Angiographic Coronary Slow Flow Is Not a Valid Surrogate for Invasively Diagnosed Coronary Microvascular Dysfunction

BACKGROUND

Ischemia with no obstructive coronary arteries is frequently caused by coronary microvascular dysfunction (CMD). Consensus diagnostic criteria for CMD include baseline angiographic slow flow by corrected TIMI (Thrombolysis In Myocardial Infarction) frame count (cTFC), but correlations between slow flow and CMD measured by invasive coronary function testing (CFT) are uncertain.

OBJECTIVES

The aim of this study was to investigate relationships between cTFC and invasive CFT for CMD.

METHODS

Adults with ischemia with no obstructive coronary arteries underwent invasive CFT with thermodilution-derived baseline coronary blood flow, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). CMD was defined as abnormal CFR (<2.5) and/or abnormal IMR (≥25). cTFC was measured from baseline angiography; slow flow was defined as cTFC >25. Correlations between cTFC and baseline coronary flow and between CFR and IMR and associations between slow flow and invasive measures of CMD were evaluated, adjusted for covariates. All patients provided consent.

RESULTS

Among 508 adults, 49% had coronary slow flow. Patients with slow flow were more likely to have abnormal IMR (36% vs 26%; P = 0.019) but less likely to have abnormal CFR (28% vs 42%; P = 0.001), with no difference in CMD (46% vs 51%). cTFC was weakly correlated with baseline coronary blood flow (r = -0.35; 95% CI: -0.42 to -0.27), CFR (r = 0.20; 95% CI: 0.12 to 0.28), and IMR (r = 0.16; 95% CI: 0.07-0.24). In multivariable models, slow flow was associated with lower odds of abnormal CFR (adjusted OR: 0.53; 95% CI: 0.35 to 0.80).

CONCLUSIONS

Coronary slow flow was weakly associated with results of invasive CFT and should not be used as a surrogate for the invasive diagnosis of CMD.

Fatigue in children who have recently completed treatment for acute lymphoblastic leukemia: a longitudinal study

BACKGROUND

This study examined fatigue in patients treated for childhood acute lymphoblastic leukemia (ALL) over a 2-year period (3- to 27-months post-treatment completion), from the perspective of children and parent caregivers, compared to a healthy comparison group.

METHODS

Eighty-three patients (4-16 years at enrolment) and their parents, reported on the child's fatigue using the Pediatric Quality of Life Inventory- Multidimensional Fatigue Scale (PedsQL-MFS), at 3- 15- and 27-months post-treatment completion, and 53 healthy children and their parents reported on fatigue across the same timepoints.

RESULTS

Parent proxy-reporting showed that parents of ALL patients reported more total fatigue than parents of the comparison group at all time points, with all subscales elevated (general, cognitive, and sleep/rest fatigue). In contrast, patient self-report of fatigue over this period differed from the comparison children for the general fatigue subscale only. Self-reported total fatigue was worse than the comparison group at the 27-month timepoint, with cognitive and sleep/rest fatigue symptoms contributing to this difference. Expected improvements in fatigue over time were not evident in either patient or parent report and no demographic risk factors were identified. Parents and children from both groups reported significantly more fatigue at all time points compared to commonly utilised normative population data.

CONCLUSIONS

Patients treated for childhood ALL are impacted by fatigue symptoms in the post-treatment and early survivorship period. These findings highlight that patients in the 2-years following treatment require increased symptom surveillance and may benefit particularly from interventions that target cognitive and sleep/rest fatigue.

The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status

Background

Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function.

Aims

The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function.

Methods

In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction.

Results

Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03).

Conclusions

After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.

Atmospheric molecular blobs shape up circumstellar envelopes of AGB stars

During their thermally pulsing phase, asymptotic giant branch (AGB) stars eject material that forms extended dusty envelopes1. Visible polarimetric imaging found clumpy dust clouds within two stellar radii of several oxygen-rich stars2-6. Inhomogeneous molecular gas has also been observed in multiple emission lines within several stellar radii of different oxygen-rich stars, including W Hya and Mira7-10. At the stellar surface level, infrared images have shown intricate structures around the carbon semiregular variable R Scl and in the S-type star π1 Gru11,12. Infrared images have also shown clumpy dust structures within a few stellar radii of the prototypical carbon AGB star IRC+10°216 (refs. 13,14), and studies of molecular gas distribution beyond the dust formation zone have also shown complex circumstellar structures15. Because of the lack of sufficient spatial resolution, however, the distribution of molecular gas in the stellar atmosphere and the dust formation zone of AGB carbon stars is not known, nor is how it is subsequently expelled. Here we report observations with a resolution of one stellar radius of the recently formed dust and molecular gas in the atmosphere of IRC+10°216. Lines of HCN, SiS and SiC2 appear at different radii and in different clumps, which we interpret as large convective cells in the photosphere, as seen in Betelgeuse16. The convective cells coalesce with pulsation, causing anisotropies that, together with companions17,18, shape its circumstellar envelope.

Performance-Based Assessment of Trauma Systems: Estimates for the State of Ohio

OBJECTIVES

There are no widely accepted metrics to determine the optimal number and geographic distribution of trauma centers (TCs). We propose a Performance-based Assessment of Trauma System (PBATS) model to optimize the number and distribution of TCs in a region using key performance metrics.

METHODS

The proposed PBATS approach relies on well-established mathematical programming approach to minimize the number of level I (LI) and level II (LII) TCs required in a region, constrained by prespecified system-related under-triage (srUT) and over-triage (srOT) rates and TC volume. To illustrate PBATS, we collected 6002 matched (linked) records from the 2012 Ohio Trauma and EMS registries. The PBATS-suggested network was compared to the 2012 Ohio network and also to the configuration proposed by the Needs-Based Assessment of Trauma System (NBATS) tool.

RESULTS

For this data, PBATS suggested 14 LI/II TCs with a slightly different geographic distribution compared to the 2012 network with 21 LI and LII TC, for the same srUT≈.2 and srOT≈.52. To achieve UT ≤ .05, PBATS suggested 23 LI/II TCs with a significantly different distribution. The NBATS suggested fewer TCs (12 LI/II) than the Ohio 2012 network.

CONCLUSION

The PBATS approach can generate a geographically optimized network of TCs to achieve prespecified performance characteristics such as srUT rate, srOT rate, and TC volume. Such a solution may provide a useful data-driven standard, which can be used to drive incremental system changes and guide policy decisions.

A survey of biosecurity and health management practices on Irish dairy farms engaged in contract-rearing

A survey was conducted to investigate potential differences in biosecurity and health management practices on Irish dairy farms that sent their heifers for contract-rearing (source dairy farms, SDF; n = 62) and those rearing their own heifers (control farms, CF; n = 50). Participating farmers were surveyed by postal questionnaire between September and November 2018. The overall response rate was 93%. Results show that structurally, SDF were larger, less fragmented, and more specialized than CF. Outsourcing of labor-intensive activities to external contractors was more common among SDF than CF, exposing them to potentially increased biosecurity risks associated with animal movements, use of shared equipment, and increased frequency of farm visitors. The majority of SDF sent heifers to a single-origin rearing facility (70%), with heifers most commonly arriving at the rearing unit between 2 and 4 mo (53%) and returning to the dairy farm between 18 and 21 mo of age (56%). Despite the increased biosecurity risk associated with contract-rearing, implementation of disease prevention measures was not superior on SDF compared with CF. For both farm types, there was scope for improvement to visitor biosecurity protocols, quarantine procedures, colostrum feeding practices, and hygiene of calving areas. This research provides an overview of the demographics and farm management practices implemented by dairy farmers engaged in contract-rearing of replacement heifers, and will serve to inform farmers, veterinary advisors, and policy makers.

