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Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, because the optimal hemodynamic parameters are conflicting between the two pathologies. Early thoracic endovascular aortic repair (TEVAR) is often performed, even for minimal aortic injuries, to allow for the higher blood pressure parameters required for TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy.The Aortic Trauma Foundation international prospective multicenter registry was used to identify all patients who had undergone TEVAR for BTAI in the setting of TBI from 2015 to 2020. The primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality, and aortic-related mortality. The outcomes were examined among patients who had undergone TEVAR at emergent (6 vs ≥6 hours) or urgent (24 vs ≥24 hours) intervals.A total of 100 patients (median age, 43 years; 79% men; median injury severity score, 41) with BTAI (Society for Vascular Surgery BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who had undergone TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (6 hours) to urgent repair (≥6 hours), no difference was found in delayed cerebral ischemic events (2.0% vs 4.1%; P = .614), in-hospital mortality (15.7% vs 22.4%; P = .389), or aortic-related mortality (2.0% vs 2.0%; P = .996) and no patient had experienced delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (24 hours) setting showed no differences compared with those completed in an emergent (≥24 hours) setting regarding delayed ischemic stroke (2.6% vs 4.3%; P = .548), in-hospital mortality (18.2% vs 21.7%; P = .764), or aortic-related mortality (1.3% vs 4.3%; P = .654), and no patient had experienced delayed hemorrhagic stroke.In contrast to prior retrospective efforts, results from the Aortic Trauma Foundation international prospective multicenter registry have demonstrated that neither emergent nor urgent TEVAR for patients with concomitant BTAI and TBI was associated with delayed stroke, in-hospital mortality, or aortic-related mortality. In these patients, the timing of TEVAR did not have an effect on the outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than surgical timing.

Central and systemic immune dysfunction after traumatic brain injury (TBI) can lead to infectious-related complications, which may result in delayed mortality. The role of early empiric antibiotics after TBI has not been characterized to date, but is recommended in select cases to decrease complications. We aimed to determine the relationship between early antibiotic use and in-hospital mortality in TBI patients.A retrospective review was conducted of TBI patients requiring ICU admission at an urban, academic, Level I trauma center from 01/2014 to 08/2016. Data collection included demographics, injury characteristics, details regarding antibiotic use, and outcomes. Early antibiotic administration was defined as any antibiotic given within 48 hs from admission. Patients given early antibiotics (EARLY) were compared to those who received their first dose later or did not receive any antibiotics (non-EARLY).Of the 488 TBI patients meeting inclusion criteria, 189 (38.7%) received early antibiotics. EARLY patients were younger (EARLY 54.2 versus non-EARLY 61.5 ys, P0.01) and more likely to be male (71.4% versus 60.9%, P = 0.02). Injury severity scores (23.6 versus 17.2, P0.01) and regional head abbreviated injury scale scores (3.9 versus 3.7, P0.01) were significantly higher in patients who received early antibiotics. Unadjusted in-hospital mortality rates were similar, however EARLY was associated with a lower mortality rate (AOR 0.17, 95% CI: 0.07 - 0.43, adjusted P0.01) after adjusting for confounders.Despite presenting with a higher injury burden, TBI patients who received early antibiotics had a lower associated mortality rate compared to their counterparts. Future investigations are necessary to understand the underlying mechanisms that result in this potential survival benefit.

Background: Patients with traumatic brain injury (TBI) frequently develop leukocytosis, fever, and tachycardia that may lead to extensive medical investigations to rule out an infectious process. Cerebrospinal fluid (CSF) is often acquired during this workup, however, the utility of this practice has not been studied previously. We hypothesized that CSF cultures would unlikely yield positive results in patients with TBI. Patients and Methods: A retrospective review was conducted of all patients with TBI admitted to two level 1 trauma centers at urban, academic institutions from January 2009 to December 2016. Data collected included patient demographics, presenting Glasgow Coma Score (GCS), injury profile, injury severity scores (ISS), regional abbreviated injury scale (AIS), hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and culture results. For purposes of the analysis, CSF cultures with Staphylococcus epidermidis, Staphylococcus aureus, or Candida underwent a chart review and were considered contaminates if indicated. Results: There were 145 patients who had CSF cultures obtained with a median age of 39 years; 77.2% were male. The majority of patients presented after blunt trauma with median GCS of 6, head AIS of 4, and ISS of 25. These patients had prolonged median ICU and hospital stays at 13 and 22 days, respectively. Six (4.1%) CSF cultures demonstrated growth. Four (2.8%) were deemed contaminants, with two growing Staphylococcus epidermidis only, one with both Staphylococcus epidermidis and Staphylococcus aureus, and one with Candida. Two cultures (1.4%) were positive and grew Enterobacter cloacae. Of note, both patients had prior instrumentation with an external ventricular drain. Conclusion: Obtaining CSF cultures in patients with TBI is of low yield, especially in patients without prior external ventricular drain. Other sources of infectious etiologies should be considered in this patient population.

Positive fluid balance (FB) in the intensive care unit (ICU) may be a marker for increased venous thromboembolism (VTE) risk. We hypothesized that an early positive fluid balance (FB) would be associated with increased VTE occurrence.A single-center retrospective review of surgical ICU patients was conducted from May 2011 to December 2014. Patients with a VTE were compared to those who did not develop a VTE (NVTE).There were 619 patients analyzed with 77 (12.4%) diagnosed with a VTE; these patients had longer ventilator days (12.3 vs. 5.0 days, p 0.01) and ICU stays (10.3 vs. 6.4 days, p 0.01), and were more likely to have a net FB ≥ 4L over the first three days (62% vs. 44%, p 0.01). A FB ≥ 4L over the first three ICU days was an independent predictor of VTE (AOR 1.74, p = 0.04).Patients with an early positive FB are more likely to develop a VTE.

Introduction Thromboelastography (TEG) is an assay that assesses the coagulation status. Patients with prolonged reaction time (R) require fresh frozen plasma (FFP); however, the volume required to correct the R time is unknown. We sought to quantify the volume required to correct the R time and calculate the response ratio in our surgical intensive care unit (SICU) to allow for targeted resuscitation Methods Surgical intensive care unit patients between Aug 2017 and July 2019 with a prolonged initial R time and at least two TEG tests performed within 24 hours were included. The response ratio was defined as the change in the R time divided by the number of FFP units. High responders (response ratio >5 minutes/unit) were compared to low responders (response ratio ≤5 minutes/unit). Results Forty-six patients were included. While the mean response ratio was 5 minutes/unit, there was significant variation among patients. There were 28.0 (60.9%) low responders and 18.0 (39.1%) high responders. Low responders were more likely male (64.0% vs. 33.0%, P = .04), had a higher Acute Physiology and Chronic Health Evaluation (APACHE) IV score (42.0 vs. 27.0, P = .03), and a higher mortality rate (54.0% vs. 22.0%, P = .04). Conclusions On average, one unit of FFP corrects the R time by 5 minutes; however, there was significant variation between high and low responders. Male patients with higher APACHE IV score are expected to be low responders with a higher mortality rate. These findings can guide FFP transfusion and provide additional prognostication.

