Association of Severe Acute Kidney Injury with Mortality and Healthcare Utilization Following Isolated Traumatic Brain Injury.

BACKGROUND/OBJECTIVE: Traumatic brain injury (TBI) is a leading cause of morbidity, mortality, and disability in the USA. While cardiopulmonary dysfunction can result in poor outcomes following severe TBI, the impact of acute kidney injury (AKI) is poorly understood. We examined the association of severe AKI with hospital mortality and healthcare utilization following isolate severe TBI. METHODS: We conducted a retrospective cohort study using the National Trauma Data Bank from 2007 to 2014. We identified a cohort of adult patients with isolated severe TBI and described the incidence of severe AKI, corresponding to Acute Kidney Injury Network stage 3 disease or greater. We examined the association of severe AKI with the primary outcome of hospital mortality using multivariable logistic regression models. In secondary analyses, we examined the association of severe AKI with dialysis catheter placement, tracheostomy and gastrostomy utilization, and hospital length of stay. RESULTS: There were 37,851 patients who experienced isolated severe TBI during the study period. Among these patients, 787 (2.1%) experienced severe (Stage 3 or greater) AKI. In multivariable models, the development of severe AKI in the hospital was associated with in-hospital mortality (OR 2.03, 95% CI 1.64-2.52), need for tracheostomy (OR 2.10, 95% CI 1.52-2.89), PEG tube placement (OR 1.88, 95% CI 1.45-2.45), and increased hospital length of stay (p < 0.001). CONCLUSIONS: The overall incidence of severe AKI is relatively low (2.1%), but is associated with increased mortality and multiple markers of increased healthcare utilization following severe TBI.

Laparoscopy Compared With Laparotomy for the Management of Pediatric Blunt Abdominal Trauma.

BACKGROUND: There is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate postoperative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury. METHODS: Using the 2015-2016 National Trauma Data Bank, all patients aged <18 y with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest. RESULTS: Of 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. The median age was 10 (IQR: 7-15) y, and the median ISS was 9 (IQR: 5-14). Mean hospital length of stay was 2.1 d shorter (95% confidence interval [CI]: 0.9-3.2 d) and mean intensive care unit length of stay was 1.1 d shorter (95% CI: 0.6-1.5 d) for the laparoscopy group compared with the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0%-3.0%). CONCLUSIONS: In this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.

The effect on satiety of ingesting isosweet and isoenergetic sucrose- and isomaltulose-sweetened beverages: a randomised crossover trial.

Generating feelings of satiety may be important in maintaining weight control. It has been hypothesised that the circulating concentration of glucose is a major determinant of satiety, yet the relationship between postprandial glycaemia and satiety is inconclusive. Our aim was to assess satiety following ingestion of beverages differing in glycaemic index (GI) containing either 50 g of sucrose (GI 65) or isomaltulose (PalatinoseTM) (GI 32). The beverages were matched for sweetness using a triangle sensory test. Seventy-seven participants were randomised to the order in which they received each beverage, 2 weeks apart. A standard lunch was given at 12.00 hours. Satiety was measured using 100-mm visual analogue scales (VAS) administered at 14.00 hours (baseline) and at 30, 60, 90, 120, 150 and 180 min after ingesting the beverage. Weighed diet records were kept from 17.00 to 24.00 hours. Mean differences for isomaltulose compared with sucrose AUC VAS were 'How hungry do you feel?' 109 (95 % CI -443, 661) mm × min; 'How satisfied do you feel?' 29 (95 % CI -569, 627) mm × min; 'How full do you feel?' -91 (95 % CI -725, 544) mm × min and 'How much do you think you can eat?' 300 (95 % CI -318, 919) mm × min. There was no between-treatment difference in satiety question responses or in dietary energy intake -291 (95 % CI -845, 267) kJ over the remainder of the day. In this experiment, feelings of satiety were independent of the GI of the test beverages. Any differences in satiety found between foods chosen on the basis of GI could be attributable to food properties other than the glycaemic-inducing potential of the food.

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.

