Adult Traumatic Brain Injury and Likelihood of Routine Discharge: Do Comorbidities Matter?

The current literature demonstrates an association between both size and presence of traumatic brain injury (TBI) and its effects on mortality, however it does not readily address the morbidity and associated functional outcomes of those who survive. We hypothesize that the likelihood of discharge to home decreases with advancement of age in the presence of TBI. This is a single-center study of Trauma Registry data, inclusive years July 1, 2016 to October 31, 2021. The inclusion criteria was based upon age (≥40 years), and ICD10 diagnosis of a TBI. Disposition to home without services was the dependent variable. 2031 patients were included in the analysis. We hypothesized correctly that the likelihood of discharge to home decreases (by 6%) with advancement of age (per year) in the presence of intracranial hemorrhage.

Traumatic Brain Injury Under Triage Risk: A Rural Trauma System Experience

BACKGROUND

The process of interfacility transfer may cause a delay in the necessary medical treatment, which could lead to poor outcomes and increased mortality rates. The ACS-COT considers an acceptable under triage rate of <5%. The aim of this research was to identify the likelihood of under triage among transferred-in traumatic brain injury (TBI) patients.

METHODS

This is a single-center study of Trauma Registry data, from July 1, 2016, to October 31, 2021. The inclusion criteria were based upon age (≥40 years), ICD10 diagnosis of TBI, and interfacility transfer. Under triage using the Cribari matrix method was the dependent variable. A logistic regression was performed to identify additional predictor variables on the likelihood that an adult TBI trauma patient experienced under triage.

RESULTS

878 patients were included in the analysis; 168 (19%) experienced an under triage. The logistic regression model was statistically significant (N = 837, P < .01). In addition, several significant increases in odds for under triage were identified, which included increasing injury severity score (ISS; OR 1.40, P < .01), increasing AIS head region (OR 6.19, P < .01), and personality disorders (OR 3.61, P = .02). In addition, a reduction in odds in TBI adult trauma under triage is the comorbidity of anticoagulant therapy (OR .25, P < .01).

CONCLUSIONS

The likelihood of under triage in the adult TBI trauma population is associated with increasing AIS head injuries and increasing ISS and among those with mental health comorbidities. This evidence and additional protective factors, such as patients on anticoagulant therapy, may aid in education and outreach efforts to reduce under triage among the regional referring centers.

A highly sensitive cell-based luciferase assay for high-throughput automated screening of SARS-CoV-2 nsp5/3CLpro inhibitors

Effective drugs against SARS-CoV-2 are urgently needed to treat severe cases of infection and for prophylactic use. The main viral protease (nsp5 or 3CLpro) represents an attractive and possibly broad-spectrum target for drug development as it is essential to the virus life cycle and highly conserved among betacoronaviruses. Sensitive and efficient high-throughput screening methods are key for drug discovery. Here we report the development of a gain-of-signal, highly sensitive cell-based luciferase assay to monitor SARS-CoV-2 nsp5 activity and show that it is suitable for the screening of compounds in a 384-well format. A benefit of miniaturisation and automation is that screening can be performed in parallel on a wild-type and a catalytically inactive nsp5, which improves the selectivity of the assay. We performed molecular docking-based screening on a set of 14,468 compounds from an in-house chemical database, selected 359 candidate nsp5 inhibitors and tested them experimentally. We identified two molecules which show anti-nsp5 activity, both in our cell-based assay and in vitro on purified nsp5 protein, and inhibit SARS-CoV-2 replication in A549-ACE2 cells with EC₅₀ values in the 4–8 μM range. The here described high-throughput-compatible assay will allow the screening of large-scale compound libraries for SARS-CoV-2 nsp5 inhibitors. Moreover, we provide evidence that this assay can be adapted to other coronaviruses and viruses which rely on a viral protease.