Purpose There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients. Methods A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019–6/30/2019 and 1/1/2020–6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups. Results A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p p = 0.008), compared to non-COVID patients. Conclusion This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.

Introduction Enoxaparin dosed by an anti-Xa trough level is effective at reducing venous thromboembolism (VTE) in trauma patients. We identified the patient characteristics associated with higher enoxaparin dosing based on anti-Xa trough levels. Methods A retrospective review was conducted on trauma patients admitted between August 2014 and February 2018 who received enoxaparin dosed by the anti-Xa trough level. Patients who received enoxaparin < 50 mg every 12 hours were compared to those who required ≥ 50 mg every 12 hours. Results Of the 246 patients included, 32 (13.0%) required enoxaparin ≥ 50 mg every 12 hours to achieve the prophylactic trough level. Factors associated with a higher dose of enoxaparin were male (96.8% vs. 3.2%, P < .01), younger age (39.5 vs. 52.7 years, P < .01), higher creatinine clearance (CrCl) (125.9 vs. 93.7 mL/min, P < .01), higher body surface area (2 m2 vs. 1.8 m2, P < .01), and higher injury severity score (18.4 vs. 10.8, P < .01). Height, weight, and body mass index were not significant factors. On regression analysis, CrCl was the only independent predictor for higher enoxaparin dose. There was an increased deep venous thrombosis rate in the higher dose cohort (12.5% vs. 0, P < .01) but no significant differences in transfusion rates. Conclusion Trauma patients who require higher enoxaparin doses to achieve prophylactic anti-Xa trough levels have a higher CrCl. Patients with high CrCl may benefit from an initial higher dose of enoxaparin to achieve a target anti-Xa level in a shorter time interval to decrease VTE risk.

Venous thromboembolism (VTE) in trauma patients carries significant morbidity and mortality. We previously described how titrating enoxaparin dosing by anti-Xa trough levels was associated with a lower VTE rate. We combined this strategy with a higher initial enoxaparin dose for a majority of patients and modified the electronic medical record (EMR) to encourage immediate dosing. We sought to determine if this systems-based approach was associated with a decrease in VTE rate. A retrospective review was conducted of all trauma patients on prophylactic enoxaparin at an academic, Level I Trauma Center from 01/2013 to 05/2014 (PRE) and 06/2015 to 02/2018 (POST). The patients in PRE were prescribed enoxaparin 30 mg twice daily without dose adjustments. The patients in POST received 40 mg twice daily unless exclusion criteria applied, with doses titrated to maintain anti-Xa trough levels between 0.1 and 0.2 IU/mL. There were 478 patients in the PRE and 1306 in the POST. Compared to PRE, POST patients were of similar age and were as likely to present after blunt trauma, although POST patients had lower injury severity scores (10 vs. 9, p

Purpose The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders. Methods A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019–6/30/2019 (CONTROL), 1/1/2020–3/18/2020 (PRE), 3/19/2020–6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses. Results 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05). Conclusions This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.

Floating offshore wind turbine technology has seen an increasing and continuous development in recent years. When designing the floating platforms, both experimental and numerical tools are applied, with the latter often using time-domain solvers based on hydro-load estimation from a Morison approach or a boundary element method. Commercial software packages such as OrcaFlex, or open-source software such as OpenFAST, are often used where the floater is modeled as a rigid six degree-of-freedom body with loads applied at the center of gravity. However, for final structural design, it is necessary to have information on the distribution of loads over the entire body and to know local internal loads in each component. This paper uses the TetraSpar floating offshore wind turbine design as a case study to examine new modeling approaches in OrcaFlex and OpenFAST that provide this information. The study proves the possibility of applying the approach and the extraction of internal loads, while also presenting an initial code-to-code verification between OrcaFlex and OpenFAST. As can be expected, comparing the flexible model to a rigid-body model proves how motion and loads are affected by the flexibility of the structure. OrcaFlex and OpenFAST generally agree, but there are some differences in results due to different modeling approaches. Since no experimental data are available in the study, this paper only forms a baseline for future studies but still proves and describes the possibilities of the approach and codes.

BACKGROUND: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data. METHODS: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling. RESULTS: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients. CONCLUSION: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.

Background International rotations with hands-on experience are commonly cited as a potential supplement to the current experience of surgical trainees in trauma; however, quantification of this experience remains unclear. Methods A link to an online survey was distributed by electronic mail to physicians who rotated for any period of time at the Trauma Unit of the Groote-Shuur Hospital of the University of Cape Town from January 1, 2006, to December 2016. Results Of 160 participants, 75 (47%) completed the survey. A high proportion (45%) had performed less than 25 trauma-related surgical procedures during their previous training. Most (56%) performed ≥ 10 trauma laparotomies and sternotomies/thoracotomies during their rotation, whereas 43% performed ≥ 5 vascular procedures. The level of perceived confidence in managing trauma patients increased significantly from a median of 3/10 to 7/10 (P < .05). Conclusion Rotations at large-volume trauma centers abroad offer the opportunity for a hands-on operative experience and may enhance the confidence of surgical trainees. Further standardization of these opportunities may result in a larger-scale participation of graduate residents and fellows., Highlights • This is a survey of physicians who participated in an international rotation at the Groote Schuur Hospital of the University of Cape Town. • With this survey, we found that most participants performed in excess of 10 trauma laparotomies and thoracotomies/sternotomies. • A large proportion performed 5 or more peripheral vascular procedures. • These findings are combined with a significantly increased confidence in managing trauma patients. • This report may serve in the planning of sponsored international rotations to increase the operative exposure in trauma surgery.