Predicting Discharge Disposition in Trauma Patients: Development, Validation, and Generalization of a Model Using the National Trauma Data Bank

Background

Limited work has been done in predicting discharge disposition in trauma patients; most studies use single institutional data and have limited generalizability. This study develops and validates a model to predict, at admission, trauma patients’ discharge disposition using NTDB, transforms the model into an easy-to-use score, and subsequently evaluates its generalizability on institutional data.

Methods

NTDB data were used to build and validate a binary logistic regression model using derivation-validation (ie, train-test) approach to predict patient disposition location (home vs non-home) upon admission. The model was then converted into a trauma disposition score (TDS) using an optimization-based approach. The generalizability of TDS was evaluated on institutional data from a single Level I trauma center in the U.S.

Results

A total of 614 625 patients in the NTDB were included in the study; 212 684 (34.6%) went to a non-home location. Patients with a non-home disposition compared to home had significantly higher age (69 ± 19.7 vs 48.3 ± 20.3) and ISS (11.2 ± 8.2 vs 8.2 ± 6.3); P < .001. Older age, female sex, higher ISS, comorbidities (cancer, cardiovascular, coagulopathy, diabetes, hepatic, neurological, psychiatric, renal, substance abuse), and Medicare insurance were independent predictors of non-home discharge. The logistic regression model’s AUC was 0.8; TDS achieved a correlation of 0.99 and performed similarly well on institutional data (n = 3161); AUC = 0.8.

Conclusion

We developed a score based on a large national trauma database that has acceptable performance on local institutions to predict patient discharge disposition at the time of admission. TDS can aid in early discharge preparation for likely-to-be non-home patients and may improve hospital efficiency.

Perceived cancer-related pain and fatigue, information needs, and fear of cancer recurrence among adult survivors of childhood cancer

OBJECTIVE

Pain and fatigue are under-researched late effects of childhood cancer and its treatment, and may be interpreted by survivors as indicating cancer recurrence. Moreover, unmet information needs for managing pain and fatigue may be related to fear of cancer recurrence. We investigated the complex relationships between perceived cancer-related pain and fatigue, unmet information needs for managing pain and fatigue, and fear of cancer recurrence.

METHODS

We surveyed 404 adult survivors of any form of childhood cancer (M = 16.82 years since treatment completion).

RESULTS

Many survivors reported perceived cancer-related pain (28.7%) and fatigue (40.3%), and anticipated future pain (19.3%) and fatigue (26.2%). These symptomologies were all related to unmet information needs for managing pain (18.8%) and fatigue (32.2%; all p's<.001). Survivors reporting unmet information needs for managing pain (B = .48, 95% CI = 0.19-0.76, p = .001) and fatigue (B = .32, 95% CI = 0.06-0.52, p = .015) reported higher fear of cancer recurrence than survivors reporting no information needs.

CONCLUSION

Survivors often have unmet information needs for managing pain and fatigue, and these unmet needs are related to fear of cancer recurrence.

PRACTICE IMPLICATIONS

Long-term follow-up clinics should assess pain and fatigue. Information provision about pain and fatigue may be an important tool to help manage fear of cancer recurrence.

Association of System-Level Factors With Secondary Overtriage in Trauma Patients

Importance

Studies show that secondary overtriage (SO) contributes significantly to the economic burden of injured patients; thus, the association of SO with use of the trauma system has been examined. However, the association of the underlying trauma system design with such overtriage has yet to be evaluated.

Objectives

To evaluate whether the distribution of trauma centers in a statewide trauma system is associated with SO and to identify clinical and demographic factors that may lead to SO.

Design, Setting, and Participants

A retrospective cohort study was performed using 2008-2012 data from the Ohio Trauma and Emergency Medical Services registries. All patients taken to level III or nontrauma centers from the scene of the injury with an Injury Severity Score less than 15 and discharged alive were included. Among these patients, those with SO were identified as those who were subsequently transferred to a level I or II trauma center, had no surgical intervention, and were discharged alive within 48 hours of admission. The SO group was analyzed descriptively. Multiple logistic regression was used to identify system-level factors associated with SO. Statistical analysis was performed from August 1, 2017, to January 31, 2018.

Main Outcomes and Measures

The primary outcome was the occurrence of SO.

Results

Of 34 494 trauma patients able to be matched in the 2 registries, 7881 (22.9%) met the inclusion criteria, of whom 965 (12.2%) had SO. The median age in the SO group was 40 years (interquartile range, 26-55 years), with 299 women and 666 men. After adjusting for age, sex, comorbidities, injury type, and insurance status, the study found that system-level factors (number of level I or II trauma centers in the region [>1]) were significantly associated with SO (adjusted odds ratio, 1.98; 95% CI, 1.64-2.38; P < .001; area under the curve, 0.89). The reasons for choice of destination by emergency medical services (specifically, choosing the closest facility: adjusted odds ratio, 1.65; 95% CI, 1.37-1.98; P < .001) and use of a field trauma triage protocol (adjusted odds ratio, 2.21; 95% CI, 1.70-2.87; P < .001), significantly increased the likelihood of SO.

Conclusions and Relevance

This study's findings suggest that the distribution of major trauma centers in the region is significantly associated with SO. Subsequent investigation to identify the optimal number and distribution of trauma centers may therefore be critical. Specific outreach and collaboration of level III trauma centers and nontrauma centers with level I and II trauma centers, along with the use of telemedicine, may provide further guidance to level III trauma centers and nontrauma centers on when to transfer injured patients.

The Affordable Care Act: Long-Term Financial Impact on a Level I Trauma Center

BACKGROUND

Prior studies of the impact of the Affordable Care Act on reimbursement for inpatient trauma care do not include disproportionate share hospital (DSH) funding. Because trauma centers and other safety-net hospitals are sensitive to any changes in financial support, it is essential to include DSH funding in evaluating overall reimbursement. This study analyzes the long-term financial trends, including DSH, of a level I trauma center in Ohio, a state that expanded Medicaid.

METHODS

Charges, reimbursement, sources of insurance coverage, Injury Severity Scores, and DSH funding for the trauma patient population of an Ohio American College of Surgeons level 1 trauma center were studied from 2012 to 2017. Data were collected from Transition Systems, Inc.

RESULTS

During 2012-2017, self-pay patient cases decreased from 15.0% to 4.1% and commercial insurance patients decreased from 34.2% to 27.6%. The percentage of Medicaid patients increased from 15.5% to 27.1%; however, Medicaid reimbursement average per case declined from $17,779 in 2012 to $10,115 in 2017 (a decline of 43.1%). Self-pay charges decreased from $22.0 million to $6.7 million. Total DSH funding, compensation given to hospitals that disproportionately treat underserved populations, decreased 17.4%.

