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Background Accurate estimates of gestational age (GA) at birth are important for preterm birth surveillance but can be challenging to obtain in low income countries. Our objective was to develop machine learning models to accurately estimate GA shortly after birth using clinical and metabolomic data. Methods We derived three GA estimation models using ELASTIC NET multivariable linear regression using metabolomic markers from heel-prick blood samples and clinical data from a retrospective cohort of newborns from Ontario, Canada. We conducted internal model validation in an independent cohort of Ontario newborns, and external validation in heel prick and cord blood sample data collected from newborns from prospective birth cohorts in Lusaka, Zambia and Matlab, Bangladesh. Model performance was measured by comparing model-derived estimates of GA to reference estimates from early pregnancy ultrasound. Results Samples were collected from 311 newborns from Zambia and 1176 from Bangladesh. The best-performing model accurately estimated GA within about 6 days of ultrasound estimates in both cohorts when applied to heel prick data (MAE 0.79 weeks (95% CI 0.69, 0.90) for Zambia; 0.81 weeks (0.75, 0.86) for Bangladesh), and within about 7 days when applied to cord blood data (1.02 weeks (0.90, 1.15) for Zambia; 0.95 weeks (0.90, 0.99) for Bangladesh). Conclusions Algorithms developed in Canada provided accurate estimates of GA when applied to external cohorts from Zambia and Bangladesh. Model performance was superior in heel prick data as compared to cord blood data.

OBJECTIVE To assess plasma and vaginal inflammation in three antenatal groups (HIV-uninfected women, HIV-infected women entering care on preconceptional ART, and HIV-infected women not on preconceptional ART) and whether these measures are associated with spontaneous preterm birth (sPTB). DESIGN Case--control study nested within a pregnancy cohort in Lusaka, Zambia. METHODS We analyzed 11 pro-inflammatory and two anti-inflammatory markers in 207 women with paired plasma and vaginal specimens collected between 16 and 20 gestational weeks. Among 51 HIV-infected women, we repeated the assays in 24-34-week samples. We used confirmatory factor analysis to create inflammation scores and compared them among the three groups. RESULTS At baseline, HIV-infected women not on ART had higher vaginal pro-inflammatory scores than HIV-uninfected women [mean 0.37 (95% CI -0.06 to 0.80) vs. -0.02 (-0.32 to 0.27), P = 0.02]. In repeat testing, women not on preconceptional ART had an increase in vaginal inflammation between the baseline and 24-34-week visits compared with those continuing preconceptional ART [mean 0.62 (95% CI -0.80 to 4.20) vs. -0.07 (-2.78 to 2.11), P = 0.04]. In multivariate analyses, baseline vaginal inflammation predicted sPTB (aOR 1.5; 95% CI 1.0-2.3; P = 0.02). Plasma inflammation did not differ by HIV or ART exposure and was not associated with sPTB. CONCLUSION Women not receiving ART at entry into pregnancy care had more vaginal inflammation than women entering on treatment. They also experienced an increase in vaginal inflammation between the two sampling timepoints, possibly as a consequence of ART initiation. Vaginal (but not systemic) inflammation was associated with sPTB and offers a potential mechanistic insight into this important adverse birth outcome.

A growing body of literature indicates that beta-blocker administration after traumatic brain injury (TBI) is cerebroprotective, limiting secondary injury; however, the effects of preinjury beta blocker status remain poorly understood. We sought to characterize the effects of pre- and post-injury beta-blocker administration on mortality with subanalyses accounting for head injury severity and myocardial injury. In a Level II trauma center, all admissions of patients ≥18 years with a head Abbreviated Injury Scale Score ≥2, Glasgow Coma Scale ≤13 from May 2011 to May 2013 were queried. Demographic, injury-specific, and outcome variables were analyzed using univariate analyses. Subsequent multivariate analyses were conducted to determine adjusted odds of mortality for beta-blocker usage controlling for age, Injury Severity Score, head Abbreviated Injury Scale, arrival Glasgow Coma Scale, ventilator use, and intensive care unit stay. A total of 214 trauma admissions met inclusion criteria: 112 patients had neither pre- nor postinjury beta-blocker usage, 46 patients had preinjury beta-blocker usage, and 94 patients had postinjury beta-blocker usage. Both unadjusted and adjusted odds ratios of preinjury beta-blocker were insignificant with respect to mortality. However, postinjury in-hospital administration of beta blockers was found to significantly in the decrease of mortality in both univariate ( P = 0.002) and multivariate analyses ( P = 0.001). Our data indicate that beta-blocker administration post-TBI in hospital reduces odds of mortality; however, preinjury beta-blocker usage does not. Additionally, myocardial injury is a useful indicator for beta-blocker administration post-TBI. Further research into which beta blockers confer the best benefits as well as the optimal period of beta-blocker administration post-TBI is recommended.

