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Objective: The detrimental effects of coagulopathy, hypothermia, and acidosis are well described as markers for mortality after traumatic hemorrhage. Recent military experience suggests that a high fresh frozen plasma (FFP):packed red blood cell (PRBC) transfusion ratio improves outcome; however, the appropriate ratio these transfusion products should be given remains to be established in a civilian trauma population. Methods: Data were obtained from a multicenter prospective cohort study evaluating clinical outcomes in blunt injured adults with hemorrhagic shock. Those patients who required ≥8 units PRBCs within the first 12 hours postinjury were analyzed (n = 415). Results: Patients who received transfusion products in ≥:1.50 FFP:PRBC ratio (high F:P ratio, n = 102) versus

Background The management of splenic injuries has evolved with a greater emphasis on nonoperative management. Although several institutions have demonstrated that nonoperative management of splenic injuries can be performed with an increasing degree of success, the impact of this treatment shift on outcome for all patients with splenic injuries remains unknown. We hypothesized that outcomes for patients with splenic injuries have improved as the paradigm for splenic injury treatment has shifted. Methods Consecutive patients from 1987 to 2001 with splenic injuries who were entered into a state trauma registry were reviewed. Demographic variables, injury characteristics, and outcome data were collected. Results The number of patients who were diagnosed with splenic injuries increased from 1987 through 2001, despite a stable number of institutions submitting data to the registry. The number of minor injuries and severe splenic injuries remained stable, and the number of moderately severe injuries significantly increased over time. Overall mortality rate improved but primarily reflected the decreased mortality rates of moderately severe injuries; the mortality rate for severe splenic injuries was unchanged. Conclusion Trauma centers are seeing increasing numbers of splenic injuries that are less severe in magnitude, although the number of the most severe splenic injuries is stable. The increased proportion of patients with less severe splenic injuries who are being admitted to trauma centers is a significant factor in the increased use and success rate of nonoperative management.

Increasingly, cold-stored whole blood (WB) is being considered for the resuscitation of civilian trauma patients. It is unclear whether the WB should be agitated to enhance the function of the platelets (PLTs) or whether agitation will cause RBC damage.WB units were collected by standard procedures using a PLT-sparing inline leukoreduction filter and stored between 1 and 6°C. On Storage Day 3 each unit was divided into 4 subunits that were stored under one of the following conditions for 21 days: unrocked, manually rocked once daily, continuously rocked end over end, or continuously rocked horizontally. From Day 3 to Day 10, hemolysis and the mechanical fragility index (MFI) for RBC injury were measured daily and again on Days 15 and 21 (n = 9-16 units tested each time). On Days 4 and 10, rapid thromboelastogram (rTEG) measurements were performed (n = 8-10 units tested each time).Hemolysis and MFI increased significantly between Day 3 and Day 21 (p0.0001) for all RBC rocking conditions, as well as the unrocked units. Only the manually and horizontally rocked units demonstrated higher hemolysis (on Day 21) and MFI (starting on Day 10) compared to the unrocked units. Only the α-angle and maximum amplitude in the end-over-end rocked units increased significantly between Day 4 and Day 10. There were no significant differences between the rocked and unrocked units on Day 10 for any rTEG variable.Rocking does not appear to enhance in vitro PLT activity in cold-stored WB and can lead to increased hemolysis.

An association between outcome and case volume has been demonstrated for selected complex operations. The relationship between trauma center volume and patient outcome has also been examined, but no clear consensus has been established. The American College of Surgeons (ACS) has published recommendations on optimal trauma center volume for level 1 designation. We examined whether this volume criteria was associated with outcome differences for the treatment of adult blunt splenic injuries. Using a state trauma database, ACS criteria were used to stratify trauma centers into high-volume centers (>240 patients with Injury Severity Score >15 per year) or low-volume centers, and outcome was evaluated. There were 1,829 patients treated at high-volume centers and 1,040 patients treated at low-volume centers. There was no difference in age, gender, emergency department pulse, emergency department systolic blood pressure, or overall mortality between high- and low-volume centers. Patients at low-volume centers were more likely to be treated operatively, but the overall success rate of nonoperative management between high-and low-volume centers was similar. These data suggest that ACS criteria for trauma centers level designation are not associated with differences in outcome in the treatment of adult blunt splenic injuries in this regional trauma system.

