Abstract Background Acute appendicitis is the most common cause of abdominal surgery in children. Adjuncts are used to help clinicians predict acute or perforated appendicitis, which may affect ...treatment decisions. Automated hematologic analyzers can perform more accurate automated differentials including immature granulocyte percentages (IG%). Elevated IG% has demonstrated improved accuracy for predicting sepsis in the neonatal population than traditional immature-to-total neutrophil count ratios. We intended to assess the additional discriminatory ability of IG% to traditionally assessed parameters in the differentiation between acute and perforated appendicitis. Materials and methods We identified all patients with appendicitis from July 2012–June 2013 by International Classification of Diseases-9 code. Charts were reviewed for relevant demographic, clinical, and outcome data, which were compared between acute and perforated appendicitis groups using Fisher exact and t -tests for categorical and continuous variables, respectively. We used an adjusted logistic regression model using clinical laboratory values to predict the odds of perforated appendicitis. Results A total of 251 patients were included in the analysis. Those with perforated appendicitis had a higher white blood cell count ( P = 0.0063), C-reactive protein (CRP) ( P < 0.0001), and IG% ( P = 0.0299). In the adjusted model, only elevated CRP (odds ratio 3.46, 95% confidence interval 1.40–8.54) and presence of left shift (odds ratio 2.66, 95% confidence interval 1.09–6.46) were significant predictors of perforated appendicitis. The c-statistic of the final model was 0.70, suggesting fair discriminatory ability in predicting perforated appendicitis. Conclusions IG% did not provide any additional benefit to elevated CRP and presence of left shift in the differentiation between acute and perforated appendicitis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
ABSTRACTTraumatic injury and hemorrhagic shock result in endothelial cell activation and vascular dysfunction that, if not corrected, can propagate multiorgan failure. Angiopoietin-1 and ...angiopoietin-2 are important regulators of endothelial cell function, and the ratio of plasma angiopoietin-2-to-1 is a useful indicator of overall vascular health. We therefore characterized plasma angiopoietin-2/-1 ratios over time after trauma in adults in an effort to gain insight into the pathophysiology that may drive post-traumatic vasculopathy and organ injury. We performed a single-center prospective observational study to measure plasma angiopoietin-1 and -2 levels and determine angiopoietin-2/-1 ratios in adult trauma patients upon hospital arrival and after 12, 24, and 48 h. Compared with levels in healthy adults, angiopoietin-1 levels were significantly elevated at hospital arrival, and angiopoietin-2 levels were significantly elevated at 12, 24, and 48 h. These kinetics translated in angiopoietin-2/-1 ratios that were significantly greater than controls at 24 and 48 h. After regression analysis, elevated angiopoietin-2 levels were independently associated with blunt injuries at admission, with coagulopathy at admission and 12 h, and with hemorrhagic shock at 24 and 48 h. Significant correlations were observed between both angiopoietins and 24-h transfusion requirements. Angiopoietin-2/-1 ratios correlated with mechanical ventilation duration and intensive care unit and hospital lengths of stay. In this study, we demonstrate novel temporal associations between angiopoietin dysregulation and blunt injuries, acute coagulopathy, and hemorrhagic shock. Moreover, our findings highlight the presence of endothelial activation following traumatic insults in adults that may contribute to worse clinical outcomes.
BACKGROUND:Bundle checklists are increasingly utilized in patient care, but data are inconsistent regarding their efficacy in reducing nosocomial complication rates. We examined whether checklist ...usage was associated with nosocomial complications; when documented, elements were verified by provider bedside rounds.
METHODS:We performed a retrospective cohort study of trauma patients admitted to our hospital during a three-phase implementation of a quality improvement project. For this analysis, patients were categorized under predocumentation (PD), documentation only (DO), or documentation with provider review (PR) cohort based on temporal designations. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between documentation cohorts and nosocomial complications.
RESULTS:No difference was observed in mean hospital stay, intensive care unit (ICU) days, or ventilator days. The DO cohort showed no significant differences in the risk of complications. Among ICU patients, when compared with the PD cohort, the PR cohort demonstrated a decreased risk of all complications OR 0.72 (95% CI 0.55–0.93), pulmonary embolus OR 0.29 (95% CI 0.11–0.73), pneumonia OR 0.66 (95% CI 0.50–0.88), and death OR 0.50 (95% CI 0.31–0.79).
