Unraveling quad fever: Severe hyperthermia after traumatic cervical spinal cord injury.

PURPOSE: There are many infectious and inflammatory causes for elevated core-body temperatures, though they rarely pass 40 â„ƒ (104 ℉). The term "quad fever" is used for extreme hyperpyrexia in the setting of acute cervical spinal cord injuries (SCIs). The traditional methods of treating hyperpyrexia are often ineffective and reported morbidity and mortality rates approach 100%. This study aims to identify the incidence of elevated temperatures in SCIs at our institution and assess the effectiveness of using a non-invasive dry water temperature management system as a treatment modality with mortality. METHODS: A retrospective analysis of acute SCI patients requiring surgical intensive care unit admission who experienced fevers ≥ 40 â„ƒ (104 ℉) were compared to patients with maximum temperatures < 40 â„ƒ. Patients ≥18 years old who sustained an acute traumatic SCI were included in this study. Patients who expired in the emergency department; had a SCI without radiologic abnormality; had neuropraxia; were admitted to any location other than the surgical intensive care unit; or had positive blood cultures were excluded. SAS 9.4 was used to conduct statistical analysis. RESULTS: Over the 9-year study period, 35 patients were admitted to the surgical intensive care unit with a verified SCI. Seven patients experienced maximum temperatures of ≥ 40 â„ƒ. Six of those patients were treated with the dry water temperature management system with an overall mortality of 57.1% in this subgroup. The mortality rate for the 28 patients who experienced a maximum temperature of ≤ 40 â„ƒ was 21.4% (p = 0.16). CONCLUSION: The diagnosis of quad fever should be considered in patients with cervical SCI in the presence of hyperthermia. In this study, there was no significant difference in mortality between quad fever patients treated with a dry water temperature management system versus SCI patients without quad fever. The early use of a dry water temperature management system appears to decrease the mortality rate of quad fever.

Geospatial Mapping to Target Injury Prevention for Older Adult Ground-Level Falls: A Feasibility Study.

BACKGROUND: Trauma centers target injury prevention efforts based on trauma registry and local epidemiological data. Identifying geographic patterns of injury through geospatial mapping has emerged as a technology to help identify at-risk individuals. Yet, the feasibility of using spatial analysis to target injury prevention efforts remains unknown. OBJECTIVE: This study aims to demonstrate the use of geospatial mapping of older adult ground-level falls to target injury prevention efforts. METHODS: This retrospective cohort analysis of ground-level falls among older adults was conducted from 2017 to 2020 at a Level I trauma center and safety net hospital. Trauma admissions, U.S. census median income, Hispanic percentage, and population density by zip codes were combined to create choropleth and heat maps to identify injury hot spots to target fall prevention classes. RESULTS: A total of 5,629 patients were reviewed, of which 3,002 (53%) were fall cases. Low-level falls (<10 ft) accounted for 2,224 cases; 1,449 were among older adults centered around the study hospital. Ground-level falls accounted for 1,663 patients, of whom 1,182 were older adults clustering around senior housing, assisted living facilities, nursing homes, and rehabilitation centers. As a result, our fall prevention classes are now targeted at these newly identified locations. CONCLUSION: Geospatial analysis provided powerful visualization of fall injury locations to target our fall prevention efforts. Geospatial analysis is a feasible tool for trauma centers to guide injury prevention strategies that effectively target the populations most in need.

Perioperative Multimodal Pain Management Approach in Older Adults With Polytrauma.

INTRODUCTION: The use of intravenous (IV) acetaminophen (APAP) postoperatively in older adults may be a beneficial strategy. We implemented a multimodal pain management approach in our hospital in 2015, with IV APAP being the first-line therapy. MATERIALS AND METHODS: This was a retrospective, single-center, observational cohort study of polytrauma, orthopedic surgical patients aged ≥50 y. Patients admitted in 2017, postimplementation of pain protocol, were categorized as the exposed patients. Patients in the year 2014 served as the historical cohort. The two primary outcomes evaluated were postoperative opioid consumption in morphine milligram equivalents (MMEs) and patient pain scores. RESULTS: In total, 121 eligible patients were identified for this study; 22 historical control patients and 99 exposed patients. We observed a significant reduction in postoperative opioid use up to 48 h postoperatively (20.9 ± 27 versus 4.3 ± 12.4 MME [P < 0.05] at 24 h and 19.8 ± 31.2 versus 2.1 ± 11.3 MME [P < 0.05] at 48 h, respectively). The mean opioid consumption remained significantly lower in patient subgroup of age ≥74 y with no difference in the mean pain scores (1.5 ± 1.5 versus 1.9 ± 1.6 [P = 0.48] at 24 h and 1.5 ± 1.8 versus 2.0 ± 1.5 [P = 0.21] at 48 h postoperatively in the historical versus exposed cohort, respectively). Exposed patients had a shorter hospital length of stay than control patients (5.0 [3, 7] versus 6.5 [5, 9.5] d; P = 0.01). CONCLUSIONS: The use of multimodal pain management with IV APAP as first-line therapy was associated with reduced opioid use in the perioperative setting for older adults with polytrauma.

