Preparing Veterans Health Administration Psychologists to Meet the Complex Needs of Aging Veterans.

Background: There are significant workforce shortages for geriatric mental health care. The imbalance is particularly pronounced in the Veterans Health Administration (VHA) due to the large number of aging veterans receiving care. Workforce-based educational programs are needed to train existing clinicians to meet the mental health needs of aging veterans. Observations: This article describes an expansion of the Geriatric Scholars Program to train VHA psychologists to care for aging veterans. The multicomponent program includes an introductory course and opportunities to apply geriatric knowledge and skills through quality improvement initiatives. The Geriatric Scholars Program-Psychology Track evolved to incorporate ongoing specialized elective learning opportunities for scholars. A webinar series extends the educational programs to reach the entire VHA workforce. Conclusions: The Geriatric Scholars Program-Psychology Track represents a longitudinal educational approach to training VHA psychologists in clinical geropsychology. Other community-based organizations can use this model to construct and implement similar programs.

SARS-CoV-2 wastewater variant surveillance: pandemic response leveraging FDA's GenomeTrakr network.

Wastewater surveillance has emerged as a crucial public health tool for population-level pathogen surveillance. Supported by funding from the American Rescue Plan Act of 2021, the FDA's genomic epidemiology program, GenomeTrakr, was leveraged to sequence SARS-CoV-2 from wastewater sites across the United States. This initiative required the evaluation, optimization, development, and publication of new methods and analytical tools spanning sample collection through variant analyses. Version-controlled protocols for each step of the process were developed and published on protocols.io. A custom data analysis tool and a publicly accessible dashboard were built to facilitate real-time visualization of the collected data, focusing on the relative abundance of SARS-CoV-2 variants and sub-lineages across different samples and sites throughout the project. From September 2021 through June 2023, a total of 3,389 wastewater samples were collected, with 2,517 undergoing sequencing and submission to NCBI under the umbrella BioProject, PRJNA757291. Sequence data were released with explicit quality control (QC) tags on all sequence records, communicating our confidence in the quality of data. Variant analysis revealed wide circulation of Delta in the fall of 2021 and captured the sweep of Omicron and subsequent diversification of this lineage through the end of the sampling period. This project successfully achieved two important goals for the FDA's GenomeTrakr program: first, contributing timely genomic data for the SARS-CoV-2 pandemic response, and second, establishing both capacity and best practices for culture-independent, population-level environmental surveillance for other pathogens of interest to the FDA. IMPORTANCE: This paper serves two primary objectives. First, it summarizes the genomic and contextual data collected during a Covid-19 pandemic response project, which utilized the FDA's laboratory network, traditionally employed for sequencing foodborne pathogens, for sequencing SARS-CoV-2 from wastewater samples. Second, it outlines best practices for gathering and organizing population-level next generation sequencing (NGS) data collected for culture-free, surveillance of pathogens sourced from environmental samples.

Characterization of anthropogenic noise and oyster toadfish (Opsanus tau) calling behavior in urban and small-town coastal soundscapesa).

The oyster toadfish (Opsanus tau) is an ideal model to examine the effects of anthropogenic noise on behavior because they rely on acoustic signals for mate attraction and social interactions. We predict that oyster toadfish have acclimated to living in noise-rich environments because they are common in waterways of urban areas, like New York City (NYC). We used passive acoustic monitoring at two locations to see if calling behavior patterns are altered in areas of typically high boat traffic versus low boat traffic (Pier 40, NYC, NY, and Eel Pond, Woods Hole, MA, respectively). We hypothesized that toadfish in NYC would adjust their circadian calling behavior in response to daily anthropogenic noise patterns. We quantified toadfish calls and ship noise over three 24-h periods in the summer reproductive period at both locations. We observed an inverse relationship between the duration of noise and the number of toadfish calls at Pier 40 in comparison to Eel Pond. Additionally, toadfish at Pier 40 showed significant differences in peak calling behavior compared to Eel Pond. Therefore, oyster toadfish may have acclimated to living in an urban environment by potentially altering their communication behavior in the presence of boat noise.

Management of Discharge Instructions for Children With Medical Complexity: A Systematic Review.

