Neutrophils from critically ill septic patients mediate profound loss of endothelial barrier integrity.

INTRODUCTION: Sepsis is characterized by systemic immune activation and neutrophil-mediated endothelial barrier integrity compromise, contributing to end-organ dysfunction. Studies evaluating endothelial barrier dysfunction induced by neutrophils from septic patients are lacking, despite its clinical significance. We hypothesized that septic neutrophils would cause characteristic patterns of endothelial barrier dysfunction, distinct from experimental stimulation of normal neutrophils, and that treatment with the immunomodulatory drug ß-glucan would attenuate this effect. METHODS: Blood was obtained from critically ill septic patients. Patients were either general surgery patients (Primary Sepsis (PS)) or those with sepsis following trauma (Secondary Sepsis (SS)). Those with acute respiratory distress syndrome (ARDS) were identified. Healthy volunteers served as controls. Neutrophils were purified and aliquots were untreated, or treated with fMLP or ß-glucan. Endothelial cells were grown to confluence and activated with tissue necrosis factor (TNF)-α . Electric Cell-substrate Impedance Sensing (ECIS) was used to determine monolayer resistance after neutrophils were added. Groups were analyzed by two-way analysis of variance (ANOVA). RESULTS: Neutrophils from all septic patients, as well as fMLP-normal neutrophils, reduced endothelial barrier integrity to a greater extent than untreated normal neutrophils (normalized resistance of cells from septic patients at 30 mins = 0.90 ± 0.04; at 60 mins = 0.73 ± 0.6 and at 180 mins = 0.56 ± 0.05; p < 0.05 vs normal). Compared to untreated PS neutrophils, fMLP-treated PS neutrophils caused further loss of barrier function at all time points; no additive effect was noted in stimulation of SS neutrophils beyond 30 min. Neutrophils from ARDS patients caused greater loss of barrier integrity than those from non-ARDS patients, despite similarities in age, sex, septic source, and neutrophil count. Neutrophils obtained after resolution of sepsis caused less barrier dysfunction at all time points. ß-glucan treatment of septic patients' neutrophils attenuated barrier compromise, rendering the effect similar to that induced by neutrophils obtained once sepsis had resolved. CONCLUSIONS: Neutrophils from septic patients exert dramatic compromise of endothelial barrier integrity. This pattern is mimicked by experimental activation of healthy neutrophils. The effect of septic neutrophils on the endothelium depends upon the initial inflammatory event, correlates with organ dysfunction and resolution of sepsis, and is ameliorated by ß-glucan.

A Rare Self-Inflicted Stabbing to the Neck Injuring the Distal Trachea and Proximal Esophagus.

Penetrating neck trauma poses a significant risk to multiple vital structures, which if not treated immediately may lead to devastating consequences. Our patient presented after sustaining self-inflicted stab wounds to the neck. He was taken to the operating room for a left neck exploration and median sternotomy, revealing a distal tracheal injury. Following repair of the tracheal injury, an intraoperative esophagogastroduodenoscopy demonstrated a full-thickness esophageal injury 15 cm proximal to the tracheal injury. Both injuries were the result of separate stab entries originating from the same external midline wound. To our knowledge, this case report is unique in bringing this circumstance to the literature, demonstrating the importance of full intraoperative examination to assess for concomitant wounds in stab injuries after the initial pathology has been found and the initial stab trajectory understood.

Assessing the Impact of Hands-Free Georgia on Serious Motor Vehicle Accidents.

BACKGROUND: Hands-Free Georgia Law (HB673) was designed to prevent motor vehicle collisions (MVCs) by banning drivers from using their hands for non-driving-related activities, including cell phone use. We investigate HB673 effect on trauma activations secondary to MVCs in Georgia. METHODS: The Georgia Trauma Registry (GTR) was queried for MVCs from 2017 to 2019, representing the 18 months prior and following implementation of HB673. The number of MVCs for each period and severity of MVC designated by the average injury severity score (ISS) for each trauma activation were collected. RESULTS: Prior to implementation, a total of 43 080 traumas were recorded in GTR, 11 111 (25.8%) were attributed to an MVC. Following implementation, 12 130 (23.6%) occurred secondary to MVCs. Statewide MVC-related traumas per 1000 residents increased from 1.07 to 1.14 with increased mortality rate and unchanged median ISS per MVC. CONCLUSIONS: The Hands-Free Georgia Law seems to have not had a major reduction in mortality in its early implementation.

A Trauma Center-Based Study for Victims of Domestic Violence: Protecting Women of Richmond and Surrounding Counties.

