Air Medical Blood Transfusion as a Trigger of Massive Transfusion Protocol.

Air medical services can improve access to blood products at the point of injury. Studies have shown that early activation of mass transfusion protocols (MTPs) can improve the survival of trauma patients by up to 25%. There are several scoring systems to guide early activation, but the use of a single criterion has been elusive. Our study sought to determine if air medical administration of blood products was a risk factor for massive transfusion activation and utilization of prehospital vital signs for calculation of the shock index. In our retrospective study, we evaluated adult trauma patients transfused by helicopter emergency medical services (HEMS) and as a control all patients in our institution receiving the MTP. Our study found HEMS blood transfusion was not a reliable trigger for MTP, although the sample size may have limited our findings. We found that HEMS care resulted in an overall reduction in the volume of transfusion and an improvement in hemodynamic parameters upon trauma center arrival. HEMS transfusion and a higher rate of tranexamic acid administration may have contributed to these findings. Of note, the assessment of blood consumption score and shock index were nonspecific in the study populations.

Trends in Drug Tests among Children: A 22-Year Retrospective Analysis.

There are several pathophysiological outcomes associated with substance abuse including metabolic disbalance, neurodegeneration, and disordered redox. Drug use in pregnant women is a topic of great concern due to developmental harm which may occur during gestation and the associated complications in the neonate after delivery. We sought to determine what the trajectory of drug use is like in children aged 0-4 years and mothers of neonates. Urine drug screen (UDS) results were obtained of our target demographic during 1998-2011 and 2012-2019 from LSU Health Sciences Center in Shreveport (LSUHSC-S). Statistical analysis was performed using R software. We observed an increase in cannabinoid-positive UDS results in both Caucasian (CC) and African American (AA) groups between 1998-2011 and 2012-2019 periods. Cocaine-positive UDS results decreased in both cohorts. CC children had higher UDS positive results for opiates, benzodiazepines, and amphetamines, while AA children had a higher percentage for illicit drugs such as cannabinoids and cocaine. Neonate's mothers had similar UDS trends to that in children during 2012-2019. Overall, while percentage of positive UDS results for both AA and CC 0-4 year old children started to decline for opiate, benzodiazepine, and cocaine during 2012-2019, cannabinoid- and amphetamine (CC)-positive UDS steadily increased. These results suggest a shift in the type of drug use by mothers from opiates, benzodiazepines, and cocaine to cannabinoids and/or amphetamines. We also observed that 18-year-old females who tested positive for opiates, benzodiazepine, or cocaine had higher than average chances of testing positive for cannabinoids later in life.

Dysregulated Sulfide Metabolism in Multiple Sclerosis: Serum and Vascular Endothelial Inflammatory Responses.

Multiple sclerosis (MS) is a leading cause of neurodegenerative disability in younger individuals. When diagnosed early, MS can be managed more effectively, stabilizing clinical symptoms and delaying disease progression. The identification of specific serum biomarkers for early-stage MS could facilitate more successful treatment of this condition. Because MS is an inflammatory disease, we assessed changes in enzymes of the endothelial hydrogen sulfide (H2S) pathway in response to inflammatory cytokines. Blotting analysis was conducted to detect Cystathionine γ-lyase (CSE), Cystathionine beta synthase (CBS), and 3-mercaptopyruvate sulfurtransferase (MST) in human brain microvascular endothelial apical and basolateral microparticles (MPs) and cells following exposure to tumor necrosis factor-α (TNF-α) and interferon-γ (IFN-γ). CSE was increased in MPs and cells by exposure to TNF-α/IFN-γ; CBS was elevated in apical MPs but not in cells or basolateral MPs; MST was not significantly affected by cytokine exposure. To test how our findings relate to MS patients, we evaluated levels of CSE, CBS, and MST in serum samples from healthy control and MS patients. We found significantly decreased levels of CBS and MST (p = 0.0004, 0.009) in MS serum samples, whereas serum levels of CSE were marginally increased (p = 0.06). These observations support increased CSE and lower CBS and MST expression being associated with the vascular inflammation in MS. These changes in endothelial-derived sulfide enzymes at sites of inflammation in the brain may help to explain sulfide-dependent changes in vascular dysfunction/neuroinflammation underlying MS. These findings further support the use of serum samples to assess enzymatic biomarkers derived from circulating MPs. For example, "liquid biopsy" can be an important tool for allowing early diagnosis of MS, prior to the advanced progression of neurodegeneration associated with this disease.

