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Background: The neutrophil-to-lymphocyte ratio has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. However, the initial neutrophil-to-lymphocyte ratio does not appear to be predictive of in-hospital mortality. The aim of this study is to determine the discriminative ability of the neutrophil-to-lymphocyte ratio profile over 48 h as a predictor of in-hospital mortality following major trauma. Methods: This was a case-control study involving all major trauma patients meeting the criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period. Patients were then divided into two groups, cases being major trauma patients who died at hospital discharge and controls being patients who survived. We extracted data for Day 0, Day 1 and Day 2 neutrophil-to-lymphocyte ratio values for each patient. The primary outcome was mortality at hospital discharge. Results: Data were extracted for 1689 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) patients presented after a blunt mechanism of injury. There were 165 cases that were compared to 1524 controls. Patients who died were older (p < 0.001), and had higher injury severity scores (p < 0.001) and lower revised trauma scores (p < 0.001). Analysis of response profiles demonstrated a significant difference between the trajectories of the neutrophil-to-lymphocyte ratio over time (p < 0.001). Conclusions: The profile of neutrophil-to-lymphocyte ratio over 48 h after injury shows promise as a prognostic tool in trauma and warrants further investigation. [ABSTRACT FROM AUTHOR]

Introduction: The neutrophil-to-lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. We aimed to determine the discriminative ability of initial NLR as a predictor of outcomes following major trauma. Methods: This was a registry-based cohort study involving all major trauma patients meeting criteria for inclusion into the Alfred Health Trauma Registry who presented directly from the scene of injury over a 24-month period (January 2018 to December 2019). The initial NLR was calculated for each patient and was compared against the Shock Index (SI), lactate and Revised Trauma Score (RTS). Outcomes observed were mortality at hospital discharge and intensive care unit (ICU) admission. We assessed the predictive capacity of each test using the receiver operating characteristic (ROC) curve and performed area under the ROC curve (AUROC) analysis to compare their performance. Results: Data were extracted for 1687 major trauma patients, of which 72% were male, the median age was 49 years (IQR 31–68) and most (90%) of patients presented after a blunt mechanism of injury. In-hospital mortality occurred in 165 (9.77%) patients, and 725 (42.92%) patients required ICU admission. The median NLR was 6.84 (IQR 3.89–11.52). Initial NLR performed poorly with an AUROC of 0.46 (95% confidence interval (CI): 0.40–0.52) for prediction of mortality and AUROC of 0.53 (95% CI: 0.50–0.56) for prediction of ICU admission. The AUROCs of initial NLR for both mortality at hospital discharge and ICU admission were significantly lower than SI, lactate and RTS. Conclusion: Initial NLR was not predictive of outcomes in major trauma. NLR at other time-points may provide better predictive capacity for outcomes. [ABSTRACT FROM AUTHOR]

Background: After trauma, clearance of the cervical spine refers to the exclusion of underlying serious injuries. Accurate assessment of computed tomography (CT) is commonly required prior to clearance of the cervical spine. Delays to clearance can lead to prolonged immobilization with associated patient discomfort and adverse effects. This systematic review aimed to determine performance of non‐radiologists to evaluate cervical spine CT. Methods: MEDLINE, EMBASE, Cochrane library with sources of grey literature and reference lists of selected articles were appraised from inception to April 2021. We included manuscripts that reported discordance in CT cervical spine interpretation between non‐radiologists and radiologists. The Newcastle–Ottawa scale (NOS) was used to assess quality of included studies and statistical heterogeneity was assessed using the I2 statistic. Results: There were 43 studies identified for eligibility and 4 manuscripts included in the final analysis. There were two studies that reported on the performance of radiology residents, one study on the performance of surgical residents and one on emergency physicians. The pooled discordance was 0.25 (95%CI 0.21–0.28) but was lower for radiology residents (range 0.007–0.05). There was significant statistical heterogeneity (I2 = 99.6%, P < 0.001) among studies. Conclusion: There is a paucity of evidence documenting the ability of non‐radiologists in accurately interpreting CT of the cervical spine. A number of discordant findings suggest that studies with larger sample sizes are indicated to accurately ascertain the ability of non‐radiologists in this area. [ABSTRACT FROM AUTHOR]

Objective: Inconsistency in the structure and function of team-based major trauma reception and resuscitation is common. A standardised trauma team training programme was initiated to improve quality and consistency among trauma teams across a large, mature trauma system. The aim of this manuscript is to outline the programme and report on the initial perception of participants. Methods: The Alfred Trauma Team Reception and Resuscitation Training (TTRRT) programme commenced in March 2019. Participants included critical care and surgical craft group members commonly involved in trauma teams. Training was sitespecific and included rural, urban and tertiary referral centres. The programme consisted of prescribed pre-learning, didactic lectures, skill stations and simulated team-based scenarios. Participant perceptions of the programme were collected before and after the programme for analysis. Results: The TTRRT was delivered to 252 participants and 120 responses were received. Significant improvement in participant-reported confidence was identified across all key topic areas. There was also a significant increase in both confidence and clinical exposure to trauma team leadership roles after participation in the programme (from 53 [44.2%] to 74 [61.7%; P = 0.007]). This finding was independent of clinician experience. Conclusions: A team-based trauma reception and resuscitation education programme, introduced in a large, mature trauma system led to positive participant-reported outcomes in clinical confidence and real-life team leadership participation. Wider implementation combined with longitudinal data collection will facilitate correlation with patient and staff-centred outcomes. [ABSTRACT FROM AUTHOR]

Objective: Haemorrhagic shock is a life-threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9-11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised. Methods: We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level-1 trauma centre (2009-2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9-11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non-cavitary bleeds. Results: Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH. Conclusion: The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes. [ABSTRACT FROM AUTHOR]

Objective: The present study aimed to determine the difference in force required to puncture simulated pleura comparing Kelly clamps to fine artery forceps. The treatment of symptomatic traumatic pneumothorax and haemothorax involves puncture of the parietal pleura to allow decompression. This is usually performed using Kelly clamps or fine artery forceps. Over‐puncture pulmonary injury risk increases with the force used. Methods: An experienced single operator performed puncturing of simulated parietal pleura on a thoracic mannequin while wearing a force sensor under gloves. The force imparted at the device tip onto the parietal pleura was estimated by subtracting the force required to hold the device from the total force. Outcome variables were the total maximum force and force imparted by the device. Results: There were 11 simulated procedures completed, seven using Kelly clamps and four using fine artery forceps. After subtracting the force required to hold the chosen forceps, the median value of pleural puncture force using Kelly clamps was 52.91 N (IQR 36.68–63.56) and 10.70 N (IQR 7.64–26.56) using fine artery forceps (P = 0.006). Conclusion: A significantly increased force was required to puncture simulated parietal pleura using Kelly clamps compared to fine artery forceps. This higher puncture force will be associated with increased instrument acceleration at the time of pleural puncture, which may result in an increased risk of injury to the underlying lung. Based on these data, clinicians may reduce the risk of pulmonary injury by using fine artery forceps rather than Kelly clamps when performing pleural decompression. [ABSTRACT FROM AUTHOR]

