Impact of blood alcohol concentration on hematologic and serum chemistry parameters in trauma patients: Analysis of data from a high-volume level 1 trauma center.

BACKGROUND: Alcohol (EtOH) intoxication is common among trauma patients. While providers are familiar with the clinical aspects of acute EtOH intoxication, few studies have investigated the effects that EtOH levels may have on common laboratory markers. The aim of this study was to identify hematologic and serum chemistry parameters that may be affected by the blood alcohol concentration (BAC), hypothesizing that BAC influences both comprehensive blood count (CBC) and comprehensive serum chemistry (CSC) components. METHODS: We performed an IRB-exempt institutional registry review of all trauma patients who had serum EtOH levels measured between January 2009 and June 2015. Data for each patient included: patient demographics, BAC determinations (g/dL), injury mechanism/severity information (ISS), hematologic parameters included in a CBC (hemoglobin, hematocrit, white blood cell [WBC] count, and platelet count), and CSC panel components (sodium, potassium, chloride, bicarbonate, blood urea nitrogen [BUN], creatinine, glucose, and hepatic function tests). Laboratory markers were contrasted across predefined categories of BAC: <0.10%, 10%-15%, 15%-20%, and >20%. Statistical comparisons were performed using SPSS 18 Software, employing analysis-of-covariance with adjustments performed for the patient demographics and injury characteristics. Statistical significance was set at α = 0.005. RESULTS: A total of 2167 patient records were analyzed. After adjusting for patient age, gender, and ISS, increasing BAC correlated with 4.8% increase in hemoglobin and 32.5% higher hematocrit (both P < 0.001), as well as a 27.8% decrease in WBC count. There were also statistically significant differences between low (<0.10%) and high (>0.20%) BAC groups across multiple CSC parameters, with largest impact on BUN (32.2% decrease); creatinine (31.5% decrease); and glucose (13.6% decrease) values. Elevated BAC (>0.20 g/dL) was also associated with 81.8% increase in total bilirubin, and hepatic transaminases were elevated among patients with BAC >0.10. CONCLUSION: Due to the paucity of literature relating to the effects of BAC on serum hematologic and biochemical markers in acute trauma, this study provides a foundation for further exploration of these relationships and their clinical impact. More specifically, we found that BAC levels significantly influenced key laboratory markers, suggesting that acute EtOH intoxication may lead to hematologic and CSC changes that are potentially important in acute trauma management by frontline clinical staff.

An observational study of patients' attitudes to tattoos and piercings on their physicians: the ART study.

INTRODUCTION: Perceptions regarding body art change over time as societal norms change. Previous research regarding patients' perceptions of physicians with exposed body art have been hampered by flaws in design methodology that incorporate biases into patient responses. This study was performed to determine whether emergency department (ED) patients perceived a difference in physician competence, professionalism, caring, approachability, trustworthiness and reliability in the setting of exposed body art. METHODS: Standardised surveys about physician competence, professionalism, caring, approachability, trustworthiness and reliability rating providers on a five point Likert scale were administered to patients in an ED after an encounter with a physician provider who demonstrated no body art modification, non-traditional piercings, tattoos, or both piercings and tattoos. Each provider served as their own control. Patients were blinded to the purpose of the survey. RESULTS: Patients did not perceive a difference in physician competence, professionalism, caring, approachability, trustworthiness or reliability in the setting of exposed body art. Patients assigned top box performance in all domains >75% of the time, regardless of physician appearance. CONCLUSION: In the clinical setting, having exposed body art does not significantly change patients' perception of the physician.

Exploring the association between initial serum alcohol concentration and polysubstance use: More than a simple "gateway drug" effect?

