Prediction modelling for trauma using comorbidity and 'true' 30-day outcome

BACKGROUND: Prediction models for trauma outcome routinely control for age but there is uncertainty about the need to control for comorbidity and whether the two interact. This paper describes recent revisions to the Trauma Audit and Research Network (TARN) risk adjustment model designed to take account of age and comorbidities. In addition linkage between TARN and the Office of National Statistics (ONS) database allows patient's outcome to be accurately identified up to 30 days after injury. Outcome at discharge within 30 days was previously used. METHODS: Prospectively collected data between 2010 and 2013 from the TARN database were analysed. The data for modelling consisted of 129 786 hospital trauma admissions. Three models were compared using the area under the receiver operating curve (AuROC) for assessing the ability of the models to predict outcome, the Akaike information criteria to measure the quality between models and test for goodness-of-fit and calibration. Model 1 is the current TARN model, Model 2 is Model 1 augmented by a modified Charlson comorbidity index and Model 3 is Model 2 with ONS data on 30 day outcome. RESULTS: The values of the AuROC curve for Model 1 were 0.896 (95% CI 0.893 to 0.899), for Model 2 were 0.904 (0.900 to 0.907) and for Model 3 0.897 (0.896 to 0.902). No significant interaction was found between age and comorbidity in Model 2 or in Model 3. CONCLUSIONS: The new model includes comorbidity and this has improved outcome prediction. There was no interaction between age and comorbidity, suggesting that both independently increase vulnerability to mortality after injury

Outcomes of polytrauma patients with diabetes mellitus.

BACKGROUND: The impact of diabetes mellitus in patients with multiple system injuries remains obscure. This study was designed to increase knowledge of outcomes of polytrauma in patients who have diabetes mellitus. METHODS: Data from the Trauma Audit and Research Network was used to identify patients who had suffered polytrauma during 2003 to 2011. These patients were filtered to those with known outcomes, then separated into those with diabetes, those known to have other co-morbidities but not diabetes and those known not to have any co-morbidities or diabetes. The data were analyzed to establish if patients with diabetes had differing outcomes associated with their diabetes versus the other groups. RESULTS: In total, 222 patients had diabetes, 2,558 had no past medical co-morbidities (PMC), 2,709 had PMC but no diabetes. The diabetic group of patients was found to be older than the other groups (P <0.05). A higher mortality rate was found in the diabetic group compared to the non-PMC group (32.4% versus 12.9%), P <0.05). Rates of many complications including renal failure, myocardial infarction, acute respiratory distress syndrome, pulmonary embolism and deep vein thrombosis were all found to be higher in the diabetic group. CONCLUSIONS: Close monitoring of diabetic patients may result in improved outcomes. Tighter glycemic control and earlier intervention for complications may reduce mortality and morbidity

The Water Footprint of Diets: A Global Systematic Review and Meta-analysis.

Agricultural water requirements differ between foods. Population-level dietary preferences are therefore a major determinant of agricultural water use. The "water footprint" (WF) represents the volume of water consumed in the production of food items, separated by water source; blue WF represents ground and surface water use, and green WF represents rain water use. We systematically searched for published studies using the WF to assess the water use of diets. We used the available evidence to quantify the WF of diets in different countries, and grouped diets in patterns according to study definition. "Average" patterns equated to those currently consumed, whereas "healthy" patterns included those recommended in national dietary guidelines. We searched 7 online databases and identified 41 eligible studies that reported the dietary green WF, blue WF, or total WF (green plus blue) (1964 estimates for 176 countries). The available evidence suggests that, on average, European (170 estimates) and Oceanian (18 estimates) dietary patterns have the highest green WFs (median per capita: 2999 L/d and 2924 L/d, respectively), whereas Asian dietary patterns (98 estimates) have the highest blue WFs (median: 382 L/d per capita). Foods of animal origin are major contributors to the green WFs of diets, whereas cereals, fruits, nuts, and oils are major contributors to the blue WF of diets. "Healthy" dietary patterns (425 estimates) had green WFs that were 5.9% (95% CI: -7.7, -4.0) lower than those of "average" dietary patterns, but they did not differ in their blue WFs. Our review suggests that changes toward healthier diets could reduce total water use of agriculture, but would not affect blue water use. Rapid dietary change and increasing water security concerns underscore the need for a better understanding of the amount and type of water used in food production to make informed policy decisions

The Old Man and the Manuscript

Lengthy review of Hemingway’s latest posthumously published book True at First Light by the editor of The Garden of Eden (1986), another of Hemingway’s posthumously published works. Characterizing True at First Light as a failed effort by a failing writer, Jenks outlines the events inspiring the book’s conception along with Patrick Hemingway’s difficulties in editing. Despite criticizing the book as “unformed, fragmentary, digressive, and anecdotal,” Jenks doubts its appearance will diminish Hemingway’s reputation or stem the flow of future posthumous works making their way into the marketplace

\u3cem\u3eThe Garden of Eden\u3c/em\u3e at Twenty-five

On the trials and tribulations of working with Hemingway’s manuscripts and his editorial process in bringing The Garden of Eden to press