Challenging boundaries: Organ transplants from donors with Listeria central nervous system infections.

Pretransplant mortality rates in the US remain high and are connected to effective organ donation and utilization. Thus, there is a need to maximize the utilization of available donors. In some cases, this has been safely achieved using organs from donors with infectious complications. For example, several studies describe the use of organs from donors with bacterial meningitis due to pathogens such as Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenza, and Escherichia coli, with good outcomes. Listeria is an aerobic and facultatively anaerobic, nonspore-forming, Gram-positive rod that can affect the central nervous system, causing meningitis and meningoencephalitis. Due to its virulence, ability to cause intracellular infection, and lack of clinical data, people dying with listeria may not be evaluated for organ donation, may not have organs recovered, or may have their organs recovered but not transplanted. Herein, we describe the outcomes of 7 solid organ transplant recipients who received organs from 2 donors with Listeria monocytogenes central nervous system infection.

B cells drive neuropathic pain-related behaviors in mice through IgG-Fc gamma receptor signaling.

Neuroimmune interactions are essential for the development of neuropathic pain, yet the contributions of distinct immune cell populations have not been fully unraveled. Here, we demonstrate the critical role of B cells in promoting mechanical hypersensitivity (allodynia) after peripheral nerve injury in male and female mice. Depletion of B cells with a single injection of anti-CD20 monoclonal antibody at the time of injury prevented the development of allodynia. B cell-deficient (muMT) mice were similarly spared from allodynia. Nerve injury was associated with increased immunoglobulin G (IgG) accumulation in ipsilateral lumbar dorsal root ganglia (DRGs) and dorsal spinal cords. IgG was colocalized with sensory neurons and macrophages in DRGs and microglia in spinal cords. IgG also accumulated in DRG samples from human donors with chronic pain, colocalizing with a marker for macrophages and satellite glia. RNA sequencing revealed a B cell population in naive mouse and human DRGs. A B cell transcriptional signature was enriched in DRGs from human donors with neuropathic pain. Passive transfer of IgG from injured mice induced allodynia in injured muMT recipient mice. The pronociceptive effects of IgG are likely mediated through immune complexes interacting with Fc gamma receptors (FcγRs) expressed by sensory neurons, microglia, and macrophages, given that both mechanical allodynia and hyperexcitability of dissociated DRG neurons were abolished in nerve-injured FcγR-deficient mice. Consistently, the pronociceptive effects of IgG passive transfer were lost in FcγR-deficient mice. These data reveal that a B cell-IgG-FcγR axis is required for the development of neuropathic pain in mice.

Does temporary chest wall closure with or without chest packing improve survival for trauma patients in shock after emergent thoracotomy?

BACKGROUND: Many surgeons avoid the damage-control techniques of intrathoracic packing and temporary chest wall closure after thoracotomy for trauma because of concerns about packing's effects on intrathoracic pressure and infectious risks. We hypothesized that temporary chest closure with or without intrathoracic packing (TCC-P) as a method of thoracic damage control would yield higher than expected survival rates for trauma thoracotomy patients with metabolic exhaustion, whereas traditional definitive chest closure (DEF) would exhibit predicted survival rates. METHODS: This was a retrospective cohort study by two urban Level I trauma centers on patients who (1) underwent emergent thoracotomy for trauma, (2) received ≥10 units (U) packed red blood cells and/or sustained a cardiac arrest before starting chest closure, and (3) survived to intensive care unit arrival. Demographic/physiologic data, chest closure method, and thoracic complications were gathered. Trauma injury severity scores (TRISS) were used to calculate survival probability for TCC-P and DEF. Nonparametric statistics were used for all comparisons. All values are expressed as medians and interquartile ranges (IQR). RESULTS: Sixty-one patients met inclusion criteria. Both TCC-P (n = 17) and DEF (n = 44) were severely injured (ISS=35 [IQR, 25-42] vs. 29 [IQR 19-45] and packed red blood cells = 16.5 U [IQR, 12.3-25.5 U] vs. 15 U [IQR, 11-23 U], respectively; p=ns). Patient demographics were similar except for the findings that the TCC-P cohort had higher rates of cardiac arrest before starting chest closure (TCC-P 82% vs. DEF 48%, p=0.04), significantly more severe abdominal injuries, and less severe head injuries than the DEF group. No significant differences were observed in survival of the overall samples (TCC-P=47% vs. DEF=57%), nor for observed:expected (O:E) survival ratio in 13 patients with TCC-P and 30 with DEF meeting criteria for TRISS calculation (TCC-P O:E, 46%:39%; DEF O:E, 53%:57%). No significant differences were found for TCC-P and DEF thoracic infectious (24% vs. 25%) or hemorrhagic (18% vs. 14%) complications. Surprisingly, peak inspiratory pressures on intensive care unit arrival were markedly better after TCC-P (20 cm H2O [IQR, 18-31 cm H2O]) than after DEF (32.5 cm H2O [IQR, 28-37.5 cm H2O], p=0.003). CONCLUSION: Concerns about TCC-P are not borne out as thoracic infection rates are unaffected and peak pressures are actually lower, possibly due to greater pleural volume from an open chest wall and skin-only closure. However, no significant survival benefit was seen with TCC-P.