Early recognition and treatment of trauma patients requiring massive transfusion (MT) has been shown to reduce mortality. While many risk factors predicting MT have been demonstrated, there is no universally accepted method or algorithm to identify these patients. We hypothesised that even among experienced trauma surgeons, the clinical gestalt of identifying patients who will require MT is unreliable.Transfusion and mortality outcomes after trauma were observed at 10 U.S. Level-1 trauma centres in patients who survived ≥ 30 min after admission and received ≥ 1 unit of RBC within 6h of arrival. Subjects who received ≥ 10 units within 24h of admission were classified as MT patients. Trauma surgeons were asked the clinical gestalt question "Is the patient likely to be massively transfused?" 10 min after the patients arrival. The performance of clinical gestalt to predict MT was assessed using chi-square tests and ROC analysis to compare gestalt to previously described scoring systems.Of the 1245 patients enrolled, 966 met inclusion criteria and 221 (23%) patients received MT. 415 (43%) were predicted to have a MT and 551(57%) were predicted to not have MT. Patients predicted to have MT were younger, more often sustained penetrating trauma, had higher ISS scores, higher heart rates, and lower systolic blood pressures (all p0.05). Gestalt sensitivity was 65.6% and specificity was 63.8%. PPV and NPV were 34.9% and 86.2% respectively.Data from this large multicenter trial demonstrates that predicting the need for MT continues to be a challenge. Because of the increased mortality associated with delayed therapy, a more reliable algorithm is needed to identify and treat these severely injured patients earlier.

Nitric oxide (NO) can modulate numerous genes directly; however, some genes may be modulated only in the presence of the inflammatory stimuli that increase the expression of the inducible nitric oxide synthase (iNOS). One method by which to examine changes in NO-mediated gene expression is to carry out a gene array analysis on NO-nai;ve cells. Herein, we report a gene array analysis on mRNA from iNOS-null (iNOS(-/-)) mouse hepatocytes harvested from mice exposed to NO by infection with an adenovirus expressing human iNOS (Ad-iNOS). Of the 6500 genes on this array, only approximately 200 were modulated either up or down by the increased iNOS activity according to our criteria for significance. Several clearly defined families of genes were modulated, including genes coding for proinflammatory transcription factors, cytokines, cytokine receptors, proteins associated with cell proliferation and cellular energetics, as well as proteins involved in apoptosis. Our results suggest that iNOS has a generally anti-inflammatory and anti-apoptotic role in hepatocytes but also acts to suppress proliferation and protein synthesis. The expression of iNOS results in increased expression of stress-related proteins, including heme oxygenase-1 (HO-1). We used HO-1 to confirm that a significant change identified by an analysis could be demonstrated as significant in cells and tissues. The elevation of HO-1 was confirmed at the protein level in hepatocytes in vitro. Furthermore, iNOS(-/-) mice experienced greatly increased liver injury subsequent to intestinal ischemia/reperfusion injury, associated with an inability to upregulate HO-1. This is the first study to address the global gene changes induced by iNOS in any cell type, and the findings presented herein may have clinical relevance for conditions such as septic or hemorrhagic shock in which hepatocytes, NO, and HO-1 play a crucial role.