Introduction: Early identification of trauma injury severity is important for prognostication. The neutrophil–lymphocyte ratio (NLR) has been proposed as a marker of systemic inflammation in major trauma patients that is associated with in-hospital mortality. The aim of this systematic review is to compile all the best evidence available to determine the prognostic capabilities of the NLR in trauma and to assess the NLR as a predictor of mortality in adult major trauma patients. Additionally, comparing NLR and hospital length of stay (LOS), ICU LOS, mechanical ventilation and transfusion requirements. Methods: We conducted a search of online information sources to identify manuscripts observing the NLR in adult major trauma patients. Outcomes of interest include mortality as defined by the author, hospital LOS, ICU LOS, mechanical ventilation and transfusion requirements. Quality was assessed using the Newcastle–Ottawa Scale. We aimed to conduct a meta-analysis if there were sufficient manuscripts included. Results: Eight studies fulfilled our inclusion criteria. Trials were of good methodological quality. Substantial heterogeneity present between the studies prevented a meta-analysis from being conducted. Overall, five studies demonstrated the NLR as a significantly predictive marker of mortality. NLR was observed to be significantly associated with increased ICU LOS and longer duration of mechanical ventilation. Mixed results were observed between NLR and hospital LOS and transfusion requirements. Conclusions: A potential association between NLR and mortality, ICU LOS and duration of mechanical ventilation has been reported. However, clinical utility of this measure during trauma resuscitation remains unknown. [ABSTRACT FROM AUTHOR]

The ecology of avian community assembly in subtropical climate areas with seasonal and year-to-year variability is complex and poorly understood. To test for variation in year-year and seasonal (summer-winter) avian community composition and species abundances, we established 10 transects (200 m long) and sampled twice yearly for 7 years. To differentiate year-year and seasonal (summer-winter) patterns from the potential disturbance effects caused by human activities associated with music festivals (events), we monitored community composition and species abundances on sites close to disturbance areas (impact) and sites distant from disturbances (control). Impacts from large scale music events included loud noise, and thousands of vehicle and people movements on a daily basis. Raw count, abundance-weighted, and feeding guild data were analysed using multivariate and univariate methods. Seasonal (summer-winter) patterns of food resource availability in dominant forest trees (fruit and nectar resources) were identified. We found strong signals for the influence of seasonality and seasonal resource availability on community composition and feeding guild representation (nectivores and frugivores). We detected somewhat weaker effects for location relative to disturbance (control vs impact) and weak effects for sample timing associated with disturbance from the events. Avian community composition showed high similarity between control and impact sites, was dynamic in space and time (year to year) and showed strong local and regional trends in response to seasonality. Avian species abundances were greater in less disturbed (control) forest habitats, highlighting the fundamental value of conservation reserves in protecting higher quality avian habitats. [ABSTRACT FROM AUTHOR]

Introduction: Injury is a major global health burden. Trauma registries have been used for decades to monitor the burden of injury and inform trauma care. However, the extent to which trauma registries have fulfilled their potential remains uncertain. The aims of this study were to determine the current and priority uses of trauma registries across Australia and New Zealand and to establish the priority clinical outcomes, the probability for which, if known for an individual trauma patient, would better inform that same patient's care, during hospital admission.Methods: A prospective observational study using survey methodology was conducted. Participants were sourced from the Australia New Zealand Trauma Registry (ATR) participating hospitals. The survey questions included: the current uses and priorities for both single-site trauma registries and the binational trauma registry; the five top-ranked priority outcomes for which knowing the probability, for an individual patient, would inform care; and the priority timepoints for applying patient-level outcome prediction models.Results: Of the 26 ATR-participating hospitals, 25 were represented by a total of 54 participants in the survey, including trauma service directors and trauma nurse coordinators. The main trauma registry use and priority for the single site registries was to inform the quality improvement program; for the ATR, the main use was periodic reporting and the main priority was benchmarking. For each potential purpose of the registry, the future priority level was ranked more highly than the current level of utilisation. The most highly ranked priority patient-level outcomes requiring prediction were: preventable death, missed injury, quality of life, admission costs, pulmonary embolism, post-traumatic stress disorder, length of hospital stay, errors in decision-making and deep venous thrombosis. The time period between leaving the emergency department and the 24 h mark following presentation was considered the preferred time for patient-level priority outcome prediction.Conclusion: There is a mismatch between current trauma registry uses and future priorities. The priority outcomes demanding prediction in the first 24 h of a trauma patient's stay are preventable death, missed injury, quality of life, hospital costs, thromboembolism, post-traumatic stress disorder, length of hospital stay and errors in clinical decision-making. [ABSTRACT FROM AUTHOR]

The wide‐spread use of an initial 'Glasgow Coma Scale (GCS) 8 or less' to define and dichotomise 'severe' from 'mild' or 'moderate' traumatic brain injury (TBI) is an out‐dated research heuristic that has become an epidemiological convenience transfixing clinical care. Triaging based on GCS can delay the care of patients who have rapidly evolving injuries. Sole reliance on the initial GCS can therefore provide a false sense of security to caregivers and fail to provide timely care for patients presenting with GCS greater than 8. Nearly 50 years after the development of the GCS – and the resultant misplaced clinical and statistical definitions – TBI remains a heterogeneous entity, in which 'best practice' and 'prognoses' are poorly stratified by GCS alone. There is an urgent need for a paradigm shift towards more effective initial assessment of TBI. [ABSTRACT FROM AUTHOR]