CONTEXT: Children with medical complexity (CMC) are at risk for adverse outcomes after discharge. Difficulties with comprehension of and adherence to discharge instructions contribute to these errors. Comprehensive reviews of patient-, caregiver-, provider-, and system-level characteristics and interventions associated with discharge instruction comprehension and adherence for CMC are lacking. OBJECTIVE: To systematically review the literature related to factors associated with comprehension of and adherence to discharge instructions for CMC. DATA SOURCES: PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, Web of Science (database initiation until March 2023), and OAIster (gray literature) were searched. STUDY SELECTION: Original studies examining caregiver comprehension of and adherence to discharge instructions for CMC (Patient Medical Complexity Algorithm) were evaluated. DATA EXTRACTION: Two authors independently screened titles/abstracts and reviewed full-text articles. Two authors extracted data related to study characteristics, methodology, subjects, and results. RESULTS: Fifty-one studies were included. More than half were qualitative or mixed methods studies. Few interventional studies examined objective outcomes. More than half of studies examined instructions for equipment (eg, tracheostomies). Common issues related to access, care coordination, and stress/anxiety. Facilitators included accounting for family context and using health literacy-informed strategies. LIMITATIONS: No randomized trials met inclusion criteria. Several groups (eg, oncologic diagnoses, NICU patients) were not examined in this review. CONCLUSIONS: Multiple factors affect comprehension of and adherence to discharge instructions for CMC. Several areas (eg, appointments, feeding tubes) were understudied. Future work should focus on design of interventions to optimize transitions.

Accuracy of Needle Thoracostomy Site Selection among US Army Medics.

BACKGROUND: Tension pneumothorax is a prominent cause of potentially survivable death on the battlefield. Field management for suspected tension pneumothorax is immediate needle thoracostomy (NT). Recent data noted higher NT success rates and ease of insertion at the fifth intercostal space, anterior axillary line (5th ICS AAL), leading to an amendment of the Committee on Tactical Combat Casualty Care recommendations on managing suspected tension pneumothorax to include the 5th ICS AAL as a viable alternative site for NT placement. The objective of this study was to assess the overall accuracy, speed, and ease of NT site selection and compare these outcomes between the second intercostal space, midclavicular line (2nd ICS MCL) and 5th ICS AAL among a cohort of Army medics. METHODS: We designed a prospective, observational, comparative study and recruited a convenience sample of US Army medics from a single military installation to localize and mark the anatomic location where they would perform an NT at the 2nd ICS MCL and 5th ICS AAL on 6 live human models. The marked site was compared for accuracy to an optimal site predetermined by investigators. We assessed the primary outcome of accuracy via concordance with the predetermined NT site location at the 2nd ICS MCL and 5th ICS MCL. Secondarily, we compared time to final site marking and the influence of model body mass index (BMI) and gender on accuracy of selection between sites. RESULTS: A total of 15 participants performed 360 NT site selections. We found a significant difference between participants' ability to accurately target the 2nd ICS MCL compared to the 5th ICS AAL (42.2% versus 10% respectively, p is less than 0.001). The overall accuracy rate among all NT site selections was 26.1%. We also found a significant difference in time-to-site identification between the 2nd ICS MCL and 5th ICS AAL in favor of the 2nd ICS MCL (median [IQR] 9 [7.8] seconds versus 12 [12] seconds, p is less than 0.001). CONCLUSIONS: US Army medics may be more accurate and faster at identifying the 2nd ICS MCL when compared to the 5th ICS AAL. However, overall site selection accuracy is unacceptably low, highlighting an opportunity to enhance training for this procedure.

Antiprotozoal compounds from Mikania periplocifolia (Asteraceae).