Driver see, driver crash: Associations between televised stock car races' audience size and the incidence of speed-related motor vehicle collisions in the United States.

Several studies have examined road rage, but few studies have examined other psychosocial factors that may contribute to the number of motor vehicle collisions (MVCs). One study found increases in MVCs in West Virginia following televised NASCAR races but did not account for audience size. This study examined associations between NASCAR's television viewership ratings and the incidence of speed-related MVCs in the USA using generalized estimating equations that controlled for seasonal effects, intoxication, road surface conditions, and lighting conditions. A 1% increase in the number of US households watching NASCAR races per month was associated with a 6.3% (95% confidence interval [CI], 3.0% to 9.7%; P < 0.001) increase in the incidence of speed-related MVCs-approximately 4911 (95% CI, 2353 to 7470) speed-related MVCs per month or one speed-related MVC per 595 (95% CI, 382 to 1354) viewers. As expected, similar results were not found for the total number of MVCs. These data suggest that televised NASCAR races may be associated with substantial increases in the incidence of speed-related MVCs. Making drivers aware of psychological factors that may increase risky driving behaviors could prove beneficial because self-monitoring can result in safer driving.

Improving National Trauma Data Bank® coding data reliability for traumatic injury using a prospective systems approach.

Trauma centers manage an active Trauma Registry from which research, quality improvement, and epidemiologic information are extracted to ensure optimal care of the trauma patient. We evaluated coding procedures using the Relational Trauma Scoring System™ to determine the relative accuracy of the Relational Trauma Scoring System for coding diagnoses in comparison to the standard retrospective chart-based format. Charts from 150 patients admitted to a level I trauma service were abstracted using standard methods. These charts were then randomized and abstracted by trauma nurse clinicians with coding software aide. For charts scored pre-training, percent correct for the trauma nurse clinicians ranged from 52 to 64 percent, while the registrars scored 51 percent correct. After training, percentage correct for the trauma nurse clinicians increased to a range of 80-86 percent. Our research has demonstrated implementable changes that can significantly increase the accuracy of data from trauma centers.

Clamping thoracostomy tubes: a heretical notion?

To determine the safety and complications of chest tube clamping, a retrospective chart review was conducted at Baylor University Medical Center's level I trauma center. The records of 243 patients with pneumothoraces, hemothoraces, or a combination were identified and analyzed; 134 patients underwent clamping according to the care path, and 109 did not. The demographic characteristics of age, gender, and mechanism of injury were similar in both groups, as was the frequency of pneumothoraces, hemothoraces, and combined hemo/pneumothoraces. Subsequent radiographs showing recurrence or patient symptoms were noted in 13 patients (9.7%), requiring unclamping. Nine patients (6.7%) who had passed the clamping trial prior to removal required reinsertion of a chest tube due to recurrent pneumothoraces. One clamped patient required urgent insertion of a second thoracostomy tube due to occlusive thrombus within the residing chest tube. No deaths were documented as a result of the care path or of clamping. Overall, the clamped chest tube allows for more definitive assessment of persistent occult air leaks based on a 6-hour chest radiograph and avoidance of premature removal and did not appear to have any adverse effects on patient safety. Further refinements of the clamping procedure may be needed, as some patients still required reinsertion despite an absence of pneumothorax after a 6-hour clamping trial. Given these data, a prospective study with clamping is warranted to evaluate whether or not such a system can increase the speed with which chest tubes are removed and decrease the length of stay while maintaining patient safety.