Objective: Improvement in epilepsy care requires standardized methods to assess disease severity. We report the results of implementing common data elements (CDEs) to document epilepsy history data in the electronic medical record (EMR) after 12 months of clinical use in outpatient encounters. Methods: Data regarding seizure frequency were collected during routine clinical encounters using a CDE‐based form within our EMR. We extracted CDE data from the EMR and developed measurements for seizure severity and seizure improvement scores. Seizure burden and improvement was evaluated by patient demographic and encounter variables for in‐person and telemedicine encounters. Results: We assessed a total of 1696 encounters in 1038 individuals with childhood epilepsies between September 6, 2019 and September 11, 2020 contributed by 32 distinct providers. Childhood absence epilepsy (n = 121), Lennox‐Gastaut syndrome (n = 86), and Dravet syndrome (n = 42) were the most common epilepsy syndromes. Overall, 43% (737/1696) of individuals had at least monthly seizures, 17% (296/1696) had a least daily seizures, and 18% (311/1696) were seizure‐free for >12 months. Quantification of absolute seizure burden and changes in seizure burden over time differed between epilepsy syndromes, including high and persistent seizure burden in patients with Lennox‐Gastaut syndrome. Individuals seen via telemedicine or in‐person encounters had comparable seizure frequencies. Individuals identifying as Hispanic/Latino, particularly from postal codes with lower median household incomes, were more likely to have ongoing seizures that worsened over time. Significance: Standardized documentation of clinical data in childhood epilepsies through CDE can be implemented in routine clinical care at scale and enables assessment of disease burden, including characterization of seizure burden over time. Our data provide insights into heterogeneous patterns of seizure control in common pediatric epilepsy syndromes and will inform future initiatives focusing on patient‐centered outcomes in childhood epilepsies, including the impact of telemedicine and health care disparities. [ABSTRACT FROM AUTHOR]

Injury from motor vehicle accidents remains a leading cause of death in India with increasing number of fatalities. Timely delivery of lifesaving interventions is critical for survival and in restoring physical functioning. As a part of the Australia India Trauma Systems Collaboration, the Trauma Reception and Resuscitation (TRR©)-computerized decision support system was implemented in a Level 1 Trauma Centre in India in order to determine whether this system would reduce the time in performing lifesaving interventions and improve vital sign data capture and documentation. This prospective cohort study at the Jai Prakash Narayan Apex Center, All India Institute of Medical Science, New Delhi, recruited a total of 106 participants into two groups: TRR© (76) and controls (30). During the first 30 min of resuscitation, the TRR© group recorded greater sets of vital signs in compared to the controls for medical records. More importantly, the real-time documentation of the vital signs for the TRR© group ensured accuracy for medical records. For lifesaving interventions, oxygen was administered in the TRR© group only if SpO2 < 93%, whereas oxygen was administered as standard of care in the controls. There was no statistical difference in the mean times to endotracheal intubation, intercostal catheter insertion or performance of emergency chest x-ray between the control and TRR© groups. Importantly however, these 3 comparable interventions were performed consistently within a smaller timeframe for patients receiving care with TRR© decision prompts. There was a greater variability in the time taken to perform lifesaving interventions in the control group in comparison to the clinicians assisted with computerized decision prompts. This preliminary study was not powered to measure difference in mortality and patient recruitment was limited to 8 am–5 pm when trained staff could attend to operating the TRR© system. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to report the procedural incidence and patient outcomes after the 2009 introduction of an institutional resuscitative thoracotomy (RT) programme. Emergency physicians, general surgeons and emergency nursing trauma team members were trained to perform RT on thoracic trauma patients with an unresponsive systolic blood pressure (SBP) <70 mmHg within 30 min of arrival, prior to cardiothoracic team back‐up. Methods: A retrospective cohort study was conducted on patients who underwent RT from 2009 to 2017. The primary outcome measures were the incidence of the procedure and patients' survival to hospital discharge. Variables associated with survival were assessed using univariable logistic regression analyses. Results: There were 12 399 major trauma patients, including 7657 with major thoracic trauma and 315 presenting with SBP <70 mmHg. There were 32 RTs performed (incidence of 0.4%; 95% confidence interval [CI] 0.3–0.6) among patients with major thoracic trauma and 10.2% (99% CI 7.3–13.4) among patients with major thoracic trauma and SBP <70 mmHg. There were eight (25%; 95% CI 13.2–42.1) survivors to hospital discharge and no late mortality (mean follow‐up 2.8 years). Survival was significantly associated with the procedure performed within 30 min of arrival (odds ratio 0.09; 95% CI 0.01–0.67) while mortality was associated with the procedure being performed in the setting of traumatic cardiac arrest (odds ratio 18.3; 95% CI 2.4–140.4). Conclusions: A formal training and credentialing programme was associated with a low incidence of the procedure, yet achieved a survival rate of 25%, which is comparable to other reported literature. [ABSTRACT FROM AUTHOR]

Obtaining patent protection for microbiome therapeutics has been affected profoundly by the US Supreme Court decisions in Myriad and Mayo, which redefined the scope of which natural phenomena, including microbiome therapeutics, are patent eligible. [ABSTRACT FROM AUTHOR]

Objective: This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. Methods: Patients aged 18–60 years, transported directly from scene with exsanguinating, sub‐diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202). Results: During the 14‐month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18–60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment. Conclusions: Despite considerable training and resource allocation to ensure 24‐h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14‐month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit. [ABSTRACT FROM AUTHOR]

Time‐out protocols have reportedly improved team dynamics and patients' safety in various clinical settings – particularly in the operating room. In 2016, the World Health Organization (WHO) introduced a Trauma Care checklist, which outlines steps to follow immediately after the primary and secondary surveys and prior to the team leaving the patient. The WHO Trauma Care checklist's main perceived benefit is the prompting of clinicians to complete trauma admissions as per evidence‐based guidelines. The WHO Trauma Care checklist, while likely to be successful in reducing errors of omission related to hospital admission, may be limited in its ability to reduce errors that occur in the initial 30 min of trauma reception – when most of the life‐saving decisions are made. To address this limitation a Trauma Team Time‐out protocol is proposed for initial trauma resuscitation, targeting the critical first 30 min of hospital reception. [ABSTRACT FROM AUTHOR]

Collodion remover, a solvent blend used to remove collodion glue after long-term video EEG monitoring, was implicated as a potential causative factor in patient safety events at our institution during which damage to plastic components of medical devices was noted in the intensive care unit. We sought to determine experimentally whether collodion remover could lead to degradation of multiple plastic-containing medical devices commonly used in the intensive care unit to determine whether workflow changes were needed during electrode removal. We exposed devices to collodion remover for brief, intermediate, and prolonged durations. We report that collodion remover is capable of degrading the hard plastic components of multiple medical devices after prolonged exposure; however, intermediate duration exposure was also capable of producing damage to clave connectors used with intravenous and central lines, which could plausibly lead to adverse events given the widespread use of these devices. These data suggest a pathway-based approach to collodion remover use might be beneficial in minimizing the potential impact of this solvent on plastic-containing medical devices. [ABSTRACT FROM AUTHOR]

