Reactive Arthritis Following Coronavirus 2019 Infection in a Pediatric Patient: A Rare Case Report.

Reactive arthritis (ReA) following Coronavirus 2019 (COVID-19) infection has been described mainly in adults, and only two pediatric cases have been reported. We report a third case where ReA was found to be a sequela following COVID-19 infection. A 15-year-old right-handed Caucasian girl presented with severe left-wrist pain. She was experiencing fever, rash, and migratory oligoarthritis, and laboratory work-up showed elevated inflammatory markers and a positive COVID-19 IgG antibody test. Imaging revealed inflammatory arthropathy with wrist synovitis. The patient was diagnosed with ReA following COVID-19 infection and was treated surgically by wrist arthroscopic synovectomy after the failure of conservative management. It has been 1 year after her surgery, and she is doing well. Emerging case reports are linking ReA as a delayed response to COVID-19 infection; therefore, ReA should be included in the list of differential diagnoses in all patients with joint pain following COVID-19 infection.

Revision Carpal Tunnel Release With Umbilical Cord Allograft: A Four-Year Retrospective Cohort Study.

Background: Refractory symptoms of carpal tunnel syndrome can persist or reoccur after carpal tunnel release (CTR) surgery in 1% to 25% of patients, with up to 12% of patients requiring secondary surgery. If revision surgery is required, the results are much less successful compared to primary surgery. In this study, we investigated whether cryopreserved human umbilical cord allograft placement during CTR revision surgery improved short- and long-term surgical outcomes. Methods: We conducted a single-center cohort analysis of patients between January 2015 and July 2018 who underwent secondary open revision CTR with umbilical cord allograft for recurrent or persistent compression neuropathy of the median nerve. Surgical outcomes of patients in the study group-reduction of pain, paresthesia, and weakness; complications; and Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores-were compared to the outcomes of controls without umbilical cord allograft use who were operated on by the same surgeon between December 2011 and September 2015. Results: A total of 37 patients underwent CTR with (n=26) and without (n=11) umbilical cord allograft (mean follow-up of 4 years). Following surgery, preoperative symptoms of pain (96% vs 73%, P=0.048) and paresthesia (100% vs 73%, P=0.014) were significantly improved in the patients who received umbilical cord allograft. Mean QuickDASH scores (19.0 vs 23.7, P=0.58) and preoperative weakness (90% vs 67%, P=0.14) were improved in the patients who received umbilical cord allograft but were nonsignificant. Short- and long-term complications were similar between groups (P=0.56, P=0.51, respectively). Conclusion: This study suggests that human umbilical cord allograft placement during open revision CTR is safe and effective for improving long-term symptoms of compressive neuropathy in patients with recurrent carpal tunnel syndrome.

Compartment Syndrome and Wrist Disarticulation After a Catfish Sting.

Catfish have the ability to inflict stings on their victims through spines located on their dorsal and pectoral fins. The stings of catfish can release toxins that have dermonecrotic, edemogenic, and vasospastic factors. In this case, a 56-year-old man suffered a catfish sting to his right thumb, which resulted in acute hand compartment syndrome and resultant hand fasciotomies. His hospital course was complicated by multiple irrigation and debridements, finger amputations, hand fluid cultures positive for Vibrio damsela, and eventual wrist disarticulation. The combination of envenomation, infection, and delayed presentation for treatment ultimately led to a hand amputation.

Geographic and demographic heterogeneity of SARS-CoV-2 diagnostic testing in Illinois, USA, March to December 2020.

