Acute respiratory distress syndrome, acute kidney injury, and mortality after trauma are associated with increased circulation of syndecan-1, soluble thrombomodulin, and receptor for advanced glycation end products

BACKGROUND

Disruption of the vascular endothelium and endothelial glycocalyx (EG) has been described after severe trauma. Plasma has been suggested to restore microvascular integrity by preservation and repair of the EG. We sought to evaluate whether plasma administered in a 1:1:1 ratio was associated with less endothelial marker circulation than a 1:1:2 ratio.

METHODS

This is a secondary analysis of the PROPPR trial, which investigated post-traumatic resuscitation with platelets, plasma, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio. Syndecan-1, soluble thrombomodulin (sTM), and receptor for advanced glycation end products (RAGE) were quantified for each treatment group on admission and at 2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours. Patients were excluded if they did not survive longer than 3 hours or had data from fewer than two time points.

RESULTS

Three hundred eight patients in the 1:1:1 group and 291 in the 1:1:2 group were analyzed. There were no statistically significant differences in syndecan-1, sTM, or RAGE between treatment groups at any time point ( p > 0.05). Patients who developed acute respiratory distress syndrome, acute kidney injury, and death had significantly elevated biomarker expression at most time points when compared with patients who did not develop these sequelae ( p < 0.05).

CONCLUSION

Administration of FFP in a 1:1:1 ratio does not consistently affect circulation of endothelial biomarkers following significant trauma when compared with a 1:1:2 ratio. The development of post-traumatic ARDS, AKI, and death was associated with increased endothelial biomarker circulation.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Design of the CRYPTICS Trial: A Randomized Controlled Trial Comparing Cryopreserved to Liquid Stored Platelets in Patients Undergoing Cardiac Surgery

Objective

Dimethylsulfoxide-cryopreserved platelets are being evaluated for treatment of acute hemorrhage in patients with thrombocytopenia or platelet dysfunction when liquid stored platelets are unavailable. Patients undergoing cardiac surgery with cardiopulmonary bypass with risk factors for significant bleeding represent a population for which determining efficacy and safety of cryopreserved platelets is ideal in the clinical trial setting. The primary objective is to compare blood loss in cardiopulmonary bypass patients receiving cryopreserved platelets or liquid stored platelets.

Methods

In patients undergoing cardiac surgery utilizing cardiopulmonary bypass, a standardized algorithm with transfusion triggers will be used to guide the intra- and postoperative administration of study platelets, either cryopreserved platelets or liquid stored platelets, based on the clinical presentation. The primary efficacy end point was the volume of blood loss from completion of chest closure (time 0) until the time chest tubes were removed or 24 hours after chest closure, whichever is earlier.

Results

This design article describes an ongoing multicenter, randomized, blinded trial to evaluate noninferiority or superiority of cryopreserved platelets with liquid stored platelets in controlling blood loss in patients undergoing cardiopulmonary bypass surgery.

Conclusions

Frozen storage could substantially safely extend the shelf life of stored platelets. If efficacy and safety were demonstrated in this trial, current constraints on platelet use in low resource military and civilian settings would be relieved.

Contemporary Management and Outcomes of Injuries to the Inferior Vena Cava: A Prospective Multicenter Trial From PROspective Observational Vascular Injury Treatment

INTRODUCTION

Injuries to the inferior vena cava (IVC), while uncommon, have a high mortality despite modern advances. The goal of this study is to describe the diagnosis and management in the largest available prospective data set of vascular injuries across anatomic levels of IVC injury.

METHODS

The American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry was queried from November 2013 to January 2019. Demographics, diagnostic modalities, injury patterns, and management strategies were recorded and analyzed. Comparisons between anatomic levels were made using non-parametric Wilcoxon rank-sum statistics.

RESULTS

140 patients from 19 institutions were identified; median age was 30 years old (IQR 23-41), 75% were male, and 62% had penetrating mechanism. The suprarenal IVC group was associated with blunt mechanism (53% vs 32%, P = .02), had lower admission systolic blood pressure, pH, Glasgow Coma Scale (GCS), and higher ISS and thorax and abdomen AIS than the infrarenal injury group. Injuries were managed with open repair (70%) and ligation (30% overall; infrarenal 37% vs suprarenal 13%, P = .01). Endovascular therapy was used in 2% of cases. Overall mortality was 42% (infrarenal 33% vs suprarenal 66%, P<.001). Among survivors, there was no difference in first 24-hour PRBC transfusion requirement, or hospital or ICU length of stay.

CONCLUSIONS

Current PROOVIT registry data demonstrate continued use of ligation extending to the suprarenal IVC, limited adoption of endovascular management, and no dramatic increase in overall survival compared to previously published studies. Survival is likely related to IVC injury location and total injury burden.

