bluuebunny/crossref_metadata_2025 huggingface dataset:
Best practices on team communication: interprofessional practice in oncology
Authors: D’Alimonte Laura , McLaney Elizabeth , Di Prospero Lisa
Published: January 2019

Purpose of review

Good communication is the cornerstone of interprofessional care teams providing optimized quality patient care. Over the last decade, advances in technology have provided tools to improve communication; however, opportunities still exist for innovation and implementation.

Recent findings

The literature suggests that interprofessional education and assessment of team communication are fundamental in supporting collaborative care. The literature favours an interactive, team-based approach (e.g. simulation) to learning about communication, in which communication competencies and behaviours are practiced explicitly in an open, feedback-rich environment.

Key elements of excellence in communication are embedded in three priority recommendations: first, the team must adopt a practice strategy that leverages accessible and timely communication second, the team must be open to initial and ongoing training within the domain of ‘effective communication’ third, communication must be the cornerstone to producing a high-performing team that will provide the best care possible.
The role of splanchnic congestion and the intestinal microenvironment in the pathogenesis of advanced heart failure
Authors: Polsinelli Vincenzo B. , Marteau Lara , Shah Sanjiv J.
Published: January 2019

Purpose of review

Right-sided heart failure, which is often present in the setting of advanced heart failure, is associated with cardiac cachexia, the cardiorenal syndrome, and adverse outcomes. Improved understanding of venous congestion of the splanchnic circulation, which may play a key role in the pathogenesis of right-sided heart failure, could lead to novel therapeutics to ameliorate heart failure. Here we provide an overview of right-sided heart failure, splanchnic hemodynamics, fluid homeostasis, and the intestinal microenvironment. We review recent literature to describe pathophysiologic mechanisms and possible therapeutics.

Recent findings

Several possible mechanisms centered around upregulation of sodium–hydrogen exchanger-3 (NHE3) may form a causal link between right ventricular dysfunction, splanchnic congestion, and worsening heart failure. These include an anaerobic environment in enterocytes, resulting in reduced intracellular pH; increased sodium absorption by the gut via NHE3; decreased pH at the intestinal brush border thus altering the gut microbiome profile; increased bacterial synthesis of trimethylamine N-oxide; and decreased bacterial synthesis of short-chain fatty acids causing abnormal intestinal barrier function.

Splanchnic congestion in the setting of right-sided heart failure may serve an important role in the pathogenesis of advanced heart failure, and further exploration of these mechanisms may lead to new therapeutic advances.
Lessons Learned From a Review of Malpractice Litigations Involving Obstetric Anal Sphincter Injury in the United States
Authors: Kim Edward K. , Lovejoy David A. , Patterson Danielle , Handa Victoria L.
Published: January 2019

Objective

The aim of this article is to review all litigations involving obstetric anal sphincter injury (OASIS) in the United States to highlight the most common allegations and factors that aided the involved obstetricians and gynecologists (ob/gyns).

Methods

We used Lexis Nexis, a comprehensive legal database, to search all publicly available high-profile federal and state level litigations related to OASIS.

Results

Of 68 cases that resulted and reviewed, 19 were deemed to be pertinent to the question being addressed. These 19 cases occurred between 1964 and 2011 and all alleged medical negligence. Among these 19 cases, 6 were ruled in favor of the plaintiffs, with most of them being awarded an amount ranging from US $110,000 to US $841,810.80. All 6 cases involved episiotomy. Thorough medical recordkeeping, comprehensive discharge instructions and counseling, and timely evaluation and referral to a female pelvic medicine and reconstructive surgery specialist were the key factors that aided the ob/gyns facing these litigations.

Conclusions

Avoidance of episiotomy, thorough medical recordkeeping, comprehensive discharge instruction and counseling, and timely evaluation and referral to a female pelvic medicine and reconstructive surgery specialist may help an ob/gyn prevail in OASIS-related litigations.
Urinary Incontinence and Pelvic Organ Prolapse Knowledge, Care-Seeking, and Embarrassment in Women Planning Bariatric Surgery: A Cross-sectional Study
Authors: Paka Chandhana , Hallock Jennifer L. , Trock Bruce , Steele Kimberley , James Wright E.
Published: January 2019

Objective

The objective of this study was to assess whether patients seeking bariatric surgery were at least as proficient in urinary incontinence (UI) and pelvic organ prolapse (POP) knowledge as the general population. Our secondary objective was to determine care-seeking and impact of embarrassment on knowledge of pelvic floor disorders (PFDs).

Methods

An anonymous survey was administered to adult women who attended a bariatric surgery information session from May 2015 to January 2016. The comprehensive survey included multiple data points and the Prolapse and Incontinence Knowledge Quiz. The study population was compared with a general population described in a previously published study.

