Mining raw plant transcriptomic data for new cyclopeptide alkaloids.

In recent years, genome and transcriptome mining have dramatically expanded the rate of discovering diverse natural products from bacteria and fungi. In plants, this approach is often more limited due to the lack of available annotated genomes and transcriptomes combined with a less consistent clustering of biosynthetic genes. The recently identified burpitide class of ribosomally synthesized and post-translationally modified peptide (RiPP) natural products offer a valuable opportunity for bioinformatics-guided discovery in plants due to their short biosynthetic pathways and gene encoded substrates. Using a high-throughput approach to assemble and analyze 700 publicly available raw transcriptomic data sets, we uncover the potential distribution of split burpitide precursor peptides in Streptophyta. Metabolomic analysis of target plants confirms our bioinformatic predictions of new cyclopeptide alkaloids from both known and new sources.

Plant peptides - redefining an area of ribosomally synthesized and post-translationally modified peptides.

Covering 1965 to February 2024Plants are prolific peptide chemists and are known to make thousands of different peptidic molecules. These peptides vary dramatically in their size, chemistry, and bioactivity. Despite their differences, all plant peptides to date are biosynthesized as ribosomally synthesized and post-translationally modified peptides (RiPPs). Decades of research in plant RiPP biosynthesis have extended the definition and scope of RiPPs from microbial sources, establishing paradigms and discovering new families of biosynthetic enzymes. The discovery and elucidation of plant peptide pathways is challenging due to repurposing and evolution of housekeeping genes as both precursor peptides and biosynthetic enzymes and due to the low rates of gene clustering in plants. In this review, we highlight the chemistry, biosynthesis, and function of the known RiPP classes from plants and recommend a nomenclature for the recent addition of BURP-domain-derived RiPPs termed burpitides. Burpitides are an emerging family of cyclic plant RiPPs characterized by macrocyclic crosslinks between tyrosine or tryptophan side chains and other amino acid side chains or their peptide backbone that are formed by copper-dependent BURP-domain-containing proteins termed burpitide cyclases. Finally, we review the discovery of plant RiPPs through bioactivity-guided, structure-guided, and gene-guided approaches.

A Widely Distributed Biosynthetic Cassette Is Responsible for Diverse Plant Side Chain Cross-Linked Cyclopeptides.

Cyclopeptide alkaloids are an abundant class of plant cyclopeptides with over 200 analogs described and bioactivities ranging from analgesic to antiviral. While these natural products have been known for decades, their biosynthetic basis remains unclear. Using a transcriptome-mining approach, we link the cyclopeptide alkaloids from Ceanothus americanus to dedicated RiPP precursor peptides and identify new, widely distributed split BURP peptide cyclase containing gene clusters. Guided by our bioinformatic analysis, we identify and isolate new cyclopeptides from Coffea arabica, which we named arabipeptins. Reconstitution of the enzyme activity for the BURP found in the biosynthesis of arabipeptin A validates the activity of the newly discovered split BURP peptide cyclases. These results expand our understanding of the biosynthetic pathways responsible for diverse cyclic plant peptides and suggest that these side chain cross-link modifications are widely distributed in eudicots.

National Trauma Institute prospective evaluation of the ventilator bundle in trauma patients: does it really work?

