Outcomes Associated with Using the Identification of Seniors at Risk (ISAR) Score to Determine Geriatric Evaluations of Trauma Patients with Hip Fractures

Background: Falls are a leading cause of injury in older adults in the U.S., commonly contributing to hip fractures specifically (Centers for Disease Control, 2016; Moreland, Kakara, & Henry, 2020). Many older adults who sustain a hip fracture will not return to their baseline function and may even require nursing home placement for additional care (Rubenstein & Josephson, 2006). Henry Ford Macomb Hospital (HFMH) is a community teaching hospital with Level II Adult Trauma designation. In 2013, the Trauma Quality Improvement Program (TQIP) stressed the need for specialized geriatric care (American College of Surgeons, 2013, p.5). Falls with hip fracture accounted for 15% of Trauma admissions in 2014-2016 and 21% in 2017-2019 at HFMH. In 2016, the Identification of Seniors at Risk (ISAR) screening tool was utilized for Trauma patients 60 years and older to help capture their need for a Geriatric evaluation. It is completed by a Trauma Resident upon evaluation of the patient in the Emergency Department. A Geriatric evaluation is recommended if the patient answered “yes” to two or more questions on the screening tool. If a patient is discharged prior to being seen for the evaluation, follow up information is encouraged to be provided for the Geriatric outpatient clinic. Aim: To evaluate outcomes of older adults who sustained a hip fracture after falling as related to the implementation LIMITATIONS of the ISAR tool to determine Geriatric evaluations and assess outcomes related to individual ISAR scores (0- 6). Methodology: Retrospective program evaluation conducted via chart review. July 1, 2014-June 30, 2016, and January 1, 2017, to December 31, 2019. Data Analysis: Variables were described using standard summary measures such as means and standard deviation for continuous variables and counts/percentage for nominal data. Continuous variables that did not follow a normal distribution were described via medians and interquartile ranges. The two groups were compared with Student’s t- Tests and Chi-squared tests dependent on variables. To evaluate variables related to each ISAR score, Kruskal- Wallis analysis was used. The p-value was adjusted as needed to conclude significance using Hochberg’s adjustment. Results: A total of 1,142 charts were reviewed. Thirty-six were excluded for admission to non-trauma service, and an additional forty-six charts were excluded for patients with multiple admissions. Of the qualifying patients, 380 were included in our pre-Geriatric evaluation implementation and 680 in post. In the post period, 48/680= 7% patients did not have an ISAR completed. Many of the patients admitted to the Trauma Service with hip fractures sustained an intertrochanteric fracture, followed by proximal femur fracture and then femur shaft fracture. Majority of Trauma patients sustaining a hip fracture were white, non-Hispanic, English-speaking, Caucasian females. Outcomes Compared By ISAR Score: There is a significant difference in age between each ISAR score (p=0.001), with generally higher ISAR scores as age increases. The ISS does not correlate with increasing ISAR score (p=0.102). Length of stay increases with ISAR scores (p=0.012). The longest duration of ICU stays occurred in patient with an ISAR score of three. In-hospital mortality did not increase with increasing ISAR score (p=0.664). In-hospital mortality was highest in ISAR scores of five. Readmissions were highest in those with an ISAR score of five, and an ISAR score of one had the lowest rate of readmission. Hospice was consulted more frequently as the ISAR score increases (p=0.034), with the highest prevalence of consults noted in patients with ISARs of six. Majority of patients were discharged to SNF regardless of ISAR score (p=0.092). Outcomes Compared Before and After Geriatric Evaluation: Of the 680 patients in the post-group, 434 patients received a Geriatric Evaluation. Age and ISS was significantly higher in the Geriatric evaluation population. No significant difference was found between total LOS, though did decrease by four hours (p=0.075). In the pre-group, more patients were admitted to the ICU (5.78%) than the post-group (4.14%); however, the pre-group had a shorter ICU length of stay (5.73 vs 5.89, P = 0.847). Thirty-day readmissions trended higher in the post-group with a Geriatric evaluation (p=0.106). In-hospital mortality was lower in the post-group with a Geriatric evaluation (p=0.243). Hospice consults and discharges to Hospice were higher in the post-group with a Geriatric evaluation (p=0.083). Majority of patients were discharged to a Skilled Nursing Facility (SNF) for both the pre- and post-group, followed by home with services, or home with self-care. Discharge to inpatient rehabilitation unit (IPR) decreased in the post-group with a Geriatric evaluation. Discussion: To the existing body of literature, this current study adds outcomes broken down by each individual ISAR score for patients with hip fractures and the associated outcomes using the ISAR score to guide the need for Geriatric evaluations. The ISS does not correlate with increasing ISAR score (p=0.102). It could be suggested that the individual questions that make up the ISAR score do not address the severity and/or mechanism of injury. The longest ICU LOS occurred in patients with an ISAR score of three; however, the ISAR screening tool was not originally developed to predict ICU stays. There is limited literature to support this finding and more research could be done in this area. With 30-day readmissions being the highest in those with an ISAR scores of four and five, quality and care coordination efforts could be directed towards Geriatric Trauma patients with these scores. Patients with a Geriatric evaluation, who were older and scored a higher ISS, had a shorter LOS by approximately four hours, this is vital because it can be associated with decreased costs and increased patient satisfaction. Admissions to Inpatient Rehab (IPR) decreased in the post-group, further investigation could assist with determining causal factors, though IPR admissions are typically low due to requiring a physical and medical need for admission. In-hospital mortality decreased in the post group, even with increased age and ISS. There are inconsistencies among current studies regarding the mortality of Trauma patients after undergoing a Geriatric evaluation, therefore AIM more research is needed to fully understand the impact. Limitations: More rigorous research design would be beneficial to fully understand the studied outcomes. The six-month period during which the Geriatric evaluation service was in the early stages of development and planning the use of the ISAR score was not included in the study time frame. The ISAR score can be challenging to obtain due to altered mental status or lack of family/surrogate presence to obtain accurate information at the time of screening. This study also did not verify the accuracy of the scores obtained by the Trauma Resident. This could impact the outcomes associated with each ISAR score in addition to the outcomes related to patients that received Geriatric evaluations. Compliance of the Trauma Service in following the recommendations as well as patients and family’s adherence to the plan of care may impact outcomes. In addition, this study did not address what specifically is included in a Geriatric evaluation. It also may have been helpful to know which individual ISAR questions are most often answered “yes” to validate if the specific concerns were addressed during the evaluation.https://scholarlycommons.henryford.com/nursresconf2021/1007/thumbnail.jp