INTRODUCTION: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs. METHODS: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique (NGT) meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review. RESULTS: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the NGT meeting created and refined conclusions and recommendations until consensus was achieved. CONCLUSIONS: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion.

OBJECTIVES: To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients. DESIGN: Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016. SETTING: Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program PATIENTS:: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2-10 yr). Overall mortality was 19.7% (95% CI, 16.6-23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27-0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39-0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51-1.71; p = 0.83). CONCLUSIONS: Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

Donor support for quality assurance and pharmacovigilance of anti-malarials in malaria-endemic countries.

BACKGROUND: Malaria control efforts have been strengthened by funding from donor groups and government agencies. The Global Fund to Fight AIDS, Tuberculosis and the Malaria (Global Fund), the US President's Malaria Initiative (PMI) account for the majority of donor support for malaria control and prevention efforts. Pharmacovigilance (PV), which encompasses all activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problem, is a necessary part of efforts to reduce drug resistance and improve treatment outcomes. This paper reports on an analysis of PV plans in the Global Fund and PMI and World Bank's grants for malaria prevention and control. METHODS: All active malaria grants as of September 2015 funded by the Global Fund and World Bank, and fiscal year 2015 and 2016 PMI Malaria Operational Plans (MOP) were identified. The total amount awarded for PV-related activities and drug quality assurance was abstracted. A Key-Word-in-Context (KWIC) analysis was conducted for the content of each grant. Specific search terms consisted of pharmacovigilance, pregn*, registry, safety, adverse drug, mass drug administration, primaquine, counterfeit, sub-standard, and falsified. Grants that mentioned PV activities identified in the KWIC search, listed PV in their budgets, or included the keywords: counterfeit, sub-standard, falsified, mass drug administration, or adverse event were thematically coded using Dedoose software version 7.0. RESULTS: The search identified 159 active malaria grants including 107 Global Fund grants, 39 fiscal year 2015 and 2016 PMI grants and 13 World Bank grants. These grants were primarily awarded to low-income countries (57.2%) and in sub-Saharan Africa (SSA) (70.4%). Thirty-seven (23.3%) grants included a budget line for PV- or drug quality assurance-related activities, including 21 PMI grants and 16 Global Fund grants. Only 23 (14.5%) grants directly mentioned PV. The primary focus area was improving drug quality monitoring, especially among the PMI grants. CONCLUSIONS: The results of the analysis demonstrate that funding for PV has not been sufficiently prioritized by either the key malaria donor organizations or by the recipient countries, as reflected in their grant proposal submissions and MOPs.

Firearm-related hospitalization and risk for subsequent violent injury, death, or crime perpetration: a cohort study.

BACKGROUND: Risk for violent victimization or crime perpetration after firearm-related hospitalization (FRH) must be determined to inform the need for future interventions. OBJECTIVE: To compare the risk for subsequent violent injury, death, or crime perpetration among patients with an FRH, those hospitalized for noninjury reasons, and the general population. DESIGN: Retrospective cohort study. SETTING: All hospitals in Washington. PATIENTS: Patients with an FRH and a random sample of those with a non-injury-related hospitalization in 2006 to 2007 (index hospitalization). MEASUREMENTS: Primary outcomes included subsequent FRH, firearm-related death, and the combined outcome of firearm- or violence-related arrest ascertained through 2011. RESULTS: Among patients with an index FRH (n = 613), rates of subsequent FRH, firearm-related death, and firearm- or violence-related arrest were 329 (95% CI, 142 to 649), 100 (CI, 21 to 293), and 4221 (CI, 3352 to 5246) per 100 000 person-years, respectively. Compared with the general population, standardized incidence ratios among patients with an index FRH were 30.1 (CI, 14.9 to 61.0) for a subsequent FRH and 7.3 (CI, 2.4 to 22.9) for firearm-related death. In survival analyses that accounted for competing risks, patients with an index FRH were at greater risk for subsequent FRH (subhazard ratio [sHR], 21.2 [CI, 7.0 to 64.0]), firearm-related death (sHR, 4.3 [CI, 1.3 to 14.1]), and firearm- or violence-related arrest (sHR, 2.7 [CI, 2.0 to 3.5]) than those with a non-injury-related index hospitalization. LIMITATION: Lack of information on whether patients continued to reside in Washington during follow-up may have introduced outcome misclassification. CONCLUSION: Hospitalization for a firearm-related injury is associated with a heightened risk for subsequent violent victimization or crime perpetration. Further research at the intersection of clinical care, the criminal justice system, and public health to evaluate the effectiveness of interventions delivered to survivors of firearm-related injury is warranted. PRIMARY FUNDING SOURCE: Seattle City Council and University of Washington Royalty Research Fund.

