Outcomes of Traumatic Brain Injury Patients Managed in a Non-Intensive Care Unit Setting.

INTRODUCTION: The management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non-intensive care unit (ICU) setting after stratifying them using the mBIG criteria. METHODS: A retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. RESULTS: Of the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. CONCLUSIONS: Select patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

Mental Health Care Resource Utilization of Victims of Interpersonal Violence in the Novel Coronavirus Era.

INTRODUCTION: Higher incidences of interpersonal violence were reported throughout the country during the coronavirus (COVID) time period. We aimed to compare health-care encounters and resource utilization related to interpersonal violence with mental health (MH) disorders before and during the pandemic within a year of the index visit for interpersonal violence. METHODS: A retrospective analysis of the Delaware Healthcare Claims data of all patients aged ≥16 y who suffered interpersonal violence was performed. Patients were followed up for 1 y pre and post their index visit of interpersonal violence episode during the pre-COVID (March 2018 through December 2018) and the COVID (March 2020 through December 2020) period. Census tract information was used to assess social determinants of health. RESULTS: There were 431 patients in the COVID period and 527 patients in the pre-COVID period with index violence claim encounters. African American patients were more likely to have a violence encounter during COVID (60.3% versus 47.2%, P < 0.001). Patients in the COVID period were more likely to live in a census tract with public assistance households (median 3.3% versus 2.2%, P = 0.005) and higher unemployment (7.5% versus 7.1%, P = 0.01). In the following year of index violence claim, the mean numbers of MH claim-days for COVID and pre-COVID patients were 19.5 (53.3) and 26.2 (66.2), (P = 0.51). The COVID group had fewer MH claim-days mostly in the second half of the year after the index encounter with an incidence rate ratio of 0.61, 95% CI (0.45-0.83). CONCLUSIONS: Racial and socioeconomic disparities were amplified and MH resource utilization was lower during COVID. Further injury prevention efforts should be focused on MH in future pandemics or disasters.

Evolution of cisplatin resistance through coordinated metabolic reprogramming of the cellular reductive state.

BACKGROUND: Cisplatin (CDDP) is a mainstay treatment for advanced head and neck squamous cell carcinomas (HNSCC) despite a high frequency of innate and acquired resistance. We hypothesised that tumours acquire CDDP resistance through an enhanced reductive state dependent on metabolic rewiring. METHODS: To validate this model and understand how an adaptive metabolic programme might be imprinted, we performed an integrated analysis of CDDP-resistant HNSCC clones from multiple genomic backgrounds by whole-exome sequencing, RNA-seq, mass spectrometry, steady state and flux metabolomics. RESULTS: Inactivating KEAP1 mutations or reductions in KEAP1 RNA correlated with Nrf2 activation in CDDP-resistant cells, which functionally contributed to resistance. Proteomics identified elevation of downstream Nrf2 targets and the enrichment of enzymes involved in generation of biomass and reducing equivalents, metabolism of glucose, glutathione, NAD(P), and oxoacids. This was accompanied by biochemical and metabolic evidence of an enhanced reductive state dependent on coordinated glucose and glutamine catabolism, associated with reduced energy production and proliferation, despite normal mitochondrial structure and function. CONCLUSIONS: Our analysis identified coordinated metabolic changes associated with CDDP resistance that may provide new therapeutic avenues through targeting of these convergent pathways.

Prospective study of emergency medicine provider wellness across ten academic and community hospitals during the initial surge of the COVID-19 pandemic.

BACKGROUND: While COVID-19 has had far-reaching consequences on society and health care providers, there is a paucity of research exploring frontline emergency medicine (EM) provider wellness over the course of a pandemic. The objective of this study was to assess the well-being, resilience, burnout, and wellness factors and needs of EM physicians and advanced practice providers (e.g., nurse practitioners and physician assistants; APPs) during the initial phase of the COVID-19 pandemic. METHODS: A descriptive, prospective, cohort survey study of EM physicians and APPs was performed across ten emergency departments in a single state, including academic and community settings. Participants were recruited via email to complete four weekly, voluntary, anonymous questionnaires comprised of customized and validated tools for assessing wellness (Well Being Index), burnout (Physician Work Life Study item), and resilience (Brief Resilience Scale) during the initial acceleration phase of COVID-19. Univariate and multivariate analysis with Chi-squared, Fisher's Exact, and logistic regression was performed. RESULTS: Of 213 eligible participants, response rates ranged from 31 to 53% over four weeks. Women comprised 54 to 60% of responses. Nonrespondent characteristics were similar to respondents. Concern for personal safety decreased from 85 to 61% (p < 0.001). Impact on basic self-care declined from 66 to 32% (p < 0.001). Symptoms of stress, anxiety, or fear was initially 83% and reduced to 66% (p = 0.009). Reported strain on relationships and feelings of isolation affected > 50% of respondents initially without significant change (p = 0.05 and p = 0.30 respectively). Women were nearly twice as likely to report feelings of isolation as men (OR 1.95; 95% CI 1.82-5.88). Working part-time carried twice the risk of burnout (OR, 2.45; 95% CI, 1.10-5.47). Baseline resilience was normal to high. Provider well-being improved over the four weeks (30 to 14%; p = 0.01), but burnout did not significantly change (30 to 22%; p = 0.39). CONCLUSION: This survey of frontline EM providers, including physicians and APPs, during the initial surge of COVID-19 found that despite being a resilient group, the majority experienced stress, anxiety, fear, and concerns about personal safety due to COVID-19, putting many at risk for burnout. The sustained impact of the pandemic on EM provider wellness deserves further investigation to guide targeted interventions.