CONCLUSIONS:Bedside confirmation of bundle checklists during physician extender rounds reduces the risk of pulmonary embolus, pneumonia, and death when compared to chart documentation alone. This study underscores the importance of the team approach to the bundle checklist and itʼs ability to reduce morbidity and mortality.
HIV disclosure is an important behavior with implications for HIV treatment and prevention but understudied among new to HIV care patients who face unique challenges adjusting to a new diagnosis. ...This study evaluated the factors associated with HIV disclosure status and patterns of HIV disclosure among new to HIV care patients. A cross-sectional study was conducted evaluating the iENGAGE (integrating ENGagement and Adherence Goals upon Entry) cohort. Participants were enrolled in this randomized behavioral trial between December 2013 and June 2016. The primary and secondary outcomes included HIV disclosure status (Yes/No) and patterns of disclosure (Broad, Selective and Nondisclosure), respectively. Logistic and Multinomial Logistic Regression were used to evaluate the association of participant factors with HIV disclosure and patterns of HIV disclosure, respectively. Of 371 participants, the average age was 37 ± 12 years, 79.3% were males, and 62.3% were African Americans. A majority of participants (78.4%) disclosed their HIV status at baseline, 63.1% were broad disclosers and 15.2% were selective disclosers. In multivariable regression, black race, emotional support, and unmet needs predicted any HIV and broad disclosure, whereas males, emotional support, active coping, and acceptance were associated with selective disclosure. Interventions to promote early disclosure should focus on coping strategies and unmet needs, particularly among black and male people living with HIV initiating care.
Trauma is a time-critical condition. Helicopters are thought to enhance the accessibility to trauma centers, but this benefit is poorly quantified. The aim of this study was to conduct a geographical ...analysis of the added benefit provided by helicopters, over ground transport. This study uses geospatial analysis. Helicopter bases and Level I and II designated trauma centers were geocoded. 60-minute drive-time and elliptical flight-time isochrones were mapped with ArcGIS™ (Esri, Redlands, CA). Calculations included allowance for mission ground time (MGT). We compared the proportion of the population that could be taken to Level I and II trauma centers, within 60 minutes, by road and by air. Using a 30-minute MGT model, helicopters permit 279,317 additional residents (5.8%) access to a Level I trauma center within 60 minutes. Using the 20-minute MGT model, 1,089,177 more residents (22.8%) would have access to Level I trauma center care. The benefits were marginally greater for access to Level I and II trauma center care. Helicopters enhance access to specialist trauma center care, but the benefit is small and dependent on MGT. Consideration should be given to the siting of helicopters, particularly in relation to trauma patients, MGT, and the timely response of EMS when determining the triage for helicopter transport.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
OBJECTIVESThe objective of this study was to characterize symptom prevalence, awareness of pelvic floor disorders (PFDs) in family/friends, and understanding of factors contributing to the ...development of PFDs in women aged 19 to 30 years.
METHODSThis study is a cross-sectional study via online questionnaire survey of female students aged 19 to 30 years enrolled at the University of Alabama at Birmingham. Results of “adolescent women” aged 19 to 24 years were compared with “young women” aged 25 to 30 years.
RESULTSA total of 1092 questionnaires were completed with the mean age being 23.5 ± 3.1 years. The overall rate of urinary incontinence (UI) was 10.3% without a difference between adolescent and young women (P = 0.61). There were no differences in rates of urgency UI (P = 0.061), stress UI (P = 0.29), or pelvic organ prolapse (POP) symptoms (P = 0.56) between groups. There was no difference between groups in awareness of family members with UI, fecal incontinence (FI), or POP symptoms (P ≥ 0.24). However, logistic regression showed that the young women were more likely to have received education regarding UI (adjusted odds ratio aOR, 2.6; 95% confidence interval CI, 1.8–3.6), FI (aOR, 3.3; 95% CI, 2.2–4.8), POP (aOR, 2.9; 95% CI, 2.1–4.2), and have greater understanding regarding causes of UI (aOR, 2.9; 95% CI, 1.7–4.8), FI (aOR, 1.6; 95% CI, 1.1–2.3), and POP (aOR, 1.9; 95% CI, 1.3–2.9).
