COVID-19: using chest CT of major trauma patients to monitor and evaluate the second wave in London and the development of routine monitoring in practice

AIM

To follow-up previous work evaluating incidental findings of COVID-19 signs on computed tomography (CT) images of major trauma patients to include the second wave prior to any major effects from vaccines.

MATERIALS AND METHODS

The study population included all patients admitted following major trauma between 1 January 2020 and 28 February 2021 with CT including the lungs (n=1776). Major trauma patients admitted pre-COVID-19 from alternate months from January 2019 to November 2019 comprised a control group (n=837). The assessing radiologists were blinded to the time period and used double reading in consensus to determine if the patient had signs of COVID-19. Lung appearances were classified as no evidence of COVID-19, minor signs, or major signs.

RESULTS

The method successfully tracked the second wave of the COVID-19 pandemic in London. The estimated population affected by the disease based on those with major signs was similar to estimates of the proportion of the population in London with antibodies (around 30% by end February 2021) and the total of major and minor signs produced a much higher figure of 68%, which may include all those with both antibody and just T-cell responses.

CONCLUSIONS

Incidental findings on CT from major trauma patients may provide a novel and sensitive way of tracking the virus. It is recommended that all major trauma units include a simple question on signs of COVID-19 to provide an early warning system for further waves.

Chronic airflow obstruction and ambient particulate air pollution

Smoking is the most well-established cause of chronic airflow obstruction (CAO) but particulate air pollution and poverty have also been implicated. We regressed sex-specific prevalence of CAO from 41 Burden of Obstructive Lung Disease study sites against smoking prevalence from the same study, the gross national income per capita and the local annual mean level of ambient particulate matter (PM2.5) using negative binomial regression. The prevalence of CAO was not independently associated with PM2.5 but was strongly associated with smoking and was also associated with poverty. Strengthening tobacco control and improved understanding of the link between CAO and poverty should be prioritised.

Oral health education and prevention strategies among remote Aboriginal communities: a qualitative study

BACKGROUND

The delivery of effective oral health promotion strategies is essential to improving oral health outcomes among remote Aboriginal communities. This study aimed to explore the perceptions and attitudes of Aboriginal Australians living in remote Kimberley communities towards oral health education and disease prevention.

METHODS

Semi-structured interviews and yarning circles were carried out following purposive sampling of Aboriginal adults living in the East Kimberley region of Western Australia.

RESULTS

A total of 80 community members participated in the yarning process. School-based oral health promotion and community-driven restrictions on the sale of sugary food and drink were seen as positive strategies in improving oral health. Lifestyle changes brought about by modernity, internet availability and fixed community stores were perceived to create new challenges and shift the priorities for those living in remote communities.

CONCLUSIONS

Community-based yarning may better inform future oral health strategies in the Kimberley. A neoliberal approach of shifting responsibility onto the individual ignores the complex social inequities faced by Aboriginal people living in remote communities where macro-level determinants such as remoteness, food security and education significantly influence decisions around diet and oral health.

BIMAM—a tool for imputing variables missing across datasets using a Bayesian imputation and analysis model

Motivation

Combination of multiple datasets is routine in modern epidemiology. However, studies may have measured different sets of variables; this is often inefficiently dealt with by excluding studies or dropping variables. Multilevel multiple imputation methods to impute these ‘systematically’ missing data (as opposed to ‘sporadically’ missing data within a study) are available, but problems may arise when many random effects are needed to allow for heterogeneity across studies. We show that the Bayesian IMputation and Analysis Model (BIMAM) implemented in our tool works well in this situation.

General features

BIMAM performs imputation and analysis simultaneously. It imputes both binary and continuous systematically and sporadically missing data, and analyses binary and continuous outcomes. BIMAM is a user-friendly, freely available tool that does not require knowledge of Bayesian methods. BIMAM is an R Shiny application. It is downloadable to a local machine and it automatically installs the required freely available packages (R packages, including R2MultiBUGS and MultiBUGS).

Availability

BIMAM is available at [www.alecstudy.org/bimam].