Background Patients with sepsis have significant mortality and morbidity that may improve by normalization of lactate as indication of adequate resuscitation. We sought to quantify the volume of fluid associated with correction of lactate in septic surgical patients. Material and methods A retrospective review was conducted in all patients with elevated lactate who were admitted to the SICU at a Level I trauma center from February 2016 to April 2018. Patients ≥18 years with sepsis, septic shock, infection, and lactate >2.5 mmol/l with subsequent lactate follow up were included. Patients on dialysis, liver failure, and trauma patients who received massive transfusion were excluded. Data was collected on patients’ demographics, hospital length of stay (LOS), mortality and volume of fluid given. The primary outcome was the volume of fluid required to correct lactate by 1 mmol/l. Pearson correlation coefficient was calculated to evaluate the association between fluid volume and lactate level. Results Forty-eight patients were included. The mean age was 67 (14.2) years, 56.3% were males, and mortality was 22%. The mean elevated lactate was 4.90 (3.02) mmol/l. An average of 1372 (1809) cc of fluid was needed to reduce lactate by 1 mmol/l. The average time for correction was 5.2 (5.6) hours. There was weak correlation between resuscitation fluid volume and lactate correction (r = 0.29, p = 0.05). Conclusions About 1400 cc of fluid was required to correct the lactate by 1 mmol/l. This value can help guide resuscitation in septic surgical patients. The weak correlation between resuscitation fluid volume and lactate correction highlights the importance of other interventions including the early administration antibiotics and source control.

Background This study determined the prevalence of complicated appendicitis in elderly patients diagnosed preoperatively with uncomplicated appendicitis. Methods Patients with a preoperative diagnosis of uncomplicated appendicitis at an academic hospital from 11/2013 to 05/2017 were reviewed. Patients ≥65 years were compared to those younger. Pathology reports were categorized as either uncomplicated or complicated (COMP). The primary outcome was the prevalence of COMP appendicitis. Results The prevalence of COMP appendicitis increased with age after 20 years with an abrupt increase after 65 years. Patients ≥65 years were more likely to have COMP appendicitis (48.1% vs. 15.5%; OR: 5.1; p Conclusion Nearly half of elderly patients had pathologic confirmation of complicated appendicitis despite no preoperative clinical or radiographic suspicion for complicated appendicitis. Nonoperative management of acute appendicitis in the elderly may not be appropriate due to the high rate of unexpected complicated appendicitis.

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p 0.05) as was unplanned re-operation (4.7% vs 14%, p 0.05). Lap reduced LOS (6 vs 8 days, p 0.001). Ileus was more in Lap (42% vs 18 p 0.001) operative time was 14 min higher in Lap(p 0.01) and admission to OR time was 4 h higher in Lap(0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

Background Although ejections from motor vehicles are considered a marker of a significant mechanism and a predictor of severe injuries and mortality, scant recent data exist to validate these outcomes. This study investigates whether ejections increase the mortality risk following a motor vehicle crash using data that reflect the introduction of new vehicles to the streets of a large city in the United States. Methods The Trauma and Emergency Medicine Information System of Los Angeles County was queried for patients ≥ 16 years old admitted following a motor vehicle crash between 2002 and 2012. Ejected patients were compared to nonejected. Primary outcome was mortality. A logistic regression model was used to identify predictors of mortality and severe trauma. Results A total of 9,742 (6.8%) met inclusion criteria. Of these, 449 (4.6%) were ejected; 368 (82.0%) were passengers and 81 (18.0%) were drivers. The rate of ejection decreased linearly (6.1% in 2002 to 3.4% in 2012). Compared to nonejected patients, ejected patients were more likely to require intensive care unit admission (43.7% vs 22.1%, P 25) (24.2% vs 7.3%, P 25) with adjusted odds ratio of 2.48 (P, Highlights • The rate of ejection during a motor vehicle crash has decreased since 2002. • Ejected patients had a significantly higher mortality compared to nonejected. • Ejection was a predictor of both critical injuries and mortality.

The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients. Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18–60, 61–80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias. Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18–60 years and 20.4% in the 61–80 years group, p

Elderly patients are at high risk for mortality after injury, and prevention is imperative. Several studies have captured the value of traffic calming or environmental modifications; however, limited data support its use during focused times of the day to reduce pedestrian trauma. This study's aim was to identify when the elderly are more likely to be injured from pedestrian trauma. The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for all adult pedestrians who were struck by vehicles from 2000 to 2015. Elderly (≥65 years) patients were compared with nonelderly (range, 18–64 years) patients with respect to the time of admission and mortality. The proportion of elderly pedestrian injuries peaked between 9 and 10 am (23%). Compared with their nonelderly counterparts, the elderly were more likely to have a Glasgow Coma Scale ≤8 (11% vs 7%, P < 0.01), be hypotensive (6% vs 3%, P < 0.01), and have a higher Injury Severity Score (median 9 vs 5, P < 0.01). Mortality was significantly higher in the elderly (14% vs 4%, P < 0.01). Elderly pedestrians had an almost 5-fold higher adjusted odds ratio for death: 4.72 ( P < 0.01). Preventative strategies with lower speed limits or high surveillance during these hours in highly populated areas may result in a decreased incidence of these injuries.

Introduction: Selective nonoperative management of neck injuries from penetrating mechanism has become an acceptable management strategy. We herein characterize current management strategies of cer...

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center.Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively.Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P0.01) as the only predictors for 30-d mortality.Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.

Blunt thoracic aortic injury (BTAI) is the second leading cause of death from blunt trauma. In the present study, we aimed to determine the outcomes of medical management (MM) for BTAI. We hypothesized from the results of several previously reported studies, that patients with a minimal aortic injury (BTAI grades 1 and 2) could safely be treated with definitive MM alone.The Aortic Trauma Foundation international prospective multicenter registry was used to examine the demographics, injury characteristics, management, and outcomes of patients with BTAI. We analyzed a subset of patients for whom MM was initiated as definitive therapy.From November 2016 to April 2020, 432 patients (median age, 41 years; 76% male; median injury severity score, 34) with BTAI (Society for Vascular Surgery grade 1, 23.6%; grade 2, 14.4%; grade 3, 51.2%; grade 4, 10.9%) were evaluated. Of the 432 patients, 245 (57%) had received MM in the initial period and 114 (26.4%) had received MM as the planned definitive therapy (grade 1, 59.6%; grade 2, 23.7%; grade 3, 15.8%; grade 4, 0.9%). The most common mechanism of BTAI was a motor vehicle collision (60.4%). Hypotension was present on arrival in 74 patients (17.2%). Continuous titratable infusion of antihypertensive medication was used for 49.1%, followed by intermittent bolus administration (29.8%), with beta-blockers (74.6%) the most common agent used. Treatments were targeted to a goal systolic blood pressure for 83.3%, most often to a target goal systolic blood pressure120 mm Hg (66.3%). The MM goals based on blood pressure control were attained in 64.0% (73 of 114). Twelve patients (10.5%; grade 1, 1; grade 2, 0; grade 3, 10; grade 4, 1) had required subsequent intervention after MM. Eleven patients (9.6%) had undergone thoracic endovascular aortic repair and one (0.9%) had required open repair for a grade 4 injury. The overall in-hospital mortality for patients selected for definitive MM was 7.9%. No aortic-related deaths had occurred in the patients receiving definitive MM.Approximately one in four patients with BTAI will receive MM as definitive therapy. The variation in the pharmacologic therapies used is considerable. MM for patients with minimal aortic injury (BTAI grades 1 and 2) is safe and effective, with a low overall intervention rate and no aortic-related deaths. These findings support the use of definitive MM for grade 2 BTAI.

