Effect of Preinjury Oral Anticoagulants on Outcomes Following Traumatic Brain Injury from Falls in Older Adults

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156128/2/phar2435_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156128/1/phar2435.pd

Building, scaling, and sustaining a learning health system for surgical quality improvement: A toolkit

This article describes how to start, replicate, scale, and sustain a learning health system for quality improvement, based on the experience of the Michigan Surgical Quality Collaborative (MSQC). The key components to operationalize a successful collaborative improvement infrastructure and the features of a learning health system are explained. This information is designed to guide others who desire to implement quality improvement interventions across a regional network of hospitals using a collaborative approach. A toolkit is provided (under Supporting Information) with practical information for implementation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156156/3/lrh210215.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156156/2/lrh210215-sup-0001-supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156156/1/lrh210215_am.pd

Short‐wave infrared light imaging measures tissue moisture and distinguishes superficial from deep burns

Existing clinical approaches and tools to measure burn tissue destruction are limited resulting in misdiagnosis of injury depth in over 40% of cases. Thus, our objective in this study was to characterize the ability of short‐wave infrared (SWIR) imaging to detect moisture levels as a surrogate for tissue viability with resolution to differentiate between burns of various depths. To accomplish our aim, we constructed an imaging system consisting of a broad‐band Tungsten light source; 1,200‐, 1,650‐, 1,940‐, and 2,250‐nm wavelength filters; and a specialized SWIR camera. We initially used agar slabs to provide a baseline spectrum for SWIR light imaging and demonstrated the differential absorbance at the multiple wavelengths, with 1,940 nm being the highest absorbed wavelength. These spectral bands were then demonstrated to detect levels of moisture in inorganic and in vivo mice models. The multiwavelength SWIR imaging approach was used to diagnose depth of burns using an in vivo porcine burn model. Healthy and injured skin regions were imaged 72 hours after short (20 seconds) and long (60 seconds) burn application, and biopsies were extracted from those regions for histologic analysis. Burn depth analysis based on collagen coagulation histology confirmed the formation of superficial and deep burns. SWIR multispectral reflectance imaging showed enhanced intensity levels in long burned regions, which correlated with histology and distinguished between superficial and deep burns. This SWIR imaging method represents a novel, real‐time method to objectively distinguishing superficial from deep burns.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154351/1/wrr12779_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154351/2/wrr12779.pd

Variation in amino acid and lipid composition of latent fingerprints

The enhancement of latent fingerprints, both at the crime scene and in the laboratory using an array of chemical, physical and optical techniques, permits their use for identification. Despite the plethora of techniques available, there are occasions when latent fingerprints are not successfully enhanced. An understanding of latent fingerprint chemistry and behaviour will aid the improvement of current techniques and the development of novel ones. In this study the amino acid and fatty acid content of ‘real’ latent fingerprints collected on a non-porous surface was analysed by gas chromatography–mass spectrometry. Squalene was also quantified in addition. Hexadecanoic acid, octadecanoic acid and cis-9- octadecenoic acid were the most abundant fatty acids in all samples. There was, however, wide variation in the relative amounts of each fatty acid in each sample. It was clearly demonstrated that touching sebum-rich areas of the face immediately prior to fingerprint deposition resulted in a significant increase in the amount of fatty acids and squalene deposited in the resulting ‘groomed’ fingerprints. Serine was the most abundant amino acid identified followed by glycine, alanine and aspartic acid. The significant quantitative differences between the ‘natural’ and ‘groomed’ fingerprint samples seen for fatty acids were not observed in the case of the amino acids. This study demonstrates the variation in latent fingerprint composition between individuals and the impact of the sampling protocol on the quantitative analysis of fingerprints

An essential role for complement C5a in the pathogenesis of septic cardiac dysfunction

