A recycling quality improvement project to engage the multidisciplinary team with sustainability efforts.

BACKGROUND: The provision of healthcare itself contributes to the global health crisis of the climate emergency. As critical care is a carbon hotspot within hospital medicine, healthcare professionals must take collaborative action to mitigate the environmental impact of the sector. AIMS: The purpose of the project was to engage the critical care multidisciplinary team with sustainability efforts, through involvement in a recycling Quality Improvement Project (QIP). The central QIP aimed to increase the recycling rates of single-use plastic enteral feed bottles in the intensive care unit (ICU) over a 31-day period. STUDY DESIGN: A recycling 'challenge month' was launched, and staff opinion was surveyed before and after this intervention. RESULTS: The QIP demonstrated an increase in feed bottle recycling by 53.2%, representing a carbon-saving effect of up to 6.02 kg CO2e for the intervention month. Following the central QIP, all survey respondents felt encouraged to consider their ICU's environmental impact. CONCLUSIONS: Simple successful QIPs can act as a springboard to engage the staff body with sustainability initiatives and ignite wider conversation and consideration of the climate emergency in daily practice. RELEVANCE FOR CLINICAL PRACTICE: Effective recycling constitutes only one element of responsible environmental stewardship, but authors discuss that it is an effective focus for QIPs. To maximize impact and success within critical care, nursing involvement in leading and participation is essential.

Geriatric Assessment Is Associated With Reduced Mortality at 1 Year for Older Adults Admitted to a Major Trauma Center: A Prospective Observational Study.

OBJECTIVE: To evaluate the effect of geriatrician review on 1-year mortality in older adults admitted with trauma. BACKGROUND: Comprehensive geriatric assessment (CGA) has been associated with improved outcomes in older adults with hip fracture, but has not been evaluated in a broader trauma population. METHODS: Trauma patients aged ≥ 65years admitted to an English Major Trauma Centre between November 2018 and September 2019 were included. Patients were divided into 3 cohorts: no geriatric assessment, reactive geriatric assessment, and proactive CGA. The primary outcome was time to mortality, secondary outcomes were time to discharge and frequency of complications. Analyses were adjusted for factors known to be associated with outcomes including age, frailty, injury severity, and complications. RESULTS: Five hundred eighty-five patients were included (no geriatric assessment = 125; reactive geriatric assessment = 134; proactive CGA = 326): median age was 81 years (IQR 74-88); 326 (55.7%) were women; 297 (50.8%) were living with frailty (Clinical Frailty Scale ≥5). Median Injury Severity Score was 13 (IQR9-25). At 1-year follow-up, 147 (25.1%) patients had died. In multivariate analysis, both types of geriatric assessment were associated with reduced mortality [reactive aHR = 0.31, 95% CI 0.18-0.53; proactive adjusted hazard ratio (aHR) = 0.41, 95% CI 0.26-0.64]. There was no association between either type of geriatric assessment and length of stay (reactive aHR = 0.84, 95% CI 0.62-1.15; proactive aHR = 0.80, 95% CI 0.63-1.02). CONCLUSIONS: Geriatrician assessment is associated with reduced mortality in older adults admitted following trauma. Further research should focus on defining optimal models of geriatrician intervention.

The Clinical Frailty Scale predicts adverse outcome in older people admitted to a UK major trauma centre.