Chagas disease, African trypanosomiasis and Leishmaniasis are neglected parasitic diseases which affect millions of people worldwide. In a previous work, we report the antiprotozoal activity of the dichloromethane extract of Mikania periplocifolia Hook. & Arn. (Asteraceae). The aim of this work was to isolate and identify the bioactive compounds present in the extract. The fractionation of the dichloromethane extract has led to the isolation of the sesquiterpene lactone miscandenin and the flavonoid onopordin, together with the sesquiterpene lactones mikanolide, dihydromikanolide and deoxymikanolide, which have previously shown antiprotozoal activity. Miscandenin and onopordin were assayed in vitro against Trypanosoma cruzi, T. brucei and Leishmania braziliensis. Miscandenin was active against T. cruzi trypomastigotes and amastigotes with IC50 values of 9.1 and 7.7 µg/ml, respectively. This sesquiterpene lactone and the flavonoid onopordin showed activity against T. brucei trypomastigotes (IC50 = 0.16 and 0.37 µg/ml) and L. braziliensis promastigotes (IC50 = 0.6 and 1.2 µg/ml), respectively. The CC50 values on mammalian cells were 37.9 and 53.4 µg/ml for miscandenin and onopordin, respectively. Besides, the pharmacokinetic and physicochemical properties of miscandenin were assessed in silico, showing a good drug-likeness profile. Our results highlight this compound as a promising candidate for further preclinical studies in the search of new drugs for the treatment of trypanosomiasis and leishmaniasis.

Ozonoterapia en el dolor crónico osteoarticular

Introducción: El dolor crónico es una de las causas más frecuentes de consulta médica en el mundo, las de causa osteomioarticular son las más frecuentes. Esto genera un gran consumo de medicamentos, muchos de los cuales producen efectos adversos que comprometen la calidad de vida de los pacientes. Objetivos: Obtener información sobre la efectividad de la ozonoterapia en el dolor crónico osteoarticular. Método: Se realizó una revisión bibliográfica de los artículos publicados en los últimos 15 años sobre esta temática. A través del buscador Google Académico, se revisaron documentos de carácter académico como artículos, tesis, libros, patentes, documentos relativos a congresos y resúmenes de diferentes bases de datos, como son Web of Science, MEDLINE, SciELO, pubmed, todas ellas ajustadas al ámbito biomédico. En primer lugar, se realizó una búsqueda general, y en función de lo que se vio que era más relevante con respecto al tema, se realizaron posteriormente nuevas búsquedas con términos más concretos, en los idiomas español e inglés. No se aplicó ninguna restricción de ámbito geográfico, edad, ni campo de investigación. Se encontraron 750 resultados iniciales, de los cuales se seleccionaron un total de 36. Conclusiones: Se concluye que hay artículos sobre la ozonoterapia, que respaldan su uso como una herramienta terapéutica efectiva y económica en el tratamiento del dolor crónico osteomioarticular, con mayor evidencia en el tratamiento del dolor por enfermedades del disco intervertebral.

Introduction: Chronic pain is one of the most frequent causes of medical consultation in the world, those osteoarticular causes are the most frequent. This generates a large consumption of drugs, many of which produce adverse effects that compromise the quality of life of patients. Objectives: To obtain information on the effectiveness of ozone therapy in chronic osteoarticular pain. Method: A bibliographic review of the articles published in the last 15 years on this subject was carried out. Using the Google Scholar search engine, academic documents such as articles, theses, books, patents, conference papers and abstracts from different databases, such as Web of Science, MEDLINE, SciELO, PubMed, all of them adjusted to the biomedical field, were reviewed. First, a general search was carried out, and depending on what was seen to be most relevant to the topic, new searches were subsequently carried out with more specific terms, in Spanish and English. No restriction of geographic scope, age, or field of research was applied. A total of 750 initial results were found, of which a total of 36 were selected. Conclusions: It is concluded that there are articles on ozone therapy, which support its use as an effective and economical therapeutic tool in the treatment of chronic osteoarticular pain, with greater evidence in the treatment of pain due to intervertebral disc disease.

Enhancing specialty training in geropsychology competencies: An evaluation of a VA Geriatric Scholars Program advanced topics workshop.

There is a growing need for psychologists with specialized training in geriatric mental health competencies. The Geriatric Scholars Program for Psychologists (GSP-P) was created to address this shortage within a large integrated healthcare system. In 2019, GSP-P piloted an advanced workshop designed to enhance expertise in geriatric mental health competencies among graduates of its foundational competencies core course. The workshop included 3.5 days of expert-led seminars regarding the biopsychosocial needs of older adults with chronic medical illness and was followed by completion of an individualized learning plan. This paper describes the evaluation of the course using a mixed methods with data collected prior to the workshop, immediately post-workshop, and six months post-workshop. Results indicated enthusiasm for the workshop, significant improvements in four geropsychology domains on the Pikes Peak Geropsychology Knowledge and Skill Assessment Tool, and benefit from completion of the independent learning plans. Our findings demonstrate that continued enhancement of geropsychology competencies through advanced coursework is feasible and improves knowledge and skill, particularly when combined with individualized learning plans.

