Association of Cigarette Smoking History With Drug Abuse History and Arterial Carboxyhemoglobin in Trauma Activation Patients: A Retrospective Study.

Introduction The relationship between cigarette smoking and arterial carboxyhemoglobin (CoHb) in trauma activation patients has not been investigated. The aim was to determine if cigarette smoking is associated with drug abuse history and arterial CoHb levels. Methodology This is a retrospective review of level I trauma center activations aged 18-60 during 2018-2020. A medical record audit was performed to assess each patient's cigarette smoking and drug abuse history and admission arterial CoHb level. The CoHb levels and smoking history for each patient were used to construct a receiver operating characteristic curve. Results Of the 742 trauma activations aged 18-60, 737 (99.3%) had a documented cigarette smoking history. Smoking history was positive in 49.7% (366) and negative in 50.3% (371). The positive smoking proportion was greater in patients with a drug abuse history (63.9% (234/366)) than those with a negative history (31.0% (115/371); p<0.0001; odds ratio=4.0). In 717 patients with a CoHb value, the CoHb was higher in smokers (3.9±2.2%) than in non-smokers (0.5±0.4%; p<0.0001; Cohen d=2.2). A CoHb >1.5% was higher in smokers (93.3% (333/357)) than non-smokers (1.7% (6/360); p<0.0001; odds ratio=818.6). The receiver operating characteristic curve for the relationship between CoHb and cigarette smoking history showed an area under the curve of 0.980 (p<0.0001). Using an arterial CoHb level >1.5% to predict a positive smoking history and a CoHb level ≤1.5% to predict a non-smoking history, sensitivity was 93.3% (333/357), specificity was 98.3% (354/360), and accuracy was 95.8% (687/717). Conclusion Cigarette smoking in trauma activations aged 18-60 is associated with drug abuse history and increased arterial CoHb levels on trauma center arrival.

Traumatic Brain Injury Outcome Associations With Computed Tomography and Glasgow Coma Scale Score Interactions: A Retrospective Study.

Background Numerous investigators have shown that early postinjury Glasgow Coma Scale (GCS) values are associated with later clinical outcomes in patients with traumatic brain injury (TBI), in-hospital mortality, and post-hospital discharge Glasgow Outcome Scale (GOS) results. Following TBI, early GCS, and brain computed tomography (CT) scores have been associated with clinical outcomes. However, only one previous study combined GCS scores with CT scan results and demonstrated an interaction with in-hospital mortality and GOS results. We aimed to determine if interactive GCS and CT findings would be associated with outcomes better than GCS and CT findings alone. Methodology Our study included TBI patients who had GCS scores of 3-12 and required mechanical ventilation for ≥five days. The GCS deficit was determined as 15 minus the GCS score. The mass effect CT score was calculated as lateral ventricular compression plus basal cistern compression plus midline shift. Each value was 1 for present. A prognostic CT score was the mass effect score plus subarachnoid hemorrhage (2 if present).The CT-GCS deficit score was the sum of the GCS deficit and the prognostic CT score. Results One hundred and twelve consecutive TBI patients met the inclusion criteria. Patients with surgical decompression had a lower GCS score (6.0±3.0) than those without (7.7±3.3; Cohen d=0.54). Patients with surgical decompression had a higher mass effect CT score (2.8±0.5) than those without (1.7±1.0; Cohen d=1.4). The GCS deficit was greater in patients not following commands at hospital discharge (9.6±2.6) than in those following commands (6.8±3.2; Cohen d=0.96). The prognostic CT score was greater in patients not following commands at hospital discharge (3.7±1.2) than in those following commands (3.1±1.1; Cohen d=0.52). The CT-GCS deficit score was greater in patients not following commands at hospital discharge (13.3±3.2) than in those following commands (9.9±3.2; Cohen d=1.06). Logistic regression stepwise analysis showed that the failure to follow commands at hospital discharge was associated with the CT-GCS deficit score but not with the GCS deficit. The GCS deficit was greater in patients not following commands at three months (9.7±2.8) than in those following commands (7.4±3.2; Cohen d=0.78). The CT-GCS deficit score was greater in patients not following commands at three months (13.6±3.1) than in those following commands (10.5±3.4; Cohen d=0.94). Logistic regression stepwise analysis showed that failure to follow commands at three months was associated with the CT-GCS deficit score but not with the GCS deficit. The proportion not following commands at three months was greater with a GCS deficit of 9-12 (50.9%) than with a GCS deficit of 3-8 (21.1%; odds ratio=3.9; risk ratio=2.1). The proportion of not following commands at three months was greater with a CT-GCS deficit score of 13-17 (56.0%) than with a CT-GCS deficit score of 4-12 (18.3%; OR=5.7; RR=3.1). Conclusion The mass effect CT score had a substantially better association with the need for surgical decompression than did the GCS score. The degree of association for not following commands at hospital discharge and three months was greater with the CT-GCS deficit score than with the GCS deficit. These observations support the notion that a mass effect and subarachnoid hemorrhage composite CT score can interact with the GCS score to better prognosticate TBI outcomes than the GCS score alone.

