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BackgroundLeukocytosis is a rise in white blood cell (WBC) count and clinical outcomes of moderate to severe leukocytosis in trauma patients have not been described. We hypothesized that trauma patients with severe leukocytosis (SL; ≥40.0 × 109 leukocytes/L) have higher rates of in-hospital complications and mortality than those with moderate leukocytosis (ML; 25.0-39 × 109 leukocytes/L).MethodsWe performed a retrospective analysis (2010-2017) on trauma patients developing ML or SL at a single Level-I trauma center. A multivariable logistic regression analysis for risk factors were performed.ResultsFrom 15,807 trauma admissions, 332 (2.1%) had ML or SL. Of these, 308 (92.8%) were ML and 24 (7.2%) were SL. Patients with ML and SL reached their peak WBC count in 1 and 10 days after admission respectively (p

The pathophysiology of giant cerebral aneurysms renders them difficult to treat. Advances in technology have attempted to address any shortcomings associated with open surgery or endovascular therapies. Since the introduction of the flow diversion technique, the endovascular approach with flow diversion has become the first-line modality chosen to treat giant aneurysms. A subset of these giant aneurysms may persistent despite any treatment modality. Perhaps the best option for these recurrent and/or persistent giant aneurysms is to employ a multimodal approach-both surgical and endovascular-rather than any single technique to provide a curative result with favourable patient outcomes. This paper provides a review of the histopathology and treatment options for giant cerebral aneurysms. Additionally, an illustrative case is presented to highlight the unique challenges of a curative solution for giant cerebral aneurysms that persist despite initial treatment.

Background:To provide a descriptive analysis of scrotal and testicular trauma in the USA. Additionally, we hypothesized that motorcycle collision would have a higher association with scrotal or testicular trauma and subsequent scrotal or testicular operation, compared to a bicycle collision. Methods:The National Trauma Data Bank (2007-2015) was queried to identify adult male patients with scrotal or testicular trauma. A multivariable logistic regression analysis was performed. Results:A total of 8,030 patients (0.23%) had scrotal/testicular injury, with 44.6% involved in blunt trauma. A penetrating mechanism occurred in 50.5% of cases, with assault by firearm (75.8%) being the most common. The median age of the patients was 31 years and the median injury severity score was 8. Most had isolated scrotal or testicular trauma (74.5%), with 48.3% requiring scrotal or testicular operation, most commonly repair of laceration (37.3%). Patients involved in a motorcycle collision had higher risk for scrotal/testicular trauma (OR=5.40, CI=4.40-6.61, p=0.0004) and subsequent scrotal/testicular surgery (OR=4.93, CI=3.82-6.36, p=0.0005), compared to bicycle collision. Conclusion:Scrotal or testicular trauma is rare but occurs most commonly after assault by firearm. Most patients only have isolated scrotal or testicular trauma, but nearly half require subsequent scrotal or testicular operation. Trauma patients presenting after a motorcycle collision have a higher association of scrotal or testicular trauma and subsequent surgery when compared to those involved in a bicycle collision.

BackgroundThe purpose of this study was to use point-of-care ultrasound (POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery (CCA). The effect of both primary and secondary smoking on CCA properties was evaluated.MethodsWe performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness (CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease.ResultsWe enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness.ConclusionOur data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confirm the utility of ultrasound findings of cardiovascular disease and stroke.

BACKGROUND:The purpose of this study was to assess the short-term efficacy of a 4-week ultrasound curriculum taught by American first-year medical students to general practitioners working in public health care clinics, or puskesmas, in Bandung, Indonesia. METHODS:We performed a prospective, observational study of Indonesian health care practitioners from public clinics in Bandung, Indonesia. These practitioners were enrolled in a 4-week ultrasound training course taught by first-year American medical students. A total of six sessions were held comprising of 38 ultrasound milestones. A pre-course and post-course written exam and practical exam was taken by each participant. RESULTS:We enrolled 41 clinicians in the course. The average pre-course exam score was 35.2% with a 2.4% pass rate, whereas the average post-course exam score was 82.0% with a 92.7% pass rate. The average practical score at the completion of the course was 83.2% (SD=0.145) with 82.9% of the class passing (score above 75.0%). CONCLUSION:Our data suggests that first-year medical students can effectively teach ultrasound to physicians in Indonesia using a 4-week intensive ultrasound training course. Future studies are needed to determine the amount of training required for proficiency and to evaluate the physicians' perceptions of the student-instructors' depth of knowledge and skill in point of care ultrasound.

