No abstract

BACKGROUND:Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS:An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014)(2015)(2016)(2017)(2018)(2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS:The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, −9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION:Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.

Inpatient anticoagulation care and outcomes were significantly improved by a pharmacist-managed anticoagulation service. The time to therapeutic INR was achieved appropriately and efficiently without compromising patient's safety.

Herpes simplex virus 1 (HSV-1) causes herpes stromal keratitis (HSK), a sight-threatening disease of the cornea for which no vaccine exists. A replication-defective, HSV-1 prototype vaccine bearing deletions in the genes encoding ICP8 and the virion host shutoff (vhs) protein reduces HSV-1 replication and disease in a mouse model of HSK. Here we demonstrate that combining deletion of ICP8 and vhs with virus-based expression of B7 costimulation molecules created a vaccine strain that enhanced T cell responses to HSV-1 compared with the ICP8−vhs− parental strain, and reduced the incidence of keratitis and acute infection of the nervous system after corneal challenge. Post-challenge T cell infiltration of the trigeminal ganglia and antigen-specific recall responses in local lymph nodes correlated with protection. Thus, B7 costimulation molecules expressed from the genome of a replication-defective, ICP8−vhs− virus enhance vaccine efficacy by further reducing HSK.

Burns resulting from child maltreatment are tragic causes of significant morbidity and mortality, most commonly affecting children under 3 years of age. More than one third of nonaccidental burns occur in single-parent homes or have parents with history of mental illness, substance abuse, incarceration, or Department of Children and Family Services (DCFS) involvement. The authors sought to profile pediatric burn injuries associated with DCFS investigations. They performed a retrospective chart review of pediatric burn patients, admitted between January 1, 2011 and December 31, 2014. They analyzed patient and household demographics, family composition, employment, zip code, insurance, etiology, percent TBSA burned, surgical interventions, length of hospital stay, disposition, prior DCFS involvement, and DCFS investigation outcomes. There were 126 DCFS investigations involving patients with average age of 2.6 ± 3.2 years and 5 ± 5.6% TBSA burn. Scalds were the most prevalent etiology at 76%. Parents involved with DCFS were 5 years younger than those without DCFS. Factors associated with increased odds of DCFS investigation were non-Caucasian race, single-parent homes, unemployed primary caretaker, Medicaid utilization, and prior DCFS involvement. A majority of DCFS investigations were initiated at outside hospitals, and they found one third to be substantiated cases of abuse. Non-Caucasian children, under 3 years of age, from lower socioeconomic or single-parent homes, are associated with higher rates of DCFS investigations. The majority of DCFS investigations were unsubstantiated and there were no significant epidemiological differences between unsubstantiated and substantiated cases of abuse. Improved understanding of sociodemographic risk factors for children at higher risk for negligence or intentional abuse warrants focused public health programs on regional prevention and education.