Does private vehicle transport in trauma really save you time and money?

Introduction: Current data suggest trauma patients arriving via private vehicle transport (PVT) have improved outcomes compared to patients arriving via EMS due to quicker hospital arrival. Though some researchers have speculated that this may be due to a quicker arrival to the hospital, arrival by PVT may actually impair resuscitation efforts due to the lack of pre-hospital triage leading to delayed mobilization of teams, patient drop-offs at the wrong location, more frequent transfers to another facility, and the transport of patients who may have otherwise been declared dead on scene. This study hypothesizes PVT actually lengthens time to care, impairs resuscitation efforts, and increases overall costs due to the lack of pre-hospital triage. Methods: This is a single-site retrospective study conducted at an academic, regional, Level 1 Trauma Center in Detroit from 2013-2017. Inclusion criteria were trauma patients presenting to the hospital utilizing PVT that were admitted, died in the emergency department, or transferred out of hospital. Exclusion criteria include patients transferred from outside hospitals. Patients with the same inclusion and exclusion criteria utilizing EMS transportation were the comparison group (N=4997, PVT n=1782). The data were obtained from a trauma registry and chart review. To describe statistical significance (p\u3c0.01), chi-square tests were utilized for nominal data and independent samples t-tests were utilized for continuous data. Results: In total, 36% of trauma patients utilized PVT. Of the 11% of patients were transferred out of the hospital, 60% arrived by PVT. The vast majority (76%) of patients transferred were burn or pediatric patients. The overall rate of DOA was 3%, 89% of which arrived by EMS. There was no significant difference in time from arrival to disposition from the ED overall. However time to disposition was shorter for patients arriving by PVT in patients activated at the highest level and longer for patients who were admitted to the ICU. Cost associated with patients who were transferred out of the hospital and those pronounced DOA are described. Conclusions: Though the hypothesis is supported by the significantly higher proportion of patients who arrived by PVT requiring transfer out of our hospital and associated cost, contrary to the hypothesis there was and no difference with time to disposition overall and a lower proportion of patients who were pronounced DOA. A possible explanation is extensive diagnostic studies and procedures for patients arriving by EMS as previous studies demonstrate these patients are more likely to have poly-trauma, injuries to the head or torso and higher injury severity.https://scholarlycommons.henryford.com/merf2019hvc/1007/thumbnail.jp

Strategies Information Technology Leaders Used in Implementing Remote Work During the COVID-19

With the imposed lockdown in many countries due to the spread of COVID-19, many leaders were forced to adopt online technologies in transitioning employees to remote work. Leaders not adopting online technologies or remote work during a pandemic are highly susceptible to business closure. Grounded in the technology acceptance model, the purpose of this qualitative single case study was to explore strategies information technology (IT) leaders in Kuwait used to successfully transition employees to remote work during the pandemic. The participants were six IT leaders from a single multinational IT organization who contributed to strategy development during the pandemic to sustain business continuity and transition employees to remote work. Data were collected using semistructured online interviews and public company documents. Using Yin’s 5-step analysis process, four themes emerged: (a) build a culture of trust and adaptability, (b) study market needs and adjust offerings to meet rapid change, (c) monitor employee well-being and burnout, and (d) adopt a change management concept. A key recommendation for IT leaders is to involve employees in remote team development aimed to ensure their work-life balance. The implications for positive social change include potential job opportunities for employees with health issues, ensuring a better quality of life by saving on travel costs, and achieving work-life balance by reducing work stress

DNA damage and tissue repair: What we can learn from planaria.

Faithful renewal of aging and damaged tissues is central to organismal lifespan. Stem cells (SCs) generate the cellular progeny that replenish adult tissues across the body but this task becomes increasingly compromised over time. The age related decline in SC-mediated tissue maintenance is a multifactorial event that commonly affects genome integrity. The presence of DNA damage in SCs that are under continuous demand to divide poses a great risk for age-related disorders such as cancer. However, performing analysis of SCs with genomic instability and the DNA damage response during tissue renewal present significant challenges. Here we introduce an alternative experimental system based on the planaria flatworm Schmidtea mediterranea to address at the organismal level studies intersecting SC-mediated tissue renewal in the presence of genomic instability. Planaria have abundant SCs (neoblasts) that maintain high rates of cellular turnover and a variety of molecular tools have been developed to induce DNA damage and dissect how neoblasts respond to this stressor. S. mediterranea displays high evolutionary conservation of DNA repair mechanisms and signaling pathways regulating adult SCs. We describe genetically induced-DNA damage models and highlight body-wide signals affecting cellular decisions such as survival, proliferation, and death in the presence of genomic instability. We also discuss transcriptomic changes in the DNA damage response during injury repair and propose DNA repair as key component of tissue regeneration. Additional studies using planaria will provide insights about mechanisms regulating survival and growth of cells with DNA damage during tissue renewal and regeneration

