Investigating the effects of frailty on six-month outcomes in older trauma patients admitted to UK major trauma centres: a multi-centre follow up study.

BACKGROUND: Pre-injury frailty is associated with adverse in-hospital outcomes in older trauma patients, but the association with longer term survival and recovery is unclear. We aimed to investigate post discharge survival and health-related quality of life (HRQoL) in older frail patients at six months after Major Trauma Centre (MTC) admission. METHODS: This was a multi-centre study of patients aged ≥ 65 years admitted to five MTCs. Data were collected via questionnaire at hospital discharge and six months later. The primary outcome was patient-reported HRQoL at follow up using Euroqol EQ5D-5 L visual analogue scale (VAS). Secondary outcomes included health status according to EQ5D dimensions and care requirements at follow up. Multivariable linear regression analysis was conducted to evaluate the association between predictor variables and EQ-5D-5 L VAS at follow up. RESULTS: Fifty-four patients died in the follow up period, of which two-third (64%) had been categorised as frail pre-injury, compared to 21 (16%) of the 133 survivors. There was no difference in self-reported HRQoL between frail and not-frail patients at discharge (Mean EQ-VAS: Frail 55.8 vs. Not-frail 64.1, p = 0.137) however at follow-up HRQoL had improved for the not-frail group but deteriorated for frail patients (Mean EQ-VAS: Frail: 50.0 vs. Not-frail: 65.8, p = 0.009). There was a two-fold increase in poor quality of life at six months (VAS ≤ 50) for frail patients (Frail: 65% vs. Not-frail: 30% p < 0.009). Frailty (ß-13.741 [95% CI -25.377, 2.105], p = 0.02), increased age (ß -1.064 [95% CI [-1.705, -0.423] p = 0.00) and non-home discharge (ß -12.017 [95% CI [118.403, 207.203], p = 0.04) were associated with worse HRQoL at follow up. Requirements for professional carers increased five-fold in frail patients at follow-up (Frail: 25% vs. Not-frail: 4%, p = 0.01). CONCLUSIONS: Frailty is associated with increased mortality post trauma discharge and frail older trauma survivors had worse HRQoL and increased care needs at six months post-discharge. Pre-injury frailty is a predictor of poor longer-term HRQoL after trauma and recognition should enable early specialist pathways and discharge planning.

Thoraco-lumbar-sacral orthoses in older people - A narrative literature review.

Fractures in the thoracolumbar region have a bimodal distribution, with an increasing number of older people presenting with acute vertebral fractures after atraumatic or low energy mechanisms of injury. In the absence of neurological compromise and significant vertebral instability, thoracolumbar fractures are often managed conservatively and bracing is widely recommended. However, in older cohorts, bracing is often ill fitting and poorly tolerated with non-compliance leading to prolonged immobilization. Systematic reviews and meta-analyses have challenged the motive of bracing, but as evidence quality is low, the role of exploratory analysis has been limited. This descriptive review summarises and examines the current evidence that underpins the use of spinal orthoses, specific to older patients, in an effort to streamline its judicious use in clinical practice and identify scope to direct further research.

Provision of acute care pathways for older major trauma patients in the UK.

BACKGROUND: The introduction of specific pathways of care for older trauma patients has been shown to decrease hospital length of stay and the overall rate of complications. The extent and scope of pathways and services for older major trauma patients in the UK is not currently known. OBJECTIVE: The primary objective of this study was to map the current care pathways and provision of services for older people following major trauma in the UK. METHODS: A cross-sectional survey of UK hospitals delivering care to major trauma patients (major trauma centres and trauma units). Data were collected on respondent and site characteristics, and local definitions of older trauma patients. To explore pathways for older people with major trauma, four clinical case examples were devised and respondents asked to complete responses that best illustrated the admission pathway for each. RESULTS: Responses from 56 hospitals were included in the analysis, including from 25 (84%) of all major trauma centres (MTCs) in the UK. The majority of respondents defined 'old' by chronological age, most commonly patients 65 years and over. The specialty team with overall responsibility for the patient in trauma units was most likely to be acute medicine or acute surgery. Patients in MTCs were not always admitted under the care of the major trauma service. Assessment by a geriatrician within 72 hours of admission varied in both major trauma centres and trauma units and was associated with increased age. CONCLUSIONS: This survey highlights variability in the admitting specialty team and subsequent management of older major trauma patients across hospitals in the UK. Variability appears to be related to patient condition as well as provision of local resources. Whilst lack of standardisation may be a result of local service configuration this has the potential to impact negatively on quality of care, multi-disciplinary working, and outcomes.

