Injured patients with very high blood alcohol concentrations

Objective—Most data regarding high blood alcohol concentrations (BAC) ≥400 mg/dL have been from alcohol poisoning deaths. Few studies have described this group and reported their alcohol consumption patterns or outcomes compared to other trauma patients. We hypothesized trauma patients with very high BACs arrived to the trauma center with less severe injuries than their sober counterparts. Method—Historical cohort of 46,222 patients admitted to a major trauma center between January 1, 2002 and October 31, 2011. BAC was categorized into ordinal groups by 100 mg/dL intervals. Alcohol questionnaire data on frequency and quantity was captured in the BAC ≥400 mg/dL group. The primary analysis was for BAC ≥400 mg/dL. Results—BAC was recorded in 44,502 (96.3%) patients. Those with a BAC ≥400 mg/dL accounted for 1.1% (147) of BAC positive cases. These patients had the lowest proportion of severe trauma and in-hospital death in comparison with the other alcohol groups (p\u3c0.001), and the group comprised mainly of falls. Admission Glasgow Coma Scale was a poor predictor for traumatic brain injury in the high BAC group. Readmission occurred in 22.4% (33) of patients the BAC ≥400 group. The majority of these patients reported drinking alcohol four or more days per week (81, 67.5%) and five or more drinks per day (79, 65.8%), evident of risky alcohol use. Conclusions—Most traumas admitted with BAC ≥400 mg/dL survived and their injuries were less severe than their less intoxicated and sober counterparts. They also had evidence for risky alcohol use and nearly one-quarter returned to the trauma center with another injury over the study period. Recognition of t

Assessment of patient safety culture in primary health care in Muscat, Oman: a questionnaire -based survey

Abstract Background Patient safety is a universal issue which affects countries at all stages of health system development. Patient safety research in primary care reveals that globally millions of people suffer disabilities, injuries, or death due to unsafe medical practices. This study aims to explore the understanding of frontline primary health care professionals regarding patient safety culture in health care facilities in Oman. Methods A questionnaire–based survey was conducted using a validated Hospital Survey of Patient Safety Culture tool. Invitations were sent to all 198 health professionals from each occupational category from each primary care center in Muscat, Oman. Results The total number of respondents was 186 participants out of 198 (response rate: 94%). Overall, the staff had a strong sense of teamwork within the units (85%), they reported organization learning for continuous improvement (84%) and teamwork across the units (82%). However, the four dimensions which received the lowest scores were related to communication problems between the staff (23%), non-punitive response to errors (27%), frequency of event reporting (40%), and errors occurring when transferring patients to higher levels of health care during handoffs and transitions (46%). Conclusions Overall, the participants rated patient safety in the primary health care setting as excellent or very good and the perception of patient safety was moderately positive. The core areas of strength were teamwork within the units with positivity and organization learning and continuous improvement. The weaknesses were non-punitive response to errors, inadequate staffing and hand offs and transition. The results of this study will provide policy makers and health care professionals with a detailed understanding of the current patient safety culture in primary care in Muscat, Oman. The results will be used by the Ministry of Health to inform policy and strategies to strengthen patient safety within primary health care in Oman

The Impact of Corticosteroids on Secondary Infection and Mortality in Critically Ill COVID-19 Patients

Background: Corticosteroids are part of the treatment guidelines for COVID-19 and have been shown to improve mortality. However, the impact corticosteroids have on the development of secondary infection in COVID-19 is unknown. We sought to define the rate of secondary infection in critically ill patients with COVID-19 and determine the effect of corticosteroid use on mortality in critically ill patients with COVID-19. Study Design and Methods: One hundred and thirty-five critically ill patients with COVID-19 admitted to the Intensive Care Unit (ICU) at the University of Maryland Medical Center were included in this single-center retrospective analysis. Demographics, symptoms, culture data, use of COVID-19 directed therapies, and outcomes were abstracted from the medical record. The primary outcomes were secondary infection and mortality. Proportional hazards models were used to determine the time to secondary infection and the time to death. Results: The proportion of patients with secondary infection was 63%. The likelihood of developing secondary infection was not significantly impacted by the administration of corticosteroids (HR 1.45, CI 0.75-2.82, P = 0.28). This remained consistent in sub-analysis looking at bloodstream, respiratory, and urine infections. Secondary infection had no significant impact on the likelihood of 28-day mortality (HR 0.66, CI 0.33-1.35, P = 0.256). Corticosteroid administration significantly reduced the likelihood of 28-day mortality (HR 0.27, CI 0.10-0.72, P = 0.01). Conclusion: Corticosteroids are an important and lifesaving pharmacotherapeutic option in critically ill patients with COVID-19, which have no impact on the likelihood of developing secondary infections

Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement

BackgroundIdentification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR).MethodsAn NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers. Major trauma patients were screened for an IVCD of 12 mm or less or IVCCI of 50% or less on initial focused assessment sonographic evaluations for trauma. A second IVCD was obtained 40 minutes to 60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was less than 10 mm were deemed nonrepleted (NONREPLETED), those 10 mm or greater were repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, Injury Severity Score, arterial blood gasses, length of stay, interventions, and complications were recorded. Means were compared by ANOVA and categorical variables were compared via χ. Receiver operating characteristic curves analysis was used to compare the measures as 24FR predictors.ResultsThere were 4,798 patients screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NONREPLETED. Demographics, initial hemodynamics, or laboratory measures were not significantly different. NONREPLETED had smaller IVCD (6.0 ± 3.7 mm vs. 14.2 ± 4.3 mm, p < 0.001) and higher IVCCI (41.7% ± 30.0% vs. 13.2% ± 12.7%, p < 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NONREPLETED (2503 ± 1751 mL vs. 1,243 ± 1,130 mL, p = 0.003). Receiver operating characteristic analysis indicates IVCDMIN predicted 24FR (area under the curve [AUC], 0.74; 95% confidence interval [CI], 0.64-0.84; p < 0.001) as did IVCCI (AUC, 0.75; 95% CI, 0.65-0.85; p < 0.001) but not IJVDMIN (AUC, 0.48; 95% CI, 0.24-0.60; p = 0.747) or IJVCI (AUC, 0.54; 95% CI, 0.42-0.67; p = 0.591).ConclusionUltrasound assessed IVCDMIN and IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements.Level of evidenceDiagnostic tests or criteria, level II

Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement.

BackgroundIdentification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR).MethodsAn NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers. Major trauma patients were screened for an IVCD of 12 mm or less or IVCCI of 50% or less on initial focused assessment sonographic evaluations for trauma. A second IVCD was obtained 40 minutes to 60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was less than 10 mm were deemed nonrepleted (NONREPLETED), those 10 mm or greater were repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, Injury Severity Score, arterial blood gasses, length of stay, interventions, and complications were recorded. Means were compared by ANOVA and categorical variables were compared via χ. Receiver operating characteristic curves analysis was used to compare the measures as 24FR predictors.ResultsThere were 4,798 patients screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NONREPLETED. Demographics, initial hemodynamics, or laboratory measures were not significantly different. NONREPLETED had smaller IVCD (6.0 ± 3.7 mm vs. 14.2 ± 4.3 mm, p < 0.001) and higher IVCCI (41.7% ± 30.0% vs. 13.2% ± 12.7%, p < 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NONREPLETED (2503 ± 1751 mL vs. 1,243 ± 1,130 mL, p = 0.003). Receiver operating characteristic analysis indicates IVCDMIN predicted 24FR (area under the curve [AUC], 0.74; 95% confidence interval [CI], 0.64-0.84; p < 0.001) as did IVCCI (AUC, 0.75; 95% CI, 0.65-0.85; p < 0.001) but not IJVDMIN (AUC, 0.48; 95% CI, 0.24-0.60; p = 0.747) or IJVCI (AUC, 0.54; 95% CI, 0.42-0.67; p = 0.591).ConclusionUltrasound assessed IVCDMIN and IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements.Level of evidenceDiagnostic tests or criteria, level II

Evolution of Structure and Activity of Alloy Electrocatalysts during Electrochemical Cycles: Combined Activity, Stability, and Modeling Analysis of PtIrCo(7:1:7) and Comparison with PtCo(1:1)

This study explores the changes in bulk composition/structure and oxygen reduction activity of two alloys, Pt₇IrCo₇ and PtCo, caused by Co leaching during electrochemical cycles and as a result of membrane electrode assembly (MEA) fabrication procedures. Exposure to liquid electrolyte and electrochemical cycles in a rotating disc electrode (RDE) environment resulted in substantial Co loss and no stabilization from the low levels of Ir used in the ternary material. The true composition of the ternary material was determined as Pt₈IrCo₃ following initial exposure to 0.1 M HClO₄ (before cycling) and Pt₁₁IrCo₄ after 5000 cycles. Density functional theory (DFT) modeling of the cycled catalyst compositions indicated that structures with Pt-rich upper layers would show the highest stability; however, addition of 0.25 ML oxygen adsorption favored Co segregation from second and third atomic layers. The high initial activities (>0.44A/mgPt) achieved in the RDE environment decreased with cycles and were not reproduced in MEAs. X-ray diffraction (XRD) analysis revealed a measurable increase in lattice parameter caused by the MEA preparation procedure, consistent with Co (and some Ir) leaching into the ionomer phase and relaxation of the lattice. MEA fabrication procedures and cycling in 1 M H₂SO₄ at 80^◦C showed greater changes to catalyst structure and increased Ir and Co loss compared to exposing the catalyst to RDE like conditions (0.1 M HClO₄, RT) explaining the observed discrepancy in activity between RDE and MEA