Objectives: To reduce unnecessary RBC transfusions, the computerized physician order entry (CPOE) system was programmed to require prescribers to select an indication for transfusion. An alert appeared if the patient’s hemoglobin (Hb) level was above the threshold determined by the selected indication (adaptive alerts). Methods: Data on RBC orders from the 4 months before the adaptive alerts were implemented were compared with the 10 months after implementation. Results: Significantly fewer alerts were generated after the implementation, and the rate at which the alerts were heeded also increased. There was a trend toward fewer RBC units transfused after adaptive alert implementation. A large number of RBCs were ordered using a nonspecific transfusion indication, although many of these patients had antecedent Hb values close to the threshold. Conclusions: Electronically generated alerts can reduce but are insufficient to eliminate non–evidence-based transfusions. Analysis of the alerts suggests areas for CPOE improvement.

Nitric oxide (NO) is not only an important signaling molecule, but it also regulates the expression of a number of genes in the liver. We have previously shown that apoptosis in hepatocytes exposed to tumor necrosis factor-alpha and actinomycin D is prevented by NO derived from the inducible nitric-oxide synthase (iNOS), by mechanisms that are both dependent on and independent of modulation of cyclic guanosine monophosphate (cGMP) subsequent to activation of soluble guanylyl cyclase (sGC). We hypothesize that one mechanism by which NO exerts these effects is by regulating the expression of genes involved in apoptosis. We used differential display-polymerase chain reaction to isolate NO-regulated genes in hepatocytes from iNOS knockout mice (to eliminate endogenous inducible NO production). Using this analysis, we identified a NO-suppressed gene fragment homologous with the pro-apoptotic Bcl-2 binding protein BNIP3. Northern analysis confirmed the NO-dependent suppression of BNIP3 in cultured cells. Similarly, the NO donor S-nitroso-N-acetyl-dl-penicillamine (1-1000 microm) down-regulated the expression of BNIP3 in both iNOS knockout and wild-type hepatocytes. This effect of NO was reversed by the sGC inhibitor 1H-(1,2,4)-oxadiazole[4,3-a]quinoxalon-1-one (ODQ),suggesting the involvement of the sGC/cGMP pathway in the modulation of BNIP3 by NO. We propose that suppression of BNIP3 expression is one sGC/cGMP-dependent mechanism by which NO might affect the process of hepatocyte apoptosis.

Nitric oxide (NO) can modulate numerous genes through several pathways, yet some genes may be modulated only in the presence of the inflammatory stimuli that upregulate the inducible nitric oxide synthase (iNOS) rather than by NO alone. Furthermore, the role of prior expression of iNOS in the modulation of genes by NO is unknown. We addressed these issues in hepatocytes harvested from iNOS-null (iNOS(-/-)) mice exposed to NO by treatment with NO donors or by infection with an adenovirus-expressing human iNOS (Ad-iNOS), rather than by stimulation with inflammatory cytokines. Differential display and gene array analyses performed on mRNA derived from iNOS(-/-) hepatocytes demonstrated that infection with Ad-iNOS, but not infection with a control adenovirus expressing the beta-galactosidase gene (Ad-LacZ), induced a gene fragment identical to cytochrome P450 2E1 (CYP2E1). Northern analysis performed with this fragment demonstrated that treatment of iNOS(-/-) hepatocytes with Ad-iNOS or with the NO donor S-nitroso-N-acetyl-d,l-penicillamine (SNAP), but not control treatment or infection with Ad-LacZ, resulted in increased expression of CYP2E1. Inhibition of soluble guanylyl cyclase partially blocked the induction of CYP2E1 mRNA by Ad-iNOS. Rat hepatocytes treated with SNAP also exhibited increased expression of CYP2E1 mRNA. Preliminary studies, however, suggest that the induction of CYP2E1 in the rat hepatocytes treated with cytokines was not reduced in the presence of a NOS inhibitor. Our results suggest that CYP2E1 can be induced solely by NO derived from iNOS, at least partly in a cyclic GMP-dependent manner and independently of inflammatory stimuli or of prior exposure to NO.

