ObjectivePhysical distancing and stay-at-home measures implemented to slow transmission of novel coronavirus disease (COVID-19) may intensify feelings of loneliness in older adults, especially those ...living alone. Our aim was to characterise the extent of loneliness during the first wave in a sample of older adults living in the community and assess characteristics associated with loneliness.DesignOnline cross-sectional survey between 6 May and 19 May 2020.SettingOntario, Canada.ParticipantsConvenience sample of members of a national retired educators’ organisation.Primary outcome measuresSelf-reported loneliness, including differences between women and men.Results4879 respondents (71.0% women; 67.4% 65–79 years) reported that in the preceding week, 43.1% felt lonely at least some of the time, including 8.3% who felt lonely always or often. Women had increased odds of loneliness compared with men, whether living alone (adjusted OR (aOR) 1.52, 95% CI 1.13 to 2.04) or with others (2.44, 95% CI 2.04 to 2.92). Increasing age group decreased the odds of loneliness (aOR 0.69 (95% CI 0.59 to 0.81) 65–79 years and 0.50 (95% CI 0.39 to 0.65) 80+ years compared with <65 years). Living alone was associated with loneliness, with a greater association in men (aOR 4.26, 95% CI 3.15 to 5.76) than women (aOR 2.65, 95% CI 2.26 to 3.11). Other factors associated with loneliness included: fair or poor health (aOR 1.93, 95% CI 1.54 to 2.41), being a caregiver (aOR 1.18, 95% CI 1.02 to 1.37), receiving care (aOR 1.47, 95% CI 1.19 to 1.81), high concern for the pandemic (aOR 1.55, 95% CI 1.31 to 1.84), not experiencing positive effects of pandemic distancing measures (aOR 1.94, 95% CI 1.62 to 2.32) and changes to daily routine (aOR 2.81, 95% CI 1.96 to 4.03).ConclusionsWhile many older adults reported feeling lonely during COVID-19, several characteristics—such as being female and living alone—increased the odds of loneliness. These characteristics may help identify priorities for targeting interventions to reduce loneliness.
Management of splenic trauma has changed dramatically over the past 30 years. Many of these advances were driven by the Memphis team under the leadership of Dr. Timothy Fabian. This review article ...summarizes some of those changes in clinical care, especially related to nonoperative management and angioembolization.
Frailty has been increasingly recognized as a modifiable risk factor prior to elective general surgery. There is limited evidence regarding the association of frailty with perioperative outcomes ...after specific emergency general surgery procedures.
A retrospective cohort study of 57,173 patients older than 40 y of age from 2010 to 2014 American College of Surgeons National Surgical Quality Improvement Program underwent appendectomy, cholecystectomy, large bowel resection, small bowel resection, or nonbowel resection (lysis of adhesion, ileostomy creation) on an emergent basis. Preoperative modified frailty index (mFI) was determined for each patient and was used in a multivariable logistic regression to determine the association with perioperative morbidity, mortality, and discharge destination.
A total of 57,173 patients (46% men, mean SD age 60 13 y) underwent an emergency appendectomy (n = 26,067), cholecystectomy (n = 8138), large bowel resection (n = 12,107), small bowel resection (n = 6503), or nonbowel resection (n = 4358). Among them, 14,300 (25.0%) experienced any perioperative complication, and 12,668 (22.2%) experienced a serious complication with an overall 30-d mortality of 5.1%. Highly frail patients had a 30-d mortality of 19.0% across all five operations. In multivariable analysis, mFI was associated with any complication and 30-d mortality in a step-wise fashion for each emergency operation. Intermediate and high mFI were also inversely associated with discharge home for each operation.
Frailty is associated with increased perioperative morbidity and mortality in common emergency general surgery operations. Frailty should be assessed by surgeons to inform decisions on operative intervention and to inform patients/families on expected outcomes.
Full text
Available for:
GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The current health care environment is complex. Systems often cross US state boundaries to provide care to patients with a wide variety of medical needs. The coronavirus disease 2019 pandemic is ...challenging health care systems across the globe. Systems face varying levels of complexity as they adapt to the new reality. This pandemic continues to escalate in hot spots nationally and internationally, and the worst strain on health care systems may be yet to come. The purpose of this article is to provide a road map developed from lessons learned from the experience in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health and University of Wisconsin Health, based on past experience with incident command structures in military combat operations and Federal Emergency Management Agency responses. We will discuss administrative restructuring leveraging a team-of-teams approach, provide a framework for deploying the workforce needed to deliver all necessary urgent health care and critical care to patients in the system, and consider implications for the future.
