Neonatal Fever in the COVID-19 Pandemic: Odds of a Serious Bacterial Infection.

OBJECTIVES: A sepsis workup is recommended in young infants 56 days or younger with fever to rule out a serious bacterial infection (SBI). Given the reduction in non-severe acute respiratory syndrome - coronavirus 2 viral infections observed in multiple studies during the coronavirus diseases 2019 (COVID-19) pandemic, we sought to determine if the reduction in viral infections led to a change in the incidence of SBI in this vulnerable patient population. METHODS: We performed a multicenter, retrospective study of infants 56 days or younger presenting with fever to emergency departments of 6 community hospitals. We compared the incidence of SBIs, viral meningitis, and viral bronchiolitis during March 2020 to February 2021 (pandemic year) with the same calendar months in the 2 preceding years (prepandemic years). RESULTS: From March 2018 to February 2021, 543 febrile infants presented to the emergency departments, 95 during the pandemic year (March 2020 to February 2021) compared with 231 and 217 in the prepandemic years (March 2018 to February 2019 and March 2019 to February 2020, respectively).During the pandemic year, 28.4% of infants (27 of 95) were diagnosed with an SBI compared with 11.7% and 6.9% (P < 0.001) in the prepandemic years (27 of 231 and 15 of 217, respectively). Five patients were diagnosed with bacterial meningitis over the 3-year period, 4 of them during the pandemic year (4 of 95 [4.2%]). Positivity for viral cerebrospinal fluid polymerase chain reaction during the pandemic year was 6.4% (3 of 47) compared with 20.8% (25 of 120) and 20.4% (23 of 113) in prepandemic years (P = 0.070). During the pandemic year, 2.1% (2 of 95) febrile young infants were admitted with a comorbid diagnosis of bronchiolitis compared with 4.3% and 6.0% in the prepandemic years (P = 0.310). CONCLUSIONS: The COVID-19 pandemic led to an increase in the incidence of SBIs in febrile infants 56 days or younger, likely a result of reduction in non-severe acute respiratory syndrome - coronavirus 2 viral infections. Greater vigilance is thus warranted in the evaluation of febrile infants during the COVID-19 pandemic.

Interventions to Increase Multivitamin Use Among Women in the Interconception Period: An IMPLICIT Network Study.

INTRODUCTION: Each year, 3% of infants in the Unites States (US) are born with congenital anomalies, including 3000 with neural tube defects. Multivitamins (MVIs) including folic acid reduce the incidence of these birth defects. Most women do not take recommended levels of folic acid prior to conception or during the interconception period. METHODS: The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) ICC model was implemented to screen mothers who attend well child visits (WCVs) for their children aged 0-24 months. Mothers were queried for maternal behavioral risks known to affect pregnancy including multivitamin use and use of family planning methods to enhance birth spacing. When appropriate, interventions targeted at those at risk behaviors are offered. A mixed effects logistic regression model was used to calculate the odds ratio (OR) of behavior change in MVI use among mothers who reported not using MVIs. RESULTS: 37.7% of mothers reported not using MVIs at WCVs. 64.0% of mothers received an intervention to improve MVI use in this model. Mothers who received an intervention were more likely to report taking an MVI at the subsequent WCV if they received advice to take MVIs (OR 1.64) or directly received MVI samples (OR 3.09). CONCLUSIONS: Dedicated maternal counseling during pediatric WCVs is an opportunity to influence behavioral change in women at risk of becoming pregnant. Direct provision of MVIs increases the odds that women will report taking them at a higher rate than provider advice or no counseling at all.

Effects of therapeutical and reduced levels of antibiotics on the fraction of antibiotic-resistant strains of Escherichia coli in the chicken gut.

