Search

Background: Algorithms for managing penetrating abdominal trauma are conflicting or vague regarding the role of laparoscopy. We hypothesized that laparoscopy is underutilized among hemodynamically stable patients with abdominal stab wounds., Methods: Trauma Quality Improvement Program data (2016-2019) were used to identify stable (SBP ≥110 and GCS ≥13) patients ≥16yrs with stab wounds and an abdominal procedure within 24hr of admission. Patients with a non-abdominal AIS ≥3 or missing outcome information were excluded. Patients were analyzed based on index procedure approach: open, therapeutic laparoscopy (LAP), or LAP-conversion to open (LCO). Center, clinical characteristics and outcomes were compared according to surgical approach and abdominal AIS using non-parametric analysis., Results: 5984 patients met inclusion criteria with 7 ​% and 8 ​% receiving therapeutic LAP and LCO, respectively. The conversion rate for patients initially treated with LAP was 54 ​%. Compared to conversion or open, therapeutic LAP patients had better outcomes including shorter ICU and hospital stays and less infection complications, but were younger and less injured. Assessing by abdominal AIS eliminated ISS differences, meanwhile LAP patients still had shorter hospital stays. At time of admission, 45 ​% of open patients met criteria for initial LAP opportunity as indicated by comparable clinical presentation as therapeutic laparoscopy patients., Conclusions: In hemodynamically stable patients, laparoscopy remains infrequently utilized despite its increasing inclusion in current guidelines. Additional opportunity exists for therapeutic laparoscopy in trauma, which appears to be a viable alternative to open surgery for select injuries from abdominal stab wounds., Level of Evidence: Prognostic and Epidemiological; Level IV., Competing Interests: Declaration of Competing interest The authors have no conflicts of interest or funding to disclose. All American Journal of Surgery Disclosure forms have been supplied and are provided as supplemental digital content., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Gold nanostructures were synthesized by etching away gold from heat-treated mesoporous silica-coated gold nanorods (AuNR@mSiO 2 ), providing an example of top-down modification of nanostructures made using bottom-up methodology. Twelve different types of nanostructures were made using this b ottom- u p- t hen- to p-dow n s ynthesis (BUTTONS), of which the etching of the same starting nanomaterial of AuNR@mSiO 2 was found to be controlled by how AuNR@mSiO 2 were heat treated, the etchant concentration, and etching time. When the heat treatment occurred in smooth moving solutions in round-bottomed flasks, red-shifted longitudinal surface plasmon resonance (LSPR) was observed, on the order of 10-30 min, indicating increased aspect ratios of the gold nanostructures inside the mesoporous silica shells. When the heat treatment occurred in turbulent solutions in scintillation vials, a blue shift of the LSPR was obtained within a few minutes or less, resulting from reduced aspect ratios of the rods in the shells. The influence of the shape of the glassware, which may impact the flow patterns of the solution, on the heat treatment was investigated. One possible explanation is that the flow patterns affect the location of opened pores in the mesoporous shells, with the smooth flow of solution mainly removing CTAB surfactants from the pores along the cylindrical body of mSiO 2 , therefore increasing the aspect ratios after etching, and the turbulent solutions removing more surfactants from the pores of the two ends or tips of the silica shells, hence decreasing the aspect ratios after etching. These new stable gold nanostructures in silica shells, bare and without surfactant protection, may possess unique chemical properties and capabilities. Catalysis using heat-treated nanomaterials was studied as an example of potential applications of these nanostructures., Competing Interests: The authors declare no competing financial interest., (© 2023 The Authors. Published by American Chemical Society.)

