Management of pediatric renal trauma: Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study

BACKGROUND

Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States.

METHODS

Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes.

RESULTS

In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%.

CONCLUSION

The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Chromoblastomycosis treated with posaconazole and adjunctive imiquimod: lending innate immunity a helping hand

Chromoblastomycosis (CBM) is a difficult-to-treat, chronic fungal infection of the skin and subcutaneous tissue. The evidence base for treatment is scarce, with no standardised therapeutic approach. Chronicity of CBM infection is postulated to be due in part to a failure of host cell-mediated immunity to generate a proinflammatory response sufficient for fungal clearance. We present a case of a chronic chromoblastomycosis lesion of the hand present for nearly four decades, previously refractory to itraconazole monotherapy, that was successfully treated with a combination of posaconazole and adjunctive immunotherapy with topical Imiquimod, a toll-like receptor 7 agonist. Serial biopsies and images demonstrate the clinical and histopathological improvement of the lesion. Randomised trials of antifungal therapy with adjunctive imiquimod are warranted to determine whether a combination of antifungal and host-directed therapy improves outcomes for this neglected tropical mycosis.

The Bottom Line: Trauma Center Viability During COVID-19

INTRODUCTION

The COVID-19 pandemic was a potential threat to the viability of trauma centers and health systems in general. We sought to answer the question of how COVID-19 was associated with patient characteristics as well as trauma center volume, finances, and viability.

METHODS

We reviewed 6375 patients admitted to our verified Level 1 trauma center during two time periods: pre-COVID (February 2019-February 2020) and COVID (March 2020-March 2021). Three thousand ninety-nine patients were admitted pre-COVID and 3276 were admitted during COVID. Data including case-mix index (CMI), total contribution margin, insurance status, age, race, gender, ethnicity, and injury mechanism were collected from the trauma registry and finance databases and analyzed. A P < 0.05 was considered significant.

RESULTS

Trauma admissions decreased initially during COVID but returned to and ultimately surpassed admission trends pre-COVID. Trauma revenue and patient acuity increased significantly along with a decrease in the number of underinsured patients during COVID. When evaluating all service lines, the trauma center was the highest contributor to overall hospital revenue.

CONCLUSIONS

Despite a decrease in admissions for other service lines and a pause in elective surgeries during the pandemic, the trauma center remained unaffected. In addition, trauma was the most significant contributor to the bottom line of the health system. These findings underscore the need to maintain and even increase trauma center resources and staffing to ensure that optimal care is provided to critically ill and injured patients.

Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis.

METHODS

Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology.

RESULTS

Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality.

DISCUSSION

In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema.

PROSPERO REGISTRATION NUMBER

CRD42018088759.

America's First Memorial Honoring Survivors of Sexual Violence

Over the past two decades, America taken part of a broader global trend of "memorial mania" in which memorials dedicated to remembering injustice have exploded into public space. Memorials that facilitate the centering of marginalized narratives of violence hold significant power for social change. This article focuses on one such space: The Survivors Memorial in Minneapolis, Minnesota. The Survivors Memorial opened in October 2020 and is the first public memorial honoring survivors of sexual violence. Despite the progress of the anti-rape and feminist movements as well as a variety of legal interventions designed to address sexual violence and empower, many survivors are left without a sense of justice or institutional or community recognition. Drawing on 21 in-depth, qualitative interviews with individuals involved in all aspects of the memorial project, this article documents how one community mobilized to create a space for survivors whose voices are often overlooked, disbelieved and silenced by the criminal justice system, practitioners, and communities. In focusing on how participants narrate the significance and meaning of the Survivors Memorial, this article uncovers how social, political, and local circumstances coalesced to make the Memorial possible. These factors include local leadership, the prevalence of sexual violence, the unique structure of the Minneapolis park structure, and the rise of the #MeToo movement. Interviews illuminate that participants worked to intentionally construct the Memorial as an accessible and visible space that centers on providing all sexual violence survivors with public acknowledgment of their experiences, while simultaneously engaging community members in dialogs about sexual violence, ultimately, laying the foundation for sexual violence prevention efforts.