Introduction: Injuries are a major cause of disability and lost productivity. The case for a national trauma registry has been recognized by the Australian Commission on Safety and Quality in Health Care and at a policy level. Background: The need was flagged in 1993 by the Royal Australasian College of Surgeons and the Australasian Trauma Society. In 2003, the Centre of National Research and Disability funded the Australian and New Zealand National Trauma Registry Consortium, which produced three consecutive annual reports. The bi‐national trauma minimum dataset was also developed during this time. Operations were suspended thereafter. Method: In response to sustained lobbying the Australian Trauma Quality Improvement Program including the Australian Trauma Registry (ATR) commenced in 2012, with data collection from 26 major trauma centres. An inaugural report was released in late 2014. Result The Federal Government provided funding in December 2016 enabling the work of the ATR to continue. Data are currently being collected for cases that meet inclusion criteria with dates of injury in the 2017–2018 financial year. Since implementation, the number of submitted records has been increased from fewer than 7000 per year to over 8000 as completeness has improved. Four reports have been released and are available to stakeholders. Conclusion: The commitment shown by the College, other organizations and individuals to the vision of a national trauma registry has been consistent since 1993. The ATR is now well placed to improve the care of injured people. [ABSTRACT FROM AUTHOR]

The chronic lack of investment in the capital needed to foster the development of music during the period of colonial governance in Ireland and the early years of the Free State, combined with Ireland's peripheral position in relation to the centres of musical modernism, resulted in composers in Ireland adopting modernist ideas at a very late stage, particularly in comparison with the chronology of Irish literary modernism. Previous literature on the subject of Irish musical modernism has frequently obscured any clear sense of the real extent of this delay through the conflation of the concept of "modernism" with styles that may have been perceived by Irish contemporaries as "modern" at a particular historical juncture. This essay surveys the work of the key figures of twentieth-century Irish composition, examining the degree to which they may or may not have been interested in or engaged by international ideas of modernism. It re-evaluates composers frequently regarded as modernist in the literature such as Frederick May, Brian Boydell and Seán Ó Riada; discusses the important of Seóirse Bodley's work from the 1960s; and posits the idea of an Irish avant-garde emerging in the 1970s. The essay concludes by noting the continued relevance of modernist ideas for a number of today's composers. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsDiscussionThe Glasgow Coma Scale (GCS) and pupil response to light are commonly used to assess brain injury severity and predict outcomes. The aim of this study was to investigate whether the GCS combined with pupil response (GCS-P), compared to the GCS alone, could be a better predictor of hospital mortality for patients with traumatic brain injury (TBI).A retrospective cohort study was undertaken at an adult level one trauma centre including patients with isolated TBI of Abbreviated Injury Scale above three. The GCS and pupil response were combined to an arithmetic score (GCS score (range 3–15) minus the number of nonreacting pupils (0, 1, or 2)), or by treating each factor as separate categorical variables. The association of in-hospital mortality with GCS-P as a categorical variable was evaluated using Nagelkerke’s R2 and compared using areas under the receiver operating characteristic (AUROC) curve.There were 392 patients included over the study period of 1 July 2014 and 30 September 2017, with an overall mortality rate of 15.2%. Mortality was highest at GCS-P of 1 (79%), with lowest mortality at a GCS-P 15 (1.6%). Nagelkerke’s R2 was 0.427 for GCS alone and 0.486 for GCS-P. The AUROC for GCS-P to predict mortality was 0.87 (95%CI: 0.82–0.72), higher than for GCS alone (0.85; 95%CI: 0.80–0.90; p < .001).GCS-P provided a better predictor of mortality compared to the GCS. As both the GCS and pupillary response are routinely recorded on all patients, combination of these pieces of information into a single score can further simplify assessment of patients with TBI, with some improvement in performance. [ABSTRACT FROM AUTHOR]

Objectives A multidisciplinary approach that emphasised improved triage, early pelvic binder application, early administration of blood and blood products, adherence to algorithmic pathways, screening with focused sonography ( FAST), early computed tomography scanning with contrast angiography, angio-embolisation and early operative intervention by specialist pelvic surgeons was implemented in the last decade to improve outcomes after pelvic trauma. The manuscript evaluated the effect of this multi-faceted change over a 12-year period. Methods A retrospective cohort study was conducted comparing patients presenting with serious pelvic injury in 2002 to those presenting in 2013. The primary exposure and comparator variables were the year of presentation and the primary outcome variable was mortality at hospital discharge. Potential confounders were evaluated using multivariable logistic regression analysis. Results There were 1213 patients with a serious pelvic injury ( Abbreviated Injury Scale ≥3), increasing from 51 in 2002 to 156 in 2013. Demographics, injury severity and presenting clinical characteristics were similar between the two time periods. There was a statistically significant difference in mortality from 20% in 2002 to 7.7% in 2013 ( P = 0.02). The association between the primary exposure variable of being injured in 2013 and mortality remained statistically significant (adjusted odds ratio 0.10; 95% confidence interval: 0.02-0.60) when adjusted for potential clinically important confounders. Conclusions Multi-faceted interventions directed at the spectrum of trauma resuscitation from pre-hospital care to definitive surgical management were associated with significant reduction in mortality of patients with severe pelvic injury from 2002 to 2013. This demonstrates the effectiveness of an integrated, inclusive trauma system in achieving improved outcomes. [ABSTRACT FROM AUTHOR]

Objective Neonates with hypoxic-ischemic encephalopathy (HIE) managed with therapeutic hypothermia (TH) often experience acute symptomatic seizures, prompting treatment with antiseizure medications (ASMs). Because the risk of seizure occurrence after hospital discharge is unknown, the optimal ASM treatment duration is unclear. We aimed to determine the risk of seizure occurrence after hospital discharge and the impact of ASM treatment duration on this outcome. Methods We performed a single-center, retrospective study of consecutive neonates with HIE managed with TH who received ASMs for acute symptomatic seizures from June 2010 through December 2014. Neonates were monitored with continuous electroencephalography (EEG) during TH. Results Follow-up data were available for 59 (82%) of 72 neonates who survived to discharge, with a median follow-up period of 19 months (interquartile range [IQR] 11-25). Acute symptomatic seizures occurred in 35 neonates (59%), including electrographic seizures in 21 neonates (36%). ASMs were continued upon discharge in 17 (49%) of 35 neonates. Seizures occurred in follow-up in four neonates (11%). No patient for whom ASMs were discontinued prior to discharge experienced seizures during the follow-up period. Significance Among neonates with HIE, seizures after hospital discharge were rare in those with acute symptomatic seizures and did not occur in neonates without acute symptomatic seizures. ASM discontinuation prior to discharge did not increase the risk of seizures during the follow-up period, suggesting that ASMs may be discontinued in many neonates prior to discharge. [ABSTRACT FROM AUTHOR]

