Impact of trauma centre capacity and volume on the mortality risk of incoming new admissions

INTRODUCTION

Trauma centre capacity and surge volume may affect decisions on where to transport a critically injured patient and whether to bypass the closest facility. Our hypothesis was that overcrowding and high patient acuity would contribute to increase the mortality risk for incoming admissions.

METHODS

For a 6-year period, we merged and cross-correlated our institutional trauma registry with a database on Trauma Resuscitation Unit (TRU) patient admissions, movement and discharges, with average capacity of 12 trauma bays. The outcomes of overall hospital and 24 hours mortality for new trauma admissions (NEW) were assessed by multivariate logistic regression.

RESULTS

There were 42 003 (mean=7000/year) admissions having complete data sets, with 36 354 (87%) patients who were primary trauma admissions, age ≥18 and survival ≥15 min. In the logistic regression model for the entire cohort, NEW admission hospital mortality was only associated with NEW admission age and prehospital Glasgow Coma Scale (GCS) and Shock Index (SI) (all p<0.05). When TRU occupancy reached ≥16 patients, the factors associated with increased NEW admission hospital mortality were existing patients (TRU >1 hour) with SI ≥0.9, recent admissions (TRU ≤1 hour) with age ≥65, NEW admission age and prehospital GCS and SI (all p<0.05).

CONCLUSION

The mortality of incoming patients is not impacted by routine trauma centre overcapacity. In conditions of severe overcrowding, the number of admitted patients with shock physiology and a recent surge of elderly/debilitated patients may influence the mortality risk of a new trauma admission.

Responsiveness to therapy for increased intracranial pressure in traumatic brain injury is associated with neurological outcome

In patients with severe traumatic brain injury, increased intracranial pressure (ICP) is associated with poor functional outcome or death. Hypertonic saline (HTS) is a hyperosmolar therapy commonly used to treat increased ICP; this study aimed to measure initial patient response to HTS and look for association with patient outcome. Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a large urban tertiary care facility were retrospectively enrolled. The first dose of hypertonic saline administered after admission for ICP >19mmHg was recorded and correlated with vital signs recorded at the bedside. The absolute and relative change in ICP at 1 and 2h after HTS administration was calculated. Patients were stratified by mortality and long-term (≥6 months) functional neurological outcome. We identified 46 patients who received at least 1 dose of HTS for ICP>19, of whom 80% were male, mean age 34.4, with a median post-resuscitation GCS score of 6. All patients showed a significant decrease in ICP 1h after HTS administration. Two hours post-administration, survivors showed a further decrease in ICP (43% reduction from baseline), while ICP began to rebound in non-survivors (17% reduction from baseline). When patients were stratified for long-term neurological outcome, results were similar, with a significant difference in groups by 2h after HTS administration. In patients treated with HTS for intracranial hypertension, those who survived or had good neurological outcome, when compared to those who died or had poor outcomes, showed a significantly larger sustained decrease in ICP 2h after administration. This suggests that even early in a patient's treatment, treatment responsiveness is associated with mortality or poor functional outcome. While this work is preliminary, it suggests that early failure to obtain a sustainable response to hyperosmolar therapy may warrant greater treatment intensity or therapy escalation.

Pharmacologic Treatment Reduces Pressure Times Time Dose and Relative Duration of Intracranial Hypertension

INTRODUCTION

Past work has shown the importance of the "pressure times time dose" (PTD) of intracranial hypertension (intracranial pressure [ICP] > 19 mm Hg) in predicting outcome after severe traumatic brain injury. We used automated data collection to measure the effect of common medications on the duration and dose of intracranial hypertension.

METHODS

Patients >17 years old, admitted and requiring ICP monitoring between 2008 and 2010 at a single, large urban tertiary care facility, were retrospectively enrolled. Timing and dose of ICP-directed therapy were recorded from paper and electronic medical records. The ICP data were collected automatically at 6-second intervals and averaged over 5 minutes. The percentage of time of intracranial hypertension (PTI) and PTD (mm Hg h) were calculated.