5-Aminosalicylic acid (5-ASA), a peroxisome proliferator-activated receptor gamma (PPAR-γ) agonist, is a widely used first-line medication for the treatment of ulcerative colitis, but its ...anti-inflammatory mechanism is not fully resolved. Here, we show that 5-ASA ameliorates colitis in dextran sulfate sodium (DSS)-treated mice by activating PPAR-γ signaling in the intestinal epithelium. DSS-induced colitis was associated with a loss of epithelial hypoxia and a respiration-dependent luminal expansion of
, which could be ameliorated by treatment with 5-ASA. However, 5-ASA was no longer able to reduce inflammation, restore epithelial hypoxia, or blunt an expansion of
in DSS-treated mice that lacked
expression specifically in the intestinal epithelium. These data suggest that the anti-inflammatory activity of 5-ASA requires activation of epithelial PPAR-γ signaling, thus pointing to the intestinal epithelium as a potential target for therapeutic intervention in ulcerative colitis.
An expansion of
in the fecal microbiota is a microbial signature of dysbiosis that is linked to many noncommunicable diseases, including ulcerative colitis. Here, we used
, a representative of the
, to show that its dysbiotic expansion during colitis can be remediated by modulating host epithelial metabolism. Dextran sulfate sodium (DSS)-induced colitis reduced mitochondrial activity in the colonic epithelium, thereby increasing the amount of oxygen available to fuel an
expansion through aerobic respiration. Activation of epithelial peroxisome proliferator-activated receptor gamma (PPAR-γ) signaling with 5-aminosalicylic acid (5-ASA) was sufficient to restore mitochondrial activity and blunt a dysbiotic
expansion. These data identify the host's epithelial metabolism as a potential treatment target to remediate microbial signatures of dysbiosis, such as a dysbiotic
expansion in the fecal microbiota.
The massive transfusion (MT) concept (>10-U packed red blood cells per 24 hours) is retrospective, arbitrary, and prone to survivor bias. Accounting for rate and timing is a more accurate conceptual ...framework. We redefined MT as a critical administration threshold (CAT) of 3 U/h, which is clinically pertinent and reflects hemorrhagic shock. The purpose of this study was to compare the traditional form of MT to a CAT definition in predicting mortality.
Patients receiving transfusion in the first 24 hours were included. Precise transfusion times for each unit, in minutes, were calculated from time of injury. MT and CAT were compared to determine risk of death. Univariate and multivariate analyses were used to examine inpatient mortality.
A total of 169 patients(70%, >10 New Injury Severity Score NISS) were studied; 46% were CAT+; 22% met the MT criteria. With logistic regression, a CAT of 3 U/h (CAT+) was more predictive of death compared with 2, 4, 5, or 6 U/h. CAT was met once (CAT 1), twice (CAT 2) or more than 3 times (CAT 3) in 21%, 14%, and 11%, respectively. Increasing CAT was associated with increased mortality. CAT identified 75% of all deaths; MT only identified 33% and failed to identify 42% of CAT+ deaths. CAT (relative risk RR 3.58; 95% confidence interval CI 1.80-7.15) had a stronger association with mortality compared with MT(RR, 1.82; 95% confidence interval, 1.02-3.26).
The traditional definition of MT is inadequate to reflect illness severity. Using CATs allows prospective identification of critically ill trauma patients and eliminates survivor bias. CAT may serve as an activation trigger for transfusion protocols, allowing early identification of patients with critical transfusion requirements. Clinical trials involving transfusion strategies should consider CAT as an instrument for evaluating outcomes.
Diagnostic/prognostic study, level II.
Definitions of massive transfusion (MT), 10 or more units of packed red blood cells (PRBCs) in 24 hours, focus on static volumes over fixed times. This arbitrary volume definition promotes survivor ...bias and fails to identify the "massively" transfused patient. In previous work, the critical administration threshold (CAT) was created to incorporate both rate and volume of transfusion. CAT proved a superior predictor of mortality compared with traditional MT. The purpose of this study was to prospectively validate CAT in a larger trauma population.