Level of Evidence: Literature synthesis and expert opinion, Level V., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members., Methods: Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed., Results: The algorithm is attached with detailed explanation of each step, supported by data if available., Conclusion: Blunt pancreatic trauma is rare and presents many treatment challenges., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Fragmented care and misaligned payment across Medicare and Medicaid lower care quality for dually eligible beneficiaries with mental illness. Accountable care organizations aim to improve the quality and value of care., Methods: Using Medicare fee-for-service Part A and B claims data from 2009 to 2017 and a difference-in-differences design, we compared the spending and utilization of dually eligible beneficiaries with mental illness that were and were not attributed to Medicare ACO providers before and after ACO contract entry., Results: Dually eligible beneficiaries with mental illness (N = 5,157,533, 70% depression, 22% bipolar, 27% schizophrenia and other psychotic disorders) had average annual Medicare spending of $17,899. ACO contract participation was generally not associated with spending or utilization changes. However, ACO contract participation was associated with higher rates of follow-up visits after mental health hospitalization: 1.17 and 1.30 percentage points within 7 and 30 days of discharge, respectively (p < 0.001). ACO-attributed beneficiaries with schizophrenia, bipolar, or other psychotic disorders received more ambulatory visits (393.9 per 1000 person-years, p = 0.002), while ACO-attributed beneficiaries with depression experienced fewer emergency department visits (-29.5 per 1000 person-years, p = 0.003) after ACO participation., Conclusions: Dually eligible beneficiaries served by Medicare ACOs did not have lower spending, hospitalizations, or readmissions compared with other beneficiaries. However, ACO participation was associated with timely follow-up after mental health hospitalization, as well as more ambulatory care and fewer ED visits for certain diagnostic groups., Implications: ACOs that include dually eligible beneficiaries with mental illness should tailor their designs to address the distinct needs of this population., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Abstract: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians., Level of Evidence: Consensus algorithm from the Western Trauma Association, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Extracellular vesicles (EVs) are secreted lipid bilayer vesicles that mediate cell to cell communication and are effectors of cell therapy. Previous work has shown that canonical Wnt signaling is necessary for cell and EV therapeutic potency. Tryptophan 2,3-dioxygenase (TDO2) is a target gene of canonical Wnt signaling. Augmenting TDO2 in therapeutically inert fibroblasts endows their EVs with immunomodulatory capacity including attenuating inflammatory signaling in macrophages. Transcriptomic analysis showed that macrophages treated with EVs from fibroblasts overexpressing TDO2 had blunted inflammatory response compared to control fibroblast EVs. In vivo , EVs from TDO2-overexpressing fibroblasts preserved cardiac function. Taken together, these results describe the role of a major canonical Wnt-target gene (TDO2) in driving the therapeutic potency of cells and their EVs., Competing Interests: EM owns founder stock in Capricor Therapeutics. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Peck, Ciullo, Li, Li, Morris, Marbán and Ibrahim.)

Background: Extracellular vesicles (EVs) isolated from cardiosphere-derived cells (CDC-EVs) are coming to light as a unique cell-free therapeutic. Because of their novelty, however, there still exist prominent gaps in knowledge regarding their therapeutic potential. Herein the therapeutic potential of CDC-EVs in a rat model of acute traumatic coagulopathy induced by multiple injuries and hemorrhagic shock is outlined., Methods: Extracellular vesicle surface expression of procoagulant molecules (tissue factor and phosphatidylserine) was evaluated by flow cytometry. Extracellular vesicle thrombogenicity was tested using calibrated thrombogram, and clotting parameters were assessed using a flow-based adhesion model simulating blood flow over a collagen-expressing surface. The therapeutic efficacy of EVs was then determined in a rat model of acute traumatic coagulopathy induced by multiple injuries and hemorrhagic shock., Results: Extracellular vesicles isolated from cardiosphere-derived cells are not functionally procoagulant and do not interfere with platelet function. In a rat model of multiple injuries and hemorrhagic shock, early administration of EVs significantly reduced the elevation of lactate and creatinine and did not significantly enhance coagulopathy in rats with acute traumatic coagulopathy., Conclusion: The results of this study are of great relevance to the development of EV products for use in combat casualty care, as our studies show that CDC-EVs have the potential to be an antishock therapeutic if administered early. These results demonstrate that research using CDC-EVs in trauma care needs to be considered and expanded beyond their reported cardioprotective benefits., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

There is a growing awareness that transient, sublethal embryonic exposure to crude oils cause subtle but important forms of delayed toxicity in fish. While the precise mechanisms for this loss of individual fitness are not well understood, they involve the disruption of early cardiogenesis and a subsequent pathological remodeling of the heart much later in juveniles. This developmental cardiotoxicity is attributable, in turn, to the inhibitory actions of crude oil-derived mixtures of polycyclic aromatic compounds (PACs) on specific ion channels and other proteins that collectively drive the rhythmic contractions of heart muscle cells via excitation-contraction coupling. Here we exposed Pacific herring (Clupea pallasi) embryos to oiled gravel effluent yielding ΣPAC concentrations as low as ~ 1 μg/L (64 ng/g in tissues). Upon hatching in clean seawater, and following the depuration of tissue PACs (as evidenced by basal levels of cyp1a gene expression), the ventricles of larval herring hearts showed a concentration-dependent reduction in posterior growth (ballooning). This was followed weeks later in feeding larvae by abnormal trabeculation, or formation of the finger-like projections of interior spongy myocardium, and months later with hypertrophy (overgrowth) of the spongy myocardium in early juveniles. Given that heart muscle cell differentiation and migration are driven by Ca 2+ -dependent intracellular signaling, the observed disruption of ventricular morphogenesis was likely a secondary (downstream) consequence of reduced calcium cycling and contractility in embryonic cardiomyocytes. We propose defective trabeculation as a promising phenotypic anchor for novel morphometric indicators of latent cardiac injury in oil-exposed herring, including an abnormal persistence of cardiac jelly in the ventricle wall and cardiomyocyte hyperproliferation. At a corresponding molecular level, quantitative expression assays in the present study also support biomarker roles for genes known to be involved in muscle contractility (atp2a2, myl7, myh7), cardiomyocyte precursor fate (nkx2.5) and ventricular trabeculation (nrg2, and hbegfa). Overall, our findings reinforce both proximal and indirect roles for dysregulated intracellular calcium cycling in the canonical fish early life stage crude oil toxicity syndrome. More work on Ca 2+ -mediated cellular dynamics and transcription in developing cardiomyocytes is needed. Nevertheless, the highly specific actions of ΣPAC mixtures on the heart at low, parts-per-billion tissue concentrations directly contravene classical assumptions of baseline (i.e., non-specific) crude oil toxicity., (Copyright © 2021. Published by Elsevier B.V.)