Improved Healthcare Access Reduces Requirements for Surgery in Indigent IBD Patients Using Biologic Therapy: A 'Safety-Net' Hospital Experience.

Low socioeconomic status (SES) is associated with greater morbidity and increased healthcare resource utilization (HRU) in IBD. We examined whether a financial assistance program (FAP) to improve healthcare access affected outcomes and HRU in a cohort of indigent IBD patients requiring biologics. IBD patients (>18 years) receiving care at a 'safety-net' hospital who initiated biologics as outpatients between 1 January 2010 and 1 January 2019 were included. Patients were divided by FAP status. Patients without FAP had Medicare, Medicaid, or commercial insurance. Primary outcomes were steroid-free clinical remission at 6 and 12 months. Secondary outcomes were surgery, hospitalization, and ED utilization. Multivariate logistic regression was used to calculate odds ratio (OR) and 95% confidence interval (CI). Decision tree analysis (DTA) was also performed. We included 204 patients with 258 new biologic prescriptions. FAP patients had less complex Crohn's disease (50.7% vs. 70%, p = 0.033) than non-FAP patients. FAP records indicated fewer prior surgeries (19.6% vs. 38.4% p = 0.003). There were no statistically significant differences in remission rates, disease duration, or days between prescription and receipt of biologics. In multivariable logistic regression, adjusting for baseline demographics and disease severity variables, FAP patients were less likely to undergo surgery (OR: 0.28, 95% CI [0.08−0.91], p = 0.034). DTA suggests that imaging utilization may shed light on surgical differences. We found FAP enrollment was associated with fewer surgeries in a cohort of indigent IBD patients requiring biologics. Further studies are needed to identify interventions to address healthcare disparities in IBD.

A retrospective analysis of calcium levels in pediatric trauma patients.

Traumatic injury is a major cause of morbidity and mortality in pediatric patients. Hemorrhage is a known but treatable component of these outcomes. Evidence exists that major trauma patients are at high risk for hypocalcemia but the rate of pediatric occurrence is not documented. The purpose of this study was to determine the incidence of hypocalcemia in pediatric trauma patients, as well as to investigate any correlation between hypocalcemia and the need for transfusion and operative intervention. After IRB approval a retrospective analysis was conducted of all pediatric trauma patients seen in our Adult Level One, Pediatric Level Two trauma center. Significance testing for mortality was performed using Pearson's χ2 test. For the remaining numeric variables, association was determined one-way analysis of variance (when comparing all classes) or Welch's two-sample t-test (when comparing subsets based on calcium or mortality). In any event, significance was determined using α=0.05. A total of 2,928 patients were identified, 1623 were excluded, primarily due to incomplete data. Patients were predominantly male following blunt trauma. Initial calcium levels were 8.73 mg/dL, 95% CI [4-10.9] and 8.97 mg/dL, 95% CI [6.42-13.1] when correcting for albumin levels. Acute declines were noted when comparing initial and corrected serum calcium levels in patients requiring transfusion (7.99 mg/dL and 8.72 mg/dL) and operative intervention (8.54 mg/dL and 8.91 mg/dL). 456 (34.9%) patients required operative intervention, 138 (10.6%) required transfusion and 29 (2.2%) required massive transfusion. Patients in our cohort arrived with calcium values on the low end of normal, with a trend towards hypocalcemia if operative intervention or blood transfusion was required. This has been previously associated with increased mortality. Patients requiring operative intervention and transfusion are at increased risk for hypocalcemia and recognition of this potential is key for improved outcomes.

