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Microglia and complement can mediate neurodegeneration in Alzheimer’s disease (AD). By integrative multi-omics analysis, here we show that astrocytic and microglial proteins are increased in TauP301S synapse fractions with age and in a C1q-dependent manner. In addition to microglia, we identified that astrocytes contribute substantially to synapse elimination in TauP301S hippocampi. Notably, we found relatively more excitatory synapse marker proteins in astrocytic lysosomes, whereas microglial lysosomes contained more inhibitory synapse material. C1q deletion reduced astrocyte–synapse association and decreased astrocytic and microglial synapses engulfment in TauP301S mice and rescued synapse density. Finally, in an AD mouse model that combines β-amyloid and Tau pathologies, deletion of the AD risk gene Trem2 impaired microglial phagocytosis of synapses, whereas astrocytes engulfed more inhibitory synapses around plaques. Together, our data reveal that astrocytes contact and eliminate synapses in a C1q-dependent manner and thereby contribute to pathological synapse loss and that astrocytic phagocytosis can compensate for microglial dysfunction.

Diabetic retinopathy (DR) is a common complication of diabetes. Approximately 20% of DR patients have diabetic macular edema (DME) characterized by fluid leakage into the retina. There is a genetic component to DR and DME risk, but few replicable loci. Because not all DR cases have DME, we focused on DME to increase power, and conducted a multi-ancestry GWAS to assess DME risk in a total of 1,502 DME patients and 5,603 non-DME controls in discovery and replication datasets. Two loci reached GWAS significance (p−8). The strongest association was rs2239785, (K150E) inAPOL1. The second finding was rs10402468, which co-localized toPLVAPandANKLE1in vascular / endothelium tissues. We conducted multiple sensitivity analyses to establish that the associations were specific to DME status and did not reflect diabetes status or other diabetic complications. Here we report two novel loci for risk of DME which replicated in multiple clinical trial and biobank derived datasets. One of these loci, containing the geneAPOL1, is a risk factor in African American DME and DKD patients, indicating that this locus plays a broader role in diabetic complications for multiple ancestries.

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.

Every trauma patient has a golden hour, and resuscitation efficiency within that hour has large implications for patients. We instituted simulation based trauma resuscitation training with the hypothesis that it would improve trauma team efficiency.Five simulation training sessions were conducted with immediate debriefing. Metrics collected in actual trauma resuscitations before and after simulation training included time of primary and secondary surveys and time to computed tomography (CT) scan. Study participants were from multidisciplinary specialties involved in trauma resuscitations as well as former trauma patients from the Trauma Survivors Network.Seventy-three patients undergoing trauma resuscitations were screened and 67 patients were included. Time to CT scan and secondary survey completion were significantly reduced in actual trauma patient activations following implementation of the curriculum (reduction of 23 to 16 minutes for CT scan p0.05, and reduction from 14 to 6 minutes for secondary survey, p0.05). Time to primary survey completion did not change (5 minutes).Multidisciplinary simulation training was associated with improved trauma team efficiency in the form of reduced assessment time. As emergency department length of stay is an independent predictor of hospital mortality following trauma activation, team-based simulation training has the potential to improve patient outcomes. Multidisciplinary involvement was a key factor, and Trauma Survivors Network involvement brought credibility from the patient perspective.

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.

The SARS-CoV-2/COVID-19 pandemic has significantly increased the demand for specific-pathogen-free (SPF) nonhuman primates (NHPs) for development of vaccines and therapeutics, thus straining the supply of these animals for biomedical research studies. Non-SPF animals, which are available in greater numbers and include well-characterized primate species, should be considered in lieu of limited SPF animals for appropriate research studies.

The SARS-CoV-2 pandemic has significantly increased the demand for rhesus macaques, which might outstrip the supply for COVID-19 research and for other biomedical research studies. Baboons, another well-characterized research primate model, should be considered as a promising alternative for COVID-19 disease studies.

Author(s): Chang, Michael; Kennard, Haley; Nelson, Laura; Wrubel, Katie; Gagnon, Seraphina; Monette, Rebekah; Ledford, Janine | Abstract: Since time immemorial, Qwidicca?a•tx, or the Makah Tribe, have lived on the northwest Olympic Peninsula in what is currently Washington state. Climate change has already impacted the Makah Tribe and will continue to do so in the future. Our history, archaeological archives, stories, and knowledge have proven that the Makah Tribe has an extensive history of adapting to changing climates. Traditional, cultural, and Indigenous knowledges can play an important role in climate adaptation planning, and for tribes and Indigenous peoples it can be a crucial component in ensuring that planning strategies and outcomes are culturally appropriate and aligned with community values. The Makah Climate Change Workgroup, an internal workgroup of the Makah Tribe, has begun a Makah Traditional Knowledge and Cultural Resource Assessment to complement and inform our Makah Climate Impacts Assessment and Makah Climate Adaptation Plan. In this presentation, we outline our preliminary framework demonstrating how tribes and Indigenous groups can utilize traditional and Indigenous knowledges within their own planning processes in the following ways: to (1) provide historical baselines and fill in gaps in monitoring data; (2) identify cultural resources that are vulnerable to future climate change; (3) identify potential climate adaptation and mitigation strategies; and (4) engage the community on climate change impacts.