INTRODUCTION: Domestic violence (DV) is a major health issue on both a national and global scale. In Richmond County, Georgia, there are 18.1 calls per 1000 women for DV, exceeding the national average of 5.9 and Georgia average of 15.3 calls per 1000 women. The goal of the study is to map epidemiologic and spatial trends in communities of DV survivors thereby assessing the feasibility of a prospective intervention initiative for high-risk areas. METHODS: In partnership with "SafeHomes", a local women's shelter, a retrospective review of physical addresses was compiled from first-time residential clients 18 and older from January 1, 2019 to December 31, 2019. Hot zones were overlaid with Census tracts to assess sociodemographic correlates including race, ethnicity, age, poverty, education, and employment status. RESULTS: From all records (n = 85), 5 hot zones were identified. Analysis of census tract data revealed minority predominance in all hot zones, in addition to an unemployment rate above the state average (23%, 12%, 8%, 5%, and 19%, respectively, vs 3.4%). CONCLUSION: DV affects both the inner city and suburban areas of Richmond County. Hot zone frequency was disproportionately increased in the urban center where community demographics showed minority predominance, especially of African-Americans. These hot zones also have more individuals living below the federal poverty line and experience unemployment rates greater than the state and national average of 3.4 and 3.5, respectively. This study demonstrated that mapping domestic violence epidemiologic and spatial trends is possible, allowing for targeted support and intervention to reduce the rate of domestic violence.

The Accuracy of Point-of-Care Ultrasound in the Diagnosis of Acute Cholecystitis.

PURPOSE: Acute cholecystitis (AC) affects 50-200 000 patients per year. Early surgery is the treatment of choice for AC. Therefore, timely diagnosis is important to begin proper management. Recently, emergency departments have adopted point-of-care ultrasound (POCUS) for the initial evaluation of AC. The accuracy of POCUS for AC has not been well studied. METHODS: Patients receiving POCUS for evaluation of AC in the emergency department at our tertiary care institution for 2 years were considered. Patients with previous biliary diagnoses were excluded. Patients were deemed to have AC from a recorded POCUS result or 2/3 of the following POCUS findings: pericholecystic fluid, gallbladder wall hyperemia, and sonographic Murphy's sign. Formal ultrasound and final diagnosis from surgical and pathology reports were used as gold standards for comparison. RESULTS: In total, 147 patients met inclusion criteria. POCUS had a sensitivity and specificity of .4 (95% CI: .1216-.7376) and .99 (.9483-.9982), respectively, when compared to a final diagnosis and .33 (.0749-.7007) and .94 (.8134-.9932) when compared to formal US. The modified Tokyo guidelines for suspicion of AC had a sensitivity of .2 (.0252-.5561) and specificity of .88 (.8173-.931) compared to the final diagnosis. CONCLUSION: Point-of-care ultrasound was not a better screening test than the modified Tokyo guidelines. We recommend a simplified screening approach for AC using clinical findings and laboratory data, followed by confirmatory formal imaging. This strategy could prevent unnecessary delays in surgical management and use of physician resources.

The Effects of the COVID-19 Pandemic on Trauma Presentations in a Level One Trauma Center.

BACKGROUND: Over 28 million confirmed cases of COVID-19 have been reported to date, resulting in over 900 000 deaths. With an increase in awareness regarding the virus, the behavior of general population has changed dramatically. As activities such as driving and hospital presentation patterns have changed, our study aimed to assess the differences in trauma case variables before and during the COVID-19 pandemic. METHODS: Trauma data for the period of March 1st-June 15th were compared for the years 2015-2019 (pre-COVID) and 2020 (COVID). The data were analyzed across the following categories: injury severity score, injury mechanism, motor vehicle crashes (MVCs) vs. other blunt injuries, alcohol involvement, and length of hospital stay. RESULTS: The median injury severity score pre-COVID and during COVID was 9, representing no change. There was no difference in overall distribution of mechanism of injury; however, there was a significant decrease in the percentage of MVCs pre-COVID (36.39%) vs. COVID (29.6%, P < .05). Alcohol was significantly more likely to be involved in trauma during COVID-19 (P < .05). The mean hospital stay increased from 3.87-5.4 days during COVID-19 (P < .05). DISCUSSION: We saw similar results to prior studies in terms of there being no change in trauma severity. Our observation that motor vehicle collisions have decreased is consistent with current data showing decreased use of motor vehicles during the pandemic. We also observed an increase in alcohol-related cases which are consistent with the reported changes in alcohol consumption since the pandemic began.

Advancing technologies for the diagnosis and management of infections.

Infections remain a significant problem among surgical patients. Technological advances, especially in the arena of nano-technology, have markedly improved the ability to detect, prevent and treat surgical infections. No longer limited to culture-based methods of pathogen detection or standard antimicrobial therapies, options for management of surgical infections are rapidly expanding. Such advances are critical in this era of rapidly developing resistant and virulent strains of organisms. Further, our understanding of the host pathogen interaction grows exponentially with the development of computer-based modeling, aiding in expediting research endeavors.