Improving elementary students' knowledge and behavior to prevent traumatic injury: the impact of a behavioral skills training model delivered by aspirational role models.

Trauma is the leading cause of childhood morbidity and mortality annually in the USA, accounting for 11% of deaths, most commonly due to car crashes, suffocation, drowning, and falls. Prevention is paramount for reducing the incidence of these injuries. As an adult level 1 and pediatric level 2 trauma center, there is a commitment to injury prevention through outreach and education. The Safety Ambassadors Program (SAP) was developed as part of this aim. Safety Ambassadors (SA) are high schoolers who teach elementary school students about safety/injury prevention. The curriculum addresses prevalent areas of injury risk: car/pedestrian safety, wheeled sports/helmets, and fall prevention. The study group hypothesized that participation in SAP leads to improved safety knowledge and behaviors and ultimately reduces childhood preventable injuries. Educational material was delivered by high school students (ages 16-18 years old). First and second-grade participants (ages 6-8 years old) completed pre- and post-course exams to assess knowledge (12 questions) and behavior (4 questions). Results were retrospectively reviewed, and pre/post training mean scores were calculated. Scores were calculated based on number of correct answers on pre/post exam. Comparisons were made using the Student t-test. All tests were 2-tailed with significance set at 0.05. Pre- and post-training results were assessed for 2016-2019. Twenty-eight high schools and 37 elementary schools were enrolled in the program with 8832 student participants in SAP. First graders demonstrated significant improvement in safety knowledge (pre 9 (95% CI 8.9-9.2) vs post 9.8 (95%CI 9.6-9.9), (p < 0.01)) and behavior modification (pre 3.2 (95%CI 3.1-3.2) vs post 3.6 (95% CI 3.5-3.6), (p < 0.01)). Similar findings were seen in 2nd graders: safety knowledge (pre 9.6 (95% CI 9.4-9.9) vs post 10.1 (95% CI 9.9-10.2), (p < 0.01)) and behavior (pre 3.3 (95% CI 3.1-3.4) vs post 3.5 (95%CI 3.4-3.6), (p < 0.01)).    Conclusion: SAP is a novel evidence-based educational program delivered to elementary school students by aspirational role models. This model is impactful, relatable, and engaging when provided by participants' older peer mentors. On a local level, it has demonstrated improved safety knowledge and behavior in elementary school students. As trauma is the leading cause of pediatric death and disability, enhanced education may lead to life-saving injury prevention in this vulnerable population. What is Known: • Preventable trauma is the leading cause of pediatric death in the USA and education has contributed to improvements in both safety knowledge and behavior. • The ideal delivery method for injury prevention education in children continues to be under investigation. What is New: • Our data suggest that a peer-based injury prevention model is both an effective education delivery method and easily instituted within existing school systems. • This study supports implementation of peer-based injury prevention programs to improve safety knowledge and practices. • With more widespread institution and research, we hope to ultimately reduce preventable childhood injury.

Whole transcriptome profiling of prospective endomyocardial biopsies reveals prognostic and diagnostic signatures of cardiac allograft rejection.

BACKGROUND: Heart transplantation provides a significant improvement in survival and quality of life for patients with end-stage heart disease, however many recipients experience different levels of graft rejection that can be associated with significant morbidities and mortality. Current clinical standard-of-care for the evaluation of heart transplant acute rejection (AR) consists of routine endomyocardial biopsy (EMB) followed by visual assessment by histopathology for immune infiltration and cardiomyocyte damage. We assessed whether the sensitivity and/or specificity of this process could be improved upon by adding RNA sequencing (RNA-seq) of EMBs coupled with histopathological interpretation. METHODS: Up to 6 standard-of-care, or for-cause EMBs, were collected from 26 heart transplant recipients from the prospective observational Clinical Trials of Transplantation (CTOT)-03 study, during the first 12-months post-transplant and subjected to RNA-seq (n = 125 EMBs total). Differential expression and random-forest-based machine learning were applied to develop signatures for classification and prognostication. RESULTS: Leveraging the unique longitudinal nature of this study, we show that transcriptional hallmarks for significant rejection events occur months before the actual event and are not visible using traditional histopathology. Using this information, we identified a prognostic signature for 0R/1R biopsies that with 90% accuracy can predict whether the next biopsy will be 2R/3R. CONCLUSIONS: RNA-seq-based molecular characterization of EMBs shows significant promise for the early detection of cardiac allograft rejection.

A structural explanation for the mechanism and specificity of plant branching enzymes I and IIb.