Purpose: To determine the efficacy of pegylated interferon alfa-2A in the treatment of refractory inflammatory cystoid macular edema (CME)Methods: Retrospective chart reviewResults: Treatment with pegylated interferon alfa-2A led to an improvement in CME in all eyes of seven included patients, with a mean decrease in CMT from 478 µm to 310 µm (p < .05). The vision in one patient did not improve due to preexisting retinal atrophy. All other eyes showed improvement in vision, with a mean improvement in best LogMAR visual acuity from +0.59 to +0.28 (p < .05). The treatment effect was sustained with low-dose treatment every 2 weeks or less in the majority of patients. Two patients who stopped interferon treatment given flu-like symptoms and intolerable rash, respectively, showed rapid recurrence of CME.Conclusions: Weekly administration of pegylated interferon alfa-2A is an effective treatment for refractory inflammatory CME, though side effects may limit tolerability in some patients.

Abdominal compartment syndrome (ACS), defined as the presence of intra-abdominal hypertension (IAH) and associated end-organ dysfunction, is a relatively common clinical entity encountered during the management of critically ill surgical patients. The significant derangements in both anatomy and physiology expressed in severely injured or ill surgical patients place them at an increased risk for IAH. Unrecognized IAH and ACS can rapidly progress to fulminant organ failure and death, and recognition of the physiologic manifestations of this process, along with relatively newly developed methods of dealing with complex abdominal wounds, has led to remarkable advances in the care of the most critically ill surgical patients. The incidence of ACS has decreased in recent years due to a number of different reasons, including prompt recognition and invasive and minimally invasive intervention, along with the practice of leaving the abdomen open after exploration. Leaving abdominal wounds open as a management strategy for either treating or avoiding IAH and ACS has been associated with decreased mortality when applied appropriately. However, open abdominal wounds themselves present innate challenges in the care of these complex surgical patients, and effective management often requires the clinician to integrate dynamic changes in both physiology and anatomy simultaneously to achieve optimal outcomes. This chapter will review the pathophysiology, diagnosis, and management of ACS in the emergency general surgery patient as well as management of the open abdomen.

Elderly surgical patients are common and often require evaluation and support of the cardiovascular system. Aging significantly impacts ventricular and vascular anatomy resulting in altered cardiac functionality. Physiological changes of aging include a blunted baroreflex and altered beta-adrenergic responsiveness resulting in a decreased dependence on chronotropy and an increased reliance on stroke volume in response to stress. Monitoring of the elderly cardiovascular system is valuable and can be achieved in a number of noninvasive and invasive methods. Management of shock in the elderly benefits from an understanding of the needs of the specific patient and a recognition of the risks/benefits of each cardiovascular medication.

Optimal support of critically ill surgical patients with cardiovascular dysfunction requires that the bedside clinician have both a clear understanding of basic cardiovascular physiology and thorough knowledge of the information available from invasive hemodynamic monitors, including the advantages and pitfalls of each system. Assessment of hemodynamic function in underperfused patients should start with a quantitative assessment of global cardiovascular function. Global variables can be flow derived (e.g., cardiac output), pressure derived (e.g., systolic blood pressure), or both (e.g., ventricular stroke work and power). Any assessment consistent with inadequate global hemodynamic performance should be followed by analysis of the independent determinants of cardiovascular function. These independent determinants include heart rate, preload, afterload, and myocardial contractility. Invasive hemodynamic monitors allow the bedside clinician to measure and quantitate various combinations of global performance and the determinants of cardiac function depending on the monitoring system employed. Central venous lines enable measurement of central venous pressure but limited measure of right ventricular preload. Pulmonary artery catheters offer information pertaining to several global measures and independent determinants. Devices that depend on pulse contour wave analysis, when coupled with a central venous catheter, can measure cardiac output and preload in the context of measurements of stroke volume. However, being invasive, each device carries some degree of risk to the patient, and each monitoring technique employed via these devices carries pitfalls in both measurement and interpretation. It is incumbent upon the bedside clinician to understand the physiologic derangements affecting the patient and the utility and pitfalls of the information available from each device when selecting monitoring systems to be used in any given patient and the supportive therapy that ensues. This review contains 3 figures, 1 table, and 28 references. Key words: afterload, cardiac output, central venous catheter, hemodynamic monitor, myocardial contractility, perfusion, preload, pulmonary artery catheter, pulse contour analysis, stroke volume, stroke volume variability, stroke work, ventricular power

