Implementing thrombelastography: Experiences from a level I trauma institution.

Viscoelastic hemostatic assays such as thrombelastography (TEG) and rotational thrombelastometry have proven to be important point-of-care tools in the management of acute traumatic hemorrhage. Despite the availability of prospective studies that have confirmed the utility of TEG in reducing transfusion requirements and mortality in bleeding patients when compared to conventional coagulation tests, many institutions run into barriers implementing these viscoelastic hemostatic assays due to concerns regarding cost and benefit. At our academic Level 1 trauma institution, the Division of Trauma, Critical Care, and Acute Care Surgery advocated for the addition of TEG to the clinical armamentarium of providers caring for injured patients and thus spearheaded the clinical implementation of TEG. With the approval of the central laboratory, the Division developed an extensive and well-trained team to run and interpret TEGs as well as perform machine validation and upkeep. The Division continues to perform point-of-care testing throughout the hospital today.

Tetanus Immunoglobulin G Assessment in Adults Trauma Patients.

BACKGROUND: Clostridium tetani is an anaerobic, gram-positive bacillus that causes tetanus infection. It usually enters the body through injury with contaminated objects. Tetanus differs from other diseases that can be prevented by vaccination in that it is not contagious and does not spread from person to person. The aim of this study is to evaluate the levels of Tetanus IgG in trauma patients admitted to the emergency department (ED). METHODS: The study was planned as cross-sectional, prospective, and single-center. The study was conducted from January to July 2018 in the Kahramanmaras Sütçü Imam University Hospital. Totally, 178 patients aged ≥18 years were included. For measurement of the level of Tetanus IgG, Clostridium tetani toxin 5S IgG kit (NovaLisa, NOVATEC) was used to quantitatively detect IgG type antibodies by micro-ELISA method in accordance with the manufacturer's recommendation. RESULTS: In total, 143 cases were male and 35 were female. The mean age of the cases was 40 ± 16 years. Tetanus IgG levels were found to be 0.29 ± 0.6 IU/mL in cases from rural areas and 2.14 ± 1.64 IU/mL in cases from urban areas (P < 0.001). There was a negative correlation between age and Tetanus IgG level (r: (-) 0.479; P < 0.001). The protective level of Tetanus IgG was observed to be even lower, especially in patients aged ≥40 years (n = 43, 78.9%). CONCLUSION: Measurements of Tetanus IgG levels should be performed as far as possible in the ED. In this way, unnecessary vaccination can be avoided.

Effects of modification of trauma bleeding management: A before and after study.

OBJECTIVE: We hypothesised that the association of tranexamic acid (TXA) administration and thromboelastometry-guided haemostatic therapy (TGHT) with implementation of Damage Control Resuscitation (DCR) reduced blood products (BP) use and massive transfusion (MT). METHODS: Retrospective comparison of 2 cohorts of trauma patients admitted in a university hospital, before (Period 1) and after implementation of DCR, TXA (first 3-hours) and TGHT (Period 2). Patients were included if they received at least 1 BP (RBC, FFP or platelet) or coagulation factor concentrates (fibrinogen or prothrombin complex) during the first 24-hours following the admission. RESULTS: 380 patients were included. Patients in Period 2 (n = 182) received less frequently a MT (8% vs. 33%, P < 0.01), significantly less BP (RBC: 2 units [1-5] vs. 6 [3-11]; FFP: 0 units [0-2] vs. 4 [2-8]) but more fibrinogen concentrates (3.0 g [1.5-4.5] vs. 0.0 g [0.0-3.0], P < 0.01). Multivariate logistic regression analysis identified Period 1 as being associated with an increased risk of receiving MT (OR: 26.1, 95% CI: 9.7-70.2) and decreased survival at 28 days (OR: 2.0, 95% CI: 1.0-3.9). After propensity matching, the same results were observed but there was no difference for survival and a significant decrease for the cost of BP (2370 ± 2126 vs. 3284 ± 3812 €, P: 0.036). CONCLUSION: Following the implementation of a bundle of care including DCR, TGHT and administration of TXA, we observed a decrease to the use of blood products, need for MT and an improvement of survival.

Assessment of three point-of-care platelet function assays in adult trauma patients.

