Severe influenza infection has no effective treatment available. One of the key barriers to developing host-directed therapy is a lack of reliable prognostic factors needed to guide such therapy. ...Here, we use a network analysis approach to identify host factors associated with severe influenza and fatal outcome. In influenza patients with moderate-to-severe diseases, we uncover a complex landscape of immunological pathways, with the main changes occurring in pathways related to circulating neutrophils. Patients with severe disease display excessive neutrophil extracellular traps formation, neutrophil-inflammation and delayed apoptosis, all of which have been associated with fatal outcome in animal models. Excessive neutrophil activation correlates with worsening oxygenation impairment and predicted fatal outcome (AUROC 0.817-0.898). These findings provide new evidence that neutrophil-dominated host response is associated with poor outcomes. Measuring neutrophil-related changes may improve risk stratification and patient selection, a critical first step in developing host-directed immune therapy.
ObjectivesTo establish the proportion of mild traumatic brain injury (mTBI) diagnosis among people presenting to an emergency department (ED), to determine the accuracy of recorded ED diagnoses. We ...also aimed to describe challenges in mTBI case identification and its acute hospital management.Design and settingA retrospective chart review of all ED attendances to a major trauma hospital, over a 9-month period (June 2015–February 2016).ParticipantsAdults aged 18–65 years consecutively presenting to an ED.Primary outcome measuresProportion of mTBI diagnosis among ED attendances (ie, confirmed mTBI based on the WHO criteria or indeterminate mTBI based on secondary criteria), and proportion of accurately recorded mTBI diagnosis by ED clinicians (ie, ‘mTBI’, ‘concussion’).ResultsOf 30 479 ED attendances, 351 (1.15%) confirmed mTBI diagnosis and 180 (0.6%) indeterminate diagnosis were identified. Only 81 (23.1%) individuals with a confirmed mTBI had a ‘mTBI diagnosis’ clearly recorded in the medical notes. Of the allocated discharge diagnosis codes to the two identified cohorts, 89.8% were not indicative of mTBI. Intracranial injuries were found in 31 (8.5%) confirmed cases. Glasgow Coma Scale scores were consistently assessed in the ED but identified only 117 (33.3%) confirmed mTBI cases. Post-traumatic amnesia (PTA) testing was able to confirm acute cognitive impairment in 113 (62.1%) of those who were tested (182, 51.3%).ConclusionsmTBI is a common, but an under-recognised cause for ED attendance. Despite challenges, the use of an operational definition such as the WHO diagnostic criteria can improve accuracy in mTBI identification. Acute management may be enhanced by rapid assessment of PTA.
Predicting the severity of COVID-19 remains an unmet medical need. Our objective was to develop a blood-based host-gene-expression classifier for the severity of viral infections and validate it in ...independent data, including COVID-19. We developed a logistic regression-based classifier for the severity of viral infections and validated it in multiple viral infection settings including COVID-19. We used training data (N = 705) from 21 retrospective transcriptomic clinical studies of influenza and other viral illnesses looking at a preselected panel of host immune response messenger RNAs. We selected 6 host RNAs and trained logistic regression classifier with a cross-validation area under curve of 0.90 for predicting 30-day mortality in viral illnesses. Next, in 1417 samples across 21 independent retrospective cohorts the locked 6-RNA classifier had an area under curve of 0.94 for discriminating patients with severe vs. non-severe infection. Next, in independent cohorts of prospectively (N = 97) and retrospectively (N = 100) enrolled patients with confirmed COVID-19, the classifier had an area under curve of 0.89 and 0.87, respectively, for identifying patients with severe respiratory failure or 30-day mortality. Finally, we developed a loop-mediated isothermal gene expression assay for the 6-messenger-RNA panel to facilitate implementation as a rapid assay. With further study, the classifier could assist in the risk assessment of COVID-19 and other acute viral infections patients to determine severity and level of care, thereby improving patient management and reducing healthcare burden.