Modifications of the LCLS Photoinjector Beamline

The LCLS Photoinjector beamline is now in the Design and Engineering stage. The fabrication and installation of this beamline is scheduled for the summer 2006. The Photoinjector will deliver 10 ps long electron bunches of 1nC with a normalized transverse emittance of less than 1 mm.mrad for 80% of the slices constituting the core of the bunch at 135 MeV. The calculations done to finalize the specifications of the photoinjector beamline components are described. Modifications include a new exit energy, additional focusing between the two linac modules, the insertion of a ''laser heater'', and a new geometry for the coupling cells of the RF structures. We also discuss two interesting tunings, one for the nominal charge of 1nC but using a longer laser pulse and the second one for a lower charge of 0.2nC. Sensitivity to field errors and misalignment for those two new configurations is compared to that of the nominal tuning

PARMELA VS MEASUREMENTS FOR GTF AND DUVFEL

The particle-pushing PARMELA was used to design the photo-injector beamline of the Linac Coherent Light Source (LCLS) to be built at SLAC in 2005. PARMELA predicts that projected emittances smaller than 1.2 mm.mrad and slice emittance smaller than 1.0 mm.mrad will be achievable for 1nC, 10ps electron bunches with an S-band RF gun and an emittance compensating system. To benchmark PARMELA, comparisons between simulations and measurements for two photo-injector test facilities, the Gun Test Facility (GTF) at SLAC and the Deep Ultra Violet FEL (DUVFEL) at BNL, have been performed. Aspects of the modeling of fields and initial distributions are discussed. The agreement between measured and simulated beam parameters (projected and slice emittance, Twiss parameters) is satisfying. Accordingly, it gives credibility to the extrapolation made for studying the LCLS case. PARMELA also indicates possible improvements in the tuning of those facilities to achieve the LCLS required beam properties.

