Nonconventional ventilators (NCVs), defined here as transport ventilators and certain noninvasive positive pressure devices, were used extensively as crisis-time ventilators for intubated patients ...with COVID-19. We assessed whether there was an association between the use of NCV and higher mortality, independent of other factors.
This is a multicenter retrospective observational study.
The sample was recruited from a single healthcare system in New York. The recruitment period spanned from March 1, 2020, to April 30, 2020.
The sample includes patients who were intubated for COVID-19 acute respiratory distress syndrome (ARDS).
None.
The primary outcome was 28-day in-hospital mortality. Multivariable logistic regression was used to derive the odds of mortality among patients managed exclusively with NCV throughout their ventilation period compared with the remainder of the sample while adjusting for other factors. A secondary analysis was also done, in which the mortality of a subset of the sample exclusively ventilated with NCV was compared with that of a propensity score-matched subset of the control group. Exclusive use of NCV was associated with a higher 28-day in-hospital mortality while adjusting for confounders in the regression analysis (odds ratio, 1.41; 95% CI 1.07-1.86). In the propensity score matching analysis, the mortality of patients exclusively ventilated with NCV was 68.9%, and that of the control was 60.7% (p = 0.02).
Use of NCV was associated with increased mortality among patients with COVID-19 ARDS. More lives may be saved during future ventilator shortages if more full-feature ICU ventilators, rather than NCVs, are reserved in national and local stockpiles.
To test the hypothesis that macrophage migration inhibitory factor (MIF) is elevated in the circulation of individuals with acute spinal cord injury (SCI) compared with uninjured individuals.
...Prospective, observational pilot study.
Academic medical center.
Adults with acute traumatic SCI (n=18) and uninjured participants (n=18), comparable in age and sex distribution.
Not applicable.
The primary outcome measure was the plasma MIF levels. Potential correlations were examined between MIF and clinical/demographic variables. The secondary outcome was to determine if other immune mediators were elevated in participants with acute SCI and if their levels correlated with the MIF.
MIF was significantly elevated in subjects with acute SCI compared with control subjects at 0 to 3 (P<.0029), 4 to 7 (P<.0001), and 8 to 11 (P<.0015) days postinjury (DPI). At 0 to 3 DPI, levels of cytokines interleukin-6 (P<.00017), interleukin-9 (P<.0047), interleukin-16 (P<.007), interleukin-18 (P<.014), chemokines growth-related oncogene α/chemokine (C-X-C motif) ligand 1 (P<.0127) and macrophage inflammatory protein 1-β/chemokine (C-C motif) ligand 4 (P<.0015), and growth factors hepatocyte growth factor (HGF) (P<.0001) and stem cell growth factor-β (P<.0103) were also significantly elevated in subjects with acute SCI. With the exception of interleukin-9, all of these factors remained significantly elevated at 4 to 7 DPI; a subset (interleukin-16, HGF, stem cell growth factor-β) remained elevated throughout the study. Within individuals, MIF levels correlated with HGF (P<.018) and interleukin-16 (P<.01).
These data demonstrate that MIF is significantly elevated in subjects with acute SCI, supporting further investigation of MIF and other inflammatory mediators in acute SCI, where they may contribute to primary and secondary functional outcomes.
The emotional toll and financial cost of end-of-life care can be high. Existing literature suggests that medical providers often choose to forego many aggressive interventions and life-prolonging ...therapies for themselves. To further investigate this phenomenon, we compared how providers make medical decisions for themselves versus for relatives and unrelated patients.
Between 2016 and 2019, anonymous surveys were emailed to physicians (attendings, fellows, and residents), nurse practitioners, physician assistances, and nurses at two multifacility tertiary medical centers. Participants were asked to decide how likely they would offer a tracheostomy and feeding gastrostomy to a hypothetical patient with a devastating neurological injury and an uncertain prognosis. Participants were then asked to reconsider their decision if the patient was their own family member or if they themselves were the patient. The Kruskal–Wallis H, Mann–Whitney U, and Tukey tests were used to compare quantitative data. Statistical significance was set at P < 0.05.
Seven hundred seventy-three surveys were completed with a 10% response rate at both institutions. Regardless of professional identity, age, or gender, providers were significantly more likely to recommend a tracheostomy and feeding gastrostomy to an unrelated patient than for themselves. Professional identity and age of the respondent did influence recommendations made to a family member.