Objective: The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics., Design: An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics., Key Results: In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%)., Conclusions: Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

Cardiac remodeling results from both physiological and pathological stimuli. Compared with mammalian hearts, fish hearts show a broader array of remodeling changes in response to environmental influences, providing exceptional models for dissecting the molecular and cellular bases of cardiac remodeling. We recently characterized a form of pathological remodeling in juvenile pink salmon ( Oncorhynchus gorbuscha ) in response to crude oil exposure during embryonic cardiogenesis. In the absence of overt pathology (cardiomyocyte death or inflammatory infiltrate), cardiac ventricles in exposed fish showed altered shape, reduced thickness of compact myocardium and hypertrophic changes in spongy, trabeculated myocardium. Here, we used RNA sequencing to characterize molecular pathways underlying these defects. In juvenile ventricular cardiomyocytes, antecedent embryonic oil exposure led to dose-dependent upregulation of genes involved in innate immunity and two NKX homeobox transcription factors not previously associated with cardiomyocytes, nkx2.3 and nkx3.3 Absent from mammalian genomes, the latter is largely uncharacterized. In zebrafish embryos, nkx3.3 demonstrated a potent effect on cardiac morphogenesis, equivalent to that of nkx2.5 , the primary transcription factor associated with ventricular cardiomyocyte identity. The role of nkx3.3 in heart growth is potentially linked to the unique regenerative capacity of fish and amphibians. Moreover, these findings support a cardiomyocyte-intrinsic role for innate immune response genes in pathological hypertrophy. This study demonstrates how an expanding mechanistic understanding of environmental pollution impacts - i.e. the chemical perturbation of biological systems - can ultimately yield new insights into fundamental biological processes., Competing Interests: Competing interestsThe authors declare no competing or financial interests., (© 2019. Published by The Company of Biologists Ltd.)

Success of the accountable care organization (ACO) model may require stronger financial incentives, such as including downside risk in contracts. Using the National Survey of ACOs, we explored ACO structure and contracts in 2012-18. Though the number of ACO contracts and the proportion of ACOs with multiple contracts have grown, the proportion bearing downside risk has increased only modestly.

Molecular reactions in aqueous solutions are often used as dosimetric probes. A major problem with this approach is that other species such as nanoparticles or radical scavenging chemicals can often interfere with these reactions. The results measured in the presence of nanomaterials and scavengers therefore cannot correctly indicate the true dose based on the calibrated results obtained in solutions free of the interfering species. Storing these molecular probes in nanoreactors can overcome this problem. Here we demonstrate for the first time that it is possible to place common probe molecules inside spherical mesoporous silica shells and seal the pores after impregnation for the purpose of using the so-formed nanoreactors as X-ray dose probes. The reactions are isolated from the external environment, while the sealed shells still allow X-rays to freely penetrate through the walls of the nanoreactors. These nanoreactor probes can therefore fiducially report the dose of X-rays, whether the nanoreactors are in solutions, in dry form, or in the presence of scavengers and catalysts in solution.

Background: Screening for blunt cerebrovascular injuries (BCVIs) in asymptomatic high-risk patients has become routine. To date, the length of this asymptomatic period has not been defined. Determining the time to stroke could impact therapy including earlier initiation of antithrombotics in multiply injured patients. The purpose of this study was to determine the time to stroke in patients with a BCVI-related stroke. We hypothesized that the majority of patients suffer stroke between 24 hours and 72 hours after injury., Methods: Patients with a BCVI-related stroke from January 2007 to January 2017 from 37 trauma centers were reviewed., Results: During the 10-year study, 492 patients had a BCVI-related stroke; the majority were men (61%), with a median age of 39 years and ISS of 29. Stroke was present at admission in 182 patients (37%) and occurred during an Interventional Radiology procedure in six patients. In the remaining 304 patients, stroke was identified a median of 48 hours after admission: 53 hours in the 144 patients identified by neurologic symptoms and 42 hours in the 160 patients without a neurologic examination and an incidental stroke identified on imaging. Of those patients with neurologic symptoms, 88 (61%) had a stroke within 72 hours, whereas 56 had a stroke after 72 hours; there was a sequential decline in stroke occurrence over the first week. Of the 304 patients who had a stroke after admission, 64 patients (22%) were being treated with antithrombotics when the stroke occurred., Conclusions: The majority of patients suffer BCVI-related stroke in the first 72 hours after injury. Time to stroke can help inform clinicians about initiation of treatment in the multiply injured patient., Level of Evidence: Prognostic/Epidemiologic, level III.

