Impact of comorbidities in severely injured patients with blunt chest injury: A population-based retrospective cohort study.

INTRODUCTION: Blunt chest injuries result in up to 10 % of major trauma admissions. Comorbidities can complicate recovery and increase the mortality rate in this patient cohort. A better understanding of the association between comorbidities and patient outcomes will facilitate enhanced models of care for particularly vulnerable groups of patients, such as older adults. AIMS: i) compare the characteristics of severely injured patients with blunt chest injury with and without comorbidities and ii) examine the relationship between comorbidities and key patient outcomes: prolonged length of stay, re-admission within 28 days, and mortality within 30 days in a cohort of patients with blunt chest injury admitted after severe trauma. METHODS: A retrospective cohort study using linked data from the NSW Trauma Registry and NSW mortality and hospitalisation records between 1st of January 2012 and 31st of December 2019. RESULTS: After adjusting for potential confounding factors, patients with severe injuries, chest injuries, and comorbidities were found to have a 34 % increased likelihood of having a prolonged length of stay (OR = 1.34, 95 %I = 1.17-1.53) compared to patients with no comorbidities. There was no difference in 30-day mortality for patients with a severe chest injury who did or did not have comorbidities (OR = 1.05, 95 %CI = 0.80-1.39). No significant association was found between comorbidities and re-admission within 28 days. CONCLUSION: Severely injured patients with blunt chest injury and comorbidities are at risk of prolonged length of stay.

Impact of comorbidities on survival following major injury across different types of road users.

BACKGROUND: While comorbidities and types of road users are known to influence survival in people hospitalised with injury, few studies have examined the association between comorbidities and survival in people injured in road traffic crashes. Further, few studies have examined outcomes across different types of road users with different types of pre-existing comorbidities. This study aims to examine differences in survival within 30 days of admission among different road user types with and without different pre-existing comorbidities. METHOD: Retrospective cohort study using data for all major road trauma cases were extracted from the NSW Trauma Registry Minimum Dataset (1 January 2013 - 31 July 2019) and linked to the NSW Admitted Patient Data Collection, and the NSW Registry of Births, Deaths and Marriages - death dataset. Pre-existing comorbidities and road user types were identified by the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and Charlson Comorbidity Index in the Trauma Registry, hospital admission, and death datasets. Logistic regression was used to assess the associations between six types of road users (pedestrian, pedal cycle, two- and three-wheel motorcycle, car and pick-up truck, heavy vehicle and bus, and other types of vehicle) and death within 30 days of hospital admission while controlling for comorbidities. All models used 'car and pick-up truck driver/passenger' as the road user reference group and adjusted for demographic variables, injury severity, and level of impaired consciousness. RESULTS: Within 6253 traffic injury person-records (all aged ≥15 years old, ISS>12), and in final models, injured road users with major trauma who had a history of cardiovascular diseases (including stroke), diabetes mellitus, and higher Charlson Comorbidity Index score, were more likely to die, than those without pre-existing comorbidities. Furthermore, in final models, pedestrians were more likely to die than car occupants (OR: 1.68 - 1.77, 95CI%: 1.26 - 2.29 depending on comorbidity type). CONCLUSIONS: This study highlights the need to prioritize enhanced management of trauma patients with comorbidities, given the increasing prevalence of chronic medical conditions globally, together with actions to prevent pedestrian crashes in strategies to reach Vision Zero.

Over view of major traumatic injury in Australia--Implications for trauma system design.

BACKGROUND: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. METHODS: The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). RESULTS: There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. CONCLUSION: Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

Using emergency trauma team activations to measure trauma activity and injury severity: 10 years of experience using an Australian major trauma centre registry.