BACKGROUND: Availability of SARS-CoV-2 testing in the United States (U.S.) has fluctuated through the course of the COVID-19 pandemic, including in the U.S. state of Illinois. Despite substantial ramp-up in test volume, access to SARS-CoV-2 testing remains limited, heterogeneous, and insufficient to control spread. METHODS: We compared SARS-CoV-2 testing rates across geographic regions, over time, and by demographic characteristics (i.e., age and racial/ethnic groups) in Illinois during March through December 2020. We compared age-matched case fatality ratios and infection fatality ratios through time to estimate the fraction of SARS-CoV-2 infections that have been detected through diagnostic testing. RESULTS: By the end of 2020, initial geographic differences in testing rates had closed substantially. Case fatality ratios were higher in non-Hispanic Black and Hispanic/Latino populations in Illinois relative to non-Hispanic White populations, suggesting that tests were insufficient to accurately capture the true burden of COVID-19 disease in the minority populations during the initial epidemic wave. While testing disparities decreased during 2020, Hispanic/Latino populations consistently remained the least tested at 1.87 tests per 1000 population per day compared with 2.58 and 2.87 for non-Hispanic Black and non-Hispanic White populations, respectively, at the end of 2020. Despite a large expansion in testing since the beginning of the first wave of the epidemic, we estimated that over half (50-80%) of all SARS-CoV-2 infections were not detected by diagnostic testing and continued to evade surveillance. CONCLUSIONS: Systematic methods for identifying relatively under-tested geographic regions and demographic groups may enable policymakers to regularly monitor and evaluate the shifting landscape of diagnostic testing, allowing officials to prioritize allocation of testing resources to reduce disparities in COVID-19 burden and eventually reduce SARS-CoV-2 transmission.

Geographic and demographic heterogeneity of SARS-CoV-2 diagnostic testing in Illinois, USA, March to December 2020.

Background: Availability of SARS-CoV-2 testing in the United States (U.S.) has fluctuated through the course of the COVID-19 pandemic, including in the U.S. state of Illinois. Despite substantial ramp-up in test volume, access to SARS-CoV-2 testing remains limited, heterogeneous, and insufficient to control spread. Methods: We compared SARS-CoV-2 testing rates across geographic regions, over time, and by demographic characteristics (i.e., age and racial/ethnic groups) in Illinois during March through December 2020. We compared age-matched case fatality ratios and infection fatality ratios through time to estimate the fraction of SARS-CoV-2 infections that have been detected through diagnostic testing. Results: By the end of 2020, initial geographic differences in testing rates had closed substantially. Case fatality ratios were higher in non-Hispanic Black and Hispanic/Latino populations in Illinois relative to non-Hispanic White populations, suggesting that tests were insufficient to accurately capture the true burden of COVID-19 disease in the minority populations during the initial epidemic wave. While testing disparities decreased during 2020, Hispanic/Latino populations consistently remained the least tested at 1.87 tests per 1000 population per day compared with 2.58 and 2.87 for non-Hispanic Black and non-Hispanic White populations, respectively, at the end of 2020. Despite a large expansion in testing since the beginning of the first wave of the epidemic, we estimated that over half (50-80%) of all SARS-CoV-2 infections were not detected by diagnostic testing and continued to evade surveillance. Conclusions: Systematic methods for identifying relatively under-tested geographic regions and demographic groups may enable policymakers to regularly monitor and evaluate the shifting landscape of diagnostic testing, allowing officials to prioritize allocation of testing resources to reduce disparities in COVID-19 burden and eventually reduce SARS-CoV-2 transmission.

Anterior Interosseous Nerve Palsy After Shoulder Arthroscopy Treated With Surgical Decompression: A Case Series and Systematic Review of the Literature.

Background: Anterior interosseous nerve (AIN) palsy is a very uncommon cause of upper extremity pain and weakness that comprises less than 1% of all upper extremity nerve palsies. Rarely reported but also mentioned in the literature is AIN palsy after shoulder arthroscopy. Methods: A systematic review of the literature to date using PubMed was conducted to identify patients who suffered AIN palsy after shoulder arthroscopy procedures. Articles included met the following criteria: (1) published in English; (2) primary presentation of the data; (3) patients had undergone shoulder arthroscopy before developing symptoms of AIN palsy; and (4) diagnosis was confirmed with clinical symptoms of AIN palsy. Measured outcomes included patient demographics, specific shoulder procedure, anesthesia procedure, intra-operative patient positioning, intra-operative compressive dressing, intra-operative traction, surgical versus conservative treatment, abnormal findings during decompression procedure, proposed mechanism of injury, and follow-up. Results: The search yielded 6 articles, of which 4 (13 cases) met inclusion criteria. An additional 2 cases were included in this report totaling 15 cases. The average patient age was 49 years (range: 31-64) with 73% males. At average follow-up of 24 months, 67% of patients experienced complete resolution of symptoms-more than half of which underwent surgical decompression. Patients who failed to progress experienced weakness of the flexor digitorum profundus and flexor pollicis longus muscles. Conclusions: Proposed injury mechanisms for AIN palsy after shoulder arthroscopy range from mechanical trauma, compressive hematoma, and direct anesthetic neurotoxicity. Management should be directed by clinical symptoms, imaging, and patient factors with majority of patients expected to have excellent clinical outcomes.

