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Background Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. Materials and Methods Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. Results Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. Conclusion Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.

Made available in DSpace on 2022-04-28T19:29:02Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-07-01 Medical Research Council Canada National Institute for Health Research Objectives: To develop consensus definitions for the core outcome set for pre-eclampsia. Study design: Potential definitions for individual core outcomes were identified across four formal definition development initiatives, nine national and international guidelines, 12 Cochrane systematic reviews, and 79 randomised trials. Eighty-six definitions were entered into the consensus development meeting. Ten healthcare professionals and three researchers, including six participants who had experience of conducting research in low- and middle-income countries, participated in the consensus development process. The final core outcome set was approved by an international steering group. Results: Consensus definitions were developed for all core outcomes. When considering stroke, pulmonary oedema, acute kidney injury, raised liver enzymes, low platelets, birth weight, and neonatal seizures, consensus definitions were developed specifically for low- and middle-income countries because of the limited availability of diagnostic interventions including computerised tomography, chest x-ray, laboratory tests, equipment, and electroencephalogram monitoring. Conclusions: Consensus on measurements for the pre-eclampsia core outcome set will help to ensure consistency across future randomised trials and systematic reviews. Such standardization should make research evidence more accessible and facilitate the translation of research into clinical practice. Video abstract can be available at: www.dropbox.com/s/ftrgvrfu0u9glqd/6.%20Standardising%20definitions%20in%20teh%20pre-eclampsia%20core%20outcome%20set%3A%20a%20consensus%20development%20study.mp4?dl=0. Nuffield Department of Primary Care Health Sciences University of Oxford Institute for Women’s Health University College London Department of Women and Children’s Health School of Life Course Sciences King’s College London Department of Obstetrics and Gynecology Amsterdam UMC Academic Medical Center Academic Neonatal Medicine Imperial College London Department of Renal Medicine St George Hospital and University of New South Wales Department of Obstetrics and Gynaecology Feinberg School of Medicine Northwestern University Health Services Research Unit Nuffield Department of Population Health University of Oxford Cedars-Sinai Medical Center London North West University Healthcare NHS Trust Women’s Health Care Research Group Department of Obstetrics and Gynaecology Monash University Department of Obstetrics and Gynaecology University of Adelaide Women’s Health Research Unit Barts and The London School of Medicine and Dentistry School of Health and Related Research University of Sheffield MRC North West Hub for Trials Methodology Research Department of Biostatistics University of Liverpool Centro Rosarino de Estudios Perinatales Chelsea and Westminster Hospital NHS Foundation Trust Babcock University Ailem Academic Counselling KU Leuven Universidad Nacional de Colombia Northwell Health University of Oxford Université de Montréal University of Montreal Hospital Centre Ondokuz Mayıs University Prince Sultan Military Medical City Postgraduate Institute of Medical Education and Research King's Fertility Fetal Medicine Research Institute University Hospital Limerick Drexel University University of Aberdeen University of Groningen University of Auckland Haaglanden Medisch Centrum Nottingham University Medical School Utrecht University King Edward Memorial Hospital for Women Imperial College Healthcare NHS Trust Jean-Verdier Hospital Downland Practice University of Campinas Université Lyon University of North Carolina School of Medicine South Ural State Medical University Stellenbosch University Irish Neonatal Health Alliance University of Rzeszow Royal Brisbane and Women’s Hospital Nottingham University Hospitals NHS Trust University Hospitals of Leicester North Bristol NHS Trust University of Nottingham Soroka University Medical Center Ben Gurion University of the Negev St George’s University Hospitals NHS Foundation Trust Hospitalsenhed Midt University of Glasgow Amsterdam Universitair Medische Centra All India Institute of Medical Sciences Patna Luton and Dunstable University Hospital Khyber Medical University Institution of Medical Sciences Midwife Mid Essex Hospitals NHS Trust University of Oulu University of Michigan Bastyr University Irish Nurses and Midwives Organisation University of Toronto Barts Health NHS Trust University Hospitals Plymouth NHS Trust Burnet Institute Aga Khan University Medical University of Graz Homerton University Hospital NHS Foundation Trust Mount Royal University Université de Paris Royal Surrey County Hospital University Hospital Southampton NHS Foundation Trust University of Washington School of Nursing Evelina London Children's Hospital Neonatal Unit University of Sydney University of Leicester Academic Hospital of Udine NHS Borders Weill Cornell Medical College University of Dundee University of Edinburgh South Australian Health and Medical Research Institute University of Sheffield Monash University and Monash Health United Lincolnshire Hospitals NHS Trust University of Kwa Zulu-Natal Beatrix Hospital Keele University Government Medical College Institut Catala de la Salut. IdiapJgol University College London National Center for Child Health and Development Basavatarakam Indo-American Cancer Hospital and Research Institute Axon Anaesthesia Associates Pennine Acute Hospitals NHS Trust St George's University of London Norfolk and Norwich University Hospital Jichi Medical University School of Medicine São Paulo State University National Institute of Public Health University of Kyrenia King Edward Memorial Hospital Amsterdam University Centres University of British Columbia Chulalongkorn University University of Brescia University Of British Columbia University of Montreal Women's Clinic of Tartu University Hospital Universidade Federal de São Paulo Université de Sherbrooke University Hospital of Wales University of Iowa King's College London Westmead Hospital Princess Royal Maternity Leipzig University Centre Hospitalier Public du Cotentin Lewisham and Greenwich NHS Trust Juntendo University Faculty of Medicine Western Sydney University National Institute of Health Research University of Washington Baylor College of Medicine Capelle aan den Ijssel Sanatorio Anchorena Oxford University Hospitals NHS Foundation Trust University of Leeds Institute of Medical Sciences UPMC Magee Womens Hospital Penn Medicine Princeton Health University of North Carolina at Chapel Hill São Paulo State University

Background Exercise and heat trigger dehydration and an increase in extracellular fluid osmolality, leading to deficits in exercise performance and thermoregulation. Evidence from previous studies supports the potential for deep-ocean mineral water to improve recovery of exercise performance post-exercise. We therefore wished to determine whether acute rehydration and muscle strength recovery was enhanced by deep-ocean mineral water following a dehydrating exercise, compared to a sports drink or mountain spring water. We hypothesized that muscle strength would decrease as a result of dehydrating exercise, and that recovery of muscle strength and hydration would depend on the type of rehydrating fluid. Methods Using a counterbalanced, crossover study design, female (n = 8) and male (n = 9) participants performed a dehydrating exercise protocol under heat stress until achieving 3% body mass loss. Participants rehydrated with either deep-ocean mineral water (Deep), mountain spring water (Spring), or a carbohydrate-based sports drink (Sports) at a volume equal to the volume of fluid loss. We measured relative hydration using salivary osmolality (Sosm) and muscle strength using peak torque from a leg extension maneuver. Results Sosm significantly increased (p

Feline obesity elicits a plethora of metabolic responses leading to comorbidities, with potential reversal during weight loss. The specific metabolic alterations and biomarkers of organ dysfunction are not entirely understood. Untargeted, high-throughput metabolomic technologies may allow the identification of biological components that change with weight status in cats, increasing our understanding of feline metabolism. The objective of this study was to utilize untargeted metabolomic techniques to identify biomarkers and gain mechanistic insight into the serum metabolite changes associated with reduced food intake and weight loss in overweight cats. During a four-wk baseline period, cats were fed to maintain body weight. For 18 wk following baseline, cats were fed to lose weight at a rate of ~1.5% body weight/wk. Blood serum metabolites were measured at wk 0, 1, 2, 4, 8, 12, and 16. A total of 535 named metabolites were identified, with up to 269 of them being altered (p- and q- values &lt, 0.05) at any time point. A principal component analysis showed a continual shift in metabolite profile as weight loss progressed, with early changes being distinct from those over the long term. The majority of lipid metabolites decreased with weight loss, however, ketone bodies and small lipid particles increased with weight loss. The majority of carbohydrate metabolites decreased with weight loss. Protein metabolites had a variable result, with some increasing, but others decreasing with weight loss. Metabolic mediators of inflammation, oxidative stress, xenobiotics, and insulin resistance decreased with weight loss. In conclusion, global metabolomics identified biomarkers of reduced food intake and weight loss in cats, including decreased markers of inflammation and/or altered macronutrient metabolism.

Introduction Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. Methods and analysis PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. Ethics and dissemination The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. Trial registration number NCT02984384.

