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Table 1 Contamination considerations Type of contamination Antibiotic recommendations Additional considerations Water contamination Short course, 3–5 days Salt water Doxycycline and ceftazidime Fluoroquinolone Freshwater Ciprofloxacin Levofloxacin Third or fourth-generation cephalosporin Vibrio Aeromonas Pseudomonas Soil contamination Short course, 3–5 days High-dose penicillin Clostridium sp Farm-related injuries Mammalian bites (human, dog, or cat) Short course, 3–5 days Amoxicillin-clavulanate Clindamycin plus trimethoprim-sulfamethoxazole for penicillin-allergic patients Table 2 Summary of antibiotic recommendations Injury Antibiotic recommendations Additional considerations Face and scalp Open or contaminated facial fractures Prophylactic antibiotics 24 h or less Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients Frontal sinus fracture that involves the posterior table Contaminated fractures Open mandible fractures Closed or non-contaminated operative facial fractures Preoperative antibiotics Cefazolin—coverage against GP bacteria Ceftriaxone—broader GN coverage and CNS penetration Ampicillin/sulbactam—broader GN and anaerobic coverage Clindamycin—for penicillin-allergic patients No postoperative antibiotics Fractures of the upper one-third of the face Frontal sinus fractures that do not involve the posterior table Fractures of the middle one-third of the face (LeFort, zygomaticomaxillary complex, orbital, maxillary sinus, nasal bone) Fractures of the lower one-third of the face (non-dentate segments of mandible) Non-operative facial fractures No prophylactic antibiotics Orbital fractures Upper face fractures Mid-face fractures Mandibular fractures Facial and scalp lacerations Prophylactic antibiotics 24 h or less if complex or high-risk patient Amoxicillin-clavulanate Clindamycin—for penicillin-allergic patients Communication to oral cavity High infection risk: significant tissue destruction, large dead space, extensive contamination, underlying medical problems that place a patient at high risk (diabetes, immunosuppression, steroids, extremes of age, obesity, etc) Nasal packing No prophylactic antibiotics Central nervous system Pneumocephalus No prophylactic antibiotics Associated with open skull fracture and communication to the sinuses CSF leaks No prophylactic antibiotics Associated with basilar skull fractures Penetrating brain injury Short course of prophylactic antibiotics, <3 days Cefazolin Clindamycin - for penicillin-allergic patients Visible contamination—add metronidazole Penetrating spine injury Short course of prophylactic antibiotics, no more than 48 h First and second-generation cephalosporins Ampicillin-sulbactam Piperacillin-tazobactam Clindamycin with second-generation cephalosporin Gastrointestinal involvement, specifically transcolonic Extremity Closed extremity fractures No prophylactic antibiotics if non-operative management Preoperative antibiotics within 1 h of incision First-generation cephalosporin Clindamycin—for penicillin-allergic patients Open extremity fractures Prophylactic antibiotics 24 h or less Types I and II should be treated with GP coverage First-generation cephalosporin Clindamycin - for penicillin allergic patients Type III should be treated with GP and GN coverage First-generation cephalosporin and aminoglycoside Piperacillin/tazobactam Ceftriaxone Antibiotics should be initiated within 1 h of injury and continued for 24 h Washout and debridement should take place within 24 h of injury Soft tissue injury Soft tissue Lacerations/stab wounds Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients High-risk infection Specific wound-related concerns (presence of significant contamination, crush injury, or specific at-risk anatomic sites) Underlying patient factors that would increase the risk or worsen the outcome of infection GSW Prophylactic antibiotics 24 h or less if complex or high-risk patient First-generation cephalosporin Clindamycin—for penicillin-allergic patients Surgical debridement of devitalized tissue if needed Consideration of low-energy vs. high-energy mechanism Burn injury No prophylactic antibiotics Providers should take into account their institutional antibiogram when choosing antibiotics for prophylaxis and/or treatment. Iterative selection of studies was not performed as in a systematic review, and the methodology of the literature search was at the discretion of the authors. Freshwater wounds should be managed with ciprofloxacin, levofloxacin, or a third-generation or fourth-generation cephalosporin.1 Potential clostridial contamination, such as farm-related injuries, requires high-dose penicillin irrespective of the fracture type.2 A full review of the treatment of bite injuries is beyond the scope of this document, but wounds caused by human, cat, and dog bites (the most common bite wounds encountered) are often treated with antibiotics due to the high load of more variable pathogens found in the oral cavity and the wound mechanism, with punctures that make both natural movement of the bacteria and adequate irrigation difficult.3 A course of 3–5 days of amoxicillin-clavulanate is a suggested regimen, with clindamycin plus trimethoprim-sulfamethoxazole two times per day as an alternative for patients with a penicillin allergy.4 5 While there is increasing question in the literature about the benefit of treating bite injuries with empiric antibiotics, there seems to be general consensus that injuries in high-risk locations (specifically hands, and over cartilage) and in high-risk patients should be treated.4–6 Rabies treatment should also be considered and addressed with any mammalian bite wounds (table 1). [...]there is tremendous variability in practice patterns among treating surgeons, and many providers continue antibiotic prophylaxis longer than proposed, which leads to overuse of antibiotics in this patient population.7 8 The Surgical Infection Society (SIS) recently published a guideline for prophylactic antibiotic use in patients with traumatic facial fractures.9 The authors of the SIS guidelines defined prophylactic antibiotics as antibiotics administered for more than 24 hours.