Isolated Volar Dislocation of the Fifth Carpometacarpal Joint.

Background: Isolated dislocation of the carpometacarpal (CMC) joints is a rare injury that accounts for less than 1% of hand injuries. Few cases of isolated volar dislocations of the fifth CMC joint have been reported, making such injuries worthy of reporting. Given the rarity of these injuries, they are easily overlooked in the emergency setting and thus require a high index of clinical suspicion. Case Report: A 57-year-old female sustained an isolated volar dislocation of the fifth CMC joint when she fell onto her outstretched right hand. Physical examination revealed an inability to move the fifth digit, and the patient reported severe pain over the ulnar aspect of her right hand. X-rays of the right wrist revealed the dislocation. The patient was managed with closed reduction and application of an ulnar gutter splint. Conclusion: Solitary dislocations of any CMC joint are less common than simultaneous dislocation of multiple CMC joints, especially at the fifth CMC joint with volar dislocation. Because of the potential long-term adverse effects of untreated dislocations, these injuries must not be overlooked. Thus, patients presenting to the emergency department after traumatic injury involving an axial loading force to the hand should be carefully evaluated.

TRPM8 as the rapid testosterone signaling receptor: Implications in the regulation of dimorphic sexual and social behaviors.

Testosterone regulates dimorphic sexual behaviors in all vertebrates. However, the molecular mechanism underlying these behaviors remains unclear. Here, we report that a newly identified rapid testosterone signaling receptor, Transient Receptor Potential Melastatin 8 (TRPM8), regulates dimorphic sexual and social behaviors in mice. We found that, along with higher steroid levels in the circulation, TRPM8-/- male mice exhibit increased mounting frequency indiscriminate of sex, delayed sexual satiety, and increased aggression compared to wild-type controls, while TRPM8-/- females display an increased olfaction-exploratory behavior. Furthermore, neuronal responses to acute testosterone application onto the amygdala were attenuated in TRPM8-/- males but remained unchanged in females. Moreover, activation of dopaminergic neurons in the ventral tegmental area following mating was impaired in TRPM8-/- males. Together, these results demonstrate that TRPM8 regulates dimorphic sexual and social behaviors, and potentially constitutes a signalosome for mediation of sex-reward mechanism in males. Thus, deficiency of TRPM8 might lead to a delayed sexual satiety phenomenon.

TLR4 Cross-Talk With NLRP3 Inflammasome and Complement Signaling Pathways in Alzheimer's Disease.

Amyloid plaques, mainly composed of abnormally aggregated amyloid ß-protein (Aß) in the brain parenchyma, and neurofibrillary tangles (NFTs), consisting of hyperphosphorylated tau protein aggregates in neurons, are two pathological hallmarks of Alzheimer's disease (AD). Aß fibrils and tau aggregates in the brain are closely associated with neuroinflammation and synapse loss, characterized by activated microglia and dystrophic neurites. Genome-wide genetic association studies revealed important roles of innate immune cells in the pathogenesis of late-onset AD by recognizing a dozen genetic risk loci that modulate innate immune activities. Furthermore, microglia, brain resident innate immune cells, have been increasingly recognized to play key, opposing roles in AD pathogenesis by either eliminating toxic Aß aggregates and enhancing neuronal plasticity or producing proinflammatory cytokines, reactive oxygen species, and synaptotoxicity. Aggregated Aß binds to toll-like receptor 4 (TLR4) and activates microglia, resulting in increased phagocytosis and cytokine production. Complement components are associated with amyloid plaques and NFTs. Aggregated Aß can activate complement, leading to synapse pruning and loss by microglial phagocytosis. Systemic inflammation can activate microglial TLR4, NLRP3 inflammasome, and complement in the brain, leading to neuroinflammation, Aß accumulation, synapse loss and neurodegeneration. The host immune response has been shown to function through complex crosstalk between the TLR, complement and inflammasome signaling pathways. Accordingly, targeting the molecular mechanisms underlying the TLR-complement-NLRP3 inflammasome signaling pathways can be a preventive and therapeutic approach for AD.