Addition of Occupational Therapy to an Interdisciplinary Concussion Clinic Improves Identification of Functional Impairments.

BACKGROUND: Concussions, or mild traumatic brain injuries, are prevalent among youth and young adults. These injuries may disrupt a person's daily activities (occupations) including school, physical activity, work, and socialization. Rehabilitation professionals, such as occupational therapists (OTs), are experts in providing individualized intervention to address these temporary life changes during recovery. OBJECTIVE: This article aims to identify the benefit of having an occupational therapy practitioner on an interdisciplinary treatment team when providing intervention to patients with concussion. SETTING: Concussion clinic at an academic institution. PARTICIPANTS: Participants ages 12 to 24 years with a reported history of mild traumatic brain injury or concussion were evaluated by a physician, or by a physician and OT, in an initial evaluation appointment. DESIGN: A single researcher (OT) with training in concussion qualitatively compared reported impacted occupational domains as defined in the Occupational Therapy Practice Framework, using both a retrospective and a prospective cohort. The prospective group differed from the retrospective group in that an OT was present, and participated in the initial evaluation. RESULTS: The domains of performance patterns (P = .007) and performance skills (P ≤ .001) were identified significantly more often when an occupational therapy practitioner participated in the initial evaluation. CONCLUSIONS: Rehabilitation professionals, such as OTs, play an important role in identifying impacted domains after a concussion, which can help optimize patient care.

A modified frailty index predicts complication, readmission, and 30-day mortality following the revision total hip arthroplasty.

INTRODUCTION: This study aimed to develop a modified frailty index (MFI) to predict the risks of revision total hip arthroplasty (THA). METHODS: Data from the American College of Surgeons - National Surgical Quality Improvement Program were analyzed for patients who underwent revision THA from 2015 to 2020. An MFI was composed of the risk factors, including severe obesity (body mass index > 35), osteoporosis, non-independent function status prior to surgery, congestive heart failure within 30 days of surgery, hypoalbuminemia (serum albumin < 3.5), hypertension requiring medication, type 1 or type 2 diabetes, and a history of chronic obstructive pulmonary disease or pneumonia. The patients were assigned based on the MFI scores (MFI0, no risk factor; MFI1, 1-2 risk factors; MFI2, 3-4 risk factors; and MFI3, 5+ risk factors). Confidence intervals were set at 95% with a P value less than or equal to 0.05 considered statistically significant. RESULTS: A total of 17,868 patients (45% male, 55% female) were included and had an average age of 68.5 ± 11.5 years. Odds of any complication, when compared to MFI0, were 1.4 (95% CI [1.3, 1.6]) times greater for MFI1, 3.2 (95% CI [2.8, 3.6]) times greater for MFI2, and 10.8 (95% CI [5.8, 20.0]) times greater for MFI3 (P < 0.001). Odds of readmission, when compared to MFI0, were 1.4 (95% CI [1.3, 1.7]) times greater for MFI1, 2.5 (95% CI [2.1, 3.0]) times greater for MFI2, and 4.1 (95% CI [2.2, 7.8]) times greater for MFI3 (P < 0.001). CONCLUSION: Increasing MFI scores correlate with increased odds of complication and readmission in patients who have undergone revision THA. This MFI may be used to predict the risks after revision THA.

Longitudinal Prospective Study of Emergency Medicine Provider Wellness Across Ten Academic and Community Hospitals During the Initial Surge of the COVID-19 Pandemic.