Background Nonoperative management (NOM) of blunt splenic injury is well accepted. Substantial failure rates in higher injury grades remain common, with one large study reporting rates of 19.6%, 33.3%, and 75% for grades III, IV, and V, respectively. Retrospective data show angiography and embolization can increase salvage rates in these severe injuries. We developed a protocol requiring referral of all blunt splenic injuries, grades III to V, without indication for immediate operation for angiography and embolization. We hypothesized that angiography and embolization of high-grade blunt splenic injury would reduce NOM failure rates in this population. Study Design This was a prospective study at our Level I trauma center as part of a performance-improvement project. Demographics, injury characteristics, and outcomes were compared with historic controls. The protocol required all stable patients with grade III to V splenic injuries be referred for angiography and embolization. In historic controls, referral was based on surgeon preference. Results From January 1, 2010 to December 31, 2012, there were 168 patients with grades III to V spleen injuries admitted; NOM was undertaken in 113 (67%) patients. The protocol was followed in 97 patients, with a failure rate of 5%. Failure rate in the 16 protocol deviations was 25% (p = 0.02). Historic controls from January 1, 2007 to December 31, 2009 were compared with the protocol group. One hundred and fifty-three patients with grade III to V injuries were admitted during this period, 80 (52%) patients underwent attempted NOM. Failure rate was significantly higher than for the protocol group (15%, p = 0.04). Conclusions Use of a protocol requiring angiography and embolization for all high-grade spleen injuries slated for NOM leads to a significantly decreased failure rate. We recommend angiography and embolization as an adjunct to NOM for all grade III to V splenic injuries.

Summary The immediate early gene neuronal activity-regulated pentraxin (NARP) is an α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) binding protein that is specifically enriched at excitatory synapses onto fast-spiking parvalbumin-positive interneurons (FS [PV] INs). Here, we show that transgenic deletion of NARP decreases the number of excitatory synaptic inputs onto FS (PV) INs and reduces net excitatory synaptic drive onto FS (PV) INs. Accordingly, the visual cortex of NARP −/− mice is hyperexcitable and unable to express ocular dominance plasticity, although many aspects of visual function are unimpaired. Importantly, the number and strength of inhibitory synaptic contacts from FS (PV) INs onto principle neurons in the visual cortex is normal in NARP −/− mice, and enhancement of this output recovers the expression of experience-dependent synaptic plasticity. Thus the recruitment of inhibition from FS (PV) INs plays a central role in enabling the critical period for ocular dominance plasticity.

Background Recent studies have identified unique clinical and physiologic characteristics of emergency general surgery (EGS) patients and called for outcomes data in this population. There are no data in the US literature analyzing the impact of technique on anastomotic failure rates in EGS patients. The purpose of the current study was to compare outcomes of hand-sewn (HS) versus stapled (ST) bowel anastomoses in EGS patients. Methods A retrospective chart review of all patients admitted by our EGS service undergoing bowel resection for emergent indications from January 2007 to July 2011 was performed. Time from surgery to diagnosis of anastomotic failure was recorded as were the diagnostic modality and treatment of each anastomotic failure. Specific data on damage-control techniques, if used, were also collected. Results There were 100 HS (43%), and 133 ST (57%) anastomoses in 231 patients. Operative times were shorter in ST anastomosis technique (205 minutes for HS vs. 193 minutes for ST, p = 0.02). Anastomotic failures were identified in 26 patients (11%) and were significantly higher in the ST group than the HS group (15.0% vs. 6.1%, p = 0.003). A multivariate logistic regression analysis, controlling for age and preoperative nutritional status, revealed ST technique to be an independent risk factor for anastomotic failure (odds ratio, 2.65; 95% confidence interval, 1.08-6.50; p = 0.034). Conclusion Anastomotic failures are more than twice as likely with ST than HS anastomoses in the EGS population. This is true even when controlling for markers of preoperative nutrition and demographics. These data suggest that the HS anastomosis should be the preferred method of reconstruction after bowel resection in EGS patients.

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.

It is unclear how progranulin deficiency causes frontotemporal dementia, a neurodegenerative disease characterized by TDP-43 inclusions. Chang et al. show that loss of progranulin causes impairment of autophagy and autophagy signaling, which leads to accumulation of pathological TDP-43 in neurons., Loss-of-function mutations in GRN cause frontotemporal dementia (FTD) with transactive response DNA-binding protein of 43 kD (TDP-43)–positive inclusions and neuronal ceroid lipofuscinosis (NCL). There are no disease-modifying therapies for either FTD or NCL, in part because of a poor understanding of how mutations in genes such as GRN contribute to disease pathogenesis and neurodegeneration. By studying mice lacking progranulin (PGRN), the protein encoded by GRN, we discovered multiple lines of evidence that PGRN deficiency results in impairment of autophagy, a key cellular degradation pathway. PGRN-deficient mice are sensitive to Listeria monocytogenes because of deficits in xenophagy, a specialized form of autophagy that mediates clearance of intracellular pathogens. Cells lacking PGRN display reduced autophagic flux, and pathological forms of TDP-43 typically cleared by autophagy accumulate more rapidly in PGRN-deficient neurons. Our findings implicate autophagy as a novel therapeutic target for GRN-associated NCL and FTD and highlight the emerging theme of defective autophagy in the broader FTD/amyotrophic lateral sclerosis spectrum of neurodegenerative disease.