Breast cancer recurrence: factors impacting occurrence and survival

BACKGROUND

Breast cancer mortality has decreased due to improved screening and treatment options. Nevertheless, 25-30% of patients develop disease recurrence and die from the disease dissemination. Patients who develop metastatic disease represent a heterogeneous group and management plans are dependent on molecular subtype, disease burden and metastatic site.

AIM

To determine predictive clinicopathological factors of disease recurrence and their impact on survival in the molecular era.

METHODS

Consecutive patients who breast cancer developed recurrence at our tertiary referral centre between 2000 and 2015 were included. Clinicopathological and treatment data were assessed using descriptive statistics. Oncological outcome was assessed using Cox regression and Kaplan Meier analyses.

RESULTS

Two hundred sixty-five consecutive patients who developed breast cancer recurrence were included; median age at metastasis was 59.3 years (range 27-87 years), and median time to recurrence (TTR) was 47.7 ± 38.5 months (range 3.0-194.3 months). Survival was 24.2% (64/265) 53.2% were luminal A (LABC) (141/265), 18.5% were luminal B (LBBC) (49/265), 18.5% were triple negative (TNBC) (49/265), and 9.8% were human epidermal growth factor receptor-2 overexpressing (HER2 +) (26/265). TTR for patients with LABC was 56.0 ± 41.3 months, LBBC was 48.4 ± 41.1 months, TNBC was 26.9 ± 28.5 months and HER2 + was 34.3 ± 21.8 months. Increased grade (P < 0.001), Nottingham Prognostic Indices (P < 0.001), TNBC (P < 0.001), HER2 + subtype (P < 0.001) and receiving targeted therapy (P = 0.006) predicted shorted TTR. Estrogen receptor positivity (P < 0.001), progesterone receptor positivity (P = 0.010), invasive lobular carcinoma (P = 0.009) and receiving endocrine therapy (P = 0.001) predicted longer TTR.

CONCLUSION

Readily available clinicopathological factors predict risk of metastatic dissemination. Developing a tailored program to identify patients at risk of recurrence is crucial in controlling metastatic dissemination of breast cancer.

A highly sensitive cell-based luciferase assay for high-throughput automated screening of SARS-CoV-2 nsp5/3CLpro inhibitors

Effective drugs against SARS-CoV-2 are urgently needed to treat severe cases of infection and for prophylactic use. The main viral protease (nsp5 or 3CLpro) represents an attractive and possibly broad-spectrum target for drug development as it is essential to the virus life cycle and highly conserved among betacoronaviruses. Sensitive and efficient high-throughput screening methods are key for drug discovery. Here we report the development of a gain-of-signal, highly sensitive cell-based luciferase assay to monitor SARS-CoV-2 nsp5 activity and show that it is suitable for high-throughput screening of compounds in a 384-well format. A benefit of miniaturisation and automation is that screening can be performed in parallel on a wild-type and a catalytically inactive nsp5, which improves the selectivity of the assay. We performed molecular docking-based screening on a set of 14,468 compounds from an in-house chemical database, selected 359 candidate nsp5 inhibitors and tested them experimentally. We identified four molecules, including the broad-spectrum antiviral merimepodib/VX-497, which show anti-nsp5 activity and inhibit SARS-CoV-2 replication in A549-ACE2 cells with IC 50 values in the 4-21 µM range. The here described assay will allow the screening of large-scale compound libraries for SARS-CoV-2 nsp5 inhibitors. Moreover, we provide evidence that this assay can be adapted to other coronaviruses and viruses which rely on a viral protease.

Sequential Instruction System (SIS))

This article describes a relatively simple conversational computer system to handle instructional texts or to perform a computer-aided testing. The system proceeds in a sequential mode with possibilities for branching forward or backward from where a sequential course is resumed.

Instructional or explanatory texts and/or multiple choice questions may be displayed. According to the answers the correctness or incorrectness of the reply is indicated. After each incorrect answer references or explanations are given. If desired, these explanatory frames can also be accessed after correct answers.