Impact of a Cancer Survivorship Program on Well-Being and Community Involvement: Role of OT and Future Directions

Date Presented 04/03/2022

This qualitative phenomenological study explored the lived experiences of cancer survivors in a community-based, interprofessional survivorship program and explains further exploration needs for OT. Personal themes describing impact on the individuals included (1) journey of spiritual and emotional healing, (2) growing into a new sense of self, and (3) moving from survival to life. Relational themes included (1) building a community of caring and connection and (2) embracing the value of altruism.

Primary Author and Speaker: Lynne Murphy

Contributing Authors: Kendall Ellis, Nicole Fox, Sarah Lee, Rachel Lennon, Gloria Norton

Pediatric Trauma: What Hurts?

OBJECTIVES

Pediatric trauma patients are injured during crucial developmental years and require subsequent absence from school and activities. The impact of these changes on pediatric trauma patients is not well studied. We sought to assess the functional and emotional impact of pediatric trauma. In addition, the inpatient experience was evaluated for performance improvement purposes.

METHODS

A prospective survey was conducted at our trauma center (February 2019 to May 2019) of admitted trauma patients (<18 years). Patients who died before admission and nonaccidental trauma patients were excluded. Patients completed an inpatient survey and another at 3 months postdischarge.

RESULTS

Sixty patients were enrolled; 31 completed follow-up. Patients were 10 ± 5 years, 75% being male (n = 45), with an Injury Severity Score of 7 ± 6. A total of 13% were seen by behavioral medicine while inpatient; 18% of patients had preexisting anxiety. Preexisting functional limitations existed in 7% of the patients. At 3 months, 71% were back to preinjury academics, and 58% had returned to extracurriculars. At follow-up, 10% of patients felt withdrawn, and 32% felt emotional/distracted. Only 13% of patients were undergoing therapy compared with 7% preinjury. Patients communicated their best/worst experiences.

CONCLUSION

Pediatric trauma patients experience significant functional and emotional limitations after trauma. This suggests that all pediatric trauma patients should be evaluated by behavioral medicine during their admission with postdischarge support services offered. Performance improvement opportunities were identified in areas of pain control and communication.

Impact of a Cancer Survivorship Program on Well-Being and Community Involvement: Role of OT and Future Directions

Date Presented Accepted for AOTA INSPIRE 2021 but unable to be presented due to online event limitations.

This qualitative phenomenology explored the lived experiences of cancer survivors in a community-based, interprofessional survivorship program and explains further exploration for inclusion of OT. Personal themes describing impact on the individuals included (1) journey of spiritual and emotional healing, (2) growing into a new sense of self, and (3) moving from survival to life. Relational themes included (1) building a community of caring and connection and (2) embracing the value of altruism.

Primary Author and Speaker: Lynne Murphy

Additional Authors and Speakers: Kendall Ellis, Nicole Fox, Sarah Lee, Rachel Lennon, and Gloria Norton

Pediatric Major Vascular Injuries: A 16-Year Institutional Experience From a Combined Adult and Pediatric Trauma Center

OBJECTIVES

Vascular injury in pediatric trauma patients is uncommon but associated with a reported mortality greater than 19% in some series. The purpose of this study was to characterize pediatric major vascular injuries (MVIs) and analyze mortality at a high-volume combined adult and pediatric trauma center.

METHODS

A retrospective review (January 2000 to May 2016) was conducted of all pediatric (<18 years old) trauma patients who presented with a vascular injury. A total of 177 patients were identified, with 60 (34%) having an MVI, defined as injury in the neck, torso, or proximal extremity. Patients were then further analyzed based on location of injury, mechanism, age, and race. P ≤ 0.05 was deemed significant.

