BACKGROUND Trauma is the leading cause of non-obstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of non-trauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a Perinatal Emergency Response Team (PERT) would improve time to patient and fetal evaluation and monitoring by the Obstetrics (OB) team, and improve both maternal and fetal outcomes. METHODS We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our University-affiliated, Level I Trauma Center. Patients in the pre-PERT cohort (prior to April 2015) were compared to a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, injury severity score (ISS), and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%), and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared to 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in Level I (highest acuity) trauma activations pre- and post-PERT (46% vs. 21%, p=0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. CONCLUSION Implementation of a multidisciplinary perinatal emergency response team (PERT) improves time to evaluation by the obstetrics team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE IV STUDY TYPE Retrospective review.BACKGROUND Peripheral vasoconstriction is the most critical compensating mechanism following hemorrhage to maintain blood pressure. On the battlefield, ketamine rather than opioids is recommended for pain management in case of hemorrhage but effects of analgesics on compensatory vasoconstriction are not defined. We hypothesized that fentanyl impairs but ketamine preserves the peripheral vasoconstriction and blood pressure compensation following hemorrhage. METHOD Sprague Dawley rats (11-13wk) were randomly assigned to control (saline vehicle), fentanyl, or ketamine-treated groups with or without hemorrhage (n = 8 or 9 for each group). Rats were anesthetized with Inactin (ip. 10mg/100g) and the spinotrapezius muscles were prepared for microcirculatory observation. Arteriolar arcades were observed with a Nikon microscope and vessel images and arteriolar diameters (AD) were recorded by using Nikon NIS Elements Imaging Software. After baseline perimeters were recorded, the arterioles were topically challenged witd vasodilation (78 ± 25% to 36 ± 22% of baseline during the 40 minutes after injection, p less then 0.01). CONCLUSION Ketamine affects neither systemic nor microcirculatory compensatory responses to hemorrhage, providing preclinical evidence that ketamine may help attenuate adverse physiological consequences associated with opioids following traumatic hemorrhage. Microcirculatory responses are more sensitive than systemic response for evaluation of hemodynamic stability during procedures associated with pain management.OBJECTIVE To document the clinical presentation of scurvy in children with autism spectrum disorder (ASD) and summarize the contemporary approaches to assessment and management in this population. Scurvy is a disease caused by vitamin C deficiency most often detected in populations at high risk for nutrition insufficiency (e.g., extreme poverty). Children with ASD and severe food selectivity consistent with avoidant-restrictive food intake disorder may also be at risk for scurvy. METHOD We searched MEDLINE, CINAHL, and PsycINFO databases (1990-2018) in peer-reviewed journals for studies of children with ASD and scurvy. Inclusion criteria required confirmed diagnosis of ASD and scurvy in children (birth to 18 years) with a clear description of restrictive dietary patterns. Cases of scurvy due to other causes were excluded. selleck We used a standardized protocol to independently code information; agreement between coders was high. RESULTS The systematic search identified 20 case reports involving 24 children (mean age = 9 ± 3.5; 22 boys/2 girls). The eventual diagnosis of scurvy followed a wide range of negative diagnostic testing; treatment with ascorbic acid and/or a multivitamin resulted in rapid improvement. CONCLUSIONS Symptoms of scurvy mimic other pediatric conditions (e.g., cancer). The range of diagnostic testing increased costs and healthcare risks (radiation, sedation) and delayed the diagnosis of scurvy. In children with ASD and severe food selectivity, a nutrition evaluation and laboratory testing are warranted before a more elaborate testing.BACKGROUND Hospital-based care accounts for one third of US health spending or over $1 trillion annually, yet a detailed all-payer assessment of what services contribute to this spending is not available. STUDY DESIGN Cross-sectional and longitudinal evaluation of hospital financial statements from acute-care general hospitals in California between fiscal years 2007 and 2016. The amounts spent on 41 different revenue centers were included. The primary outcome was state-level and hospital-level spending for each revenue center including decomposing growth trends into changes in volume and prices. RESULTS The analysis included 2941 annual financial statements from 331 hospitals. Between 2007 and 2016, total spending across all centers increased 66.6% from $43.7B to $72.9B. Five centers-surgery and recovery, drugs sold to patients, acute medical/surgical floor, the clinical laboratory, and emergency services-accounted for over 50% of total spending in 2016. Overall spending growths ranged from 1.1%/y (acute pediatrics) to 17.