Transportation Time In A Rural State Following Splenic Injury: Does Time Matter

Background: Failure rates remain high following attempted non-operative treatment of spleen injuries despite progress made in identifying risk factors. Over the past thirty years, transportation times were excluded from predictive models although rapid transportation was advocated to improve patient outcomes. For patients living in a rural environment, this time may prove critical. The purpose of this study was to assess the effect of transport time on survival rates and hospital length of stay for patients selected to receive non-operative versus operative treatment. Methods: A 10-year retrospective review was conducted of patients ages 13 years and older who presented to an American College of Surgeons-verified Level 1 trauma center between January 1, 2003 to December 31, 2012. Non-operative management (NOM) was defined as observation with or without the adjunctive use of angiography (AE) or splenic artery embolization (SAE) performed less than 2 hours from admission. Failed non-operative management (FNOM) was defined as AE or SAE performed greater than two hours from admission, or a planned operation greater than two hours from admission (POR) for any reason. Cox proportional hazard regression and logistic regression analysis were conducted to identify factors associated with hospital length of stay (H-LOS) and mortality. Covariates included: age, gender, injury severity score (ISS), injury type (blunt versus penetrating), treatment group (POR, NOM, or FNOM), time from admission to procedure, and transportation time from the time EMS received the 911 phone call to emergency department admission.   Results: Among the 364 patients included in the final analysis, 11.0% (n=40) died before hospital discharge. The median transport time was 64 minutes (average=92.6 ± 81 minutes, range=6 to 480 minutes). The majority (92.9%, n=338) of patients underwent NOM, with 7.1% (n=26) receiving POR. Among those 338 NOM patients, 92.3% (n=312) remained NOM after 2 hours, and others had FNOM after 2 hours (7.7%, n=26). Those who received POR or NOM were associated with 45.5% and 47.4% of the transportation time being less than 60 minutes, respectively. After two hours, average ISS score by treatment group (POR, NOM, or FNOM) of 23.83, 21.96, and 28.07, respectively. Cox proportional hazard regression analysis reported that ISS score was the only significant predictor for H-LOS. Logistic regression revealed that ISS score and age were associated with mortality. Transport time was not statistically associated with H-LOS or mortality. Conclusion: While not predictive of H-LOS or mortality, transportation time demonstrated that in rural environments longer transportation times allow physiologic symptoms to manifest prior to admission. Our results demonstrated that the majority (96%) of our FNOMs occurred less than six hours following admission and 100% less than 48 hours. We recommend intensive observation during hospital days one, with less robust surveillance through hospital day two. Discharge can be considered on hospital day three based on other injuries

Computed Tomography in Trauma Patients Accepted in Transfer:: Missed Injuries and Rationale for Repeat Imaging. Can we do Better?

Introduction. Computed tomography scans often are repeated ontrauma patient transfers, leading to increased radiation exposure,resource utilization, and costs. This study examined the incidenceof repeated computed tomography scans (RCT) in trauma patienttransfers before and after software upgrades, physician education,and encouragement to reduce RCT.Methods.xThe number of RCTs at an American College of SurgeonsCommittee on Trauma verified level 1 trauma center was measured.The trauma team was educated and encouraged to use the computedtomography scans received with transfer trauma patients as perstudy protocol. All available images were reviewed and reasons for aRCT when ordered were recorded and categorized. Impact of systemimprovements and education on subsequent RCT were evaluated.Results. A RCT was done on 47.2% (n = 76) of patients throughoutthe study period. Unacceptable image quality and possible misseddiagnoses were the most commonly reported reasons for a RCT. Preventablereasons for a RCT (attending refusal to read outside films,incompatible software, and physician preference) decreased from25.8 to 14.3% over the study periods.Conclusions. The volume of unnecessary RCT can be reduced primarilythrough software updates and physician education, therebydecreasing radiation exposure, patient cost, and inefficiencies in hospitalresource usage. Kans J Med 2019;12(1):7-10

