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Traumatic brain injury patients who require neurosurgical intervention are at the highest risk of worsening intracranial hemorrhage. This subgroup of patients has frequently been excluded from prior research regarding the timing of venous thromboembolism chemoprophylaxis. This study aims to assess the efficacy and safety of early venous thromboembolism chemoprophylaxis in patients with traumatic brain injuries requiring neurosurgical interventions. This is a single-center retrospective review (2016–2020) of traumatic brain injury patients requiring neurosurgical intervention admitted to a level I trauma center. Interventions included intracranial pressure monitoring, subdural drain, external ventricular drain, craniotomy, and craniectomy. Exclusion criteria included neurosurgical intervention after chemoprophylaxis initiation, death within 5 days of admission, and absence of chemoprophylaxis. The total population was stratified into Early (≤72 hours of intervention) versus Late (>72 hours after intervention) chemoprophylaxis initiation. A total of 351 patients met the inclusion criteria, of whom 204 (58%) had early chemoprophylaxis initiation. Overall, there were no significant differences in baseline and admission characteristics between cohorts. The Early chemoprophylaxis cohort had a statistically significant lower venous thromboembolism rate (5% vs 13%, P <.001) with no increased risk of worsening intracranial hemorrhage (10% vs 13%, P =.44) or neurosurgical reintervention (8% vs 10%, P =.7). On subgroup analysis, a total of 169 patients required either a craniotomy or a craniectomy before chemoprophylaxis. The Early chemoprophylaxis cohort had statistically significant lower venous thromboembolism rates (2% vs 11%, P <.001) with no increase in intracranial hemorrhage (8% vs 11%, P =.6) or repeat neurosurgical intervention (8% vs 10%, P =.77). Venous thromboembolism prophylaxis initiation within 72 hours of neurosurgical intervention is safe and effective. Further prospective research is warranted to validate the results of this study. [ABSTRACT FROM AUTHOR]

Patients undergoing surgical procedures are at an increased risk of venous thromboembolism events. A fixed Enoxaparin dosing regimen is the standard of care for chemoprophylaxis in most institutions; however, breakthrough venous thromboembolism events are still reported. We aimed to systematically review the literature to determine the ability of various Enoxaparin dosing regimens to achieve adequate prophylactic anti-Xa levels for venous thromboembolism prevention in hospitalized general surgery patients. Additionally, we aimed to assess the correlation between subprophylactic anti-Xa levels and the development of clinically significant venous thromboembolism events. A systematic review was conducted using major databases from January 1, 1993, to February 17, 2023. Two independent researchers screened titles and abstracts, followed by a full-text review. Articles were included if Enoxaparin dosing regimens were evaluated by anti-Xa levels. Exclusion criteria included systematic reviews, pediatric population, nongeneral surgery (defined as trauma, orthopedics, plastics, and neurosurgery), and non-Enoxaparin chemoprophylaxis. The primary outcome was peak Anti-Xa level measured at steady state concentration. The risk of bias was assessed using the Risk of Bias in Nonrandomized studies-of Intervention tool. A total of 6,760 articles were extracted, of which 19 were included in the scoping review. Nine studies included bariatric patients, whereas 5 studies explored abdominal surgical oncology patients. Three studies assessed thoracic surgery patients, and 2 studies included patients undergoing "general surgery" procedures. A total of 1,502 patients were included. The mean age was 47 years, and 38% were males. The percentages of patients reaching adequate prophylactic anti-Xa levels were 39%, 61%, 15%, 50%, and 78% across the 40 mg daily, 40 mg twice daily, 30 mg twice daily, and weight-tiered, and body mass index-based groups, respectively. The overall risk of bias was low to moderate. Fixed Enoxaparin dosing regimens are not correlated with adequate anti-Xa levels in general surgery patients. Additional research is warranted to assess the efficacy of dosing regimens based on novel physiologic parameters (such as estimated blood volume). [ABSTRACT FROM AUTHOR]