Development of antibiotic resistance in the microbiota of farm animals and spread of antibiotic-resistant bacteria in the agricultural sector not only threaten veterinary use of antibiotics, but jeopardize human health care as well. The effects of exposure to antibiotics on spread and development of antibiotic resistance in Escherichia coli from the chicken gut were studied. Groups of 15 pullets each were exposed under strictly controlled conditions to a 2-day course of amoxicillin, oxytetracycline, or enrofloxacin, added to the drinking water either at full therapeutic dose, 75% of that, or at the carry-over level of 2.5%. During treatment and for 12 days afterwards, the minimal inhibitory concentration (MIC) for the applied antibiotics of E. coli strains isolated from cloacal swabs was measured. The full therapeutic dose yielded the highest percentage of resistant strains during and immediately after exposure. After 12 days without antibiotics, only strains from chickens that were given amoxicillin were significantly more often resistant than the untreated control. Strains isolated from pullets exposed to carry-over concentrations were only for a few days more often resistant than those from the control. These results suggest that, if chickens must be treated with antibiotics, a short intensive therapy is preferable. Even short-term exposure to carry-over levels of antibiotics can be a risk for public health, as also under those circumstances some selection for resistance takes place.

Clotting Propensity in Trauma Patients According to Marijuana Use: A Descriptive Analysis.

Marijuana use has been reported to promote hypercoagulable states among trauma patients, particularly respecting venous thromboembolism (VTE), a major contributor to morbidity and mortality in patients sustaining traumatic injury. We sought to investigate this further through a retrospective, single institutional study performed from January 2018 through June 2021, utilizing data from patients presenting to a Level 1 Trauma Center as a trauma activation. We observed less frequent VTE development in the marijuana-positive group compared to the marijuana-negative group, with patient thromboelastography revealing a longer mean R-time in the marijuana-positive group. Overall occurrence of VTE was too low for definitive conclusions, but a trend toward reduction in VTE frequency among marijuana users compared to nonusers was noted. More studies with larger populations and more VTE occurrences are needed to confirm a potential correlation between marijuana use and VTE development.

Continuous-flow reactor-based enzymatic synthesis of phosphorylated compounds on a large scale.

Acid phosphatase, an enzyme that is able to catalyze the transfer of a phosphate group from cheap pyrophosphate to alcoholic substrates, was covalently immobilized on polymethacrylate beads with an epoxy linker (Immobeads-150 or Sepabeads EC-EP). After immobilization 70% of the activity was retained and the immobilized enzyme was stable for many months. With the immobilized enzyme we were able to produce and prepare D-glucose-6-phosphate, N-acetyl-D-glucosamine-6-phosphate, allyl phosphate, dihydroxyacetone phosphate, glycerol-1-phosphate, and inosine-5'-monophosphate from the corresponding primary alcohol on gram scale using either a fed-batch reactor or a continuous-flow packed-bed reactor.

Comparing Smoking Cessation Interventions among Underserved Patients Referred for Lung Cancer Screening: A Pragmatic Trial Protocol.

Smoking burdens are greatest among underserved patients. Lung cancer screening (LCS) reduces mortality among individuals at risk for smoking-associated lung cancer. Although LCS programs must offer smoking cessation support, the interventions that best promote cessation among underserved patients in this setting are unknown. This stakeholder-engaged, pragmatic randomized clinical trial will compare the effectiveness of four interventions promoting smoking cessation among underserved patients referred for LCS. By using an additive study design, all four arms provide standard "ask-advise-refer" care. Arm 2 adds free or subsidized pharmacologic cessation aids, arm 3 adds financial incentives up to $600 for cessation, and arm 4 adds a mobile device-delivered episodic future thinking tool to promote attention to long-term health goals. We hypothesize that smoking abstinence rates will be higher with the addition of each intervention when compared with arm 1. We will enroll 3,200 adults with LCS orders at four U.S. health systems. Eligible patients include those who smoke at least one cigarette daily and self-identify as a member of an underserved group (i.e., is Black or Latinx, is a rural resident, completed a high school education or less, and/or has a household income <200% of the federal poverty line). The primary outcome is biochemically confirmed smoking abstinence sustained through 6 months. Secondary outcomes include abstinence sustained through 12 months, other smoking-related clinical outcomes, and patient-reported outcomes. This pragmatic randomized clinical trial will identify the most effective smoking cessation strategies that LCS programs can implement to reduce smoking burdens affecting underserved populations. Clinical trial registered with clinicaltrials.gov (NCT04798664). Date of registration: March 12, 2021. Date of trial launch: May 17, 2021.