Contralateral pneumothorax after central line placement in COVID-19 positive patients.

Contralateral pneumothorax after percutaneous central venous catheter placement has not been previously reported. Three patients who required intubation and mechanical ventilation for acute respiratory failure due to COVID-19 were identified with a new pneumothorax on routine post-placement chest roentgenogram on the side opposite the catheter placement.  Retrospective review of charts, radiographs, and laboratory studies.  No causative relationship was identified between the percutaneous placement of the central venous catheters and the subsequent pneumothoraces identified on the contralateral side, other than the presence of active COVID-19 viral pneumonia. The timing of the contralateral pneumothoraces were coincidental the placement of the central venous catheters.  We believe these pneumothoraces were a consequence of the pulmonary pathology of the COVID-19 virus.

Reducing Catheter-Associated Urinary Tract Infection: The Impact of Routine Screening in the Geriatric Hip Fracture Population.

BACKGROUND: Catheter-associated urinary tract infection (CAUTI) is a noted complication among geriatric hip fracture patients. This complication results in negative outcomes for both the patients and the institution providing care. Screening measures to identify predisposing factors, with early diagnosis and treatment of urinary tract infection (UTI) present on admission, may lead to reduced rates of CAUTI. OBJECTIVE: The goals of this study were to determine the prevalence of UTI on admission among geriatric hip fracture patients and whether routine screening for UTI or predisposing factors at presentation resulted in reduced rates of CAUTI. METHODS: A retrospective observational study of geriatric hip fracture patients from January 2017 to December 2018 at a Level I trauma center was performed. Rates of UTI on admission and CAUTI were calculated using routine admission urinalysis. RESULTS: Of the 183 patients in the sample, 36.1% had UTI on admission and 4.4% of patients developed CAUTI. There were no significant differences in patient demographics, comorbidities, and complications between those with UTI on admission and those without. CONCLUSIONS: Urinary tract infection on admission may be present among a large portion of geriatric hip fracture patients, leading to increased rates of CAUTI. Routine screening for UTI and its predisposing factors at admission can identify these patients earlier and lead to earlier treatments and prevention of CAUTI.

The Impact of an ICU "Bed Ahead" Policy on ED Length of Stay and Patient Outcomes.

OBJECTIVE: To assess the impact of preassigning a single bed in the surgical intensive care unit (SICU) for the next trauma admission. BACKGROUND: Prolonged emergency department (ED) dwell time before admission to a critical care unit has an adverse effect on patient outcomes and is often due to the lack of an available bed in the intensive care unit (ICU). METHODS: A "Bed Ahead" policy was instituted at an urban level 1 Trauma Public Safety Net Teaching Hospital to preassign 1 SICU bed for the next trauma patient who warrants a critical care admission. A retrospective review of all trauma patients admitted to the SICU before and after implementation of this policy was performed to assess the impact on ED dwell time, ICU and hospital lengths of stay, complications, and in-hospital mortality. RESULTS: ED length of stay (ED-LOS); ICU length of stay (ICU-LOS); hospital length of stay (HLOS); complications; and in-hospital mortality were compared before (PRE) and after (POST)implementation of the Bed Ahead policy. Statistically significant improvements were seen in the POST period for ED-LOS, HLOS, complications, and in-hospital mortality. CONCLUSIONS: Preassigning 1 ICU for the yet to arrive next injured patient decreases ED dwell times, complications, HLOS, and in-hospital mortality.

Management and Outcomes of Isolated Axillary Artery Injury: A Five-Year National Trauma Data Bank Analysis.