Objective Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment.Study Design A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted.Results Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p Conclusion Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.

Vaginal dysbiosis has been shown to increase the risk of some adverse birth outcomes. HIV infection may be associated with shifts in the vaginal microbiome. We characterized microbial communities in vaginal swabs collected between 16–20 gestational weeks in the Zambian Preterm Birth Prevention Study to investigate whether HIV and its treatment alter the microbiome in pregnancy. We quantified relative abundance and diversity of bacterial taxa by whole-genome shotgun sequencing and identified community state types (CST) by hierarchical clustering. Associations between exposures—HIV serostatus (HIV+ vs HIV-) and preconceptional ART (ART+ vs ART-)—and microbiome characteristics were tested with rank-sum, and by linear and logistic regression, accounting for sampling by inverse-probability weighting. Of 261 vaginal swabs, 256 (98%) had evaluable sequences; 98 (38%) were from HIV+ participants, 55 (56%) of whom had preconceptional ART exposure. Major CSTs were dominated by: L. crispatus (CST 1; 17%), L.] iners (CST 3; 32%), Gardnerella vaginalis (CST 4-I; 37%), G. vaginalis & Atopobium vaginae (CST 4-II; 5%), and other mixed anaerobes (CST 4-III; 9%). G. vaginalis was present in 95%; mean relative abundance was higher in HIV+ (0.46±0.29) compared to HIV- participants (0.35±0.33; rank-sum p = .01). Shannon diversity was higher in HIV+/ART+ (coeff 0.17; 95%CI (0.01,0.33), p = .04) and HIV+/ART- (coeff 0.37; 95%CI (0.19,0.55), p < .001) participants compared to HIV-. Anaerobe-dominant CSTs were more prevalent in HIV+/ART+ (63%, AOR 3.11; 95%CI: 1.48,6.55, p = .003) and HIV+/ART- (85%, AOR 7.59; 95%CI (2.80,20.6), p < .001) compared to HIV- (45%). Restricting the comparison to 111 women in either CST 3 (L. iners dominance) or CST 1 (L. crispatus dominance), CST 3 frequency was similar in HIV- (63%) and HIV+/ART- participants (67%, AOR 1.31; 95%CI: (0.25,6.90), p = .7), but higher in HIV+/ART+ (89%, AOR 6.44; 95%CI: (1.12,37.0), p = .04). Pregnant women in Zambia, particularly those with HIV, had diverse anaerobe-dominant vaginal microbiota.

Dysphagia is a common complication after cervical spine trauma with spinal cord injury. We sought to characterize the prevalence of dysphagia within a total cervical spinal injury (CSI) population, considering the implications of spinal cord injury status and age on dysphagia development. We hypothesized that while greater rates of dysphagia would be found in geriatric and spinal cord-injured subgroups, all patients presenting with CSI would be at heightened risk for swallowing dysfunction.All trauma admissions to a level II trauma center from January 2010 to April 2014 with CSI were retrospectively reviewed. CSI was classified as any ligamentous or cervical spinous fracture with or without cord injury. Patients failing a formal swallow evaluation were considered dysphagic. The implications of dysphagia development on age and spinal cord injury status were assessed in univariate and multivariate analyses.A total of 481 patients met study inclusion criteria, of which 123 (26%) developed dysphagia. Within the dysphagic subpopulation, 90 patients (73%) were geriatric, and 23 (19%) sustained spinal cord injury. The dysphagic subpopulation was predominantly free from spinal cord injury (81%). Multivariate analyses found age (adjusted odds ratio: 1.06; 95% confidence interval 1.04-1.07; P0.001) and spinal cord injury (adjusted odds ratio: 2.69; 95% confidence interval 1.30-5.56; P = 0.008) to be significant predictors of dysphagia development.Despite spinal cord-injured patients being at increased risk for dysphagia, most of the dysphagic subpopulation was free from spinal cord injury. Geriatric and CSI patients with or without cord injury should be at heightened suspicion for dysphagia development.

