Prior differences in previous trauma exposure primarily drive the observed racial/ethnic differences in posttrauma depression and anxiety following a recent trauma

BACKGROUND

Racial and ethnic groups in the USA differ in the prevalence of posttraumatic stress disorder (PTSD). Recent research however has not observed consistent racial/ethnic differences in posttraumatic stress in the early aftermath of trauma, suggesting that such differences in chronic PTSD rates may be related to differences in recovery over time.

METHODS

As part of the multisite, longitudinal AURORA study, we investigated racial/ethnic differences in PTSD and related outcomes within 3 months after trauma. Participants (n = 930) were recruited from emergency departments across the USA and provided periodic (2 weeks, 8 weeks, and 3 months after trauma) self-report assessments of PTSD, depression, dissociation, anxiety, and resilience. Linear models were completed to investigate racial/ethnic differences in posttraumatic dysfunction with subsequent follow-up models assessing potential effects of prior life stressors.

RESULTS

Racial/ethnic groups did not differ in symptoms over time; however, Black participants showed reduced posttraumatic depression and anxiety symptoms overall compared to Hispanic participants and White participants. Racial/ethnic differences were not attenuated after accounting for differences in sociodemographic factors. However, racial/ethnic differences in depression and anxiety were no longer significant after accounting for greater prior trauma exposure and childhood emotional abuse in White participants.

CONCLUSIONS

The present findings suggest prior differences in previous trauma exposure partially mediate the observed racial/ethnic differences in posttraumatic depression and anxiety symptoms following a recent trauma. Our findings further demonstrate that racial/ethnic groups show similar rates of symptom recovery over time. Future work utilizing longer time-scale data is needed to elucidate potential racial/ethnic differences in long-term symptom trajectories.

Penetrating torso injuries in older adults: increased mortality likely due to "failure to rescue"

PURPOSE

Approximately 8 % of injuries in the elderly are from penetrating mechanisms. The natural history of potentially survivable penetrating torso wounds in the elderly is not well studied. Older adults with penetrating injuries to the torso may have worse outcomes than matched, younger patients due to a failure to rescue after complications.

METHODS

A retrospective chart review of all patients ≥55 (older) with a penetrating injury (GSW or SW) to the torso over 20 years was performed. All patients with a maximum AIS chest or abdomen >1 and <6 were included. A matched cohort (mechanism, AIS chest and abdomen, ISS and sex) of patients between the ages of 20-40 years (young) was created (3 young, 1 older). Differences in hemodynamics, complications, length of stay and mortality were analyzed.

RESULTS

105 older met inclusion criteria were compared to 315 young patients. Hemodynamic status was similar between the groups. Older patients required ICU care more often than younger patients, p < 0.05. Older patients required longer ICU stays, p < 0.001 and longer hospitalizations, p = 0.0012. More older patients (41.0 %) suffered post-injury complications compared to the young (26.4 %), p = 0.005. Older patients who suffered a complication had a higher mortality (30.2 %) than the young after a complication (10.8 %), p = 0.007.

CONCLUSIONS

While uncommon, penetrating injuries to older adults are associated with higher rates of post-injury complications and increased mortality. This may represent a "failure to rescue" and represent an opportunity for improved post-injury care in older adults who suffer potentially survivable penetrating torso injuries.

Effect of mannitol and hypertonic saline on cerebral oxygenation in patients with severe traumatic brain injury and refractory intracranial hypertension

BACKGROUND

The impact of osmotic therapies on brain oxygen has not been extensively studied in humans. We examined the effects on brain tissue oxygen tension (PbtO(2)) of mannitol and hypertonic saline (HTS) in patients with severe traumatic brain injury (TBI) and refractory intracranial hypertension.

METHODS

12 consecutive patients with severe TBI who underwent intracranial pressure (ICP) and PbtO(2) monitoring were studied. Patients were treated with mannitol (25%, 0.75 g/kg) for episodes of elevated ICP (>20 mm Hg) or HTS (7.5%, 250 ml) if ICP was not controlled with mannitol. PbtO(2), ICP, mean arterial pressure, cerebral perfusion pressure (CPP), central venous pressure and cardiac output were monitored continuously.