RESULTS

Of the 60 patients with MVI, the mean age was 14.3 years (range, 4-17 years). Mean intensive care unit length of stay (LOS) was 5.4 days, and mean hospital LOS was 12.5 days. Blunt mechanism was more common in patients 14 years or younger; penetrating trauma was more common amongst patients older than 14 years. Overall, blunt injuries had a longer intensive care unit LOS compared with penetrating trauma (7.8 vs 3.1 days; P = 0.016). A total of 33% (n = 20) of MVIs occurred in the torso, with 50% (n = 10) of these from blunt trauma. Location of injury did correlate with mortality; 45% (n = 9) of torso MVIs resulted in death (penetrating n = 7, blunt n = 2). Overall mortality from an MVI was 15.3% (n = 9); all were torso MVIs. Higher Injury Severity Score and Glasgow Coma Scale score were found to be independently associated with mortality.

CONCLUSIONS

Our experience demonstrates that MVIs are associated with a significant mortality (15.3%), with a majority of those resulting from gunshot wounds, more than 9-fold greater than the overall mortality of pediatric trauma patients at our institution (1.6%). Further research should be aimed at improving management strategies specific for MVIs in the pediatric trauma patient as gun violence continues to afflict youth in the United States.

Sexual Assault Prevalence and Community College Students: Challenges and Promising Practices

Recently, much research has been dedicated to understanding how to prevent and address the aftermath of sexual assault (SA) on traditional 4-year college and university campuses in the United States. However, less scholarly attention has been paid to 2-year institutions, commonly known as community colleges. This review illuminates the different situational contexts faced by community college students, compared with students at 4-year colleges. These differences are shaped by community college characteristics, student demographics, and geographic location of their students. Community colleges enroll a higher percentage of women, first-generation students, and low-income students than 4-year colleges. Furthermore, community colleges are academic homes to the most racially and ethnically diverse student population, with higher numbers of African Americans, Latinos, immigrants, and nonnative English speakers. These populations (e.g., women, racial minorities, first-generation, low-income) are at a greater risk for SA; yet, 2-year institutions have less funding and resources available to address SA on their campuses. Thus, this article reviews the problem of campus SA on community colleges and highlights the challenges that 2-year institutions face in comparison with those that 4-year institutions face when implementing SA prevention and response strategies. Then, a case study of a 3-year project on one nonresidential and seven community colleges is presented, which illustrates how 2-year institutions can forge relationships with community professionals to address SA on their campuses.

Biomarker and Clinical Trial Design Support for Disease-Modifying Therapies: Report of a Survey of the EU/US: Alzheimer's Disease Task Force

BACKGROUND

Disease-modifying therapies are urgently needed for the treatment of Alzheimer's disease (AD). The European Union/United States (EU/US) Task Force represents a broad range of stakeholders including biopharma industry personnel, academicians, and regulatory authorities.

OBJECTIVES

The EU/US Task Force represents a community of knowledgeable individuals who can inform views of evidence supporting disease modification and the development of disease-modifying therapies (DMTs). We queried their attitudes toward clinical trial design and biomarkers in support of DMTs.

DESIGN/SETTING/PARTICIANTS

A survey of members of the EU/US Alzheimer's Disease Task Force was conducted. Ninety-three members (87%) responded. The details were analyzed to understand what clinical trial design and biomarker data support disease modification.

MEASUREMENTS/RESULTS/CONCLUSIONS

Task Force members favored the parallel group design compared to delayed start or staggered withdrawal clinical trial designs to support disease modification. Amyloid biomarkers were regarded as providing mild support for disease modification while tau biomarkers were regarded as providing moderate support. Combinations of biomarkers, particularly combinations of tau and neurodegeneration, were regarded as providing moderate to marked support for disease modification and combinations of all three classes of biomarkers were regarded by a majority as providing marked support for disease modification. Task Force members considered that evidence derived from clinical trials and biomarkers supports clinical meaningfulness of an intervention, and when combined with a single clinical trial outcome, nearly all regarded the clinical trial design or biomarker evidence as supportive of disease modification. A minority considered biomarker evidence by itself as indicative of disease modification in prevention trials. Levels of evidence (A,B,C) were constructed based on these observations.