After completion of a course the score is displayed. SIS produces a log for the instructor including answers to individual questions and summary scores.

The system is written in FORTRAN. It is designed to run under O.S. on IBM 360 series computers with 2260 cathode ray tube (CRT) displays. It exists in two versions, one operating under a stand-alone attention handler for local displays, the other requiring the B.E.S.T. (Baylor Executive System for Teleprocessing) as message control program. In this case, remote CRT’s, teletypes and typewriter-type terminals may also serve as user terminals.

Though a few courses have been implemented, SIS is the basic vehicle, not the content of courses.

Adipose-Derived Stem Cells in Novel Approaches to Breast Reconstruction: Their Suitability for Tissue Engineering and Oncological Safety

Adipose-derived stem cells (ADSCs) are rapidly becoming the gold standard cell source for tissue engineering strategies and hold great potential for novel breast reconstruction strategies. However, their use in patients with breast cancer is controversial and their oncological safety, particularly in relation to local disease recurrence, has been questioned. In vitro, in vivo, and clinical studies using ADSCs report conflicting data on their suitability for adipose tissue regeneration in patients with cancer. This review aims to provide an overview of the potential role for ADSCs in breast reconstruction and to examine the evidence relating to the oncologic safety of their use in patients with breast cancer.

Can 'Hot Spotting' Prove to be a Useful Tool to Identify Disproportionate ED Use in the Rural General Hospital Setting?

'Hot spotting' allows the identification of areas with disproportionate use of Emergency Department (ED) services. To date, 'hot spotting' has focused on large urban centres. The aim of this study was to determine if there are geographic hotspots for ED use in the rural general hospital. ED attendances were logged between 1st July 2013 and 30th June 2014. Frequent users and super users were isolated. Addresses were cross referenced against national census data to determine number of users per 500 population in geographically distinct regions. The number of frequent users ranged from 1.00/500 population to 4.88/500 population. Four out of nineteen areas had > or equals; 4 frequent users per 500 population. There was no correlation between number of users and distance from MGH (p=0.44). 77% of frequent users presented with mixed aetiologies. Nineteen percent of frequent attenders presented via GP referral only, 13% attended via self-referral only and 88% attended via GP and self-referral routes.

Survival of Ruptured Abdominal Aortic Aneurysms in the West of Ireland: Do Prognostic Indicators of Outcome Exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male:female ratio was 8:1 and the mean age was 74 years (range 55–89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age =70 versus age <70, shocked versus stable, and preoperative hemoglobin (Hb) =10 vs >10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of <0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.

Endovascular Repair of Early Rupture of Dacron Aortic Graft

Complications after open aortic surgery pose a challenge both to the vascular surgeon and the patient because of aging population, widespread use of cardiac revascularization, and improved survival after aortic surgery. The perioperative mortality rate for redo elective aortic surgery ranges from 5% to 29% and increases to 70–100% in emergency situation. Endovascular treatment of the postaortic open surgery (PAOS) patient has fewer complications and a lower mortality rate in comparison with redo open surgical repair. Two cases of ruptured abdominal aortic aneurysm (AAA) were managed with the conventional open surgical repair. Subsequently, spiral contrast computer tomography scans showed reperfusion of the AAA sac remnant mimicking a type III endoleak. These graft-related complications presented as vascular emergencies, and in both cases endovascular aneurysm repair (EVAR) procedure was performed successfully by aortouniiliac (AUI) stent graft and femorofemoral crossover bypass. These 2 patients add further merit to the cases reported in the English literature. This highlights the crucial importance of endovascular grafts in the management of such complex vascular problems.

An unusual cause for massive inflation

Chagas disease is a rare condition but with an increasing incidence. Megacolon is a known sequelae. Surgical management remains the only disease modifying treatment option; with variable long-term success. We highlight an interesting case to emphasize attention to this rare condition as a differential diagnosis in any patient presenting with massive intestinal dilatation.

