A designated trauma social worker improves coordination of patient care by coordinating ancillary consults

Trauma patients face unique challenges that require coordination by social workers knowledgeable in the intricacies of trauma patient psychosocial support which is often achieved by obtaining ancillary consultations. The impact of employing a designated trauma social worker (DTSW) in the utilization of these consults has not been described. A retrospective review was conducted of trauma patients admitted to an academic, urban Level 1 trauma center. The pre-intervention cohort (n = 272) corresponded to patients admitted before the presence of a DTSW (01/2013 to 06/2013), while the post-intervention cohort (n = 282) corresponded to patients admitted afterward (09/2015 to 01/2016). Data collection included demographics, injury profile, and types of interdisciplinary or therapy consultations. Post-intervention patients were found to be older and admitted with more injuries. Supportive care, physical therapy and occupational therapy consultations were more likely to be obtained in the post-intervention cohort. Hospital length of stay remained unchanged. This study suggests that the implementation of a DTSW significantly facilitates the utilization of interdisciplinary consultations. Length of stay remains unchanged, suggesting that a DTSW helps to coordinate care in a timely manner without increasing the hospital stay. DTSW implementation may be considered in trauma centers where one does not currently exist.

What Happens After a Stop the Bleed Class? The Contrast Between Theory and Practice

OBJECTIVE

The Department of Homeland Security launched the Stop the Bleed initiative, a campaign intended to teach bystanders hemorrhage control strategies. Despite the program's popularity, little is known about actions taken by participants afterwards. We sought to determine how often participants acquired the equipment that is necessary in applying the skills taught.

DESIGN

A standardized survey instrument was distributed to all American College of Surgeons Bleeding Control Basic (B-Con) class participants from 05/2017 to 01/2018. The instrument queried about the likelihood of applying skills and obtaining materials. A web-based survey was administered one month later inquiring whether materials were obtained and barriers that would prohibit acquisition.

SETTING

Academic, urban, Level I trauma center.

PARTICIPANTS

Healthcare and nonhealthcare personnel.

RESULTS

There were 336 and 183 participants who completed the initial and subsequent web-based survey, respectively. Participants indicated a high likelihood of applying a tourniquet (95.5%), applying pressure (97.9%), and packing a wound (96.4%), if required. Additionally, 74.7% and 76.2% reported a high likelihood of obtaining a tourniquet and packing material, respectively. However, only 21.3% and 50.8% obtained a tourniquet and packing material, respectively, 1 month later. Cost, time, and accessibility of items during a time of need were cited to be common reasons for not obtaining these materials.

CONCLUSIONS

Despite reporting a high likelihood of utilizing hemorrhage control skills upon completion of the B-Con class, few went on to acquire the materials needed to apply these skills among those who responded. These results may be impacted by loss of follow up and response bias. Developing strategies that allow for easy access to materials is imperative and may lead to both better implementation of the purposes of the program and improved dissemination of its principles within the community.

Nonoperative Management of Blunt Splenic Trauma in Patients with Traumatic Brain Injury: Feasibility and Outcomes

INTRODUCTION

Preventing secondary insult to the brain is imperative following traumatic brain injury (TBI). Although TBI does not preclude nonoperative management (NOM) of splenic injuries, development of hypotension in this setting may be detrimental and could therefore lead trauma surgeons to a lower threshold for operative intervention and a potentially higher risk of failure of NOM (FNOM). We hypothesized that the presence of a TBI in patients with blunt splenic injury would lead to a higher risk of FNOM.

METHODS

Patients with blunt splenic injury were selected from the National Trauma Data Bank research datasets from 2007 to 2011. TBI was defined as AIS head ≥ 3 and FNOM as patients who underwent a spleen-related operation after 2 h from admission. TBI patients were compared to those without head injury. The primary outcome was FNOM.

RESULTS

Of 47,713 patients identified, 41,436 (86.8%) underwent a trial of NOM. FNOM was identical (10.6 vs. 10.8%, p = 0.601) among patients with and without TBI. TBI patients had lower adjusted odds for FNOM (AOR 0.66, p < 0.001), even among those with a high-grade splenic injury (AOR 0.68, p < 0.001). No difference in adjusted mortality was noted when comparing TBI patients with and without FNOM (AOR 1.01, p = 0.95).