Objective: We sought to develop a practical Bedside Score for the diagnosis of cholecystitis and test its accuracy against the Tokyo Guidelines (TG13).Methods: We conducted a retrospective study of 438 patients undergoing urban, academic Emergency Department (ED) evaluation of RUQ pain. Symptoms, physical signs, ultrasound signs, and labs were scoring system candidates. A random split-sample approach was used to develop and validate a new clinical score. Multivariable regression analysis using development data was conducted to identify predictors of cholecystitis. Cutoff values were chosen to ensure positive/negative predictive values (PPV, NPV) of at least 0.95. The score was externally validated in 80 patients at a different hospital undergoing RUQ pain evaluation.Results: 230 patients (53%) had cholecystitis. Five variables predicted cholecystitis and were included in the scores: gallstones, gallbladder thickening, clinical or ultrasonographic Murphy's sign, RUQ tenderness, and post-prandial symptoms. A clinical prediction score was developed. When dichotomized at 4, overall accuracy for acute cholecystitis was 90% for the development cohort, 82% and 86% for the internal and external validation cohorts; TG13 accuracy was 62%-79%.Conclusions: A clinical prediction score for cholecystitis demonstrates accuracy equivalent to TG13. Use of this score may streamline work-up by decreasing the need for comprehensive ultrasound evaluation and CRP measurement and may shorten ED length of stay. [ABSTRACT FROM AUTHOR]

Background The emergency surgery score is a mortality-risk calculator for emergency general operation patients. We sought to examine whether the emergency surgery score predicts 30-day morbidity and mortality in a high-risk group of patients undergoing emergent laparotomy. Methods Using the 2011–2012 American College of Surgeons National Surgical Quality Improvement Program database, we identified all patients who underwent emergent laparotomy using (1) the American College of Surgeons National Surgical Quality Improvement Program definition of “emergent,” and (2) all Current Procedural Terminology codes denoting a laparotomy, excluding aortic aneurysm rupture. Multivariable logistic regression analyses were performed to measure the correlation (c-statistic) between the emergency surgery score and (1) 30-day mortality, and (2) 30-day morbidity after emergent laparotomy. As sensitivity analyses, the correlation between the emergency surgery score and 30-day mortality was also evaluated in prespecified subgroups based on Current Procedural Terminology codes. Results A total of 26,410 emergent laparotomy patients were included. Thirty-day mortality and morbidity were 10.2% and 43.8%, respectively. The emergency surgery score correlated well with mortality (c-statistic = 0.84); scores of 1, 11, and 22 correlated with mortalities of 0.4%, 39%, and 100%, respectively. Similarly, the emergency surgery score correlated well with morbidity (c-statistic = 0.74); scores of 0, 7, and 11 correlated with complication rates of 13%, 58%, and 79%, respectively. The morbidity rates plateaued for scores higher than 11. Sensitivity analyses demonstrated that the emergency surgery score effectively predicts mortality in patients undergoing emergent (1) splenic, (2) gastroduodenal, (3) intestinal, (4) hepatobiliary, or (5) incarcerated ventral hernia operation. Conclusion The emergency surgery score accurately predicts outcomes in all types of emergent laparotomy patients and may prove valuable as a bedside decision-making tool for patient and family counseling, as well as for adequate risk-adjustment in emergent laparotomy quality benchmarking efforts. [ABSTRACT FROM AUTHOR]

Abstract: Characterizing the dynamic mechanical properties of brain tissue is deemed important for developing a comprehensive knowledge of the mechanisms underlying brain injury. The results gathered to date on the tissue properties have been mostly obtained in vitro. Learning how these results might differ quantitatively from those encountered in vivo is a critical step towards the development of biofidelic brain models. The present study provides novel and unique experimental results on, and insights into, brain biorheology in vivo, in situ and in vitro, at large deformations, in the quasi-static and dynamic regimes. The nonlinear dynamic response of the cerebral cortex was measured in indentation on the exposed frontal and parietal lobes of anesthetized porcine subjects. Load–unload cycles were applied to the tissue surface at sinusoidal frequencies of 10, 1, 0.1 and 0.01Hz. Ramp–relaxation tests were also conducted to assess the tissue viscoelastic behavior at longer times. After euthanasia, the indentation test sequences were repeated in situ on the exposed cortex maintained in its native configuration within the cranium. Mixed gray and white matter samples were subsequently excised from the superior cortex to be subjected to identical indentation test segments in vitro within 6–7h post mortem. The main response features (e.g. nonlinearities, rate dependencies, hysteresis and conditioning) were measured and contrasted in vivo, in situ and in vitro. The indentation response was found to be significantly stiffer in situ than in vivo. The consistent, quantitative set of mechanical measurements thereby collected provides a preliminary experimental database, which may be used to support the development of constitutive models for the study of mechanically mediated pathways leading to traumatic brain injury. [Copyright &y& Elsevier]