Results

Three hundred fifteen participants completed the survey (88% response rate). Mean ± SD age was 41.1 ± 11.3 years (range, 18–69 years), and mean body mass index was 47.4 ± 9.6 kg/m2 (range, 26.7–104.5 kg/m2). A total of 196 women (62.2%) had at least one bothersome PFD symptom. The study population was at least as proficient in UI knowledge as the general population (P < 0.0001), but not for POP knowledge (P < 0.946). Among participants with symptomatic PFD, 91.7% of those with UI symptoms and 70% of those with POP symptoms reported that they would seek care. There was a difference in knowledge proficiency between women who were and were not embarrassed to discuss UI (P = 0.77) or POP (P = 0.99).

Conclusions

The study population demonstrated less POP knowledge than the general population, but not for UI knowledge. A high proportion of women with UI or POP symptoms would seek care, but embarrassment to discuss UI or POP negatively impacted knowledge.
Lower Urinary Tract Symptoms in a Chronic Pelvic Pain Population
Authors: Sammarco Anne G. , Kobernik Emily K. , Haefner Hope K. , Till Sara R. , Berger Mitchell B.
Published: January 2019

Objectives

This study aimed to characterize the prevalence of lower urinary tract symptoms in a chronic pain population.

Methods

In this observational cohort study, patients referred to a female pelvic pain clinic completed several validated questionnaires assessing bladder symptoms, central sensitization, pain symptoms, depression, anxiety, and neuropathic pain. Patients diagnosed as having interstitial cystitis were excluded. Patient demographic characteristics and survey responses were compared across American Urological Association Symptom Index (AUA-SI) severity categories. Multivariable logistic regression was performed to identify independent predictors of moderate-to-severe AUA-SI scores.

Results

A total of 177 patients were included in the analysis. American Urological Association Symptom Index data showed that 48.8% of patients had mild, 31.2% had moderate, and 20.0% had severe symptoms. Patients reporting moderate or severe AUA-SI scores had higher mean Central Sensitization Inventory (CSI) scores (46.7 ± 16.0 vs 32.9 ± 13.8, P < 0.0001), McGill scores (median, 25 [interquartile range, 16–38] vs 13 [5–27]; P = 0.0003), Patient-Reported Outcomes Measurement Information System depression T-scores (median, 53.9 [interquartile range, 46.2–61.6] vs 51.2 [37.1–55.3]; P = 0.009), Pelvic Pain and Urgency/Frequency Symptoms Scale scores (18.4 ± 6.2 vs 12.5 ± 5.4, P < 0.0001), and Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs scores (median, 10.5 [interquartile range, 3.0–16.5] vs 6.0 [1.0–12.0]; P = 0.02). The odds of moderate-to-severe AUA-SI symptoms were higher with a positive PUF and CSI score and were lower with a diagnosis of vestibular pain.

Conclusions

There is a high prevalence of lower urinary tract symptoms among patients with chronic pelvic pain. Vestibulodynia was associated with lower odds of bladder symptoms. High PUF and CSI scores were significantly associated with moderate-to-severe bladder symptoms.
Gel-Infused Translabial Ultrasound in the Evaluation of Female Urethral Stricture
Authors: Sussman Rachael D. , Kozirovsky Mariana , Telegrafi Shpetim , Peyronnet Benoit , Palmerola Ricardo , Smilen Scott , Pape Dominique M. , Rosenblum Nirit , Nitti Victor W. , Brucker Benjamin M.
Published: January 2019

Objectives

The aims of this study were to describe our technique of gel-infused translabial ultrasound (GITLUS) to assess the female urethra for stricture and to highlight its utility when compared with other diagnostic techniques.

Methods

Consecutive patients presenting with prior diagnosis and/or suspicion for female urethral stricture underwent evaluation with uroflowmetry, postvoid residual, video urodynamics, and cystoscopy at the surgeon's discretion. All patients underwent GITLUS; 8-MHz curvilinear and 6-MHz linear high-frequency transducers were used to image the urethra from meatus to bladder neck while instilling 20 mL of lidocaine jelly to distend the urethra. Stricture location, length, caliber, and presence of periurethral fibrosis were assessed. Two healthy volunteers underwent GITLUS to serve as a comparison.

Results

Eight patients with suspected stricture underwent GITLUS. In all cases, GITLUS identified and characterized stricture and demonstrated periurethral fibrosis. Two healthy volunteers underwent GITLUS, which demonstrated a patent urethra and no evidence of fibrosis. Cystoscopy and video urodynamics on patients with stricture did not perform as well at identifying and fully assessing strictures. Six patients underwent definitive surgical repair, and GITLUS findings were confirmed. One patient had a postoperative GITLUS demonstrating resolution of the stricture and periurethral fibrosis.

