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.

NaV1.7 mRNA and protein expression in putative projection neurons of the human spinal dorsal horn.

NaV1.7, a membrane-bound voltage-gated sodium channel, is preferentially expressed along primary sensory neurons, including their peripheral & central nerve endings, axons, and soma within the dorsal root ganglia and plays an integral role in amplifying membrane depolarization and pain neurotransmission. Loss- and gain-of-function mutations in the gene encoding NaV1.7, SCN9A, are associated with a complete loss of pain sensation or exacerbated pain in humans, respectively. As an enticing pain target supported by human genetic validation, many compounds have been developed to inhibit NaV1.7 but have disappointed in clinical trials. The underlying reasons are still unclear, but recent reports suggest that inhibiting NaV1.7 in central terminals of nociceptor afferents is critical for achieving pain relief by pharmacological inhibition of NaV1.7. We report for the first time that NaV1.7 mRNA is expressed in putative projection neurons (NK1R+) in the human spinal dorsal horn, predominantly in lamina 1 and 2, as well as in deep dorsal horn neurons and motor neurons in the ventral horn. NaV1.7 protein was found in the central axons of sensory neurons terminating in lamina 1-2, but also was detected in the axon initial segment of resident spinal dorsal horn neurons and in axons entering the anterior commissure. Given that projection neurons are critical for conveying nociceptive information from the dorsal horn to the brain, these data support that dorsal horn NaV1.7 expression may play an unappreciated role in pain phenotypes observed in humans with genetic SCN9A mutations, and in achieving analgesic efficacy in clinical trials.

Training on a virtual reality cricothyroidotomy simulator improves skills and transfers to a simulated procedure.

Objective: The virtual airway skills trainer (VAST) is a virtual reality simulator for training in cricothyroidotomy (CCT). The goal of the study is to test the effectiveness of training and transfer of skills of the VAST-CCT. Methods: Two groups, control (no training) and simulation (2 weeks of proficiency-based training), participated in this study. Subjects in the control condition did not receive any training on the task whereas those in the simulation received a proficiency-based training on the task during a period of 2 weeks. Two weeks post-training, both groups performed CCT on the TraumaMan to demonstrate the transfer of skills. Results: A total of (n=20) subjects participated in the study. The simulation group performed better than the control group at both the post-test (p<0.001) and retention test (p<0.001) on the simulator. The cumulative sum analysis showed that all subjects in the simulation group reached proficiency with acceptable failure rate within the 2 weeks of training. On the transfer test, the simulation group performed better on skin cut (p<0.001), intubation (p<0.001) and total score (p<0.001) than the control group. Conclusions: The VAST-CCT is effective in training and skills transfer for the CCT procedure. Level of evidence: Not applicable. Simulator validation study.

Why is the Surgical Leader also a Manager?

The surgeon acts as a manager in the operating room, ward, classroom, and in daily life to control time. Skills cross all boundaries of medicine with specific needs in each area. Without leadership skills the nonmedical aspect of practice becomes more difficult and can make the physician less successful. Learning to manage, therefore, becomes critical.

Presumptive antibiotics in tube thoracostomy for traumatic hemopneumothorax: a prospective, Multicenter American Association for the Surgery of Trauma Study.

BACKGROUND: Thoracic injuries are common in trauma. Approximately one-third will develop a pneumothorax, hemothorax, or hemopneumothorax (HPTX), usually with concomitant rib fractures. Tube thoracostomy (TT) is the standard of care for these conditions, though TTs expose the patient to the risk of infectious complications. The controversy regarding antibiotic prophylaxis at the time of TT placement remains unresolved. This multicenter study sought to reconcile divergent evidence regarding the effectiveness of antibiotics given as prophylaxis with TT placement. METHODS: The primary outcome measures of in-hospital empyema and pneumonia were evaluated in this prospective, observational, and American Association for the Surgery of Trauma multicenter study. Patients were grouped according to treatment status (ABX and NoABX). A 1:1 nearest neighbor method matched the ABX patients with NoABX controls. Multilevel models with random effects for matched pairs and trauma centers were fit for binary and count outcomes using logistic and negative binomial regression models, respectively. RESULTS: TTs for HPTX were placed in 1887 patients among 23 trauma centers. The ABX and NoABX groups accounted for 14% and 86% of the patients, respectively. Cefazolin was the most frequent of 14 antibiotics prescribed. No difference in the incidence of pneumonia and empyema was observed between groups (2.2% vs 1.5%, p=0.75). Antibiotic treatment demonstrated a positive but non-significant association with risk of pneumonia (OR 1.61; 95% CI: 0.86~3.03; p=0.14) or empyema (OR 1.51; 95% CI: 0.42~5.42; p=0.53). CONCLUSION: There is no evidence to support the routine use of presumptive antibiotics for post-traumatic TT to decrease the incidence of pneumonia or empyema. More investigation is necessary to balance optimal patient outcomes and antibiotic stewardship. LEVEL OF EVIDENCE: II Prospective comparative study.

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.

Alcohol and drug toxicology screens at time of hospitalization do not predict PTSD or depression after traumatic injury.

BACKGROUND: Identifying risk factors for the development of PTSD and depression is critical for intervention and recovery after injury. Given research linking toxicology screens and substance use and the evidenced relationship between substance misuse and distress, the current study aimed to gauge the predictive value of toxicology testing on PTSD and depression. METHODS: Patients admitted to a Level I Trauma Center (N = 379) completed the PC-PTSD, PCL-C, and PHQ-8 at baseline, 3, 6, and 12 months. RESULTS: Results showed 52% of tested patients had a positive toxicology test, 51% screened for PTSD, and 54% screened for depression. Positive drug or alcohol toxicology tests were not significantly associated with PTSD or depression. CONCLUSIONS: Toxicology testing may not meaningful predict depression or PTSD in traumatic injury patients. Future research using validated measures of problematic substance use is needed to better understand how misuse may influence the development of psychological distress.

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.

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.

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.