The relationship between processes and outcomes for injured older adults: a study of a statewide trauma system.

PURPOSE: Age is a risk factor for death, adverse outcomes, and health care use following trauma. The American College of Surgeons' Trauma Quality Improvement Program (TQIP) has published "best practices" of geriatric trauma care; adoption of these guidelines is unknown. We sought to determine which evidence-based geriatric protocols, including TQIP guidelines, were correlated with decreased mortality in Pennsylvania's trauma centers. METHODS: PA's level I and II trauma centers self-reported adoption of geriatric protocols. Survey data were merged with risk-adjusted mortality data for patients ≥65 from a statewide database, the Pennsylvania Trauma Systems Foundation (PTSF), to compare mortality outlier status and processes of care. Exposures of interest were center-specific processes of care; outcome of interest was PTSF mortality outlier status. RESULTS: 26 of 27 eligible trauma centers participated. There was wide variation in care processes. Four trauma centers were low outliers; three centers were high outliers for risk-adjusted mortality rates in adults ≥65. Results remained consistent when accounting for center volume. The only process associated with mortality outlier status was age-specific solid organ injury protocols (p = 0.04). There was no cumulative effect of multiple evidence-based processes on mortality rate (p = 0.50). CONCLUSIONS: We did not see a link between adoption of geriatric best-practices trauma guidelines and reduced mortality at PA trauma centers. The increased susceptibility of elderly to adverse consequences of injury, combined with the rapid growth rate of this demographic, emphasizes the importance of identifying interventions tailored to this population. LEVEL OF EVIDENCE: III. STUDY TYPE: Descriptive.

Penetrating torso injuries in older adults: increased mortality likely due to "failure to rescue".

PURPOSE: Approximately 8 % of injuries in the elderly are from penetrating mechanisms. The natural history of potentially survivable penetrating torso wounds in the elderly is not well studied. Older adults with penetrating injuries to the torso may have worse outcomes than matched, younger patients due to a failure to rescue after complications. METHODS: A retrospective chart review of all patients ≥55 (older) with a penetrating injury (GSW or SW) to the torso over 20 years was performed. All patients with a maximum AIS chest or abdomen >1 and <6 were included. A matched cohort (mechanism, AIS chest and abdomen, ISS and sex) of patients between the ages of 20-40 years (young) was created (3 young, 1 older). Differences in hemodynamics, complications, length of stay and mortality were analyzed. RESULTS: 105 older met inclusion criteria were compared to 315 young patients. Hemodynamic status was similar between the groups. Older patients required ICU care more often than younger patients, p < 0.05. Older patients required longer ICU stays, p < 0.001 and longer hospitalizations, p = 0.0012. More older patients (41.0 %) suffered post-injury complications compared to the young (26.4 %), p = 0.005. Older patients who suffered a complication had a higher mortality (30.2 %) than the young after a complication (10.8 %), p = 0.007. CONCLUSIONS: While uncommon, penetrating injuries to older adults are associated with higher rates of post-injury complications and increased mortality. This may represent a "failure to rescue" and represent an opportunity for improved post-injury care in older adults who suffer potentially survivable penetrating torso injuries.

Initial venous lactate levels in patients with isolated penetrating extremity trauma: a retrospective cohort study.

INTRODUCTION: Elevated initial lactate levels have been shown to be associated with severe injury in trauma patients, but some patients who do not appear to be in shock also presented with elevated lactate levels. We hypothesized that in hemodynamically stable patients with isolated penetrating extremity trauma, initial lactate level does not predict clinically significant bleeding. METHODS: A 5-year institutional database review was performed. Hemodynamically stable patients (HR < 101, SBP > 90) with isolated penetrating extremity trauma with an initial lactate sent were included. The exposure of interest was captured as a dichotomous variable by initial lactate level normal (N ≤ 2.2 mEq/L), elevated (E > 2.2 mEq/L). The primary outcome measurement was clinically significant bleeding, defined by need for intervention (operation, angioembolization, or transfusion) or laboratory evidence of bleeding (presenting Hg < 7 g/dL, or Hg decrease by >2 g/dL/24 h). Chi-squared and Mann-Whitney tests were used to compare variables. RESULTS: A total of 132 patients were identified. There were no differences in demographics or mechanism of injury between the N (n = 43, 7%) and E (n = 89, 14%) groups. Median lactate levels were 1.6 (IQR 1.2-1.9) mEq/dL vs. 3.8 (IQR 2.8-5.2) in the N and E groups, p < 0.001. Lactate was elevated in 89 (67%) patients but was not associated with clinically significant bleeding (37% elevated vs. 39 % not elevated p = 0.82). CONCLUSIONS: In hemodynamically stable patients with isolated penetrating trauma to the extremity, elevated initial venous lactate levels (>2.2 mEq/L) are not associated with bleeding or need for interventions. Clinical judgment remains the gold standard for evaluation and management of these patients.