CONCLUSION

The survey indicates the view of knowledgeable stakeholders regarding evidence derived from clinical trial design and biomarkers in support of disease modification. Results of this survey can assist in designing clinical trials of DMTs.

EU/US/CTAD Task Force: Lessons Learned from Recent and Current Alzheimer's Prevention Trials

At a meeting of the EU/US/Clinical Trials in Alzheimer's Disease (CTAD) Task Force in December 2016, an international group of investigators from industry, academia, and regulatory agencies reviewed lessons learned from ongoing and planned prevention trials, which will help guide future clinical trials of AD treatments, particularly in the pre-clinical space. The Task Force discussed challenges that need to be addressed across all aspects of clinical trials, calling for innovation in recruitment and retention, infrastructure development, and the selection of outcome measures. While cognitive change provides a marker of disease progression across the disease continuum, there remains a need to identify the optimal assessment tools that provide clinically meaningful endpoints. Patient- and informant-reported assessments of cognition and function may be useful but present additional challenges. Imaging and other biomarkers are also essential to maximize the efficiency of and the information learned from clinical trials.

'Whore stigma' as a transformative experience: altered cognitive expectations among Jewish-Israeli street-based sex workers

While the scholarship on sex work is substantial, it neglects to explore whether sex work and associated stigma affect sex workers' cognitive expectations. Drawing on observations of street-based sex work as well as in-depth interviews with Jewish-Israeli sex workers, this study suggests that because stigma is a moral experience that threatens and often destroys what really matters to stigmatised individuals, it leads to recurrent disappointments, which, in turn, may alter sex workers' cognitive expectations. Sex workers learn to see certain life goals, including maintaining healthy social relationships and a workspace free of violence and humiliation, as unobtainable. However, they also begin to see other aspects of their lives, such as economic autonomy, as achievable through sex work. Tracing how whore stigma becomes a transformative experience allows us to add another layer to the heretofore suggested link between the structural, cultural and individual aspects of stigmatisation.

Defining Disease Modifying Therapy for Alzheimer's Disease

BACKGROUND

Disease-modifying therapies (DMTs) are urgently needed to treat the growing number of individuals with Alzheimer's disease (AD) or at immanent risk for AD. A definition of DMT is required to facilitate the process of DMT drug development.

PROCESS

This is a review of the state of the science with regard to definition and development of DMTs.

RESULTS

A DMT is as an intervention that produces an enduring change in the clinical progression of AD by interfering in the underlying pathophysiological mechanisms of the disease process that lead to cell death. Demonstration of DMT efficacy is garnered through clinical trial designs and biomarkers. Evidence of disease modification in the drug development process is based on trial designs such as staggered start and delayed withdrawal showing an enduring effect on disease course or on combined clinical outcomes and correlated biomarker evidence of an effect on the underlying pathophysiological processes of the disease. Analytic approaches such as showing change in slope of cognitive decline, increasing drug-placebo difference over time, and delay of disease milestones are not conclusive by themselves but support the presence of a disease modifying effect. Neuroprotection is a related concept whose demonstration depends on substantiating disease modification. No single type of evidence in itself is sufficient to prove disease modification - consistency, robustness, and variety of sources of data will all contribute to convincing stakeholders that an agent is a DMT.

CONCLUSION

DMT is defined by its enduring effect on processes leading to cell death. A variety of types of data can be used to support the hypothesis that disease modification has occurred.

