Desert Regional Medical Center

Critical closing pressure (CCP) and the vascular waterfall have long been used to explain perfusion failure in shock, yet their physiological meaning has been inconsistently interpreted. CCP is frequently treated as a continuous downstream pressure and inserted into formulas such as mean arterial pressure (MAP) - CCP, implying that a collapse threshold behaves like an opposing pressure even when vessels remain open. Drawing on classical vascular mechanics, whole-bed flow studies, microvascular models, and contemporary clinical physiology, we show that this interpretation is incorrect. Tone-dependent arteriolar collapse does not behave as a Starling resistor: CCP is a threshold at which smooth-muscle tension exceeds intraluminal pressure and vessels close, not a pressure governing flow in patent vessels. Perfusion becomes heterogeneous because different vascular beds reach their collapse thresholds at different pressures (via excessive tone, extrinsic compression, or profound hypotension), disconnecting macro-haemodynamics from microcirculatory flow. This explains why systemic variables such as MAP and systemic vascular resistance (SVR) may appear adequate even while tissues are under-perfused, a phenomenon now termed haemodynamic incoherence. Reframing CCP as a binary collapse threshold resolves longstanding contradictions in the literature, clarifies why MAP-centred targets often fail, and unifies the behaviour of shock states within a four-interface model of circulatory coupling. Therapeutically, the aim is not to "restore a waterfall" but to reopen closed vascular territories by lowering excessive tone, relieving external pressure, or raising truly low arterial inflow. This mechanistic reinterpretation provides a more coherent, physiologically grounded approach to personalised perfusion management in critical illness.

ABSTRACTAimBecause no conclusive data demonstrate superiority among NK1 receptor antagonists (RA), existing antiemetic guidelines regard them as interchangeable. This individual patient data (IPD) meta-analysis compared the efficacy of NEPA (netupitant/fosnetupitant) and aprepitant/fosaprepitant-based regimens in preventing chemotherapy-induced nausea and vomiting (CINV).Materials & MethodsHead-to-head comparative studies published between 2003 and 2022 that evaluated antiemetic prophylaxis of aprepitant or fosaprepitant versus oral or intravenous (IV) NEPA in patients with various cancers receiving highly (HEC) or moderately emetogenic chemotherapy (MEC) were identified through a literature search. We combined individual patient data to assess complete response (no emesis/no rescue medication) and no significant nausea using a two-stage approach.ResultsA total of six studies involving 2,767 patients were included evaluating NEPA plus dexamethasone versus aprepitant/fosaprepitant plus any 5-HT3RA plus dexamethasone for patients with cancer receiving HEC/MEC. Complete response and no significant nausea rates were similar during the acute (0–24 h) phase but NEPA showed significantly higher rates than aprepitant during the delayed ( > 24–120 h) and overall (0–120 h) phases and on Days 3–5 following chemotherapy.ConclusionImproved CINV prevention was observed with NEPA-based regimens, particularly during Days 3–5, highlighting its potential for managing prolonged nausea and vomiting associated with emerging anticancer targeted therapies.

Background/Objectives: Pancreatic cancer (PC) is a diagnosis with a poor prognosis which can be associated with significant distress and may hinder a patient's ability to understand treatment details. Educating patients based on their learning preferences (LPs) and emotions may allow for personalized, enhanced care. Methods: This prospective project enrolled patients with non-metastatic PC. Phase 1 utilized the Learning Preference Barometer (LPB) and Emotional Journey Barometer (EJB), which are digital instruments co-designed by CANCER101 (C101) and the Health Collaboratory, to assess patient LPs and emotional states. Phase 2 provided information prescriptions aligned with LPs through C101's Prescription to Learn® (P2L) platform. Collected data included demographics, treatment, LPs (auditory, kinesthetic, linguistic, visual), patient engagement with P2L, and patient emotional states with qualitative verbal validation. Descriptive variables were used to report outcomes. Results: Primary LPs in the 47 participating patients were as follows: linguistic 45%, visual 34%, auditory 11%, and kinesthetic 9%, with secondary preferences in the majority (53%). Those patients (66%) who accessed P2L had linguistic and visual preferences; the majority accessed 1- 2 resources out of the 25 provided. Resources accessed aligned to 88% of patient LPs. The majority of patients (60%) initiated treatment prior to initial EJB, and 40% were treatment naive. Common baseline emotions were optimistic (47% vs. 36%, respectively), satisfied (11% vs. 25%), acceptance (11% vs. 11%), and overwhelmed (5% vs. 11%). Conclusions: Assessing LPs and emotional state allows for personalized patient education and clinical encounters for PC patients. Future work includes examining the effects of personalized approaches on patient satisfaction, decision-making, health outcomes, and the overall patient-clinician relationship.

