Coagulopathy in Penetrating Ballistic Cranial Trauma: A 7-Year Experience.

BACKGROUND AND OBJECTIVES: Penetrating ballistic cranial trauma (PBCT) carries significant mortality when compared with blunt trauma. The development of coagulopathy in PBCT is a strong predictor of mortality. The goal of the study was to describe the incidence and risk factors of coagulopathy in PBCT and to report the value of tranexamic acid administration in PBCT. METHODS: We retrospectively analyzed 270 patients who presented with PBCT to a single, Level 1 trauma center between 2016 and 2023. RESULTS: A total of 47% (127/270) of patients with PBCT developed coagulopathy at presentation. Fifty-seven patients received tranexamic acid at presentation, which did not affect the development of coagulopathy. Coagulopathic patients were more likely to have more serious injury patterns (bihemispheric [adjusted odds ratio, aOR: 2.6 CI: 1.4-4.9, P = .004] or transventricular trajectories [aOR: 4.9 CI: 1.9-19.6, P = .03]). In addition, they presented with a larger base deficit (aOR: 0.9 CI: 1.002-1.2 per mEq/L, P = .006) which negatively correlated with the international normalized ratio (ρ: -0.46, P < .0001, Spearman correlation). Using thromboelastography helped to identify an additional 20% of patients who presented with normal coagulation on conventional testing. CONCLUSION: Coagulopathy is prevalent in approximately 50% of patients with PBCT and is persistent despite treatment in a substantial subset of patients. The addition of thromboelastography with its increased coagulopathy sensitivity can potentially guide treatment more efficiently than traditional coagulopathy laboratory tests and fibrinogen alone. Patients with a significant base deficit on arterial blood gas are at higher risk for coagulopathy.

Certain Rooms in Intensive Care Units May Harbor Risk for Clostridioides difficile Infection.

Abstract Background: Clostridioides difficile infection (CDI) is a common and sometimes life-threatening illness. Patient-, care-, and room hygiene-specific factors are known to impact CDI genesis, but care provider training and room topography have not been explored. We sought to determine if care in specific intensive care unit (ICU) rooms asymmetrically harbored CDI cases. Patients and Methods: Surgical intensive care unit (SICU) patients developing CDI (July 2009 to June 2018) were identified and separated by service (green/gold). Each service cared for their respective 12 rooms, otherwise differing only in resident team composition (July 2009 to August 2017: green, anesthesia; gold, surgery; August 2017 to June 2018: mixed for both). Fixed/mobile room features and provider traffic in three room zones (far/middle/near in relation to the toilet) were compared between high-/low-incidence rooms using observation via telecritical care video cameras. Results: Seventy-four new CDI cases occurred in 7,834 consecutive SICU admissions. In period one, green CDI cases were almost double gold cases (39 vs. 21; p = 0.02) but were similar in period two in which trainee service allocation intermixed. High-incidence rooms had closer toilet-to-intravenous pole proximity than low-incidence rooms (7.7 + 1.8 feet vs. 3.9 + 1.5 feet; p = 0.02). High-incidence rooms consistently housed mobile objects (patient bed, table-on-wheels) farther away from the toilet. Although physician time spent in each zone was similar, nurses spending more than 15 minutes in-room more frequently stayed in the far/middle zones in high-incidence rooms. Conclusions: Distinct SICU room features relative to toilet location and bedside clinician behaviors interact to alter patient CDI acquisition risk. This suggests that CDI risk occurs as a structural aspect of ICU care, offering the potential to reduce patient risk through deliberate room redesign.

Targeting gut dysbiosis as a means to enhance recovery from surgical brain injury.

BACKGROUND: Surgical brain injury (SBI) impacts roughly 800,000 people who undergo neurosurgical procedures each year. SBI is the result of unavoidable parenchymal damage, vessel disruption, and thermal injury that is an inherent part of all neurosurgical procedures. Clinically, SBI has been associated with postoperative seizures and long-term neurobehavioral deficits. Current therapies are aimed at providing symptom relief by reducing swelling and preventing seizures. However, there are no therapies aimed at reducing the extent of SBI preoperatively. The microbiome-gut-brain axis may serve as a potential target for the development of new preventative therapies due to its extensive involvement in central nervous system function. METHODS: An extensive literature review was conducted to determine whether there is a potential role for dysbiosis treatment in reducing the extent of SBI. RESULTS: Treatment of gut dysbiosis deserves further exploration as a potential means of reducing the extent of unavoidable SBI. Dysbiosis has been correlated with increased neuroinflammation through impaired immune regulation, increased blood-brain barrier permeability, and increased production of reactive metabolites. Recently, dysbiosis has also been linked to acute neurological dysfunction in the postoperative state. Importantly, treatment of dysbiosis has been correlated with better patient outcomes and decreased length of stay in surgical patients. CONCLUSION: Current literature supports the role of dysbiosis treatment in the preoperative setting as a means of optimizing neurological recovery following unavoidable SBI that results from all neurosurgical procedures.

Characterization of Veterinary Pharmacy and Pharmacology Literature and its Availability to Pharmacy Education.

Objective. To characterize the veterinary pharmacy and pharmacology literature cited by veterinary drug monographs and journal articles and describe the database indexing and availability of this literature in libraries serving pharmacy schools. Methods. Citations in American Academy of Veterinary Pharmacology and Therapeutics monographs, Journal of Veterinary Pharmacology and Therapeutics (JVPT) articles, and Plumb's Veterinary Drug Handbook, Eighth Edition (Plumb's) were analyzed for publication type and age. Three zones of cited journals were determined by Bradford's Law of Scattering based on citation counts. Results. Monographs most often cited journal articles (1886 [64.7%]), unpublished "grey" literature (632 [21.7%]), and books (379 [13.0%]), but only a few cited proceedings (16 [0.5%]). In JVPT, articles predominated (9625 [91.9%]). Articles comprised 54.8% (1,959) of Plumb's citations; proceedings, 27.0%; books, 15.7%; and grey literature, 2.5%. The age of cited items varied, with 17.1% of monograph citations less than five years old, compared to 26.3% of cited items in JVPT and 40.5% of cited items in Plumb's being less than five years old. Zone 1 consisted of three veterinary journals for monographs, four veterinary journals for Plumb's, and 16 veterinary and human journals for JVPT. Indexing coverage was above 92% in Web of Science, Scopus, and PubMed for zone 1 and 2 journals. Libraries serving both pharmacy and veterinary education programs subscribe to 95% of zone 1 journals, while libraries serving pharmacy education at institutions without a veterinary program subscribe to an average of 59% of zone 1 journals. Conclusion. Veterinary pharmacy and pharmacology literature relies on journals from human and veterinary practice, veterinary proceedings, and, less often, books and drug manufacturer information. Libraries supporting pharmacy programs could contribute to the education of future pharmacists who will be filling veterinary prescriptions by increasing access to this literature.