Occurrence of Numerous Cerebral White Matter Hyperintensities in Trauma Patients With Cerebral Fat Embolism: A Systematic Review and Report of Two Cases.

There has been little effort to identify an overall occurrence of numerous cerebral white matter hyperintensities (NCWMH) on relevant brain magnetic resonance imaging (MRI) sequences in postinjury cerebral fat embolism syndrome (CFES) patients. Also, quantification of pre-CFES cognitive status, degree of neurologic deterioration, and presence of a skeletal fracture with CFES is nominal. The authors performed a PubMed search and identified 24 relevant manuscripts. Two case reports from the authors' institution were also used. The presence of NCWMH was assessed by reviewing T2-weighted image (T2WI), diffusion-weighted image (DWI), fluid-attenuated inversion recovery (FLAIR) figures and captions, and by evaluating manuscript descriptions. When pre-CFES cognitive status was described, it was categorized as Glasgow Coma Scale (GCS) score = 14-15 (yes or no). When the degree of neurologic deterioration was noted with CFES, it was classified as coma or GCS ≤ 8 (yes or no). When skeletal fractures were itemized, they were categorized as yes or no. The total number of CFES patients was 133 (literature search was 131 and two author-described case reports). Of the 131 patients with manuscript MRI figures or descriptive statements, 120 (91. 6%) had NCWMH. Of 63 patients with a delineation of the MRI sequence, NCWMH appeared on DWI in 24, on T2WI in 57, and on FLAIR in 10 patients. Pre-CFES cognitive status was GCS 14-15 in 93.5% (58/62) of the patients. The CFES neurologic deterioration was coma or GCS ≤ 8 in 52.5% (62/118) of the patients. A skeletal fracture was present in 99.0% (101/102) of the CFES patients. The presence of NCWMH in trauma patients with hospital-acquired neurologic deterioration and the presence of a skeletal fracture is consistent with CFES.

Trauma activation patient preinjury toxicology-positive proportions and associated risk conditions: A retrospective study.

BACKGROUND: Unlike prior guidelines for a positive toxicology screen, the 2022 national trauma data bank dictionary requires the exclusion of postinjury drugs. We aimed to (1) investigate the proportion of drugs in the toxicology screen that were given postinjury; (2) determine preinjury toxicology-positive associations with smoking, psychiatric, and drug abuse histories in an activation patient (ACT-Pt) cohort; and (3) explore whether ACT-Pt varied toxicology testing rates would produce similar preinjury toxicology-positive results. METHODS: In this retrospective study, the historic parent database included consecutive trauma center admissions where toxicology testing was discretionary. A supplementary electronic medical record audit of ACT-Pts age 18-60 years assessed smoking, psychiatric, and drug abuse histories. Subsequently, ACT-Pt age 18-100 years testing was encouraged by attending surgeons and, later routine testing was implemented. RESULTS: Of 2,076 patients in the historic parent database, discretionary toxicology testing occurred in 23.9% (n = 496) and the positive proportion was 58.9% (n = 292). However, 23.6% (n = 69) of the positive screens had the drug given postinjury. The preinjury positive-toxicology proportion was 45.0% (223/496). Preinjury toxicology positivity was greater in ACT-Pts age 18-60 years (52.3%) than in other patients (activations >60 years of age or consultations) (33.7%; p < 0.0001; odds ratio [OR] = 2.2). Smoking, psychiatric, and drug abuse histories were more common in ACT-Pts age 18-60 years preinjury toxicology-positive patients (74.4%, 51.3%, and 98.7%) than in negative patients (36.6%, 25.2%, and 25.2%; p < 0.0001). In ACT-Pts age 18-100 years, when compared to historic discretionary testing (32.7%), testing was increased with encouraged testing (62.1%; p < 0.0001; OR = 3.4) and routine testing (73.1%; p < 0.0001; OR = 5.6). ACT-Pt preinjury toxicology positivity was similar for historic discretionary (47.9%), encouraged (57.6%), and routine (51.3%) (p = 0.3670) testing. The meta-analytic toxicology-positive proportion for the three testing strategies was 49.8%. CONCLUSIONS: Substantial toxicology-positive findings are due to postinjury drug administration. Toxicology positivity is associated with ACT-Pts age 18-60 years and smoking, psychiatric, and drug abuse histories. ACT-Pt age 18-100 years preinjury toxicology positivity is 50% and does not vary with different testing proportions and strategies.

Influence of a Stay-At-Home Order on Trauma Volume and Injury Patterns at a Level I Trauma Center in Ohio.

