A pioneer in the management of Australian psychiatric services: Dr Richard Greenup (1803-1866).

OBJECTIVES: To provide a brief biography of Dr Richard Greenup and to explore the legacy he has left to one of Australia's longest operating psychiatric services. METHODS: This history was obtained by consulting staff working within Cumberland Hospital, New South Wales and by examining primary and secondary sources. RESULTS: Greenup was the second surgeon superintendent of 'The Parramatta Lunatic Asylum' from 1852 until 1866 when he was fatally stabbed with a pair of scissors by a patient. Greenup was involved in establishing The University of Sydney and advocated for expanded and improved services for people diagnosed with mental disorders. CONCLUSIONS: Greenup recognised the needs of the mentally ill and sought to address similar social and demographic determinants of health to those that we face today. The challenges he faced, and his tragic end remind us of the importance of delivering patient-centred care whilst being mindful of associated risks.

Impact of a Streamlined Trauma-Focused Smartphone Application on Protocol Compliance and Delivery of Care.

BACKGROUND: In November 2015, an institution-specific mobile application (app) was created to provide rapid access to trauma protocols. The app was tested, and the results suggested that the app was difficult to use as it linked to web-based databases. In June 2018, the app was redesigned with protocol infographics and algorithms that are available offline, eliminating the need to scroll through web pages. We tested the redesigned app's ability to provide information quickly, in a user-friendly manner. METHODS: This was a prospective, experimental analysis of a streamlined, institution-specific trauma app. Participants included general surgery residents, advanced practice providers, and attending trauma surgeons. The primary outcomes of measure were time to complete an exam with trauma scenarios and the number of questions answered correctly. The primary exposure of interest was access to the app during the exam. RESULTS: There were 35 study participants: 17 with the 2018 version of the app to complete the quiz and 18 without app access. The group with access scored higher than those without access (70% versus 50%, P = 0.0005) as well as those with the old version of the app in the 2015 study (70% versus 55%, P = 0.0250). App access eliminated a significant difference in exam scores between residents and attendings that was present without the app. CONCLUSIONS: A mobile app with offline access to protocol infographics and algorithms gives providers access to recommended practices and may improve delivery of trauma care. The app is helpful to residents and helps bridge the knowledge gap between groups when the app is not available. LEVEL OF EVIDENCE: Level III.

Smart Trauma: Improving the Delivery of Evidence-Based Trauma Care.

BACKGROUND: Mobile technology can aid in healthcare decision-making at the point of care. We created a Web-based trauma-specific smartphone application containing links to local protocols and national organization guidelines for trauma providers. We hypothesized that smartphone access to these guidelines would facilitate application of knowledge in a timely fashion. MATERIALS AND METHODS: Trauma providers were randomized to have or not have access to their smartphone during a timed, 10-question examination of trauma scenarios based on Eastern Association for the Surgery of Trauma, Western Trauma Association, and local protocols. Participants were then surveyed regarding their experience with the application. Groups were compared based on time with completion and percentage of correct answers. Subgroup analyses were completed to assess the utility of the application. RESULTS: Of 30 participants, 16 were randomized to smartphone use. Smartphone users took longer to complete the examination than nonusers (9:18 versus 6:36, P = 0.007) but answered a greater proportion of questions correctly (50% versus 40%, P = 0.159). Smartphone users had a higher percentage correct for Eastern Association for the Surgery of Trauma and Western Trauma Association protocol-based questions (78% versus 52%, P = 0.027; 70% versus 39%, P = 0.011), but no difference for local protocol-based questions (29% versus 37%, P = 0.48). Smartphone users who reported recent application use had the longest time to completion (11:44, P = 0.023) but the highest percentage correct (60%, P = 0.03). CONCLUSIONS: Smartphone use among those familiar with our trauma application resulted in the highest percentage correct but increased times to completion. The application interface should be streamlined, and providers educated to improve usage and reduce time to access information.

Splenic Embolization After Trauma: An Opportunity to Improve Best Immunization Practices.