Plasma hydrogen sulfide: A biomarker of Alzheimer's disease and related dementias.

While heart disease remains a common cause of mortality, cerebrovascular disease also increases with age, and has been implicated in Alzheimer's disease and related dementias (ADRD). We have described hydrogen sulfide (H2 S), a signaling molecule important in vascular homeostasis, as a biomarker of cardiovascular disease. We hypothesize that plasma H2 S and its metabolites also relate to vascular and cognitive dysfunction in ADRD. We used analytical biochemical methods to measure plasma H2 S metabolites and MRI to evaluate indicators of microvascular disease in ADRD. Levels of total H2 S and specific metabolites were increased in ADRD versus controls. Cognition and microvascular disease indices were correlated with H2 S levels. Total plasma sulfide was the strongest indicator of ADRD, and partially drove the relationship between cognitive dysfunction and white matter lesion volume, an indicator of microvascular disease. Our findings show that H2 S is dysregulated in dementia, providing a potential biomarker for diagnosis and intervention.

Experimental Evaluation of the Elson Test Efficiency Following Central Slip Injury.

Purpose: The purpose of this article is to explore the amount of work, quantitated by flexion and extension cycles, that is needed to obtain a positive Elson test following a central slip injury. Methods: Thirteen frozen cadaveric fingers from individuals with an average age of 79.6 years were used. Testing was performed by imposing sinusoidal displacement of the 2 tendons, with loads ranging from 30 N to 2 N at 1 Hz. Following transection to the central slip, each finger was cycled 1,000 times using the same protocol adopted for the control. Following 100, 200, 300, and 1,000 cycles, we measured the extension angles of the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints from the flexed position and the distance between landmarks of the extensor apparatus and simulated an Elson test. Results: In both the fingers, the range of motion of the metacarpophalangeal and distal interphalangeal joints measured in the controls remained unchanged, whereas the range of motion of the proximal interphalangeal joint was significantly reduced immediately after central slip transection. Combining both ring and middle fingers, for a displacement of 5 mm, the force measured in the control (1.05 ± 0.69 N) increased to the value of 2.36 ± 0.97 N at the 1,000th cycle. Although the middle finger has shown a significant difference in force at 100 cycles following central slip transection, 200 cycles were needed to observe a difference on the ring finger. Conclusions: In controlled conditions, there is a variation in resistance to flexion of the distal interphalangeal joint. However, the amplitude of the forces is so small that they are likely imperceptible clinically. Delayed testing should be considered to increase the sensitivity of the test or in patients experiencing pain. Type of study/level of evidence: Diagnostic V.

Risk Stratification in Post-ERCP Pancreatitis: How Do Procedures, Patient Characteristics and Clinical Indicators Influence Outcomes?

