Assessment of the effectiveness of weight-adjusted antibiotic administration,for reduced duration,in surgical prophylaxis of primary hip and knee arthroplasty

BACKGROUND Prophylactic antibiotics have significantly led to a reduction in the risk of postoperative surgical site infections(SSI)in orthopaedic surgery.The aim of using antibiotics for this purpose is to achieve serum and tissue drug levels that exceed,for the duration of the operation,the minimum inhibitory concentration of the likely organisms that are encountered.Prophylactic antibiotics reduce the rate of SSIs in lower limb arthroplasty from between 4%and 8%to between 1%and 3%.Controversy,however,still surrounds the optimal frequency and dosing of antibiotic administration.AIM To evaluate the impact of introduction of a weight-adjusted antibiotic prophylaxis regime,combined with a reduction in the duration of administration of post-operative antibiotics on SSI incidence during the 2 years following primary elective total hip and knee arthroplasty METHODS Following ethical approval,patients undergoing primary total hip arthroplasty(THA)/total knee arthroplasty(TKA)with the old regime(OR)of a preoperative dose[cefazolin 2 g intravenously(IV)],and two subsequent doses(2 h and 8 h),were compared to those after a change to a new regime(NR)of a weight-adjusted preoperative dose(cefazolin 2 g IV for patients<120 kg;cefazolin 3g IV for patients>120 kg)and a post-operative dose at 2 h.The primary outcome in both groups was SSI rates during the 2 years post-operatively.RESULTS A total of n=1273 operations(THA n=534,TKA n=739)were performed in n=1264 patients.There was no statistically significant difference in the rate of deep(OR 0.74%(5/675)vs NR 0.50%(3/598);fishers exact test P=0.72),nor superficial SSIs(OR 2.07%(14/675)vs NR 1.50%(9/598);chi-squared test P=0.44)at 2 years postoperatively.With propensity score weighting and an interrupted time series analysis,there was also no difference in SSI rates between both groups[RR 0.88(95%CI 0.61 to 1.30)P=0.46].CONCLUSION A weight-adjusted regime,with a reduction in number of post-operative doses had no adverse impact on SSI incidence in this population.

Enhancing the clinical relevance of haemorrhage prediction models in trauma

We read with interest the recent systematic reviewaArtificial intelligence and machine learning for hemorrhagic trauma careoby Peng et al.[1],which evaluated literature on machine learning(ML)in the management of traumatic haemorrhage.We thank the authors for their contribution to the role of ML in trauma.

Safety of tranexamic acid in surgically treated isolated spine trauma

BACKGROUND Tranexamic acid(TXA),a synthetic antifibrinolytic drug,effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown.This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma.AIM To assess the safety of TXA in isolated spine trauma.The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion,respectively.METHODS This prospective observational study included patients aged≥17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom.RESULTS We identified 67 patients:26(39%)and 41(61%)received and did not receive TXA,respectively.Both groups were matched in terms of age,gender,American Society of Anesthesiologists grade,and mechanism of injury.A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score>4(74%vs 56%).All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min,compared with 24 patients(58%)in the non TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min.Among patients who received TXA,blood loss was<150 and 150–300 mL in 8(31%)and 15(58%)patients,respectively.There were no cases of thromboembolic events in any patient who received TXA.CONCLUSION Our study demonstrated that TXA is safe for isolated spine trauma.It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases.Further,larger studies are necessary to explore the rate,dosage,and mode of administration of TXA.

Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial?

AIM: To identify risk factors related to pancreatic fistula in patients undergoing distal pancreatectomy (DP) and to determine the effectiveness of using a stapled and a sutured closed of pancreatic stump. METHODS: Sixty-four patients underwent DP during a 10-year period. Information regarding diagnosis, operative details, and perioperative morbidity or mortality was collected. Eight risk factors were examined. RESULTS: Indications for DP included primary pancreatic disease (n = 38, 59%) and non-pancreatic malignancy (n = 26, 41%). Postoperative mortality and morbidity rates were 1.5% and 37% respectively; one patient died due to sepsis and two patients required a reoperation due to postoperative bleeding. Pancreatic fistula was developed in 14 patients (22%); 4 of fistulas were classified as Grade A, 9 as Grade B and only 1 as Grade C. Incidence of pancreatic fistula rate was significantly associated with four risk factors: pathology, use of prophylactic octreotide therapy, concomitant splenectomy, and texture of pancreatic parenchyma. The role that technique (either stapler or suture) of pancreatic stump closure plays in the development of pancreatic leak remains unclear. CONCLUSION: The pancreatic fistula rate after DP is 22%. This is reduced for patients with non-pancreatic malignancy, fibrotic pancreatic tissue, postoperative prophylactic octreotide therapy and concomitant splenectomy.