BACKGROUND: The aim of this study is to evaluate recent national trends in the clinical characteristics, management, and outcomes of patients with isolated axillary artery injuries. METHODS: The National Trauma Data Bank was queried to identify records submitted from 2011 to 2015 that contained an ICD-9-CM diagnosis code for an injury to axillary artery (903.01) and an external cause of injury code indicating blunt or penetrating trauma. Records that contained a diagnosis code for an injury to an additional blood vessel (900.00-903.00, 903.2-904.9), an injury to a nonupper extremity or unclassifiable body region, or whose operative management could not be discerned were excluded. The final study sample included 221 patients with isolated axillary artery injury. The patient's clinical management was the primary outcome of interest. The study sample was stratified by trauma type, and descriptive statistics were performed on all variables. RESULTS: Seventy-one percent of patients received operative management. Patients with penetrating injury were 24% more likely to be managed operatively than bluntly injured patients (76.9% vs. 62.1%, P = 0.0178). In operatively managed patients, the open repair rate was 82.8% and endovascular repair rate was 10.2%. Graft repair was performed most often (28.0%), followed by placement of a temporary intravenous shunt (17.8%) and surgical occlusion (10.2%). Surgical vessel occlusion was significantly more likely to be performed on patients with penetrating injury than with blunt injury (14.6% vs. 1.9%, P = 0.0124). Patients with penetrating injury had significantly shorter median emergency department length of stay (87.0 min vs. 152.0 min, P < 0.0001), intensive care unit length of stay (2.0 days vs. 3.0 days, P < 0.0388), hospital length of stay (4.0 days vs. 5.0 days, P = 0.0026), and time-to-operative management (1.6 hr vs. 3.9 hr, P < 0.001) compared to bluntly injured patients. Patients with blunt injury had a higher reportable in-hospital complication rate (13.8% vs. 6.0%, P = 0.0477). The overall mortality rate was 3.1% for isolated axillary artery injuries and did not significantly differ by trauma type. CONCLUSIONS: Axillary artery injury is more often caused by penetrating trauma. Despite introduction of novel endovascular techniques, the majority of patients with isolated axillary artery injury are managed using open repair. Penetrating axillary artery injury is significantly more likely to be managed using open repair and by surgical occlusion. Patients with blunt injury have higher complication rates and longer hospital length of stays. The mortality rate is lower than previously published.

Disparities in length of stay for hip fracture treatment between patients treated in safety-net and non-safety-net hospitals.

BACKGROUND: Length of hospital stay (LOS) for hip fracture treatments is associated with mortality. In addition to patient demographic and clinical factors, hospital and payer type may also influence LOS, and thus mortality, among hip fracture patients; accordingly, outcome disparities between groups may arise from where patients are treated and from their health insurance type. The purpose of this study was to examine if where hip fracture patients are treated and how they pay for their care is associated with outcome disparities between patient groups. Specifically, we examined whether LOS differed between patients treated at safety-net and non-safety-net hospitals and whether LOS was associated with patients' insurance type within each hospital category. METHODS: A sample of 48,948 hip fracture patients was extracted from New York State's Statewide Planning and Research Cooperative System (SPARCS), 2014-2016. Using means comparison and X2 tests, differences between safety-net and non-safety-net hospitals on LOS and patient characteristics were examined. Relationships between LOS and hospital category (safety-net or non-safety-net) and LOS and insurance type were further evaluated through negative binomial regression models. RESULTS: LOS was statistically (p ≤ 0.001) longer in safety-net hospitals (7.37 days) relative to non-safety-net hospitals (6.34 days). Treatment in a safety-net hospital was associated with a LOS that was 11.7% (p = 0.003) longer than in a non-safety-net hospital. Having Medicaid was associated with a longer LOS relative to having commercial health insurance. CONCLUSION: Where hip fracture patients are treated is associated with LOS and may influence outcome disparities between groups. Future research should examine whether outcome differences between safety-net and non-safety-net hospitals are associated with resource availability and hospital payer mix.

Does a Surgical Post-Acute Unit Help Elders With Rib Fractures? Definitely Maybe!