BACKGROUND: Frailty assessment using the Clinical Frailty Scale (CFS) has been mandated for older people admitted to English major trauma centres (MTC) since April 2019. Little evidence is available as to CFS-associated outcomes in the trauma population. OBJECTIVE: To investigate post-injury outcomes stratified by the CFS. METHODS: A single centre prospective observational cohort study was undertaken. CFS was prospectively assigned to patients ≥ 65 years old admitted to the MTC over a 5-month period. Primary outcome was 30-day post-injury mortality. Secondary outcomes were length of hospital stay, complications and discharge level of care. RESULTS: In 300 patients median age was 82; 146 (47%) were frail (CFS 5-9) and 28 (9.3%) severely frail (CFS 7-9). Frail patients had lower injury severity scores (median 9 vs 16) but greater 30-day mortality (CFS 5-6 odds ratio (OR) 5.68; P < 0.01; CFS 7-9 OR 10.38; P < 0.01). Frailty was associated with delirium (29.5% vs 17.5%; P = 0.02), but not complication rate (50.7% vs 41.6%; P = 0.20) or length of hospital stay (13 vs 11 days; P = 0.35). Mild to moderate frailty was associated with increased care level at discharge (OR 2.31; P < 0.01). CONCLUSIONS: Frailty is an independent predictor of 30-day mortality, inpatient delirium and increased care level at discharge in older people experiencing trauma. CFS can therefore be used to identify those at risk of poor outcome who may benefit from comprehensive geriatric review, validating its inclusion in the 2019 best practice tariff for major trauma.

An observational study evaluating the demand of major trauma on different surgical specialities in a UK Major Trauma Centre.

INTRODUCTION: Major Trauma Centres (MTCs) should ideally have all key surgical specialities on site. This may not always be the case since trauma is only one factor influencing speciality location. The implications of this can only be understood when the demands on specific specialities are established and this is not well documented. We investigated surgical speciality demand by quantifying the frequency and urgency of surgical trauma interventions. PATIENTS AND METHODS: Data on adult trauma admissions for a UK MTC were retrieved from the UK Trauma Audit and Research Network for a 2-year period and analysed to establish the frequency and urgency of surgical interventions. RESULTS: Of 1285 trauma patients with an ISS > 15 presenting in the study year period 713 (55.5%) required surgery. Neurosurgical (59.9%) and orthopaedic (55.1%) operations were most frequent. Cardiothoracic, general surgery, plastic surgery and maxillofacial operations were required infrequently. General surgery was commonly needed urgently, 45% within 4 h of MTC arrival. Urgency was also common in interventional radiology and vascular surgery. Cardiothoracic interventions were mainly urgent interventions (thoracotomy 1/3) and less urgent (rib fixation 2/3). DISCUSSION: Neurosurgery and orthopaedic surgery are key on-site trauma specialities and required frequently. General surgery, interventional radiology and cardiothoracic interventions are required less frequently but often urgently. This confirms a need for MTC on-site capability and possibly training to maintain competency in occasional trauma operators, particularly in general surgery. Maxillofacial surgery, ENT and urology are required neither frequently nor urgently and on-site presence may be less critical. CONCLUSION: Demand for specific surgical specialities was reported in a cohort of UK trauma patients. This confirmed the need for rapid on-site capability in key specialities and highlights possible training requirements for occasional trauma operators in specialities with low frequency but high urgency.

Successful non-operative management of haemodynamically unstable traumatic splenic injuries: 4-year case series in a UK major trauma centre.

PURPOSE: Management of traumatic splenic injury may be operative or non-operative (including embolization and conservative management). Traditionally, haemodynamic instability has been an indication for operative intervention. We aimed to report our experience of managing traumatic splenic injury at a regional major trauma centre in the UK over a 4-year period, with a particular focus on the non-operative management (NOM) of haemodynamically unstable patients. METHODS: All patients with splenic injuries admitted to North Bristol NHS Trust from April 2012 to March 2016 were included. Patients were classified for analyses by injury severity (low or high grade), haemodynamic instability (defined as a reverse shock index < 1) and management category (operative or non-operative). RESULTS: 106 patients were included. Overall 85.8% of patients received NOM: 79.2% conservative and 6.6% interventional radiology. Two patients (2.4%) managed conservatively required further intervention. Haemodynamically stable and unstable patients were equally likely to receive NOM (89.7 and 81.3% respectively, p = 1). All unstable patients with low-grade injuries were managed conservatively and only one (2.7%) required further intervention. Two unstable patients with high-grade injuries (28.6%) underwent NOM successfully. CONCLUSIONS: These data support the safe application of non-operative management to haemodynamically unstable patients with traumatic splenic injury, particularly in those with low-grade injuries. Additional prospective work is required to define the subgroup of patients for whom this is appropriate and to determine the long-term outcomes of NOM.