BACKGROUND: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains common, and severe complications are associated with ERCP. There is no previous study detailing the effect of race and gender in a US-based population on risk of PEP. METHODS: Data were collected on 269 "first-performed" consecutive ERCPs followed by division by race (White vs. African-American) and sex (Female vs. Male). A total of 53 probable risk factors were evaluated by uni- and multivariate analysis followed by outcomes expressed as an odds ratio (OR) (with a 95% confidence interval, 95% CI). Finally, a principal component analysis was performed to construct a risk prediction model for PEP, which can be used by clinicians at bedside. RESULTS: After analyzing the risk factors based on race and gender-based groups, Caucasian males with PEP are more likely to have prior history of pancreatitis (p = 0.009), lower hemoglobin (p = 0.02)/blood urea nitrogen (BUN) (p = 0.01)/creatinine before ERCP (p = 0.07) and lower BUN (p = 0.01)/creatinine after ERCP (p = 0.07), while Caucasian females with PEP are more likely to have higher white blood cell (WBC) count before ERCP (p = 0.08) and lower amylase (p = 0.10)/bilirubin (p = 0.09)/aspartate aminotransferase (AST) after ERCP (p = 0.08). African-American males with PEP are more likely to have lower weight (p = 0.001)/smaller height (p = 0.0005)/lower alkaline phosphatase (p = 0.002)/AST (p = 0.04)/alanine transaminase (ALT) (p = 0.03) before ERCP and lower alkaline phosphatase (p = 0.002)/AST (p = 0.01)/ALT (p = 0.004) after ERCP, while African-American females with PEP are more likely to have prior history of pancreatitis (p = 0.004)/higher lipase before (p = 0.0001) and after (p = 0.05) ERCP along with increased risk with pancreatic duct cannulation (p = 0.0001) and injection (p = 0.0001)/biliary sphincterotomy (p = 0.0001). Importantly, prior history of ERCP, elevated AST after ERCP, and BUN prior to ERCP were found to be important clinical features predicting post-ERCP pancreatitis. To our knowledge, this is a first known attempt at developing a risk scoring system for PEP in a US population with decision tree learning. CONCLUSIONS: It is very evident that both patient and procedure-related risk factors vary by race and gender in the US population, leading to the development of a new risk assessment tool for PEP that can be used in clinical practice. We need to follow up with a larger prospective study to validate this novel race and gender-based risk scoring system for PEP.

Incidence of Hypocalcemia and Role of Calcium Replacement in Major Trauma Patients Requiring Operative Intervention.

Traumatic injury is a major cause of morbidity and mortality, and hemorrhage is a primary factor. Evidence exists that major trauma patients are at high risk of hypocalcemia. The purpose of this study was to determine the incidence and rate of calcium replacement in major trauma patients requiring operative intervention, and to investigate the impact of hypocalcemia on rate of transfusion and mortality. A retrospective analysis was conducted of all top-tier trauma activations presenting to our institution during a 12-month period. A total of 638 activations were identified; 441 were excluded, primarily because of lack of operative intervention. Patients were predominantly male following blunt trauma. The mean initial calcium level was 8.11 mg/dL and 8.64 mg/dL, correcting for albumin levels. An acute decline was noted when initial serum calcium levels and intraoperative calcium levels were compared (7.51 mg/dL). Intraoperative ionized calcium levels were on the low end of the normal range, and 28.42% received supplemental calcium. Patients in our cohort arrived hypocalcemic, which has been previously associated with increased mortality. Patients requiring operative intervention are at increased risk of hypocalcemia. Recognition of this potential is key for improved outcomes.

(-)-Oleocanthal as a Dual c-MET-COX2 Inhibitor for the Control of Lung Cancer.

Lung cancer (LC) represents the topmost mortality-causing cancer in the U.S. LC patients have overall poor survival rate with limited available treatment options. Dysregulation of the mesenchymal epithelial transition factor (c-MET) and cyclooxygenase 2 (COX2) initiates aggressive LC profile in a subset of patients. The Mediterranean extra-virgin olive oil (EVOO)-rich diet already documented to reduce multiple malignancies incidence. (-)-Oleocanthal (OC) is a naturally occurring phenolic secoiridoid exclusively occurring in EVOO and showed documented anti-breast and other cancer activities via targeting c-MET. This study shows the novel ability of OC to suppress LC progression and metastasis through dual targeting of c-MET and COX-2. Western blot analysis and COX enzymatic assay showed significant reduction in the total and activated c-MET levels and inhibition of COX1/2 activity in the lung adenocarcinoma cells A549 and NCI-H322M, in vitro. In addition, OC treatment caused a dose-dependent inhibition of the HGF-induced LC cells migration. Daily oral treatment with 10 mg/kg OC for 8 weeks significantly suppressed the LC A549-Luc progression and prevented metastasis to brain and other organs in a nude mouse tail vein injection model. Further, microarray data of OC-treated lung tumors showed a distinct gene signature that confirmed the dual targeting of c-MET and COX2. Thus, the EVOO-based OC is an effective lead with translational potential for use as a prospective nutraceutical to control LC progression and metastasis.