Conclusions

Gel-infused translabial ultrasound is a novel and accurate technique that in this small series appeared to identify and further characterize female urethral stricture in cases where it was utilized. Further research is needed to determine its role in preoperative planning and in providing a definitive diagnosis of stricture when other studies are equivocal.
Blunt small bowel perforation (SBP): An Eastern Association for the Surgery of Trauma multicenter update 15 years later
Authors: Fakhry Samir M. , Allawi Ahmed , Ferguson Pamela L. , Michetti Christopher P. , Newcomb Anna B. , Liu Chang , Brownstein Michelle R.
Published: January 2019

BACKGROUND

Previous work demonstrated diagnostic delays in blunt small bowel perforation (SBP) with increased mortality and inability of scans to reliably exclude the diagnosis. We conducted a follow-up multicenter study to determine if these challenges persist 15 years later.

METHODS

We selected adult cases with blunt injury, International Classification of Diseases, Ninth Revision or current procedural terminology (CPT) indicating small bowel surgery, no other major injury and at least one abdominal computed tomography (CT) within initial 6 hours. Controls had blunt trauma with abdominal CT but not SBP. After institutional review board approval, data from each center were collected and analyzed.

RESULTS

Data from 39 centers (from October 2013 to September 2015) showed 127,919 trauma admissions and 94,743 activations. Twenty-five centers were Level 1. Centers submitted 77 patients (mean age, 39; male, 68%; mean length of stay, 11.3 days) and 131 controls (mean age, 44; male, 64.9%; length of stay, 3.6 days). Small bowel perforation cases were 0.06% of admissions and 0.08% of activations. Mean time to surgery was 8.7 hours (median, 3.7 hours). Initial CT showed free air in 31 cases (43%) and none in controls. Initial CT was within normal in three cases (4.2%) and 84 controls (64%). Five cases had a second scan; two showed free air (one had an initial normal scan). One death occurred among the patients (mortality, 1.4%; and time to surgery, 16.9 hours). Regression analysis showed sex, abdominal tenderness, distention, peritonitis, bowel wall thickening, free fluid, and contrast extravasation were significantly associated with SBP.

CONCLUSIONS

Blunt SBP remains relatively uncommon and continues to present a diagnostic challenge. Trauma centers have shortened time to surgery with decreased case mortality. Initial CT scans continue to miss a small number of cases with potentially serious consequences. We recommend (1) intraperitoneal abnormalities on CT scan should always evoke high suspicion and (2) strong consideration of additional diagnostic/therapeutic intervention by 8 hours after arrival in patients who continue to pose a clinical challenge.

LEVEL OF EVIDENCE

Observational study, level III.
Extracorporeal potassium binding for the management of hyperkalemia in an anephric model of crush injury
Authors: Hoareau Guillaume L. , Beyer Carl A. , Wilson Christopher , Kashtan Harris , Wishy Andrew , Grayson J. Kevin , Walker Lauren , Ross James D. , Stewart Ian J.
Published: January 2019

BACKGROUND

Potassium-binding polymers have shown promising results in an anephric porcine hyperkalemia model. The benefits of the polymer in a clinically relevant injury model remain unknown. We hypothesized that potassium-binding cartridges would control serum potassium concentration in a porcine hemorrhagic shock model with supraceliac aortic occlusion and a limb crush injury.

METHODS

Ten Yorkshire-cross swine were anesthetized and instrumented. Pigs underwent splenectomy and bilateral nephrectomy. Hemorrhagic shock was induced for 30 minutes while a leg compression device was applied. Pigs underwent supraceliac aortic occlusion for 60 minutes and were resuscitated with shed blood. The leg compression device was removed 20 minutes after balloon deflation. After 20 minutes of reperfusion, animals were randomized to extracorporeal circulation with (treatment) or without (control) the potassium binding cartridges. In both groups, blood was circulated through a hemodialyzer with a peristaltic pump. In the treatment group, the ultrafiltrate was diverted from the hemodialyzer through cartridges containing the polymer and returned to the extracorporeal circuit. Animals were resuscitated with 0.9% saline boluses and a norepinephrine infusion. The change in serum potassium concentration (ΔK) was calculated as serum [K+]T390 − serum [K+]T0.

RESULTS

There was a significant difference in serum potassium concentration between groups (p < 0.001). ΔK was significantly higher in the control than the treatment group (3.75 [3.27–4.42] and 1.15 [0.62–1.59] mmol/L, respectively; p = 0.03). There were no differences in mean arterial pressure (p = 0.14), isotonic crystalloids requirement (p = 0.51), or norepinephrine dose (p = 0.83) between groups. Serum lactate concentration was significantly higher in the control group (p < 0.001). At the end of the experiment, the [K+] was reduced by 25% (24.9%–27.8%) across the cartridges.

CONCLUSION

The cartridges controlled serum potassium concentrations without dialysate and retained potassium binding capabilities over 4 hours. There were no deleterious effects on hemodynamic parameters. Those cartridges might be beneficial adjuncts for hyperkalemia management in austere environments.

