Plasma proteomic signatures predict dementia and cognitive impairment.

INTRODUCTION: Biomarker discovery of dementia and cognitive impairment is important to gather insight into mechanisms underlying the pathogenesis of these conditions. METHODS: In 997 adults from the InCHIANTI study, we assessed the association of 1301 plasma proteins with dementia and cognitive impairment. Validation was conducted in two Alzheimer's disease (AD) case-control studies as well as endophenotypes of AD including cognitive decline, brain amyloid burden, and brain volume. RESULTS: We identified four risk proteins that were significantly associated with increased odds (peptidase inhibitor 3 (PI3), trefoil factor 3 (TFF3), pregnancy associated plasma protein A (PAPPA), agouti-related peptide (AGRP)) and two protective proteins (myostatin (MSTN), integrin aVb5 (ITGAV/ITGB5)) with decreased odds of baseline cognitive impairment or dementia. Of these, four proteins (MSTN, PI3, TFF3, PAPPA) were associated cognitive decline in subjects that were cognitively normal at baseline. ITGAV/ITGB5 was associated with lower brain amyloid burden, MSTN and ITGAV/ITGB5 were associated with larger brain volume and slower brain atrophy, and PI3, PAPPA, and AGRP were associated with smaller brain volume and/or faster brain atrophy. DISCUSSION: These proteins may be useful as non-invasive biomarkers of dementia and cognitive impairment.

Severe dysphagia requiring gastrostomy following cervical spine fracture fixation.

BACKGROUND: The incidence of severe dysphagia requiring gastrostomy tube (GT) placement following operative fixation of traumatic cervical spine fractures is unknown. Risk factors for severe dysphagia are not well identified and GT placement is often delayed due to the belief that it will resolve quickly. We hypothesized that patient and clinical factors could be used to predict severe dysphagia requiring GT placement in this population. METHODS: A retrospective multicenter review of all adult patients requiring operative fixation of cervical spine fractures was performed. Data on demographics, injury severity score, presence of spinal cord injury, operative approach, presence of severe traumatic brain injury, and the need and timing of tracheostomy and GT were collected. The timing, number and results of formal speech, and language pathology examinations were also recorded. RESULTS: 243 patients underwent cervical spine fixation for traumatic fractures, of which 72 (30%) required GT placement. Patients requiring gastrostomy were significantly older, 54 versus 45 years (p=0.002), and had higher injury severity scores at 24 versus 18 (p<0.0001). Tracheostomy was strongly associated with severe dysphagia; GT was required in 83% of patients who underwent tracheostomy versus 5% of those who did not require tracheostomy. 50% of patients underwent tracheostomy and GT on the same day after injury, with the remaining patients having an average of 9 days delay between procedures. The need for gastrostomy placement was also higher in patients undergoing combined operative approach versus anterior or posterior approach alone (p=0.02). There were no GT-related complications. CONCLUSIONS: Severe dysphagia requiring GT placement occurs commonly (30%) in patients who undergo operative fixation of cervical spine fractures. Gastrostomy placement was delayed in 50%. Tracheostomy was strongly associated with the need for GT placement. Earlier GT placement, especially in patients requiring tracheostomy, would improve patient care and disposition.

Management of colonic injuries in the setting of damage-control laparotomy: one shot to get it right.

BACKGROUND: The optimal management of colonic injuries in patients requiring damage-control laparotomy (DCL) remains controversial. Primary repair, delayed anastomosis, or colostomy have all been advocated after DCL; however, some evidence suggests that colon-related complications are increased in patients with delayed primary fascial closure. We hypothesized that increased complications associated with colonic repair/anastomosis occur in those patients undergoing DCL who cannot achieve fascial closure on their initial reoperation. METHODS: A retrospective review of adult patients sustaining colonic injury between 2001 and 2010 who survived four or more days was performed. Patients were classified as having all their abdominal injuries managed during a single laparotomy (SL), DCL with complete treatment and fascial closure on the initial reoperation (DCL1), or DCL with open abdomen for more than two operations (DCL2). Data on postoperative complications and need for intervention were collected. Kruskal-Wallis analysis of variance was used to determine differences between groups. RESULTS: A total of 317 patients with colonic injuries were treated during the study period; 70 were excluded, leaving 247 patients as the study group. The group was primarily male (93%), with a mean age of 29 years. Ninety-two percent sustained penetrating injuries. Injury Severity Scores (ISSs) were similar between groups. Mean (SD) time for the DCL1 was 1.2 (0.6) days after injury and 4.1 (2.8) days for DCL2. Inability to achieve fascial closure by the time of the initial reoperation was associated with significant increase in intra-abdominal abscess (SL, 17% vs. DCL1, 31% vs. DCL2, 50%; p < 0.001) and anastomotic leaks (SL, 2% vs. DCL1, 2% vs. DCL2, 19%; p < 0.001). CONCLUSION: Primary repair or delayed anastomosis following DCL is feasible, with complication rates similar to SL when successful fascial closure is completed on the first post-DCL reoperation. However, if fascial closure is not possible on the second operation, patients should be treated with a stoma because there is an eightfold increase in the incidence of anastomotic leak. We believe that these data indicate that there is a single opportunity for reestablishing colonic continuity following DCL. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Unrelenting violence: an analysis of 6,322 gunshot wound patients at a Level I trauma center.