CONCLUSIONS

Self-pay charges and self-pay patients decreased dramatically; Medicaid patients and charges increased substantially in the years after the implementation of the Affordable Care Act at our trauma center. However, there was a decrease in commercial insurance, which had the highest reimbursement for our hospital, and a significant decline in DSH, a critical supplemental source of funding for safety-net hospitals.

Right Heart Function in Critically Ill Patients at Risk for Acute Right Heart Failure: A Description of Right Ventricular-Pulmonary Arterial Coupling, Ejection Fraction and Pulmonary Artery Pulsatility Index

BACKGROUND

The gold standard for right heart function is the assessment of right ventricular-pulmonary arterial coupling defined as the ratio of arterial to end-systolic elastance (Ea/Emax). This study demonstrates the use of the volumetric pulmonary artery (PA) catheter for estimation of Ea/Emax and describes trends of Ea/Emax, right ventricular ejection fraction (RVEF), and pulmonary artery pulsatility index (PAPi) during initial 48hours of resuscitation in the trauma surgical intensive care unit (ICU).

METHODS

Review of prospectively collected data for 32 mechanically ventilated adult trauma and emergency general surgery patients enrolled within 6hours of admission to the ICU. Haemodynamics, recorded every 12hours for 48hours, were compared among survivors and non-survivors to hospital discharge.

RESULTS

Mean age was 49±20 years, 69% were male, and 84% were trauma patients. Estimated Ea/Emax was associated with pulmonary vascular resistance and inversely related to pulmonary arterial capacitance and PA catheter derived RVEF. Seven (7) trauma patients did not survive to hospital discharge. Non-survivors had higher estimated Ea/Emax, suggesting right ventricular-pulmonary arterial uncoupling, with a statistically significant difference at 48hours (2.3±1.7 vs 1.0±0.58, p=0.018). RVEF was significantly lower in non-survivors at study initiation and at 48hours. PAPi did not show a consistent trend.

CONCLUSIONS

Estimation of Ea/Emax using volumetric PA catheter is feasible. Serial assessment of RVEF and Ea/Emax may help in early identification of right heart dysfunction in critically ill mechanically ventilated patients at risk for acute right heart failure.

Team-Based Learning in the Surgery Clerkship: Impact on Student Examination Scores, Evaluations, and Perceptions

OBJECTIVE

There is little evidence for effectiveness of team-based learning (TBL) in specialties such as Surgery. We developed and instituted TBLs in surgery clerkship and compared National Board of Medical Examiners (NBME) Surgery Subject Exam scores before and after implementation. We also analyzed students' feedback for their perception of TBLs.

DESIGN, SETTING, AND PARTICIPATNTS

The TBLs were transitioned into the curriculum during the 2013-2014 academic year. The "before" and "after" implementation periods were 2011-2013 and 2014-2016, respectively. NBME Surgery Subject Examination scores at our institution and nationally were compared using the independent samples t test. Satisfaction with the clerkship was assessed with Association of American Medical Colleges Graduate Questionnaire data. Student feedback regarding TBL was gathered at the end of each surgery rotation and were analyzed for themes, both positive and negative.

RESULTS

Mean NBME score was higher at our institution than nationally, both before (77.10 ± 8.75 vs. 75.20 ± 8.95, p = 0.032) and after (74.65 ± 8.0 vs. 73.10 ± 8.55, p = 0.071) TBL implementation. The mean score decreased following TBL implementation at our medical school (77.10 ± 8.75 vs. 74.65 ± 8.00, p = 0.039), but it was also lower nationally (75.20 ± 8.95 vs. 73.10 ± 8.55, p < 0.001). Further, students were more likely to rate the surgery clerkship as "good and/or excellent" on the Association of American Medical Colleges Graduate Questionnaire after TBL implementation (84.6% vs. 73.7%). In qualitative assessment, learners stated that TBLs were informative, helpful in studying for the shelf exam, and viewed them as an opportunity for interactive learning, and thus requested more TBLs. Areas for improvement included reading materials, directions, and organization of sessions.

CONCLUSIONS

Student perception of TBL into our surgery clerkship has been both positive and provided feedback for improvement. In addition, our medical school graduates have continued to assess their surgery experience as "good" or "excellent" by a large majority. Concurrently, our NBME scores remain above the national mean. We believe our medical students benefit from a well-organized TBL and its active approach to learning during the surgery clerkship with no loss of fundamental surgery knowledge.

Global Health Education for Medical Students: When Learning Objectives Include Research

BACKGROUND

The Luke Commission, a provider of comprehensive mobile health outreach in rural Swaziland, focuses on human immunodeficiency virus testing and prevention, including the performance of over 100 circumcisions weekly. Educational objectives for medical student global health electives are essential. Learning research methodology while engaging in clinical activities reinforces curriculum goals. Medical care databases can produce clinically significant findings affecting international health policy. Engaging in academic research exponentially increased the educational value of student experiences during an international medical elective.

METHODS

Staff of the Luke Commission, a nongovernmental organization, collected and deidentified information from 1500 Swazi male patients undergoing circumcision from January through June of 2014. Medical students designed studies and analyzed these data to produce research projects on adverse event rates, pain perception, and penile malformations. Institutional review board approval was obtained from the home institution and accompanying senior surgical faculty provided mentorship.

RESULTS

First-year medical students enrolled in an international medical elective to explore resource availability, cultural awareness, health care provision, and developing world endemic diseases. While in country, students learned research methodology, collected data, and engaged in research projects. Following the trip, students presented posters at over 10 regional and national meetings. All 4 articles are accepted or under consideration for publication by major journals.

CONCLUSIONS

During international medical electives the combination of clinical experiences and access to databases from health aid organizations provides the foundation for productive medical student research. All participants benefit from the relationships formed by aid organizations, medical students, and patient populations. Global health research has many complexities, but through careful planning and cultural awareness, medical students can increase their research skills and contribute to the medical literature, bringing attention to and improving health care policies around the world. In sum, the educational experience of medical students is enhanced through the interaction of delivering patient care and completing clinical research studies.

Discovery of methyl silane and confirmation of silyl cyanide in IRC +10216

We report the discovery in space of methyl silane, CH3SiH3, from observations of ten rotational transitions between 80 and 350 GHz (Ju from 4 to 16) with the IRAM 30 m radio telescope. The molecule was observed in the envelope of the C-star IRC +10216. The observed profiles and our models for the expected emission of methyl silane suggest that the it is formed in the inner zones of the circumstellar envelope, 1-40 R*, with an abundance of (0.5-1) × 10-8 relative to H2. We also observed several rotational transitions of silyl cyanide (SiH3CN), confirming its presence in IRC +10216 in particular, and in space in general. Our models indicate that silyl cyanide is also formed in the inner regions of the envelope, around 20 R*, with an abundance relative to H2 of 6×10-10. The possible formation mechanisms of both species are discussed. We also searched for related chemical species but only upper limits could be obtained.

