Ventilator-associated pneumonia (VAP) carries significant mortality and morbidity. Predicting which patients will become infected could lead to measures to reduce the incidence of VAP.
The goal was ...to begin constructing a model for VAP prediction in critically-injured trauma patients, and to identify differentially expressed genes in patients who go on to develop VAP compared to similar patients who do not. Gene expression profiles of lipopolysaccharide stimulated blood cells in critically injured trauma patients that went on to develop ventilator-associated pneumonia (n=10) was compared to those that never developed the infection (n=10). Eight hundred and ten genes were differentially expressed between the two groups (ANOVA, P<0.05) and further analyzed by hierarchical clustering and principal component analysis. Functional analysis using Gene Ontology and KEGG classifications revealed enrichment in multiple categories including regulation of protein translation, regulation of protease activity, and response to bacterial infection. A logistic regression model was developed that accurately predicted critically-injured trauma patients that went on to develop VAP (VAP+) and those that did not (VAP-). Five genes (PIK3R3, ATP2A1, PI3, ADAM8, and HCN4) were common to all top 20 significant genes that were identified from all independent training sets in the cross validation. Hierarchical clustering using these five genes accurately categorized 95% of patients and PCA visualization demonstrated two discernable groups (VAP+ and VAP-).
A logistic regression model using cross-validation accurately predicted patients that developed ventilator-associated pneumonia and should now be tested on a larger cohort of trauma patients.
Full text
Available for:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Multidrug-resistant (MDR) strains of both Acinetobacter baumannii (AB) and Pseudomonas aeruginosa (PA) as causative ventilator-associated pneumonia (VAP) pathogens are becoming increasingly common. ...Still, the risk factors associated with this increased resistance have yet to be elucidated. The purpose of this study was to examine the changing sensitivity patterns of these pathogens over time and determine which risk factors predict MDR in trauma patients with VAP.
Patients with either AB or PA VAP over 10 years were stratified by pathogen sensitivity (sensitive SEN and MDR), age, severity of shock, and injury severity. Prophylactic and empiric antibiotic days, risk factors for severe VAP, and mortality were compared. Multivariable logistic regression was performed to determine which risk factors were independent predictors of MDR.
Three hundred ninety-seven patients were identified with AB or PA VAP. There were 173 episodes of AB (91 SEN and 82 MDR) and 224 episodes of PA (170 SEN and 54 MDR). The incidence of MDR VAP did not change over the study (p = 0.633). Groups were clinically similar with the exception of 24-hour transfusions (14 vs. 19 units, p = 0.009) and extremity Abbreviated Injury Scale (AIS) score (1 vs. 3, p < 0.001), both significantly increased in the MDR group. Antibiotic exposure as well as multiple episodes of inadequate empiric antibiotic therapy (mIEAT) (63% vs. 81%, p < 0.001) were significantly increased in the MDR group. Multivariable logistic regression identified prophylactic antibiotic days (odds ratio, 23.1; 95% confidence interval, 16.7-28, p < 0.001) and mIEAT (odds ratio, 18.1; 95% confidence interval, 12.2-26.1, p = 0.001) as independent predictors of MDR after adjusting for severity of shock, injury severity, severity of VAP, and antibiotic exposure.
Prolonged exposure to unnecessary antibiotics remains one of the strongest predictors for the development of antibiotic resistance. Multivariable logistic regression identified prophylactic antibiotic days and mIEAT an independent risk factors for MDR VAP. Thus, limiting prophylactic antibiotic days is the only potentially modifiable risk factor for the development of MDR VAP in trauma patients.
Level IV Therapeutic; level III Prognostic.
To evaluate efficacy and safety of a novel device that combines an inferior vena cava (IVC) filter and central venous catheter (CVC) for prevention of pulmonary embolism (PE) in critically ill ...patients.
In a multicenter, prospective, single-arm clinical trial, the device was inserted at the bedside without fluoroscopy and subsequently retrieved before transfer from the intensive care unit (ICU). The primary efficacy endpoint was freedom from clinically significant PE or fatal PE 72 hours after device removal or discharge, whichever occurred first. Secondary endpoints were incidence of acute proximal deep venous thrombosis (DVT), catheter-related thrombosis, catheter-related bloodstream infections, major bleeding events, and clinically significant thrombus (occupying > 25% of volume of filter) detected by cavography before retrieval.
The device was placed in 163 critically ill patients with contraindications to anticoagulation; 151 (93%) were critically ill trauma patients, 129 (85%) had head or spine trauma, and 102 (79%) had intracranial bleeding. The primary efficacy endpoint was achieved for all 163 (100%) patients (95% confidence interval CI, 97.8%-100%, P < .01). Diagnosis of new or worsening acute proximal DVT was time dependent with 11 (7%) occurring during the first 7 days. There were no (0%) catheter-related bloodstream infections. There were 5 (3.1%) major bleeding events. Significant thrombus in the IVC filter occurred in 14 (8.6%) patients. Prophylactic anticoagulation was not initiated for a mean of 5.5 days ± 4.3 after ICU admission.