BACKGROUND: Antiplatelet (AP) medication use is common among trauma patients and is associated with poor outcomes. Management options for platelet dysfunction in trauma patients are controversial, expensive, and potentially harmful. Although light transmission platelet aggregometry is considered the standard test to assess platelet function, it is cumbersome and not generally available. Currently, there are no widely accepted platelet function point-of-care tests for acute trauma. STUDY DESIGN: Prospective observational study from 2014 to 2015. Baseline Multiplate aggregometry aspirin area under the platelet aggregation curve (ASPI AUC), Thrombelastography Platelet Mapping percent inhibition of arachidonic acid (TEG-PM AA), and VerifyNow Aspirin Test (ARU) were compared for ability to detect any AP medication use (aspirin or clopidogrel), platelet dysfunction, and identify patients at risk for intracranial hemorrhage (ICH) progression by calculating the area under receiver operating characteristic curves (AUC), sensitivity, specificity, and positive and negative predictive values. Adenosine diphosphate assays were similarly evaluated. RESULTS: Sixty-four patients were enrolled, 25 were taking AP medications. AP patients were older (71.6 versus 35.0 y, P < 0.001) and received more platelet transfusions, but other baseline characteristics were similar. Median ASPI AUC (22.0 versus 53.5 P < 0.001) and VerifyNow ARU (503.5 versus 629.0, P < 0.001) were lower, whereas TEG-PM AA (51.8% versus 18.3%, P < 0.001) was higher in AP patients. Multiplate ASPI AUC, TEG-PM AA percent inhibition, and VerifyNow ARU could identify AP medication use (AUC: 0.90, 0.77, and 0.90, respectively). Adenosine diphosphate assays did not correlate with AP medication use in this population. TEG-PM AA percent inhibition and VerifyNow ARU correlated well with Multiplate ASPI AUC to identify platelet dysfunction (AUC: 0.78, 0.89, respectively). ICH occurred in 29 patients; 12 of which had progression of their injury. ASPI AUC (AUC: 0.50) and VerifyNow ARU (AUC: 0.59) did not correlate, and TEG-PM AA percent inhibition (AUC: 0.66) minimally correlated with progression. CONCLUSIONS: Multiplate, TEG-PM, and VerifyNow are useful point-of-care tests which identify AP medication use and platelet dysfunction in trauma patients. Initial TEG-PM AA percent inhibition may be associated with risk for ICH progression. However, additional large, prospective studies are needed.

[Injuries under the influence of alcohol]. / Verletzungen unter Alkoholeinfluss.

BACKGROUND: In Germany, an average of 9.5 L of pure alcohol is consumed per capita per year. Alcohol is known to negatively influence psychomotor abilities. The aim of this study was to evaluate injuries that lead to hospital admission with and without prior intake of alcohol. PATIENTS AND METHODS: Over a 7-month period, all 1317 patients who were admitted to the hospital because of an injury were evaluated with respect to their blood-alcohol level. Patient data of both groups (139 injuries under alcohol influence and 1178 injuries without alcohol influence) were compared with respect to the mechanism and type of injury, patient demographics, and treatment costs. RESULTS: At the time of presentation, 11 % (n = 139) of all admitted patients had detectable blood-alcohol levels of more than 0.1 g/L with an average blood-alcohol level of 2.21 g/L. Female patients had an average of 1.96 g/L and males an average of 2.28 g/L (N.S.). Almost every fifth male patient (109 out of 570, 19 %) had a detectable blood-alcohol level, compared to only 4 % of all admitted female patients. Among the patients admitted between 11:00 p.m. and 5:00 a.m., 35 % had detectable blood-alcohol levels and among the 20- to 30-year-old patients, 24 % had detectable blood-alcohol levels. The leading mechanisms of injury among intoxicated patients were falls (50 %, n = 70) and physical violence (18 %, n = 25). The latter was recorded significantly (p = 0.01) less among sober patients (0.17 %, n = 2). The most frequent diagnosis was a mild concussion in both intoxicated (60%, n = 84) and sober (34 %, n = 402) patients (p = 0.04). The time to discharge averaged 4.3 days for intoxicated and 5.6 days for sober patients. CONCLUSIONS: Injuries that occur while under the influence of alcohol that lead to hospital admission are particularly frequent in male patients aged between 20 and 30 years. They do not necessarily lead to more severe injuries.

Assessment of key plasma metabolites in combat casualties.