Rectal Injury After Foreign Body Insertion: Secondary Analysis From the AAST Contemporary Management of Rectal Injuries Study Group

BACKGROUND

Retained rectal foreign bodies are a common but incompletely studied problem. This study defined the epidemiology, injury severity, and outcomes after rectal injuries following foreign body insertion.

METHODS

Twenty-two level I trauma centers retrospectively identified all patients sustaining a rectal injury in this AAST multi-institutional trial (2005-2014). Only patients injured by foreign body insertion were included in this secondary analysis. Exclusion criteria were death before rectal injury management or ≤48 h of admission. Demographics, clinical data, and outcomes were collected. Study groups were defined as partial thickness (AAST grade I) versus full thickness (AAST grades II-V) injuries. Subgroup analysis was performed by management strategy (nonoperative versus operative).

RESULTS

After exclusions, 33 patients were identified. Mean age was 41 y (range 18-57), and 85% (n = 28) were male. Eleven (33%) had full thickness injuries and 22 (67%) had partial thickness injuries, of which 14 (64%) were managed nonoperatively and 8 (36%) operatively (proximal diversion alone [n = 3, 14%]; direct repair with proximal diversion [n = 2, 9%]; laparotomy without rectal intervention [n = 2, 9%]; and direct repair alone [n = 1, 5%]). Subgroup analysis of outcomes after partial thickness injury demonstrated significantly shorter hospital length of stay (2 ± 1; 2 [1-5] versus 5 ± 2; 4 [2-8] d, P = 0.0001) after nonoperative versus operative management.

CONCLUSIONS

Although partial thickness rectal injuries do not require intervention, difficulty excluding full thickness injuries led some surgeons in this series to manage partial thickness injuries operatively. This was associated with significantly longer hospital length of stay. Therefore, we recommend nonoperative management after a retained rectal foreign body unless full thickness injury is conclusively identified.

'Step Up' approach to the application of REBOA technology in a rural

Our group has developed a ‘Step Up’ approach to the application of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a rural trauma system. This incorporates viewing REBOA as a spectrum of technology. Examples of REBOA technology use to improve outcomes and provision of our system’s clinical practice guideline for the Step-Up application of REBOA technology in the care of trauma patients are presented.

Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke

Background. Effective treatment methods are needed for moderate/severely impairment chronic stroke. Objective. The questions were the following: (1) Is there need for long-dose therapy or is there a mid-treatment plateau? (2) Are the observed gains from the prior-studied protocol retained after treatment? Methods. Single-blind, stratified/randomized design, with 3 applied technology treatment groups, combined with motor learning, for long-duration treatment (300 hours of treatment). Measures were Arm Motor Ability Test time and coordination-function (AMAT-T, AMAT-F, respectively), acquired pre-/posttreatment and 3-month follow-up (3moF/U); Fugl-Meyer (FM), acquired similarly with addition of mid-treatment. Findings. There was no group difference in treatment response (P ≥ .16), therefore data were combined for remaining analyses (n = 31; except for FM pre/mid/post, n = 36). Pre-to-Mid-treatment and Mid-to-Posttreatment gains of FM were statistically and clinically significant (P < .0001; 4.7 points and P < .001; 5.1 points, respectively), indicating no plateau at 150 hours and benefit of second half of treatment. From baseline to 3moF/U: (1) FM gains were twice the clinically significant benchmark, (2) AMAT-F gains were greater than clinically significant benchmark, and (3) there was statistically significant improvement in FM (P < .0001); AMAT-F (P < .0001); AMAT-T (P < .0001). These gains indicate retained clinically and statistically significant gains at 3moFU. From posttreatment to 3moF/U, gains on FM were maintained. There were statistically significant gains in AMAT-F (P = .0379) and AMAT-T P = .003.

Damage Control Resuscitation

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

The research agenda for trauma critical care

In this research agenda on the acute and critical care management of trauma patients, we concentrate on the major factors leading to death, namely haemorrhage and traumatic brain injury (TBI). In haemostasis biology, the results of randomised controlled trials have led to the therapeutic focus moving away from the augmentation of coagulation factors (such as recombinant factor VIIa) and towards fibrinogen supplementation and administration of antifibrinolytics such as tranexamic acid. Novel diagnostic techniques need to be evaluated to determine whether an individualised precision approach is superior to current empirical practice. The timing and efficacy of platelet transfusions remain in question, while new blood products need to be developed and evaluated, including whole blood variants, lyophilised products and novel red cell storage modalities. The current cornerstones of TBI management are intracranial pressure control, maintenance of cerebral perfusion pressure and avoidance of secondary insults (such as hypotension, hypoxaemia, hyperglycaemia and pyrexia). Therapeutic hypothermia and decompressive craniectomy are controversial therapies. Further research into these strategies should focus on identifying which subgroups of patients may benefit from these interventions. Prediction of the long-term outcome early after TBI remains challenging. Early magnetic resonance imaging has recently been evaluated for predicting the long-term outcome in mild and severe TBI. Novel biomarkers may also help in outcome prediction and may predict chronic neurological symptoms. For trauma in general, rehabilitation is complex and multidimensional, and the optimal timing for commencement of rehabilitation needs investigation. We propose priority areas for clinical trials in the next 10 years.