Microbialite response to an anthropogenic salinity gradient in Great Salt Lake, Utah

A railroad causeway across Great Salt Lake, Utah (GSL), has restricted water flow since its construction in 1959, resulting in a more saline North Arm (NA; 24%-31% salinity) and a less saline South Arm (SA; 11%-14% salinity). Here, we characterized microbial carbonates collected from the SA and the NA to evaluate the effect of increased salinity on community composition and abundance and to determine whether the communities present in the NA are still actively precipitating carbonate or if they are remnant features from prior to causeway construction. SSU rRNA gene abundances associated with the NA microbialite were three orders of magnitude lower than those associated with the SA microbialite, indicating that the latter community is more productive. SSU rRNA gene sequencing and functional gene microarray analyses indicated that SA and NA microbialite communities are distinct. In particular, abundant sequences affiliated with photoautotrophic taxa including cyanobacteria and diatoms that may drive carbonate precipitation and thus still actively form microbialites were identified in the SA microbialite; sequences affiliated with photoautotrophic taxa were in low abundance in the NA microbialite. SA and NA microbialites comprise smooth prismatic aragonite crystals. However, the SA microbialite also contained micritic aragonite, which can be formed as a result of biological activity. Collectively, these observations suggest that NA microbialites are likely to be remnant features from prior to causeway construction and indicate a strong decrease in the ability of NA microbialite communities to actively precipitate carbonate minerals. Moreover, the results suggest a role for cyanobacteria and diatoms in carbonate precipitation and microbialite formation in the SA of GSL.

The FIELDS Instrument Suite for Solar Probe Plus: Measuring the Coronal Plasma and Magnetic Field, Plasma Waves and Turbulence, and Radio Signatures of Solar Transients

NASA's Solar Probe Plus (SPP) mission will make the first in situ measurements of the solar corona and the birthplace of the solar wind. The FIELDS instrument suite on SPP will make direct measurements of electric and magnetic fields, the properties of in situ plasma waves, electron density and temperature profiles, and interplanetary radio emissions, amongst other things. Here, we describe the scientific objectives targeted by the SPP/FIELDS instrument, the instrument design itself, and the instrument concept of operations and planned data products.

A new test for plant bioaccessibility in sulphidic wastes and soils: A case study from the Wheal Maid historic tailings repository in Cornwall, UK

Currently, bioaccessibility testing at contaminated sites is dominated by techniques designed to assess oral bioaccessibility to humans. Determining the plant bioaccessibility of toxic trace elements is also important. In mining landscapes, sulphides are an important source of potentially toxic elements. Simple tests to evaluate readily leachable metals and metalloids exist but do not extract elements temporarily constrained within the sulphide fraction. Sequential extractions describe the association of trace elements with different geochemical fractions but are time consuming, costly and provide excessive detail. This paper proposes a new test for plant bioaccessibility in sulphidic mine wastes and soils that uses hydrogen peroxide to simulate environmental oxidation. The bioaccessible fraction determined is operationally defined and does not predict actual plant uptake. The test targets a) the portion of an element that is currently available in the pore water for uptake by plant roots and also b) the fraction that is temporarily constrained in sulphide minerals but may become available upon oxidation of the substrate. A case study was conducted at a historic mine waste repository site in Cornwall, U.K. where near total As concentrations were extremely elevated and Cd, Cu, Pb, Sb and Zn were also high. Our test determined that bioaccessible concentrations of As, Cd, Cu and Zn and to a lesser extent Sb and Pb were highest in samples of pyritic grey tailings. This is attributed to sulphide mineral oxidation and, particularly for Cd and Zn, the dissolution of soluble secondary minerals. High As concentrations in the marbled tailings were not bioaccessible. Results from the case study show that this new test provides useful information on the future bioaccessibility of contaminants, allowing for classification of mineralised sulphidic waste materials which otherwise cannot be obtained using established geochemical and mineralogical techniques. Furthermore, the test is rapid, repeatable and cost effective.

Lost in translation: Focused documentation improvement benefits trauma surgeons

INTRODUCTION

There is a translational gap between physicians who document in the medical record and coders, who ultimately determine which codes are submitted. This gap exists because physicians are never formally educated about documentation strategies despite the fact that the quality of physician documentation directly affects revenue, outcomes and public profiling. We evaluated the effect of a formal model of focused documentation improvement (FDI) on the trauma/critical care division. We hypothesized that FDI would improve physician documentation, resulting in revenue recovery and a shift in the case mix index (CMI) to more accurately reflect the clinical complexity of trauma patients.