Trauma patients have a high risk for venous thromboembolism (VTE) such that an increased enoxaparin dose is necessary to reduce related complications. Given that most trauma patients require an enoxaparin dose of at least 40 mg every 12 hours for VTE prophylaxis, we sought to identify which patients require enoxaparin 30 mg every 12 hours and hypothesized that both weight and low creatinine clearance (CrCl) would more likely determine enoxaparin dosing than age, body mass index (BMI), or body surface area (BSA). Single institution data were collected on trauma patients between August 2014 and February 2018 to compare trauma patients who required enoxaparin 30 mg to those who required ≥40 mg every 12 hours. Of the 245 patients included, 86 (35.1%) required enoxaparin at 30 mg to achieve the goal anti-factor Xa trough level. Factors associated with low dose enoxaparin were older age (59.6 vs. 46.2 years, P ≤ .01) and lower CrCl (81.5 mL/min vs. 93.7 mL/min, P ≤ .01). Weight, BSA, and BMI did not alter the dose of enoxaparin. A regression model determined that only CrCl predicted the need for low dose enoxaparin (adjusted odds ratio .982, 95% CI: .975-.990, P < .01). Although an initial dose of enoxaparin 40 mg is appropriate for most trauma patients, patients with low CrCl should receive 30 mg. Increased age and low weight were not associated with the need for a lower enoxaparin dose.

Aim Pedestrian fatalities commonly involve alcohol. We sought to characterize alcohol intoxication among pedestrians struck by vehicles and examine correlations between admission time and injury severity. Methods The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for pedestrians struck by vehicles over a 16-year period starting January 2000. Subjects aged ≥18 years with available time and day of admission were selected. Patients with available blood alcohol content (BAC) were analyzed and those with positive (+) BAC (≥ 0.01%) were compared with those with negative (−) BAC. The primary outcome was mortality. Result 35 840 patients met criteria, with 12 122 (33.8%) tested for BAC. 71.2% were (+) BAC. The proportion of (+) BAC pedestrians peaked at 02:00 (48.9% of admitted pedestrians, 88.5% of BAC tested pedestrians). Patients with a (+) BAC were more likely hypotensive (3.5% vs 2.7%, P = .019) and admitted with a Glasgow Coma Scale ≤ 8 (9.4% vs 7.1%, P < .001). Overall mortality was 4.6%. Those admitted from 06:00 to 11:00 had the highest odds of mortality in (+) BAC patients (4.7%, adjusted odds ratio 3.16, adjusted P < .001). Conclusion Pedestrians struck by vehicles during late hours are commonly intoxicated. These findings could help legislators to implement changes and strategies to decrease the risk and burden of injury in intoxicated pedestrians.

Phase I of the OC6 project is focused on examining why offshore wind design tools underpredict the response (loads/motion) of the OC5-DeepCwind semisubmersible at its surge and pitch natural frequencies. Previous investigations showed that the underprediction was primarily related to nonlinear hydrodynamic loading, so two new validation campaigns were performed to separately examine the different hydrodynamic load components. In this paper, we validate a variety of tools against this new test data, focusing on the ability to accurately model the low-frequency loads on a semisubmersible floater when held fixed under wave excitation and when forced to oscillate in the surge direction. However, it is observed that models providing better load predictions in these two scenarios do not necessarily produce a more accurate motion response in a moored configuration. The authors would like to acknowledge the support of the MARINET2 project (European Union’s Horizon 2020 grant agreement 731084), which supplied the tank test time and travel support to accomplish the testing campaign. The support of MARIN in the preparation, execution of the modeltests, and the evaluation of the uncertainties was essential for this study. MARIN’s contribution was partly funded by the Dutch Ministry of Economic Affairs through TKI-ARD funding programs. This work was authored in part by the National Renewable Energy Laboratory, operated by Alliance for Sustainable Energy, LLC, for the U.S. Department of Energy (DOE) under Contract No. DE-AC36- 08GO28308. Funding provided by the U.S. Department of Energy Office of Energy Efficiency and Renewable Energy Wind Energy Technologies Office. The views expressed in the article do not necessarily represent the views of the DOE or the U.S. Government. The U.S. Government retains and the publisher, by accepting the article for publication, acknowledges that the U.S. Government retains a nonexclusive, paid-up, irrevocable, worldwide license to publish or reproduce the published form of this work, or allow others to do so, for U.S. Government purposes.

BACKGROUND Increasing evidence supports the limited use of magnetic resonance imaging (MRI) for cervical spine (C-spine) clearance following blunt trauma. We sought to characterize the utilization of MRI of the C-spine at a Level I trauma center. METHODS All blunt trauma patients undergoing a computed tomography (CT) of the C-spine between January 2009 and December 2018 were reviewed. The CT and MRI results, demographics, clinical presentation, subspecialty consultations, and interventions were recorded. The MRI results were considered clinically significant if they resulted in cervical thoracic orthosis/halo placement or surgical intervention. Linear regression models were utilized to identify trends. RESULTS There were 9,101 patients that underwent a CT of the C-spine, with 513 (5.6%) being positive for an acute injury. MRI was obtained for 375 (4.1%) of patients. A linear increase in the proportion of patients undergoing an MRI was noted, from 0.9% in 2009 to 5.6% in 2018 (p < 0.01). Of the 513 patients with a positive CT, 290 (56.5%) had an MRI. In 40 (13.8%) of them, the CT demonstrated a minor injury. Clinically significant MRI findings were noted only in two (5.0%) of the 40 patients, and both had a neurologic deficit on initial examination. Of the 8,588 patients with a negative CT, 85 (1.0%) underwent an MRI. Of those, 9 (10.6%) had a clinically significant MRI with all but one presenting with a neurological deficit. CONCLUSION MRI is increasingly utilized for C-spine clearance following blunt trauma. MRI was exceedingly unlikely to demonstrate a clinically significant finding in the absence of a neurological deficit, when the CT was negative or included minor injuries. Trauma centers are encouraged to constantly evaluate their own practices and intervene with education and collaboration to limit the excessive use of unnecessary resources. LEVEL OF EVIDENCE Therapeutic/Care Management Study, Level III or IV. Diagnostic test, level IV.