Increasing Onshore Oil Production: An Unexpected Explosion in Trauma Patients

Introduction. Few data currently exist which are focused on typeand severity of onshore oil extraction-related injuries. The purposeof this study was to evaluate injury patterns among onshore oil fieldoperations. Methods. A retrospective review was conducted of all traumapatients aged 18 and older with an onshore oil field-related injuryadmitted to an American College of Surgeons-verified level 1 traumacenter between January 1, 2003 and June 30, 2012. Data collectedincluded demographics, injury severity and details, hospital outcomes,and disposition. Results. A total of 66 patients met inclusion criteria. All patientswere male, of which the majority were Caucasian (81.8%, n = 54)with an average age of 36.5 ± 11.8 years, injury severity score of 9.4 ±8.9, and Glasgow Coma Scale score of 13.8 ± 3.4. Extremity injurieswere the most common (43.9%, n = 29), and most were the resultof being struck by an object (40.9%, n = 27). Approximately onethirdof patients (34.8%, n = 23) were admitted to the intensive careunit. Nine patients (13.6%) required mechanical ventilation while27 (40.9%) underwent operative treatment. The average hospitallength of stay was 5.8 ± 16.6 days, and most patients (78.8%, n = 52)were discharged home. Four patients suffered permanent disabilities,and there were two deaths. Conclusions. Increased domestic onshore oil production inevitablywill result in higher numbers of oil field-related traumas. By focusingon employees who are at the greatest risk for injuries and by targetingthe main causes of injuries, training programs can lead to a decreasein injury incidence. Kans J Med 2018;11(2):34-37

Comparisons of Medical Student Knowledge Regarding Life-Threatening CT Images Before and After Clinical Experience

Introduction. Currently, no national standard exists for educatingmedical students regarding radiography or formal research indicatingthe level of improvement regarding computed tomography(CT) interpretation of medical students during clinical rotations. Methods. Students were evaluated based on their response totwenty-two open-ended questions regarding diagnosis and treatmentof eleven de-identified CT images of life-threatening injuries.The number of incorrect answers was compared withcorrect or partially correct answers between students startingthird-year clinical rotations and those starting their fourth year. Results. Survey results were collected from 65 of 65 (100%) beginningthird-year students and 9 of 60 (15%) beginning fourthyearstudents. Students in their fourth-year had less incorrectanswers compared to third-year students, with five questionsreflecting a statistically significant reduction in incorrect responses.The image with the least incorrect for both groups wasepidural hemorrhage, 33.9% and 18.5% incorrect for third-yearstudents for diagnosis and treatment, respectively, and 11.1%and 0% incorrect for fourth-year students. Outside of this image,the range of incorrect answers for third-year students was75.4% to 100% and 44.4% to 100% for fourth-year students. Conclusion. Baseline CT knowledge of medical students,regardless of clinical experience, indicated a strong deficit,as more students were incorrect than correct for themajority of CT images. KS J Med 2017;10(3):55-58

Head CT Guidelines Following Concussion Among the Youngest Trauma Patients: Can We Limit Radiation Exposure Following Traumatic Brain Injury?

Introduction. Recent studies have provided guidelines on the use ofhead computed tomography (CT) scans in pediatric trauma patients.The purpose of this study was to identify the prevalence of theseguidelines among concussed pediatric patients. Methods. A retrospective review was conducted of patients fouryears or younger with a concussion from blunt trauma. Demographics,head injury characteristics, clinical indicators for head CT scan(severe mechanism, physical exam findings of basilar skull fracture,non-frontal scalp hematoma, Glasgow Coma Scale score, loss ofconsciousness, neurologic deficit, altered mental status, vomiting,headache, amnesia, irritability, behavioral changes, seizures, lethargy),CT results, and hospital course were collected. Results. One-hundred thirty-three patients (78.2%) received a headCT scan, 7 (5.3%) of which demonstrated fractures and/or bleeds. Allpatients with skull fractures and/or bleeds had at least one clinicalindicator present on arrival. Clinical indicators that were observedmore commonly in patients with positive CT findings than in thosewith negative CT findings included severe mechanism (100% vs.54.8%, respectively, p = 0.020) and signs of a basilar skull fracture(28.6% vs. 0.8%, respectively, p = 0.007). Severe mechanism alonewas found to be sensitive, but not specific, whereas signs of a basilarskull fracture, headache, behavioral changes, and vomiting were specific,but not sensitive. No neurosurgical procedures were necessary,and there were no deaths. Conclusions. Clinical indicators were present in patients with positiveand negative CT findings. However, severe mechanism of injuryand signs of basilar skull fracture were more common for patients withpositive CT findings. Kans J Med 2018;11(2):38-43

Pediatric Farm Injuries: Morbidity and Mortality

Introduction. Agriculture is an industry where family members oftenlive and work on the same premises. This study evaluated injury patternsand outcomes in children from farm-related accidents. Methods. A 10-year retrospective review of farm-accident relatedinjuries was conducted of patients 17 years and younger. Data collectedincluded demographics, injury mechanism, accident details, injuryseverity and patterns, treatments required, hospitalization details, anddischarge disposition. Results. Sixty-five patients were included; 58.5% were male and themean age was 9.7 years. Median Injury Severity Score and GlasgowComa Scale were 5 and 15, respectively. Accident mechanisms includedanimal-related (43.1%), fall (21.5%), and motor vehicle (21.5%).Soft tissue injuries, concussions and upper extremity fractures werethe most common injuries observed (58.5%, 29.2%, and 26.2%,respectively). Twenty-six patients (40%) required surgical intervention.Mean hospital length of stay was 3.4 ± 4.7 days. The majority ofpatients were discharged to home (n = 62, 95.4%) and two patientssuffered permanent disability. Conclusion. Overall, outcomes for this population were favorable,but additional measures to increase safety, such as fall prevention,animal handling, and driver safety training should be advocated.KS J Med 2017;10(4):92-95