Perinatal High-Fat Diet and Bisphenol A: Effects on Behavior and Gene Expression in the Medial Prefrontal Cortex.

Both high-fat diets (HFD) and bisphenol A (BPA), an environmental endocrine disruptor, are prevalent in industrialized societies. Previous studies have detected separate effects of BPA and HFD; however, none have assessed possible interactive effects. Here, pregnant dams consumed 0, 40, or 400 µg BPA/kg/day and were fed either a control (CON; 15.8% kcal fat) or HFD (45% kcal fat) from gestational day 2 through parturition. The pups were individually dosed with BPA from postnatal days (P) 1-10, while the dams continued to consume one of the two diets. Maternal behavior increased with the HFD while the offspring's periadolescent social play decreased with BPA, but no interactive effects were observed. Neither HFD nor BPA exposure changed performance on a social recognition task, and only BPA had an effect on the elevated plus maze. BPA increased several cytokines in the medial prefrontal cortex (mPFC) of P10 males but not females. Expression of several genes related to hormone synthesis and receptors, inflammation, oxidative stress, and apoptosis in the mPFC on P10 and P90 were altered due to BPA and/or HFD exposure with rare interactive effects. BPA resulted in an increase in the gene expression of Esr1 in the mPFC of females on both P10 and P90. Epigenetic analysis on P90 did not show a change in methylation or in the levels of pre-mRNA or microRNA. Thus, perinatal BPA and HFD have separate effects but rarely interact.

Perineural Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Upper Extremity Orthopedic Surgery: A Prospective and Randomized Pilot Study.

BACKGROUND: Upper extremity surgery is commonly performed in the ambulatory setting and is associated with moderate to severe postoperative pain. METHODS: Patients scheduled for upper extremity orthopedic surgery with a peripheral nerve block were randomized to receive either an ultrasound-guided single-injection supraclavicular block or ultrasound-guided median, ulnar, and radial nerve blocks (forearm blocks) performed at the level of the mid to proximal forearm with liposomal bupivacaine (Exparel) combined with a short-acting supraclavicular block. A sham block was performed in an attempt to blind enrollees in the control group. We administered the EuroQol 5D-5L questionnaire preoperatively and on postoperative days 1-3 and considered the results the primary outcome of our investigation. Block procedure times, postanesthesia care unit (PACU) length of stay, instances of nausea/vomiting, need for narcotic administration, and patient satisfaction were also assessed. RESULTS: We observed no significant differences in postoperative EuroQol scores between the 2 groups and no significant differences in patient demographics, PACU length of stay, or side effects in the PACU. In some instances, the short-acting supraclavicular block resolved in the PACU, and these patients reported higher pain scores and required titration of analgesics prior to discharge. CONCLUSION: Larger prospective studies are needed to determine the safety and efficacy of liposomal bupivacaine in patients undergoing upper extremity surgery. Liposomal bupivacaine is currently only approved for local anesthetic infiltration use.

Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study.

PURPOSE: Limited data exist regarding the role of perineural blockade of the distal median, ulnar, and radial nerves as a primary anesthetic in patients undergoing hand surgery. We conducted a prospective and randomized pilot study to compare these techniques to brachial plexus blocks as a primary anesthetic in this patient population. METHODS: Sixty patients scheduled for hand surgery were randomized to receive either an ultrasound-guided supraclavicular, infraclavicular, or axillary nerve block (brachial plexus blocks) or ultrasound-guided median, ulnar, and radial nerve blocks performed at the level of the mid to proximal forearm (forearm blocks). The ability to undergo surgery without analgesic or local anesthetic supplementation was the primary outcome. Block procedure times, postanesthesia care unit length of stay, instances of nausea/vomiting, and need for narcotic administration were also assessed. RESULTS: The 2 groups were similar in terms of the need for conversion to general anesthesia or analgesic or local anesthetic supplementation, with only 1 patient in the forearm block group and 2 in the brachial plexus block group requiring local anesthetic supplementation or conversion to general anesthesia. Similar durations in surgical and tourniquet times were also observed. Both groups reported similarly low numerical rating scale pain scores as well as the need for postoperative analgesic administration (2 patients in the forearm block group and 1 in the brachial plexus block group reported numerical rating scale pain scores > 0 and required opioid administration in the postanesthesia care unit). Block procedure characteristics were similar between the 2 groups. CONCLUSIONS: Forearm blocks may be used as a primary anesthetic in patients undergoing hand surgery. Further research is warranted to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Compartment syndrome in a patient treated with perineural liposomal bupivacaine (Exparel).

