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Malignant Arrhythmia and Cardiac Arrest Following Intentional Yew Tree Leaf Ingestion Salvaged by VA‐ECMO
This case emphasizes the role of multidisciplinary involvement and early decision‐making in yew tree (Taxus baccata) poisoning. Taxus baccata contains taxine alkaloids that predispose to malignant arrhythmia. Here, we present a case of Taxus baccata toxicity presenting with refractory cardiac arrest, salvaged ultimately by VA‐ECMO.
Journal Article
Evaluation of noninvasive hemoglobin measurements in trauma patients
Reliable, accurate, noninvasive, and continuous determination of hemoglobin would be an important advance in the care of trauma patients. The aim of this study was to evaluate the utility of the Masimo Radical 7 device in severely injured trauma patients.
Highest level trauma activation patients were enrolled over a 1-year period. Laboratory hemoglobin values were compared with Masimo hemoglobin values using Bland-Altman analysis.
A total of 525 patients were enrolled in the study. Comparison of 861 paired values from 418 patients showed a variance of 3.89 to −3.84 g/dL, showing a nonsignificant correlation between Masimo hemoglobin and laboratory hemoglobin values.
The Masimo Radical 7 system evaluated in this study holds promise, but it is not ready to be used as an initial noninvasive evaluation tool in the acute treatment of severely injured trauma patients. There was a poor correlation between Masimo hemoglobin and laboratory hemoglobin and large numbers of missing data. On the basis of the poor correlation, the Masimo Radical 7 device cannot currently be used to guide transfusion therapy.
Journal Article
Evolution of whole blood trauma resuscitation in childbearing age females: practice patterns and trends
BackgroundThe use of low titer group O whole blood (LTOWB) for resuscitation of patients with traumatic hemorrhage is becoming increasingly common. Practices regarding the administration of RhD-positive LTOWB to childbearing age females (CBAFs) vary between institutions due to concerns about RhD alloimmunization. This study examined practices related to LTOWB transfusion as they pertain to age and sex.MethodsThis was a secondary analysis of the Shock, Whole blood, and Assessment of TBI (traumatic brain injury) trial, a prospective, multicenter observational cohort study where outcomes following LTOWB transfusion were analyzed at seven level 1 trauma centers between 2018 and 2021, as well as a survey on transfusion practices at these centers conducted in 2023. The proportion of patients who received LTOWB or components was examined over the course of the study and grouped by age and sex, and the RhD group of injured CBAFs was documented.ResultsA total of 1046 patients were evaluated: 130 females aged <50 years (CBAFs), 77 females aged ≥50 years; 661 males aged <50 years, and 178 males aged ≥50 years. Among them, 26.2% of CBAFs received RhD-positive LTOWB, whereas 57.1%–66.3% of other sex/age groups received LTOWB. The proportion of CBAFs who received LTOWB increased significantly throughout the 4 years of this study. Except for older women in years 2 and 4, CBAFs were significantly less likely to receive LTOWB than all other groups for the study period and individual years. Among the 33 CBAFs who received LTOWB and for whom an RhD type was available, 4/33 (12.1%) were RhD-negative, while 9/95 (9.5%) CBAFs who received component therapy were RhD-negative. RhD blood product selection practices varied considerably between institutions.ConclusionsMany institutions transfused LTOWB to CBAFs. Policies regarding RhD product selection varied. Of the total cohort, the proportion of RhD-negative CBAFs who received LTOWB increased over time but remained lower than all other groups.Level of evidence3.
Journal Article
Impact of therapeutic strategy on disease‐free and overall survival of early‐stage cervical cancer: Surgery alone versus preoperative radiation
Background and Objectives There is no international consensus for management of early‐stage cervical cancer (ESCC). This study aimed to retrospectively investigate disease‐free survival (DFS) and overall survival (OS) in patients with ESCC according to the therapeutic strategy used, surgery alone versus preoperative radiation following by surgery. Methods Data were retrospectively collected from 1998 to 2015 using the Gynecological Cancer Registry of the Côte d'Or. The inclusion criteria were FIGO 2018 ≤ IB2; squamous cell carcinoma, adenocarcinoma or adenosquamous type. Survival curves were compared using the log‐rank test. Results One hundred twenty‐six patients were included. Median survival was 90 months. There was no significant difference in DFS (HR = 0.91, 95%CI [0.32–2.53], p = 0.858) or in OS between surgery alone versus preoperative radiation following by surgery (HR = 0.97, 95%CI [0.31–2.99], p = 0.961). In the subgroup of patients with stage ≥IB1, there was no significant difference in DFS (HR = 3.26, p = 0.2) or in OS (HR = 3.87, p = 0.2). Conclusion Our study did not identify any difference in survival according to the treatment strategy. Preoperative radiation following by surgery can be an alternative to surgery alone for ESCC.
