Specific Types Of Patients Research Articles

Large-scale tumor-associated collagen signatures identify high-risk breast cancer patients.

The notion of personalized medicine demands proper prognostic biomarkers to guide the optimal therapy for an invasive breast cancer patient. However, various risk prediction models based on conventional clinicopathological factors and emergent molecular assays have been frequently limited by either a low strength of prognosis or restricted applicability to specific types of patients. Therefore, there is a critical need to develop a strong and general prognosticator.Methods: We observed five large-scale tumor-associated collagen signatures (TACS4-8) obtained by multiphoton microscopy at the invasion front of the breast primary tumor, which contrasted with the three tumor-associated collagen signatures (TACS1-3) discovered by Keely and coworkers at a smaller scale. Highly concordant TACS1-8 classifications were obtained by three independent observers. Using the ridge regression analysis, we obtained a TACS-score for each patient based on the combined TACS1-8 and established a risk prediction model based on the TACS-score. In a blind fashion, consistent retrospective prognosis was obtained from 995 breast cancer patients in both a training cohort (n= 431) and an internal validation cohort (n = 300) collected from one clinical center, and in an external validation cohort (n = 264) collected from a different clinical center.Results: TACS1-8 model alone competed favorably with all reported models in predicting disease-free survival (AUC: 0.838, [0.800-0.872]; 0.827, [0.779-0.868]; 0.807, [0.754-0.853] in the three cohorts) and stratifying low- and high-risk patients (HR 7.032, [4.869-10.158]; 6.846, [4.370-10.726], 4.423, [2.917-6.708]). The combination of these factors with the TACS-score into a nomogram model further improved the prognosis (AUC: 0.865, [0.829-0.896]; 0.861, [0.816-0.898]; 0.854, [0.805-0.894]; HR 7.882, [5.487-11.323]; 9.176, [5.683-14.816], and 5.548, [3.705-8.307]). The nomogram identified 72 of 357 (~20%) patients with unsuccessful 5-year disease-free survival that might have been undertreated postoperatively.Conclusions: The risk prediction model based on TACS1-8 considerably outperforms the contextual clinical model and may thus convince pathologists to pursue a TACS-based breast cancer prognosis. Our methodology identifies a significant portion of patients susceptible to undertreatment (high-risk patients), in contrast to the multigene assays that often strive to mitigate overtreatment. The compatibility of our methodology with standard histology using traditional (non-tissue-microarray) formalin-fixed paraffin-embedded (FFPE) tissue sections could simplify subsequent clinical translation.

Characterization of specific and distinct patient types in clinical trials of acute schizophrenia using an uncorrelated PANSS score matrix transform (UPSM)

Understanding the specificity of symptom change in schizophrenia can facilitate the evaluation antipsychotic efficacy for different symptom domains. Previous work identified a transform of PANSS using an uncorrelated PANSS score matrix (UPSM) to reduce pseudospecificity among symptom domains during clinical trials of schizophrenia. Here we used UPSM-transformed factor scores to identify 5 distinct patient types, each having elevated and specific severity among each of 5 symptom domains. Subjects from placebo-controlled clinical trials of acute schizophrenia were clustered (baseline) and classified (post-baseline) by a machine-learning algorithm. At baseline, all 5 patient types were similar in PANSS total score. Post-baseline, subjects’ memberships among the 5 UPSM patient types were relatively stable over treatment duration and were relatively insensitive to overall improvements in symptoms, in contrast to other methods based on untransformed PANSS items. Using UPSM-transformed PANSS, drug treatment effect sizes versus placebo were doubly-dissociated for specificity across symptom domains and within specific patient types. This approach illustrates how broader clinical trial populations can nevertheless be utilized to characterize the specificity of new mechanisms across the dimensions of schizophrenia psychopathology.

Cost-Effectiveness Analysis of Virtual Surgical Planning in Mandibular Reconstruction.