ABO incompatible renal transplants:Good or bad?

ABO incompatible kidney transplantation(ABOi-KT) was previously considered to be an absolute contraindication for patients with end-stage kidney disease(ESKD) due to hyperacute rejection related to blood type barrier. Since the first successful series of ABOi-KT was reported, ABOi-KT is performed increasingly all over the world. ABOi-KT has led to an expanded donor pool and reduced the number of patients with ESKD awaiting deceased kidney transplantation(KT). Intensified immunosuppression and immunological understanding has helped to shape current desensitization protocols. Consequently, in recent years, ABOi-KT outcome is comparable to ABO compatible KT(ABOc-KT). However, many questions still remain unanswered. In ABOi-KT, there is an additional residual immunological risk that maylead to allograft damage, despite using current diverse but usually intensified immunosuppressive protocols at the expense of increasing risk of infection and possibly malignancy. Notably, in ABOi-KT, desensitization and antibody reduction therapies have increased the cost of KT. Reassuringly, there has been an evolution in ABOiKT leading to a simplification of protocols over the last decade. This review provides an overview of the history, outcome, protocol, advantages and disadvantages in ABOi-KT, and focuses on whether ABOi-KT should be recommended as a therapeutic option of KT in the future.

Surgical management of chronic pancreatitis

BACKGROUND: Treatment of chronic pancreatitis (CP) is a challenging condition for surgeons. During the last decades, increasing knowledge about pathophysiology of CP, improved results of major pancreatic resections, and integration of sophisticated diagnostic methods in clinical practice have resulted in significant changes in surgery for CP. DATA SOURCES: To detail the indications for CP surgery, the surgical procedures, and outcome, a Pubmed database search was performed. The abstracts of searched articles about surgical management of CP were reviewed. The articles could be identified and further scrutinized. Further references were extracted by cross-referencing. RESULTS: Main indications of CP for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The goal of surgical treatment is to improve the quality of life of patients. The surgical approach to CP should be individualized according to pancreatic anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. The approach usually involves pancreatic duct drainage and resection including longitudinal pancreatojejunostomy, pancreatoduodenectomy (Whipple’s procedure), pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum- preserving pancreatic head resection (Beger’s procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey’s procedure). Non-pancreatic and endoscopic management of pain has also been advocated. CONCLUSIONS: Surgical procedures provide long-term pain relief, a good postoperative quality of life withpreservation of endocrine and exocrine pancreatic function, and are associated with low early and late mortality and morbidity. In addition to available results from randomized controlled trials, new studies are needed to determine which procedure is the most effective for the management of patients with CP.

Is there a role for arterial reconstruction in surgery for pancreatic cancer?

Surgery remains the only potentially curative treatment for patients with pancreatic cancer. Locally advanced pancreatic cancer with vascular involvement remains a surgical challenge because high perioperative risk and the uncertainty of a survival benefit. Whilst portal vein resection has started to gather momentum because the perioperative morbidity and long term survival is comparable to standard pancreatectomy, there isn't yet a consensus on arterial resections. There have been various reports and case series of arterial resections in pancreatic cancer, with mixed survival results. Mollberg et al have appraised the heterogeneous published literature available on arterial resection in pancreatic cancer in an attempt to compare this to standard pancreatectomy. In this article, we discuss the results of this systematic review and meta-analysis, and the limitations associated with analysing results from heterogenous data. We have outlined the important features in surgery for pancreatic cancer and specifically to arterial resections, and compared arterial resections to the published literature on venous resections.