CONCLUSIONS

NOM of blunt splenic trauma in TBI patients has higher adjusted odds for success. This could be related to interventions targeting prevention of secondary brain injury. Further studies are required to identify those specific practices that lead to a higher success rate of NOM of splenic trauma in TBI patients.

The risk of delayed intracranial hemorrhage with direct acting oral anticoagulants after trauma: A two-center study

BACKGROUND

The aim of this study was to characterize the risk of a delayed intracranial hemorrhage (ICH) in trauma patients on direct-acting oral anticoagulants (DOACs).

METHODS

Patients on DOACs admitted to two Level I Trauma Centers between 2014 and 2017 were reviewed. Only patients with a negative admission CT brain were included. The primary outcome was a delayed ICH.

RESULTS

Overall, 249 patients were included. The median age was 81 years with 82% undergoing a repeat CT. Three patients developed a delayed ICH (1.2%). One developed an ICH after receiving tissue plasminogen activator for a cerebrovascular accident after two negative CTs. Excluding this patient, the incidence dropped to 0.8%. None required neurosurgical intervention.

CONCLUSION

For patients at risk for a TBI who are on DOACs, repeat cross-sectional imaging of the brain when the initial imaging is negative is not necessary. A period of clinical observation may be warranted.

Helicopter Transport Use for Trauma Patients Is Decreasing Significantly Nationwide but Remains Overutilized

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 ( P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period ( P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.

Helicopter Transport Use for Trauma Patients Is Decreasing Significantly Nationwide but Remains Overutilized

Rapid transfer of trauma patients to a trauma center for definitive management is essential to increase survival. The utilization of helicopter transportation for this purpose remains heavily debated. The purpose of this study was to characterize the trends in helicopter transportations of trauma patients in the United States over the last decade. Subjects with a primary mode of either ground or helicopter transportation were selected from the National Trauma Data Bank datasets 2007 to 2015. Over this period, the proportion of patients transported by a helicopter decreased significantly in a linear fashion from 17 per cent in 2007 to 10.2 per cent in 2015 (P < 0.001). The overall mortality of this population was 7.6 per cent and remained unchanged over the study period (P = 0.545). Almost 3 of 10 subjects (29.4%) transported by a helicopter had an Injury Severity Score <9. The proportion of elderly (>65 years) patients requiring helicopter transportation increased by 69.1 per cent, whereas their associated mortality decreased by 21.5 per cent. The use of a helicopter for the transportation of trauma patients has significantly decreased over the last decade without any significant change in mortality, possibly indicating more effective utilization of available resources. Overtriage of patients with minor injuries remained relatively unchanged.

Testing the photon-number statistics of a quantum key distribution light source

A commonly held tenet is that lasers well above threshold emit photons in a coherent state, which follow Poissonian statistics when measured in photon number. This feature is often exploited to build quantum-based random number generators or to derive the secure key rate of quantum key distribution systems. Hence the photon number distribution of the light source can directly impact the randomness and the security distilled from such devices. Here, we propose a method based on measuring correlation functions to experimentally characterize a light source's photon statistics and use it in the estimation of a quantum key distribution system's key rate. This promises to be a useful tool for the certification of quantum-related technologies.

The risk factors of venous thromboembolism in massively transfused patients

BACKGROUND

Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown.

METHODS

A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE.

RESULTS

Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03).

CONCLUSIONS

The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.

Decreased transport time to the surgical intensive care unit

INTRODUCTION

Extended stay in the emergency department (ED) is associated with worse outcomes in critically ill trauma patients. We conducted a human factors analysis to better understand impediments for patient flow when a surgical ICU (SICU bed is available in order to reduce ED LOS.

METHODS

This is a retrospective review of all trauma patients admitted to a protected SICU through the ED during 2011 and 2014. In 2010, a 24-hour protected SICU bed protocol was implemented to make a bed readily available. During 2013 human factors analysis helped to describe flow disruptions; related interventions were introduced to facilitate rapid transport from the ED to SICU. The interventions required the following prior to CT scanning: immediate ICU bed orders placed by the ED physician and ED to ICU personnel communication. Direct transport from the CT scanner to the ICU was mandated. Data including patient demographics, injury severity, ED LOS, ICU LOS, and hospital LOS was collected and compared between 2011 (PRE) and 2014 (POST).