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 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.

Emergent operations are thought to carry higher morbidity and mortality than nonemergent cases. However, there is a lack of specific outcomes data for emergent general surgery procedures. The objective of our study was to assess and quantify postoperative morbidity and mortality for emergency versus nonemergency general surgery operations. All general surgery inpatients were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 database. Preoperative, intraoperative, and postoperative clinical metrics and occurrences were assessed. A total of 25,770 emergent and 98,867 nonemergent cases were identified. Postoperative morbidity was significantly worse in the emergent group, including ventilation more than 48 hours, bleeding requiring transfusion, deep vein thrombosis, renal failure, and need for reoperation. Overall, emergent cases had significantly more postoperative complications (22.8% vs 14.2%) and higher mortality rates (6.5% vs 1.4%). General surgery patients who undergo emergent operations have significantly poorer outcomes when compared with nonemergent patients; our analysis has quantified these differences. Emergent patients seem to manifest unique clinical, pathophysiologic, and inflammatory responses to their surgical disease. This data suggests that there is a need for improvement in both methods and systems of care for the emergent population.

BACKGROUND: : The early resuscitation occurs in the emergency department (ED) where intensive care unit protocols do not always extend and monitoring capabilities vary. Our hypothesis is that increased ED length of stay (LOS) leads to increased hospital mortality in patients not undergoing immediate surgical intervention. METHODS: : We examined all trauma activation admissions from January 2002 to July 2009 admitted to the Trauma Service (n = 3,973). Exclusion criteria were as follows: patients taken to the operating room within the first 2 hours of ED arrival, nonsurvivable brain injury, and ED deaths. Patients spending >5 hours in the ED were not included in the analysis because of significantly lower acuity and mortality. RESULTS: : Patients spent a mean of 3.2 hours ± 1 hour in the ED during their initial evaluation. Hospital mortality increases for each additional hour a patient spends in the ED, with 8.3% of the patients staying in the ED between 4 hours and 5 hours ultimately dying (p = 0.028). ED LOS measured in minutes is an independent predictor of mortality (odds ratio, 1.003; 95% confidence interval, 1.010-1.006; p = 0.014) when accounting for Injury Severity Score, Revised Trauma Score, and age. Linear regression showed that a longer ED LOS was associated with anatomic injury pattern rather than physiologic derangement. CONCLUSION: : In this patient population, a longer ED LOS is associated with an increased hospital mortality even when controlling for physiologic, demographic, and anatomic factors. This highlights the importance of rapid progression of patients through the initial evaluation process to facilitate placement in a location that allows implementation of early goal directed trauma resuscitation. Language: en

Homeostatic synaptic scaling alters the strength of synapses to compensate for prolonged changes in network activity, and involves both excitatory and inhibitory neurons. The immediate-early gene termed Narp (Neuronal activity-regulated pentraxin) encodes a secreted synaptic protein that can bind and cluster AMPA receptors (AMPARs). Here, we report that Narp prominently accumulates at excitatory synapses on Parvalbumin-expressing interneurons (PV-INs). Increasing network activity results in a homeostatic increase of excitatory synaptic strength onto PV-INs that increases inhibitory drive, and this response is absent in neurons cultured from Narp knock-out (Narp−/−) mice. Activity-dependent changes in the strength of excitatory inputs on PV-INs in acute hippocampal slices are also dependent on Narp, and Narp−/− mice display increased sensitivity to kindling-induced seizures. We propose that Narp recruits AMPARs at excitatory synapses onto PV-INs to rebalance network excitation/inhibition dynamics following episodes of increased circuit activity.

We appreciate the thoughts and comments provided by Allen et al in their correspondence to the editor. The care of the trauma patient requires an interdisciplinary approach. The American College of Surgeons Committee on Trauma (ACS COT), along with its partner organizations, such as American College of Emergency Physicians (ACEP), has diligently tried to make trauma center criteria centered on the patient and the multidisciplinary team concept. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has emerged as a potential technique for controlling previously lethal truncal hemorrhage in trauma patients, but its optimal role in the management of hemorrhagic shock has yet to be established. The purpose of the ACS and ACEP joint statement is to keep the focus on patient safety in the use of this device. We believe there is insufficient evidence to support the widespread adoption of REBOA1 in both civilian trauma centers and non-trauma centers where there is not immediate access to definitive hemorrhage control . This stance is due to concerns of the negative consequences of (1) prolonged ischemia and (2) delay of hemorrhage control as documented in published studies.2 In addition, the Joint Trauma Systems Clinical Practice Guideline notes, ‘… there is currently a paucity of evidence to guide the specific length …