Objective To evaluate whether maternal HIV serostatus and plasma viral load (VL) are associated with midtrimester cervical length (CL). Methods The Zambian Preterm Birth Prevention Study (ZAPPS) is an ongoing prospective cohort that began enrolling in Lusaka in August 2015. Pregnant women undergo ultrasound to determine gestational age and return for CL measurement at 16-28 weeks. We evaluated crude and adjusted associations between dichotomous indicators and short cervix (≤2.5 cm) via logistic regression, and between VL and CL as a continuous variable via linear regression. Results This analysis includes 1171 women enrolled between August 2015 and September 2017. Of 294 (25.1%) HIV-positive women, 275 (93.5%) had viral load performed close to CL measurement; of these, 148 (53.8%) had undetectable virus. Median CL was 3.6 cm (IQR 3.5-4.0) and was similar in HIV-infected (3.7 cm, IQR 3.5-4.0) versus uninfected (3.6 cm, IQR 3.5-4.0) participants (P=0.273). The odds of short CL were similar by HIV serostatus (OR 0.64; P=0.298) and detectable VL among those infected (OR 2.37, P=0.323). We observed no association between log VL and CL via linear regression (-0.12 cm; P=0.732). Conclusion We found no evidence of association between HIV infection and short CL.

Evidence-based guidelines for the care of severe traumatic brain injury have been available from the Brain Trauma Foundation (BTF) since 1995. A total of 15 recommendations compose the current guidelines. Although each individual guideline has been validated in isolation, to date, little research has examined the guidelines in composite. We examined the relationship between compliance with the BTF severe TBI guidelines and mortality.In a Pennsylvania-verified, mature Level II trauma centre, patients with an admission Glasgow Coma Scale (GCS) ≤ 8 and an abnormal head CT from 2007 to 2012 were queried from the trauma registry. Exclusion criteria included: patients who sustained a non-survivable injury (AIS head 6), died ≤ 24 h, and/or were transferred to a paediatric trauma centre. Strict adherence to the BTF guidelines was determined in a binary fashion (yes/no). We then calculated each patient's percent compliance with total number of guidelines. Bivariate analysis was used to find significant predictors of mortality (p0.05), including percent BTF guidelines compliance. Significant factors were added to a multivariable logistic regression model to look at mortality rates across the percent compliance spectrum.185 Patients met inclusion criteria. Percent compliance ranged from 28.6% to 94.4%, (median=71.4%). Following adjustment for age, AIS head, and GCS motor, patients with 55-75% compliance (AOR: 0.20; 95%CI: 0.06-0.70) and75% compliance (AOR: 0.27; 95%CI: 0.08-0.94) had reduced odds of mortality, as compared to55% compliance to the BTF guidelines. When the unadjusted rate of mortality was compared across the compliance spectrum, the odds of mortality decreased as compliance increased until 75%, and then reversed.Our data indicate that full compliance with all 15 severe TBI guidelines is difficult to achieve and may not be necessary to optimally care for patients.

In busy emergency departments (EDs), elderly patients on anticoagulation (AC) sustaining minor injuries who are triaged to a lower priority for evaluation are at risk for potentially serious consequences. We sought to determine if a novel ED protocol prioritizes workup and improves outcome. In a Pennsylvania-verified Level II trauma center, the ACT (AntiCoagulation and Trauma) Alert was implemented in March 2012. Triage parameters include: age 65 years or older, AC agents, Glasgow Coma Score (GCS) 13 or greater, and head trauma 24 hours or less. ACTAlerts are announced overhead in the ED and require assessment by an ED physician, nurse, and phlebotomist in 15 minutes or less. Furthermore, they necessitate Point of Care international normalized ratio (INR) 20minutes or less and head computed tomography (CT) scan 30 minutes or less. Positive CT findings mandate trauma service consultation. ACTAlert patients from March to December 2012 were compared with ED patients 65 years or older, GCS 13 or greater, on AC with the same chief complaints as ACT Alerts from June 2011 to February 2012 (control). A P value ≤ 0.05 was considered significant. Of 752 study patients, 415 were ACTand 337 were controls. There were no significant differences between groups in age, elevated INR, or head bleeds. ACT patients had significantly shorter median times from ED arrival to INR (ACT 13 minutes vs control 80 minutes; P < 0.001) and to head CT (ACT 35 minutes vs control 65 minutes; P < 0.001). Of admitted patients, ACT had a significantly shorter median length of stay (LOS) (ACT 3.7 days vs control 5.0 days; P < 0.001). Although trends toward improved outcome were noted, no statistically significant differences were identified. The ACT Alert improves ED throughput and reduces hospital LOS while effectively identifying at-risk, mildly head injured geriatric patients on AC.