The associations of psoas and masseter muscles with sarcopenia and related adverse outcomes in older trauma patients: a retrospective study.

BACKGROUND: There is an emerging role for radiological evaluation of psoas muscle as a marker of sarcopenia in trauma patients. Older trauma patients are more likely to undergo cranial than abdomino-pelvic imaging. Identifying sarcopenia using masseter cross-sectional area (M-CSA) has shown correlation with mortality. We sought to determine the correlation between psoas: lumbar vertebral index (PLVI) and the M-CSA, and their association with health outcomes. METHODS: Patients aged 65 or above, who presented as a trauma call over a 1-year period were included if they underwent cranial or abdominal CT imaging. Images were retrospectively analysed to obtain PLVI and mean M-CSA measurements. Electronic records were abstracted for outcomes. Logistic regression methods, log scale analyses, Cox regression model and Kaplan-Meier plots were used to determine association of sarcopenia with outcomes. RESULTS: There were 155 eligible patients in the M-CSA group and 204 patients in the PLVI group. Sarcopenia was defined as the lowest quartile in each group. Pearson's correlation indicated a weakly positive linear relationship (r = 0.35, p < 0.001) between these. There was no statistical association between M-CSA sarcopenia status and any measured outcomes. Those with PLVI sarcopenia were more likely to die in hospital (adjusted OR 3.38, 95% CI 1.47-9.73, p = 0.006) and at 2 years (adjusted HR 1.90, 95% CI 1.11-3.25, p = 0.02). Only 29% patients with PLVI sarcopenia were discharged home, compared with 58% without sarcopenia (p = 0.001). CONCLUSION: Sarcopenia, defined by PLVI, is predictive of increased in-patient and 2-year mortality. Our study did not support prognostic relevance of M-CSA.

Use of a modified Delphi process to develop research priorities in major trauma.

PURPOSE: The burden of major trauma within the UK is ever increasing. There is a need to establish research priorities within the field. Delphi methodology can be used to develop consensus opinion amongst a group of stakeholders. This can be used to prioritise clinically relevant, patient-centred research questions to guide future funding allocations. The aim of our study was to identify key future research priorities pertaining to the management of major trauma in the UK. METHODS: A three-phased modified Delphi process was undertaken. Phase 1 involved the submission of research questions by members of the trauma community using an online survey (Phase 1). Phases 2 and 3 involved two consecutive rounds of prioritisation after questions were subdivided into 6 subcategories: Brain Injury, Rehabilitation, Trauma in Older People, Pre-hospital, Interventional, and Miscellaneous (Phases 2 and 3). Cut-off points were agreed by consensus amongst the steering subcommittees. This established a final prioritised list of research questions. RESULTS: In phase 1, 201 questions were submitted by 65 stakeholders. After analysis and with consensus achieved, 186 questions were taken forward for prioritisation in phase 2 with 114 included in phase 3. 56 prioritised major trauma research questions across the 6 categories were identified with a clear focus on long-term patient outcomes. Research priorities across the patient pathway from roadside to rehabilitation were deemed of importance. CONCLUSIONS: Consensus within the major trauma community has identified 56 key research questions across 6 categories. Dissemination of these questions to funding bodies to allow for the development of high-quality research is now required. There is a clear indication for targeted multi-centre multi-disciplinary research in major trauma.