RESULTS

A total of 305 trauma patients admitted from the ED to the SICU were analyzed; 174 patients in 2011 (PRE) and 131 in 2014 (POST). Average age was 46 years and patients had a mean admission GCS and injury severity score (ISS) of 12.3 and 15.9, respectively. The cohorts were similar in age, mechanism of injury, initial vital signs, and injury severity. After implementing the human factors interventions, decreases were noted in the mean ED LOS (2.4 v. 3.0 hours, p=0.005) and ICU LOS (4.0 v. 4.8 days, p=0.023). No differences in hospital LOS or mortality were observed.

CONCLUSIONS

While an open SICU bed protocol may facilitate rapid transport of trauma patients from the ED to the ICU, additional human factors interventions emphasizing improved communication and coordination can further reduce time spent in the ED.

LEVEL OF EVIDENCE

Level IV, Economic/Decision.

Type 1 Diabetes Genetic Risk Score: A Novel Tool to Discriminate Monogenic and Type 1 Diabetes

Distinguishing patients with monogenic diabetes from those with type 1 diabetes (T1D) is important for correct diagnosis, treatment, and selection of patients for gene discovery studies. We assessed whether a T1D genetic risk score (T1D-GRS) generated from T1D-associated common genetic variants provides a novel way to discriminate monogenic diabetes from T1D. The T1D-GRS was highly discriminative of proven maturity-onset diabetes of young (MODY) (n = 805) and T1D (n = 1,963) (receiver operating characteristic area under the curve 0.87). A T1D-GRS of >0.280 (>50th T1D centile) was indicative of T1D (94% specificity, 50% sensitivity). We then analyzed the T1D-GRS of 242 white European patients with neonatal diabetes (NDM) who had been tested for all known NDM genes. Monogenic NDM was confirmed in 90, 59, and 8% of patients with GRS <5th T1D centile, 50-75th T1D centile, and >75th T1D centile, respectively. Applying a GRS 50th T1D centile cutoff in 48 NDM patients with no known genetic cause identified those most likely to have a novel monogenic etiology by highlighting patients with probable early-onset T1D (GRS >50th T1D centile) who were diagnosed later and had less syndromic presentation but additional autoimmune features compared with those with proven monogenic NDM. The T1D-GRS is a novel tool to improve the use of biomarkers in the discrimination of monogenic diabetes from T1D.

Efficient decoy-state quantum key distribution with quantified security

We analyse the finite-size security of the efficient Bennett-Brassard 1984 protocol implemented with decoy states and apply the results to a gigahertz-clocked quantum key distribution system. Despite the enhanced security level, the obtained secure key rates are the highest reported so far at all fibre distances.

TCL1 shows a regulated expression pattern in chronic lymphocytic leukemia that correlates with molecular subtypes and proliferative state

Expression of the human oncogene TCL1 in transgenic mice produces B-cell tumors that resemble chronic lymphocytic leukemia (CLL) suggesting its role in B-cell tumorigenesis. To clarify the expression pattern and regulation of TCL1 in CLL, we assessed 213 primary tumors by immunohistochemistry (IHC), flow-cytometry and/or Western blot, using a new monoclonal antibody. TCL1 protein was detectable in the majority of CLL (90% by IHC) but showed marked variations across cases with virtual absence in approximately 10% of tumors. Higher TCL1 levels correlated with markers of the 'pre-germinal center' CLL subtype including unmutated VH status (P=0.005), ZAP70 expression (P=0.007), and presence of chromosome 11q22-23 deletions (P=0.04). Intratumoral heterogeneity in TCL1 levels was also prominent and explained in part by markedly lower TCL1 expression in proliferating tumor cells. In vitro exposure of CLL cells to interleukin-4 (but not other growth factors) produced progressive and irreversible decrease in TCL1 protein levels in association with the onset of proliferation. TCL1 expression patterns in CLL are complex and highly dynamic and appear to reflect both the histogenetic subtypes of the disease and the growth parameters of individual tumors. The observed regulation pattern suggests that TCL1 may exert its effects predominantly in the unmutated/ZAP70-positive tumor subset.

Increased sural nerve epineurial blood flow in human subjects with painful diabetic neuropathy

AIMS/HYPOTHESIS

The pathogenesis of painful diabetic neuropathy remains unknown. As a consequence we still do not have any effective, rational treatments and a greater understanding of the mechanisms is urgently required. Previous studies have shown no consistent morphological differences in the nerves of patients with and without painful neuropathy. The aim of this study was to compare epineurial haemodynamics in patients with chronic painful and painless neuropathy.