BACKGROUND To date, there are almost 500 accountable care organizations (ACOs) across the United States emphasizing cost-effective care. Readmission largely impacts health care cost; therefore, we sought to determine factors associated with geriatric trauma readmissions (recidivism) within our institution. METHODS All admissions from 2000 to 2011 attributed to patients 65 years or older at our Level II trauma center, recently verified by Medicare as an ACO, were queried. Patients were classified as recidivist or nonrecidivist. The first admissions of recidivist patients were compared with the nonrecidivist admissions with respect to sex, age, race, primary insurance, admission Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), hospital length of stay, mechanism of injury (MOI), preexisting conditions, and discharge destination. Factors found to be significant predictors of recidivism in univariate analyses were subsequently incorporated into a multivariate logistic regression model. In addition, the second admission's MOI was compared with the first admission's MOI, and the proportion of first, second, and third admissions attributed to falls was calculated. A p < 0.05 was significant. RESULTS Between 2000 and 2011, a total of 4,963 unique patients were admitted to the trauma center at 65 years or older. This population was composed of 287 recidivists (5.8%) and 4,676 nonrecidivists (94.2%). When placed in a multivariate logistic regression, female sex, admission GCS score of 15, history of head trauma, and preexisting pulmonary disease were identified as significant predictors of recidivism. A trend toward increasing proportion of injuries attributed to falls was found with each subsequent trauma admission (81.5% [234 of 287] of first admissions, 88.2% [253 of 287] of second admissions, and 90.5% [19 of 21] of third admissions). CONCLUSION Our study identifies specific factors that should be targeted by social service and prevention resources to inhibit recidivism in the elderly. In the brave new world of ACOs, trauma centers must identify high-risk populations for the consumption of limited resources. LEVEL OF EVIDENCE Care management study, level IV. Prognostic study, level III.

Approximately one in three older adults fall each year, resulting in a significant proportion of geriatric traumatic injuries. In a hospital with a focus on geriatric fall prevention, we sought to characterize this population to develop targeted interventions. As mild hyponatremia, defined as a serum sodium135meq/L, has been reported to be associated with falls, unsteadiness and attention deficits, we hypothesized that hyponatremia is associated with falls in our geriatric trauma population.Gender, age, pre-existing conditions (cardiac disease, diabetes, hematologic disorder, liver disease, malignancy, musculoskeletal disorder, neurological disorder, obesity, psychiatric disorder, pulmonary disease, renal disease, thyroid disease), mechanism of injury and admitting serum sodium level were queried for all geriatric trauma admissions from 2008 to 2011. Mechanism of injury was coded as falls admissions and non-falls admissions. Admitting serum sodium levels were coded as hyponatremic (135mmol/L) and not hyponatremic (≥135mmol/L).Of the 2370 geriatric trauma admissions during the study period, there were 1841 (77.7%) falls admissions and 293 (12.4%) patients who were hyponatremic. Gender, age, neurological disorder, hematologic disorder, and hyponatremia were found to be significant predictors of falls in both univariate and multivariable analyses.Hyponatremic patients are significantly more likely to be admitted for a fall than non-hyponatremic patients, when adjusting for age, neurological disorder, and hematologic disorder. Consequently, hyponatremia identification and management should be an integral part of any geriatric trauma fall prevention programme. Additionally, if hyponatremia is found during a geriatric fall workup, it should be corrected prior to discharge and closely monitored by a primary care physician to prevent recurrent episodes of falls.

Compassion fatigue (CF), a state of physical/emotional distress caused by repeatedly caring for those experiencing traumatic episodes, is a prevalent issue for today's healthcare provider. We sought to characterize levels of CF within a surgeon population, particularly comparing trauma surgery with other surgical specialties. A survey containing the Professional Quality of Life Scale (ProQOL), a validated tool assessing compassion satisfaction (CS), CF, and burnout (BO) was distributed via electronic newsletter to members of the American College of Surgeons. Demographic data and Professional Quality of Life Scale scores for CS, BO, and CF were collected and compared within specialty and gender subgroups. A total of 178 surgeons completed surveys. Respondents were predominantly male, general surgeons, >55 years old. Trauma surgeons composed the second largest subgroup. Levels of CS were significantly lower in the trauma surgeon subgroup compared to other surgical specialties (trauma: 37.1 ± 5.28, other: 39.5 ± 6.30; P = 0.044). Female surgeons from all specialties exhibited significantly higher levels of BO (female: 26.7 ± 6.10, male: 24.6 ± 6.79; P = 0.035) and CF (female: 24.2 ± 6.29, male: 21.9 ± 6.11; P = 0.021) compared with male surgeons. Subanalyses comparing female trauma surgeons to female surgeons in other specialties found female trauma surgeons exhibited significantly lower levels of CS (trauma: 34.8 ± 4.63, other: 38.8 ± 5.99; P = 0.038) and higher levels of BO (trauma: 29.1 ± 3.14, other: 25.3 ± 6.41; P = 0.049). Trauma surgeons, particularly female trauma surgeons, may be at a heightened risk for developing a poorer overall professional quality of life compared with surgeons of other specialties. In addition, female surgeons may be at greater risk for developing CF compared with male counterparts.

