Age-related injury patterns resulting from knife violence in an urban population.

Interpersonal violence involving knives is a major public health problem. The majority of patients are young people in urban areas, but little is known about age-specific patterns of injury and recent trends in injury characteristics. We performed a retrospective cohort study of all patients presenting to an urban major trauma centre with stab injuries resulting from assault between 2012 and 2018. A total of 3583 patients were included. Young people (age under 25) were more likely to have sustained multiple stab wounds compared to older people (43% vs 35%, p < 0.001) and had significantly higher rates of stab injuries involving the lower limbs, groin and buttocks. The annual number of injuries increased steadily during the study period in patients aged under 25 (r2 = 0.82, p = 0.005) and those over 25 (r2 = 0.95, p < 0.001). Over time, limb and junctional injuries accounted for an increasing proportion of stab wounds in young people, overtaking torso injuries as most common pattern of injury by the end of the study period. These findings illustrate the influence of age on injury patterns resulting from knife violence, and support the expansion of outreach initiatives promoting bystander-delivered haemorrhage control of extremity wounds.

Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial.

PURPOSE: Contemporary trauma resuscitation prioritizes control of bleeding and uses major haemorrhage protocols (MHPs) to prevent and treat coagulopathy. We aimed to determine whether augmenting MHPs with Viscoelastic Haemostatic Assays (VHA) would improve outcomes compared to Conventional Coagulation Tests (CCTs). METHODS: This was a multi-centre, randomized controlled trial comparing outcomes in trauma patients who received empiric MHPs, augmented by either VHA or CCT-guided interventions. Primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of massive transfusion (10 or more red cell transfusions). Secondary outcomes included 28-day mortality. Pre-specified subgroups included patients with severe traumatic brain injury (TBI). RESULTS: Of 396 patients in the intention to treat analysis, 201 were allocated to VHA and 195 to CCT-guided therapy. At 24 h, there was no difference in the proportion of patients who were alive and free of massive transfusion (VHA: 67%, CCT: 64%, OR 1.15, 95% CI 0.76-1.73). 28-day mortality was not different overall (VHA: 25%, CCT: 28%, OR 0.84, 95% CI 0.54-1.31), nor were there differences in other secondary outcomes or serious adverse events. In pre-specified subgroups, there were no differences in primary outcomes. In the pre-specified subgroup of 74 patients with TBI, 64% were alive and free of massive transfusion at 24 h compared to 46% in the CCT arm (OR 2.12, 95% CI 0.84-5.34). CONCLUSION: There was no difference in overall outcomes between VHA- and CCT-augmented-major haemorrhage protocols.

Multiple organ dysfunction after trauma.

BACKGROUND: The nature of multiple organ dysfunction syndrome (MODS) after traumatic injury is evolving as resuscitation practices advance and more patients survive their injuries to reach critical care. The aim of this study was to characterize contemporary MODS subtypes in trauma critical care at a population level. METHODS: Adult patients admitted to major trauma centre critical care units were enrolled in this 4-week point-prevalence study. MODS was defined by a daily total Sequential Organ Failure Assessment (SOFA) score of more than 5. Hierarchical clustering of SOFA scores over time was used to identify MODS subtypes. RESULTS: Some 440 patients were enrolled, of whom 245 (55·7 per cent) developed MODS. MODS carried a high mortality rate (22·0 per cent versus 0·5 per cent in those without MODS; P < 0·001) and 24·0 per cent of deaths occurred within the first 48 h after injury. Three patterns of MODS were identified, all present on admission. Cluster 1 MODS resolved early with a median time to recovery of 4 days and a mortality rate of 14·4 per cent. Cluster 2 had a delayed recovery (median 13 days) and a mortality rate of 35 per cent. Cluster 3 had a prolonged recovery (median 25 days) and high associated mortality rate of 46 per cent. Multivariable analysis revealed distinct clinical associations for each form of MODS; 24-hour crystalloid administration was associated strongly with cluster 1 (P = 0·009), traumatic brain injury with cluster 2 (P = 0·002) and admission shock severity with cluster 3 (P = 0·003). CONCLUSION: Contemporary MODS has at least three distinct types based on patterns of severity and recovery. Further characterization of MODS subtypes and their underlying pathophysiology may lead to future opportunities for early stratification and targeted interventions.