BACKGROUND: Previous studies have indicated that hemorrhagic shock and injury cause significant early changes in metabolism. Recently, global changes in metabolism have been described using metabolomics in animal models and civilian trauma. We evaluated metabolic changes associated with combat injury to identify early biomarkers and aid in triage. METHODS: Plasma obtained at emergency department presentation and intervals thereafter from patients injured during combat operations in Iraq (n = 78) were compared with healthy control subjects (n = 40). Using proton Nuclear Magnetic Resonance (NMR), water-soluble metabolites were detected and quantified. Resulting metabolic profiles were analyzed with partial least squares discriminant analysis, Receiver Operating Characteristic (ROC), and cluster analyses to identify features of combat injury and mortality. RESULTS: Significant alterations to metabolism resulted from traumatic injury. Metabolic profiles of injured patients differed from those of healthy controls, driven by increased 5-aminolevulinate and hypoxanthine that persisted through 24 hours. Among combat-injured patients, increased succinate and malonate best discriminated between those who survived from those who did not. Higher levels of succinate and hypoxanthine were associated with increased injury severity. ROC analysis showed that these metabolites had equivalent or superior performance to lactate in distinguishing the presence of trauma, injury severity, and mortality. CONCLUSION: Combat injury is associated with several changes at the metabolic level compared with healthy individuals. Novel potential biomarkers of mortality (succinate, malonate), injury severity (succinate, hypoxanthine), and the presence of trauma (hypoxanthine, 5-aminolevulinate) perform as well as or better than the common clinical standard, lactate. LEVEL OF EVIDENCE: Prognostic study, level III.

Ex vivo recapitulation of trauma-induced coagulopathy and preliminary assessment of trauma patient platelet function under flow using microfluidic technology.

BACKGROUND: Relevant to trauma-induced coagulopathy diagnostics, microfluidic assays allow controlled hemodynamics for testing of platelet and coagulation function using whole blood. METHODS: Hemodilution or hyperfibrinolysis was studied under flow with modified healthy whole blood. Furthermore, platelet function was also measured using whole blood from trauma patients admitted to a Level I trauma center. Platelet deposition was measured with PPACK-inhibited blood perfused over collagen surfaces at a wall shear rate of 200 s, whereas platelet/fibrin deposition was measured with corn trypsin inhibitor-treated blood perfused over tissue factor (TF)/collagen. RESULTS: In hemodilution studies, PPACK-treated blood displayed almost no platelet deposition when diluted to 10% hematocrit with saline, platelet-poor plasma, or platelet-rich plasma. Using similar dilutions, platelet/fibrin deposition was essentially absent for corn trypsin inhibitor-treated blood perfused over TF/collagen. To mimic hyperfibrinolysis during trauma, exogenous tissue plasminogen activator (50 nM) was added to blood before perfusion over TF/collagen. At both venous and arterial flows, the generation and subsequent lysis of fibrin were detectable within 6 minutes, with lysis blocked by addition of the plasmin inhibitor, ε-aminocaproic acid. Microfluidic assay of PPACK-inhibited whole blood from trauma patients revealed striking defects in collagen response and secondary platelet aggregation in 14 of 21 patients, whereas platelet hyperfunction was detected in three of 20 patients. CONCLUSION: Rapid microfluidic detection of (1) hemodilution-dependent impairment of clotting, (2) clot instability because of lysis, (3) blockade of fibrinolysis, or (4) platelet dysfunction during trauma may provide novel diagnostic opportunities to predict trauma-induced coagulopathy risk.

A possible new paradigm? A survey-based assessment of the use of thawed group A plasma for trauma resuscitation in the United States.

BACKGROUND: Although evidence supporting this practice is limited, some centers use thawed group A plasma for the initial resuscitation of trauma patients. STUDY DESIGN AND METHODS: To better understand the current use of plasma in trauma resuscitation, a survey was developed, validated, and distributed via e-mail to 121 American trauma centers. RESULTS: A total of 61 responses were received. Most were from Level 1 trauma centers (56/61, 92%) in urban settings (47/61, 77%). Virtually all centers reported maintaining A thawed plasma inventory (59/61, 97%). Among the 56 Level 1 trauma center respondents, most keep thawed A immediately available (49/56, 88%) and many use group A plasma for trauma recipients of unknown ABO group (34/49, 69%). Half of the surveyed centers implemented this practice within the past year. The majority do not limit the amount of A plasma that can be administered to a patients of unknown ABO group (21/34, 62%), and most do not titer for anti-B (27/34, 79%). CONCLUSION: The majority of Level 1 trauma centers maintain thawed plasma inventories and use group A plasma for trauma recipients of unknown ABO group. Most centers do not limit the amount of group A plasma used in this situation or titer the anti-B.