A surgical post-acute treatment unit (SPA) was developed for acutely injured elderly patients who no longer warranted acute care in an intensive care setting to decrease complications by focusing increased bedside attention to cognition, nutrition, respiration, and mobilization. A retrospective review was performed comparing patients 65 years and older with isolated rib fractures treated before the SPA was opened with patients treated in the SPA. The 2 populations were comparable except the SPA group had a higher mean Injury Severity Score. Nine complications occurred in the pre-SPA group, and no complications occurred in the SPA patient population. Four patients in the pre-SPA group died compared with zero deaths for the SPA group. The rates of complications and mortality between elderly patients with isolated rib fractures were not statistically different between patients treated with a traditional admission to an inpatient ward and patients admitted to the SPA, even though the SPA patients had significantly more severe chest injuries. Establishing a physical environment to support the needs of elderly trauma patients with isolated rib fractures who no longer need the intensive care unit (ICU) is effective in decreasing the complications and unplanned returns to the ICU.

Potato Spindle Tuber Viroid Modulates Its Replication through a Direct Interaction with a Splicing Regulator.

Viroids are circular noncoding RNAs (ncRNAs) that infect plants. Despite differences in the genetic makeup and biogenesis, viroids and various long ncRNAs all rely on RNA structure-based interactions with cellular factors for function. Viroids replicating in the nucleus utilize DNA-dependent RNA polymerase II for transcription, a process that involves a unique splicing form of transcription factor IIIA (TFIIIA-7ZF). Here, we provide evidence showing that potato spindle tuber viroid (PSTVd) interacts with a TFIIIA splicing regulator (ribosomal protein L5 [RPL5]) in vitro and in vivo PSTVd infection compromises the regulatory role of RPL5 over splicing of TFIIIA transcripts, while ectopic expression of RPL5 reduces TFIIIA-7ZF expression and attenuates PSTVd accumulation. Furthermore, we illustrate that the RPL5 binding site on the PSTVd genome resides in the central conserved region critical for replication. Together, our data suggest that viroids can regulate their own replication and modulate specific regulatory factors leading to splicing changes in only one or a few genes. This study also has implications for understanding the functional mechanisms of ncRNAs and elucidating the global splicing changes in various host-pathogen interactions.IMPORTANCE Viroids are the smallest replicons among all living entities. As circular noncoding RNAs, viroids can replicate and spread in plants, often resulting in disease symptoms. Potato spindle tuber viroid (PSTVd), the type species of nuclear-replicating viroids, requires a unique splicing form of transcription factor IIIA (TFIIIA-7ZF) for its propagation. Here, we provide evidence showing that PSTVd directly interacts with a splicing regulator, RPL5, to favor the expression of TFIIIA-7ZF, thereby promoting viroid replication. This finding provides new insights to better understand viroid biology and sheds light on the noncoding RNA-based regulation of splicing. Our discovery also establishes RPL5 as a novel negative factor regulating viroid replication in the nucleus and highlights a potential means for viroid control.

Improved outcomes following implementation of a multidisciplinary care pathway for elderly hip fractures.

BACKGROUND: Hip fractures in patients 65 years and older are associated with significant morbidity and mortality. With the steady increase in the elderly population, we implemented an evidence-based clinical practice guideline for the management of hip fractures to optimize patient care and surgical outcomes. AIMS: To evaluate the effects of a multidisciplinary hip fracture care pathway on patient outcomes in the care of elderly patients. METHODS: A retrospective analysis of the differences in outcomes prior to (January-October 2014) and after (November 2014-April 2016) implementation of a hip fracture care pathway at a regional Level I trauma center was performed. RESULTS: There were 80 patients in the pre-pathway group and 191 patients in the post-pathway group with an average age of 83.18 ± 8.24 years. The analysis demonstrated that the post-pathway group had a lower incidence of in-hospital complications (9.95 vs 30.00%; p ≤ 0.001), shorter emergency room length of stay (3.76 ± 2.43 vs 6.78 ± 2.88 h; p ≤ 0.0001), and shorter overall hospital length of stay (5.03 ± 3.46 vs 7.44 ± 6.66 days; p = 0.0028). The in-hospital mortality rate was similar between groups (4.71 vs 6.25%; p = 0.6018). DISCUSSION: The development of a multidisciplinary approach to the care of elderly patients with hip fractures improved morbidity and showed a downward trend in mortality. CONCLUSIONS: Elderly patients with hip fractures treated at our trauma center had improved clinical outcomes after the implementation of a multidisciplinary care pathway.