Signal transducer and activator of transcription 3 (STAT3) is constitutively activated in many cancers where it acts to promote tumor progression. A STAT3-specific transcription factor decoy has been developed to suppress STAT3 downstream signaling, but a delivery strategy is needed to improve clinical translation. Ultrasound-targeted microbubble destruction (UTMD) has been shown to enhance image-guided local delivery of molecular therapeutics to a target site. The objective of this study was to deliver STAT3 decoy to squamous cell carcinoma (SCC) tumors using UTMD to disrupt STAT3 signaling and inhibit tumor growth. Studies performed demonstrated that UTMD treatment with STAT3 decoy-loaded microbubbles inhibited STAT3 signaling in SCC cells in vitro. Studies performed in vivo demonstrated that UTMD treatment with STAT3 decoy-loaded microbubbles induced significant tumor growth inhibition (31-51% reduced tumor volume vs. controls, p < 0.05) in mice bearing SCC tumors. Furthermore, expression of STAT3 downstream target genes (Bcl-xL and cyclin D1) was significantly reduced (34-39%, p < 0.05) in tumors receiving UTMD treatment with STAT3 decoy-loaded microbubbles compared to controls. In addition, the quantity of radiolabeled STAT3 decoy detected in tumors eight hours after treatment was significantly higher with UTMD treatment compared to controls (70-150%, p < 0.05). This study demonstrates that UTMD can increase delivery of a transcription factor decoy to tumors in vivo and that the decoy can inhibit STAT3 signaling and tumor growth. These results suggest that UTMD treatment holds potential for clinical use to increase the concentration of a transcription factor signaling inhibitor in the tumor.

Background: Liver cirrhosis is a chronic disease that is known as a "silent killer" and its true prevalence is difficult to describe. It is imperative to accurately characterize the prevalence of cirrhosis because of its increasing healthcare burden. Methods: In this retrospective cohort study, trends in cirrhosis prevalence were evaluated using administrative data from one of the largest national health insurance providers in the US. (2011–2018). Enrolled adult (≥18-years-old) patients with cirrhosis defined by ICD-9 and ICD-10 were included in the study. The primary outcome measured in the study was the prevalence of cirrhosis 2011–2018. Results: Among the 371,482 patients with cirrhosis, the mean age was 62.2 (±13.7) years; 53.3% had commercial insurance and 46.4% had Medicare Advantage. The most frequent cirrhosis etiologies were alcohol-related (26.0%), NASH (20.9%) and HCV (20.0%). Mean time of follow-up was 725 (±732.3) days. The observed cirrhosis prevalence was 0.71% in 2018, a 2-fold increase from 2012 (0.34%). The highest prevalence observed was among patients with Medicare Advantage insurance (1.67%) in 2018. Prevalence increased in each US. state, with Southern states having the most rapid rise (2.3-fold). The most significant increases were observed in patients with NASH (3.9-fold) and alcohol-related (2-fold) cirrhosis. Conclusion: Between 2012–2018, the prevalence of liver cirrhosis doubled among insured patients. Alcohol-related and NASH cirrhosis were the most significant contributors to this increase. Patients living in the South, and those insured by Medicare Advantage also have disproportionately higher prevalence of cirrhosis. Public health interventions are important to mitigate this concerning trajectory of strain to the health system. [ABSTRACT FROM AUTHOR]