Background:\ud COVID-19 has the potential to cause outbreaks in hospitals. Given the comorbid and elderly cohort of patients hospitalized, hospital-acquired COVID-19 infection is often fatal. Pathogen genome sequencing is becoming increasingly important in infection prevention and control (IPC).\ud \ud Aim:\ud To inform the understanding of in-hospital SARS-CoV-2 transmission in order to improve IPC practices and to inform the future development of virological testing for IPC.\ud \ud Methods:\ud Patients detected COVID-19 positive by polymerase chain reaction on Ward A in April and May 2020 were included with contact tracing to identify other potential cases. Genome sequencing was undertaken for a subgroup of cases. Epidemiological, genomic, and cluster analyses were performed to describe the epidemiology and to identify factors contributing to the outbreak.\ud \ud Findings:\ud Fourteen cases were identified on Ward A. Contact tracing identified 16 further patient cases; in addition, eight healthcare workers (HCWs) were identified as being COVID-19 positive through a round of asymptomatic testing. Genome sequencing of 16 of these cases identified viral genomes differing by two single nucleotide polymorphisms or fewer, with further cluster analysis identifying two groups of infection (a five-person group and a six-person group).\ud \ud Conclusion:\ud Despite the temporal relationship of cases, genome sequencing identified that not all cases shared transmission events. However, 11 samples were found to be closely related and these likely represented in-hospital transmission. This included three HCWs, thereby confirming transmission between patients and HCWs.

Organ transplantation is a preferred treatment option for patients with end-stage organ failure. However, transplant induces a robust rejection response that necessitates life-long immunosuppression, which often leads to a plethora of comorbidities. Thus, the goal of transplantation is to achieve a state of tolerance wherein the host permanently accepts the transplanted organ while maintaining normal immune responses to other antigens. Regulatory T cells (Tregs) play an important role in realizing this goal and are being explored in both animal models and human clinical trials. In this chapter, we discuss the key principles of transplant rejection and Treg biology, as well as the status of human clinical trials utilizing Tregs as cellular therapy. We discuss how the current immunosuppressive drugs are utilized in transplantation in favoring an increased Treg to T effector cell ratio, different approaches in generation of therapeutic Tregs, and various facets in Treg trial designs in the clinic. Such clinical trials provided many opportunities to leverage our understanding of Tregs in transplantation. They also demonstrated Tregs as a safe cellular therapy for human use, but the efficacy of this treatment has yet to be fully realized.

REBOA is a minimally invasive technique using a balloon catheter to temporarily occlude large vessels in support of hemorrhage control.

Background Elderly trauma patients are at risk for undertriage, resulting in substantial morbidity and mortality. The objective of this study was to determine whether implementation of geriatric-specific trauma team activation (TTA) protocols appropriately identified severely-injured elderly patients. Methods This single-center retrospective study evaluated all severely injured (injury severity score [ISS] >15), geriatric (≥65 years) patients admitted to our Level 1 tertiary-care hospital between January 2014 and September 2017. Undertriage was defined as the lack of TTA despite presence of severe injuries. The primary outcome was all-cause in-hospital mortality; secondary outcomes were mortality within 48 hours of admission and urgent hemorrhage control. A multivariable logistic regression analysis was performed to identify predictors of appropriate triage in this study. Results Out of 1039 severely injured geriatric patients, 628 (61%) did not undergo TTA. Undertriaged patients were significantly older and had more comorbidities. In-hospital mortality was 5% and 31% in the undertriaged and appropriately triaged groups, respectively ( P < .0001). One percent of undertriaged patients needed urgent hemorrhage control, compared to 6% of the appropriately triaged group ( P < .0001). One percent of undertriaged patients died within 48 hours compared to 19% in the appropriately triaged group ( P < .0001). Predictors of appropriate triage include GCS, heart rate, systolic blood pressure, lactic acid, ISS, shock, and absence of dementia, stroke, or alcoholism. Discussion Geriatric-specific TTA guidelines continue to undertriage elderly trauma patients when using ISS as a metric to measure undertriage. However, undertriaged patients have much lower morbidity and mortality, suggesting the geriatric-specific TTA guidelines identify those patients at highest risk for poor outcomes.

Disruption of the normal gut microbiome (dysbiosis) is implicated in the progression and severity of myriad disorders, including hypercholesterolemia and cardiovascular disease. Probiotics attenuate and reverse gut dysbiosis to improve cardiovascular risk factors like hypertension and hypercholesterolemia. Lactobacillus reuteri is a well-studied lactic acid-producing probiotic with known cholesterol-lowering properties and anti-inflammatory effects. In the present study, we hypothesized that L. reuteri delivered to hypercholesterolemic low-density lipoprotein receptor knockout (LDLr KO) mice will reduce cholesterol levels and minimize cardiac injury from an ischemic insult. L. reuteri [1 × 10(9) or 50 × 10(6) colony-forming units (CFU)/day] was administered by oral gavage to wild-type mice and LDLr KO for up to 6 wk followed by an ischemia-reperfusion (I/R) protocol. After 4 wk of gavage, total serum cholesterol in wild-type mice receiving saline was 113.5 ± 5.6 mg/dL compared with 113.3 ± 6.8 and 101.9 ± 7.5 mg/dL in mice receiving 1 × 10(9) or 50 × 10(6) CFU/day, respectively. Over the same time frame, administration of L. reuteri at 1 × 10(9) or 50 × 10(6) CFU/day did not lower total serum cholesterol (283.0 ± 11.1, 263.3 ± 5.0, and 253.1 ± 7.0 mg/dL; saline, 1 × 10(9) or 50 × 10(6) CFU/day, respectively) in LDLr KO mice. Despite no impact on total serum cholesterol, L. reuteri administration significantly attenuated cardiac injury following I/R, as evidenced by smaller infarct sizes compared with controls in both wild-type and LDLr KO groups. In conclusion, daily L. reuteri significantly protected against cardiac injury without lowering cholesterol levels, suggesting anti-inflammatory properties of L. reuteri uncoupled from improvements in serum cholesterol. NEW & NOTEWORTHY We demonstrated that daily delivery of Lactobacillus reuteri to wild-type and hypercholesterolemic lipoprotein receptor knockout mice attenuated cardiac injury following ischemia-reperfusion without lowering total serum cholesterol in the short term. In addition, we validated protection against cardiac injury using histology and immunohistochemistry techniques. L. reuteri offers promise as a probiotic to mitigate ischemic cardiac injury.

Cerebral palsy (CP) is caused by a variety of factors attributed to early brain damage, resulting in permanently impaired motor control, marked by weakness and muscle stiffness. To find out if altered physiology of spinal motoneurons (MNs) could contribute to movement deficits, we performed whole-cell patch-clamp in neonatal rabbit spinal cord slices after developmental injury at 79% gestation. After preterm hypoxia-ischemia (HI), rabbits are born with motor deficits consistent with a spastic phenotype including hypertonia and hyperreflexia. There is a range in severity, thus kits are classified as severely affected, mildly affected, or unaffected based on modified Ashworth scores and other behavioral tests. At postnatal day (P)0-5, we recorded electrophysiological parameters of 40 MNs in transverse spinal cord slices using whole-cell patch-clamp. We found significant differences between groups (severe, mild, unaffected and sham control MNs). Severe HI MNs showed more sustained firing patterns, depolarized resting membrane potential, and fired action potentials at a higher frequency. These properties could contribute to muscle stiffness, a hallmark of spastic CP. Interestingly altered persistent inward currents (PICs) and morphology in severe HI MNs would dampen excitability (depolarized PIC onset and increased dendritic length). In summary, changes we observed in spinal MN physiology likely contribute to the severity of the phenotype, and therapeutic strategies for CP could target the excitability of spinal MNs.