Evaluating the impact of cycle helmet use on severe traumatic brain injury and death in a national cohort of over 11000 pedal cyclists: a retrospective study from the NHS England Trauma Audit and Research Network dataset.

OBJECTIVES: In the last 10 years there has been a significant increase in cycle traffic in the UK, with an associated increase in the overall number of cycling injuries. Despite this, and the significant media, political and public health debate into this issue, there remains an absence of studies from the UK assessing the impact of helmet use on rates of serious injury presenting to the National Health Service (NHS) in cyclists. SETTING: The NHS England Trauma Audit and Research Network (TARN) Database was interrogated to identify all adult (≥16 years) patients presenting to hospital with cycling-related major injuries, during a period from 14 March 2012 to 30 September 2017 (the last date for which a validated dataset was available). PARTICIPANTS: 11 patients met inclusion criteria. Data on the use of cycling helmets were available in 6621 patients. OUTCOME MEASURES: TARN injury descriptors were used to compare patterns of injury, care and mortality in helmeted versus non-helmeted cohorts. RESULTS: Data on cycle helmet use were available for 6621 of the 11 192 cycle-related injuries entered onto the TARN Database in the 66 months of this study (93 excluded as not pedal cyclists). There was a significantly higher crude 30-day mortality in un-helmeted cyclists 5.6% (4.8%-6.6%) versus helmeted cyclists 1.8% (1.4%-2.2%) (p<0.001). Cycle helmet use was also associated with a reduction in severe traumatic brain injury (TBI) 19.1% (780, 18.0%-20.4%) versus 47.6% (1211, 45.6%-49.5%) (p<0.001), intensive care unit requirement 19.6% (797, 18.4%-20.8%) versus 27.1% (691, 25.4%-28.9%) (p<0.001) and neurosurgical intervention 2.5% (103, 2.1%-3.1%) versus 8.5% (217, 7.5%-9.7%) (p<0.001). There was a statistically significant increase in chest, spinal, upper and lower limb injury in the helmeted group in comparison to the un-helmeted group (all p<0.001), though in a subsequent analysis of these anatomical injury patterns, those cyclists wearing helmets were still found to have lower rates of TBI. In reviewing TARN injury codes for specific TBI and facial injuries, there was a highly significant decrease in rates of impact injury between cyclists wearing helmets and those not. CONCLUSIONS: This study suggests that there is a significant correlation between use of cycle helmets and reduction in adjusted mortality and morbidity associated with TBI and facial injury.

Systemic Acyl-CoA:cholesterol acyltransferase inhibition reduces inflammation and improves vascular function in hypercholesterolemia.

