The Association of Trauma Center Transport and Long-term Functional Outcomes in Head-injured Older Adults Transported by Emergency Medical Services.

OBJECTIVE: It is unclear whether trauma center care is associated with improved outcomes in older adults with traumatic brain injury (TBI) compared to management at nontrauma centers. Our primary objectives were to describe the long-term outcomes of older adults with TBI and to evaluate the association of trauma center transport with long-term functional outcome. METHODS: This was a prospective, observational study at five emergency medical services (EMS) agencies and 11 hospitals representing all 9-1-1 transfers within a county. Older adults (≥55 years) with TBI (defined as closed head injury associated with loss of consciousness and/or amnesia, abnormal Glasgow Coma Scale [GCS] score, or traumatic intracranial hemorrhage) and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and emergency department (ED) and hospital data were abstracted. Functional outcomes were measured using the Extended Glasgow Outcome Scale (GOS-E) at 3- and 6-month intervals by telephone follow-up. Reasons for disabilities were coded as due to head injury, due to illness or injury to other part of body, or due to a mixture of both. To evaluate the association of trauma center transport and functional outcomes, we conducted multivariate ordinal logistic regression analyses on multiple imputed data for 1) all patients with TBI and 2) patients with traumatic intracranial hemorrhage. RESULTS: We enrolled 350 patients with TBI; the median (Q1, Q3) age was 70 (61, 84) years, 187 (53%) were male, and 91 patients (26%) had traumatic intracranial hemorrhage on initial ED cranial computed tomography (CT) imaging. A total of 257 patients (73%) were transported by EMS to a Level I or II trauma center. Sixty-nine patients (20%) did not complete follow-up at 3 or 6 months. Of the patients with follow-up, 119 of 260 patients (46%) had moderate disability or worse at 6 months, including 55 of 260 patients (21%) who were dead at 6-month follow-up. Death or severe disabilities were more commonly attributed to non-TBI causes while moderate disabilities or better were more commonly due to TBI. On adjusted analysis, an abnormal GCS score, higher Charlson Comorbidity Index scores, and the presence of traumatic intracranial hemorrhage on initial ED cranial imaging were associated with worse GOS-E scores at 6 months. Trauma center transport was not associated with GOS-E scores at 6 months for TBI patients and in patients with traumatic intracranial hemorrhage on initial ED CT imaging. CONCLUSIONS: In older adults with TBI, moderate disability or worse is common 6 months after injury. Over one in five of older adults with TBI died by 6 months, usually due to nonhead causes. Patients with TBI or traumatic intracranial hemorrhage did not have improved functional outcomes with initial triage to a trauma center.

The Incidence of Traumatic Intracranial Hemorrhage in Head-Injured Older Adults Transported by EMS with and without Anticoagulant or Antiplatelet Use.

Field triage guidelines recommend transport of head-injured patients on anticoagulants or antiplatelets to a higher-level trauma center based on studies suggesting a high incidence of traumatic intracranial hemorrhage (tICH). We compared the incidence of tICH in older adults transported by emergency medical services (EMS) with and without anticoagulation or antiplatelet use and evaluated the accuracies of different sets of field triage criteria to identify tICH. This was a prospective, observational study at five EMS agencies and 11 hospitals. Older adults (≥55 years) with head trauma and transported by EMS from August 2015 to September 2016 were eligible. EMS providers completed standardized data forms and patients were followed through emergency department (ED) or hospital discharge. We enrolled 1304 patients; 1147 (88%) received a cranial computed tomography (CT) scan and were eligible for analysis. Four hundred thirty-four (33%) patients had anticoagulant or antiplatelet use and 112 (10%) had tICH. The incidence of tICH in patients with (11%, 95% confidence interval [CI] 8%-14%) and without (9%, 95% CI 7%-11%) anticoagulant or antiplatelet use was similar. Anticoagulant or antiplatelet use was not predictive of tICH on adjusted analysis. Steps 1-3 criteria alone were not sensitive in identifying tICH (27%), whereas the addition of anticoagulant or antiplatelet criterion improved sensitivity (63%). Other derived sets of triage criteria were highly sensitive (>98%) but poorly specific (<11%). The incidence of tICH was similar between patients with and without anticoagulant or antiplatelet use. Use of anticoagulant or antiplatelet medications was not a risk factor for tICH. We were unable to identify a set of triage criteria that was accurate for trauma center need.

Out-of-Hospital Triage of Older Adults With Head Injury: A Retrospective Study of the Effect of Adding "Anticoagulation or Antiplatelet Medication Use" as a Criterion.