Made available in DSpace on 2022-04-28T19:28:54Z (GMT). No. of bitstreams: 0 Previous issue date: 2020-11-01 National Institute for Health Research Barts Charity Objective: To develop a core outcome set for pre-eclampsia. Design: Consensus development study. Setting: International. Population: Two hundred and eight-one healthcare professionals, 41 researchers and 110 patients, representing 56 countries, participated. Methods: Modified Delphi method and Modified Nominal Group Technique. Results: A long-list of 116 potential core outcomes was developed by combining the outcomes reported in 79 pre-eclampsia trials with those derived from thematic analysis of 30 in-depth interviews of women with lived experience of pre-eclampsia. Forty-seven consensus outcomes were identified from the Delphi process following which 14 maternal and eight offspring core outcomes were agreed at the consensus development meeting. Maternal core outcomes: death, eclampsia, stroke, cortical blindness, retinal detachment, pulmonary oedema, acute kidney injury, liver haematoma or rupture, abruption, postpartum haemorrhage, raised liver enzymes, low platelets, admission to intensive care required, and intubation and ventilation. Offspring core outcomes: stillbirth, gestational age at delivery, birthweight, small-for-gestational-age, neonatal mortality, seizures, admission to neonatal unit required and respiratory support. Conclusions: The core outcome set for pre-eclampsia should underpin future randomised trials and systematic reviews. Such implementation should ensure that future research holds the necessary reach and relevance to inform clinical practice, enhance women's care and improve the outcomes of pregnant women and their babies. Tweetable abstract: 281 healthcare professionals, 41 researchers and 110 women have developed #preeclampsia core outcomes @HOPEoutcomes @jamesmnduffy. [Correction added on 29 June 2020, after first online publication: the order has been corrected.]. Nuffield Department of Primary Care Health Sciences University of Oxford Institute for Women's Health University College London Department of Obstetrics and Gynaecology Amsterdam UMC Academic Medical Centre Academic Neonatal Medicine Imperial College London Department of Renal Medicine St George Hospital and University of New South Wales Department of Women and Children's Health School of Life Course Sciences King's College London Department of Obstetrics and Gynecology Feinberg School of Medicine Northwestern University Health Services Research Unit Nuffield Department of Population Health University of Oxford Cedars-Sinai Medical Center Vascular Biology Research Centre Molecular and Clinical Sciences Research Institute St George's University of London London North West University Healthcare NHS Trust Department of Obstetrics and Gynaecology Monash University Department of Obstetrics and Gynaecology University of Adelaide Women's Health Research Unit Barts and the London School of Medicine and Dentistry School of Health and Related Research University of Sheffield MRC North West Hub for Trials Methodology Research Department of Biostatistics University of Liverpool Centro Rosarino de Estudios Perinatales Chelsea and Westminster Hospital NHS Foundation Trust Babcock University Ailem Academic Counselling KU Leuven Universidad Nacional de Colombia Northwell Health University of Oxford Université de Montréal University of Montreal Hospital Centre Ondokuz Mayis University Prince Sultan Military Medical City Postgraduate Institute of Medical Education and Research Chandigarh University Hospital Limerick Drexel University University of Aberdeen University of Groningen University of Auckland Haaglanden Medisch Centrum Nottingham University Medical School Utrecht University King Edward Memorial Hospital for Women Imperial College Healthcare NHS Trust Jean-Verdier Hospital Downland Practice University of Campinas Université Lyon University of North Carolina School of Medicine South Ural State Medical University Stellenbosch University Irish Neonatal Health Alliance University of Rzeszow Royal Brisbane and Women's Hospital Nottingham University Hospitals NHS Trust University Hospitals of Leicester North Bristol NHS Trust University of Nottingham Soroka University Medical Centre Ben Gurion University of the Negev St George's University Hospitals NHS Foundation Trust Hospitalsenhed Midt University of Glasgow Postgraduate Institute of Medical Education and Research Amsterdam Universitair Medische Centra All India Institute of Medical Sciences Patna Luton and Dunstable University Hospital Khyber Medical University Institution of Medical Sciences Midwife Mid Essex Hospitals NHS Trust University of Oulu University of Michigan Bastyr University Irish Nurses and Midwives Organisation University of Toronto Barts Health NHS Trust University Hospitals Plymouth NHS Trust Burnet Institute Aga Khan University Medical University of Graz Homerton University Hospital NHS Foundation Trust Mount Royal University Université de Paris Royal Surrey County Hospital University Hospital Southampton NHS Foundation Trust University of Washington School of Nursing Evelina London Children's Hospital Neonatal Unit University of Sydney University of Leicester Academic Hospital of Udine NHS Borders Weill Cornell Medical College University of Dundee University of Edinburgh South Australian Health and Medical Research Institute University of Sheffield Monash University and Monash Health United Lincolnshire Hospitals NHS Trust University of Kwa Zulu-Natal Beatrix Hospital Keele University Government Medical College Nagpur Institut Catala de la Salut. IdiapJgol University College London National Centre for Child Health and Development Basavatarakam Indo-American Cancer Hospital and Research Institute Axon Anaesthesia Associates Pennine Acute Hospitals NHS Trust St George's University of London Norfolk and Norwich University Hospital Jichi Medical University School of Medicine São Paulo State University National Institute of Public Health University of Kyrenia King Edward Memorial Hospital Amsterdam University Centres University of British Columbia Chulalongkorn University University of Brescia University of Montreal Women's Clinic of Tartu University Hospital Universidade Federal de São Paulo Université de Sherbrooke University Hospital of Wales University of Iowa King's College London Westmead Hospital Princess Royal Maternity Leipzig University Centre Hospitalier Public du Cotentin Lewisham and Greenwich NHS Trust Juntendo University Faculty of Medicine Western Sydney University National Institute of Health Research University of Washington Baylor College of Medicine Capelle aan den Ijssel Sanatorio Anchorena Oxford University Hospitals NHS Foundation Trust University of Leeds Institute of Medical Sciences Lahore UPMC Magee Womens Hospital Penn Medicine Princeton Health University of North Carolina at Chapel Hill USA and Dr Arnold G. Zermansky University of Leeds São Paulo State University

OBJECTIVE To determine effects of restriction feeding of a moderate-protein, high-fiber diet on loss of body weight (BW), voluntary physical activity, body composition, and fecal microbiota of overweight cats. ANIMALS 8 neutered male adult cats. PROCEDURES After BW maintenance for 4 weeks (week 0 = last week of baseline period), cats were fed to lose approximately 1.5% of BW/wk for 18 weeks. Food intake (daily), BW (twice per week), body condition score (weekly), body composition (every 4 weeks), serum biochemical analysis (weeks 0, 1, 2, 4, 8, 12, and 16), physical activity (every 6 weeks), and fecal microbiota (weeks 0, 1, 2, 4, 8, 12, and 16) were assessed. RESULTS BW, body condition score, serum triglyceride concentration, and body fat mass and percentage decreased significantly over time. Lean mass decreased significantly at weeks 12 and 16. Energy required to maintain BW was 14% less than National Research Council estimates for overweight cats and 16% more than resting energy requirement estimates. Energy required for weight loss was 11% more, 6% less, and 16% less than American Animal Hospital Association recommendations for weight loss (80% of resting energy requirement) at weeks 1 through 4, 5 through 8, and 9 through 18, respectively. Relative abundance of Actinobacteria increased and Bacteroidetes decreased with weight loss. CONCLUSIONS AND CLINICAL RELEVANCE Restricted feeding of a moderate-protein, high-fiber diet appeared to be a safe and effective means for weight loss in cats. Energy requirements for neutered cats may be overestimated and should be reconsidered.

Nonoperative management (NOM) of blunt splenic injury, initially touted for the care of pediatric patients, has become the standard of care for stable trauma patients of all ages. In our institution, trauma patients younger than 16 years are managed by the pediatric surgery service and patients 16 years or older are managed by the adult trauma service. Angioembolization is routinely used for adults with blunt splenic injury but rarely used for pediatric patients. A retrospective chart review was performed to determine if more liberal use of angioembolization increases the success rate of NOM of blunt splenic injury in adolescents.Using our institutional trauma registry, we performed a retrospective chart review of 13- to 18-year-olds admitted with blunt splenic injury from 2007 to 2015. One hundred thirty-three patients were identified; 59 were 13- to 15-year-olds and cared for by the Pediatric Trauma service, whereas 74 were 16- to 18-year-olds and cared for by the Adult Trauma service. The cohorts were compared with respect to imaging performed, grade of injury, Injury Severity Score, presence of active extravasation or pseudoaneurysm, interventions performed, blood transfused, intensive care unit days, length of stay, complications, and 30-day mortality rates.There were no significant differences in Injury Severity Score, incidence of active extravasation or pseudoaneurysm identified on computed tomography, or grade of injury between the two cohorts. More patients underwent angioembolization in the "adult" group (p = 0.001) with no difference in the success rate of NOM (p = 0.117). The overall failure rate of NOM of high-grade injuries was only 4.1%.Failure of NOM in high-grade injuries is rare; as a result, the number needed to treat with prophylactic angioembolization would be around 37 patients, resulting in undue risk to many patients with no therapeutic benefit. No improvement in failure rate was seen with aggressive angioembolization, though a larger sample size is needed to rule out type 2 error.Therapeutic, level IV.

Age has been shown to play a significant role in the etiology of complicated intra-abdominal infections (cIAIs), but the correlation between age and outcomes after therapy was not investigated in the Study to Optimize Peritoneal Infection Therapy (STOP-IT) trial.Data were obtained by post hoc analysis of the STOP-IT trial database. Patients were stratified by age65 or ≥65 years. Primary outcomes were surgical site infection (SSI), recurrent IAI (recIAI), and death. Multivariable analysis was performed to identify independent predictors of outcomes.There were 398 subjects65 and 120 ≥ 65 years. Overall baseline characteristics of the two groups were similar. The site of infection was similar between groups except: Colon or rectum (48.3% vs. 29.9%, p = 0.0002) and biliary tree (16.7% vs. 9.1%, p = 0.02), which were more common in the older group, whereas small intestine (6.7% vs. 16.3%, p = 0.008) and appendix (4.2% vs.17.1%, p = 0.0004) were more common in the younger group. Among the primary outcomes, only death was significantly different between the age groups and was more prevalent in the ≥65 years group (4 [3.3%] vs. 1 [0.3%], p = 0.01). Surgical site infection (9.2% vs. 7.3%, p = 0.50), recIAI (15.8% vs. 14.4%, p = 0.69), and a composite outcome (26.7% vs. 20.4%, p = 0.14) were statistically similar between the age groups, and this remained true when controlling for other co-variables. Multivariable analyses did not reveal age as an independent predictor of the composite or individual outcomes.Patients with a more advanced age demonstrated variable sources of infection relative to the younger cohort, yet received similar treatments. Patient age was not an independent predictor of the undesired cIAI outcomes. These findings suggest that advanced age itself does not play a significant role in predicting these adverse outcomes for cIAIs and does not necessitate an altered treatment tactic.