CONCLUSIONSWomen aged 25 to 30 years had more awareness and understanding of PFDs compared with adolescent women. These data may have implications for primary prevention strategies of PFDs.
Acute kidney injury (AKI) and disordered fluid balance are common in premature neonates; a positive fluid balance dilutes serum creatinine, and a negative fluid balance concentrates serum creatinine, ...both of which complicate AKI diagnosis. Correcting serum creatinine for fluid balance may improve diagnosis and increase diagnostic accuracy for AKI.
To determine whether correcting serum creatinine for fluid balance would identify additional neonates with AKI and alter the association of AKI with short-term and long-term outcomes.
This study was a post hoc cohort analysis of the Preterm Erythropoietin Neuroprotection Trial (PENUT), a phase 3, randomized clinical trial of erythropoietin, conducted at 19 academic centers and 30 neonatal intensive care units in the US from December 2013 to September 2016. Participants included extremely premature neonates born at less than 28 weeks of gestation. Data analysis was conducted in December 2022.
Diagnosis of fluid-corrected AKI during the first 14 postnatal days, calculated using fluid-corrected serum creatinine (defined as serum creatinine multiplied by fluid balance calculated as percentage change from birth weight divided by total body water estimated 80% of birth weight).
The primary outcome was invasive mechanical ventilation on postnatal day 14. Secondary outcomes included death, hospital length of stay, and severe bronchopulmonary dysplasia (BPD). Categorical variables were analyzed by proportional differences with the χ2 test or Fisher exact test. The t test and Wilcoxon rank sums test were used to compare continuous and ordinal variables, respectively. Odds ratios (ORs) and 95% CIs for the association of exposure with outcomes of interest were estimated using unconditional logistic regression models.
A total of 923 premature neonates (479 boys 51.9%; median IQR birth weight, 801 668-940 g) were included, of whom 215 (23.3%) received a diagnosis of AKI using uncorrected serum creatinine. After fluid balance correction, 13 neonates with AKI were reclassified as not having fluid-corrected AKI, and 111 neonates previously without AKI were reclassified as having fluid-corrected AKI (ie, unveiled AKI). Therefore, fluid-corrected AKI was diagnosed in 313 neonates (33.9%). Neonates with unveiled AKI were similar in clinical characteristics to those with AKI whose diagnoses were made with uncorrected serum creatinine. Compared with those without AKI, neonates with unveiled AKI were more likely to require ventilation (81 neonates 75.0% vs 254 neonates 44.3% and have longer hospital stays (median IQR, 102 84-124 days vs 90 71-110 days). In multivariable analysis, a diagnosis of fluid-corrected AKI was associated with increased odds of adverse clinical outcomes, including ventilation (adjusted OR, 2.23; 95% CI, 1.56-3.18) and severe BPD (adjusted OR, 2.05; 95% CI, 1.15-3.64).
In this post hoc cohort study of premature neonates, fluid correction increased the number of premature neonates with a diagnosis of AKI and was associated with increased odds of adverse clinical outcomes, including ventilation and BPD. Failing to correct serum creatinine for fluid balance underestimates the prevalence and impact of AKI in premature neonates. Future studies should consider correcting AKI for fluid balance.
ClinicalTrials.gov Identifier: NCT01378273.
Objectives
Specialist healthcare cannot be provided in all locations. Helicopters can help to reduce the inherent geographical inequity caused by long distances or difficult terrain. However, the ...selective use of aeromedical retrieval could lead to other forms of health disparities. The aim of this project was to evaluate such inequities in access to helicopter transport.
Methods
This was a geospatial analysis of publicly available flight tracking data for 18 emergency medical helicopters in the state of Alabama for a 90‐day period between March 2019 and June 2019. Data are presented as the number of incidents attended per population, by population (total, insured, and uninsured), as funnel plots, by county. This method allows the identification of positive and negative outliers.