King-Devick testing and concussion recovery time in collegiate athletes.

OBJECTIVES: To assess whether the King-Devick (KD) test is useful as a prognostic test for prolonged concussion symptoms by examining the relationship between a) change in performance on KD test from baseline to within two days post-injury and b) the absolute KD time at post-concussion testing, with an outcome of time to return to play (RTP). DESIGN: Prospective Cohort Study. METHODS: Collegiate varsity athletes in the Concussion Assessment, Research, and Education (CARE) Consortium completed baseline and post-injury King-Devick tests from 2014 to 2018. Two exposures were evaluated: 1) change in KD score from baseline to within two days post-injury and 2) absolute KD score within two days post-injury, adjusted for baseline KD. We used Cox proportional hazards models to analyze the relationships between these exposures and time to RTP post-concussion. RESULTS: A total of 309 concussion injuries were included. Median baseline KD score was 40.0 s (IQR: 35.8, 45.2). Median post-injury KD score was 45.8 s (IQR: 39.8, 57.1). Median number of days until RTP in this cohort was 11 (IQR: 8, 17). Post-injury KD score adjusted for baseline KD had a stronger association with time to RTP duration (HR: 0.99 (0.98, 1.00), p = 0.03) than the difference in KD score from baseline to post-injury (HR: 0.99 (0.99, 1.00), p = 0.07). CONCLUSIONS: Higher post-injury KD scores are associated with longer RTP. The association between KD post-concussion test and longer RTP warrants further investigation to assess the utility of the KD for prognostication in a clinical setting.

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.

INTRODUCTION: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs. METHODS: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review. RESULTS: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved. CONCLUSIONS: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Prior Arrest, Substance Use, Mental Disorder, and Intent-Specific Firearm Injury.

INTRODUCTION: Substance use, mental disorders, and arrest are markers of increased firearm injury risk. It is unclear how these markers vary by intent. Examining these interrelated factors together can clarify their associations with assault-related, self-inflicted, unintentional, and legal intervention firearm injuries, informing intent-specific interventions. METHODS: In 2017-2018, 2-year diagnosis and arrest histories of intent-specific firearm injury cases were compared with those of unintentionally injured motor vehicle collision passenger controls. Fatal and nonfatal firearm and motor vehicle collision injury records in Seattle (2010-2014) were linked to statewide hospitalization and arrest records. Multinomial logistic regression models compared odds of prior arrest, substance use, and mental disorder diagnoses among intent-specific firearm injury cases relative to controls, adjusting for age, race, and gender. RESULTS: A total of 763 cases and 335 controls were identified. Unintentional and self-inflicted cases did not differ significantly from controls in arrest history. Legal intervention cases resembled assault-related cases in their arrest history, and self-inflicted cases in their hospitalization history. The legal intervention cases were more likely than controls to have a prior felony arrest (OR=7.72, 95% CI=2.63, 20.97), and diagnoses involving alcohol (OR=4.06, 95% CI=1.04, 15.84); cannabis (OR=11.00, 95% CI=1.01, 119.36); depression/anxiety (OR=7.22, 95% CI=1.89, 27.67); psychosis (OR=6.99, 95% CI=1.35, 36.24); or conduct disorder (OR=22.01, 95% CI=1.44, 335.93). CONCLUSIONS: Individuals with intent-specific firearm injuries have distinct patterns of prior substance use, mental disorder, and arrest. Many injuries occur after a series of encounters with institutions meant to help individuals during crises that can fail to provide longer-term solutions.