Hepatocellular carcinoma survival in uninsured and underinsured patients.

BACKGROUND: The incidence of hepatitis C virus (HCV) and hepatocellular carcinoma (HCC) is increasing. The purpose of this study is to establish baseline survival in a medically-underserved population and to evaluate the effect of HCV seropositivity on our patient population. MATERIALS AND METHODS: We reviewed clinicopathologic parameters from a prospective tumor registry and medical records from the Harris County Hospital District (HCHD). Outcomes were compared using Kaplan-Meier survival analysis and log-rank tests. RESULTS: A total of 298 HCC patients were identified. The median survival for the entire cohort was 3.4 mo. There was no difference in survival between the HCV seropositive and the HCV seronegative groups (3.6 mo versus 2.6 mo, P = 0.7). Patients with a survival \u3c1 mo had a significant increase in\u3eαfetoprotein (AFP), international normalized ratio (INR), model for end-stage liver disease (MELD) score, and total bilirubin and decrease in albumin compared with patients with a survival ≥ 1 mo. CONCLUSIONS: Survival for HCC patients in the HCHD is extremely poor compared with an anticipated median survival of 7 mo reported in other studies. HCV seropositive patients have no survival advantage over HCV seronegative patients. Poorer liver function at diagnosis appears to be related to shorter survival. Further analysis into variables contributing to decreased survival is needed

Handover Practices in Trauma and Acute Care Surgery: A Multicenter Survey Study

BACKGROUND: The handover period has been identified as a particularly vulnerable period for communication breakdown leading to patient safety events. Clear and concise handover is especially critical in high-acuity care settings such as trauma, emergency general surgery, and surgical critical care. There is no consensus for the most effective and efficient means of evaluating or performing handover in this population. We aimed to characterize the current handover practices and perceptions in trauma and acute care surgery. METHODS: A survey was sent to 2265 members of the Eastern Association for the Surgery of Trauma via email regarding handoff practices at their institution. Respondents were queried regarding their practice setting, average census, level of trauma center, and patients (trauma, emergency general surgery, and/or intensive care). Data regarding handover practices were gathered including frequency of handover, attendees, duration, timing, and formality. Finally, perceptions of handover including provider satisfaction, desire for improvement, and effectiveness were collected. RESULTS: Three hundred eighty surveys (17.1%) were completed. The majority (73.4%) of respondents practiced at level 1 trauma centers (58.9%) and were trauma/emergency general surgeons (86.5%). Thirty-five percent of respondents reported a formalized handover and 52% used a standardized tool for handover. Only 18% of respondents had ever received formal training, but most (51.6%) thought this training would be helpful. Eighty-one percent of all providers felt handover was essential for patient care, and 77% felt it prevented harm. Seventy-two percent thought their handover practice needed improvement, and this was more common as the average patient census increased. The most common suggestions for improvement were shorter and more concise handover (41.6%), different handover medium (24.5%), and adding verbal communication (13.9%). CONCLUSION: Trauma and emergency general surgeons perceive handover as essential for patient care and the majority desire improvement of their current handover practices. Methods identified to improve the handover process include standardization, simplification, and verbal interaction, which allows for shared understanding. Formal education and best practice guidelines should be developed

Tomographic Separation of Composite Spectra. VIII. The Physical Properties of the Massive Compact Binary in the Triple Star System HD 36486 (delta Orionis A)

Double-lined spectroscopic orbital elements have recently been found for the central binary in the massive triple, delta Orionis A based on radial velocities from cross-correlation techniques applied to IUE high dispersion spectra and He I 6678 spectra obtained at Kitt Peak. The primary and secondary velocity amplitudes were found to be 94.9 +/- 0.6 km/s and 186 +/- 9 km/s respectively. Tomographic reconstructions of the primary and secondary stars' spectra confirm the O9.5 II classification of the primary and indicate a B0.5 III type for the secondary. The widths of the UV cross-correlation functions are used to estimate the projected rotational velocities, Vsin i = 157 +/- 6 km/s and 138 +/- 16 km/s for the primary and secondary, respectively implying that both stars rotate faster than their orbital motion. We used the spectroscopic results to make a constrained fit of the Hipparcos light curve of this eclipsing binary, and the model fits limit the inclination to the range between 67 and 77 degrees. The i = 67 degrees solution, which corresponds to a near Roche-filling configuration, results in a primary mass of 11.2 solar masses and a secondary mass of 5.6 solar masses, both of which are substantially below the expected masses for stars of their luminosity. This binary may have experienced a mass ratio reversal caused by Case A Roche lobe overflow, or the system may have suffered extensive mass loss through a binary interaction, perhaps during a common envelope phase, in which most of the primary's mass was lost from the system rather than transferred to the secondary.Comment: 27 pages, 15 figures in press, the Astrophysical Journal, February 1, 200