Target Affinity and Structural Analysis for a Selection of Norovirus Aptamers.

Aptamers, single-stranded oligonucleotides that specifically bind a molecule with high affinity, are used as ligands in analytical and therapeutic applications. For the foodborne pathogen norovirus, multiple aptamers exist but have not been thoroughly characterized. Consequently, there is little research on aptamer-mediated assay development. This study characterized seven previously described norovirus aptamers for target affinity, structure, and potential use in extraction and detection assays. Norovirus-aptamer affinities were determined by filter retention assays using norovirus genotype (G) I.1, GI.7, GII.3, GII.4 New Orleans and GII.4 Sydney virus-like particles. Of the seven aptamers characterized, equilibrium dissociation constants for GI.7, GII.3, GII.4 New Orleans and GII.4 Sydney ranged from 71 ± 38 to 1777 ± 1021 nM. Four aptamers exhibited affinity to norovirus GII.4 strains; three aptamers additionally exhibited affinity toward GII.3 and GI.7. Aptamer affinity towards GI.1 was not observed. Aptamer structure analysis by circular dichroism (CD) spectroscopy showed that six aptamers exhibit B-DNA structure, and one aptamer displays parallel/antiparallel G-quadruplex hybrid structure. CD studies also showed that biotinylated aptamer structures were unchanged from non-biotinylated aptamers. Finally, norovirus aptamer assay feasibility was demonstrated in dot-blot and pull-down assays. This characterization of existing aptamers provides a knowledge base for future aptamer-based norovirus detection and extraction assay development and aptamer modification.

Lessons Learned During COVID-19 That Can Move Telehealth in Primary Care Forward.

INTRODUCTION: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic. INITIAL WORK: Implementation of telehealth began in 2017. Health system barriers, provider and patient reluctance, and inadequate reimbursement prevented widespread adoption at the time. COVID-19 served as the catalyst to accelerate telehealth efforts. IMPLEMENTATION: COVID-19 resulted in the need for patient care with "social distancing." In addition, due to the pandemic, the Centers for Medicare and Medicaid Services and other insurers began expanded reimbursement for telehealth. More than 2000 providers received virtual health training in less than 2 weeks. In March 2020, we provided 2376 virtual visits, and in April 5293, which was more than 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual. LESSONS LEARNED: Several key lessons are important for future efforts regarding clinical implementation: (1) prepare for innovation, (2) cultivate an innovation mindset, (3) standardize (but not too much), (4) technological innovation is necessary but not sufficient, and (5) communicate widely and often.

Improving Geropsychology Competencies of Veterans Affairs Psychologists.

Older adults are more likely to seek mental health care through integrated care settings such as primary care. Currently, there exists a significant shortage of mental health providers trained in geropsychology and integrated care competencies. To address this need within the Veterans Health Administration, a national workforce development program was extended to include psychologists, which is called the Geriatric Scholars Program-Psychology Track (GSP-P). The GSP-P has two overarching educational program aims: (1) to improve geropsychology competencies of practicing VA psychologists, particularly those working within integrated settings (e.g., primary care) and (2) enrich psychologists' abilities to enact change in their clinical settings. Ninety-eight VA clinicians participated in the GSP-P, which includes a multi-day in-person course, from 2014 to 2018. Participants completed measures assessing confidence and self-reported knowledge in geropsychology and integrated care competencies pre-course and 3-months post-completion. Two-weeks post-course participants responded to open-ended survey questions regarding their perceptions of the course and potential applications of learning. Significant improvements in confidence in and knowledge of geropsychology and integrated care competencies emerged from pre-course to 3-months post-completion. Qualitative findings demonstrated that participants valued the face-to-face, integrated multimodal educational program. Findings provided insights regarding clinicians' planned application of the knowledge acquired, such as modifying treatments for older patients. Specialized workforce programs such as the GSP-P have a significant, positive impact on the care of older Veterans.

Unmasking Our Grief.

