Splenic artery embolization improves outcomes and decreases the length of stay in hemodynamically stable blunt splenic injuries - A level 1 Australian Trauma centre experience.

BACKGROUND: Splenic injuries are the most common visceral injury following blunt abdominal trauma. Increasingly, non-operative management (NOM) and the use of adjunctive splenic angioembolization (ASE) is favoured over operative management (OM) for the hemodynamically stable patient. However, clinical predictors for successful NOM, particularly the role of ASE as an adjunct, remain poorly defined. This study aims to evaluate the outcomes of patients undergoing ASE vs NOM. METHODS: A retrospective clinical audit was performed of all patients admitted with blunt splenic injury (BSI) from January 2005 to January 2018 at the Royal Adelaide Hospital. The primary outcome was ASE or NOM failure rate. Secondary outcomes were grade of splenic injury, Injury Severity Score (ISS), length of hospital stay (LOS), and delayed OM or re-angioembolization rates. RESULTS: Of 208 patients with BSI, 60 (29%) underwent OM, 54 (26%) ASE, and 94 (45%) NOM only. Patients were predominantly male 165 (79%), with a median age of 33 (IQR 24-51) years. The median ISS was 29 (20-38). There was no difference in the overall success rates for each modality of primary management (48 (89%) ASE vs 77 (82%) NOM, p = 0.374), though patients managed with ASE were older (38 vs 30 years, p = 0.029), had higher grade of splenic injury (grade ≥ IV 42 (78%) vs 8 (8.5%), p<0.001), with increased rates of haemo-peritoneum (46 (85%) vs 51 (54%), p<0.001) and contrast blush (42 (78%) vs 2 (2%), p<0.001). However, for grade III splenic injury, patients managed with ASE had a trend towards better outcome with no failures when compared to the NOM group (0 (0%) vs 8 (35%), p = 0.070) with a significant reduction in LOS (7.2 vs 10.8 days, p = 0.042). Furthermore, the ASE group overall had a significantly shorter LOS compared to the NOM group (10.0 vs 16.0 days, p<0.001). CONCLUSION: ASE as an adjunct to NOM significantly reduces the length of stay in BSI patients and is most successful in managing AAST grade III injuries.

LncRNA HOXA-AS2 accelerates the proliferation and migration and inhibits the apoptosis of vascular smooth muscle cells by absorbing miRNA-877-3p.

OBJECTIVE: The aim of this study was to clarify the role of long non-coding RNA (lncRNA) HOXA-AS2 in influencing the proliferative, migratory and apoptotic abilities of human aortic vascular smooth muscle cells (HA-VSMCs) by absorbing microRNA-877-3p (miRNA-877-3p). MATERIALS AND METHODS: HOXA-AS2 level in HA-VSMCs treated with different doses of oxidized low-density lipoprotein (ox-LDL) and for different time points was determined by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR). After transfection of si-HOXA-AS2 in HA-VSMCs undergoing ox-LDL treatment, the viability, apoptotic rate and migration of cells were detected, respectively. Meanwhile, the subcellular distribution of HOXA-AS2 was analyzed. The Dual-Luciferase reporter gene assay was applied to verify the binding relationship between HOXA-AS2 and miRNA-877-3p. MiRNA-877-3p level in HA-VSMCs treated with different doses of ox-LDL was determined as well. Furthermore, the regulatory effects of HOXA-AS2/miRNA-877-3p axis on cellular behaviors of HA-VSMCs were determined. RESULTS: HOXA-AS2 expression was upregulated by ox-LDL treatment in a time- and dose-dependent manner. After being treated with 100 mg/L ox-LDL for 48 h, the proliferative and migratory abilities of HA-VSMCs were significantly enhanced, while apoptosis was inhibited. Conversely, these changes were reversed by transfection of si-HOXA-AS2. HOXA-AS2 was mainly distributed in the nuclear fraction. Dual-Luciferase reporter gene assay confirmed the direct binding relationship between HOXA-AS2 and miRNA-877-3p. Moreover, miRNA-877-3p was markedly downregulated after transfection of si-HOXA-AS2. MiRNA-877-3p expression decreased gradually with an increased dose of ox-LDL. In addition, knockdown of miRNA-877-3p could reverse the regulatory effects of HOXA-AS2 on proliferative, migratory and apoptotic abilities of HA-VSMCs. CONCLUSIONS: HOXA-AS2 is upregulated after HA-VSMCs injury, which accelerates the proliferative and migratory abilities, and inhibits the apoptosis of vascular smooth muscle cells by absorbing miRNA-877-3p.

Lessons learned from relocating an acute surgical unit to a new quaternary referral centre in Adelaide, South Australia: a tale of two hospitals.

BACKGROUND: On 4 September 2017, patient care was relocated from one quaternary hospital that was closing, to another proximate greenfield site in Adelaide, Australia, this becoming the new Royal Adelaide Hospital. There are currently no data to inform how best to transition hospitals. We conducted a 12-week prospective study of admissions under our acute surgical unit to determine the impact on our key performance indicators. We detail our results and describe compensatory measures deployed around the move. METHODS: Using a standard proforma, data were collected on key performance indicators for acute surgical unit patients referred by the emergency department (ED). This was supplemented by data obtained from operative management software and coding data from medical records to build a database for analysis. RESULTS: Five hundred and eight patients were admitted during the study period. Significant delays were seen in times to surgical referral, surgical review and leaving the ED. Closely comparable was time spent in the surgical suite. Uptake of the Ambulatory Care Pathway fell by 67% and the Rapid Access Clinic by 46%. Overall mortality and patient length of stay were not affected. CONCLUSION: We found the interface with ED was most affected. Staff encountered difficulties familiarizing with a new environment and an anecdotally high number of ED presentations. Delays to referral and surgical review resulted in extended patient stay in ED. Once in theatre, care was comparable pre- and post-transition. This was likely from early identification of patients requiring an emergency operation, close consultant surgeon involvement and robust working relationships between surgeons, anaesthetists and nurses.

Lightweight Lead Aprons: The Emperor's New Clothes in the Angiography Suite?

OBJECTIVE: The aim was to determine whether lead containing and lead free composite garments in current use provide the level of radiation protection stated by manufacturers. METHODS: Fifteen garments, produced by five different manufacturers using eight different composites, were randomly selected for testing from four hospitals in South Australia. Labelling, material composition, design, and condition of the garments were assessed by direct garment examination, garment label, and product information. Garment attenuation was tested in a simulated angiography suite using a Siemens Ysio Max digital Xray machine. The front and back panels of each garment were tested under direct beam at 100 kVp. A Perspex phantom was used to simulate the density and scatter properties of the human abdomen. The front panels of each garment were tested under scattered radiation at Xray tube voltages of 50 and 70 kVp. RESULTS: Forty-seven per cent of front panels and 90% of back panels provided lower lead equivalence than claimed by the manufacturer. Twenty per cent of front panels and 62% of back panels tested did not meet the minimum International Electrotechnical Commission requirements for angiographic use. There was a 38 fold difference in front panel performance of garments to scatter radiation, which were all labelled 0.5 mm lead equivalence. 56% of garments had differences in scatter transmission of at least 49% when tested at 50 and 70 kVp. CONCLUSION: The results show that lead containing and lead free composite garments probably provide less radiation protection than manufacturer stated lead equivalence. The demonstrated wide variations in attenuation of scatter radiation are greater than previously reported. It was found that most garments failed to comply with labelling standards. The study highlights challenges in radiation shielding and the need to identify composites that consistently provide better attenuation per unit weight than lead.