Because of the complex nature of osteocutaneous free flap mandibular reconstruction, modern technologies such as virtual surgical planning have become popularized to refine the procedure. Compared with usual care, virtual surgical planning has been suggested to reduce operative time and improve accuracy of outcomes. The aim of this study was to examine the cost-effectiveness of virtual surgical planning versus usual care in mandibular reconstruction. A decision-analytic model was constructed to comparatively understand cost-effectiveness of virtual surgical planning and usual care treatments based on additional costs of virtual surgical planning, and costs attributed to probabilities of postoperative complications. Model structure was informed through qualitative clinical interviews from the University of North Carolina, and supported through University of North Carolina clinical data and literature. Costs and complication probabilities were estimated from the literature. Sensitivity analyses of all uncertain model parameters were performed, and distributional parameters were selected based on best practices. Results of base-case analysis indicated that virtual surgical planning was more costly by a difference of $7099 per person and did not reduce the risk of complications or flap loss. Virtual surgical planning cases had an increased incidence of flap loss by 0.6 percent and an increased incidence of mandibular infection by 6.5 percent. Virtual surgical planning has upfront expenses that do not necessarily translate into downstream reduction in complications or improved outcomes. Clinical decision-makers would benefit from future research to identify thresholds whereby virtual surgical planning may result in more cost-savings for particular types of patients.

Prospective Observational Study of Pazopanib in Patients with Advanced Renal Cell Carcinoma (PRINCIPAL Study).

Real-world data are essential to accurately assessing efficacy and toxicity of approved agents in everyday practice. PRINCIPAL, a prospective, observational study, was designed to confirm the real-world safety and efficacy of pazopanib in patients with advanced renal cell carcinoma (RCC). Patients with clear cell advanced/metastatic RCC and a clinical decision to initiate pazopanib treatment within 30 days of enrollment were eligible. Primary objectives included progression-free survival (PFS), overall survival (OS), objective response rate (ORR), relative dose intensity (RDI) and its effect on treatment outcomes, change in health-related quality of life (HRQoL), and safety. We also compared characteristics and outcomes of clinical-trial-eligible (CTE) patients, defined using COMPARZ trial eligibility criteria, with those of non-clinical-trial-eligible (NCTE) patients. Secondary study objectives were to evaluate clinical efficacy, safety, and RDI in patient subgroups. Six hundred fifty-seven patients were enrolled and received ≥1 dose of pazopanib. Median PFS and OS were 10.3 months (95% confidence interval [CI], 9.2-12.0) and 29.9 months (95% CI, 24.7 to not reached), respectively, and the ORR was 30.3%. HRQoL showed no or little deterioration over time. Treatment-related serious adverse events (AEs) and AEs of special interest occurred in 64 (9.7%), and 399 (60.7%) patients, respectively. More patients were classified NCTE than CTE (85.2% vs. 14.8%). Efficacy of pazopanib was similar between the two groups. PRINCIPAL confirms the efficacy and safety of pazopanib in patients with advanced/metastatic RCC in a real-world clinical setting. PRINCIPAL is the largest (n = 657) prospective, observational study of pazopanib in patients with advanced/metastatic renal cell carcinoma, to the authors' knowledge. Consistent with clinical trial results that often contain specific patient types, the PRINCIPAL study demonstrated that the effectiveness and safety of pazopanib is similarly safe and effective in patients with advanced kidney cancer in a real-world clinical setting. The PRINCIPAL study showed that patients with advanced kidney cancer who are treated with first-line pazopanib generally do not show disease progression for approximately 10 months and generally survive for nearly 30 months.

Characterization of aspirin esterase activity in health and disease: In vitro and ex vivo studies

Due to its ability to irreversibly inactivate platelet cyclooxygenase, low-dose aspirin (ASA) is the most widely used antithrombotic agent. Although, studies in specific types of patients with cardiovascular disease (CVD) have shown an incomplete inhibition of platelet’s cyclooxygenase, which may increase the variability in drug response. Some aspects of ASA pharmacokinetics (PK) still need further investigation. In this study, we aimed to characterise the contribution of esterase enzymes to ASA hydrolysis in the peripheral blood and to assess their activity in 36 healthy subjects (Ctrl) and 77 CVD patients. To this aim, an in vitro assay testing esterase activity in parallel to a liquid chromatography-tandem mass spectrometry method simultaneously detecting ASA and its main metabolites salicylic (SA) and gentisic acids, have been developed. Michaelis-Menten constant (Km) calculation, ASA esterase isoforms characterisation, and ASA PK study were then achieved. The calculated Km identified plasma esterases as the enzymes with the higher affinity for the substrate compared to the RBC ones. Both rivastigmine and 4-bis-nitrophenyl phosphate inhibited plasma esterase activities, suggesting that acetylcholinesterase and carboxylesterase largely contribute to ASA hydrolysis. The feasibility of the method here developed has been explored in Ctrl and CVD patients. The effect of ASA treatment on enzyme activity was further evaluated on an age, sex and BMI matched subgroup of patients and Ctrl (n = 10 for each subgroup, on and off ASA). No overall variations were evidenced in both CVD and Ctrl groups, even when the effect of ASA treatment was tested. This result suggests the absence of any influence of disease state, drug treatments, and comorbidities on plasma esterase and the inability of ASA intake to induce esterase function. In conclusion, the method here developed allows a better characterisation of ASA esterase activity and could be helpful to define the PK-related determinants of ASA responsiveness in order to personalise regimen in specific pathological conditions.

