Older Patients With Severe Traumatic Brain Injury: National Variability in Palliative Care.

BACKGROUND: Older patients with traumatic brain injury (TBI) have higher mortality and morbidity than their younger counterparts. Palliative care (PC) is recommended for all patients with a serious or life-limiting illness. However, its adoption for trauma patients has been variable across the nation. The goal of this study was to assess PC utilization and intensity of care in older patients with severe TBI. We hypothesized that PC is underutilized despite its positive effects. MATERIALS AND METHODS: The National Inpatient Sample database (2009-2013) was queried for patients aged ≥55 y with International Classification of Diseases, Ninth Revision codes for TBI with loss of consciousness ≥24 h. Outcome measures included PC rate, in-hospital mortality, discharge disposition, length of stay (LOS), and intensity of care represented by craniotomy and or craniectomy, ventilator use, tracheostomy, and percutaneous endoscopic gastrostomy. RESULTS: Of 5733 patients, 78% died in hospital with a median LOS of 1 d, and 85% of the survivors were discharged to facilities. The overall PC rate was 35%. Almost 40% of deaths received PC, with nearly half within 48 h of admission. PC was used in 26% who had neurosurgical procedures, compared with 35% who were nonoperatively managed (P = 0.003). PC was associated with less intensity of care in the entire population. For survivors, those with PC had significantly shorter LOS, compared with those without PC. CONCLUSIONS: Despite high mortality, only one-third of older patients with severe TBI received PC. PC was associated with decreased use of life support and lower intensity of care. Significant efforts need to be made to bridge this quality gap and improve PC in this high-risk population.

Disproportionally low funding for trauma research by the National Institutes of Health: A call for a National Institute of Trauma.

BACKGROUND: Trauma is a major cause of death and disability in all ages. Previous reviews have suggested that National Institutes of Health (NIH) funding for trauma is not commensurate with its burden of disease, but a detailed analysis has been lacking. We postulated that NIH spending on trauma research was lower than previously thought and was distributed widely, preventing a comprehensive research strategy that could decrease trauma morbidity and mortality. METHODS: The NIH Research Portfolio Online Reporting Tool was initially screened using a search of over 20 terms including "trauma," "injury," "shock," "MVC," and excluding clearly unrelated conditions, for example, "cancer." The details of all grants that screened positive underwent manual review to identify true trauma-related grants. An expert panel was used to adjudicate any ambiguity. RESULTS: In FY2016, NIH awarded 50,137 grants, of which 6,401 (13%) were captured by our initial screen. Following review, 1,888 (28%) were identified as trauma-related; 3.7% of all NIH grants. These grants (US $720 million) represent only 2.9% of the NIH extramural budget. In addition, the grants were funded and administered by 24 of the institutes and centers across the NIH ranging from 0.01% (National Cancer Institute) to 11% (National Institute of Neurological Disorders and Stroke and National Institute of Arthritis and Musculoskeletal and Skin Diseases) of their extramural portfolios. CONCLUSION: Given the extreme burden of trauma-related disability and years of life lost, this review of extramural NIH funding definitively demonstrates that trauma is severely underfunded. The lack of a dedicated home for trauma research at NIH leads to a diffusion of grants across many institutes and makes it impossible to direct a focused and effective national research endeavor to improve outcomes. These data demonstrate the need for a National Institute of Trauma at the NIH to help set an agenda to reach the national goal of Zero Preventable Deaths.

Opportunities to reduce overuse of antibiotics for perinatal group B streptococcal disease prevention and management of preterm premature rupture of membranes.

OBJECTIVE: To identify opportunities to reduce overuse of antibiotics for prevention of perinatal group B streptococcal (GBS) disease and management of preterm premature rupture of membranes (pPROM). METHODS: An anonymous written questionnaire was sent to each of 1031 Fellows of the American College of Obstetricians and Gynecologists, and the responses were subjected to statistical analysis. RESULTS: Among those of the 404 respondents who saw obstetric patients in 2001, most (84%) screened for GBS colonization, and 22% of these prescribed prenatal antibiotics to try to eradicate GBS colonization. Of the 382 respondents (95%) who prescribed antibiotics for pPROM, 36% continued antibiotics for more than 7 days despite negative results from GBS cultures collected before initiation of treatment. Having more years of clinical experience (adjusted odds ratio (OR) 3.0, 95% confidence interval (CI) 1.5 to 6.2), working in a non-academic setting (adjusted OR 2.7, 95% CI 1.0 to 6.9), and prescribing antibiotics prenatally for GBS colonization (adjusted OR 2.0, 95% CI 1.1 to 3.4) were associated with prescribing prolonged antibiotics for pPROM. CONCLUSION: Prenatal antibiotic treatment for GBS colonization and prolonged antibiotic treatment for pPROM contribute to overuse of antibiotics in obstetrics.