Background: There are few reproducible models of blast injury, so it is difficult to evaluate new or existing therapies. We developed a clinically relevant polytrauma model to test the hypothesis that cerebrovascular resuscitation is optimized when intravenous fluid is restricted. Study design: Anesthetized swine (42±5 kg, n=35) received blasts to the head and bilateral chests with captive bolt guns, followed by hypoventilation (4 breaths/min; FiO2 =0.21). After 30 minutes, resuscitation was divided into phases to simulate typical prehospital, emergency room, and ICU care. For 30 to 45 minutes, group 1, the control group (n=5), received 1L of normal saline (NS). For 45 to 120 minutes, additional NS was titrated to mean arterial pressure (MAP) > 60 mmHg. After 120 minutes, mannitol (1g/kg) and phenylephrine were administered to manage cerebral perfusion pressure (CPP) > 70 mmHg, plus additional NS was given to maintain central venous pressure (CVP) > 12 mmHg. In group 2 (n=5), MAP and CPP targets were the same, but the CVP target was>8 mmHg. Group 3 (n=5) received 1 L of NS followed only by CPP management. Group 4 (n=5) received Hextend (Abbott Laboratories), instead of NS, to the same MAP and CPP targets as group 2. Results: Polytrauma caused 13 deaths in the 35 animals. In survivors, at 30 minutes, MAP was 60 to 65 mmHg, heart rate was >100 beats/min, PaO2 was < 50 mmHg, and lactate was>5 mmol/L. In two experiments, no fluid or pressor was administered; the tachycardia and hypotension persisted. The first liter of intravenous fluid partially corrected these variables, and also partially corrected mixed venous O2, gastric and portal venous O2, cardiac output, renal blood flow, and urine output. Additional NS (total of 36±1 mL/kg/h and 17±6 mL/kg/h, in groups 1 and 2, respectively) correlated with increased intracranial pressure to 38±4 mmHg (group 1) and 26±4 mmHg (group 2) versus 22±4 mmHg in group 3 (who received 5±1 mL/kg/h). CPP was maintained only after mannitol and phenylephrine. By 5 hours, brain tissue PO2 was>20 mmHg in groups 1 and 2, but only 6±1 mmHg in group 3. In contrast, minimal Hextend (6±3 mL/kg/h) was needed; the corrections in MAP and CPP were immediate and sustained, intracranial pressure was lower (14±2 mmHg), and brain tissue PO2 was> 20 mmHg. Neuropathologic changes were consistent with traumatic brain injury, but there were no statistically significant differences between groups. Conclusions: After polytrauma and resuscitation to standard MAP and CPP targets with mannitol and pressor therapy, we concluded that intracranial hypertension was attenuated and brain oxygenation was maintained with intravenous fluid restriction; cerebrovascular resuscitation was optimized with Hextend versus NS; and longer term studies are needed to determine neuropathologic consequences. [Copyright &y& Elsevier]

