The American Association for the Surgery of Trauma renal injury grading scale: Implications of the 2018 revisions for injury reclassification and predicting bleeding interventions.

BackgroundIn 2018, the American Association for the Surgery of Trauma (AAST) published revisions to the renal injury grading system to reflect the increased reliance on computed tomography scans and non-operative management of high-grade renal trauma (HGRT). We aimed to evaluate how these revisions will change the grading of HGRT and if it outperforms the original 1989 grading in predicting bleeding control interventions.MethodsData on HGRT were collected from 14 Level-1 trauma centers from 2014 to 2017. Patients with initial computed tomography scans were included. Two radiologists reviewed the scans to regrade the injuries according to the 1989 and 2018 AAST grading systems. Descriptive statistics were used to assess grade reclassifications. Mixed-effect multivariable logistic regression was used to measure the predictive ability of each grading system. The areas under the curves were compared.ResultsOf the 322 injuries included, 27.0% were upgraded, 3.4% were downgraded, and 69.5% remained unchanged. Of the injuries graded as III or lower using the 1989 AAST, 33.5% were upgraded to grade IV using the 2018 AAST. Of the grade V injuries, 58.8% were downgraded using the 2018 AAST. There was no statistically significant difference in the overall areas under the curves between the 2018 and 1989 AAST grading system for predicting bleeding interventions (0.72 vs. 0.68, p = 0.34).ConclusionAbout one third of the injuries previously classified as grade III will be upgraded to grade IV using the 2018 AAST, which adds to the heterogeneity of grade IV injuries. Although the 2018 AAST grading provides more anatomic details on injury patterns and includes important radiologic findings, it did not outperform the 1989 AAST grading in predicting bleeding interventions.Level of evidencePrognostic and Epidemiological Study, level III

Identifying molecules as biosignatures with assembly theory and mass spectrometry

The search for alien life is hard because we do not know what signatures are unique to life. We show why complex molecules found in high abundance are universal biosignatures and demonstrate the first intrinsic experimentally tractable measure of molecular complexity, called the molecular assembly index (MA). To do this we calculate the complexity of several million molecules and validate that their complexity can be experimentally determined by mass spectrometry. This approach allows us to identify molecular biosignatures from a set of diverse samples from around the world, outer space, and the laboratory, demonstrating it is possible to build a life detection experiment based on MA that could be deployed to extraterrestrial locations, and used as a complexity scale to quantify constraints needed to direct prebiotically plausible processes in the laboratory. Such an approach is vital for finding life elsewhere in the universe or creating de-novo life in the lab

A novel tool for arrhythmic risk stratification in desmoplakin gene variant carriers

Background and Pathogenic desmoplakin (DSP) gene variants are associated with the development of a distinct form of arrhythmogenic car-Aims diomyopathy known as DSP cardiomyopathy. Patients harbouring these variants are at high risk for sustained ventricular arrhythmia (VA), but existing tools for individualized arrhythmic risk assessment have proven unreliable in this population. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods Patients from the multi-national DSP-ERADOS (Desmoplakin SPecific Effort for a RAre Disease Outcome Study) Network patient registry who had pathogenic or likely pathogenic DSP variants and no sustained VA prior to enrolment were followed longitudinally for the development of first sustained VA event. Clinically guided, step-wise Cox regression analysis was used to develop a novel clinical tool predicting the development of incident VA. Model performance was assessed by c-statistic in both the model development cohort (n = 385) and in an external validation cohort (n = 86). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results In total, 471 DSP patients [mean age 37.8 years, 65.6% women, 38.6% probands, 26% with left ventricular ejection fraction (LVEF) < 50%] were followed for a median of 4.0 (interquartile range: 1.6–7.3) years; 71 experienced first sustained VA events {2.6% [95% confidence interval (CI): 2.0, 3.5] events/year}. Within the development cohort, five readily available clinical parameters were identified as independent predictors of VA and included in a novel DSP risk score: female sex [hazard ratio (HR) 1.9 (95% CI: 1.1–3.4)], history of non-sustained ventricular tachycardia [HR 1.7 (95% CI: 1.1–2.8)], natural logarithm of 24-h premature ventricular contraction burden [HR 1.3 (95% CI: 1.1–1.4)], LVEF < 50% [HR 1.5 (95% CI: .95–2.5)], and presence of moderate to severe right ventricular systolic dysfunction [HR 6.0 (95% CI: 2.9–12.5)]. The model demonstrated good risk discrimination within both the development [c-statistic .782 (95% CI: .77–.80)] and external validation [c-statistic .791 (95% CI: .75–.83)] cohorts. The negative predictive value for DSP patients in the external validation cohort deemed to be at low risk for VA (<5% at 5 years; n = 26) was 100%. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions The DSP risk score is a novel model that leverages readily available clinical parameters to provide individualized VA risk assessment for DSP patients. This tool may help guide decision-making for primary prevention implantable cardioverter-defibrillator placement in this high-risk population and supports a gene-first risk stratification approach