STUDY OBJECTIVE: Field triage guidelines recommend that emergency medical services (EMS) providers consider transport of head-injured older adults with anticoagulation use to trauma centers. However, the triage patterns and the incidence of intracranial hemorrhage or neurosurgery in these patients are unknown. Our objective is to describe the characteristics and outcomes of older adults with head trauma who are transported by EMS, particularly for patients who do not meet physiologic, anatomic, or mechanism-of-injury (steps 1 to 3) field triage criteria but are receiving anticoagulant or antiplatelet medications. METHODS: This was a retrospective study at 5 EMS agencies and 11 hospitals (4 trauma centers, 7 nontrauma centers). Patients aged 55 years or older with head trauma who were transported by EMS were included. The primary outcome was the presence of intracranial hemorrhage. The secondary outcome was a composite measure of inhospital death or neurosurgery. RESULTS: Of the 2,110 patients included, 131 (6%) had intracranial hemorrhage and 41 (2%) had inhospital death or neurosurgery. There were 162 patients (8%) with steps 1 to 3 criteria. Of the remaining 1,948 patients without steps 1 to 3 criteria, 566 (29%) had anticoagulant or antiplatelet use. Of these patients, 52 (9%) had traumatic intracranial hemorrhage and 15 (3%) died or had neurosurgery. The sensitivity (adjusted for clustering by EMS agency) of steps 1 to 3 criteria was 19.8% (26/131; 95% confidence interval [CI] 5.5% to 51.2%) for identifying traumatic intracranial hemorrhage and 34.1% (14/41; 95% CI 9.9% to 70.1%) for death or neurosurgery. The additional criterion of anticoagulant or antiplatelet use improved the sensitivity for intracranial hemorrhage (78/131; 59.5%; 95% CI 42.9% to 74.2%) and death or neurosurgery (29/41; 70.7%; 95% CI 61.0% to 78.9%). CONCLUSION: Relatively few patients met steps 1 to 3 triage criteria. For individuals who did not have steps 1 to 3 criteria, nearly 30% had anticoagulant or antiplatelet use. A relatively high proportion of these patients had intracranial hemorrhage, but a much smaller proportion died or had neurosurgery during hospitalization. Use of steps 1 to 3 triage criteria alone is not sufficient in identifying intracranial hemorrhage and death or neurosurgery in this patient population. The additional criterion of anticoagulant or antiplatelet use improves the sensitivity of the instrument, with only a modest decrease in specificity.

Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma?

OBJECTIVE: Prehospital provider assessment of the use of anticoagulant or antiplatelet medications in older adults with head trauma is important. These patients are at increased risk for traumatic intracranial hemorrhage and therefore field triage guidelines recommend transporting these patients to centers capable of rapid evaluation and treatment. Our objective was to evaluate EMS ascertainment of anticoagulant and antiplatelet medication use in older adults with head trauma. METHODS: A retrospective study of older adults with head trauma was conducted throughout Sacramento County. All 5 transporting EMS agencies and all 11 hospitals in the county were included in the study, which ran from January 2012 to December 2012. Patients ≥55 years who were transported to a hospital by EMS after head trauma were included. We excluded patients transferred between two facilities, patients with penetrating head trauma, prisoners, and patients with unmatched hospital data. Anticoagulant and antiplatelet use were categorized as: warfarin, direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, and apixaban), aspirin, and other antiplatelet agents (e.g., clopidogrel and ticagrelor). We calculated the percent agreement and kappa statistic for binary variables between EMS and emergency department (ED)/hospital providers. A kappa statistic ≥0.60 was considered acceptable agreement. RESULTS: After excluding 174 (7.6%) patients, 2,110 patients were included for analysis; median age was 73 years (interquartile range 62-85 years) and 1,259 (60%) were male. Per ED/hospital providers, the use of any anticoagulant or antiplatelet agent was identified in 595 (28.2%) patients. Kappa statistics between EMS and ED/hospital providers for the specific agents were: 0.76 (95% CI 0.71-0.82) for warfarin, 0.45 (95% CI 0.19-0.71) for DOAC agents, 0.33 (95% CI 0.28-0.39) for aspirin, and 0.51 (95% CI 0.42-0.60) for other antiplatelet agents. CONCLUSIONS: The use of antiplatelet or anticoagulant medications in older adults who are transported by EMS for head trauma is common. EMS and ED/hospital providers have acceptable agreement with preinjury warfarin use but not with DOAC, aspirin, and other antiplatelet use.

Screening for resistance to adult spittlebugs (Hemiptera: Cercopidae) in Brachiaria spp.: methods and categories of resistance.