To characterize the epidemiology, diagnostic approach, management, and outcomes of blunt pharyngoesophageal injuries. These injuries remain exceedingly rare. Clinical symptoms and signs may not be revealing. Most recommendations regarding diagnosis and management are extrapolated from penetrating aerodigestive injuries. High-resolution computerized tomography has emerged as the most useful initial imaging modality that may guide the need for additional studies and/or intervention. Esophagography and endoscopic evaluation remain of paramount importance when an injury is confirmed or suspected as they can assist in determining therapeutic actions. Non-operative management is feasible and should be considered selectively to avoid septic complications. Blunt pharyngoesophageal injuries can be managed similarly to those from penetrating mechanism. The use of computerized tomography should be more liberal to rule out associated injuries, as blunt trauma patients are at risk for having additional occult life-threatening injuries. Non-operative managements should be carefully deployed.

Background How recurrent traumatic brain injury (rTBI) alters brain function years after insult is largely unknown. This study aims to characterize the mechanistic cause for long-term brain deterioration following rTBI using a rat model. Methods Eighteen Sprague-Dawley wild-type rats underwent bilateral rTBI using a direct skull impact device or sham treatment, once per week for 5 weeks, and were euthanized 56 weeks after the first injury. Weekly rotarod performance measured motor deficits. Beam walk and grip strength were also assessed. Brain tissue were stained and volume was computed using Stereo Investigator's Cavalieri Estimator. The L5 cortical layer proximal to the injury site was microdissected and submitted for sequencing with count analyzed using R "DESeq2" and "GOStats." Brain-derived neurotrophic factor (BDNF) levels were determined using enzyme-linked immunosorbent assay. Results Rotarod data demonstrated permanent deficits 1 year after rTBI. Decreased beam walk performance and grip strength was noted among rTBI rodents. Recurrent traumatic brain injury led to thinner cortex and thinner corpus callosum, enlarged ventricles, and differential expression of 72 genes (25 upregulated, 47 downregulated) including dysregulation of those associated with TBI (BDNF, NR4A1/2/3, Arc, and Egr) and downregulation in pathways associated with neuroprotection and neuroplasticity. Over the course of the study, BDNF levels decreased in both rTBI and sham rodents, and at each time point, the decrease in BDNF was more pronounced after rTBI. Conclusion Recurrent traumatic brain injury causes significant long-term alteration in brain health leading to permanent motor deficits, cortical and corpus callosum thinning, and expansion of the lateral ventricles. Gene expression and BDNF analysis suggest a significant drop in pathways associated with neuroplasticity and neuroprotection. Although rTBI may not cause immediate neurological abnormalities, continued brain deterioration occurs after the initial trauma in part due to a decline in genes associated with neuroplasticity and neuroprotection.

The benefits of vasopressor (VP) use to improve clinical outcomes in traumatic brain injury (TBI) is unknown. We sought to characterize the use of VP in TBI patients and evaluate its impact on mortality.A retrospective review was conducted of all TBI patients admitted to an ICU at a Level I trauma center from January 2014 to August 2016. Patients who had any VP administered (VP+) were compared to those who did not (VP-).Among the 556 patients analyzed, 83 (14.9%) received VP. The overall mortality was 9.2%, significantly higher in the VP + cohort (42.2% vs. 3.4%, p 0.01). After adjusting for confounding factors, VP + patients had a significantly higher risk for in-hospital mortality (Adjusted Hazard Ratio: 2.77, adjusted p = 0.01).Although VP may be temporarily useful in avoiding secondary insult to the brain in TBI patients, their use is not associated with improved survival.

Wind farm load assessment is typically conducted using Computational Fluid Dynamics (CFD) or aeroelastic simulations, which need a lot of computer power. A number of applications, for example wind farm layout optimisation, turbine lifetime estimation and wind farm control, requires a simplified but sufficiently detailed model for computing the turbine fatigue load. In addition, the effect of turbine curtailment is particularly important in the calculation of the turbine loads. Therefore, this paper develops a fast and computationally efficient method for wind turbine load assessment in a wind farm, including the wake effects. In particular, the turbine fatigue loads are computed using a surrogate model that is based on the turbine operating condition, for example, power set-point and turbine location, and the ambient wind inflow information. The Turbine to Farm Loads (T2FL) surrogate model is constructed based on a set of high fidelity aeroelastic simulations, including the Dynamic Wake Meandering model and an artificial neural network that uses the Bayesian Regularisation (BR) and Levenberg–Marquardt (LM) algorithms. An ensemble model is used that outperforms model predictions of the BR and LM algorithms independently. Furthermore, a case study of a two turbine wind farm is demonstrated, where the turbine power set-point and fatigue loads can be optimised based on the proposed surrogate model. The results show that the downstream turbine producing more power than the upstream turbine is favourable for minimising the load. In addition, simulation results further demonstrate that the accumulated fatigue damage of turbines can be effectively distributed amongst the turbines in a wind farm using the power curtailment and the proposed surrogate model.

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 ( P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period ( P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score 65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.

The presence of an abdominal seatbelt sign (ASBS) following a motor vehicle collision (MVC) is associated with a high risk for occult intra-abdominal injury, prompting imaging studies and a prolonged period of clinical observation. The aim of this study was to determine how a negative computed tomography (CT) of the abdomen/pelvis (A/P) can serve in the safe disposition of these patients. Our hypothesis was that in the setting of a negative CT, the presence of occult intra-abdominal injuries requiring a delayed intervention is extremely unlikely.The medical charts of patients admitted from January 2014 to December 2016 to a Level I trauma center following an MVC were reviewed for a documentation of an ASBS. Patients who did not have a CT A/P upon admission were excluded. The CT A/P of the remaining patients were then classified as negative if there were no findings of acute vascular, visceral or bony injury or positive if any of these findings was present. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT A/P for the presence of an intra-abdominal injury were calculated.Over the 3-year study period, 1,108 patients were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation and 183 (93.4%) of 196 underwent a CT A/P. A total of 114 (62.3%) of 183 had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a delayed laparotomy. The sensitivity of CT A/P in identifying patients requiring an exploratory laparotomy was 100.0%, specificity was 67.9%, NPV was 100.0%, and PPV was 21.7%. The negative likelihood ratio was 0.00.For patients with an ASBS following an MVC, a negative CT A/P may be sufficient for safe discharge from the emergency department without any need for additional clinical observation.Therapuetic, level IV.

The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes.A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR).The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) ≥16 (68.5% vs. 45.1%, p 0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p 0.001 and AHR: 10.59, p = 0.028, respectively) compared to patients with a positive culture at day six or later.Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with "damage control cultures" obtained on admission to aid with early targeted treatment might be justified.