Assessment of Modification of Diet in Renal Disease Equation to Predict Reference Serum Creatinine Value in Severe Trauma Patients: Lessons From an Observational Study of 775 Cases.

OBJECTIVE: We assessed the Modification of Diet in Renal Disease (MDRD) performance to predict serum creatinine (SCr) in severe trauma population and determined the best theoretical glomerular filtration rate (GFR) to use in this estimation. BACKGROUND: Baseline SCr may be misestimated in severe trauma patients because of their specific demographic characteristics including renal hyperfiltration. However, the back-calculated MDRD equation is supposed to estimate SCr using a predetermined GFR of 75 mL/min/1.73 m. METHODS: All severe trauma patients with a normal SCr were retrospectively included between January 2005 and January 2011. For each patient, the lowest SCr (oSCr) observed during the first week was used to estimate the GFR. The median GFR in period 1 (2005-2006) was determined. The back-calculated MDRD performance was assessed in period 2 (2007-2011) to predict oSCr by agreement, precision, and accuracy using a GFR of 75 mL/min/1.73 m (eSCr75-MDRD) or the median GFR observed in period 1 (eSCrTRAUMA-MDRD). RESULTS: A total of 775 patients were studied: mean age, 37.7 ±â€Š17 years; mean Injury Severity Score, 19 ±â€Š11; 75% of male. In period 1 (n = 243), median GFR was 121 mL/min/1.73 m. In period 2 (n = 532), eSCrTRAUMA-MDRD demonstrated better agreement in predicting oSCr than eSCr75-MDRD (mean bias 2 vs 35 µmol/L; P < 0.001). Both precision (14 vs 39 µmol/L, respectively) and accuracy were significantly improved with eSCrTRAUMA-MDRD. Proportion of estimated SCr values that deviated less than 15%, 30%, or 50% was also higher with eSCrTRAUMA-MDRD (P < 0.001). CONCLUSIONS: The eSCr75-MDRD equation systematically overestimates oSCr of severe trauma patients. The eSCrTRAUMA-MDRD equation determined was statistically superior allowing more accurate qualification of acute kidney injury.

A critical appraisal of point-of-care coagulation testing in critically ill patients.

Derangement of the coagulation system is a common phenomenon in critically ill patients, who may present with severe bleeding and/or conditions associated with a prothrombotic state. Monitoring of this coagulopathy can be performed with conventional coagulation assays; however, point-of-care tests have become increasingly attractive, because not only do they yield a more rapid result than clinical laboratory testing, but they may also provide a more complete picture of the condition of the hemostatic system. There are many potential areas of study and applications of point-of-care hemostatic testing in critical care, including patients who present with massive blood loss, patients with a hypercoagulable state (such as in disseminated intravascular coagulation), and monitoring of antiplatelet treatment for acute arterial thrombosis, mostly acute coronary syndromes. However, the limitations of near-patient hemostatic testing has not been fully appreciated, and are discussed here. The currently available evidence indicates that point-of-care tests may be applied to guide appropriate blood product transfusion and the use of hemostatic agents to correct the hemostatic defect or to ameliorate antithrombotic treatment. Disappointingly, however, only in cardiac surgery is there adequate evidence to show that application of near-patient thromboelastography leads to an improvement in clinically relevant outcomes, such as reductions in bleeding-related morbidity and mortality, and cost-effectiveness. More research is required to validate the utility and cost-effectiveness of near-patient hemostatic testing in other areas, especially in traumatic bleeding and postpartum hemorrhage.

Exploring structural relationships between blood alcohol concentration and signs and clinical assessment of intoxication in alcohol-involved injury cases.