LEVEL OF EVIDENCE

Translational science study, level I.
Massive transfusion in the pediatric population: A systematic review and summary of best-evidence practice strategies
Authors: Kamyszek Reed W. , Leraas Harold J. , Reed Christopher , Ray Candice M. , Nag Uttara P. , Poisson Jessica L. , Tracy Elisabeth T.
Published: January 2019

BACKGROUND

Pediatric patients require massive transfusion (MT) in a variety of settings. Multiple studies of adult MT support balanced ratio transfusion to improve outcomes; however, it is unclear if these findings can be extrapolated to pediatric populations. The use of balanced transfusion ratios, MT protocols, hemostatic adjuncts, and even the definition of a MT in children are all open questions. This review presents details of care from current practices in pediatric MT and summarizes practice strategies while providing insight from our single-center experience.

METHODS

PubMed, EMBASE, and Web of Science were searched using MeSH index and free-text terms for articles from 1946 to 2017. Articles were independently reviewed by two reviewers. Studies were assessed for definition of MT, factors predicting MT, MT complications, blood product ratios, hemostatic adjuncts, protocol logistics, and clinical outcomes.

RESULTS

A heterogeneous composite of 29 articles was included in the analysis. Of these, 45% reported a formal transfusion protocol or adopted one during the study. Seven unique definitions of pediatric MT were reported; the most common was >1 total blood volume within 24 hours. A total of 18,369 patients were assessed, and 1,163 received MT (6.3%). Overall mortality for patients requiring MT in studies reporting mortality was high (range 14.7% to 51.2%). We identified 14 patients receiving MT at our center with an age range of 8 months to 18 years and average transfusion of 38.1 mL/kg red blood cells (range: 22.1 mL/kg to 156.7 mL/kg).

CONCLUSIONS

Current practices of pediatric MT demonstrate a variety of site-specific interventions with a persistently high mortality rate. A national focus on improving techniques of MT in children has the potential to save the lives of these children.

LEVEL OF EVIDENCE

Systematic review, levels IV and V.
Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side
Authors: Derickson Michael J. , Kuckelman John P. , Phillips Cody J. , Barron Morgan R. , Marko Shannon T. , Eckert Matthew J. , Martin Matthew J. , Cuadrado Daniel G.
Published: January 2019

BACKGROUND

During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions.

METHODS

Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups.

RESULTS

Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05).

CONCLUSION

Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed.

LEVEL OF EVIDENCE

Basic science.
Application of electronic medical record–derived analytics in critical care: Rothman Index predicts mortality and readmissions in surgical intensive care unit patients
Authors: Alarhayem Abdul Q. , Muir Mark T. , Jenkins Donald J. , Pruitt Basil A. , Eastridge Brian J. , Purohit Maulik P. , Cestero Ramon F.
Published: January 2019

INTRODUCTION

The Rothman Index (RI) is an objective measurement of a patient's overall condition, automatically generated from 26 variables including vital signs, laboratory data, cardiac rhythms, and nursing assessments. The purpose of this study was to assess the validity of RI scores in predicting surgical ICU (SICU) readmission rates and mortality.

METHODS

We conducted a single-center retrospective analysis of surgical patients who were transferred from the SICU to the surgical floor from December 2014 to December 2016. Data included demographics, length of stay (LOS), mortality, and RI at multiple pretransfer and post-transfer time points.

RESULTS

A total of 1,445 SICU patients were transferred to the surgical floor; 79 patients (5.5%) were readmitted within 48 hours of transfer. Mean age was 52 years, and 67% were male. Compared to controls, patients readmitted to the SICU within 48 hours experienced higher LOS (29 vs. 11 days, p < 0.05) as well as higher mortality (2.5% vs. 0.6%, p < 0.05). Patients requiring readmission also had a lower RI at 72, 48, and 24 hours before transfer as well as at 24 and 48 hours after transfer (p < 0.05 for all). Rothman Index scores were categorized into higher-risk (<40), medium-risk (40–65), and lower-risk groups (>65); RI scores at 24 hours before transfer were inversely proportional to overall mortality (RI < 40 = 2.5%, RI 40–65 = 0.3%, and RI > 65 = 0%; p < 0.05) and SICU readmission rates (RI < 40 = 9%, RI 40–65 = 5.2%, and RI > 65 = 2.8%; p < 0.05). Patients transferred with RI scores greater than 83 did not require SICU readmission within 48 hours.

CONCLUSION

Surgical ICU patients requiring readmission within 48 hours of transfer have a significantly higher mortality and longer LOS compared to those who do not. Patients requiring readmission also have significantly lower pretransfer and post-transfer RI scores compared to those who do not. Rothman Index scores may be used as a clinical tool for evaluating patients before transfer from the SICU. Prospective studies are warranted to further validate use of this technology.

LEVEL OF EVIDENCE

Retrospective database review, level III.
A trauma mortality prediction model based on the ICD-10-CM lexicon: TMPM-ICD10
Authors: Osler Turner M. , Glance Laurent G. , Cook Alan , Buzas Jeffrey S. , Hosmer David W.
Published: January 2019

BACKGROUND

Outcome prediction models allow risk adjustment required for trauma research and the evaluation of outcomes. The advent of ICD-10-CM has rendered risk adjustment based on ICD-9-CM codes moot, but as yet no risk adjustment model based on ICD-10-CM codes has been described.