The Joint Statement from the American College of Surgeons Committee on Trauma and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is intended to serve as a guide for the safe introduction and use of REBOA as a resuscitative tool for a select group of critically ill civilian trauma patients.1 Patient safety and quality care are at the forefront of these recommendations and we stand behind the statement. In no way did we intend to diminish or impair the Department of Defense physician leadership’s ability to implement combat casualty care clinical practice guidelines for REBOA implementation in deployed settings. We admire and appreciate the numerous contributions to care of the injured patient that have emerged from the years of conflict in Iraq and Afghanistan. They are a testimony to what unity of purpose, resiliency and creativity can bring in the quest …

Correct targeting of proteins to axons and dendrites is crucial for neuronal function. We showed previously that axonal accumulation of the cell adhesion molecule L1/neuron-glia cell adhesion molecule (NgCAM) depends on endocytosis (Wisco, D., E.D. Anderson, M.C. Chang, C. Norden, T. Boiko, H. Folsch, and B. Winckler. 2003. J. Cell Biol. 162:1317–1328). Two endocytosis-dependent pathways to the axon have been proposed: transcytosis and selective retrieval/retention. We show here that axonal accumulation of L1/NgCAM occurs via nondegradative somatodendritic endosomes and subsequent anterograde axonal transport, which is consistent with transcytosis. Additionally, we identify the neuronal-specific endosomal protein NEEP21 (neuron-enriched endosomal protein of 21 kD) as a regulator of L1/NgCAM sorting in somatodendritic endosomes. Down-regulation of NEEP21 leads to missorting of L1/NgCAM to the somatodendritic surface as well as to lysosomes. Importantly, the axonal accumulation of endogenous L1 in young neurons is also sensitive to NEEP21 depletion. We propose that small endosomal carriers derived from somatodendritic recycling endosomes can serve to redistribute a distinct set of membrane proteins from dendrites to axons.

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.

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.

Based on a large body of literature concerning the subject, trauma surgeons are becoming more comfortable with anastomosis rather than stoma creation in patients with destructive colon injuries requiring resection. This literature was largely generated before the widespread acceptance of the importance of damage control laparotomy (DCL). Thus, when such injuries occur in patients initially left in colonic discontinuity after DCL, the question of anastomosis versus stoma becomes more difficult, and there are no data to guide management decisions. The goal of this report is to describe the results of our early experience with delayed anastomosis (DA) after destructive colon injury in the setting of DCL. We reviewed the records of patients with destructive colon injuries at our Level I trauma center over a 5.5-year period for demographics, injury characteristics, and outcome. Studied outcomes included anastomotic leak, intra-abdominal abscess, and colon injury-related death. The decision to proceed with DA was based on individual surgeon opinion at the time of re-exploration. From January 1, 2000 to July 31, 2006, 92 patients sustained colon injury, 55 of which required resection (31 blunt mechanism and 24 penetrating). Twenty-two resections occurred in the setting of DCL. Six of these patients underwent stoma creation and 11 underwent DA. Three died before reoperation, and two had an anastomosis created during the initial DCL. The remaining 33 resections occurred during initial definitive operation, and 21 underwent anastomosis, whereas 12 had a stoma created. Comparing the 11 patients undergoing DA with the 21 undergoing immediate anastomosis, the anastomotic leak rate (0% vs 5%), abscess rate (36% vs 24%), and colon related-death rate (9% vs 0%; all P > 0.05) were similar. Six patients undergoing DA had a right hemicolectomy with ileocolonic anastomosis, four had a segmental left colon resection, and one had a near total abdominal colectomy with ileosigmoid anastomosis. Delayed anastomosis of colon injuries after DCL is safe in selected patients and has a similar complication rate as resection and anastomosis performed during initial definitive operation. DA avoids stoma creation in some patients who are not candidates for anastomosis during initial DCL. To our knowledge, this represents the first reported series of DA after DCL, an area in which further work is needed to carefully define indications for the safe application of this concept.