OBJECTIVES: To describe the outcomes of Emergency Department trauma team activations over a 10-year period with respect to injury severity and hospital length of stay. METHODS: This was a retrospective study using trauma registry data at a single Major Trauma Centre in Australia. All trauma team activations and arrivals on pre-hospital major trauma (T1) protocol recorded in the trauma registry between June 2006 and July 2016 were included. The outcome of interest was major trauma, defined as an Injury Severity Score (ISS) >12 or length of stay >3 days or requiring urgent operative intervention or admission to the Intensive Care Unit following trauma. RESULTS: A total of 9876 hospital trauma activations were analysed from January 2006 to June 2016. Of these 53.3% were admitted as an in-patient and 16.6% were classified as having an ISS >15. Major trauma occurred in 38% of cases. With respect to hospital utilisation, patients with an ISS <16 accounted for around half of total cumulative in-patient bed-days. CONCLUSIONS: Analysis of data from trauma team activations in ED has allowed a description of trauma activity and hospital bed day utilisation as a function of injury severity. The results confirm that those with minor trauma accounted for the vast majority of cases and around half of all hospital in-patient bed-days.

The psychological impact of traffic injuries sustained in a road crash by bicyclists: A prospective study.

OBJECTIVE: The objective of this study was to investigate the psychological impact of traffic injuries in bicyclists (cyclists) in comparison to car occupants who also sustained traffic injuries. Factors predictive of elevated psychological distress were also investigated. METHODS: An inception cohort prospective design was used. Participants included cyclists aged ≥17 years (mean age 41.7 years) who sustained a physical injury (n = 238) assessed within 28 days of the crash, following medical examination by a registered health care practitioner. Injury included musculoskeletal and soft tissue injuries and minor/moderate traumatic brain injury (TBI), excluding severe TBI, spinal cord injury, and severe multiple fractures. Assessment also occurred 6 months postinjury. Telephone-administered interviews assessed a suite of measures including sociodemographic, preinjury health and injury factors. Psychological impact was measured by pain catastrophization, trauma-related distress, and general psychological distress. The psychological health of the cyclists was compared to that of the car occupants (n = 234; mean age 43.1 years). A mixed model repeated measures analysis, adjusted for confounding factors, was used to determine differences between groups and regression analyses were used to determine contributors to psychological health in the cyclists 6 months postinjury. RESULTS: Cyclists had significantly better psychological health (e.g., lower pain catastrophizing, lower rates of probable posttraumatic stress disorder [PTSD], and lower general distress levels) compared to car occupants at baseline and 6 months postinjury. Factors predictive of cyclists' psychological distress included younger age, greater perceived danger of death, poorer preinjury health, and greater amount of time in hospital after the injury. CONCLUSIONS: These data provide insight into how cyclists perceive and adjust to their traffic injuries compared to drivers and passengers who sustain traffic injuries, as well as direction for preventing the development of severe psychological injury. Future research should examine the utility of predictors of psychological health to improve recovery.

Manganese oxide octahedral molecular sieve K-OMS-2 as catalyst in post plasma-catalysis for trichloroethylene degradation in humid air.

The total oxidation of trichloroethylene (TCE) in air at low relative humidity (RH=10%) in the presence of CO2 (520ppmv) was investigated in function of energy density using an atmospheric pressure negative DC luminescent glow discharge combined with a cryptomelane catalyst positioned downstream of the plasma reactor at a temperature of 150°C. When using Non-Thermal Plasma (NTP) alone, it is found a low COx (x=1-2) yield in agreement with the detection of gaseous polychlorinated by-products in the outlet stream as well as ozone which is an harmful pollutant. Introduction of cryptomelane enhanced trichloroethylene removal, totally inhibited plasma ozone formation and increased significantly the COx yield. The improved performances of the hybrid system were mainly ascribed to the total destruction of plasma generated ozone on cryptomelane surface to produce active oxygen species. Consequently these active oxygen species greatly enhanced the abatement of the plasma non-reacted TCE and completely destroyed the hazardous plasma generated polychlorinated intermediates. The facile redox of Mn species associated with oxygen vacancies and mobility as well as the textural properties of the catalyst might also contribute as a whole to the efficiency of the process.

Health status and return to work in trauma patients at 3 and 6 months post-discharge: an Australian major trauma centre study.