METHODS

The National Trauma Data Bank provided data from 773,388 injured patients who presented to one of 747 trauma centers in 2016 with traumatic injuries ICD-10-CM codes and Injury Severity Score (ISS). We constructed an outcome prediction model using only ICD-10-CM acute injury codes and compared its performance with that of the ISS.

RESULTS

Compared with ISS, the TMPM-ICD-10 discriminated survivors from non-survivors better (ROC TMPM-ICD-10 = 0.861 [0.860–0.872], ROC [reviever operating curve] ISS = 0.830 [0.823–0.836]), was better calibrated (HL [Hosmer-Lemeshow statistic] TMPM-ICD-10 = 49.01, HL ISS = 788.79), and had a lower Akaike information criteria (AIC TMPM-ICD10 = 30579.49; AIC ISS = 31802.18).

CONCLUSIONS

Because TMPM-ICD10 provides better discrimination and calibration than the ISS and can be computed without recourse to Abbreviated Injury Scale coding, the TMPM-ICD10 should replace the ISS as the standard measure of overall injury severity for data coded in the ICD-10-CM lexicon.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level II.
From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings
Authors: Goodwin Tress , Moore Krista N. , Pasley Jason David , Troncoso Ruben , Levy Matthew J. , Goolsby Craig
Published: January 2019

Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world—in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.
The “Top 10” research and development priorities for battlefield surgical care: Results from the Committee on Surgical Combat Casualty Care research gap analysis
Authors: Martin Matthew J. , Holcomb John B. , Polk Travis , Hannon Matthew , Eastridge Brian , Malik Saafan Z. , Blackman Virginia S. , Galante Joseph M. , Grabo Daniel , Schreiber Martin , Gurney Jennifer , Butler Frank K. , Shackelford Stacy
Published: January 2019

BACKGROUND

The US Military has achieved the highest casualty survival rates in its history. However, there remain multiple areas in combat trauma that present challenges to the delivery of high-quality and effective trauma care. Previous work has identified research priorities for pre-hospital care, but there has been no similar analysis for forward surgical care.

METHODS

A list of critical “focus areas” was developed by the Committee on Surgical Combat Casualty Care (CoSCCC). Individual topics were solicited and mapped to appropriate focus areas by group consensus and review of Eastern Association for the Surgery of Trauma (EAST) and Joint Trauma System guidelines. A web-based survey was distributed to the CoSCCC and the military committees of EAST and the American Association for the Surgery of Trauma. Topics were rated on a Likert scale from 1 (low) to 10 (high priority). Descriptives, univariate statistics, and inter-rater correlation analysis was performed.

RESULTS

13 research focus areas were identified (eight clinical and five adjunctive categories). Ninety individual topics were solicited. The survey received 64 responses. The majority of respondents were military (90%) versus civilians (10%). There was moderate to high agreement (inter-rater correlation coefficient = 0.93, p < 0.01) for 10 focus areas. The top five focus areas were Personnel/Staffing (mean, 8.03), Resuscitation and Hemorrhage Management (7.49), Pain/Sedation/Anxiety Management (6.96), Operative Interventions (6.9), and Initial Evaluation (6.9). The “Top 10” research priorities included four in Personnel/Staffing, four in Resuscitation/Hemorrhage Management, and three in Operative Interventions. A complete list of the topics/scores will be presented.

CONCLUSIONS

This is the first objective ranking of research priorities for combat trauma care. The “Top 10” priorities were all from three focus areas, supporting prioritization of personnel/staffing of austere teams, resuscitation/hemorrhage control, and damage-control interventions. This data will help guide Department of Defense research programs and new areas for prioritized funding of both military and civilian researchers.

LEVEL OF EVIDENCE

Study design, level IV.
A prospective study in severely injured patients reveals an altered gut microbiome is associated with transfusion volume
Authors: Nicholson Susannah E. , Burmeister David M. , Johnson Taylor R. , Zou Yi , Lai Zhao , Scroggins Shannon , DeRosa Mark , Jonas Rachelle B. , Merrill Daniel R. , Zhu Caroline , Newton Larry M. , Stewart Ronald M. , Schwacha Martin G. , Jenkins Donald H. , Eastridge Brian J.
Published: January 2019

BACKGROUND

Traumatic injury can lead to a compromised intestinal epithelial barrier and inflammation. While alterations in the gut microbiome of critically injured patients may influence clinical outcomes, the impact of trauma on gut microbial composition is unknown. Our objective was to determine if the gut microbiome is altered in severely injured patients and begin to characterize changes in the gut microbiome due to time and therapeutic intervention.