Journal Article
Damage control laparotomy trial: design, rationale and implementation of a randomized controlled trial
BackgroundDamage control laparotomy (DCL) is an abbreviated operation intended to prevent the development of hypothermia, acidosis, and coagulopathy in seriously injured patients. The indications for DCL have since been broadened with no high-quality data to guide treatment. For patients with an indication for DCL, we aim to determine the effect of definitive laparotomy on patient morbidity.MethodThis is a pragmatic, parallel-group, randomized controlled pilot trial. Emergent laparotomy is defined as admission directly to the operating room from the emergency department within 90 min of arrival. DCL indications excluded from the study include packing of the liver or retroperitoneum, abdominal compartment syndrome prophylaxis, to expedite interventional radiology for hemorrhage control, and the need for ongoing transfusions and/or continuous vasopressor support. When a surgeon determines a DCL is indicated, the patient will be screened for inclusion and exclusion criteria. Patients with any indication for DCL that is not excluded are eligible for randomization. Patients will be randomized intraoperatively to DCL (control) or definitive fascial closure of the laparotomy (intervention). The primary outcome will be major abdominal complication or death within 30 days. Major abdominal complication is a composite outcome including fascial dehiscence, organ/space surgical site infection, enteric suture line failure, and unplanned reopening of the abdomen. Outcomes will be compared using both frequentist and Bayesian statistics.DiscussionIn patients with an indication for DCL, this trial will determine the effect of definitive laparotomy on major abdominal complications and death and will inform clinicians on the risks and benefits of this procedure. Regardless of the study outcome, the results will improve the quality of care provided to injured patients.Trial registration numberNCT02706041.
Journal Article
Cover Crop Effectiveness Varies in Cover Crop-Based Rotational Tillage Organic Soybean Systems Depending on Species and Environment
Organic farming relies heavily on tillage for weed management, however, intensive soil disturbance can have detrimental impacts on soil quality. Cover crop-based rotational tillage (CCBRT), a practice that reduces the need for tillage and cultivation through the creation of cover crop mulches, has emerged as an alternative weed management practice in organic cropping systems. In this study, CCBRT systems using cereal rye and triticale grain species are evaluated with organic soybean directly seeded into a rolled cover crop. Cover crop biomass, weed biomass, and soybean yields were evaluated to assess the effects of cereal rye and winter triticale cover crops on weed suppression and yields. From 2016 to 2018, trials were conducted at six locations in Wisconsin, USA, and Southern France. While cover crop biomass did not differ among the cereal grain species tested, the use of cereal rye as the cover crop resulted in higher soybean yields (2.7 t ha−1 vs. 2.2 t ha−1) and greater weed suppression, both at soybean emergence (231 vs. 577 kg ha−1 of weed biomass) and just prior to soybean harvest (1178 vs. 1545 kg ha−1). On four out of six sites, cover crop biomass was lower than the reported optimal (<8000 kg ha−1) needed to suppress weeds throughout soybean season. Environmental conditions, in tandem with agronomic decisions (e.g., seeding dates, cultivar, planters, etc.), influenced the ability of the cover crop to suppress weeds regardless of the species used. In a changing climate, future research should focus on establishing flexible decision support tools based on multi-tactic cover crop management to ensure more consistent results with respect to cover crop growth, weed suppression, and crop yields.