Emergency general surgery (EGS) services are designed to increase the availability of timely, high-quality care to patients with urgent surgical problems. One of the most commonly performed operations on such services is cholecystectomy. Improved outcomes have recently been described in early cholecystectomy for cholecystitis. We hypothesized that, as our EGS service matured, time from imaging to operating room (OR) for cholecystectomy would decrease. At an academic referral center, we identified patients undergoing inpatient cholecystectomy for acute cholecystitis during three time periods: before the formation of an EGS service from 2005 to 2007, during the first years of the service from 2008 to 2010, and five years after its development from 2013 to 2014. Charts were reviewed for patient demographics, operative events, and findings. The time of radiologic diagnosis and operation start time were recorded, and time between diagnosis and operation was calculated. A total of 217 patients who met the study criteria were identified, 88 in 2005 to 2007, 84 in 2008 to 2010, and 45 in 2013 to 2014. Time from radiologic diagnosis to OR decreased over the study period, from a median of 48.4 hours in 2005 to 2007 to 32.4 hours in 2008 to 2010 during the early years of the EGS service. Time to OR further decreased to a median of 16.6 hours during 2013 to 2014. The formation and maturation of an EGS service was associated with decreased time to OR after radiologic diagnosis of acute cholecystitis at this institution. This decrease in preoperative time may lead to lower costs and improved outcomes.

Cerebral palsy (CP) is caused by a variety of factors attributed to early brain damage, resulting in permanently impaired motor control, marked by weakness and muscle stiffness. To find out if altered physiology of spinal motoneurons (MNs) could contribute to movement deficits, we performed whole cell patch clamp in neonatal rabbit spinal cord slices after developmental injury at 79% gestation. After preterm hypoxia-ischemia (HI), rabbits are born with motor deficits consistent with a spastic phenotype including hypertonia and hyperreflexia. There is a range in severity, thus kits are classified as severely affected, mildly affected, or unaffected based on modified Ashworth scores and other behavioral tests. At postnatal day (P)0-5, we recorded electrophysiological parameters of 40 MNs in transverse spinal cord slices using whole cell patch clamp. Using a multivariate analysis of neuronal parameters, we found significant differences between groups (severe, mild, unaffected and sham control MNs), age (P0 to P5) and spinal cord region (cervical to sacral). Severe HI MNs showed more sustained firing patterns, depolarized resting membrane potential, and a higher threshold for action potentials. These properties could contribute to both muscle stiffness and weakness, respectively, hallmarks of spastic CP. Interestingly altered persistent inward currents (PICs) and morphology in severe HI MNs would dampen excitability (reduced normalized PIC amplitude and increased dendritic length). In summary, changes we observed in spinal MN physiology likely contribute to severity of the phenotype including weakness and hypertonia, and therapeutic strategies for CP could target excitability of spinal MNs.Key PointsPhysiology of neonatal spinal motoneurons is altered after in utero hypoxia-ischemic injuryIn motoneurons from severely affected animals there is more sustained firing (lower ΔI values), a depolarized resting potential, but a higher voltage threshold for action potential firing.Altered motoneuron excitability could contribute directly to muscle stiffness and spasticity in cerebral palsy.

Background The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS. Study Design We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores. Results There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement. Conclusions An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Posterior component separation with transversus abdominis release and implantation of synthetic mesh in the retromuscular space is a durable type of repair for many large incisional hernias with recurrence rates consistently less than 10%. The purported advantage of biologic prostheses in contaminated fields has recently been challenged, and the concern for placing synthetic mesh in contaminated fields may be overstated. There are almost no data specifically addressing the use of this type of repair for chronic incisional hernias in trauma and emergency general surgery patients, so research is needed on this patient population. In this review, a case of a trauma patient receiving posterior component separation with transversus abdominis release and implantation of synthetic mesh for a chronic incisional hernia resulting from a gunshot wound to the abdomen is presented, the technique is explained, and relevant literature is reviewed.

Background A recent prospective, multicenter, randomized controlled trial found that 4 days of antibiotics after source control of complicated intra-abdominal infections resulted in similar outcomes when compared with longer duration. We hypothesized that the subset of patients presenting with sepsis have similar outcomes when treated with the shorter course of antibiotics. Study Design Patients from the STOP-IT (Study to Optimize Peritoneal Infection Therapy) trial database meeting criteria for sepsis (ie, temperature 38°C and a WBC count 3 or >12,000 cells/mm 3 ) were analyzed. Patients had been randomized to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 calendar days of therapy (n = 45), or to receive a fixed short-course of antibiotics for 4 ± 1 calendar days (n = 67). Outcomes included incidence of and time to surgical site infection, recurrent intra-abdominal infection, Clostridium difficile infection, and extra-abdominal infections, as well as hospital days and mortality. Results One hundred and twelve of the 588 patients in the STOP-IT database met criteria for sepsis and were adherent to the protocol. With regard to short- vs long-course therapy, surgical site infection (11.9% vs 8.9%; p = 0.759), recurrent intra-abdominal infection (11.9% vs 13.3%; p = 1.00), extra-abdominal infection (11.9% vs 8.9%; p = 0.759), hospital days (7.4 ± 5.5 days vs 9.0 ± 7.5 days; p = 0.188), days to recurrent intra-abdominal infection (12.5 ± 6.6 days vs 18.0 ± 8.1 days; p = 0.185), days to extra-abdominal infection (12.6 ± 5.8 days vs 17.3 ± 3.9 days; p = 0.194), and mortality (1.5% vs 0%; p = 1.00) were similar. There were no cases of C difficile infection. Days to surgical site infection (6.9 ± 3.5 days vs 21.3 ± 6.1 days; p Conclusions There was no difference in outcomes between short and long-course antimicrobial therapy in patients with complicated intra-abdominal infection presenting with sepsis. Our findings suggest that the presence of systemic illness does not mandate a longer antimicrobial course if source control of complicated intra-abdominal infection is obtained.

Venous thromboembolism (VTE) is a leading cause of death in multisystem trauma patients; the importance of VTE prevention is well recognized. Presently, standard dose enoxaparin (30 mg BID) is used as chemical prophylaxis, regardless of weight or physiologic status. However, evidence suggests decreased bioavailability of enoxaparin in critically ill patients. Therefore, we hypothesized that a weight-based enoxaparin dosing regimen would provide more adequate prophylaxis (as indicated by antifactor Xa levels) for patients in our trauma intensive care unit (TICU).These data were prospectively collected in TICU patients admitted over a 5-month period given twice daily 0.6 mg/kg enoxaparin (actual body weight). Patients were compared with a historical cohort receiving standard dosing. Anti-Xa levels were collected at 11.5 hours (trough, goal ≥0.1 IU/mL) after each evening administration. Patient demographics, admission weight, dose, and daily anti-Xa levels were recorded. Patients with renal insufficiency or brain, spine, or spinal cord injury were excluded. Data were collected from 26 patients in the standard-dose group and 37 in the weight-based group. Sixty-four trough anti-Xa measurements were taken in the standard dose group and 74 collected in the weight-based group. Evaluating only levels measured after the third dose, the change in dosing of enoxaparin from 30 to 0.6 mg/kg resulted in an increased percentage of patients with goal antifactor Xa levels from 8 per cent to 61 per cent ( P < 0.0001). Examining all troughs, the change in dose resulted in an increase in patients with a goal anti-Xa level from 19 to 59 per cent ( P < 0.0001). Weight-based dosing of enoxaparin in trauma ICU patients yields superior results with respect to adequate anti-Xa levels when compared with standard dosing. These findings suggest that weight-based dosing may provide superior VTE prophylaxis in TICU patients. Evaluation of the effects of this dosing paradigm on actual VTE rate is ongoing at our institution.

BackgroundThe successful treatment of intraabdominal infection requires a combination of anatomical source control and antibiotics. The appropriate duration of antimicrobial therapy remains unclear.MethodsWe randomly assigned 518 patients with complicated intraabdominal infection and adequate source control to receive antibiotics until 2 days after the resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of therapy (control group), or to receive a fixed course of antibiotics (experimental group) for 4±1 calendar days. The primary outcome was a composite of surgical-site infection, recurrent intraabdominal infection, or death within 30 days after the index source-control procedure, according to treatment group. Secondary outcomes included the duration of therapy and rates of subsequent infections.ResultsSurgical-site infection, recurrent intraabdominal infection, or death occurred in 56 of 257 patients in the experimental group (21.8%), as compared with 58 of 260 patients in the control group (22.3%) (absolute difference, -0.5 percentage point; 95% confidence interval [CI], -7.0 to 8.0; P=0.92). The median duration of antibiotic therapy was 4.0 days (interquartile range, 4.0 to 5.0) in the experimental group, as compared with 8.0 days (interquartile range, 5.0 to 10.0) in the control group (absolute difference, -4.0 days; 95% CI, -4.7 to -3.3; P

As general surgery trainees continue to enter specialty practice at a high rate, fewer and fewer are caring for emergency general surgery (EGS) patients. Thus EGS has become one of the cornerstones of the practice of acute care surgery. With the centralization of this area of surgical care in many areas of the country, a clear understanding of the issues associated with this becomes vital. Understanding the public health implications with respect to burden of care and cost will allow for appropriate planning and resource allocation in the future. In addition, the development of validated severity modeling will help with risk stratification in future study of these diseases.