BACKGROUND: Changes in injury patterns during the COVID pandemic have been reported in other states. The objective was to explore changes to trauma service volume and admission characteristics at a trauma center in northeast Ohio during a stay-at-home order (SAHO) and compare the 2020 data to historic trauma census data. METHODS: Retrospective chart review of adult trauma patients admitted to a level I trauma center in northeast Ohio. Trauma admissions from January 21 to July 21, 2020 (COVID period) were compared to date-matched cohorts of trauma admissions from 2018 to 2019 (historic period). The COVID period was further categorized as pre-SAHO, active-SAHO, and post-SAHO. RESULTS: The SAHO was associated with a reduction in trauma center admissions that increased after the SAHO (P = .0033). Only outdoor recreational vehicle (ORV) injuries (P = .0221) and self-inflicted hanging (P = .0028) mechanisms were increased during the COVID period and had substantial effect sizes. Glasgow Coma Scores were lower during the COVID period (P = .0286) with a negligible effect size. Violence-related injuries, injury severity, mortality, and admission characteristics including alcohol and drug testing and positivity were similar in the COVID and historic periods. DISCUSSION: The SAHO resulted in a temporary decrease in trauma center admissions. Although ORV and hanging mechanisms were increased, other mechanisms such as alcohol and toxicology proportions, injury severity, length of stay, and mortality were unchanged.

Trauma center admission risk conditions and the probability for developing alcohol withdrawal syndrome: A retrospective study.

BACKGROUND: Because the proportion of trauma patients developing alcohol withdrawal syndrome (AWS) is low, AWS risk conditions have not been precisely delineated. We aimed to create multifactor screening strategies to assess probabilities for the likelihood of developing AWS. METHODS: We performed a retrospective chart review of 1,011 trauma patients admitted to a Level I trauma center to investigate the associations between AWS and probable AWS risk conditions. Included patients were adults who met trauma registry inclusion criteria and had blood alcohol concentration (BAC) testing performed. Patients were excluded if they had a traumatic brain injury with a Glasgow Coma Score (GCS) ≤ 8, or no BAC testing performed. We defined heavy drinking as daily drinking or >7 per week. RESULTS: AWS had univariate associations with heavy drinking history, Injury Severity Score (ISS) ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, Intensive Care Unit (ICU) admission, serum aspartate aminotransferase (AST) ≥40 U/L, and cognitive preservation (GCS ≥13 with BAC ≥100 mg/dL) (all, p < 0.05). ICU admission, AST ≥40 U/L, cognitive preservation, male sex, and age ≥45 had associations with ISS ≥15 or alcohol misuse (all, p < 0.0001). For patients with age ≥45 and heavy drinking history or age <45 and heavy drinking history with ISS ≥15 and ICU admission, the AWS proportion (15.3%) was greater in comparison to other patients (0.3%). The AWS risk score was the sum of the following nine conditions, assigned a zero when the condition was absent and one when present (range 0-9): ISS ≥15, psychiatric disorders, liver disease, smoking history, in-hospital bronchodilator administration, age ≥45, male sex, AST ≥40 U/L, and cognitive preservation. The AWS proportion was greater with a risk score of 5-9 (16.8%) than of 0-4 (1.2%; p < 0.0001). CONCLUSIONS: AWS in the setting of traumatic injury is associated with multiple risk conditions. The presence of multiple risk conditions might have additive effects that could contribute toward a clinical manifestation of AWS. The identified risk conditions may be associated with a hyperadrenergic state.

Establishing an open and robotic pancreatic surgery program in a level 1 trauma center community teaching hospital and comparing its outcomes to high-volume academic center outcomes: a retrospective review.

BACKGROUND: The debate of whether to centralize hepato-pancreato-biliary surgery has been ongoing. The principal objective was to compare outcomes of a community pancreatic surgical program with those of high-volume academic centers. METHODS: The current pancreatic surgical study occurred in an environment where (1) a certified abdominal transplant surgeon performed all surgeries; (2) complementary quality enhancement programs had been developed; (3) the hospital's trauma center had been verified; and (4) the hospital's surgical training had been accredited. Pancreatic surgical outcomes at high-volume academic centers were obtained through PubMed literature searches. Articles were selected if they described diverse surgical procedures. Two-tailed Fisher exact and mid-P tests were used to perform 2 × 2 contingency analyses. RESULTS: The study patients consisted of 64 consecutive pancreatic surgical patients. The study patients had a similar pancreaticoduodenectomy proportion (59.4%) when compared to literature patients (66.8%; P = 0.227). The study patients also had a similar distal pancreatectomy proportion (25.0%) when compared to literature patients (31.9%; P = 0.276). The study patients had a significantly higher American Society of Anesthesiologists physical status ≥ 3 proportion (100%) than literature patients (28.1%; P < 0.001). The 90-day study mortality proportion (0%) was similar to the literature proportion (2.3%; P = 0.397). The study postoperative pancreatic fistula proportion was lower (3.2%), when compared to the literature proportion (18.4%; P < 0.001; risk ratio = 5.8). The study patients had a lower reoperation proportion (3.1%) than the literature proportion (8.7%; mid-P = 0.051; risk ratio = 2.8). The study patients had a lower surgical site infection proportion (3.1%) than those in the literature (21.1%; P < 0.001; risk ratio = 6.8). The study patients had equivalent delayed gastric emptying (15.6%) when compared to literature patients (10.6%; P = 0.216). The study patients had decreased Clavien-Dindo grades III-IV complications (10.9%) compared to the literature patients (21.8%; mid-P = 0.018). Lastly, the study patients had a similar readmission proportion (20.3%) compared to literature patients (18.4%; P = 0.732). CONCLUSION: Despite pancreatic surgical patients having greater preoperative medical comorbidities, the current community study outcomes were comparable to or better than high-volume academic center results.