Importance: Little is known about the types of primary care practices that have chosen to participate in the Comprehensive Primary Care Plus (CPC+) program or about how participation could affect disparities., Objective: To describe practices that joined the CPC+ model and compare hospital service areas with and without CPC+ practices., Design, Setting, and Participants: This comparative cross-sectional study identified 2647 CPC+ practices in round 1 (from January 1, 2017; round 1 is ongoing through 2021). Using IMS Health Care Organization Services data, ownership and characteristics of health systems and practices were extracted. Practices participating in the CPC+ program were compared with practices with similar proportions of primary care physicians (>85%) within the 14 regions designated as eligible to participate by the Centers for Medicare & Medicaid Services. Within eligible regions, hospital service areas with (n = 434) and without (n = 322) 1 or more CPC+ practice were compared. Characteristics compared included area-level population demographics (from the US Census Bureau), health system characteristics (from the IMS Health Care Organization Services), and use of health services by Medicare fee-for-service enrollees (Dartmouth Atlas)., Main Outcomes and Measures: Area-level characteristics of all eligible CPC+ regions, areas without a CPC+ practice, and areas with 1 or more CPC+ practices., Results: Of 756 eligible service areas, 322 had no CPC+ practices and 434 had at least 1 CPC+ practice. Of 2647 CPC+ practices, 579 (21.9%) had 1 physician and 1791 (67.7%) had 2 to 10 physicians. In areas without CPC+ practices, the population had a lower median income ($43 197 [interquartile range, $42 170-$44 224] vs $57 206 [interquartile range, $55 470-$58 941]), higher mean share of households living in poverty (17.8% [95% CI, 17.2%-18.4%] vs 14.4% [95% CI, 13.9%-15.0%]), higher mean educational attainment of high school or less (52.7% [95% CI, 51.7%-53.6%] vs 43.1% [95% CI, 42.1%-44.2%]), higher mean proportion of disabled residents (17.7% [95% CI, 17.3%-18.2%] vs 14.2% [13.8%-14.6%]), higher mean participation in Medicare (21.9% [95% CI, 21.3%-22.4%] vs 18.8% [95% CI, 18.3%-19.1%]) and Medicaid (22.2% [95% CI, 21.5%-22.9%]) vs 18.5% [95% CI, 17.8%-19.2%]), and higher mean proportion of uninsured residents (12.4% [95% CI, 11.9%-12.9%] vs 10.3% [95% CI, 9.9%-10.7%]) (P < .001 for all) compared with areas that had a CPC+ practice., Conclusions and Relevance: According to this study, although a diverse set of practices joined the CPC+ program, practices in areas characterized by patient populations with greater advantage were more likely to join, which may affect access to advanced primary care medical home models such as CPC+, by vulnerable populations.

Background: Extracellular vesicles (EVs) and exosomes are nano-sized, membrane-bound vesicles shed by most eukaryotic cells studied to date. EVs play key signaling roles in cellular development, cancer metastasis, immune modulation and tissue regeneration. Attempts to modify exosomes to increase their targeting efficiency to specific tissue types are still in their infancy. Here we describe an EV membrane anchoring platform termed "cloaking" to directly embed tissue-specific antibodies or homing peptides on EV membrane surfaces ex vivo for enhanced vesicle uptake in cells of interest. The cloaking system consists of three components: DMPE phospholipid membrane anchor, polyethylene glycol spacer and a conjugated streptavidin platform molecule, to which any biotinylated molecule can be coupled for EV decoration., Results: We demonstrate the utility of membrane surface engineering and biodistribution tracking with this technology along with targeting EVs for enhanced uptake in cardiac fibroblasts, myoblasts and ischemic myocardium using combinations of fluorescent tags, tissue-targeting antibodies and homing peptide surface cloaks. We compare cloaking to a complementary approach, surface display, in which parental cells are engineered to secrete EVs with fusion surface targeting proteins., Conclusions: EV targeting can be enhanced both by cloaking and by surface display; the former entails chemical modification of preformed EVs, while the latter requires genetic modification of the parent cells. Reduction to practice of the cloaking approach, using several different EV surface modifications to target distinct cells and tissues, supports the notion of cloaking as a platform technology.

