Markers of Futile Resuscitation in Traumatic Hemorrhage: A Review of the Evidence and a Proposal for Futility Time-Outs during Massive Transfusion.

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility.

Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock.

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

Leveraging Public Health and Public School Partnerships for Local Surveillance of Positive Childhood Experiences.

Childhood psychosocial experiences can have a lifelong effect on health. These experiences can be measured together as positive and adverse childhood experiences or individually as positive childhood experiences (PCEs) or adverse childhood experiences. Most research on PCEs has focused on how PCEs promote health outcomes. However, limited research has been conducted on the prevalence of PCEs among adolescents in local areas served by public health departments. The St. Joseph County Department of Health developed a study to test the feasibility of surveillance of PCEs through local public health departments and to establish a prevalence for PCE exposure among a population of urban public-school students in Indiana. We conducted a survey in spring 2022 that collected demographic information on students at 2 high schools and 1 middle school and assessed exposure to PCEs. We assessed prevalence of PCEs on a 5-point Likert scale (0 = never, 1 = rarely, 2 = sometimes, 3 = usually, 4 = always). PCE scores were grouped into low (0-2), medium (3-5), and high (6 or 7). The prevalence of individual PCE items ranged from 35.6% to 86.8%. Among 798 respondents, 189 (23.7%) reported low PCE scores, 396 (49.6%) reported medium scores, and 213 (26.7%) reported high scores. This research demonstrates the feasibility of school-based PCE surveillance and establishes a baseline prevalence of PCE exposure among a population of middle and high school students. These methods are applicable to different contexts and can provide both local health departments and school systems with a new tool to address adverse childhood experiences.

Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation.

Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.

Results of a Shortened Quarantine Protocol on a Midwestern College Campus.

A shortened quarantine protocol after severe acute respiratory syndrome coronavirus 2 exposure was implemented on a college campus. We assessed data on exposures, symptoms, and tests in 1152 unvaccinated individuals released from quarantine on day 7. A shortened quarantine period for asymptomatic individuals testing negative can be implemented with low risk.

Response to a COVID-19 Outbreak on a University Campus - Indiana, August 2020.

Institutions of higher education adopted different approaches for the fall semester 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic. Approximately 45% of colleges and universities implemented online instruction, more than one fourth (27%) provided in-person instruction, and 21% used a hybrid model (1). Although CDC has published COVID-19 guidance for institutions of higher education (2-4), little has been published regarding the response to COVID-19 outbreaks on college and university campuses (5). In August 2020, an Indiana university with approximately 12,000 students (including 8,000 undergraduate students, 85% of whom lived on campus) implemented various public health measures to reduce transmission of SARS-CoV-2, the virus that causes COVID-19. Despite these measures, the university experienced an outbreak involving 371 cases during the first few weeks of the fall semester. The majority of cases occurred among undergraduate students living off campus, and several large off-campus gatherings were identified as common sources of exposure. Rather than sending students home, the university switched from in-person to online instruction for undergraduate students and instituted a series of campus restrictions for 2 weeks, during which testing, contact tracing, and isolation and quarantine programs were substantially enhanced, along with educational efforts highlighting the need for strict adherence to the mitigation measures. After 2 weeks, the university implemented a phased return to in-person instruction (with 85% of classes offered in person) and resumption of student life activities. This report describes the outbreak and the data-driven, targeted interventions and rapid escalation of testing, tracing, and isolation measures that enabled the medium-sized university to resume in-person instruction and campus activities. These strategies might prove useful to other colleges and universities responding to campus outbreaks.

Adverse Childhood Experiences and Trust in the Medical Profession among Young Adults.

Attachment theory suggests that adverse childhood experiences (ACEs) should predict lower trust in the medical profession. To test this theory, a cross-sectional survey was administered to young adults self-identifying as homeless. The purpose of the survey was to examine the relationship of ACEs, attachment style, and trust in the medical profession. Hierarchical linear regression was used to determine if ACEs predict variance in trust in the medical profession after controlling for participants' attachment style and demographics. Results indicated ACEs were a robust predictor of lower trust in the medical profession over the controls. Since lower trust in the medical profession is associated with less willingness to seek care and follow provider recommendations, the established link between poorer health and ACEs may partially result from lower trust in the medical profession. The paper concludes with a discussion of the results' implications for future research and practice with ACE survivors.

Changing the culture of a medical school by orienting students and faculty toward community medicine.

Oklahoma's health status has been ranked among the worst in the country. In 1972, the University of Oklahoma established the Tulsa branch of its College of Medicine (COM) to expand the physician workforce for northeastern Oklahoma and to provide care for the uninsured patients of the area. In 2008, the Tulsa branch launched a distinct educational track, the University of Oklahoma COM's School of Community Medicine (SCM), to prepare providers equipped and committed to addressing prevalent health disparities.The authors describe the Tulsa branch's Summer Institute (SI), a signature program of the SCM, and how it is part of SCM's process of institutional transformation to align its education, service, and research missions toward improving the health status of the entire region. The SI is a weeklong, prematriculation immersion experience in community medicine. It brings entering medical and physician assistant students together with students and faculty from other disciplines to develop a shared culture of community medicine. The SI uses an unconventional curriculum, based on Scharmer's Theory U, which emphasizes appreciative inquiry, critical thinking, and collaborative problem solving. Also, the curriculum includes Professional Meaning conversations, small-group sessions to facilitate the integration of students' observations into their professional identities and commitments. Development of prototypes of a better health care system enables participants to learn by doing and to bring community medicine to life.The authors describe these and other curricular elements of the SI, present early evaluation data, and discuss the curriculum's incremental evolution. A longitudinal outcomes evaluation is under way.

Hypertension in an Adolescent Secondary to Performance-Enhancement Supplement Use.

Objective: To describe the effects of performance-enhancing supplements and caffeine on the blood pressure (BP) of an adolescent male. Case Summary: An adolescent male presented to his primary care provider for a preseason athletic physical. On physical exam, his BP was 162/90, exceeding the 99th percentile for his age. It had been elevated during the previous 2 yearly physicals. He was referred to the Pediatric Preventive Cardiology Clinic for follow-up. Illegal substance use and renal trauma were ruled out. During the evaluation, the patient acknowledged using energy drinks and performance-enhancing supplements, the majority of which were caffeine-based. His intention was to continue the use of supplements, so lisinopril was initiated. On follow-up, however, the patient reported supplement discontinuation, intermittent medication adherence, and lower home-based BP readings. He was subsequently lost to follow-up. An objective causality assessment revealed that the adverse drug event was probable. Discussion: When working with adolescent patients, it is particularly important to conduct an in-depth interview reflecting lifestyle choices. Use of performance-enhancing supplements and caffeine for adolescent athletes has been well reported in the literature. Adolescent use of supplements may be driven by misguided beliefs and lack of knowledge about potentially detrimental health effects, such as altered heart rate and elevated BP. Little evidence-based research is available to provide treatment guidance for clinicians regarding potential effects. Conclusions: A thorough patient history, including specific questions probing for any recent or chronic use of nutritional supplements, including energy drinks, will help identify substances that may contribute to BP variations. Even mild BP elevations in adolescents should lead clinicians to further investigate supplement use and include specific questions on any product use within the past 24 hours, several days, or longer. Adolescents may not consider the potential for adverse health effects when ingesting performance-enhancing supplements or energy drinks.