BACKGROUND: Perceptions of violence are too often driven by individual sensational events, yet "routine" gunshot wound (GSW) injuries are largely underreported. Previous studies have mostly focused on fatal GSW. To illuminate this public health problem, we studied the health care burden of interpersonal GSW at a Level I trauma center. METHODS: Retrospective analysis of GSW injuries (excluding self and law enforcement) treated from January 2000 to December 2011. Data collected included body regions injured, number of wounds per patient, and mortality. Costs were calculated using Medicare cost-charge modifiers. Geographic information system mapping of the incident location and home addresses were determined to identify hot spot locations and the characterization of those neighborhoods. RESULTS: A total of 6,322 patients were treated. There were significant increases in patients with three or more wounds (13-22%, p < 0.0001) and three or more body regions injured (6-16%, p < 0.0001). Mortality increased from 9% to 14% (p < 0.0001). Nineteen percent of the patients were never seen by the trauma service. Geographic information system mapping revealed significant clustering of GSWs. Five cities accounted for 85% of the GSWs, with rates per 100,000 ranging from 19 to 108 compared with a national rate of 20. Only 19% of the census tracts had no GSWs during the period, and 39% of the census tracts had at least one GSW per year for 12 years. Fifteen percent of the census tracts accounted for 50% of the GSWs. Seventy percent of the patients were shot in their home city, 25% within 168 m, and 55% within 1,600 m of their home. Total inpatient cost was $115 million, with cost per patient increasing more than three times over the course of the study; 75% were unreimbursed. CONCLUSION: GSW violence remains a significant public health problem, with escalating mortality and health costs. Relying on trauma registry data seriously underestimates GSW numbers. In contrast to episodic mass casualties, routine GSW violence is geographically restricted and not random. To combat this problem, policy makers must understand that the determinants of firearm violence reside at the community level. LEVEL OF EVIDENCE: Epidemiologic study, level II.

Bacteremia and ventilator-associated pneumonia: a marker for contemporaneous extra-pulmonic infection.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a well-known complication of mechanical ventilation in severely injured patients. A subset of patients with VAP develop an associated bacteremia (B-VAP), but the risk factors, microbiology, morbidity, and mortality in this group are not well described. The goal of this study was to examine the incidence, predictors, and outcome of B-VAP in adult trauma patients. METHODS: We conducted a retrospective review of trauma patients who developed VAP or B-VAP from January 2007 to December 2009 at a single, university-affiliated medical center. Ventilator-associated pneumonia was defined as a clinician-documented instance of VAP together with confirmed positive respiratory cultures (bronchoalveolar lavage [BAL] fluid specimen with ≥10(4) colony forming units (CFU)/mL or tracheal aspirate with moderate-to-many organisms and polymorphonuclear neutrophils [PMN]). Bacteremia associated with VAP (B-VAP) was defined as the blood culture of an organism that matched the pulmonary pathogen in a case of VAP. We reviewed the demographic data, injury severity, transfusion data, and microbiology of patients who developed VAP and B-VAP. Outcome data included the number of days of care in the intensive care unit (ICU) and hospital length of stay, number of days of mechanical ventilation, and survival. A Student t-test, χ(2) test, or logistic regression was used as appropriate for data analysis. RESULTS: During the 36-mo period of the study, 4,018 adult patients were admitted to the hospital. Ventilator-associated pneumonia was diagnosed in 206 (5%) of these patients, and 26 of these latter patients (13%) had an associated bacteremia. The mean time from admission to the development of VAP was 5 d (95% CI 4.6-5.8). Patients who had B-VAP received significantly more units of red blood cell concentrates (PRBC) than those who did not have B-VAP (23 units vs. 9 units of PRBC, respectively, p<0.05). Patients with B-VAP also had higher rates of simultaneous non-pulmonary infections than those with VAP alone (69% vs. 38%, respectively), a greater number of days of mechanical ventilator support (24 d vs. 14 d, respectively, p<0.05), a greater number of days in the ICU (26 d vs. 17 d, respectively, p<0.05), and a greater hospital length of stay (50 d vs. 30 d, respectively, p<0.05). Patients with B-VAP showed a trend toward lower survival than those without B-VAP, but B-VAP was not an independent predictor of mortality. CONCLUSIONS: Trauma patients with B-VAP have a similar mortality but greater morbidity than those with VAP alone. The number of PRBC received is the most significant risk factor for developing B-VAP. More than two-thirds of patients with B-VAP have contemporaneous extra-pulmonic infections. Trauma patients with B-VAP may benefit from increased surveillance for additional concomitant infections and from more aggressive empiric antimicrobial coverage.