Ketamine for Acute Pain After Trauma: the Kapt Randomized Controlled Trial

BACKGROUND: Evidence for effective pain management and opioid minimization of intravenous ketamine in elective surgery has been extrapolated to acutely injured patients, despite limited supporting evidence in this population. This trial seeks to determine the effectiveness of the addition of sub-dissociative ketamine to a pill-based, opioid-minimizing multi-modal pain regimen (MMPR) for post traumatic pain. METHODS: This is a single-center, parallel-group, randomized, controlled comparative effectiveness trial comparing a MMPR to a MMPR plus a sub-dissociative ketamine infusion. All trauma patients 16 years and older admitted following a trauma which require intermediate (IMU) or intensive care unit (ICU) level of care are eligible. Prisoners, patients who are pregnant, patients not expected to survive, and those with contraindications to ketamine are excluded from this study. The primary outcome is opioid use, measured by morphine milligram equivalents (MME) per patient per day (MME/patient/day). The secondary outcomes include total MME, pain scores, morbidity, lengths of stay, opioid prescriptions at discharge, and patient centered outcomes at discharge and 6 months. DISCUSSION: This trial will determine the effectiveness of sub-dissociative ketamine infusion as part of a MMPR in reducing in-hospital opioid exposure in adult trauma patients. Furthermore, it will inform decisions regarding acute pain strategies on patient centered outcomes. TRIAL REGISTRATION: The Ketamine for Acute Pain Management After Trauma (KAPT) with registration # NCT04129086 was registered on October 16, 2019

The Geriatric Nutritional Risk Index as a Predictor of Complications in Geriatric Trauma Patients

BACKGROUND: Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients. METHODS: This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes. RESULTS: A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home. CONCLUSIONS: Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III

Sensing Senses: Tactile Feedback for the Prevention of Decubitus Ulcers

Decubitus ulcers, also known as pressure sores, is a major problem in health care, in particular for patients with spinal cord injuries. These patients cannot feel the discomfort that would urge healthy people to change their posture. We describe a system that uses a sensor mat to detect problematic postures and provides tactile feedback to the user. The results of our preliminary study with healthy subjects show that the tactile feedback is a viable option to spoken feedback. We envision the system being used for rehabilitation games, but also for everyday Decubitus ulcers prevention

Are Trauma Surgeons Prepared? A Survey of Trauma Surgeons’ Disaster Preparedness Before and During the COVID-19 Pandemic

OBJECTIVE: US trauma centers (TCs) must remain prepared for mass casualty incidents (MCIs). However, trauma surgeons may lack formal MCI training. The recent COVID-19 pandemic drove multiple patient surges, overloaded Emergency Medical Services (EMS) agencies, and stressed TCs. This survey assessed trauma surgeons\u27 MCI training, experience, and system and personal preparedness before the pandemic compared with the pandemic\u27s third year. METHODS: Survey invitations were emailed to all 1544 members of the American Association for the Surgery of Trauma in 2019, and then resent in 2022 to 1575 members with additional questions regarding the pandemic. Questions assessed practice type, TC characteristics, training, experience, beliefs about personal and hospital preparedness, likelihood of MCI scenarios, interventions desired from membership organizations, and pandemic experiences. RESULTS: The response rate was 16.7% in 2019 and 12% in 2022. In 2022, surgeons felt better prepared than their hospitals for pandemic care, mass shootings, and active shooters, but remained feeling less well prepared for cyberattack and hazardous material events, compared with 2019. Only 35% of the respondents had unintentional MCI response experience in 2019 or 2022, and even fewer had experience with intentional MCI. 78% had completed a Stop the Bleed (STB) course and 63% own an STB kit. 57% had engaged in family preparedness activities; less than 40% had a family action plan if they could not come home during an MCI. 100% of the respondents witnessed pandemic-related adverse events, including colleague and coworker illness, patient surges, and resource limitations, and 17% faced colleague or coworker death. CONCLUSIONS: Trauma surgeons thought that they became better at pandemic care and rated themselves as better prepared than their hospitals for MCI care, which is an opportunity for them to take greater leadership roles. Opportunities remain to improve surgeons\u27 family and personal MCI preparedness. Surgeons\u27 most desired professional organization interventions include advocacy, national standards for TC preparedness, and online training. LEVEL OF EVIDENCE: VII, survey of expert opinion