Ground-level falls (GLFs) are the number one cause of injury and death in the older adult population. We compared injury profiles of GLFs at SNFs to those at homes, hypothesizing that GLFs at SNFs would lead to higher risks for serious (AIS ≥ 3) traumatic brain injury (TBI) and lower extremity (LE) injuries compared to GLFs at home. The 2015-2016 Trauma Quality Improvement Program was used to compare patients sustaining GLFs at home and SNFs. From 15,873 patients sustaining GLFs, 14,306 (90.1%) occurred at home while 1,567 (9.9%) at SNFs. More patients with GLFs at SNFs were female, older, and had greater incidence of congestive heart failure, end-stage renal disease, and dementia (p < 0.001) compared to those at home. Although, GLF SNF patients had lower injury severity scores (9 vs. 10, p < 0.001) and incidence for TBI (28.0% vs 33.4%, p < 0.001), they had a higher rate of femur fractures (55.1% vs. 38.9%, p < 0.001). After controlling for female, end stage renal disease, smoking, dementia, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, and stroke, patients falling at SNFs had an increased risk of sustaining serious LE injury AIS (OR 1.64, p < 0.001), but not serious TBI AIS (OR 0.89, p = 0.073). In conclusion, compared to GLFs at home, those at SNFs have a higher risk for serious LE injury, with femur fractures being the most common. However, GLFs at SNFs and homes had no significant difference in risk for serious TBI. Future studies are warranted to evaluate preventative measures to reduce LE injuries at SNFs. [ABSTRACT FROM AUTHOR]

Background: The practice patterns of a hybrid open cerebrovascular/neuroendovascular (CVNV) neurosurgeon in early academic practice is unknown., Methods: We performed a multi-institutional retrospective cohort study of patients with cerebral aneurysms that were treated within the first 24 months of the neurosurgeon's practice., Results: A total of 533 aneurysms were treated by the three senior authors within the first 24 months of their academic practice. Of these aneurysms, 172 were treated with microsurgical clipping, 191 with coiling, and 170 with flow diversion. Treatment in the setting of acute subarachnoid hemorrhage (SAH) occurred in 23% (122/533) of the aneurysms. Majority of the clipped aneurysms (70%, 121/172) were anterior cerebral artery (ACA), anterior communicating artery (ACOM), or middle cerebral artery (MCA) in location. In comparison, only 23% (82/361) of aneurysms treated with coiling or flow diversion therapy were ACA, ACOM, or MCA in location ( P < 0.05). Additionally, majority of the flow diverted aneurysm (65%, 111/170) were cavernous or ophthalmic/paraophthalmic in location. During the second year of practice, there appeared to be a trend towards more aneurysms treated with neuroendovascular techniques (22% increase), particularly in flow diversion., Conclusion: Although the CVNV neurosurgeon treats cerebral aneurysms more commonly with neuroendovascular techniques, a third of the cerebral aneurysms are still selected for microsurgical clipping. Aneurysms located along the ACA/ACOM or MCA are the most frequent aneurysms reserved for microsurgical clipping. The CVNV neurosurgeon must be prepared to manage a high percentage of ACA/ACOM or MCA aneurysms microsurgically., Competing Interests: ALC is a proctor for the Woven Endobridge (WEB) device (Sequent Medical, Aliso Viejo, CA), a proctor for the Surpass device (Stryker Neurovascular, Fremont, CA) and a consultant for Stryker Neurovascular, a proctor for the Pipeline Embolization Device (Medtronic Neurovascular, Irvine, CA) and a consultant for Medtronic, and a proctor for the FRED device (MicroVention, Tustin, CA) and consultant for MicroVention. GPC is a consultant for Medtronic, MicroVention and participates in clinical trials for Medtronic and Stryker. LML is a proctor for the Pipeline Embolization Device (Medtronic Neurovascular, Irvine, CA), a consultant for MicroVention and participates in clinical trial for Stryker. The other authors have no conflict of interest. No author received financial support in conjunction with the generation of this submission.