In patients with blunt splenic injury (BSI), patient selection, angiography, and embolization have contributed to low nonoperative management (NOM) failure rates. Despite these advances, some patients will fail NOM. We noted that a significant proportion of NOM failures had subcapsular hematomas (SCHs) identified on imaging. We sought to determine if there is a correlation between SCH and higher risk of NOM failure after BSI.Our institutional trauma registry was queried for all patients with BSI during a 2-year period. Charts were reviewed to determine grade, presence of SCH, and outcome of NOM. Under current institutional protocol, all stable patients with BSI Grades III to V and those with contrast blush on computed tomography are referred for angiography and embolization. Failure of NOM was declared if splenectomy was required for bleeding after an initial plan of nonoperation.From May 2012 to May 2014, 312 patients with BSI were identified. A total of 253 patients (81%) underwent NOM. Overall, 15 (5.9%) failed NOM. Of those undergoing NOM, 34 had SCH and 12 failed (35.3% vs. 1.5% without SCH, p = 0.0001). Failure rates in Grades 1 to 4 were 2.3%, 3.8%, 8.8%, and 19.2%, respectively. NOM failure rates in the subset with SCH for Grades I to IV were 20%, 25%, 30.8%, and 80%, respectively. These are significantly higher than patients without SCH in Grades II to IV (0%, p = 0.003; 2.3%, p = 0.008; and 4.8%, p = 0.016) and approach significance in Grade I (1.2%, p = 0.11). There were no SCHs and no failures of NOM in Grade V injuries.The NOM failure rate of BSI patients with SCH is significantly higher than those without SCH. Patients with BSI Grades I to III slated for NOM must be observed as the failure rate approaches 30%. Splenectomy should be considered in patients with Grade IV BSI with SCH, as NOM failure rate is 80%.Therapeutic study, level IV.

The reconstruction process in compressive sensing is an underdetermined problem. Existing reconstruction algorithms in compressive sensing approaches this problem using the standard sparsity model, where nonzero terms are randomly isolated among the signal. However, natural signals are tended to show group sparsity which may help in the reduction of computational complexity and acceleration of recovery processes of signals if being incorporated in algorithm designs. GOMP, modified from OMP, includes the concept of groups, yet because of fixed group division, GOMP suffers low column selection accuracy. Besides, the group distribution is unknown in most cases, fixed group division in GOMP is impractical. In this paper, we propose a new reconstruction algorithm, dynamic group allocation reconstruction (DGAR). The results show that the proposed method has better column selection accuracy in the context of group sparsity compared to its predecessors. Proposed DGAR algorithm is 50% and 100% higher in accuracy compared to GOMP algorithm and StOMP respectively when sparsity is 40 and group sparsity is 2.

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.

Severe injury and shock are frequently associated with abnormalities in patient body temperature. Substantial increases in mortality have been associated with profound hypothermia, especially below 35 degrees C. The purpose of this study was to further characterize the impact of hypothermia in a large dataset of trauma patients. This study was a retrospective analysis of the 2004 version of the National Trauma Data Bank (NTDB), which contains approximately 1.1 million patients from over 400 trauma centers. Admission temperature was analyzed with respect to mortality, injury severity score (ISS), base deficit (BD), Glasgow Coma Score (GCS), and hospital outcomes. The NTDB contained 701,491 patients with temperatures recorded upon trauma center admission. Of these, 11,026 patients had admission temperatures35 degrees C, and 802 had temperatures32 degrees C. Comparison of core temperature versus mortality revealed that as temperature decreased, the mortality rate increased, reaching approximately 39% at 32 degrees C, and remained constant at lower temperatures. Surprisingly, 477 patients (59.5%) survived with temperatures32 degrees C. Similarly, BD increased as hypothermia worsened until body temperature reached 31 degrees C, below which there was little further increase. Patients with admission temperatures less than 35 degrees C had significantly greater mortality (25.5% vs. 3.0%, P0.001) and BD (7.8 vs. 3.7, P0.001) when compared with patients with temperaturesor=35 degrees C. In survivors, average ventilator days and intensive care unit (ICU) days were 14.4 and 12.8, respectively, for patients with temperatures35 degrees C as opposed to more normothermic patients who demonstrated an average of 9.5 ventilator days and 9.1 ICU days (P0.001). When grouped by individual ISS, BD level, and GCS motor score, mortality was significantly greater when admission temperature was below 35 degrees C (ISS mean difference = 11.4%, BD mean difference = 22.8%, and GCS motor mean difference = 9.85%). Logistic regression revealed that hypothermia remains an independent determinant of mortality after correction for confounding variables (odds ratio = 1.54, 95% confidence interval 1.40-1.71). Admission hypothermia is associated with greater mortality, increased injury severity, more profound acidosis, and prolonged ICU/ventilator courses. However, although mortality at32 degrees C is high, patients with temperatures this low do survive. As temperatures drop below 32 degrees C, mortality rates remain constant, which may indicate a threshold below which physiologic mechanisms are unable to correct body temperature regardless of injury severity. Although shock severity is highly indicative of outcome, hypothermia independently contributes to the substantial mortality associated with severe injury.