BACKGROUND: Since its introduction by the Institute for Healthcare Improvement, the ventilator bundle (VB) has been credited with a reduction in ventilator-associated pneumonia (VAP). The VB consists of stress ulcer prophylaxis, deep venous thrombosis prophylaxis, head-of-bed elevation, and daily sedation vacation with weaning assessment. While there is little compelling evidence that the VB is effective, it has been widely accepted. The Centers for Medical and Medicaid Services has suggested that VAP should be a "never event" and may reduce payment to providers. To provide evidence of its efficacy, the National Trauma Institute organized a prospective multi-institutional trial to evaluate the utility of the VB. METHODS: This prospective observational multi-institutional study included six Level I trauma centers. Entry criteria required at least 2 days of mechanical ventilation of trauma patients in an intensive care unit (ICU). Patients were followed up daily in the ICU until the development of VAP, ICU discharge, or death. Compliance for each VB component was recorded daily, along with patient risk factors and injury specifics. Primary outcomes were VAP and death. VB compliance was analyzed as a time-dependent covariate using Cox regression as it relates to outcomes. RESULTS: A total 630 patients were enrolled; 72% were male, predominately with blunt injury; and mean age, Injury Severity Score (ISS), and 24-hour Glasgow Coma Scale (GCS) score were 47, 24, and 8.7, respectively. VAP occurred in 36%; mortality was 15%. Logistic regression identified male sex and pulmonary contusion as independent predictors of VAP and age, ISS, and 24-hour Acute Physiology and Chronic Health Evaluation as independent predictors of death. Cox regression analysis demonstrated that the VB, as a time-dependent covariate, was not associated with VAP prevention. CONCLUSION: In trauma patients, VAP is independently associated with male sex and chest injury severity and not the VB. While quality improvement activities should continue efforts toward VAP prevention, the Institute for Healthcare Improvement VB is not the answer. Financial penalties for VAP and VB noncompliance are not warranted. LEVEL OF EVIDENCE: Therapeutic study, level III.

Impact of age and anticoagulation: need for neurosurgical intervention in trauma patients with mild traumatic brain injury.

BACKGROUND: Of the 500,000 brain injuries in the United States annually, 80% are considered mild (mild traumatic brain injury). Unfortunately, 2% to 3% of them will subsequently deteriorate and result in severe neurologic dysfunction. Intracerebral changes in the elderly, chronic oral anticoagulation, and platelet inhibition may contribute to the development of intracranial bleeding after minor head injury. We sought to investigate the association of age and the use of anticoagulation and antiplatelet therapy with neurologic deterioration and the need for neurosurgical intervention in patients presenting with mild traumatic brain injury. METHODS: A retrospective review of all adult (>14 years) patients admitted to our Level I trauma service with a Glasgow Coma Scale (GCS) score of 14 to 15 who underwent neurosurgical intervention during their hospital stay was performed. Patients were stratified into two groups, age <65 years and age ≥ 65 years. Each group was then further stratified by the use of anticoagulants: warfarin, aspirin, clopidogrel, or a combination. Mechanism of injury, prehospital complaints, admission GCS, type of neurosurgical intervention, intensive care unit length of stay, hospital length of stay, and discharge disposition were evaluated. Z test and logistic regression were used to compare proportions or percentages from different groups. RESULTS: Of the 7,678 patients evaluated during the study period, 101 (1.3%) required neurosurgical intervention. The ≥ 65 years population underwent significantly more interventions as did those patients on anticoagulants. CONCLUSION: All patients aged 65 years or older who present with a GCS score of >13 after head trauma should undergo a screening computed tomography of the head regardless of prehospital use of anticoagulation. Patients younger than 65 years can be selectively screened based on presenting complaints and mechanism of injury provided they are not on anticoagulation.

A randomized, double-blind, placebo-controlled study to assess the effect of recombinant human erythropoietin on functional outcomes in anemic, critically ill, trauma subjects: the Long Term Trauma Outcomes Study.

BACKGROUND: Achieving a higher hemoglobin (Hb) level might allow the anemic, critically ill, trauma patient to have an improved outcome during rehabilitation therapy. METHODS: Patients with major blunt trauma orthopedic injuries were administered epoetin alfa or placebo weekly both in hospital and for up to 12 weeks after discharge or until the Hb level was >12.0 g/dL, whichever occurred first. The 36-question Short Form Health Assessment questionnaire (SF-36) was used to evaluate physical function (PF) outcomes at baseline, at hospital discharge, and at several time points posthospital discharge. RESULTS: One hundred ninety-two patients were enrolled (epoetin alfa [n = 97], placebo [n = 95]). Hb increased from baseline to hospital discharge in both groups (epoetin alfa: 1.2 g/dL vs placebo: 0.9 g/dL), and transfusion requirements were similar between groups. Both groups showed improvements in SF-36 PF; there were no significant differences in the average of all posthospital discharge scores (epoetin alfa: 27.3 vs placebo 30.9; P = 0.38). Thromboembolic events were similar between groups. CONCLUSIONS: No differences were observed in physical function outcomes or safety in anemic, critically ill, trauma patients treated with epoetin alfa compared with placebo.