Significance of slow wave sleep: considerations from a clinical viewpoint.

Previous experimental observations, almost exclusively carried out with young healthy subjects, have been interpreted as showing a particular restorative role for human slow wave sleep (SWS). This article considers whether findings from polygraphic sleep studies in patients and elderly subjects lead to similar inferences about the meaning or "function" of SWS. The question was approached in three different ways: (a) by presenting results from a long-term study in elderly subjects whose SWS data were correlated with baseline medical and psychometric findings and with 5-year follow-up results; (b) by correlating nonmanipulated wake-time during days with parameters of SWS on subsequent nights in a group of 30 demented inpatients undergoing 72-h continuous sleep-wake recording; (c) by reviewing and comparing published polygraphic sleep studies for a number of psychiatric conditions. None of these three approaches provided unequivocal evidence for a clinically significant role for SWS. Reasons for the different outcome of SWS studies in young experimental subjects and clinical populations are discussed.

Seventy-two hour polygraphic and behavioral recordings of wakefulness and sleep in a hospital geriatric unit: comparison between demented and nondemented patients.

Continuous 72-h polygraphic recordings were carried out in 30 hospitalized, mostly severely demented patients and 14 nondemented control patients. Mean age was greater than 80 years in both groups. In the dementia group, the diagnoses were senile dementia Alzheimer type (n = 16), multi-infarct dementia (n = 8), and mixed or undefined dementia (MIX) (n = 6). The nondemented controls suffered from various medical or psychiatric disorders or were recovering from previous accidents. Dementia patients had less stage 2 and REM sleep and thus less total sleep time than did control subjects. No statistically significant differences were noted between dementia subgroups. There were no differences between controls and demented patients in terms of NREM-REM cycle, and there was no association between the severity of the clinical condition and any of the sleep parameters in the demented patients. In contrast to healthy elderly and old persons, women and men patients with dementia showed no differences in their sleep patterns. In both patient groups, most sleep occurred at night, and wakefulness was predominant during the day. Only three of the dementia patients displayed somewhat more daytime than nighttime sleep. The main conclusions were that polygraphic sleep recordings did not contribute to a better differential diagnosis in patients with advanced dementia and that inversion of the sleep/wakefulness rhythm was uncommon in these separately roomed demented patients.

Evaluation of fetal growth by estimation of neonatal body composition.

To characterize the variation in normal fetal growth by body composition analysis, 188 neonates from uncomplicated singleton term pregnancies were evaluated within 24 hours of birth. Anthropometric measures used to estimate lean body mass and body fat included the following: birth weight 3553 +/- 462 g, lean body mass 3060 +/- 377 g (86.3%), fat mass 495 +/- 196 g (13.7%), and ponderal index 2.65 +/- 0.25. There was a significant linear correlation between birth weight and lean body mass (r2 = 0.83, P = .0001), fat mass (r2 = 0.46, P = .0001), and ponderal index (r2 = 0.22, P = .001). Although the ponderal index has been used as an index of corpulence, the correlation between ponderal index and percent body fat was poor (r2 = 0.15). These results suggest that although neonatal fat mass constitutes only 14% of total birth weight, it explains 46% of its variance. In contrast, the ponderal index explains only 22% of the variance in birth weight and correlates poorly with percent body fat. Body composition analysis explains a significant amount of the variance in normal birth weight.

Antidepressant drug therapy: associated risks.

Aspects of risks associated with treatment with three classes of antidepressants: tricyclic (TCA), second generation ("new") antidepressants and monoamine oxidase inhibitor (MAOI), are discussed. Moclobemide, a benzamide derivative, is a new MAOI antidepressant with reversible and preferential inhibition of the A-form of monoamine oxidase. Moclobemide is free of liver toxicity and the risk of a pressor response with tyramine-containing food is so low that strict diet restrictions are unnecessary. That MAOIs have a low incidence of side effects, particularly so called anticholinergic side effects is also true for moclobemide. A serious risk with antidepressant drugs is that the patient will use them to attempt suicide. Therefore important aspects of antidepressants are that they should take effect rapidly and be safe in overdose. No deaths from overdose have been observed with toloxatone, the only reversible MAOI antidepressant on the market to date. It is concluded that the new reversible MAOI antidepressant moclobemide is similar to other antidepressants in terms of efficacy but very noticeably superior in terms of tolerance and safety.

Adherence behaviors in research protocols: comparison of two interventions.