INTRODUCTION: Helmet laws remain controversial. Opponents believe negative findings are a result of biased statistical analyses that fail to account for the impact of alcohol and drugs. In this study, we evaluated the effect that helmet use had upon injury severity, outcome controlling for alcohol or drug use, resource utilization, and financial burden using the National Trauma Data Bank (NTDB). METHODS:: Two groups of patients, helmeted and non-helmeted motorcyclists, were identified using the NTDB over an 8-year period. Group differences were compared using nonparametric Wilcoxon tests for continuous variables and Fisher's exact test for dichotomous outcomes. To evaluate the effect that alcohol or drug use had on mortality, logistic regression models were created. RESULTS:: A total of 9,769 patients were identified by the NTDB of which 6756 (69.2%) were helmeted and 3013 (30.8%) were non-helmeted. Helmet use was associated with lower injury severity, mortality, and resource utilization. Non-helmeted motorcyclists accrued greater hospital charges and were significantly less likely to have health insurance. When controlling for alcohol or drug use, mortality continued to be significantly associated with non-helmet use. CONCLUSION:: Non-helmeted motorcyclists have worse outcomes than their helmeted counterparts independent of the use of alcohol or drugs. Furthermore, they monopolize more hospital resources, incur higher hospital charges, and as non-helmeted motorcyclists frequently do not have insurance, reimbursement in this group of patients is poor. Thus, the burden of caring for these patients is transmitted to society as a whole.

Recent randomized prospective data suggest that early hyperglycemia is associated with excess mortality in critically ill patients, and tight glucose control leads to improved outcome. This concept has not been carefully examined in trauma patients, and the relationship of early hyperglycemia to mortality from sepsis in this population is unclear. The objective of this study was to determine the relationship different levels of early blood glucose elevation to outcome in a trauma ICU population.The records of all patients admitted to the ICU over a 2-year period at a Level I trauma center were reviewed for age, injury severity scores (ISS), admission Glasgow Coma Scale (GCS) score, base deficit (BD), blood glucose, and mortality. Three possible cutoffs in defining hyperglycemia were examined (glucoseor =110 mg/dL,or =150 mg/dL,or =200 mg/dL) in relation to infection and mortality. Early hyperglycemia was defined as elevated blood glucose on hospital days 1 or 2. Those with diabetes mellitus were excluded.From 1/00-12/01, 516 eligible patients were admitted to the ICU after injury. Early hyperglycemia occurred in 483 at theor =110 mg/dL level, 311 at theor =150 mg/dL level, and 90 patients at theor =200 mg/dL level. Univariate logistic regression demonstrated a significant relationship between ISS and subsequent infection(p = 0.02) and a trend toward such a relationship in GCS score, glucoseor =150 mg/dL, and glucoseor =200 mg/dL (p = 0.06, 0.12, and 0.06). A similar analysis for the relationship of these variables to eventual mortality showed a significant correlation with all examined variables except glucoseor =110 mg/dL. Multiple logistic regression to control for the effect of age, ISS, GCS score, and BD found early glucoseor =200 mg/dL to be an independent predictor of both infection and mortality while no such relationship was found withor = 110 mg/dL oror =150 mg/dL.Early hyperglycemia as defined by glucoseor =200 mg/dL is associated with significantly higher infection and mortality rates in trauma patients independent of injury characteristics. This was not true at the cutoffs ofor =110 mg/dL oror =150 mg/dL. These data support the need for a prospective analysis of tight glucose control, keeping serum glucose200 mg/dL in critically ill trauma patients. However, aggressive maintenance of levels110 mg/dL as reported by others may not be necessary.

Each year, the U.S. National Institutes of Health (NIH) invests substantial resources in core facilities that provide access to advanced cutting-edge technologies, expert consultation, and other services to scientific investigators. The facilities offer a number of services, ranging from systematic analysis and data processing, using specialized instrumentation, to access and expert advice on experimental design and evaluation needs, such as biostatistics, patient outreach, and clinical regulatory issues. The largest fraction of support for cores comes from the institutes and centers of the NIH, for example, through the National Cancer Institute (NCI) and National Center for Advancing Translational Sciences (NCATS). Significant NIH investment is spent on Center Core grants, particularly the NCI Cancer Centers, and the Clinical Translational Sciences Award Program supported by NCATS. The Office of the NIH Director’s Division of Program Coordination, Planning, and Strategic Initiatives (DPCPSI) also has a substantial investment in animal and biologic resource centers that provide models of human biology and disease for basic to clinical studies to researchers around the world. Many of these centers function like cores, as they provide the following: 1) high-quality, disease-free animals; 2) access to sophisticated technologies and facilities, as well as specialized animals; and 3) expert training by professional staff and consultation services. As an example, the NIH-supported National Primate Research Centers provide facilities, animals, and expertise for investigators who use nonhuman primates for biomedical research, facilitating >1000 individual research projects annually. The DPCPSI investment in core facilities also includes support through its Shared Instrument Grant program to purchase or upgrade expensive, specialized, commercially available instruments or integrated systems. This program promotes cost effectiveness; encourages optimal sharing among investigators, research groups, and departments; and fosters a collaborative, multidisciplinary environment. In many settings, the instrument is integrated in a centralized core facility. Through these investments and many other programs not listed, NIH’s annual support for research cores is estimated conservatively at $900 million. Given this large investment, it is critical that both NIH and the research institutions receiving support for these resources identify and implement approaches that enhance core resource efficiencies.