Health care reform at trauma centers--mortality, complications, and length of stay.

OBJECTIVE: The Trauma Quality Improvement Program has demonstrated existence of significant variations in risk-adjusted mortality across trauma centers. However, it is unknown whether centers with lower mortality rates also have reduced length of stay (LOS), with associated cost savings. We hypothesized that LOS is not primarily determined by unmodifiable factors, such as age and injury severity, but is primarily dependent on the development of potentially preventable complications. METHODS: The National Trauma Data Bank (2002-2006) was used to include patients (older than 16 years) with at least one severe injury (Abbreviated Injury Scale score ≥ 3) from Level I and II trauma centers (217,610 patients, 151 centers). A previously validated risk-adjustment algorithm was used to calculate observed-to-expected mortality ratios for each center. Poisson regression was used to determine the relationship between LOS, observed-to-expected mortality ratios, and complications while controlling for confounding factors, such as age, gender, mechanism, insurance status, comorbidities, and injuries and their severity. RESULTS: Large variations in LOS (median, 4-8 days) were observed across trauma centers. There was no relationship between mortality and LOS. The most important predictor of LOS was complications, which were associated with a 62% increase. Injury severity score, shock, gunshot wounds, brain injuries, intensive care unit admission, and comorbidities were less important predictors of LOS. CONCLUSION: Quality improvement programs focusing on mortality alone may not be associated with reduced LOS. Hence, the Trauma Quality Improvement Program should also focus on processes of care that reduce complications, thereby shortening LOS, which may lead to significant cost savings at trauma centers.

Hips can lie: impact of excluding isolated hip fractures on external benchmarking of trauma center performance.

BACKGROUND: Trauma centers (TCs) vary in the inclusion of patients with isolated hip fractures (IHFs) in their registries. This inconsistent case ascertainment may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS: Data were derived from the National Trauma Data Bank (2007-8.1). We included patients (aged 16 years or older) with Injury Severity Score value ≥ 9 who were admitted to Level I and II TCs. To ensure data quality, we limited the study to TC that routinely reported comorbidities and Abbreviated Injury Scale codes. IHF were defined as patients, aged 65 years or older, injured as a result of falls, with Abbreviated Injury Scale codes for hip fracture and without other significant injuries. TCs were stratified according to their reported inclusion of IHF in their registry. Observed-to-expected mortality ratios were used to rank TC performance first with and then, without the inclusion of patients with IHF. RESULTS: In total, 91,152 patients in 132 TCs were identified; 5% (n = 4,448) were IHF. The proportion of IHF per TC varied significantly, ranging from 0% to 31%. When risk-adjusted mortality was evaluated, excluding patients with IHF had significant effects: 37% (n = 49) of TCs changed their performance rank by ≥ 3 (range, 1-25) and 12% of centers changed their performance quintile. The greatest change in rank performance was evident in centers that routinely include IHF in their registries. CONCLUSIONS: Given the fact that IHFs in the elderly significantly influence risk-adjusted outcomes and are variably reported by TCs, these patients should be excluded from subsequent benchmarking efforts.

Family presence during trauma resuscitation: ready for primetime?