METHODS

FDI is defined as targeted physician education followed by concurrent inpatient chart review for documentation improvement opportunities by a clinical documentation specialist (CDS). All trauma surgeons (n=9) at our Level 1 trauma center first completed three hours of mandatory training on documentation improvement. A CDS was subsequently assigned to the trauma service. They reviewed the charts of Medicare patients (n=776) from January-December 2014 to identify opportunities for documentation improvement, participated in ICU rounds and provided ongoing education. Requests to clarify documentation (queries) were posted in the electronic medical record (EMR) and physicians were required to respond within 48h. Data was collected on physician response rate, CMI and revenue recovery.

RESULTS

411 of 776 (57%) charts were reviewed. Opportunities for FDI were identified in 177 (43%) cases. The physician response rate to queries was 100%. The CMI for reviewed cases increased (1.80 (SD 0.15) vs. 2.11 (SD 0.19); p<0.001) after FDI. Overall revenue recovery was $1,132,581 with an average of $154,092 in revenue recovery/clinical full time equivalent. The total cost for administration of FDI was $353,265 resulting in a 220% return on investment (ROI).

CONCLUSION

FDI is an effective strategy to engage physicians in documentation improvement. It provides an infrastructure to assist physicians and yields a significant ROI.

“Watch Over Us Sweet Angels”

This article considers how parents constructed social identities for babies who died before, at, or shortly after birth between 1992 and 2008 at Overbrook Hospital, a large academic medical center in the northeastern United States. We find that parents constructed their own and their children’s social identities through deeply embodied shared senses of physicality, through processes of naming, and with a deep awareness of what they imagined would be ongoing relations. For many, these ongoing relations took place with an eye toward heaven. We situate our findings in historical context and draw out their theoretical implications for contemporary scholarship.

Non-destructive monitoring of viability in an ex vivo organ culture model of osteochondral tissue

Organ culture is an increasingly important tool in research, with advantages over monolayer cell culture due to the inherent natural environment of tissues. Successful organ cultures must retain cell viability. The aim of this study was to produce viable and non-viable osteochondral organ cultures, to assess the accumulation of soluble markers in the conditioned medium for predicting tissue viability. Porcine femoral osteochondral plugs were cultured for 20 days, with the addition of Triton X-100 on day 6 (to induce necrosis), camptothecin (to induce apoptosis) or no toxic additives. Tissue viability was assessed by the tissue destructive XTT (2,3-bis[2-methoxy-4-nitro-5-sulfophenyl]-2H-tetrazolium-5-carboxyanilide tetrazolium salt) assay method and LIVE/DEAD® staining of the cartilage at days 0, 6 and 20. Tissue structure was assessed by histological evaluation using haematoxylin & eosin and safranin O. Conditioned medium was assessed every 3-4 days for glucose depletion, and levels of lactate dehydrogenase (LDH), alkaline phosphatase (AP), glycosaminoglycans (GAGs), and matrix metalloproteinase (MMP)-2 and MMP-9. Necrotic cultures immediately showed a reduction in glucose consumption, and an immediate increase in LDH, GAG, MMP-2 and MMP-9 levels. Apoptotic cultures showed a delayed reduction in glucose consumption and delayed increase in LDH, a small rise in MMP-2 and MMP-9, but no significant effect on GAGs released into the conditioned medium. The data showed that tissue viability could be monitored by assessing the conditioned medium for the aforementioned markers, negating the need for tissue destructive assays. Physiologically relevant whole- or part-joint organ culture models, necessary for research and pre-clinical assessment of therapies, could be monitored this way, reducing the need to sacrifice tissues to determine viability, and hence reducing the sample numbers necessary.