Bispectral Index Alterations and Associations With Autonomic Changes During Hypnosis in Trauma Center Researchers: Formative Evaluation Study.

BACKGROUND: Previous work performed by our group demonstrated that intermittent reductions in bispectral index (BIS) values were found during neurofeedback following mindfulness instructions. Hypnosis was induced to enhance reductions in BIS values. OBJECTIVE: This study aims to assess physiologic relaxation and explore its associations with BIS values using autonomic monitoring. METHODS: Each session consisted of reading a 4-minute baseline neutral script and playing an 18-minute hypnosis tape to 3 researchers involved in the BIS neurofeedback study. In addition to BIS monitoring, autonomic monitoring was performed, and this included measures of electromyography (EMG), skin temperature, skin conductance, respiratory rate, expired carbon dioxide, and heart rate variability. The resulting data were analyzed using two-tailed t tests, correlation analyses, and multivariate linear regression analyses. RESULTS: We found that hypnosis was associated with reductions in BIS (P<.001), EMG (P<.001), respiratory rate (P<.001), skin conductance (P=.006), and very low frequency power (P=.04); it was also associated with increases in expired carbon dioxide (P<.001), skin temperature (P=.04), high frequency power (P<.001), and successive heart interbeat interval difference (P=.04) values. Decreased BIS values were associated with reduced EMG measures (R=0.76; P<.001), respiratory rate (R=0.35; P=.004), skin conductance (R=0.57; P<.001), and low frequency power (R=0.32; P=.01) and with increased high frequency power (R=-0.53; P<.001), successive heart interbeat interval difference (R=-0.32; P=.009), and heart interbeat interval SD (R=-0.26; P=.04) values. CONCLUSIONS: Hypnosis appeared to induce mental and physical relaxation, enhance parasympathetic neural activation, and attenuate sympathetic nervous system activity, changes that were associated with BIS values. Findings from this preliminary formative evaluation suggest that the current hypnosis model may be useful for assessing autonomic physiological associations with changes in BIS values, thus motivating us to proceed with a larger investigation in trauma center nurses and physicians.

Detecting delayed intracranial hemorrhage with repeat head imaging in trauma patients on antithrombotics with no hemorrhage on the initial image: A retrospective chart review and meta-analysis.

BACKGROUND: There is debate regarding routine repeat head computed tomography (CT) in blunt trauma patients on a pre-injury antithrombotic when the initial CT is negative for intracranial hemorrhage (ICH). DATA SOURCES: Retrospective chart review and systematic literature review with meta-analysis. CONCLUSIONS: In the chart review, 32.1% did not have a repeat head CT and 67.9% did. The delayed ICH incidence between those with and without a repeat head CT was similar (1.7% vs 0, p = .3101). The current study was combined with the identified 24 studies. Delayed ICH with or without routine repeat CT was similar between antiplatelet and anticoagulant categories (1.4% vs. 1.3%, p = .5322). Delayed ICH was lower for patients without routine repeat CT compared to those with routine repeat CT (0.8% vs 1.7%, p = .0008). For this patient population, repeat scans should be discretionary. Routine repeat CT may identify a larger proportion of minor delayed ICH.

Diffuse glioneuronal tumour with oligodendroglioma-like features and nuclear clusters (DGONC) - a molecularly defined glioneuronal CNS tumour class displaying recurrent monosomy 14.

AIMS: DNA methylation-based central nervous system (CNS) tumour classification has identified numerous molecularly distinct tumour types, and clinically relevant subgroups among known CNS tumour entities that were previously thought to represent homogeneous diseases. Our study aimed at characterizing a novel, molecularly defined variant of glioneuronal CNS tumour. PATIENTS AND METHODS: DNA methylation profiling was performed using the Infinium MethylationEPIC or 450 k BeadChip arrays (Illumina) and analysed using the 'conumee' package in R computing environment. Additional gene panel sequencing was also performed. Tumour samples were collected at the German Cancer Research Centre (DKFZ) and provided by multinational collaborators. Histological sections were also collected and independently reviewed. RESULTS: Genome-wide DNA methylation data from >25 000 CNS tumours were screened for clusters separated from established DNA methylation classes, revealing a novel group comprising 31 tumours, mainly found in paediatric patients. This DNA methylation-defined variant of low-grade CNS tumours with glioneuronal differentiation displays recurrent monosomy 14, nuclear clusters within a morphology that is otherwise reminiscent of oligodendroglioma and other established entities with clear cell histology, and a lack of genetic alterations commonly observed in other (paediatric) glioneuronal entities. CONCLUSIONS: DNA methylation-based tumour classification is an objective method of assessing tumour origins, which may aid in diagnosis, especially for atypical cases. With increasing sample size, methylation analysis allows for the identification of rare, putative new tumour entities, which are currently not recognized by the WHO classification. Our study revealed the existence of a DNA methylation-defined class of low-grade glioneuronal tumours with recurrent monosomy 14, oligodendroglioma-like features and nuclear clusters.