The growth of carbon chains in IRC +10216 mapped with ALMA

Linear carbon chains are common in various types of astronomical molecular sources. Possible formation mechanisms involve both bottom-up and top-down routes. We have carried out a combined observational and modeling study of the formation of carbon chains in the C-star envelope IRC +10216, where the polymerization of acetylene and hydrogen cyanide induced by ultraviolet photons can drive the formation of linear carbon chains of increasing length. We have used ALMA to map the emission of λ 3 mm rotational lines of the hydrocarbon radicals C2H, C4H, and C6H, and the CN-containing species CN, C3N, HC3N, and HC5N with an angular resolution of ~1″. The spatial distribution of all these species is a hollow, 5-10″ wide, spherical shell located at a radius of 10-20″ from the star, with no appreciable emission close to the star. Our observations resolve the broad shell of carbon chains into thinner sub-shells which are 1-2″ wide and not fully concentric, indicating that the mass loss process has been discontinuous and not fully isotropic. The radial distributions of the species mapped reveal subtle differences: while the hydrocarbon radicals have very similar radial distributions, the CN-containing species show more diverse distributions, with HC3N appearing earlier in the expansion and the radical CN extending later than the rest of the species. The observed morphology can be rationalized by a chemical model in which the growth of polyynes is mainly produced by rapid gas-phase chemical reactions of C2H and C4H radicals with unsaturated hydrocarbons, while cyanopolyynes are mainly formed from polyynes in gas-phase reactions with CN and C3N radicals.

Is nasotracheal intubation safe in facial trauma patients?

BACKGROUND

In the prehospital setting, oral intubation is preferred in facial trauma patients due to the potential for further injury during nasotracheal intubation. This study compared the complications of nasal vs. oral vs. nasal + oral intubations performed by first responder crews in facial trauma patients. Our objective was to assess patient outcomes and complications to determine the risk of nasal intubation in facial trauma patients in the prehospital setting.

METHODS

Patients with facial trauma between 2008 and 13 were abstracted from the Miami Valley Hospital trauma registry: 50 were nasal only (n), 27 nasal + oral (no), and 135 oral only (o) intubation. Analysis of variance with the post-hoc Least Significance Difference Test and the chi square test were used in the analysis.

RESULTS

The oral group was older [41.1 ± 17.6 (o) vs. 36.2 ± 14.1 (n) vs. 33.0 ± 15.7 (no), p = 0.032] and had a higher facial abbreviated injury severity (AIS) mean score (1.8 ± 0.6 vs. 1.3 ± 0.5 vs. 1.5 ± 0.5, p < 0.001). The three groups did not differ in mortality (n = 20% vs. o = 18% vs. no = 30%, p = 0.37). The n + o group was intubated longer (p < 0.001) and had longer ICU and hospital lengths of stay (p = 0.015 and p = 0.023). The three groups did not differ on the composite of any pulmonary complication - i.e., any one of sinusitis, pneumonia, atelectasis, and respiratory failure - 44% (no) vs. 24% (o) vs. 30% (n), p = 0.10). However, nasal + oral patients were more likely to have one or more of the eight complication studied [63% (no) vs. 28% (o) vs. 34% (n), p = 0.002], and have a longer ICU and HLOS.

CONCLUSIONS

Prehospital nasal intubation is a viable short-term alternative to oral intubation in patients with facial trauma and warrants further research.

Infancy and pediatric cancer: an exploratory study of parent psychological distress

BACKGROUND

Research on the psychological experiences of parents of infants within pediatric oncology is sparse. This study examined rates and indicative risk factors for psychological distress in parents where there is either an infant patient or infant sibling of a patient.

METHODS

Participants were mothers (n = 41) and fathers (n = 25) of infants under 2 years who either had a cancer diagnosis (n = 37; infant patients) or was an infant sibling of an older child with cancer (n = 29; infant siblings) recruited from a single oncology center. There were 21 couple dyads. Parents completed the Depression Anxiety Stress Scales short form and the Posttraumatic Stress Disorder Checklist.

RESULTS

Mothers (47.5%) and fathers (37.5%) reported elevated, cancer-related posttraumatic stress symptoms. Rates of depression (12.2% of mothers and 12.0% of fathers) and anxiety symptoms (17.1% of mothers and 8.0% of fathers) were lower. Compared with parents of infant patients, parents of infant siblings reported significantly higher rates of depressive symptoms and trends toward higher rates of posttraumatic stress symptoms and anxiety symptoms. Parent anxiety was higher with increased time post diagnosis. No demographic or illness-related variables were associated with psychological distress, with the exception of the number of children in the family.

CONCLUSIONS

Parent-child relationships are of fundamental importance during infancy. This study provides novel data highlighting the psychological impact for parents when a cancer diagnosis is made during this critical developmental period, including the contribution of family structure to parental distress. Results provide further support for applying a traumatic stress framework when exploring parent experiences of pediatric cancer. Copyright © 2016 John Wiley & Sons, Ltd.

Differentiating between detrimental and beneficial interruptions: a mixed-methods study

INTRODUCTION

Efforts to understand interruptions now span much of the last decade and a half. Often thought to negatively impact patient safety, some now acknowledge that interruptions may be beneficial and actually necessary for safety and high quality care. This study seeks a framework for differentiating between interruptions that are detrimental and those that are beneficial.

METHODS

A mixed-methods approach at a US Level 1 trauma centre included direct observation of 13 registered nurses (RNs), survey of 47 RNs, retrospective observation of hands-free communication devices, and modelling of observed interruptions to key performance measures.

RESULTS

On average, RNs were interrupted every 11 min, with 20.3% of their workload triggered by interruptions. While 85% of RNs agreed that interruptions place their patients at risk, only 21% agreed that all should be eliminated. During one 90-min period, 18 original events spawned 68 interruptions, 50 of these repeat messages. A statistical model, with patient measures of time and comfort, revealed that alarms and call lights returning RN's attention to the patient outside the patient room are beneficial, while interruptions in the patient room are generally detrimental. Triangulating the results, we present an emerging framework for differentiating between beneficial and detrimental interruptions based on the impact of interruptions on the RN's steady treatment and attention to the patient.

CONCLUSIONS

A mixed-methods approach can help distinguish between detrimental and beneficial interruptions. While interruptions breaking the delivery of steady treatment and attention to the patient are detrimental, those returning the RN's focus to the patient, as well as those supporting patient-clinician and clinician-clinician communications are beneficial. This insight may be helpful to healthcare delivery teams tasked with improving interruption-laden processes.

Parent perceptions of managing child behavioural side-effects of cancer treatment: a qualitative study

BACKGROUND

Very little research has examined the role of parenting in managing behavioural side-effects of cancer treatment. The purpose of this paper was to explore parent perceptions of (a) parenting in the context of childhood cancer; (b) the parenting strategies used in the context of managing child behavioural side-effects of cancer treatment; and (c) the perceived impact that cancer-specific parenting strategies have on child behaviour.

METHODS

Participants were 15 mothers of children aged 2-6 years in the maintenance phase of treatment for acute lymphoblastic leukaemia at the Royal Children's Hospital Children's Cancer Centre, Melbourne, Australia. Mothers participated in a one-on-one semi-structured telephone interview using an interview guide which included questions on parenting in the context of childhood cancer, specifically in relation to behavioural side-effects (problems with behaviour, sleep and eating) and any perceived impact cancer-specific parenting may have on the ill child.