ObjectivesThe American Association for the Surgery of Trauma (AAST) Critical Care Committee chose handoffs and transitions of care in the intensive care unit (ICU) as a clinically relevant topic for review. This clinical consensus document aims to provide practical guidance to the surgical intensivist on the best practices for patient handoffs and transitions of care.MethodsA working group was formed from the committee-at-large to complete this work. The members of the working group were each assigned a subtopic to review using research to date. The research on which the recommendations are based was compiled at the discretion of the working group. Any topic with discrepant or minimal supporting literature was reviewed by the AAST Critical Care Committee through an anonymous survey.ResultsRecommendations for healthcare handovers include formally recognized handoffs at dedicated times, an interactive verbal exchange including all patients with a focus on what to anticipate or what is needs to be completed, tools to record and maintain information, and training to new providers on the handoff process and technology.ConclusionAs clinicians, we strive to provide the best evidence-based care to our patients. It is essential to study these high states, ICU handoffs to enhance the safety, efficiency, and effectiveness of patient care transitions, ultimately leading to better patient outcomes and provider satisfaction.Level of evidenceV.

While this recommendation is modest, we find it difficult to make any clinical practice change given that the reported VTE rate is lower than what has previously been published with pelvic fractures alone.2 That aside, we do question two of the choices made by the authors. [...]the data is a mixture of screening bilateral versus diagnostic unilateral duplex studies that is further complicated by the lack of a standardized time of imaging. [...]some of the patients still had packs in place at the time of screening.

The role of advanced life support (ALS) versus basic life support (BLS) in blunt trauma is controversial. Previous studies have shown no mortality benefit with ALS for penetrating trauma but the blunt population has mostly remained unaddressed. A retrospective cohort study was conducted at a Level 1 trauma center comparing outcomes in blunt trauma patients managed by ALS versus BLS from July 1, 2014 to December 31, 2014. Both Injury Severity Score (ISS) and select Abbreviated Injury Score (AIS) were used to determine differences in mortality, length of stay (LOS) and complications based on mode of transportation, prehospital time, and number of prehospital interventions. 698 total patients were identified. Mortality and complications were grossly higher in ALS patients (p = 0.01 and < 0.001, respectively). When accounting for ISS and AIS there was no difference in mortality (p=<0.001–0.003). Prehospital interventions did not increase prehospital time (p = 0.7) but did correlate with increased mortality (p < 0.001). There is no mortality advantage for blunt trauma patients managed by ALS versus BLS. •ALS does not decrease blunt trauma mortality, compared to BLS.•There is no difference between ALS and BLS with complications.•There is no difference between ALS and BLS with length of stay.•Prehospital interventions do not increase prehospital time.•Prehospital interventions do increase mortality.

High-grade liver injuries with extravasation (HGLI ​+ ​Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial angiography (IR), however, it is unclear if OBS is safe for HGLI ​+ ​Extrav. Therefore, we evaluated the management of HGLI ​+ ​Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality. HGLI ​+ ​Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality. From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p ​= ​0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p ​> ​0.05). Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI ​+ ​Extrav patients. •Comparable LRC rates between HGLI patients managed initially with OBS vs. IR.•Comparable mortality rates between HGLI patients managed initially with OBS vs. IR.•Initial OBS strategy reasonable for appropriately selected patients with HGLI ​+ ​Extrav.