Who Skips the Ambulance? A Study Examining Which Patients Choose Private Vehicle Transport Over EMS in Trauma

Introduction: Current data suggest trauma patients arriving via private vehicle transport (PVT) have improved outcomes forpenetrating trauma compared to patients arriving via EMS. These studies suggest patients that utilize EMS overprivate vehicle transport (PVT) have worse outcomes and are described as older, hypotensive, higher injury severityscore (ISS) and lower GCS. While previous studies focus on national data, regional behaviors likely play a role in selection of PVT. This study tests the hypothesis that these findings will also be reflected on a regional level in Detroit. Methods: This study was conducted at an academic, regional, Level 1 Trauma Center in Detroit from 2013-2017. Inclusion criteria were trauma patients presenting to the hospital utilizing PVT that were admitted, died in the emergencydepartment, or transferred out of hospital. Exclusion criteria includes patients transferred from outside hospitals,burn patients and pediatric patients defined as age less than 15 years old. Patients with the same inclusion and exclusion criteria utilizing EMS were the comparison group (N=4568, PVT n=1498). The data were obtained from a trauma registry and chart review. To describe statistical significance (p\u3c0.01), chi-square tests were utilized for nominal data, and independent samples t-tests were utilized for continuous data. Results: 32.8% of trauma patients arrived via PVT. Of the 16% with penetrating injuries, 39.5% arrived via PVT. Patients arriving via PVT were found to have a significantly higher GCS and lower injury severity, intubation rate, activation level, poly-trauma rate, injury to critical anatomic locations, length of stay, ICU admissions and deaths. Significant differences were also observed with anticoagulation use, self-pay patients, and cognitively impaired patients. Race,age, gender, preexisting comorbidities, intoxication status, vital signs on arrival, and disposition to operating roomor general admission were not different between groups. Conclusions: Findings suggest patients arriving by PVT are in less critical condition with improved outcomes than those arriving by EMS as evidenced by higher GCS, lower intubation rates, lower activation levels, fewer admissions to ICU and lower mortality rates. Though this may suggest a survival benefit, the observation may be because patients arechoosing to call EMS because they recognize a more critical condition. These findings are similar to studies conducted on a national level, however, the rate of utilization of PVT is significantly higher in Detroit suggesting the role of regional factors in PVT utilization.https://scholarlycommons.henryford.com/merf2019clinres/1064/thumbnail.jp

Trauma Patients Still Use Private Vehicle Transport Despite Improvement in EMS Response Times

Introduction: Recently, Detroit has seen a gradual improvement in Emergency Medical Service (EMS) response times. The historically long response times have been implicated in contributing to the high rates of private vehicle transportation (PVT) in Detroit, up to 3 times higher than the national average. This study tests the hypothesis that as EMS arrival times improve, the utilization of PVT in Detroit would decrease. Methods: This is a retrospective study at an academic, regional, Level 1 trauma center in Detroit over 28 months. Inclusion criteria were trauma patients that were admitted, transferred out of hospital, or died. Patients transferred from outside hospitals were excluded (N=2285). The data were obtained from hospital data registry and the city of Detroit’s performance dashboards. Correlation studies were then conducted between average EMS response time and percent PVT utilization and repeated for subgroup analysis by injury severity and trauma cause, and linear regression was conducted if correlation was significant.Results: Though correlation studies show a decline in EMS response time over 28 months with an R2 value of 0.817, there was a weak relationship between PVT usage and time (R2=0.017) and between PVT usage and EMS response time (R2=0.0058). Similar results were seen with subgroup analysis, with the largest R2 value being 0.273 in serious injuries. Conclusions: Despite continued improvement in EMS response times, we did not observe a corresponding decrease in PVT utilization. Potential explanations include a delay in this observation due to a long history of long EMS response time, the general public being unaware of this improvement, or the notion that factors other than historically high EMS arrival times play into this regional phenomenon which we explore through first-responder interviews and patient surveys.https://scholarlycommons.henryford.com/merf2019clinres/1061/thumbnail.jp

SUMOylation controls stem cell proliferation and regional cell death through Hedgehog signaling in planarians.