Clinical review: surgical management of locally advanced and recurrent colorectal cancer

AIM

Recurrent and locally advanced colorectal cancers frequently require en bloc resection of involved organs to achieve negative margins. The aim of this review is to evaluate the most current literature related to the surgical management of locally advanced and recurrent colorectal cancer.

METHODS

A literature review was performed on the electronic databases MEDLINE from PubMed, EMBASE and the Cochrane library for publications in the English language from January 1993 to July 2013. The MeSH search terms 'locally advanced colorectal cancer', 'recurrent colorectal cancer' and 'surgical management' were used.

RESULTS

A total of 1,470 patients with recurrent or locally advanced primary colorectal cancer were included in 22 studies. Surgical removal of the tumour with negative margins (R0) offers the best prognosis in term of survival with a 5-year survival of up to 70 %. MVR is needed in approximately 10 % with the most commonly involved organ being the bladder. The mean post-operative morbidity is 40 %, mainly relating to superficial surgical site infection, pelvic collections and delayed wound healing. Most patients will undergo radiotherapy and/or chemotherapy pre- or post-operatively. The mean 5-year overall survival for R0 resection is 50 % for recurrent and locally advanced primary tumours while survival following R1 or R2 is 12 and <5 %, respectively.

CONCLUSION

Multimodal therapy and extended surgery to achieve clear margins offers good prognosis to patients with recurrent and locally advanced colorectal cancers.

A benign psoas teratoma of the non-pelvic retroperitoneal space: A case report

This case report is of a benign retroperitoneal teratoma which was adherent to the psoas muscle of a 53-year-old female cadaver with a history of metastatic bladder cancer as a cause of death. Teratomas possess derivatives of all three germ cell layers and are usually seen either in children or in the lower pelvic region of adults. The finding of this mass deep to the inferior pole of the kidney is quite unusual. Few studies mention a possible association between metastatic cancer and teratoma growth in extrapelvic locations. The following report is a detailed account of this unusual finding and a summary of the literature on growths of this kind.

Recombinant erythropoietin (Epo)/darbepoetin (Darb) associated venous thromboembolism (VTE) in the oncology setting: Findings from the Research on Adverse Drug Events And Reports (RADAR) project

2552

Background: Cancer patients are at increased risk for VTE as compared to the general population, making VTE as a sADR difficult to detect in the oncology setting. In 2004, two phase III trials identified higher mortality rates among epo-treated cancer patients who were receiving chemotherapy in “off-label” settings- with these studies identifying higher VTE rates in the treatment arms. We reviewed data on epo/darb-associated VTE in the oncology setting. Methods: Data sources were meta-analyses and the FDA’s MedWatch database. Results: Since 1996, only 259 VTE reports (darb: n=30, epo: n=229) of VTE in the setting of chemotherapy and epo/darb were reported to MedWatch. Meta-analyses findings are tabulated below: Conclusions: In 2004, package inserts for Epo/Darb were revised, identifying increased risks of VTE with these agents in the oncology setting. Identification of this adverse drug reaction thirteen years after Epo received FDA approval for this indication (and had been prescribed to > 500,000 cancer patients) illustrates difficulties inherent with current pharmacovigilance efforts.

[Table: see text]

No significant financial relationships to disclose.

Salvage of critical limb ischemia with the "trellis reserve'' of subintimal superficial femoral-popliteal artery occlusion: a new modality in managing critical limb ischemia--a case report

Subintimal angioplasty is a safe, effective, but nondurable procedure in treating long superficial femoral artery occlusions in patients with severe lower limb ischemia. The authors report a case of acute thrombosis that presented 16 weeks after subintimal angioplasty. The ;;Trellis'' percutaneous thrombolytic infusion system permitted a controlled site-specific infusion of recombinant tissue-type plasminogen activator (rtPA). The unique design of the ;;Trellis'' allowed complete aspiration of thrombus and avoiding regional and systemic thrombolytic side effects. The ;;Trellis'' system is effective in percutaneous management of thrombotic lesions; however, intimal dissection may need to be addressed.