NFκB1 is a suppressor of neutrophil-driven hepatocellular carcinoma

Hepatocellular carcinoma (HCC) develops on the background of chronic hepatitis. Leukocytes found within the HCC microenvironment are implicated as regulators of tumour growth. We show that diethylnitrosamine (DEN)-induced murine HCC is attenuated by antibody-mediated depletion of hepatic neutrophils, the latter stimulating hepatocellular ROS and telomere DNA damage. We additionally report a previously unappreciated tumour suppressor function for hepatocellular nfkb1 operating via p50:p50 dimers and the co-repressor HDAC1. These anti-inflammatory proteins combine to transcriptionally repress hepatic expression of a S100A8/9, CXCL1 and CXCL2 neutrophil chemokine network. Loss of nfkb1 promotes ageing-associated chronic liver disease (CLD), characterized by steatosis, neutrophillia, fibrosis, hepatocyte telomere damage and HCC. Nfkb1^S340A/S340Amice carrying a mutation designed to selectively disrupt p50:p50:HDAC1 complexes are more susceptible to HCC; by contrast, mice lacking S100A9 express reduced neutrophil chemokines and are protected from HCC. Inhibiting neutrophil accumulation in CLD or targeting their tumour-promoting activities may offer therapeutic opportunities in HCC.

The role of neutrophils in cancer development is not widely appreciated. Here, the authors show that NF-κB-deficient hepatocytes overproduce chemokines, leading to hepatocellular carcinoma due to excessive neutrophil recruitment, and that neutrophil depletion prevents liver cancer in these mice.

Preclinical trials in autosomal dominant AD: implementation of the DIAN-TU trial

The Dominantly Inherited Alzheimer's Network Trials Unit (DIAN-TU) was formed to direct the design and management of interventional therapeutic trials of international DIAN and autosomal dominant Alzheimer's disease (ADAD) participants. The goal of the DIAN-TU is to implement safe trials that have the highest likelihood of success while advancing scientific understanding of these diseases and clinical effects of proposed therapies. The DIAN-TU has launched a trial design that leverages the existing infrastructure of the ongoing DIAN observational study, takes advantage of a variety of drug targets, incorporates the latest results of biomarker and cognitive data collected during the observational study, and implements biomarkers measuring Alzheimer's disease (AD) biological processes to improve the efficiency of trial design. The DIAN-TU trial design is unique due to the sophisticated design of multiple drugs, multiple pharmaceutical partners, academics servings as sponsor, geographic distribution of a rare population and intensive safety and biomarker assessments. The implementation of the operational aspects such as home health research delivery, safety magnetic resonance imagings (MRIs) at remote locations, monitoring clinical and cognitive measures, and regulatory management involving multiple pharmaceutical sponsors of the complex DIAN-TU trial are described.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

The neutropenic diet reviewed: moving toward a safe food handling approach

For decades, the concept of a neutropenic diet has implied a strict limitation of foods allowed for consumption, as a presumptive means of reducing the risk of infection in cancer patients. The rationale was to limit the introduction of potentially harmful bacteria into the gastrointestinal tract by the restriction of certain foods that might harbor those organisms. However, this concept has not been substantiated with direct proof, and no universal definition of the neutropenic diet exists. Exactly which foods are restricted varies greatly by institution, but most notable is the restriction of fresh fruits and vegetables. Research evaluating potential benefits of a neutropenic diet is very limited, but the diet is still prescribed in many institutions with the hope that it will prevent foodborne infection and/or bacteremia in neutropenic patients. Review of the pathophysiology of foodborne illness and pertinent studies about the neutropenic diet lead to the conclusion that there is no clear benefit from the longstanding dietary restrictions that may be imposed during neutropenia. Instead, we propose adoption of standard safe food handling methods to allow for a more liberalized diet in the neutropenic patient.

"God must have been sleeping": faith as an obstacle and a resource for Rwandan genocide survivors in the United States

In 1994, 1 million Rwandans were violently killed in only 100 days. Devastating for some Rwandan survivors was the significant role that some Catholic parishes and leaders took in ignoring, facilitating, and even perpetuating the genocide. This article seeks to understand how Rwandan genocide survivors draw on religion as they negotiate their postgenocide identities in the United States and comprehend their current faiths, beliefs, and practices. Based on qualitative interviews with Rwandan survivors now located within the United States, I argue that the experiences of religiosity postgenocide serve as both an obstacle and a resource in postgenocide life, creating significant individual and local ramifications for community engagement, reconciliation, and trauma recovery.