Challenges in the PREHOSPITAL emergency management of geriatric trauma patients - a scoping review.

BACKGROUND: Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group. METHODS AND FINDINGS: A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review. CONCLUSIONS: Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further.

Feasibility and accuracy of ED frailty identification in older trauma patients: a prospective multi-centre study.

BACKGROUND: The burden of frailty on older people is identifiable by its adverse effect on mortality, morbidity and long term functional and health outcomes. In patients suffering from a traumatic injury there is increasing evidence that it is frailty rather than age that impacts greatest on these outcomes and that early identification can guide frailty specific care. The aim of this study was to evaluate the feasibility of nurse-led assessment of frailty in older trauma patients in the ED in patients admitted to major trauma centres. METHODS: Patients age 65 years and over attending the Emergency Departments (ED) of five Major Trauma Centres following traumatic injury were enrolled between June 2019 and March 2020. Patients were assessed for frailty whilst in the ED using three different screening tools (Clinical Frailty Scale [CFS], Program of Research to Integrate Services for the Maintenance of Autonomy 7 [PRIMSA7], and the Trauma Specific Frailty Index [TSFI]) to compare feasibility and accuracy. Accuracy was determined by agreement with geriatrician assessment of frailty. The primary outcome was identification of frailty in the ED using three different assessment tools. RESULTS: We included 372 patients whose median age was 80, 53.8% of whom were female. The most common mechanism of injury was fall from less than 2 m followed by falls greater than 2 m. Completion rates for the tools were variable, 31.9% for TSFI, compared to 93% with PRISMA7 and 98.9% with the CFS. There was substantial agreement when using CFS between nurse defined frailty and geriatrician defined frailty. Agreement was moderate using PRISMA7 and slight using TSFI. CONCLUSIONS: This prospective study has demonstrated that screening for frailty in older major trauma patients within the Emergency Department is feasible and accurate using CFS. TRIAL REGISTRATION: ISRCTN, ISRCTN10671514 . Registered 22 October 2019.

Collaborative working on a 7-day rota reduces length of stay.

A 7-day consultant-geriatrician-led service across five surgical wards, with integrated working among surgeons and physicians, was implemented in response to the COVID-19 pandemic. Our model has shown to increase discharge rates and improve MDT wellbeing. Embedded physician working with surgeons could be key in the recovery to COVID-19.

The Utility of Psoas Muscle Assessment in Predicting Frailty in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: The rise in an ageing population has resulted in an increase in the prevalence of aortic stenosis. With the advent and rapid expansion in the use of transcatheter aortic valve replacements (TAVRs), patients with severe aortic stenosis, traditionally thought too high risk for surgical intervention, are now being treated with generally favourable results. Frailty is an important factor in determining outcome after a TAVR, and an assessment of frailty is fundamental in the identification of appropriate patients to treat. OBJECTIVE: The objective of the study was to identify if the psoas muscle area is associated with frailty in TAVR patients and outcome after intervention. METHOD: In this prospective study, we measured outcomes of 62 patients who underwent TAVR procedures against the psoas muscle area and the Reported Edmonton Frail Scale (REFS). Our aim was to assess if psoas muscle assessment can be used as a simple method to predict frailty in our population group. RESULTS: A total of 60 patients met the study criteria. Mean psoas-lumbar vertebral index was 0.61, with a lower value in the frail group. There was not a statistically significant correlation between the psoas measures, REFS score (indicative of frailty), and mortality. However, there was a statistically significant relationship between the psoas size and REFS score (p=0.043). CONCLUSION: Psoas assessment can be useful in providing additional information when planning for patients to undergo a TAVR and can be used as a screening tool to help identify frail patients within this high-risk group.

Head injury in the elderly - an overview for the physician.