Recurrent pneumothorax (rPTX) is a common complication following thoracostomy tube (TT) removal in chest trauma patients. While chest X-ray (CXR) is most commonly used to detect a rPTX, bedside ultraportable ultrasound (UPUS) is a feasible, low cost, and radiation free alternative. No consensus exists with regards to the optimal timing of diagnostic imaging to assess for rPTX post-TT removal. Accordingly, we sought to identify an ideal UPUS timing to detect a rPTX We conducted a single center prospective study of adult (≥18years) patients admitted with a chest trauma. UPUS examinations were performed using the Butterfly iQ+™ ultrasound. Three intercostal spaces (ICS) were evaluated (2nd through 4th). Post-TT UPUS examinations were performed at different timepoints following tube removal (1–6 h). A rPTX on UPUS was defined as the absence of lung-sliding in one or more intercostal spaces, and was considered a clinically concerning rPTX if lung-sliding was absent in ≥2 ICS. UPUS findings were compared to CXR. Ninety-two patients (97 hemi-thoraces) were included in the analysis. A total of 58 patients had a post-TT removal rPTX of which 11 were either clinically concerning or expanding. Comparing UPUS findings to CXR, the 3-hour post-TT removal ultrasound examinations were associated with the highest sensitivity. By hour 4, no rPTX showed expansion in size. Three patients required an intervention for a clinically concerning rPTX, all of whom were detected on UPUS 3-hour post-TT removal. Bedside UPUS performed at 3-hour post-TT removal has the highest sensitivity in detecting clinically concerning rPTX. Size of rPTX appears to stabilize by hour 4. In the absence of clinical symptoms, repeat imaging or observation of non-significant rPTX beyond 4 h may not provide added clinical benefit. Level II, Diagnostic Tests or Criteria [ABSTRACT FROM AUTHOR]

Traumatic rib fracture is associated with a high morbidity rate and identifying patients at risk of developing pulmonary complications (PC) can guide management and potentially decrease unnecessary intensive care admissions. Therefore, we sought to assess and compare the utility of a physiologic parameter, vital capacity (VC), with the admission radiologic findings (RibScore) in predicting PC in patients with rib fractures. This is a single-center retrospective review (2015–2018) of all adult (≥18 years) patients admitted to a Level I trauma center with traumatic rib fracture. Exclusion criteria included no CT scan and absence of VC within 48 h of admission. The cohort was stratified into two groups based on presence or absence of PC (pneumonia, unplanned intubation, unplanned transfer to the intensive care unit for a respiratory concern, or the need for a tracheostomy). Multivariable logistic regression models were constructed to identify predictors of PC. A total of 654 patients met the inclusion criteria of whom 70 % were males. The median age was 51 years and fall (48 %) was the most common type of injury. A total of 36 patients (5.5 %) developed a pulmonary complication. These patients were more likely to be older, had a higher ISS, and were more likely to require a tube thoracostomy placement. On multivariable logistic regression, first VC ≤30 % (AOR: 4.29), day 1 VC ≤30 % (AOR: 3.61), day 2 VC ≤30 % (AOR: 5.54), Δ(Day2-Day1 VC) (AOR: 0.96), and RibScore ≥2 (AOR: 3.19) were significantly associated with PC. On discrimination analysis, day 2 VC had the highest area under the receiver operating characteristic curve (AuROC), 0.81, and was superior to first VC and day 1 VC in predicting PC. There was no statistically significant difference in predicting PC between day 2 VC and RibScore. On multivariable analysis, first VC ≤30 %, day 1 VC ≤30 %, day 2 VC ≤30 %, and admission RibScore ≥2 were associated with prolonged hospital and ICU LOS. VC and RibScore emerged as independent predictors of PC. However, VC was not found to be superior to RibScore in predicting PC. Further prospective research is warranted to validate the findings of this study. [ABSTRACT FROM AUTHOR]