INTRODUCTION: The aim of this study was to describe post-discharge outcomes, and determine predictors of 3 and 6 months health status outcomes in a population of trauma patients at an inner city major trauma centre. METHODS: This was a prospective cohort study of adult trauma patients admitted to this hospital with 3 and 6 months post-discharge outcomes assessment. Outcome measures were the Physical Component Scores (PCS) and Mental Component Scores (MCS) of the Short Form 12, EQ-5D, and return to work (in any capacity) if working prior to injury. Repeated measures mixed models and generalised estimating equation models were used to determine predictors of outcomes at 3 and 6 months. RESULTS: One hundred and seventy-nine patients were followed up. Patients with lower limb injuries reported lower mean PCS scores between 3 and 6 months (coefficient -4.21, 95 % CI -7.58, -0.85) than those without lower limb injuries. Patients involved in pedestrian incidents or assaults and those with pre-existing mental health diagnoses reported lower mean MCS scores. In adjusted models upper limb injuries were associated with reduced odds of return to work at 3 and 6 months (OR 0.20, 95 % CI 0.07, 0.57) compared to those without upper limb injuries. DISCUSSION: Predictors of poorer physical health status were lower limb injuries and predictors of mental health were related to the mechanism of injury and past mental health. Increasing injury severity score and upper limb injuries were the only predictors of reduced return to work. The results provide insights into the feasibility of routine post-discharge follow-up at a trauma service level.

Distribution of glial cells in the auditory brainstem: normal development and effects of unilateral lesion.

Auditory brainstem networks facilitate sound source localization through binaural integration. A key component of this circuitry is the projection from the ventral cochlear nucleus (VCN) to the medial nucleus of the trapezoid body (MNTB), a relay nucleus that provides inhibition to the superior olivary complex. This strictly contralateral projection terminates in the large calyx of Held synapse. The formation of this pathway requires spatiotemporal coordination of cues that promote cell maturation, axon growth, and synaptogenesis. Here we have examined the emergence of distinct classes of glial cells, which are known to function in development and in response to injury. Immunofluorescence for several astrocyte markers revealed unique expression patterns. Aldehyde dehydrogenase 1 family member L1 (ALDH1L1) was expressed earliest in both nuclei, followed by S100ß, during the first postnatal week. Glial fibrillary acidic protein (GFAP) expression was seen in the second postnatal week. GFAP-positive cell bodies remained outside the boundaries of VCN and MNTB, with a limited number of labeled fibers penetrating into the margins of the nuclei. Oligodendrocyte transcription factor 2 (OLIG2) expression revealed the presence of oligodendrocytes in VCN and MNTB from birth until after hearing onset. In addition, ionized calcium binding adaptor molecule 1 (IBA1)-positive microglia were observed after the first postnatal week. Following hearing onset, all glial populations were found in MNTB. We then determined the distribution of glial cells following early (P2) unilateral cochlear removal, which results in formation of ectopic projections from the intact VCN to ipsilateral MNTB. We found that following perturbation, astrocytic markers showed expression near the ectopic ipsilateral calyx. Taken together, the developmental expression patterns are consistent with a role for glial cells in the maturation of the calyx of Held and suggest that these cells may have a similar role in maturation of lesion-induced connections.

Refining the trauma triage algorithm at an Australian major trauma centre: derivation and internal validation of a triage risk score.