This letter, signed by over 50 academic chairs of emergency medicine, urges the ACGME to reconsider a proposed mandate requiring all emergency medicine residency programs to adopt a four-year training model. The authors argue that current three-year programs are supported by data demonstrating equivalent educational and clinical outcomes compared to four-year formats. They criticize the flawed survey methodology underpinning the proposal, note the loss of milestone-based training flexibility, and highlight the lack of added scholarly or clinical value in the fourth year. The letter also outlines negative consequences for fellowship participation, workforce development, trainee debt, and diversity. The signatories advocate for maintaining the current flexible training model to preserve excellence, equity, and innovation in emergency medicine education.

The inferior vena cava (IVC) is a large, retroperitoneal vein that ascends anterolaterally along the right side of the vertebral column, draining venous blood from both lower extremities, the pelvis, and the abdomen to the right atrium of the heart. The IVC undergoes complex embryological development during the fourth to eighth weeks of gestation, which can result in many anatomical variations, including duplication of the IVC. This study presents the case of duplicated IVCs in a 79-year-old male donor patient. While the second IVC on the left side of the body generally terminates by draining into the left renal vein, the individual described here demonstrated an extension superior to the renal veins, with the renal and gonadal veins draining into the ipsilateral IVCs. The two IVCs joined at T9 and passed as one into the right atrium at T8. The IVC's role as the largest vein in the body is important to consider when assessing any vascular abnormality present in the IVC and its potential implications, which may include a higher risk of venous thromboembolism or pulmonary embolism.

Fireworks are commonly used during holidays in the United States. Firework related injuries (FWRIs) have been rising throughout the country since 2012. Here, we describe injury trends and patterns in patients with FWRIs. The trauma registry at Desert Regional Medical Center’s Level I Trauma Center was queried from July 2016 to August 2021. Injury patterns and procedures performed were reviewed. The data were reviewed, and a description of the most common injury types and the association between FWRIs and holiday celebrations, alcohol use, and toxicology results is presented. Ten patients were identified for inclusion during the study period. Fifty percent of the patients were found to be under the influence of alcohol, and 40% had other substances on board. The most common drug found was methamphetamine, accounting for 30% of patients. Ninety percent of patients suffered injuries to hands. Fifty percent of the injured patients presented around the time of either New Year’s or Independence Day celebrations. Neither holiday and alcohol use nor toxicology results were associated with differences in Injury Severity Score. Patients with injuries related to fireworks are presenting to our nation’s emergency rooms at an increasing rate. In this descriptive case series, we found that hand injuries are the most common, followed by face injuries. Most patients had either alcohol or drugs on board at the time of presentation. Findings from this paper will help trauma programs prepare for the presentation of these patients and design outreach programs and future research.

Empty sella (ES) is a radiographic finding defined by the presence of cerebrospinal fluid in the sella turcica, with associated compression of the pituitary gland. Empty sella syndrome (ESS) is the combination of this radiographic finding with endocrine, ophthalmological, and/or neurological symptoms. The focus of this literature review is to synthesize information about asymptomatic or incidental ES specifically, meaning the radiologic finding of an empty sella without symptoms. This condition is typically discovered incidentally through imaging when patients present with unrelated pathologies. Our intention is to strengthen the existing body of work on this clinical presentation and call for a standardized management protocol of ES. This literature review was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Data were extracted on paper characteristics, epidemiology, diagnostics, management, and outcomes.Overall, patients with radiographic findings of ES have a good prognosis. The majority of patients never become symptomatic (progression to ESS), and if symptoms do arise, they usually have little impact on quality of life. However, despite its inherent asymptomatic nature, given ES's estimated prevalence within society, the possibility of a critical underlying pathology, and the potential for subsequent development of consequential symptoms, this paper calls for the implementation of a standardized management protocol. We suggest that all patients with this finding and an unidentified underlying etiology, at a minimum, receive an endocrine panel for evaluation of pituitary function and a referral to ophthalmology for formal assessment of papilledema. We then recommend tailored management and referrals based on the results of these evaluations, as well as treatment of any subsequent symptomatology. While these are our recommendations based on a thorough review of the literature, further studies are necessary to reach a consensus on best clinical practices.