Transverse emittance measurements on an S-band photoinjector rf electron gun

Proposed fourth generation light sources using SASE FELs to generate short pulse, coherent, X-rays require demonstration of high brightness electron sources. The Gun Test Facility (GTF) at SLAC was built to test high brightness sources for the proposed Linac Coherent Light Source at SLAC. The transverse emittance measurements are made at nearly 30 MeV by measuring the spot size on a YAG screen using the quadrupole scan technique. The emittance was measured to vary from 1 to 3.5 mm-mrad as the charge is increased from 50 to 350 pC using a laser pulse width of 2 ps FWHM. The measurements are in good agreement with simulation results using the LANL version of PARMELA.Comment: 12 pages, 4 figures, contributed to The 23rd Int. FEL Conf., Darmstadt, 20-24 Aug. 200

An Ultra-high Sulfur Keratin Gene is Expressed Specifically During Hair Growth

To study the regulation of the hair cycle in the mouse, we have isolated and characterized a gene for ultra high sulfur keratin that is expressed specifically during the active hair growth cycle. The gene (gUHSK-704Eco) was isolated as a member of a gene cluster on a recombinant phage with a DNA insert of 18kb that was isolated by screening a murine genomic library at low stringency with a synthetic oligonucleotide derived from a sheep high sulfur keratin gene (Powell, Nucleic Acids Res. 1983 11, 5327). The murine ultrahigh sulfur keratin gene has no intervening sequence; the 558 nucleotide of the coding region specify 186 amino acids, of which 70(37%) are cysteine. A Cys-Cys-Gln-Pro repeat is found 12 times within the coding region. RNA dot blots show that the ultra-high sulfur keratin gene is expressed during the hair cycle concomitant with the anterior-posterior temporal pattern of the normal murine hair cycle

Decidual and placental NOD1 is associated with inflammation in normal and preeclamptic pregnancies

Introduction: Inflammation is a normal physiological process that increases to harmful levels in preeclampsia. It affects the interaction between maternal immune cells and fetal trophoblasts at both sites of the maternal-fetal interface; decidua and placenta. The pattern recognition receptor nucleotide-binding oligomerization domain-containing protein (NOD)1 is expressed at both sites. This study aimed to characterize the cellular expression and functionality of NOD1 at the maternal-fetal interface of normal and preeclamptic pregnancies. Methods: Women with normal or preeclamptic pregnancies delivered by caesarean section were included. Decidual (n = 90) and placental (n = 91) samples were analyzed for NOD1 expression by immunohistochemistry and an automated image-based quantification method. Decidual and placental explants were incubated with or without the NOD1-agonist iE-DAP and cytokine responses measured by ELISA. Results: NOD1 was markedly expressed by maternal cells in the decidua and by fetal trophoblasts in both decidua and placenta, with trophoblasts showing the highest NOD1 expression. Preeclampsia with normal fetal growth was associated with a trophoblast-dependent increase in decidual NOD1 expression density. Compared to normal pregnancies, preeclampsia demonstrated stronger correlation between decidual and placental NOD1 expression levels. Increased production of interleukin (IL)-6 or IL-8 after in vitro explant stimulation confirmed NOD1 functionality. Discussion: These findings suggest that NOD1 contributes to inflammation at the maternal-fetal interface in normal pregnancies and preeclampsia and indicate a role in direct maternal-fetal communication. The strong expression of NOD1 by all trophoblast types highlights the importance of combined assessment of decidua and placenta for overall understanding of pathophysiological processes at the maternal-fetal interface.publishedVersio