BACKGROUND: The spleen is the second most commonly injured solid organ during blunt abdominal trauma. Although total splenectomy is frequently performed for injury, splenic rupture can also be managed by splenic embolization. For these patients, current Advisory Committee on Immunization Practices (ACIP) recommendations indicate that if 50% or more of the splenic mass is lost, patients should be treated as though they are asplenic. We have previously demonstrated that compliance with ACIP guidelines regarding immunization after splenectomy is poor. Compliance with vaccination in the setting of splenic embolization for trauma is unknown and we hypothesized patients would not receive the recommended immunizations. MATERIALS AND METHODS: All admissions at our level 1 trauma center requiring splenic embolization secondary to traumatic injury between January 1, 2010, and November 1, 2015, were reviewed. Demographic and injury data, dates and imaging of splenic embolizations, immunization documentation, subsequent vaccination boosters received, and outcomes were collected from the medical record. The proportion of spleen embolized was estimated by review of angiographic imaging using an established method. RESULTS: Nine thousand nine hundred sixty-five trauma patients were admitted during the period studied. Nineteen patients met inclusion and exclusion criteria. Median age of the patient population was 35 y, 85% were male, and median injury severity score was 28. Of these, 15 patients underwent a splenic embolization, in which 50% or more of their splenic mass was lost through embolization. Eight patients received at least one immunization before discharge. Six received initial immunizations against Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae, while three received only the initial immunization against S pneumoniae. None of the 15 patients received any ACIP-recommended booster. Of the four patients having less than 50% of their spleen embolized, three wrongly received immunization against encapsulated organisms before hospital discharge. CONCLUSIONS: Trauma patients undergoing splenic embolization at our institution receive postsplenectomy immunizations incorrectly and had no recorded booster vaccines. We speculate that this is common among the U.S. trauma centers. Review of immunization practices in our trauma and nontrauma patient populations is underway in our health system to improve the care of these patients, and our experience may serve as a guide for other centers to reduce complications associated with asplenia.

Underreporting of Concussions and Concussion-Like Symptoms in Female High School Athletes.

Underreporting of concussions and concussion-like symptoms in athletes continues to be a serious medical concern and research focus. Despite mounting worry, little evidence exists examining incidence of underreporting and documenting characteristics of head injury in female athletes participating in high school sports. This study examined the self-reporting behaviors of female high school athletes. Seventy-seven athletes participated, representing 14 high school sports. Nearly half of the athletes (31 participants) reported a suspected concussion, with 10 of the 31 athletes refraining from reporting symptoms to training staff after injury. Only 66% reported receiving concussion education. Concussion education appeared to have no relationship with diagnosed concussion rates in athletes, removing athletes from play, or follow-up medical care after injury. In conclusion, female high school athletes underreport signs and symptoms of concussions. Concussion education should occur at higher rates among female athletes to influence reporting behaviors.

Developing a Comprehensive, Interdisciplinary Concussion Program.

There has been a growing trend of local and national coverage of and interest in concussion injuries over the past 2 decades. Increasing public concern over potential catastrophic and unknown long-term effects of sports-related concussion injuries has led to an acknowledgment of the strong public health need for addressing all concussion injuries, regardless of mechanism of injury. In efforts to address this need for concussion prevention and management, both in sports and nonsports, The University of Kansas Health System initiated the interdisciplinary Center for Concussion Management program in 2012. The program was created as a virtual clinic concept and includes voluntary participation from various providers across the institution, limited budget, and space obstacles. Since its inception, the program has continued to operate as its initial design of a multidisciplinary team model outside the sole ownership of 1 department, and has expanded to include education and outreach to local and regional schools and groups.

An opportunity for improvement in trauma care: 8-week booster vaccination adherence among patients after trauma splenectomy.

BACKGROUND: Splenectomies are common after abdominal trauma, and measures must be taken to prevent infection, namely, the administration of available conjugate vaccinations against encapsulated organisms. While initial immunization is frequently completed prior to discharge, the Advisory Council on Immunization Practices recommends administration of an 8-week vaccination booster against S. pneumoniae, and compliance with this practice is unknown. We hypothesized that patients undergoing splenectomy for trauma would not routinely receive the recommended immunization and subsequent booster. METHODS: All trauma admissions at our center who required splenectomy secondary to trauma between 2010 and 2015 were included. Demographic and injury data, splenectomy dates, immunization documentation, subsequent boosters received, and outcomes were collected from the medical record. RESULTS: Of the 9,965 patients observed, 44 patients underwent splenectomy, with 31 patients meeting inclusion/exclusion criteria. Two patients received subsequent boosters during office or hospital visits; however, no patient received any booster within Advisory Council on Immunization Practices' recommended timeframe with median time to subsequent boosters of 22 months. Seven patients have had a subsequent admission for infection or sepsis, with one presenting with S. pneumoniae meningitis. None of the patients subsequently admitted for infection or sepsis had received boosters. CONCLUSION: While trauma patients at our institution receive recommended immunizations after splenectomy prior to discharge, they receive boosters at a suboptimal rate and beyond the advised timeframe. We speculate that this phenomenon is widespread in the American trauma population. These data suggest a need for improved patient and provider education and coordination with primary care practitioners to ensure ideal defense against infectious complications.

