Veno-Venous Extracorporeal Membrane Oxygenation (V V ECMO): Indications, Preprocedural Considerations, and Technique.

Veno-venous extracorporeal membrane oxygenation (V V ECMO) has been used for refractory respiratory failure. We describe the indications, technical aspects, and outcomes of placing V V ECMO in adults using a dual-lumen, single-cannula catheter.

Patterns and predictors of follow-up in patients with mild traumatic brain injury.

BACKGROUND: This study was undertaken to identify factors that influence follow-up for patients with mild traumatic brain injury (MTBI). METHODS: One hundred and ninety-nine consecutive inpatients diagnosed with MTBI at a Trauma Centre (or TC) were monitored for establishment of care with a brain injury specialist after discharge. Bivariate statistics were calculated to determine subject characteristics impacting the decision to pursue TBI-related specialty care. RESULTS: One hundred and nineteen patients (59.8%) followed up with the TC for routine post-injury care. Patients who followed up were older (age >40: OR = 2.48, p = 0.01, 95% CI = 1.03-8.96) and had longer hospital lengths of stay (LOS > 3 days: OR = 2.99, p < 0.001, 95% CI = 1.33-7.67). Upon follow-up, providers identified 20 patients (16.8%) with persistent neurologic symptoms, seven (3.5%) of whom saw a brain injury specialist. Lack of insurance significantly decreased the likelihood of follow-up with the TC and/or establishment of care with a TBI specialist. (OR = 0.76, p = 0.01, 95% CI = 0.62-0.95). CONCLUSIONS: Being insured was strongly predictive for follow-up at the TC and for establishing with a brain injury specialist post-MTBI. The TC post-injury visit identified MTBI patients with persistent symptoms, suggesting post-acute TC follow-up is an important venue for MTBI sequelae screening and referral.

Psychological morbidity in children 18 months after Kashmir Earthquake of 2005.

A severe earthquake occurred in Kashmir in 2005. The epicentre was close to Muzzafarabad. We collected data on over 1,100 children 18 months after the earthquake to look at symptoms of PTSD and behavioural and emotional problems using well established questionnaires. We found that 64.8% of children had significant symptoms of PTSD. Girls were more likely to suffer from these symptoms. The proportion of children suffering from emotional and behaviour difficulties was 34.6%. This percentage was not different from other studies of children from Pakistan within areas which were not affected by the earthquake. The rate of emotional symptoms was higher in girls while hyperactivity was more frequent in boys. This pattern is similar to other studies from across the world.

Early presynaptic and late postsynaptic components contribute independently to brain-derived neurotrophic factor-induced synaptic plasticity.

Trophin-induced synaptic plasticity consists of both presynaptic and postsynaptic processes. The potential interdependence of these mechanisms and their temporal relationships are undefined. The synaptic vesicle protein Rab3A is required for the early, initial 10 min phase but not for the later phase of BDNF-enhanced transmission. We now examine the temporal distinction and mechanistic relationships between these phases of BDNF action. Rab3A mutant cells did not exhibit increased miniature EPSC frequency in response to BDNF in cell culture, indicating an absence of the presynaptic component. In contrast, BDNF enhanced postsynaptic glutamate-induced current in the mutant neurons as in the wild type, indicating that the postsynaptic component of the response was intact. Finally, the postsynaptic NMDA receptor subunit NR2B was phosphorylated at Tyr1472 by BDNF in Rab3A knock-outs, as shown previously in wild type. Our results are the first to demonstrate that presynaptic and postsynaptic components of BDNF-enhanced synaptic activity are independent and temporally distinct.

A 61-year-old woman develops polyuria after hip revision.

A 61-year-old previously healthy woman developed progressive hearing and visual loss over a period of 2-3 months prior to admission. Her medical/surgical history was remarkable for a left hip arthroplasty 11 years ago requiring revision approximately 6 months prior to admission. After dislocating the revised hip, she re-presented to her surgeon and underwent a closed reduction. Several weeks following the reduction, the patient began having polyuria and symptoms of hearing and vision loss along with numbness in her extremities and abdominal region.

Abdominal compartment syndrome in trauma patients: New insights for predicting outcomes.