BACKGROUND: The concept of family presence during trauma resuscitation (FPTR) remains controversial. Healthcare providers have expressed concern that resuscitation of severely injured trauma patients is inappropriate for family members as they may have psychologic distress, disrupt resuscitative efforts, or misinterpret provider actions, which can ultimately impact satisfaction with care. The minimal evidence that exists is descriptive or anecdotal. METHODS: Using a previously developed FPTR protocol, a prospective, comparative study assessing 50 adult family members, who were present (n = 25) or not present (n = 25) with their severely injured adult family member during resuscitation, was conducted. Family member anxiety was assessed using State-Trait Anxiety Inventory, satisfaction using a Revised-Critical Care Family Needs Inventory, and well-being using Family Member Well-being Index within 48 hours of intensive care unit admission. Mean total scores were compared for both groups with independent t tests. Significance was set at p < 0.05. RESULTS: Age and Injury Severity Score were statistically equivalent in all patients. Anxiety, satisfaction, and well-being were not statistically different in family members present compared with those not present during resuscitation. There were no untoward events during resuscitation efforts. Family members present felt they benefited the patient and gained a better understanding of the situation. Conversely, family members not present commented that they would have preferred to have been present during resuscitation. CONCLUSIONS: Family members present during trauma resuscitation suffered no ill psychologic effects and scored equivalent to those family members who were not present on anxiety, satisfaction, and well-being measures. Quality of care during trauma resuscitation was maintained. The fact that all the family members would repeat experience again supports the idea that FPTR was not too traumatic for those who chose to be present.

Centers for Medicare and Medicaid services quality indicators do not correlate with risk-adjusted mortality at trauma centers.

OBJECTIVES: The Centers for Medicare and Medicaid Services (CMS) publicly reports hospital compliance with evidence-based processes of care as quality indicators. We hypothesized that compliance with CMS quality indicators would correlate with risk-adjusted mortality rates in trauma patients. METHODS: A previously validated risk-adjustment algorithm was used to measure observed-to-expected mortality ratios (O/E with 95% confidence interval) for Level I and II trauma centers using the National Trauma Data Bank data. Adult patients (>or=16 years) with at least one severe injury (Abbreviated Injury Score >or=3) were included (127,819 patients). Compliance with CMS quality indicators in four domains was obtained from Hospital Compare website: acute myocardial infarction (8 processes), congestive heart failure (4 processes), pneumonia (7 processes), surgical infections (3 processes). For each domain, a single composite score was calculated for each hospital. The relationship between O/E ratios and CMS quality indicators was explored using nonparametric tests. RESULTS: There was no relationship between compliance with CMS quality indicators and risk-adjusted outcomes of trauma patients. CONCLUSIONS: CMS quality indicators do not correlate with risk-adjusted mortality rates in trauma patients. Hence, there is a need to develop new trauma-specific process of care quality indicators to evaluate and improve quality of care in trauma centers.

The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility.

OBJECTIVE: The American College of Surgeons Committee on Trauma has created a "Trauma Quality Improvement Program" (TQIP) that uses the existing infrastructure of Committee on Trauma programs. As the first step toward full implementation of TQIP, a pilot study was conducted in 23 American College of Surgeons verified or state designated Level I and II trauma centers. This study details the feasibility and acceptance of TQIP among the participating centers. METHODS: Data from the National Trauma Data Bank for patients admitted to pilot study hospitals during 2007 were used (15,801 patients). A multivariable logistic regression model was developed to estimate risk-adjusted mortality in aggregate and on three prespecified subgroups (1: blunt multisystem, 2: penetrating truncal, and 3: blunt single-system injury). Benchmark reports were developed with each center's risk adjusted mortality (expressed as an observed-to-expected [O/E] mortality ratio and 90% confidence interval [CI]) and crude complication rates available for comparison. Reports were deidentified with only the recipient having access to their performance relative to their peers. Feedback from individual centers regarding the utility of the reports was collected by survey. RESULTS: Overall crude mortality was 7.7% and in cohorts 1 to 3 was 16.4%, 12.4%, and 5.1%, respectively. In the aggregate risk-adjusted analysis, three trauma centers were low outliers (O/E and 90% CI <1) and two centers were high outliers (O/E and 90% CI >1) with the remaining 18 centers demonstrating average mortality. Challenges identified were in benchmarking mortality after penetrating injury due to small sample size and in the limited capture of complications. Ninety-two percent of survey respondents found the report clear and understandable, and 90% thought that the report was useful. Sixty-three percent of respondents will be taking action based on the report. CONCLUSIONS: Using the National Trauma Data Bank infrastructure to provide risk-adjusted benchmarking of trauma center mortality is feasible and perceived as useful. There are differences in O/E ratios across similarly verified or designated centers. Substantial work is required to allow for morbidity benchmarking.

