Health Services Use and Functional Recovery Following Blunt Trauma in Older Persons - A National Multicentre Prospective Cohort Study.

OBJECTIVE: Frailty is associated with morbidity and mortality in older injured patients. However, for older blunt-trauma patients, increased frailty may not manifest in longer length of stay at index admission. We hypothesized that owing to time spent in hospital from readmissions, frailty would be associated with less total time at home in the 1-year postinjury period. DESIGN: Prospective, nationwide, multicenter cohort study. SETTING AND PARTICIPANTS: All Singaporean residents aged ≥55 years admitted for blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS) ≥10 from March 2016 to July 2018. METHODS: Frailty (by modified Fried criteria) was assessed at index admission, based on questions on preinjury weight loss, slowness, exhaustion, physical activity, and grip strength at the time of recruitment. Low time at home was defined as >14 hospitalized days within 1 year postinjury. The contribution of planned and unplanned readmission to time at home postinjury was explored. Functional trajectory (by Barthel Index) over 1 year was compared by frailty. RESULTS: Of the 218 patients recruited, 125 (57.3%) were male, median age was 72 years, and 48 (22.0%) were frail. On univariate analysis, frailty [relative to nonfrail: odds ratio (OR) 3.45, 95% confidence interval (CI) 1.33-8.97, P = .01] was associated with low time at home. On multivariable analysis, after inclusion of age, gender, ISS, intensive care unit admission, and surgery at index admission, frailty (OR 5.21, 95% CI 1.77-15.34, P < .01) remained significantly associated with low time at home in the 1-year postinjury period. Unplanned readmissions were the main reason for frail participants having low time at home. Frail participants had poorer function in the 1-year postinjury period. CONCLUSIONS AND IMPLICATIONS: In the year following blunt trauma, frail older patients experience lower time at home compared to patients who were not frail at baseline. Screening for frailty should be considered in all older blunt-trauma patients, with a view to being prioritized for postdischarge support.

Negative and positive experiences of caregiving among family caregivers of older blunt trauma patients.

OBJECTIVES: Family caregivers play a fundamental role in the care of the older blunt trauma patient. We aim to identify risk factors for negative and positive experiences of caregiving among family caregivers. DESIGN: Prospective, nationwide, multi-center cohort study. SETTING AND PARTICIPANTS: 110 family caregivers of Singaporeans aged≥55 admitted for unintentional blunt trauma with an Injury Severity Score (ISS) or New Injury Severity Score (NISS)≥10 were assessed for caregiving-related negative (disturbed schedule and poor health, lack of family support, lack of finances) and positive (esteem) experiences using the modified-Caregiver Reaction Assessment (m-CRA) three months post-injury. METHODS: The association between caregiver and patient factors, and the four m-CRA domains were evaluated via linear regression. RESULTS: Caregivers of retired patients and caregivers of functionally dependent patients (post-injury Barthel score <80) reported a worse experience in terms of disturbed schedule and poor health (ß-coefficient 0.42 [95% Confidence Interval 0.10, 0.75], p = .01; 0.77 [0.33, 1.21], p = .001), while male caregivers and caregivers who had more people in the household reported a better experience (-0.39 [-0.73, -0.06], p = .02; -0.16 [-0.25, -0.07], p = .001). Caregivers of male patients, retired patients, and patients living in lower socioeconomic housing were more likely to experience lack of family support (0.28, [0.03, -0.53], p = .03; 0.26, [0.01, 0.52], p = .05; 0.34, [0.05, -0.66], p = .02). In the context of lack of finances, caregivers of male patients and caregivers of functionally dependent patients reported higher financial strain (0.74 [0.31, 1.17], p = .001; 0.84 [0.26, 1.43], p = .01). Finally, caregivers of male patients reported higher caregiver esteem (0.36 [0.15, 0.57], p = .001). CONCLUSIONS AND IMPLICATIONS: Negative and positive experiences of caregiving among caregivers of older blunt trauma patients are associated with pre-injury disability and certain patient and caregiver demographics. These factors should be considered when planning the post-discharge support of older blunt trauma patients.

Singapore Advanced Cardiac Life Support Guidelines 2021.

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

Frailty and length of stay in older adults with blunt injury in a national multicentre prospective cohort study.

BACKGROUND: Patients suffering moderate or severe injury after low falls have higher readmission and long-term mortality rates compared to patients injured by high-velocity mechanisms such as motor vehicle accidents. We hypothesize that this is due to higher pre-injury frailty in low-fall patients, and present baseline patient and frailty demographics of a prospective cohort of moderate and severely injured older patients. Our second hypothesis was that frailty was associated with longer length of stay (LOS) at index admission. METHODS: This is a prospective, nation-wide, multi-center cohort study of Singaporean residents aged ≥55 years admitted for ≥48 hours after blunt injury with an injury severity score or new injury severity score ≥10, or an Organ Injury Scale ≥3, in public hospitals from 2016-2018. Demographics, mechanism of injury and frailty were recorded and analysed by Chi-square, or Kruskal-Wallis as appropriate. RESULTS: 218 participants met criteria and survived the index admission. Low fall patients had the highest proportion of frailty (44, 27.3%), followed by higher level fallers (3, 21.4%) and motor vehicle accidents (1, 2.3%) (p < .01). Injury severity, extreme age, and surgery were independently associated with longer LOS. Frail patients were paradoxically noted to have shorter LOS (p < .05). CONCLUSION: Patients sustaining moderate or severe injury after low falls are more likely to be frail compared to patients injured after higher-velocity mechanisms. However, this did not translate into longer adjusted LOS in hospital at index admission.

Grape seed proanthocyanidins induce pro-oxidant toxicity in cardiomyocytes.

Grape seed proanthocyanidin extract (GSPE), a polyphenolic compound with antioxidant properties, may protect against cardiac ischemia and reperfusion injury. However, its potential toxicity at higher doses is unknown. The authors tested the effects of GSPE on reactive oxygen species (ROS) generation, cell survival, lactate dehydrogenase (LDH) release, and caspase- 3 activity using chick cardiomyocytes incubated with GSPE at 5, 10, 50, 100, or 500 micrograms/mL in medium for 8 h. Exposure to increasing concentrations of GSPE (100 or 500 micrograms/mL) resulted in an increase in ROS generation and cell death as measured by propidium iodide uptake and LDH release. Caspase-3 activity was significantly increased fourfold in cells exposed to GSPE 500 micrograms/ mL compared to controls; this was abolished by the selective caspase-3 inhibitor Ac-Asp-Gln-Thr-Asp-H (50 microM), which also significantly reduced the cell death resulting from GSPE (500 micrograms/mL). The antioxidant N-acetylcysteine (NAC, 100 microM) reduced cell death induced by GSPE (500 micrograms/mL) but failed to attenuate caspase-3 activation. Collectively, the authors conclude that higher doses of GSPE could cause apoptotic cell injury via effector caspase-3 activation and subsequent induction of ROS generation. Consumers may take higher doses of dietary supplements in the belief that natural herbs have no major side effects. This study demonstrates that dosages of GSPE should be optimized to avoid potential harmful pro-oxidant effects.

Synergistic effect of Scutellaria baicalensis and grape seed proanthocyanidins on scavenging reactive oxygen species in vitro.

Scutellaria baicalensis (SbE) is a commonly used Chinese herb medicine and grape seed proanthocyanidins is a popular herbal supplement in the United States. Both herbs have been shown to possess potent antioxidant effects. Using an in vitro model to produce the reactive oxygen species (ROS) generation (H2O2/FeSO4 for hydroxyl radicals, xanthine/xanthine oxidase for suproxide), we observed that Scutellaria baicalensis and grape seed proanthocyanidins acted synergistically to scavenge ROS. Our data suggest that a combination of these two herbs can potentially enhance their antioxidant efficacy, allowing lower dosages of each drug to be used. This has the advantage of avoiding possible side effects that may arise when higher doses of a single herb are used in an attempt to achieve a maximum degree of antioxidant activity.

Do emergency nurses and doctors agree in their triage assessment of dyspneic patients?

OBJECTIVES: This study investigated the inter-observer agreement (IOA) between doctors and nurses on triaging adult ED dyspneic patients. METHODS: This was a prospective observational study comparing eight trained ED nurses with doctors. Each patient was assessed by a nurse and two doctors (1 and 2) who decided on four-point Patient Acuity Category (PAC) and triage management steps. The primary outcome was the proportion of resuscitation room escalations from consult. Secondary outcomes included proportions and IOA of assigned PAC and steps in triage management. The investigators reported IOA as the k statistic (95% CIs) and percent agreement. DATA/RESULTS: There were 22/302 (7.3%) escalations; one from clinical deterioration. Proportions of assigned PAC status by nurses, Drs 1 and 2 were: PAC 1: 20.2-24.2%; PAC 2: 71.5-72.8%; PAC 3: 4.3-7.0%; PAC 4: 0.0-0.7%. The IOA was at least fair to moderate [k: 0.33 (0.22-0.43) to 1.00] in all steps of management except for electrocardiogram [k: 0.19 (0.10-0.27) to 0.45 (0.35-0.55)] ordering. The percent agreement ranged from 81 to 100% for all management steps except for chest Xray (66-73%) and electrocardiogram (61-71%) ordering. CONCLUSION: Trained ED nurses were safe and managed adult dyspneic patients as well as doctors at triage.

Profiling acute presenting symptoms of geriatric patients attending an urban hospital emergency department.

OBJECTIVE: To study the profile of geriatric patients warded to the emergency department (ED) of an Asian acute care general hospital and determine if they are 'more ill', more likely to have atypical presentations and have a higher utilisation of healthcare resources when compared to a younger group of patients. MATERIALS AND METHODS: This is a retrospective chart review of consecutive patients aged 45 years and above presenting to the study ED over a period of 4 weeks from 4 June 2006 to 1 July 2006. The following data were obtained: (i) demographics, (ii) mode of arrival and triage acuity, (iii) presence of co-morbidities, (iv) investigations ordered in the ED, (v) clinical symptoms and diagnoses, (vi) disposition, (vii) length of hospital stay, (viii) injuries and outcomes of elderly fallers. The study population was divided into 2 groups--a study group with patients aged 65 years and above, and a control group with patients aged 45 to 64. RESULTS: There were 2847 patients in the study group and these were compared against 2875 in the control group. Those 65 years and above had greater representation in the ED population compared to the general population. In the study group, the proportion of females, the number arriving by ambulance and the likelihood of having a higher triage acuity increased with age. The elderly had higher rates of co-morbidities. They also had a higher resource utilisation rate. Falls was their commonest presenting complaint. CONCLUSION: It is crucial that EDs recognise the special needs of elderly patients due to the growing ageing population. Healthcare policy makers when allocating resources should take into account the profile of elderly patients presenting to an ED and their resource utilisation.

Hypothermia-induced cardioprotection using extended ischemia and early reperfusion cooling.

Optimal timing of therapeutic hypothermia for cardiac ischemia is unknown. Our prior work suggests that ischemia with rapid reperfusion (I/R) in cardiomyocytes can be more damaging than prolonged ischemia alone. Also, these cardiomyocytes demonstrate protein kinase C (PKC) activation and nitric oxide (NO) signaling that confer protection against I/R injury. Thus we hypothesized that hypothermia will protect most using extended ischemia and early reperfusion cooling and is mediated via PKC and NO synthase (NOS). Chick cardiomyocytes were exposed to an established model of 1-h ischemia/3-h reperfusion, and the same field of initially contracting cells was monitored for viability and NO generation. Normothermic I/R resulted in 49.7 +/- 3.4% cell death. Hypothermia induction to 25 degrees C was most protective (14.3 +/- 0.6% death, P < 0.001 vs. I/R control) when instituted during extended ischemia and early reperfusion, compared with induction after reperfusion (22.4 +/- 2.9% death). Protection was completely lost if onset of cooling was delayed by 15 min of reperfusion (45.0 +/- 8.2% death). Extended ischemia/early reperfusion cooling was associated with increased and sustained NO generation at reperfusion and decreased caspase-3 activation. The NOS inhibitor N(omega)-nitro-L-arginine methyl ester (200 microM) reversed these changes and abrogated hypothermia protection. In addition, the PKCepsilon inhibitor myr-PKCepsilon v1-2 (5 microM) also reversed NO production and hypothermia protection. In conclusion, therapeutic hypothermia initiated during extended ischemia/early reperfusion optimally protects cardiomyocytes from I/R injury. Such protection appears to be mediated by increased NO generation via activation of protein kinase Cepsilon; nitric oxide synthase.

Transient and partial mitochondrial inhibition for the treatment of postresuscitation injury: getting it just right.

OBJECTIVE: Within minutes of reperfusing ischemic cardiomyocytes, oxidant stress dramatically increases and is associated with postresuscitation injury. Because mitochondria produce deleterious oxidants and useful metabolic substrates, utilization of electron transport chain inhibitors against reperfusion injury, though promising, must not overly compromise recovery of mitochondrial function. This study sought to further characterize the oxidant source at reperfusion and develop a strategy for therapeutic intervention by manipulation of dose, duration, and the degree of reversibility of mitochondrial inhibition. DESIGN: Comparative laboratory investigation. SETTING: Laboratory of a research university. SUBJECTS: Embryonic chick cardiomyocytes. INTERVENTIONS: Synchronously contracting chick cardiomyocytes were exposed to 1 hr of simulated ischemia and 3 hrs of reperfusion and were monitored for cell viability (propidium iodide) and oxidant generation (dichlorofluorescein). Inhibitors were administered either all course or for the first 15 mins of reperfusion. MEASUREMENTS AND MAIN RESULTS: : Application of diethyldithiocarbamic acid, 2-anthracene-carboxylic acid (rhein tech), and alpha-nicotinamide adenine dinucleotide dehydrogenase (NADH) demonstrated attenuation of the oxidant burst. In addition, diethyldithiocarbamic acid (1 mM), rhein tech (0.1 microM), and alpha-NADH (20 microM) significantly attenuated cell death from a control of 49.7% +/- 6.7% to 15.7% +/- 4.7% (n = 5, p < .01), 26.1% +/- 4.1% (n = 5, p < .01), and 13.8% +/- 1.3% (n = 5, p < .001), respectively. All doses of stigmatellin attenuated reactive oxygen species, but only a 2-20 nM dose during the first 15 mins of reperfusion abrogated cell death from 53.8% +/- 3.5% to 10.8% +/- 2.9% (n = 5, p < .001). Increased doses and durations of stigmatellin abolished reactive oxygen species but augmented injury. Although rotenone (5 microM) attenuated reactive oxygen species, no dose or duration of exposure that ameliorated cell death was found. CONCLUSIONS: Early events of reperfusion are marked by rapid mitochondrial oxidant generation and postresuscitation injury. Electron transport chain blockade provides an effective method of attenuating reactive oxygen species. However, inhibitor administration should be both transient and reversible to necessitate cardioprotection and successful metabolic recovery.