Neurogranin Regulates Alcohol Sensitivity through AKT Pathway in the Nucleus Accumbens.

Dysfunction of glutamate neurotransmission in the nucleus accumbens (NAc) has been implicated in the pathophysiology of alcohol use disorders (AUD). Neurogranin (Ng) is exclusively expressed in the brain and mediates N-methyl-d-aspartate receptor (NMDAR) hypo-function by regulating the intracellular calcium-calmodulin (Ca2+ -CaM) pathway. Ng null mice (Ng-/- mice) demonstrate increased alcohol drinking compared to wild-type mice, while also showing less tolerance to the effect of alcohol. To identify the molecular mechanism related to alcohol seeking, both in vivo microdialysis and label-free quantification proteomics comparing Ng genotype and effects of alcohol treatment on the NAc are utilized. There is significant difference in glutamate and gamma-aminobutyric acid (GABA) neurotransmission between genotypes; however, alcohol administration normalizes both glutamate and GABA levels in the NAc. Using label-free proteomics, 427 protein expression changes are identified against alcohol treatment in the NAc among 4347 total proteins detected. Bioinformatics analyses reveal significant molecular differences in Ng null mice in response to acute alcohol treatment. Ingenuity pathway analysis found that the AKT network is altered significantly between genotypes, which may increase the sensitivity of alcohol in Ng null mice. The pharmacoproteomics results presented here illustrate a possible molecular basis of the alcohol sensitivity through Ng signaling in the NAc.

A Retrospective Study of Transfusion Requirements in Trauma Patients Receiving Tranexamic Acid.

The Military Application of Tranexamic Acid in Trauma Emergency Resuscitation Study (MATTERs) and Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage-2 (CRASH-2) studies demonstrate that tranexamic acid (TXA) reduces mortality in patients with traumatic hemorrhage. However, their results, conducted in foreign countries and U.S. military soldiers, provoke concerns over generalizability to civilian trauma patients in the United States. We report the evaluation of patient outcomes and transfusion requirements following treatment with TXA by a civilian air medical program. We conducted a retrospective chart review of trauma patients transported by air service to a Level 1 trauma center. For the purposes of intervention evaluation, patients meeting this criterion for the 2 years (2012-2014) prior to therapy implementation were compared with patients treated during the 2-year study period (2014-2016). Goals were to evaluate morbidity, mortality, transfusion requirements, and length of stay. During the review, 52 control (non-TXA) and 43 study (TXA) patients were identified as meeting inclusion criteria. Patients in the control group were found to be less acute, which correlated with shorter hospitals stays. There was reduced mortality for patients receiving TXA in spite of their increased acuity and decreased likelihood of survival. Trauma patients from this cohort study receiving TXA demonstrate decreased mortality in spite of increased acuity. This increased acuity is associated with increased transfusion requirements. Future research should evaluate patient selection with concern for fibrinolysis and provider bias. Randomized controlled trial is needed to evaluate the role of TXA administration in the United States.

GatewayNet: a form of sequential rule mining.

BACKGROUND: The gateway hypothesis (and particularly the prediction of developmental stages in drug abuse) has been a subject of protracted debate since the 1970s. Extensive research has gone into this subject, but has yielded contradictory findings. We propose an algorithm for detecting both association and causation relationships given a discrete sequence of events, which we believe will be useful in addressing the validity of the gateway hypothesis. To assess the gateway hypothesis, we developed the GatewayNet algorithm, a refinement of sequential rule mining called initiation rule mining. After a brief mathematical definition, we describe how to perform initiation rule mining and how to infer causal relationships from its rules ("gateway rules"). We tested GatewayNet against data for which relationships were known. After constructing a transaction database using a first-order Markov chain, we mined it to produce a gateway network. We then discuss various incarnations of the gateway network. We then evaluated the performance of GatewayNet on urine drug screening data collected from the emergency department at LSU Health Sciences Center in Shreveport. A de-identified database of urine drug screenings ordered by the department between August 1998 and June 2011 was collected and then restricted to patients having at least one screening succeeding their first positive drug screening result. RESULTS: In the synthetic data, a chain of gateway rules was found in the network which demonstrated causation. We did not find any evidence of gateway rules in the empirical data, but we were able to isolate two documented transitions into benzodiazepine use. CONCLUSIONS: We conclude that GatewayNet may show promise not only for substance use data, but other data involving sequences of events. We also express future goals for GatewayNet, including optimizing it for speed.