Background: While the coronavirus (COVID-19) has had far-reaching consequences on society and health care providers, there is a paucity of research exploring emergency medicine (EM) provider wellness over the course of a pandemic. The objective of this study was to assess the well-being, resilience, burnout, and wellness factors and needs of EM physicians and advanced practice providers (APPs) during the initial phase of the COVID-19 pandemic. Methods: A longitudinal, descriptive, prospective cohort survey study of 213 EM physicians and APPs was performed across ten emergency departments in a single state, including academic and community settings. Participants were recruited via email to complete four weekly, voluntary, anonymous questionnaires comprised of customized and validated tools for assessing wellness (Well Being Index), burnout (Physician Work Life Study item), and resilience (Brief Resilience Scale) during the initial acceleration phase of COVID-19. Univariate and multivariate analysis with Chi-squared, Fisher’s Exact, and logistic regression was performed. Results: Of 213 eligible participants, response rates ranged from 31 to 53% over four weeks. Women comprised 54 to 60% of responses. Nonrespondent characteristics were similar to respondents. Concern for personal safety decreased from 85% to 61% (p<0.001). Impact on basic self-care declined from 66% to 32% (p<0.001). Symptoms of stress, anxiety or fear was initially 83% and reduced to 66% (p=0.009). Reported strain on relationships and feelings of isolation affected >50% of respondents initially without significant change (p=0.05 and p=0.30 respectively). Women were nearly twice as likely to report feelings of isolation as men (OR 1.95; 95%CI 1.82-5.88). Working part-time carried twice the risk of burnout (OR, 2.45; 95% CI, 1.10-5.47). Baseline resilience was normal to high. Provider well-being improved over the four-weeks (30% to 14%; p=0.01), but burnout did not significantly change (30% to 22%; p=0.39). Conclusion: This survey of frontline EM providers during the initial surge of COVID-19 found that despite being a resilient group, the majority experienced stress, anxiety, fear, and concerns about personal safety due to COVID-19, with many at risk for burnout. The sustained impact of the pandemic on EM provider wellness deserves further investigation to guide targeted interventions.

Locating gaps in the California Current System ocean acidification monitoring network.

Ocean acidification is a global issue with particular regional significance in the California Current System, where social, economic, and ecological impacts are already occurring. Although ocean acidification is a concern that unifies the entire West Coast region, managing for this phenomenon at a regional scale is complex and further complicated by the large scale and dynamic nature of the region. Currently, data collection relevant to ocean acidification on the West Coast is piecemeal, and cannot capture the primary sources of variability in ocean acidification through time and across the region, hindering collaboration among regional managers. We developed a tool to analyze gaps in the West Coast ocean acidification monitoring network. We describe this tool and discuss how it can enable scientists and marine managers in the California Current System to fill information gaps and better understand and thus respond to ocean acidification through the implementation of management solutions at the local level.

Identification of Protective CD8 T Cell Responses in a Mouse Model of Zika Virus Infection.

Many flaviviruses including dengue (DENV), and Zika (ZIKV) have attracted significant attention in the past few years. As many flaviviruses are spread by arthropods, most of the world's population is at risk of encountering a flavivirus, and infection with these viruses has created a significant disease burden worldwide. Vaccination against flaviviruses is thought to be one of the most promising avenues for reducing the disease burden associated with these viruses. The optimism surrounding a vaccine approach is supported by the highly successful vaccines for yellow fever and Japanese encephalitis. Central to the development of new successful vaccines is the understanding of the correlates of protection that will be necessary to engineer into new vaccines. To aid in this endeavor we have directed our efforts to identify correlates of protection that will reduce the disease burden associated with ZIKV and DENV. Within this study we have identified a novel murine ZIKV specific CD8+ T cell epitope, and shown that the ZIKV epitope specific CD8+ T cell response has a distinct immunodominance hierarchy present during acute infection and is detectible as part of the memory T cell responses. Our studies confirm that ZIKV-specific CD8+ T cells are an important correlate of protection for ZIKV and demonstrate that both naïve and ZIKV immune CD8+ T cells are sufficient for protection against a lethal ZIKV infection. Overall this study adds to the body of literature demonstrating a role for CD8+ T cells in controlling flavivirus infection.

Usability Evaluation of a Mobile Monitoring System to Assess Symptoms After a Traumatic Injury: A Mixed-Methods Study.

BACKGROUND: Victims of trauma are at high risk for mental health conditions such as posttraumatic stress disorder and depression. Regular assessment of mental health symptoms in the post-trauma period is necessary to identify those at greatest risk and provide treatment. The multiple demands of the acute post-trauma period present numerous barriers to such assessments. Mobile apps are a method by which to overcome these barriers in order to regularly assess symptoms, identify those at risk, and connect patients to needed services. OBJECTIVE: The current study conducted a usability evaluation of a system to monitor mental health symptoms after a trauma. The system was developed to promote ease of use and facilitate quick transmission of data. METHODS: A sample of 21 adults with a history of trauma completed a standardized usability test in a laboratory setting followed by a qualitative interview. RESULTS: Usability testing indicated that the app was easy to use and that patients were able to answer several questions in less than 1 minute (mean [SD] 29.37 [7.53]; range 15-57). Qualitative analyses suggested that feedback should be included in such an app and recommendations for the type of feedback were offered. CONCLUSIONS: The results of the current study indicate that a mobile app to monitor post-trauma mental health symptoms would be well received by victims. Personalized feedback to the user was identified as critical to promote the usability of the software.