BACKGROUND: Circulating lipids may initiate and progress atherosclerosis by causing vascular inflammation. Monocytes and tissue macrophages are involved and regulate lipid metabolism in the vascular wall through acetylation of cholesterol by acyl-CoA:cholesterol acyltransferase (ACAT). ACAT inhibition reduces atherosclerosis in animal models by mechanisms that may be independent of their effects on circulating lipids. Because endothelial dysfunction is an important factor in atherosclerosis, we tested the hypothesis that systemic ACAT inhibition would improve endothelial function in hypercholesterolemic humans and assessed its effects on circulating lipids and markers of systemic inflammation. METHODS AND RESULTS: We studied 21 hypercholesterolemic subjects in a double-blind, randomized-crossover, placebo-controlled trial with assessments of circulating lipids, markers of inflammation, resistance-vessel endothelial function (with venous occlusion plethysmography), and conduit-vessel vasoreactivity (brachial artery flow-mediated dilation at baseline and after placebo or treatment with avasimibe 750 mg QDS for 8 weeks. There was a small change in total cholesterol with treatment (326+/-25 to 311+/-22 mg/dL, P=0.04). Circulating tumor necrosis factor-alpha was significantly reduced (4.0+/-0.3 to 3.6+/-0.2 pg/mL, P=0.02); resistance vessel responses to acetylcholine, bradykinin, and verapamil were significantly enhanced; and responses to nitroglycerin and conduit-vessel vasoreactivity were unchanged after ACAT inhibition. CONCLUSIONS: Systemic ACAT inhibition reduces circulating tumor necrosis factor-alpha levels in hypercholesterolemic subjects and improves resistance-vessel endothelial function, with small effects on circulating cholesterol. This may be a novel therapeutic strategy to target vascular inflammation and endothelial dysfunction in atherosclerosis.

Prevention of inflammation-induced endothelial dysfunction: a novel vasculo-protective action of aspirin.

BACKGROUND: Inflammation and infection may initiate and promote atherosclerosis or its complications by adverse effects on the vascular endothelium. The mechanisms by which aspirin reduces cardiovascular risk might involve anti-inflammatory actions or direct effects on the endothelium in addition to its antiplatelet action. We investigated the role of aspirin in modulating endothelial dysfunction induced by an experimental inflammatory stimulus. METHODS AND RESULTS: An inflammatory response was generated in healthy volunteers by Salmonella typhi vaccination. Venous occlusion plethysmography was used to assess resistance vessel responses (16 hours before and 8 hours after vaccination) to the endothelium-dependent dilator bradykinin (BK) and the endothelium-independent dilator glyceryl-trinitrate (GTN). Twelve subjects were randomized to receive either aspirin 1.2 g orally or placebo 2 hours before vaccination. After vaccination alone there was suppression of the response to BK in the placebo group (P=0.01), with no change in response to GTN. In the aspirin group there was no change in the response to either BK or GTN after vaccination. Aspirin treatment prevented vaccine-induced elevation of interleukin-1 receptor antagonist but enhanced the generation of tumor necrosis factor-alpha compared with placebo. In an additional 5 individuals, local intrabrachial aspirin (10 mg/min for 15 minutes) failed to restore responses to BK after vaccination. CONCLUSIONS: Experimental inflammation produces endothelial dysfunction, which can be prevented by pretreatment with aspirin. Locally administered aspirin does not reverse vaccine-induced endothelial dysfunction once established. The protective effects of aspirin on inflammation-induced endothelial dysfunction may be through modulation of the cytokine cascade.

Microscopic thymoma and parathyroid adenoma: rare combination of two distinct pathologies.

While there is an intimate anatomical and embryological relationship between the inferior parathyroid gland and thymus, concurrent pathology is rare. Three cases have been reported in the literature of a parathyroid adenoma in conjunction with a thymoma. We present a case report of a 60-year-old female with a past medical history of hypercalcemia subsequently found to have primary hyperparathyroidism. Sestamibi scan of the parathyroid revealed increased uptake in the lower left neck consistent with a parathyroid adenoma. A standard transverse neck incision was performed with exploration of the lower left thyroid pole. Further dissection was required to identify the parathyroid gland which was intimately associated with thymic tissue in the superior mediastinum. Both thymic tissue and the parathyroid gland were sent for pathology. Permanent pathology subsequently revealed a parathyroid adenoma with an incidental spindle cell thymoma. The embryological relationship of the inferior parathyroid glands and the thymus is well known as both are derived from the third branchial pouch. However, there are only 3 other previous reports of parathyroid adenoma associated with a thymoma in the current literature. Interestingly, up to 16% of parathyroid adenomas are found in the mediastinum, and the current literature states the incidence of thymoma varies from 10-42%.