The effectiveness of an enhanced preparation intervention was compared with the standard preparation intervention for accuracy in overnight urine specimen collections. The sample consisted of 179 individuals with type I insulin-dependent diabetes mellitus (IDDM). Subjects were assigned randomly to an enhanced or standard preparation group. The enhanced preparation included written instructions, a reminder to post instructions in the bathroom, a toilet seat cover with a reminder to save urine, and a nurse-initiated telephone call to review the instructions. The standard preparation included written instructions and a telephone number to call with any questions. For subjects without previous collection experience, significantly fewer inaccurate collections were reported in the enhanced preparation group than in the standard group (chi 2 = 4.61, P < .05). There were no differences in collection accuracy between enhanced and standard groups for subjects with collection experience (chi 2 = .4598, P > .05).

Personal illness models of diabetes: preadolescents and adolescents.

The purpose of this research study was to explore personal illness models of preadolescents and adolescents regarding diabetes mellitus. Personal illness models were defined as the adolescents' cognitive representations of their disease. Sixty children ages 10 to 17 years with a diagnosis of insulin-dependent diabetes mellitus were interviewed using a semistructured questionnaire. Data were content analyzed for common themes. Although most participants expressed an understanding that their disease would last a lifetime, they were hopeful for a cure. Participants wanted healthcare professionals to provide strategies for controlling blood glucose to prevent future complications. Family and friends who followed the same diet as the adolescent with diabetes were viewed as supportive. The majority of adolescents were responsible for much of their own disease management. Their greatest fears concerned insulin reactions and long-term complications such as amputation of limbs.

Personal illness models of diabetes: parents of preadolescents and adolescents.

The purpose of this research was to explore personal illness models of parents of preadolescents and adolescents regarding diabetes mellitus. Personal illness models were defined as the parents' cognitive representations of the disease. Fifty-five parents of children ages 10 to 17 years with a diagnosis of insulin-dependent diabetes mellitus were interviewed using a semistructured questionnaire. Data were content analyzed for common themes. Parents attributed the cause of diabetes to genetics coupled with a viral infection. Most believed the diabetes would last a lifetime but they were hopeful for a cure. Parents requested ongoing education for their children, support groups, counseling, one consistent healthcare provider, and intensive insulin therapy. Parents reported that the major problems caused by diabetes were increased structure of daily routines and that their children with diabetes felt different from healthy peers. Parents' fears about diabetes included long-term complications, early death, and severe insulin reactions.

Effects of acute ethanol on indices of cognitive-behavioral performance in rats.

The present experiment examined the effects of ethanol on several complex operant behaviors in rats. Tasks included: temporal response differentiation (TRD) to assess timing behavior; differential reinforcement of low response rates (DRL) to assess timing and response inhibition; incremental repeated acquisition (IRA) to assess learning; conditioned position responding (CPR) to assess auditory, visual, and position discrimination; and progressive ratio (PR) to assess motivation. Ethanol (0.0, 0.5, 1.0, 1.5, 2.0, and 3.0 g/kg via orogastric gavage) reduced accuracy and/or percent task completed for the TRD, DRL, and CPR tasks. For CPR, this reduction was accompanied by a reduction in response rates. Ethanol also reduced response rates on the PR task. There were no effects of ethanol on IRA performance. These data suggest that ethanol can selectively impair performance on cognitive-behavioral tasks and that these effects can occur at doses that do not affect the subjects' ability to respond.

Management of asymptomatic term neonates whose mothers received intrapartum antibiotics--Part 2: Diagnostic tests and management strategies. Center of Disease Control and Prevention.

The evaluation of the potentially septic newborn is often a source of frustration for practitioners. In the past, it has often been standard practice to evaluate and treat empirically all neonates whose mothers received antibiotics during labor, regardless of whether the infant had any signs or symptoms suggestive of infection. With the advent of recommendations for intrapartum antibiotic therapy to prevent early-onset neonatal group B streptococcal infections, this strategy is no longer practicable because too many infants would thus be evaluated and treated needlessly. This two-part review addresses the issues involved in managing asymptomatic newborns whose mothers received intrapartum antibiotics. Part I, published separately, reviewed the rationale behind strategies for preventing intrapartum transmission of bacterial infection. This final part addresses the evaluation and management of the newborn. A number of diagnostic tests are often used in looking for bacterial infections in the neonate. Unfortunately, none of these is both rapid and reliable. A clinical pathway provided here can serve as a useful guide for the clinician, but uncertainty will always remain. Ultimately, each practitioner must determine the degree of risk or uncertainty that he or she can accept on the basis of clinical experience.

