Management of injured patients who were Jehovah's Witnesses, where blood transfusion may not be an option: a retrospective review.

INTRODUCTION: Management of major haemorrhage as a result of trauma is particularly challenging when blood is not an option (BNAO). Evidence on therapeutic strategies in this situation is limited. The aim of this study was to evaluate the management and outcomes of patients who identified themselves as Jehovah's Witnesses (who usually refuse blood products) with traumatic haemorrhage at an Australian major trauma centre. METHODS: A retrospective review of patients from The Alfred Trauma Registry was conducted, including patients who were Jehovah's Witnesses presenting between January 2010 and January 2017. We examined demographics, injury characteristics, clinical progress, therapeutic interventions and outcomes at hospital discharge. RESULTS: There were 34 patients meeting inclusion criteria, with 50% suffering major trauma. Anaemia was a clinical problem for 13 (38·2%) patients, with haemoglobin levels reaching a nadir of 69·7 g/l (95% CI: 56·7-82·7) on average 5·1 days (95% CI: 2·5-7·7) post admission. Various strategies were employed to reduce blood loss including six (46·2%) patients receiving tranexamic acid, nine (29·2%) patients receiving oral or intravenous iron and five (38·5%) receiving erythropoietin. Three patients received packed red cells, and two patients received synthetic haemoglobin-based oxygen carriers. CONCLUSIONS: Numerous therapeutic strategies were employed inconsistently in this unique population of patients. Augmenting circulatory volume with an oxygen carrier acceptable to JW patients presents a novel approach to be considered in adjunct to other strategies. An international resource centre would assist clinicians faced with anaemia and BNAO.

Over view of major traumatic injury in Australia--Implications for trauma system design.

BACKGROUND: Trauma registries are known to drive improvements and optimise trauma systems worldwide. This is the first reported comparison of the epidemiology and outcomes at major centres across Australia. METHODS: The Australian Trauma Registry was a collaboration of 26 major trauma centres across Australia at the time of this study and currently collects information on patients admitted to these centres who die after injury and/or sustain major trauma (Injury Severity Score (ISS) > 12). Data from 1 July 2016 to 30 June 2017 were analysed. Primary endpoints were risk adjusted length of stay and mortality (adjusted for age, cause of injury, arrival Glasgow coma scale (GCS), shock-index grouped in quartiles and ISS). RESULTS: There were 8423 patients from 24 centres included. The median age (IQR) was 48 (28-68) years. Median (IQR) ISS was 17 (14-25). There was a predominance of males (72%) apart from the extremes of age. Transport-related cases accounted for 45% of major trauma, followed by falls (35.1%). Patients took 1.42 (1.03-2.12) h to reach hospital and spent 7.10 (3.64-15.00) days in hospital. Risk adjusted length of stay and mortality did not differ significantly across sites. Primary endpoints across sites were also similar in paediatric and older adult (>65) age groups. CONCLUSION: Australia has the capability to identify national injury trends to target prevention and reduce the burden of injury. Quality of care following injury can now be benchmarked across Australia and with the planned enhancements to data collection and reporting, this will enable improved management of trauma victims.

A checklist for trauma quality improvement meetings: A process improvement study.

BACKGROUND: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM. METHODS: This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop. RESULTS: There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001). CONCLUSION: This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.

A novel approach to improving the interpretation of CT brain in trauma.

BACKGROUND: Computed tomography of the brain (CTB) has a fundamental role in the diagnosis and management of traumatic brain injury (TBI). There may be substantial discordance between initial CTB interpretation by emergency clinicians and the final radiology report. This study aimed to assess the utility of a structured reporting template in improving the accuracy of CTB interpretation by emergency clinicians. METHOD: A prospective pre- and post-intervention cohort study was undertaken using a study population of emergency medicine trainees. The CTB reporting template was created with consultation from radiology, emergency medicine and trauma specialists. Participants reported on a set of randomly selected trauma CTBs first without, and then with, the reporting template. Each case was independently assessed for concordance with the radiology report by two blinded assessors (including a radiologist) and the proportion of concordant reports in each phase calculated. RESULTS: There were 26 participants recruited to the study who reported on a total of 320 CTBs. In the pre-intervention phase, 121 (76%) cases were concordant with the radiology report compared to 147 (92%) post-intervention (p<0.01). The AUROC was 0.84 (95% CI: 0.78-0.89) pre-intervention and improved to 0.94 (95% CI: 0.88-0.99) with the intervention (p=0.01). A higher level of baseline accuracy was observed in advanced trainees (78%) compared to basic trainees (72%), but both improved to a similar level of 92% with the use of the CTB reporting template. There was a marked reduction in false negative errors, with increased identification of critical diagnoses such as cerebral herniation and diffuse axonal injury. CONCLUSION: The use of the CTB reporting template significantly increased the accuracy of emergency medicine trainees and reduced the number of missed critical diagnoses. Reporting templates may represent an effective strategy to improve CTB interpretation and enhance the initial care of head injured patients.