The modified rapid emergency medicine score: A novel trauma triage tool to predict in-hospital mortality.

BACKGROUND: Trauma systems currently rely on imperfect and subjective tools to prioritize responses and resources, thus there is a critical need to develop a more accurate trauma severity score. Our objective was to modify the Rapid Emergency Medicine (REMS) Score for the trauma population and test its accuracy as a predictor of in-hospital mortality when compared to other currently used scores, including the Revised Trauma Score (RTS), the Injury Severity Score (ISS), the "Mechanism, Glasgow Coma Scale, Age and Arterial Pressure" (MGAP) score, and the Shock Index (SI) score. METHODS: The two-part study design involved both a modification step and a validation step. The first step incorporated a retrospective analysis of a local trauma database (3680 patients) where three components of REMS were modified to more accurately represent the trauma population. Using clinical judgment and goodness-of-fit tests, systolic blood pressure was substituted for mean arterial pressure, the weighting of age was reduced, and the weighting of Glasgow Coma Scale was increased. The second part comprised validating the new modified REMS (mREMS) score retrospectively on a U.S. National Trauma Databank (NTDB) that included 429,711 patients admitted with trauma in 2012. The discriminate power of mREMS was compared to other trauma scores using the area under the receiver operating characteristic (AUC) curve. RESULTS: Overall the mREMS score with an AUC of 0.967 (95% CI: 0.963-0.971) was demonstrated to be higher than RTS (AUC 0.959 [95% CI: 0.955-0.964]), ISS (AUC 0.780 [95% CI 0.770-0.791]), MGAP (AUC 0.964 [95% CI: 0.959-0.968]), and SI (AUC 0.670 [95% CI: 0.650-0.690]) in predicting in-hospital mortality on the NTDB. CONCLUSION: In the trauma population, mREMS is an accurate predictor of in-hospital mortality, outperforming other used scores. Simple and objective, mREMS may hold value in the pre-hospital and emergency department setting in order to guide trauma team responses.

Posterior paramedian subrhomboidal analgesia versus thoracic epidural analgesia for pain control in patients with multiple rib fractures.

BACKGROUND: Rib fractures are common in trauma admissions and are associated with an increased risk of pulmonary complications, intensive care unit admissions, and mortality. Providing adequate pain control in patients with multiple rib fractures decreases the risk of adverse events. Thoracic epidural analgesia is currently the preferred method for pain control. This study compared outcomes in patients with multiple acute rib fractures treated with posterior paramedian subrhomboidal (PoPS) analgesia versus thoracic epidural analgesia (TEA). METHODS: This prospective study included 30 patients with three or more acute rib fractures admitted to a Level I trauma center. Thoracic epidural analgesia or PoPS catheters were placed, and local anesthesia was infused. Data were collected including patients' pain level, adjunct morphine equivalent use, adverse events, length of stay, lung volumes, and discharge disposition. Nonparametric tests were used and two-sided p < 0.05 were considered statistically significant. RESULTS: Nineteen (63%) of 30 patients received TEA and 11 (37%) of 30 patients received PoPS. Pain rating was lower in the PoPS group (2.5 vs. 5; p = 0.03) after initial placement. Overall, there was no other statistically significant difference in pain control or use of oral morphine adjuncts between the groups. Hypotension occurred in eight patients, 75% with TEA and only 25% with PoPS. No difference was found in adverse events, length of stay, lung volumes, or discharge disposition. CONCLUSION: In patients with rib fractures, PoPS analgesia may provide pain control equivalent to TEA while being less invasive and more readily placed by a variety of hospital staff. This pilot study is limited by its small sample size, and therefore additional studies are needed to prove equivalence of PoPS compared to TEA. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Comparison of tissue dosimetry in the mouse following chronic exposure to arsenic compounds.