Application of a trauma intensivist model to a Level II community hospital trauma program improves intensive care unit throughput.

BACKGROUND: Critical care-trained trauma surgeons are the ideal care provider for severely injured patients. This "captain of the ship" (COS) assumes complete responsibility of the patient, from initial resuscitation to eventual discharge. Unlike American College of Surgeons-verified Level I centers, many nonacademic, community hospital trauma centers use a more fragmented approach, with care in the intensive care unit (ICU) delegated to a committee of multiple specialists. We hypothesized that dedicated trauma intensivists as COS in a community hospital could improve ICU outcome. METHOD: Beginning from September 2005, dedicated full-time trauma intensivists, without any resident coverage, assumed primary responsibility of all trauma patients admitted to a Level II Pennsylvania state verified trauma center. The ICU care was uninterrupted 24 hours a day, 365 days a year. Subspecialty consultations, for recommendations in care only, were selectively obtained as clinically indicated. We compared the 3 years before the implementation of the COS model (PRE: 2003-2005) with the 3 years after the model (POST: 2006-2008). A p-value ≤ 0.05 was considered significant. RESULTS: There were equal numbers of patients admitted to the ICU setting in both the periods. In the PRE and POST periods, both age (46.9 years vs. 52.4 years; p < 0.001) and Injury Severity Score (16.1 vs. 16.7; p = 0.01) were of significance. We observed significant differences in ventilator days (mean, 8 days vs. 6 days; p = 0.002) and mean ICU days (4.9 days vs. 4.4 days; p < 0.001) across the study periods. Days to tracheostomy also achieved statistical significance (9.1 vs. 8.1; p = 0.03). The number of medical consults decreased by 19% in the POST group (p < 0.001). Hospital stay days were not statistically different (7.4 vs. 7.2; p = 0.18). After adjusting for higher age and Injury Severity Score in the POST period, we noted no difference in the expected mortality rate. CONCLUSION: A trauma intensivist-driven model can be successfully adopted in a nonacademic community trauma program, without the need for a residency program. A decentralized ICU care model produces inefficiencies, diminishes the role of the trauma service, and decreases the overall throughput of trauma patients.

An analysis of pediatric social vulnerability in the Pennsylvania trauma system.

BACKGROUND: The social vulnerability index (SVI) is used to assess resilience to external influences that may affect human health. Social vulnerability has been noted to be a barrier to healthcare access for pediatric patients. We hypothesized that Pennsylvania (PA) pediatric trauma patients high on the social vulnerability index would have significantly lower rates of rehab admission following admission to a hospital for traumatic injury. METHODS: The SVI was determined for each PA zip code area utilizing the census tract based 2014 SVI provided by the CDC along with a weighted crosswalk between census tracts and zip code areas using the Housing and Urban Development zip code crosswalk files. The rate of the uninsured population was extracted from the CDC SVI files in addition to other US Census variables based upon estimates from the 2014 American Community Survey (ACS). We also included the individual primary payer status of each subject. Pediatric (age <15 years) trauma admissions with in-hospital mortality excluded, were extracted from the PA Healthcare Cost Containment Council (PHC4) for all hospital admissions for the period of 2003-2015 (n = 63,545). Complete case analysis was conducted based upon the final model providing a sample of 52,794. Cases were coded as rehab patients based upon discharge status (n = 603; 1.1%). A multi-level logistic model was used to determine if subjects had a higher odds of being discharged to rehab based on SVI, undertriage rates of their zip code area of residence and their own primary payer status; this was adjusted for age, multi-system injury and a head, chest or abdomen injury with abbreviate injury scale (AIS) severity > = 3. RESULTS: SVI and undertriage rates of the zip code areas of residence were not significantly associated with admission to rehab. The individual primary payer status of the subject was significantly associated with admission to rehab (OR 95%CI vs. self/uninsured; Medicaid 3.65 1.84-7.24; Commercial = 3.09 1.56-6.11; other/unknown = 2.85 1.02-7.93). Admission to rehab was also significantly associated with age, injury severity (ISS), head or chest injury with AIS scores > = 3, year of admission and hospital type. CONCLUSION: Individual patient level factors (primary payer of patient) may be associated with the odds of rehab admission rather than neighborhood factors. LEVEL OF EVIDENCE: Epidemiologic: Level III.