Trauma and other disease registries have been used to improve patient care and outcomes at the system level. Paradoxically, registries have had little role in informing the care of any individual patient while that care is being determined and delivered. The lack of timeliness of useful data is a major barrier to the value of registries in improving individual patient care real‐time. What do trauma and emergency care providers require from their trauma registries to inform real‐time patient‐tailored improvements in trauma care? Research is urgently needed to improve the usefulness of disease registries, and to develop innovative processes and applications using patient data to inform patient care real‐time, thereby improving patient outcomes. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to ascertain factors which influenced dental hygienists to choose the profession and identify ADHA resources which promote and sustain members' professional identity. Methods: This was a quantitative, cross-sectional, nonexperimental study. A 48-item web-based survey was designed and pilot tested. Multiple choice, Likert-scale, and open-ended questions regarding demographics (10), career choice (4), and professional identity (34) were used. The survey was disseminated by the American Dental Hygienists' Association to student and professional members. Descriptive and inferential statistics were used to analyze data. Results: A total of 1,983 surveys (n=1,983) were returned, response rate of 6.3%. The majority (n=1,699, 86%) of respondents were professional members. Most participants were female (n=1,940, 98%), White (n=1,668, 84%), and 55+ years of age (n=727, 37%). Both student and professional members rated a desire to work in a health field as the most influential reason for entering the profession (n=59, 21% and n=468, 28%, respectively). Both groups identified continuing education and evidence-based research resources as positively affecting their professional identity (4.11.0 and 4.11.0, p=0.41, respectively) and (4.11.0 and 4.01.0, p=0.13, respectively). Advocacy efforts, Journal of Dental Hygiene, and Access Magazine had a significantly greater positive influence on Professional Members' professional identity (p=0.001, p=0.028, and p=0.001, respectively). Student members reported greater influence on their professional identity in the areas of patient care resources (p=0.01) and support of their career (p<0.001). Conclusion: The desire to have a career in a health field was the most influential factor for career choice. Continuing education and evidence-based research resources most positively affects all members' professional identity. [ABSTRACT FROM AUTHOR]

Summary: Inferior vena cava (IVC) filters are used in certain patients to help prevent the occurrence of pulmonary embolism (PE). IVC filters are generally recommended to be removed once PE prophylaxis is no longer required. Long‐dwelling IVC filters are associated with higher complication rates (Vasa 2020; 49: 449), being more difficult to retrieve and associated with higher retrieval complications (Cardiovasc Diagn Ther 2016; 6: 632). This report describes the pre‐procedural work‐up and removal of an IVC filter with a prolonged dwell time of 5,117 days (14 years, 3 days) using the loop snare advanced retrieval technique. As far as the authors are aware this case is the longest‐described successful retrieval of a Cook Celect IVC filter at 5,117 days. [ABSTRACT FROM AUTHOR]

Abstract: Introduction and aims: The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality. Methods: A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1L of pre-hospital crystalloid and spent over 30min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers. Results: There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI≥1.0, calculated after at least 1L of crystalloid transfusion, identified patients with a high specificity (93.5%; 95% CI: 91.8–94.8) for receiving a blood transfusion within 4h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car. Conclusions: A shock index≥1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index≥1.0 despite fluid resuscitation as the clinical trigger for administration. [Copyright &y& Elsevier]

Background: Patients with a history of asthma-related hospitalizations are at high risk of readmission and generally consume a large amount of health-care resources. It is not clear if the secondary care provided by specialists after an episode of asthma-related hospitalization is associated with better outcomes compared with the primary care provided by general practitioners.Methods: Using population-based administrative health data from the province of British Columbia, Canada, we created a propensity-score-matched cohort of individuals who received primary vs secondary care in the 60 days after discharge from asthma-related hospitalization. Total direct asthma-related medical costs (primary outcome) and health service use and measures of medication adherence (secondary outcomes) were compared for the next 12 months.Results: Two thousand eighty-eight individuals were equally matched between the primary and secondary care groups. There was no difference in the direct asthma-related costs (difference $567; 95% CI, -$276 to $1,410) and rate of readmission (rate ratio [RR] = 1.06; 95% CI, 0.85-1.32) between the secondary and the primary care groups. Patients under secondary care had a higher rate of asthma-related outpatient service use (RR = 1.22; 95% CI, 1.11-1.35) but a lower rate of short-acting β-agonist dispensation (RR = 0.91; 95% CI, 0.85-0.98). The proportion of days covered with a controller medication was higher among the secondary care group (difference of 3.2%; 95% CI, 0.4%-6.0%).Conclusions: Compared with those who received only primary care, patients who received secondary care showed evidence of more appropriate treatment. Nevertheless, there were no differences in the costs or the risk of readmission. Adherence to asthma medication in both groups was poor, indicating the need for raising the quality of care provided by generalists and specialists alike. [ABSTRACT FROM AUTHOR]

The article discusses a study that examined whether secondary care after an asthma-related hospitalization is associated with better outcomes compared with the primary care provided by general practitioners. Population-based administrative health data from British Columbia were used in the study. Findings show that patients who received secondary care had more appropriate treatment than those who received only primary care. Both groups had poor adherence to asthma medication.

The organic peroxide explosive triacetone triperoxide ( TATP) is regularly encountered by law enforcement agents in various stages of its production, storage, or usage. In a previous study, it has been demonstrated that isolated, rigorously purified, TATP may degrade to form a series of chlorinated acetones when directly treated with excess concentrated hydrochloric acid. The current study extends this work to examine whether this phenomenon may be measured during the more feasible scenario of aging of rudimentarily purified TATP contaminated with trace reaction mixture. It was demonstrated that solid-phase microextraction gas chromatography/mass spectrometry analyses of aged TATP that was synthesized utilizing hydrochloric acid catalyst may identify the presence of the degradation products chloroacetone and 1,1-dichloroacetone. Upon aging of TATP synthesized utilizing either sulfuric or nitric acid catalyst, no acid specific degradation products could be identified. These findings may be exploited by forensic chemists in the analyses of TATP samples. [ABSTRACT FROM AUTHOR]