Journal Article
Observer-based tools for non-technical skills assessment in simulated and real clinical environments in healthcare: a systematic review
BackgroundOver the past three decades multiple tools have been developed for the assessment of non-technical skills (NTS) in healthcare. This study was designed primarily to analyse how they have been designed and tested but also to consider guidance on how to select them.ObjectivesTo analyse the context of use, method of development, evidence of validity (including reliability) and usability of tools for the observer-based assessment of NTS in healthcare.DesignSystematic review.Data sourcesSearch of electronic resources, including PubMed, Embase, CINAHL, ERIC, PsycNet, Scopus, Google Scholar and Web of Science. Additional records identified through searching grey literature (OpenGrey, ProQuest, AHRQ, King’s Fund, Health Foundation).Study selectionStudies of observer-based tools for NTS assessment in healthcare professionals (or undergraduates) were included if they: were available in English; published between January 1990 and March 2018; assessed two or more NTS; were designed for simulated or real clinical settings and had provided evidence of validity plus or minus usability. 11,101 articles were identified. After limits were applied, 576 were retrieved for evaluation and 118 articles included in this review.ResultsOne hundred and eighteen studies describing 76 tools for assessment of NTS in healthcare met the eligibility criteria. There was substantial variation in the method of design of the tools and the extent of validity, and usability testing. There was considerable overlap in the skills assessed, and the contexts of use of the tools.ConclusionThis study suggests a need for rationalisation and standardisation of the way we assess NTS in healthcare and greater consistency in how tools are developed and deployed.
Journal Article
Multi-modal Analgesic Strategies for Trauma (MAST): protocol for a pragmatic randomized trial
BackgroundPain management after injury is critically important for functional recovery. Although opioids have been a mainstay for treatment of pain, they are associated with adverse events and may contribute to long-term use or abuse. Opioid-minimizing multimodal pain regimens have the potential to reduce exposure to opioids without compromising pain control. This article details an ongoing clinical trial comparing two pill-based, opioid-minimizing, multimodal pain strategies.MethodsThis is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing two multimodal pain regimens in adult trauma patients. All patients 16 years and older admitted to the Red Duke Trauma Institute are eligible unless they are pregnant, a prisoner, under observation status, or a non-acute trauma patient. At admission to the trauma service, patients are enrolled and randomized to one of two multimodal pain regimens. The primary outcome is opioid use, measured by morphine milligram equivalents per patient per day. The secondary outcomes include pain scores, ventilator days, hospital and intensive care unit lengths of stay, occurrence of opioid-related complications, hospital and pharmacy costs, and incidence of hospital discharge with opioid prescription. Outcomes will be compared using Bayesian methods.DiscussionThis trial will determine the effectiveness of two multimodal pain treatment strategies on reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will compare the two strategies on pain control and patient safety. Knowledge gained in this study can improve quality of care at this hospital and other trauma centers regardless of which medication regimen proves superior.
Journal Article
Cyclooxygenase-2 expression in primary breast cancers predicts dissemination of cancer cells to the bone marrow
Purpose Cyclooxygenase-2 (COX2) plays a role in breast cancer progression at various stages starting from pre-malignant phenotype to clinical metastasis. Breast cancer metastasizes commonly to the bone and preclinical studies suggest an involvement of COX2 in this process. Detection of disseminated tumor cells in the bone marrow of patients at the time of surgery correlates with the subsequent development of clinical bone metastasis. Therefore, to investigate whether COX2 is important for breast cancer metastasis in humans, we analyzed COX2 protein expression by immunostaining of primary tumors from 112 operable stages I, II, or III patients and determined its correlation with bone marrow micrometastasis (BMM). Methods We detected COX2 protein in primary tumors by immunostaining with a monoclonal antibody, and tumor cells present in the bone marrow by immunostaining for epithelial cytokeratins and by morphological criteria. Results COX2 expression in primary breast cancer correlated with BMM in a highly statistically significant manner (P = 0.006). Our statistical analyses of correlations of the COX2 positivity in primary tumor with other clinically relevant indicators revealed that COX2 positivity correlates with high nuclear grade (P = 0.0004). Furthermore, we were able to detect COX2 protein in BMM by immunostaining. Conclusions These studies indicate that COX2 produced in primary breast cancer cells may be vital to the initial development of BMM that may subsequently lead to osteolytic bone metastases in patients with breast cancer, and that COX2 inhibitors may be useful in halting this process.
Journal Article