Bioinformatics Analyses Determined the Distinct CNS and Peripheral Surrogate Biomarker Candidates Between Two Mouse Models for Progressive Multiple Sclerosis.

Previously, we have established two distinct progressive multiple sclerosis (MS) models by induction of experimental autoimmune encephalomyelitis (EAE) with myelin oligodendrocyte glycoprotein (MOG) in two mouse strains. A.SW mice develop ataxia with antibody deposition, but no T cell infiltration, in the central nervous system (CNS), while SJL/J mice develop paralysis with CNS T cell infiltration. In this study, we determined biomarkers contributing to the homogeneity and heterogeneity of two models. Using the CNS and spleen microarray transcriptome and cytokine data, we conducted computational analyses. We identified up-regulation of immune-related genes, including immunoglobulins, in the CNS of both models. Pro-inflammatory cytokines, interferon (IFN)-γ and interleukin (IL)-17, were associated with the disease progression in SJL/J mice, while the expression of both cytokines was detected only at the EAE onset in A.SW mice. Principal component analysis (PCA) of CNS transcriptome data demonstrated that down-regulation of prolactin may reflect disease progression. Pattern matching analysis of spleen transcriptome with CNS PCA identified 333 splenic surrogate markers, including Stfa2l1, which reflected the changes in the CNS. Among them, we found that two genes (PER1/MIR6883 and FKBP5) and one gene (SLC16A1/MCT1) were also significantly up-regulated and down-regulated, respectively, in human MS peripheral blood, using data mining.

Effect of sedative agent selection on morbidity, mortality and length of stay in patients with increase in intracranial pressure.

BACKGROUND: To identify the effects of sedative agent selection on morbidity, mortality, and length of stay in patients with suspected increase in intracranial pressure. Recent trends and developments have resulted in changes to medications that were previously utilized as pharmacological adjuncts in the sedation and intubation of patients with suspected increases in intracranial pressure. Medications that were previously considered contraindicated are now being used with increasing regularity without demonstrated safety and effectiveness. The primary objective of this study is to evaluate and compare the use of Ketamine as an induction agent for patients with increased intracranial pressure. The secondary objective was to evaluate and compare the use of Etomidate, Midazolam, and Ketamine in patients with increased intracranial pressure. METHODS: We conducted a retrospective chart review of patients transported to our facility with evidence of intracranial hypertension that were intubated before trauma center arrival. Patients were identified during a 22-month period from January 2014 to October 2015. Goals were to evaluate the impact of sedative agent selection on morbidity, mortality, and length of stay. RESULTS: During the review 148 patients were identified as meeting inclusion criteria, 52 were excluded due to incomplete data. Of those the patients primarily received; Etomidate, Ketamine, and Midazolam. Patients in the Ketamine group were found to have a lower mortality rate after injury stratification. CONCLUSION: Patients with intracranial hypertension should not be excluded from receiving Ketamine during intubation out of concern for worsening outcomes.

Pharmacoproteomics Profile in Response to Acamprosate Treatment of an Alcoholism Animal Model.