Comparison of Sepsis Screening Tools' Ability to Detect Sepsis Accurately

BACKGROUND

Sepsis is the primary cause of perioperative mortality among general surgery patients and is the leading cause of death in non-cardiac intensive care units. To address this issue, the Surviving Sepsis Campaign Guidelines advocate for sepsis screening. However, there is little information in the current medical literature to suggest which sepsis screening tool is optimal. The purpose of this study was to compare a sepsis screening tool that we have validated and published previously, the Sepsis Screening Score (SSS), with a commercially available sepsis screening tool, the St. John's Sepsis Agent (SJSA) developed by Cerner (Kansas City, MO).

METHODS

This prospective observational study compares the accuracy of the SSS with that of the SJSA in the same patient population. The SSS was performed on each patient in our surgical intermediate care unit (SIMU) twice daily. The SJSA monitored these same patients continuously via the electronic medical record (EMR). Epidemiologic data related to sepsis were collected prospectively, and the performance characteristics of the two tests were compared using the two-sample test of proportions.

RESULTS

A total of 348 patients were included in the study, and 47 (13.5%) of these patients developed sepsis. The SJSA was determined to have a sensitivity of 44.7%, a specificity of 84.7%, a positive predictive value (PPV) of 31.3%, and a negative predictive value (NPV) of 90.7%, while the SSS was determined to have a sensitivity of 74.5%, a specificity of 86.4%, a PPV of 46.1%, and an NPV of 95.6%. The differences in sensitivity (p < 0.001), PPV (p < 0.001), and NPV (p = 0.011) were found to be statistically significant.

CONCLUSION

Despite the fact that SJSA had constant surveillance over patients' EMRs, it still detected fewer septic patients than the SSS, which was performed twice per day. The difference in sensitivities and NPVs between the two tests is of particular importance, because this indicates that the SSS is more effective in identifying patients with sepsis. This study establishes a basis for the utilization of the SSS instead of the SJSA.

Abstract WP149: Greater Recovery of Upper Limb Function in Moderate/Severely Impaired Chronic Stroke in Response to Customized Whole Limb vs Prescribed Focused Training

Introduction: The purpose of this study was to compare the following three treatments of upper limb motor impairment in chronic moderate/severely impaired stroke survivors: 1) Customized whole limb motor learning (Whole ML), including shoulder/elbow robotics (ROB) and functional electrical stimulation (FES); 2) prescribed shoulder/elbow ROB + motor learning (S/E ROB ML); and 3) prescribed wrist/hand FES + ML (W/H FES ML).

Methods: Subjects with chronic stroke were stratified according to relative level of impairment (Fugl-Meyer coordination Test) in wrist/hand versus shoulder/elbow. Their stratification category dictated the treatment group to which they were allocated, as follows: 1) WHOLE ML (n=18), equal distal and proximal impairment; 2) S/E ROB ML (n=10 ), greater shoulder/elbow impairment; and 3) FES ML (n=8), greater wrist/hand impairment. Treatment was 5 days/wk, 5 hrs/day, 60 sessions. Primary measure was the Arm Motor Assessment Tool, 13 complex tasks, Functional Scale (AMAT-F), acquired at baseline and at follow-up, 3 months after last treatment. Secondary measures were subscales, AMAT-F Shoulder/Elbow (AMAT-F S/E) and AMAT Wrist/Hand (AMAT-F W/H). Statistical analyses were Kruskal Wallace model to account for group size differences; group comparisons and within-group pre-/follow-up comparisons were analyzed (and multiple comparisons corrections).

Results: All three groups had significant within-group gain for AMAT-F (p=.0007; p=.039; p=.047, respectively; similar results were shown for AMAT S/E subscale. Only the Whole ML group had significant gain in AMAT W/H (p=.007). Gain for all three groups exceeded the threshold for clinically significant gain in AMAT-F (.21 points), as follows: Whole ML (.66 points, 3 x’s the threshold); S/E ROB ML (.53 points, 2.5 x’s); W/H FES ML (.46 points, 2 x’s).

Conclusion: For the customized whole limb motor learning group there was greater improvement in upper limb function versus the two groups that received prescribed, focused training for either shoulder/elbow or wrist/hand, according to the AMAT-F clinically significant threshold and according to the AMAT-F W/H subscale.