Mechanisms underlying anteroposterior body axis differences during adult tissue maintenance and regeneration are poorly understood. Here, we identify that post-translational modifications through the SUMO (Small Ubiquitin-like Modifier) machinery are evolutionarily conserved in the Lophotrocozoan Schmidtea mediterranea. Disruption of SUMOylation in adult animals by RNA-interference of the only SUMO E2 conjugating enzyme Ubc9 leads to a systemic increase in DNA damage and a remarkable regional defect characterized by increased cell death and loss of the posterior half of the body. We identified that Ubc9 is mainly expressed in planarian stem cells (neoblasts) but it is also transcribed in differentiated cells including neurons. Regeneration in Ubc9(RNAi) animals is impaired and associated with low neoblast proliferation. We present evidence indicating that Ubc9-induced regional cell death is preceded by alterations in transcription and spatial expression of repressors and activators of the Hedgehog signaling pathway. Our results demonstrate that SUMOylation acts as a regional-specific cue to regulate cell fate during tissue renewal and regeneration

The planarian Schmidtea mediterranea is a new model to study host-pathogen interactions during fungal infections.

Candida albicans is one of the most common fungal pathogens of humans. Currently, there are limitations in the evaluation of C. albicans infection in existing animal models, especially in terms of understanding the influence of specific infectious stages of the fungal pathogen on the host. We show that C. albicans infects, grows and invades tissues in the planarian flatworm Schmidtea mediterranea, and that the planarian responds to infection by activating components of the host innate immune system to clear and repair host tissues. We study different stages of C. albicans infection and demonstrate that planarian stem cells increase division in response to fungal infection, a process that is likely evolutionarily conserved in metazoans. Our results implicate MORN2 and TAK1/p38 signaling pathways as possible mediators of the host innate immune response to fungal infection. We propose the use of planarians as a model system to investigate host-pathogen interactions during fungal infections

The value of PET, CT and in-line PET/CT in patients with gastrointestinal stromal tumours: long-term outcome of treatment with imatinib mesylate

Purpose: Gastrointestinal stromal tumours (GIST) are mesenchymal neoplasms of the gastrointestinal tract that are unresponsive to standard sarcoma chemotherapy. Imaging of GIST patients is done with structural and functional methods such as contrast-enhanced helical computed tomography (ceCT) and positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG). The aim of this study was to compare the prognostic power of PET and ceCT and to evaluate the clinical role of PET/CT imaging. Methods: All patients with GIST undergoing PET or PET/CT examinations were prospectively included in this study, and the median overall survival, time to progression and treatment duration were documented. The prognostic significance of PET and ceCT criteria of treatment response was assessed and PET/CT was compared with PET and ceCT imaging. Data for 34 patients (19 male, 15 female, 21-76 years) undergoing PET or PET/CT for staging or restaging were analysed. Results: In 28 patients, PET/CT and ceCT were available after introduction of treatment with the tyrosine kinase inhibitor imatinib mesylate (Gleevec; Novartis, Basel, Switzerland). Patients without FDG uptake after the start of treatment had a better prognosis than patients with residual activity. In contrast, ceCT criteria provided insufficient prognostic power. However, more lesions were found on ceCT images than on PET images, and FDG uptake was sometimes very variable. PET/CT delineated active lesions better than did the combination of PET and ceCT imaging. Conclusion: Both PET and PET/CT provide important prognostic information and have an impact on clinical decision-making in GIST patients. PET/CT precisely delineates lesions and thus allows for the correct planning of surgical intervention

A circular RNA generated from an intron of the insulin gene controls insulin secretion.

Fine-tuning of insulin release from pancreatic β-cells is essential to maintain blood glucose homeostasis. Here, we report that insulin secretion is regulated by a circular RNA containing the lariat sequence of the second intron of the insulin gene. Silencing of this intronic circular RNA in pancreatic islets leads to a decrease in the expression of key components of the secretory machinery of β-cells, resulting in impaired glucose- or KCl-induced insulin release and calcium signaling. The effect of the circular RNA is exerted at the transcriptional level and involves an interaction with the RNA-binding protein TAR DNA-binding protein 43 kDa (TDP-43). The level of this circularized intron is reduced in the islets of rodent diabetes models and of type 2 diabetic patients, possibly explaining their impaired secretory capacity. The study of this and other circular RNAs helps understanding β-cell dysfunction under diabetes conditions, and the etiology of this common metabolic disorder