Use of the vestibular and oculomotor examination for concussion in a pediatric emergency department

BackgroundConcussion guidelines recommend a vestibular and oculomotor (VOM) examination be performed for all patients with concern for concussion, however the feasibility of performing testing is unknown. We aimed to measure rates of exam performance after implementation of training and support tools in a pediatric emergency department. MethodsWe conducted a retrospective study of patients age 6 to 18 years old presenting over a 12-month period. Charts were obtained via natural language processing, where concussion was suggested as a diagnosis in the electronic health record, and then manually reviewed to record patient and provider factors. A multivariable logistic regression was performed to determine factors associated with exam performance, and a classification and regression tree (CART) analysis was performed to determine if a specific patient type was at risk for not having testing performed. ResultsFour hundred patients were included in the analysis. Sixty-four percent received a VOM examination (including 73% of those diagnosed with concussion). Provider type, concussion history, symptom burden, injury mechanism, and final diagnosis were all significantly associated with exam performance. CART analysis determined patients with a non-concussion diagnosis, a non-sports injury mechanism, no prior history of concussion, and two or fewer symptoms had the lowest likelihood (46%) of receiving the exam. ConclusionPerforming a VOM examination for concussion is feasible in the acute setting following provider education and using clinical support tools. The exam is more likely to be performed on those children with history or exam findings associated with perceived risk for ongoing symptoms.

Interactive design of patient-oriented video-games for rehabilitation: concept and application

Purpose: Serious video-games are innovative tools used to train the motor skills of subjects affected by neurological disorders. They are often developed to train a specific type of patients and the rules of the game are standardly defined. A system that allows the therapist to design highly patient-oriented video-games, without specific informatics skills, is proposed.Method: The system consists of one personal computer, two screens, a Kinect™ sensor and a specific software developed here for the design of the video-games. It was tested with the collaboration of three therapists and six patients, and two questionnaires were filled in by each patient to evaluate the appreciation of the rehabilitative sessions.Results: The therapists learned easily how to use the system, and no serious difficulties were encountered by the patients. The questionnaires showed an overall good satisfaction by the patients and highlighted the key-role of the therapist in involving the patients during the rehabilitative session.Conclusions: It was found that the proposed system is effective for developing patient-oriented video-games for rehabilitation. The two main advantages are that the therapist is allowed to (i) develop personalized video-games without informatics skills and (ii) adapt the game settings to patients affected by different pathologies.Implications for rehabilitationVirtual reality and serious video games offer the opportunity to transform the traditional therapy into a more pleasant experience, allowing patients to train their motor and cognitive skills.Both the therapists and the patients should be involved in the development of rehabilitative solutions to be highly patient-oriented.A system for the design of rehabilitative games by the therapist is described and the feedback of three therapists and six patients is reported.

Clinical interview in psychiatric difficult situations

There are here described a number of basic principles underlying an effective clinical interview in psychiatric difficult situations (violent or suicidal patients, victims of serious physical and psychological damages, authors of inadequate or anti-social requests to the therapist). The aim of the present study is to provide the psychiatric operator with useful skills for the optimal management of the interview in difficult situations both at diagnostically and therapeutically level. The methodology was based on examination of the literature and personal experience of the authors. The authors highlighted 18 working hypothesis that may represent beneficial instruments in situations of difficult psychiatric interview. Further studies will deepen under the clinical, actuarial and statistical validity the principles covered in various clinical and crisis situations with difficulty to the interview, in relation also to specific types of patients for a more updated training of the operators in the field of mental health.