The impact of do-not-resuscitate (DNR) orders has not been systematically evaluated in acute trauma research. We determined the frequency, timing, and impact on mortality-based effect estimates for patients with DNR orders in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study.Trauma patients surviving at least 30 minutes and transfused one or greater unit of red blood cell within 6 hours of admission (n = 1,245) from 10 Level 1 centers were enrolled. We report descriptive statistics and results from survival analysis to compare the association of blood product transfusion ratios with outcome defined as mortality and as a composite, DNR, and death.DNRs were reported for 95 patients (7.6%), with 94 in-hospital deaths. There were 172 deaths without DNRs. Of 90 known DNR order times, the median was 53 hours (interquartile range, 9-186 hours) after admission; the median DNR-to-death time was 10 hours (2-32 hours). DNRs were for comfort measures only (43%), no cardiopulmonary resuscitation (40%), and no intubation or cardiopulmonary resuscitation (16%). Compared with the 116 non-DNR deaths that occurred after the earliest DNR order (2 hours), the DNR decedents were significantly older with a less severe base deficit, fewer red blood cell and plasma transfusions, and a later median time of death (98 [21-230] hours vs. 17 [4-91] hours). In multivariable Cox models that accounted for time-varying blood product ratios, the associations were consistent, regardless of whether outcome was defined as mortality or the composite.DNR orders were instituted after the 24-hour period of highest mortality risk and more often in older patients not in severe shock. Findings from the primary PROMMTT analyses of the impact of blood product ratios on survival did not materially change when the original mortality outcome was redefined as a composite of DNR or death. DNR orders are potentially an important mediating variable that should be systematically evaluated in trauma research.

Background In the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, waiver of consent was used because previous literature reported low response rates and subsequent bias. The goal of this article was to examine the rationale and tradeoffs of using waiver of consent in PROMMTT. Methods PROMMTT enrolled trauma patients receiving at least 1 U of red blood cells within 6 hours after admission at 10 US Level 1 trauma centers. Local institutional review boards (IRBs) from all sites approved the study. Site 8 was required by their IRB to attempt consent but was allowed to retain data on patients unable to be consented. Results Of 121 subjects enrolled at Site 8, 55 consents were obtained (46%), and no patient or legally authorized representative refused to give consent. Of the patients, 36 (30%) died, and 6 (5%) were discharged before consent could be attempted. Consent was attempted but not possible among 24 patients (20%). Of the 10 clinical sites, 6 of the local IRBs approved collection of residual blood samples, 1 had previous approval to collect timed blood samples under a separate protocol, and 3 reported that their local IRBs would not approve collection of residual blood under a waiver of consent. Conclusion Waiver of consent was used in PROMMTT because of the potential adverse impact of consent refusals; however, there were no refusals. If the IRB for Site 8 had required withdrawal of patients unable to consent and destruction of their data, a serious bias would likely have been introduced. Other tradeoffs included a reduction in sites participating in residual blood collection and a smaller than expected amount of residual blood collected among sites operating under a waiver of consent. Noninterventional emergency research studies should consider these potential tradeoffs carefully before deciding whether waiver of consent would best achieve the goals of a study.

BACKGROUND: Prediction of outcome after injury is fraught with uncertainty and statistically beset by misspecified models. Single-time point regression only gives prediction and inference at one time, of dubious value for continuous prediction of ongoing bleeding. New statistical machine learning techniques such as SuperLearner (SL) exist to make superior prediction at iterative time points while evaluating the changing relative importance of each measured variable on an outcome. This then can provide continuously changing prediction of outcome and evaluation of which clinical variables likely drive a particular outcome. METHODS: PROMMTT data were evaluated using both naive (standard stepwise logistic regression) and SL techniques to develop a time-dependent prediction of future mortality within discrete time intervals. We avoided both underfitting and overfitting using cross validation to select an optimal combination of predictors among candidate predictors/machine learning algorithms. SL was also used to produce interval-specific robust measures of variable importance measures (VIM resulting in an ordered list of variables, by time point) that have the strongest impact on future mortality. RESULTS: Nine hundred eighty patients had complete clinical and outcome data and were included in the analysis. The prediction of ongoing transfusion with SL was superior to the naive approach for all time intervals (correlations of cross-validated predictions with the outcome were 0.819, 0.789, 0.792 for time intervals 30-90, 90-180, 180-360, >360 minutes). The estimated VIM of mortality also changed significantly at each time point. CONCLUSION: The SL technique for prediction of outcome from a complex dynamic multivariate data set is superior at each time interval to standard models. In addition, the SLVIM at each time point provides insight into the time-specific drivers of future outcome, patient trajectory, and targets for clinical intervention. Thus, this automated approach mimics clinical practice, changing form and content through time to optimize the accuracy of the prognosis based on the evolving trajectory of the patient. (Copyright (C) 2013 by Lippincott Williams & Wilkins)