The hidden war: humanitarian surgery in a combat zone

BACKGROUND

Humanitarian surgical care (HSC) provided during wartime plays a substantial role in military operations, but has not been described or quantified beyond individual experiences.

METHODS

Prospective survey was conducted of all military members deployed to Iraq or Afghanistan between 2002 and 2011.

RESULTS

There were 266 responses. On average, surgeons had been in practice for 3 years at their 1st deployment and the majority were not fellowship trained. HSC was performed on all body systems and patient populations, including surgery for malignancy. Although 30% of responders performed surgeries they had never done before as a staff surgeon, 84% felt well prepared by their residency. The majority felt that performing HSC improved unit readiness (60%), benefited local population (64%), and contributed to counterinsurgency operations (54%).

CONCLUSION

Over our 10-year period, hundreds of military surgeons performed countless HSC cases in Iraq and Afghanistan and the majority felt that HSC had numerous benefits.

Abstract 16: Pattern Of Brain Function Change In Multiple Regions Predicts Mitigation Of Spasticity Following Intensive Arm Neurorehabilitation In Chronic Stroke

Background: Spasticity can prevent productive practice of skilled movement that should occur during neurorehabilitation of coordinated arm movements after stroke. Studies showed that spasticity could be reduced following an intervention that inhibited activation of the contralesional primary motor region (M1) using non-invasive transcranial magnetic or electric stimulation. However, there is little understanding of how the mitigation of spasticity might be controlled by the multiple sensorimotor control brain regions. Therefore, the aim of this study was to evaluate the change in activation patterns of multiple sensorimotor regions that predict the mitigation of spasticity, in response to intensive upper limb neurrehabiltiation.

Methods: Twenty three stroke subjects (>6 months after stroke) with persistent arm motor deficits were treated with intensive upper extremity rehabilitation (5 hours/day, 5 days/week for 12 weeks). Baseline and post-rehab evaluation consisted of three measures: 1) functional magnetic resonance imaging (fMRI) during a shoulder/elbow reach task for the paretic arm, 2) a skilled motor function (Arm Motor Assessment test (AMAT)), and 3) spasticity (Modified Ashworth Scale(MAS)). Volume of brain activation (voxel count) during the reach task was calculated for sensory and motor control regions using SPM05 (London, UK) and in-house software in MATLAB (Natick, MA). Paired t-test analysis was conducted for pre- vs post-treatment comparisons. Multiple linear regression analysis was conducted, where post-rehab AMAT was the dependent variable, the co-variate was pre-rehab score, and the predictors were change from pre- to post-rehab in voxel count in bilateral M1, somatosensory (SS), posterior parietal (PP), lateral premotor (LPM) and supplementary motor (SMA) areas.

Results: Subject characteristics were as follows: mean age, 56.3 ±12.8years; 41%, female; and 1.8±1.1 years after first ever stroke. Change in the activation pattern in a number of regions significantly predicted mitigated spasticity (R2=.86). Specifically, in response to treatment, increased activation, in ipsilesional SMA (p=.002) and contralesional M1 (p=.002), predicted mitigated spasticity. Reduction in activation volume, in ipsilesional PP region (p=.0009), contralesional SS (p=.008) and SMA (p=.006), predicted mitigated spasticity. AMAT score improved from 1636.63±668.41 to 1213.67±6643.79 seconds (p<.0001) and MAS scores improved from 6.81±2.75 to 1.86±1.49 (p<.0001).

Conclusions: A specific pattern of functional brain change across multiple regions predicted mitigation of spasticity following neurorehabilitation; skill functional recovery occurred, as well. This information could be used in constructing study design for future research that would investigate brain training to mitigate spasticity and improve skilled functional task performance.

A keratin biomaterial gel hemostat derived from human hair: evaluation in a rabbit model of lethal liver injury

Effective hemostatic dressings that are compatible with tissues are needed. Keratins are a class of biomaterials that can be derived by extraction of proteins from human hair. We have recently discovered that keratin biomaterials have hemostatic characteristics and hypothesize that a keratin hydrogel having the ability to absorb fluid and bind cells may be an effective hemostat. The goal of this study was to test a keratin hydrogel and evaluate it compared to current hemostats. Thirty-two New Zealand white rabbits received a lethal liver injury. Eight animals each were assigned to negative control, QuickClot, HemCon bandage, and keratin treatment groups. Vital stats and other data were recorded during surgery and all surviving animals were sacrificed after 72 h. Histology was conducted on all surviving animals. Twenty-four-hour survival rates were 0%, 62.5%, 62.5%, and 75% for the negative control, QuickClot, HemCon, and keratin groups, respectively. Other outcomes included blood loss, mean arterial pressure, heart rate, shock index, and liver histology. All of the hemostats were statistically better than the negative control group at late operative time points. The keratin group consistently performed as well as, or better than, the commercial hemostats. Histology showed an interesting healing response at the hemostat-liver interface in the keratin group.