To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill patients.In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying25% of volume of filter) detected by cavography before retrieval.The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval [CI], 97.8%-100%, P.01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission.This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.

Background Emergency general surgery outcomes vary widely across the United States. The utilization of quality indicators can reduce variation and assist providers in administering care aligned with established recommendations. Previous quality indicators have not focused on emergency general surgery patients. We identified indicators of high-quality emergency general surgery care and assessed patient- and hospital-level compliance with these indicators. Methods We utilized a modified Delphi technique (RAND Appropriateness Methodology) to develop quality indicators. Through 2 rankings, an expert panel ranked potential quality indicators for validity. We then examined historic compliance with select quality indicators after 4 nonelective procedures (cholecystectomy, appendectomy, colectomy, small bowel resection) at 4 academic centers. Results Of 25 indicators rated as valid, 13 addressed patient-level quality and 12 addressed hospital-level quality. Adherence with 18 indicators was assessed. Compliance with performing a cholecystectomy for acute cholecystitis within 72 hours of symptom onset ranged from 45% to 76%. Compliance with surgery start times within 3 hours from the decision to operate for uncontained perforated viscus ranged from 20% to 100%. Compliance with exploration of patients with small bowel obstructions with ischemia/impending perforation within 3 hours of the decision to operate was 0% to 88%. For 3 quality indicators (auditing 30-day unplanned readmissions/operations for patients previously managed nonoperatively, monitoring time to source control for intra-abdominal infections, and having protocols for bypass/transfer), none of the hospitals were compliant. Conclusion Developing indicators for providers to assess their performance provides a foundation for specific initiatives. Adherence to quality indicators may improve the quality of emergency general surgery care provided for which current outcomes are potentially modifiable.

Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients.Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes.Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality).These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.

Background The staged laparotomy in the operative management of emergency general surgery (EGS) patients is an extension of trauma surgeons operating on this population. Indications for its application, however, are not well defined, and are currently based on the lethal triad used in physiologically-decompensated trauma patients. This study sought to determine the acute indications for the staged, rapid source control laparotomy (RSCL) in EGS patients. Methods All EGS patients undergoing emergent staged RSCL and non-RSCL over 3 years were studied. Demographics, physiologic parameters, perioperative variables, outcomes, and survival were compared. Logistic regression models determined the influence of physiologic parameters on mortality and postoperative complications. EGS-RSCL indications were defined. Results 215 EGS patients underwent emergent laparotomy; 53 (25 %) were staged RSCL. In the 53 patients who underwent a staged RSCL based on the lethal triad, adjusted multivariable regression analysis shows that when used alone, no component of the lethal triad independently improved survival. Staged RSCL may decrease mortality in patients with preoperative severe sepsis / septic shock, and an elevated lactate (≥3); acidosis (pH ≤ 7.25); elderly (≥70); male gender; and multiple comorbidities (≥3). Of the 162 non-RSCL emergent laparotomies, 27 (17 %) required unplanned re-explorations; of these, 17 (63 %) had sepsis preoperatively and 9 (33 %) died. Conclusions The acute physiologic indicators that help guide operative decisions in trauma may not confer a similar survival advantage in EGS. To replace the lethal triad, criteria for application of the staged RSCL in EGS need to be defined. Based on these results, the indications should include severe sepsis / septic shock, lactate, acidosis, gender, age, and pre-existing comorbidities. When correctly applied, the staged RSCL may help to improve survival in decompensated EGS patients.

Open wounds are commonly seen in the critical care setting, and appropriate management contributes significantly to the overall outcome of the patient. There are two broad categories that are most commonly dealt with. First is the soft tissue defect. This may stem from inability to close a wound due to tissue loss or a planned open wound due to contamination or compartment syndrome. The most common ways in which these wounds are dealt with are wound packing and negative pressure dressings. The second major type is the open abdomen after damage control laparotomy or as treatment/prevention of abdominal compartment syndrome. Many methods for managing this entity have been described, but today, the large majority are dressed with negative pressure dressings. This chapter describes the wound types and the specifics of wound dressings commonly used for these situations.

Appropriate initial antibiotic therapy for presumed pneumonia in critically ill patients decreases the mortality rate. To achieve this goal, treatment guidelines developed by groups such as the American Thoracic Society (ATS) have been stressed. However, often overlooked is the importance of incorporating local microbiologic data into an empiric algorithm. Our hypothesis was that an empiric algorithm supported by our locally-driven analysis would predict more accurate coverage than one defined strictly by an unmodified guideline-driven approach.Retrospective review of all first hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) pathogens in consecutive trauma intensive care unit (TICU) patients over 18 months. Microbiologic data were analyzed to update our TICU-specific empiric algorithm. The ATS guidelines define patients at risk for multidrug-resistant (MDR) organisms on the basis of standardized criteria and time since admission (early5 days; late ≥5 days).A total of 164 pathogens caused 117 pneumonias. For early coverage, ATS guidelines stress identification of MDR risks; these criteria failed to identify 8 of 13 (62%) early MDR pneumonias. For early HAP/VAP with no MDR risks, the ATS guidelines recommend monotherapy; susceptibility differed (49% to ciprofloxacin, 68% to ampicillin-sulbactam, 83% to ceftriaxone). A total of 15% of early pathogens were MDR gram-positive, so addition of vancomycin resulted in adequate predicted coverage of 100%, 79%, and 95% for ciprofloxacin, ampicillin-sulbactam, and ceftriaxone, respectively. For late HAP/VAP, ATS recommends regimens based on broad-spectrum drugs. Vancomycin with ciprofloxacin, cefepime, or piperacillin-tazobactam had predicted coverage of 95%, 94%, and 93%, respectively.The empiric algorithm derived from analysis of local microbiologic data predicted significantly better coverage than one defined by an unmodified guideline-driven approach for early HAP/VAP. Our locally-derived TICU algorithm of ceftriaxone+vancomycin for early pneumonia and piperacillin-tazobactam+vancomycin for late pneumonia optimizes the adequacy of initial therapy. Understanding local patterns of pneumonia ensures the creation and maintenance of empiric algorithms that achieve the best clinical outcomes.

The Acute Physiology and Chronic Health Evaluation II (APACHE II) score has never been validated to risk-adjust between critically ill trauma (TICU) and general surgical (SICU) intensive care unit patients, yet it is commonly used for such a purpose. To study this, we evaluated risk of death in TICU and SICU patients with pneumonia. We hypothesized that mortality for a given APACHE II would be significantly different and that using APACHE II to directly compare TICU and SICU patients would not be appropriate. We conducted a retrospective review of patients admitted to the TICU or SICU at a tertiary medical center over an 18-month period with pneumonia. Admission APACHE II scores, in-hospital mortality, demographics, and illness characteristics were recorded. One hundred eighty patients met inclusion criteria, 116 in the TICU and 64 in the SICU. Average APACHE II scores were not significantly different in the TICU versus SICU (25 vs 24; P = 0.4607), indicating similar disease severity; overall mortality rates, however, were significantly different (24 vs 50%; P = 0.0004). Components of APACHE II, which contributed to this mortality differential, were Glasgow Coma Score, age, presence of chronic health problems, and operative intervention. APACHE II fails to provide a valid metric to directly compare the severity of disease between TICU and SICU patients with pneumonia. These groups represent distinct populations and should be separated when benchmarking outcomes or creating performance metrics in ICU patients. Improved severity scoring systems are needed to conduct clinically relevant and methodologically valid comparisons between these unique groups.

Background Pulmonary contusion (PC) is a common injury associated with blunt chest trauma. Complications such as pneumonia and adult respiratory distress syndrome (ARDS) occur in up to 50% of patients with PC. The ability to predict which PC patients are at increased risk of developing complications would be of tremendous clinical utility. In this study, we test the hypothesis that a novel method that objectively measures percent PC can be used to identify patients at risk to develop ARDS after injury. Methods Patients with unilateral or bilateral PC with an admission chest computed tomographic angiogram were identified from the trauma registry. Demographic, infectious, and outcome data were collected. Percent PC was determined on admission chest computed tomography using our novel semiautomated, attenuation-defined computer-based algorithm, in which the lung was segmented with minimal manual editing. Factors contributing to the development of ARDS were identified by both univariate and multivariable logistic regression analyses. ARDS was defined as PaO2/FiO2 ratio of less than 200 with diffuse bilateral infiltrates on chest radiograph with no evidence of congestive heart failure. Results Quantifying percent PC from our objective computer-based approach proved successful. We found that a contusion size of 24% of total lung volume or greater was most significant at predicting ARDS, which occurred in 78% of these patients. Such patients also had a significantly higher incidence of pneumonia when compared with those with contusions less than 24%. The specificity of contusion size of 24% or greater was 94%, although sensitivity was 37%; positive predictive value was 78%, and negative predictive value was 72%. Conclusion We developed and describe a software-based methodology to accurately measure the size of lung contusion in patients of blunt trauma. In our analyses, contusions of 24% or greater most significantly predict the development of ARDS. Such an objective approach can identify patients with PC who are at increased risk for developing respiratory complications before they happen. Further research is needed to use this novel methodology as a means to prevent posttraumatic lung injury in patients with blunt trauma. Level of evidence Prognostic/epidemiologic study, level III; diagnostic study, level IV.