Resistance of Gram-negative bacilli isolated from patients in ICU

Objective: to determine the spectrum of pathogens associated with nosocomial infections among ICU patients, to summarize the level of antimicrobial resistance of common pathogens and provide an overview of strategies to prevent the spread of resistance. Methods: A prospective microbiologic study of 781 strains isolated from adult patients after cardiac surgery at ICU was conducted, during the period 2010-2014. Results. The results of the study, 52.3% of the isolated strains (409) were Gram-negative, among which the share of non-fermenting Gram-negative bacteria accounted for 34.4% of the isolates (269), of which most frequently was Acinetobacter baumannii - 20,9% (164) and Pseudomonas aeruginosa - 13,4% (105). A. baumannii showed a high level of resistance to the III generation cephalosporins (ceftazidime - 96.9%, cefotaxime - 97.6%, ceftriaxone - 93.5%), to carbapenems at the level of 88%. Resistant strains of Pseudomonas aeruginosa to carbapenems was 63%. Among the representatives of the family Enterobacteriaceae, the highest resistance was observed in strains of Klebsiella pneumoniae, 100% resistance to cephalosporins III generation (ceftriaxone, ceftazidime), the lowest resistance to carbapenems observed (4.2% of meropenem, imipenem 11.1%). Conclusion: In order to reduce the emergence and spread of drug-resistant strains in the ICU, it is strongly recommended to carry out microbiological monitoring and optimization of the use of antibiotics in each hospital. Therefore local resistance surveillance programs have the greatest value in the development of appropriate therapeutic recommendations for specific types of patients and infections.

Global, Prospective, Non-Interventional, Observational Study of Presentation, Treatment Patterns, and Outcomes in Multiple Myeloma Patients: The Insight-MM Study

Global, Prospective, Non-Interventional, Observational Study of Presentation, Treatment Patterns, and Outcomes in Multiple Myeloma Patients: The Insight-MM Study

Openness to and preference for attributes of biologic therapy prior to initiation among patients with rheumatoid arthritis: patient and rheumatologist perspectives and implications for decision making.

PurposeDespite American College of Rheumatology recommendations, appropriate and timely initiation of biologic therapies does not always occur. This study examined openness to and preference for attributes of biologic therapies among patients with rheumatoid arthritis (RA), differences in patients’ and rheumatologists’ perceptions, and discussions around biologic therapy initiation.Patients and methodsA self-administered online survey was completed by 243 adult patients with RA in the US who were taking disease-modifying antirheumatic drugs (DMARDs) and had never taken, but had discussed biologic therapy with a rheumatologist. Patients were recruited from a consumer panel (n=142) and patient advocacy organization (n=101). A separate survey was completed by 103 rheumatologists who treated at least 25 patients with RA per month with biologic therapy. Descriptive and bivariate analyses were conducted separately for patients and rheumatologists. Attributes of biologic therapy included route of administration (intravenous infusion or subcutaneous injection), frequency of injections/infusions, and duration of infusion.ResultsOver half of patients (53.1%) were open to both intravenous infusion and subcutaneous injection, whereas rheumatologists reported 40.7% of patients would be open to both. Only 26.3% of patients strongly preferred subcutaneous injection, whereas rheumatologists reported 35.2%. Discrepancies were even more pronounced among specific patient types (eg, older vs younger patients and Medicare recipients). Among patients, 23% reported initiating discussion about biologics and 54% reported their rheumatologist initiated the discussion. A majority of rheumatologists reported discussing in detail several key aspects of biologics, whereas a minority of patients reported the same.ConclusionPreferences differed among patients with RA from rheumatologists’ perceptions of these preferences for biologic therapy, including greater openness to intravenous infusion among patients than assumed by rheumatologists and relative lack of discussion about key aspects of biologic therapy perceived by patients. There is a need for more open communication about treatment options, which may encourage more appropriate, timely transition to biologic therapy.

Improving the Treatment and Assessment of Moderate and Severe Pain in a Pediatric Emergency Department.