Scientific and logistical challenges in designing the CONTROL trial: recombinant factor VIIa in severe trauma patients with refractory bleeding

BACKGROUND

Clinical research in trauma patients poses multiple challenges in study design. These reflect the heterogeneity of injury and treatment, the paucity of acceptable study endpoints aside from mortality, and the difficulties inherent in obtaining informed consent in acutely ill populations. A current example of this problem is the study of recombinant factor VIIa (rFVIIa), which has attracted considerable interest as a systemic procoagulant agent for use in trauma patients with exsanguinating hemorrhage.

PURPOSE

To report on the implementation of an international trial - CONTROL - intended to assess the efficacy and safety of rFVIIa in trauma, and discuss trauma research study design in light of this experience.

METHODS

The CONTROL trial international steering committee confronted a number of barriers in the design of the CONTROL trial. They addressed methodologies for (1) standardizing entry criteria for trauma patients suffering inherently heterogeneous injuries, (2) obtaining informed consent in an acutely injured population with altered levels of consciousness, (3) avoiding futile care, while recruiting subjects with incompletely diagnosed injuries, (4) standardizing trauma intensive care across different investigating sites and countries, and (5) establishing study endpoints that were both clinically relevant and convincing to regulatory authorities. The resulting study methodology is reported.

RESULTS

The CONTROL trial began active recruitment in October 2005, and was halted on June 11, 2008 because the observed mortality in the 576 enrolled patients was so far below expectations that the study would lack sufficient statistical power at the planned number of subjects to demonstrate a benefit. The utility of the endpoints selected for study will not be known until completion of data analysis.

LIMITATIONS

Any clinical trial in trauma patients must cope with the urgency of care required, issues of patient heterogeneity, standardization of care across multiple centers, and the difficulties of obtaining informed consent.

CONCLUSION

Research in acutely hemorrhaging trauma patients presents numerous scientific and ethical challenges. The methodology of the CONTROL study is presented as an example of how some of these challenges can be approached and managed, and of the pitfalls that may arise.

Development and testing of the Gait Assessment and Intervention Tool (G.A.I.T.): a measure of coordinated gait components

Recent neuroscience methods have provided the basis upon which to develop effective gait training methods for recovery of the coordinated components of gait after neural injury. We determined that there was not an existing observational measure that was, at once, adequately comprehensive, scored in an objectively-based manner, and capable of assessing incremental improvements in the coordinated components of gait. Therefore, the purpose of this work was to use content valid procedures in order to develop a relatively inexpensive, more comprehensive measure, scored with an objectively-based system, capable of incrementally scoring improvements in given items, and that was both reliable and capable of discriminating treatment response for those who had a stroke. Eight neurorehabilitation specialists developed criteria for the gait measure, item content, and scoring method. In subjects following stroke (>12 months), the new measure was tested for intra- and inter-rater reliability using the Intraclass Correlation Coefficient; capability to detect treatment response using Wilcoxon Signed Ranks Test; and discrimination between treatment groups, using the Plum Ordinal Regression. The Gait Assessment and Intervention Tool (G.A.I.T.) is a 31-item measure of the coordinated movement components of gait and associated gait deficits. It exhibited the following advantages: comprehensive, objective-based scoring method, incremental measurement of improvement within given items. The G.A.I.T. had good intra- and inter-rater reliability (ICC=.98, p=.0001, 95% CI=.95, .99; ICC=.83, p=.007, 95% CI=.32, .96, respectively. The inexperienced clinician who had training, had an inter-rater reliability with an experienced rater of ICC=.99 (p=.0001, CI=.97, .999). The G.A.I.T. detected improvement in response to gait training for two types of interventions: comprehensive gait training (z=-2.93, p=.003); and comprehensive gait training plus functional electrical stimulation (FES; z=-3.3, p=.001). The G.A.I.T. was capable of discriminating between two gait training interventions, showing an additive advantage of FES to otherwise comparable comprehensive gait training (parameter estimate=1.72, p=.021; CI, .25, 3.1).