BACKGROUND: Health care systems have been calling for trainings on the topics of self-care and burnout to help staff cope with the impact of the COVID-19 pandemic. The geriatric care workforce in particular has been hard hit by the stresses of COVID-19 and social inequities for themselves and their patients. These stresses have led to trauma and grief among our colleagues and ourselves. OBSERVATIONS: Self-care techniques in and of themselves are not an adequate salve for the massive, collective, and many times unrecognized grief that the geriatric care workforce has faced over the course of this pandemic. We must acknowledge, name, and make space for the grief that is exhausting the entire elder care workforce and we must do so at an organizational level. In this paper, we briefly discuss the distress affecting the geriatric care workforce, reflect on our efforts to cope as health care workers, and offer recommendations at individual and organization levels to help address our collective grief. CONCLUSIONS: This pandemic has revealed our vulnerabilities as well as our strengths. These experiences also present us with opportunities to be better and do better as both professionals and people. We hope that teams and organizations will take advantage of these opportunities for self-reflection and continue unmasking our grief, healing our wounds, and honoring our shared humanity.

An exploratory study of factors motivating Mexican women to undertake and continue with nutritional programs.

The purpose of this paper is to study and provide a framework for the motivations of women to engage in and maintain a nutritional program in Mexico. Focusing on a physician-dietician counseling program, 10 in-depth interviews were conducted with women age 30-60 engaged in the program. Two different sets of motivations for women were found, intrinsic and extrinsic, consistent with the self-determination theory. A model presents each set of motivations including subsets that explain specifically what makes women want to continue a nutrition program. Also, marketing implications from these motivations are discussed.

Human Fat-Derived Mesenchymal Stem Cells Xenogenically Implanted in a Rat Model Show Enhanced New Bone Formation in Maxillary Alveolar Tooth Defects.

BACKGROUND: Due to restorative concerns, bone regenerative therapies have garnered much attention in the field of human oral/maxillofacial surgery. Current treatments using autologous and allogenic bone grafts suffer from inherent challenges, hence the ideal bone replacement therapy is yet to be found. Establishing a model by which MSCs can be placed in a clinically acceptable bone defect to promote bone healing will prove valuable to oral/maxillofacial surgeons. METHODS: Human adipose tissue-derived MSCs were seeded onto Gelfoam® and their viability, proliferation, and osteogenic differentiation was evaluated in vitro. Subsequently, the construct was implanted in a rat maxillary alveolar bone defect to assess in vivo bone healing and regeneration. RESULTS: Human MSCs were adhered, proliferated, and uniformly distributed, and underwent osteogenic differentiation on Gelfoam®, comparable with the tissue culture surface. Data confirmed that Gelfoam® could be used as a scaffold for cell attachment and a delivery vehicle to implant MSCs in vivo. Histomorphometric analyses of bones harvested from rats treated with hMSCs showed statistically significant increase in collagen/early bone formation, with cells positive for osteogenic and angiogenic markers in the defect site. This pattern was visible as early as 4 weeks post treatment. CONCLUSIONS: Xenogenically implanted human MSCs have the potential to heal an alveolar tooth defect in rats. Gelfoam®, a commonly used clinical biomaterial, can serve as a scaffold to deliver and maintain MSCs to the defect site. Translating this strategy to preclinical animal models provides hope for bone tissue engineering.

Developing a program to increase geropsychology competencies of Veterans Health Administration (VHA) psychologists.

There is an alarming supply and demand gap for geropsychology expertise within the United States. Health policy experts called for increasing geriatric mental health competencies for all mental health providers, including within Veterans Health Administration (VHA), to address this problematic gap. The VHA Geriatrics Scholar Program (GSP) Psychology Track was developed because there were no commercially available trainings in geropsychology for licensed psychologists. Developing the GSP Psychology Track was based on an evidence-based educational model for the VHA primary care workforce; and included a stepwise curriculum design, pilot implementation, and program evaluation. The educational program was pilot tested with eight VHA psychologists. Evaluation results demonstrated feasibility of implementing an innovative integrated multimodal educational program in geropsychology. Furthermore, this program was associated with reports of increased confidence in geropsychology competencies and self-reported implementation of geropsychology knowledge, indicating the potential for this educational model to improve mental health care for older Veterans.

Better understanding the utilization of damage control laparotomy: A multi-institutional quality improvement project.