RESULTS

A total of 98 patients with 664 treatment instances were identified. Baseline PTD ranged from 27 (before administration of propofol and fentanyl) to 150 mm Hg h (before mannitol). A "small" dose of hypertonic saline (HTS; ≤250 mL 3%) reduced PTD by 38% in the first hour and 37% in the second hour and reduced the time with ICP >19 by 38% and 39% after 1 and 2 hours, respectively. A "large" dose of HTS reduced PTD by 40% in the first hour and 63% in the second (PTI reduction of 36% and 50%, respectively). An increased dose of propofol or fentanyl infusion failed to decrease PTD but reduced PTI between 14% (propofol alone) and 30% (combined increase in propofol and fentanyl, after 2 hours). Barbiturates failed to decrease PTD but decreased PTI by 30% up to 2 hours after administration. All reductions reported are significantly changed from baseline, P < .05.

CONCLUSION

Baseline PTD values before drug administration reflects varied patient criticality, with much higher values seen before the use of mannitol or barbiturates. Treatment with HTS reduced PTD and PTI burden significantly more than escalation of sedation or pain management, and this effect remained significant at 2 hours after administration.

Study on characteristics of in vitro culture and intracellular transduction of exogenous proteins in fibroblast cell line of Liaoning cashmere goat

Establishment of fibroblast cell lines of endangered goat breeds and research on the gene or protein functions based on the cells made a significant contribution to the conservation and utilization of genetic resources. In this study, a fibroblast cell line of Liaoning cashmere goat, frozen in 174 cryovials with 5 × 10(6) cells each, was successfully established from 60 goats ear marginal tissues using explant culture and cryopreservation techniques. Biological analysis of in vitro cultured cell line showed that, the cells were morphologically consistent with fibroblasts; the average viability of the cells was 94.9 % before freezing and 90.1 % after thawing; the growth process of cells was consisted of a lag phase, a logarithmic phase and a plateau phase; cell population doubling time was 65.5 h; more than 90 % of cells were diploid prior to the 6th generation; Neither microbial contamination nor cross-contamination was detected. To determine cell permeability, intracellular path and stability of exogenous proteins during the transduction, a TAT protein transduction domain was fused to the C-terminus of enhanced green fluorescent protein, the established fibroblast cell line was treated with the purified exogenous proteins at various concentrations by adding them to the cell culture media for 1-24 h and assayed cell morphology and protein presence, it was found that the purified exogenous proteins readily entered cells at a concentration of 0.1 mg/ml within 1.5 h and some of them could translocate into nucleus, moreover, the exogenous proteins appeared to be stable inside cells for up to 24 h.

Stability of thermally hypersensitised phosphosilicate waveguides and the characteristic growth curve

Low temperature (80 0 C) hypersensitised hydrogen-loaded phosphosilicate optical fibre is found to be unstable, decaying progressively at room temperature. However, the hypersensitisation process linearises the grating growth characteristic curve. Further, a negative index contribution is inferred at low fluence in the presence of hydrogen.

Low-temperature hypersensitization of phosphosilicate waveguides in hydrogen

Conventional hydrogen loading of phosphosilicate optical fibers at relatively low temperatures (80 degrees C) is sufficient to enhance the fiber's photosensitivity after hydrogen outdiffusion, allowing permanent Bragg grating structures to be produced. Thermal sensitization is proposed to be a major contributor to stable index change.

Ultraviolet-induced absorption losses in hydrogen-loaded optical fibers and in presensitized optical fibers

Reduced hydroxyl formation in presensitized fibers exposed to cw 244-nm light after hydrogen outdiffusion is reported. The OH band in the presensitized fiber shifts toward 1390 nm. In the fully hydrogen-loaded fiber the OH band is centered at 1397 nm and does not shift with fluence.

