Body Mass Index Does Not Predict Injury Pattern or Outcome After Motorcycle Crash.

INTRODUCTION: The obesity epidemic plagues the United States, affecting approximately 42% of the population. The relationship of obesity with injury severity and outcomes has been poorly studied among motorcycle collisions (MCC). This study aimed to compare injury severity, mortality, injury regions, and hospital and intensive care unit length of stay (LOS) between obese and normal-weight MCC patients. METHODS: Trauma registries from three Pennsylvania Level 1 trauma centers were queried for adult MCC patients (January 1, 2016, and December 31, 2020). Obesity was defined as adult patients with body mass index ≥ 30 kg/m2 and normal weight was defined as body mass index < 30 kg/m2 but > 18.5 kg/m2. Demographics and injury characteristics including injury severity score (ISS), abbreviated injury score, mortality, transfusions and LOS were compared. P ≤ 0.05 was considered significant. RESULTS: One thousand one hundred sixty-four patients met the inclusion criteria: 40% obese (n = 463) and 60% nonobese (n = 701). Comparison of ISS demonstrated no statistically significant difference between obese and normal-weight patients with median ISS (interquartile range) 9 (5-14) versus 9 (5-14), respectively (P = 0.29). Obese patients were older with median age 45 (32-55) y versus 38 (26-54) y, respectively (P < 0.01). Comorbidities were equally distributed among both groups except for the incidence of hypertension (30 versus 13.8%, P < 0.01) and diabetes (11 versus 4.4%, P < 0.01). There was no statistically significant difference in Trauma Injury Severity Score or abbreviated injury score. Hospital LOS, intensive care unit LOS, and 30-day mortality among both groups were similar. CONCLUSIONS: Obese patients experiencing MCC had no differences in distribution of injury, mortality, or injury severity, mortality, injury regions, and hospital compared to normal-weight adults. Our study differs from current data that obese motorcycle drivers may have different injury characteristics and increased LOS.

Geriatric Motorcycle-Related Outcomes: A Pennsylvania Multicenter Study.

INTRODUCTION: Geriatric patients (GeP) often experience increased morbidity and mortality following traumatic insult and as a result, require more specialized care due to lower physiologic reserve and underlying medical comorbidities. Motorcycle injuries (MCCI) occur across all age groups; however, no large-scale studies evaluating outcomes of GeP exist for this particular subset of patients. Data thus far are limited to elderly participation in recreational activities such as water and alpine skiing, snowboarding, equestrian, snowmobiles, bicycles, and all-terrain vehicles. We hypothesized that GeP with MCCI will have a higher rate of mortality when compared with their younger counterparts despite increased helmet usage. METHODS: We performed a multicenter retrospective review of MCCI patients at three Pennsylvania level I trauma centers from January 2016 to December 2020. Data were extracted from each institution's electronic medical records and trauma registry. GeP were defined as patients aged more than or equal to 65 y. The primary outcome was mortality. Secondary outcomes included ventilator days; hospital, intensive care unit, and intermediate unit length of stays; complications; and helmet use. 3:1 nongeriatric patients (NGeP) to GeP propensity score matching (PSM) was based on sex, abbreviated injury scale (AIS), and injury severity score (ISS). P ≤ 0.05 was considered significant. RESULTS: One thousand five hundred thirty eight patients were included (GeP: 7% [n = 113]; NGP: 93% [n = 1425]). Prior to PSM, GeP had higher median Charlson Comorbidity Index (GeP: 3.0 versus NGeP: 0.0; P ≤ 0.001) and greater helmet usage (GeP: 73.5% versus NGeP: 54.6%; P = 0.001). There was a statistically significant difference between age cohorts in terms of ISS (GeP: 10.0 versus NGeP: 6.0, P = 0.43). There was no significant difference for any AIS body region. Mortality rates were similar between groups (GeP: 1.7% versus NGeP: 2.6%; P = 0.99). After PSM matching for sex, AIS, and ISS, GeP had significantly more comorbidities than NGeP (P ≤ 0.05). There was no difference in trauma bay interventions or complications between cohorts. Mortality rates were similar (GeP: 1.8% versus NGeP: 3.2%; P = 0.417). Differences in ventilator days as well as intensive care unit length of stay, intermediate unit length of stay, and hospital length of stay were negligible. Helmet usage between groups were similar (GeP: 64.5% versus NGeP: 66.8%; P = 0.649). CONCLUSIONS: After matching for sex, ISS, and AIS, age more than 65 y was not associated with increased mortality following MCCI. There was also no significant difference in helmet use between groups. Further studies are needed to investigate the effects of other potential risk factors in the aging patient, such as frailty and anticoagulation use, before any recommendations regarding management of motorcycle-related injuries in GeP can be made.