Background: Intoxication often prevents clinical clearance of the cervical spine (Csp) after trauma leading to prolonged immobilization even with a normal computed tomography (CT) scan. We evaluated the accuracy of CT at detecting clinically significant Csp injury, and surveyed participants on related opinions and practice., Methods: A prospective multicenter study (2013-2015) at 17 centers. All adult blunt trauma patients underwent structured clinical examination and imaging including a Csp CT, with follow-up thru discharge. alcohol- and drug-intoxicated patients (TOX+) were identified by serum and/or urine testing. Primary outcomes included the incidence and type of Csp injuries, the accuracy of CT scan, and the impact of TOX+ on the time to Csp clearance. A 36-item survey querying local protocols, practices, and opinions in the TOX+ population was administered., Results: Ten thousand one hundred ninety-one patients were prospectively enrolled and underwent CT Csp during the initial trauma evaluation. The majority were men (67%), had vehicular trauma or falls (83%), with mean age of 48 years, and mean Injury Severity Score (ISS) of 11. The overall incidence of Csp injury was 10.6%. TOX+ comprised 30% of the cohort (19% EtOH only, 6% drug only, and 5% both). TOX+ were significantly younger (41 years vs. 51 years; p < 0.01) but with similar mean Injury Severity Score (11) and Glasgow Coma Scale score (13). The TOX+ cohort had a lower incidence of Csp injury versus nonintoxicated (8.4% vs. 11.5%; p < 0.01). In the TOX+ group, CT had a sensitivity of 94%, specificity of 99.5%, and negative predictive value (NPV) of 99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable Csp injuries missed by CT (NPV, 100%). When CT Csp was negative, TOX+ led to longer immobilization versus sober patients (mean, 8 hours vs. 2 hours; p < 0.01), and prolonged immobilization (>12 hrs) in 25%. The survey showed marked variations in protocols, definitions, and Csp clearance practices among participating centers, although 100% indicated willingness to change practice based on these data., Conclusion: For intoxicated patients undergoing Csp imaging, CT scan was highly accurate and reliable for identifying clinically significant spine injuries, and had a 100% NPV for identifying unstable injuries. CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization. There was wide disparity in practices, definitions, and opinions among the participating centers., Level of Evidence: Diagnostic tests or criteria, level II.

Background: For blunt trauma patients who have failed the NEXUS (National Emergency X-Radiography Utilization Study) low-risk criteria, the adequacy of computed tomography (CT) as the definitive imaging modality for clearance remains controversial. The purpose of this study was to prospectively evaluate the accuracy of CT for the detection of clinically significant cervical spine (C-spine) injury., Methods: This was a prospective multicenter observational study (September 2013 to March 2015) at 18 North American trauma centers. All adult (≥18 years old) blunt trauma patients underwent a structured clinical examination. NEXUS failures underwent a CT of the C-spine with clinical follow-up to discharge. The primary outcome measure was sensitivity and specificity of CT for clinically significant injuries requiring surgical stabilization, halo, or cervical-thoracic orthotic placement using the criterion standard of final diagnosis at the time of discharge, incorporating all imaging and operative findings., Results: Ten thousand seven hundred sixty-five patients met inclusion criteria, 489 (4.5%) were excluded (previous spinal instrumentation or outside hospital transfer); 10,276 patients (4,660 [45.3%] unevaluable/distracting injuries, 5,040 [49.0%] midline C-spine tenderness, 576 [5.6%] neurologic symptoms) were prospectively enrolled: mean age, 48.1 years (range, 18-110 years); systolic blood pressure 138 (SD, 26) mm Hg; median, Glasgow Coma Scale score, 15 (IQR, 14-15); Injury Severity Score, 9 (IQR, 4-16). Overall, 198 (1.9%) had a clinically significant C-spine injury requiring surgery (153 [1.5%]) or halo (25 [0.2%]) or cervical-thoracic orthotic placement (20 [0.2%]). The sensitivity and specificity for clinically significant injury were 98.5% and 91.0% with a negative predictive value of 99.97%. There were three (0.03%) false-negative CT scans that missed a clinically significant injury, all had a focal neurologic abnormality on their index clinical examination consistent with central cord syndrome, and two of three scans showed severe degenerative disease., Conclusions: For patients requiring acute imaging for their C-spine after blunt trauma, CT was effective for ruling out clinically significant injury with a sensitivity of 98.5%. For patients with an abnormal neurologic examination as the trigger for imaging, there is a small but clinically significant incidence of a missed injury, and further imaging with magnetic resonance imaging is warranted., Level of Evidence: Diagnostic tests, level II.

