Trauma in adults experiencing homelessness Miller, Jean-Philippe; O’ Reilly, Gerard M.; Mackelprang, Jessica L. ...
Injury,
April 2020, 2020-Apr, 2020-04-00, 20200401, Letnik:
51, Številka:
4
Journal Article
Recenzirano
•Homeless patients were more likely to present after assault or intentional self-harm and with penetrating injury and lower injury severity scores.•Homeless patients had higher rates of psychiatric ...admissions and discharging against medical advice.•Lack of standardized definitions and identification procedures are barriers to effectively studying the needs of patients who are homeless.•Systematic methods for documenting homelessness in healthcare settings are required in order to better understand and serve this population. Further research is required in order to fully understand injury epidemiology among homeless patients and to optimize trauma outcomes in this population.
Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients.
A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or ‘No fixed abode’ address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism.
Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2–10), compared to 9(4–17) for domiciled patients (p < 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS>12 (OR 0.5, 95% CI: 0.3–0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1–3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09).
Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services
Zoonomia is the largest comparative genomics resource for mammals produced to date. By aligning genomes for 240 species, we identify bases that, when mutated, are likely to affect fitness and alter ...disease risk. At least 332 million bases (~10.7%) in the human genome are unusually conserved across species (evolutionarily constrained) relative to neutrally evolving repeats, and 4552 ultraconserved elements are nearly perfectly conserved. Of 101 million significantly constrained single bases, 80% are outside protein-coding exons and half have no functional annotations in the Encyclopedia of DNA Elements (ENCODE) resource. Changes in genes and regulatory elements are associated with exceptional mammalian traits, such as hibernation, that could inform therapeutic development. Earth's vast and imperiled biodiversity offers distinctive power for identifying genetic variants that affect genome function and organismal phenotypes.
To estimate the generalizability of treatment effects observed in the VANCO trial to a broader population of patients with tibial plateau or pilon fractures.
Design and Setting: Clinical trial data ...from 36 United States trauma centers and Trauma Quality Programs registry data from more than 875 Level I-III trauma centers in the United States and Canada.Patient Selection Criteria: Patients enrolled in the VANCO trial treated with intrawound vancomycin powder from January 2015 to June 2017 and 31,924 VANCO-eligible TQP patients admitted in 2019 with tibial plateau and pilon fractures.Outcome Measure and Comparisons: Deep surgical site infection and gram-positive deep surgical site infection estimated in the TQP sample weighed by the inverse probability of trial participation.
The 980 patients in the VANCO trial were highly representative of 31,924 TQP VANCO-eligible patients (Tipton generalizability index 0.96). It was estimated that intrawound vancomycin powder reduced the odds of deep surgical infection by odds ratio (OR) = 0.46 (95% confidence interval CI 0.25-0.86) and gram-positive deep surgical infection by OR = 0.39 (95% CI, 0.18-0.84) within the TQP sample of VANCO-eligible patients. For reference, the trial average treatment effects for deep surgical infection and gram-positive deep surgical infection were OR = 0.60 (95% CI, 0.37-0.98) and OR = 0.44 (95% CI, 0.23-0.80), respectively.
This generalizability analysis found that the inferences of the VANCO trial generalize and might even underestimate the effects of intrawound vancomycin powder when observed in a wider population of patients with tibial plateau and pilon fractures.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study ...compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation.
This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work.
The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval CI = 2.0 to 10.7). Improvements were largest for pilon/ankle fractures and complex injury patterns.
Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Abstract Autosomal dominant osteopetrosis type II (ADO2) is a heritable osteosclerotic bone disorder due to dysfunctional osteoclast activity. ADO2 is caused by missense mutations in the chloride ...channel 7 ( CLCN7 ) gene characterized by osteosclerosis with multiple fractures. ADO2 can result in osteomyelitis, visual loss and bone marrow failure. Currently, there is no cure for ADO2, and until recently no appropriate animal model of ADO2 existed to understand better the pathogenesis of this disease and to test new therapies. Therefore, we created ADO2 knock-in mouse model with a G213R (human homolog of G215R) missense mutation in the Clcn7 gene on 129S1 background, and demonstrated that this mouse model phenocopies human ADO2. As ADO2 gives rise to incomplete penetrance (66%) in human and marked phenotypic variability is observed among patients with the same mutation, we hypothesized that the severity and penetrance of ADO2 will also vary in mouse models on different genetic backgrounds. To test this, we created ADO2 mouse models in DBA/D2, C57BL/6J/B6 and Balb/c strains, and compared bone phenotypes and performed serum biochemical analysis between strain- and age-matched wild-type (WT) and ADO2 mice. At 3 months of age, whole body aBMD was higher (4
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7% in male; 1
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5% in female) in the ADO2 mice compared to their wild-type littermates. In addition, ADO2 male mice on 129 background displayed highest percent increase of BV/TV (106%), followed by D2 (92%), B6 (46%), and Balb/c (33%) compared to strain-matched wild-type mice. We observed similar differences for BV/TV between ADO2 and wild-type mice on different genetic backgrounds in female: 129 (96%) > D2 (73%) > Balb/c (39%) and B6 (36%). Serum calcium, phosphorus , alkaline phosphatase and P1NP levels were similar in the WT and ADO2 mice on all genetic backgrounds but TRAP was higher (76% to 220% in male; 33
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95% in female) and CTX/TRAP ratio was lower (39
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65% in male and 3
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41% in female) in the ADO2 mice compared to their strain-matched wild-type littermates. We also found that young ( 3 months ) ADO2 mice on 129S1 background exhibited 200% higher trabecular BV/TV whereas old (18 months) ADO2 mice displayed 400
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700% higher BV/TV compared to their age-matched wild-type controls. In summary, phenotypic severity in ADO2 mice varied markedly on different genetic backgrounds (129 > D2 > Balb/c > B6) and became more pronounced with age, which resembles the wide variations in phenotype observed in ADO2 patients. These mouse models will help us to identify genes/factors that influence severity and penetrance of ADO2, and test innovative therapies to treat this disease.
It is well established that magnetic components may be reduced in size by operating at high frequency. Miniaturization of magnetic components is ideally suited to microelectronics technologies such ...as thick films, which lend them to planar geometries. This paper describes new analytical models, which predict inductance- and frequency-dependent eddy-current losses in magnetic substrates. Prototype devices were fabricated by a thick-film process with four layers of conductors on a single ferrite substrate and in a sandwich configuration, consisting of conductors between ferrite slabs. The prototype devices were tested in the frequency range 10 kHz-100 MHz. The measurements confirm the validity of the analytical models. Simulation with finite-element analysis was employed to identify different sources of losses: eddy current losses in ferrite substrates; proximity effect losses in conductors; and dielectric losses.
Global intelligent networking issues at the physical, transport, routing, and service levels are discussed. Factors that are required for global intelligent networking in the coming age in terms of ...architecture and technology are identified. Areas in which extensive studies and technical breakthroughs are required for realization of the global intelligent network are described.< >
