Failure to Rescue in Geriatric Trauma: The Impact of Any Complication Increases with Age and Injury Severity in Elderly Trauma Patients

INTRODUCTION

The interaction of increasing age, Injury Severity Score (ISS), and complications is not well described in geriatric trauma patients. We hypothesized that failure to rescue rate from any complication worsens with age and injury severity.

METHODS

The National Trauma Data Bank (NTDB) was queried for injured patients aged 65 years or older from January 1, 2013 through December 31, 2016. Demographics and injury characteristics were used to compare groups. Mortality rates were calculated across subgroups of age and ISS, and captured with heatmaps. Multivariable logistic regression was performed to identify independent predictors of mortality.

RESULTS

614,496 geriatric trauma patients were included; 151,880 (24.7%) experienced a complication. Those with complications tended to be older, female, non-white, have non-blunt mechanism, higher ISS, and hypotension on arrival. Overall mortality was highest (19%) in the oldest (≥86 years old) and most severely injured (ISS ≥ 25) patients, with constant age increasing across each ISS group was associated with a 157% increase in overall mortality (P < .001, 95% CI: 148-167%). Holding ISS stable, increasing age group was associated with a 48% increase in overall mortality (P < .001, 95% CI: 44-52%). After controlling for standard demographic variables at presentation, the existence of any complication was an independent predictor of overall mortality in geriatric patients (OR: 2.3; 95% CI: 2.2-2.4).

CONCLUSIONS

Any complication was an independent risk factor for mortality, and scaled with increasing age and ISS in geriatric patients. Differences in failure to rescue between populations may reflect critical differences in physiologic vulnerability that could represent targets for interventions.

Impact of Integral Dose on the Maintenance of Pain Relief in Patients with Idiopathic Trigeminal Neuralgia Treated with Upfront Gamma Knife Radiosurgery

BACKGROUND

Integral dose (ID) defined as the product of mean dose and target volume, is a measure of the absorbed radiation energy.

OBJECTIVE

To evaluate the effect of ID on the duration of pain relief after primary Gamma knife stereotactic radiosurgery (GKSRS) in trigeminal neuralgia.

PATIENTS AND METHODS

A total of 78 patients who achieved initial pain response of I-III on the Barrow Neurological Institute Pain Scale (BNI-PS) following primary GKSRS for idiopathic trigeminal neuralgia were included in this study. A Cox regression model was used to compute the prognostic factor with respect to the ID within the 50% isodose line. Facial pain relief maintenance interval was defined as time interval between the day of improved BNI-PS grade and pain level back to the BNI-PS IV or V. The median duration of follow-up was 42 months (range 6-108 months).

RESULTS

After the initial GKSRS, patients achieved pain relief at a median of 0.5 months (range, 7 days to 6 months); 28 patients developed recurrence of pain. There was a positive correlation between the pain relief maintenance and increasing ID within 50% isodose line (hazard ratio 1.85, P = 0.04) on multivariable Cox-regression analysis. Using logistic regression analysis, we found that ID was not predictive of developing post-stereotactic radiosurgery hypoesthesia (P = 0.64, hazard ratio 1.057).

CONCLUSIONS

Stereotactic radiosurgery can be individualized based on trigeminal nerve morphology to achieve durable pain relief in patients with trigeminal neuralgia. ID calculation aids in planning an optimal radiation dose based on the nerve morphology to provide durable pain relief of idiopathic trigeminal neuralgia.

Sudden progression of a glioblastoma in partial remission?

There are only sparse data on viral CNS infections in patients with malignant glioma. We report a case of fatal herpes encephalitis in a patient with glioblastoma in partial remission and provide a short review of the literature.

Spatial and temporal disease progression of adult-onset subacute sclerosing panencephalitis

An adult-onset case of subacute sclerosing panencephalitis with occipitofrontal spread of the infection documented clinically and by MRI is reported. Autopsy revealed numerous intranuclear viral inclusions and widespread demyelination in both frontal lobes. In the occipital lobes where the disease started 5 years previously, inclusions were rare, but degenerative tissue changes were prominent. This case underlines the importance of measles virus migration for the progression of this fatal disorder.