Management of asymptomatic term neonates whose mothers received intrapartum antibiotics--Part 1: Rationale for intrapartum antibiotic therapy.

The evaluation of the potentially septic newborn is often a source of frustration for practitioners. In the past, it has often been standard practice to evaluate and treat empirically all neonates whose mothers received antibiotics during labor, regardless of whether the infant had any signs or symptoms suggestive of infection. With the advent of recommendations for intrapartum antibiotic therapy to prevent early-onset neonatal group B streptococcal infections, this strategy is no longer practicable because too many infants would thus be evaluated and treated needlessly. This two-part review addresses the issues involved in managing asymptomatic newborns whose mothers received intrapartum antibiotics. This first part reviews the rationale behind strategies for preventing intrapartum transmission of bacterial infection. The administration of intravenous antibiotics to laboring mothers appears to reduce the incidence of group B streptococcal infections in neonates. Additionally, intrapartum antibiotic therapy for maternal chorioamnionitis may inhibit transmission of infection to the infant. Part 2--to be published separately--will address the evaluation and management of the newborn.

Toxic effects of repeated ethanol intubations to chicks.

Dosages of 95% ethanol (0, .5, or 1 ml) with variable quantities of water were administered to mixed sex chicks (263 g initial weight) on each of 7 consecutive days. The 1 ml dosage of ethanol significantly reduced body weight gains and feed consumption and increased liver weight per 100 g of body weight. Gross crop lesions (accumulation of exudates and hemorrhage) were observed for both the .5 and 1 ml dosage level of ethanol. For birds given the .5 ml ethanol dosage, dilution with water tended to reduce the severity of crop lesions but not for birds given 1 ml ethanol. All levels of ethanol produced mild ataxia within 5 to 10 min of dosage. Mild or moderate hepatocellular fatty change was present in livers from 5 to 6 birds given 1 ml ethanol. Crop exudates were composed of necrotic cells, fibrin and bacteria. Crop walls of birds given 1 ml of undiluted ethanol were ulcerated and inflamed. Areas within the crop wall were hemorrhagic, edematous, and infiltrated by heterophils and mononuclear cells.

The pharmacology of reversible monoamine oxidase inhibitors.

The older monoamine oxidase inhibitors (MAOIs) are mechanism-based, irreversible inhibitors of MAO; most inhibit both the A and B forms of MAO. Several of the drugs are hydrazine derivatives which have non-specific effects other than MAO inhibition. These properties convey disadvantages, which may be seen as serious, though infrequent, adverse events--the 'cheese effect', hepatotoxicity, amphetamine-like activity, orthostatic hypotension and anticholinergic effects. New, reversible MAOIs stem from a variety of chemical classes and are more specific in their effects, with relatively rapid onset of action, direct relationship between plasma concentration and pharmacological effect, and no prolonged carry-over phenomena.

Cardiotonic steroids induce anti-angiogenic and anti-proliferative profiles in first trimester extravillous cytotrophoblast cells.

OBJECTIVE: Preeclampsia (preE), is characterized by abnormal placental invasion and function. Marinobufagenin (MBG), a cardiotonic steroid (CTS), inhibits cytotrophoblast (CTB) cell functions that are critical for normal placental development. This study tests the hypothesis that CTSs induce anti-angiogenic and anti-proliferative effects in CTB cells. METHODS: Human extravillous CTB cells of the line Sw-71, derived from first trimester chorionic villus tissue, were incubated with 0, 0.1, 1, 10, and 100 nM of each of three CTSs (MBG, cinobufatalin (CINO) and ouabain (OUB)) for 48 h. Thereafter, levels of pro-angiogenic (vascular endothelial growth factor (VEGF165), placental growth factor (PlGF)) and anti-angiogenic (soluble fms-like tyrosine kinase-1 (sFlt-1), soluble endoglin (sEng)) factors were measured in culture media using ELISA kits. Expression of three receptors (VEGF receptor 1 (VEGFR1), angiogenic angiotensin type 1 receptor (AT1) and anti-angiogenic angiotensin type 2 receptor (AT2)) were assayed using immunoblotting (western blots) in cell lysates. RESULTS: sFlt-1 and sEng secretion were increased while VEGF165 and PIGF were decreased in the culture media of CTB cells treated with 1 nM or more of each CTSs (p < 0.01 for each). The AT2 receptor expression was up-regulated (p < 0.05) in CTB cells treated with 1 nM or more of MBG and CINO and with 100 nM OUB, while AT1 and VEGFR1 expressions decreased (p < 0.05) with 1 nM or more of MBG and 10 nM or more of CINO and OUB. CONCLUSIONS: CTSs influence extravillous CTB cells to induce an anti-angiogenic and anti-proliferative profile.