Betwixt and between: a surgical post-acute treatment unit (SPA) for the optimal care of elderly patients with isolated hip fractures.

BACKGROUND: A performance improved project identified elderly trauma patients to have a disproportionate incidence of complications. AIMS: The purpose of this study was to assess the efficacy of a small specialty care unit to decrease complications in patients who no longer warrant care in an intensive care unit (ICU). METHODS: A surgical post-acute treatment unit (SPA) was developed with focused attention to cognition, nutrition, respiration, and mobilization needs of patients who no longer had physiologic need for an intensive care unit environment, but were still in need of increased attention at the bedside. RESULTS: While ICU and hospital lengths of stay were unchanged, patients placed in the SPA experienced less complications and required less unplanned ICU re-admissions. DISCUSSION: Geriatric patients, especially the elderly, are not simply old adults. They have unique needs as a consequence of the aging process, which can be encompassed by four pillars of intercession: cognition, nutrition, respiration, and mobilization. CONCLUSIONS: By adapting a physical environment supported by bedside attention to address the interwoven needs of geriatric and elderly patients who no longer care in an ICU, complications and unplanned return admissions to the ICU can be decreased. LEVEL OF EVIDENCE: III.

Impact of the Pediatric Emergency Care Applied Research Network (PECARN) guidelines on emergency department use of head computed tomography at a level I safety-net trauma center.

PURPOSE: To evaluate whether the emergency department usage of head computed tomography (CT) on pediatric patients with minor head trauma changed after publication of the Pediatric Emergency Care Applied Research Network (PECARN) head CT guidelines and to identify risk factors associated with performing head CT on patients without a PECARN guideline indication. METHODS: This retrospective study included 484 patients 18 years of age or younger who presented to the emergency department with head injury and a total Glasgow Coma Scale score ≥ 14 between September 2005 and July 2014. Based on the guideline publication date of September 2009, the study cohort was stratified into pre-guideline and post-guideline groups. Head CT performance, indications, and findings were compared between study periods. Logistic regression was used to identify risk factors associated with performing a non-indicated head CT. RESULTS: The rate of head CTs performed did not significantly change in the post-guideline period (96.6% vs. 95.7%, p = 0.63). There was no significant difference in the proportion of head CTs performed in patients with indications for head CT (100.0% vs. 100.0%) nor in patients without an indication for head CT (85.7% vs. 82.6%, p = 0.65) between the study periods. Females were significantly more likely to have a non-indicated head CT (OR: 2.73, 95% CI: 1.67-4.45) performed. CONCLUSIONS: Head CT ordering practices for pediatric patients with head injury did not change at a level I trauma center after publication of the PECARN head CT guidelines.

Burnout, Perceived Stress, and Job Satisfaction Among Trauma Nurses at a Level I Safety-Net Trauma Center.

Nurses are at the forefront of our health care delivery system and have been reported to exhibit a high level of burnout. Burnout and stress in trauma nurses at a safety-net hospital can negatively impact patient care. Safety-net hospitals are confronted with unique social, financial, as well as resource problems that can potentially make the work environment frustrating. The purpose of this study was to explore the levels of burnout, stress, and job satisfaction in nurses providing care to trauma patients at a Level I safety-net trauma center. A cross-sectional survey design was used to investigate principal factors including personal and professional demographics, burnout, perceived stress, and job satisfaction. Trauma nurses working at a Level I safety-net trauma center are stressed and exhibited moderate degree of burnout. The extent of emotional exhaustion experienced by the nurses varied with work location and was highest in surgical intensive care unit nurses. The level of job satisfaction in terms of opportunities for promotion differed significantly by race and the health status of the nurses. Satisfaction with coworkers was lowest in those nurses between the ages of 60-69 years. Female nurses were more satisfied with their coworkers than male nurses. In addition, the study revealed that significant relationships exist among perceived stress, burnout, and job satisfaction. Work environment significantly impacts burnout, job satisfaction, and perceived stress experienced by trauma nurses in a safety-net hospital. Nursing administration can make an effort to understand the levels of burnout and strategically improve work environment for trauma nurses in order to minimize stressors leading to attrition and enhance job satisfaction.

Adrenal Injuries: Historical Facts and Modern Truths.