Brainwave Self-Regulation During Bispectral IndexTM Neurofeedback in Trauma Center Nurses and Physicians After Receiving Mindfulness Instructions.

Fifty-seven level I trauma center nurses/physicians participated in a 4-day intervention to learn relaxed alertness using mindfulness-based instructions and EEG neurofeedback. Neurofeedback was provided by a Bispectral IndexTM (BIS) system that continuously displays a BIS value (0-100) on the monitor screen. Reductions in the BIS value indicate that power in a high-frequency band (30-47 Hz) is decreased and power in an intermediate band (11-20 Hz) is increased. A wellbeing tool with four positive affect and seven negative affect items based on a 5-category Likert scale was used. The wellbeing score is the sum of the positive affect items (positive affect score) and the reverse-scored negative affect items (non-stress score). Of functional concern were four negative affect items rated as moderately, quite a bit, or extremely in a large percent. Of greater concern were all four positive affect items rated as very slightly or none at all, a little, or moderately in over half of the participants. Mean and nadir BIS values were markedly decreased during neurofeedback when compared to baseline values. Post-session relaxation scores were higher than pre-session relaxation scores. Post-session relaxation scores had an inverse relationship with mean and nadir BIS values. Mean and nadir BIS values were inversely associated with NFB cognitive states (i.e., widening the visual field, decreasing effort, attention to space, and relaxed alertness). For all participants, the wellbeing score was higher on day 4 than on day 1. Participants had a higher wellbeing score on day 4 than a larger group of nurses/physicians who did not participate in the BIS neurofeedback trial. Eighty percent of participants demonstrated an improvement in the positive affect or non-stress score on day 4, when compared to day 1; the wellbeing, non-stress, and positive affect scores were substantially higher on day 4 than on day 1. Additionally, for that 80% of participants, the improvements in wellbeing and non-stress were associated with reductions in day 3 BIS values. These findings indicate that trauma center nurses/physicians participating in an EEG neurofeedback trial with mindfulness instructions had improvements in wellbeing. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT03152331. Registered May 15, 2017.

Psychometric properties of the St. Elizabeth Youngstown hospital wellbeing inventory and non-burnout inventory for physicians and nurses.

BACKGROUND: Physicians and nurses have substantial problems with wellbeing and burnout. We examined the reliability and construct validity of a wellbeing inventory (WBI) administered to some physicians and nurses working in St. Elizabeth Youngstown Hospital (SEYH). METHODS: The SEYH-WBI, consisting of 4 positive affect (PA) items and 7 negative affect (NA) items developed from 5 validated surveys, was administered (n = 419). A non-burnout inventory (SEYH-NBI) consisting of 2 PA items and 3 NA items was derived from the SEYH-WBI. The Positive and Negative Affect Schedule (PANAS), a validated survey consisting of 10 PA items and 10 NA items, was conducted (n = 191). The Maslach Burnout Inventory (MBI), a validated survey consisting of 3 domains (3 items each), was completed (n = 150). RESULTS: For the SEYH-WBI, Cronbach coefficients were 0.76 for PA items and 0.83 for NA items. The NA item loading on factor 1 was 0.55-0.84 and the PA item loading on factor 2 was 0.47-0.89. Confirmatory indices were as follows: root mean square residual, 0.07 and Bentler Comparative Fit Index, 0.92. For the SEYH-NBI, Cronbach coefficients were 0.76 for PA items and 0.79 for NA items. The NA item loading on factor 1 was 0.80-0.87 and the PA item loading on factor 2 was 0.89-0.90. Confirmatory indices were as follows: root mean square residual, 0.02; and Bentler Comparative Fit Index, 0.99. PANAS correlations were as follows: SEYH-WBI PA and PANAS PA scores, r = 0.9; p <  0.0001; SEYH-WBI NA and PANAS NA scores, r = 0.9; p <  0.0001; SEYH-NBI PA and PANAS PA scores, r = 0.8; p <  0.0001; and SEYH-NBI NA and PANAS NA scores, r = 0.7; p <  0.0001. Correlations for SEYH-NBI and MBI were as follows: total NBI and total MBI, r = - 0.6, p <  0.0001; NA and emotional exhaustion, r = 0.6, p <  0.0001; PA and personal accomplishment, r = 0.3, p = 0.0003; and NA and depersonalization, r = 0.3, p = 0.0008. CONCLUSIONS: Validation assessments indicate that the SEYH-WBI and SEYH-NBI have acceptable psychometric performance. Similar findings in a larger cohort would be more compelling.

Effectiveness of computed tomography scanning to detect blunt bowel and mesenteric injuries requiring surgical intervention: A systematic literature review.