Natural killer cell immunodeficiency in HIV disease is manifest by profoundly decreased numbers of CD16+CD56+ cells and expansion of a population of CD16dimCD56- cells with low lytic activity

Natural killer (NK) cells were enumerated by three-color immunofluorescence in 255 uninfected and 399 human immunodeficiency virus-infected adults. Several dramatic alterations were observed. First, the median number and percentage of CD16+CD56+ NK cells, the subset that comprises > 90% of the NK cells in healthy adults, were severely decreased (median, 175/mm3 in uninfected controls; 63/mm3 in HIV-infected non-AIDS subjects). Even subjects with > 800 CD4+ cells/mm3 had decreased CD16+CD56+ NK cell levels (97/mm3). Second, the number of CD16+CD56- cells, an NK population that is rare in healthy adults, was elevated (median, 20/mm3 in uninfected controls; 64/mm3 in HIV-seropositive non-AIDS subjects). Third, the expression of CD16 on the NK cells was markedly reduced; some CD56+ cells and virtually all CD56- cells were CD16dim. Fourth, fluorescence-activated cell-sorting studies revealed little NK- or antibody-dependent cellular cytotoxic activity in the CD16dimCD56- cell population. These results indicate that the pathogenesis of HIV disease includes numerical alterations in subpopulations of NK cells. A better understanding of how HIV infection causes this aspect of pathogenesis is needed.

An audio-video system for automated data acquisition in the clinical environment. LOTAS Group

OBJECTIVE

Our objective was to develop an audiovideo data acquisition system that facilitates studying the activities of anesthesia care providers in the clinical environment.

METHOD

Ceiling-mounted miniature video cameras, vital sign monitors, and videocassette recorders (VCRs) were interfaced to digital computers in two patient admitting areas and two operating rooms of a trauma center. This video data acquisition system network (VASNET) is simple to operate. Insertion of a videotape activates the system and begins video overlay of updated vital signs onto the video image every 5 sec. Recorded data is passed via a local area network, allowing remote monitoring of the data acquisition process. To facilitate analysis of the video at a later time, the image, soundtrack, and vital signs data are stamped with the same time code. Each tape is initialized by recording the data file name and wall clock time for 30 sec at the start of taping. This initialization enables comparison of the video recordings with anesthesia, surgical, and nursing records.

RESULTS

During 2 years of operation, VASNET was used to record over 100 cases of acute trauma management. Vital signs overlaid onto the video image identified when patient monitors were in use and providing data. Participants found videotape review useful in assessing their own performance. VASNET was nonintrusive and acquired data with minimum user interaction. In one operating room, separate from the trauma center, VASNET was installed to function as a remote monitor, with the option of videotaping. Although users were aware of when videotaping occurred, once patient management was underway, the activities of the anesthesia care providers did not appear to be influenced by the videocassette recording. Equipment maintenance was not excessive. The most frequent problems were changes to the VCR control settings and disconnection of the power supply or interface connections.

CONCLUSIONS

Videotapes of the process of anesthetizing and resuscitating trauma patients provided a record of the activities of anesthesia care providers. Video vignettes may be useful training tools. Excerpts from real scenarios can be incorporated into anesthesia stimulators. The soundtrack and timing of real events from such video acquisition may be useful in the development of multimedia simulations of trauma patient resuscitation. The data collection may be useful for research into human performance, ergonomics, training techniques, quality assurance, and certification of anesthesia care providers in trauma patient management. Potential additional applications of VASNET include remote monitoring of patients in the operating room, in the intensive care unit, during transportation, in hazardous environments, and in the field. Such VASNET telemetry may facilitate the availability of expert opinions during medical and other consultations.

Two Isomeric α and β Aspartyl Dodecapeptides and Their Cyclic Amino Succinyl Analogue From the Australian Green Tree Frog Litoria gilleni

Three related peptides, caeridins 1.1-1.3, have been isolated from the green tree frog Litoria gilleni. Caeridins 1.1 and 1.2 are dodecapeptides differing only in having α and β Asp at residue 4 [viz. Gly Leu Leu Asp Gly Leu Leu Gly Thr Leu Gly Leu (NH2)]. Caeridin 1.3 is the corresponding cyclic amino succinyl derivative derived formally by cyclization of Asp(4) and Gly (5). Hydrolysis of caeridin 1.3 yields caeridin 1.1 and 1.2 in the ratio 3:1. This constitutes a rare case of the isolation of three such related peptides from a natural system.