We demonstrate that medical practitioners make different end-of-life care decisions for themselves compared with others. It is worth investigating further why there is such a discrepancy between what medical providers choose for themselves compared with what they recommend for others.
Individuals with SCI are severely affected by immune system changes, resulting in increased risk of infections and persistent systemic inflammation. While recent data support that immunological ...changes after SCI differ in the acute and chronic phases of living with SCI, only limited immunological phenotyping in humans is available. To characterize dynamic molecular and cellular immune phenotypes over the first year, we assess RNA (bulk-RNA sequencing), protein, and flow cytometry (FACS) profiles of blood samples from 12 individuals with SCI at 0-3 days and at 3, 6, and 12 months post injury (MPI) compared to 23 uninjured individuals (controls). We identified 967 differentially expressed (DE) genes in individuals with SCI (FDR <0.001) compared to controls. Within the first 6 MPI we detected a reduced expression of NK cell genes, consistent with reduced frequencies of CD56
, CD56
NK cells present at 12 MPI. Over 6MPI, we observed increased and prolonged expression of genes associated with inflammation (e.g. HMGB1, Toll-like receptor signaling) and expanded frequencies of monocytes acutely. Canonical T-cell related DE genes (e.g. FOXP3, TCF7, CD4) were upregulated during the first 6 MPI and increased frequencies of activated T cells at 3-12 MPI. Neurological injury severity was reflected in distinct whole blood gene expression profiles at any time after SCI, verifying a persistent 'neurogenic' imprint. Overall, 2876 DE genes emerge when comparing motor complete to motor incomplete SCI (ANOVA, FDR <0.05), including those related to neutrophils, inflammation, and infection. In summary, we identify a dynamic immunological phenotype in humans, including molecular and cellular changes which may provide potential targets to reduce inflammation, improve immunity, or serve as candidate biomarkers of injury severity.
There is increasing evidence of a link between the coronavirus disease 2019 (COVID-19) and venous and arterial thrombotic events. Here, we report a 60-year-old male patient with severe COVID-19 who ...developed extensive arterial thromboses and limb ischemia despite being on therapeutic-dose anticoagulation. While the exact mechanism for such events is unknown, our report highlights the importance of maintaining a high degree of suspicion in critically ill patients. Further research should focus on the mechanistic pathways along with the optimal anticoagulation and/or antithrombotic strategy.
This study aimed to determine whether a geriatrics-focused hospitalist trauma comanagement program improves quality of care. A pre-/post-implementation study compared older adult trauma patients who ...were comanaged by a hospitalist with those prior to comanagement at a level 1 trauma center. One-to-one propensity score matching was performed based on age, gender, Injury Severity Score, comorbidity index, and critical illness on admission. Outcomes included orders for geriatrics-focused quality indicators, as well as hospital mortality and length of stay. Wilcoxon rank-sum test (continuous variables) and chi-square or Fisher exact test (categorical variables) were used to assess differences. Propensity score matching resulted in 290 matched pairs. The intervention group had decreased use of restraints (P = 0.04) and acetaminophen (P = 0.01), and earlier physical therapy (P = 0.01). Three patients died in the intervention group compared with 14 in the control (P = 0.0068). This study highlights that a geriatrics-focused hospitalist trauma comanagement program improves quality of care.
Abstract Objective To test the hypothesis that the proinflammatory cytokine macrophage migration inhibitory factor (MIF) is elevated in the circulation of patients with chronic spinal cord injury ...(SCI) relative to uninjured subjects, and secondarily to identify additional immune mediators that are elevated in subjects with chronic SCI. Design Prospective, observational pilot study. Setting Outpatient clinic of a department of physical medicine and rehabilitation and research institute in an academic medical center. Participants Individuals with chronic (>1y from initial injury) SCI (n=22) and age- and sex-matched uninjured subjects (n=19). Interventions Not applicable. Main Outcome Measures Plasma levels of MIF, as determined by a commercially available multiplex suspension immunoassay. The relationship between MIF levels and clinical/demographic variables was also examined. As a secondary outcome, we evaluated other cytokines, chemokines, and growth factors. Results Plasma MIF levels were significantly higher in subjects with chronic SCI than in control subjects ( P <.001). Elevated MIF levels were not correlated significantly with any one clinical or demographic characteristic. Subjects with SCI also exhibited significantly higher plasma levels of monokine induced by interferon-gamma/chemokine C-X-C motif ligand 9 ( P <.03), macrophage colony stimulating factor ( P <.035), interleukin-3 ( P <.044), and stem cell growth factor beta (SCGF-β) ( P <.016). Among subjects with SCI, the levels of SCGF-β increased with the time from initial injury. Conclusions These data confirm the hypothesis that MIF is elevated in subjects with chronic SCI and identify additional novel immune mediators that are also elevated in these subjects. This study suggests the importance of examining the potential functional roles of MIF and other immune factors in subjects with chronic SCI.