CONTEXT: Abdominal compartment syndrome (ACS) is associated with high morbidity and mortality among trauma patients. Several clinical and laboratory findings have been suggested as markers for ACS, and these may point to different types of ACS and complications. AIMS: This study aims to identify the strength of association of clinical and laboratory variables with specific adverse outcomes in trauma patients with ACS. SETTINGS AND DESIGN: A 5-year retrospective chart review was conducted at three Level I Trauma Centers in the City of Chicago, IL, USA. SUBJECTS AND METHODS: A complete set of demographic, pre-, intra- and post-operative variables were collected from 28 patient charts. STATISTICAL ANALYSIS: Pearson's correlation coefficient was used to determine the strength of association between 29 studied variables and eight end outcomes. RESULTS: Thirty-day mortality was associated strongly with the finding of an initial intra-abdominal pressure >20 mmHg and moderately with blunt injury mechanism. A lactic acid >5 mmol/L on admission was moderately associated with increased blood transfusion requirements and with acute renal failure during the hospitalization. Developing ACS within 48 h of admission was moderately associated with increased length of stay in the Intensive Care Unit (ICU), more ventilator days, and longer hospital stay. Initial operative intervention lasting more than 2 h was moderately associated with risk of developing multi-organ failure. Hemoglobin level <10 g/dL on admission, ongoing mechanical ventilation, and ICU stay >7 days were moderately associated with a disposition to long-term support facility. CONCLUSIONS: Clinical and lab variables can predict specific adverse outcomes in trauma patients with ACS. These findings may be used to guide patient management, improve resource utilization, and build capacity within trauma centers.

Genetic determinants of arterial calcification associated with atherosclerosis.

Increasing research interest has focused on arterial calcification in the setting of atherosclerosis. Many features of atherosclerosis-related calcification provide useful clinical information. For example, calcium mineral deposits frequently form in atherosclerotic plaque, and intimal arterial calcification can be used as a surrogate marker for atherosclerosis; also, calcium deposits are readily and noninvasively quantified, which is useful because greater amounts of coronary calcification predict a higher risk of myocardial infarction and death. Several mechanisms leading to calcification associated with atherosclerosis have been proposed; however, no direct testing of proposed mechanisms has yet been reported. Studies in genetically altered animals and in humans have shed light on potential genetic determinants, which in turn could form the basis for a more comprehensive understanding of the factors affecting calcification within plaque and the associated pathobiologic implications. We review proposed molecular and cellular mechanisms of atherosclerosis-associated arterial calcification, summarize genetic influences, and suggest areas in which further investigation is needed. Understanding the molecular and genetic determinants of specific structural plaque components such as calcification can provide a solid foundation for the development of novel therapeutic approaches to favorably alter plaque structure and minimize vulnerability to arterial rupture.

Outpatient follow-up after traumatic injury: Challenges and opportunities.

BACKGROUND: It has been shown that rates of ambulatory follow-up after traumatic injury are not optimal, but the association with insurance status has not been studied. AIMS: To describe trauma patient characteristics associated with completed follow-up after hospitalization and to compare relative rates of healthcare utilization across payor types. SETTING AND DESIGN: Single institution retrospective cohort study. MATERIALS AND METHODS: We compared patient demographics and healthcare utilization behavior after discharge among trauma patients between April 1, 2005 and April 1, 2010. Our primary outcome of interest was outpatient provider contact within 2 months of discharge. STATISTICAL ANALYSIS: Multivariate logistic regression was used to determine the association between characteristics including insurance status and subsequent ambulatory and acute care. RESULTS: We reviewed the records of 2906 sequential trauma patients. Patients with Medicaid and those without insurance were significantly less likely to complete scheduled outpatient follow-up within 2 months, compared to those with private insurance (Medicaid, OR 0.67, 95% CI 0.51-0.88; uninsured, OR 0.29, 95% CI 0.23-0.36). Uninsured and Medicaid patients were twice as likely as privately insured patients to visit the Emergency Department (ED) for any reason after discharge (uninsured patients (Medicaid, OR 2.6, 95% CI 1.50-4.53; uninsured, OR 2.10, 94% CI 1.31-3.36). CONCLUSION: We found marked differences between patients in scheduled outpatient follow-up and ED utilization after injury associated with insurance status; however, Medicaid seemed to obviate some of this disparity. Medicaid expansion may improve outpatient follow-up and affect patient outcome disparities after injury.