Head injury is a common cause for hospital admission and additionally 250,000 UK inpatients fall during hospital admissions annually. Head injury most commonly occurs as a result of falls from standing height in older adults. Older adults are frequently frail and multi-morbid; many have indications for anticoagulation and antiplatelet agents. The haemorrhagic complications of head injury occur in up to 16% of anticoagulated patients sustaining a head injury. These patients suffer adverse outcomes from surgery as a result of medical complications. Although geriatric trauma models are evolving to meet the demand of an ageing trauma population, medical support to trauma services is commonly delivered by general physicians, many of whom lack experience and training in this field. Determining the role of surgery and interrupted anticoagulation requires careful personalised risk assessment. Appreciation of the opposing risks can be challenging; it requires an understanding of the evidence base in both surgery and medicine to rationalise decision making and inform communication. This article aims to provide an overview for the physician with clinical responsibility for patients who have sustained head injury.

Major trauma in the elderly: Frailty decline and patient experience after injury.

INTRODUCTION: The prevalence of major trauma in the elderly is increasing with ageing western societies. Frailty is now a well-recognised predictor of poor outcome after injury; however, few studies have focused on the progression of frailty and patients' perceptions of their injuries after discharge. AIM: We hypothesised that the number of elderly patients that survive major trauma is low and, of those that do, frailty post injury worsens with overall negative views about quality of life. To investigate this, we examined mortality, frailty and patient experience for elderly major trauma admissions to a level 1 trauma centre at one year after admission. METHOD: All consecutive patients > 75 with an injury severity score of > 15 were included in the study. Patients were invited to participate in a structured telephone interview to assess change in frailty status as well as assess patient experience after injury. RESULTS: A total of 79 patients met inclusion criteria; 34 patients had died and 17 were uncontactable; 88% had become more frail (p < 0.05), and more than half commented positively on their overall quality of life following injury. CONCLUSIONS: These findings highlight the elevated mortality in elderly major trauma patients, but also indicate that preconceived opinions on quality of life, post injury, might not be appropriate.

Cervical spine immobilisation in the elderly: a literature review.

Developed populations are ageing rapidly and by 2040, approximately 1 in 4 adults will be over 65 years of age. This is resulting in higher incidence of traumatic injury in older patients. Cognitive and physical comorbidities in this group can pose significant challenges. Due to mechanisms of injury and pre-existing degenerative spinal disease, cervical spine fractures are particularly prevalent in elderly patients. These are associated with significant morbidity and mortality. In this literature review we examine current evidence surrounding the use of cervical spine immobilisation in elderly patients in the pre-hospital and emergency department setting and also as a treatment option for cervical spine fractures. We explore evidence surrounding the complications that can arise from cervical spine immobilisation, including the development of pressure sores, raised intracranial pressure, dysphagia, breathing difficulties, delirium, compliance issues, mobility and functional outcome.

Comparative Analysis of Mosquito Trap Counts In the Peruvian Amazon: Effect of Trap Type and Other Covariates On Counts and Diversity.

Efficient detection of multiple species of adult mosquitoes in various habitats using effective traps is a crucial 1st step in any disease prevention program. Novel trap types that target tropical vectors of human diseases require field testing in the habitat of the vector-disease system in question. This paper analyzes a series of mosquito trapping studies conducted at Mapacocha, San Juan Bautista District, Loreto, Peru, during August-September 2013 and April-May 2014. Six trap configurations were evaluated in forest and rural locations. Adult mosquito counts were analyzed using full Bayesian inference of multilevel generalized linear models and posterior probability point estimates of the difference of means of the combined trap catch by trap type comparisons of all species. Light traps (Centers for Disease Control and Prevention [CDC] incandescent, white light-emitting diode [LED], and ultraviolet LED) caught greater numbers of mosquitoes compared with traps baited with yeast-generated CO2 and Biogents Sentinel™ traps (battery powered traps without light and passive box traps). However, diversity measures (species richness, evenness, and similarity) were consistently nearly equal among trap types. Arbovirus vectors were more common in forest locations, while malaria vectors were more common near human habitations. Location had a significant effect on trap effectiveness and mosquito diversity, with traps from forest locations having greater numbers and greater species richness, compared with traps set near human habitations. The results of this study will inform mosquito surveillance trap choices in remote regions of central South America, including regions with emerging tropical diseases, such and dengue and Zika virus.