BACKGROUND: Computed tomography (CT) diagnostic accuracy for blunt bowel and mesenteric injuries (BBMI) is controversial. DATA SOURCES: A literature review to compute aggregate CT performance and individual CT sign sensitivity, specificity, and positive predictive value (PPV) for operative BBMI. CONCLUSIONS: Sensitivity, specificity, and PPV were: overall CT performance 85.3%, 96.1%, 51.4%; abnormal wall enhancement 30.1%, 95.7%, 64.0%; bowel wall discontinuity 22.3%, 99.0%, 87.9%; bowel wall hematoma 22.5%, 100%, 19.5%; bowel wall thickening 35.2%, 96.5%, 32.1%; free air 32.0%, 98.7%, 57.1%; free fluid 65.6%, 85.0%, 25.5%; mesenteric air 27.6%, 99.1%, 85.3%; mesenteric extravasation 22.9%, 99.6%, 73.9%; mesenteric hematoma/fluid 33.9%, 98.7%, 52.8%; mesenteric stranding/streaking 34.3%, 91.8%, 31.6%; mesenteric vessel beading 32.1%, 97.2%, 60.4%; mesenteric vessel termination 31.6%, 97.2%, 63.5%; oral contrast extravasation 10.0%, 100%, 100%; retroperitoneal air 9.4%, 94.9%, 55.6%; and retroperitoneal fluid 44.2%, 49.4%, 38.5%. Sensitivity, specificity, and PPV vary substantially among known signs. Other clinical factors are necessary for comprehensive BBMI identification.

Learning receptive awareness via neurofeedback in stressed healthcare providers: a prospective pilot investigation.

OBJECTIVE: Because physicians and nurses are commonly stressed, Bispectral Index™ (BIS) neurofeedback, following trainer instructions, was used to learn to lower the electroencephalography-derived BIS value, indicating that a state of receptive awareness (relaxed alertness) had been achieved. RESULTS: Ten physicians/nurses participated in 21 learning days with 9 undergoing ≤ 3 days. The BIS-nadir for the 21 days was decreased (88.7) compared to baseline (97.0; p < 0.01). From 21 wellbeing surveys, moderately-to-extremely rated stress responses were a feeling of irritation 38.1%; nervousness 14.3%; over-reacting 28.6%; tension 66.7%; being overwhelmed 38.1%; being drained 38.1%; and people being too demanding 52.4% (57.1% had ≥ 2 stress indicators). Quite a bit-to-extremely rated positive-affect responses were restful sleep 28.6%; energetic 0%; and alert 47.6% (90.5% had ≥ 2 positive-affect responses rated as slightly-to-moderately). For 1 subject who underwent 4 learning days, mean BIS was lower on day 4 (95.1) than on day 1 (96.8; p < 0.01). The wellbeing score increased 23.3% on day 4 (37) compared to day 1 (30). Changes in BIS values provide evidence that brainwave self-regulation can be learned and may manifest with wellbeing. These findings suggest that stress and impairments in positive-affect are common in physicians/nurses. Trial Registration ClinicalTrials.gov NCT03152331. Registered May 15, 2017.

Hypertonic saline administration and complex traumatic brain injury outcomes: a retrospective study.

Although hypertonic saline (HTS) decreases intracranial pressure (ICP) with traumatic brain injury (TBI), its effects on survival and post-discharge neurologic function are less certain. We assessed the impact of HTS administration on TBI outcomes and hypothesized that favorable outcomes would be associated with larger amounts of 3% saline. This is a retrospective study of consecutive-patients with the following criteria: blunt trauma, age 18-70 years, intracranial hemorrhage, Glasgow Coma Scale score (GCS) 3-12, and mechanical ventilation ≥ 5 days. The need for craniotomy or craniectomy denoted surgical decompression patients. Amounts of HTS were during the first-5 trauma center days. Traits for the 112 patients during 2012-2016 were as follows: GCS, 6.8 ± 3.2; subdural hematoma, 71.4%; cerebral contusion, 31.3%, ICP device, 47.3%; surgical decompression, 51.8%; ventilator days, 14.8 ± 6.7; trauma center mortality, 13.4%; and no commands at 3 months 35.5%. In surgically decompressed patients, trauma center mortality was greater with ≤ 8.0 mEq/kg sodium (38.9%) than with > 8.0 mEq/kg (7.5%; P = 0.0037). In surgically decompressed patients, following commands at 3 months was greater with ≥ 1400 mEq sodium (76.9%) than with < 1400 mEq (50.0%; P = 0.0489). For trauma center surviving non-decompression patients with no ICP device, those following commands at 3 months received more sodium (513 ± 784 mEq) than individuals not following commands (82 ± 144 mEq; P = 0.0142). For patients with a GCS 5-8, following commands at 3 months was greater with ≥ 1350 mEq sodium (92.3%) than with < 1350 mEq (60.0%; P = 0.0214). In patients with subdural hematoma or cerebral contusion, following commands at 3 months was greater with ≥ 1400 mEq sodium (84.2%) than with < 1400 mEq (61.8%; P = 0.0333). Patients with ICP > 20 mmHg for ≤ 10 hours (mean hours 2.0) received more sodium (16.5 ± 11.5 mEq/kg) when compared to ICP elevation for ≥ 11 hours (mean hours 34) (9.4 ± 6.3 mEq/kg; P = 0.0139). These observations demonstrate that hypertonic saline administration in patients with complex traumatic brain injury is associated with 1) mitigation of intracranial hypertension, 2) trauma center survival, and 3) following commands at 3 months post-injury.