Small Bowel Obstruction Secondary to Endometriosis and Hydrosalpinx.

We describe the case of a 32-year-old female who presented to the emergency department (ED) with a 3-day history of severe epigastric abdominal pain accompanied by nausea, vomiting, and constipation. Past medical history was significant for known right hydrosalpinx and previous pelvic inflammatory disease (PID), without past surgical history. Clinical examination revealed a hemodynamically stable patient with a soft but distended abdomen, tenderness in the epigastric region, without signs of peritonitis. Bloodwork including white blood cell count, electrolytes, and lactic acid was unremarkable. Initial computed tomography (CT) scan of the abdomen and pelvis with contrast demonstrated a small bowel obstruction (SBO) with a transition point in the right lower quadrant, accompanied by mesenteric edema and free fluid. Exploratory laparotomy was performed and revealed obstruction secondary to dense adhesions involving the terminal ileum, appendix, sigmoid colon, and right ovary. Lysis of adhesions, appendectomy, and excision of a right paratubal cyst were performed. Histopathology demonstrated endometriosis of the appendix and a benign paratubal cyst.

The Efficacy of Liposomal Bupivacaine in Regional Nerve Blocks for Below Knee Amputations.

Postamputation pain is highly prevalent. Opioids are often utilized postoperatively; however, they have significant side effects. Liposomal bupivacaine (LB) was introduced to extend nerve blocks from hours into days. Regional nerve blocks with LB for below knee amputation (BKA) is a novel approach which may reduce opioid use after surgery. A retrospective review was conducted for patients who had received LB nerve blocks compared to none for postoperative pain control in BKAs. Daily average opioid consumption was evaluated from the time in postoperative acute care unit until day of discharge in oral morphine equivalents (OME). 69 patients who underwent below knee amputations were reviewed. The mean average daily OME was lower in the LB group compared to control group(25.0 vs 50.5 OME, respectively; P = .002) A higher percentage of patients in the study group were categorized in the minimal opioid use when compared to the control group LB regional nerve blocks for the BKA population are considered a novel approach in pain control. Our exploratory study shows that patients who received LB nerve blocks may have decreased opioid consumption after surgery.

Primary Splenic Ectopic Pregnancy Managed With Angioembolization and Splenectomy.

A primary splenic ectopic pregnancy is an extremely rare entity; one that is fraught with life-threatening risks due to potential for acute hemorrhage. The diagnosis is challenging to make, and once detected, there is a distinct sense of urgency to perform operative intervention (splenectomy) prior to any impending rupture. This report describes the case of a 34-year-old female, gravida 5, para 3013, at estimated 4 weeks gestation with a 2.1 × 1.3 cm ectopic pregnancy abutting the splenic hilum. Through multidisciplinary management with Obstetrics/Gynecology (OB/GYN), Interventional Radiology (IR), and General Surgery teams, the patient received preoperative non-elective splenic artery embolization to mitigate risk of rupture, followed by open splenectomy while remaining hemodynamically stable throughout the course of her treatment. As evidenced by this case, a multidisciplinary approach to this unusual clinical presentation leads to successful patient outcomes and prevents the devastating complication of acute hemorrhage.

A phase 1 study of ruxolitinib, steroids and lenalidomide for relapsed/refractory multiple myeloma patients.

