design of diamond anvil cell experiments in order to avoid carbon transport to the sample