Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock.

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

Bilateral Deep Brain Stimulation of the Ventral Intermediate Nucleus of the Thalamus Improves Objective Acoustic Measures of Essential Vocal Tremor.

BACKGROUND AND OBJECTIVES: Deep brain stimulation of the ventral intermediate nucleus of the thalamus (VIM-DBS) is an established treatment for medically refractory essential tremor. However, the effect of VIM-DBS on vocal tremor remains poorly understood, with results varying by method of vocal tremor assessment and stimulation laterality. This single-center study measures the effect of bilateral VIM-DBS on essential vocal tremor using blinded objective acoustic voice analysis. METHODS: Ten patients with consecutive essential tremor with comorbid vocal tremor receiving bilateral VIM-DBS underwent voice testing before and after implantation of DBS in this prospective cohort study. Objective acoustic measures were extracted from the middle one second of steady-state phonation including cepstral peak prominence, signal-to-noise ratio, percentage voicing, tremor rate, extent of fundamental frequency modulation, and extent of intensity modulation. DBS surgery was performed awake with microelectrode recording and intraoperative testing. Postoperative voice testing was performed after stable programming. RESULTS: Patients included 6 female and 4 male, with a mean age of 67 ± 6.7 years. The VIM was targeted with the following coordinates relative to the mid-anterior commissure:posterior commissure point: 13.2 ± 0.6 mm lateral, 6.2 ± 0.7 mm posterior, and 0.0 mm below. Mean programming parameters were amplitude 1.72.0 ± 0.6 mA, pulse width 63.0 ± 12.7 µs, and rate 130.6 ± 0.0 Hz. VIM-DBS significantly improved tremor rate from 4.43 ± 0.8 Hz to 3.2 ± 0.8 Hz (P = .001) CI (0.546, 1.895), jitter from 1 ± 0.94 to 0.53 ± 0.219 (P = .02) CI (-0.124, 1.038), cepstral peak prominence from 13.6 ± 3.9 to 18.8 ± 2.9 (P = .016) CI (-4.100, -0.235), signal-to-noise ratio from 15.7 ± 3.9 to 18.5 ± 3.7 (P = .02) CI (-5.598, -0.037), and articulation rate from 0.77 ± 0.2 to 0.82 ± .14 (P = .04) CI (-0.097, 0.008). There were no major complications in this series. CONCLUSION: Objective acoustic voice analyses suggest that bilateral VIM-DBS effectively reduces vocal tremor rate and improves voicing. Further studies using objective acoustic analyses and laryngeal imaging may help refine surgical and stimulation techniques and evaluate the effect of laterality on vocal tremor.

Dietary specialization and Eucalyptus species preferences in Queensland koalas (Phascolarctos cinereus).

Koalas specialize on Eucalyptus leaves, but also feed selectively. Food choice is not random, but depends on various factors that are not well understood, although most research has focused on the role of secondary plant compounds. We studied the feeding choices of four adult male koalas housed at the San Diego Zoo. All subjects had a choice of nine types of Eucalyptus leaves over the eight-week study. The most preferred species was E. camuldulensis, but individual males exhibited different feeding preferences. We conclude that food selectivity among koalas is probably due to multiple factors, rather than only a consequence of secondary plant chemicals. A combination of intrinsic factors, such as developmental trajectory and reproductive state, as well as extrinsic factors, such as leaf chemical fingerprint and moisture, probably interact to shape koala foraging preferences. Koalas forage almost exclusively on Eucalyptus species, but have evolved an adaptive flexibility, enabling them to exploit various Eucalyptus species.

Effects of siblings on reproductive maturation and infanticidal behavior in cooperatively breeding Mongolian gerbils.

Mongolian gerbils living with their natal families undergo delayed reproductive maturation while helping to rear their younger siblings, whereas those housed away from their natal families may mature earlier but often respond aggressively to unfamiliar pups. We tested whether cohabitation with pups contributes to reproductive suppression and inhibition of infanticidal behavior, using young males and females housed with (1) their parents and younger siblings (pups), (2) parents without pups, (3) mixed-sex littermate groups, or (4) mixed-sex groups of unrelated peers. Maturation in males was inhibited by cohabitation with the parents, while maturation in females was further suppressed in the presence of pups. Males in all housing conditions showed little aggression towards unfamiliar pups, whereas females were usually infanticidal unless housed with pups. Aggression toward pups was especially pronounced in females that were pregnant or undergoing ovulatory cycles. Thus, cohabitation with younger siblings may intensify reproductive suppression and inhibit infanticidal behavior in female gerbils, whereas male gerbils exhibit parentally induced reproductive suppression and low rates of infanticide even in the absence of younger siblings.