BACKGROUND:Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS:An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014)(2015)(2016)(2017)(2018)(2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS:The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, −9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION:Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.

No abstract

Objective: Although developmental stages and identity have been studied as part of aging, one category of both identity and biological difference that has received little attention in the medical and public health literature is that of older adults who were born deaf and/or who identify as part of the signing Deaf community. Research Method: Researchers conducted a systematic search of the literature for barriers to care access related to both aging and deafness. Results: Lack of cultural competence among providers, coupled with inconsistent access to interpreters in medical settings, puts deaf individuals at risk for treatment without adequate consent, or insufficient care due to communication barriers or misperceptions of expression or culture. Conclusions/Implications: Individuals may face unusual challenges, indicating a serious public health crisis on the horizon as the demographic of deaf older adults continues to grow. This paper will discuss what is known about the intersection of aging, Deaf culture, and health care access, and suggest policy and practice recommendations for the future. Impact and ImplicationsWith 60% of deaf Americans over the age of 65, barriers to care for members of the Deaf community who use ASL as their primary language are substantial and pose great risk to health and well-being. Health care providers often view deafness as pathology instead of with a patient-centered view of Deaf culture. Training is required in order to understand the unique health care needs and barriers to care with members of the Deaf community. Deaf older adults report lower subjective health status and demonstrate increased incidences of high-risk health concerns, including obesity, suicidal ideation, and history of intimate partner violence. Domains such as end-of-life care, long-term care, and mental health assessment pose particular risk as there are no validated tools for cognitive assessment in ASL and direct translation is challenging. Deaf older adults are at increased risk for depression, isolation, and erosion of their autonomy and personal agency.

For individuals with dementia, disorientation and both external and internal stimuli may trigger behaviors that are difficult to manage or dangerous to health-care providers. Identification of correlational risk factors to aggressive behavior in patients who are unknown to the hospital can allow providers to adapt patient care quickly. Records for patients aged 60þ who spent at least 24 hours at the hospital other than in the psychiatric unit were used (N ¼ 14 080). The first 4000 records and every 10th person who met criteria (N ¼ 5008) were searched for documentation of dementia (n ¼ 505). Logistic regressions and w 2 tests were used to examine relationships between variables. Recognition of delirium (P ¼ .014, Exp(B) ¼ 2.53), coupled with an existing prescription for antipsychotic medication at intake (P < .001, Exp(B) < 4.37), may be a reliable means of screening for risk and intervening at the earliest possible contact, improving quality of care and safety in acute care for individuals with dementia.