Acute traumatic coagulopathy (ATC) occurs after severe injury and shock and is associated with increased bleeding, morbidity, and mortality. The effects of ATC and hemostatic resuscitation on outcome are not well-explored. The PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study provided a unique opportunity to characterize coagulation and the effects of resuscitation on ATC after severe trauma.Blood samples were collected upon arrival on a subset of PROMMTT patients. Plasma clotting factor levels were prospectively assayed for coagulation factors. These data were analyzed with comprehensive PROMMTT clinical data.There were 1,198 patients with laboratory results, of whom 41.6% were coagulopathic. Using international normalized ratio of 1.3 or greater, 41.6% of patients (448) were coagulopathic, while 20.5% (214) were coagulopathic using partial thromboplastin time of 35 or greater. Coagulopathy was primarily associated with a combination of an Injury Severity Score (ISS) of greater than 15 and a base deficit (BD) of less than -6 (p0.05). Regression modeling for international normalized ratio-based coagulopathy shows that prehospital crystalloid (odds ratio [OR], 1.05), ISS (OR, 1.03), Glasgow Coma Scale (GCS) score (OR, 0.93), heart rate (OR, 1.08), systolic blood pressure (OR, 0.96), BD (OR, 0.92), and temperature (OR, 0.84) were significant predictors of coagulopathy (all p0.03). A subset of 165 patients had blood samples collected and coagulation factor analysis performed. Elevated ISS and BD were associated with elevation of aPC and depletion of factors (all p0.05). Reductions in factors I, II, V, VIII and an increase in aPC drive ATC (all p0.04). Similar results were found for partial thromboplastin time-defined coagulopathy.ATC is associated with the depletion of factors I, II, V, VII, VIII, IX, and X and is driven by the activation of the protein C system. These data provide additional mechanistic understanding of the drivers of coagulation abnormalities after injury. Further understanding of the drivers of ATC and the effects of resuscitation can guide factor-guided resuscitation and correction of coagulopathy after injury.

To relate in-hospital mortality to early transfusion of plasma and/or platelets and to time-varying plasma:red blood cell (RBC) and platelet:RBC ratios.Prospective cohort study documenting the timing of transfusions during active resuscitation and patient outcomes. Data were analyzed using time-dependent proportional hazards models.Ten US level I trauma centers.Adult trauma patients surviving for 30 minutes after admission who received a transfusion of at least 1 unit of RBCs within 6 hours of admission (n = 1245, the original study group) and at least 3 total units (of RBCs, plasma, or platelets) within 24 hours (n = 905, the analysis group).In-hospital mortality.Plasma:RBC and platelet:RBC ratios were not constant during the first 24 hours (P.001 for both). In a multivariable time-dependent Cox model, increased ratios of plasma:RBCs (adjusted hazard ratio = 0.31; 95% CI, 0.16-0.58) and platelets:RBCs (adjusted hazard ratio = 0.55; 95% CI, 0.31-0.98) were independently associated with decreased 6-hour mortality, when hemorrhagic death predominated. In the first 6 hours, patients with ratios less than 1:2 were 3 to 4 times more likely to die than patients with ratios of 1:1 or higher. After 24 hours, plasma and platelet ratios were unassociated with mortality, when competing risks from nonhemorrhagic causes prevailed.Higher plasma and platelet ratios early in resuscitation were associated with decreased mortality in patients who received transfusions of at least 3 units of blood products during the first 24 hours after admission. Among survivors at 24 hours, the subsequent risk of death by day 30 was not associated with plasma or platelet ratios.