Ruxolitinib with lenalidomide and dexamethasone shows anti-myeloma effects in vitro and in vivo. MUC1 leads to lenalidomide resistance in multiple myeloma (MM) cells, and ruxolitinib blocks its expression. Thus, ruxolitinib may restore sensitivity to lenalidomide. A phase I trial was conducted to determine the safety and efficacy of ruxolitinib with lenalidomide and methylprednisolone for patients with relapsed/refractory (RR)MM who had been treated with lenalidomide, steroids and a proteasome inhibitor and showed progressive disease at study entry. A traditional 3 + 3 dose escalation design was used to enroll subjects in four cohorts. Subjects received ruxolitinib twice daily, lenalidomide daily on days 1-21 of a 28 day cycle and methylprednisolone orally every other day. Primary endpoints were safety, clinical benefit rate (CBR) and overall response rate (ORR). Forty-nine patients were enrolled. The median age was 64 years and they had received a median of six prior treatments including lenalidomide and steroids to which 94% were refractory. No dose limiting toxicities occurred. The CBR and ORR were 49% and 36%, respectively. All responding patients were refractory to lenalidomide. Grade 3 or 4 adverse events (AEs) included anemia (17%), decreased lymphocyte count (15%), and hypophosphatemia (10%). Most common serious AEs included sepsis (9.8%) and pneumonia (7.8%). This Phase I trial demonstrates that a JAK inhibitor, ruxolitinib, can overcome refractoriness to lenalidomide and steroids for patients with RRMM. These results represent a promising novel therapeutic approach for treating MM. NCT03110822.

Comparison of the Impact of the Mediterranean Diet, Anti-Inflammatory Diet, Seventh-Day Adventist Diet, and Ketogenic Diet Relative to Cognition and Cognitive Decline.

PURPOSE OF REVIEW: Increasing evidence points toward the importance of diet and its impact on cognitive decline. This review seeks to clarify the impact of four diets on cognition: the Mediterranean diet, the anti-inflammatory diet, the Seventh Day Adventist diet, and the Ketogenic diet. RECENT FINDINGS: Of the diets reviewed, the Mediterranean diet provides the strongest evidence for efficacy. Studies regarding the anti-inflammatory diet and Seventh Day Adventist diet are sparse, heterogeneous in quality and outcome measurements, providing limited reliable data. There is also minimal research confirming the cognitive benefits of the Ketogenic diet. Increasing evidence supports the use of the Mediterranean diet to reduce cognitive decline. The MIND-diet, a combination of the Mediterranean and DASH diets, seems especially promising, likely due to its anti-inflammatory properties. The Ketogenic diet may also have potential efficacy; however, adherence in older populations may be difficult given frequent adverse effects. Future research should focus on long-term, well-controlled studies confirming the impact of various diets, as well as the combination of diets and lifestyle modification.

Use of serum B-cell maturation antigen levels to predict outcomes for myeloma patients treated with ruxolitinib, lenalidomide and methylprednisolone.

Previous retrospective studies have shown that serum B-cell maturation antigen (sBCMA) levels predict outcomes among patients with multiple myeloma (MM) undergoing new treatments. Specifically, baseline levels and changes during treatment of this protein predict both progression free survival (PFS) and overall survival. However, prospective studies are lacking evaluating sBCMA for determining outcomes among MM patients undergoing new treatments. Thus, we evaluated whether its baseline levels and changes during treatment in the amount of this serum marker predict outcomes among 38 relapsed/refractory MM patients treated with ruxolitinib, lenalidomide and methylprednisolone in a phase 1 trial. Patients with baseline sBCMA levels in the lowest three quartiles had longer PFS (median PFS 136 vs. 28 days; p < 0.0001). This was also shown for patients with baseline levels below the median (median PFS 140 vs. 77 days; p = 0.0225). PFS was shorter for patients whose sBCMA levels increased ≥25% through their first cycle (median PFS: 50 vs. 134 days, p = 0.0022), second cycle (median PFS: 50 vs. 141 days, p = 0.0273), and during the first three cycles of study treatment (median PFS: 50 vs. 220 days, p < 0.0001). No patient whose sBCMA increased ≥25% during cycle 1 responded whereas the majority (58%) of patients whose level increased <25% responded. This is the first prospective study to determine whether sBCMA levels predict outcomes for MM patients undergoing a non-BCMA directed treatment regimen and demonstrates that baseline levels and its changes during treatment predict PFS and the likelihood of responding to their treatment. These results add to the growing literature suggesting that this serum marker will be useful for determining outcomes for patients undergoing treatment for MM.