Obesity does not increase morbidity and mortality after laparotomy for trauma.

Obesity has been suggested to be a risk factor for increase morbidity and mortality after trauma and surgery. Trauma laparotomy provides an opportunity to assess the effect of body mass index (BMI) on patients subjected to both trauma and surgery. We hypothesized that obesity would have a deleterious effect on outcomes. A retrospective review was conducted of all patients 18 years of age or older undergoing laparotomy for trauma between July 2001 and June 2011. Patients were stratified according to BMI into the following four groups: underweight (16 to 22 kg/m(2)), normal (23 to 27 kg/m(2)), overweight (28 to 34 kg/m(2)), and obese (35 kg/m(2) or higher). Data on the patient's hospital course included length of stay, mortality, respiratory failure, infectious complications, wound dehiscence, and organ failure. A total of 1,297 patients underwent laparotomy. Seven per cent of the study group was obese and 24 per cent was underweight. There was no difference among mean Injury Severity Score, percent of patients arriving in shock, and mean number of units of packed red blood cells administered during their hospital stay. Obese patients had longer intensive care unit and hospital lengths of stay. There were no differences in ventilator days or mortality. Using univariate statistics, obese patients had increased rates of respiratory and renal failure, bacteremia with and without septic shock, and abdominal wound dehiscence. Subjecting the data to logistic regression analysis, BMI was no longer an independent predictor of any complication. Although obese trauma patients do have increased infectious morbidity, wound dehiscence, and a prolonged length of stay, increased BMI is not an independent predictor of increased morbidity or mortality after trauma laparotomy.

Annual pediatric pedestrian education does not improve pedestrian behavior.

BACKGROUND: Pediatric pedestrian injuries are a major health care concern, specifically in urban centers. An educational program (WalkSafe), given one time during the school year, has been shown to improve childhood pedestrian safety. We examined whether this program could create similar long-term cognitive and behavioral changes in our school-aged children. METHODS: An established pediatric pedestrian curriculum was modified slightly for use in our area. Students K-fourth grade were exposed to the program once annually for 2 years. The program was carried out weekly for 3 consecutive weeks. The first and third sessions consisted of an educational module given by the classroom teacher. The second week consisted of an interactive assembly that allowed the children to demonstrate good pedestrian safety using a simulated street. Short- and intermediate-term cognitive knowledge was evaluated using standardized pre-, post- and 3-month follow-up tests. Long-term knowledge was assessed by comparing scores as students advanced in grade from year 1 to 2 of the program (K to first, first to second, etc.). At six schools during year 2, pedestrian behavior was measured through direct observation of children on city streets before and after administering the program. The project was approved by university and school board institutional review boards. RESULTS: During the 2 years, 1,564 students from nine schools were educated. In both years of the program, students in all grades had a significant gain in test scores immediately after and at 3 months compared with baseline knowledge. In contrast, only students moving from grade 3 to 4 demonstrated long-term retention (K→1: 7.7 vs. 6.7; grade 1→2: 7.8 vs. 6.7; grade 2→3: 7.3 vs. 6.8; grade 3→4: 7.1 vs. 8.0; all p < 0.05 year 2 pretest vs. year 1 3-month posttest; analysis of variance and generalized linear model). Only 30% of children walk with an adult. Direct observation showed 64% of children stopped at the curb but only 8% looked left-right-left. Children walking alone were more likely to cross mid-block compared with those walking with an adult (12% vs. 3%; p < 0.001) and also tend to look left-right-left significantly more than those walking with an adult (67% vs. 20%; p < 0.0001). CONCLUSIONS: A one-time annual educational program resulted in long-term knowledge retention between grades 3 and 4 only. In contrast, scores in younger grades reverted to baseline pretest values seen in year 1. Short- and intermediate-term knowledge gains were seen in all grades for both years. Because older children more often walk alone, we postulate that the improved retention may be the result of repeated exposure and practice as a pedestrian. Cognitive knowledge did not appear to translate into improved pedestrian behavior. Walking with an adult also had a negative impact on observed pedestrian safety behavior. The efficacy and impact of a one-time educational program may be insufficient to change long-term behavior and must be reevaluated.

Gender differences in glucose variability after severe trauma.

Gender differences in the physiological response to trauma can affect outcome. Both hyperglycemia and blood glucose (BG) variability predict a poor outcome after trauma. This study examined the hypothesis that both BG levels and the degree of BG variability after trauma are gender-specific and correlate with mortality and morbidity. A retrospective observational cohort study of 1915 trauma patients requiring critical care was performed. Admission BG as well as all BG values obtained during the first week while in the intensive care unit were analyzed. In each patient, the mean BG and the degree of BG variability were calculated. A total of 1560 males and 355 females were studied with an overall mortality rate of 12 per cent. Seventy-six per cent of deaths had a BG greater than 125 mg/dL on admission and as BG variability worsened, the mortality rate also increased. There was a significant difference in male BG variability when comparing survivors with nonsurvivors. Female BG variability did not predict mortality. Failed glucose homeostasis is an important marker of endocrine dysfunction after severe injury. Increased BG variability in males is associated with a higher mortality rate. In females, mortality cannot be predicted based on BG levels or BG variability. These data have significant implications for gender-related differences in postinjury management.