The Influence of Subintimal Angioplasty on Level of Amputation and Limb Salvage Rates in Lower Limb Critical Ischaemia: A 15-year Experience

OBJECTIVES

The aim of this study is to assess the influence of subintimal angioplasty (SIA) on lower limb amputation rate and level in critically ischaemic limbs.

METHODS

Between January 1989 and March 2004, 1268 patients were admitted for treatment of lower limb critical ischaemia. Eight hundred and twenty-nine patients underwent revascularisation (bypass 671 and angioplasty 158), while 439 patients had primary amputations. A retrospective analysis of a prospectively maintained vascular registry was performed. Patients were divided into two groups, those who were admitted prior to the availability of subintimal angioplasty and those treated post-introduction of angioplasty. The two groups were compared with regards to age, sex, diabetes mellitus, ASA grade, Rutherford classification and level of disease. Outcome was assessed by the limb salvage rate, 30-day morbidity and mortality, and length of hospital stay.

RESULTS

The average number of revascularisation increased with the introduction of subintimal angioplasty, from 53 to 96 per year (p<0.001). The overall limb salvage rate increased significantly from 42 to 70% (p<0.001). The cumulative limb salvage rate following revascularisation rose from 72 to 86% (p<0.001). The level of amputation (AKA:BKA) did not vary significantly. Thirty-day morbidity, mortality and length of hospital stay were significantly lower in the post-angioplasty group.

CONCLUSIONS

Technical advances have resulted in a steadying of amputation numbers despite an ageing population.

Benign mixed tumour of the skin with extensive ossification and marrow formation: a case report

Benign mixed tumour of the skin (chondroid syringoma) is an uncommon skin adnexal tumour, usually presenting as a slow growing solitary painless nodule. The morphological appearances are similar to those of a pleomorphic adenoma of the salivary gland. Hair matrix and sebaceous differentiation can be seen in some lesions. Focal ossification is a rare finding. This report presents a case of a similar tumour arising in the cheek of a 43 year old white man, showing extensive ossification. Clinical, radiological, and pathological correlation and diagnosis proved to be difficult preoperatively. Only two cases of a benign mixed tumour with pronounced ossification have been reported so far, both in Japanese patients. This is the first reported case seen in a white man. Awareness of these lesions will avoid potential diagnostic pitfalls.

Carotid stump syndrome. A case report and literature review

Carotid stump syndrome occurs infrequently. Diagnosis and management requires flow studies with duplex ultrasound scan as well as anatomical delineation of the affected vessel by magnetic resonance angiography. Surgical exclusion of the internal carotid artery is safe and effective and is the gold standard of treatment with best medical therapy.

Subintimal Angioplasty as a Primary Modality in the Management of Critical Limb Ischemia:Comparison to Bypass Grafting for Aortoiliac and Femoropopliteal Occlusive Disease

PURPOSE

To compare the 30-day morbidity, mortality, length of hospital stay, and patency rates in patients with critically ischemic limbs treated with subintimal angioplasty (SA) versus standard bypass surgery.

METHOD

Between October 2001 and August 2003, 137 patients (74 women; mean age 70 years, range 43-92) with critical limb ischemia underwent subintimal angioplasty (n=88) or bypass surgery (n=49) for superficial femoral artery (SFA) or aortoiliac lesions. All patients had lesions classified as C or D according to the TransAtlantic Inter-Society Consensus. Data was retrieved from hospital inpatient inquiry and VascuBase. Parallel group comparison was used in performing a prospective observational study.

