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All-terrain vehicle (ATV)-related injuries have increased. The purpose of this study was to determine if the increase in injuries correlates with the expiration of government mandates. ATV-injured patients admitted to a level I trauma center were reviewed over the years 1985-1999 and 2000-2005. Several demographic variables and injuries sustained were analyzed. There were a total of 433 injuries, which increased from 164 between 1985 and 1999, to 269 between 2000 and 2005. By comparing the time periods we observed a decrease in closed-head injury (53.6% vs 27.5%; P < .001), spinal cord injury (11.6% vs 5.2%; P < .05), and soft-tissue injury (62.8% vs 45.3%; P < .01), but an increase in long-bone fractures (18.9% vs 33.0%; P < .05). No differences were observed in other injuries. The number of patients sustaining ATV-related injuries has increased and correlates with the expiration of government mandates. Even though ATVs remain dangerous, injury prevention strategies such as helmet laws may be having a positive impact.

The Surgical Care Improvement Project (SCIP) was designed to reduce perioperative complications. We describe our institutional experience in 6 major areas: surgical site infection, venous thromboembolism prevention, use of perioperative β-blockade, serum glucose level greater than 200 mg/dL, normothermia, and the use of electric razors for hair removal. This was a retrospective review of surgical cases. Evidence-based training and standardization of system and process were undertaken. Compliance with SCIP guidelines was determined. Overall SCIP compliance improved from 80% to 94% over a 2-year period. Standardized antibiotic dosing times improved compliance to more than 90%. Appropriate preoperative antibiotic choice improved to 100%. Cessation of antibiotics postoperatively within 24 hours remains a difficult task. Venous thromboembolism prophylaxis has been difficult to achieve because of postoperative bleeding concerns. Administration of β-blockers has remained one of the most difficult problems to correct because of the multiplicity of avenues by which a patient may arrive to the operating suite. Achievement of the SCIP goals is a formidable, but achievable, process requiring individual, cultural, systems, and institutional changes to achieve success.

Background The natural response to injury is dynamic and normally consists of complex temporal and spatial cellular changes in gene expression, which, when acting in synchrony, result in patent tissue repair and, in some instances, regeneration. However, current therapeutic regiments are static and most rely on matrices, gels and engineered skin tissue. Accordingly, there is a need to design next-generation grafting materials to enable biotherapeutic spatiotemporal targeting from clinically approved matrices. To this end, rather then focus on developing completely new grafting materials, we investigated whether phage display could be deployed onto clinically approved synthetic grafts to identify peptide motifs capable of linking pharmaceutical drugs with differential affinities and eventually, control drug delivery from matrices over both space and time. Methods To test this hypothesis, we biopanned combinatorial peptide libraries onto different formulations of a wound-healing matrix (Integra ® ) and eluted the bound peptides with 1) high salt, 2) collagen and glycosaminoglycan or 3) low pH. After three to six rounds of biopanning, phage recovery and phage amplification of the bound particles, any phage that had acquired a capacity to bind the matrix was sequenced. Results In this first report, we identify distinct classes of matrix-binding peptides which elute differently from the screened matrix and demonstrate that they can be applied in a spatially relevant manner. Conclusions We suggest that further applications of these combinatorial techniques to wound-healing matrices may offer a new way to improve the performance of clinically approved matrices so as to introduce temporal and spatial control over drug delivery.

Introduction: Under the trimodal distribution, most trauma deaths occur within the first hour. Determination of cause of death without autopsy review is inaccurate. The goal of this study is to determine cause of death, in hourly intervals, in trauma patients who died in the first 24 h, as determined by autopsy. Materials and Methods: Trauma deaths that occurred within 24 h at a Level I trauma center were reviewed over a six-year period ending December 2005. Timing of death was separated into 0–1, 1–3, 3–6, 6–12 and 12–24 h intervals. Cause of death was determined by clinical course and AIS scores, and was confirmed by autopsy results. Results: Overall, 9,388 trauma patients were admitted, of which 185 deaths occurred within 24 h, with 167 available autopsies. Blunt and penetrating were the injury mechanisms in 122 (73%) and 45 (27%) patients, respectively. Of 167 deaths, 73 (43.7%) occurred within the first hour. Brain injury, when compared to other body areas, was the most likely cause of death in all hourly intervals, but hemorrhage was as or more important than brain injury as the cause of death during the first 3 h and up to 6 h. No deaths were attributable to hemorrhage after 12 h. Conclusions: The temporal distribution of the cause of death varies in the first 24 h after admission. Hemorrhage should not be overlooked as the cause of death, even after survival beyond 1 h. Understanding the temporal relationship of causes of early death can aid in the targeting of management and surgical training to optimize patient outcome.