A comparison of adolescent penetrating trauma patients managed at pediatric versus adult trauma centers in a mature trauma system.

BACKGROUND: While there is little debate that pediatric trauma centers (PTC) are uniquely equipped to manage pediatric trauma patients, the extent to which adolescents benefit from treatment there remains controversial. We sought to elucidate differences in management approach and outcome between PTC and adult trauma centers (ATC) for the adolescent penetrating trauma population. We hypothesized that improved mortality would be observed at ATC for this subset of patients. METHODS: Adolescent patients (age, 15-18 years), presenting to Pennsylvania-accredited trauma centers between 2003 and 2017 with penetrating injury, were queried from the Pennsylvania Trauma Outcome Study database. Dead on arrival, transfer patients, and those admitted to a Level III or Level IV trauma center were excluded from analysis. Patient length of stay, number of complications, surgical intervention, and mortality were compared between ATC and PTC. Multilevel mixed effects logistic regression models with trauma center as the clustering variable were used to assess the impact of center type (ATC/PTC) on management approach and mortality adjusted for appropriate covariates. RESULTS: A total of 2,630 adolescent patients met inclusion criteria (PTC: n = 428 [16.3%]; ATC: n = 2,202 [83.7%]). Pediatric trauma centers had a lower adjusted odds of mortality (adjusted odds ratio [AOR], 0.35; 95% confidence interval [CI], 0.17-0.74; p = 0.006) and a lower adjusted odds of surgery (AOR, 0.67; 95% CI, 0.0.48-0.93; p = 0.016) than their ATC counterparts. There were no differences in complication rates (AOR, 0.94; 95% CI, 0.57-1.55; p = 0.793) or length of stay longer than 4 days (AOR, 0.95; 95% CI, 0.61-1.48; p = 0.812) between the PTCs and ATCs. There were also differences in penetrating injury type between PTC and ATC. CONCLUSION: The adolescent penetrating trauma patient population treated at PTC had less surgery performed with improved mortality compared with ATC. LEVEL OF EVIDENCE: Therapeutic, Level IV.

An analysis of outcomes and predictors of intensive care unit bouncebacks in a mature trauma system.

BACKGROUND: With the recent birth of the Pennsylvania TQIP Collaborative, statewide data identified unplanned admissions to the intensive care unit (ICU) as an overarching issue plaguing the state trauma community. To better understand the impact of this unique population, we sought to determine the effect of unplanned ICU admission/readmission on mortality to identify potential predictors of this population. We hypothesized that ICU bounceback (ICUBB) patients would experience increased mortality compared with non-ICUBB controls and would likely be associated with specific patterns of complications. METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2012 to 2015 for all ICU admissions. Unadjusted mortality rates were compared between ICUBB and non-ICUBB counterparts. Multilevel mixed-effects logistic regression models assessed the adjusted impact of ICUBB on mortality and the adjusted predictive impact of 8 complications on ICUBB. RESULTS: A total of 58,013 ICU admissions were identified from 2012 to 2015. From these, 53,715 survived their ICU index admission. The ICUBB rate was determined to be 3.82% (2,054/53,715). Compared with the non-ICUBB population, ICUBB patients had a significantly higher mortality rate (12% vs. 8%; p < 0.001). In adjusted analysis, ICUBB was associated with a 70% increased odds ratio for mortality (adjusted odds ratio, 1.70; 95% confidence interval, 1.44-2.00; p < 0.001). Adjusted analysis of predictive variables revealed unplanned intubation, sepsis, and pulmonary embolism as the strongest predictors of ICUBB. CONCLUSION: Intensive care unit bouncebacks are associated with worse outcomes and are disproportionately burdened by respiratory complications. These findings emphasize the importance of the TQIP Collaborative in identifying statewide issues in need of performance improvement within mature trauma systems. LEVEL OF EVIDENCE: Epidemiological study, level III.