Use of three-dimensional printing in preoperative planning in orthopaedic trauma surgery: A systematic review and meta-analysis

BACKGROUND With the increasing complexity of surgical interventions performed in orthopaedic trauma surgery and the improving technologies used in threedimensional(3D)printing,there has been an increased interest in the concept.It has been shown that 3D models allow surgeons to better visualise anatomy,aid in planning and performing complex surgery.It is however not clear how best to utilise the technique and whether this results in better outcomes.AIM To evaluate the effect of 3D printing used in pre-operative planning in orthopaedic trauma surgery on clinical outcomes.METHODS We performed a comprehensive systematic review of the literature and a metaanalysis.Medline,Ovid and Embase were searched from inception to February 8,2018.Randomised controlled trials,case-control studies,cohort studies and case series of five patients or more were included across any area of orthopaedic trauma.The primary outcomes were operation time,intra-operative blood loss and fluoroscopy used.RESULTS Seventeen studies(922 patients)met our inclusion criteria and were reviewed.The use of 3D printing across all specialties in orthopaedic trauma surgery demonstrated an overall reduction in operation time of 19.85%[95%confidence intervals(CI):(-22.99,-16.71)],intra-operative blood loss of 25.73%[95%CI:(-31.07,-20.40)],and number of times fluoroscopy was used by 23.80%[95%CI:(-38.49,-9.10)].CONCLUSION Our results suggest that the use of 3D printing in pre-operative planning in orthopaedic trauma reduces operative time,intraoperative blood loss and the number of times fluoroscopy is used.

Increasing the use of biocompatible,glucose-free peritoneal dialysis solutions

A major concern inhibiting some clinicians from embracing peritoneal dialysis(PD) as the preferred first modality of dialysis is the effects of PD solutions on the peritoneal membrane. These anatomical and functional changes predispose to complications like peritonitis,encapsulating peritoneal sclerosis and ultrafiltration failure. In recent years, "biocompatible" and glucosesparing PD regimens have been developed to minimize damage to the peritoneal membrane. Can the use of these more expensive solutions be justified on current evidence? In this review of the literature, we explore how we may individualize the prescription of biocompatible PD fluid.

Acute arterial mesenteric ischemia and reperfusion:Macroscopic and MRI findings, preliminary report

AIM:To explore the physiopathology and magnetic resonance imaging(MRI)findings in an animal model of acute arterial mesenteric ischemia(AAMI)with and without reperfusion.METHODS:In this study,8 adult Sprague-Dawley rats underwent superior mesenteric artery(SMA)ligation and were then randomly divided in two groups of 4.In groupⅠ,the ischemia was maintained for 8 h.In groupⅡ,1-h after SMA occlusion,the ligation was removed by cutting the thread fixed on the back of the animal,and reperfusion was monitored for 8 h.MRI was performed using a 7-T system.RESULTS:We found that,in the case of AAMI without reperfusion,spastic reflex ileus,hypotonic reflex ileus,free abdominal fluid and bowel wall thinning are present from the second hour,and bowel wall hyperintensity in T2-W sequences are present from the fourth hour.The reperfusion model shows the presence of early bowel wall hyperintensity in T2-W sequences after 1 h and bowel wall thickening from the second hour.CONCLUSION:Our study has shown that MRI can assess pathological changes that occur in the small bowel and distinguish between the presence and absence of reperfusion after induced acute arterial ischemia.

Adolescent Lisfranc injury treated with TightRope^(TM):A case report and review of literature

BACKGROUND Lisfranc injuries are rare and can be easily missed. This injury is extremely rare in children, with limited published data. Different treatment options have been described; one of the options in adults is the "mini" TightRope^(TM) Syndesmosis Device that provides non-rigid fixation with impressive results. However, there is no reference regarding the use of this device in children.CASE SUMMARY We describe the case of an 11-year-old girl who sustained a Lisfranc injury of her right foot that was initially missed in the Accident and Emergency department of her local hospital. This case was a ligamentous/periosteal sleeve avulsion type of Lisfranc injury and a percutaneous technique using the "mini" TightRope^(TM)syndesmosis device was used. Clinical and radiological results were excellent at final follow up.CONCLUSION The "mini" TightRope^(TM) syndesmosis device is a promising method of fixation for children with certain Lisfranc injuries. This method has many advantages,including the non-rigid type of the fixation and no need for subsequent metalwork removal.

The relationship between second trimester alpha fetoprotein levels and adverse pregnancy outcome

Design: Retrospective analysis. Setting: East London Hospital. Subjects: 724 women who had maternal serum alphafetoprotein levels measured between 15 to 19 weeks gestation. Main outcome measure: The main outcome measures were defined as any case of preeclampsia, small-for-gestational age (SGA) birth- weight th centile, placental abruption, stillbirth or early neonatal death. Methods: Women with MSAFP > 2.0 Multiples of Median (MoM) were classified as screen positive. Results: 41 (5.7%) women developed preeclampsia. Women with MSAFP > 2.0 Multiples of the Median (MoM) were significantly more likely to develop preeclampsia (p th centile

Foot and ankle history and clinical examination:A guide to everyday practice

This review summarises the key points in taking a history and performing a comprehensive clinical examination for patients with foot and/or ankle problems. It is a useful guide for residents who are preparing for their specialty exams, as well as family doctors and any other doctor who has to deal with foot and ankle problems in adults.

