Injury patterns and outcomes associated with elderly trauma victims in Kingston, Ontario.

OBJECTIVE: To characterize the common injuries incurred by elderly trauma victims and to identify the most frequent complications and outcomes. METHODS: We undertook a retrospective descriptive chart review of 125 consecutive patients who were over age 65 years and who were admitted to an academic hospital in Kingston, Ontario, over a 3-year period with an injury severity score (ISS) > 12. Complete data about the mechanism of injury (MOI), age, date, sex, specific injury, principal and secondary diagnoses, comorbid conditions, intensive care unit (ICU) and hospital length of stay and discharge disposition were recorded for 99 of these patients. RESULTS: Elderly trauma cases accounted for 125 of the total 460 trauma admissions over 3 years. For that same period, more than 50% of trauma deaths occurred among elderly patients, of whom 65 were men and 34 were women. Their mean age was 77 (standard deviation [SD] 6) years, with an age range of 66-95 years. The average ISS score was 23 (SD 13), with a range of 12-75. MOI included falls (64%), motor vehicle collision (27%), injury from machinery (3%), injury from natural and environmental causes (2%), suicide or self-inflicted injury (3%) and burns (1%). The mean length of stay was 14.6 days, but this ranged from 1 to 111 days. Of the 99 patients, 14 were admitted to the ICU for a total of 37 days, and 9 of these died. Of the total of 67 (67%) patients who were discharged from hospital, 46% were discharged home and 32% died. Falls accounted for the most frequent MOI, followed by motor vehicle collisions. The most common injury in the falls group was subdural hematoma, whereas fractures were the most common injuries in the motor vehicle collision group. The most frequent complications included urinary tract infections and aspiration pneumonias. Neither age nor MOI was correlated with injury severity. Increasing age and injury severity were predictors for complications and mortality while in hospital. CONCLUSIONS: Despite severe injuries, most elderly patients can survive traumatic injuries. The data suggest that, although elderly patients are prone to incur complications and have greater risk of dying as a result of their injuries, most of these patients will survive their traumatic accidents. The data also show that nosocomial complications play a significant role in the risk of mortality in elderly trauma victims.

Dissemination of the Canadian clinical practice guidelines for nutrition support: results of a cluster randomized controlled trial.

OBJECTIVE: To compare the effectiveness of active to passive dissemination of the Canadian clinical practice guidelines (CPGs) for nutrition support for the mechanically ventilated critically ill adult patient. DESIGN: A cluster-randomized trial with a cross-sectional outcome assessment at baseline and 12 months later. SETTING: Intensive care units in Canada. PATIENTS: Consecutive samples of mechanically ventilated patients at each time period. INTERVENTIONS: In the active group, we provided multifaceted educational interventions including Web-based tools to dietitians. In the passive group, we mailed the CPGs to dietitians. MEASUREMENTS AND MAIN RESULTS: The primary end point of this study was nutritional adequacy of enteral nutrition; secondary end points measured were compliance with the CPGs, glycemic control, duration of stay in intensive care unit and hospital, and 28-day mortality. Fifty-eight sites were randomized. At baseline and follow-up, 623 and 612 patients were evaluated. Both groups were well matched in site and patient characteristics. Changes in enteral nutrition adequacy between the active and passive arms were similar (8.0% vs. 6.2 %, p = .54). Median time spent in the target glucose range increased 10.1% in the active compared with 1.8% in the passive group (p = .001). In the subgroup of medical patients, enteral nutrition adequacy improved more in the active arm compared with the passive group (by 8.1%, p = .04), whereas no such differences were observed in surgical patients. When groups were combined, during the year of dissemination activities, there was an increase in enteral nutrition adequacy (from 43% to 50%, p < .001), an increase in the use of feeding protocols (from 64% to 76%, p = .03), and a decrease in patients on parenteral nutrition (from 26% to 21%, p = .04). There were no differences in clinical outcomes between groups or across time periods. CONCLUSIONS: Although active dissemination of the CPGs did improve glycemic control, it did not change other nutrition practices or patient outcomes except in a subgroup of medical patients. Overall, dissemination of the CPGs improved other important nutrition support practices but was not associated with improvements in clinical outcomes.

Inhibition of cervical cancer cell growth in vitro and in vivo with lentiviral-vector delivered short hairpin RNA targeting human papillomavirus E6 and E7 oncogenes.

In this study, we investigated the suppressive effect of a short hairpin RNA delivered by a lentiviral vector (LV-shRNA) against human papillomavirus (HPV) type 18 E6 on the expression of the oncogenes E6 and E7 in cervical cancer HeLa cells both in vitro and in vivo. The LV-shRNA effectively delivered the shRNA to HeLa cells and lead to a dose-dependent reduction of E7 protein and the stabilization of E6 target proteins, p53 and p21. Low-dose infection of HeLa cells with LV-shRNA caused reduced cell growth and the induction of senescence, whereas a high-dose infection resulted in specific cell death via apoptosis. Transplant of HeLa cells infected with a low dose of LV-shRNA into Rag-/- mice significantly reduced the tumor weight, whereas transplant of cells infected with a high dose resulted in a complete loss of tumor growth. Systemic delivery of LV-shRNA into mice with established HeLa cell lung metastases led to a significant reduction in the number of tumor nodules. Our data collectively suggest that lentiviral delivery is an effective way to achieve stable suppression of E6/E7 oncogene expression and induce inhibition of tumor growth both in vitro and in vivo. These results encourage further investigation of this form of RNA interference as a promising treatment for cervical cancer.

Do medical students have the knowledge needed to maximize organ donation rates?

INTRODUCTION: The chronic shortage of organs for donation could be improved by increasing the numbers of potential and actual donors. Physicians can play a key role in solving this problem but may miss opportunities because they lack knowledge about organ donation to answer questions or concerns. Education of physicians early in their careers may lead to better procurement rates for donor organs. We carried out a study at Queen's University in Kingston, Ont., to determine whether medical students have sufficient knowledge of topics shown to affect organ donation rates. METHODS: Medical students from years 1-4 completed a self-administered questionnaire. Section 1 tested general knowledge about organ donation; section 2 tested the students' ability to identify potential donors; and section 3 dealt with the approach to the potential donor's family. Univariate predictors of mean test scores were assessed using the t-test. RESULTS: Of 322 medical students who received the questionnaire, 260 (81%) responded. The mean age of the students was 25 years and 54% were men. The mean knowledge score was 6.7 out of a possible score of 14. Third-year students had the best knowledge scores (7.6), followed by fourth- (7.4), second- (6.6) and first-year students (5.7). Teaching about organ donation and a student's comfort with approaching a family for organ donation were also predictive of higher knowledge scores. There was no correlation between knowledge score and age, gender or whether the student was carrying a signed donor card. Knowledge scores were low in all 3 sections. Thirty-six percent of students did not know that brain death means that the patient is dead rather than in a coma. Half the medical students believed that people of certain religious groups should not be approached about organ donation. CONCLUSIONS: Medical students possess limited knowledge about organ donation topics important for maximizing procurement rates. A teaching intervention designed to target these shortcomings may be beneficial.