A tension empyema, in which purulent material accumulates in the chest cavity and leads to cardiopulmonary dysfunction, is a rare complication of empyemas. Moreover, fungal empyemas that grow Candida albicans and cause tension physiology have not yet been previously described. In this report, we present an immunocompetent 30-year-old male who presented to the emergency department with worsening shortness of breath and was found to have a left-sided fungal empyema causing tension physiology. Left chest thoracostomy yielded approximately 4 liters of purulent fluid. Pleural cultures eventually grew C albicans, and after antifungal therapy, surgical decortication of the lung, and a prolonged intensive care unit stay, the patient was discharged home in stable condition. While mortality from C albicans empyemas that cause respiratory compromise is exceedingly high, our case highlights that aggressive management with rapid chest thoracostomy and antifungal therapy can lead to a favorable outcome.

Investigating patterns among the outcomes of patients involved in motor vehicle accidents (MVAs) can provide information necessary to guide targeted interventions to improve road traffic safety. Our purpose is to identify any differences between passenger and driver injury severity and overall clinical course after MVAs. We performed a retrospective review and analysis of 3,693 patients involved in MVAs from 2016 to 2021. We divided the data into two groups, drivers and passengers, and compared the Injury Severity Score (ISS),Revised Trauma Score (RTS) on admission, days in the Intensive Care Unit (ICU), length of hospital stay (LOS), post Emergency Department (ED) disposition, discharge (DC) disposition, and signs of life on arrival (SOLA) to the ED. We compared mean ISS, New Injury Severity Score (NISS), RTS, length in ICU and LOS using a student's T-test and SOLA, post-ED and DC disposition using Chi-squareanalysis. We did not find any statistically significant difference in ISS, RTS, days in ICU, LOS, or SOLA between the drivers and passengers. However, we did find a statistically significant difference in the post-ED (X2= 113.743, p=<0.0001) and DC disposition (X2=41.172, p=<0.0001) of drivers and passengers.After the ED and DC, morepassengers were transferred to a higher level of care than expected, while the inverse was true for drivers. The number of drivers discharged to Skilled Nursing Facilities (SNFs) was also higher than expected, further contributingto the observed difference in DC disposition. Conclusion:Our study found no statistically significant difference between driver and passenger injury severity, length of hospital stay, days in ICU, and SOLA after an MVA. The clinical courses of the two groups were found to be significantly different based on post-ED and DC disposition data. We identified limitations, such as a relatively small sample size and insufficient data on specific car seat locations for passengers, underscoring the need for a more nuanced exploration. Future research must broaden its scope to encompass diverse crash scenarios, vehicle design and safety technologies, seat belt dynamics, and age- and gender-specific vulnerabilities.

Severe traumatic injury (sTBI) continues to be a common source of morbidity and mortality. While there have been several advances in understanding the pathophysiology of this injury, the clinical outcome has remained grim. These trauma patients often require multidisciplinary care and are admitted to a surgical service line, depending on hospital policy. A retrospective chart review spanning 2019-2022 was completed using the electronic health record of the neurosurgery service. We identified 140 patients with a Glasgow Coma Scale (GCS) of eight or less, ages 18-99, who were admitted to a level-one trauma center in Southern California. Seventy patients were admitted under the neurosurgery service, while the other half were admitted to the surgical intensive care unit (SICU) service after initial assessment in the emergency department by both services to evaluate for multisystem injury. Between both groups, the injury severity scores that evaluated patients' overall injuries were not significantly different. The results demonstrate a significant difference in GCS change, modified Rankin Scale (mRS) change, and Glasgow Outcome Scale (GOS) change between the two groups. Furthermore, the mortality rate differed between neurosurgical care and other service care by 27% and 51%, respectively, despite similar Injury Severity Scores (ISS) (p=0.0026). Therefore, this data demonstrates that a well-trained neurosurgeon with critical care experience can safely manage a severe traumatic brain injury patient with an isolated head injury as a primary service while in the intensive care unit. Since injury severity scores did not differ between these two service lines, we further theorize that this is likely due to a deep understanding of the nuances of neurosurgical pathophysiology and Brain Trauma Foundation (BTF) guidelines.