Importance of the basement membrane protein SPARC for viability and fertility in Caenorhabditis elegans.

The basement membrane is a specialized extracellular matrix located at epithelial-mesenchymal boundaries that supports cell adhesion, migration, and proliferation; it is highly conserved between invertebrates and vertebrates [1,2]. One of its component proteins, SPARC (osteonectin/BM-40), binds calcium and collagens, and can modulate cell-matrix interactions, so altering cell shape, growth, and differentiation [3,5]. The tissue distribution of a secreted fusion protein containing SPARC and green fluorescent protein (GFP) was analyzed in Caenorhabditis elegans. The protein localized to most basement membranes along body wall and sex muscles, and was also deposited around the pharynx and the gonad, in the spermatheca and at the distal tip cells. The contributions of SPARC to C. elegans development were determined using RNA interference, which accurately phenocopies loss-of-function defects [6-8]. A reduction in the amount of SPARC protein resulted in embryonic or larval lethality in a significant proportion of progeny. Those that survived developed a 'clear' phenotype characterized by a lack of gut granules, which made the animals appear transparent, plus small size, and sterility or reduced fecundity. No significant morphological abnormalities were observed, indicating that SPARC plays a regulatory rather than structural role in modulating cell-matrix interactions during normal development and reproduction.

Biochemical mass spectrometry: worth the weight?

The utility of mass spectrometry for the analysis of biological molecules has been enhanced by the development of two techniques that generate gas-phase ions via nondestructive vaporization and ionization. These techniques can be used not only to determine the primary structure of biological molecules with unprecedented accuracy, but also to map noncovalent biomolecular interactions.

Probing the chemical basis of binding activity in an SH3 domain by protein signature analysis.

BACKGROUND: Modifying the covalent structure of a protein is an effective empirical route to probing three-dimensional structure and biological function. Here we describe a combinatorial protein chemistry strategy for studying structure-activity relationships in proteins. Our approach (termed 'protein signature analysis') involves functional selection from an array of self-encoded protein analogs prepared by total synthesis, coupled to a simple chemical readout that unambiguously identifies the modified proteins in the resulting active and inactive populations. RESULTS: Protein signature analysis was used to study the interaction of the amino-terminal SH3 domain from the cellular adaptor protein c-Crk with its cognate proline-rich peptide, C3G. Using a functional selection assay, the qualitative effects of scanning a series of synthetic analog units through the amino-acid sequence of the SH3 domain were evaluated. The analog units were designed to alter both amino-acid sidechains and the polypeptide backbone within the protein. These chemical studies revealed that the sidechain of Asp 150 in the SH3 domain is essential for ligand binding and that changes in the structure of the polypeptide backbone can also result in loss of binding activity. CONCLUSIONS: These chemical studies have provided new insight into how ligand binding is related to the covalent structure of the SH3 domain. Protein signature analysis is a powerful and conceptually novel way of studying the molecular and chemical basis of protein function; it combines the advantages of systematic modification of a protein's chemical structure with the practical convenience of combinatorial synthesis.

Key factors in the optimization of paediatric X-ray practice.

Justification of radiological requests, standardization of procedures and optimization of protection measures are key principles in the protection of individuals exposed to ionizing radiation for diagnostic purposes. Nowhere is this more pertinent than in the imaging of children and, following the recent introduction of the Ionising Radiation (Medical Exposure) Regulations, there is now a regulatory requirement for diagnostic radiology departments to demonstrate compliance with these principles. A study was undertaken to compare all aspects of paediatric radiological practice at two specialist and two non-specialist centres. An initial study involved analysis of nearly 3000 patient doses. The second phase of the project involved assessment of referral criteria, radiographic technique and approximately 100 radiographs at each centre by two consultant paediatric radiologists. While all radiographs were found to be diagnostically acceptable, major differences in technique were evident, reflecting the disparity in experience between staff at the specialist and non-specialist centres. The large number of sub-optimum films encountered at the latter suggests that there is a need for specific training of less experienced radiographic and clinical staff.

The use of a microprocessor in routine cardiac assessment.

