Critical care medicine at Walter Reed Army Medical Center in support of the global war on terrorism

Cell-free Determination of Binary Complexes That Comprise Extended Protein-Protein Interaction Networks of Yersinia pestis

Binary protein interactions form the basic building blocks of molecular networks and dynamic assemblies that control all cellular functions of bacteria. Although these protein interactions are a potential source of targets for the development of new antibiotics, few high-confidence data sets are available for the large proteomes of most pathogenic bacteria. We used a library of recombinant proteins from the plague bacterium Yersinia pestis to probe planar microarrays of immobilized proteins that represented ∼85% (3552 proteins) of the bacterial proteome, resulting in >77,000 experimentally determined binary interactions. Moderate (K_D ∼μm) to high-affinity (K_D ∼nm) interactions were characterized for >1600 binary complexes by surface plasmon resonance imaging of microarrayed proteins. Core binary interactions that were in common with other gram-negative bacteria were identified from the results of both microarray methods. Clustering of proteins within the interaction network by function revealed statistically enriched complexes and pathways involved in replication, biosynthesis, virulence, metabolism, and other diverse biological processes. The interaction pathways included many proteins with no previously known function. Further, a large assembly of proteins linked to transcription and translation were contained within highly interconnected subregions of the network. The two-tiered microarray approach used here is an innovative method for detecting binary interactions, and the resulting data will serve as a critical resource for the analysis of protein interaction networks that function within an important human pathogen.

Evaluation of military trauma system practices related to complications after injury

BACKGROUND

The Joint Theater Trauma System (JTTS) was developed with the vision that every soldier, marine, sailor, and airman injured on the battlefield would have the optimal chance for survival and maximum potential for functional recovery. In this analysis, we hypothesized that injury and complication after injury surveillance information diffusion through the JTTS, via the dissemination of clinical practice guidelines and process improvements, would be associated with improved combat casualty clinical outcomes.

METHODS

The current analysis was designed to profile different aspects of trauma system performance improvement, including monitoring of frequent posttraumatic complications, the assessment of an emerging complication trend, and measurement of the impact of the system interventions to identify potential practices for future performance improvement. Data captured from the Joint Theater Trauma Registry on patients admitted to military medical treatment facilities as a result of wounds incurred in Iraq and Afghanistan from 2003 to 2010 were retrospectively analyzed to determine the potential impact of complication surveillance and process improvement initiatives on clinical practice.

RESULTS

Developed metrics demonstrated that the surveillance capacity and evidence-based quality improvement initiatives disseminated through the JTTS were associated with improved identification and mitigation of complications following battlefield injury.

CONCLUSION

The Joint Trauma System enables evidence-based practice across the continuum of military trauma care. Concurrent data collection and performance improvement activities at the local and system level facilitate timely clinical intervention on identified trauma complications and the subsequent measurement of the effectiveness of those interventions.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

A model to advance nursing science in trauma practice and injury outcomes research

AIMS

This discussion paper reports development of a model to advance nursing science and practice in trauma care based on an analysis of the literature and expert opinion.

BACKGROUND

The continuum of clinical care provided to trauma patients extends from the time of injury through to long-term recovery and final outcomes. Nurses bring a unique expertise to meet the complex physical and psychosocial needs of trauma patients and their families to influence outcomes across this entire continuum.

DATA SOURCES

Literature was obtained by searching CINAHL, PubMed and OvidMedline databases for 1990-2010. Search terms included trauma, nursing, scope of practice and role, with results restricted to those published in English. Manual searches of relevant journals and websites were undertaken.

DISCUSSION

Core concepts in this trauma outcomes model include environment, person/family, structured care settings, long-term outcomes and nursing interventions. The relationships between each of these concepts extend across all phases of care. Intermediate outcomes are achieved in each phase of care and influence and have congruence with long-term outcomes. Implications for policy and practice.  This model is intended to provide a framework to assist trauma nurses and researchers to consider the injured person in the context of the social, economic, cultural and physical environment from which they come and the long-term goals that each person has during recovery. The entire model requires testing in research and assessment of its practical contribution to practice.

CONCLUSION

Planning and integrating care across the trauma continuum and recognition of the role of the injured person's background, family and resources will lead to improved long-term outcomes.

Advancing critical care: joint combat casualty research team and joint theater trauma system

Despite the severity and complexity of injuries, survival rates among combat casualties are equal to or better than those from civilian trauma. This article summarizes the evidence regarding innovations from the battlefield that contribute to these extraordinary survival rates, including preventing hemorrhage with the use of tourniquets and hemostatic dressings, damage control resuscitation, and the rapid evacuation of casualties via MEDEVAC and the US Air Force Critical Care Air Transport Teams. Care in the air for critically injured casualties with pulmonary injuries and traumatic brain injury is discussed to demonstrate the unique considerations required to ensure safe en route care. Innovations being studied to decrease sequelae associated with complex orthopedic and extremity trauma are also presented. The role and contributions of the Joint Combat Casualty Research Team and the Joint Theater Trauma System are also discussed.

Preparedness lessons from modern disasters and wars

Disasters come in all shapes and forms, and in varying magnitudes and intensities. Nevertheless, they offer many of the same lessons for critical care practitioners and responders. Among these, the most important is that well thought out risk assessment and focused planning are vital. Such assessment and planning require proper training for providers to recognize and treat injury from disaster, while maintaining safety for themselves and others. This article discusses risk assessment and planning in the context of disasters. The article also elaborates on the progress toward the creation of portable, credible, sustainable, and sophisticated critical care outside the walls of an intensive care unit. Finally, the article summarizes yields from military-civilian collaboration in disaster planning and response.