Background: Blunt pharyngoesophageal injuries pose a management challenge to the trauma surgeon. The purpose of this study was to explore whether these injuries can be managed expectantly without neck exploration. Methods: The National Trauma Databank datasets 2007–2011 were reviewed for blunt trauma patients who sustained a pharyngeal injury, including an injury to the cervical esophagus. Patients who survived over 24 h and were not transferred from other institutions were divided into two groups based on whether a neck exploration was performed. Outcomes included mortality and hospital stay. Results: A total of 545 (0.02%) patients were identified. The median age was 18 years and 69% were male. Facial fractures were found in 16%, while 13% had an associated traumatic brain injury. Of the 284 patients who survived over 24 h and were not transferred from another institution, 65 (23%) underwent a neck exploration. The injury burden was significantly higher in this group as indicated by the higher median Injury Severity Score (17 vs 10, p Conclusion: Pharyngoesophageal injuries are rare following blunt trauma. Only a quarter require a neck exploration and this decision appears to be dictated by the injury burden. Selective non-operative management based on clinical status seems to be feasible and is not associated with increased mortality.

Background Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown. Methods A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE. Results Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03). Conclusions The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.

Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers.The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration.From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003).Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial.Therapeutic/care management, level III.

The use of vasopressors (VP) in the resuscitation of massively transfused trauma patients might be considered a marker of inadequate resuscitation. We sought to characterize the utilization of VP in patients receiving massive transfusion and examine the association of their use with mortality.Trauma patients admitted from January 2011 to October 2016 receiving massive transfusion, defined as 3 units of pRBC within the first hour from admission, were selected for analysis. Demographics, admission vital signs and labs, use of VP, surgical interventions and outcomes were collected. Standard statistical tools were utilized.Over the 5-year study period, 120 trauma patients met inclusion criteria. The median age was 39 years with 77% being male and 41% sustaining a penetrating injury. Patients who received VP [VP (+)] were more likely to have a lower admission GCS (median 4.5 vs. 14.0, p0.01) and less likely to have a penetrating injury (31% vs. 54%, p=0.02). The overall mortality was 49% and significantly higher in the VP (+) cohort (60% vs. 34%, AHR: 9.9, adjusted p=0.03). Mortality increased in a stepwise fashion with increasing number of VP utilized, starting at 34% for no VP, to 78% for 3 VP, and 100% for 5 or more. The majority of deaths in the VP (-) group (88%) occurred within one day from admission. For the VP (+) group, 57% of deaths occurred within one day, with the remaining 43% occurring at a later time.In the era of massive transfusion protocols, vasopressors are commonly utilized in exsanguinating trauma patients and their use is associated with a higher mortality risk. Deaths in patients receiving vasopressors are more likely to occur later compared to those in patients who do not receive vasopressors. Further research to characterize the role of these agents in the resuscitation of trauma patients is required.

Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice.A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered.Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p0.01), and prolonged immobilization (12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data.For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers.Diagnostic tests or criteria, level II.

Introduction Rigid cervical collars are routinely placed in the pre-hospital setting after significant blunt trauma. Patients who are deemed competent by field personnel (Glasgow Coma Scale (GCS) ≥13, no major distracting injury and not grossly intoxicated) may refuse cervical collar placement. Material and methods A retrospective review was conducted of all adult trauma patients presenting to a Level 1 trauma center after blunt trauma with a GCS≥13 and no distracting injury or gross intoxication from January 2014 to December 2014. Pre-hospital data was collected from emergency medical service reports and hospital data from patient charts. Cervical spine injury was identified by International Classification of Disease-9th Revision codes. Patients refusing cervical spine immobilization prior to arrival are compared to those who were compliant. Results A total of 629 patients met inclusion criteria. Cervical spine immobilization was refused by 28 patients, while 601 complied. There were 16 cervical spine injuries (2.5%), with 3 (10.7%) in noncompliant patients and 13 (2.2%) among those who were complaint (p = 0.03). Conclusion The incidence of cervical spine injuries in patients refusing cervical collar immobilization is higher than in compliant patients. Patients arriving for initial evaluation having refused cervical collar immobilization should be treated with caution.

Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received

BACKGROUND Injuries sustained by civilians from interaction with police are a polarizing contemporary sociopolitical issue. Few comprehensive studies have been published using national hospital-based data. The aim of this study was to examine the epidemiology of these injuries to better understand this mechanism of injury. METHODS Patients entered into the National Trauma Data Bank (NTDB) (January 2007 to December 2012) with E-codes E970.0 to E976.0 (International Classification of Diseases, Ninth Revision, Clinical Modification), identifying injuries associated with law enforcement in the course of legal action, were enrolled. Patients' demographics, injury characteristics, procedures, and outcomes were collected and analyzed. Patients injured by other civilians (E960.0-E968.0) were used for comparison. RESULTS Of 4,146,428 patients in the NTDB, 7,203 (0.17%) were injured during interaction with police. The numbers of patients in consecutive study years were 858, 1,103, 1,148, 1,274, 1,316, and 1,504. The incidence of these injuries was stable over time (0.17-0.18%) (p = 0.129). Patients had a median age of 31 years (range, 0-108), and 94.3% were male. Median injury severity score was 9 (interquartile range [IQR], 4-17). The most common mechanism of injury was gunshot wound (44%).Patients were white, 43%; black, 30%; Hispanic, 17%; Asian, 1%; and Other, 9%. As a proportion of the total race-specific NTDB trauma population, there was an average of 1.13 white patients, 2.71 Hispanic patients, and 3.83 black patients per 1,000. Mechanism, injury severity score, and outcomes did not vary by race. Compared to patients injured by civilians, patients injured by police are more likely to be white (43% vs 25%, p < 0.001) and injured by gunshot wounds (44% vs 32%, p < 0.001). CONCLUSIONS Based on data from trauma centers across the United States, the rate of injuries sustained during interactions with police has been stable over time. Gunshot wounds are the most common mechanism of injury. Proportionally, black patients are the most frequently injured race. When compared to patients injured by civilians, however, patients injured by police are more likely to be white. This study provides a step toward a better understanding of police-associated injuries. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Background Type I interferon activation is a hallmark event in Sjogren's syndrome. L1 retroelements stimulate plasmacytoid dendritic cells, activating the type I interferons, and are regulated by various mechanisms, including the APOBEC3 deaminases. As L1s are potential trigger factors in autoimmunity, we aimed to investigate the immunohistochemical localization of L1 ORF2p and its inhibitor APOBEC3B protein in minor salivary glands of Sjogren's syndrome patients. Methods Twenty minor salivary gland-tissue samples from 20 Sjogren's syndrome patients, classified according to Tarpley's histological criteria, and 10 controls were evaluated for L1 ORF2p and APOBEC3B expression via immunohistochemistry. Results L1 ORF2p was expressed in 17/20 SS patients and all controls. APOBEC3B expression was observed in 15/20 Sjogren's syndrome patients, 5/5 chronic sialadenitis, and 3/5 normal minor salivary glands. Both antibodies stained the cytoplasm of the ductal epithelial cells. Negative staining was observed in the acinar cells. L1 ORF2p-positive immunostaining was significantly lower in Tarpley IV Sjogren's syndrome patients than controls (P = .039), and APOBEC3B-positive staining was significantly lower in Tarpley I compared to Tarpley II Sjogren's syndrome patients (P = .008) and controls (P = .035). Conclusions L1 ORF2p and APOBEC3B are expressed in the ductal epithelial cells of minor salivary glands that are among the key targets in Sjogren's syndrome. L1 ORF2p expression may promote the L1 ability to act as an intrinsic antigen in Sjogren's syndrome. The potential future use of L1 ORF2-reverse transcriptase inhibitors in autoimmunity supports further investigation of L1 epigenetic regulation by APOBEC3 enzymes.