Branching enzymes (BEs) are essential in the biosynthesis of starch and glycogen and play critical roles in determining the fine structure of these polymers. The substrates of these BEs are long carbohydrate chains that interact with these enzymes via multiple binding sites on the enzyme's surface. By controlling the branched-chain length distribution, BEs can mediate the physiological properties of starch and glycogen moieties; however, the mechanism and structural determinants of this specificity remain mysterious. In this study, we identify a large dodecaose binding surface on rice BE I (BEI) that reaches from the outside of the active site to the active site of the enzyme. Mutagenesis activity assays confirm the importance of this binding site in enzyme catalysis, from which we conclude that it is likely the acceptor chain binding site. Comparison of the structures of BE from Cyanothece and BE1 from rice allowed us to model the location of the donor-binding site. We also identified two loops that likely interact with the donor chain and whose sequences diverge between plant BE1, which tends to transfer longer chains, and BEIIb, which transfers exclusively much shorter chains. When the sequences of these loops were swapped with the BEIIb sequence, rice BE1 also became a short-chain transferring enzyme, demonstrating the key role these loops play in specificity. Taken together, these results provide a more complete picture of the structure, selectivity, and activity of BEs.

The Utility of Lower Extremity Screening Duplex for the Detection of Deep Vein Thrombosis in Trauma.

BACKGROUND: Trauma patients are high-risk for venous thromboembolism (VTE). Lower extremity screening duplex ultrasonography (LESDUS) is controversial and not standardized for early VTE diagnosis. By implementing risk stratification and selective screening, we aim to optimize resource utilization. MATERIALS AND METHODS: A retrospective review were conducted at a Level-1 Trauma Center, January 2015-October 2019. LESDUS was performed within 72-h of presentation, then weekly. Demographics, VTE data, and outcomes were collected from the trauma registry. Risk assessment profile (RAP) score was calculated based on collected data. RESULTS: Of 5,645 patients included, 2,813 (49.8%) were screened for lower extremity deep vein thrombosis (LEDVT). Of 187 patients with LEDVT, 154 were diagnosed on LESDUS, 18 after negative LESDUS, and 15 in unscreened patients. Patients with VTE were older (61y versus 55, P < 0.01), more often male (70.9% versus 29.1%, P = 0.03), had higher ISS (16 versus 10, P < 0.01), longer hospital length of stay (LOS) (11.5 d versus 3, P < 0.01), longer ICU LOS (4.5 d versus 1, P < 0.01), and increased mortality (9.1% versus 4.3%, P = 0.01). RAP was higher in VTE patients versus those without (nine versus three, P < 0.01). RAP ≥8 was 62.5% sensitive and 70.4% specific for VTE. Chemoprophylaxis delay also correlated with increased VTE (OR = 1.48, 95% CI = 1.03-2.12). CONCLUSIONS: VTE remains a significant complication in trauma patients. Despite a universal LESDUS protocol, only 50% of patients underwent screening and 20% of all LE DVTs were not identified on LESDUS. To optimize resource utilization and protocol adherence, LESDUS should only be performed if RAP ≥8 or if unable to administer timely chemoprophylaxis.

Age is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery.

BACKGROUND: Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS: A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS: Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS: DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.

Pregnancy Outcomes After Living Liver Donation: A Multi-Institutional Study.

Nearly half of living liver donors in North America are women of child-bearing age. Fetal and maternal outcomes after donation are unknown. We conducted a retrospective cohort study of female living liver donors (aged 18-50 years at donation) from 6 transplant centers. Participants were surveyed about their pregnancies and fertility. Outcomes were compared between predonation and postdonation pregnancies. Generalized estimating equations were clustered on donor and adjusted for age at pregnancy, parity, and pregnancy year. Among the 276 donors surveyed, 151 donors responded (54.7% response rate) and reported 313 pregnancies; 168/199 (68.8%) of the predonation pregnancies and 82/114 (71.9%) of the postdonation pregnancies resulted in live births, whereas 16.6% and 24.6% resulted in miscarriage, respectively. Women with postdonation pregnancies were older (32.0 versus 26.7 years; P < 0.001) and more frequently reported abnormal liver enzymes during pregnancy (3.5% versus 0.0%; P = 0.02) and delivery via cesarean delivery (35.4% versus 19.7%; P = 0.01). On adjusted analysis, there was no difference in cesarean delivery (odds ratio [OR], 2.44; 95% confidence interval [95% CI], 0.98-6.08), miscarriage (OR, 1.59; 95% CI, 0.78-3.24), combined endpoints of pregnancy-induced hypertension and preeclampsia (OR, 1.27; 95% CI, 0.36-4.49), or intrauterine growth restriction and preterm birth (OR, 0.91; 95% CI, 0.19-4.3). Of the 49 women who attempted pregnancy after donation, 11 (22.5%) self-reported infertility; however, 8/11 (72.7%) eventually had live births. Aside from increased reporting of abnormal liver enzymes and cesarean deliveries, there was no significant difference in pregnancy outcomes before and after living liver donation. One-fifth of women who attempt pregnancy after liver donation reported infertility, and although the majority went on to successful live births, further exploration is needed to understand the contributing factors. Future research should continue to monitor this patient-centered outcome across a large cohort of donors.

Kidney transplant outcomes from donation after circulatory death donors of advanced age.