Author Correction: Drivers of seedling establishment success in dryland restoration efforts

1 Pág. Correción errata.In the version of this Article originally published, the surname of author Tina Parkhurst was incorrectly written as Schroeder. This has now been corrected.Peer reviewe

Multicenter study of US trauma centers examining the effect of the COVID-19 pandemic on injury causes, diagnoses and procedures

Background The COVID-19 pandemic resulted in nationwide social distancing and shelter-in-place orders meant to curb transmission of the SARS-CoV-2 virus. The effect of the pandemic on injury patterns has not been well described in the USA. The study objective is to determine the effect of the COVID-19 pandemic on the distribution and determinants of traumatic injuries.Methods This retrospective multi-institutional cohort study included all hospital admissions for acute traumatic injury at six community level I trauma centers. Descriptive statistics were used to compare injury causes, diagnoses and procedures over two similar time periods: prepandemic (March 11–June 30, 2019) and pandemic (March 11–June 30, 2020).Results There were 7308 trauma patients included: 3862 (53%) prepandemic and 3446 (47%) during the pandemic. Cause of injury significantly differed by period (p&lt;0.001). During the pandemic, there were decreases in motor vehicle crashes (from 17.0% to 14.0%, p&lt;0.001), worksite injuries (from 5.2% to 4.1%, p=0.02), pedestrian injuries (from 3.0% to 2.2%, p=0.02) and recreational injuries (from 3.0% to 1.7%, p&lt;0.001), while there were significant increases in assaults (6.9% to 8.5%, p=0.01), bicycle crashes (2.8% to 4.2%, p=0.001) and off-road vehicle injuries (1.8% to 3.0%, p&lt;0.001). There was no change by study period in falls, motorcycle injuries, crush/strikes, firearm and self-inflicted injuries, and injuries associated with home-improvement projects. Injury diagnoses differed between time periods; during the pandemic, there were more injury diagnoses to the head (23.0% to 27.3%, p&lt;0.001) and the knee/leg (11.7% to 14.9%, p&lt;0.001). There were also increases in medical/surgical procedures (57.5% to 61.9%, p&lt;0.001), administration of therapeutics/blood products (31.4% to 34.2%, p=0.01) and monitoring (11.0% to 12.9%, p=0.01).Discussion Causes of traumatic injury, diagnoses, and procedures were significantly changed by the pandemic. Trauma centers must adjust to meet the changing demands associated with altered injury patterns, as they were associated with increased use of hospital resources.Level of evidence III (epidemiological)

IMPROVEMENT OF SACCADIC EYE MOVEMENTS AFTER HEAD-EYE VESTIBULAR MOTION (HEVM) THERAPY AND NEURO-PSYCHIATRIC CONSIDERATIONS

Introduction: Eye movement pathology can assist in the identification, diagnosis and treatment of mental health disorders. Eyetracking paradigms have been utilized to provide greater ecological validity, and directly capture the detailed sequence of processes in perception and attention, while quantifying classifiers in mood, anxiety, and psychotic disorders. Saccadic eye movements serve as an endophenotype for various mental health disorders. Subjects and methods: Patients suffering from post-concussive syndrome and mental health concerns performed saccadic eye movements that were quantified for amplitude, velocity, latency and accuracy before and after Head-Eye Vestibular Motion therapy (HEVM). Results: HEVM therapy is associated with statistical and substantive significant improvements in mental health and in saccadic metrics. Conclusions: Oculomotor dysfunction is related to the symptom dimensions of mental health disorders that may be treated with physical rehabilitation modalities. We feel it reasonable to suggest that psychiatrists and others involved in the treatment of mental health disorders quantify eye movements and use them as biomarkers in the evaluation of the outcomes of varied therapies

Hospice and palliative care utilization in 16 004 232 medicare claims: comparing trauma to surgical and medical inpatients