Defective cardiac function during sepsis has been referred to as “cardiomyopathy of sepsis.” It is known that sepsis leads to intensive activation of the complement system. In the current study, cardiac function and cardiomyocyte contractility have been evaluated in rats after cecal ligation and puncture (CLP). Significant reductions in left ventricular pressures occurred in vivo and in cardiomyocyte contractility in vitro. These defects were prevented in CLP rats given blocking antibody to C5a. Both mRNA and protein for the C5a receptor (C5aR) were constitutively expressed on cardiomyocytes; both increased as a function of time after CLP. In vitro addition of recombinant rat C5a induced dramatic contractile dysfunction in both sham and CLP cardiomyocytes, but to a consistently greater degree in cells from CLP animals. These data suggest that CLP induces C5aR on cardiomyocytes and that in vivo generation of C5a causes C5a–C5aR interaction, causing dysfunction of cardiomyocytes, resulting in compromise of cardiac performance

Hips Can Lie: Impact of Excluding Isolated Hip Fractures on External Benchmarking of Trauma Center Performance

BACKGROUND: Trauma centers (TCs) vary in the inclusion of patients with isolated hip fractures (IHFs) in their registries. This inconsistent case ascertainment may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS: Data were derived from the National Trauma Data Bank (2007-8.1). We included patients (aged 16 years or older) with Injury Severity Score value ≥ 9 who were admitted to Level I and II TCs. To ensure data quality, we limited the study to TC that routinely reported comorbidities and Abbreviated Injury Scale codes. IHF were defined as patients, aged 65 years or older, injured as a result of falls, with Abbreviated Injury Scale codes for hip fracture and without other significant injuries. TCs were stratified according to their reported inclusion of IHF in their registry. Observed-to-expected mortality ratios were used to rank TC performance first with and then, without the inclusion of patients with IHF. RESULTS: In total, 91,152 patients in 132 TCs were identified; 5% (n = 4,448) were IHF. The proportion of IHF per TC varied significantly, ranging from 0% to 31%. When risk-adjusted mortality was evaluated, excluding patients with IHF had significant effects: 37% (n = 49) of TCs changed their performance rank by ≥ 3 (range, 1-25) and 12% of centers changed their performance quintile. The greatest change in rank performance was evident in centers that routinely include IHF in their registries. CONCLUSIONS: Given the fact that IHFs in the elderly significantly influence risk-adjusted outcomes and are variably reported by TCs, these patients should be excluded from subsequent benchmarking efforts

Factors associated with optimal patient outcomes after operative repair of isolated hip fractures in the elderly

Background: Increased time to operative intervention is associated with a greater risk of mortality and complications in adults with a hip fracture. This study sought to determine factors associated with timeliness of operation in elderly patients presenting with an isolated hip fracture and the influence of surgical delay on outcomes. Methods: Trauma quality collaborative data (July 2016 to June 2019) were analyzed. Inclusion criteria were patients ≥65 years with an injury mechanism of fall, Abbreviated Injury Scale (AIS) 2005 diagnosis of hip fracture, and AIS extremity ≤3. Exclusion criteria included AIS in other body regions >1 and non-operative management. We examined the association of demographic, hospital, injury presentation, and comorbidity factors on a surgical delay >48 hours and patient outcomes using multivariable regression analysis. Results: 10 182 patients fit our study criteria out of 212 620 patients. Mean age was 82.7±8.6 years and 68.7% were female. Delay in operation >48 hours occurred in 965 (9.5%) of patients. Factors that significantly increased mortality or discharge to hospice were increased age, male gender, emergency department hypotension, functionally dependent health status (FDHS), advanced directive, liver disease, angina, and congestive heart failure (CHF). Delay >48 hours was associated with increased mortality or discharge to hospice (OR 1.52; 95% CI 1.13 to 2.06; p48 hours were male gender, FDHS, CHF, chronic renal failure, and advanced directive. Admission to the orthopedic surgery service was associated with less incidence of delay >48 hours (OR 0.43; 95% CI 0.29 to 0.64; p<0.001). Discussion: Hospital verification level, admission service, and patient volume did not impact the outcome of mortality/discharge to hospice. Delay to operation >48 hours was associated with increased mortality. The only measured modifiable characteristic that reduced delay to operative intervention was admission to the orthopedic surgery service. Level of evidence: III

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication