Drugs, Delirium, and Trauma: Substance Use and Incidence of Delirium After Traumatic Brain Injury.

INTRODUCTION: There is a paucity of data on the effect of preinjury substance (alcohol, drugs) abuse on the risk of delirium in patients with traumatic brain injury (TBI). This study aimed to assess the incidence of delirium among patients with blunt TBI in association with different substances. METHODS: We analyzed the 2020 American College of Surgeons-Trauma Quality Improvement Program. We included all adult (≥18 y) patients with blunt TBI who had a recorded substance (drugs and alcohol) screening. Our primary outcome was the incidence of delirium. RESULTS: A total of 72,901 blunt TBI patients were identified. The mean (standard deviation) age was 56 (20) years and 68.0% were males. The median (interquartile range) injury severity score was 17 (10-25). Among the study population, 23.1% tested positive for drugs (Stimulants: 3.0%; Depressants: 2.9%, hallucinogens: 5.1%, Cannabinoids: 13.4%, TCAs: 0.1%), and 22.8% tested positive for Alcohol. Overall, 1856 (2.5%) experienced delirium. On univariate analysis, patients who developed delirium were more likely to have positive drug screening results. On multivariable regression analyses, positive screen tests for isolated stimulants (adjusted odds ratio [aOR]: 1.340, P = 0.018), tricyclic antidepressants (aOR: 3.107, P = 0.019), and cannabinoids (aOR: 1.326, P ≤ 0.001) were independently associated with higher odds of developing delirium. CONCLUSIONS: Nearly one-fourth of adult patients with blunt TBI had an initial positive substance screening test. Patients with positive results for isolated stimulants, tricyclic antidepressants, and cannabinoids were at a higher risk of developing delirium, whereas this association was not evident with other drugs and alcohol-positive tests. These findings emphasize the need for early drug screening in TBI patients and close monitoring of patients with positive screening tests.

Final Lifelines: The Implications and Outcomes of Thoracic Damage Control Surgeries.

INTRODUCTION: There is a lack of data on the outcomes of thoracic damage control surgery (TDCS). This study aimed to describe the characteristics and outcomes of patients undergoing TDCS. METHODS: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2021). All trauma patients who underwent emergency thoracotomy and packing with temporary closure were included. Patients were stratified based on the age groups (pediatric [<18 y], adults [18-64 y], and older adults [≥65 y]). Our primary outcome measures included 6-h, 24-h, and in-hospital mortality. Secondary outcomes were major complications. RESULTS: We identified 14,192 thoracotomies, out of which 213 underwent TDCS (pediatric [n = 17], adults [n = 175], and older adults [n = 21]). The mean (SD) age was 37 (18), and 86% were male. The mean shock index was 1.1 (0.4) on presentation with a median [IQR] Glasgow Coma Scale of 4 [3-14], and 22.1% had a prehospital cardiac arrest. The study population was profoundly injured with a median injury severity scoreand chest-abbreviated injury scale of 26 [17-38] and 4 [3-5], respectively, with lung (76.5%) being the most injured intrathoracic organs. Overall, the rates of 6-h, 24-h, and in-hospital mortality were 22.5%, 33%, and 53%, respectively, and 51% developed major complications. There was no significant difference in terms of in-hospital mortality (P = 0.800) and major complications (0.416) among pediatrics, adults, and older adults. CONCLUSIONS: One in three patients undergoing TDCS die within the first 24 h, and more than half of them develop major complications and die in the hospital, with no difference among pediatric, adults, and older adults. Future efforts should be directed to improve the survival of these severely injured, metabolically depleted, challenging patients.

The Synergy Factor: Trauma and Cancer.

INTRODUCTION: Trauma and cancer are the leading causes of death in the US. There is a paucity of data describing the impact of cancer on trauma patients. We aimed to determine the influence of cancer on outcomes of trauma patients. METHODS: In this retrospective analysis of American College of Surgeons-Trauma Quality Improvement Program 2019-2021, we included all adult trauma patients (≥18 y) and excluded patients with severe head injuries and nonmelanomatous skin cancers. Patients were stratified into cancer (C), and no cancer (No-C). Propensity score matching (1:3) was performed. Outcomes were complications and mortality. RESULTS: A matched cohort of 3236 patients (C, 809; No-C, 2427) was analyzed. The mean age was 70 y, 50.5% were males, and the median injury severity score was 8 (4-10). There were no differences in terms of receiving thromboprophylaxis (C 51%: No-C 50%, P = 0.516). Compared to No-C group, the C group had higher rates of deep vein thrombosis (C 1.1% versus No-C 0.3%, P = 0.004), but there was no difference in terms of overall complications. Patients in the C group had higher mortality (C 7.5% versus No-C 2.7%, P < 0.001). CONCLUSIONS: Trauma patients with cancer have nearly 4 times higher odds of deep vein thrombosis and 3 times higher odds of mortality. Developing pathways specific to cancer patients might be necessary to improve the outcomes of trauma patients with cancer.

Endovascular Versus Open Repair in Adolescent Patients With Difficult-to-Access Vascular Injuries.

INTRODUCTION: Management of subclavian artery injuries (SAI) and iliac artery injuries (IAI) in adolescent trauma patients poses a considerable challenge due to their complex anatomical locations. The aim of our study was to determine the association between the injury mechanism and type of repair with the outcomes of patients with traumatic SAI and IAI. METHODS: In this retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program database2017-2020, adolescent (<18 y) patients with SAI and IAI undergoing either endovascular or open repair were included. Patients were stratified by mechanism (blunt versus penetrating) and type of repair (endovascular [E] versus open [O]) and compared. Outcomes measured were mortality and major complications. Multivariable logistic regression analyses were performed. RESULTS: Over 4 y, 170 pediatric patients were identified, of which 73 (43%) sustained an SAI and 97 (57%) had IAI. The mean age was 15 and 79% were male. Overall, 39% were managed endovascularly. Both groups had comparable median injury severity score (E: 23 versus O: 25, P = 0.278). For patients with blunt injury (n = 60), the type of repair was neither associated with major complications (E: 39% versus O: 33%, P = 0.694) nor mortality (E: 2.6% versus O: 4.8%, P = 0.651). For patients with penetrating injuries (n = 110), the endovascular repair had significantly lower morbidity (19% versus 41%, P = 0.034) and mortality (3.7% versus 21%, P = 0.041). On multivariable logistic regression, endovascular repair was identified as the only modifiable risk factor associated with reduced mortality (adjusted odds ratio: 0.201, 95% confidence interval [0.14-0.76], P = 0.038). CONCLUSIONS: Difficult-to-access vascular injuries result in significant morbidity and mortality. Endovascular repair was found to be the only modifiable factor associated with decreased mortality of patients with penetrating injury, whereas the type of repair was not associated with mortality in those with blunt injury.

Development and Validation of Futility of Resuscitation Measure in Older Adult Trauma Patients.

INTRODUCTION: This study aimed to develop and validate Futility of Resuscitation Measure (FoRM) for predicting the futility of resuscitation among older adult trauma patients. METHODS: This is a retrospective analysis of the American College of Surgeons-Trauma Quality Improvement Program database (2017-2018) (derivation cohort) and American College of Surgeons level I trauma center database (2017-2022) (validation cohort). We included all severely injured (injury severity score >15) older adult (aged ≥60 y) trauma patients. Patients were stratified into decades of age. Injury characteristics (severe traumatic brain injury [Glasgow Coma Scale ≤ 8], traumatic brain injury midline shift), physiologic parameters (lowest in-hospital systolic blood pressure [≤1 h], prehospital cardiac arrest), and interventions employed (4-h packed red blood cell transfusions, emergency department resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta, emergency laparotomy [≤2 h], early vasopressor requirement [≤6 h], and craniectomy) were identified. Regression coefficient-based weighted scoring system was developed using the Schneeweiss method and subsequently validated using institutional database. RESULTS: A total of 5562 patients in derivation cohort and 873 in validation cohort were identified. Mortality was 31% in the derivation cohort and FoRM had excellent discriminative power to predict mortality (area under the receiver operator characteristic = 0.860; 95% confidence interval [0.847-0.872], P < 0.001). Patients with a FoRM score of >16 had a less than 10% chance of survival, while those with a FoRM score of >20 had a less than 5% chance of survival. In validation cohort, mortality rate was 17% and FoRM had good discriminative power (area under the receiver operator characteristic = 0.76; 95% confidence interval [0.71-0.80], P < 0.001). CONCLUSIONS: FoRM can reliably identify the risk of futile resuscitation among older adult patients admitted to our level I trauma center.

A High-Performance, Low-Cost, and Integrated Hairpin Topology RF Switched Filter Bank for Radar Applications.

Switched filter banks find widespread application in frequency-hopping radar systems and communication networks with multiple operating frequencies, especially in situations demanding elevated filter element isolation. In this paper, the design and implementation of a highly isolated switchable narrow-bandpass filter bank architecture using hairpin microstrip topology is presented. The filter bank has four discrete bandpass filters with passbands of 2.0-2.2 GHz, 2.3-2.5 GHz, 3.1-3.3 GHz, and 3.9-4.1 GHz. These filters span the radar S-frequency band (2.0-4.0 GHz). In order to switch between channels with a switching speed of nanoseconds, low-loss and highly isolated SP4T switches are implemented. Advanced design system (ADS) software is used to design the various filter functionalities, and the entire system is tested on a vector network analyzer (VNA). The proposed architecture makes it much easier to put the filter bank into practice and switch it to the desired frequency, which is useful for radar receiver applications.

Coronary Artery Aneurysms and Acute Coronary Syndrome: An Interventionalist's Dilemma.

We report three cases of coronary artery aneurysm (CAA) in adults who presented with acute coronary syndrome. Two of these patients did not have traditional coronary artery disease risk factors. Management of CAA poses a significant challenge to interventionalists. We discuss the etiologic mechanisms, risk factors, pathophysiology, and diagnosis using angiography, intravascular ultrasound, and coronary computed tomography. We also highlight management options, including medical therapy and catheter-based interventions such as stenting, coil embolization, stent-assisted coil embolization, and surgical exclusion.

Neurokinin B Administration Induces Dose Dependent Proliferation of Seminal Vesicles in Adult Rats.

BACKGROUND: Neurokinin B; an endogenous decapeptide, mediates its reproductive physiological actions through gonadotropin releasing hormone. Despite the potential role of Neurokinin B on seminal vesicles, its effects on seminal vesicles in adult male mammals remain elusive. We aimed to investigate the potentials of variable doses of Neurokinin B, its agonist and antagonist on histomorphology and expression of NK3R on seminal vesicles, and secretory activity of seminal vesicles in adult male rats. METHODS: Adult male Sprague Dawley rats (n=10 in each group) were administered intraperitoneally with Neurokinin B in three variable doses: 1 µg, 1 ηg and 10 ρg while, Senktide (Neurokinin B agonist) and SB222200 (Neurokinin B antagonist) in 1 µg doses consecutively for 12 days. After 12 days of peptide treatment, half of the animals (n=05) in each group were sacrificed while remaining half (n=05) were kept for another 12 days without any treatment to investigate treatment reversal. Seminal vesicles were dissected and excised tissue was processed for light microscopy, immunohistochemistry and estimation of seminal fructose levels. RESULTS: Treatment with Neurokinin B and Senktide significantly increased while SB222200 slightly decrease the seminal vesicles weight, epithelial height and seminal fructose levels as compared to control. Light microscopy revealed increased epithelial height and epithelial folding as compared to control in all Neurokinin B and Senktide treated groups while decreased in SB222200. Effects of various doses of Neurokinin B, Senktide and SB222200 on seminal vesicles weight, epithelial height, seminal fructose levels and histomorphology were reversed when rats were maintained without treatments. Immuno-expression of Neurokinin B shows no change in treatment and reversal groups. CONCLUSION: Continuous administration of Neurokinin B and Senktide effect positively while SB222200 have detrimental effects on cellular morphology, epithelial height and seminal fructose levels in seminal vesicles. Effects of peptide treatments depicted a reversal towards control group when rats were kept without any treatment.

Survivorship Struggles: Navigating Etiologies and Clinical Parameters of Febrile Neutropenia During Induction Chemotherapy in Acute Leukemia Patients.

Background Acute leukemia, characterized by the uncontrolled proliferation of immature white blood cell precursors, poses significant challenges during induction chemotherapy, including the elevated risk of febrile neutropenia and its associated complications. Our study aims to explain the clinical and etiological parameters of these patients in a resource-limited setting. Methods This retrospective study focused on a total of 102 adult patients with acute leukemia who developed febrile neutropenia during the induction chemotherapy phase. Patients with disease relapse, prior bone marrow transplantation, and cases of acute promyelocytic leukemia were excluded from the study. Demographical characteristics, symptoms at presentation, diagnoses, infectious causes, and outcomes were systematically reported. Infectious etiologies and detailed culture reports were meticulously tabulated, and subsequent data were analyzed. Results Of the 102 patients, 43 (42.2%) were males, with a mean age of 31.9 ± 6.5 years. During the induction chemotherapy, a total of 31 patients died of complicated febrile neutropenia. Severe vomiting was the most common symptom present in 37 (36.2%), followed by cough in 35 (34.3%) and loose stools in 28 (27.5%). Community-acquired pneumonia, neutropenic sepsis, and neutropenic colitis were among the most common etiologies of febrile neutropenia. A total of 72 (70.6%) patients had culture-proven multidrug-resistant Gram-negative bacteremia that contributed to poor outcomes. Conclusions Acute leukemia patients undergoing induction chemotherapy face high infection-associated mortality due to their immunocompromised state. Inadequate infection control measures and antimicrobial resistance contribute to the emergence of multidrug-resistant organisms. Enhanced infection prevention strategies and evidence-based antibiotic prescription guidelines are need of time in resource-limited settings such as Pakistan to address febrile neutropenia complications and bridge the existing care gap in its management.

Predicting the time of mortality among older adult trauma patients: Is frailty the answer?

INTRODUCTION: This study aims to evaluate the temporal trends of mortality among frail versus non-frail older adult trauma patients during index hospitalization. METHODS: We performed a 3-year (2017-2019) analysis of ACS-TQIP. We included all older adult (age ≥65 years) trauma patients. Patients were stratified into two groups (Frail vs. Non-Frail). Outcomes were acute (<24 â€‹h), early (24-72 â€‹h), intermediate (72 hours-1 week), and late (>1 week) mortality. RESULTS: A total of 1,022,925 older adult trauma patients were identified, of which 19.7 â€‹% were frail. The mean(SD) age was 77(8) years and 57.4 â€‹% were female. Median[IQR] ISS was 9[4-10] and both groups had comparable injury severity (p â€‹= â€‹0.362). On multivariable analysis, frailty was not associated with acute (aOR 1.034; p â€‹= â€‹0.518) and early (aOR 1.190; p â€‹= â€‹0.392) mortality, while frail patients had independently higher odds of intermediate (aOR 1.269; p â€‹= â€‹0.042) and late (aOR 1.835; p â€‹< â€‹0.001) mortality. On sub-analysis, our results remained consistent in mild, moderate, and severely injured patients. CONCLUSION: Frailty is an independent predictor of mortality in older adult trauma patients who survive the initial 3 days of admission, regardless of injury severity.

Finding The Sweet Spot: The Association Between Whole Blood to Red Blood Cells Ratio and Outcomes of Hemorrhaging Civilian Trauma Patients.

PURPOSE: To evaluate the dose-dependent effect of Whole Blood (WB) on the outcomes of civilian trauma patients with hemorrhagic shock. METHODS: We performed a 2-year (2020-2021) retrospective analysis of the ACS-TQIP dataset. Adult (≥18) trauma patients with a shock index (SI) >1 who received at least 5 units of PRBC and one unit of WB within the first 4 hours of admission were included. Primary outcomes were 6-hr, 24-hr, and in-hospital mortality. Secondary outcomes were major complications and hospital and ICU length of stay (LOS). RESULTS: A total of 830 trauma patients with a mean (SD) age of 38 (16) were identified. The median [IQR] 4-hour WB and PRBC requirements were 2[2-4] U and 10[7-15] U, respectively, with a median WB:RBC ratio of 0.2 [0.1-0.3]. Every 0.1 increase in WB:RBC ratio was associated with decreased odds of 24-hour mortality (aOR:0.916, p = 0.035) and in-hospital mortality (aOR:0.878, p < 0.001). Youden's index identified 0.25 (1 U of WB for every 4 U of PRBC) as the optimal WB:PRBC ratio to reduce 24-hour mortality. High ratio (≥0.25) group had lower adjusted odds of 24-hour mortality (aOR:0.678, p = 0.021) and in-hospital mortality (aOR:0.618, p < 0.001) compared to the Low ratio group. CONCLUSIONS: A higher WB:PRBC ratio was associated with improved early and late mortality in trauma patients with hemorrhagic shock. Given the availability of WB in trauma centers across the United States, at least one unit of WB for every four units of PRBC may be administered to improve the survival of hemorrhaging civilian trauma patients.

Early Vasopressor Requirement Among Hypotensive Trauma Patients: Does It Cause More Harm Than Good?

BACKGROUND: Optimal utilization of vasopressors during early post-injury resuscitation remains unclear. Our study aims to describe the relationship between the timing of vasopressor administration and outcomes among hypotensive trauma patients. METHODS: This was a retrospective analysis of the 2017-2018 ACS-TQIP database. We included adult (≥18 years) trauma patients presenting with hypotension (lowest SBP <90 mmHg) who received vasopressors within 6 hours of admission. We excluded patients who had a severe head injury (Head-AIS >3) and those with spinal cord injury (Spine-AIS >3). Patients were stratified based on the time to receive vasopressors. Multivariable regression analyses were performed to identify the independent association between timing of vasopressor initiation and outcomes. RESULTS: 1049 patients were identified. Mean age was 55 ± 20 years, and 70% of patients were male. The median ISS was 16 [9-24], 80% had a blunt injury, and the mean SBP was 61 ± 24 mmHg. The median time to first vasopressor administration was 319 [68-352] minutes. Overall, 24-hour and in-hospital mortality rates were 19% and 33%, respectively. Every one-hour delay in vasopressor administration beyond the first hour was independently associated with decreased odds of 24-hour mortality (aOR: 0.65, P < 0.001), in-hospital mortality (aOR: 0.65, P < 0.001), major complications (aOR: 0.77, P = 0.003), and increased odds of longer ICU LOS (ß + 2.53, P = 0.012). There were no associations between the timing of early vasopressor administration and 24-hour PRBC transfusion requirements (P > 0.05). CONCLUSION: Earlier vasopressor requirement among hypotensive trauma patients was independently associated with increased mortality and major complications. Further research on the utility and optimal timing of vasopressors during the post-injury resuscitative period is warranted. LEVEL OF EVIDENCE: III therapeutic/care management.

The implications of poor nutritional status on outcomes of geriatric trauma patients.

BACKGROUND: Malnutrition is shown to be associated with worse outcomes among surgical patients, yet its postdischarge outcomes in trauma patients are not clear. This study aimed to evaluate both index admission and postdischarge outcomes of geriatric trauma patients who are at risk of poor nutritional status. METHODS: This is a secondary analysis of the prospective observational American Association of Surgery for Trauma Frailty Multi-institutional Trial. Geriatric (≥65 years) patients presenting to 1 of the 17 Level I/II/III trauma centers (2019-2021) were included and stratified using the simplified Geriatric Nutritional Risk Index (albumin [g/dL] + body mass index [kg/m2]/10) into severe (simplified Geriatric Nutritional Risk Index <5), moderate (5.5> simplified Geriatric Nutritional Risk Index ≥5), mild level of nutritional risk (6> simplified Geriatric Nutritional Risk Index ≥5.5), and good nutritional status (simplified Geriatric Nutritional Risk Index ≥6) and compared. RESULTS: Of the 1,321 patients enrolled, 22% were at risk of poor nutritional status (mild: 13%, moderate: 7%, severe: 3%). The mean age was 77 ± 8 years, and the median [interquartile range] Injury Severity Score was 9 [5-13]. Patients at risk of poor nutritional status had greater rates of sepsis, pneumonia, discharge to the skilled nursing facility and rehabilitation center, index-admission mortality, and 3-month mortality (P < .05). On multivariable analyses, being at risk of severe level of nutritional risk was independently associated with sepsis (adjusted odds ratio 6.21, 95% confidence interval 1.68-22.90, P = .006), pneumonia (adjusted odds ratio 4.40, 95% confidence interval 1.21-16.1, P = .025), index-admission mortality (adjusted odds ratio 3.16, 95% confidence interval 1.03-9.68, P = .044), and 3-month mortality (adjusted odds ratio 8.89, 95% confidence interval 2.01-39.43, P = .004) compared with good nutrition state. CONCLUSION: Nearly one quarter of geriatric trauma patients were at risk of poor nutritional status, which was identified as an independent predictor of worse index admission and 3-month postdischarge outcomes. These findings underscore the need for nutritional screening at admission.

A Case Of Takotsubo Syndrome Precipitated By Diabetic Ketoacidosis.

Takotsubo syndrome (TTS), Takotsubo cardiomyopathy, or stress-induced cardiomyopathy are interchangeable terms characterized by transient left ventricular systolic dysfunction, electrocardiographic changes, and cardiac biomarker elevation similar to acute coronary syndrome (ACS), without the presence of obstructive epicardial coronary artery disease. It predominantly affects postmenopausal females and manifests in the presence of stressful triggers such as severe physical or emotional stress, natural disasters, unexpected death of relatives, acute medical illnesses, etc. TTS was initially considered to be a benign condition however recent studies have shown that it may be associated with complications and mortality similar to ACS. Rare reports of TTS triggered by diabetic ketoacidosis (DKA) have been published. Herein we describe a case of an elderly female with a history of type II diabetes mellitus (DM) who was admitted with DKA and subsequently developed TTS that resolved after treatment of DKA and implementation of heart failure therapies.

A Rare Case of Nutcracker Phenomenon Associated With Midgut Malrotation and Congenital Solitary Kidney.

Medical conditions such as the nutcracker phenomenon, midgut malrotation, and congenital solitary kidney are rare. Hereby, we present a 21-year-old South Asian male referred to the nephrology clinic for hypertension and increased serum creatinine and was diagnosed with all three conditions. We briefly reviewed the literature on this subject. We present this case report to highlight the complex interplay of multiple renal and gastrointestinal anomalies and to emphasize the importance of a multidisciplinary approach in patient care to optimize outcomes and quality of life.

Health-Seeking Behaviors and Treatments Received for Menopause Symptoms: A Questionnaire Survey among Midlife Women Attending Primary Healthcare Clinics in Malaysia.

OBJECTIVES: This study aimed to assess menopause symptoms, treatment-seeking behaviors, treatments received, and factors associated with seeking consultation from healthcare providers (HCPs). METHODS: Using a self-administered Menopause Quick-6 in the Malay language (MQ6[M]) questionnaire, we surveyed 349 women aged 40-60 years attending primary healthcare clinics in four states in Malaysia for their menopause symptoms. Health-seeking behaviors for menopause symptoms were assessed using questions regarding HCPs consulted and treatments prescribed. Binary logistic regression was employed on factors associated with seeking consultation for menopause symptoms. RESULTS: Using MQ6(M), we observed that 125 (31.3%) women reported at least one menopause symptom, with joint pains (42.8%), menstrual changes (39.5%), and hot flashes (29.3%) being the most frequent symptoms. Furthermore, 60% of the women were prescribed vitamins, and only 13% were administered Hormone Replacement Therapy (HRT). Medical comorbidities, the presence of at least one gynecological condition, menopause status, and MQ6(M) score were associated with seeking consultation with an HCP. For women with medical conditions, the odds of seeking consultation increased by a factor of 1.34 (adjusted odds ratio [AOR], 1.34; 95% confidence interval [CI], 1.11-1.76) for every additional comorbidity. The odds of seeking consultation from an HCP increased by a factor of 1.26 (AOR, 1.26; 95% CI, 1.04-1.47) with a unit increase in MQ6(M) score. CONCLUSIONS: Most women had menopause symptoms but favored the use of complementary and alternative medicine over HRT. Screening and awareness of menopause treatments need to be improved at primary healthcare clinics.