METHODS

We conducted a prospective, observational study in adult patients (n = 72) sustaining severe injury admitted to a Level I Trauma Center. Healthy volunteers (n = 13) were also examined. Fecal specimens were collected on admission to the emergency department and at 3, 7, 10, and 13 days (±2 days) following injury. Microbial DNA was isolated for 16s rRNA sequencing, and α and β diversities were estimated, according to taxonomic classification against the Greengenes database.

RESULTS

The gut microbiome of trauma patients was altered on admission (i.e., within 30 minutes following injury) compared to healthy volunteers. Patients with an unchanged gut microbiome on admission were transfused more RBCs than those with an altered gut microbiome (p < 0.001). Although the gut microbiome started to return to a β-diversity profile similar to that of healthy volunteers over time, it remained different from healthy controls. Alternatively, α diversity initially increased postinjury, but subsequently decreased during the hospitalization. Injured patients on admission had a decreased abundance of traditionally beneficial microbial phyla (e.g., Firmicutes) with a concomitant decrease in opportunistic phyla (e.g., Proteobacteria) compared to healthy controls (p < 0.05). Large amounts of blood products and RBCs were both associated with higher α diversity (p < 0.001) and a β diversity clustering closer to healthy controls.

CONCLUSION

The human gut microbiome changes early after trauma and may be aided by early massive transfusion. Ultimately, the gut microbiome of trauma patients may provide valuable diagnostic and therapeutic insight for the improvement of outcomes postinjury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological, level III.
Association between age and acute respiratory distress syndrome development and mortality following trauma
Authors: Killien Elizabeth Y. , Mills Brianna , Vavilala Monica S. , Watson R. Scott , O'Keefe Grant E. , Rivara Frederick P.
Published: January 2019

BACKGROUND

Improved understanding of the relationship between patient age and acute respiratory distress syndrome (ARDS) development and mortality following traumatic injury may help facilitate generation of new hypotheses about ARDS pathophysiology and the role of novel treatments to improve outcomes across the age spectrum.

METHODS

We conducted a retrospective cohort study of trauma patients included in the National Trauma Data Bank who were admitted to an intensive care unit from 2007 to 2016. We determined ARDS incidence and mortality across eight age groups for the entire 10-year study period and by year. We used generalized linear Poisson regression models adjusted for underlying mortality risk (injury mechanism, Injury Severity Score, admission Glasgow Coma Scale score, admission heart rate, and admission hypotension).

RESULTS

Acute respiratory distress syndrome occurred in 3.1% of 1,297,190 trauma encounters. Acute respiratory distress syndrome incidence was lowest among pediatric patients and highest among adults aged 35 to 64 years. Acute respiratory distress syndrome mortality was highest among patients 80 years or older (43.9%), followed by 65 to 79 years (30.6%) and 4 years or younger (25.3%). The relative risk of mortality associated with ARDS was highest among the pediatric age groups, with an adjusted relative risk (aRR) of 2.06 (95% confidence interval [CI], 1.72–2.70) among patients 4 years or younger compared with an aRR of 1.51 (95% CI, 1.42–1.62) for the entire cohort. Acute respiratory distress syndrome mortality increased over the 10-year study period (aRR, 1.03 per year; 95% CI, 1.02–1.05 per year), whereas all-cause mortality decreased (aRR, 0.98 per year; 95% CI, 0.98–0.99 per year).

CONCLUSIONS

While ARDS development following traumatic injury was most common in middle-aged adults, patients 4 years or younger and 65 years or older with ARDS experienced the highest burden of mortality. Children 4 years or younger were disproportionately affected by ARDS relative to their low underlying mortality following trauma that was not complicated by ARDS. Acute respiratory distress syndrome–associated mortality following trauma has worsened over the past decade, emphasizing the need for new prevention and treatment strategies.

LEVEL OF EVIDENCE

Prognostic/epidemiological study, level III.
Complications in low-risk older adult trauma patients: A case-control study
Authors: Tessler Robert A. , Rangel Melissa M. , Rosser Micaela L. , Rivara Frederick P. , Bulger Eileen , Vavilala Monica S. , Reed May J. , Arbabi Saman
Published: January 2019

BACKGROUND

Although some geriatric trauma patients may be at low risk of complications, poor outcomes are pronounced if complications do occur. Prevention in this group decreases the risk of excess morbidity and mortality.

METHODS

We performed a case-control study of trauma patients 65 years or older treated from January 2015 to August 2016 at a Level I trauma center with a Trauma Quality Improvement Program–predicted probability of complication of less than 20%. Cases had one of the following complications: unplanned admission to the intensive care unit (ICU), unplanned intubation, pneumonia, or unplanned return to the operating room. Two age-matched controls were randomly selected for each case. We collected information on comorbidities, home medications, and early medical care and calculated odds ratios using multivariable conditional logistic regression.