BACKGROUND: Continued comparison of kidney transplant outcomes between older DCD and donation after brain death (DBD) donors is needed to safely expand the deceased donor pool. METHODS: We performed a retrospective cohort study using the UNOS/OPTN transplant registry from donors >50 years old between 1994 and 2016. Donor age was stratified into 4 groups: 50-54, 55-59, 60-64, and >65 years old. Rates of delayed graft function (DGF) and primary non-function (PNF) were compared. Multivariable Cox regression models were constructed to identify factors associated with time to graft failure. RESULTS: The DCD donors within each age group had fewer comorbidities than the DBD donors. Graft survival for DCD kidneys was equivalent or superior to DBD kidneys in all donor age groups. DGF rates were significantly greater for DCD kidneys in all age groups. PNF rates across all groups were similar. In multivariable analysis, DCD status was not independently associated with time to all-cause graft failure in the 50-54 donor age group (HR = 1.02, 95% CI = 0.93-1.13), 55-59 donor age group (HR = 1.07, 95% CI = 0.96-1.19), or 60-64 donor age group (HR = 1.135, 95% CI = 0.97-1.32). CONCLUSION: Kidneys from carefully selected older DCD donors, particularly ages 50-64, are a potential means to safely expand the deceased donor pool.

Application of Prescription Drug Monitoring Program to detect underreported controlled substance use in patients evaluated for liver transplant.

Presurgical controlled substance use predicts postoperative complications, increased readmissions, and mortality. We aimed to examine if a Prescription Drug Monitoring Program (PDMP) would detect underreported controlled substance use in patients undergoing liver transplant evaluation. We performed a retrospective cohort study at a tertiary referral center of patients undergoing liver transplant evaluation in 2017. PDMP reviews were performed on all 360 patients and urine drug screen (UDS) results were reviewed when available to evaluate dispensed controlled substances. These results were compared to the patient's self-reported medication list at evaluation to identify any underreporting. The primary outcome was the number of self-reported controlled substance discrepancies on the medication list identified by PDMP and UDS at the time of evaluation. Among the 360 patients, 87 (24%) had a discrepancy where PDMP revealed a controlled substance prescription that the patient did not report on their medication list. Seventy-seven (67/87) of these discrepancies involved opiates. Of the 360 patients, 219 (61%) had a negative UDS, but 70 (32%) of these patients had at least one controlled substance listed on PDMP. PDMP is a promising screening tool when used in conjunction with the UDS for detecting underreported controlled substance use in liver transplant candidates.

Do patients get better? A review of outcomes from a crisis house and home treatment team partnership.

Aims and methodThe Tower Hamlets Crisis House (voluntary sector), in partnership with the local home treatment team, offers a brief residential alternative to psychiatric hospital admission. Here, we review clinician-reported (Health of the Nation Outcome Scales; HoNOS) and patient-reported (DIALOG) outcome scores collected from successive admissions between June 2015 and December 2016, to assess the effectiveness of the service model. We identified 153 successive admissions, and of these, 85 (55.6%) and 91 (59.5%) patients completed both admission and discharge DIALOG and HoNOS questionnaires, respectively. We analysed ten out of twelve HoNOS domains and eight patient-reported outcome measure DIALOG domains. RESULTS: We found a statistically significant improvement in nine out of ten domains of HoNOS and three out of eight domains of DIALOG.Clinical implicationsA partnership between a home treatment team and crisis house can result in positive outcomes for patients, as determined by both clinicians and patients.Declaration of interestNone.

Fluid overload at 48 hours is associated with respiratory morbidity but not mortality in a general PICU: retrospective cohort study.

OBJECTIVE: Recent evidence suggests that fluid overload may be deleterious to critically ill children. The purpose of this study was to investigate the association of early fluid overload with respiratory morbidity and mortality in patients admitted to a general PICU. DESIGN: Retrospective cohort study. SETTING: Single, tertiary referral PICU. PATIENTS SIX HUNDRED THIRTY-SIX: patients aged 0-16 years invasively ventilated at 48 hours post admission, admitted between April 1, 2009, and March 31, 2013. MEASUREMENTS AND MAIN RESULTS: Data collected included demographics, diagnosis, Pediatric Index of Mortality 2 score, and fluid overload percent at 48 hours from admission. Fluid overload percent was calculated as (cumulative fluid in - cumulative fluid out (L))/hospital admission weight (kg) × 100%. Outcome measures were oxygenation index at 48 hours from admission, death, and invasive ventilation days in survivors. Data are reported as median (interquartile range) and were analyzed using nonparametric tests. The median age was 1.05 years (0.3-4.2 yr). Fifty-three patients (8%) died. Median duration of ventilation in survivors was 5 days (3-8 d). Fluid overload percent correlated significantly with oxygenation index (Spearman ρ, 0.318; p < 0.0001) and with invasive ventilation days in survivors (Spearman ρ, 0.274; p < 0.0001). There was no significant difference in fluid overload percent between survivors and nonsurvivors. Regression analysis demonstrated that fluid overload percent was a significant predictor of both oxygenation index at 48 hours (p < 0.001) and invasive ventilation days (p = 0.002). CONCLUSIONS: Fluid overload at 48 hours was associated with oxygenation index at 48 hours and invasive ventilation days in survivors in a general PICU population. There was no association of fluid overload at 48 hours with mortality.