PURPOSE: To derive and internally validate a clinical prediction rule for trauma triage. METHODS: Ambulance presentations requiring trauma team activation between 2007 and 2011 at a single inner city major trauma centre were analysed. The primary outcome was major trauma, defined as Injury Severity Score >15, intensive care unit admission or in-hospital death. Demographic details, vital signs on arrival at hospital, mechanism of injury and injured body regions were used in the modelling process. Multivariable logistic regression was used on a randomly selected derivation sample. Receiver operating characteristic (ROC) analysis and Hosmer-Lemeshow tests were used to assess the discrimination and calibration of the derived model. The model was further tested using bootstrapping cross-validation. RESULTS: A total of 3027 patients were identified. Predictors selected for the prediction model were age ≥65 years (OR 1.58, 95 %CI 1.08-2.32, p = 0.02), abnormal vital signs (OR 3.72, 95 %CI 2.64-5.25), Glasgow Coma Scale score ≤13 (OR 14, 95 %CI 9.23-23.34 p < 0.001), penetrating injury (OR 5.13, 95 %CI 2.76-9.54, p < 0.001), multiregion injury (OR 4.72 95 %CI 3.45-6.46, p < 0.001), falls (OR 1.51 95 %CI 1.06-2.15, p = 0.02) and motor vehicle crashes (OR 0.56, 95 %CI 0.35-0.90, p = 0.02). The ROC area under the curve (AUC) for the final model was 0.85 (95 %CI 0.83-0.87) with a Hosmer-Lemeshow test statistic p = 0.83. Bootstrapping cross-validation demonstrated an identical AUC. CONCLUSION: We have derived and internally validated a trauma risk prediction rule using trauma registry data. This may assist with the formulation of revised local and regional trauma triage protocols. External validation is required before implementation.

Probing time-dependent molecular dipoles on the attosecond time scale.

Photoinduced molecular processes start with the interaction of the instantaneous electric field of the incident light with the electronic degrees of freedom. This early attosecond electronic motion impacts the fate of the photoinduced reactions. We report the first observation of attosecond time scale electron dynamics in a series of small- and medium-sized neutral molecules (N(2), CO(2), and C(2)H(4)), monitoring time-dependent variations of the parent molecular ion yield in the ionization by an attosecond pulse, and thereby probing the time-dependent dipole induced by a moderately strong near-infrared laser field. This approach can be generalized to other molecular species and may be regarded as a first example of molecular attosecond Stark spectroscopy.

Prevention of endemic healthcare-associated Clostridium difficile infection: reviewing the evidence.

OBJECTIVES: Clostridium difficile is the most common infectious cause of healthcare-associated diarrhea. Because of the increasing incidence and severity of endemic C. difficile infection (CDI), interventions to prevent healthcare-associated CDI are essential. We undertook a systematic review of interventions to reduce healthcare-associated CDI. METHODS: We searched multiple computerized databases, and manually searched for relevant articles to determine which interventions are useful in preventing CDI. Studies were required to be controlled in design and to report the incidence of endemic CDI as an outcome. Data on the patient population, intervention, study design, and outcomes were abstracted and reviewed using established criteria. RESULTS: Few randomized controlled trials exist in the area of CDI prevention. The interventions with the greatest evidence for the prevention of CDI include antimicrobial stewardship, glove use, and disposable thermometers. Environmental decontamination also may decrease CDI rates, although the level of evidence is not as strong as for the other proven interventions. Treatment of asymptomatic carriage of C. difficile is not recommended. There is insufficient evidence to make a recommendation for or against the use of probiotics. In cases of known or suspected CDI, hand hygiene with soap and water is preferred over use of waterless alcohol hand rub. Many nonrandomized trials included in our analysis used multiple interventions concurrently, making the independent role of each preventive strategy difficult to determine. We chose to include only studies that focused on endemic CDI because studies of outbreaks have used multiple strategies, making it difficult to measure the relative efficacy of each strategy. Environmental disinfection and probiotics need to be studied further to evaluate their roles in the prevention of CDI. Although there have been no studies assessing the utility of isolation and cohorting for the prevention of endemic CDI specifically, it is a widely used intervention for containment of this and other similar multidrug-resistant pathogens. CONCLUSIONS: Antimicrobial stewardship, glove use, hand hygiene, and disposable thermometers should be routinely used for the prevention of CDI. Environmental disinfection and probiotics should be studied further for their role in reducing CDI.

Cryptogenic liver disease in HIV-seropositive men.