RESULTS

Primary technical success was 100% for both SA and bypass grafting. Thirty-day survival was 100% in the SFA-SA and aortoiliac bypass groups and 96% and 93%, respectively, in the SFA bypass and aortoiliac SA groups. Limb salvage was 97% and 82% in the SFA-SA and SFA bypass groups, respectively; at the aortoiliac levels, the rates were 100% and 86% for SA versus bypass. Subintimal angioplasty significantly reduced hospital stay (p<0.001). Primary patency was not statistically different in the SA versus bypass groups; however, secondary patency was higher in the SFA bypass group.

CONCLUSIONS

Frequent clinical follow-up and a duplex surveillance program are necessary to maintain patency in this cohort. Subintimal angioplasty is increasingly replacing bypass surgery in the management of critical limb ischemia without compromising primary patency, limb salvage, patient survival, or subsequent vascular intervention.

A controlled trial of inpatient and outpatient geriatric evaluation and management

BACKGROUND

Over the past 20 years, both inpatient units and outpatient clinics have developed programs for geriatric evaluation and management. However, the effects of these interventions on survival and functional status remain uncertain.

METHODS

We conducted a randomized trial involving frail patients 65 years of age or older who were hospitalized at 11 Veterans Affairs medical centers. After their condition had been stabilized, patients were randomly assigned, according to a two-by-two factorial design, to receive either care in an inpatient geriatric unit or usual inpatient care, followed by either care at an outpatient geriatric clinic or usual outpatient care. The interventions involved teams that provided geriatric assessment and management according to Veterans Affairs standards and published guidelines. The primary outcomes were survival and health-related quality of life, measured with the use of the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36), one year after randomization. Secondary outcomes were the ability to perform activities of daily living, physical performance, utilization of health services, and costs.

RESULTS

A total of 1388 patients were enrolled and followed. Neither the inpatient nor the outpatient intervention had a significant effect on mortality (21 percent at one year overall), nor were there any synergistic effects between the two interventions. At discharge, patients assigned to the inpatient geriatric units had significantly greater improvements in the scores for four of the eight SF-36 subscales, activities of daily living, and physical performance than did those assigned to usual inpatient care. At one year, patients assigned to the outpatient geriatric clinics had better scores on the SF-36 mental health subscale, even after adjustment for the score at discharge, than those assigned to usual outpatient care. Total costs at one year were similar for the intervention and usual-care groups.

CONCLUSIONS

In this controlled trial, care provided in inpatient geriatric units and outpatient geriatric clinics had no significant effects on survival. There were significant reductions in functional decline with inpatient geriatric evaluation and management and improvements in mental health with outpatient geriatric evaluation and management, with no increase in costs.

Relationship between acute morphine and the course of PTSD in children with burns

OBJECTIVE

To investigate the relationship between the dose of morphine administered during a child's hospitalization for an acute burn and the course of posttraumatic stress disorder (PTSD) symptoms over the 6-month period following discharge from the hospital.

METHOD

Twenty-four children admitted to the hospital for an acute burn were assessed twice with the Child PTSD Reaction Index: while in the hospital and 6 months after discharge. The Colored Analogue Pain Scale was also administered during the hospitalization. All patients received morphine while in the hospital. The mean dose of morphine (mg/kg/day) was calculated for each subject through chart review.

RESULTS

The Pearson product moment correlation revealed a significant association between the dose of morphine received while in the hospital and a 6-month reduction in PTSD symptoms. Children receiving higher doses of morphine had a greater reduction in PTSD symptoms over 6 months.

CONCLUSIONS

This study suggests the possibility that acute treatment with morphine can secondarily prevent PTSD. This result is discussed in terms of the possible effect of morphine on fear conditioning and the consolidation of traumatic memory.

How to write a recruiting policy

Occupational health professionals have an important role to play in ensuring that individuals recruited by any organization are medically capable of performing their required duties in an efficient manner. To achieve this, the physician's knowledge of the workplace should be used to establish the necessary medical standards whilst their occupational health expertise and experience should be called upon to establish the relevant means of objectively assessing attainment of the established criteria. A written policy detailing the procedures, both medical and administrative is essential.