Several chronic bioassays have been conducted in multiple strains of mice in which various concentrations of arsenate or arsenite were administered in the drinking water without a tumorigenic effect. However, one study (Ng et al., 1999) reported a significant increase in tumor incidence in C57Bl/6J mice exposed to arsenic in their drinking water throughout their lifetime, with no tumors reported in controls. A physiologically based pharmacokinetic model for arsenic in the mouse has previously been developed (Gentry et al., 2004) to investigate potential differences in tissue dosimetry of arsenic species across various strains of mice. Initial results indicated no significant differences in blood, liver, or urine dosimetry in B6C3F1 and C57Bl/6 mice for acute or subchronic exposure. The current work was conducted to compare model-predicted estimates of tissue dosimetry to additional kinetic information from the (C57Bl/6 xCBA)F1 and TgAc mouse. The results from the current modeling indicate that the pharmacokinetic parameters derived based on information in the B6C3F1 mouse adequately describe the measured concentrations in the blood/plasma, liver, and urine of both the (C57Bl/6 x CBA)F1 and TgAc mouse, providing further support that the differences in response observed in the chronic bioassays are not related to strain-specific differences in pharmacokinetics. One significant finding was that no increases in skin or lung concentrations of arsenic species in the (C57Bl/6 x CBA)F1 strain were observed following administration of low concentrations (0.2 or 2 mg/U of arsenate in the drinking water, even though differences in response in the skin were reported. These data suggest that pharmacodynamic changes may be observed following exposure to arsenic compounds without an observable change in tissue dosimetry. These results provided further indirect support for the existence of inducible arsenic efflux in these tissues.

Analysis of genomic dose-response information on arsenic to inform key events in a mode of action for carcinogenicity.

A comprehensive literature search was conducted to identify information on gene expression changes following exposures to inorganic arsenic compounds. This information was organized by compound, exposure, dose/concentration, species, tissue, and cell type. A concentration-related hierarchy of responses was observed, beginning with changes in gene/protein expression associated with adaptive responses (e.g., preinflammatory responses, delay of apoptosis). Between 0.1 and 10 microM, additional gene/protein expression changes related to oxidative stress, proteotoxicity, inflammation, and proliferative signaling occur along with those related to DNA repair, cell cycle G2/M checkpoint control, and induction of apoptosis. At higher concentrations (10-100 microM), changes in apoptotic genes dominate. Comparisons of primary cell results with those obtained from immortalized or tumor-derived cell lines were also evaluated to determine the extent to which similar responses are observed across cell lines. Although immortalized cells appear to respond similarly to primary cells, caution must be exercised in using gene expression data from tumor-derived cell lines, where inactivation or overexpression of key genes (e.g., p53, Bcl-2) may lead to altered genomic responses. Data from acute in vivo exposures are of limited value for evaluating the dose-response for gene expression, because of the transient, variable, and uncertain nature of tissue exposure in these studies. The available in vitro gene expression data, together with information on the metabolism and protein binding of arsenic compounds, provide evidence of a mode of action for inorganic arsenic carcinogenicity involving interactions with critical proteins, such as those involved in DNA repair, overlaid against a background of chemical stress, including proteotoxicity and depletion of nonprotein sulfhydryls. The inhibition of DNA repair under conditions of toxicity and proliferative pressure may compromise the ability of cells to maintain the integrity of their DNA.

Review and evaluation of the potential impact of age- and gender-specific pharmacokinetic differences on tissue dosimetry.

In standard risk assessment methods for carcinogenic or noncarcinogenic chemicals, quantitative methods for evaluating interindividual variability are not explicitly considered. These differences are currently considered by the use of statistical confidence limits or default uncertainty factors. This investigation consisted of multiple tasks aimed at making quantitative predictions of interindividual differences in susceptibility by using physiologically based pharmacokinetic (PBPK) models. Initially, a systematic, comprehensive review of the literature was conducted to identify any quantitative information related to gender- or age-specific physiological and biochemical factors that could influence susceptibility to chemical exposure. These data were then organized from a pharmacokinetic perspective by process and by chemical class to identify key factors likely to have a significant impact on susceptibility as it relates to internal target tissue dose. Overall, a large number of age- and gender-specific quantitative differences in pharmacokinetic parameters were identified. The majority of these differences were identified between neonates/children and adults, with fewer differences identified between young adults and the elderly. The next phase of this work consists of using PBPK models to develop examples of approaches through the development of case studies. The goal of the case studies is to continue to develop a methodology that incorporates PBPK modeling to assess the likelihood that a chemical or class of chemicals may present an age- or gender-specific risk. The case studies should also demonstrate practical methods for quantitatively incorporating information on age- and gender-specific pharmacokinetic differences in risk assessments for chemicals.