Airworthiness testing of medical maggots.

An investigation was conducted to test and certify medicinal maggots to facilitate rapid healing of traumatic and chronic wound infections in Wounded warriors being transported onboard military aircraft. Our specific aims included (1) to test the ability of medical grade larvae to withstand the rigors of U.S. Army aeromedical certification, including tolerance to change in pressure, temperature, and humidity inside ground-based chambers; (2) to evaluate the efficacy of the medical grade larvae during a high-vibration rotary-wing medical transport flight; and (3) to gain U.S. Army aeromedical certification and U.S. Air Force safe-to-fly approval and begin the steps needed to deploy/implement the use of medicinal maggots in patient care regimes for medical airlift standard operating procedures. This report outlines the ground-based and initial air-based tests performed during the study. Maggot mortality was very low during all tests, with a mortality rate of less than 1%. Maggot growth rates in wound arenas were mixed but generally depended on temperature. Overall, the results of these tests suggest that medicinal maggots can withstand the rigors of aeromedical evacuation flights in simulated flight environments and rotary- or fixed-wing aircraft.

Use of a highly sensitive immunomarking system to characterize face fly (Diptera: Muscidae) dispersal from cow pats.

We tested an immunomarking system that used egg white as marker and enzyme-linked immunosorbent assay as a detection assay to characterize face fly (Musca autumnalis DeGeer) dispersal from cow pats in a pastured beef cattle operation. In microcage assays, adult flies acquired marker after contact with cow pats that were treated with marker and field aged up to 11 d. In arena assays on sprayed full-size cow pats, 77% of eclosed face flies acquired the marker. In a field-marking study, four applications of egg white marker were applied on freshly deposited cow pats over a summer at two peripheral paddocks to a main grazing pasture of ≍50 head of beef cattle. Of the 663 face flies captured, 108 were positive for the egg white marker (16.3%). Of the marked flies, ≍ twofold more male than female flies were captured. Sex-specific dispersal distances were roughly equal up to 450 m, with 11% of female flies dispersing >450 m. Dispersal capability of face flies is discussed in relation to efficacy of rotational grazing and other IPM strategies.

Evaluation of sunlight-exposed pyrethroid-treated netting for the control of face fly and housefly (Diptera: Muscidae).

BACKGROUND: Face flies, Musca autumnalis De Geer (Diptera: Muscidae), and houseflies, Musca domestica L. (Diptera: Muscidae), have a significant impact on livestock and dairy production throughout North America. Pyrethroid insecticide efficacy can be affected by exposure to direct sunlight, and the rate of photodegradation is substrate and formulation dependent. Insecticide-treated netting (ITN) is finding new applications in crop and livestock production systems. A baseline study using long-duration no-choice assays has been carried out to gauge the effectiveness of ITN treated with ß-cyfluthrin, λ-cyhalothrin and bifenthrin on face flies and houseflies. RESULTS: After 12 weeks in direct sunlight, ITN treated with ß-cyfluthrin was still highly insecticidal to face flies and houseflies, producing 100% mortality in petri dish assays. However, sunlight reduced the insecticidal activity of λ-cyhalothrin, with 3% of face flies and 50% of houseflies surviving after exposure to ITN that had been deployed for 10 weeks. Insecticidal activity was greatly reduced on bifenthrin-treated netting, with 20% of face flies and 50% of houseflies surviving in assays with netting deployed for only 3 weeks. CONCLUSION: With careful choice of the pyrethroid applied, treated netting could be an important component of livestock integrated pest management programs focused on sustainable practices.

Maggot debridement therapy in modern army medicine: perceptions and prevalence.