Background: The natural history of many chronic diseases is characterized by periods of increased disease activity, commonly referred to as flare-ups or exacerbations. Accurate characterization of the burden of these exacerbations is an important research objective. Methods: The purpose of this work was to develop a statistical framework for nuanced characterization of the three main features of exacerbations: their rate, duration, and severity, with interrelationships among these features being a particular focus. We jointly specified a zero-inflated accelerated failure time regression model for the rate, an accelerated failure time regression model for the duration, and a logistic regression model for the severity of exacerbations. Random effects were incorporated into each component to capture heterogeneity beyond the variability attributable to observed characteristics, and to describe the interrelationships among these components. Results: We used pooled data from two clinical trials in asthma as an exemplary application to illustrate the utility of the joint modeling approach. The model fit clearly indicated the presence of heterogeneity in all three components. A novel finding was that the new therapy reduced not just the rate but also the duration of exacerbations, but did not have a significant impact on their severity. After controlling for covariates, exacerbations among more frequent exacerbators tended to be shorter and less likely to be severe. Conclusions: We conclude that a joint modeling framework, programmable in available software, can provide novel insights about how the rate, duration, and severity of episodic events interrelate, and enables consistent inference on the effect of treatments on different disease outcomes. Trial registration Ethics approval was obtained from the University of British Columbia Human Ethics Board (H17-00938). [ABSTRACT FROM AUTHOR]

A build/cocpie/pak (B/C/P) strategy was employed to generate a library of 7936 stereochemically diverse 12-membered rrtacrolactams. All 8 stereoisomers of a common linear amine precursor were eltibu fitted to form the corresponding 8 stereoisomers of two regioisomeric macrocyclic scaftoids via head-to-tail cydutftiim. Subsequently, these 16 scaffolds were further diversified via sopine of two tirnalities on SynPhase Lanterns. Reagents used for solid-phase diversirication were selected using 2 sparse matrix design strategy with the aim of maximizing coverage of chemical space while adhering to a preset range of physicochcmicai properties. [ABSTRACT FROM AUTHOR]

Background: The Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns (body weight (kg)×%TBSA burnt=mls in the first 2h) was adopted by Ambulance Victoria in 2007 for the early and consistent correction of fluid deficit in major burns patients. The aim of this study was to evaluate the associated change in pre-hospital fluid administration. Methods: A retrospective explicit chart review of patient records was conducted of all patients with major burns presenting to The Alfred Emergency & Trauma Centre over a 10 year period. Patient demographics, fluid resuscitation and outcomes in the period before the introduction of the new formula were compared to those in the post-introduction period. Results: There were 126 patients with major burns (≥20% total body surface area burnt) included in the study. The median fluid volume administration pre-hospital after introduction of The Alfred formula was 0.35 (0.22–0.44) mL/kg/%TBSA burnt, which was significantly higher than 0.14 (0.04–0.26) mL/kg/%TBSA administered in the prior period (p =0.013). There was no significant change in physiological endpoints associated with the increased volume. At 24h, the volume of fluid administered in patients when The Alfred formula was used was 4.9±1.6mL/kg/%TBSA, which was not significantly higher than the volume administered before 2007 of 4.8±2.2mL/%TBSA/kg (p =0.802). Discussion: The Alfred pre-hospital fluid formula has resulted in patients receiving significantly more fluids early, although still below volumes suggested by the Parkland formula. There were no adverse effects of this increased volume detected over the study period. The Alfred pre-hospital fluid formula appears to be safe and more effective in delivering fluid volumes predicted by the current ‘gold standard’. [Copyright &y& Elsevier]

Injury is a major global health problem. India suffers more deaths from vehicle collisions than any other country. Since 2004 The Alfred Hospital in Melbourne, Australia has established strong linkages with Christian Medical College (CMC) in Ludhiana, the Punjab, India and Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka, supporting trauma care capacity-building. In response to the demand for a systematic approach to trauma care in India and Sri Lanka, The Alfred Trauma Team Training Program was developed, funded by the Australian Agency for International Development, The Alfred and its participating staff, CMC and THK. The aim of the programme was to enhance the understanding and skill in reception and resuscitation of critically injured patients in a cohort of providers of emergency care. Participants were selected from nine sites: CMC, five government hospitals across the Punjab, Delhi, THK and Teaching Hospital Peradeniya in Kandy, Sri Lanka. The programme was conducted at CMC, with follow-up visits to THK and Teaching Hospital Peradeniya, and focused on team-based scenarios. The faculty included emergency clinicians from The Alfred. Participants showed improvement in the knowledge and skills of trauma reception and resuscitation. Observed programme challenges included the variety of health systems from which the participants were sourced. The Trauma Team Training Program allowed Australian emergency clinicians to impart some skills towards improving the level of trauma reception and resuscitation by 26 participants from nine sites. The team-based systematic approach to the delivery of emergency trauma care was valued by the participants. [ABSTRACT FROM AUTHOR]

The organic peroxide explosive triacetone triperoxide (TATP) is regularly encountered by law enforcement agents in various stages of its production. This study utilizes solid-phase microextraction (SPME) and gas chromatography/mass spectrometry (GC/MS) to examine sulfuric acid-, hydrochloric acid-, and nitric acid-catalyzed TATP syntheses during the initial 24 h of these reactions at low temperatures (5-9°C). Additionally, aging of the reaction mixtures was examined at both low and ambient temperatures (19-21°C) for a further 9 days. For each experiment, TATP could be readily identified in the headspace above the reaction mixture 1 h subsequent to the combination of reagents; at 24 h, TATP and diacetone diperoxide (DADP) were prominent. TATP degraded more rapidly than DADP. Additionally, chlorinated acetones chloroacetone and 1,1,-dichloroacetone were identified in the headspace above the hydrochloric acid-catalyzed TATP reaction mixture. These were not present when the catalyst was sulfuric acid or nitric acid. [ABSTRACT FROM AUTHOR]

Objective: A low case incidence and variable skill level prompted the development of a credentialing programme and specific surgical training in resuscitative thoracotomy for emergency physicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service. Methods: A review of the incidence of traumatic pericardial tamponade and the objectives of resuscitative thoracotomy were undertaken. Results: A training programme involving pre-reading of a 17 page teaching manual, a 40 min didactic lecture and a 2 h surgical skills station using anaesthetized pigs were developed. The specific indication for resuscitative thoracotomy for this programme is ultrasound demonstrated cardiac tamponade secondary to blunt or penetrating truncal trauma in a haemodynamically unstable patient with a systolic blood pressure of less than 70 mmHg despite pleural decompression and intravenous volume replacement. Cardiac electrical activity must be present. The primary aims of resuscitative thoracotomy taught are release of cardiac tamponade, control of haemorrhage and access for internal cardiac massage. Conclusion: Emergency physicians working in high-volume Trauma Centres are expected to diagnose cardiac tamponade and on occasion decompress the pericardium. Specific training in the procedure should be undertaken. [ABSTRACT FROM AUTHOR]