Nanosilver becomes labile upon entering the human body or the environment. This lability creates silver species with antimicrobial properties that make nanosilver attractive as active components in many consumer products, wound dressings, and agricultural applications. Because lability depends strongly on morphology, it is imperative to use a material with constant lability throughout kinetic studies so that accurate lability data can be acquired with efficient detection. Here 2.5nm thick silver was coated onto 90-nm diameter gold nanosphere cores and this surface silver layer was gradually removed by either chemical or X-ray radiation etching. The most sensitive region of a sigmoidal surface plasmon resonance (SPR) response as a function of silver thickness was found for the first time between 0.9- and 1.6-nm thick silver, revealing a new nanosilver standard for lability studies. The SPR peak position detection sensitivity is 8nm (SPR peak shift)/nm (silver thickness change) within this steepest region of the plasmon response curve whereas outside, sensitivity drops to 1nm/nm. Since the centroid of SPR profiles can be discerned with 0.25nm precision, the 8-nm/nm sensitivity means it is possible to detect a 0.3-angstrom or sub-monolayer change in silver thickness. The SPR response simulated by discrete dipole approximation (DDA) was an identical sigmoidal function between 0 and 2nm of silver coating. These findings were supported by several other analytical measurements, which confirmed no silver recoating during these etching processes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The 1989 Exxon Valdez disaster exposed embryos of pink salmon and Pacific herring to crude oil in shoreline spawning habitats throughout Prince William Sound, Alaska. The herring fishery collapsed four years later. The role of the spill, if any, in this decline remains one of the most controversial unanswered questions in modern natural resource injury assessment. Crude oil disrupts excitation-contraction coupling in fish heart muscle cells, and we show here that salmon and herring exposed as embryos to trace levels of crude oil grow into juveniles with abnormal hearts and reduced cardiorespiratory function, the latter a key determinant of individual survival and population recruitment. Oil exposure during cardiogenesis led to specific defects in the outflow tract and compact myocardium, and a hypertrophic response in spongy myocardium, evident in juveniles 7 to 9 months after exposure. The thresholds for developmental cardiotoxicity were remarkably low, suggesting the scale of the Exxon Valdez impact in shoreline spawning habitats was much greater than previously appreciated. Moreover, an irreversible loss of cardiac fitness and consequent increases in delayed mortality in oil-exposed cohorts may have been important contributors to the delayed decline of pink salmon and herring stocks in Prince William Sound.

Here we present the results of a stepwise synthesis of multiple large silica nanoparticles encapsulated in hollow, micron sized silica shells for future display applications. In the first step, 200-nm diameter silica nanoparticles were modified with 3-(trimethoxysilyl) propylmethacrylate (MPS) coupling agent. These nanoparticles were then embedded in micron-sized polystyrene particles synthesized through dispersion polymerization. To form silica shells on the polymer composite particles, tetraethylorthosilicate (TEOS) was added with cetyltrimethylammonium bromide (CTAB) surfactant. These three steps resulted in the formation of silica shell-covered solid polystyrene particles, each containing multiple silica nanoparticles. In the last step, polystyrene content was removed via calcination to achieve a multiple-silica-core-in-hollow-silica-shell composite structure. Dynamic light scattering (DLS) analysis and transmission electron microscopy (TEM) confirmed the core/shell morphology of the composite structure., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Resuscitation with blood products improves survival in patients with traumatic hemorrhage. However, the risk of venous thromboembolic (VTE) complications associated with fresh frozen plasma (FFP) resuscitation is unknown. We hypothesized that a higher ratio of FFP to packed red blood cells (PRBCs) given during acute resuscitation increases the risk of VTE independent of severity of injury and shock., Methods: The records of patients admitted from April 2007 to December 2011 who had surveillance lower extremity duplex ultrasounds were retrospectively reviewed. Patients who received at least 1 U of PRBCs within 24 hours of admission were included. Patients who died without VTE were excluded. The relationship between FFP and VTE was evaluated using logistic regression., Results: A total of 381 patients met inclusion criteria, of whom 77 (20.2%) developed VTE. In patients who required less than 4 U of PRBCs, increasing units of FFP were associated with an increasing risk for VTE, with each unit of FFP having an adjusted odds ratio of 1.27 (95% confidence interval, 1.04-1.54, p = 0.015). Conversely, in patients who required four or greater units of PRBCs, FFP in equal or greater ratios than PRBCs was not associated with VTE., Conclusion: Each unit of FFP increased VTE risk by 25% in patients who required less than 4 U of PRBCs. In patients who required 4 U or greater PRBCs, FFP administration conferred no increased risk of VTE. This suggests that FFP should be used cautiously when early hemodynamic stability can be achieved with less than 4 U of PRBCs., Level of Evidence: Care management study, level III.