Background: There is a wide variety of techniques to secure intravenous cannulas but little objective evidence to support their relative efficacy. This study compares the security of the two most ...common methods used within a major Australian Emergency Department. Methods: The plastic sheaths of four needle-less intravenous cannulas were secured to the skin surface (not intravenously) of 40 volunteers using two different taping styles, an ＂under and over＂ method with one of the tapes applied to the posterior surface of the hub then crossed anteriorly to adhere to the opposite skin surface or ＂horizontal＂ taping with the tapes applied horizontally across the anterior surface of the hub. The peak force required to dislodge the taped cannulas using each of these different methods was then measured in both an anterograde and retrograde direction of force using a force transducer. Results: The force required to dislodge a cannula taped in an 'under and over' taping style was significantly higher than that required for the horizontal taping in both anterograde and retrograde directions of force (p ＜ 0.001). Conclusions: The results of this study suggest that the ＂under and over＂ taping technique offers significantly more security than ＂horizontal＂ taping and should be considered as a more effective method for securing intravenous cannulas.
Clean-catch urine is essential in the investigation of an unwell child but can unfortunately be difficult to obtain in nontoilet-trained children. To this end, we compared the difference in time ...taken to collect clean-catch urine in nontoilet-trained children via the use of point-of-care ultrasound and traditional methods.
A single-center randomized controlled trial was conducted at an urban pediatric emergency department, recruiting 80 patients, of which 73 underwent data analyses. Participants were randomized to either the control arm, which consisted of the traditional "watch and wait" method of collecting a clean-catch sample, or to the intervention arm, which used point-of-care ultrasound to assess bladder volume and to stimulate the micturition reflex. The primary outcome measured was the mean time taken to collect a clean-catch urine sample.
Eighty patients (ultrasound, n = 41; standard care, n = 39) underwent randomization using a random number generator. Seven patients were removed from final analysis due to loss to follow-up for various reasons. Seventy-three patients (ultrasound, n = 37; standard care, n = 36) underwent statistical analysis. The ultrasound group had a median time to clean-catch urine of 40 minutes (interquartile range, 52) and mean time of 52 minutes (standard deviation, 42), and the control group had a median time of 55 minutes (interquartile range, 81), and mean time of 82 minutes (standard deviation, 90). This reached statistical significance (1-tail t test, P = 0.033). The baseline characteristics were similar between both groups for sex and age distribution; however, the mean ages were significantly different (2-tail t test, P = 0.049) with 8.4 months in the control group, and 12.3 months in the ultrasound group.
We found that there was a statistically and clinically significant reduction in mean time taken to collect clean-catch urine in nontoilet-trained children using point-of-care ultrasound compared with the traditional watch and wait method.
Objective
Patients intubated in the ED are at an increased risk of post‐intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to ...describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction.
Methods
This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre‐ and post‐intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre‐ and post‐intubation was the primary measure of haemodynamic stability.
Results
From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre‐intubation SBP exceeding 20%. Both propofol (P = 0.01) and ketamine (P = 0.01) had an independent and dose‐dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9.
Conclusion
Propofol was associated with post‐intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index; however, there was also an association with post‐intubation hypotension.
This multicentre study from Australia and New Zealand used prospectively collected data to determine haemodynamic changes in rapid sequence induction agents used in the ED. It found that propofol and ketamine had a dose‐dependent association with a reduction of systolic BP of >20% post‐intubation. Thiopentone was not associated with a reduction in BP.
•MRI assess severity of muscle injuries.•Specific imaging features estimate the return to play time.•Three clinico-radiological categories guide rehabilitation.
Injuries to the lower limb muscles are ...a common cause of absence from training and competition in athletes. The different muscular groups of the thigh and leg are involved in various activities with kicking and sprinting being responsible for the largest number of injuries. The muscle acts on bone through the tendon and the fascia. The failure of one or more of these structures results in various degrees of loss of function of the muscle(s) involved. Usually, the point of weakness is the interface between different structures with different elastic properties (myofascial, myotendinous, avulsion). Diagnostic imaging is best performed by MRI that provides valuable information about the severity of the injury and its anatomical extent. In this article, we will review the MRI features of muscle injuries which can be used to guide return to play. We will emphasize the clinical implications of the MRI findings by dividing the muscle injuries into three categories “The Good, The Bad and The Ugly” to help the clinician in the planning of the most appropriate rehabilitation strategy.
Several measures of medication exposure are associated with adverse outcomes in older people. Exposure to and the clinical outcomes of these measures in robust versus frail older inpatients are not ...known.
In older robust and frail patients admitted to hospital after a fall, we investigated the prevalence and clinical impact of fall-risk-increasing drugs (FRIDs), total number of medications, and drug-drug interactions (DDIs).