RESULTS

Many parents reported that following their child's cancer diagnosis, they had to implement a suite of 'new' strategies that 'pre-diagnosis' were used only in moderation, if at all. The most salient theme that emerged was parents' perception that their parenting became more lax since their child's diagnosis. Parents further reported specific parenting strategies for each of the main child behavioural side-effects of cancer treatment.

CONCLUSION

Data from the current qualitative exploratory study highlight the role of specific parenting strategies in managing or assisting child behavioural side-effects of cancer treatment. Further quantitative research is needed to more fully examine the association between parenting and child behavioural outcomes in order to develop modifiable approaches to improving child behavioural side-effects in a paediatric oncology context.

Discovery of SiCSi in IRC +10216: A missing link between gas and dust carriers of Si-C bonds

We report the discovery in space of a disilicon species, SiCSi, from observations between 80 and 350 GHz with the IRAM 30m radio telescope. Owing to the close coordination between laboratory experiments and astrophysics, 112 lines have now been detected in the carbon-rich star CW Leo. The derived frequencies yield improved rotational and centrifugal distortion constants up to sixth order. From the line profiles and interferometric maps with the Submillimeter Array, the bulk of the SiCSi emission arises from a region of 6″ in radius. The derived abundance is comparable to that of SiC2. As expected from chemical equilibrium calculations, SiCSi and SiC2 are the most abundant species harboring a Si-C bond in the dust formation zone and certainly both play a key role in the formation of SiC dust grains.

The prevalence of positive drug and alcohol screens in elderly trauma patients

BACKGROUND

Alcohol and drug abuse are recognized to be significantly prevalent in trauma patients, and are frequent harbingers of injury. The incidence of substance abuse in elderly trauma patients has, however, been limitedly examined. The authors sought to identify the spectrum of positive alcohol and drug toxicology screens in patients ≥65 years admitted to a Level I trauma center.

METHODS

Patients ≥65 years old admitted to an American College of Surgeons (ACS) Level I trauma center over a 60--month period were identified from the trauma registry. Demographic data, blood alcohol content (BAC), and urine drug screen (UDS) results at admission were obtained and analyzed. The positive results were compared with individuals below 65 years in different substance categories using Fisher's exact test.

RESULTS

In the 5-year period studied, of the 4139 patients ≥65 years, 1302 (31.5%) underwent toxicological substance screening. A positive BAC was present in 11.1% of these patients and a positive UDS in 48.3%. The mean BAC level in those tested was 163 mg/dL and 69% of patients had a level >80 mg/dL.

CONCLUSIONS

These data show that alcohol and drug abuse are an issue in patients ≥65 years in our institution, though not as pervasive a problem as in younger populations. Admission toxicology screens, however, are important as an aid to identify geriatric individuals who may require intervention.

Work-related stress and reward: an Australian study of multidisciplinary pediatric oncology healthcare providers

OBJECTIVE

Managing staff stress and preventing long-term burnout in oncology staff are highly important for both staff and patient well-being. Research addressing work-related stress in adult oncology is well documented; however, less is known about this topic in the pediatric context. This study examined sources of work-related stress and reward specific to multidisciplinary staff working in pediatric oncology in Australia.

METHOD

Participants were 107 pediatric oncology clinicians, including medical, nursing, and allied health staff from two Australian pediatric oncology centers. Participants completed an online survey using two newly developed measures: the work stressors scale-pediatric oncology and the work rewards scale-pediatric oncology.

RESULTS

The most commonly reported sources of both stress and reward are related to patient care and interactions with children. Results indicated that levels of work-related stress and reward were similar between the professional disciplines and between the two hospitals. Regression analyses revealed no demographic or organizational factors that were associated with either stress or reward.

CONCLUSIONS

Work-related stress and reward are not mutually exclusive; particular situations and events can be simultaneously stressful and rewarding for healthcare providers. Although patient care and interactions with children was found to be the most stressful aspect of working in this speciality, it was also the greatest source of reward. Results are discussed in relation to workplace approaches to staff well-being and stress reduction.

Early psychological reactions in parents of children with a life threatening illness within a pediatric hospital setting

RESEARCH IN CONTEXT

Parents of children with life threatening illness or injuries are at elevated risk of distress reactions, involving symptoms of acute stress disorder, depression and anxiety. Currently, the impact of child illness factors is unclear, and to date research systematically examining the prevalence of these psychological reactions across different illness groups with an acute life threat is sparse. This is important to explore given that studies show that parent functioning impacts on the psychological adjustment and recovery of the ill child. WHAT DOES THIS STUDY ADD?: At four weeks following a child's diagnosis of a serious illness, 49-54% of parents met DSM-IV criteria for acute stress disorder, across a number of illness groups, whereas 15-27% of parents were in the moderate/severe range for depression and anxiety, and 25-31% for stress. Results from this study demonstrate that rates and severity of these psychological reactions in parents of seriously ill children do not vary according to illness type.

BACKGROUND

A life threatening childhood illness/injury can lead to significant distress reactions in parents, with independent studies finding such reactions in several different illness groups. To date, there is limited research systematically comparing the prevalence of adverse parental psychological reactions across different childhood illness groups with an acute life threat. This study aimed to investigate the frequency and severity of symptoms of acute traumatic stress, depression, anxiety and general stress in parents, following admission of their child to hospital for a life threatening illness. The study also aimed to explore the relationship between these symptoms, and to determine whether they differ according to illness/injury.

METHODS

Cross-sectional data from a prospective, longitudinal study are reported. Participants were 194 parents of 145 children (49 couples), admitted to cardiology (n=53), oncology (n=40) and pediatric intensive care units (n=52), for serious illnesses/injuries. Parents completed self-report questionnaires within four weeks of hospital admission.

RESULTS

Rates of acute traumatic stress (P=0.262), depression (P=0.525), anxiety (P=0.453) and general stress symptoms (P=0.720) in parents were comparable across illness type, with 49-54% reaching criteria for acute stress disorder, 15-27% having clinical levels of depression and anxiety, and 25-31% for general stress. Anxiety was most strongly associated with acute traumatic stress (r=0.56), closely followed by stress (r=0.52) and depression (r=0.49), with all correlations highly significant (P<0.001).

CONCLUSIONS

These findings provide evidence that the child's medical condition is not associated with parents' experience of clinically significant psychological symptoms, and emphasize the importance for health care providers to be aware of these potential psychological reactions in parents, regardless of the type of illness.