Congenital Hypothalamic "Hamartoblastoma" Versus "Hamartoma": Suggestions for Neuropathologic Terminology Emanating From a Mid-gestational Autopsy Case of Pallister-Hall Syndrome.

Pallister-Hall syndrome (PHS) is a rare malformative disorder that is due to truncating functional repressor mutations in GLI3. Since the seminal publication in 1980, hypothalamic tumors have been recognized to be a cardinal feature of PHS. In their original description of the neuropathologic features of PHS, Clarren et al. coined the term "hamartoblastoma" to characterize what they deemed to be a dual malformative and neoplastic mass of the hypothalamus. In subsequent published cases/series of PHS, the term "hamartoma" was often substituted for hamartoblastoma given what appeared to be a benign natural history of this lesion. Additional confusion in the literature has ensued since most hypothalamic hamartomas (HH) encountered on the clinical neuropathology service are "isolated" in nature (ie, no other congenital malformations) and present in a very different and stereotypical fashion with gelastic seizures and/or precocious puberty. While genomic investigations of isolated HH have begun to uncover a mutational profile of these cases, GLI3 mutations have only been recognized in a small subset of isolated HH. Herein, we describe the autopsy findings from a 21-week gestational age fetus with features of PHS. Moreover, we provide a detailed description of the hypothalamic tumor affecting this fetus and propose a novel subclassification of HH, distinguishing syndromic from isolated forms based upon the presence or absence of neocortical-like areas.

Comparison of Bispectral Index™ values during the flotation restricted environmental stimulation technique and results for stage I sleep: a prospective pilot investigation.

OBJECTIVE: To determine whether Bispectral Index™ values obtained during flotation-restricted environment stimulation technique have a similar profile in a single observation compared to literature-derived results found during sleep and other relaxation-induction interventions. RESULTS: Bispectral Index™ values were as follows: awake-state, 96.6; float session-1, 84.3; float session-2, 82.3; relaxation-induction, 82.8; stage I sleep, 86.0; stage II sleep, 66.2; and stages III-IV sleep, 45.1. Awake-state values differed from float session-1 (%difference 12.7%; Cohen's d = 3.6) and float session-2 (%difference 14.8%; Cohen's d = 4.6). Relaxation-induction values were similar to float session-1 (%difference 1.8%; Cohen's d = 0.3) and float session-2 (%difference 0.5%; Cohen's d = 0.1). Stage I sleep values were similar to float session-1 (%difference 1.9%; Cohen's d = 0.4) and float session-2 (%difference 4.3%; Cohen's d = 1.0). Stage II sleep values differed from float session-1 (%difference 21.5%; Cohen's d = 4.3) and float session-2 (%difference 19.6%; Cohen's d = 4.0). Stages III-IV sleep values differed from float session-1 (%difference 46.5%; Cohen's d = 5.6) and float session-2 (%difference 45.2%; Cohen's d = 5.4). Bispectral Index™ values during flotation were comparable to those found in stage I sleep and nadir values described with other relaxation-induction techniques.

Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients.

BACKGROUND: In 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). Therefore, we investigated whether intraoperative reverse Trendelenburg positioning (RTP) decreases POH and POPA rates. METHODS: Consecutive ASA I-IV surgical patients who had preoperative pulmonary stability requiring general anesthesia with endotracheal intubation were evaluated. Using pulse oximetry, hypoxemia was documented intraoperatively and during the 48 h following PACU discharge. POPA was the presence of a pulmonary infiltrate with hypoxemia. In early 2015, a multifaceted effort was undertaken to enhance anesthesiologist and operating nurse awareness of RTP to potentially decrease POH and POPA rates. Analyses included (1) combining 2012 and 2015 cohorts to assess risk conditions, (2) comparing post-campaign 2015 (increased RTP) and 2012 cohorts, and (3) comparing 2015 patients with audit-documented RTP during surgery to the other 2015 patients. RESULTS: Combining the 500 patients in 2012 with the 1000 in 2015 showed that POH had increased mortality (2.3%), compared to no POH (0.2%; p = 0.0004). POH had increased postoperative length of stay (LOS) (4.6 days), compared to no POH (2.0 days; p < 0.0001). POPA had increased mortality (7.7%) and LOS (8.8 days), compared to no POPA (0.4%; p = 0.0004; 2.3 days; p < 0.0001). Open aortic, cranial, laparotomy, and neck procedures had greater POH (41.3%) and LOS (4.0 days), compared to other procedures (16.3%; p < 0.0001; 2.2 days; p < 0.0001). Glycopyrrolate on induction had lower POH (17.4%) and LOS (1.9 days), compared to no glycopyrrolate (21.6%; p = 0.0849; 2.7 days; p < 0.0001). POH was lower (18.1%) in 2015, than in 2012 (25.6%; p = 0.0007). POPA was lower with RTP in 2015 (0.6%), than in 2012 (4.8%; p = 0.0088). For the 2015 patients, LOS was lower with audit-documented RTP (2.2 days), compared to other patients (2.7 days; p = 0.0246). CONCLUSIONS: These findings are only hypothesis-generating. A randomized clinical trial is needed to confirm whether RTP has an inverse association with POH and POPA, and if RTP and glycopyrrolate are associated with improved outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02984657.