A fate worse than death? Long-term outcome of trauma patients admitted to the surgical intensive care unit.

INTRODUCTION: Trauma centers successfully save lives of severely injured patients who would have formerly died. However, survivors often have multiple complications and morbidities associated with prolonged intensive care unit (ICU) stays. Because the reintegration of patients into the society to lead an active and a productive life is the ultimate goal of trauma center care, we questioned whether our "success" may condemn these patients to a fate worse than death? METHODS: Charts on all patients > or =18 years with ICU stay > or =10 days, discharged alive between June 1, 2002, and May 31, 2005, were reviewed. Patients with complete spinal cord injuries were excluded. Demographics, Injury Severity Score (ISS), presence of severe traumatic brain injury (TBI; Head Abbreviated Injury Scale [AIS] score = 4 or 5), presence of extremity fractures, need for operative procedures, ventilator days, complications, and discharge disposition were collected. Glasgow Outcome Scale score was calculated on discharge. Patients were contacted by phone to determine general health, work status, and using this data, Glasgow Outcome Scale score and a modified Functional Independence Measure (FIM) score were calculated. RESULTS: Two hundred and forty-one patients met inclusion criteria. Thirty-three patients died postdischarge from the hospital and 39 were known to be alive from the electronic medical records but were unable to be contacted. Sixty-nine patients could not be tracked down and were ultimately considered as lost to follow-up. The remaining 100 patients who were successfully contacted participated in the study. Eighty-one percent were men with a mean age of 42 years, mean and median ISS of 28. Severe TBI was present in 50 (50%) patients. Mean and median follow-up was 3.3 years from discharge. At the time of follow-up, 92 (92%) patients were living at home, 5 in nursing homes, and 3 in assisted living, a shelter, or halfway house. FIM scores ranged from 6 to 12 with 55% reached a maximal FIM score of 12. One quarter of patients had FIM scores < or =10 and 10% had locomotion scores of < or =2 (very dependent). Seventy percent considered themselves to be less active. Seventy-six patients were either working or in full-time school before their trauma. Of the 24 patients not working preinjury, 12 were > or =55 years of age. At the time of follow-up, 37 patients (49%) were back to work or school. Severe TBI patients (57%, 21 of 37) were less likely to return to work when compared with 38% (12 of 38; p = 0.03) without severe TBI. There was no relationship with age, ISS, presence of any TBI, head AIS, presence of any extremity fracture, extremity AIS, or ventilator days in patients who did or did not return to work. CONCLUSIONS: These data demonstrate that ICU survivors >3 years after severe injury have significant impairments including inability to return to work or regain previous levels of activity and that the goal of reintegrating patients back into the society is not being met. Further studies better defining the limitations and barriers to improved quality of life are necessary. Survival, although important, is no longer a sufficient outcome to measure trauma center success.

Changing the culture around end-of-life care in the trauma intensive care unit.

BACKGROUND: Ten percent to 20% of trauma patients admitted to the intensive care unit (ICU) will die from their injuries. Providing appropriate end-of-life care in this setting is difficult and often late in the patients' course. Patients are young, prognosis uncertain, and conflict common around goals of care. We hypothesized that early, structured communication in the trauma ICU would improve end-of-life care practice. METHODS: Prospective, observational, prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into standard ICU care. The program included part I, early (at admission) family bereavement support, assessment of prognosis, and patient preferences, and part II (within 72 hours) interdisciplinary family meeting. Data on goals of care discussions, do-not-resuscitate (DNR) orders and withdrawal of life support (W/D) were collected from physician rounds, family meetings, and medical records. RESULTS: Eighty-three percent of patients received part I and 69% part II intervention. Discussion of goals of care by physicians on rounds increased from 4% to 36% of patient-days. During intervention, rates of mortality (14%), DNR (43%), and W/D (24%) were unchanged, but DNR orders and W/D were instituted earlier in hospital course. ICU length of stay was decreased in patients who died. CONCLUSIONS: Structured communication between physician and families resulted in earlier consensus around goals of care for dying trauma patients. Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU.

CT diagnosis of Rib fractures and the prediction of acute respiratory failure.