Optical spectra of the silicon-terminated carbon chain radicals SiCnH (n = 3,4,5)

The gas-phase optical spectra of three silicon-terminated carbon chain radicals, SiCnH (n = 3 - 5), formed in a jet-cooled discharge of silane and acetylene, have been investigated by resonant two-color two-photon ionization and laser-induced fluorescence/dispersed fluorescence. Analysis of the spectra was facilitated by calculations performed using equation-of-motion coupled cluster methods. For SiC3H and SiC5H, the observed transitions are well-described as excitations from a (2)Π ground state to a (2)Σ state, in which vibronic coupling, likely involving a higher-lying Π state with a very large predicted f-value (close to unity), is persistent. The lowest (2)Σ states of both species are characterized by a rare silicon triple bond, which was identified previously [T. C. Smith, H. Y. Li, D. J. Clouthier, C. T. Kingston, and A. J. Merer, J. Chem. Phys. 112, 3662 (2000)] in the lowest (2)Σ state of SiCH. Although a strong Π - Π transition is predicted for SiC4H, the observed spectrum near 505 nm more likely corresponds to excitation to a relatively dark Σ state which is vibronically coupled to a nearby Π state. In contrast to the chains with an odd number of carbon atoms, which exhibit relatively sharp spectral features and lifetimes in the 10-100 ns range, SiC4H shows intrinsically broadened spectral features consistent with a ∼100 fs lifetime, and a subsequent long-lived decay (>50 μs) which we ascribe to mixing with a nearby quartet state arising from the same electronic configuration. The spin-orbit coupling constants for both SiC3H and SiC5H radicals were determined to be approximately 64 cm(-1), similar to that of SiCH (69.8 cm(-1)), suggesting that the unpaired electron in these species is localized on the silicon atom. Motivated by the new optical work, the rotational spectrum of linear SiC3H was detected by cavity Fourier-transform microwave spectroscopy in the 13-34 GHz range. Each rotational transition from the [Formula: see text] ground state exhibits well-resolved Λ-doubling and hyperfine structure; the derived rotational constant of B = 2.605 GHz is in excellent agreement with our calculations.

Filtration effectiveness of HVAC systems at near-roadway schools

Concern for the exposure of children attending schools located near busy roadways to toxic, traffic-related air pollutants has raised questions regarding the environmental benefits of advanced heating, ventilation, and air-conditioning (HVAC) filtration systems for near-road pollution. Levels of black carbon and gaseous pollutants were measured at three indoor classroom sites and at seven outdoor monitoring sites at Las Vegas schools. Initial HVAC filtration systems effected a 31-66% reduction in black carbon particle concentrations inside three schools compared with ambient air concentrations. After improved filtration systems were installed, black carbon particle concentrations were reduced by 74-97% inside three classrooms relative to ambient air concentrations. Average black carbon particle concentrations inside the schools with improved filtration systems were lower than typical ambient Las Vegas concentrations by 49-96%. Gaseous pollutants were higher indoors than outdoors. The higher indoor concentrations most likely originated at least partially from indoor sources, which were not targeted as part of this intervention.

PRACTICAL IMPLICATIONS

Recent literature has demonstrated adverse health effects in subjects exposed to ambient air near major roadways. Current smart growth planning and infill development often require that buildings such as schools are built near major roadways. Improving the filtration systems of a school's HVAC system was shown to decrease children's exposure to near-roadway diesel particulate matter. However, reducing exposure to the gas-phase air toxics, which primarily originated from indoor sources, may require multiple filter passes on recirculated air.

Circulating cellular and humoral elements of immune function following splenic arterial embolisation or splenectomy in trauma patients

BACKGROUND

Splenectomy impairs the ability to combat infection, especially with encapsulated organisms. However, there is limited understanding of the impact of splenic arterial embolisation on immune function. Our hypothesis was that embolisation would not impair systemic immune function. This study examines elements of cellular and humoral immunity in patients undergoing splenic embolisation or splenectomy for trauma.

PATIENTS AND METHODS

Splenic embolisation (SE) and splenectomy patients (S) were compared to blunt trauma patients without splenic injury (NS). Lymphocyte counts, natural-killer cells, serum complement (C3, C4), and properdin levels were assayed.

RESULTS

No significant differences in total, helper, or suppressor T-lymphocytes, complement (C3, C4), or properdin were found. B-lymphocyte counts were higher in S (602±445cells/mm(3)) than SE (238±114cells/mm(3)) or NS (293±153cells/mm(3)) (p=.003 for pairwise comparisons). S also had more natural killer T-cells than NS (325±170cells/mm(3) vs. 174±116cells/mm(3), p=.004).

CONCLUSION

Splenic embolisation does not alter the measured immunologic parameters. The absence of sensitive markers for splenic immune function limits the ability to assess the impact of embolisation for trauma.

Does platelet administration affect mortality in elderly head-injured patients taking antiplatelet medications?

A significant portion of patients sustaining traumatic brain injury (TBI) take antiplatelet medications (aspirin or clopidogrel), which have been associated with increased morbidity and mortality. In an attempt to alleviate the risk of increased bleeding, platelet transfusion has become standard practice in some institutions. This study was designed to determine if platelet transfusion reduces mortality in patients with TBI on antiplatelet medications. Databases from two Level I trauma centers were reviewed. Patients with TBI 50 years of age or older with documented preinjury use of clopidogrel or aspirin were included in our cohort. Patients who received platelet transfusions were compared with those who did not to assess outcome differences between them. Demographics and other patient characteristics abstracted included Injury Severity Score, Glasgow Coma Scale, hospital length of stay, and warfarin use. Three hundred twenty-eight patients comprised the study group. Of these patients, 166 received platelet transfusion and 162 patients did not. Patients who received platelets had a mortality rate of 17.5 per cent (29 of 166), whereas those who did not receive platelets had a mortality rate of 16.7 per cent (27 of 162) (P = 0.85). Transfusion of platelets in patients with TBI using antiplatelet therapy did not reduce mortality.

Neurologic outcomes with cerebral oxygen monitoring in traumatic brain injury

BACKGROUND

Optimizing cerebral oxygenation is advocated to improve outcome in head-injured patients. The purpose of this study was to compare outcomes in brain-injured patients treated with 2 types of monitors.

METHODS

Patients with traumatic brain injury and a Glasgow Coma Scale score<8 were identified on admission. A polarographic cerebral oxygen/pressure monitor (Licox) or fiberoptic intracranial pressure monitor (Camino) was inserted. An evidence-based algorithm for treatment was implemented. Elements from the prehospital and emergency department records and the first 10 days of intensive care unit (ICU) care were collected. Glasgow Outcome Scores (GOS) were determined every 3 months after discharge.

RESULTS

Over a 3-year period, 145 patients were entered into the study; 81 patients in the Licox group and 64 patients in the Camino group. Mortality, hospital length of stay, and ICU length of stay were equivalent in the 2 groups. More patients in the Licox group achieved a moderate/recovered GOS at 3 months than in the Camino Group (79% vs 61%; P = .09).

CONCLUSION

Three-month GOS revealed a clinically meaningful 18% benefit in patients undergoing cerebral oxygen monitoring and optimization. Six-month outcomes were also better. Unfortunately, these important differences did not reach significance. Continued study of the benefits of cerebral oxygen monitoring is warranted.

Impact of splenic injury guidelines on hospital stay and charges in patients with isolated splenic injury

BACKGROUND

The purpose of this study was to assess the impact of care guidelines for patients with isolated blunt splenic trauma on length of stay (LOS) and patient charges.

METHODS

We conducted a review of the hospital trauma registry and identified patients admitted with blunt splenic injury from 2000 to 2007. Splenic injury guidelines were initiated in November 2004. Patients with other major injuries were excluded. Patients were grouped according to their American Association for the Surgery of Trauma (AAST) splenic injury grade, I-V. Hospital LOS, intensive care unit (ICU) LOS, and patient charges before and after the guidelines were compared.