Background As emergency general surgery (EGS) evolves, an EGS patient-tracking database (EGS registry [EGSR]) similar to the National Trauma Data Bank (NTDB) will be essential to study outcomes and improve care. The goal of this study was to establish diagnostic ICD-9 codes to define EGS patients. The hypothesis was that creating standardized ICD-9-based inclusion criteria would facilitate patient identification for an EGSR and aid in its ongoing development. Study Design We conducted a retrospective review of EGS admissions over a 9-month period to define ICD-9 diagnostic codes of patients admitted to our EGS service. Subsequently, prospective data were collected into the EGSR by testing ICD-9-based inclusion criteria over 1 month. Patient, hospital, and severity scoring variables, as well as quality assurance information, were identified. Results We identified 959 admissions to the EGS service over 9 months with 306 ICD-9 diagnosis codes that define EGS patients; the prospective population of the EGSR confirmed feasibility of ICD-9-based inclusion criteria. The EGSR captures 107 data points and 33 comorbidities per patient over 11 categories, akin to the 10 NTDB categories. Conclusions Following the model of the NTDB, we have successfully completed creation and initial implementation of an EGSR by using ICD-9-based inclusion criteria. Our comprehensive EGSR creates a prospective data-collection modality to capture and define EGS patients. A uniform patient-tracking EGSR, akin to the NTDB, will advance the science of acute care surgery, improve EGS patient outcomes, and facilitate multi-institutional collaboration.

Hyperglycemia after severe injury has been associated with an increased risk of infection and death. Strict glycemic control has been found to be valuable in select surgical populations. Varying amounts of insulin by infusion are required to maintain blood glucose levels within normal limits. Little is known about how insulin requirements are affected by the presence of infection, and therefore, the purpose of this study was to characterize this relationship.Medical records of all intubated, injured patients admitted to the intensive care unit during a 16-month period were reviewed. Patients were included if they were managed with an insulin infusion, and they had a single bronchoalveolar lavage (BAL) culture performed for presumed pneumonia between 48 hours and 8 days. Mean hourly and 24-hour insulin requirements were analyzed before BAL was performed and then compared with values after cultures were obtained. This difference was then compared between patients with and without pneumonia.Eighty-two patients met inclusion criteria during the 16-month study period. The hourly and 24-hour insulin requirements significantly increased from before to after BAL was performed in patients with pneumonia (n = 54) and not in those without (n = 28) (p = 0.008). The 24-hour insulin requirement increased by 26.2 units from before to after BAL in the pneumonia group versus 7.6 units in the nonpneumonia group (p = 0.029). A mean hourly insulin requirement increase of 1.2 units more than the pre-BAL level demonstrated an 86% positive predictive value and 89% specificity for pneumonia.An increase in insulin requirements at the time of obtaining pulmonary cultures is associated with the presence of pneumonia and may represent a valuable tool for earlier recognition.

Chemokines direct leukocytes to areas of inflammation or injury. In general, CC chemokines (MCP-1, MIP-1alpha, RANTES) are chemoattractants for mononuclear cells and CXC (CINC-1, MIP-2alpha) for polymorphonuclear cells (PMNs). Herein we describe an open chest model of pulmonary contusion (PC) in a rodent (rat) and have identified a possible role for CC and CXC chemokines in the pathogenesis of PC.Sprague-Dawley rats (350 g) underwent thoracotomy. The exposed lung was struck with a piston at 5.2 m/s (150 J/M2). Blood, bronchoalveolar lavage (BAL), and lung tissue were collected at 3 hours and 24 hours after injury. PaO2/FiO2 (P/F) ratio was calculated at 15-minute intervals for 3 hours after contusion. Serum was evaluated for cytokine and chemokine expression using ELISA. Cell count/differential was performed on BAL, and lung tissue was obtained for histologic analysis, protein expression and wet to dry weights. Data are reported as pg/mL +/- SE. Data were analyzed using Student's t test to identify significant differences (por = 0.05 significant) between sham and injured animals.Piston impact caused PC based upon morphologic and histologic criteria. BAL cell count and lung wet to dry weights were increased and P/F ratio was decreased after PC. Systemic levels of IL-ra, MCP-1, and the CXC chemokines MIP-2alpha and CINC-1 were significantly elevated at 3 hours when sham and injured animals were compared. All chemokines were found to be significantly elevated at 24 hours, consistent with the early PMN and subsequent mononuclear infiltration observed in the contused lung. Pulmonary expression of TNF-alpha, IL-1beta, CINC-1, MIP-2alpha, ICAM-1, and elastase were increased and activated systemic neutrophils showed increased CD-11b.A model of PC is described in which innate inflammation is activated locally and systemically. Systemic levels of CC and CXC chemokines are increased after PC. This correlates with elevated PMN CD-11b expression, enhanced pulmonary ICAM-1 expression, and mononuclear and PMN infiltration into the lung and alveolar space. Elevated levels of CC and CXC chemokines are seen after PC and may be involved in the lung's inflammatory response to injury.

Background: Ventilator associated pneumonia (VAP) is common in trauma patients, and accurate diagnosis of VAP may improve survival. With the risk of development of bacterial resistance, we also strive to minimize the use of unnecessary antibiotics. Recent studies suggest that quantitative deep endotracheal aspirate (QDEA) is adequate in VAP diagnosis. We currently use bronchoalveolar lavage (BAL) diagnosis. The purpose of this study was to examine the accuracy of QDEA as compared with BAL in diagnosing VAP in trauma patients. Methods: We prospectively compared the results of BAL and QDEA in intubated patients suspected of having VAP during an 8-month period. Indication for BAL was pulmonary infiltrate, systemic inflammatory response syndrome, and C-reactive protein >17 mg/dL at ≥48 hours after admission. Study patients underwent QDEA immediately before BAL, and quantitative cultures were compared for both specimens. The techniques differ in that QDEA involves the direct culture of sputum suctioned from the distal trachea, whereas BAL involves lavage of the bronchoalveolar tree with sterile saline, which is then cultured. VAP was diagnosed on BAL if ≥10 5 cfu/mL was present on culture. The ability of QDEA to diagnose pneumonia was examined at cutoffs of ≥10 5 cfu/mL and ≥10 4 cfu/mL, as compared with BAL at ≥10 5 . Results: Sixty-one patients underwent BAL during this period, and 39 of these underwent both BAL and QDEA for the study. Of the 39 studied patients between March 16, 2002, and November 4, 2002, 20 (51%) were found to have VAP by BAL (≥10 5 cfu/mL). Using this cutoff for QDEA, 18 of 20 (90%) would have been correctly diagnosed. Using ≥10 4 cfu/mL for QDEA, the rate of correct diagnosis would increase to 19 of 20 (95%). However, of the 19 who did not have pneumonia according to BAL, 6 (31%) would have been incorrectly diagnosed with VAP using the QDEA cutoff of ≥10 5 cfu/mL. A QDEA cutoff of ≥10 4 cfu/mL would result in the even higher false-positive rate of 8 of 19 patients (42%). Conclusion: Whereas most patients with pneumonia by BAL would have been diagnosed by QDEA, use of QDEA in treatment decisions would have led to needless antibiotic administration in 31% of VAP-negative patients at a cutoff of ≥10 5 cfu/mL and 42% at ≥10 4 cfu/mL. The use of QDEA in VAP diagnosis is limited because of the rate of over-diagnosis. With the increasing problems associated with excess antibiotic use, we believe these results support the use of BAL over QDEA in the diagnosis of VAP in the ventilated trauma patient.