Both nymphal and adult stages of several species of spittlebugs (Hemiptera: Cercopidae) are key economic pests of brachiariagrasses (Brachiaria spp.) in tropical America. Progress has been made in the characterization and development of antibiosis resistance to nymphs in brachiariagrasses. Essentially no attention has been given to screening germplasm for resistance to adults. To support current breeding programs, a series of experiments was conducted to develop a methodology to screen for adult damage and to study categories of resistance to adult feeding damage. Six host brachiariagrass genotypes were used: two susceptible checks (CIAT 0606 and CIAT 0654) and four nymph-resistant genotypes (CIAT 6294, CIAT 36062, CIAT 36087, and SX01NO/0102). Test insects were Aeneolamia varia (F.) and Zulia carbonaria (Lallemand). None of the nymph-resistant genotypes was antibiotic to adults. All four nymph-resistant genotypes showed tolerance to A. varia and Z. carbonaria feeding damage. The levels of tolerance to adults of Z. carbonaria, a larger, more aggressive species, were lower. Of the four nymph-resistant genotypes, only CIAT 6294 and CIAT 36087 showed some tolerance to Z. carbonaria expressed as lower leaf damage scores, less chlorophyll loss, and lower functional plant loss indices. The fact that a genotype like SX01NO/0102, which is highly antibiotic to nymphs, is susceptible to adult damage suggests that mechanisms of resistance to the two spittlebug life stages may be independent. Results of these studies suggest a need to incorporate routine screening for tolerance to adult feeding damage as an additional selection criterion in the breeding scheme.

Sublethal effects of antibiosis resistance on the reproductive biology of two spittlebug (Hemiptera: Cercopidae) species affecting Brachiaria spp.

Several greenhouse experiments were used to measure how high levels of antibiosis resistance to nymphs in two interspecific Brachiaria (brachiariagrass) hybrids affect life history parameters of the spittlebugs Aeneolamia varia (F.) and Zulia carbonaria (Lallemand), two of the most important spittlebug (Hemiptera: Cercopidae) species affecting Brachiaria production in Colombia. The A. varia-resistant hybrid CIAT 36062, the Z. carbonaria-resistant hybrid SX01NO/0102, and the susceptible accession CIAT 0654 were used to compare the effect of all possible combinations of food sources for nymphs and adults. Calculation of growth indexes showed a significant impact of antibiosis resistance on the biology of immature stages of both species. Median survival times of adults feeding on resistant genotypes did not differ from those recorded on the susceptible genotype, suggesting that factors responsible for high mortality of nymphs in the resistant hybrids did not affect adult survival. Rearing nymphs of A. varia on CIAT 36062 and of Z. carbonaria on SX01NO/0102 had deleterious sublethal effects on the reproductive biology of resulting adult females. It is concluded that high nymphal mortality and subsequent sublethal effects of nymphal antibiosis on adults should have a major impact on the demography of the two spittlebug species studied.

Development of Colombian isolates of Leishmania (Viannia) panamensis, Le. (V.) guyanensis and Le. (V.) braziliensis in the sandfly Lutzomyia intermedia (Lutz & Neiva, 1912) under experimental conditions

The development of Colombian Leishmania species of the subgenus Viannia in Lutzomyia intermedia was similar to that observed with Brazilian Le. (V.) braziliensis: colonization of the pylorus by paramastigotes; promastigotes in the midgut and massive infection of stomodeal valve. Difference was observed in the number of paramastigotes colonizing the pylorus, which was smaller in Colombian Leishmania species than Brazilian Le. braziliensis

Notas sobre algunos flebotomas lutzomyia (diptera: psychodidae) en tres focos de leishmaniasis cutanea en el occidente de Colombia / Notes about some flebotomus lutzomyia (diptero: psychodidae) in three focus of cutaneous leishmaniasis in western Colombia

Se estudiaron los jejenes flebotomos que transmiten la leishmaniasis cutanea en tres focos principales de la enfermedad en el occidente de Colombia: Iguapi del Guadual, Bajo Calima y Villa Hermosa. En total se investigaron 19 lugares en Narino y 15 en el Valle del Cauca, de donde se obtuvieron 29 y 14 especies, respectivamente. En Iguapi del Guadual se capturaron 18 especies de Lutzomyia. De ellas, L. Trapidoi, L. panamensis, L. Gomezi y L. Hartmanni tambien estaban presentes en Bajo Calima. Ademas, en Inguapi se colecto L. gorbitzi por primera vez; es nuevo registro geografico para Colombia