RESULTS

We identified 137 patients with isolated splenic injuries. Sixty-three patients were admitted before and 70 patients after implementation of the guidelines. ICU and hospital LOS were significantly decreased after the guidelines (ICU LOS, 1.35 days before, 0.80 after [P < .01]; and hospital LOS, 4.17 before, 3.27 after [P < .01]). When grouped by AAST grade, grade II injuries had a decrease in hospital LOS (4.5 before vs 2.29 after; P < .01) and ICU LOS (1.43 before vs 0.29 after; P < .01). Adjusted hospital charges showed no significant increase overall after the guideline implementation (mean hospital charges before $23,047 vs after, $24,116; P = .62).

CONCLUSION

Implementing guidelines for the observation of blunt splenic injury decreased the overall hospital LOS and ICU LOS at our institution, but hospital charges remained the same. Trauma programs should institute splenic injury guidelines to reduce resources needed for the care of isolated splenic injuries.

The impact of splenic artery embolization on the management of splenic trauma: an 8-year review

BACKGROUND

Splenic artery embolization (SAE) is an adjunct to nonoperative management (NOM) of splenic injuries. We reviewed our experience with SAE to identify its impact on splenic operations.

METHODS

Patients admitted with splenic injuries over an 8-year period were identified and the initial method of management noted (simple observation, SAE, or splenic surgery). The first 4 years (period 1) during which SAE was introduced was compared with the latter 4 years (period 2) when it was used frequently.

RESULTS

There were 304 patients in period 1 and 416 in period 2. NOM was initial management in 59.9% in period 1% and 60.1% in period 2 (P = 1.0) and failure rates were 5.3% versus 2.9%, respectively (P = .12). More SAE procedures were performed in period 2 -- 13.7% versus 4.9% (P < or = .001) -- and there was a reduction in the proportion of splenic operations -- 35.2% versus 26.2% (P <.01).

CONCLUSIONS

SAE is associated with a reduction in splenic operations, although it did not alter the failure rate of NOM.

The prevalence of incidental findings on abdominal computed tomography scans of trauma patients

BACKGROUND

Abdominal computed tomography scanning (AbdCTS) is the standard of care in the evaluation of blunt trauma patients. The liberal use of AbdCTS coupled with advancing imaging technology often results in the detection of incidental findings.

OBJECTIVES

We sought to characterize the incidence and prevalence of such findings, describe the lesions most frequently seen on AbdCTS performed on patients admitted to a Level I trauma center, and develop a plan for follow-up through our performance improvement process.

METHODS

AbdCTS reports of all admissions to a Level I trauma center between January 2000 and December 2002 were reviewed. Incidental findings identified were classified into benign anatomic variants, benign pathologic lesions, and pathologic lesions requiring further work-up.

RESULTS

A total of 3,113 patients were evaluated by AbdCTS during this time period. There were 1474 incidental findings in 1,103 patients. Seventy-five percent of patients with incidental lesions had no traumatic findings. Benign anatomic variants were present in 1.8%, benign pathologic findings in 27.5%, and pathologic findings requiring work-up in 6.1%. Congenital renal anomalies and duplicate inferior vena cava were the most common benign anatomical findings. Renal and hepatic cysts were the most frequent benign lesions and non-calcified pulmonary nodules and adrenal masses were the pathologic lesions most commonly seen.

CONCLUSIONS

Incidental findings are seen in up to 35% of trauma AbdCTS. No concomitant traumatic injuries are present in up to 75% of these patients. Protocols for appropriate intervention or arrangements for follow-up care need to be incorporated into the care of the trauma patients.

Bladder incarceration following anterior external fixation of a traumatic pubic symphysis diastasis treated with immediate open reduction and internal fixation

Anterior pelvic ring disruptions are often associated with injuries to the genitourinary structures with the potential for considerable resultant morbidity. Herniation of the bladder into the symphyseal region after injury with subsequent entrapment upon reduction of the symphyseal diastasis has seldom been reported in the literature. We report such a case involving bladder herniation and subsequent entrapment after attempted closed reduction with anterior pelvic external fixation immediately treated with open reduction and internal fixation along with a review of the literature.

Clinical parameters do not adequately predict outcome in necrotizing enterocolitis: a multi-institutional study

OBJECTIVE

Necrotizing enterocolitis (NEC) remains a major cause of neonatal morbidity and mortality. Some infants recover uneventfully with medical therapy whereas others develop severe disease (that is, NEC requiring surgery or resulting in death). Repeated attempts to identify clinical parameters that would reliably identify infants with NEC most likely to progress to severe disease have been unsuccessful. We hypothesized that comprehensive prospective data collection at multiple centers would allow us to develop a model which would identify those babies at risk for progressive NEC.

STUDY DESIGN

This prospective, observational study was conducted at six university children's hospitals. Study subjects were neonates with suspected or confirmed NEC. Comprehensive maternal and newborn histories were collected at the time of enrollment, and newborn clinical data were collected prospectively, thereafter. Multivariate logistic regression analysis was used to develop a predictive model of risk factors for progression.

RESULT

Of 455 neonates analyzed, 192 (42%) progressed to severe disease, and 263 (58%) advanced to full feedings without operation. The vast majority of the variables studied proved not to be associated with progression to severe disease. A total of 12 independent predictors for progression were identified, including only 3 not previously described: having a teenaged mother (odds ratio, OR, 3.14; 95% confidence interval, CI, 1.45 to 6.96), receiving cardiac compressions and/or resuscitative drugs at birth (OR, 2.51; 95% CI, 1.17 to 5.48), and having never received enteral feeding before diagnosis (OR, 2.41; 95% CI, 1.08 to 5.52).

CONCLUSION

Our hypothesis proved false. Rigorous prospective data collection of a sufficient number of patients did not allow us to create a model sufficiently predictive of progressive NEC to be clinically useful. It appears increasingly likely that further analysis of clinical parameters alone will not lead to a significant improvement in our understanding of NEC. We believe that future studies must focus on advanced biologic parameters in conjunction with clinical findings.

Management of acute appendicitis by an acute care surgery service: is operative intervention timely?

BACKGROUND

Trauma services are increasingly providing emergency surgery care by creating "acute care surgery" teams. We compared two periods at a Level I trauma center to determine if trauma service coverage would negatively impact timely management of acute appendicitis.

STUDY DESIGN

All patients admitted through the emergency department of a Level I trauma center who underwent appendectomies between March 2005 and May 2006 (Trauma period) were identified. During this period, the trauma service covered most surgical emergencies. Comparison was made with the earlier 15-month period (Pretrauma). Emergency department to operating room (OR) time, procedure length, and negative appendectomy rates were obtained.

RESULTS

In the Pretrauma period, 273 patients underwent appendectomy, compared with 279 in the Trauma period. Two-thirds (66%) of appendectomies in the Trauma period were performed by trauma surgeons. There was no difference in both periods with regard to mean emergency department to OR time (10.5 hours versus 9.9 hours; p = 0.4509), perforation rates (12% Pretrauma versus 7.5% Trauma; p = 0.1134), or negative appendectomy rates (17.9% Pretrauma versus 18.2% Trauma; p = 1.0). In the Trauma period, more appendectomies were completed laparoscopically (84.6% Trauma versus 66.6% Pretrauma; p < 0.0001), and mean OR time was shorter (57.4 minutes versus 67 minutes; p = 0.0006).