The incidence of geriatric traumatic brain injury (TBI) is increasing throughout the United States, with many of these patients taking anticoagulation (AC) medication. The purpose of this investigation was to determine the effect of time to international normalized ratio (INR) reversal on intracranial hemorrhage evolution in TBI patients taking prehospital AC medication. We hypothesized that rapid reversal of INR improves outcomes of head-injured patients taking AC medication. Admissions to a Level II trauma center between February 2011 and December 2013 were reviewed. Patients presenting with an initial INR of 2.0 or more, computed tomographic scan positive for intracranial hemorrhage, and INR reversal to less than 1.5 in hospital were included. Patients with nontraumatic intracranial hemorrhage were excluded. Reversal of INR was achieved using some combination of fresh frozen plasma, prothrombin complex concentrate, and vitamin K. A binary logistic regression model assessed the adjusted impact of rapid INR reversal on intracranial hemorrhage evolution. Significance was defined as p < .05. One hundred subjects were included. Four patients with nontraumatic intracranial hemorrhage were excluded, resulting in a final study population of 96 patients. The most common intracranial hemorrhage in the study population was subarachnoid hemorrhage (71.9%), followed by subdural hemorrhage (35.4%). Reversal of INR of less than 5 hr was not associated with intracranial hemorrhage evolution; however, reversal of less than 10 hr was found to be associated with a decreased odds ratio for intracranial hemorrhage evolution (p = .043). Rapid reversal of elevated INR levels (

The delayed development of splenic artery pseudoaneurysm (SAP) can complicate the nonoperative management of splenic injuries. We sought to determine the utility of repeat imaging in diagnosing SAP in patients managed nonoperatively without angioembolization. We hypothesized that a significant rate of SAPs would be found in this population on repeat imaging. Patients undergoing nonoperative splenic injury management from January 2011 to June 2015 were queried from the trauma registry. Rates of repeat imaging, angioembolization, readmission, and SAP development were analyzed. Further, subanalyses investigating the incidence of SAP in patients managed nonoperatively without angioembolization were conducted. A total of 133 patients met inclusion criteria. Repeat imaging rate was 40 per cent, angioembolization rate was 26 per cent, and readmission rate was 6 per cent. Within the study population, nine SAPs were found (8/9 in patients with splenic injury grade ≥III). Of these nine SAPs, three (33%) were identified on initial scans and embolized, whereas six (67%) were found on repeat imaging in patients not initially receiving angioembolization. Splenic injuries are typically managed nonoperatively without serious complications. Our results suggest patients with splenic injuries grade ≥III managed nonoperatively without angioembolization should have repeat imaging within 48 hours to rule out the possibility of SAP.

Little is known about nursing care's impact on trauma outcomes. The Magnet Recognition Program recognizes hospitals for quality patient care and nursing excellence based on objective standards. We hypothesized that Magnet-designated trauma centers would have improved survival over their non-Magnet counterparts.All 2009 to 2011 admissions to Pennsylvania's Level I and II trauma centers with more than 500 admissions during the study period (10 Magnet and 17 non-Magnet hospitals) were extracted from the Pennsylvania Trauma Systems Foundation State Registry. A logistic regression model with mortality as the dependent variable included the following variables: Magnet status, age, sex, admitting temperature, logit transformation of mortality probability predicted by the Trauma Mortality Prediction Model (TMPM-ais), systolic blood pressure, mechanism of injury, paralytic drug use, and Glasgow Coma Scale motor (GCSm) score.A total of 73,830 patients from the Pennsylvania Trauma Outcome Study database met inclusion criteria for this study. The Magnet and non-Magnet hospital groups were statistically indistinguishable with respect to level of designation, medical school association, surgical residency programs, in-house surgeons, and urban locations. Patients admitted to a Magnet hospital had a significantly decreased odds of mortality when compared with their non-Magnet counterparts (odds ratio, 0.83; 95% confidence interval, 0.70-0.99; p = 0.033), when controlling for numerous factors. Overall, the model has outstanding discrimination with a receiver operating characteristic curve of 0.93.Admission to a Magnet-designated hospital is associated with a 20% reduction in mortality. We believe that the Magnet program's attention to nursing competence has important consequences for trauma patients, as reflected in the improved survival rates in trauma patients admitted to Magnet-designated hospitals.Epidemiologic/prognostic study, level III. Care management study, level IV.