RESULTS

Ninety-four patients experienced unplanned admission to ICU (n = 51), unplanned intubation (n = 14), pneumonia (n = 21), and unplanned return to the operating room (n = 8). The 188 controls were more frequently intubated and had higher median ISS but were otherwise similar to cases. The adjusted odds of complication were higher for patients on a home β-blocker (adjusted odds ratio [aOR], 2.2; 95% confidence interval [CI], 1.2–4.0) and home anticoagulation (aOR, 2.2; 95% CI, 1.2–4.1). Patients with diabetes (aOR 2.0; 95% CI, 1.1–3.7) and dementia (aOR, 2.0; 95% CI, 1.0–4.3) also had higher odds of complication. The adjusted odds of complication for patients receiving geriatrics consultation was 0.4 (95% CI, 0.2–1.0; p = 0.05). Pain service consultation and indwelling pain catheter placement may be protective, but CIs included 1. There was no association between opiates, benzodiazepines, fluid administration, or blood products in the first 24 hours and odds of complication.

CONCLUSIONS

Geriatrics consultation was associated with lower odds of unplanned admission to the ICU, unplanned intubation, pneumonia, and unplanned return to the operating room in low-risk older adult trauma patients. Pathways that support expanding comanagement strategies with geriatricians are needed.

LEVEL OF EVIDENCE

Therapeutic/Care management, Level IV.
The why and how our trauma patients die: A prospective Multicenter Western Trauma Association study
Authors: Callcut Rachael A. , Kornblith Lucy Z. , Conroy Amanda S. , Robles Anamaria J. , Meizoso Jonathan P. , Namias Nicholas , Meyer David E. , Haymaker Amanda , Truitt Michael S. , Agrawal Vaidehi , Haan James M. , Lightwine Kelly L. , Porter John M. , San Roman Janika L. , Biffl Walter L. , Hayashi Michael S. , Sise Michael J. , Badiee Jayraan , Recinos Gustavo , Inaba Kenji , Schroeppel Thomas J. , Callaghan Emma , Dunn Julie A. , Godin Samuel , McIntyre Robert C. , Peltz Erik D. , O'Neill Patrick J. , Diven Conrad F. , Scifres Aaron M. , Switzer Emily E. , West Michaela A. , Storrs Sarah , Cullinane Daniel C. , Cordova John F. , Moore Ernest E. , Moore Hunter B. , Privette Alicia R. , Eriksson Evert A. , Cohen Mitchell Jay
Published: January 2019

BACKGROUND

Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality.

METHODS

Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed.

RESULTS

One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32–75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care.

CONCLUSION

Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research.

LEVEL OF EVIDENCE

Epidemiologic, level II.
The Role Multimodal Pain Management Plays With Successful Total Knee and Hip Arthroplasty
Authors: Warren Kevin G. , Froehlich Morgan , Feldman Daniel L.
Published: January 2019

Approaching the best way to treat and manage a patient's surgical pain following total joint arthroplasty is a challenging task. To reduce the use of opioids, we utilize many different methods working together in a synergistic way. This is the true core of multimodal pain control. This task can be accomplished with a driven effort from the interdisciplinary team mostly comprising of but not limited to the surgeon, regional anesthesiologist, nurse, and physical therapist. The team addresses education of the patient, anesthesia type, medications, and nonpharmacological interventions within the development of the pain management plan. Achieving the goal of safe, effective pain management, in this population, will lead to improved outcomes, patient satisfaction, and enhanced functional life of patients.
Bilingualism in Primary Progressive Aphasia
Authors: Costa Ana S. , Jokel Regina , Villarejo Alberto , Llamas-Velasco Sara , Domoto-Reilley Kimiko , Wojtala Jennifer , Reetz Kathrin , Machado Álvaro
Published: January 2019

Background:

Primary progressive aphasia (PPA) is a neurodegenerative disorder characterized by progressive deterioration of language. Being rare, reports of PPA in multilingual individuals are scarce, despite more than half of the world population being multilingual.

Methods:

We describe clinical characteristics of 33 bilingual patients with PPA, including symptom presentation and language deficits pattern in their first (L1) and second language (L2), through a systematic literature review and new cases retrospectively identified in 5 countries.

Results:

In total, 14 patients presented with nonfluent/agrammatic variant, 6 with semantic variant, and 13 with logopenic variant, with a median symptom onset of 2 years. Word-finding difficulties was the first symptom in 65% of all cases, initially noticed in L2, and not always the dominant language. Our group had 22 different languages as L1, and 9 as L2. At the whole-group level there was a tendency for parallel impairment in both languages, in line with the shared bilingual neural substrate hypothesis, but each PPA variant showed some heterogeneity.

Discussion:

Each PPA variant showed heterogeneity, showing the need for comprehensive language and cognitive assessment across languages, as well as further clarification on the role of language mediators.
Spectrum of GABAA receptor variants in epilepsy
Authors: Maljevic Snezana , Møller Rikke S. , Reid Christopher A. , Pérez-Palma Eduardo , Lal Dennis , May Patrick , Lerche Holger
Published: January 2019

Purpose of review

Recent publications point to an increasingly important role of variants in genes encoding GABAA receptor subunits associated with both common and rare forms of epilepsies. The aim of this review is to give an overview of the current clinical phenotypes, genetic findings and pathophysiological mechanisms related to GABAA receptor variants.