Background. The Janeway Children's Hospital previously enacted a number of measures to improve pain management for patients in its emergency department (ED). While improvements were demonstrated, rates for the timely assessment and treatment of pain remain below standards of care. Objectives. The study objectives are to investigate the impact of the previous attempts to improve the treatment of pain and to explore ways to further improve pain management in the ED. Methods. Key informant interviews and a focus group were conducted with nurses, physicians, and parents whose children were identified as having severe pain. Results. Interviews were conducted with 31 parents or children, 9 physicians, and 8 nurses. The focus group was attended by 15 nurses. Previous initiatives were viewed as improvements. Continued barriers include difficulties in accurately capturing the level of pain, issues in treating pain for specific types of patients, and inadequacy in addressing patients in severe pain. Conclusion. Changes in pain treatment protocols can result in positive impacts but are likely insufficient on their own to achieve desired standards of care. Consistent measurement and engagement with staff can identify additional opportunities for improving pain management within an ED setting.

A qualitative study on discrimination and ethical implications in stroke care in contemporary Greece

Contemporary stroke care is diverse, contributing to complex ethical dilemmas and controversies. In Greece, continuing austerity measures and an ageing population are expected to increase the burden of stroke on health care delivery. We sought to explore ethical views and stances of health care professionals caring for stroke patients in Greece. Forms of discrimination against elderly hospitalized patients were also addressed. A qualitative design was adopted whereby an informal focus group interview and follow-up, face-to-face individual interviews were undertaken. The sample consisted of 12 nurses working in clinical areas with stroke patients. Their mean age was 31 years with a mean work experience of 10 years. Individual discussions were audio taped after subject consent and were transcribed verbatim subsequently for keywords-in-context analysis. Analysis of the focus interview revealed several recurring themes, namely, ward destination, admission policies, the concepts of age as related to stroke. Individual interviews highlighted several other topics, such as preferences for specific types of patients, communication capacity of the patient's condition, and his or her individual characteristics as a favoring or limiting factors, and challenges to age-related criteria for treatment. There is an age-related criteria of 65 years for ward destination after stroke as set by a ministerial decree, which is still practiced. Moreover, younger stroke patients may be offered more thorough assessments and clinical tests and therapies. Discrepancies in the level of care pose an ethical concern regarding levels of care for older stroke patients in Greece. A longstanding, age-related national policy in Greece regarding hospital admission criteria is shown to be a detrimental influence on ward admission for stroke patients. This policy, coupled with prehospital care protocols, was shown to promote ageism against this patient group. The age-related agenda in the Greek health care system has suffused care delivery with pockets of discrimination.

Prehospital Helicopter Air Ambulances Part 1: Access, Protocols, and Utilization

ObjectiveIn the prehospital setting, helicopter air ambulances (HAAs) are used to bring advanced care to patients and reduce time to definitive care. Research related to emergency medical service (EMS) professionals’ access to medical helicopters, protocols for HAA use, and prevalence of HAA transport for different patient types is sparse. Our first objective was to describe EMS professionals’ access to HAA and the prevalence of written protocols regarding their use. Next, we looked at HAA use for specific patient types (trauma, nontraumatic chest pain, stroke, and pediatric). MethodsWe conducted a census survey of nationally certified EMS professionals. Descriptive analyses were performed. ResultsThere were 15,366 responses. Over 90% of nationally certified EMS professionals had access to at least 1 HAA service. Of these, 86% had the authority to request a medical helicopter, and two thirds reported having written HAA protocols. Although HAAs were used mostly for trauma patients, EMS professionals also used these resources for nontrauma transports of patients with time-sensitive conditions. ConclusionMost nationally certified EMS professionals had access to a medical helicopter service and used these resources mainly for trauma patients. About one third reported they did not have or were unsure if their agency had written protocols for HAA use.

Review of a two-year methicillin-resistant Staphylococcus aureus screening program and cost-effectiveness analysis in Singapore.