Background Hospice and palliative care (PC) utilization is increasing in geriatric inpatients, but limited research exists comparing rates among trauma, surgical and medical specialties. The goal of this study was to determine whether there are differences among these three groups in rates of hospice and PC utilization.Methods Patients from Centers for Medicare &amp; Medicaid Services (CMS) Inpatient Standard Analytical Files for 2016–2020 aged ≥65 years were analyzed. Patients with a National Trauma Data Standard-qualifying ICD-10 injury code with abbreviated injury score ≥2 were classified as ‘trauma’; the rest as ‘surgical’ or ‘medical’ using CMS MS-DRG definitions. Patients were classified as having PC if they had an ICD-10 diagnosis code for PC (Z51.5) and as hospice discharge (HD) if their hospital disposition was ‘hospice’ (home or inpatient). Use proportions for specialties were compared by group and by subgroups with increasing risk of poor outcome.Results There were 16M hospitalizations from 1024 hospitals (9.3% trauma, 26.3% surgical and 64.4% medical) with 53.7% women, 84.5% white and 38.7% &gt;80 years. Overall, 6.2% received PC and 4.1% a HD. Both rates were higher in trauma patients (HD: 3.6%, PC: 6.3%) versus surgical patients (HD: 1.5%, PC: 3.0%), but lower than in medical patients (HD: 5.2%, PC: 7.5%). PC rates increased in higher risk patient subgroups and were highest for inpatient HD.Conclusions In this large study of Medicare patients, HD and PC rates varied significantly among specialties. Trauma patients had higher HD and PC utilization rates than surgical, but lower than medical. The presence of comorbidities, frailty and/or severe traumatic brain injury (in addition to advanced age) may be valuable criteria in selection of trauma patients for hospice and PC services. Further studies are needed to inform the most efficient use of hospice and PC resources, with particular focus on both timing and selection of subgroups most likely to benefit from these valuable yet limited resources.Level of evidence Level III, therapeutic/care management

Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures

Objective The perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures.Methods This retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ2 tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative.Results There were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28–4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14–1.82), p=0.30). Postoperative hemoglobin values &lt;8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43).Conclusion Women taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury.Level of evidence I

The grass is not always greener: a multi-institutional pilot study of marijuana use and acute pain management following traumatic injury

Abstract Background Widespread legislative efforts to legalize marijuana have increased the prevalence of marijuana use and abuse. The effects of marijuana on pain tolerance and analgesic pain management in the acute pain setting have not been reported. Although marijuana has been shown to have antinociceptive effects and is approved for medical use to treat chronic pain, anecdotal evidence suggests marijuana users admitted with traumatic injuries experience poorer pain control than patients who do not use marijuana. We hypothesized that marijuana users would report higher pain scores and require more opioid analgesia following traumatic injury. Methods This retrospective pilot study included all patients involved in motor vehicle crashes, consecutively admitted to four trauma centers from 1/1/2016–4/30/2016. Marijuana status was examined as non-use and use, and was further categorized as chronic and episodic use. We performed a repeated measures mixed model to examine the association between marijuana use and a) average daily opioid consumption and b) average daily pain scores (scale 0–10). Opioid analgesics were converted to be equianalgesic to 1 mg IV hydromorphone. Results Marijuana use was reported in 21% (54/261), of which 30% reported chronic use (16/54). Marijuana use was reported more frequently in Colorado hospitals (23–29%) compared to the hospital in Texas (6%). Drug use with other prescription/street drugs was reported in 9% of patients. Other drug use was a significant effect modifier and results were presented after stratification by drug use. After adjustment, marijuana users who did not use other drugs consumed significantly more opioids (7.6 mg vs. 5.6 mg, p <  0.001) and reported higher pain scores (4.9 vs. 4.2, p <  0.001) than non-marijuana users. Conversely, in patients who used other drugs, there were no differences in opioid consumption (5.6 mg vs. 6.1 mg, p = 0.70) or pain scores (5.3 vs. 6.0, p = 0.07) with marijuana use compared to non-use, after adjustment. Chronic marijuana use was associated with significantly higher opioid consumption compared to episodic marijuana use in concomitant drug users (11.3 mg vs. 4.4 mg, p = 0.008) but was similar in non-drug users (p = 0.41). Conclusion These preliminary data suggest that marijuana use, especially chronic use, may affect pain response to injury by requiring greater use of opioid analgesia. These results were less pronounced in patients who used other drugs