Background: Older patients with traumatic brain injury (TBI) may be at high risk of death after hospitalization. The purpose of this study was to characterize long-term mortality of older TBI patients who survived to discharge. We hypothesized that predictors of postdischarge mortality differed from those of inpatient mortality., Methods: A retrospective cohort study was performed on TBI patients older than 55 years admitted to our Level I trauma center between July 1, 2006, and December 31, 2011. Postdischarge deaths were identified by matching patient data with local vital records up to December 31, 2011, when data collection was terminated (censoring). Patients were categorized by age, comorbidities, history of preinjury anticoagulant/prescription antiplatelet agent therapy, injury severity indices, initial TBI type, prehospital living status, discharge location, and discharge condition. The effect of risk factors on postdischarge mortality was evaluated by Cox proportional hazards modeling., Results: Of 353 patients, 322 (91.2%) survived to discharge. Postdischarge mortality was 19.8% (n = 63) for the study period. Of the postdischarge deaths, 54.0% died within 6 months of discharge, and 68.3% died within 1 year. Median days to death after discharge or censoring were 149 and 410, respectively. Factors associated with death after discharge included age, preinjury anticoagulant use, higher number of Charlson comorbidities, discharge to a long-term care facility, and severe disability. Factors related to injury severity (i.e., Injury Severity Score [ISS], initial Glasgow Coma Scale [GCS] score) and preinjury prescription antiplatelet agent use, previously found to predict inpatient death, did not predict postdischarge mortality., Conclusion: Older TBI patients who survive to discharge have a significant risk of death within 1 year. Predictors of postdischarge mortality and inpatient death differ. Death after discharge is largely a function of overall health status. Monitoring health status and continued aggressive management of comorbidities after discharge may be essential in determining long-term outcomes., Level of Evidence: Epidemiologic study, level III.

Background: Traumatic brain injury (TBI) is considered an independent risk factor of venous thromboembolism (VTE). However, the role of TBI severity in VTE risk has not been determined. We hypothesized that increased severity of brain injury in patients with isolated TBI (iTBI) is associated with an increased incidence of VTE., Methods: The records of patients admitted from June 2006 to December 2011 were reviewed for injury data, VTE risk factors, results of lower extremity surveillance ultrasound, and severity of TBI. Patients were identified by DRG International Classification of Diseases-9th Rev. codes for TBI, and only those with a nonhead Abbreviated Injury Scale (AIS) score of 1 or lower, indicating minimal associated injury, were included. The association of iTBI and VTE was determined using a case-control design. Among iTBI patients, those diagnosed with VTE (cases) were matched for age, sex, and admission year to those without VTE (controls). Data were analyzed using conditional logistic regression., Results: There were 345 iTBI patients: 41 cases (12%) and 304 controls (88%). A total of 151 controls could not be matched to an appropriate case and were excluded. Of the remaining 153 controls, 1 to 16 controls were matched to each of the 41 VTE cases. Compared with the controls, the cases had a higher mean head-AIS score (4.4 vs. 3.9, p = 0.001) and overall Injury Severity Score (20.4 vs. 16.8, p = 0.001). Following adjustment for all factors found to be associated with VTE (ventilator days, central line placement, operative time > 2 hours, chemoprophylaxis, history of VTE, and history of cancer), the cases were significantly more likely to have a greater head injury severity (head-AIS score ≥ 5; odds ratio, 5.25; 95% confidence interval, 1.59-17.30; p = 0.006)., Conclusion: The incidence of VTE in iTBI patients was significantly associated with the severity of TBI. VTE surveillance protocols may be warranted in these high-risk patients, as early detection of VTE could guide subsequent therapy., Level of Evidence: Epidemiologic/prognostic study, level III.

Background: Anticoagulants and prescription antiplatelet (ACAP) agents widely used by older adults have the potential to adversely affect traumatic brain injury (TBI) outcomes. We hypothesized that TBI patients on preinjury ACAP agents would have worse outcomes than non-ACAP patients., Methods: This was a 5.5-year retrospective review of patients 55 years and older admitted to a Level I trauma center with blunt force TBI. Patients were categorized as ACAP (warfarin, clopidogrel, dipyridamole/aspirin, enoxaparin, subcutaneous heparin, or multiple agents) or non-ACAP. ACAP patients were further stratified by class of agent (anticoagulant or antiplatelet). Initial and subsequent head computerized tomographic results were examined for type and progression of TBI. Patient preadmission living status and discharge destination were identified. Primary outcome was in-hospital mortality. Secondary outcomes were progression of initial TBI, development of new intracranial hemorrhage (remote from initial), and the need for an increased level of care at discharge., Results: A total of 353 patients met inclusion criteria: 273 non-ACAP (77%) and 80 ACAP (23%). Upon exclusion of three patients taking a combination of agents, 350 were available for advanced analyses. ACAP status was significantly related to in-hospital mortality. After adjustment for patient and injury characteristics, anticoagulant users were more likely than non-ACAP patients to show progression of initial hemorrhage and develop a new hemorrhagic focus. However, compared with non-ACAP users, antiplatelet users were more likely to die in the hospital. Among survivors to discharge, anticoagulant users were more likely to be discharged to a care facility, but this finding was not robust to adjustment., Conclusion: Older TBI patients on preinjury ACAP agents experience a comparatively higher rate of inpatient mortality and other adverse outcomes caused by the effects of antiplatelet agents. Our findings should inform decision making regarding prognosis and caution against grouping anticoagulant and antiplatelet users together in considering outcomes., Level of Evidence: Therapeutic study, level IV.

Background: Reliance on chest-abdomen-pelvis computed tomography (CAP) in the initial evaluation of blunt trauma is a major source of patient radiation exposure. Our trauma surgeon group (TSG) modified its practice to limit the use of CAP. We evaluated the effect of this practice change on patient radiation exposure and diagnostic accuracy., Methods: We compared data on blunt injury trauma activations evaluated by the five-member TSG for two 6-month intervals, before (T1) and after (T2) instituting the practice change. Patient demographic and injury data, complications, torso imaging and radiation dosage were collected. Following analysis of T1, the surgeon with the lowest CAP use was identified and found to have no errors or delays in diagnosis. The TSG agreed to adopt that surgeon's focus on findings of the physical examination and Focused Assessment Sonography for Trauma to reduce CAP use in the initial evaluation. T2 was analyzed to assess the effect of implementation of this guideline., Results: There were 897 patients in T1 and 948 in T2. In the two intervals, patients did not differ by age, sex, mortality, or probability of survival. CAP use decreased by 38.5% with a significant drop in mean patient radiation exposure (p < 0.001). There were no missed injuries or delays in diagnosis in either interval., Conclusion: The use of CAP and its associated radiation burden in the initial evaluation of blunt trauma can be reduced without diagnostic errors by comparing use and identifying best practice. This process has implications for optimal trauma care., Level of Evidence: Diagnostic study, level IV; case management study, level IV.

Background: Trauma centers are more frequently evaluating patients who are receiving anticoagulant or prescription antiplatelet (ACAP) therapy at the time of injury. Because there are reports of delayed intracranial hemorrhage (ICH) after blunt trauma in this patient group, we evaluated patients receiving ACAP with a head computed tomography (CT) on admission (CT1) followed by a routine repeat head CT (CT2) in 6 hours. We hypothesized that among patients with no traumatic findings on CT1 and a normal or unchanged interval neurologic examination, the incidence of clinically significant delayed ICH would be zero., Methods: We retrospectively reviewed adult blunt trauma patients admitted to our Level I trauma center from January 2006 to August 2009 who were receiving preinjury ACAP therapy. We reviewed medications, mechanism of injury, head CT results, and outcomes. Demographic data, injury severity scores, international normalized ratio, and neurologic examinations were recorded. We determined the incidence of delayed ICH on CT2 for patients with a negative CT1., Results: Five hundred patients qualified for the protocol. Of these, 424 patients (85%) had a negative CT1. Among these patients, mean age was 75 years; 210 (50%) were male. Fall from standing was the most common mechanism of injury found in 357 patients (84%). Warfarin alone was taken in 68%, clopidogrel alone in 24%, and other agents in 2%. Six percent of patients were taking two agents. Mean international normalized ratio for patients on warfarin was 2.5. Among patients with a negative CT1, CT2 was obtained in 362 patients (85%) and was negative in 358 patients (99%). Four patients (1%) with a negative CT1 had a positive (n = 3) or equivocal (n = 1) CT2. All the changes on CT2 were minor and had either resolved or stabilized on third head CT. Of the four patients with positive or equivocal CT2, none had a change in neurologic examination; however, two had symptoms that could be attributed to head injury. Three were discharged home and one died of cardiac disease unrelated to head trauma., Conclusions: The incidence of delayed ICH in our study was 1%. However, none of the delayed findings were clinically significant. Among patients on ACAP therapy with a negative CT1 and a normal or unchanged neurologic examination, a routine CT2 is unnecessary. We recommend a period of observation to recognize those patients with symptoms that could be due to delayed ICH.

A competitive enzyme-linked immunosorbent assay was developed to quantitate vitellogenin (VTG) in plasma and serum of coho (Oncorhynchus kisutch) and chinook (O. tshawytscha) salmon. The working range of the assay was 9 to 313 ng/ml (80-20% binding), with 50% binding at 54 ng/ml. The intra-assay and interassay variations at approximately 50% binding were 8.1% (n = 9) and 9.0% (n = 9), respectively. Dilution curves of plasma or serum from coho and chinook females and estrogen-treated males were parallel to the purified coho VTG standard curve. Male plasma samples could be assayed at a minimum dilution of 1:40 (chinook) or 1:75 (coho) without assay interference because of high sample concentration, whereas minimum acceptable dilutions of male serum samples were 1:200 (chinook) or 1:600 (coho). Identification of proper techniques for preserving VTG integrity in plasma and serum samples showed that VTG from both species was robust; both sample types required no protease inhibitor despite subjection to two freeze-thaw cycles. To test its applicability, this assay was used to measure VTG in out-migrating juvenile chinook that were collected from urban and nonurban areas in Puget Sound, Washington, USA. Results showed a small but significant plasma VTG elevation at two urban sites, suggesting that these juveniles may be exposed to environmental estrogens at an early life stage. Also, wild fish tended to have higher plasma VTG levels than hatchery fish collected in the field. Elevation of mean VTG levels was similar to that previously reported in male English sole from the same area, where both males and females exhibited alterations in timing of spawning., (© 2010 SETAC.)