Odontoid fractures in the elderly: should we operate?

BACKGROUND: : Treatment of odontoid fractures remains controversial. There are conflicting data in the literature with regard to timing of operative fixation (OP), as well as whether OP should be performed. Within our own institution, treatment is variable depending largely on surgeon preference. This study was undertaken in an attempt to develop management consensus by examining outcomes in elderly patients with odontoid fractures and comparing OP to a nonoperative (non-OP) approach. METHODS: : The trauma registry of our level I trauma center was queried for elderly (age > or = 60) patients with odontoid fractures from January 2000 to May 2006. Patients were then grouped according to treatment, early-OP (< or =3 days posttrauma), late-OP (>3 days), or non-OP treatment. Patient characteristics that were evaluated and compared among the three groups included age, Injury Severity Score, preexisting conditions, and the type of odontoid fracture. Outcomes evaluated included in-hospital mortality, ventilator days, hospital length of stay (HLOS), need for tracheostomy and percutaneous endoscopic gastrostomy (PEG), and the complications of urinary tract infection (UTI), deep vein thrombosis (DVT), and pneumonia. Differences among groups were tested using analysis of variance, Students t test, chi, and Fishers exact test. RESULTS: : The non-OP patients were significantly older than either operative group (mean, 82.4 for non-OP; 77.4 for early-OP; and 76.4 for late-OP; p = 0.006 non-OP compared with either operative group). Injury Severity Score, number of preexisting conditions, mechanism of injury, and distribution of type of odontoid fractures were similar among all three groups. There was no statistically significant difference in mortality among the three groups (11.7% early-OP, 8.7% late-OP, and 17.6% non-OP). There was also no difference among all three groups with respect for the need for tracheostomy and PEG and the development of UTI or pneumonia. However, there were significantly less DVTs in the non-OP group compared with the early-OP group (2.9% vs. 17.6%, p = 0.02). The percentage of patients discharged to a skilled nursing facility was similar among all three groups. The non-OP group had a significant decrease in both ventilator days and HLOS when compared with the operative groups. Only 2.9% of non-OP patients returned for OP for nonunion of the odontoid fracture. CONCLUSIONS: : Despite being an older population, elderly patients with odontoid fracture who were managed non-OP had similar mortality, UTI, and pneumonia rates compared with their younger counterparts who underwent OP. The need for tracheostomy and PEG and discharge disposition was similar among all three groups. Elderly patients with odontoid fracture managed non-OP had a reduction in HLOS and ventilator days compared with either operative group and less DVT compared with the early operative group. Based on these results, non-OP management should be given strong consideration in elderly patients with traumatic odontoid fractures.

Preventability classification in mortality cases: a reliability study.

BACKGROUND: The Pennsylvania Trauma Systems Foundation ad hoc Outcomes Committee developed the Pennsylvania Outcomes and Performance Improvement Measurement System (POPIMS) software program that provided a consistent outcomes reporting template for trauma centers in the state. This study was performed to evaluate inter-rater reliability of POPIMS software for mortality classification. METHODS: All trauma centers in the state were instructed to submit one preventable (P), one potentially preventable (PP), and one nonpreventable (NP) POPIMS mortality report to the Pennsylvania Trauma Systems Foundation office. The reports were blinded, an equal number of P, PP, and NP classified mortalities were randomly selected, and a meeting of trauma directors who submitted cases was convened. Institutional classification (IC) was compared with reviewing trauma directors (reviewer classification [RC]) to evaluate inter-rater reliability of software. Chi-square test was used to analyze differences. Inter-rater reliability among reviews was assessed using Cronbach's alpha coefficient. RESULTS: Twenty-eight trauma surgeons reviewed 34 cases (11 preventable, 12 PP, 11 nonpreventable), each having a minimum of 10 reviews. When compared with IC, RC was significantly different (p < 0.001). In addition, factors contributing to mortality were different when comparing IC and RC reviews of different mortality preventability classes. There was a moderate level of inter-rater reliability among reviewers as measured by Cronbach's alpha coefficient of 0.64. CONCLUSIONS: POPIMS is the first statewide PI reporting system to share outcomes information between trauma centers. Significant differences between IC of mortality and that provided by reviewers suggest that more objective criteria for mortality classification are needed. Realizing limitations of preventability classification, additional outcomes parameters should be pursued.