Expression Elements Derived From Plant Sequences Provide Effective Gene Expression Regulation and New Opportunities for Plant Biotechnology Traits.

Plant biotechnology traits provide a means to increase crop yields, manage weeds and pests, and sustainably contribute to addressing the needs of a growing population. One of the key challenges in developing new traits for plant biotechnology is the availability of expression elements for efficacious and predictable transgene regulation. Recent advances in genomics, transcriptomics, and computational tools have enabled the generation of new expression elements in a variety of model organisms. In this study, new expression element sequences were computationally generated for use in crops, starting from native Arabidopsis and maize sequences. These elements include promoters, 5' untranslated regions (5' UTRs), introns, and 3' UTRs. The expression elements were demonstrated to drive effective transgene expression in stably transformed soybean plants across multiple tissues types and developmental stages. The expressed transcripts were characterized to demonstrate the molecular function of these expression elements. The data show that the promoters precisely initiate transcripts, the introns are effectively spliced, and the 3' UTRs enable predictable processing of transcript 3' ends. Overall, our results indicate that these new expression elements can recapitulate key functional properties of natural sequences and provide opportunities for optimizing the expression of genes in future plant biotechnology traits.

Understanding the course of COVID-19-induced pneumomediastinum.

ABSTRACT: Since its discovery, COVID-19 has infected nearly 112 million people and caused about 2.5 millions deaths worldwide. Our understanding of the clinical presentation and complications of COVID-19 is still evolving. Bilateral pulmonary ground-glass opacities on imaging have become characteristic in the diagnosis of COVID-19, but pneumomediastinum has now also been reported in some patients with COVID-19. Reports on the overall prognosis for these patients are conflicting and little information exists regarding long-term complications. This article describes the clinical course of a patient who did not need mechanical ventilation but developed spontaneous pneumomediastinum.

Age is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery.

BACKGROUND: Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS: A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS: Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS: DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.

Dose Fractionation During Puberty Is More Detrimental to Mammary Gland Development Than an Equivalent Acute Dose of Radiation Exposure.

PURPOSE: Computed tomographic (CT) scans in adolescents have increased dramatically in recent years. However, the effects of cumulative low-dose exposures on the development of radiation sensitive organs, such as the mammary gland, is unknown. The purpose of this work was to define the effects of dose rate on mammary organ formation during puberty, an especially sensitive window in mammary development. We used a fractionated low-dose x-ray exposure to mimic multiple higher dose CT scans, and we hypothesized that fractionated exposure would have less of an effect on the number of mammary gland defects compared with an acute exposure. METHODS AND MATERIALS: Female mice were subjected to fractionated low-dose x-ray exposure (10 cGy/d for 5 days), acute x-ray exposure (1 × 50 cGy), or sham exposure. As the wide genetic diversity in humans can play a role in a person's response to irradiation, 2 genetically diverse mouse strains differing in radiation sensitivity (BALB/c-sensitive; C57BL/6-resistant) were used to investigate the role of genetic background on the magnitude of the effect. RESULTS: Unexpectedly, our data reveal that multiple low-dose exposures produce greater immune and mammary defects for weeks after exposure compared with controls. The most pronounced defects being increased ductal branching in both strains and a greater percentage of terminal end buds in the BALB/c strain of mice exposed to fractionated radiation compared with sham. Radiation-induced defects near the terminal end bud were also increased in both strains. CONCLUSIONS: The findings suggest that fractionated low-dose exposures are potentially more damaging to organ development compared with an equivalent, single acute exposure and that genetic background is an important parameter modifying the severity of these effects.