Patients receiving at least 1 U of PRBCs within the first day of admission were identified prospectively. Administration time of each unit of PRBCs was recorded in minutes. CAT status, defined as receipt of at least 3 U of blood in a 60-minute period, was identified for the first 24 hours. CAT+ patients were quantified by the number of times CAT+ was reached, that is, once (CAT1), twice (CAT2), three times (CAT3), or 4 or more times (CAT4). A multivariable Cox proportional hazard model with a time-varying covariate was used to quantify a patient's risk of death with increasing CAT status.
A total of 316 met inclusion criteria, 161 of whom were CAT+. Seventy-six percent were male, mean age was 38 years, and median Injury Severity Score (ISS) was 15. CAT+ was associated with a twofold increased risk of death (hazard ratio, 1.809; 95% confidence interval, 1.020-3.209). Ninety-one patients were CAT+ and received less than 10 U of blood, thereby MT- (CAT+/MT-). CAT+/MT- had significant injury patterns, with a median ISS of 14, 43% penetrating injury, and 10% mortality.
CAT allows early identification of injured patients at greatest risk of death. Encompassing both rate and volume of transfusion, CAT is a tool more sensitive than common MT definitions. Studies examining large-volume blood transfusions should use CAT to identify patients, to accurately identify cohorts of interest.
Diagnostic tests, level II.
Aggressive screening to diagnose blunt cerebrovascular injury (BCVI) results in early treatment, leading to improved outcomes and reduced stroke rates. While computed tomographic angiography (CTA) ...has been widely adopted for BCVI screening, evidence of its diagnostic sensitivity is marginal. Previous work from our institution using 32-channel multidetector CTA in 684 patients demonstrated an inadequate sensitivity of 51% (Ann Surg. 2011,253: 444-450). Digital subtraction angiography (DSA) continues to be the reference standard of diagnosis but has significant drawbacks of invasiveness and resource demands. There have been continued advances in CT technology, and this is the first report of an extensive experience with 64-channel multidetector CTA.
Patients screened for BCVI using CTA and DSA (reference) at a Level 1 trauma center during the 12-month period ending in May 2012 were identified. Results of CTA and DSA, complications, and strokes were retrospectively reviewed and compared.
A total of 594 patients met criteria for BCVI screening and underwent both CTA and DSA. One hundred twenty-eight patients (22% of those screened) had 163 injured vessels: 99 (61%) carotid artery injuries and 64 (39%) vertebral artery injuries. Sixty-four-channel CTA demonstrated an overall sensitivity per vessel of 68% and specificity of 92%. The 52 false-negative findings on CTA were composed of 34 carotid artery injuries and 18 vertebral artery injuries; 32 (62%) were Grade I injuries. Overall, positive predictive value was 36.2%, and negative predictive value was 97.5%. Six procedure-related complications (1%) occurred with DSA, including two iatrogenic dissections and one stroke.
Sixty-four-channel CTA demonstrated a significantly improved sensitivity of 68% versus the 51% previously reported for the 32-channel CTA (p = 0.0075). Sixty-two percent of the false-negative findings occurred with low-grade injuries. Considering complications, cost, and resource demand associated with DSA, this study suggests that 64-channel CTA may replace DSA as the primary screening tool for BCVI.
Diagnostic study, level III.
Objective: The proliferation of electric scooter sharing companies has inundated many municipalities with electric scooters. The primary objective of this study is to characterize the epidemiology of ...injuries from this new mode of transportation in order to inform injury prevention efforts.
Methods: A multicenter, retrospective study was conducted at two level 1 trauma centers in an urban setting. Patients seen in the emergency department from September 4, 2018 to November 4, 2018 were included if injury coding and chart review identified a scooter-related injury. Demographics, injury patterns, and other injury related factors were obtained via chart review.
Results: Ninety-two patients were identified over the study period in 2018 with electric scooter-related injuries. Of the patients utilizing an electric scooter; none used protective gear and 33% used alcohol prior to presentation. More than 60% of patients required medical intervention including laceration repair (26%), fracture reduction (17%), operative fixation of a fracture (7%), or arterial embolization for an associated arterial injury (1%). Approximately 10% of patients required inpatient admission and one required an admission to the intensive care unit.
Conclusion: We found a substantial increase in the number of scooter-related injuries during the first two months of electric scooter legalization. There was a lack of safety equipment utilization and concomitant alcohol utilization was common. These may offer areas of focus for injury prevention efforts. Additionally, standardization of injury coding for electric scooter related injury is critical to future studies and will help better understand the impact of this new mode of transportation.
Full text
Available for:
BFBNIB, GIS, IJS, KISLJ, NUK, PNG, UL, UM, UPUK
PDF
