Cribari, does it apply in real time? An analysis of a community level 1 trauma center.

BACKGROUND: Major Trauma Code 1 (TC1) activations require significant resources to provide immediate treatment to potentially unstable, critically ill, patients. The Cribari Matrix Method (CMM) and Need For Trauma Intervention (NFTI) are two ways to determine over and undertriage in trauma. We studied the overtriage rate at a community level 1 trauma center using these two methods to determine the efficacy of the triage criteria in TC1 activations. METHOD: A retrospective review of all patients in the trauma registry of a level 1 American College of Surgeons trauma program from May to October 2021 was performed. Overtriage rates were determined using CMM and NFTI criteria. RESULTS: The overtriage rate of 552 activations using CMM alone was 73%. CMM combined with NFTI resulted in a 56% overtriage rate. CONCLUSION: The Cribari method can be used to determine the effectiveness of a system's trauma code 1 criteria but cannot delineate which criteria should be reviewed.

Novel association of Dandy-Walker malformation with CAPN15 variants expands the phenotype of oculogastrointestinal neurodevelopmental syndrome.

Oculogastrointestinal neurodevelopmental syndrome has been described in seven previously published individuals who harbor biallelic pathogenic variants in the CAPN15 gene. Biallelic missense variants have been reported to demonstrate a phenotype of eye abnormalities and developmental delay, while biallelic loss of function variants exhibit phenotypes including microcephaly and craniofacial abnormalities, cardiac and genitourinary malformations, and abnormal neurologic activity. We report six individuals from three unrelated families harboring biallelic deleterious variants in CAPN15 with phenotypes overlapping those previously described for this disorder. Of the individuals affected, four demonstrate radiographic evidence of the classical triad of Dandy-Walker malformation including hypoplastic vermis, fourth ventricle enlargement, and torcular elevation. Cerebellar anomalies have not been previously reported in association with CAPN15-related disease. Here, we present three unrelated families with findings consistent with oculogastrointestinal neurodevelopmental syndrome and cerebellar pathology including Dandy-Walker malformation. To corroborate these novel clinical findings, we present supporting data from the mouse model suggesting an important role for this protein in normal cerebellar development. Our findings add six molecularly confirmed cases to the literature and additionally establish a new association of Dandy-Walker malformation with biallelic CAPN15 variants, thereby expanding the neurologic spectrum among patients affected by CAPN15-related disease.

Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients.

Background: High morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient's survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort. Methods: A retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital's trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis. Results: There were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded. Conclusions: A negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.

Intrarater and Interrater Reliability of the Soong Classification for Distal Radius Volar Locking Plate Placement.

Background: The purpose of this study was to analyze the intrarater and interrater reliability of the Soong classification for volar locking plate placement on a randomly selected, consecutive series of radiographs. Our hypothesis was that the classification would be reliable. Methods: Six physicians of differing levels of training (orthopedic surgery intern to fellowship-trained upper extremity staff) were asked to review 40 radiographs in a random order on 2 separate occasions, 4 weeks apart. All observers graded each image (0, 1, or 2) based on the corresponding Soong grade. A weighted κ was used to determine the intrarater agreement. The interrater agreement was determined using an intraclass coefficient: Results: The intrarater reliability using a weighted κ ranged from 0.229 (95% confidence interval [CI]: 0.048-0.411) to 0.946 (95% CI: 0.840-1.051). The interrater intraclass coefficient for Randomization 1 was 0.944 (95% 0.912-0.967) and Randomization 2 was 0.877 (95% CI: 0.797-0.930). Conclusion: The Soong classification is a reliable tool, both interrater and intrarater, for assessing distal radius volar locking plate placement. The classification system remained reliable despite a randomly selected, consecutive series of images and physician observers of varying levels of training.

Four-Week Unstructured Break Improved Athletic Performance in Collegiate Rugby Players.

Jensen, CD, Gleason, D, and VanNess, JM. Four-week unstructured break improved athletic performance in collegiate rugby players. J Strength Cond Res 32(6): 1671-1677, 2018-This study analyzed the changes in athletic performance and anthropometric characteristics in collegiate male club rugby athletes (n = 14) after a 4-week winter break. All measurements were collected before and after the break. Body composition was assessed by body mass index and hydrostatic weighing. Performance measurements were as follows: V[Combining Dot Above]O2max, vertical jump, 10-yard sprint, squat max, and bench press max. Before testing, each subject was acclimated to the protocols to reduce learning effects. During the 4-week break, no workouts were provided for the athletes; it was unsupervised and unstructured. Participants were required to maintain and submit self-reported nutritional and activity logs during this period. After the break, the athletes demonstrated a 5.0% improvement in V[Combining Dot Above]O2max (absolute increase of 2.25 ml·kg·min), 6.8% improvement in vertical jump (1.50 inches), and a 14.3% increase in squat max (38.64 lb). Although increases in body mass (1.0%) were not significant, the body fat percentage exhibited a relative increase of 19.3% (absolute change from 13.35 to 15.93%). A significant discriminate function analysis indicated statistical differences between groups based on these variables. Self-reported behavior logs confirmed participation in >3 days of moderate to intense physical activity per week but somewhat poor dietary habits. These results indicate that collegiate rugby athletes may not need prescribed exercise routines during seasonal breaks in the athletic schedule. However, it may be beneficial to provide structured nutritional advice during unsupervised periods.

Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients.

Objective: Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods: We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results: After eliminating patients who were not eligible to receive TEA, the average patient bill was $59,123 ($10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -$21,429.55- -$7,794.66) and a 24% reduction in per-day billing (99% CI = -$3,745.99- -$1,276.14). Conclusions: Patients who received TEA were more severely injured and required longer treatments; controlling for these variables, the use of TEA associated with reductions in the cost of receiving care. From an administrative and insurance perspective, more frequent reliance on TEA may be indicated.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures.

OBJECTIVE: Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. METHODS: We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. RESULTS: Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. CONCLUSION: Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

A phase I dose escalation study of hypofractionated IMRT field-in-field boost for newly diagnosed glioblastoma multiforme.

OBJECTIVES: To describe the results of a Phase I dose escalation trial for newly diagnosed glioblastoma multiforme (GBM) using a hypofractionated concurrent intensity-modulated radiotherapy (IMRT) boost. METHODS: Twenty-one patients were enrolled between April 1999 and August 2003. Radiotherapy consisted of daily fractions of 1.8 Gy with a concurrent boost of 0.7 Gy (total 2.5 Gy daily) to a total dose of 70, 75, or 80 Gy. Concurrent chemotherapy was not permitted. Seven patients were enrolled at each dose and dose limiting toxicities were defined as irreversible Grade 3 or any Grade 4-5 acute neurotoxicity attributable to radiotherapy. RESULTS: All patients experienced Grade 1 or 2 acute toxicities. Acutely, 8 patients experienced Grade 3 and 1 patient experienced Grade 3 and 4 toxicities. Of these, only two reversible cases of otitis media were attributable to radiotherapy. No dose-limiting toxicities were encountered. Only 2 patients experienced Grade 3 delayed toxicity and there was no delayed Grade 4 toxicity. Eleven patients requiring repeat resection or biopsy were found to have viable tumor and radiation changes with no cases of radionecrosis alone. Median overall and progression-free survival for this cohort were 13.6 and 6.5 months, respectively. One- and 2-year survival rates were 57% and 19%. At recurrence, 15 patients received chemotherapy, 9 underwent resection, and 5 received radiotherapy. CONCLUSIONS: Using a hypofractionated concurrent IMRT boost, we were able to safely treat patients to 80 Gy without any dose-limiting toxicity. Given that local failure still remains the predominant pattern for GBM patients, a trial of dose escalation with IMRT and temozolomide is warranted.

Cavity-directed radiosurgery as adjuvant therapy after resection of a brain metastasis.

OBJECT: As a strategy to delay or avoid whole-brain radiotherapy (WBRT) after resection of a brain metastasis, the authors used high-resolution MR imaging and cavity-directed radiosurgery for the detection and treatment of further metastases. METHODS: Between April 2001 and October 2009, 112 resection cavities in 106 patients with no prior WBRT were treated using radiosurgery directed to the tumor cavity and for any synchronous brain metastases detected on high-resolution MR imaging at the time of radiosurgical planning. A median dose of 17 Gy to the 50% isodose line was prescribed to the gross tumor volume, defined as the rim of enhancement around the resection cavity. Patients were followed up via serial imaging, and new brain metastases were generally treated using additional radiosurgery, with salvage WBRT typically reserved for local treatment failure at a resection cavity, numerous failures, or failures occurring at short time intervals. Local and distant treatment failures were determined based on imaging results. Kaplan-Meier curves were generated to estimate local and distant treatment failure rates, overall survival, neurological cause-specific survival, and time delay to salvage WBRT. RESULTS: Radiosurgery was delivered to the resection cavity alone in 57.5% of patients, whereas 24.5% of patients also received treatment for 1 synchronous metastasis, 11.3% also received treatment for 2 synchronous metastases, and 6.6% also received treatment for 3-10 additional lesions. The median overall survival was 10.9 months. Overall survival at 1 year was 46.8%. The local tumor control rate at 1 year was 80.3%. The disease control rate in distant regions of the brain at 1 year was 35.4%, with a median time of 6.9 months to distant failure. Thirty-nine of 106 patients eventually received salvage WBRT, and the median time to salvage WBRT was 12.6 months. Kaplan-Meier estimates showed that the rate of requisite WBRT at 1 year was 45.9%. Neurological cause-specific survival at 1 year was 50.1%. Leptomeningeal failure occurred in 8 patients. One patient had treatment failure within the resection tract. Seven patients required reoperation: 2 for resection cavity recurrence, 3 for radiation necrosis, 1 for hydrocephalus, and 1 for a CSF cutaneous fistula. On multivariate analysis, a preoperative tumor diameter > 3 cm was predictive of local treatment failure. CONCLUSIONS: Cavity-directed radiosurgery combined with high-resolution MR imaging detection and radiosurgical treatment of synchronous brain metastases is an effective strategy for delaying and even foregoing WBRT in most patients. This technique provides acceptable local disease control, although distant treatment failure remains significant.