Previous studies have described an increased risk of developing an additional connective tissue disease (CTD) when one such ailment is present. We examine here the likelihood that individuals with systemic lupus erythematosus (SLE) screen positive for one or more of the following five autoimmune CTDs: Sjögren’s syndrome, scleroderma, rheumatoid arthritis, dermatomyositis/polymyositis, and mixed connective tissue disorder. Five hundred SLE-diagnosed subjects were asked to complete a CTD screening questionnaire (CSQ). The results were analyzed according to the set of diagnostic criteria given by the American College of Rheumatology to identify probable cases of each CTD. Significant standardized prevalence ratios and comorbidities indicate an increased risk for the other autoimmune CTDs. In all, 96% of the subjects screened positive for at least one additional CTD, and 13% screened positive for at least two additional CTDs. We see that the SLE-diagnosed population may benefit from further attention regarding the presence of additional CTDs, which may further inform treatment strategies. We also see the application of the CSQ as a potentially important tool for clinical practice, and we describe the present study’s limitations along with possible ways that these can be addressed.

Appropriate to assist with conflict among treating physicians and/or family members/surrogates. N Engl J Med 1988 Dec 22;319(25):1635–8.34 Role of surgery with comfort focus Surgery should be carefully considered based on individual preferences, impact on quality of life, and potential for symptom management. Table 2 ACS Trauma Quality Improvement Program Palliative Care Best Practices Guidelines: palliative care screening for injured patients Previous functional status Injury severity Disability Surprise Question response* Negative screen Healthy, no serious chronic illness Non-life-threatening injuries Non-disabling injuries Yes Positive screen (category 1) One or more serious illnesses, frailty, older age Potentially life-threatening injuries Potentially disabling injuries Maybe or No Positive screen (category 2) Chronic serious illness, frailty, older age Anticipated high risk of hospital mortality due to injury Permanent disability or functional outcome incompatible with patient’s wishes No Adapted with permission of the American College of Surgeons, Chicago, Illinois. Table 3 ACS Trauma Quality Improvement Program Palliative Care Best Practices Guidelines: palliative care screening recommendations for injured patients Positive screen category Assessment and recommendations Category 1 Uncertainty regarding long-term functional recovery or survival due to severe traumatic injuries, age, frailty, comorbidities, or a combination of these factors.

Despite associations, fecal leukocyte analysis of one or more white blood cells/high powered field is only 25 per cent sensitive for inpatient cases and is not diagnostic.2 Empiric medical therapy with oral metronidazole or vancomycin should be started in any patient awaiting results of a diagnostic assay for exotoxins A and B. Often metronidazole is used as initial therapy for mild cases and vancomycin is reserved for more advanced cases or those that fail with metronidazole.3 Fidax- omicin is a bacteriostatic antibiotic that might be considered as an alternative to vancomycin. Severe cases in- clude those with peritonitis, toxic megacolon, shock, sepsis, or admission to intensive care.3 Despite the decrease in mortality compared with medical therapy alone, colectomy carries a substantial risk of death and may require permanent ileostomy.

Plato's Animals examines the crucial role played by animal images, metaphors, allusions, and analogies in Plato's Dialogues. These fourteen lively essays demonstrate that the gadflies, snakes, stingrays, swans, dogs, horses, and other animals that populate Plato's work are not just rhetorical embellishments. Animals are central to Plato's understanding of the hierarchy between animals, humans, and gods and are crucial to his ideas about education, sexuality, politics, aesthetics, the afterlife, the nature of the soul, and philosophy itself. The volume includes a comprehensive annotated index to Plato's bestiary in both Greek and English.

Prior to the genome-wide association era, candidate gene studies were a major approach in schizophrenia genetics. In this invited review, we consider the current status of 25 historical candidate genes for schizophrenia (for example, COMT , DISC1 , DTNBP1 and NRG1 ). The initial study for 24 of these genes explicitly evaluated common variant hypotheses about schizophrenia. Our evaluation included a meta-analysis of the candidate gene literature, incorporation of the results of the largest genomic study yet published for schizophrenia, ratings from informed researchers who have published on these genes, and ratings from 24 schizophrenia geneticists. On the basis of current empirical evidence and mostly consensual assessments of informed opinion, it appears that the historical candidate gene literature did not yield clear insights into the genetic basis of schizophrenia. A likely reason why historical candidate gene studies did not achieve their primary aims is inadequate statistical power. However, the considerable efforts embodied in these early studies unquestionably set the stage for current successes in genomic approaches to schizophrenia.