Home Medication Regimens Increase in Complexity After Admission for Fall in the Older Trauma Patient.

BACKGROUND: Hospitalization for the older trauma patient is an opportunity to assess polypharmacy. We hypothesized that medication regimen complexity (RxCS) and pain medication prescriptions (PRxs) would increase in older home-going patients admitted for a fall. METHODS: We retrospectively chart reviewed patients ≥45 years old admitted for a fall at a level 1 trauma center who were discharged home with full medication documentation. RxCS was compared pre-admission and post-discharge with Wilcoxon signed-rank tests; opioid and non-opioid PRxs were compared with Fisher's exact test, α = .05. RESULTS: 103 patients met inclusion criteria; 58% were ≥65 years old. RxCS (9 [.5-13] to 11 [4.5-15], P < .01) increased on discharge. Opioid PRx rates increased significantly in all age groups. Non-opioid PRx rates increased significantly for patients <65 but not for patients ≥65. CONCLUSIONS: Admission for a fall was associated with increases in RxCS, while PRx changes were age-dependent. Providers should recognize that admissions for older patients who fall after trauma are underutilized opportunities to address polypharmacy in high-risk patients.

Post-Trauma Discharge Instructions: Are We Dropping the Ball?

INTRODUCTION: Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors). METHODS: We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05). RESULTS: We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors. CONCLUSION: Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.

Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study.

Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.

Variations in Discharge Destination Following Severe Traumatic Brain Injury across the United States.

BACKGROUND: Discharge destination after traumatic brain injury (TBI) may be influenced by non-patient factors such as regional or institutional practice patterns. We hypothesized that non-patient factors would be associated with discharge destination in severe TBI patients. METHODS: All patients in the ACS Trauma Quality Improvement Program 2016 data set with severe TBI, defined as head Abbreviated Injury Scale ≥3, were categorized by discharge destination. Logistic regression was used to assess factors associated with each destination; odds ratios and 95% confidence level are reported. Regressions were adjusted for age, gender, race, insurance, GCS, ISS, polytrauma, mechanism, neurosurgical procedure, geographic region, teaching status, trauma center level, hospital size, and neurosurgeon group size. RESULTS: 75,690 patients met inclusion criteria. 51% were discharged to home, 16% to rehab, 14% to SNF, and 11% deceased. Mortality was similar across geographic region, teaching status, and hospital size. Southern patients were more likely to be discharged to home while Northeastern patients were more likely to be discharged to rehab. Treatment by groups of 3 or more neurosurgeons was associated with SNF discharge as was treatment at community or non-teaching hospitals. Patients treated at larger hospitals were less likely to be discharged to rehab and more likely to go to SNF. CONCLUSIONS: Geographic region, neurosurgeon group size, teaching status, and hospital size are significantly associated with variation in discharge destination following severe TBI. Regional and institutional variation in practice patterns may play important roles in recovery for some patients with severe TBI.

Variation in neurosurgical intervention for severe traumatic brain injury: The challenge of measuring quality in trauma center verification.

BACKGROUND: Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution. METHODS: We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval). RESULTS: We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement. CONCLUSION: Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification. LEVEL OF EVIDENCE: Epidemiological, level III; Care management/Therapeutic level III.

Draft Genome Sequences of Staphylococcus Podophages JBug18, Pike, Pontiff, and Pabna.

We report here the draft genome sequences of Staphylococcus bacteriophages JBug18, Pike, Pontiff, and Pabna, which infect and lyse S. epidermidis and S. aureus strains. All bacteriophages belong to the morphological family Podoviridae and constitute attractive candidates for use as whole-phage therapeutics due to their compact genomes and lytic lifestyles.

Dysregulation of the Mitochondrial Unfolded Protein Response Induces Non-Apoptotic Dopaminergic Neurodegeneration in C. elegans Models of Parkinson's Disease.

Due to environmental insult or innate genetic deficiency, protein folding environments of the mitochondrial matrix are prone to dysregulation, prompting the activation of a specific organellar stress-response mechanism, the mitochondrial unfolded protein response (UPRMT). In Caenorhabditis elegans, mitochondrial damage leads to nuclear translocation of the ATFS-1 transcription factor to activate the UPRMT After short-term acute stress has been mitigated, the UPRMT is eventually suppressed to restore homeostasis to C. elegans hermaphrodites. In contrast, and reflective of the more chronic nature of progressive neurodegenerative disorders such as Parkinson's disease (PD), here, we report the consequences of prolonged, cell-autonomous activation of the UPRMT in C. elegans dopaminergic neurons. We reveal that neuronal function and integrity decline rapidly with age, culminating in activity-dependent, non-apoptotic cell death. In a PD-like context wherein transgenic nematodes express the Lewy body constituent protein α-synuclein (αS), we not only find that this protein and its PD-associated disease variants have the capacity to induce the UPRMT, but also that coexpression of αS and ATFS-1-associated dysregulation of the UPRMT synergistically potentiate dopaminergic neurotoxicity. This genetic interaction is in parallel to mitophagic pathways dependent on the C. elegans PINK1 homolog, which is necessary for cellular resistance to chronic malfunction of the UPRMT Given the increasingly recognized role of mitochondrial quality control in neurodegenerative diseases, these studies illustrate, for the first time, an insidious aspect of mitochondrial signaling in which the UPRMT pathway, under disease-associated, context-specific dysregulation, exacerbates disruption of dopaminergic neurons in vivo, resulting in the neurodegeneration characteristic of PD.SIGNIFICANCE STATEMENT Disruptions or alterations in the activation of pathways that regulate mitochondrial quality control have been linked to neurodegenerative diseases due in part to the central role of mitochondria in metabolism, ROS regulation, and proteostasis. The extent to which these pathways, including the mitochondrial unfolded protein response (UPRMT) and mitophagy, are active may predict severity and progression of these disorders, as well as sensitivity to compounding stressors. Furthermore, therapeutic strategies that aim to induce these pathways may benefit from increased study into cellular responses that arise from long-term or ectopic stimulation, especially in neuronal compartments. By demonstrating the detrimental consequences of prolonged cellular activation of the UPRMT, we provide evidence that this pathway is not a universally beneficial mechanism because dysregulation has neurotoxic consequences.