Hepatic angioembolization in trauma patients: indications and complications.

BACKGROUND: Hepatic angiography (HA) and hepatic angioembolization (HAE) are increasingly used to diagnose and treat intrahepatic arterial injuries. This study was performed to review indications, outcomes, and complications of HA/HAE in blunt trauma patients who underwent HAE as adjunct management of hepatic injury. METHODS: A retrospective review of consecutive cases of HA/HAE at a Level I trauma center during an 8-year period. Data include demographics, physiologic condition, liver injury grade, HA/HAE indications, outcomes, morbidity, and mortality. RESULTS: Seventy-nine patients underwent diagnostic HA; 31 (39%) had subsequent HAE. Fifty-eight hemodynamically stable patients had computerized axial tomographic (CT) scan followed by HA. HA was performed for contrast blush on CT in 30 (52%) of 58 patients, high-grade liver injury in 4 (7%), subsequent hemodynamic instability in 15 (27%), and angiography planned for other purpose in 9 (17%). HA confirmed arterial injury and led to HAE in 50% of patients with contrast blush on CT or high-grade liver injury. HA was negative when performed for hemodynamic instability or for other primary purposes. Twenty-one hemodynamically unstable patients underwent emergent laparotomy followed by postoperative HA with 11 (50%) requiring HAE. Overall mortality in HAE group was 16%, and liver-related morbidity was 29% usually presenting as gallbladder or liver necrosis. CONCLUSION: HA/HAE should be used when CT scan suggests associated intrahepatic arterial or high-grade injury in the management of hepatic injuries and should also be considered after laparotomy and perihepatic packing to control inaccessible intrahepatic hemorrhage. Mortality related to HAE is uncommon, but morbidity occurs frequently.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Preinjury warfarin worsens outcome in elderly patients who fall from standing.

INTRODUCTION: Fall from standing (FFS) has become one of the most common mechanisms of injury for admission to the trauma center in the elderly population. Many of these patients present anticoagulated with warfarin. This two-center study was designed to examine the effects of preinjury warfarin use on outcome in the elderly. METHODS: A retrospective review of prospectively collected registry data at two Level I trauma centers was conducted from 2003 to 2006. The study population included patients age > or = 65 admitted to the trauma center after an FFS. These centers are relatively close geographically and have similar patient demographics. Data collected included: age, Injury Severity Score, Abbreviated Injury Score (AIS) for head, mortality, admission Glasgow Coma Score, and admission international normalized ratio (INR). Patients were divided into two groups based on the preinjury condition of warfarin use. Statistical differences were determined by unpaired t test for continuous variables and chi and odds ratios (ORs) for dichotomous variables. RESULTS: Of the 27,812 patients admitted to these two trauma centers over this time period, 2,791 (10.0%) were of age > or = 65 and admitted after an FFS. INR was 2.8 +/- 1.1 in warfarin group (+warf). The number of patients with AIS head 4 and 5 was similar between groups (-warf 22.1%, +warf 25.9%). Overall, preinjury warfarin use had a negative effect on the in-hospital mortality rate, +warf 8.6% and -warf 5.7% (OR 1.54, 1.09-2.19, p = 0.015). There was no difference in mortality between groups in patients with an AIS head < 4. The negative impact of preinjury warfarin use on mortality was most pronounced in patients with an AIS head 4 and 5 who presented awake (Glasgow Coma Score 14 and 15), +warf 13.5% and -warf 6.4% (OR 2.30, 95% confidence interval 1.12-4.70, p = 0.019). CONCLUSION: Preinjury warfarin use has an adverse effect on outcome (mortality) in elderly FFS patients. Importantly, this effect is most prominent in patients admitted awake with significant findings on computed tomography scan. This argues for rapid emergency department triage to computed tomography scan and rapid INR correction in this population.