Non-thermal emission processes in massive binaries

In this paper, I present a general discussion of several astrophysical processes likely to play a role in the production of non-thermal emission in massive stars, with emphasis on massive binaries. Even though the discussion will start in the radio domain where the non-thermal emission was first detected, the census of physical processes involved in the non-thermal emission from massive stars shows that many spectral domains are concerned, from the radio to the very high energies. First, the theoretical aspects of the non-thermal emission from early-type stars will be addressed. The main topics that will be discussed are respectively the physics of individual stellar winds and their interaction in binary systems, the acceleration of relativistic electrons, the magnetic field of massive stars, and finally the non-thermal emission processes relevant to the case of massive stars. Second, this general qualitative discussion will be followed by a more quantitative one, devoted to the most probable scenario where non-thermal radio emitters are massive binaries. I will show how several stellar, wind and orbital parameters can be combined in order to make some semi-quantitative predictions on the high-energy counterpart to the non-thermal emission detected in the radio domain. These theoretical considerations will be followed by a census of results obtained so far, and related to this topic... (see paper for full abstract)Comment: 47 pages, 5 postscript figures, accepted for publication in Astronomy and Astrophysics Review. Astronomy and Astrophysics Review, in pres

Association of Accelerometry-Measured Physical Activity and Cardiovascular Events in Mobility-Limited Older Adults: The LIFE (Lifestyle Interventions and Independence for Elders) Study.

BACKGROUND:Data are sparse regarding the value of physical activity (PA) surveillance among older adults-particularly among those with mobility limitations. The objective of this study was to examine longitudinal associations between objectively measured daily PA and the incidence of cardiovascular events among older adults in the LIFE (Lifestyle Interventions and Independence for Elders) study. METHODS AND RESULTS:Cardiovascular events were adjudicated based on medical records review, and cardiovascular risk factors were controlled for in the analysis. Home-based activity data were collected by hip-worn accelerometers at baseline and at 6, 12, and 24 months postrandomization to either a physical activity or health education intervention. LIFE study participants (n=1590; age 78.9±5.2 [SD] years; 67.2% women) at baseline had an 11% lower incidence of experiencing a subsequent cardiovascular event per 500 steps taken per day based on activity data (hazard ratio, 0.89; 95% confidence interval, 0.84-0.96; P=0.001). At baseline, every 30 minutes spent performing activities ≥500 counts per minute (hazard ratio, 0.75; confidence interval, 0.65-0.89 [P=0.001]) were also associated with a lower incidence of cardiovascular events. Throughout follow-up (6, 12, and 24 months), both the number of steps per day (per 500 steps; hazard ratio, 0.90, confidence interval, 0.85-0.96 [P=0.001]) and duration of activity ≥500 counts per minute (per 30 minutes; hazard ratio, 0.76; confidence interval, 0.63-0.90 [P=0.002]) were significantly associated with lower cardiovascular event rates. CONCLUSIONS:Objective measurements of physical activity via accelerometry were associated with cardiovascular events among older adults with limited mobility (summary score >10 on the Short Physical Performance Battery) both using baseline and longitudinal data. CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT01072500

The Galactic O-Star Spectroscopic Survey. I. Classification System and Bright Northern Stars in the Blue-Violet at R~2500

We present the first installment of a massive spectroscopic survey of Galactic O stars, based on new, high signal-to-noise ratio, R~2500 digital observations from both hemispheres selected from the Galactic O-Star Catalog of Ma\'iz Apell\'aniz et al. (2004) and Sota et al. (2008). The spectral classification system is rediscussed and a new atlas is presented, which supersedes previous versions. Extensive sequences of exceptional objects are given, including types Ofc, ON/OC, Onfp, Of?p, Oe, and double-lined spectroscopic binaries. The remaining normal spectra bring this first sample to 184 stars, which is close to complete to B=8 and north of delta = -20 and includes all of the northern objects in Ma\'iz Apell\'aniz et al. (2004) that are still classified as O stars. The systematic and random accuracies of these classifications are substantially higher than previously attainable, because of the quality, quantity, and homogeneity of the data and analysis procedures. These results will enhance subsequent investigations in Galactic astronomy and stellar astrophysics. In the future we will publish the rest of the survey, beginning with a second paper that will include most of the southern stars in Ma\'iz Apell\'aniz et al. (2004).Comment: Accepted for publication in ApJS. 73 pages and 20 figures. Figure 19 is shown at a degraded resolution due to arXiv limitations. If interested in the high-resolution version, please contact the autho