Predictors of assault among urban female trauma patients.

BACKGROUND: Assault is a common mechanism of injury among female trauma victims. This paper identifies risk factors for assault in female victims and explores the interplay between identified predictors of assault and their combined contribution to female violent victimization. MATERIALS AND METHODS: A retrospective analysis of all female trauma patients was performed using the Illinois Department of Public Health Trauma Registry from 1999-2003. Patients with assault listed as their mechanism of injury were compared to patients with other mechanisms of injury. Bivariate and multivariate analyses were performed using STATA statistical software to identify independent risk factors for assault. Finally, interaction affects were studied among these identified risk factors. RESULTS: Female victims of assault were more likely to be African American (OR 1.32, P < 0.001), lack insurance (OR 1.79, P < 0.001), and to have tested positive for drugs (OR 1.32, P < 0.001) than women with other mechanisms of injury. In addition to the independent effects of these variables, patient drug use and lack of insurance demonstrated interaction effects (OR 1.67, P = 0.02). CONCLUSION: In this study, women of color, the uninsured, and those using drugs were disproportionately represented among assault victims, highlighting further evidence of trauma disparities. Most significantly, this study demonstrates that predictors of assault in women frequently coexist and both independently and in combination may increase the risk for female violent victimization.

Prevalence and psychosocial risk factors of PTSD: 18 months after Kashmir earthquake in Pakistan.

BACKGROUND: On average in a year 939 earthquakes of a magnitude between 5 and 8 on the Richter scale occur around the world. In earthquakes developing countries are prone to large-scale destruction because of poor structural quality of buildings, and preparedness for earthquakes. On 8th October 2005, a major earthquake hit the remote and mountainous region of northern Pakistan and Kashmir. We wanted to find out the rate of PTSD in a randomly selected sample of participants living in earthquake area and the correlates of the PTSD. METHOD: The study was conducted 18 months after the earthquake. We selected a sample of men and women living in the houses and tents for interviews. Using well established instruments for PTSD and general psychiatric morbidity we gathered information from over 1200 people in face to face interviews. We gathered information about trauma exposure and loss as well. RESULTS: 55.2% women and 33.4% men suffered from PTSD. Living in a joint family was protective against the symptoms of PTSD. Dose of exposure to trauma was associated with the symptoms of PTSD. Living in a tent was associated with general psychiatric morbidity but not with PTSD. LIMITATIONS: We used questionnaire instead of interviews to detect the symptoms of psychiatric disorders. CONCLUSIONS: The symptoms of PTSD are common 18 months after the earthquake and they are specifically associated with the dose of trauma exposure. This may have implications for rehabilitation of this population.

Osteoblast elastic modulus measured by atomic force microscopy is substrate dependent.

The actin and microtubule cytoskeleton have been found to contribute to the elastic modulus of cells, which may be modulated by adhesion to extracellular matrix (ECM) proteins and subsequent alterations in the cytoskeleton. In this study, the apparent elastic modulus (Eapp) of osteoblast-like MC3T3-E1 cells adhered to fibronectin (FN), vitronectin (VN), type I collagen (COLI), fetal bovine serum (FBS), or poly-l-lysine (PLL), and bare glass were determined using an atomic force microscope (AFM). The E(app) of osteoblasts adhered to ECM proteins (FN, VN, COLI, and FBS) that bind cells via integrins were higher compared to cells on glass and PLL, which adhere cells through nonspecific binding. Also, osteoblasts adhered to FN, VN, COLI, and FBS had F-actin stress fiber formation, while osteoblasts on glass and PLL showed few F-actin fibers. Disruption of the actin cytoskeleton decreased E(app) of osteoblasts plated on FN to the level of osteoblasts plated on glass, while microtubule disruption had no significant effect. This suggests that the elevated modulus of osteoblasts adhered to FN was due to remodeling of the actin cytoskeleton upon adhesion to ECM proteins. Modulation of cell stiffness upon adhesion to various substrates may influence mechanosignal transduction in osteoblasts.