BACKGROUND: Prior to the advent of whole body computed tomography, injuries of the adrenal gland were almost exclusively identified on postmortem examinations and were associated with severe injury. Recent literature has continued to identify an association between adrenal injuries and high ISS. The purpose of this study was to assess the influence of adrenal trauma on ISS and mortality while controlling for potential confounding factors. METHODS: A 15-year retrospective review for all adrenal gland injuries from a Level 1 Trauma Center's Trauma Registry was performed. Based on the characteristics of that patient population, the same Trauma Registry was then queried for case-matched patients, and the two groups compared to assess the influence of adrenal gland injuries on mortality. RESULTS: Seventy-two patients with adrenal injuries were identified and compared to 1026 case-matched patients. The adrenal gland injury was not a contributing factor in any of the study group mortalities. The mean ISS for the adrenal gland injured group was higher than the overall Registry ISS (18.7 vs 10.6) but almost identical to the ISS of patients case matched for abdominal injuries. CONCLUSION: Case-matched analysis based on multiple clinical variables demonstrates that the ISS of patients with adrenal gland injuries were similar to the ISS of patients with other injuries to the abdominal region and were in fact associated with a 0.02% decrease in mortality.

Risk factors associated with in-hospital mortality in elderly patients admitted to a regional trauma center after sustaining a fall.

BACKGROUND AND AIMS: Falls are a significant cause of mortality in the elderly patients. Despite this, the literature on in-hospital mortality related to elderly falls remains sparse. Our study aims to determine the risk factors associated with in-hospital mortality in elderly patients admitted to a regional trauma center after sustaining a fall. METHODS: All elderly case records with fall-related injuries between 2003 and 2013 were retrospectively analyzed for demographic characteristics, injury severities, comorbidity factors and clinical outcomes. Logistic regression analysis was used to examine the risk factors associated with in-hospital mortality. RESULTS: In total, 1026 elderly patients with fall-related injuries were included in the study. The average age of patients was 80.94 ± 8.16 years. Seventy seven percent of the patients had at least one comorbid condition. Majority of the falls occurred at home. More than half of the patients fell from ground level. Overall, the in-hospital mortality rate was 16 %. Head injury constituted the most common injury sustained in patients who died (77 %). In addition to age, ISS, GCS, ICU admission and anemia were significantly (P < 0.05) associated with in-hospital deaths in elderly fall patients. CONCLUSION: Ground-level falls in the elderly can be devastating and carry a significant mortality rate. Elderly patients with anemia were two times more likely to die in the hospital after sustaining a fall in our study population. Increased focus on anemia which is often underappreciated in elderly fall patients can be beneficial in improving outcomes and reducing in-hospital mortality.

Thoracotomy in the emergency department for resuscitation of the mortally injured.

PURPOSE: Emergency department resuscitative thoracotomy is an intervention of last resort for the acutely dying victim of trauma. In light of improvements in pre-hospital emergency systems, improved operative strategies for survival such as damage control and improvements in critical care medicine, the most extreme of resuscitation efforts should be re-evaluated for the potential survivor, with success properly defined as the return of vital signs which allow transport of the patient to the operating room. METHODS: A retrospective review of all patients at a suburban level I trauma center who underwent emergency department resuscitative thoracotomy as an adjunct to the resuscitation efforts normally delivered in the trauma receiving area over a 22 year period was performed. Survival of emergency department resuscitative thoracotomy was defined as restoration of vital signs and transport out of the trauma resuscitation area to the operating room. RESULTS: Sixty-eight patients were identified, of whom 27 survived the emergency department resuscitative thoracotomy and were transported to the operating room. Review of pre-hospital and initial hospital data between these potential long term survivors and those who died in the emergency department failed to demonstrate trends which were predictive of survival of emergency department resuscitative thoracotomy. The only subgroup which failed to respond to emergency department resuscitative thoracotomy was patients without signs of life at the scene who arrived to the treatment facility without signs of life. CONCLUSION: The patient population of the "potential survivor" has been expanded due to advances in critical care practices, technology, and surgical technique and every opportunity for survival should be provided at the outset. Emergency department resuscitative thoracotomy is warranted for any patient with thoracic or subdiaphragmatic trauma who presents in extremis with a history of signs of life at the scene or organized cardiac activity upon arrival. Patients who have no evidence of signs of life at the scene and have no organized cardiac activity upon arrival should be pronounced.

