Cribari, does it apply in real time? An analysis of a community level 1 trauma center.

BACKGROUND: Major Trauma Code 1 (TC1) activations require significant resources to provide immediate treatment to potentially unstable, critically ill, patients. The Cribari Matrix Method (CMM) and Need For Trauma Intervention (NFTI) are two ways to determine over and undertriage in trauma. We studied the overtriage rate at a community level 1 trauma center using these two methods to determine the efficacy of the triage criteria in TC1 activations. METHOD: A retrospective review of all patients in the trauma registry of a level 1 American College of Surgeons trauma program from May to October 2021 was performed. Overtriage rates were determined using CMM and NFTI criteria. RESULTS: The overtriage rate of 552 activations using CMM alone was 73%. CMM combined with NFTI resulted in a 56% overtriage rate. CONCLUSION: The Cribari method can be used to determine the effectiveness of a system's trauma code 1 criteria but cannot delineate which criteria should be reviewed.

A case report of necrotizing fasciitis caused by Haemophilus influenzae co-infection in the setting of COVID-19 pneumonia.

INTRODUCTION AND IMPORTANCE: Necrotizing fasciitis is an aggressive skin and soft tissue infection that is a surgical emergency, and Haemophilus influenzae (H. flu) is a rare cause. We present a case of H. flu co-infection causing necrotizing fasciitis in the setting of COVID-19 pneumonia. CASE PRESENTATION: A 56-year-old male presented with 2 weeks of upper respiratory symptoms. He was unvaccinated against COVID-19 and tested positive for COVID-19 five days prior. He developed respiratory failure requiring intubation, and was treated with dexamethasone, remdesivir, and tocilizumab for COVID-19 pneumonia. On hospital day 2, he was hypotensive with new rapidly evolving erythematous lesions with crepitus of his lower extremities suspicious for necrotizing fasciitis. He underwent wide excision and debridement with significant hemodynamic improvements. H. flu co-infection was identified from blood cultures. Aberrant cells with 94 % lymphocytes were noted and suggested chronic lymphocytic leukemia (CLL) that was not previously known. He developed progressive lesions globally, concerning for purpura fulminans with clinical disseminated intravascular coagulation and neurological decline ultimately leading to withdrawal of care. CLINICAL DISCUSSION: COVID-19 infection is often associated with concomitant opportunistic infections. Our patient was also immunocompromised by CLL, diabetes, chronic steroids, and initial appropriate COVID-19 treatments. Despite appropriate treatments, he could not overcome his medical comorbidities and multiple infections. CONCLUSION: Necrotizing fasciitis caused by H. flu is rare, and we present the first case as a co-infection in the setting of COVID-19 pneumonia. Due to the patient's immunocompromised state with underlying CLL, this proved to be fatal.

Hospital-based, acute care within 30 days following discharge for acute burn injury.

BACKGROUND: While the acute management of burn injury has received substantial attention, patients may undergo additional hospital based, acute care following initial management. We conducted this study to quantify and describe patients' full hospital based, acute care needs within 30 days following an acute burn injury. METHODS: Using Florida, Nebraska, and New York state inpatient and emergency department databases, we identified adult patients discharged for an acute burn injury from January 1, 2010-November 30, 2014. The primary outcome was the frequency of hospital based, acute care (ED visit or hospital admission) within 30 days of initial discharge. Multivariable logistic regression modeling was used to identify patient factors associated with more frequent hospital based, acute care in the overall population. RESULTS: The final sample included 126,685 patients who sustained an acute burn injury and were initially managed through the ED (88.3%) or by hospital admission (11.7%). Overall, 16.5% of patients experienced at least one hospital based, acute care encounter within 30 days of discharge of their initial encounter. Most commonly, these were ED visits not undergoing hospital admission for wound care, ongoing burn care, or infectious complications. Patient-level factors associated with more frequent encounters included a history of opioid misuse or abuse (Adjusted Odds Ratio = 2.23, [95% Confidence Interval 2.01-2.47]), chronic obstructive pulmonary disease (AOR = 1.25, [1.12-1.38]), diabetes mellitus (AOR = 1.13, [1.04-1.23]), and mental health diagnoses (AOR = 1.22, [1.11-1.34]). CONCLUSIONS: Hospital based, acute care encounters are common after initial burn management. Further efforts are needed to improve the transition to outpatient care.

Acute and chronic temperature dependence of Na+/H+ exchange activity of Pimephales promelas gills.