Neuroendocrine tumors (NETs) account for 30% of small bowel (SB) neoplasms. The objectives of this study were to evaluate the incidence of multifocality in primary small bowel neuroendocrine tumors (SBNETs) and to examine the associated outcomes. Patients with multifocal SBNET were compared to those with a solitary lesion. Only patients who underwent diagnostic workup and surgical intervention at our institution were included in this study. The primary aim of our study was surgical outcomes and mortality and recurrence. The second aim of our study was to evaluate the utility of double-balloon enteroscopy (DBE) and capsule endoscopy. Of 178 patients with SBNETs during the study period, 85 met inclusion criteria. The mean age was 61.0 ± 12.6 years and 44.7% were male. The ileum was the primary tumor site for 66 patients (77.7%). Of DBE patients, 28 (62.2%) had additional lesions identified, of which 23 (82.1%) had NET confirmed on pathology. Average tumor size was 1.8 cm and most were well differentiated (89.9%), with Ki-67 of ≥ 2% (65.8%); 74.4% had nodal metastases and 51% of patients had stage IV disease. Forty-six patients (54.1%) had multifocal disease, of whom 37 (80.5%) had an ileal primary. No differences in survival or recurrence were seen for multifocal versus solitary disease. SBNETs have a high incidence of multifocality. DBE can be used in the preoperative assessment to detect multifocal NET. Multifocality has no impact on survival or recurrence outcomes.

Although guidelines for the performance of an emergency department thoracotomy (EDT) are available, high level evidence remains scarce potentially leading to variation in decisions and practices among trauma surgeons. The National Trauma Databank was queried for all subjects who died in the emergency department (ED) between 2007 and 2011. Trauma centers were divided into four quartiles based on the rate of EDTamong ED deaths. A total of 31,623 subjects admitted to 729 trauma centers met inclusion criteria. Most of of these centers (n = 328, 53%) never performed an EDT during the study period. Very few outlier centers (1.1%) performed this procedure in 50.0 per cent or more of all patients who died in the ED. Trauma centers in the highest quartiles in performing EDT were more likely to intervene with both surgical and nonsurgical procedures in patients who died in the ED, independent of the performance of an EDT. There are significant variations among trauma centers in the management of trauma patients who expire in the ED. Further research at a national level toward standardizing the management of the trauma patient in extremis and the decision to perform an EDT is necessary, given the extremely low survival associated with this procedure.

Background High-flow nasal cannula (HFNC) is increasingly used to reduce reintubations in patients with respiratory failure. Benefits include providing positive end expiratory pressure, reducing anatomical dead space, and decreasing work of breathing. We sought to compare outcomes of critically ill surgical patients extubated to HFNC versus conventional therapy. Methods A retrospective review was conducted in the surgical intensive care unit of an academic center during August 2015 to February 2016. Data including demographics, ventilator days, oxygen therapy after extubation, reintubation rates, surgical intensive care unit and hospital length of stay, and mortality were collected. Self and palliative extubations were excluded. Characteristics and outcomes, with the primary outcome being reintubation, were compared between those extubated to HFNC versus cool mist/nasal cannula (CM/NC). Results Of the 184 patients analyzed, 46 were extubated to HFNC and 138 to CM/NC. Mean age and days on ventilation before extubation were 57.8 years and 4.3 days, respectively. Both cohorts were similar in age, sex, and had a similar prevalence of cardiopulmonary diagnoses at admission. Although prior to extubation HFNC had lengthier ventilation requirements (7.1 versus 3.4 days, P Conclusions Ventilated patients at risk for recurrent respiratory failure have reduced reintubation rates when extubated to HFNC. Patients with prolonged intubation or those with high-risk comorbidities may benefit from extubation to HFNC.

Background Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury. Methods Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score

BACKGROUND Access to centers with extracorporeal membrane oxygenation (ECMO) capabilities varies by region and may affect overall outcomes. We assessed the outcomes of trauma patients requiring ECMO support and compared the overall survival of all patients with trauma at facilities with and without ECMO capabilities. METHODS A retrospective review of the National Trauma Data Bank was performed to identify all trauma patients receiving care at ECMO and non-ECMO centers. Baseline patient characteristics and outcomes were analyzed. Adjusted odds ratio (OR) was used to compare survival at ECMO and non-ECMO facilities. RESULTS Between 2007 and 2015, a total of 5 781 123 patients with trauma were identified with 1 983 986 (34%) admitted to an ECMO facility and 3 797 137 (66%) admitted to a non-ECMO facility. A total of 522 (0.03%) patients required ECMO. Both the number of patients with trauma requiring ECMO support and the number of trauma facilities utilizing ECMO increased over the 9-year-study period (4.9 to 13.8 patients per 100 000 admissions, and 18 to 77 centers, respectively). The mortality for ECMO patients was 40.5%. Patients with trauma admitted to ECMO facilities had more severe injuries (injury severity score: 9.0 vs 8.0; P

Background Electric scooters are popular in Southern California due to their ease of use, affordability, and availability. The objective of this study was to characterize how hospital admissions and outcomes varied due to electric scooter injury among Southern California trauma centers. Study Design Trauma registry data from 9 urban trauma centers were queried for patients sustaining injury while operating an electric scooter from January to December 2018. Data collection included patient demographics, diagnoses, interventions, and outcomes. Results During the 1-year study period, 87 patients required trauma surgeon care due to scooter-related injury, with a mean age of 35.1 years; 71.3% were male with 20.7% and 17.2% of patients requiring ICU admission and a surgical intervention, respectively. One (1.1%) patient died. The head and face were most commonly injured, followed by the extremities. Helmet use was uncommon (71.3%). High variability in patient volume was noted, with 2 centers considered high-incidence and the remaining low-incidence. Conclusions Injuries from electric scooter crashes are primarily to the head, face, and extremities, with approximately 1 in 5 patients requiring ICU admission and/or a surgical intervention. There is significant variation in patient volume among Southern California trauma centers that could affect the delivery of care with the abrupt introduction of this technology. Targeted public health interventions and policies might better address community use of the electric scooter.