OBJECTIVES: In the era of highly active antiretroviral therapy (HAART), liver disease has become a leading cause of morbidity and mortality in HIV-seropositive individuals. Although liver disease is commonly caused by viral co-infection, it has also been described in patients without viral hepatitis. In this study, we determined clinical factors associated with the development of cryptogenic liver disease in HIV-infected individuals. METHODS: HIV-seropositive and -seronegative patients undergoing evaluation for liver transplantation were selected if they met clinical criteria for cryptogenic liver disease. Clinical data were collected retrospectively, and radiological and histological data were reviewed separately. RESULTS: Nine HIV-seropositive individuals were compared with 41 HIV-seronegative patients with cryptogenic liver disease. Only one HIV-seropositive patient (11%) had cirrhosis, compared to 39 HIV-seronegative patients (93%) (P<0.001). Three HIV-infected patients (33%) had histological evidence of nodular regenerative hyperplasia. HIV-seropositive patients had significantly lower body mass indices, and lower Child-Pugh-Turcotte and Model for Endstage Liver Disease scores than HIV-seronegative patients (P<0.05). CONCLUSIONS: Advanced cryptogenic liver disease in HIV-infected patients is infrequently caused by cirrhosis, and more frequently by nodular regenerative hyperplasia. This disease entity may become more common in the HAART era, and may contribute to an increased morbidity in HIV-infected individuals.

Left ventricular hamartoma associated with ventricular tachycardia.

Cardiac hamartomas are a rare type of benign tumor affecting the heart. We describe a 33-year-old patient who presented with a wide complex tachycardia. Diagnostic imaging revealed a mass in the patient's left ventricular wall, near the apex of the heart. The mass was surgically resected and appeared benign. Its pathology was that of a hamartoma of mature cardiac myocytes. Postoperative electrophysiology evaluation showed no inducible focus and the patient remains alive and asymptomatic after 2 years of follow-up.

Numerical chromosomal changes in DNA hypodiploid solid tumors: restricted loss and gain of certain chromosomes.

BACKGROUND: DNA hypodiploidy is a unique and rare finding associated with aggressive behavior in solid tumors. Identifying the chromosomal changes underlying this feature may provide important information on the development and progression of these neoplasms. METHODS: Fluorescence in situ hybridization analysis using alpha-satellite probes for nine autosomes and the two sex chromosomes was performed on interphase cells from 27 solid tumors which had been shown to be DNA hypodiploid by flow cytometry. The chromosomal abnormalities were correlated with the DNA index and tumor subtypes. RESULTS: The data show mutually exclusive loss of certain chromosomes and compensatory gain of other chromosomes in different tumors. The net loss was slightly more than the net gain for the chromosomes tested. Polysomy of chromosome 7 and monosomy of chromosomes 17, X and loss Y were found in most tumors. Significant differential loss of chromosomes 6,10, and 12 among DNA hypodiploid breast, kidney and lung carcinomas was noted. CONCLUSIONS: Our study shows (i) gain of chromosome 7 and loss chromosome 17 in most DNA hypodiploid tumors, (ii) specific chromosomal loss was noted in breast and renal cell carcinomas, and (iii) that different mechanisms for DNA hypodiploid and hyperdiploid development may exist.

Chromosomal and DNA ploidy characterization of salivary gland neoplasms by combined FISH and flow cytometry.

Concurrent DNA ploidy by flow cytometry and interphase FISH analysis of chromosomes 6 through 12, 17, 18, X, and Y were prospectively performed on 22 salivary gland neoplasms (four benign and 18 malignant) to investigate the diagnostic and biological implications of their alterations in these neoplasms. Our results show that benign neoplasms lack DNA aneuploidy and numerical chromosomal abnormalities. Low-grade malignant neoplasms, except for two lesions, manifested small chromosomal gains and losses and were generally DNA diploid or near-diploid aneuploid, whereas all high-grade tumors showed marked polysomy and were DNA aneuploid. Marked intratumoral and intertumoral chromosomal heterogeneity also were noted in and between individual tumors. Although polysomy was the main finding in DNA aneuploid lesions, monosomy was more noted in DNA diploid neoplasms and was restricted to chromosomes 8, 11, and 17. Significant correlation between the DNA index, chromosomal aneusomy, histological grade, and tumor stage was noted. Our study indicates that (1) benign salivary gland neoplasms lack gross DNA content and numerical chromosomal abnormalities, (2) clonal chromosomal alterations are manifested in most DNA diploid and all DNA aneuploid malignant tumors, (3) chromosomal gain is the most common alteration; chromosomal loss is less frequent and restricted to certain chromosomes, and (4) DNA aneuploidy and chromosomal aneusomy characterize tumors with aggressive features.