Na+/H+ exchangers (NHE) mediate at least part of Na+ entry into gill epithelia via Na+/NH4+ exchange. For homeostasis, Na+ entry into and exit via Na+/K+ ATPase from gill epithelia must balance. Na+/K+ ATPase activity is reduced in cold- compared to warm-acclimated freshwater temperate fish. We hypothesized gill NHE activity is greater in warm- than cold-acclimated fish when measured at acclimation temperatures, and NHE activity displays a temperature dependence similar to Na+/K+ ATPase. Since NHE mRNA expression does not differ, we measured the Na+-dependence of pH-induced Na+ fluxes in gill vesicles from warm- and cold-acclimated fathead minnows at 20o and 7 °C, and calculated maximum transport rates (Vmax) and Na+ K1/2s. We also measured NH4+-induced Na+ fluxes and Na+-induced H+ fluxes. In vesicles from warm-acclimated fish, NHE Vmaxs were 278 ± 33 and 149 ± 23 arbitrary unit/s (au/s) and Na+ K1/2s were 12 ± 4 and 6 ± 4 mmol/l when assayed at 20o and 7 °C (p < 0.004), respectively. In vesicles from cold-acclimated fish, Vmaxs were 288 ± 35 and 141 ± 13 au/s and Na+ K1/2s 17 ± 5 and 7 ± 2 mmol/l when assayed at 20o and 7 °C (p < 0.002), respectively. Na+-induced H+ fluxes were 98 ± 8 and 104 ± 26 au/s in warm- and cold-acclimated fish assayed at 20 °C, respectively. Na+/NH4+ exchange was 120 ± 11 and 158 ± 13 au/s in warm- and cold-acclimated fish, respectively. Conclusions: Gill NHE activity was greater in warm- than cold-acclimated fish assayed at acclimation temperatures. The temperature dependence of NHE activity was similar in both groups, but differed from that reported for Na+/K+ ATPase suggesting complex mechanisms to maintain Na+ homeostasis.

Activity changes in gill ion transporter enzymes in response to salinity and temperature in fathead minnows (Pimephales promelas).

Fathead minnows, Pimephales promelas, are found throughout the continental United States in waters in which salinity can change with tides and temperatures vary seasonally. They have been used extensively in studies of environmental toxicology and are commercially important. In a very recent study in our labs RNA Seq was used to assemble transcriptomes from the gills of fatheads acclimated to either 5° or 22 °C. By comparison with published genomes, transcripts were identified for a number of ion transporters, ion channels, and signal molecule receptors, as well as enzymes that generate ammonia. H-ATPase and Na/K-ATPase activities were measured in supernatants of gill homogenates from fish acclimated to water sodium concentrations of 1.6, 3.1 or 124 mM sodium. As the water sodium concentration increased, in vitro activities of Na/K-ATPase activity and gill glutamate dehydrogenase activity decreased while H-ATPase activity increased. In a second series of experiments minnows were acclimated to 5 °C, 12.5 °C or 22 °C. In vitro activity of Na/K-ATPase decreased but activities of H-ATPase and glutamate dehydrogenase increased as temperature increased in gill membranes. These data do not support a primary role for apical H-ATPase in sodium influx under all conditions but do suggest a role for glutamate dehydrogenase production of ammonium to act as a counter-ion for sodium uptake by NHE-3.

Transcriptomic analysis of changes in gene expression of immune proteins of gill tissue in response to low environmental temperature in fathead minnows (Pimephales promelas).

In the face of ongoing climate change, it is imperative to understand better the effects of temperature on immune function in freshwater teleosts. It is unclear whether previously observed changes were caused by temperature per se. We studied changes in the gill transcriptome of fathead minnows (Pimephales promelas) at low temperature to understand better the effects of temperature on immune function. De novo assembly of the transcriptome using Trinity software resulted in 73,378 assembled contigs. Annotation using the Trinotate package yielded 58,952 Blastx hits (accessions). Expression of 194 unique mRNA transcripts changed in gill tissue of fathead minnows acclimatized to 5° compared to controls at 22 °C. At 5 °C mRNAs coding for proteins involved in innate immune responses were up-regulated. Those included proteins that block early-stage viral replication and macrophage activation. Expression of mRNAs coding for pro-inflammatory molecules and mucus secretion were also enhanced. Messenger RNAs coding for proteins associated with adaptive immune responses were down-regulated at 5 °C. Those included antigen-presenting proteins and proteins involved in immunoglobin production. Messenger RNAs coding for proteins that stimulate the cell cycle were also down-regulated at 5 °C. Histological comparison revealed that gills of cold acclimated fish had fewer mucus cells but cells contained larger mucus droplets. We conclude that decreased temperature modifies the immune systems of freshwater teleosts, leading to genome-wide upregulation of innate immunity and down regulation of adaptive immunity. Such acclimation likely evolved as an adaptive strategy against seasonal changes in infectious insults.