T cells in pancreatic cancer stroma

Pancreatic ductal adenocarcinoma(PDAC)is a highly devastating disease with a dismal 5-year survival rate.PDAC has a complex tumour microenvironment;characterised by a robust desmoplastic stroma,extensive infiltration of immunesuppressive cells such as immature myeloid cells,tumour-associated macrophages,neutrophils and regulatory T cells,and the presence of exhausted and senescent T cells.The cross-talk between cells in this fibrotic tumour establishes an immune-privileged microenvironment that supports tumour cell escape from immune-surveillance,disease progression and spread to distant organs.PDAC tumours,considered to be non-immunogenic or cold,express low mutation burden,low infiltration of CD8+cytotoxic lymphocytes that are localised along the invasive margin of the tumour border in the surrounding fibrotic tissue,and often display an exhausted phenotype.Here,we review the role of T cells in pancreatic cancer,examine the complex interactions of these crucial effector units within pancreatic cancer stroma and shed light on the increasingly attractive use of T cells as therapy.

Total hip arthroplasty in patients with Paget's disease of bone: A systematic review

AIM To investigate the clinical and functional outcomes following total hip arthroplasty(THA) in patients with Paget's disease.METHODS We carried out a systematic review of the literature to determine the functional outcome, complications and revision rates of THA in patients with Paget's disease. Eight studies involving 358 hips were reviewed. The mean age was 70.4 years and follow-up was 8.3 years. There were 247 cemented THAs(69%), 105 uncemented THAs(29%) and 6 hybrid THAs(2%). RESULTS All studies reported significant improvement in hip function following THA. There were 19 cases of aseptic loosening(5%) at a mean of 8.6 years. Three cases occurred in the uncemented cohort(3%) at a mean of 15.3 years and 16 cases developed in the cemented group(6%) at a mean of 7.5 years(P = 0.2052). There were 27 revisions in the 358 cases(8%) occurring at a mean of 7 years. Six revisions occurred in the uncemented cohort(6%) at a mean of 8.6 years and 21 in the cemented cohort(9%) at a mean of 6.5 years(P = 0.5117). CONCLUSION The findings support the use of THA in patients with Paget's disease hip arthropathy. The post-operative functional outcome is largely similar to other patients; however, the revision rate is higher with aseptic loosening being the most common reason for revision. Uncemented implants appear to be associated with a lower failure rate, however, there were no modern stem designs fixed using current generation cementing techniques used in the reported studies, and as such, caution is advised when drawing any conclusions.

Incidence, risk factors, and outcome of BK polyomavirus infection after kidney transplantation