BACKGROUND: Rates of damage control laparotomy (DCL) vary widely and consensus on appropriate indications does not exist. The purposes of this multicenter quality improvement (QI) project were to decrease the use of DCL and to identify indications where consensus exists. METHODS: In 2016, six US Level I trauma centers performed a yearlong, QI project utilizing a single QI tool: audit and feedback. Each emergent trauma laparotomy was prospectively reviewed. Damage control laparotomy cases were adjudicated based on the majority vote of faculty members as being appropriate or potentially, in retrospect, safe for definitive laparotomy. The rate of DCL for 2 years prior (2014 and 2015) was retrospectively collected and used as a control. To account for secular trends of DCL, interrupted time series was used to effectiveness of the QI interventions. RESULTS: Eight hundred seventy-two emergent laparotomies were performed: 73% definitive laparotomies, 24% DCLs, and 3% intraoperative deaths. Of the 209 DCLs, 162 (78%) were voted appropriate, and 47 (22%) were voted to have been potentially safe for definitive laparotomy. Rates of DCL ranged from 16% to 34%. Common indications for DCL for which consensus existed were packing (103/115 [90%] appropriate) and hemodynamic instability (33/40 [83%] appropriate). The only common indication for which primary closure at the initial laparotomy could have been safely performed was avoiding a planned second look (16/32 [50%] appropriate). CONCLUSION: A single faceted QI intervention failed to decrease the rate of DCL at six US Level I trauma centers. However, opportunities for improvement in safely decreasing the rate of DCL were present. Second look laparotomy appears to lack consensus as an indication for DCL and may represent a target to decrease the rate of DCL after injury. LEVEL OF EVIDENCE: Epidemiological study with one negative criterion, level III.

Effect of damage control laparotomy on major abdominal complications and lengths of stay: A propensity score matching and Bayesian analysis.

BACKGROUND: In patients for whom surgical equipoise exists for damage control laparotomy (DCL) and definitive laparotomy (DEF), the effect of DCL and its associated resource utilization are unknown. We hypothesized that DEF would be associated with fewer abdominal complications and less resource utilization. METHODS: In 2016, six US Level I trauma centers performed a yearlong, prospective, quality improvement project with the primary aim to safely decrease the use of DCL. From this cohort of patients undergoing emergent trauma laparotomy, those who underwent DCL but were judged by majority faculty vote at each center to have been candidates for potential DEF (pDEF) were prospectively identified. These pDEF patients were matched 1:1 using propensity scoring to the DEF patients. The primary outcome was the incidence of major abdominal complications (MAC). Deaths within 5 days were excluded. Outcomes were assessed using both Bayesian generalized linear modeling and negative binomial regression. RESULTS: Eight hundred seventy-two total patients were enrolled, 639 (73%) DEF and 209 (24%) DCL. Of the 209 DCLs, 44 survived 5 days and were judged to be patients who could have safely been closed at the primary laparotomy. Thirty-nine pDEF patients were matched to 39 DEF patients. There were no differences in demographics, mechanism of injury, Injury Severity Score, prehospital/emergency department/operating room vital signs, laboratory values, resuscitation, or procedures performed during laparotomy. There was no difference in MAC between the two groups (31% DEF vs. 21% pDEF, relative risk 0.99, 95% credible interval 0.60-1.54, posterior probability 56%). Definitive laparotomy was associated with a 72%, 77%, and 72% posterior probability of more hospital-free, intensive care unit-free, and ventilator-free days, respectively. CONCLUSION: In patients for whom surgeons have equipoise for DCL versus definitive surgery, definitive abdominal closure was associated with a similar probability of MAC, but a high probability of fewer hospital-free, intensive care unit-free, and ventilator-free days. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