Recent findings

Early work showed that inherited variants in GABRG2 and GABRA1 cause relatively mild forms of monogenic epilepsies in large families. More recent studies have revealed that de novo variants in several GABAA receptor genes cause severe developmental and epileptic encephalopathies, inherited variants cause remarkably variable phenotypes within the same pedigrees ranging from asymptomatic carriers to developmental and epileptic encephalopathies, and variants in all GABAA receptor genes are enriched in common forms of epilepsy, namely rolandic epilepsy and genetic generalized epilepsy. Analyses from cellular expression systems and mouse models suggest that all variants cause a loss of GABAA receptor function resulting in GABAergic disinhibition.

Genetic studies have revealed a crucial role of the GABAergic system in the underlying pathogenesis of various forms of common and rare epilepsies. Our understanding of functional consequences of GABAA receptor variants provide an opportunity to develop precision-based therapeutic strategies that are hopefully free from the side-effect burden seen with currently available GABAergic drugs.
Teratogenicity of antiepileptic drugs
Authors: Tomson Torbjörn , Battino Dina , Perucca Emilio
Published: January 2019

Purpose of review

We review data on the comparative teratogenicity of antiepileptic drugs (AEDs), focusing on major congenital malformations (MCMs), intrauterine growth restriction, impaired cognitive development, and behavioral adverse effects following prenatal exposure.

Recent findings

Prospective registries and meta-analyses have better defined the risk of MCMs in offspring exposed to individual AEDs at different dose levels. Valproate is the drug with the highest risk, whereas prevalence of MCMs is lowest with lamotrigine, levetiracetam, and oxcarbazepine. For valproate, phenobarbital, phenytoin, carbamazepine, and lamotrigine, the risk of MCMs is dose-dependent. Prenatal exposure to valproate has also been confirmed to cause an increased risk of cognitive impairments and autistic traits. In a population-based study, the risk of AED-induced autistic traits was attenuated by periconceptional folate supplementation.

The risk of adverse fetal effects differs in relation to the type of AED and for some AEDs also the daily dose. Although for MCMs the risk is primarily associated with the first trimester of gestation, influences on cognitive and behavioral development could extend throughout pregnancy. Available information now permits a more rational AED selection in women of childbearing potential, and evidence-based counseling on optimization of AED treatment before conception.
Petroclival Meningioma Presenting With an Ipsilateral Sixth Nerve Palsy and a Contralateral Homonymous Quadrantanopia: A Unique and Topographically Localizing Syndrome
Authors: Sharifi Ardalan , Lyons Lance J. , Vickers Aroucha , Lee Andrew G.
Published: January 2019

An 84-year-old woman reported onset of headaches, diplopia, and blurred vision. On examination, she was found to have a left sixth nerve palsy and an incongruous right homonymous hemianopia. Brain MRI demonstrated a left petroclival meningioma, causing this unusual combination of clinical findings. The patient was treated with radiation therapy and has remained stable over 4 years of follow-up.
A Retrospective Study of Cognitive Improvement Following Electroconvulsive Therapy in Schizophrenia Inpatients
Authors: Seow Lee Seng Esmond , Subramaniam Mythily , Chan Yi Wen Christopher , Martin Donel M. , Abdin Edimansyah , Chong Siow Ann , Liu Jianlin , Peh Chao Xu , Tor Phern Chern
Published: January 2019

Objectives

Findings on the cognitive effect of electroconvulsive therapy (ECT) in individuals with schizophrenia have brought mixed results, with few recent studies beginning to report cognitive improvements after treatment. Cognitive change in inpatients with schizophrenia who were referred for an acute course of ECT was examined in the current study. Furthermore, the study aimed to determine the profile of patients who experience cognitive improvement and the potential use of a brief cognitive battery to detect this positive cognitive change, if any.

Methods

Montreal Cognitive Assessment (MoCA) was conducted at baseline and posttreatment after 6 sessions of ECT. The Brief ECT Cognitive Screen was also administered to determine its predictive ability on cognitive gain of 2 points or higher in MoCA total scores for the 2 consecutive time points.

Results

A total of 81 inpatients were included in the study. Retrospective analysis revealed significant improvements in MoCA total score and domains of visuospatial/executive function and attention. Cognitive improvement was more pronounced among those who had worse pre-MoCA score before ECT.

Conclusions

The study provided support to the existing literature where cognitive improvement has been reported among individuals with schizophrenia after ECT. Future studies should consider the use of randomized controlled trials to examine the possible cognitive benefits of ECT. In a setting where there is a high volume of patients receiving ECT, the monitoring of patients' cognitive status through the course of ECT continues to be warranted and the Brief ECT Cognitive Screen may be useful as a quick measure to detect such ECT-related cognitive change.