METHODS

The techniques of microlightguide spectrophotometry and fluorescein angiography were used to measure epineurial intravascular oxygen saturation and blood flow respectively. Eleven patients with painful and eight with painless neuropathy were studied, with the groups matched carefully in terms of severity of neuropathy and diabetes control.

RESULTS

Intravascular oxygen saturation was higher in the painful neuropathy group compared to those without pain (median 73.8% vs 67.7%, respectively; p=0.021). Fluorescein rise time was also faster in those with painful symptoms (median 18.3 s vs 53.6 s; p=0.046) indicating higher epineurial blood flow in these subjects.

CONCLUSION/INTERPRETATION

These results indicate that there are distinct differences in haemodynamics within the epineurium of the sural nerve in subjects with painful and painless neuropathy. Haemodynamic factors could therefore have an important role in the pathogenesis of neuropathic pain and might offer further insight into potential treatments for this distressing condition.

Prediction of prognosis in patients with uveal melanoma using fluorescence in situ hybridisation

BACKGROUND/AIMS

Uveal melanoma is the commonest malignancy of the eye, with a high proportion of patients dying of metastatic disease. Tumours showing a loss of chromosome 3 and gains of chromosome 8 are associated with a worse prognosis. The efficiency of fluorescence in situ hybridisation (FISH) in determining copy numbers of these chromosomes was assessed in individual tumours and related to patient survival.

METHODS

33 fresh frozen samples were analysed with centromeric probes for chromosomes 3 and 8. Patient outcomes were divided into two groups: (1) absence of genetic abnormalities (no genetic imbalance) and (2) presence of genetic abnormalities (genetic imbalance). The log rank test was used to compare survival, which was represented by Kaplan-Meier survival curves.

RESULTS

Of the 33 tumours analysed, 16 showed evidence of genetic imbalances. Of these 16 tumours, 14 patients had died by the end of the study, with 10 having died of liver metastases. Of the tumours without evidence of genetic imbalances, five patients had died by the end of the study, although none had died as a result of either liver metastases or from the primary uveal melanoma. The difference in survival between the two groups was highly significant (p<0.0001).

CONCLUSION

The authors have shown that FISH analysis for chromosome 3 and 8 is a reliable and efficient technique in the analysis of fresh frozen tumour specimens and is valuable in the prediction of prognosis in individuals with uveal melanomas.

Impact of moods and social context on eating behavior

The relationship of moods and social context to energy and nutrient intakes was examined to ascertain if these variables interact or function independently. The subjects were 78 predominantly white, obese women participating in weight-loss studies. Mean age was 36.7 (SD=7.6) and mean Body Mass Index was 32.1 (SD=3.6). Subjects completed 2-week baseline food diaries recording everything they ate, including moods and people present during the meals. Meals eaten in positive and negative moods were significantly larger than meals eaten in a neutral mood. Meals eaten with other people were significantly larger than meals eaten alone. There were no significant moods by social context interactions for total energy intake. Moods and social context functioned additively to increase the risk of over-eating. Macro nutrient analysis revealed only a main effect for social context. Percentage of calories from fat and protein were greater, whereas the percentage of carbohydrate was less in social context meals compared to meals eaten alone. Clinicians should conduct a functional analysis to assess exposure to the frequency and types of risky situations. Teaching people to cope more effectively with social situations and moods may increase the efficacy of weight loss and maintenance programs.

Preoperative localization of a parathyroid adenoma with Tc-99m sestamibi imaging in a patient with concomitant nontoxic multinodular goiter

Preoperative localization of parathyroid adenomas is useful in patients undergoing parathyroidectomy. The authors report a patient with hyperparathyroidism and an associated nontoxic nodular goiter. Technetium-99m sestamibi scintigraphy localized and differentiated the parathyroid adenoma from the multinodular goiter. Excellent correlation was found between preoperative radionuclide imaging and surgical pathology. Technetium-99m sestamibi parathyroid imaging may be a simple and helpful test in the surgical management of parathyroid adenomas, particularly in patients with nontoxic multinodular goiter.

The hot clot sign. A new finding in deep venous thrombosis on bone scintigraphy

Focal Tc-99m MDP uptake on bone scanning in regions of deep venous thrombosis (DVT) is reported in two patients with documented DVT. It is speculated that this uptake may be related to localized calcification or ossification, which is occasionally observed on radiographs of patients with chronic DVT.