Results
We identified 672 likely scene retrieval flights. Twelve counties were probable (outside of 99% confidence interval CI) high outliers (more helicopter retrievals than expected), and 4 were possible (outside of 95% CI) high outliers. There were 5 possible low outliers (fewer helicopter retrievals than expected) and 6 probable low outliers. Analysis by insurance status revealed similar results. However, there was no easily discernible geographic pattern to this variability.
Conclusion
There is considerable geographical variability in the number of helicopter retrievals, with no easily discernable pattern. Some of this variability may be due to differences in injury epidemiology, but others may be due to case selection. However, the present data are insufficient to come to firm conclusions, and additional study is warranted.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
BackgroundTrauma is a major public health issue. In 2015, the White House launched the “Stop the Bleed” (STB) campaign, which aims to equip would-be bystanders with the ability and equipment to ...assist in bleeding emergencies. This study sought to estimate the number of patients who might benefit from STB intervention, in an everyday setting, and their spatial injury profile.MethodsThis is a retrospective analysis of trauma registry and medical examiners’ data, collected between 2013 and 2017. The majority of patients were male. The median age was 32 years. Incidents were geocoded by ZIP code, and mapped using Quantum Geographic Information System (QGIS).ResultsWe identified 139 patients from medical examiner records and UAB’s trauma registry who might have benefitted from STB intervention. The number of incidents per year ranged from 22 to 35, averaging 2.3 incidents per month. There was no evidence of geographical clustering, although the small number of incidents precluded a formal geostatistical analysis.ConclusionThe number of patients who might benefit from STB interventions on a daily basis is small, and incident locations are difficult to predict. Educating the public in how to stop bleeding is appealing, but providing easy and widespread access to STB kits may be difficult. Although there are parallels to the provision of cardiopulmonary resuscitation and defibrillation for cardiac arrest, there are also differences, which should not be overlooked.
PURPOSE:To present information about a study of risk factors for development of pressure ulcers (PrUs) in trauma patients.
TARGET AUDIENCE:This continuing education activity is intended for ...physicians and nurses with an interest in skin and wound care.
OBJECTIVES/OUTCOMES:After participating in this educational activity, the participant should be better able to:1. Describe the previous PrU research, scope of the problem, and methodology of the study.2. Explain the results of the study identifying PrU risk factors for trauma patients.
ABSTRACT OBJECTIVE:Pressure ulceration prevention has been emphasized over the past several years in inpatient hospital settings with subsequent decreases in the development of pressure ulcers (PrUs). However, there remains a subset of trauma and burn patients that develop PrUs despite standard screening methodology and prophylaxis. This study determines the conditions that predict development of pressure ulcers (PrUs) despite conventional prophylaxis and screening. METHODSDemographic and PrU data were collected over a 5-year period from June 2008 to May 2013. Patients diagnosed with PrUs upon arrival in the trauma bay were excluded from analysis. An ordinal logistic regression of PrU stage was used to estimate odds ratios (ORs) and associated 95% confidence intervals (CIs) for the association between characteristics of interest and odds of a PrU. A backward selection process was used to select the most parsimonious model. RESULTSDuring the study period, 14,616 trauma patients were admitted and had available data. A total of 124 patients (0.85%) that met inclusion criteria went on to develop PrUs during their hospital course. Factors associated with the development of PrUs included spine Abbreviated Injury Scale (AIS) >3 (OR, 5.72; CI, 3.63–9.01), mechanical ventilation (OR, 1.95; CI, 1.23–3.10) and age 40 to 64 (OR, 2.09; CI, 1.24–3.52) and age ≥ 65 (OR, 4.48; CI, 2.52–7.95). Interestingly, head injury AIS >3 was protective from the development of PrUs (OR, 0.56; CI, 0.32–0.96). Hypotension and shock defined as systolic BP <90 mm Hg and base deficit less than –6 were not associated with the development of PrUs. In addition, body mass index was not associated with PrU development. CONCLUSIONSSpinal injuries, older than age 40, and mechanical ventilation predict the development of PrUs for a subset of patients, despite conventional prophylaxis and screening. Advanced prevention methods, such as low-air-loss mattresses for these patient subgroups should be considered immediately upon identification of these risk factors during the hospital course.
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