Increasing use is being made of microprocessors in medicine to perform routine clinical measurements. Physiological parameters whose measurement involves data processing on the part of hospital technicians can in many cases be better obtained using such instrumentation. The application of a microprocessor to the measurement of ST-segment elevations in the electrocardiogram is described to illustrate the use of programmable instrumentation in medicine and demonstrate some of the ensuing benefits.

Early predictors of health-related quality of life outcomes in polytrauma patients with spine injuries: a level 1 trauma center study.

Study Design Retrospective review on clinical-quality trauma registry prospective data. Objective To identify early predictors of suboptimal health status in polytrauma patients with spine injuries. Methods A retrospective review on a prospective cohort was performed on spine-injured polytrauma patients with successful discharge from May 2009 to January 2011. The Short Form 12-Questionnaire Health Survey (SF-12) was used in the health status assessment of these patients. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, blood sugar level, vital signs, brain trauma severity, comorbidities, coagulation profile, spine trauma-related neurologic status, and spine injury characteristics of the patients. Results The SF-12 had a 52.3% completion rate from 915 patients. The patients who completed the SF-12 were younger, and there were fewer patients with severe spinal cord injuries (American Spinal Injury Association classifications A, B, and C). Other comparison parameters were satisfactorily matched. Multivariate logistic regression revealed five early predictive factors with statistical significance (p ≤ 0.05). They were (1) tachycardia (odds ratio [OR] = 1.88; confidence interval [CI] = 1.11 to 3.19), (2) hyperglycemia (OR = 2.65; CI = 1.51 to 4.65), (3) multiple chronic comorbidities (OR = 2.98; CI = 1.68 to 5.26), and (4) thoracic spine injuries (OR = 1.54; CI = 1.01 to 2.37). There were no independent early predictive factors identified for suboptimal mental health-related qualify of life outcomes. Conclusion Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes.

Epidemiological trends of spine trauma: an Australian level 1 trauma centre study.

Knowledge of current epidemiology and spine trauma trends assists in public resource allocation, fine-tuning of primary prevention methods, and benchmarking purposes. Data on all patients with traumatic spine injuries admitted to the Alfred Hospital, Melbourne between May 1, 2009, and January 1, 2011, were collected from the Alfred Trauma Registry, Alfred Health medical database, and Victorian Orthopaedic Trauma Outcomes Registry. Epidemiological trends were analyzed as a general cohort, with comparison cohorts of nonsurvivors versus survivors and elderly versus nonelderly. Linear regression analysis was utilized to demonstrate trends with statistical significance. There were 965 patients with traumatic spine injuries with 2,333 spine trauma levels. The general cohort showed a trimodal age distribution, male-to-female ratio of 2:2, motor vehicle accidents as the primary spine trauma mechanism, 47.7% patients with severe polytrauma as graded using the Injury Severity Score (ISS), 17.3% with traumatic brain injury (TBI), the majority of patients with one spine injury level, 7% neurological deficit rate, 12.8% spine trauma operative rate, and 5.2% mortality rate. Variables with statistical significance trending toward mortality were the elderly, motor vehicle occupants, severe ISS, TBI, C1-2 dissociations, and American Spinal Injury Association (ASIA) A, B, and C neurological grades. Variables with statistical significance trending toward the elderly were females; low falls; one spine injury level; type 2 odontoid fractures; subaxial cervical spine distraction injuries; ASIA A, B, and C neurological grades; and patients without neurological deficits. Of the general cohort, 50.3% of spine trauma survivors were discharged home, and 48.1% were discharged to rehabilitation facilities. This study provides baseline spine trauma epidemiological data. The trimodal age distribution of patients with traumatic spine injuries calls for further studies and intervention targeted toward the 46- to 55-year age group as this group represents the main providers of financial and social security. The study's unique feature of delineating variables with statistical significance trending toward both mortality and the elderly also provides useful data to guide future research studies, benchmarking, public health policy, and efficient resource allocation for the management of spine trauma.

Inception of an Australian spine trauma registry: the minimum dataset.