The roles of cell surface attachment molecules and coagulation Factor X in adenovirus 5-mediated gene transfer in pancreatic cancer cells

Transduction of 11 pancreatic cancer cell lines with a replication-deficient adenovirus 5 expressing enhanced green fluorescent protein (Ad5EGFP) was analyzed and variable EGFP levels were observed, ranging from <1% to ∼40% of cells transduced, depending on the cell line. Efficient Ad5EGFP transduction was associated mainly with higher levels of cell surface Coxsackie and adenovirus receptor (CAR) but not with expression of α(v)β(3) and α(v)β(5) integrins and was fiber dependent. Reduction of CAR by RNA interference resulted in a corresponding decrease in Ad5EGFP transduction. Pre-treatment of Ad5EGFP with blood coagulation Factor X increased virus entry even in the presence of low CAR levels generated by RNA interference, suggesting a potential alternative route of Ad5 entry into pancreatic cancer cells. Immunohistochemistry carried out on 188 pancreatic ductal adenocarcinomas and 68 matched controls showed that CAR was absent in 102 (54%) of adenocarcinomas, whereas moderate and strong staining was observed in 58 (31%) and 28 (15%) cases, respectively. Weak or absent CAR immunolabeling correlated with poor histological differentiation of pancreatic cancer. In normal tissue, strong immunolabeling was detected in islet cells and in the majority of inter- and intralobular pancreatic ducts.

Phase Ib study of mapatumumab in combination with sorafenib in patients with advanced hepatocellular carcinoma (HCC) and chronic viral hepatitis

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Background: Mapatumumab is a fully human agonist monoclonal antibody to the tumor necrosis factor-related apoptosis-inducing ligand receptor 1 (TRAIL-R1). Sorafenib targets Mcl-1, a key TRAIL resistance protein, and accordingly could enhance mapatumumab's pro-apoptotic activity. Based on this and on preclinical data on mapatumumab in HCC cell lines, the current dose-escalation study is evaluating mapatumumab in combination with sorafenib in patients with advanced HCC.

Methods: Eligible patients had advanced HCC, Child-Pugh A or Model for End-Stage Liver Disease score < 15, and were positive for hepatitis B surface antigen or hepatitis C antibody. Intravenous mapatumumab was administered at 3, 10 or 30 mg/kg every 21 days with sorafenib (400 mg twice daily) until disease progression or unacceptable toxicity. Dose-limiting toxicities (DLTs) included events considered at least possibly related to mapatumumab and/or its interaction with sorafenib. Tumor measurements were performed every 2 cycles. Dose escalation required at least 3 patients in a cohort to receive >= 50% of full-dose sorafenib in the first 2 cycles.

Results: To date, 19 patients have been enrolled in the 3 mg/kg (n=6), 10 mg/kg (n=9) and 30 mg/kg (n=4) cohorts and have received a median of 4 cycles (range 1 to 24 cycles); 4 patients have received >= 11 cycles. The maximum tolerated dose has not been reached. DLTs that prompted expansion of the 3 mg/kg and 10 mg/kg cohorts were elevations of amylase and/or lipase (1 at 3 mg/kg, 1 at 10 mg/kg). Other Grade 3-4 events considered at least possibly related to mapatumumab and/or its interaction with sorafenib included hepatic pain (1/17), thrombocytopenia (1/17), increased aspartate aminotransferase (1/17), increased lipase (1/17), and increased gamma-glutamyltransferase (1/17). Two patients have had a partial response and 4 patients have had stable disease lasting > 12 weeks, based on investigator assessment.

Conclusions: Mapatumumab was well-tolerated at doses up to 30 mg/kg in combination with sorafenib in patients with HCC and viral hepatitis. A randomized phase II study of this combination in patients with advanced HCC is planned.

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