Mortality outcomes in trauma patients undergoing prehospital red blood cell transfusion: a systematic literature review.

The value of prehospital red blood cell (RBC) transfusion for trauma patients is controversial. The purposes of this literature review were to determine the mortality rate of trauma patients with hemodynamic instability and the benefit of prehospital RBC transfusion. A 30-year systematic literature review was performed in 2016. Eligible studies were combined for meta-analysis when tests for heterogeneity were insignificant. The synthesized mortality was 35.6% for systolic blood pressure ≤ 90 mmHg; 51.1% for ≤ 80 mmHg; and 63.9% for ≤ 70 mmHg. For patients with either hypotension or emergency trauma center transfused RBCs, the synthesized Injury Severity Score (ISS) was 27.0 and mortality was 36.2%; the ISS and mortality correlation was r = 0.766 (P = 0.0096). For civilian patients receiving prehospital RBC transfusions, the synthesized ISS was 27.5 and mortality was 39.5%. One civilian study suggested a decrement in mortality with prehospital RBC transfusion; however, patient recruitment was only one per center per year and mortality was < 10% despite an ISS of 37. The same study created a matched control subset and indicated that mortality decreased using multivariate analysis; however, neither the assessed factors nor raw mortality was presented. Civilian studies with patients undergoing prehospital RBC transfusion and a matched control subset showed that the synthesized mortality was similar for those transfused (37.5%) and not transfused (38.7%; P = 0.8933). A study of civilian helicopter patients demonstrated a similar 30-day mortality for those with and without prehospital blood product availability (22% versus 21%; P = 0.626). Mortality in a study of matched military patients was better for those receiving prehospital blood or plasma (8%) than the controls (20%; P = 0.013). However, transfused patients had a shorter prehospital time, more advanced airway procedures, and higher hospital RBC transfusion (P < 0.05). A subset with an ISS > 16 showed similar mortality with and without prehospital RBC availability (27.6% versus 32.0%; P = 0.343). Trauma patient mortality increases with the magnitude of hemodynamic instability and anatomic injury. Some literature evidence indicates no survival advantage with prehospital RBC availability. However, other data suggesting a potential benefit is confounded or likely to be biased.

Lethal Trauma Pulmonary Embolism Is a Black Swan Event in Patients at Risk for Deep Vein Thrombosis: An Evidence-Based Review.

We delineated the incidence of trauma patient pulmonary embolism (PE) and risk conditions by performing a systematic literature review of those at risk for deep vein thrombosis (DVT). The PE proportion was 1.4 per cent (95% confidence interval = 1.2-1.6) in at-risk patients. Of 10 conditions, PE was only associated with increased age (P < 0.01) or leg injury (P < 0.01; risk ratio = 1.6). As lower extremity DVT (LEDVT) proportions increased, mortality proportions (P = 0.02) and hospital stay (P = 0.0002) increased, but PE proportions did not (P = 0.13). LEDVT was lower with chemoprophylaxis (CP) (4.9%) than without CP (19.1%; P < 0.01). PE was lower with CP (1.0%) than without CP (2.2%; P = 0.0004). Mortality was lower with CP (6.6%) than without CP (11.6%; P = 0.002). PE was similar with (1.2%) and without (1.9%; P = 0.19) mechanical prophylaxis (MP). LEDVT was lower with MP (8.5%) than without MP (12.2%; P = 0.0005). PE proportions were similar with (1.3%) and without (1.5%; P = 0.24) LEDVT surveillance. Mortality was higher with LEDVT surveillance (7.9%) than without (4.8%; P < 0.01). A PE mortality of 19.7 per cent (95% confidence interval = 18-22) × a 1.4 per cent PE proportion yielded a 0.28 per cent lethal PE proportion. As PE proportions increased, mortality (P = 0.52) and hospital stay (P = 0.13) did not. Of 176 patients with PE, 76 per cent had no LEDVT. In trauma patients at risk for DVT, PE is infrequent, has a minimal impact on outcomes, and death is a black swan event. LEDVT surveillance did not improve outcomes. Because PE was not associated with LEDVT and most patients with PE had no LEDVT, preventing, diagnosing, and treating LEDVT may be ineffective PE prophylaxis.