The geriatric trauma patient: A neglected individual in a mature trauma system.

BACKGROUND: Those older than 65 years represent the fastest growing demographic in the United States. As such, their care has been emphasized by trauma entities such as the American College of Surgeons Committee on Trauma. Unfortunately, much of that focus has been of their care once they reach the hospital with little attention on the access of geriatric trauma patients to trauma centers (TCs). We sought to determine the rate of geriatric undertriage (UT) to TCs within a mature trauma system and hypothesized that there would be variation and clustering of the geriatric undertriage rate (UTR) within a mature trauma system because of the admission of geriatric trauma patient to nontrauma centers (NTCs). METHODS: From 2003 to 2015, all geriatric (age >65 years) admissions with an Injury Severity Score of greater than 9 from the Pennsylvania Trauma Systems Foundation (PTSF) registry and those meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from the Pennsylvania Health Care Cost Containment Council (PHC4) database were included. Undertriage rate was defined as patients not admitted to TCs (n = 27) divided by the total number of patients as from the PHC4 database. The PHC4 contains all inpatient admissions within Pennsylvania (PA), while PTSF reports admissions to PA TCs. The zip code of residence was used to aggregate calculations of UTR as well as other aggregate patient and census demographics, and UTR was categorized into lower, middle box, and upper quartiles. ArcGIS Desktop: Version 10.7, ESRI, Redlands, CA and GeoDa: Version 1.14.0, Open source license were used for geospatial mapping of UT with a spatial empirical Bayesian smoothed UTR, and Stata: Version 16.1, Stata Corp., College Station TX was used for statistical analyses. RESULTS: Pennsylvania Trauma Systems Foundation had 58,336 cases, while PHC4 had 111,626 that met the inclusion criteria, resulting in a median (Q1-Q3) smoothed UTR of 50.5% (38.2-60.1%) across PA zip code tabulation areas. Geospatial mapping reveals significant clusters of UT regions with high UTR in some of the rural regions with limited access to a TC. The lowest quartile UTR regions tended to have higher population density relative to the middle or upper quartile UTR regions. At the patient level, the lowest UTR regions had more racial and ethnic diversity, a higher injury severity, and higher rates of treatment at a TC. Undertriage rate regions that were closer to NTCs had a higher odds of being in the upper UTR quartile; 4.48 (2.52-7.99) for NTC with less than 200 beds and 8.53 (4.70-15.47) for NTC with 200 beds or greater compared with zip code tabulation areas with a TC as the closest hospital. CONCLUSION: There are significant clusters of geriatric UT within a mature trauma system. Increased emphasis needs to focus prehospital on identifying the severely injured geriatric patient including specific geriatric triage protocols. LEVEL OF EVIDENCE: Epidemiological, Level III.

Locked chromophore analogs reveal that photoactive yellow protein regulates biofilm formation in the deep sea bacterium Idiomarina loihiensis.

Idiomarina loihiensis is a heterotrophic deep sea bacterium with no known photobiology. We show that light suppresses biofilm formation in this organism. The genome of I. loihiensis encodes a single photoreceptor protein: a homologue of photoactive yellow protein (PYP), a blue light receptor with photochemistry based on trans to cis isomerization of its p-coumaric acid (pCA) chromophore. The addition of trans-locked pCA to I. loihiensis increases biofilm formation, whereas cis-locked pCA decreases it. This demonstrates that the PYP homologue regulates biofilm formation in I. loihiensis, revealing an unexpected functional versatility in the PYP family of photoreceptors. These results imply that I. loihiensis thrives not only in the deep sea but also near the water surface and provide an example of genome-based discovery of photophysiological responses. The use of locked pCA analogs is a novel and generally applicable pharmacochemical tool to study the in vivo role of PYPs irrespective of genetic accessibility. Heterologously produced PYP from I. loihiensis (Il PYP) absorbs maximally at 446 nm and has a pCA pK(a) of 3.4. Photoexcitation triggers the formation of a pB signaling state that decays with a time constant of 0.3 s. FTIR difference signals at 1726 and 1497 cm(-1) reveal that active-site proton transfer during the photocycle is conserved in Il PYP. It has been proposed that a correlation exists between the lifetime of a photoreceptor signaling state and the time scale of the biological response that it regulates. The data presented here provide an example of a protein with a rapid photocycle that regulates a slow biological response.