Acute compartment syndrome is a condition that may result in sensorimotor deficits and loss of function of the affected limb as a result of ischemic injury. It is considered a surgical emergency and prompt diagnosis and treatment results in more favorable outcomes. The use of regional anesthesia is controversial in patients at risk for compartment syndrome due to concern of its potential to mask symptoms of the condition. A 44-year-old African American male presented to surgery for open reduction and internal fixation of a comminuted distal radius fracture. As part of an off-label, investigator-initiated, and institutional review board-approved study, he received a perineural injection of liposomal bupivacaine (Exparel) around the median, ulnar, and radial nerves at the level of the proximal forearm. The following morning, his initial complaints of numbness and incisional pain progressively evolved into worsening numbness, diffuse discomfort, and pain with passive movement. A diagnosis of compartment syndrome was made and he underwent an emergency fasciotomy. The diagnosis of compartment syndrome requires a high index of suspicion and prompt treatment. This patient's changing pattern of symptoms-rather than his pain complaints alone-resulted in the diagnosis of compartment syndrome treated with emergent fasciotomy in spite of finger numbness that was initially attributed to the liposomal bupivacaine. While the use of liposomal bupivacaine did not preclude the diagnosis of compartment syndrome in our patient, it should be used with caution in patients at risk for compartment syndrome until additional data, particularly regarding block characteristics, are available.

Long-term effects of adolescent exposure to bisphenol A on neuron and glia number in the rat prefrontal cortex: Differences between the sexes and cell type.

Bisphenol A (BPA), an endocrine disruptor used in a variety of consumer products, has been found to alter the number of neurons in multiple brain areas in rats following exposure in perinatal development. Both the number of neurons and glia also change in the medial prefrontal cortex (mPFC) during adolescence, and this process is known to be influenced by gonadal hormones which could be altered by BPA. In the current study, we examined Long-Evans male and female rats that were administered BPA (0, 4, 40, or 400µg/kg/day) during adolescent development (postnatal days 27-46). In adulthood (postnatal day 150), the number of neurons and glia in the mPFC were stereologically assessed in methylene blue/azure II stained sections. There were no changes in the number of neurons, but there was a significant dose by sex interaction in number of glia in the mPFC. Pairwise comparisons between controls and each dose showed a significant increase in the number of glia between 0 and 40µg/kg/day in females, and a significant decrease in the number of glia between 0 and 4µg/kg/day in males. In order to determine the type of glial cells that were changing in these groups in response to adolescent BPA administration, adjacent sections were labelled with S100ß (astrocytes) and IBA-1 (microglia) in the mPFC of the groups that differed. The number of microglia was significantly higher in females exposed to 40µg/kg/day than controls and lower in males exposed to 4µg/kg/day than controls. There were no significant effects of adolescent exposure to BPA on the number of astrocytes in male or females. Thus, adolescent exposure to BPA produced long-term alterations in the number of microglia in the mPFC of rats, the functional implications of which need to be explored.

Distal peripheral nerve blockade for patients undergoing hand surgery: a pilot study.