Background: Few cohort studies of pregnancy in sub-Saharan Africa use rigorous gestational age dating and clinical phenotyping. As a result, incidence and risk factors of adverse birth outcomes are inadequately characterized. Methods: The Zambian Preterm Birth Prevention Study (ZAPPS) is a prospective observational cohort established to investigate adverse birth outcomes at a referral hospital in urban Lusaka. This report describes ZAPPS phase I, enrolled August 2015 to September 2017. Women were followed through pregnancy and 42 days postpartum. At delivery, study staff assessed neonatal vital status, birthweight, and sex, and assigned a delivery phenotype. Primary outcomes were: (1) preterm birth (PTB; delivery th percentile weight-for-age at birth), and (3) stillbirth (SB; delivery of an infant without signs of life). Results: ZAPPS phase I enrolled 1450 women with median age 27 years (IQR 23–32). Most participants (68%) were multiparous, of whom 41% reported a prior PTB and 14% reported a prior stillbirth. Twins were present in 3% of pregnancies, 3% of women had short cervix ( Conclusions: This study confirms high rates of PTB, SGA, and SB among pregnant women in Lusaka, Zambia. Accurate gestational age dating and careful ascertainment of delivery data are critical to understanding the scope of adverse birth outcomes in low-resource settings.

Background: Sub-Saharan Africa bears a disproportionate burden of preterm birth and other adverse outcomes. A better understanding of the demographic, clinical, and biologic underpinnings of these adverse outcomes is urgently needed to plan interventions and inform new discovery. Methods: The Zambian Preterm Birth Prevention Study (ZAPPS) is a prospective observational cohort established at the Women and Newborn Hospital (WNH) in Lusaka, Zambia. We recruit pregnant women from district health centers and the WNH and offer ultrasound examination to determine eligibility. Participants receive routine obstetrical care, lab testing, midtrimester cervical length measurement, and serial fetal growth monitoring. At delivery, we assess gestational age, birthweight, vital status, and sex and assign a delivery phenotype. We collect blood, urine, and vaginal swab specimens at scheduled visits and store them in an on-site biorepository. In September 2017, enrollment of the ZAPPS Phase 1—the subject of this report—was completed. Phase 2, which is limited to HIV-uninfected women, reopened in January 2018. Results: Between August 2015 and September 2017, we screened 1784 women, of whom 1450 (81.2%) met inclusion criteria and were enrolled. The median age at enrollment was 27 years (IQR 23–32) and median gestational age was 16 weeks (IQR 13–18). Among women with a previous pregnancy (n=1042), 19% (n=194) reported a prior miscarriage. Among parous women (n=992), 41% (n=411) reported a prior preterm birth and 14% (n=126) reported a prior stillbirth. The HIV seroprevalence was 24%. Discussion: We have established a large cohort of pregnant women and newborns at the WNH to characterize the determinants of adverse birth outcomes in Lusaka, Zambia. Our overarching goal is to elucidate biological mechanisms in an effort to identify new strategies for early detection and prevention of adverse outcomes. We hope that findings from this cohort will help guide future studies, clinical care, and policy.

Transmissible spongiform encephalopathies (TSE), also known as prion diseases, are characterized by rapid and fatal neurological decline. They not only detrimentally affect the patient, but also present additional challenges to healthcare systems due to the infectivity of the tissues and the difficulty of inactivating the prion. The most common TSE is Creutzfeldt-Jakob disease (CJD), which can occur after familial, spontaneous or acquired transmission. TSEs received more attention after the development of variant CJD (vCJD), also known as Mad Cow Disease, in the UK during the mid-1990s. Unlike familial or spontaneous CJD, this variant was connected to consumption of cattle contaminated with the prion disease, bovine spongiform encephalopathy.This development increased interest in the etiology of CJD and other TSEs and the risk it presents as an infectious disease. The following details the case of a 59-year-old male infected with CJD presented to our level II trauma center for treatment following a self-inflicted gunshot wound to the head.