Non-aortic arterial injuries are common and are associated with high morbidity and mortality. Historically, open surgical repair (OSR) was the conventional method of repair. With recent advancements in minimally invasive techniques, endovascular repair (ER) has gained popularity. We sought to compare outcomes in patients undergoing endovascular and open repairs of traumatic non-aortic penetrating arterial injuries. A systematic review and meta-analysis was conducted using MEDLINE (OVID), Web of Science, Cochrane Library, and Scopus Database from January 1st, 1990, to March 20th, 2023. Titles and abstracts were screened, followed by full text review. Articles assessing clinically important outcomes between OSR and ER in penetrating arterial injuries were included. Exclusion criteria included blunt injuries, aortic injuries, pediatric populations, review articles, and non-English articles. Odds ratios (OR) and Cohen's d ratios were used to quantify differences in morbidity and mortality. A total of 3770 articles were identified, of which 8 met inclusion criteria and were included in the review. The articles comprised a total of 8369 patients of whom 90 % were male with a median age of 28 years. 85 % of patients were treated with OSR while 15 % underwent ER. With regards to injury characteristics, those who underwent ER were less likely to present with concurrent venous injuries (OR: 0.41; 95 %CI: 0.18, 0.94; p = 0.03). Regarding hospital outcomes, patients who underwent ER had a lower likelihood of in-hospital or 30-day mortality (OR: 0.72; 95 %CI: 0.55, 0.95; p = 0.02) and compartment syndrome (OR: 0.29, 95 %CI: 0.12, 0.71; p = 0.007). The overall risk of bias was moderate. Endovascular repair of non-aortic penetrating arterial injuries is increasingly common, however open repair remains the most common approach. Compared to ER, OSR was associated with higher odds of compartment syndrome and mortality. Further prospective research is warranted to determine the patient populations and injury patterns that most significantly benefit from an endovascular approach. : Level III, Systematic Reviews & Meta-Analyses [ABSTRACT FROM AUTHOR]

• Mesh use is associated with increased risk of surgical site infection. • Mesh use is not associated with improved recurrence. • The benefits of reinforcing mesh placement are questionable. Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012–12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH. [ABSTRACT FROM AUTHOR]

Background Bile spillage (BS) occurs frequently during laparoscopic cholecystectomy, yet its impact on postoperative outcomes remains unknown. We hypothesized that BS increases the risk of surgical site infections (SSI) after laparoscopic cholecystectomy. Study Design Patients older than 18, who were admitted to an academic hospital for a laparoscopic (or laparoscopic converted to open) cholecystectomy, from May 2010 to March 2017, were prospectively included. Open cholecystectomies were excluded. Patients were assessed clinically during hospitalization and 2 to 4 weeks after discharge. We compared those who had BS during the operation with those who did not. Our primary endpoint was the rate of SSI. Stepwise logistic regression was used to identify independent predictors of SSI. Results Of 1,001 patients, 49.9% underwent laparoscopic cholecystectomy for acute cholecystitis, 20.9% for symptomatic cholelithiasis or biliary colic, 12.8% for gallstone pancreatitis, and 16.4% for other indications. Bile was spilled intraoperatively in 591 patients (59.0%), with hydrops noted in 10.5% and empyema in 14.6% of them. In 202 (20.2%) patients, BS was accompanied by stone spillage. Patients with BS were older (median age of 52 vs 42, p < 0.001) and were more frequently male (44.8% vs 27.8%, p < 0.001). Conversion to open was more likely in operations with BS (13.0% vs 4.4%, p < 0.001). Bile spillage was associated with a higher SSI rate (7.1% vs 2.4%, p = 0.001) and longer hospital stay (median of 3 vs 2 days, p < 0.001). In the multivariable analysis, BS, conversion to open, and American Society of Anesthesiologists (ASA) score > 2 were independent predictors of SSI (odds ratios: 2.29, 2.46, and 2.1 respectively, p < 0.05). Conclusions Bile spillage is associated with SSI, and surgeons should take extra caution to avoid it during laparoscopic cholecystectomy. [ABSTRACT FROM AUTHOR]