OBJECTIVE To determine whether increasing distance between helicopter ambulance airbase and either home residence or referring facility is associated with an increased risk of injury-related mortality. BACKGROUND A dramatic increase in the absolute number and utilization of Helicopter Emergency Medical Services transports has occurred in the management of the critically injured patients. HEMS are resource intensive, and the most efficient geographic distribution of airbases necessary to improve patient outcomes is unknown. METHODS We performed a retrospective analysis of 244,293 adult trauma patients who were treated at a designated trauma center (TC) in Pennsylvania during the period 1997 to 2007, using the Pennsylvania Trauma Outcomes Study data set. We performed a multivariate analysis, adjusting for differences in case mix, to determine whether airbase proximity to either residence or referring facility is associated with injury-related mortality. RESULTS For patients residing distant (>20 miles) from a TC, increasing distance from an airbase is associated with an increased risk of death; for each mile, the risk of mortality increases by approximately 1% (adjusted odds ratio, 1.011; 95% confidence interval, 1.002-1.018; P = 0.02). There is no additional benefit to living close (

Background Recently, concern has been raised that the use of massive transfusion protocols (MTPs) in nontrauma (ie, general medical/surgical [GMS]) patients might be inefficient due to protocol overactivation (activation in patients who do not ultimately receive massive transfusion). The current study was designed to investigate whether an MTP could be used effectively in GMS patients without detrimentally impacting resource allocation. Study Design A retrospective analysis was performed using institutional blood bank records from 2011. Trauma and GMS patients who had ≥10 U packed RBC issued to them in a single release were identified and categorized into MTP and no MTP (nMTP) cohorts. Results The protocol was overactivated in 53.8% of GMS patients. Activation of the MTP accelerated the delivery of component products for all patients. In GMS MTP patients, fresh frozen plasma units were issued a median of 7 minutes earlier than in GMS nMTP patients (MTP: median 1.0 minute; interquartile range [IQR] 0.0 to 2.0 minutes vs nMTP: median 8.0 minutes; IQR 0.0 to 37.5 minutes; p = 0.009), and platelet units were issued 17 minutes earlier (MTP: median 7.0 minutes; IQR 0.0 to 15.0 minutes vs nMTP: median 24.0 minutes; IQR 9.0 to 96.0 minutes; p = 0.010). In GMS MTP patients, there was a statistically significant increase in the percentage of platelet units wasted (MTP 12.8% vs nMTP 8.1%; p = 0.046). This increase was also seen in trauma MTP patients (MTP 12.2% vs nMTP 4.0%; p Conclusions Despite finding that our MTP is overactivated in GMS patients, we could identify no unique disadvantages to its use with respect to resource allocation. In fact, a potential advantage to MTP activation exists, as products are issued more quickly with less variability. Our findings of increased platelet waste were not unique to GMS patients and should be used as a metric for quality improvement.

BACKGROUND Recent data suggest that patients undergoing massive transfusion have lower mortality rates when ratios of plasma and platelets to red blood cells (RBCs) of ≥ 1:2 are used. This has not been examined independently in women and men. A gender dichotomy in outcome after severe injury is known to exist. This study examined gender-related differences in mortality after high product ratio massive transfusion. METHODS A retrospective study was conducted using a database containing massively transfused trauma patients from 23 Level I trauma centers. Baseline demographic, physiologic, and biochemical data were obtained. Univariate and logistic regression analyses were performed. Adjusted mortality in patients receiving high (≥ 1:2) or low (