[Magnetic resonance imaging diagnosis of craniobasal cerebrospinal fluid fistulas by 3D-CISS sequence]

Recently, a Magnetic Resonance Imaging (MRI)-technique has been developed to diagnose the exact anatomical location of fistulas of the cerebrospinal fluid (CSF). This method is called 3D-constructive interference steady state-sequence (CISS) but it is not well known in clinical practice. Aim of the study was the evaluation of specificity and sensitivity of CISS-MRI. 12 patients with rhinoliquorrhea after head injury (n = 7) or skull base tumours (n = 5) were examined by CISS-MRI. The examinations were performed with a 1.5 T whole body MRI scanner in prone position and coronal plane sections. In cases of CSF leckage the sensitivity for detection of a CSF fistula was 100%. In comparison with intraoperative findings, specificity was 100%: in all cases, a dural lesion in anatomical correlation to MRI was detected. Further advantages of this method are its non-invasive character, no need for contrast application, no radiation exposure, and exact localisation of additional anatomical findings (brain herniation, brain contusions).

[Computerized tomography (CT) and magnetic resonance tomography (MRI) in diseases of the pelvic floor]

CT and MRI have become more frequently established in the diagnosis of the pelvis for the last few years. CT and even more MRI are technically essential for the diagnosis of problems of the pelvis like anal carcinoma, anal atresia, anal fistula of the anal canal and rectum. Modern technical equipment allow a scanning time of a few seconds, especially important in patients with bad condition.

Pulmonary histiocytosis in tree shrews (Tupaia belangeri)

Granulomatous lesions similar to those of pulmonary histiocytosis in rats developed spontaneously in the lungs of captive tree shrews. Incidence peaked in 3-year-old tree shrews. Sex dependency was not observed, and development of the granulomas was unrelated to experimental procedures because the lesions were observed in animals from the breeding stock as well. The granulomas consisted of amorphous material, foam cells, and a few foreign body-type multinuclear giant cells; they also contained acicular clefts, often with some fibrous material. Alveolar septa within and adjacent to the granulomas were thickened in most instances, but did not contain inflammatory cells in appreciable numbers or amyloid. Only traces of cholesterol and calcium were detected in the amorphous material; neutral fat was stored in the foam cells and the amorphous masses. Fibers without birefringency were documented by polarization and scanning electron microscopy in the vicinity of granulomas, which in energy-dispersive X-ray microanalysis consisted mostly of calcium, but lacked silicon.

Tumors of the respiratory tract observed at the German Primate Center, 1978-1994

Eight spontaneous pulmonary tumors (four bronchiolar tubular adenomas, two bronchiolar adenocarcinomas, two squamous-cell carcinomas) occurred in a total of 54 adult tree shrews (Tupaia belangeri) of the GPC colonies between 1978 and 1994. The adenomas and adenocarcinomas consisted of tubularly or trabecularly arranged cuboidal to cylindrical cells interspersed with some PAS-positive goblet cells, thus resembling the epithelial lining of respiratory bronchioles of tree shrews. The two squamous-cell carcinomas probably originated from the pulmonary alveoles. Three more pulmonary tumors (one small-cell carcinoma, one bronchial adenoma, one squamous-cell carcinoma) developed in 409 adult callitrichids of the GPC colonies during the same period, and one more bronchial adenoma was observed in a common marmoset (Callithrix jacchus) of another colony located in Göttingen. With regard to the adenomas and squamous-cell carcinomas, a similar cellular origin with the three shrews is assumed. The small-cell carcinoma possibly developed from the bronchial epithelium, provided a pathogenesis parallel to that of human small-cell carcinoma is suggested. Four of the tree shrew pulmonary adenomas/adenocarcinomas and the small-cell Ca were macroscopically visible as yellowish-grey nodules of 1 mm x 1 mm to 15 mm x 15 mm diameter, predominantly involving the main lobes (2 x right main lobes, 2 x left main lobes, 1 x all lobes). The pulmonary tumors of the other animals were below macroscopical detectability.

[Indications for coagulation in diabetic maculopathy]

Macular changes of 333 eyes of 266 diabetic patients were analized regarding number of microaneurysms, area of intraretinal lipids and hermorrhages and the amount of leckage and capillary occlusion in fluorescein angiography. The changes were observed in a central and peripheral area centered around the fovea. The distribution of the changes observed were correlated with the visual acuity of the patients. Only the number of peripheral microaneurysms and the presence of foveal intraretinal edema correlated with a reduction in visual acuity. These parameters are therefore clinical indicators for the severity of diabetic maculopathy. Regarding the visual acuity after a minimal follow up of six months the presence of foveal intraretinal edema was the most important factor with a high risk of short term visual loss. The presence of fovealmacular edema might therefore be the most important indicator for macular photocoagulation treatment.