Background The establishment of a spine trauma registry collecting both spine column and spinal cord data should improve the evidential basis for clinical decisions. This is a report on the pilot of a spine trauma registry including development of a minimum dataset. Methods A minimum dataset consisting of 56 data items was created using the modified Delphi technique. A pilot study was performed on 104 consecutive spine trauma patients recruited by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data analysis and collection methodology were reviewed to determine its feasibility. Results Minimum dataset collection aided by a dataset dictionary was uncomplicated (average of 5 minutes per patient). Data analysis revealed three significant findings: (1) a peak in the 40 to 60 years age group; (2) premorbid functional independence in the majority of patients; and (3) significant proportion being on antiplatelet or anticoagulation medications. Of the 141 traumatic spine fractures, the thoracolumbar segment was the most frequent site of injury. Most were neurologically intact (89%). Our study group had satisfactory 6-month patient-reported outcomes. Conclusion The minimum dataset had high completion rates, was practical and feasible to collect. This pilot study is the basis for the development of a spine trauma registry at the Level 1 trauma center.

Systemic RNAi in Caenorhabditis elegans.

RNA interference (RNAi) in Caenorhabditis elegans induced by ingestion or injection of double-stranded RNA (dsRNA) spreads throughout the organism and is even transmitted to the progeny. We have identified two proteins required for spreading of RNAi, SID-1 and SID-2, whose structure, subcellular localization, and expression pattern have been informative for how dsRNA can be transported into and between cells. SID-1 is a transmembrane protein that functions as a pore or channel that transports dsRNA into and out of cells. Proteins homologous to SID-1 are present in a wide range of invertebrate and vertebrate animals but are absent from plants. SID-2 is a small transmembrane protein that is expressed in the gut and localizes strongly to the luminal membrane where it appears to act as a receptor for uptake of dsRNA from the environment. Characterization of SID-2 activity in a variety of Caenorhabditis nematodes indicates that C. elegans SID-2 may have a novel activity.

Characterization and sequence analysis of the human ornithine decarboxylase gene.

This report describes the characterization and complete sequence of the human ornithine decarboxylase (ODC) gene. Genomic Southern blot analysis shows only a single gene hybridizing at high stringency, in contrast to the murine multigene family. A Pst I restriction fragment length polymorphism was identified and an allele of the human ODC gene containing the polymorphic Pst I site was cloned and sequenced. The ODC gene is divided into 12 exons and spans 8 kb. Comparison of the human, rat, and mouse ODC genes shows striking conservation of genomic organization, as well as 82% identity in the first 148 bp of the 5'-flanking region. This region contains a TATA box, cAMP-responsive element, CCAAT box, and AP-2 binding site and is consistent with induction of ODC gene expression by both the cAMP and protein kinase C-mediated signaling pathways. The first intron of the human gene is 2,849 bp in length, and contains two putative Sp1 binding sites, as well as an Ap1 binding site, suggesting a role for the first intron in transcriptional regulation. The 5' noncoding region of the predicted mRNA contains regions of virtual identity with that of mouse and rat ODC mRNA, suggesting sequences involved in translational regulation. In addition, it was found that the exon segments corresponding to the amino and carboxyl termini of Saccharomyces cerevisiae and Trypanosoma b. brucei are unrelated to their mammalian counterparts, whereas the middle segments of the protein are conserved. These differences may influence the difference in protein half-life seen between T. b. brucei and mammalian ODC.

Mass spectrometry of nucleic acids: the promise of matrix-assisted laser desorption-ionization (MALDI) mass spectrometry.

In the past several years, significant progress has been made in the application of matrix-assisted laser desorption-ionization (MALDI) mass spectrometry to the analysis of large biopolymers, including nucleic acids. By isolating analyte molecules in an appropriate matrix and irradiating the sample with a high-intensity, pulsed laser beam, MALDI can generate intact, gas-phase ions of these analytes. Primarily used with time-of-flight mass spectrometers, this relatively new, soft ionization technique has allowed for the routine analysis of oligonucleotides up to 60 or so nucleotides in length. Recent results have also shown that base specific, matrix-dependent fragmentation is an important factor in the MALDI analysis of oligonucleotides. Further extension of the technique to longer oligonucleotides will rely on both the continued search for new matrix materials and an increased understanding of the desorption and ionization process in MALDI.

Mass spectrometry as a readout of protein structure and function.

Proteins have evolved to carry out very specific functions within the cell by interacting with a diverse set of biomolecules. Understanding how a protein's higher order structure relates to its function is important for defining the molecular basis of these interactions. In recent years, mass spectrometry has become an important tool for dissecting protein structure and function. Using electrospray ionization (ESI)- and matrix-assisted laser desorption/ionization (MALDI)-based approaches, it has been possible to monitor protein folding, characterize noncovalent protein complexes, and assess the contribution of individual amino acid residues to a protein's function. Here, it is our goal to summarize these approaches and highlight recent, biologically relevant applications where mass spectrometry has provided unique insight into the mysteries of protein structure and function.