Acamprosate is an FDA-approved medication for the treatment of alcoholism that is unfortunately only effective in certain patients. Although acamprosate is known to stabilize the hyper-glutamatergic state in alcoholism, pharmacological mechanisms of action in brain tissue remains unknown. To investigate the mechanism of acamprosate efficacy, the authors employ a pharmacoproteomics approach using an animal model of alcoholism, type 1 equilibrative nucleoside transporter (ENT1) null mice. The results demonstrate that acamprosate treatment significantly decreased both ethanol drinking and preference in ENT1 null mice compared to that of wild-type mice. Then, to elucidate acamprosate efficacy mechanism in ENT1 null mice, the authors utilize label-free quantification proteomics comparing both genotype and acamprosate treatment effects in the nucleus accumbens (NAc). A total of 1040 protein expression changes are identified in the NAc among 3634 total proteins detected. The proteomics and Western blot result demonstrate that acamprosate treatment decreased EAAT expression implicating stabilization of the hyper-glutamatergic condition in ENT1 null mice. Pathway analysis suggests that acamprosate treatment in ENT1 null mice seems to rescue glutamate toxicity through restoring of RTN4 and NF-κB medicated neuroimmune signaling compared to wild-type mice. Overall, pharmacoproteomics approaches suggest that neuroimmune restoration is a potential efficacy mechanism in the acamprosate treatment of certain sub-populations of alcohol dependent subjects.

Tranexamic Acid: Promise or Panacea: The Impact of Air Medical Administration of Tranexamic Acid on Morbidity, Mortality, and Length of Stay.

The MATTERs and CRASH-2 studies demonstrate that tranexamic acid (TXA) reduces mortality in patients with traumatic hemorrhage. However, their results, conducted in foreign countries and with U.S. military soldiers, provoke concerns over generalizability to civilian trauma patients in the United States was reported. The evaluation of patient outcomes following treatment with TXA by a civilian air medical program. A retrospective chart review of trauma patients transported by air service to a Level 1 trauma center was conducted. For the purposes of intervention evaluation, patients meeting this criterion for the 2 years (2012-2014) prior to therapy implementation were compared with patients treated during the 2-year study period (2014-2016). Goals were to evaluate morbidity, mortality, and length of stay. During the review, 82 control and 49 study patients were identified as meeting inclusion criteria. Patients in the control group were found to be less acute, which correlated with shorter hospital stays and better discharge outcomes. Multiple patients in the study group who should have expired according to a significantly elevated Trauma Revised Injury Severity Score (TRISS) survived, whereas multiple patients in the control group expired despite a low TRISS calculation. This is the first outcome-based study conducted in a U.S. trauma system. The outcomes in civilian trauma patients in the United States do not follow that of the previous MATTERs and CRASH-2 studies. However, this study still shows benefit to TXA administration and reduced risk for administration to patients with head trauma and occurrence of venous thromboembolism. Randomized control trials are needed to evaluate the role of TXA administration in the United States.

Theiler's Virus-Mediated Immunopathology in the CNS and Heart: Roles of Organ-Specific Cytokine and Lymphatic Responses.