BACKGROUND: Data are limited regarding the use of peripheral nerve blockade at the level of the forearm, and most studies regard these procedures as rescue techniques for failed or incomplete blocks. The purpose of the study was to investigate patients undergoing hand surgery with distal peripheral nerve (forearm) blocks and compare them with patients having similar procedures under more proximal brachial plexus blockade. No investigations comparing distal nerve blockade to proximal approaches are currently reported in the literature. METHODS: Medical records were retrospectively reviewed for patients who had undergone hand surgery with a peripheral nerve block between November 2012 and October 2013. The primary outcome was the ability to provide a primary anesthetic without the need for general anesthesia or local anesthetic supplementation by the surgical team. Secondary outcome measures included narcotic administration during the block and intraoperative procedures, block performance times, and the need for rescue analgesics in the post anesthesia care unit (PACU). RESULTS: No statistical difference in conversion rates to general anesthesia was observed between the two groups. Total opiate administration for the block and surgical procedure was lower in the forearm block group. There was no difference in block performance times or need for rescue analgesics in the PACU. CONCLUSIONS: Forearm blocks are viable alternatives to proximal blockade and are effective as a primary anesthetic technique in patients undergoing hand surgery. Compared to the more proximal approaches, these blocks have the benefits of not causing respiratory compromise, the ability to be performed bilaterally, and may be safer in anticoagulated patients.

Gonadectomy before puberty increases the number of neurons and glia in the medial prefrontal cortex of female, but not male, rats.

The human prefrontal cortex, important for executive functions, loses gray matter throughout the adolescent period. In rats, our laboratory demonstrated that a loss of neurons between adolescence and adulthood partially underlies the loss of volume, and this loss is greater in females than males. Here, we examine whether being deprived of gonadal hormones before puberty through adulthood influences the number of neurons in the medial prefrontal cortex (mPFC). Prior to puberty, the testes or ovaries were removed in male and female rats. In adulthood, the number of neurons and glia in the mPFC were quantified using unbiased stereology, and the volume of the frontal white matter was measured. Prepubertal ovariectomy resulted in a higher number of neurons and glia and a larger volume of white matter compared to sham control littermates. Castrated males were not different from sham males on any measure. Thus ovarian hormones secreted after puberty influence the cellular composition of the medial prefrontal cortex.

How we select our residents--a survey of selection criteria in general surgery residents.

INTRODUCTION: The future of general surgery depends on the quality of the resident trainees, and successful resident selection is a factor that is important in the process of high-quality surgical education. METHODS: A 36-question survey regarding resident selection and the interview process was sent to surgical program directors, department chairs, and associate program directors across the United States and Canada. RESULTS: In all, 262 valid replies were received (65%), of which 83% were program directors. University hospital programs accounted for 49% of the completed surveys. The mean yearly applicant number per residency program was 571. Most programs indicated that they strictly adhere to their selection criteria (82%). The screening selection is made by the program director in 62%. Only 31% of programs show their selection criteria on their web page. United States Medical Licensing Examination (USMLE) Step 1 is the single most important factor in screening criteria (37%), followed by USLME Step 2 (24%). A total of 96% of all programs have female residents, 66% have non-Liaison Committee on Medical Education graduates, and 38% have Doctor of Osteopathy (DO) residents. Final selection is made by the program director in 49%. Although research experience is considered in selection criteria (80%), only 46% of programs offer research opportunities to their residents and only 13% require 1-year of research. On a Likert 5-point scale, the interview is by far the most important factor (4.69), followed by Step 1 score (4.21), and letters of recommendation (4.02). CONCLUSIONS: Even though all general surgery programs have a wide range of screening/selection criteria, USLME Step 1 is the single most important factor for preliminary screening, and the interview is the most important factor in determining the final selection. The final selection is relatively subjective and based on a combination of interview, USLME scores, research experience, and personal judgment.

Comparison of conservative and operative treatment for blunt carotid injuries: analysis of the National Trauma Data Bank.