Geriatric living facilities have been associated with a high rate of falls. We sought to develop an innovative intervention approach targeting geriatric living facilities that would reduce geriatric fall admissions to our Level II trauma center. In 2011, a Trauma Prevention Taskforce visited 5 of 28 local geriatric living facilities to present a fall prevention protocol composed of three sections: fall education, risk factor identification, and fall prevention strategies. To determine the impact of the intervention, the trauma registry was queried for all geriatric fall admissions attributed to patients living at local geriatric living facilities. The fall admission rate (total fall admissions/total beds) of the pre-intervention period (2010–2011) was compared with that of the postintervention period (2012–2013) at the 5 intervention and 23 control facilities. A P value < 0.05 was considered statistically significant. From 2010 to 2013, there were 487 fall admissions attributed to local geriatric living facilities (intervention: 179 fall admissions; control: 308 fall admissions). The unadjusted fall rate decreased at intervention facilities from 8.9 fall admissions/bed pre-intervention to 8.1 fall admissions/bed postintervention, whereas fall admission rates increased at control sites from 5.9 to 7.7 fall admissions/bed during the same period [control/intervention odds ratio (OR), 95% confidence interval (CI) = 1.32, 1.05–1.67; period OR, 95%CI = 1.55,1.18–2.04, P = 0.002; interaction of control/intervention group and period OR 95% CI = 0.68, 0.46–1.00, P = 0.047]. An aggressive intervention program targeting high-risk geriatric living facilities resulted in a statistically significant decrease in geriatric fall admissions to our Level II trauma center.

Background Gun violence continues to be a source of trauma patient morbidity and mortality annually in the United States. We sought to characterize gun violence in the combined suburban and rural county of Lancaster, PA, and compare it with gun violence results obtained in urban areas. Materials and methods All gunshot wound (GSW) admissions from January 2000–December 2013 were queried from trauma registry. Patients sustaining ball bearing/ball bullet (BB) or pellet gun injury were excluded. Data collected included mortality, injury severity score (ISS), number of GSW per patient, and cost data. Linear trend tests assessed the change in mortality, patients with three or more GSWs, and patients with an ISS ≥15 and ISS ≥25 over the study period. Statistical significance was defined as P Results A total of 478 patients met our inclusion criteria. Linear trend tests revealed no significant changes in percent mortality ( P = 0.973), percent of patients with three or more GSWs ( P = 0.692), percent of patients with an ISS ≥15 ( P = 0.545), and percent of patients with an ISS ≥25 ( P = 0.343) over the 14-y study period. No significant change in cost per case was observed over the study period ( P = 0.246); however, percent reimbursement significantly increased ( P = 0.012). Conclusions In the relatively affluent suburban and rural community of Lancaster, PA, there is a low-level pattern of gunshot violence and subsequent mortality that has not changed over time. This continuing pattern of gunshot violence speaks to the need for development of innovative preventative measures, as well as continuing efforts against gunshot violence by health care and law-enforcement personnel in suburban and urban centers alike.

Importance Vena cava filter (VCF) placement for pulmonary embolism (PE) prophylaxis in trauma is controversial. Limited research exists detailing trends in VCF use and occurrence of PE over time. Objective To analyze state and nationwide temporal trends in VCF placement and PE occurrence from 2003 to 2015 using available data sets. Design, Setting, and Participants A retrospective trauma cohort study was conducted using data from the Pennsylvania Trauma Outcome Study (PTOS) (461 974 patients from 2003 to 2015), the National Trauma Data Bank (NTDB) (5 755 095 patients from 2003 to 2014), and the National (Nationwide) Inpatient Sample (NIS) (24 449 476 patients from 2003 to 2013) databases. Main Outcomes and Measures Temporal trends in VCF placement and PE rates, filter type (prophylactic or therapeutic), and established predictors of PE (obesity, pregnancy, cancer, deep vein thrombosis, major procedure, spinal cord paralysis, venous injury, lower extremity fracture, pelvic fracture, central line, intracranial hemorrhage, and blood transfusion). Prophylactic filters were defined as VCFs placed before or without an existing PE, while therapeutic filters were defined as VCFs placed after a PE. Results Of the 461 974 patients in PTOS, the mean (SD) age was 47.2 (26.4) and 61.6% (284 621) were men; of the 5 755 095 patients in NTDB, the mean age (SD) was 42.0 (24.3) and 63.7% (3 666 504) were men; and of the 24 449 476 patients in NIS, the mean (SD) age was 58.0 (25.2) and 49.7% (12 160 231) were men. Of patients receiving a filter (11 405 in the PTOS, 71 029 in the NTDB, and 189 957 in the NIS), most were prophylactic VCFs (93.6% in the PTOS, 93.5% in the NTDB, and 93.3% in the NIS). Unadjusted and adjusted temporal trends for the PTOS and NTDB showed initial increases in filter placement followed by significant declines (unadjusted reductions in VCF placement rates, 76.8% in the PTOS and 53.3% in the NTDB). The NIS demonstrated a similar unadjusted trend, with a slight increase and modest decline (22.2%) in VCF placement rates over time; however, adjusted trends showed a slight but significant increase in filter rates. Adjusted PE rates for the PTOS and NTDB showed significant initial increases followed by slight decreases, with limited variation during the declining filter use periods. The NIS showed an initial increase in PE rates followed by a period of stagnation. Conclusions and Relevance Despite a precipitous decline of VCF use in trauma, PE rates remained unchanged during this period. Taking this association into consideration, VCFs may have limited utility in influencing rates of PE. More judicious identification of at-risk patients is warranted to determine individuals who would most benefit from a VCF.

