BACKGROUND/OBJECTIVES The Emergency Department (ED) is an important venue for initial sepsis recognition and care. We sought to determine contemporary estimates of the epidemiology of United States (US) ED visits for sepsis. DESIGN Analysis of data from the National Hospital Ambulatory Medical Care Survey. SETTING US Emergency Departments visits, 2009–2011. PARTICIPANTS Adult (age≥18 years) ED sepsis patients. We defined serious infection as an ED diagnosis of a serious infection or a triage temperature >38 °C or <36 °C. We defined three ED sepsis classifications: 1) [Original ED Sepsis] serious infection + ED diagnosis of organ dysfunction, endotracheal intubation, or systolic blood pressure ≤90 mmHg, or explicit sepsis ED diagnoses; 2) [qSOFA ED Sepsis] serious infection + presence of ≥2 “quick” Sepsis-related Organ Failure Assessment (qSOFA) criteria (Glasgow Coma Scale ≤14, respiratory rate ≥22 breaths/min, or systolic blood pressure ≤100 mmHg); and 3) [Revised ED Sepsis] Original or qSOFA ED Sepsis. INTERVENTIONS None MEASUREMENTS AND RESULTS We used survey design and weighting variables to produce national estimates of annual adult ED visits using updated sepsis classifications. Over 2009–2011, there were 103,257,516 annual adult ED visits. The estimated number of ED sepsis visits were: 1) Original ED Sepsis 665,319 (0.64%; 95% CI 0.57–0.73); 2) qSOFA ED Sepsis 318,832 (0.31%; CI 0.26–0.37); and 3) Revised ED Sepsis 847,868 (0.82%; 95% CI 0.74–0.91). CONCLUSIONS Sepsis continues to present a major burden to US Emergency Departments, affecting up to nearly 850,000 ED visits annually. Updated sepsis classifications may impact national estimates of ED sepsis epidemiology.

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OBJECTIVE: The transfusion of older packed red blood cells (PRBC) may be harmful in critically ill patients. We sought to determine the association between PRBC age and mortality among trauma patients requiring massive PRBC transfusion. Competing interests: JRH receives patent royalties from the United States Army and the University of Maryland for improved red blood cell storage solutions. The rest of the authors declare that they have no competing interests.

Our purposes were to 1) develop an animal model where intravenously (iv) administered d-glucose consistently inhibited antral motility, and 2) use this model to assess whether iv glucose acts to inhibit motility from a peripheral or a central nervous system site and to elucidate the factor(s) that determine(s) whether stomach motor function is sensitive to changes in blood glucose. Rats were anesthetized with alpha-chloralose-urethane, and antral motility was measured by a strain-gauge force transducer sutured to the antrum. In some cases, antral motility and gastric tone were measured by monitoring intragastric balloon pressure. Increases in blood glucose were produced by continuous iv infusion of 25% d-glucose at 2 ml/h. Inhibition of antral motility and gastric tone was observed when gastric contractions were induced by hypoglycemia (subcutaneously administered insulin, 2.5 IU/animal). In contrast, no inhibition of gastric motor function was observed when glucose infusion was tested on gastric contractions that were 1) spontaneously occurring, 2) evoked by iv administered bethanechol in vagotomized animals, and 3) evoked by the TRH analog RX77368, microinjected into the dorsal motor nucleus of the vagus. Using the model of insulin-induced hypoglycemia to increase gastric motor activity, we found that neither sectioning the hepatic branch of the vagus (n = 5), nor treating animals with capsaicin to destroy sensory vagal afferent nerves (n = 5) affected the ability of iv d-glucose to inhibit gastric motor function. Our results indicate that an important factor determining whether stomach motor function will be sensitive to changes in blood glucose is the method used to stimulate gastric contractions, and that the primary site of the inhibitory action of iv glucose on gastric motility is the central nervous system rather than the periphery.

The purpose of this study was to activate a vagovagal reflex by using esophageal distension and nicotine and test whether hindbrain nitric oxide and norepinephrine are involved in this reflex function. We used double-labeling immunocytochemical methods to determine whether esophageal distension (and nicotine) activates c-Fos expression in nitrergic and noradrenergic neurons in the nucleus tractus solitarii (NTS). We also studied c-Fos expression in the dorsal motor nucleus of the vagus (DMV) neurons projecting to the periphery. Esophageal distension caused 19.7 +/- 2.3% of the noradrenergic NTS neurons located 0.60 mm rostral to the calamus scriptorius (CS) to be activated but had little effect on c-Fos in DMV neurons. Intravenous administration of nicotine caused 19.7 +/- 4.2% of the noradrenergic NTS neurons 0.90 mm rostral to CS to be activated and, as reported previously, had no effect on c-Fos expression in DMV neurons. To determine whether norepinephrine and nitric oxide were central mediators of esophageal distension-induced decrease in intragastric pressure (balloon recording), N(G)-nitro-L-arginine methyl ester microinjected into the NTS (n = 5), but not into the DMV, blocked the vagovagal reflex. Conversely, alpha2-adrenergic blockers microinjected into the DMV (n = 7), but not into the NTS, blocked the vagovagal reflex. These data, in combination with our earlier pharmacological microinjection data with nicotine, indicate that both esophageal distension and nicotine produce nitric oxide in the NTS, which then activates noradrenergic neurons that terminate on and inhibit DMV neurons.

Hemorrhage is a preventable cause of death among trauma patients, and management often includes transfusion, either whole blood or a combination of blood components (packed red blood cells, platelets, fresh frozen plasma). We used the 2009 National Trauma Data Bank to evaluate the relationship between transfusion type and mortality in adult major trauma patients (n = 1745). Logistic regression analysis identified three independent predictors of mortality: Injury Severity Score, emergency transfer time, and type of blood transfusion, whole blood or components. Transfusion of whole blood was associated with reduced mortality; thus, may provide superior survival outcomes in this population.

This family illustrates the importance of awareness of the lack of specificity of DNA cross-linking agent tests for FA, particularly in situations where the clinical features are atypical. In addition, one of the cases represents the first use of bone marrow transplantation for NBS that we are aware of; this treatment may have a future role for other patients with the syndrome.