INTRODUCTION: Polysubstance abuse (PSA) is a significant problem affecting our society. In addition to negatively affecting the health and well-being of substance users, alcohol and/or drug abuse is also associated with heavy injury burden. The goal of this study was to determine if elevated serum alcohol (EtOH) levels on initial trauma evaluation correlate with the simultaneous presence of other substances of abuse (SOAs). We hypothesized that PSA would be more common among patients who present with EtOH levels in excess of the legal blood alcohol content (BAC) (≥0.10%). METHODS: An audit of trauma registry records from January 2009 to June 2015 was performed. Abstracted data included patient demographics, BAC measurements, all available formal determinations of urine/serum "drug screening," Glasgow Coma Scale (GCS) assessments, injury mechanism/severity, and 30-day mortality. Stratification of BAC was based on the 0.10% cutoff. Parametric and nonparametric statistical testing was performed, as appropriate, with significance set at α = 0.05. RESULTS: We analyzed 1550 patients (71% males, mean age: 38.7 years) who had both EtOH and SOA screening. Median GCS was 15 (interquartile range [IQR]: 14-15). Median ISS was 9 (IQR: 5-17). Overall 30-day mortality was 4.25%, with no difference between elevated (≥0.10) and normal (<0.10) EtOH groups. For the overall study sample, the median BAC was 0.10% (IQR: 0-0.13). There were 1265 (81.6%) patients with BAC <0.10% and 285 (18.4%) patients with BAC ≥0.10%. The two groups were similar in terms of mechanism of injury (both, ∼95% blunt). Patients with BAC ≥0.10% on initial trauma evaluation were significantly more likely to have the findings consistent with PSA (e.g., EtOH + additional substance) than patients with BAC <0.10% (377/1265 [29.8%] vs. 141/285 [49.5%], respectively, P < 0.001). Among polysubstance users, BAC ≥0.10% was significantly associated with cocaine, marijuana, and opioid use. CONCLUSIONS: This study confirms that a significant proportion of trauma patients with admission BAC ≥0.10% present with the evidence of additional substance use. Cocaine and opioids were most strongly associated with acute alcohol intoxication. Our findings support the need for further research in this important area of public health concern. In addition, specific efforts should focus on primary identification, remediation of withdrawal symptoms, prevention of drug-drug interactions, and early PSA intervention.

Traditional autopsy versus computed tomography imaging autopsy in trauma: A case of "synergistic disagreement".

BACKGROUND: Decreases in the rates of traditional autopsy (TA) negatively impact traumatology, especially in the areas of quality improvement and medical education. To help enhance the understanding of trauma-related mortality, a number of initiatives in imaging autopsy (IA) were conceived, including the postmortem computed tomography ("CATopsy") project at our institution. Though IA is a promising concept, few studies directly correlate TA and IA findings quantitatively. Here, we set out to increase our understanding of the similarities and differences between key findings on TA and IA in a prospective fashion with blinding of pathologist and radiologist evaluations. METHODS: A prospective study of TA versus IA was conducted at an Academic Level I Trauma Center (June 2001-May 2010). All decedents underwent a postmortem, whole-body, noncontrast computed tomography that was interpreted by an independent, blinded, board-certified radiologist. A blinded, board-certified pathologist then performed a TA. Autopsy results were grouped into predefined categories of pathologic findings. Categorized findings from TA and IA were compared by determining the degree of agreement (kappa). The χ(2) test was used to detect quantitative differences in "potentially fatal" findings (eg, aortic trauma, splenic injury, intracranial bleeding, etc) between TA and IA. RESULTS: Twenty-five trauma victims (19 blunt; 9 female; median age 33 years) had a total of 435 unique findings on either IA or TA grouped into 34 categories. The agreement between IA and TA was worse than what chance would predict (kappa = -0.58). The greatest agreement was seen in injuries involving axial skeleton and intracranial/cranio-facial trauma. Most discrepancies were seen in soft tissue, ectopic air, and "incidental" categories. Findings determined to be "potentially fatal" were seen on both TA/IA in 48/435 (11%) instances with 79 (18%) on TA only and 53 (12%) on IA only. TA identified more "potentially fatal" solid organ and heart/great vessel injuries, while IA revealed more spine injuries, "potentially fatal" procedure-related findings, and the presence of ectopic air/fluid. CONCLUSION: This limited study does not support substitution of noncontrast, computed tomography-based IA for TA. Our quantitative analyses suggest that TA and IA evaluations may be complementary and synergistic when performed concurrently. There are potential benefits to using IA in trauma process/quality improvement and in educational settings. Further research should focus on the value (and limitations) of the information provided by IA in the absence of TA.

The differential effects of heat-shocking on the viability of spores from Bacillus anthracis, Bacillus subtilis, and Clostridium sporogenes after treatment with peracetic acid- and glutaraldehyde-based disinfectants.