Repair of the thoracic wall with an extracellular matrix scaffold in a canine model

Naturally derived extracellular matrix (ECM) scaffolds have been successfully used to promote constructive remodeling of injured or missing tissue in a variety of anatomical locations, including abdominal wall repair. Furthermore, ECM scaffolds have shown the ability to resist infection and adhesion formation. The present study investigated the utility of an ECM scaffold, specifically, porcine urinary bladder matrix (UBM), for repair of a 5 x 5 cm full-thickness lateral thoracic wall defect in a canine model (n = 6) including 5-cm segments of the 6th and 7th rib. The resected portion of the 7th rib was replaced as an interpositional graft along with the UBM scaffold. As a control, a Gore-Tex patch was used to repair the same defect (n = 2). The control animals healed by encapsulation of the Gore-Tex patch by dense collagenous tissue. The remodeled UBM grafts showed the presence of site-specific tissue, including organized fibrous connective tissue, muscle tissue, adipose tissue, and bone. Upon fluoroscopic examination, it was shown that both bony defects were replaced with new calcified bone. In the 6th rib space, new bone bridged the entire span. In the 7th rib space, there was evidence of bone formation between the interpositional graft and the existing bone, as well as de novo formation of organized bone in the shape of the missing rib segment parallel to the interpositional graft. This study shows that a naturally occurring ECM scaffold promotes site-specific constructive remodeling in a large thoracic wall defect.

Causes of death in US Special Operations Forces in the global war on terrorism: 2001-2004

INTRODUCTION

Effective combat trauma management strategies depend on an understanding of the epidemiology of death on the battlefield, resulting in evidence-based equipment, training, and research requirements.

METHODS

All Special Operations Forces (SOF) fatalities (combat and noncombat) in Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) from October 2001 until November 2004 were reviewed. All available autopsy and treatment records and photographs were used. In most cases, the immediate tactical situation was unknown. The review was performed by a multidisciplinary group including forensic pathologists, an SOF combat medic, and trauma surgeons. Fatalities were classified as having wounds that were either nonsurvivable or potentially survivable with existing training, equipment, and expertise on the battlefield. A structured review was performed evaluating the need for new equipment, training, or research requirements. Results were compared to autopsy data from Vietnam and modern civilian trauma center data. The study was approved by the Institutional Review Boards of the Armed Forces Institute of Pathology and the US Army Institute of Surgical Research.

RESULTS

During the study period, 82 SOF fatalities were identified. Autopsies were performed on 77 Soldiers. Five casualties died secondary to aircraft crash, their bodies were not recovered from the ocean. For the purposes of this study they were considered nonsurvivable. Eighty-five percent (n = 70) of the fatalities sustained wounds that were nonsurvivable, while the remaining 15% (n = 12) had wounds that were potentially survivable. Injury Severity Score (ISS) was higher in the nonsurvivable group (p < 0.05). Truncal hemorrhage accounted for 47% of deaths while extremity hemorrhage accounted for 33%. One casualty was noted at autopsy to have a tension pneumothorax as well as multiple sources of internal hemorrhage, one suffered an airway death, while another died of sepsis 56 days after injury. Of those casualties deemed to be nonsurvivable, there were 31 patients with 40 Abbreviated Injury Score (AIS) 6 injuries (p = .0011), and 53 patients with 104 AIS 5 injuries. Among the 12 deaths deemed to be potentially survivable, there were only 8 AIS 5 injuries. Deaths were largely caused by explosions (n = 35), gunshot wounds (n = 23), and aircraft accidents (n = 19). No new training or equipment needs were identified for 53% of the potentially survivable deaths while improved methods of truncal hemorrhage control need to be developed for the remainder. The review panel concluded that 85% of the deaths would not have been prevented at a civilian Level I facility. Available records, in most cases, did not contain information about the use of body armor, time to death after injury, or the ongoing tactical situation.

CONCLUSIONS

The majority of deaths on the modern battlefield are nonsurvivable. Current results are not different from previous conflicts. In Vietnam, reported potentially preventable death rates range from 5% to 35% and civilian data reports potentially preventable death rates ranging from 12% to 22%. Military munitions cause multiple lethal injuries. Current trauma training and equipment is sufficient to care for 53% of the potentially survivable deaths. Improved methods of intravenous or intracavitary noncompressible hemostasis combined with rapid surgery are required for the remaining 47% of the decedents.

Admission physiology criteria after injury on the battlefield predict medical resource utilization and patient mortality

BACKGROUND

Medical resources and resource allocation including operating room and blood utilization are of prime importance in the modern combat environment. We hypothesized that easily measurable admission physiologic criteria and injury site as well as injury severity calculated after diagnostic evaluation or surgical intervention, would be strongly correlated with resource utilization and in theater mortality outcomes.

METHODS

We retrospectively reviewed the Joint Theater Trauma Registry for all battlefield casualties presenting to surgical component facilities during Operation Iraqi Freedom from January to July 2004. Data were collected from the composite population of 1,127 battlefield casualty patients with respect to demographics, mechanism, presentation physiology (blood pressure, heart rate, temperature), base deficit, admission hematocrit, Glasgow Coma Score (GCS), Injury Severity Score (ISS), operating room utilization, blood transfusion, and mortality. Univariate and multivariate analyses were conducted to determine the degree to which admission physiology and injury severity correlated with blood utilization, necessity for operation, and acute mortality.