BACKGROUND: The number of rib fractures has been reported to correlate with mortality after blunt chest trauma. These reports, however, predate routine truncal helical computed tomographic (CT) scanning and their conclusions are based on data derived from plain chest radiographs (CXR). CT scan provides better anatomic definition of chest injuries than plain CXR, and we hypothesized CT evaluation of rib fracture number and patterns would provide a better prediction of respiratory failure and mortality after chest injury than the data derived from the initial CXR. METHODS: The charts on all patients of 16 years or older with one or more rib fractures after blunt trauma admitted from January 2003 through December 2005 were reviewed. Both the initial CXR and the helical CT scans were systematically re-read for the number and location of rib fractures and presence of pulmonary contusions. Anatomic fracture location (anterior, posterior, lateral) was determined using a standardized template. Outcomes data included pneumonia, respiratory failure (>/=3 ventilator days), need for trachestomy, and mortality. Logistic regression was performed to identify factors that predicted pulmonary morbidity. RESULTS: Three hundred and eighty eight patients had >/=1 rib fracture. The mean (+/-standard deviation) age was 44 +/- 18. injury severity score was 21 +/- 11. Mortality was 6% (22 of 388). Sixty-three (16%) patients developed respiratory failure. The mean number of rib fractures per patient was four (range, 1-23); 21% of patients had one rib fracture and 17% had six or more fractures. 208 (54%) of the initial CXRs were read as having no rib fractures. The mean number of rib fractures per patient in this group was 3.1 (CI95 2.9-3.2). In 43% (179 of 388) of patients, the CT radiology report incorrectly identified the number and location of the fractured ribs. Of these reports, 72% (129 of 179) differed from the prospective review by more than one fracture. The number of fractures was higher in patients who died (7 +/- 5 vs. 4 +/- 3; p = 0.02) and in those developing respiratory failure (6 +/- 4 vs. 3 +/- 3; p = 0.02). Any rib fracture or pulmonary contusion visible on the initial plain CXR significantly increased the incidence of pulmonary morbidity or mortality. CT determination of fracture location had no effect on respiratory failure, pneumonia, or mortality when fractures were confined to one anatomic location. The presence of rib fracture in more than anatomic region doubled the incidence of respiratory failure (24% vs. 12%; p = 0.002) but had no effect on mortality. Logistic regression identified only injury severity score and presence of a parenchymal injury on plain CXR as independent predictors of subsequent respiratory failure. CONCLUSIONS: Rib fracture mortality was lower than that in the previously published studies and is likely reflect the increased sensitivity of CT scan in diagnosing rib fractures. Screening CXRs miss rib fractures more than 50% of the time. Radiology reports are often not sufficiently descriptive or are incomplete with respect to the number and location fracture and reliance on these data will lead to erroneous conclusions. Using CT scanning, only the finding of rib fractures in multiple locations was associated with increased incidence of respiratory failure. In contrast, the presence of any parenchymal injury or visible rib fracture on the screening CXR significantly increases the risk for subsequent pulmonary morbidity (odds ratio, 3.8; CI95, 2.2-6.6). Although truncal CT scanning markedly improved the diagnosis and delineation of rib fractures, the screening CXR was a better predictor of subsequent pulmonary morbidity and mortality.

Effect of an educational video on emergency department patient stroke knowledge.

The purpose of this study was to explore whether passive watching of a stroke videotape in the Emergency Department waiting room could be an effective method for patient education. The setting was an urban, inner city teaching hospital. After providing informed consent, subjects were randomized into two arms: those watching a 12-min educational video on stroke developed by the American Stroke Association (video group) and those not undergoing an intervention (control group). Both groups were administered a 13-question quiz covering different stroke-related issues, but only the video group received this same test again after the completion of the educational program. Those enrolled were contacted after 1 month to determine knowledge retention via the same test. Immediately after watching the educational program, participants demonstrated improved knowledge of stroke-related questions, with an increase of test scores from 6.7 +/- 2.5 to 9.5 +/- 2.6 (p < 0.01). Even at the 1-month follow-up, the video group had significantly higher test scores than the control group. A stroke educational videotape improves the knowledge of this dangerous disease and may be a valuable and relatively low-cost tool for focused patient education in the Emergency Department waiting room.

Hormonally active women tolerate shock-trauma better than do men: a prospective study of over 4000 trauma patients.

OBJECTIVE: To test the hypothesis that comparably injured women, especially those in the hormonally active age groups, would manifest a better preserved hemodynamic response and tissue perfusion after major trauma than do men. SUMMARY BACKGROUND DATA: The notion that premenopausal women are more resistant than men to shock and trauma has been shown in numerous preclinical models. However, human studies on the effects of gender on outcome after shock-trauma are less clear, and none has examined the effect of gender on the immediate postinjury response to major trauma. METHODS: Prospective series of all patients at a Level I trauma center from January 2000 to December 2005. Study patients were all patients arriving to the trauma area of the emergency department and having a serum lactate drawn within 30 minutes of arrival. Demographic data, injury severity indices, blood utilization, and lactate levels were recorded. Lactate was used as a marker of the hemodynamic response to injury, because it has been shown to be an excellent and accurate indicator of inadequate tissue perfusion. RESULTS: : A total of 5192 patients were eligible for the study of which 4106 fulfilled the study requirements and were enrolled. Initial serum lactate levels were significantly lower in premenopausal (age 14-44) and perimenopausal (age 45-54) women than in men of the same age groups (P < 0.001), even though the Injury Severity Score of the women was significantly higher than that of the men (24 vs. 18; P < 0.1). When patients were stratified into major injury groups as well as groups receiving blood transfusions, the premenopausal women were also found to have lower initial serum lactate levels and receive less blood, while having a greater magnitude of injury as reflected in their Injury Severity Score. CONCLUSION: The data firmly establishes a proof of principle that hormonally active human women have a better physiologic response to similar degrees of shock and trauma than do their male counterparts. These gender-based differences should be taken into account in designing studies evaluating the response to shock-trauma.