American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank.

BACKGROUND: This study attempts to validate the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for spleen, liver, and kidney injuries using the National Trauma Data Bank (NTDB). STUDY DESIGN: All NTDB entries with Abbreviated Injury Scale codes for spleen, liver, and kidney were classified by OIS grade. Injuries were stratified either as an isolated intraabdominal organ injury or in combination with other abdominal injuries. Isolated abdominal solid organ injuries were additionally stratified by presence of severe head injury and survival past 24 hours. The patients in each grading category were analyzed for mortality, operative rate, hospital length of stay, ICU length of stay, and charges incurred. RESULTS: There were 54,148 NTDB entries (2.7%) with Abbreviated Injury Scale-coded injuries to the spleen, liver, or kidney. In 35,897, this was an isolated abdominal solid organ injury. For patients in which the solid organ in question was not the sole abdominal injury, a statistically significant increase (p < or = 0.05) in mortality, organ-specific operative rate, and hospital charges was associated with increasing OIS grade; the exception was grade VI hepatic injuries. Hospital and ICU lengths of stay did not show substantial increase with increasing OIS grade. When isolated organ injuries were examined, there were statistically significant increases (p < or = 0.05) in all outcomes variables corresponding with increasing OIS grade. Severe head injury appears to influence mortality, but none of the other outcomes variables. Patients with other intraabdominal injuries had comparable quantitative outcomes results with the isolated abdominal organ injury groups for all OIS grades. CONCLUSIONS: This study validates and quantifies outcomes reflective of increasing injury severity associated with increasing OIS grades for specific solid organ injuries alone, and in combination with other abdominal injuries.

Outcome after decompressive craniectomy for the treatment of severe traumatic brain injury.

BACKGROUND: Using decompressive craniectomy as part of the treatment regimen for severe traumatic brain injury (STBI) has become more common at our Level I trauma center. This study was designed to examine this practice with particular attention to long-term functional outcome. METHODS: A retrospective review of prospectively collected data was performed for patients with STBI admitted from January 1, 2003 to December 31, 2005. Our institution manages patients using the Brain Trauma Foundation Guidelines. Data collected from patients undergoing decompressive craniectomy included: age, Injury Severity Score, admission and follow-up Glasgow Coma Score, timing of, and indication for decompressive craniectomy, and procedure-related complications. The Extended Glasgow Outcome Scale (GOSE) was performed by a experienced trauma clinical research coordinator using a structured phone interview to assess long-term outcome in the survivors. Student's t test and chi2 were used to examine differences between groups. RESULTS: Forty STBI patients were treated with decompressive craniectomy; 24 were performed primarily in conjunction with urgent evacuation of extra-axial hemorrhage and 16 were performed primarily in response to increased intracranial pressure with 4 of these after an initial craniotomy. Decompressive craniectomy was very effective at lowering intracranial pressure in these 16 patients (35.0 mm Hg +/- 13.5 mm Hg to 14.6 mm Hg +/- 8.7 mm Hg, p = 0.005). Twenty-two decompressive craniectomy patients did not survive to hospital discharge, whereas admission Glasgow Coma Score and admission pupil size and reactivity correlated with outcome, age, and Injury Severity Score did not. At a mean of 11 months (range, 3-26 months) after decompressive craniectomy, 6 survivors had a poor functional outcome (GOSE 1-4), whereas 12 survivors had a good outcome (GOSE 5-8). Therefore, 70% of these patients had an unfavorable outcome (death or severe disability), and 30% had a favorable long-term functional outcome. Fifteen of 18 survivors went on to cranioplasty, whereas 4 of 18 had cerebrospinal infection. CONCLUSION: The majority of survivors after decompressive craniectomy have a good functional outcome as analyzed by GOSE. Overall, 30% of patients with STBI who underwent decompressive craniectomy had a favorable long-term outcome. Improving patient selection and optimizing timing of this procedure may further improve outcome in these very severely brain injured patients.