RESULTS

Univariate analysis demonstrated a significant (p < 0.05) association between hypothermia (T < 34 degrees C) and the subsequent requirement for operation and mortality. In addition, the outcome variable total blood product utilization was significantly correlated with base deficit (r = 0.61), admission hematocrit (r = 0.51), temperature (r = 0.47), and ISS (r = 0.54). Using multiple logistic regression techniques, blood pressure, GCS, and ISS together demonstrated a significant association (p < 0.05) with mortality (area under ROC curve = 95%). Multiple linear regression established that blood pressure, heart rate, temperature, hematocrit, and ISS had a collective significant effect (p < 0.05) on total blood product utilization explaining 67% of the variance in this outcome variable.

CONCLUSION

Admission physiology and injury characteristics demonstrate a strong capacity to predict resource utilization in the contemporary battlefield environment. In the future, such predictive yield could potentially have significant implications for triage and medical logistics in the resource constrained environment of war and potentially in mass casualty and disaster incidents in the civilian trauma setting which will likely have mechanistic similarity with war related injury.

A randomized controlled trial of functional neuromuscular stimulation in chronic stroke subjects

BACKGROUND AND PURPOSE

Conventional therapies fail to restore normal gait to many patients after stroke. The study purpose was to test response to coordination exercise, overground gait training, and weight-supported treadmill training, both with and without functional neuromuscular stimulation (FNS) using intramuscular (IM) electrodes (FNS-IM).

METHODS

In a randomized controlled trial, 32 subjects (>1 year after stroke) were assigned to 1 of 2 groups: FNS-IM or No-FNS. Inclusion criteria included ability to walk independently but inability to execute a normal swing or stance phase. All subjects were treated 4 times per week for 12 weeks. The primary outcome measure, obtained by a blinded evaluator, was gait component execution, according to the Tinetti gait scale. Secondary measures were coordination, balance, and 6-minute walking distance.

RESULTS

Before treatment, there were no significant differences between the 2 groups for age, time since stroke, stroke severity, and each study measure. FNS-IM produced a statistically significant greater gain versus No-FNS for gait component execution (P=0.003; parameter estimate 2.9; 95% CI, 1.2 to 4.6) and knee flexion coordination (P=0.049).

CONCLUSIONS

FNS-IM can have a significant advantage versus No-FNS in improving gait components and knee flexion coordination after stroke.

Schizophrenia spectrum disorders: an autosomal-wide scan in multiplex pedigrees

Genome-wide linkage studies, examining the relationship between the schizophrenia syndrome(s) and possible susceptibility regions within the human genome have identified multiple regions within which linkage to the syndrome may be explored. No regions have been found to provide supportive evidence for linkage in all cohorts. These findings are consistent with the schizophrenia syndrome being genetically heterogeneous, with genetic susceptibility arising from multiple sites which are differentially distributed in from pedigree to pedigree. The authors present data from an autosomal-wide scan of 30 multiplex pedigrees, each with a mean of 4.1 members affected with a schizophrenia spectrum disorder with respect to regions of interest for linkage with the schizophrenia spectrum disease(s). Partial, though not significant replications of susceptibility sites at D1S518 (P=0.029) described by Shaw et al. (1998: Shaw, S.H., Kelly, M., Smith, A.B., Shields, G., Hopkins, P.J., Loftus, J., Laval, S.H., Vita, A., DeHert, M., Cardon, L.R., Crow, T.J., Sherrington, R., DeLisi, L.E., 1998. A Genome-wide search for schizophrenia susceptibility genes. Am. J. Med. Genet. (Neuropsychiatric Genet.) 81, 364-376.), and at D5S426 (P=0.015) described by : Silverman, J.M., Greenberg, D.A., Altstiel, L.D., Siever, L.J., Mohs, R.C., Smith, C.J., Zhou, G., Hollander, T.Y., Yang, X.-P., Kedache, M., Li, G., Zaccario, M.L., Davis, K.L., 1996. Evidence of a locus for schizophrenia and related disorders on the short arm of chromosome 5 in a large pedigree. Am. J. Med. Genet. 67, 162-171.) were documented using multipoint non-parametric (NPL) statistics. Two additional novel regions worthy of further investigation were identified at D1S1150 (P=0.004) and at D20S171 (P=0.009). Previously reported genomic regions of interest for the schizophrenias are reviewed in the context of the same/flanking markers utilized with the present cohort of pedigrees. The data further suggests that only a fraction of pedigrees multiplex for schizophrenia link at any single susceptibility region.