Isolated thoracolumbar transverse process fractures: call physical therapy, not spine.

BACKGROUND: Historically, thoracolumbar spine transverse process fractures (TVPFx) found on "plain films" of the spine were occasionally associated with occult, mechanically significant vertebral fractures. Thus, "log-roll precautions" have been used pending formal spine evaluation and further imaging. As integrated helical computed tomography (CT) scans of the torso have become routine screening tools in high-energy trauma, TVPFx have been diagnosed with far greater frequency. Yet, where no associated spine injuries are found initially, such isolated TVPFx appear to be benign. METHODS: We retrospectively reviewed the diagnosis and management of TVPFx in a large Level I trauma center in the period between 2002 and 2005. Of 314 patients with TVPFx who survived more than 48 hours, 17% had fractures of the weight-bearing columns of the thoracolumbar spine noted on the same CT scan and were excluded from study. The management and outcome of the remaining "isolated" TVPFx were assessed by review of trauma registry and charted data. RESULTS: The 248 patients included sustained 2.3 +/- 1.5 (SD) TVPFx. They spent 29 hours +/- 32 hours on log-roll precautions while being evaluated by spine consultants and "cleared" before initiating physical therapy. Despite this prolonged immobilization and substantial further investigation, none of the patients with TVPFx judged to be isolated on the basis of screening truncal CT scan proved to have a missed injury of a major vertebral element on further study. CONCLUSIONS: Isolated thoracolumbar TVPFx are found frequently when helical CT scan is used to screen the torso after high-energy injury. TVPFx are usually multiple. They can be markers for visceral injuries, and in this study, 17% were associated with "significant" fractures. TVPFx require careful pain management and benefit by early mobilization. Yet, where no other vertebral fracture is seen on an adequate screening CT scan, investigation may reasonably end. Further imaging and consultations with spine services waste scarce resources, and lead to prolonged log-roll precautions, which delay mobilization and are potentially deleterious to overall patient care.

A prospective evaluation of the value of repeat cranial computed tomography in patients with minimal head injury and an intracranial bleed.

BACKGROUND: Patients with minimal head injury (MHI) and intracranial bleed (ICB) detected on cranial computed tomography (CT) scan routinely undergo a repeat cranial CT within 24 hours after injury to assess for progression of intracranial injuries. While this is clearly beneficial in patients with a deteriorating neurologic status, it is of questionable value in patients with a normal neurologic examination. The goal of this study was to prospectively assess the value of a repeat cranial CT in patients with a MHI and an ICB who have a normal neurologic examination. METHODS: A prospective analysis of all adult patients admitted to a Level I trauma center after blunt trauma causing a MHI (defined as the loss of consciousness or posttraumatic amnesia with a Glasgow Coma Scale (GCS) score of greater or equal to 13) and an ICB on the initial cranial CT during a 12-month period (July 2002 through July 2003) was performed. All patients with MHI were prospectively evaluated and followed until discharge. Data collected included demographics, neurologic examination and findings on the initial and repeat cranial CT scan. Outcome data included neurologic deterioration, neurosurgical intervention, and Glasgow Outcome Scale (GOS) on discharge. RESULTS: In all, 161 consecutive patients with MHI and a positive cranial CT scan were identified. The initial cranial CT lead to a neurosurgical intervention (1 craniotomy, 4 intracranial pressure monitors) in 4% of cases. The remaining 130 patients who met inclusion criteria, underwent a repeat cranial CT scan within 24 hours postadmission. Ninety nine (76%) patients had a normal neurologic examination at the time of their repeat cranial CT. After the repeat cranial CT none required immediate neurosurgical intervention or had delayed neurologic deterioration related to their head injury. Fifteen patients underwent additional neuroradiologic studies but none showed further progression of their ICB or lead to a change in management. One patient died from non-traumatic brain injury related causes and of the remaining 26 patients, 98% had an overall favorable GOS score (> 3) on discharge. In this group of patients with MHI and ICB, the negative predictive value of a normal neurologic examination was 100%. CONCLUSIONS: Repeat cranial CT, in patients with a MHI and a normal neurologic examination, resulted in no change in management or neurosurgical intervention and is therefore not indicated. A multicenter prospective study would further validate these conclusions, reduce unnecessary CT scans, and likely improve our current standard of care in these patients.

A randomized, clinical trial comparing the efficacy of continuous nebulized albuterol (15 mg) versus continuous nebulized albuterol (15 mg) plus ipratropium bromide (2 mg) for the treatment of acute asthma.