This novel device prevented clinically significant and fatal PE among critically ill trauma patients with low risk of complications.
Few injuries have produced as much debate with respect to management as have blunt cerebrovascular injuries (BCVIs). Without question, early anticoagulation is the mainstay of therapy for these ...injuries. However, the role of endovascular stenting for BCVI remains controversial. Our purpose was to examine the use of endovascular stents for BCVI and outcomes and describe which injuries are being treated with stents.
Patients with BCVI from 2011 to 2016 were identified and stratified by age, sex, and injury severity. Patients were then divided into two groups (previous study PS = 2011-2012 and current study CS = 2013-2016) based on a paradigm shift in BCVI diagnosis and treatment at our institution. Beginning in 2013, a multidisciplinary team assumed care of patients with BCVI from interventional radiology. Digital subtraction angiography was used to confirmatory injuries in both groups and heparin used for initial therapy.
In the CS, 237 patients were diagnosed with BCVI compared with 128 patients in the PS. Both groups were clinically similar with no difference in distribution of vessels injured. Beginning in 2013, there was a significant decrease in the use of stents for these injuries. In fact, in the CS, only 21 (8.9%) patients were treated with endovascular stenting compared to 44 (34%) patients in the PS. Of patients in the CS, 14 had grade III pseudoaneurysms and seven had grade II dissections. Despite this reduction in stenting, there was no significant change in the BCVI-related stroke rate between the CS and the PS (4.2% vs. 3.9%).
Anticoagulation alone is adequate therapy for the majority of BCVI. Nevertheless, there is still a role for endovascular stents in the treatment of BCVI. Their use should be reserved for enlarging carotid pseudoaneurysms and dissections with significant narrowing. The prospect of determining which injuries benefit from stent placement warrants prospective investigation.
Therapuetic/care management, level IV.
ABSTRACT The associate membership of the American Association for the Surgery of Trauma (AAST) was established in 2019 to create a defined but incorporated entity within the larger AAST for the next ...generation of acute care surgeons. The Associate Member Council (AMC) was subsequently established in 2020 to provide the new AM with an elected group of leaders who would represent them within the AAST. In its inaugural year, this cohort of junior faculty and surgical trainees had developed for the AM a set of bylaws, a mission statement, a strategic vision, and a succession plan. The experience of the AAST AMC is exemplary of what can be accomplished with collaboration, mentorship, innovation, and tenacity. It has the potential to serve as a template for the creation and vitalization of future professional groups. In this piece, the AMC proposes a blueprint for the successful conception of a new organization.
Trauma health literacy: In need of remediation Shahan, Charles P; Weinberg, Jordan A; Magnotti, Louis J ...
The journal of trauma and acute care surgery,
12/2016, Volume:
81, Issue:
6
Journal Article
Peer reviewed
Little is known regarding health literacy among trauma patients. Anecdotal experience at our institution has suggested that a profound lack of understanding of basic health care information exists at ...some level in our patients after hospital discharge. The purpose of this study was to report the results of a pilot quality improvement project to determine trauma patient injury comprehension and how this affects their overall satisfaction with care received.
Trauma patients were surveyed for knowledge of their injuries, operations, and satisfaction with their care at the first outpatient visit following hospital discharge from a Level 1 trauma center.
One hundred seventy-five surveys were distributed and 35 were returned complete and eligible for analysis. Average time from discharge to survey completion was 16 days. Seventy-five percent of patients were male, and the mean age was 37. Fifty-six percent of the injuries were from a blunt mechanism. Seventy-one percent reported household income of less than $25,000 per annum, and 61% had an education level of high school diploma or less. Forty percent of patients were unable to correctly recall their injuries, and 54% were unable to correctly recall operations performed. Seventy-two percent were unable to recall the name of any physician that provided care during their hospital stay. Nonetheless, 90% of patients were at least somewhat satisfied with their injury understanding, and only 3% felt that their level of understanding had a negative impact on their overall satisfaction with care received. There was no correlation between education or income level and ability to correctly recall injuries or operations. In addition, there was no correlation between ability to recall injuries or operations and patients' satisfaction.
The observed deficiency in postdischarge health literacy among our patients is alarming and demonstrates that current hospital discharge education is lacking. Although this deficit did not affect satisfaction with care, we feel a responsibility to improve the health literacy of our patients. The next step at our institution will be to implement a revised discharge education program followed by surveillance to evaluate for improvement.
Therapeutic/care management study, level IV.