CONCLUSIONS

In comparing two periods with and without the trauma service coverage of surgical emergencies, no difference was found in emergency department to OR time, perforation rates, or negative appendectomy rates in the management of acute appendicitis. There was a decrease in operative time and an increase in the proportion of laparoscopic appendectomies in the Trauma period. Trauma services can effectively incorporate emergency surgical coverage of procedures, such as appendectomies, without compromising timely intervention.

The rotational spectrum of CN−

The rotational spectrum of the molecular negative ion CN(-) has been detected in the laboratory at high resolution. The four lowest transitions were observed in a low pressure glow discharge through C(2)N(2) and N(2). Conclusive evidence for the identification was provided by well-resolved nitrogen quadrupole hyperfine structure in the lowest rotational transition, and a measurable Doppler shift owing to ion drift in the positive column of the discharge. Three spectroscopic constants (B, D, and eQq) reproduce the observed spectrum to within one part in 10(7) or better, allowing the entire rotational spectrum to be calculated well into the far IR to within 1 km s(-1) in equivalent radial velocity. CN(-) is an excellent candidate for astronomical detection, because the CN radical is observed in many galactic molecular sources, the electron binding energy of CN(-) is large, and calculations indicate CN(-) should be detectable in IRC+10216-the carbon star where C(6)H(-) has recently been observed. The fairly high concentration of CN(-) in the discharge implies that other molecular anions containing the nitrile group may be within reach.

Laparoscopy in the contemporary management of acute appendicitis

BACKGROUND

We sought to compare laparoscopic appendectomy (LA) with open appendectomy (OA) focusing on the negative appendectomy rate (NAR), emergency department (ED) to operating room (OR) time, procedure length, and histopathological correlation.

METHODS

All appendectomies for appendicitis over a 6-year period at a single hospital were reviewed. Open and laparoscopic procedures were compared.

RESULTS

There were 1,312 appendectomies (54.6% OA and 45.4% LA) Mean ED to OR time was as follows: LA 10.8 hours (standard deviation [SD] +/- 9.0) versus 9.8 hours (SD +/- 8.5) OA (P = .0333). Mean OR time was 61.2 minutes (SD +/- 29.1) LA versus 57.7 minutes (SD +/- 28) OA (P = .0293). NAR was 18.3%, LA 23.3% versus 14.0% OA (P < .0001). Postoperative correlation with histopathology was 86% for LA versus 92% OA (P = .0003). In the LA group, 9.9% with a "normal" appendix had appendicitis by histopathology.

CONCLUSIONS

LA is associated with increased presentation to procedure time, operative time, and negative appendectomy rate. Removing a "normal" appendix during LA in the absence of alternate pathology is recommended.

Rotational spectroscopy of the isotopic species of silicon monosulfide, SiS

Pure rotational transitions of silicon monosulfide ((28)Si(32)S) and its rare isotopic species have been observed in their ground as well as vibrationally excited states by employing Fourier transform microwave (FTMW) spectroscopy of a supersonic molecular beam at centimetre wavelengths (13-37 GHz) and by using long-path absorption spectroscopy at millimetre and submillimetre wavelengths (127-925 GHz). The latter measurements include 91 transition frequencies for (28)Si(32)S, (28)Si(33)S, (28)Si(34)S, (29)Si(32)S and (30)Si(32)S in upsilon = 0, as well as 5 lines for (28)Si(32)S in upsilon = 1, with rotational quantum numbers J''< or = 52. The centimetre-wave measurements include more than 300 newly recorded lines. Together with previous data they result in almost 600 transitions (J'' = 0 and 1) from all twelve possible isotopic species, including (29)Si(36)S and (30)Si(36)S, which have fractional abundances of about 7 x 10(-6) and 4.5 x 10(-6), respectively. Rotational transitions were observed from upsilon = 0 for the least abundant isotopic species to as high as upsilon = 51 for the main species. Owing to the high spectral resolution of the FTMW spectrometer, hyperfine structure from the nuclear electric quadrupole moment of (33)S was resolved for species containing this isotope, as was much smaller nuclear spin-rotation splitting for isotopic species involving (29)Si. By combining the measurements here with previously published microwave and infrared data in one global fit, an improved set of spectroscopic parameters for SiS has been derived which include several terms describing the breakdown of the Born-Oppenheimer approximation. With this parameter set, highly accurate rotational frequencies for this important astronomical molecule can now be predicted well into the terahertz region.

Prehospital Hypoxia Affects Outcome in Patients With Traumatic Brain Injury: A Prospective Multicenter Study

BACKGROUND

The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospital discharge.

METHODS

Trauma patients with suspected brain injuries underwent continuous blood pressure and pulse oximetry monitoring during helicopter transport. Postadmission inclusion criteria were (1) diagnosis of acute traumatic brain injury (TBI) confirmed by computed tomography (CT) scan, operative findings, or autopsy findings; and (2) Head Abbreviated Injury Scale (AIS) score of > or = 3 or Glasgow Coma Scale (GCS) score of < or = 12 within the first 24 hours of admission. Patients were excluded with (1) no abnormal intracranial findings on the patient's CT scan; (2) determination of a nonsurvivable injury (based on an AIS score of 6 for any body region; or, (3) death in less than 12 hours after injury. Primary outcome measures included mortality and Disability Rating Scale score at discharge.

RESULTS

We enrolled 150 patients into the study. Fifty-seven patients had at least one secondary insult; 37 had only hypoxic episodes, 14 had only hypotensive episodes, and 6 patients had both. Demographics and injury characteristics did not differ between those with and those without secondary insults. The mortality for patients without secondary insults was 20%, compared with 37% for patients with hypoxic episodes, 8% for patients with hypotensive episodes, and 24% for patients with both. The Disability Rating Scale score at discharge was significantly higher in patients with secondary insults. Using multivariate analysis, the calculated odds ratio of mortality caused by prehospital hypoxia after head injury was 2.66 (p < 0.05).

CONCLUSIONS

Secondary insults after TBI are common, and these insults are associated with disability. Hypoxia in the prehospital setting significantly increases the odds of mortality after brain injury controlled for multiple variables.

Detection of low-frequency lambda-doublet transitions of the free 12CH and 13CH radicals

By Fourier transform microwave spectroscopy, lambda-doubling transitions of (12)CH and (13)CH in the lowest rotational levels of the X(2) product operator(1/2) ground state have been directly detected, which has not been done previously. For both radicals, hyperfine-split lines have been measured to an accuracy of better than 1 ppm between 3 and 15 GHz, an improvement of at least 2 orders of magnitude over previous laboratory data. The measured frequencies have been combined with all previous data for CH and (13)CH in the v = 0 level of the X(2) product operator electronic state to determine improved hyperfine parameters. The production of CH from various gases also has been studied and, with methanol, the yield of CH relative to OH. Astronomical studies of CH in higher rotational levels and (13)CH can now be undertaken on the basis of the present work.