ANTECEDENTES: La naturaleza del síndrome de disfunción orgánica múltiple (Multiple Organ Dysfunction Syndrome, MODS) resultante de un traumatismo está evolucionando a medida que avanzan las prácticas de reanimación y más pacientes sobrevive a las lesiones y pueden recibir cuidados críticos. El objetivo de este estudio fue caracterizar los subtipos actuales MODS en atención crítica de trauma a nivel poblacional. MÉTODOS: Los pacientes adultos ingresados en unidades de cuidados intensivos de trauma se incluyeron en este estudio de prevalencia puntual de 4 semanas. MODS se definió como una puntuación total diaria de la escala de Evaluación de Fallo Orgánico Secuencial (Sequential Organ Failure Assessment, SOFA) > 5. Se utilizó el agrupamiento jerárquico de las puntuaciones SOFA a lo largo del tiempo para determinar los subtipos MODS. RESULTADOS: Se incluyeron 440 pacientes, de los cuales 245 (56%) presentaron MODS. MODS conllevó una alta mortalidad (22% versus 1%, P < 0,001) y 24% de las muertes fueron precoces, durante las primeras 48 horas tras el traumatismo. Se identificaron tres patrones de MODS, estando todos presentes al ingreso. En el tipo 1, MODS se resolvió de forma temprana, con una mediana de tiempo de recuperación de 4 días y una mortalidad del 14%. El tipo 2 presentaba un tiempo de recuperación retardado (mediana 13 días) y una mortalidad del 35%. El tipo 3 presentaba un tiempo de recuperación prolongado (mediana 25 días) y una mortalidad asociada alta del 46%. El análisis multivariable reveló asociaciones clínicas diferentes para cada tipo de MODS, con la administración de cristaloides durante 24 horas fuertemente asociada al tipo 1 (P < 0,001); el traumatismo craneal al tipo 2 (P < 0,01); y la gravedad del shock al ingreso al tipo 3 (P < 0,01). CONCLUSIÓN: Los MODS actuales presentan al menos tres tipos distintos basados en patrones de gravedad y recuperación. La caracterización de los subtipos de MODS y su fisiopatología subyacente puede contribuir a futuras oportunidades de estratificación temprana e intervenciones dirigidas.

Trends in urgent referrals for suspected colorectal cancer: an increase in quantity, but not in quality.

INTRODUCTION An understanding of the volume of incoming referrals to a colorectal cancer (CRC) service is essential for adequate delivery of service. We hypothesised that the number of 2-week-wait (2WW) referrals has increased over recent years, with a concomitant increase in demand for endoscopic and imaging investigations. METHODS A retrospective review of all referrals from primary care with suspected malignancy to Barking, Havering and Redbridge NHS Trust (BHRNHST, London, UK) from 2009 to 2014 was undertaken. Annual numbers of CRC diagnoses, colonoscopies and CT scans among these patients were reviewed. Linear regression models were used to determine the significance of observed trends. RESULTS Annual number of 2WW referrals for all cancers increased steadily from 14,031 to 19,983 during the study period (p<0.01). Referrals for suspected CRC increased from 1,706 to 2,874 (p=0.02). Number of colonoscopies and CT scans carried out in 2WW patients also increased significantly. Proportion of patients referred as a 2WW diagnosed with CRC decreased from 7.9% in 2009 to 4.7% in 2014 (p=0.02). DISCUSSION Number of referrals for suspected cancer from primary care to BHRNHST is increasing steadily, which has implications for service provision. Prevalence of cancer diagnoses from these referrals is decreasing. CONCLUSIONS There has been a sustained and substantial increase in the number of urgent referrals for suspected CRC at BHRNHST over recent years, without an increase in the number of resulting cancer diagnoses.

Persistent lymphopenia is an independent predictor of mortality in critically ill emergency general surgical patients.

INTRODUCTION: Lymphopenia has been associated with poor outcome following sepsis, burns and trauma. This study was designed to establish whether lymphocyte count was associated with mortality in emergency general surgery (EGS) patients, and whether persistent lymphopenia was an independent predictor of mortality. METHODS: A retrospective review of a prospectively compiled database of adult patients requiring ICU admission between 2002 and 2013 was performed. EGS patients with acute intra-abdominal pathology and organ dysfunction were included. Lymphocyte counts obtained from the day of ICU admission through to day 7 were examined. Multivariate logistic regression models were used to determine the relationship between persistent lymphopenia and outcome. The primary outcome measure was in-hospital mortality. RESULTS: The study included 173 patients, of whom 135 (78 %) had a low lymphocyte count at admission to ICU and 91 % (158/173) developed lymphopenia on at least one occasion. Lymphocyte counts were lower among non-survivors compared with survivors on each day from day 2 (0.62 vs 0.81, p = 0.03) through to day 7 (0.87 vs 1.15, p < 0.01). Patients with a persistently low lymphocyte count during the study period had significantly higher mortality when compared to patients with other lymphocyte patterns (64 vs 29 %, p < 0.01). On multivariate regression analysis, persistent lymphopenia was independently associated with increased in-hospital mortality [odds ratio 3.5 (95 % CI 1.7-7.3), p < 0.01]. CONCLUSION: Lymphopenia is commonly observed in critically ill EGS patients. Patients with persistent lymphopenia are 3.5 times more likely to die and lymphopenia is an independent predictor of increased mortality in this patient group.

Operative repair of an incidentally diagnosed giant hepatic artery aneurysm.

Hepatic Artery Aneurysms (HAA) are rare vascular lesions which are associated with significant morbidity and mortality in the event of rupture. Early diagnosis and expedient management are therefore important to optimise outcome. Here we report a case of a giant Hepatic Artery Aneurysms (HAA) found incidentally on Computerised Tomography, successfully managed without complication by elective surgical repair.