National estimates of the use and outcomes of extracorporeal membrane oxygenation after acute trauma.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe acute respiratory distress syndrome is gaining greater acceptance among trauma intensivists. The objective of this study was to review ECMO usage in trauma patients in the USA. METHODS: The National Inpatient Sample (NIS) from years 2002 to 2012 was queried for patients aged 15 and older treated with ECMO who had one or more acute traumatic injuries as defined by the International Diagnostic Codes, Ninth Edition (ICD-9). The primary outcomes of interest were incidence of ECMO and overall inpatient mortality. RESULTS: A total of 1347 patients were identified in the NIS database who had both ECMO performed and ICD-9 codes consistent with trauma. Patients were predominantly aged 15 to 29 years (31.4%) and were male (65.5%). The incidence of ECMO for patients after traumatic injuries has increased 66-fold during the 10-year period. In-hospital mortality was 48.0% overall, with a decreasing trend during the study period that approached statistical significance (p=0.06). DISCUSSION: Although ECMO use in patients in the post-trauma setting remains controversial, there is an increasing trend to use ECMO nationwide, suggesting an increasing acceptance and/or increased availability at trauma centers. Given the decrease in mortality during the study period, ECMO as a salvage method in trauma patients remains a potentially viable option. Evaluation in a prospective manner may clarify risks and benefits. LEVEL OF EVIDENCE: Level IV, epidemiological.

Emergency Department Interventions for Older Adults: A Systematic Review.

OBJECTIVES: To evaluate the effect of emergency department (ED) interventions on clinical, utilization, and care experience outcomes for older adults. DESIGN: A conceptual model informed, protocol-based systematic review. SETTING: Emergency Department (ED). PARTICIPANTS: Older adults 65 years of age and older. METHODS AND MEASUREMENT: Medline, Embase, CINAHL, and PsycINFO were searched for English-language studies published through December 2017. Studies evaluating the use of one or more eligible intervention strategies (discharge planning, case management, medication safety or management, and geriatric EDs including those that cited the 2014 Geriatric ED Guidelines) with adults 65 years of age and older were included. Studies were classified by the number of intervention strategies used (ie, single strategy or multi-strategy) and key intervention components present (ie, assessment, referral plus follow-up, and contact both before and after ED discharge ["bridge"]). The effect of ED interventions on clinical (functional status, quality of life [QOL]), patient experience, and utilization (hospitalization, ED return visit) outcomes was evaluated. RESULTS: A total of 2000 citations were identified; 17 articles describing 15 unique studies (9 randomized and 6 nonrandomized) met eligibility criteria and were included in analyses. ED interventions showed a mixed pattern of effects. Overall, there was a small positive effect of ED interventions on functional status but no effects on QOL, patient experience, hospitalization at or after the initial ED index visit, or ED return visit. CONCLUSION: Studies using two or more intervention strategies may be associated with the greatest effects on clinical and utilization outcomes. More comprehensive interventions, defined as those with all three key intervention components present, may be associated with some positive outcomes.

Complications Associated With Placement of Chest Tubes: A Trauma System Perspective.

BACKGROUND: The insertion of a chest tube is a common procedure in trauma care, and the Advanced Trauma Life Support program teaches the insertion of chest tubes as an essential and life-saving skill. It is also recognized that the insertion of chest tubes is not without risks or complications. The purpose of this study was to evaluate complications of chest tube placement in a level 1 trauma center compared with those placed in surrounding referral hospitals. METHODS: A retrospective matched cohort study of trauma patients was performed between those who underwent chest tube placement at the level 1 trauma center and those with a chest tube placed before transfer to the level 1 center between 2004 and 2013. Conditional logistic regression was used to compare the likelihood of complications and death between chest tube placement groups. RESULTS: Four thousand two hundred and sixteen trauma patients had a chest tube placed at the level 1 center, and 364 patients had a chest tube placed at an outside hospital before transfer. Two hundred and eighty-one patients were matched. Patients with a chest tube placed outside the trauma center had an increased likelihood of malposition (OR 7.2, 95% CI 3.6-14.6), residual hemothorax (OR 6.3, 95% CI 3.4-11.6), residual pneumothorax (OR 6.7, 95% CI 3.9-11.4), and having a second chest tube placed (OR 3.77, 95% CI 2.37-6.01). However, the patients with a chest tube placed outside of the trauma center were also less likely to develop pneumonia (OR 0.32, 95% CI 0.14-0.73). There were no differences in the odds of developing an empyema, the need for video-assisted thoracoscopic surgery, thoracotomy, or death. CONCLUSIONS: There are opportunities for improving the care of patients who require chest tubes at both referring hospitals and the receiving trauma center. Improving the care of patients who require intercostal drainage requires a systems-based approach, focusing on training and quality improvement.