Maggot debridement therapy (MDT), despite its long history and safety profile, finds limited use in the military health care system. Although new methods are continually being investigated to debride wounds more quickly and effectively, MDT remains largely a therapy of last resort. We evaluated the frequency of MDT in the Army sector of the MHS and the decision-making process surrounding its use. A 22 question survey of Army physicians was prepared and distributed through select Medical Corps Consultants in specialties likely to practice debridement. 83% of respondents were familiar with MDT, and of those familiar, 63% were aware of FDA approval for the product and 10% had used the product themselves. The three most frequently cited reasons for not using the therapy were no need (52%), no access (23%), and insufficient experience (19%). Informing the 37% of physicians who are not aware of FDA approval is an obvious target for program improvement. However, as many do not find a need for MDT, targeted improvements to MDT access and education for those physicians who encounter indications for MDT would permit them to apply MDT where there is an unmet need.

Biocompatibility of antimicrobials to maggot debridement therapy: medical maggots Lucilia sericata (Diptera: Calliphoridae) exhibit tolerance to clinical maximum doses of antimicrobials.

The larvae of calliphorid flies are used to debride wounds of patients with severe tissue destruction, often concurrently with antimicrobials. The current study evaluates the effects of ceftazidime, tobramycin, amikacin, gentamicin, polymyxin B, doxycycline, paromomycin, amphotericin B, sodium stibogluconate, and miltefosine at 1, 10, and 100 x the Maximum Clinical Concentration (mg/kg/d) in raw liver assays. Effects on larvae were small and depended on dose and antimicrobial formulation, with hours in assay (24 or 48 h) having a significant effect on larval survival. Sodium stibgluconate had the strongest effect on maggot survival (80.0% at 48 h). These results suggest that the antimicrobials tested here may be used simultaneously with maggot debridement therapy, and may actually increase the effectiveness of maggot debridement therapy in certain applications where >1 x Maximum Clinical Concentration is indicated, such as topical creams for cutaneous leishmaniasis.

Causal relationship of susceptibility genes to ischemic stroke: comparison to ischemic heart disease and biochemical determinants.

Interrelationships between genetic and biochemical factors underlying ischemic stroke and ischemic heart disease are poorly understood. We: 1) undertook the most comprehensive meta-analysis of genetic polymorphisms in ischemic stroke to date; 2) compared genetic determinants of ischemic stroke with those of ischemic heart disease, and 3) compared effect sizes of gene-stroke associations with those predicted from independent biochemical data using a mendelian randomization strategy. Electronic databases were searched up to January 2009. We identified: 1) 187 ischemic stroke studies (37,481 cases; 95,322 controls) interrogating 43 polymorphisms in 29 genes; 2) 13 meta-analyses testing equivalent polymorphisms in ischemic heart disease; and 3) for the top five gene-stroke associations, 146 studies (65,703 subjects) describing equivalent gene-biochemical relationships, and 28 studies (46,928 subjects) describing biochemical-stroke relationships. Meta-analyses demonstrated positive associations with ischemic stroke for factor V Leiden Gln506, ACE I/D, MTHFR C677T, prothrombin G20210A, PAI-1 5G allele and glycoprotein IIIa Leu33Pro polymorphisms (ORs: 1.11 - 1.60). Most genetic associations show congruent levels of risk comparing ischemic stroke with ischemic heart disease, but three genes--glycoprotein IIIa, PAI-1 and angiotensinogen--show significant dissociations. The magnitudes of stroke risk observed for factor V Leiden, ACE, MTHFR and prothrombin, but not PAI-1, polymorphisms, are consistent with risks associated with equivalent changes in activated protein C resistance, ACE activity, homocysteine, prothrombin, and PAI-1 levels, respectively. Our results demonstrate causal relationships for four of the most robust genes associated with stroke while also showing that PAI-1 4G/5G polymorphism influences cardiovascular risk via a mechanism not simply related to plasma levels of PAI-1 (or tPA) alone.