BACKGROUND Polyomavirus-associated nephropathy is a leading cause of kidney allograft failure. Therapeutic options are limited and prompt reduction of the net state of immunosuppression represents the mainstay of treatment. More recent application of aggressive screening and management protocols for BK-virus infection after renal transplantation has shown encouraging results. Nevertheless,long-term outcome for patients with BK-viremia and nephropathy remains obscure. Risk factors for BK-virus infection are also unclear.AIM To investigate incidence, risk factors, and outcome of BK-virus infection after kidney transplantation.METHODS This single-centre observational study with a median follow up of 57(31-80) mo comprises 629 consecutive adult patients who underwent kidney transplantation between 2007 and 2013. Data were prospectively recorded and annually reviewed until 2016. Recipients were periodically screened for BK-virus by plasmaquantitative polymerized chain reaction. Patients with BK viral load ≥ 1000 copies/mL were diagnosed BK-viremia and underwent histological assessment to rule out nephropathy. In case of BK-viremia, immunosuppression was minimized according to a prespecified protocol. The following outcomes were evaluated: patient survival, overall graft survival, graft failure considering death as a competing risk, 30-d-event-censored graft failure, response to treatment,rejection, renal function, urologic complications, opportunistic infections, newonset diabetes after transplantation, and malignancies. We used a multivariable model to analyse risk factors for BK-viremia and nephropathy.RESULTS BK-viremia was detected in 9.5% recipients. Initial viral load was high(≥ 10000 copies/mL) in 66.7% and low(< 10000 copies/mL) in 33.3% of these patients.Polyomavirus-associated nephropathy was diagnosed in 6.5% of the study population. Patients with high initial viral load were more likely to experience sustained viremia(95% vs 25%, P < 0.00001), nephropathy(92.5% vs 15%, P <0.00001), and polyomavirus-related graft loss(27.5% vs 0%, P = 0.0108) than recipients with low initial viral load. Comparison between recipients with or without BK-viremia showed that the proportion of patients with Afro-Caribbean ethnicity(33.3% vs 16.5%, P = 0.0024), panel-reactive antibody ≥ 50%(30% vs14.6%, P = 0.0047), human leukocyte antigen(HLA) mismatching > 4(26.7% vs13.4%, P = 0.0110), and rejection within thirty days of transplant(21.7% vs 9.5%; P= 0.0073) was higher in the viremic group. Five-year patient and overall graft survival rates for patients with or without BK-viremia were similar. However,viremic recipients showed higher 5-year crude cumulative(22.5% vs 12.2%, P =0.0270) and 30-d-event-censored(22.5% vs 7.1%, P = 0.001) incidences of graft failure than control. In the viremic group we also observed higher proportions of recipients with 5-year estimated glomerular filtration rate < 30 mL/min than the group without viremia: 45% vs 27%(P = 0.0064). Urologic complications were comparable between the two groups. Response to treatment was complete in55%, partial in 26.7%, and absent in 18.3% patients. The nephropathy group showed higher 5-year crude cumulative and 30-d-event-censored incidences of graft failure than control: 29.1% vs 12.1%(P = 0.008) and 29.1% vs 7.2%(P <0.001), respectively. Our multivariable model demonstrated that Afro-Caribbean ethnicity, panel-reactive antibody > 50%, HLA mismatching > 4, and rejection were independent risk factors for BK-virus viremia whereas cytomegalovirus prophylaxis was protective.CONCLUSION Current treatment of BK-virus infection offers sub-optimal results. Initial viremia is a valuable parameter to detect patients at increased risk of nephropathy. Panelreactive antibody > 50% and Afro-Caribbean ethnicity are independent predictors of BK-virus infection whereas cytomegalovirus prophylaxis has a protective effect.

Return to sport after lower limb arthroplasty-why not for all?

BACKGROUND Total hip and knee replacements are being performed in increasing numbers in progressively younger patients with higher activity demands. Many such patients have expectations of returning to athletic activity post-operatively yet are not always able to do so and the reasons behind this have not been extensively examined. We hypothesise that any reasons for a failure to return to athletic activity post-operatively are multi-factorial.AIM To quantify the return to athletic activity following lower limb joint arthroplasty and understand qualitative reasons for altered activity participation.METHODS A single centre, single surgeon retrospective questionnaire for hip and knee arthroplasty patients under age 60 years, minimum two years post-surgery with exclusion criteria of multiple degenerative joint involvement and multiple medical co-morbidities. Outcomes were validated joint-specific(Oxford hip and knee) and lifestyle questionnaires [short form 12(SF-12) and University of California, Los Angeles(UCLA)] and an activity questionnaire assessing ability participation in athletic activity post-operatively. Statistical analysis was performed on the validated outcome data, including comparison between hip and knee replacements. Frequency tables were produced to quantify the different athletic activities participated in by patients.RESULTS Responses were received from 64 patients(80% response rate). There was a statistically significant improvement in Oxford hip and knee scores following surgery. SF-12 scores also improved for all patients, but no statistically significant difference was seen between joints(P = 0.88). Mean UCLA scores pre-operatively were 7.67 and at two years post-operatively were 7.69, with no statistically significant change(P = 0.91). All patients reported high satisfaction and improved ability to perform athletic activity at a higher frequency compared to pre-operatively. The most common reasons for changing activity participation were not wanting to stress their joint replacement or instructions by other doctors or the lead surgeon. There was no difference in the responses to the questionnaire based on type of joint replacement(P = 0.995).CONCLUSION Patients receiving a joint replacement are able to participate in athletic activity to high levels and are satisfied with their outcomes. Reasons for non-participation are multi-factorial.