Acinetobacter organisms, which are a common cause of ventilator-associated pneumonia (VAP) in some health care centers, are becoming more resistant to such first-line agents as imipenem-cilastatin ...(Imi-Cil). Sulbactam has good in vitro activity against Acinetobacter organisms; thus, ampicillin-sulbactam (Amp-Sulb) may be a viable treatment alternative. The outcomes for critically ill trauma patients with Acinetobacter VAP treated with either Amp-Sulb or Imi-Cil were compared retrospectively. A total of 77 episodes in 75 patients were studied. Fourteen patients were treated with Amp-Sulb, and 63 patients were treated with Imi-Cil. Treatment efficacy was similar in the Amp-Sulb and Imi-Cil groups (93% vs. 83%, respectively; P > .05). No statistically significant differences between groups were noted with regard to associated mortality, duration of mechanical ventilation, or length of stay in the intensive care unit or hospital. However, adjunctive aminoglycoside therapy was used more often in the Amp-Sulb group. Patients generally received Amp-Sulb because of imipenem resistance. Amp-Sulb was effective in treating a small number of patients with Acinetobacter VAP; however, more data are needed.
Full text
Available for:
BFBNIB, NUK, PNG, UL, UM, UPUK
Data linking ballistics to injury are lacking. To address this data chasm, a partnership with law enforcement was developed to describe clinical outcomes from specific firearms.
A random sample of ...patients with gunshot wounds over a 20-year period ending in 2015, was identified. Circumstances of incident, firearm type, and/or caliber were extracted from police reports. Data on demographics, mortality, injury severity, and clinical outcomes were collected from the trauma registry, and these datasets were linked. Firearms were stratified by velocity (high > 2,500 ft/sec; low < 1,200 ft/sec) and caliber (large = .40 and .45; small = .20 and .25) and compared over time.
Police reports were obtained on 366 patients who had a gun type or caliber documented. The majority were male (82%) with a median age of 28 years. Twenty-one percent of patients had an Injury Severity Score > 25, 60% required immediate operative intervention, and overall mortality was 13%. The use of large caliber firearms increased from 4% (1996 to 2000) to 33% (2011 to 2015); small caliber guns decreased from 33% to 7% over the same time period (p < 0.0001). High velocity firearm usage significantly increased (p = 0.0320). Recovered shell casings doubled from the first decade to the second (2 vs 4; p = 0.0006). Both median New Injury Severity Score (p = 0.0488) and hospital days (p = 0.0321) increased from 1996 to 2015.
Larger caliber and higher velocity firearms have significantly increased over the past 20 years in conjunction with injury severity, hospital days, and mean number of gun-related homicides per year (112 in 1996 to 2000 vs 143 in 2011 to 2015). Robust data sharing partnerships can be built between police and trauma centers to address the dearth of data on firearm crime and resulting injury.
Gun violence remains a significant public health problem that is both understudied and underfunded, and plagued by inadequate or inaccessible data sources. Over the years, numerous trauma centers ...have attempted to use local registries to study single-institutional trends, however, this approach limits generalizability to our national epidemic. In fact, even easily accessible, health-centered data from the CDC lack national relevance because they are limited to those enrolled states only. We sought to examine how publicly available law enforcement data from all 50 states might complement our understanding of circumstances and demographics surrounding national firearm death and help forge the first step in partnering law enforcement with trauma centers.
All homicide that occurred in the US during a 37-year period ending in 2016 was analyzed. Primary data files were obtained from the Federal Bureau of Investigation and comprised the database. Data analyzed included homicide type, situation, circumstance, firearm type, and demographic characteristics of victims and offenders. The proportion of firearm-related homicide was stratified by year and compared over time using simple linear regression.
There were 485,288 incidents of firearm homicide analyzed (64% of 752,935 total homicides). Most victims were male (85%), black (53%), and a mean age of 33 years; offenders were predominantly male (67%), black (39%), and a mean age of 30 years. Fifty-four percent of all homicide involved a single victim and single offender, followed by a single victim and unknown offender(s) (31%); 4% of firearm homicide had multiple victims. Overall, handguns, shotguns, and rifles accounted for 76%, 7%, and 5% of all firearm homicide, respectively; 11% had no firearm type listed and <1% were other gun or unknown. Linear regression analysis identified a significant increase in the proportion of firearm-related homicide from 61% in 1980 to 71% in 2016 (β = 0.25; p < 0.0001).
Gun violence represents an ongoing public health concern, with the proportion of firearm homicide steadily and significantly increasing from 1980 to 2016. Homicide data from the Federal Bureau of Investigation can serve to supplement trauma registry data by helping to define gun violence patterns. However, stronger partnerships between local law enforcement agencies and trauma centers are necessary to better characterize firearm type and resultant injury patterns, direct prevention efforts and firearm policy, and reduce gun-related deaths.
Display omitted
PDF