Theiler's murine encephalomyelitis virus (TMEV) induces different diseases in the central nervous system (CNS) and heart, depending on the mouse strains and time course, with cytokines playing key roles for viral clearance and immune-mediated pathology (immunopathology). In SJL/J mice, TMEV infection causes chronic TMEV-induced demyelinating disease (TMEV-IDD) in the spinal cord about 1 month post-inoculation (p.i.). Unlike other immunopathology models, both pro- and anti-inflammatory cytokines can play dual roles in TMEV-IDD. Pro-inflammatory cytokines play beneficial roles in viral clearance while they are also detrimental in immune-mediated demyelination. Anti-inflammatory cytokines suppress not only protective anti-viral immune responses but also detrimental autoreactive immune responses. Conversely, in C3H mice, TMEV infection induces a non-CNS disease, myocarditis, with three distinctive phases: phase I, viral pathology with interferon and chemokine responses; phase II, immunopathology mediated by acquired immune responses; and phase III, cardiac fibrosis. Although the exact mechanism(s) by which a single virus, TMEV, induces these different diseases in different organs is unclear, our bioinformatics approaches, especially principal component analysis (PCA) of transcriptome data, allow us to identify the key factors contributing to organ-specific immunopathology. The PCA demonstrated that in vitro infection of a cardiomyocyte cell line reproduced the transcriptome profile of phase I in TMEV-induced myocarditis; distinct interferon/chemokine-related responses were induced in vitro in TMEV-infected cardiomyocytes, but not in infected neuronal cells. In addition, the PCA of the in vivo CNS transcriptome data showed that decreased lymphatic marker expressions were weakly associated with inflammation in TMEV infection. Here, dysfunction of lymphatic vessels is shown to potentially contribute to immunopathology by delaying the clearance of cytokines and immune cells from the inflammatory site, although this can also confine the virus at these sites, preventing virus spread via lymphatic vessels. On the other hand, in the heart, dysfunction of lymphatics was associated with reduced lymphatic muscle contractility provoked by pro-inflammatory cytokines. Therefore, TMEV infection may induce different patterns of cytokine expressions as well as lymphatic vessel dysfunction by rather different mechanisms between the CNS and heart, which might explain observed patterns of organ-specific immunopathology.

Urine Drug Screen Trends from 1998 through 2011 Among Emergency Department Patients Treated in a University Teaching Hospital.

The emergency department (ED) at Louisiana State University-Health Science Center in Shreveport (LSUHSC-S) serves an urban population with a large rural catchment area. This study focuses on demographic variables in substance abuse trends in this region based on urine drug screen (UDS) results. A database of de-identified UDSs ordered in the ED at LSUHSC-S between 1998 and 2011 was analyzed. Samples were tested for the presence of amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, 3,4-methylenedioxymethamphetamine (MDMA), methadone, methamphetamine, opiates, phencyclidine, and propoxyphene. The patient population was categorized by age group, gender, and race. The majority of tests were performed on African-American and Caucasian patients ages 18 to 54 followed by the 0 to 11-year-old group. Of the drugs tested, cannabinoids represented the highest percentage of positive results in both the African-American and Caucasian populations. Opiates returned the highest percent of positive results among all prescription drugs. The Caucasian population predominated in positive tests for prescription drugs (opiates and benzodiazepines), while the African-American population predominated in results positive for illicit drugs (cannabinoids and cocaine). The increasing presence of opiates and cannabinoids, particularly in very young patients, should prompt policy makers and healthcare providers to develop intervention strategies to protect the most vulnerable populations.

What and how are EM residents being taught to respond to the next disaster?

OBJECTIVE: Disasters, both natural and man-made, have become commonplace and emergency physicians serve on the front line. Residency may be the only time that emergency physicians are exposed to a disaster, through training, until one happens in their department; therefore, it is critical to provide residents with appropriate and timely disaster education. The goal of this study was to assess the current status of disaster education in emergency medicine (EM) residencies in the United States. METHODS: A list of disaster topics was generated by reviewing disaster literature and validated by subject matter experts. Between May and December 2016, the authors conducted a national computerized survey of the 229 US EM residencies listed by the American Osteopathic Association and the American Medical Association. It focused on the methods of instruction and amount of time devoted to each topic. RESULTS: Of the 229 eligible residency programs, 183 (79.9 percent) completed the survey. Of those, 98.9 percent report teaching disaster management topics. Nine of 18 disaster medicine topics were taught at >60 percent of responding programs. The most common topics were emergency management principles and mass casualty triage, while the least common was hazard vulnerability analysis. The most common method of instruction was lecture (68.5 percent) and the least common methods were journal club and field exercises. CONCLUSIONS: Broad education in disaster medicine is provided in most US EM residencies. Standardization of topics is still lacking and would be beneficial to encourage comprehensive education. Addressing the educational gaps and curriculum methodology changes identified in this survey would increase curriculum standardization.