Thoracic aortic and thoracic vascular injuries

Patients with thoracic vascular injuries fall into two groups: those who are exsanguinating and require an empiric operation with a high mortality and those with contained injuries that permit preoperative evaluation. The unstable group requires judgment to determine the appropriate empiric position, exposure, and operation. Unlike abdominal trauma, which is addressed by way of a midline incision, there are multiple thoracic incisions that can be used to access thoracic vascular injuries. Thus, the stable group may benefit from preoperative imaging, which then can suggest a patient position, incision, and operative approach. Avoiding overaggressive resuscitation, obtaining appropriate imaging studies, choosing an operative strategy to achieve proximal and distal control, and using adjuncts based on the injury can make the care of these patients a rewarding but challenging activity.

Forward surgical stabilization of penetrating lower extremity fractures: circular casting versus external fixation

OBJECTIVE

There are two choices for the stabilization of penetrating lower extremity fractures in the forward surgical environment: bivalved circular casting and external fixation. The material and equipment requirements of these methods are of paramount importance in the austere forward surgical environment.

METHODS

Casualties from the Battle of the Black Sea in Somalia 1993 were examined. Penetrating lower extremity fractures requiring immobilization were identified. The relative packing volume and weight for each method of immobilization were analyzed. Finally, the current literature concerning the treatment of penetrating lower extremity fractures sustained in combat was reviewed.

RESULTS

The consumable material requirements of cast immobilization are 22.9 times greater by weight and 3.16 times greater by packing volume. Cast immobilization also has a greater durable equipment requirement. External fixation has multiple clinical advantages but is considerably more expensive.

CONCLUSION

Based on these variables, the authors determined that external fixation is the treatment of choice for penetrating lower extremity fractures in the forward surgical environment.

Quadrupole ion storage tandem mass spectrometry and high-resolution mass spectrometry: complementary application in the measurement of 2,3,7,8-chlorine substituted dibenzo-p-dioxins and dibenzofurans in US foods

The US Food and Drug Administration has simultaneously utilized both high-resolution mass spectrometry (HRMS) and quadrupole ion storage tandem mass spectrometry (QISTMS) in the measurement of polychlorinated dibenzo-p-dioxins/dibenzofurans (PCDD/Fs) in 147 food samples collected in 1998 and 1999 in the US. In 1998, 20 egg samples, six scallop, 10 blue crab, eight American lobster, 10 pollack, 15 striped bass, five rockfish, 10 crawfish, seven aqua-cultured and 13 wild-caught salmon, along with 19 cream and 18 mozzarella cheese samples were measured for PCDD/Fs. QISTMS provided limits of detection (LODs) close to those produced using HRMS for many congeners in 56 samples analyzed by both techniques in 1998 and three salmon and three striped bass collected in 1999. The I-TEQs of the mean levels for measured congeners in 40 samples of fish and shellfish and 16 cheese and eggs from 1998 analyzed by HRMS and QISTMS were 0.99 and 1.1 ng/kg wet weight, respectively. The I-TEQ for mean congener levels in the 40 fish and shellfish measured by HRMS was 1.4 ng/kg wet weight. A higher sample throughput with greater data quality at a lower cost is achievable by using both QISTMS and HRMS.

Divalproex sodium in sex offenders with bipolar disorders and comorbid paraphilias: an open retrospective study

BACKGROUND

This study evaluated divalproex response in sex offenders with a bipolar disorder.

METHODS

We reviewed the records of all sex offenders who participated in a residential rehabilitative program who received divalproex for treatment of a bipolar disorder. Patients' mood symptoms and, when present, comorbid paraphilic symptoms, were retrospectively assessed using the CGI severity scale.

RESULTS

Sex offenders displayed significant improvement in manic symptoms with divalproex treatment. However, there was no significant improvement in paraphilic symptoms in the subset of patients admitting to these symptoms.

CONCLUSION

Divalproex may be effective for manic symptoms in sex offenders with a bipolar disorder. However, for bipolar sex offenders with comorbid paraphilias, the drug may not be effective for paraphilic symptoms.

LIMITATIONS

This study was limited by its retrospective, open-label design, lack of systematic means of assessing manic and paraphilic symptoms, and small sample size.

CLINICAL RELEVANCE

Divalproex may be a helpful adjunct in the treatment of the subset of sex offenders who have a bipolar disorder.

The role of administrative data in measurement and reporting of quality of hospital care

Changes in the financing and delivery of health care in the 1980s, originally driven by ever-escalating costs, led to increasing demands for accountability from providers to payers and consumers. The inability of the health care industry to articulate a vision, or even a definition of quality of care, allowed the promulgation of the use of extant data sources (claims data) in efforts to define quality. Although such data sources are limited in their ability to measure quality of care, the application of increasingly sophisticated computer algorithms has led to widespread public reporting of such information and a need for physicians to understand and participate in efforts to measure and report outcomes of medical interventions.