Patients ≥60 years of age admitted with a fall to a tertiary referral teaching hospital in Sydney were recruited and frailty was assessed. Data were collected at admission, discharge, and 2 months after admission.
A total of 204 patients were recruited (mean age 80.5 ± 8.3 years), with 101 robust and 103 frail. On admission, compared with the robust, frail participants had significantly higher mean ± SD number of FRIDs (frail 3.4 ± 2.2 vs. robust 1.6 ± 1.5, P < 0.0001), total number of medications (9.8 ± 4.3 vs. 4.4 ± 3.3, P < 0.0001), and DDI exposure (35 vs. 5 %, P = 0.001). Number of FRIDs on discharge was significantly associated with recurrent falls odds ratio (OR) 1.7 (95 % confidence interval CI 1.3-2.1), which were most likely to occur with 1.5 FRIDs in the frail and 2.5 FRIDs in the robust. Number of medications on discharge was also associated with recurrent falls OR 1.2 (1.0-1.3), but DDIs were not.
Exposure to FRIDs and other measures of high-risk medication exposures is common in older people admitted with falls, especially the frail. Number of FRIDs and to a lesser extent total number of medicines at discharge were associated with recurrent falls.
The Prevent Alcohol and Risk-related Trauma in Youth (P.A.R.T.Y.) program is an immersive hospital-based education program designed to reduce trauma in adolescents. The efficacy of the program in ...reducing risk-taking attitudes and preventing traumatic injuries has been proven through various methodologies. However, there is currently no study that has investigated the efficacy of the program using a validated, multi-domain questionnaire. This study outlines the design of the P.A.R.T.Y. Program Questionnaire (PPQ) and validates it through examining its construct and criterion validity as well as its internal consistency. Its capacity to risk-stratify participants was compared against the RT-18, a robust, 18-item risk-profiling instrument. The PPQ and the RT-18 were completed by New South Wales school students (N = 458) aged 15 to 18. The PPQ was designed in consultation with relevant field experts to optimise engagement and sensitivity. Examination of the construct validity of the PPQ was performed through exploratory factor analysis which demonstrated the presence of two underlying factors which aligned with the constructed two-scenario questionnaire format. The PPQ was shown to be internally consistent with a Cronbach's alpha of 0.77. Individual scenarios were shown to be internally consistent as well (α = 0.69, α = 0.66). The PPQ also identified high risk and low risk participants effectively as demonstrated by comparison against the risk stratification performed with the RT-18 (p-value < 0.001). This suggests the PPQ demonstrates criterion validity. Hence, the PPQ is an effective and valid tool for assessing risk-taking attitudes in adolescent populations.
Objective
To evaluate the association between time from ED presentation to intensive care unit (ICU) transfer on mortality in patients presenting with septic shock.
Methods
Adult patients with ...suspected septic shock enrolled in the Australasian Resuscitation in Sepsis Evaluation trial were included. The primary outcome of this post‐hoc analysis was 90‐day mortality. ED‐to‐ICU time was analysed as both a continuous variable and a binary variable (≤ vs >4 h). Analysis incorporated mixed effects regression, with ICU site as a random effect, time‐to‐event analysis and competing risks regression; all with and without inverse probability of treatment weighting to account for confounding baseline covariates.
Results
Data from 1301 patients were included. Median (interquartile range IQR) ED‐to‐ICU time was 4.3 (3.1, 6.3) hours, with 588 patients (45%) transferred within 4 h. The ≤4‐h group were younger, 64 (51, 74) versus 67 (52, 76) years (P = 0.04), with higher APACHE III scores, 50 (37, 65) versus 47 (35, 62) (P = 0.002), and higher unadjusted 90‐day mortality, odds ratio (OR) 1.53 (95% confidence interval 1.15, 2.03), P = 0.01. After adjustment for pre‐specified confounders, the 90‐day mortality OR was 1.09 (0.83, 1.44), P = 0.52. Adjusted for death as a competing event and illness severity, hospital length of stay was similar between groups, whereas ICU duration remained longer for the ≤4‐h group.
Conclusion
In patients presenting to the ED with septic shock, ED‐to‐ICU time less than 4 h was not associated with altered 90‐day mortality, although this should be interpreted with caution due to study limitations.
Evaluating the association between time from ED presentation to ICU transfer on mortality in patients presenting with septic shock in Australasia.
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