This study investigated (1) the susceptibility of Bacillus anthracis (Ames strain), Bacillus subtilis (ATCC 19659), and Clostridium sporogenes (ATCC 3584) spores to commercially available peracetic acid (PAA)- and glutaraldehyde (GA)-based disinfectants, (2) the effects that heat-shocking spores after treatment with these disinfectants has on spore recovery, and (3) the timing of heat-shocking after disinfectant treatment that promotes the optimal recovery of spores deposited on carriers. Suspension tests were used to obtain inactivation kinetics for the disinfectants against three spore types. The effects of heat-shocking spores after disinfectant treatment were also determined. Generalized linear mixed models were used to estimate 6-log reduction times for each spore type, disinfectant, and heat treatment combination. Reduction times were compared statistically using the delta method. Carrier tests were performed according to AOAC Official Method 966.04 and a modified version that employed immediate heat-shocking after disinfectant treatment. Carrier test results were analyzed using Fisher's exact test. PAA-based disinfectants had significantly shorter 6-log reduction times than the GA-based disinfectant. Heat-shocking B. anthracis spores after PAA treatment resulted in significantly shorter 6-log reduction times. Conversely, heat-shocking B. subtilis spores after PAA treatment resulted in significantly longer 6-log reduction times. Significant interactions were also observed between spore type, disinfectant, and heat treatment combinations. Immediately heat-shocking spore carriers after disinfectant treatment produced greater spore recovery. Sporicidal activities of disinfectants were not consistent across spore species. The effects of heat-shocking spores after disinfectant treatment were dependent on both disinfectant and spore species. Caution must be used when extrapolating sporicidal data of disinfectants from one spore species to another. Heat-shocking provides a more accurate picture of spore survival for only some disinfectant/spore combinations. Collaborative studies should be conducted to further examine a revision of AOAC Official Method 966.04 relative to heat-shocking.

Recurrent hypoglycemia in a toddler.

Idiopathic ketotic hypoglycemia is the most common cause of hypoglycemia in toddlers. This diagnosis should be considered in any hypoglycemic toddler with no prior history of abnormal growth who is developmentally normal when toxic ingestions and sepsis are inconsistent with the clinical picture. Diagnosis is important in preventing serious long-term sequelae and is made in the setting of hypoglycemia, ketonuria, and ketonemia. Therefore, checking urine and blood ketones is an essential part of the evaluation in any hypoglycemic toddler. We report the case of a 3-year-old girl with recurrent hypoglycemia secondary to idiopathic ketotic hypoglycemia.

Comorbidity-Polypharmacy Score as Predictor of Outcomes in Older Trauma Patients: A Retrospective Validation Study.

INTRODUCTION: Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient's hospitalization. The comorbidity-polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset. METHODS: A retrospective study of patients ages≥45 years was performed using an administrative trauma database from St. Luke's University Hospital's Level I Trauma Center. The study period was from 1 January 2008 to 31 December 2013. Abstracted data included patient demographics, injury mechanism and severity [injury characteristics and severity score (ISS)], Glasgow coma scale (GCS), hospital and intensive care unit lengths of stay (HLOS and ILOS, respectively), morbidity, post-discharge destination, and in-hospital mortality. Univariate analyses were conducted with mortality, all-cause morbidity, and discharge destination as primary end-points. Variables reaching statistical significance (p≤0.20) were included in a multivariate logistic regression model. Data are presented as adjusted odds ratios (AORs), with p<0.05 denoting statistical significance. RESULTS: A total of 5863 patient records were analyzed. Average patient age was 68.5±15.3 years (52% male, 89% blunt mechanism, mean GCS 14.3). Mean HLOS and ILOS increased significantly with increasing CPS (p<0.01). Independent predictors of mortality included age (AOR 1.05, p<0.01), CPS (per-unit AOR 1.08, p<0.02), GCS (AOR 1.43 per-unit decrease, p<0.01), and ISS (per-unit 1.08, p<0.01). Independent predictors of all-cause morbidity included age (AOR 1.02, p<0.01), GCS (AOR per-unit decrease 1.08, p<0.01), ISS (per-unit AOR 1.09, p<0.01), and CPS (per-unit AOR 1.04, p<0.01). CPS did not independently predict need for discharge to a facility. CONCLUSIONS: This study confirms that CPS is an independent predictor of all-cause morbidity and mortality in older trauma patients. However, CPS was not independently associated with need for discharge to a facility. Prospective multicenter studies are needed to evaluate the use of CPS as a predictive and interventional tool, with special focus on correlations between specific pre-existing conditions, pharmacologic interactions, and morbidity/mortality patterns.

The differential susceptibility of spores from virulent and attenuated Bacillus anthracis strains to aldehyde- and hypochlorite-based disinfectants.