Neuronal polarity is, at least in part, mediated by the differential sorting of membrane proteins to distinct domains, such as axons and somata/dendrites. We investigated the pathways underlying the subcellular targeting of NgCAM, a cell adhesion molecule residing on the axonal plasma membrane. Following transport of NgCAM kinetically, surprisingly we observed a transient appearance of NgCAM on the somatodendritic plasma membrane. Down-regulation of endocytosis resulted in loss of axonal accumulation of NgCAM, indicating that the axonal localization of NgCAM was dependent on endocytosis. Our data suggest the existence of a dendrite-to-axon transcytotic pathway to achieve axonal accumulation. NgCAM mutants with a point mutation in a crucial cytoplasmic tail motif (YRSL) are unable to access the transcytotic route. Instead, they were found to travel to the axon on a direct route. Therefore, our results suggest that multiple distinct pathways operate in hippocampal neurons to achieve axonal accumulation of membrane proteins.

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

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

The ideal approach to diagnosis and management of patients with ventilator-associated pneumonia (VAP) has not been defined. Trauma patients with suspected VAP underwent bronchoscopy for collection of quantitative bacterial cultures and were randomized to receive either prompt empiric broad

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) provides a new tool in selected patients for the management of non-compressible torso hemorrhage.1–3 Recent improvements in technology have facilitated more rapid placement through smaller femoral access sheaths, which may reduce access-related complications.4 However, high grade evidence to guide REBOA use is limited, and there is a substantial complication risk should this approach be used inappropriately.5 To address the current state of implementation of this new therapeutic strategy, the American College of Surgeons Committee on Trauma (ACS COT) has worked in collaboration with the American College of Emergency Physicians to issue this joint policy statement which addresses the current practice relevant to patient indications, potential complications, implementation, patient management, and training of providers. We urge trauma centers to consider these factors in the adoption of this approach.

The U.S. National Institutes of Health (NIH) invests substantial resources in core research facilities (cores) that support research by providing advanced technologies and scientific and technical expertise as a shared resource. In 2010, the NIH issued an initiative to consolidate multiple core facilities into a single, more efficient core. Twenty-six institutions were awarded supplements to consolidate a number of similar core facilities. Although this approach may not work for all core settings, this effort resulted in consolidated cores that were more efficient and of greater benefit to investigators. The improvements in core operations resulted in both increased services and more core users through installation of advanced instrumentation, access to higher levels of management expertise; integration of information management and data systems; and consolidation of billing; purchasing, scheduling, and tracking services. Cost recovery to support core operations also benefitted from the consolidation effort, in some cases severalfold. In conclusion, this program of core consolidation resulted in improvements in the effective operation of core facilities, benefiting both investigators and their supporting institutions.

Placental abruption (PA) is a common cause of fetal demise in pregnant trauma patients. Diagnosis of PA may be difficult, and multiple diagnostic clues are currently used including uterine/ abdominal pain and tenderness, bleeding, maternal hemodynamic instability, and evidence of PA by ultrasonography or other fetal monitoring. Although diagnosis may be problematic fetal and maternal survival are dependent on early diagnosis and intervention. The purpose of this study is to determine predictive factors present at admission associated with PA in trauma victims. Records of all pregnant trauma patients admitted to Wake Forest University Baptist Medical Center over a 5-year period were reviewed for injury characteristics and outcome. Inclusion criteria included a confirmed pregnancy and fetal disposition. Specific admission parameters evaluated included temperature, heart rate, systolic blood pressure, partial pressure of CO2 in arterial blood, total white blood cell count (WBC) and differential, hematocrit, base deficit, and lactic acid. PA is defined as a spontaneous abortion in the first trimester or abruptio placenta in the second or third trimester. Between April 1, 1996 and October 30, 2000, 30 patients met study criteria. Six of 30 patients were found to have PA (20%). Of the studied parameters WBC was significantly elevated in PA patients (27 ± 4.6 vs 17 ± 7.8 WBC x 103/mm3; P = 0.005) as was band count (10 ± 6.6% vs 4 ± 6.1%; P = 0.03). Hematocrit was lower in the PA group (27 ± 4.3% vs 32 ± 5.4%; P = 0.04). Within this group of variables which differed on univariate analysis, WBC was the best discriminator between patients with and without PA (sensitivity 100%, specificity 79%, negative predictive value 100%, and positive predictive value 54%). In pregnant trauma patients WBC >20,000/mm3 on admission should raise suspicion of the possibility of PA, and close monitoring is warranted. Conversely WBC 3 rules out PA in the pregnant trauma patient (negative predictive value of 100%).