OBJECTIVES: Blunt carotid injury (BCI) is uncommon but potentially devastating. The best treatment modality for this injury remains undetermined. We conducted this study to better understand the hospital course and treatment outcomes for patients with BCI who received different interventions. METHODS: BCI and related vascular procedures were identified by ICD-9-CM codes from the National Trauma Data Bank(1) using data gathered from 2002 to 2006. Conservative and operative treatment groups were compared by variables of patient demographics, initial assessment in the emergency department (ED), hospital course, and treatment outcomes. Open surgical and endovascular interventions were further compared. RESULTS: A total of 842 BCI were identified from 1,633,126 discharged blunt trauma patients (0.05%). Of these, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between these treatment groups. On initial assessment, no differences between conservative and operative treatment groups were noted with regard to vital signs, Glasgow coma scale, presence of drugs or alcohol in blood, or Trauma Related Injury Severity Score survival probability. Significant differences were seen in terms of the presence of a base deficit (-3.1 +/- 6.8 vs -7.6 +/- 8.3; P = .01), likelihood of a positive head computed tomography (CT) scan (58.6% vs 26.1%; P = .003), and total Injury Severity Score (29.8 +/- 13.3 vs 26.1 +/- 14.1; P = .02). Hospital course and treatment outcomes were comparable, with no differences in hospital length of stay (13.4 +/- 15.3 days vs 13.7 +/- 13.6 days; P = .86), total Functional Independence Measure (8.8 +/- 3.3 vs 9.3 +/- 3.1; P = .38), progression of original neurologic insult (7.5% vs 4.6%; P = .61) or mortality (28.1% vs 19%; P = .08). When comparing open surgical to endovascular interventions (46 open, 34 endovascular, including 3 combined), the only significant differences were in the total Injury Severity Score (22.4 +/- 12.2 vs 31.4 +/- 15.4; P = .01) and length of intensive care unit (ICU) and hospital stay (5.0 +/- 6.0 days vs 10.7 +/- 10.4 days; P = .01, and 10.3 +/- 9.2 days vs 19.3 +/- 17.7 days; P = .01). Multivariate regression analysis confirmed that neither Functional Independence Measure (FIM) nor mortality was associated with conservative or operative treatment. CONCLUSION: BCI is rare and carries a poor prognosis. Operative intervention is not associated with functional improvement or a survival advantage. This study was unable to support that less invasive endovascular treatment improves treatment outcome when compared to open surgery.

National and surgical health care expenditures, 2005-2025.

OBJECTIVE AND BACKGROUND: Health care expenditures for 2005 in the United States were $1.9733 trillion and 15.9% of the gross domestic product (GDP). Twenty-nine percent of those expenditures were secondary to surgical revenues. Health care expenditures are increasing 2(1/2) times the rate of the general US economy and are being fed by new technologies, new medications, the aging population, more services provided per patient, defensive medicine and little tort reform, the insurance system, and the free rider problem, ie, patients are cared for as emergencies regardless of insurance coverage and legality, which all have contributed to rising health care and surgical expenditures over the last 50 years. METHODS: The purpose of this study was to project aggregate national health care expenditures, aggregate surgical health care expenditures, and the United States GDP for the years 2005-2025. Model building and existing state and national data were used. Aggregate surgical health care expenditures were computed as 29% of aggregate health care expenditures using a unique model developed by the late Dr. Francis D. Moore. The model of Dr. Moore which used 1981 federal data was verified/tested using data from UMDNJ-University Hospital, and New Jersey and national data from 2005. From 1965 to 2005 mean health care expenditures increased at 4.9% per year, and US GDP increased at a mean of 2.1% per year. RESULTS: Aggregate surgical expenditures are expected to grow from $572 billion in 2005 (4.6% of US GDP) to $912 billion (2005 dollars) in the year 2025 (7.3% of US GDP). Aggregate health care expenditures are projected to increase from $5572 per capita (15.9% of GDP) in 2005 to $8832 per capita (2005 dollars) in 2025 (25.2% of US GDP). Both surgery and national health care expenditures are expected to expand by almost 60% during the period 2005-2025. Thus, surgical health care expenditures by 2025 are likely to be 1/14 of the US economy, and health care expenditures will be (1/4) of the US economy. CONCLUSIONS: Real per capita GDP growth is relatively flat in the United States. Rising surgical health care expenditures and national health care expenditures are a significant issue for the US population. Unfortunately, programs at the state and federal level as well as private programs, for the last 50 years have not been able to slow the growth in health care expenditures. These trends are likely to continue and the effects will be: * A change in the US standard of living as surgical and health care expenditures become a larger part of the earned dollar per American especially with the current volatility of the US economy, * A rise in the cost of products made in the United States to pay the rising health care bill with a concomitant change in our national and international standard of living, and * An increasing debt and increases in federal and state taxes which will be required to maintain the current health care system, ie, Medicare, Medicaid, and the private health care insurance payment scheme, which has not changed substantially over the past 40 to 50 years. Surgeons must look at the incremental benefit of new technologies and procedures and determine which to choose if we are to slow the growth of surgical health care expenditures.