Protracted laminitis and the resultant stress often results in prolonged, elevated cortisol secretion and this may contribute to the persistence and refractoriness of laminitis. Cushing’s disease is a condition in which increased secretion of pituitary pars intermedia-derived pro-opiomelanocortin (POMC) peptides leads to perpetually enhanced adrenal secretion of cortisol (hyperadrenocorticism), the physiological glucocorticoid (GC) in the equine species. The vasoconstrictive responses of equine digital arteries to catecholamines is potentiated by GCs leading to interference with hoof lamellar perfusion. The level of the steroid-transforming enzyme, 11β-hydroxysteroid dehydrogenase type 1 is sometimes elevated in hoof lamellar tissues during laminitis as a result of locally high cortisol concentrations within hoof lamellae. Obesity has been shown to be a significant risk factor for the development of laminitis. Obesity-associated laminitis may be similar to the metabolic syndrome (MS) in obese humans. Development of MS is a risk factor in humans for stroke and atherosclerosis and there may be a similar risk for laminitis in horses. GCs cause insulin resistance (IR) by inhibiting the action of insulin thus promoting the availability of glucose for cells in the CNS and other cells that do not depend on insulin for glucose uptake. GCs may impair lamellar perfusion by direct action on vascular smooth muscle and indirectly by causing IR. Equine hoof lamellar keratinocytes appear to have an exceptionally high glucose requirement and maintenance of the lamellar may rely on glucose delivery to and uptake by these keratinocytes. Chronic IR, characterized by hyperglycemia and hyperinsulinemia, subjects cells that are not dependent on insulin for glucose uptake to relatively high glucose levels over time. Glucotoxic endotheliopathy is characterized by increased production of endothelin-1 and reduced release of NO by endothelial cells and these constricting factors may impair lamellar perfusion and risk of laminitis. Horse owners and veterinarians should recognize that obesity is associated with multiple endocrinological changes that might predispose to laminitis. Feeding high glycemic index rations during long periods of physical inactivity promotes the development of obesity. A diagnosis of metabolic syndrome (MS) should be considered in horses with abnormal body fat distribution and laminitis. Identification of IR represents the most useful clinical approach to diagnosing MS in horses and rations for horses with MS should have a low glycemic index. Diagnosis of pituitary pars intermedia dysfunction (PPID) in teenage (and younger) horses before the development of the “classic” signs of hirsutism and weight loss is being reported more commonly using the e-ACTH criterion. Therefore, veterinary diagnosticians must be careful to differentiate whether obese teenage horses might be affected with either or both IR and PPID before the appearance of the more “classic” Cushing’s phenotype is evident. The extent to which these two endocrinological disturbances are related deserves further investigation.

Objective To compare the outcomes and associated morbidity in patients with blunt aortic injury (BAI) repaired using cardiopulmonary bypass versus no bypass. Special consideration is given to the influence of bypass in the outcome of complex injuries or repair circumstances. Background Data There are conflicting data concerning the utility of bypass techniques in the operative management of BAI, and controversy over the subject persists. During the last decade, surgeons at the authors' institution have undergone a change in philosophy concerning management of these injuries and began almost exclusively using cardiopulmonary bypass for the repair in 1996. This project explores the effects of this change in the management of BAI. Methods The records of all patients with BAI admitted to a level 1 trauma center over a period of 12 years were reviewed for demographics, injury characteristics, operative technique, and outcome. The bypass group was compared to the no bypass group with respect to morbidity and mortality. Those with a complex injury or repair (CI/R) were examined as a subgroup. CI/R was defined as the presence of an injury with extension proximal to the subclavian artery, involvement of branch vessels, or requirement of maneuvers interfering with anastomosis construction, such as cardiac massage. Results From January 1, 1990, to December 31, 2001, 91 patients were admitted to Wake Forest University Baptist Medical Center with BAI. Sixty-five of these underwent operative repair. Sixty (32 no bypass, 28 bypass) survived to the immediate postoperative period. Injury Severity Score was similar (33 no bypass, 31 bypass, P =.48), as was admission base deficit (-9.2 m Eq/L no bypass vs. -7.0 mEq/L B, P =.13). Paraplegia occurred in four (12%) of the no bypass group as opposed to 0 of the bypass group (P =.05). No patient in the bypass group experienced complications related to heparinization, and two (7%) experienced bypass-related complications (cerebral edema, femoral vein laceration). Mean clamp time for the entire group was 27 minutes. Examination of the 10 patients with CI/R who survived the operating room showed markedly longer clamp times (59 minutes vs. 22 minutes, P

Obesity has been a major concern in the horse industry for many years, and the recent discovery of leptin and leptin receptors in numerous nonequine species has provided a basis for new approaches to study this problem in equine. The objectives were to: 1) clone a partial sequence of the equine leptin and leptin receptor genes so as to enable the design of primers for RT-PCR determination of leptin and leptin receptor gene presence and distribution in tissues, 2) develop a radioimmunoassay to quantify peripheral concentrations of leptin in equine, 3) determine if peripheral concentrations of leptin correlate with body condition scores in equine, and 4) determine if changing body condition scores would influence peripheral concentrations of leptin in equine. In Experiment 1, equine leptin (GenBank accession number AF179275) and the long-form of the equine leptin receptor (GenBank accession number AF139663) genes were partially sequenced. Equine leptin receptor mRNA was detected in liver, lung, testis, ovary, choroid plexus, hypothalamus, and subcutaneous adipose tissues using RT-PCR. In Experiment 2, 71 horses were categorized by gender, age, and body condition score and blood samples were collected. Sera were assayed for leptin using a heterologous leptin radioimmunoassay developed for equine sera. Serum concentrations of leptin increased in horses with body condition score (1 = thin to 9 = fat; r = 0.64; P = 0.0001). Furthermore, serum concentrations of leptin were greater in geldings and stallions than in mares (P = 0.0002), and tended to increase with age of the animal (P = 0.08). In Experiment 3, blood samples, body weights, and body condition scores were collected every 14 d from 18 pony mares assigned to gain or lose weight over a 14-wk interval based on initial body condition score. Although statistical changes (P = 0.001) in body condition scores were achieved, congruent statistical changes in peripheral concentrations of leptin were not observed, likely due to the small range of change that occurred. Nonetheless, serum concentrations of leptin tended to be greater in fat-restricted mares than in thin-supplemented mares (P = 0.09). We conclude that leptin and leptin receptors are present in equine tissues and that peripheral concentrations of leptin reflect a significant influence of fat mass in equine.

Patients with blunt aortic injury (BAI) often have concomitant liver or spleen (L/S) injuries. With increasing use of cardiopulmonary bypass with heparinization in repair of BAI, many advocate operative management of the L/S injury before aortic repair to eliminate risk of hemorrhage. We evaluated the safety of nonoperative management (NOM) of blunt L/S injuries in patients undergoing acute BAI repair with bypass.All patients admitted over a 6-year period with BAI were identified from the registry of our Level I trauma center. Patients with isolated L/S injuries without BAI admitted over the same period served as controls. Groups were compared with regard to demographics, injury characteristics, hospital course, and mortality.Eighty-four patients were diagnosed with BAI from 1994 to 2000; 28 (33%) also had blunt abdominal trauma. Three patients with severe brain injury did not undergo BAI repair, and five required laparotomy before BAI repair for other intra-abdominal injuries (two for hemodynamic instability with splenic injury, and three for concomitant bowel injury). Therefore, 20 of 28 (71.4%) BAI patients with grade I or II L/S injury (Aorta L/S group) underwent planned NOM. All BAIs were repaired using partial bypass with full heparinization. These 20 patients are compared with 894 patients with grade I or II L/S injuries with no BAI (L/S group) over the same time period. There was no difference in the nonoperative failure rate of the Aorta L/S group versus the L/S group (0% vs. 1.7%). Both groups had similar complication rates. The Aorta L/S group was also compared with 56 BAIs without solid organ injury (Aorta group). Although the Aorta L/S group was more severely injured than the Aorta group (Injury Severity Score of 35.3 vs. 26.8,0.0001), transfusion rates (5.7 U of packed red blood cells vs. 8.0 U of packed red blood cells, p = NS), hospital days (17.9 vs. 19.1, p = NS) and mortality (10% vs. 9%, p = NS) were similar.NOM of patients with grade I or II L/S injury who undergo systemic anticoagulation with heparin for repair of BAI is safe and associated with transfusion rates similar to BAI alone. Patients with low-grade liver or spleen injuries do not require laparotomy before BAI repair using partial bypass.

Background: During the past decade, nonoperative management (NOM) of hemodynamically stable blunt trauma patients with liver (L) or spleen (S) injury has become the standard of care. This trend has led to concerns over missed associated intra-abdominal injuries with concomitant morbidity. To better understand the incidence and risk of missed injury, patterns of associated intra-abdominal injury were examined in all patients with blunt liver and spleen injuries, and missed injuries were reviewed in patients undergoing NOM. Methods: Patients were identified from the registry of a Level I trauma center over a 3-year period. Records were reviewed for demographics, injury characteristics, and associated injuries. Indications for primary operation were hemodynamic instability or significant associated intra-abdominal injury. Missed injury was defined as unsuspected intra-abdominal injury requiring laparotomy in patients otherwise undergoing NOM for liver or spleen injury. Results: Eight hundred three patients (338 in the L group, 345 in the S group, and 120 in the L + S group) were treated between December 1995 and December 1998. Rates of planned NOM were 89% (L group), 78% (S group), and 75% (L + S group). On examination of all patients with blunt liver or spleen injuries, the incidence of associated intra-abdominal injury was higher in the L group at 5% as compared with 1.7% in the S group (p = 0.02). The associated intra-abdominal injury rate in the L + S group was similar to the L group at 4.2%. Although in the L and S groups, rates of diaphragm (0.5% vs. 1%, p = 0.45) and intra-abdominal bladder injury (0.3% vs. 0.3%, p = 0.99) were similar, bowel injury was more common in the L group (11% vs. 0%, p = 0.0004), as was pancreatic injury (7% vs. 0%, p = 0.007). In NOM patients, missed injury occurred in seven (2.3%) L patients versus zero S patients (p = 0.012). No L + S patient had unexpected injuries. Missed injuries included two small bowel, three diaphragm, one pancreas, and one mesenteric tear. Conclusion: Damage to the pancreas and bowel is significantly associated with liver as opposed to spleen injuries. Actual missed intra-abdominal injury with NOM mirrors this pattern, occurring more often with liver than with spleen injuries. However, the overall incidence of missed injury is quite low, and should not influence decisions concerning eligibility for NOM. We speculate that the greater amount and/or different vector of energy transfer needed to injure the liver versus the spleen accounts for the greater rate of associated injuries to the pancreas/small bowel.