Background Benchmarking the quality of intraoperative care by comparing the rates of intraoperative adverse events (iAEs) necessitates adequate risk adjustment. We sought to identify the patient- and procedure-related risk factors for iAEs. Study Design Our 2007 to 2012 institutional American College of Surgeons NSQIP and administrative databases were linked and then screened for iAEs using the Patient Safety Indicator “Accidental Puncture/Laceration.” Intraoperative adverse events were confirmed by systematic review of medical records. Comorbidities were assessed using American College of Surgeons NSQIP variables. Adhesiolysis was determined using CPT codes for lysis of adhesions. Operative complexity was determined using relative value units. Multivariable models were constructed to identify independent predictors of iAEs. Sensitivity analyses were performed in uniform samples of operations. Results Of 9,292 patients, 218 iAEs were confirmed in 183 patients. Median patient age was 56 years old and 54% were female. Compared with patients without iAEs, iAE patients were older (median 61 vs 56 years; p < 0.001), more functionally dependent (9% vs 5%; p = 0.028), and had higher American Society of Anesthesiologists class (≥3 in 45% vs 35%; p = 0.004); their procedures were more complex (median relative value units 29 vs 23; p < 0.001), more likely open (48% vs 21%; p < 0.001), and more often required adhesiolysis (44% vs 18%; p < 0.001). In multivariable analyses, adhesiolysis (odds ratio = 2.34; 95% CI, 1.71–3.21; p < 0.001), higher operative complexity (third vs first relative value units quartile: odds ratio = 3.36; 95% CI, 1.66–6.78; p < 0.001; fourth vs first quartile: odds ratio = 5.97; 95% CI, 3.01–11.86; p < 0.001), and open surgical approach (odds ratio = 2.04; 95% CI, 1.39–3.01; p < 0.001) independently predicted iAEs. Sensitivity analyses confirmed adhesiolysis and higher operative complexity as independent iAE predictors. Conclusions Adhesiolysis and higher operative complexity predict an increased risk for iAE. Attempts to benchmark the quality of intraoperative care need to adequately risk adjust for these factors. [ABSTRACT FROM AUTHOR]

Background Computed tomography angiography (CTA) has been increasingly used in traumatic brain injury (TBI) patients to uncover vascular lesions that might have preceded the trauma and caused the bleed. This study aims to evaluate the usefulness of head CTA in the initial care of blunt TBI patients. Study Design We conducted a retrospective case-control analysis of adult TBI patients, admitted to our Level I trauma center from January 1, 2012 to December 31, 2012. The patients were grouped as those with and without a CTA of the head. The primary outcomes included a change in management after the findings of head CTA and secondary outcomes included rate of admission to the ICU, ICU length of stay, hospital length of stay, discharge disposition, and mortality. Results Six hundred adult patients had blunt TBI and underwent head CT as a part of their evaluation. Of these 600 patients, 132 (22%) underwent head CTA in addition to CT. Only one patient had altered management after the CTA results; the patient had a diagnostic angiogram that was negative. Ninety-eight patients did not have any additional findings on CTA. Of the remaining 33 patients with additional CTA findings, 12 had incidental vascular malformations, which showed no acute pathology and were not related to the injury. In the matched comparisons, patients with CTA had a longer hospital stay, higher rate of ICU admission, and longer ICU stay. There was no significant difference in mortality and discharge disposition between the 2 groups. Conclusions Head CTA is commonly used after blunt TBI but does not alter management and should be abandoned in the absence of clear indications. [ABSTRACT FROM AUTHOR]

Abstract: It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax. [Copyright &y& Elsevier]

Background: Management of severe traumatic brain injury has centered on continuous intracranial pressure (ICP) monitoring with intraparenchymal ICP monitors (IPM) or extracranial ventricular drains (EVD). Our hypothesis was that neurologic outcomes are unaffected by the type of ICP monitoring device. Study Design: We reviewed 377 adult patients with traumatic brain injury requiring ICP monitoring. Primary outcome was Glasgow Outcome Score (GOS) 1 month after injury. Secondary outcomes included mortality, monitoring-related complications, and length of ICU and hospital stay. Results: There were 253 patients managed with an IPM and 124 with an EVD. There was no difference in Glasgow Outcome Score (2.7 ± 1.3 vs 2.5 ± 1.3, p = 0.45), mortality (30.9% vs 32.2%, p = 0.82), and hospital length of stay (LOS) (15.6 ± 12.4 days vs 16.4 ± 10.7 days, p = 0.57). Device-related complications (11.9% vs 31.1%, p < 0.001), duration of ICP monitoring (3.8 ± 2.6 days vs 7.3 ± 5.6 days, p < 0.001), and ICU LOS (7.6 ± 5.6 days vs 9.5 ± 6.2 days, p = 0.004) were longer in the EVD group. Age, opening ICP, and size of midline shift were independent predictors for neurologic outcomes and mortality, when type and severity of brain injury, as well as overall injury severity were controlled for. Duration of ICP monitoring and opening ICP were independent predictors for hospital LOS and the former predicted prolonged ICU stay. Device-related complications were affected by type of device. Conclusions: Use of EVDs in adult traumatic brain injury patients is associated with prolonged ICP monitoring, ICU LOS, and more frequent device-related complications. [ABSTRACT FROM AUTHOR]