Use of an Electronic C-Spine Clearance Strategy to Ensure Compliance With Confrontational Examinations: A Performance Improvement Patient Safety Project.

The implementation of electronic medical records (EMRs) represents one of the most significant changes taking place in the medical field today. The purpose of this Performance Improvement Patient Safety initiative was to evaluate and improve the documentation of c-spine clearances by standardizing the confrontational spine examination for patients sustaining blunt trauma using the EMR. A retrospective audit of trauma charts was performed over a 6-month period to evaluate c-spine clearance documentation. Following the initial audit, a strategy, using the Donabedian Principle of problem identification, process establishment, and outcome measure, was created resulting in a template in the EMR whereby clearance of the cervical spine (confrontational examination) in nonobtunded trauma patients was standardized for all providers. Outcomes before and after implementation of the EMR protocol were compared. The initial audit revealed that 71% of records lacked appropriate documentation. Of those with documentation, 26% simply stated "c-spine cleared" or "collar removed" with no documentation to support the clinical examination performed. This is in contrast to a 95% compliance rate following the use of the EMR protocol. Up to 80% of collars were removed within 3 hours of admission thereby reducing complications associated with c-collars. The use of the EMR allowed for the standardization of the cervical spine clearance, improved documentation, and allowed for the monitoring of compliance with evidenced-based c-spine protocols. Practice implications and lessons learned in the implementation of this successful Performance Improvement Patient Safety are also described.

Genome-wide transcriptional profiling of appressorium development by the rice blast fungus Magnaporthe oryzae.

The rice blast fungus Magnaporthe oryzae is one of the most significant pathogens affecting global food security. To cause rice blast disease the fungus elaborates a specialised infection structure called an appressorium. Here, we report genome wide transcriptional profile analysis of appressorium development using next generation sequencing (NGS). We performed both RNA-Seq and High-Throughput SuperSAGE analysis to compare the utility of these procedures for identifying differential gene expression in M. oryzae. We then analysed global patterns of gene expression during appressorium development. We show evidence for large-scale gene expression changes, highlighting the role of autophagy, lipid metabolism and melanin biosynthesis in appressorium differentiation. We reveal the role of the Pmk1 MAP kinase as a key global regulator of appressorium-associated gene expression. We also provide evidence for differential expression of transporter-encoding gene families and specific high level expression of genes involved in quinate uptake and utilization, consistent with pathogen-mediated perturbation of host metabolism during plant infection. When considered together, these data provide a comprehensive high-resolution analysis of gene expression changes associated with cellular differentiation that will provide a key resource for understanding the biology of rice blast disease.

Potential exposure of pollinators to neonicotinoid insecticides from the use of insecticide seed treatments in the mid-southern United States.

Research was done during 2012 to evaluate the potential exposure of pollinators to neonicotinoid insecticides used as seed treatments on corn, cotton, and soybean. Samples were collected from small plot evaluations of seed treatments and from commercial fields in agricultural production areas in Arkansas, Mississippi, and Tennessee. In total, 560 samples were analyzed for concentrations of clothianidin, imidacloprid, thiamethoxam, and their metabolites. These included pollen from corn and cotton, nectar from cotton, flowers from soybean, honey bees, Apis mellifera L., and pollen carried by foragers returning to hives, preplanting and in-season soil samples, and wild flowers adjacent to recently planted fields. Neonicotinoid insecticides were detected at a level of 1 ng/g or above in 23% of wild flower samples around recently planted fields, with an average detection level of about 10 ng/g. We detected neonicotinoid insecticides in the soil of production fields prior to planting at an average concentration of about 10 ng/g, and over 80% of the samples having some insecticide present. Only 5% of foraging honey bees tested positive for the presence of neonicotinoid insecticides, and there was only one trace detection (< 1 ng/g) in pollen being carried by those bees. Soybean flowers, cotton pollen, and cotton nectar contained little or no neonicotinoids resulting from insecticide seed treatments. Average levels of neonicotinoid insecticides in corn pollen ranged from less than 1 to 6 ng/g. The highest neonicotinoid concentrations were found in soil collected during early flowering from insecticide seed treatment trials. However, these levels were generally not well correlated with neonicotinoid concentrations in flowers, pollen, or nectar. Concentrations in flowering structures were well below defined levels of concern thought to cause acute mortality in honey bees. The potential implications of our findings are discussed.