Multiple studies have examined adding nebulized ipratropium bromide to intermittent albuterol for the treatment of acute asthma. Although continuous nebulized treatments in themselves offer benefits; few data exist regarding the efficacy of adding ipratropium bromide to a continuous nebulized system. To compare continuous nebulized albuterol alone (A) vs. albuterol and ipratropium bromide (AI) in adult Emergency Department (ED) patients with acute asthma, a prospective, randomized, double-blind, controlled clinical trial was conducted on a convenience sample of patients (IRB approved). The setting was an urban ED. Consenting patients > 18 years of age with peak expiratory flow rates (PEFR) < 70% predicted, between October 15 and December 28, 1999, were randomized to albuterol (7.5 mg/h) + ipratropium bromide (1.0 mg/h), or albuterol alone via continuous nebulization using the Hope Nebulizer (B&B Technologies Inc., Orangevale, CA) for 2 h. Main outcome measures were changed in mean improvement at 60 and 120 min PEFR compared to baseline (time 0). Secondary measures were admission rates. Data were analyzed using appropriate parametric and non-parametric tests (p < 0.05 statistically significant). Sixty-two patients (30 women) completed enrollment: 32 in (AI) and (30) in (A). Four (A) and 2 (AI) patients are without 120 min data: 3 (A) and 1 (AI) were discharged after 60 min, whereas one each (A) and (AI) worsened and were admitted before 120 min. There were no statistically significant differences between treatment groups in age, sex, predicted or initial PEFR. Thirteen (19.4%) patients were admitted. There was no statistically significant difference in improvement of mean PEFR at 60 min or 120 min compared to baseline, between groups, using repeated measures analysis of variance. Mean improvement in PEFR at 60 min compared to baseline (time 0): (A) = 93.2 L/min (95% confidence interval [CI] 64.5-121.8), (AI) = 86.6 L/min (95% CI 58.9-114.3); mean improvement in PEFR at 120 min compared to baseline (time 0) (A) = 116.5 L/min (95% CI 84.5-148.5), (AI) = 126.4 L/min (95% CI 95.4-157.4). There was no statistically significant difference in admission rates between groups: 5/30 (A) and 8/32 (AI) (p = 0.62). There were no significant differences in mean improvement of PEFR at either 60 or 120 min between ED patients with acute asthma receiving continuous albuterol alone vs. those receiving albuterol in combination with ipratropium bromide.

The prevalence of urinary tract infections and sexually transmitted disease in women with symptoms of a simple urinary tract infection stratified by low colony count criteria.

OBJECTIVES: Urinary tract infections (UTIs) and early pelvic infections due to sexually transmitted disease (STD) may cause similar symptoms. Therefore, a simple history and urine dip to establish a diagnosis of UTI may result in overtreatment of UTIs and undertreatment of STDs. The objective of this study was to determine the proportion of women with symptoms suggestive of a UTI who are urine culture positive versus urine culture negative, the prevalence of STDs between groups, and if elements of the history or examination may predict those requiring STD screening. METHODS: This was a prospective cohort study in an urban emergency department. Women 18-55 years of age with urinary frequency, urgency, dysuria, and no new vaginal discharge or change in discharge were enrolled. The following were performed: detailed history; bladder catheterization for urinalysis, urine dip, and urine culture; pelvic examination and cervical samples for gonorrhea and Chlamydia trachomatis DNA ligase; and wet mount examinations. Main outcome measurements were the percentage of women who were urine culture positive (using low count criteria of 10(2) colony-forming units [CFU]/mL), the proportion of STDs between urine culture groups, and univariate analysis and logistic regression of historical and examination elements. RESULTS: Ninety-two patients were enrolled; the mean age was 26 years (range, 18-51 years). All had samples for DNA ligase (one quantity not sufficient) and urinalysis or urine dip, while 75 of 92 had urine cultures performed. A total of 57.3% (43/75) were urine culture positive at 10(2) CFU/mL, while the STD rate for those with urine cultures was 17.3% (13/75). There was no statistically significant difference in the number of STDs between urine culture positive and urine culture negative groups. The only variable on logistic regression predictive of an STD (based on all 91 patients) was more than one sex partner in the past year (p = 0.013). No other element of the history or pelvic examination helped differentiate those who tested positive for an STD. CONCLUSIONS: A total of 17.3% of women with symptoms of a UTI in this study had an STD, while only 57.3% were urine culture positive by catheterization using low count criteria. The proportion of STDs between those with and without a UTI was not significantly different.

Recovery at one year following isolated traumatic brain injury: a Western Trauma Association prospective multicenter trial.