Objective: Hemorrhage remains a leading cause of early death in injured patients, and definitive control of bleeding remains a fundamental principle of trauma management. Therapeutic interventional radiology (IR) procedures have increasingly become essential in the acute management of traumatic injury. The importance of time to control of hemorrhage for therapeutic IR procedures has not been adequately characterized. Methods: A retrospective analysis was performed by using data derived from the National Trauma Data Bank, version 7.1. Inclusion criteria included the following: adult, hypotensive patients, scene admission, patients who underwent early therapeutic IR vascular occlusive procedures within in 3 hours of admission at a level I or II designated trauma center (n = 1,748). Exclusion criteria included intracranial or venous occlusion procedures, patients who underwent any abdominal, thoracic, vascular, or intracranial operative procedures throughout their entire hospital stay. Logistic regression analysis was used to analyze the independent mortality risk associated with DELAY to IR procedures after controlling for important confounders. Results: The majority of patients who died did so within the first 48 hours from injury (80%). Regression analysis revealed that DELAY to IR was independently associated with more than a twofold higher risk of mortality (odds ratio 2.7, 95% confidence interval 1.6-4.9, p < 0.001). For every hour delay, the risk of mortality increased by 47%. These findings were independent of injury mechanism and most pertinent to level I trauma centers. Conclusion: In hemodynamically unstable trauma patients undergoing therapeutic catheter-based IR procedures, delay to IR was independently associated with more than a twofold higher risk of mortality. These results suggest that therapeutic IR procedures should be performed as expeditiously as possible and held to the same dogma as applied to definitive operative control of hemorrhage.

In the trauma population, the use of retrievable inferior vena cava filters (RIVCF) is rapidly gaining acceptance in patients at high risk for venous thromboembolism. This study reports the impact of an institutional protocol on retrieval rates of RIVCF at a level I trauma center.A review of an institutional Trauma Registry identified 94 consecutive patients who received RIVCF between January 2004 and February 2007 (group I) before the protocol was instituted. Under the protocol, 61 consecutive trauma patients received RIVCF between August 2007 and July 2008 (group II) and were prospectively followed.Filter retrieval eligibility criteria were met in 81% (76/94) of patients in group I and in 61% (37/61) of patients in group II. Of those eligible, retrieval-attempt rates were 42% (32/76) in group I versus 95% (35/37) in group II (P.001). Clinician oversight of the filter accounted for 89% (39/44) of failure of retrieval attempts; patient noncompliance accounted for the rest in group I. In group II, the latter accounted for all such failures. Retrieval was successful in 37% (28/76) and in 84% (31/37) of the eligible patients in groups I and II, respectively (P.001). No retrieval procedure-related complications occurred.An institutional protocol for prospective monitoring of RIVCF significantly increases filter retrieval rate.

During the initial assessment and early resuscitation phase, a multiple trauma patient (25-year-old man) is determined to be in hemorrhagic shock and has the following findings: Multiple abrasions (head, torso, and extremities) Dilated right pupil Precordial bruises (chest x-ray demonstrates fully expanded bilateral lungs with an endotracheal tube above the carina; a widened mediastinum; obliterated pulmonary-aortic window and aortic knob) Soft abdomen Unstable pelvic fracture (pneumatic garment is now inflated)