In response to the Indian Ocean tsunami of 2004, the Health for the South project, Capacity-Building programme was implemented in Galle, Sri Lanka. The objectives of the Capacity-Building programme were to develop the emergency and trauma service capability at Teaching Hospital Karapitiya in Galle. Over 15 months, ED clinicians, from the Alfred Hospital and Royal Children's Hospital in Melbourne, provided training in the Emergency Treatment Unit of the main referral hospital for the south of Sri Lanka. This programme, completed in June 2008, significantly improved the hospital's ability to conduct trauma resuscitation, and to attain an increased level of disaster preparedness. In addition, valuable lessons were noted that will guide future initiatives in trauma care training in similar contexts. [ABSTRACT FROM AUTHOR]

Summary: Improvements in pre-hospital care and the development of integrated Trauma Systems have streamlined access for the severely injured to sophisticated, specialist Trauma Centre reception and resuscitation. We describe the initial care of a survivor of combined ruptures of the left ventricle and left atrium secondary to blunt injury. This case emphasises the contribution of such a Trauma System in achieving a favourable outcome for a severely injured trauma patient with injuries previously considered non-survivable. [Copyright &y& Elsevier]

In response to the Indian Ocean tsunami of December 2004, the Health for the South Project was developed for Sri Lanka. The capacity-building component of this project involves the provision of trauma and emergency care training to the staff of Teaching Hospital Karapitiya (THK) in Galle, Sri Lanka. A principal objective of this training for THK is an increased capacity to respond to future disasters in the south of Sri Lanka. Key elements of the capacity-building programme include the on-site emergency care training by teams of Australian emergency physicians and emergency nurses, working alongside the staff of the Emergency Treatment Unit in THK. It is expected that the programme will continue for at least 2 years, during which time a new Emergency and Trauma Centre will be constructed. [ABSTRACT FROM AUTHOR]

Objectives: To determine the drug use in injured Victorian drivers involved in motor vehicle collisions and subsequently transported to a major adult trauma centre in Victoria. Methods: A blood sample was obtained from patients who had been taken to The Alfred Emergency & Trauma Centre (Prahran, Vic., Australia) following a motor vehicle collision. This was performed at the same time and under the same law as compulsory blood screening in Victoria (Section 56 of the Road Safety Act). Four hundred and thirty-six specimens were analysed. Blood stored in vacutainer tubes containing preservative were screened for drugs using enzyme-linked immunosorbent assay and gas chromatography–mass spectometry analysis. Medically administered drugs were excluded from the results. Results: Four hundred and thirty-six specimens were analysed. Metabolites of cannabis were the most commonly found drug (46.7%), the active form of cannabis (Δ9-tetrahydrocannabinol) was found in 33 specimens (7.6%). The next most prevalent drugs were benzodiazepines (15.6%), opiates (11%), amphetamines (4.1%) and methadone (3%). Cocaine was detected in 1.4% of cases. Of the motor vehicle collisions 66% involved males and females of 15–44 years old and Δ9-tetrahydrocannabinol was almost exclusively found in this age group. In motor vehicle collisions involving older drivers there was an increasing use of benzodiazepines. In women >65 years old 30% were positive for benzodiazepines. Conclusions: Drug usage found in this group of injured drivers was disturbingly high. The introduction of further initiatives to decrease the prevalence of drug use in motor vehicle drivers is required. [ABSTRACT FROM AUTHOR]

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision-making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point-of-care computer technology linked to real-time decision-making and trauma team coordination may achieve error reduction through standardized decision-making and a corresponding reduction in preventable mortality and morbidity. [ABSTRACT FROM AUTHOR]

Road trauma in India is a significant health and socio-economic burden which requires urgent attention. When compared to countries with established trauma systems, those injured in India have up to a six-fold higher mortality rate. The death rate would be reduced with better organized systems of trauma care. This is dependent on state authorities introducing systems that fund accident prevention along with the organized care of the injured. The goal of an effective trauma system should be to provide universal emergency care with equity of access. The belief that trauma care cannot be cost-effective in low-income settings needs to be refuted. Better planning will result in cost-effective improvements in patient outcomes. However, without protected and guaranteed funding schemes, the development of trauma systems in India will fail. [ABSTRACT FROM AUTHOR]

The article focuses on the development of video audit and a new approach to the care of the injured who had made an enhancement of trauma resuscitation. The advancement was a response to the occurrence of frequent errors during emergency care that relates to resuscitation. Simulation and clinical settings have utilized video audit to improve the management of emergency hospital situations so that uninterrupted raw data can be retrieved whenever needed for audit.

Background: The Parkland formula is established as the ‘gold standard’ for initial fluid resuscitation for major burns. The purpose of this study was to review our fluid resuscitation practice for major burns to determine whether anecdotal observations of significant variations from the Parkland formula were wide spread and whether any difference could be used as a basis for a revision of fluid resuscitation in major burns. Methods: A retrospective review of 127 presentations to The Alfred Burns Unit with total body surface area (TBSA) affected ≥15% was conducted. A retrospective review of the resuscitation data from these patients was compared with the Parkland formula as well as other studies. Results: A total of 49 patients with complete data on fluid administration and uncomplicated burns were included in the analysis. Significantly larger volumes of fluid (5.58 mL/kg per %TBSA) were given to these patients in the first 24 h than predicted by the Parkland formula. Mean arterial pressure, pulse rate and urine output were at satisfactory levels. Clinically evident complications from fluid administration were minimal. Mortality was similar to that in other centres. Conclusion: Fluid resuscitation volumes significantly higher than those predicted by the Parkland formula were given, without adverse consequences. This retrospective review supports a prospective, multicentre, randomized, controlled study comparing this study with the Parkland formula, resulting in a better guide to initial fluid resuscitation in major burns. [ABSTRACT FROM AUTHOR]