AIMS: Although the relationship between the Y90 (blood alcohol concentration, BAC) and Y91 (clinician intoxication assessment) ICD-10 codes has received attention recently, the role of 10 signs of intoxication in the Y91-Y90 relationship has not been studied yet. This work examines these signs in the estimation of alcohol intoxication levels of patients in medical settings. METHODS: Collected and analyzed were data on 1997 injured emergency room patients from 17 countries worldwide reporting drinking prior to injury or presenting with a non-zero BAC from 17 countries worldwide. A model is estimated describing how the 10 signs inform the Y91, Y90 prediction with the goal of the use of observations on patients in place of a biological measure. RESULTS: Signs were consistent with a single underlying construct that strongly predicted Y91. Smell of alcohol on breath predicted Y91 above its contribution through the construct and was stronger for those with tolerance to alcohol than for those without. Controlling for Y91, no sign further contributed to prediction of Y90 indicating that Y91 incorporated all intoxication sign information in predicting Y90. Variance explained was high for Y91 (R(2) = 0.84) and intoxication signs (above 0.72 for all but smell on the breath, 0.57) and lower for Y90 (0.38). CONCLUSION: Intoxication assessments are well predicted by overall intoxication severity, which itself is well represented by intoxication signs along with differential emphasis on smell of alcohol on breath, especially for those with alcohol tolerance. However, BAC levels remain largely unexplained by intoxication signs with a clinician's assessment serving as the primary predictive measure.

Diagnostic accuracy of a single point-of-care prehospital serum lactate for predicting outcomes in pediatric trauma patients.

BACKGROUND: Preliminary evidence suggests that a single prehospital lactate level (pLA) improves prediction of morbidity and mortality in adult trauma patients independent of vital signs. However, the value of pLA for pediatric trauma patients is unknown. Our objective was to determine whether pLA is associated with the need for critical care in pediatric trauma patients. METHODS: We conducted a cohort study of 217 patients transported by helicopter to a level I pediatric trauma center over 24 months. The primary outcome was the need for predefined critical care measures. Covariates included vital signs and Glasgow Coma Scale (GCS) scores documented by prehospital providers. RESULTS: Forty-one subjects required critical care. Abnormal prehospital vital signs were not associated with need for critical care. Overall, median pLA level for patients who required critical care was 2.1 mmol/L (interquartile range [IQR], 1.6-2.7 mmol/L) versus 1.7 mmol/L (IQR, 1.2-2.2 mmol/L) for those who did not (P = 0.01). In addition, there were 85 subjects who had normal vital signs and a normal GCS during transport. Of these, 11 (13%) required critical care. In the subset of patients with normal prehospital vital signs and GCS, median pLA level for patients who required critical care was 2.6 mmol/L (IQR, 1.8-2.6 mmol/L) versus 1.7 mmol/L (IQR, 1-2.1 mmol/L) for those who did not (P = 0.01). CONCLUSIONS: Prehospital lactate level was higher in pediatric trauma patients who required critical care, including those who had normal prehospital vital signs and GCS. In this cohort, lactate was an early identifier of children with severe traumatic injuries.

Alcohol use increases diagnostic testing, procedures, charges, and the risk of hospital admission: a population-based study of injured patients in the emergency department.

BACKGROUND: Alcohol use may alter mental status and vital signs in injured patients, leading to increased testing during emergency department (ED) evaluation. We hypothesized that alcohol use increases the hospital charges when caring for these injured patients. METHODS: The National Hospital Ambulatory Medical Care Survey collects weighted population-based estimates of ED use. We analyzed injury-related visits of adult patients, and resource use and admission rates were compared by the presence of alcohol. RESULTS: Alcohol was involved in 6.0% of injury-related ED visits. Alcohol-present patients arrived by ambulance more frequently (45% vs 21%, P < .001), had a 26% longer ED stay (211 vs 167 minutes, P < .001), and underwent more diagnostic testing. They were twice as likely to be admitted (14.0% vs 6.5%, P < .001). Additional ED charges were over $217 million. CONCLUSIONS: Patients with alcohol-related injuries use significantly more resources, with a significant added financial burden. Insurance companies in many states can deny coverage for injuries caused by alcohol use, shifting these expenses to trauma centers.

Initial assessment of the role of CXC chemokine receptor 4 after polytrauma.