Improving the treatment of trauma, a leading cause of death worldwide, is of great clinical and public health interest. This analysis introduces flexible statistical methods for estimating center-level effects on individual outcomes in the context of highly variable patient populations, such as those of the PRospective, Observational, Multi-center Major Trauma Transfusion study. Ten US level I trauma centers enrolled a total of 1,245 trauma patients who survived at least 30 minutes after admission and received at least one unit of red blood cells. Outcomes included death, multiple organ failure, substantial bleeding, and transfusion of blood products. The centers involved were classified as either large or small-volume based on the number of massive transfusion patients enrolled during the study period. We focused on estimation of parameters inspired by causal inference, specifically estimated impacts on patient outcomes related to the volume of the trauma hospital that treated them. We defined this association as the change in mean outcomes of interest that would be observed if, contrary to fact, subjects from large-volume sites were treated at small-volume sites (the effect of treatment among the treated). We estimated this parameter using three different methods, some of which use data-adaptive machine learning tools to derive the outcome models, minimizing residual confounding by reducing model misspecification. Differences between unadjusted and adjusted estimators sometimes differed dramatically, demonstrating the need to account for differences in patient characteristics in clinic comparisons. In addition, the estimators based on robust adjustment methods showed potential impacts of hospital volume. For instance, we estimated a survival benefit for patients who were treated at large-volume sites, which was not apparent in simpler, unadjusted comparisons. By removing arbitrary modeling decisions from the estimation process and concentrating on parameters that have more direct policy implications, these potentially automated approaches allow methodological standardization across similar comparativeness effectiveness studies.

Methods We performed a retrospective analysis of elderly TBI patients (>=65 years) with evidence of brain hemorrhage on computed tomography (CT) scan at our institution from 2006-2010. Patient demographics, injury severity, clinical course, length of stay, and disposition were collected. Statistical analyses were performed to compare groups and identify predictors of mortality, complication, infection, neurosurgical intervention, and hemorrhage progression. Results 1552 patients were identified with 543 aspirin only (AO), 97 clopidogrel only (CO), 218 warfarin only (WO), 193 clopidogrel/aspirin (CA), and 501 patients on no antithrombotic medication (NAT). Significant differences existed in abbreviated injury score (AIS) (p=0.012), Glasgow Coma Scale (GCS) score (p=0.013), and Marshall score (p

Management of critically ill patients by physicians with advanced training in critical care medicine has been associated with improved outcomes in a variety of disease states, such as acute lung injury [2] and intracranial hemorrhage [3], as well as following traumatic injury [4] and aortic [5] or esophageal [6] surgery. Additionally, a systematic review revealed that outcomes were better in a cohort of critically-ill patients managed by intensivists in high-intensity ICUs (defi ned as closed ICUs or ICUs with mandated intensivist consultation) as compared to low-intensity ICUs, with an overall reduction in the relative risk (RR) of both hospital and ICU mortality [7]. Furthermore, experts predict that there will be a shortage of critical care physicians in the very near future that is projected to increase dramatically as the population ages Expanded Abstract Citation Levy MM, Rapoport J, Lemeshow S, Chalfi n DB, Phillips G, and Danis M: Association between Critical Care Physician Management and Patient Mortality in the Intensive Care Unit. Ann Intern Med 2008 Jun 3, 148(11): 801-9 [1]. Background Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefi t from management by critical care physicians, but evidence of this benefi t is scant. Methods Objective: To examine the association between hospital mortality in critically ill patients and management by critical care physicians. Design: Retrospective analysis of a large, prospectively collected database of critically ill patients. Setting: 123 ICUs in 100 U.S. hospitals. Subjects: 101,832 critically ill adults. Intervention: None. Outcomes: Through use of a random-eff ects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non-critical care physicians. An expanded Simplifi ed Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for diff erences in the probability of selective referral of patients to critical care physicians. Results Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The diff erence in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM. Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized. Conclusion In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.

1 Clinical Fellow, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA 2 Assistant Professor, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA 3 Assistant Professor, Departments of Critical Care Medicine and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA

Intervention: Both studies used a crossover design. Interns were randomly assigned to either a traditional or intervention call schedule. The traditional call schedule involved in-house call every 3 night with a limit of 30 hours of consecutive work. The intervention schedule involved call every 4 night with a limit of 16 hours of consecutive work. Interns recorded their sleep and work hours and were followed by physician observers to detect medical errors. In addition, nurse chart reviewers assessed medical records for medical errors and a computer error detection program was utilized. The interns also underwent continuous ambulatory polysomnography at least 3 times per week to assess for periods of sleep and inattentiveness. All data were reviewed by investigators blinded to the interns’ schedules.