Abstract: Background: We have previously demonstrated that treatment with histone deacetylase inhibitors (HDACI), such as valproic acid (VPA) and suberoylanilide hydroxamic acid (SAHA), can improve survival after hemorrhagic shock in animal models. Hemorrhage results in hypoacetylation of proteins which is reversed by HDACI. These agents are known to acetylate insulin receptor substrate-I (IRS-I), which in turn activates the Akt survival pathway. This study investigated whether HDACI exert their beneficial effects through the Akt survival pathway. Methods: Wistar–Kyoto rats (N =21) underwent hemorrhage (60% blood loss) and were randomized into 3 groups; no resuscitation (NR), and treatment with VPA or SAHA. Kidneys were harvested at 1, 6, and 24h after HDACI treatment and analyzed for acetylated histone 3 at lysine 9 residue (Ac-H3K9), phosphorylated Akt (phospho-Akt), BAD and Bcl-2 proteins. Results: Hemorrhaged animals were in severe shock, with mean arterial pressures of 25–30mmHg and lactic acid 7–9mg/ml. Only animals treated with VPA and SAHA survived to the 6- and 24-h timepoints. Treatment with HDACI produced a biologic effect on rat kidney cells inducing acetylation of histone H3K9, which peaked after 1h of treatment, and was statistically significant in the VPA group (p =0.01) compared to NR. Phospho-Akt protein increased in the VPA group with a reciprocal decrease in the pro-apoptotic BAD protein in both groups which was statistically significant in the VPA group after 1h (p =0.007) and 24h (p =0.006) of treatment and in the SAHA group after 24h of treatment (p =0.028). Anti-apoptotic Bcl-2 protein markedly increased after 6 (p =0.04) and 24h (p =0.014) of VPA treatment. Bcl-2 also increased in the SAHA group, but failed to reach statistical significance. Conclusion: Treatment with HDACI increases phosphorylation of Akt with a subsequent decrease in the pro-apoptotic BAD protein. The above mechanism facilitates the action of anti-apoptotic protein Bcl-2. HDACI protect kidney cells subjected to hemorrhagic shock in rodents through the Akt survival pathway. [Copyright &y& Elsevier]

Summary: Background: Chromatin remodeling through histone acetylation is a key control mechanism in gene transcription. We have shown previously that fluid resuscitation in rodents is coupled with highly structured post-translational modifications of cardiac histones. The current experiment was performed to validate this concept in a clinically relevant large animal model of hemorrhage and resuscitation, and to correlate the changes in histone acetylation with altered expression of immediate-early response genes. Study design: Yorkshire swine (n =49, 7/group, weight=40–58kg) were subjected to combined uncontrolled and controlled hemorrhage (40% of estimated blood volume) and randomly assigned to the following resuscitation groups: (1) 0.9% saline (NS), (2) racemic lactated Ringer''s (dl-LR), (3) l-isomer lactated Ringer''s (l-LR), (4) Ketone Ringer''s (KR), (5) 6% hetastarch in saline (Hespan). KR contained an equimolar substitution of lactate with beta-hydroxybutyrate. No hemorrhage (NH) and no resuscitation (NR) groups were included as controls. Cardiac protein was used in Western blotting to analyze total protein acetylation and histone acetylation specifically. Lysine residue-specific acetylation of histone subunits H3 and H4 was further evaluated. In addition, Chromatin Immunoprecipitation (ChIP) technique was used to separate the DNA bound to acetylated histones (H3 and H4 subunits), followed by measurement of genes that are altered by hemorrhage/resuscitation, including immediate-early response genes (c-fos and c-myc), and heat shock protein (HSP) 70. Results: The type of fluid used for resuscitation influenced the patterns of cardiac histone acetylation. Resuscitation with dl-LR and KR induced hyperacetylation on H3K9. KR resuscitation was also associated with increased acetylation on H3K14 and H4K5, and hypoacetylation on H3K18. The expression of genes was also fluid specific, with the largest number of changes following KR resuscitation (increased c-fos and c-myc, HSP 70 linked with H3; and increased c-myc linked with H4). Among the histone subunits studied, altered H3 acetylations were associated with the majority of changes in immediate-early gene expression. Conclusions: Acetylation status of cardiac histones, affected by hemorrhage, is further modulated by resuscitation producing a fluid-specific code that is preserved in different species. Resuscitation with KR causes histone acetylation at the largest number of lysine sites (predominately H3 subunit), and has the most pronounced impact on the transcriptional regulation of selected (immediate-early response) genes. [Copyright &y& Elsevier]