Post Cholecystectomy Diarrhoea—A Systematic Review

Introduction: Post-cholecystectomy diarrhoea (PCD) is probably the most distressing postoperative non-pain symptom. Its nature is not fully understood. The aim of this systematic review was to assess the prevalence, aetiology, predisposing factors and management of PCD from the past study reports. Methods: We conducted a wide ranged review of published literature on PubMed, Web of Knowledge, and the Cochrane library without any time limitation. Results: Twenty five studies were included. The prevalence of PCD was 9.1% (302/3306) with no significant difference between genders. The prevalence of bile acid malabsorption (BAM), the most important suggested aetiological factor, was seen in 65.5% (36/55) patients with PCD. There were no obvious predisposing factors. We found 92% (23/25) of patients with PCD responded to cholestyramine therapy. The cure rate for cholecystectomy on preoperative cholegenic diarrhoea was 54.5% (121/222). The prevalence of post-cholecystectomy new onset constipation was 7.9% (78/987). Conclusion: The aetiology of PCD is unknown and appears to be multifactorial. The BAM prevalence was only 65.5%, however 92% of PCD patients responded to cholestyramine therapy suggesting that cholestyramine therapy could also have curative effect on other unknown aetiological factors related to bile metabolism. The complexity of the aetiology of PCD is more projected by considering the curative effect of cholecystectomy on preoperative cholegenic diarrhoea, and the occurrence of post-cholecystectomy new onset constipation. However, the relationship between cholecystectomy and PCD is an undeniable fact.

Pancreatic cancer organotypics: High throughput, preclinical models for pharmacological agent evaluation

Pancreatic cancer carries a terrible prognosis,as the fourth most common cause of cancer death in the Western world.There is clearly a need for new therapies to treat this disease.One of the reasons no effective treatment has been developed in the past decade may in part,be explained by the diverse influences exerted by the tumour microenvironment.The tumour stroma cross-talk in pancreatic cancer can influence chemotherapy delivery and response rate.Thus,appropriate preclinical in vitro models which can bridge simple 2D in vitro cell based assays and complex in vivo models are required to understand the biology of pancreatic cancer.Here we discuss the evolution of 3D organotypic models,which recapitulare the morphological and functional features of pancreatic ductal adenocarcinoma(PDAC).Organotypic cultures are a valid high throughput preclinical in vitro model that maybe a useful tool to help establish new therapies for PDAC.A huge advantage of the organotypic model system is that any component of the model can be easily modulated in a short timeframe.This allows new therapies that can target the cancer,the stromal compartment or both to be tested in a model that mirrors the in vivo situation.A major challenge for the future is to expand the cellular composition of the organotypic model to further develop a system that mimics the PDAC environment more precisely.We discuss how this challenge is being met to increase our understanding of this terrible disease and develop novel therapies that can improve the prognosis for patients.

Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre

BACKGROUND Despite motor-vehicle safety advancements and increasingly rigorous workplace safety regulations,trauma/suicide remains the leading cause of death under the age of 45 in the United Kingdom.To promote centralisation of care and optimisation of major trauma outcomes,in 2012 the National Health Service introduced the Trauma Network System.To our knowledge,this is the first study to analyse the epidemiology of pelvic and acetabular trauma over a one-year period at a level-1 trauma centre in the United Kingdom,since nationwide introduction of the Trauma Network System.AIM To characterize the epidemiology of high-energy pelvic and acetabular fractures over a one-year period at a level-1 trauma centre,and explore both resources required to care for these patients and opportunities for future research and injury prevention initiatives.METHODS 227 consecutive patients at a level-1 trauma centre with pelvic and acetabular fractures were analysed between December 2017-December 2018.Paediatric patients(<18 years)and fragility fractures were excluded,leaving 175 patients for inclusion in the study.Statistical analysis was performed using Fisher’s exact test for categorical variables.RESULTS 72%of pelvic and acetabular fractures occurred in male patients at a median age of 45 years.15%were the result of a suicide attempt.48%of patients required pelvic or acetabular surgery,with 38%undergoing further surgery for additional orthopaedic injuries.43%of patients were admitted to intensive care.The median inpatient stay was 13 days,and the 30-day mortality was 5%.Pelvic ring trauma was more commonly associated with abdominal injury(P=0.01)and spine fractures(P<0.001)than acetabular fractures.Vertical shear pelvic ring fractures were associated with falls(P=0.03)while lateral compression fractures were associated with road traffic accidents(P=0.01).CONCLUSION High energy pelvic and acetabular fractures are associated with concomitant orthopaedic fractures(most commonly spine and lower limb),intensive care admission and prolonged inpatient stays.Most pelvic ring injuries secondary to road traffic accidents are lateral compression type,demonstrating the need for future research to drive advancements in lateral impact vehicle safety along with mental health surveillance for those deemed to be potential suicide risks.