Fifteen new risk loci for coronary artery disease highlight arterial-wall-specific mechanisms

Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide. Although 58 genomic regions have been associated with CAD thus far, most of the heritability is unexplained, indicating that additional susceptibility loci await identification. An efficient discovery strategy may be larger-scale evaluation of promising associations suggested by genome-wide association studies (GWAS). Hence, we genotyped 56,309 participants using a targeted gene array derived from earlier GWAS results and performed meta-analysis of results with 194,427 participants previously genotyped, totaling 88,192 CAD cases and 162,544 controls. We identified 25 new SNP-CAD associations (P < 5 × 10(-8), in fixed-effects meta-analysis) from 15 genomic regions, including SNPs in or near genes involved in cellular adhesion, leukocyte migration and atherosclerosis (PECAM1, rs1867624), coagulation and inflammation (PROCR, rs867186 (p.Ser219Gly)) and vascular smooth muscle cell differentiation (LMOD1, rs2820315). Correlation of these regions with cell-type-specific gene expression and plasma protein levels sheds light on potential disease mechanisms

Fever, hyperglycaemia and swallowing dysfunction management in acute stroke: A cluster randomised controlled trial of knowledge transfer

Background: Hyperglycaemia, fever, and swallowing dysfunction are poorly managed in the admission phase of acute stroke, and patient outcomes are compromised. Use of evidence-based guidelines could improve care but have not been effectively implemented. Our study aims to develop and trial an intervention based on multidisciplinary team-building to improve management of fever, hyperglycaemia, and swallowing dysfunction in patients following acute stroke. Methods and design: Metropolitan acute stroke units (ASUs) located in New South Wales, Australia will be stratified by service category (A or B) and, within strata, by baseline patient recruitment numbers (high or low) in this prospective, multicentre, single-blind, cluster randomised controlled trial (CRCT). ASUs then will be randomised independently to either intervention or control groups. ASUs allocated to the intervention group will receive: unit-based workshops to identify local barriers and enablers; a standardised core education program; evidence-based clinical treatment protocols; and ongoing engagement of local staff. Control group ASUs will receive only an abridged version of the National Clinical Guidelines for Acute Stroke Management. The following outcome measures will be collected at 90 days post-hospital admission: patient death, disability (modified Rankin Score); dependency (Barthel Index) and Health Status (SF-36). Additional measures include: performance of swallowing screening within 24 hours of admission; glycaemic control and temperature control. Discussion: This is a unique study of research transfer in acute stroke. Providing optimal inpatient care during the admission phase is essential if we are to combat the rising incidence of debilitating stroke. Our CRCT will also allow us to test interventions focussed on multidisciplinary ASU teams rather than individual disciplines, an imperative of modern hospital services

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Leukocyte Tyrosine Kinase Functions in Pigment Cell Development

A fundamental problem in developmental biology concerns how multipotent precursors choose specific fates. Neural crest cells (NCCs) are multipotent, yet the mechanisms driving specific fate choices remain incompletely understood. Sox10 is required for specification of neural cells and melanocytes from NCCs. Like sox10 mutants, zebrafish shady mutants lack iridophores; we have proposed that sox10 and shady are required for iridophore specification from NCCs. We show using diverse approaches that shady encodes zebrafish leukocyte tyrosine kinase (Ltk). Cell transplantation studies show that Ltk acts cell-autonomously within the iridophore lineage. Consistent with this, ltk is expressed in a subset of NCCs, before becoming restricted to the iridophore lineage. Marker analysis reveals a primary defect in iridophore specification in ltk mutants. We saw no evidence for a fate-shift of neural crest cells into other pigment cell fates and some NCCs were subsequently lost by apoptosis. These features are also characteristic of the neural crest cell phenotype in sox10 mutants, leading us to examine iridophores in sox10 mutants. As expected, sox10 mutants largely lacked iridophore markers at late stages. In addition, sox10 mutants unexpectedly showed more ltk-expressing cells than wild-type siblings. These cells remained in a premigratory position and expressed sox10 but not the earliest neural crest markers and may represent multipotent, but partially-restricted, progenitors. In summary, we have discovered a novel signalling pathway in NCC development and demonstrate fate specification of iridophores as the first identified role for Ltk