Trends in prenatal cares settings: association with medical liability.

BACKGROUND: Medical liability concerns centered around maternity care have widespread public health implications, as restrictions in physician scope of practice may threaten quality of and access to care in the current climate. The purpose of this study was to examine national trends in prenatal care settings based on medical liability climate. METHODS: Analysis of prenatal visits in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1997 to 2004 (N = 21,454). To assess changes in rates of prenatal visits over time, we used the linear trend test. Multivariate logistic regression modeling was developed to determine characteristics associated with visits made to hospital outpatient departments. RESULTS: In regions of the country with high medical liability (N = 11,673), the relative number, or proportion, of all prenatal visits occurring in hospital outpatient departments increased from 11.8% in 1997-1998 to 19.4% in 2003-2004 (p < .001 for trend); the trend for complicated obstetrical visits (N = 3,275) was more pronounced, where the proportion of prenatal visits occurring in hospital outpatient departments almost doubled from 22.7% in 1997-1998 to 41.6% in 2003-2004 (p = .004 for trend). This increase did not occur in regions of the country with low medical liability (N = 9,781) where the proportion of visits occurring in hospital outpatient departments decreased from 13.3% in 1997-1998 to 9.0% in 2003-2004. CONCLUSION: There has been a shift in prenatal care from obstetrician's offices to safety net settings in regions of the country with high medical liability. These findings provide strong indirect evidence that the medical liability crisis is affecting patterns of obstetric practice and ultimately patient access to care.

Trends in broad-spectrum antibiotic prescribing for children with acute otitis media in the United States, 1998-2004.

BACKGROUND: Overuse of broad-spectrum antibiotics is associated with antibiotic resistance. Acute otitis media (AOM) is responsible for a large proportion of antibiotics prescribed for US children. Rates of broad-spectrum antibiotic prescribing for AOM are unknown. METHODS: Analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 1998 to 2004 (N = 6,878). Setting is office-based physicians, hospital outpatient departments, and emergency departments. Patients are children aged 12 years and younger prescribed antibiotics for acute otitis media. Main outcome measure is percentage of broad-spectrum antibiotics, defined as amoxicillin/clavulanate, macrolides, cephalosporins and quinolones. RESULTS: Broad-spectrum prescribing for acute otitis media increased from 34% of visits in 1998 to 45% of visits in 2004 (P < .001 for trend). The trend was primarily attributable to an increase in prescribing of amoxicillin/clavulanate (8% to 15%; P < .001 for trend) and macrolides (9% to 15%; P < .001 for trend). Prescribing remained stable for amoxicillin and cephalosporins while decreasing for narrow-spectrum agents (12% to 3%; P < .001 for trend) over the study period. Independent predictors of broad-spectrum antibiotic prescribing were ear pain, non-white race, public and other insurance (compared to private), hospital outpatient department setting, emergency department setting, and West region (compared to South and Midwest regions), each of which was associated with lower rates of broad-spectrum prescribing. Age and fever were not associated with prescribing choice. CONCLUSION: Prescribing of broad-spectrum antibiotics for acute otitis media has steadily increased from 1998 to 2004. Associations with non-clinical factors suggest potential for improvement in prescribing practice.

An analysis of pediatric trauma center undertriage in a mature trauma system.