Rapid upper airway obstruction after arteriovenous malformation rupture in a patient with neurofibromatosis

Neurofibromatosis type 1 is rarely associated with arteriovenous malformation rupture. We present a case of a rapidly compromised upper airway due to extrinsic compression as a consequence of the rupture of an arteriovenous malformation fed by the inferior thyroid artery which required emergency cricothyroidotomy following failed attempts at orotracheal intubation. While the patient had a good overall outcome, our reflection on the management of this case highlights several important learning points. These include the importance of clear communication between different medical specialties to promote shared situation awareness, the importance of training anaesthetists in the limitations of standard difficult airway management algorithms, and the implications of the skillset mix of doctors responding to airway emergencies in district general hospitals.

Racial disparities in the use of mechanical circulatory support devices in cardiogenic shock

Background

Racial bias has always been a concern for healthcare. Lack of guideline directed utilization of mechanical circulatory support (MCS) devices in cardiogenic shock (CS) may lead to implicit and racial bias.

Purpose

To identify the racial differences in the use of mechanical circulatory support in cardiogenic shock and its association with outcomes.

Methods

National Inpatient Database from 2015–2018 using ICD 10 codes was used. Patients >18 years of age admitted for cariogenic shock were included.

Results

Among 1,021,274 patients hospitalized for cardiogenic shock, overall MCS was utilized in 11.4% (N=116,539). Use of MCS for patients stratified by race was 12.2% white (N=85543), 8% Blacks (N=14688), 11.3% Hispanics (N=11067), 13.8% Asian (N=4417), 12.3% Native American (N=825). IABP was the most commonly used MCS device, followed by Impella, ECMO and LVAD. Overall odds of MCS insertion was significantly higher in white population [1.18 (1.13–1.23) <0.001] and significantly lower in Blacks [0.65 (0.61–0.69) <0.001] and Hispanics [0.89 (0.83–0.97) 0.004]. Among black patients with CS requiring MCS, odds of LVAD insertion were similar compared to other races [1.03 (0.89–1.19) 0.714], while odds of all other types of MCS devices including ECMO [0.83 (0.72–0.95) 0.009], IABP [0.63 (0.59–0.68) <0.001] and Impella [0.61 (0.54–0.70) <0.001] were significantly lower compared to other races. This trend also holds true for patients with CS associated with acute myocardial infarction. Among all patients with CS, the odds of mortality were significantly lower among white patients [0.92 (0.90–0.95) <0.001], on the contrary, odds of mortality were significantly higher in Blacks [1.06 (1.02–1.10) 0.001] and Asians [1.11 (1.02–1.20) 0.012]. Interestingly, when only comparing patients who underwent MCS utilization for CS, odds of mortality were similar in black population compared to other races. [1.03 (0.91–1.17) 0.636].

Conclusion(s)

There still exist significant racial differences in the use of mechanical circulatory devices for cardiogenic shock potentially leading to significantly higher mortality in black population compared to whites. This difference in mortality is mitigated with equal use of MCS devices in cardiogenic shock among all races.

Funding Acknowledgement

Type of funding sources: None.

589 Role of Liver Support Systems in The Management of Post Hepatectomy Liver Failure: A Meta-Analysis and Systematic Review of Literature

Aim

Post hepatectomy liver failure (PHLF) is a rare but serious complication following liver resection. PHLF is associated with high mortality of up to 50% in severe cases. With limited treatment options available, there is a need to evaluate the role of systems that support the function of the liver as treatment modalities following PHLF development.

Method

The aim of this study was to review the literature and summarise the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications were extracted, pooled where possible, and analysed.

Results

Systematic review identified ten studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF development. The sample sizes of included studies were small, ranging from N = 2 to N = 13. Across all studies, the pooled 90-day mortality rate was 40% (95% CI: 15% - 68%). However, there was substantial heterogeneity (I2=64%), likely since the studies used a variety of definitions for PHLF and had different selection criteria for patient eligibility for LSS treatment.

Conclusions

Despite potential benefits, the current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicentre, prospective studies evaluating the conventional and newer modalities of support systems with a view to improve the outcomes in this group of patients.