The main objective of the Offshore Code Comparison Collaboration Continuation, with Correlation (OC5) project is validation of aero-hydro-servo-elastic simulation tools for offshore wind turbines (OWTs) through comparison of simulated results to the response data of physical systems. Phase III of the OC5 project validates OWT models against the measurements recorded on a Senvion 5M wind turbine supported by the OWEC Quattropod from the alpha ventus offshore wind farm. The following operating conditions of the wind turbine were chosen for the validation: (1) idling below the cut-in wind speed, (2) rotor-nacelle assembly (RNA) rotation maneuver below the cut-in wind speed, (3) power production below and above the rated wind speed, and (4) shutdown. A number of validation load cases were defined based on these operating conditions. The following measurements were used for validation: (1) strains and accelerations recorded on the support structure and (2) pitch, yaw, and azimuth angles, generator speed, and electrical power recorded from the RNA. Strains were not directly available from the majority of the OWT simulation tools; therefore, strains were calculated based on out-of-plane bending moments, axial forces, and cross-sectional properties of the structural members. The simulation results and measurements were compared in terms of time series, discrete Fourier transforms, power spectral densities, and probability density functions of strains and accelerometers. A good match was achieved between the measurements and models setup by OC5 Phase III participants. OWEC Tower is acknowledged for releasing the jacket substructure, transition piece, and foundation design data for Phase III. Senvion is acknowledged for sharing the definition of the Senvion 5M wind turbine and its tower. The RAVE consortium is acknowledged for releasing the measurement data from the alpha ventus wind farm. This work was authored (in part) by the National Renewable Energy Laboratory, operated by Alliance for Sustainable Energy, LLC, for the U.S. Department of Energy (DOE) under Contract No. DE-AC36-08GO28308. Funding provided by the U.S. Department of Energy Office of Energy Efficiency and Renewable Energy Wind Energy Technologies Office. The views expressed in the article do not necessarily represent the views of the DOE or the U.S. Government. The submitted manuscript has been created by UChicago Argonne, LLC, Operator of Argonne National Laboratory (“Argonne”). Argonne, a U.S. Department of Energy Office of Science laboratory, is operated under Contract No. DE-AC02-06CH11357. The Department of Energy will provide public access to these results of federally sponsored research in accordance with the DOE Public Access Plan. http://energy.gov/downloads/doe-public-accessplan Peer Reviewed Wojciech Popko / Fraunhofer IWES, Fraunhofer Institute for Wind Energy Systems / , Division Wind Turbine and System Technology, Am Luneort 100, Bremerhaven 27572 / , Germany / Amy Robertson / National Renewable Energy Laboratory, 15013 Denver West Parkway, Golden, CO 80401 / Jason Jonkman / National Renewable Energy Laboratory, 15013 Denver West Parkway, Golden, CO 80401 / Fabian Wendt / National Renewable Energy Laboratory, 15013 Denver West Parkway, Golden, CO 80401 / Philipp Thomas / Fraunhofer IWES, Fraunhofer Institute for Wind Energy Systems / , Division Wind Turbine and System Technology, Am Luneort 100, Bremerhaven 27572 / , Germany / Kolja Müller / University of Stuttgart / , Allmandring 5b, Stuttgart Wind Energy, Stuttgart 70569 / , Germany / Matthias Kretschmer / University of Stuttgart / , Allmandring 5b, Stuttgart Wind Energy, Stuttgart 70569 / , Germany / Torbjørn Ruud Hagen / OWEC Tower AS, Sommerrogata 17, Oslo 0255 / , Norway / Christos Galinos / Technical University of Denmark / , Department of Wind Energy, Frederiksborgvej 399, Roskilde 4000 / , Denmark / Jean-Baptiste Le Dreff / Electricitéde France, Recherche et Développement, 13 Boulevard Gaspard Monge, Palaiseau 91120 / , France / Philippe Gilbert / IFP Energies Nouvelles, 1 et 4 avenue de Bois-Préau, 92852 Rueil-Malmaison Cedex / , France / Bertrand Auriac / Principia La Ciotat, 215 Voie Ariane, La Ciotat 13600 / , France / Sho Oh / Nippon Kaiji Kyokai (ClassNK), 4-7 Kioicho, Chiyoda-Ku, Tokyo 102-8567 / , Japan / Jacob Qvist / 4Subsea, Hagaløkkveien 26, 1383 Asker, Hvalstad / , Norway / Stian Høegh Sørum / Norwegian University of Science and Technology / , Department of Marine Technology, Trondheim 7491 / , Norway / Loup Suja-Thauvin / Simis AS, Leonardveien 3, Malm 7790 / , Norway / Hyunkyoung Shin / University of Ulsan / , School of Naval Architecture and Ocean Engineering, Ulsan / , South Korea / Climent Molins / Polytechnic University of Catalonia / , Campus Nord, Carrer de Jordi Girona, 1, 3, Barcelona 08034 / , Spain / Pau Trubat / Polytechnic University of Catalonia / , Campus Nord, Carrer de Jordi Girona, 1, 3, Barcelona 08034 / , Spain / Paul Bonnet / Siemens Industry Software, Luis, Carrer Lluís Muntadas, No. 5, Cornellà de Llobregat, Barcelona 08940 / , Spain / Roger Bergua / Envision Energy Limited, 8/F, Building B, SOHO Zhongshan Plaza, 1065 West Zhongshan Road, Shanghai 200051 / , China / Kai Wang / Envision Energy Limited, 8/F, Building B, SOHO Zhongshan Plaza, 1065 West Zhongshan Road, Shanghai 200051 / , China / Pengcheng Fu / China General Certification Center, Room 1108, Yiheng Building No. 28, North 3rd Ring Road East, Chaoyang District, Beijing 100013 / , China / Jifeng Cai / China General Certification Center, Room 1108, Yiheng Building No. 28, North 3rd Ring Road East, Chaoyang District, Beijing 100013 / , China / Zhisong Cai / China General Certification Center, Room 1108, Yiheng Building No. 28, North 3rd Ring Road East, Chaoyang District, Beijing 100013 / , China / Armando Alexandre / DNV GL, One Linear Park, Avon Street, Temple Quay, Bristol BS2 0PS / , UK / Robert Harries / DNV GL, Edificio Trovador, Plaza de Antonio Beltrán Martínez, Zaragoza 50002 / , Spain