BACKGROUND: Improved mortality as a result of appropriate triage has been well established in adult trauma and may be generalizable to the pediatric trauma population as well. We sought to determine the overall undertriage rate (UTR) in the pediatric trauma population within Pennsylvania (PA). We hypothesized that a significant portion of pediatric trauma population would be undertriaged. METHODS: All pediatric (age younger than 15) admissions meeting trauma criteria (International Classification of Diseases, Ninth Revision: 800-959) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database and the Pennsylvania Trauma Systems Foundation (PTSF) registry. Undertriage was defined as patients not admitted to PTSF-verified pediatric trauma centers (n = 6). The PHC4 contains inpatient admissions within PA, while PTSF only reports admissions to PA trauma centers. ArcGIS Desktop was used for geospatial mapping of undertriage. RESULTS: A total of 37,607 cases in PTSF and 63,954 cases in PHC4 met criteria, suggesting UTR of 45.8% across PA. Geospatial mapping reveals significant clusters of undertriage regions with high UTR in the eastern half of the state compared to low UTR in the western half. High UTR seems to be centered around nonpediatric facilities. The UTR for patients with a probability of death 1% or less was 39.2%. CONCLUSION: Undertriage is clustered in eastern PA, with most areas of high undertriage located around existing trauma centers in high-density population areas. This pattern may suggest pediatric undertriage is related to a system issue as opposed to inadequate access. LEVEL OF EVIDENCE: Retrospective study, without negative criteria, Level III.

A preliminary analysis of Level IV trauma centers within an organized trauma system.

BACKGROUND: The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared preaccreditation to postaccreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. METHODS: The Pennsylvania Trauma Systems Foundation collects predesignation and postdesignation data from hospitals pursuing accreditation. Data from Pennsylvania Trauma Systems Foundation between 2012 and 2017 were analyzed. Variables of interest included patient demographics, injury severity, mortality, and incidence of surgical interventions precredentialingto postcredentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania. RESULTS: Five hospitals underwent Level IV credentialing from 2012 to 2017, providing data on 5,076 cases (pre, 2,395 [47.2%]; post, 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed preaccreditation to postaccreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p < 0.014) and adjusted analyses (adjusted odds ratios, 1.13, p = 0.389). There was a trend toward reduced odds of mortality postcredentialing (adjusted odds ratios, 0.59, p = 0.261). Major surgical intervention decreased (Pre, 0.42%; Post, 0.04%; p = 0.004). CONCLUSION: Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Photosensing in chemotrophic, non-phototrophic bacteria: let there be light sensing too.

Putative light-sensing proteins are ubiquitously encoded in the genomes of chemotrophic, non-photosynthetic bacteria. Surprisingly, these are not limited to UV-receptors: the metagenome of the chemotrophic prokaryotes encodes representatives of all known major families of photoreceptors. Insight into the mechanism of light-mediated signaling is relatively advanced, but most light-induced physiological and behavioral responses in chemotrophic bacteria are not well understood. In the current era of 'omics' studies, this knowledge gap could be closed rapidly. Here we review the state of the art in this field. Because light signals can be manipulated accurately, these photoreceptors might help provide a systems-level understanding of the cytology of bacteria.

Early neurological deterioration in older adults with traumatic brain injury.

INTRODUCTION: Traumatic brain injuries (TBIs) and resulting fatalities among older adults increased considerably in recent years. Neurological deterioration often goes unrecognized at the injury scene and patients arrive at emergency departments with near-normal Glasgow Coma Scale (GCS) scores. This study examined the proportion of older adults experiencing early neurological deterioration (prehospital to emergency department), associated factors, and association of the magnitude of neurological deterioration with TBI severity. METHODS: This secondary analysis of National Trauma Data Bank Research Datasets included patients who were age ⩾65, sustained a TBI, and transported from the injury scene to an emergency department. Data analysis included chi-square analysis, t-tests, and logistic regression. Long-term anticoagulant/antiplatelet therapy was not associated with deterioration. RESULTS: Of the sample of 91,886 patients, 13,913 (15.1%) experienced early neurological deterioration. Adjusting for covariates, age, gender, head AISmax injury severity, and probability of death were associated with early deterioration. Patients with severe and critical head injuries had the highest odds of early neurological deterioration (OR=1.41 [CI=1.22-1.63] and OR=1.98 [CI=1.63-2.40], p<0.001). DISCUSSION/CONCLUSIONS: Prehospital providers, nurses, physicians, and other providers have opportunities to optimize outcomes from older adult TBI through early recognition of neurological deterioration, rapid transport to facilities for definitive treatment, and targeted rehabilitation.