Background: Traumatic abdominal wall hernia is seldom seen. Rarer still is delayed presentation of a traumatic lumbar hernia. Expedient diagnosis and early surgical intervention are the hallmarks of management. Case Study: A 37-year-old restrained male driver was involved in a high-speed rollover motor vehicle accident. Initial trauma evaluation, including abdominal ultrasound, was negative. 2 weeks later the patient presented to our institution with progressively worsening right flank pain. An abrasion (seat belt sign) was noticed above the iliac crest. Abdominal CT scan revealed a right lumbar hernia at the iliac crest. Intraoperatively, a 7-cm hernia defect was identified and repaired. The patient had an uneventful recovery and remains symptom-free at 6-month follow-up. Discussion: Traumatic abdominal wall hernia secondary to blunt trauma is a relatively uncommon injury. The fascia defect is usually located at anatomic weak points in the lower abdominal wall lateral to the rectus sheath or in the inguinal region. Up to two thirds of patients with large traumatic abdominal wall hernias have associated intraabdominal injuries. This is the rare case of a traumatic hernia in the inferior lumbar triangle. It emphasizes the need for a high index of suspicion for this injury and also underscores the importance of choosing appropriate adjunctive modalities to facilitate diagnosis. [PUBLICATION ABSTRACT]

Although craving states are important to both cocaine dependence (CD) and pathological gambling (PG), few studies have directly investigated neurobiological similarities and differences in craving between these disorders. We used functional magnetic resonance imaging (fMRI) to assess brain activity in 103 participants (30 CD, 28 PG, and 45 controls) while they watched videos depicting cocaine, gambling, and sad scenarios to investigate the neural correlates of craving. We observed a three-way urge type × video type × diagnostic group interaction in self-reported craving, with CD participants reporting strong cocaine cravings to cocaine videos, and PG participants reporting strong gambling urges to gambling videos. Neuroimaging data revealed a diagnostic group × video interaction in anterior cingulate cortex/ventromedial prefrontal cortex (mPFC), activating predominantly to cocaine videos in CD participants, and a more dorsal mPFC region that was most strongly activated for cocaine videos in CD participants, gambling videos in PG participants, and sad videos in control participants. Gender × diagnosis × video interactions identified dorsal mPFC and a region in posterior insula/caudate in which female but not male PG participants showed increased responses to gambling videos. Findings illustrate both similarities and differences in the neural correlates of drug cravings and gambling urges in CD and PG. Future studies should investigate diagnostic- and gender-specific therapies targeting the neural systems implicated in craving/urge states in addictions.

This study used functional magnetic resonance imaging (fMRI) to examine the association between brain activation during exposure to cocaine-related cues and relapse to drug use in cocaine-dependent (CD) patients. We imaged 17 CD subjects during a 2-week in-patient stay. The subjects then entered a 10-week outpatient placebo-controlled, double-blind randomized clinical trial where urine toxicologies were assessed three times weekly to calculate the treatment effectiveness score (TES). Worse TES correlated with BOLD activation in the left precentral, superior temporal, and posterior cingulate cortices (PCC), and right middle temporal and lingual cortices (R>0.65; P<0.005). The left PCC activation also distinguished eight nonrelapsers (TES above mean and completed treatment) from nine relapsers. Cocaine-free urines were significantly greater in the nonrelapsers (92%) than in the relapsers (66%), who also remained in treatment for an average of only 3.2 weeks. Self-reports of craving during fMRI did not differ between nonrelapsers and relapsers and did not correlate with TES. Relapse to cocaine abuse was associated with increased activation in the sensory association cortex, the motor cortex, and PCC while viewing images of cocaine-related cues. These results suggest that relapse to cocaine abuse is associated with increased brain activation to cocaine cues in sensory, motor, and cognitive-emotional processing areas. This physiological activation was a better predictor of relapse than subjective reports of craving, and may be a useful target for treatment development.

Cocaine dependence is associated with white matter impairments that may compromise cognitive function and hence drug users’ abilities to engage in and benefit from treatment. The main aim of this study was to assess whether white matter integrity correlates with treatment outcome measures in cocaine dependence. Diffusion tensor imaging (DTI) was used to assess the white matter (WM) of 16 treatment-seeking cocaine-dependent patients before 8 weeks of therapy. The measures for treatment outcome were longest self-reported duration of continuous cocaine abstinence, percent of urine screens negative for cocaine, and duration (weeks) of treatment retention. Correlations between treatment outcome measures and DTI parameters (fractional anisotropy (FA), longitudinal eigenvalue ( λ 1 ), perpendicular eigenvalue ( λ T ), and mean diffusivity (MD)) were analyzed. Longest self-reported abstinence from cocaine and percent of cocaine-negative urine samples during treatment positively correlated with FA values and negatively correlated with λ 1 , λ T , and MD values across extensive brain regions including the corpus callosum, frontal, parietal, temporal, and occipital lobes, and cerebellum. The findings of an association between better WM integrity at treatment onset and longer abstinence suggest that strategies for improving WM integrity warrant consideration in developing new interventions for cocaine dependence.