This study compared the sensitivity of spores from virulent and attenuated Bacillus anthracis strains in suspension to inactivation by various chemical disinfectants. Spore suspensions from two virulent strains (A0256 and A0372) and two attenuated strains (Sterne and A0141) of B. anthracis were tested against two aldehyde-based disinfectants and one hypochlorite-based disinfectant. A novel statistical model was used to estimate 4-log(10) reduction times for each disinfectant/strain combination. Reduction times were compared statistically using approximate Z and χ(2) tests. Although there was no consistent correlation between virulence and increased sporicidal resistance across all three disinfectants, spores from the two virulent and two attenuated strains did display significantly different susceptibilities to different disinfectants. Significant disinfectant-strain interactions were observed for two of the three disinfectants evaluated. The comparative results suggest that the use of surrogate organisms to model the inactivation kinetics of virulent B. anthracis spores may be misleading. The accuracy of such extrapolations is disinfectant dependent and must be used with caution.

A quadruplex real-time PCR assay for rapid detection and differentiation of the Clostridium botulinum toxin genes A, B, E and F.

Clostridium botulinum is the aetiological agent of botulism, a disease marked by flaccid paralysis that can progress to asphyxiation and death. This species is defined by the production of one of the botulinum neurotoxins (BoNTs), which are the most potent toxins known. Because of their potency, these toxins have the potential to be used as biological weapons, and therefore C. botulinum has been classified as a category A select agent. There are four related but antigenically distinct BoNT types that cause disease in humans, A, B, E and F. The mouse bioassay is the current gold standard by which BoNTs are confirmed. However, this method is expensive, slow and labour-intensive. Although PCR-based assays have been used extensively for the detection of BoNT-producing bacteria in food, animals and faecal samples, and recently to help diagnose disease in humans, no real-time quantitative PCR (qPCR) assay has yet been developed that can identify and differentiate all four BoNTs that cause disease in humans. This report describes the development of a qPCR single-tube assay that uniquely identifies these four BoNTs responsible for human disease. A total of 79 C. botulinum isolates with varying toxin types was evaluated in this study, as well as numerous near-neighbours and other bacterial species. The results showed that this quadruplex assay was capable of detecting any of the four toxin genes in a given sample at a sensitivity of about 130-840 fg genomic DNA and could detect the presence of up to all four BoNT genes simultaneously in a given sample. The assay was also functional in the presence of extraneous organic matter commonly found in various environmental samples.

Francisella tularensis type A strains cause the rapid encystment of Acanthamoeba castellanii and survive in amoebal cysts for three weeks postinfection.

Francisella tularensis, the causative agent of the zoonotic disease tularemia, has recently gained increased attention due to the emergence of tularemia in geographical areas where the disease has been previously unknown and to the organism's potential as a bioterrorism agent. Although F. tularensis has an extremely broad host range, the bacterial reservoir in nature has not been conclusively identified. In this study, the ability of virulent F. tularensis strains to survive and replicate in the amoeba Acanthamoeba castellanii was explored. We observe that A. castellanii trophozoites rapidly encyst in response to F. tularensis infection and that this rapid encystment phenotype is caused by factor(s) secreted by amoebae and/or F. tularensis into the coculture medium. Further, our results indicate that in contrast to the live vaccine strain LVS, virulent strains of F. tularensis can survive in A. castellanii cysts for at least 3 weeks postinfection and that the induction of rapid amoeba encystment is essential for survival. In addition, our data indicate that pathogenic F. tularensis strains block lysosomal fusion in A. castellanii. Taken together, these data suggest that interactions between F. tularensis strains and amoebae may play a role in the environmental persistence of F. tularensis.

A quadruplex real-time PCR assay for the detection of Yersinia pestis and its plasmids.

Yersinia pestis, the aetiological agent of the plague, causes sporadic disease in endemic areas of the world and is classified as a National Institute of Allergy and Infectious Diseases Category A Priority Pathogen because of its potential to be used as a bioweapon. Health departments, hospitals and government agencies need the ability to rapidly identify and characterize cultured isolates of this bacterium. Assays have been developed to perform this function; however, they are limited in their ability to distinguish Y. pestis from Yersinia pseudotuberculosis. This report describes the creation of a real-time PCR assay using Taqman probes that exclusively identifies Y. pestis using a unique target sequence of the yihN gene on the chromosome. As with other Y. pestis PCR assays, three major genes located on each of the three virulence plasmids were included: lcrV on pCD1, caf1 on pMT1 and pla on pPCP1. The quadruplex assay was validated on a collection of 192 Y. pestis isolates and 52 near-neighbour isolates. It was discovered that only 72 % of natural plague isolates from the states of New Mexico and Utah harboured all three virulence plasmids. This quadruplex assay proved to be 100 % successful in differentiating Y. pestis from all near neighbours tested and was able to reveal which of the three virulence plasmids a particular isolate possessed.