Delivering Interconception Care During Well-Child Visits: An IMPLICIT Network Study.

BACKGROUND: Preterm birth, birth defects, and unintended pregnancy are major sources of infant and maternal morbidity, mortality, and associated resource use in American health care. Interconception Care (ICC) is recommended as a strategy to improve birth outcomes by modifying maternal risks between pregnancies, but no established model currently exists. The Interventions to Minimize Preterm and Low Birth Weight Infants through Continuous Improvement Techniques (IMPLICIT) Network developed and implemented a unique approach to ICC by assessing mothers during their baby's well-child visits (WCVs) up to 24 months. METHODS: Mothers who accompanied their children to WCVs at eleven eastern US family medicine residency programs underwent screening for four risk factors (tobacco use, depression risk, contraception use to avoid unintended pregnancy and prolong interpregnancy interval, and use of a multivitamin with folic acid). Positive screens in women were addressed through brief interventions or referrals to treatment. RESULTS: Mothers accompanied their babies to 92.7% of WCVs. At more than half of WCVs (69.1%), mothers were screened for presence of ICC behavioral risks, although significant practice variation existed. Risk factors were identified at significant rates (tobacco use, 16.2%; depression risk, 8.1%; lack of contraception use, 28.2%; lack of multivitamin use, 45.4%). Women screened positive for 1 or more ICC risk factor at 64.6% of WCVs. Rates of documented interventions for women who screened positive were also substantial (tobacco use, 80.0%; depression risk, 92.8%; lack of contraception use, 76.0%; lack of multivitamin use, 58.2%). CONCLUSION: WCVs provide a reliable point of contact with mothers and a unique opportunity to assess and address behavioral risks for future poor birth outcomes.

Undertriage in trauma: Does an organized trauma network capture the major trauma victim? A statewide analysis.

BACKGROUND: Proper triage of critically injured trauma patients to accredited trauma centers (TCs) is essential for survival and patient outcomes. We sought to determine the percentage of patients meeting trauma criteria who received care at non-TCs (NTCs) within the statewide trauma system that exists in the state of Pennsylvania. We hypothesized that a substantial proportion of the trauma population would be undertriaged to NTCs with undertriage rates (UTR) decreasing with increasing severity of injury. METHODS: All adult (age ≥15) hospital admissions meeting trauma criteria (ICD-9, 800-959; Injury Severity Score [ISS], > 9 or > 15) from 2003 to 2015 were extracted from the Pennsylvania Health Care Cost Containment Council (PHC4) database, and compared with the corresponding trauma population within the Pennsylvania Trauma Systems Foundation (PTSF) registry. PHC4 contains all hospital admissions within PA while PTSF collects data on all trauma cases managed at designated TCs (Level I-IV). The percentage of patients meeting trauma criteria who are undertriaged to NTCs was determined and Network Analyst Location-Allocation function in ArcGIS Desktop was used to generate geospatial representations of undertriage based on ISSs throughout the state. RESULTS: For ISS > 9, 173,022 cases were identified from 2003 to 2015 in PTSF, while 255,263 cases meeting trauma criteria were found in the PHC4 database over the same timeframe suggesting UTR of 32.2%. For ISS > 15, UTR was determined to be 33.6%. Visual geospatial analysis suggests regions with limited access to TCs comprise the highest proportion of undertriaged trauma patients. CONCLUSION: Despite the existence of a statewide trauma framework for over 30 years, approximately, a third of severely injured trauma patients are managed at hospitals outside of the trauma system in PA. Intelligent trauma system design should include an objective process like geospatial mapping rather than the current system which is driven by competitive models of financial and health care system imperatives. LEVEL OF EVIDENCE: Epidemiological study, level III; Therapeutic, level IV.