Background: Induction of a profound hypothermia for emergency preservation and resuscitation in severe hemorrhagic shock can improve survival from lethal injuries, but the impact of hypothermia on bleeding and infectious complications has not been completely determined. Study Design: Uncontrolled hemorrhage was induced in 26 swine (95 to 135 lbs) by creating an iliac artery and vein injury, and 30 minutes later, by lacerating the descending thoracic aorta. Through a left thoracotomy approach, profound total body hypothermia (10° C) was induced (2° C/min) by infusing cold organ preservation solution into the aorta. The experimental groups were: vascular injuries alone (group 1, n=10), vascular and colon injuries (group 2, n=8), and vascular, colon, and splenic injuries (group 3, n=8). All injuries were repaired during 60 minutes of low-flow cardiopulmonary bypass (CPB) with hemodilution and profound hypothermia; then the animals were slowly rewarmed (0.5° C/min) back to normothermia. Survivors were monitored for 6 weeks for postoperative bleeding, neurologic deficits, cognitive function (learning new skills), organ dysfunction, and septic complications. Results: Six-week survival rates were 90% in group 1, 87.5% in group 2, and 75% in group 3 (p > 0.05). One animal in each group died from acute cardiac failure during the early postoperative phase. Splenic salvage was possible in all animals, and none required complete splenectomy for hemorrhage control. All surviving animals were neurologically intact, displayed normal learning capacity, and had no longterm organ dysfunction. None of the animals had postoperative hemorrhage or experienced septic complications. One animal in group 3 died on the ninth postoperative day because of bowel obstruction (volvulus). Conclusions: Induction of profound hypothermia can preserve the viability of key organs during repair of lethal injuries. This strategy can be used even in the presence of solid organ and bowel injuries to improve survival, without any considerable increase in postoperative complication rates. [Copyright &y& Elsevier]

Background: Falls from a height are a major cause of morbidity and hospital cost. Spinal injury is frequently associated with falls from height, but reliable predictive factors have not been identified. Diagnostic evaluation of the spine is complex and debated. Our objective was to characterize spinal injury after falls from height and identify predictive factors of spinal injuries. Study design: Medical records of patients with falls from height > 10 feet admitted in a Level I trauma center during a period of 66 months were reviewed. Univariate and multivariate analyses were performed to identify independent risk factors of spinal injuries. Results: Of 414 patients, 127 (31%) suffered 277 spinal injuries. Multiple spinal injuries at different levels were found in 62 (49%) patients; in 19 (15%) spinal injuries were at noncontinuous levels. The only independent predictor of spinal injury was alcohol intoxication (odds ratio = 3.305; 95% CI, 1.75−6.242; p < 0.001) but the number of intoxicated patients was low and the predictive ability weak. Level of falls from height did not correlate with likelihood of spinal injury. Twenty-four of 107 (22%) patients with spinal injuries and a reliable clinical examination had no symptoms related to the spine; all but 2 had distracting injuries. Conclusions: Spinal injury is frequent among survivors of falls from height > 10 feet. Because of the absence of reliable predictors of spinal injury, the possibility of multiple noncontinuous fractures, and the presence of distracting injuries clouding the clinical presentation, aggressive evaluation of the entire spine is warranted. [Copyright &y& Elsevier]