RESULTS

42 episodes of intracranial hypertension, treated with mannitol (n = 28 boluses) or HTS (n = 14 boluses), were analysed. HTS treatment was associated with an increase in PbtO(2) (from baseline 28.3 (13.8) mm Hg to 34.9 (18.2) mm Hg at 30 min, 37.0 (17.6) mm Hg at 60 min and 41.4 (17.7) mm Hg at 120 min; all p<0.01) while mannitol did not affect PbtO(2) (baseline 30.4 (11.4) vs 28.7 (13.5) vs 28.4 (10.6) vs 27.5 (9.9) mm Hg; all p>0.1). Compared with mannitol, HTS was associated with lower ICP and higher CPP and cardiac output.

CONCLUSIONS

In patients with severe TBI and elevated ICP refractory to previous mannitol treatment, 7.5% hypertonic saline administered as second tier therapy is associated with a significant increase in brain oxygenation, and improved cerebral and systemic haemodynamics.

Hemorrhagic shock resuscitation with a low molecular weight starch reduces neutrophil-endothelial interactions and vessel leakage in vivo

BACKGROUND

The polymorphonuclear neutrophil (PMN) has been implicated in the pathogenesis of endothelial cell (EC) damage and organ injury following hemorrhagic shock. Pentastarch (PTS), a low substituted medium molecular weight (MW) colloid, improves hemodynamics in hypovolemic shock and cardiac surgery. No data exist comparing the immunomodulation of PTS and Ringer's lactate (RL) on the activation of PMN in hemorrhagic shock in vivo.

METHODS

Using an in vivo murine hemorrhagic shock model (blood withdrawal to maintain 50 mmHg x 45 min), circulating PMN were observed every 15 minutes using intravital microscopy on cremaster muscle. EC-PMN interactions (videorecorded and subsequently analyzed blindly), vessel leakage (live epifluorescence after injection of 50 mg/kg fluorescent albumin) and PMN expression of L-selectin (immunofluorescent monoclonal antibodies and flow cytometry) were evaluated in three resuscitation groups: PTS (7.14 mL/kg 10% pentastarch/0.9% NaCl + shed blood, n = 13), RL (RL [2 x shed blood volume] + shed blood, n = 13) and SHAM (0 hemorrhage, 0 resuscitation, n = 9). Significance was evaluated by ANOVA with Bonferroni correction.

RESULTS

PMN rolling was significantly diminished in PTS and SHAM as compared to RL animals at all time points. Similar differences were found in PMN adherence to EC at most time points onwards from 15 minutes following resuscitation. In vivo vessel permeability was lowest in SHAM and PTS animals (mean 0.274 +/- 0.07 and 0.356 +/- 0.15, respectively, p > 0.05) and highest in RL animals (0.667 +/- 0.09, p < 0.001 vs PTS or SHAM). PMN L-selectin expression tended to be higher in the RL group than either SHAM and PTS groups. There were no flow-mechanics differences between groups (vessel diameter, mean red cell velocity, shear stress, shear rate).

CONCLUSIONS

10% pentastarch reduces RL-associated EC-PMN interactions and vessel leakage following hemorrhagic shock. These results support the use of low MW starches to resuscitate hemorrhagic shock, potentially reducing PMN-mediated tissue injury.

[Adenocarcinoma of the cardia: results of distal esophagectomy and total enlarged gastrectomy using left thoracophrenolaparotomy]

An analysis was made of the results obtained in terms of postoperative complications, mortality and the 5-year survival rate in a series of 23 patients diagnosed as adenocarcinoma of the cardias who underwent total gastrectomy with distal esophagectomy via left thoracophrenolaparotomy, with esophagojejunostomy on a Roux-en-Y loop. We consider the results as favorable and conclude that this procedure has an application in adequately selected patients.