A Phase I Study of Ruxolitinib, Lenalidomide, and Steroids for Patients with Relapsed/Refractory Multiple Myeloma.

PURPOSE: Ruxolitinib with lenalidomide and dexamethasone shows antimyeloma effects in vitro and in vivo. MUC1 leads to lenalidomide resistance in multiple myeloma cells, and ruxolitinib blocks its expression. Thus, ruxolitinib may restore sensitivity to lenalidomide. Therefore, a phase I trial was conducted to determine the safety and efficacy of ruxolitinib with lenalidomide and methylprednisolone for patients with relapsed/refractory multiple myeloma (RRMM) who had been treated with lenalidomide/steroids and a proteasome inhibitor and showed progressive disease at study entry. PATIENTS AND METHODS: A traditional 3+3 dose escalation design was used to enroll subjects in four cohorts with planned total enrollment of 28 patients. Subjects received ruxolitinib twice daily, lenalidomide daily on days 1-21 of a 28-day cycle, and methylprednisolone orally every other day. Primary endpoints were safety, clinical benefit rate (CBR), and overall response rate (ORR). RESULTS: Twenty-eight patients were enrolled. The median age was 67 years and received a median of six prior treatments including lenalidomide and steroids to which 93% were refractory. No dose-limiting toxicities occurred. The CBR and ORR were 46% and 38%, respectively. All 12 responding patients were refractory to lenalidomide. Grade 3 or grade 4 adverse events (AE) included anemia (18%), thrombocytopenia (14%), and lymphopenia (14%). Most common serious AEs included sepsis (11%) and pneumonia (11%). CONCLUSIONS: This phase I trial demonstrates that a JAK inhibitor, ruxolitinib, can overcome refractoriness to lenalidomide and steroids for patients with RRMM. These results represent a promising novel therapeutic approach for treating multiple myeloma (ClinicalTrials.gov number, NCT03110822).

Surgeons in surge - the versatility of the acute care surgeon: outcomes of COVID-19 ICU patients in a community hospital where all ICU patients are managed by surgical intensivists.

BACKGROUND: Reported characteristics and outcomes of critically ill patients with COVID-19 admitted to the intensive care unit (ICU) are widely disparate with varying mortality rates. No literature describes outcomes in ICU patients with COVID-19 managed by an acute care surgery (ACS) division. Our ACS division manages all ICU patients at a community hospital in New Jersey. When that hospital was overwhelmed and in crisis secondary to COVID-19, we sought to describe outcomes for all patients with COVID-19 admitted to our closed ICU managed by the ACS division. METHODS: This was a prospective case series of the first 120 consecutive patients with COVID-19 admitted on March 14 to May 10, 2020. Final follow-up was May 27, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: One hundred and twenty patients were included (median age 64 years (range 25-89), 66.7% men). The most common comorbidities were hypertension (75; 62.5%), obesity (61; 50.8%), and diabetes (50; 41.7%). One hundred and thirteen (94%) developed acute respiratory distress syndrome, 89 (74.2%) had shock, and 76 (63.3%) experienced acute kidney injury. One hundred (83.3%) required invasive mechanical ventilation (IMV). Median ICU length of stay (LOS) was 8.5 days (IQR 9), hospital LOS was 14.5 days (IQR 13). Mortality for all ICU patients with COVID-19 was 53.3% and 62% for IMV patients. CONCLUSIONS: This is the first report of patients with COVID-19 admitted to a community hospital ICU managed by an ACS division who also provided all surge care. Mortality of critically ill patients with COVID-19 admitted to an overwhelmed hospital in crisis may not be as high as initially thought based on prior reports. While COVID-19 is a non-surgical disease, ACS divisions have the capability of successfully caring for both surgical and medical critically ill patients, thus providing versatility in times of crisis. LEVEL OF EVIDENCE: Level V.