Objective
We aimed to assess differences in (1) first‐pass intubation success, (2) frequency of a hypoxic event, and (3) time from decision to intubate to successful intubation among direct ...laryngoscopy (DL) versus video laryngoscopy (VL) intubations in emergency department (ED) patients with traumatic injuries.
Methods
This retrospective cohort study was performed at a Level I trauma center ED where trauma activations are video recorded. All patients requiring a Level I trauma activation and intubation from 2016 through 2019 were included. Multivariable logistic regression was used to assess the association between initial method of intubation and first‐pass success. Differences in frequency of a hypoxic event and time to successful intubation were assessed using bivariate tests.
Results
Of 164 patients, 68 (41.5%) were initially intubated via DL and 96 (58.5%) were initially intubated via VL. First‐pass success for DL and VL were 63.2% and 79.2%, respectively. In multivariable regression analysis, VL was associated with higher odds of first‐pass intubation success compared with DL (odds ratio: 2.28; 95% confidence interval: 1.04, 4.98), independent of mechanism of injury, presence of airway hemorrhage or obstruction, and experience of intubator. Frequency of a hypoxic event during intubation was not significantly different (13.2% for DL and 7.3% VL; P = 0.1720). Median time from decision to intubate to successful intubation was 7 minutes for both methods.
Conclusions
Video laryngoscopy, compared with direct laryngoscopy, was associated with higher odds of first‐pass intubation success among a sample of ED trauma patients. Frequency of a hypoxic event during intubation and time to successful intubation was not significantly different between the 2 intubation methods.
Objective:
To identify clinical or demographic variables that influence long-term mortality, as well as in-hospital mortality, with a particular focus on the effects of age.
Summary and Background ...Data:
Cervical spine fractures with or without spinal cord injury (SCI) disproportionately impact the elderly who constitute an increasing percentage of the US population.
Methods:
We analyzed data collected for 10 years at a state-designated level I trauma center to identify variables that influenced in-hospital and long-term mortality among elderly patients with traumatic cervical spine fracture with or without SCI. Acute in-hospital mortality was determined from hospital records and long-term mortality within the study period (2003-2013) was determined from the National Death Index. Univariate and multivariate regression analyses were used to identify factors influencing survival.
Results:
Data from patients (N = 632) with cervical spine fractures were analyzed, the majority (66%) of whom were geriatric (older than age 64). Most patients (62%) had a mild/moderate injury severity score (ISS; median, interquartile range: 6, 5). Patients with SCI had significantly longer lengths of stay (14.1 days), days on a ventilator (3.5 days), and higher ISS (14.9) than patients without SCI (P < .0001 for all). Falls were the leading mechanism of injury for patients older than age 64. Univariate analysis identified that long-term survival decreased significantly for all patients older than age 65 (hazard ratio HR: 1.07; P < .0001). Multivariate analysis demonstrated age (HR: 1.08; P < .0001), gender (HR: 1.60; P < .0007), and SCI status (HR: 1.45, P < .02) significantly influenced survival during the study period.
Conclusion:
This study identified age, gender, and SCI status as significant variables for this study population influencing long-term survival among patients with cervical spine fractures. Our results support the growing notion that cervical spine injuries in geriatric patients with trauma may warrant additional research.
Isolated traumatic injuries to the pancreas are extremely unusual and diagnosis may be difficult due to delay in presentation and subtlety of symptoms.
We describe a patient who presented 24 hours ...after sustaining blunt abdominal trauma and was found to have a complete pancreatic neck transection on computed tomography with no other injuries. The patient underwent a distal pancreatectomy and splenectomy which was complicated by a postoperative abscess on day 15. This was treated with percutaneous drainage and he has recovered well.
Pancreatic transection in the absence of associated injuries is rarely seen after blunt trauma but can result in devastating outcomes if left unrecognized. A high index of suspicion and early intervention are critical.
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