BACKGROUND: Age has been shown to be a primary determinant of survival following isolated traumatic brain injury (TBI). We have previously reported that patients > or =65 years who survived mild TBI have decreased functional outcome at 6 months compared with younger patients. The purpose of this study was to further investigate the effect of age on outcome at 1 year in all patients surviving isolated TBI. METHODS: The Western Trauma Association multicenter prospective study included all patients sustaining isolated TBI defined as Abbreviated Injury Scale score for Head > or = 3 with an Abbreviated Injury Scale score in any other body area < or = 1. Outcome data included discharge disposition, Glasgow Outcome Scale score (1 = dead to 5= full recovery) and modified Functional Independence Measure (FIM) score measuring feeding, expression, and locomotion (1 = total dependence to 4 = total independence) for each component at discharge and 1 year. RESULTS: In all, 295 patients were enrolled with a follow-up of 82%, resulting in 241 study patients. An additional five patients died from non-TBI causes and were excluded. The mean and median times for the last follow-up in the 236 remaining patients were 307 and 357 days, respectively. Patients were divided into four age ranges: 18 to 29 years (n = 66), 30 to 44 years (n = 54), 45 to 59 years (n = 50), and > or =60 years (n = 65). More severe TBIs, as measured by admitting Glasgow Coma Scale (GCS), were observed in the youngest group compared with all others but there were no differences in mean GCS between the remaining three groups. There were no differences in neurosurgical intervention between the groups. Age was a major determinant in the outcome at discharge and last follow-up. Patients over 60 years discharged with a GOS < or =4 were less likely to improve at 1 year than all other groups (37% versus 63 to 85%; p < or = 0.05). Patients between 18 and 29 years of age had the lowest mean Glasgow Outcome Scale and discharge FIM scores, which correlated with the low admission GCS. Despite the increased severity of TBI, this group had the best FIM score at 1 year. In contrast, patients older than 60 years had the least improvement and had a significantly lower final FIM score at 1 year compared with all other groups. CONCLUSION: Older patients following isolated TBI have poorer functional status at discharge and make less improvement at 1 year compared with all other patients. These worse outcomes occur despite what appears to be less severe TBI as measured by a higher GCS upon admission. Differences in outcome begin to appear even in patients between 45 and 59 years. Further investigations with more detailed outcome instruments are required to better understand the qualitative limitations of a patient's recovery and to devise strategies to maximize functional improvement following TBI. Age is an exceedingly important parameter affecting recovery from isolated TBI.

Prospective study of neutrophil chemokine responses in trauma patients at risk for pneumonia.

Neutrophil hyperactivity contributes to organ failure, whereas hypofunction permits sepsis. The chemokine receptors CXCR1 and CXCR2 are central to polymorphonuclear neutrophil (PMN) function. We prospectively assessed CXCR function and expression in PMNs from trauma patients at high risk for pneumonia and their matched volunteer controls. CXCR2-specific calcium flux and chemotaxis were desensitized by injury, returning toward normal after 1 week. CXCR1 responses were relatively maintained. These defects appeared to be caused by preferential suppression of CXCR2 surface expression. To evaluate potential mechanisms of in vivo chemokine receptor regulation further we studied cross-desensitization of chemokine receptors in normal PMNs. Susceptibility to desensitization was in the order CXCR2 > CXCR1 > formyl peptide or C5a receptors. Trauma desensitizes CXC receptors, with CXCR2 being especially vulnerable. Desensitization is most marked immediately postinjury, generally resolving by Day 7. High-affinity chemoattractant receptors responsible for PMN chemotaxis from bloodstream to tissue appear to be regulated by injury. Receptors for end-target chemoattractants regulate CXCR1 and CXCR2 but resist suppression themselves and respond normally after injury. CXCR2 desensitization occurs before pneumonia, which developed in 44% of these patients. Suppression of high-affinity PMN receptors, like CXCR2, may predispose to pneumonia after trauma or other inflammatory conditions that lead to systemic inflammatory response syndrome.

Civilian craniocerebral gunshot wounds: an update in predicting outcomes.

Given the high mortality in patients sustaining intracranial injury secondary to gunshot wounds (GSWs), predictors to identify patients at increased risk of death are needed to assist clinicians early in determining optimal treatment. There have been few recent studies involving penetrating craniocerebral injuries, and most studies have been restricted to small numbers of patients, which do not allow for adequate prediction of mortality. A retrospective chart review of 298 patients who sustained GSWs to the head between 1992 and 2003 was conducted at a level 1 trauma center. Demographics, bullet trajectory, admitting Glasgow Coma Scale (GCS), head Abbreviated Injury Score (AIS), as well as admission blood pressure and respiratory rate were evaluated. Univariate testing followed by multivariate logistic regression was performed to identify independent predictors of death. In-hospital mortality for patients with intracranial injury secondary to GSW was 51 per cent. A GCS <5 on admission and a high Injury Severity Score (ISS >25) was associated with mortality as compared with survivors (P < 0.05). Of those patients presenting with a GCS of 3, there were seven survivors to discharge. Logistic regression identified the following variables as predictors of death: respiratory arrest on admission, hypotension on admission, transhemispheric and transventricular GSW. Identification of those patients at the highest risk of death secondary to a craniocerebral GSW allows clinicians to better predict outcome and prognosis. This is not only important in determining treatment algorithms for physicians but also for appropriate counseling of family members to educate them with regard to patients' outcomes.