Background: The pathophysiology of pulmonary contusion (PC) is poorly understood, and only minimal advances have been made in management of this entity over the past 20 years. Improvement in understanding of PC has been hindered by the fact that there has been no accurate way to quantitate the amount of pulmonary injury. With this project, we examine a method of accurately measuring degree of PC by quantifying contusion volume relative to pulmonary function and outcome. Methods: Patients with PC from isolated chest trauma who had admission chest computed tomographic scan were identified from the registry of a Level I trauma center over a 1.5-year period. Subsequently, prospective data on all patients admitted to the intensive care unit with PC during a 5-month period were collected and added to the retrospective database. Using computer-generated three-dimensional reconstruction from admission chest computed tomographic scan, contusion volume was measured and expressed as a percentage of total lung volume. Admission pulmonary function variables (Pao 2 /FiO 2 , static compliance), injury descriptors (chest Abbreviated Injury Score, Injury Severity Score, injury distribution), and indicators of degree of shock (admission systolic blood pressure, admission base deficit) were documented. Outcomes included maximum positive end-expiratory pressure, ventilator days, pneumonia, and acute respiratory distress syndrome (ARDS). Results: Forty-nine patients with PC (35 bilateral) were identified. The average severity of contusion was 18% (range, 5-55%). Patients were classified using contusion volume as severe PC (≥20%, n = 17) and moderate PC (

The saphenous vein is among the most commonly used conduits for renal artery revascularization in adults. Vein grafts are more durable in the renal artery bed than in coronary and peripheral beds, and mechanisms of potential graft failure vary. Coronary vein grafts often fail because of atherosclerotic degeneration, whereas lower extremity grafts fail because of intimal hyperplasia or progression of underlying disease. In contrast, renal vein grafts may dilate over time but seldom fail. This may relate to the distinct hemodynamic environment of the renal bed with low-resistance, high-velocity blood flow. However, frank aneurysmal degeneration of renal vein grafts is rare with only a single report of rupture in the literature. We report an additional case of rupture of a late graft aneurysm and review the literature and our own experience with renal revascularization to underscore the rarity of this serious complication. The saphenous vein for aortorenal bypass grafting continues to be a favorable conduit for renal revascularization. Long-term duplex ultrasound scanning follow-up is recommended to survey the reconstructed artery and perhaps more important, to evaluate progression of subclinical disease in the contralateral renal artery. (J Vasc Surg 2000;32:612-5.)

Since its introduction by the Institute for Healthcare Improvement, the ventilator bundle (VB) has been credited with a reduction in ventilator-associated pneumonia (VAP). The VB consists of stress ulcer prophylaxis, deep venous thrombosis prophylaxis, head-of-bed elevation, and daily sedation vacation with weaning assessment. While there is little compelling evidence that the VB is effective, it has been widely accepted. The Centers for Medical and Medicaid Services has suggested that VAP should be a "never event" and may reduce payment to providers. To provide evidence of its efficacy, the National Trauma Institute organized a prospective multi-institutional trial to evaluate the utility of the VB.This prospective observational multi-institutional study included six Level I trauma centers. Entry criteria required at least 2 days of mechanical ventilation of trauma patients in an intensive care unit (ICU). Patients were followed up daily in the ICU until the development of VAP, ICU discharge, or death. Compliance for each VB component was recorded daily, along with patient risk factors and injury specifics. Primary outcomes were VAP and death. VB compliance was analyzed as a time-dependent covariate using Cox regression as it relates to outcomes.A total 630 patients were enrolled; 72% were male, predominately with blunt injury; and mean age, Injury Severity Score (ISS), and 24-hour Glasgow Coma Scale (GCS) score were 47, 24, and 8.7, respectively. VAP occurred in 36%; mortality was 15%. Logistic regression identified male sex and pulmonary contusion as independent predictors of VAP and age, ISS, and 24-hour Acute Physiology and Chronic Health Evaluation as independent predictors of death. Cox regression analysis demonstrated that the VB, as a time-dependent covariate, was not associated with VAP prevention.In trauma patients, VAP is independently associated with male sex and chest injury severity and not the VB. While quality improvement activities should continue efforts toward VAP prevention, the Institute for Healthcare Improvement VB is not the answer. Financial penalties for VAP and VB noncompliance are not warranted.Therapeutic study, level III.

As acute care surgery evolves, more trauma surgeons are caring for critically ill general surgery as well as trauma patients. However, these two populations are unique, and infectious complications may need to be addressed differently, as the causative organisms may not be the same in the two groups. To study this, we evaluated ventilator-associated (VAP) and hospital-acquired (HAP) pneumonia in the trauma (TICU) and general surgical (SICU) intensive care units to investigate differences in the causative pathogens. Our hypothesis was that SICU patients would have a higher incidence of multi-drug-resistant (MDR) organisms causing VAP/HAP, possibly contributing to inadequate empiric antibiotic (IEA) coverage.Retrospective review of 116 patients admitted with VAP or HAP over a one-year period to the TICU (n = 72) or SICU (n = 44) at a tertiary medical center. Culture was followed by initiation of empiric antibiotics on the basis of an antibiotic algorithm derived from trauma patients. Demographics, illness, and pneumonia characteristics were assessed; MDR organisms were identified.Multi-drug-resistant organisms caused 30.6% of first pneumonias in the TICU vs. 65.9% in the SICU (p = 0.0002). Subsequent pneumonias were seen in 31.8% of SICU patients and 16.7% of TICU patients (p = 0.0576). Inadequate empiric antibiotic coverage was documented in 38.6% of SICU pneumonias vs. 26.4% in the TICU (p = 0.12).Multiply-resistant pathogens cause a significantly greater number of VAP/HAPs in the SICU than in the TICU. Associated with this, when using an antibiotic algorithm based on TICU bacterial pathogens, there is a trend toward a greater likelihood of subsequent pneumonias and toward more IEA coverage in the SICU population compared with TICU patients. Our results indicate that these distinct patient populations have different pathogens causing VAP/HAP and affirm the necessity for population-specific algorithms to tailor empiric coverage for presumed VAP/HAP.

Similar to all pelvic arteries, the aberrant obturator artery (AOA) and its branches are at risk for injury when the pelvic ring is fractured; however, because of its unique origin, bleeding from this artery may be unrecognized and, thus, treatment ineffective. The purpose of this study was to describe the incidence of the AOA using angiography and determine the sensitivity of 64-slice computed tomography angiography (CTA) at identifying the AOA.Imaging from patients undergoing pelvic angiography, for any reason, during 2009 was retrospectively reviewed to determine the incidence of the AOA. The angiographically determined arterial anatomy was the compared with CTA findings.Pelvic angiography, performed in 174 patients, identified the AOA in 60.0% of males, 52.3% of females, 55.1% of all patients, and 38.4% of hemipelvises. The sensitivity/specificity of CTA at identifying the AOA is 90.0%/100% and 63.6%/92.3% in nonpelvic fracture and pelvic fracture patients, respectively; the sensitivity difference being significant (p=0.0351). Three of the 13 (23.1%) AOA identified in pelvic fracture patients demonstrated extravasation when the inferior epigastric artery was cannulated; however, flush angiography failed to demonstrate the extravasation.The AOA is a common arterial variant occurring in more than half of the population and, if present in pelvic fracture patients, commonly injured. Although CTA is effective at identifying the AOA in nonpelvic trauma patients, it is not as effective in pelvic fracture patients. Failure to consider this arterial variant may result in untreated arterial bleeding with the attendant consequences.

During a period of 5 years, 33 newborns with congenital diaphragmatic hernia were treated. Three groups presenting with respiratory distress in the delivery room were identified. These included 8 newborns with agenesis (group 1) and 4 newborns with nonagenesis (group 2), all of whom died. There were 19 nonagenesis survivors (group 3), giving an overall survival rate of 61%. Two newborns who presented beyond 6 hours of life were excluded. No one specific arterial blood gas value or ventilation parameter obtained preoperatively could predict survival. Postmortem right and left lung weights, lung/body weight ratio, and radial alveolar counts demonstrate that agenesis is a unique subgroup with profound pulmonary hypoplasia and a dismal prognosis.