Research Spotlight

Shafi, S., A. W. Collinsworth, K. M. Richter, H. B. Alam, L. B. Becker, M. R. Bullock, J. M. Ecklund, J. Gallagher, R. Gandhi, E. R. Haut, Z. L. Hickman, H. Hotz, J. McCarthy, A. B. Valadka, J. Weigelt and J. B. Holcomb (2016). “Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients – translating knowledge into practice.” J Trauma Acute Care Surg: 2016 Jul [Epub ahead of print].

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BACKGROUND: Hemorrhagic shock and traumatic brain injury (TBI) are the 2 leading causes of death after injuries. Evidence-based practice guidelines for managing patients with these conditions have been developed, but their adoption remains suboptimal. Bundles of care for other conditions have been shown to improve compliance with evidence-based practices and patient outcomes. We sought to develop evidence-based bundles of care for early management of hemorrhagic shock and severe TBI. METHODS: We conducted a literature review to identify current treatment recommendations and supporting evidence for hemorrhagic shock and severe TBI. A multispecialty panel of 14 experienced surgeons, physicians, nurses and a former trauma patient reviewed the recommendations. The Delphi method was used to reach consensus. RESULTS: After an extensive literature review and three rounds of the Delphi process, the panel recommended 5 interventions for managing each condition. The bundle for resuscitation from hemorrhagic shock include: 1) Activate massive transfusion protocol; 2) Measure lactate or base deficit upon arrival; 3) Transfuse packed red blood cells, plasma, and platelets in a 1:1:1 ratio; 4) Measure coagulopathy using viscoelastic methods upon arrival; and 5) Do not use large volume crystalloid resuscitation. The bundle for early management of severe TBI included: 1) Avoid and treat hypoxia; 2) Avoid and treat hypotension; 3) Avoid excessive hyperventilation; 4) Evaluate and treat intracranial hypertension; and 5) Do not use steroids. CONCLUSIONS: We have proposed 2 evidence-based bundles of care for the early management of injured patients presenting with hemorrhagic shock and severe TBI. Further studies are needed to assess implementation of these bundles and their impact on patient outcomes.

Agtarap, S., W. Scott, A. M. Warren and Z. Trost (2016). “Validation of the injustice experiences questionnaire in a heterogeneous trauma sample.” Rehabil Psychol: 2016 Jul [Epub ahead of print].

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PURPOSE/OBJECTIVE: A recent study by Trost et al. (2015) investigated the influence of perceived injustice-reflecting appraisals of the severity and irreparability of loss following injury, blame, and unfairness-on physical and psychological outcomes in a sample of patients 12 months after sustaining a traumatic injury. This brief report examines the psychometric properties of the Injustice Experiences Questionnaire (IEQ) using the previous sample from Trost et al. (2015) with added trauma patients (total N = 206). RESEARCH METHOD/DESIGN: Primary analyses included confirmatory and exploratory factor analyses to validate the measurement model of the IEQ in patients 12 months after traumatic injury. Reliability analyses were conducted and construct validity was assessed by examining associations between the IEQ and other pain-related, psychological, and health-related outcome variables of interest. RESULTS: Results replicated both one- and two-factor structures from past research, with a high factor correlation in confirmatory factor analyses and cross-loadings in exploratory factor analysis. Item characteristics analysis demonstrated overall strong internal consistency (alpha = .95). In addition, significant associations with psychosocial variables provide additional construct validity in regards to related outcomes. CONCLUSION/IMPLICATIONS: The IEQ shows strong psychometric properties and is suitable for use in a sample of diverse traumatic injury. However, results suggest the use of a one-factor model for the IEQ in this sample. Future trauma and rehabilitation research can use the IEQ to explore how injustice perceptions related to traumatic injury can prospectively influence physical and psychological outcomes.

Badhwar, V., V. H. Thourani, G. Ailawadi and M. Mack (2016). “Transcatheter mitral valve therapy: The event horizon.” J Thorac Cardiovasc Surg 152(2): 330-336.

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Transcatheter aortic valve replacement has entered the clinical armamentarium mainstream of surgeons and interventional cardiologists in the management of high- and extreme-risk patients with aortic stenosis. Transcatheter mitral valve therapies are closely following suit. A flurry of global innovation, research, and clinical activity over the last 10 years have led to dynamic changes to the technologic landscape. With 1 device commercially approved, and several more in early feasibility studies in the United States with significant equity investments by major device manufacturers, the point of no return for this field of therapy finding its way into daily clinical practice is upon us. The current progress and future development of transcatheter mitral valve repair (TMVr) and transcatheter mitral valve replacement (TMVR) are outlined.

Castillo, J. J., R. Garcia-Sanz, E. Hatjiharissi, R. A. Kyle, X. Leleu, M. McMaster, G. Merlini, M. C. Minnema, E. Morra, R. G. Owen, S. Poulain, M. J. Stone, C. Tam, M. Varettoni, M. A. Dimopoulos, S. P. Treon and E. Kastritis (2016). “Recommendations for the diagnosis and initial evaluation of patients with waldenstrom macroglobulinaemia: A task force from the 8th international workshop on waldenstrom macroglobulinaemia.” Br J Haematol: 2016 Jul [Epub ahead of print].

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The diagnosis of Waldenstrom macroglobulinaemia (WM) can be challenging given the variety of signs and symptoms patients can present. Furthermore, once the diagnosis of WM is established, the initial evaluation should be thorough as well as appropriately directed. During the 8th International Workshop for WM in London, United Kingdom, a multi-institutional task force was formed to develop consensus recommendations for the diagnosis and initial evaluation of patients with WM. In this document, we present the results of the deliberations that took place to address these issues. We provide recommendations for history-taking and physical examination, laboratory studies, bone marrow aspiration and biopsy analysis and imaging studies. We also provide guidance on the initial evaluation of special situations, such as anaemia, hyperviscosity, neuropathy, Bing-Neel syndrome and amyloidosis. We hope these recommendations serve as a practical guidance to clinicians taking care of patients with a suspected or an established diagnosis of WM.

Collinsworth, A. W. and A. L. Masica (2016). “Authors’ response.” J Intensive Care Med 31(7): 494-495.

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Use of “care bundles” has been advocated as a means to accelerate the adoption of multiple care processes into routine clinical practice, benchmark performance, and improve patient outcomes. We recently implemented the Awakening and Breathing Coordination, Delirium Monitoring, and Early Mobility (ABCDE) bundle in 12 Baylor Scott and White Health ICUs and found that bundling these care processes was associated with improved adherence to the individual care processes for delirium prevention and mitigation within the bundle and improved patient outcomes. Although some sites participated in structured educational workshops during the early phases of bundle implementation, we found that the greatest improvement in bundle uptake occurred after we modified the electronic health record (EHR) to facilitate clinical workflow around bundle delivery and documentation.3 This finding suggests that establishing tools that facilitate integration of delirium prevention measures into clinical workflow, such as structured forms for documentation of bundle elements within the EHR, should be the first step in the implementation process followed by educational sessions on the importance of delirium prevention and use of the tools.