Fatal pulmonary embolism is the third most common cause of death after major trauma. We hypothesised that the Trauma Embolic Scoring System (TESS) would have adequate calibration and discrimination in a group of severely injured trauma patients in predicting venous thromboembolism (VTE), and could be used to predict fatal and non-fatal symptomatic pulmonary embolism. Calibration and discrimination of the TESS were assessed by the slope and intercept of the calibration curve and the area under the receiver operating characteristic curve, respectively. Of the 357 patients included in the study, 74 patients (21%) developed symptomatic VTE after a median period of 14 days following injury. The TESS predicted risks of VTE were higher among patients who developed VTE than those who did not (14 versus 9%, P=0.001) and had a moderate ability to discriminate between patients who developed VTE and those who did not (area under the receiver operating characteristic curve 0.71, 95% confidence interval 0.65 to 0.77). The slope and intercept of the calibration curve were 2.76 and 0.34, respectively, suggesting that the predicted risks of VTE were not sufficiently extreme and overall, underestimated the observed risks of VTE. Using 5% predicted risk of VTE as an arbitrary cut-point, TESS had a high sensitivity and negative predictive value (both ≥0.97) in excluding fatal and non-fatal pulmonary embolism. In summary, the TESS had a reasonable ability to discriminate between patients who developed VTE and those who did not and may be useful to select different preventive strategies to prevent VTE in severely injured patients.

Background As we enter the brave new world of the Patient Protection and Affordable Care Act of 2010, it is imperative that trauma centers provide not only excellent but also cost-effective trauma care. To that end, we sought to determine those factors that contribute significantly to barrier days (BDs), when a patient is medically cleared for discharge but unable to leave the hospital. We hypothesized that there would be significant demographic and payor factors associated with BDs. Methods All trauma admissions to a Level II trauma center discharged alive from 2010 to 2012 were queried from the trauma registry. BDs were identified and recorded at daily sign-out. Patients with a hospital length of stay of 24 hours or less or transferred to another hospital were excluded. Univariate logistic regression was used to analyze which factors were significant (p ≤ 0.05) for BDs. Significant variables were then included in a multivariate logistic regression model. Results A total of 3,056 patients were included in the study, 105 (3.44%) of whom had at least one BD. Multivariate analysis revealed that patients awaiting nursing home placement and rehabilitation placement were at 6.39 and 2.79 times higher odds of having significant barriers to discharge, respectively, compared with patients who were discharged home. The multivariate model also showed that Medicaid coverage, one or more comorbidities, Injury Severity Score of 9 or greater, and one or more ventilation days had a significant correlation with the incidence of BDs. Conclusion This study suggests that discharge destination is a significant factor associated with BDs. Understanding what type of patient is prone to develop barriers to discharge will allow case managers and social workers to intervene with discharge planning early in that patient's hospital course to secure placement and possibly reduce health care costs and improve functional outcome. Level of evidence Prognostic/epidemiologic study, level III.

Understanding the characteristics of trauma recidivists may allow trauma centers to tailor prevention programs. We hypothesized that there would be an increased incidence of violent injuries and falls in the urban vs. rural recidivists, respectively. Trauma admissions from 2000 to 2011 were queried for incidences of recidivism. Age (