CXC chemokine receptor (CXCR)-4 agonists have been shown to attenuate inflammation and organ injury in various disease models, including trauma/hemorrhage. The pathophysiological role of CXCR4 during the early response to tissue injury, however, remains unknown. Therefore, we investigated the effects of AMD3100, a drug that antagonizes binding of stromal cell-derived factor (SDF)-1α and ubiquitin to CXCR4 during the initial response to polytrauma in pigs. Fifteen minutes before polytrauma (femur fractures/lung contusion; control: sham), 350 nmol/kg AMD3100, equimolar AMD3100 and ubiquitin (350 nmol/kg each) or vehicle were administered intravenously. After a 60-min shock period, fluid resuscitation was performed for 360 min. Ubiquitin binding to peripheral blood mononuclear cells was significantly reduced after intravenous AMD3100. SDF-1α plasma levels increased transiently >10-fold with AMD3100 in all animals. In injured animals, AMD3100 increased fluid requirements to maintain hemodynamics and enhanced increases in peripheral blood granulocytes, lymphocytes and monocytes, compared with its effects in uninjured animals. Cytokine release from leukocytes in response to Toll-like receptor (TLR)-2 and TLR-4 activation was increased after in vitro AMD3100 treatment of normal whole blood and after in vivo AMD3100 administration in animals subjected to polytrauma. Coadministration of AMD3100/ubiquitin reduced lactate levels, prevented AMD3100-induced increases in fluid requirements and sensitization of the tumor necrosis factor (TNF)-α and interleukin (IL)-6 release upon TLR-2/4 activation, but did not attenuate increases in leukocyte counts and SDF-1α plasma levels. Our findings suggest that CXCR4 controls leukocyte mobilization after trauma, regulates leukocyte reactivity toward inflammatory stimuli and mediates protective effects during the early phase of trauma-induced inflammation.

Subtance use and type and severity of injury among hospitalized trauma cases: Ohio, 2004-2007.

OBJECTIVE: The purpose of this study was to determine whether persons who were injured severely enough to require hospitalization suffered more severe injury when substance use was involved. This was accomplished by evaluating four proxy outcome measures with Ohio Trauma Registry data from January 2004 through December 2007. METHOD: Four injury outcomes were identified: injury severity score, admission to an intensive care unit, presence of at least one medical complication, and hospital length of stay. We examined their association with substance (alcohol and/or other drug) use stratified by the likelihood of being tested for substance use, mechanism of injury, sex, age, race, and insurance status. Relative risks and t test scores were calculated. RESULTS: Among 89,129 trauma cases reported to the Ohio Trauma Registry during 2004-2007, more than 21% were substance users. Those younger than 45 years of age were 65% more likely to use substances than those 45 or older, men were 110% more likely than women, Blacks were 86% more likely than non-Blacks, and uninsured persons were 127% more likely than insured persons. Stratified analyses yielded 16 comparisons (4 Injury Outcomes × 4 Age-Insurance Subgroups). For 13 of these 16 comparisons, injury severity was significantly worse (p < .0001) among substance users than nonusers. CONCLUSIONS: The evidence is strong enough to conclude that, among hospitalized trauma patients, use of substances (alcohol and/or drug) was associated with increased injury severity. These findings appear to be true for the young and old, regardless of insurance status.

Multi-level analysis of alcohol-related injury and drinking pattern: emergency department data from 19 countries.

Aim While drinking in the event is an important factor in injury occurrence, the pattern of usual drinking may also be important in risk of injury. Explored here is the relationship of an alcohol-related injury with an individual usual drinking pattern. Design Alcohol-related injury is examined using hierarchical linear models, taking into account individual usual volume of consumption over the past 12 months, as well as aggregate-level detrimental drinking pattern (DDP) and alcohol policy measures. Setting Data analyzed are from emergency departments (EDs) in 19 countries, comprising three collaborative studies on alcohol and injury, all of which used a similar methodology. Participants The sample comprised 14 132 injured drinkers across 46 emergency room (ER) studies. Measurements Alcohol-related injury was measured, separately, by any self-reported drinking prior to injury, a blood alcohol concentration (BAC) ≥ 0.08 and self-reported causal attribution of injury to drinking. Findings While individual usual volume strongly predicted an alcohol-related injury for all three measures, usual drinking pattern also predicted an alcohol-related injury (controlling for volume), with episodic heavy and frequent heavy drinking both more predictive of alcohol-related injury than other drinking patterns. When individual usual volume and drinking pattern were controlled, DDP was no longer a significant predictor of alcohol-related injury. Alcohol policy measures were predictive of both BAC and causal attribution (the stronger the policy the lower the rates of alcohol-related injury). Conclusions Volume of alcohol typically consumed and occurrence of heavy drinking episodes are associated independently with incidence of alcohol-related injury. The stronger the anti-alcohol policies in a country, the lower the rates of alcohol-related injury.

Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center.

OBJECTIVE: To evaluate the potential influence of acute intoxication and dependence to alcohol on extrautilisation of health care resources by ethnic minority trauma patients in a level I trauma center. METHODS: We analysed the data of 1493 patients enrolled in a study that evaluated the effectiveness of brief alcohol intervention among ethnic minority trauma patients. The database included detailed demographic, injury-related and drinking-related characteristics (including acute intoxication and alcohol dependency status). Patients were categorised into the following groups: non-intoxicate/nondependent(NI/ND), non-intoxicated/dependent (NI/D), intoxicated/non-dependent (I/ND) and intoxicated/dependent (I/D). We compared utilisation of several diagnostic and therapeutic procedures among these four categories. We placed special emphasis on ethnicity as a potential effect modifier. RESULTS: Relative to NI/ND trauma patients, I/ND patients (relative risk (RR): 1.8, 95% CI: 1.2­2.8) and I/D patients (RR: 2.4, 95% CI: 1.6­3.6) had significantly higher chance of being evaluated by abdominal ultrasound during the first 24 h of hospital arrival. Similar pattern was observed for head CT scan (with the corresponding RRs of 2.1 and 2.6, respectively). Chance of admission to the intensive care unit (ICU)was not associated with intoxication/dependence status. Length of hospital stay was negatively associated with drinking status with the shortest length of stay for I/D. Including ethnicity in the models,did not change the results and conclusions. DISCUSSION: Acute intoxication and dependence to alcohol are both associated with more frequent utilisation of selected health care resources and the utilisation pattern was not associated with patient ethnicity. This emphasises on the importance of routine screening for drinking problems among all trauma patients, regardless of their blood alcohol level in the ED.

Diagnosis-dependent relationships between cytokine levels and survival in patients admitted for surgical critical care.

BACKGROUND: Death after trauma, infection, or other critical illness has been attributed to unbalanced inflammation, in which dysregulation of cytokines leads to multiple organ dysfunction and death. We hypothesized that admission cytokine profiles associated with death would differ based on admitting diagnosis. STUDY DESIGN: This 5-year study included patients admitted for trauma or surgical intensive care for more than 48 hours at 2 academic, tertiary care hospitals between October 2001 and May 2006. Cytokine analysis for interleukin (IL)-1, -2, -4, -6, -8, -10, -12, interferon-gamma, and tumor necrosis factor (TNF)-alpha was performed using ELISA on specimens drawn within 72 hours of admission. Mann-Whitney U test was used to compare median admission cytokine levels between alive and deceased patients. Relative risks and odds of death associated with admission cytokines were generated using univariate analysis and multivariate logistic regression models, respectively. RESULTS: There were 1,655 patients who had complete cytokine data: 290 infected, nontrauma; 343 noninfected, nontrauma; and 1,022 trauma. Among infected patients, nonsurvivors had higher median admission levels of IL-2, -8, -10, and granulocyte macrophage-colony stimulating factor; noninfected, nontrauma patients had higher IL-6, -8, and IL-10; and nonsurviving trauma patients had higher IL-4, -6, -8, and TNF-alpha. IL-4 was the most significant predictor of death and carried the highest relative risk of dying in trauma patients, and IL-8 in nontrauma, noninfected patients. In infected patients, no cytokine independently predicted death. CONCLUSIONS: Cytokine profiles of certain disease states may identify persons at risk of dying and allow for selective targeting of multiple cytokines to prevent organ dysfunction and death.

Control of hyperglycaemia in paediatric intensive care (CHiP): study protocol.

BACKGROUND: There is increasing evidence that tight blood glucose (BG) control improves outcomes in critically ill adults. Children show similar hyperglycaemic responses to surgery or critical illness. However it is not known whether tight control will benefit children given maturational differences and different disease spectrum. METHODS/DESIGN: The study is an randomised open trial with two parallel groups to assess whether, for children undergoing intensive care in the UK aged