Interphase cytogenetics in mammographically detected breast lesions.

Chromosomal aneuploidy in 25 mammographically detected breast lesions (MDBL) were determined on cytological smears using directly labeled pericentromeric probes for chromosomes 7 to 12, 17, 18 and X. The lesions included seven nonproliferative (NP) lesions, seven atypical hyperplasias (AHs), and 11 carcinomas (CAs). No other significant histological findings were identified in the remaining specimens except in two mammographically detected NP lesions, where foci of AH were present in adjacent sections; therefore, these two specimens were included in the AH lesion group (moderately increased risk lesions). Corresponding tissue sections were evaluated, and the results were correlated with fluorescent in situ hybridization (FISH) results. Monosomy was defined as the loss of one signal in > or = 15% of cells, and trisomy or tetrasomy was defined by the presence of three or more signals in > or = 3% of cells. Chromosomal aberrations were detected in 2 of 5 NP, 9 of 9 AH, and 11 of 11 CA groups. The mean number of cells with three or more signals, for all chromosomes, was 1.04 +/- 0.9 in the NP group, 8.5 +/- 9.4 in the AH group, and 20.2 +/- 5.4 in the CAs. A significant statistical difference was noted between the different groups (P = .0001). Chromosomal gain was the most common aberration and involved all chromosomes. The X chromosome was the only individual chromosome with significant differences in NP, AH, and CA groups. Chromosomal loss was observed in five specimens (20%) and involved chromosomes 8, 10, 17, and 18. The authors conclude (1) significant chromosomal aberrations can be detected in AH lesions and in NP epithelium from patients with moderately increased risk lesions; (2) numerical chromosomal aberrations tend to increase with progression of disease; (3) the frequent chromosomal gains/losses involving AH suggest that some AH may display submicroscopic features of malignancy; and (4) combined chromosomal aberrations allow for significant categorization of breast lesions, especially in cytology specimens.

Genotypic analysis of primary head and neck squamous carcinoma by combined fluorescence in situ hybridization and DNA flow cytometry.

Concurrent DNA flow cytometric (FCM) and fluorescence in situ hybridization (FISH) analyses were prospectively performed on 24 primary untreated head and neck squamous carcinomas for characterization of the genotypic and phenotypic DNA aberrations of these neoplasms. Eleven tumors (42.0%) manifested DNA diploidy (DI = 1.00) and 15 (58.0%) had DNA aneuploidy (DI < or > 1.00) by FCM. Fluorescence in situ hybridization results showed aneusomy in the majority of DNA diploid and in all DNA aneuploid tumors. The extent of the abnormalities for individual chromosomes and the number of involved chromosomes in a given DNA diploid or aneuploid tumor were significantly different. Overall, a statistical correlation between the FCM DNA index (DI) and the magnitude of the chromosomal aberration by FISH was found. Our results also show a significant association between the DI and histologic differentiation and stage of disease in these neoplasms. In conclusion, (1) chromosomal aneusomy characterizes most DNA diploid (DI = 1.00) and all DNA aneuploid (DI < or > 1.00) head and neck squamous carcinomas; (2) polysomy is the most prevalent finding; (3) loss of the Y chromosome in tumors from male patients is a consistent feature; (4) the FCM DI reflects net chromosomal gains or losses in these neoplasms; and (5) DNA aneuploidy is associated with tumor aggressiveness.