Up to 80% of injuries sustained by U.S. soldiers in Operation Enduring Freedom and Operation Iraqi Freedom were the result of blast exposure from improvised explosive devices. Some soldiers experience multiple blasts while on duty, and it has been suggested that symptoms of repetitive blast are similar to those that follow multiple non-blast concussions, such as sport-related concussion. Despite the interest in the effects of repetitive blast exposure, it remains unknown whether an initial blast renders the brain more vulnerable to subsequent exposure, resulting in a synergistic injury response. To investigate the effect of multiple primary blasts on the brain, organotypic hippocampal slice cultures were exposed to single or repetitive (two or three total) primary blasts of varying intensities. Long-term potentiation was significantly reduced following two Level 2 (92.7 kPa, 1.4 msec, 38.5 kPa·msec) blasts delivered 24 h apart without altering basal evoked response. This deficit persisted when the interval between injuries was increased to 72 h but not when the interval was extended to 144 h. The repeated blast exposure with a 24 h interval increased microglia staining and activation significantly but did not significantly increase cell death or damage axons, dendrites, or principal cell layers. Lack of overt structural damage and change in basal stimulated neuron response suggest that injury from repetitive primary blast exposure may specifically affect long-term potentiation. Our studies suggest repetitive primary blasts can exacerbate injury dependent on the injury severity and interval between exposures.

The field of minimally invasive cardiac surgery has undergone rapid transformation over recent years. In this review, we provide a summary of the most current evidence supporting the use of minimally invasive aortic and mitral valve replacement techniques, as well as transcatheter approaches for aortic and mitral valve disease. As an adjunct, the use of robotically assisted coronary bypass surgery and hybrid coronary revascularization procedures is discussed. In order to obtain optimal patient outcomes, a collaborative, heart-team approach between cardiac surgeons and interventional cardiologists is necessary.

Introduction Massive transfusion activations (MTAs) are commonly used in the care of the trauma patient. However, MTA for trauma patients constitutes only a small fraction of MpTA at our institution. The aim of this study was to characterize MTA in non-trauma patients to better understand how this strategy is employed at a larger tertiary hospital. Methods All MTA involving non-trauma patients from January 2017 to April 2019 were reviewed. Patients with unclear indications for MTA were excluded. Data collected included patient demographics, reason for MTA, transfusion ratios, use of adjunctive antifibrinolytics, use of viscoelastic testing, and vasopressor administration at the time of MTA. Results There were 328 patients and 353 MTA identified over the study period. The mean age was 52.0 years and 40.9% were male. Patients were most commonly under the care of a medical service (55.2%), while 25.3% were obstetric patients and 19.5% were surgical patients. Compliance with 1:1:1 transfusion ratios was low. Concomitant vasopressor use was high (70.8%), while antifibrinolytic agents (13.0%) and viscoelastic testing (19.0%) were used less commonly. The overall mortality of the study population was 56.1%. Conclusions Massive transfusion activations are frequently used in non-trauma patients. There was a low rate of adherence to 1:1:1 transfusion ratios as well as utilization of adjuncts and tools that could allow for targeted resuscitation. Understanding practice patterns relating to MTA may allow for an opportunity for improvement.

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