Objective: Application of the Trauma and Injury Severity Score (TRISS) to a trauma population identifies patients with ‘unexpected survival’. This study used TRISS analysis to identify ‘unexpected survivors’ suffering major thoracic trauma, who survived to hospital discharge. Further analysis determined prehospital interventions that appeared to contribute to ‘unexpected survival’. Methods: The present study was a single-centre, retrospective case review with comparative statistical analysis. Patients were identified from the Alfred Trauma Registry between 1 July 2002 and 30 June 2003. Results: There were 336 adult trauma patients treated at The Alfred Trauma Centre with an Injury Severity Score >15 (major trauma) and at least one thoracic Anatomical Injury Score of 3 (severe) or greater. Of the eligible patients, 322/336 (95.8%, 95%[confidence interval] CI 95.1–96.5%) had complete data available for analysis. The study population mortality was 42/322 (13.0%, 95% CI 12.3–13.7%). There were 20 ‘unexpected survivors’ (5.9%) and 5 (1.5%) ‘unexpected deaths’ on TRISS analysis. Chest decompression and/or endotracheal intubation prehospital was performed on 16/20 ‘unexpected survivors’. GCS for ‘unexpected survivors’ and ‘expected deaths’ (3.8 vs 3.5, P = 0.27) was not a predictor of survival. Respiratory rate per minute (16.2 vs 8.8, P = 0.01) and systolic blood pressure – mmHg (98 vs 80, P = 0.03) were significantly greater in the ‘unexpected survivors’ group compared with the ‘expected death’ group. Conclusion: For patients sustaining severe thoracic blunt trauma, prehospital intubation and chest decompression appear to be associated with unexpected survival. A low GCS at scene is not predictive of ‘unexpected survival’ or ‘expected death’. [ABSTRACT FROM AUTHOR]

Blunt cardiac injuries are a leading cause of fatalities following motor-vehicle accidents. Injury to the heart is involved in 20% of road traffic deaths. Structural cardiac injuries (i.e. chamber rupture or perforation) carry a high mortality rate and patients rarely survive long enough to reach hospital. Chamber rupture is present at autopsy in 36–65% of death from blunt cardiac trauma, whereas in clinical series it is present in 0.3–0.9% of cases and is an uncommon clinical finding. Patients with large ruptures or perforations usually die at the scene or in transit – the rupture of a cardiac cavity, coronary artery or intrapericardial portion of a major vein or artery is usually instantly fatal because of acute tamponade. The small, rare, remaining group of patients who survive to hospital presentation usually have tears in a cavity under low pressure and prompt diagnosis and surgery can now lead to a survival rate of 70–80% in experienced trauma centres. As regional trauma systems evolve, patients with severe, but potentially survivable cardiac injury are surviving to ED. Two distinct syndromes are apparent – haemorrhagic shock and cardiac tamponade. Any patient with severe chest trauma, hypotension disproportionate to estimated loss of blood or with an inadequate response to fluid administration should be suspected of having a cardiac cause of shock. For patients with severe hypotension or in extremis, the treatment of choice is resuscitative thoracotomy with pericardotomy. Closed chest cardiopulmonary resuscitation is ineffective in these circumstances. Blunt traumatic cardiac injury presenting with shock is associated with a poor prognosis. The majority of survivors of blunt or penetrating cardiac injury present to the ED/trauma centre with vital signs. The main pathophysiologic determinant for most survivors is acute pericardial tamponade. The presence of normal clinical signs or normal ECG studies does not exclude tamponade. In recent years the widespread availability and use of ultrasound for the initial assessment of severely injured patients has facilitated the early diagnosis of cardiac tamponade and associated cardiac injuries. Two cases of survival from blunt traumatic cardiac trauma are described in the present paper to demonstrate survivability in the context of rapid assessment and intervention. [ABSTRACT FROM AUTHOR]

Background: Recurrent symptoms or failure after fasciotomy for exertional anterior compartment syndrome is not uncommon. Hypothesis: Symptoms from high compartment pressures can be secondary to involvement of the entire compartment or to localized constrictions from postsurgical fibrosis, as well as to entrapment of the superficial peroneal nerve. Study Design: Case series; Level of evidence, 4. Methods: Eighteen patients who underwent revision surgery for exertional anterior compartment syndrome were available for follow-up. All were athletes who had either a failure or a recurrence of symptoms at a mean of 23.5 months (range, 8-54 months) after the index fasciotomy. Pressure measurements using a slit catheter at rest, at 1 minute postexercise, and at 5 minutes postexercise were performed in 2 places within the compartment: in the area of the previous incision and in the proximal muscle belly of the tibialis anterior. Surgical technique consisted of a 2-incision approach with partial fasciectomy, exploration and decompression of the superficial peroneal nerve, and excision of all fibrotic tissue. An objective examination and a comprehensive subjective questionnaire previously described were performed at a mean follow-up of 42 months (range, 22-67 months). Results: Sixty percent of patients had abnormal pressures only in a localized area, whereas 40% had high pressures through- out the compartment. Eight of 18 (44%) patients had symptoms, signs, and surgical findings of entrapment of the superficial peroneal nerve. At follow-up, 72% of patients had a satisfactory outcome (5 excellent, 8 good), and 28% had an unsatisfactory outcome for intense running sports (4 fair, 1 poor), although 3 patients with the fair results reported improvement with low- level activity. All 8 patients with documented peroneal nerve entrapment had a satisfactory outcome. Conclusion: Symptoms from high pressures can be secondary to involvement of the entire compartment or localized to a certain area from postsurgical fibrosis. Pressure measurements should be performed in at least 2 separate areas. [ABSTRACT FROM AUTHOR]

Although forested habitats in eastern Australia have attracted significant conservation-related research, this work has focused strongly on endothermic vertebrates. Threatened reptile taxa have received less attention, but information on their habitat requirements should be central to management planning. The arboreal elapid snake Hoplocephalus stephensii is largely restricted to remnant forests in eastern Australia, and is listed as a threatened species under wildlife legislation. We collated 84 records of the current New South Wales geographical distribution of H. stephensii, and compared attributes of these locations to those of randomly chosen points within the same forests, in adjacent forests, in timber plantations and on freehold land across the geographical range of the taxon. Data on climatic and topographic characteristics of these sites were obtained from Geographic Information Systems databases and entered into a principal components analysis. Unsurprisingly, locations where snakes were recorded differed from the random sites in several respects (e.g. rainfall, elevation, seasonality of precipitation). Within a given forest, H. stephensii was generally found in areas similar to randomly chosen points. Comparison of vegetation communities used with those available within forests provided no evidence for active habitat selection. Comparisons of Geographic Information Systems-derived data for snake-collection localities along roads versus those within the forest revealed significant biases, and we warn that such methodological errors could generate spurious conclusions about non-random habitat use by threatened species. In combination with previous data from radio-tracking, we conclude that although H. stephensii is highly specialized in its arboreality and dependence upon hollow trees, its broad tolerance with respect to other factors (climatic conditions, vegetation communities, food types, etc.) allows populations to persist so long as large areas of forest with high numbers of hollow-bearing trees are available. These requirements are similar to those of many other components of the Australian forest fauna. Thus, the findings of this study support the idea that the same kinds of management programmes can effectively conserve a wide range of taxa, if such programmes protect critical habitat components at suitable spatial scales. [ABSTRACT FROM AUTHOR]