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) poses an increasingly large disease and economic burden worldwide. The effectiveness of screening programs in the tropics is poorly understood. The aims of this study are: (i) to analyze the factors affecting MRSA colonization at admission and acquisition during hospitalization and (ii) to evaluate the cost-effectiveness of a screening program which aims to control MRSA incidence during hospitalization.MethodsWe conducted a retrospective case–control study of patients admitted to the Communicable Disease Centre (CDC) in Singapore between Jan 2009 and Dec 2010 when there was an ongoing selective screening and isolation program. Risk factors contributing to MRSA colonization on admission and acquisition during hospital stay were evaluated using a logistic regression model. In addition, a cost-effectiveness analysis was conducted to determine the cost per disability-adjusted life year (DALY) averted due to implementing the screening and isolation program.ResultsThe average prevalence rate of screened patients at admission and the average acquisition rate at discharge during the study period were 12.1 and 4.8 % respectively. Logistic regression models showed that older age (adjusted odds ratio (OR) 1.03, 95 % CI 1.02–1.04, p < 0.001) and dermatological conditions (adjusted OR 1.49, 95 % CI 1.11–1.20, p = 0.008) were independently associated with an increased risk of MRSA colonization at admission. Age (adjusted OR 1.02, 95 % CI 1.01–1.03, p = 0.002) and length of stay in hospital (adjusted OR 1.04, 95 % CI 1.03–1.06, p < 0.001) were independent factors associated with MRSA acquisition during hospitalization. The screening and isolation program reduced the acquisition rate by 1.6 % and was found to be cost saving. For the whole study period, the program cost US$129,916, while it offset hospitalization costs of US$103,869 and loss of productivity costs of US$50,453 with −400 $/DALY averted.DiscussionThis study is the first to our knowledge that evaluates the cost-effectiveness of screeningand isolation of MRSA patients in a tropical country. Another unique feature of the analysis is the evaluationof acquisition rates among specific types of patients (dermatological, HIV and infectious disease patients)and the comparison of the cost-effectiveness of screening and isolation between them.ConclusionsOverall our results indicate high MRSA prevalence that can be cost effectively reduced by selective screening and isolation programs in Singapore.

Bridging the Gap between Translational and Outcome Research in Cardiovascular Disease

Bridging the Gap between Translational and Outcome Research in Cardiovascular Disease

High throughput tools to access images from clinical archives for research.

Historically, medical images collected in the course of clinical care have been difficult to access for secondary research studies. While there is a tremendous potential value in the large volume of studies contained in clinical image archives, Picture Archiving and Communication Systems (PACS) are designed to optimize clinical operations and workflow. Search capabilities in PACS are basic, limiting their use for population studies, and duplication of archives for research is costly. To address this need, we augment the Informatics for Integrating Biology and the Bedside (i2b2) open source software, providing investigators with the tools necessary to query and integrate medical record and clinical research data. Over 100 healthcare institutions have installed this suite of software tools that allows investigators to search medical record metadata including images for specific types of patients. In this report, we describe a new Medical Imaging Informatics Bench to Bedside (mi2b2) module (www.mi2b2.org), available now as an open source addition to the i2b2 software platform that allows medical imaging examinations collected during routine clinical care to be made available to translational investigators directly from their institution’s clinical PACS for research and educational use in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Omnibus Rule. Access governance within the mi2b2 module is customizable per institution and PACS minimizing impact on clinical systems. Currently in active use at our institutions, this new technology has already been used to facilitate access to thousands of clinical MRI brain studies representing specific patient phenotypes for use in research.

Is It Time to Embrace Telephone Genetic Counseling in the Oncology Setting?

Is It Time to Embrace Telephone Genetic Counseling in the Oncology Setting?

Comparison of Outcomes for Children With Cervical Spine Injury Based on Destination Hospital From Scene of Injury

Pediatric cervical spine injury is rare. As a result, evidence-based guidance for prehospital triage of children with suspected cervical spine injuries is limited. The effects of transport time and secondary transfer for specialty care have not previously been examined in the subset of children with cervical spine injuries. The primary objective was to determine if prehospital destination choice affects outcomes for children with cervical spine injuries. The secondary objectives were to describe prehospital and local hospital interventions for children ultimately transferred to pediatric trauma centers for definitive care of cervical spine injuries. The authors searched the Pediatric Emergency Care Applied Research Network (PECARN) cervical spine injury data set for children transported by emergency medical services (EMS) from scene of injury. Neurologic outcomes in children with cervical spine injuries transported directly to pediatric trauma centers were compared with those transported to local hospitals and later transferred to pediatric trauma centers, adjusting for injury severity, indicated by altered mental status, focal neurologic deficits, and substantial comorbid injuries. In addition, transport times and interventions provided in the prehospital, local hospital, and pediatric trauma center settings were compared. Multiple imputation was used to handle missing data. The PECARN cervical spine injury cohort contains 364 patients transported from scene of injury by EMS. A total of 321 met our inclusion criteria. Of these, 180 were transported directly to pediatric trauma centers, and 141 were transported to local hospitals and later transferred. After adjustments for injury severity, odds of a normal outcome versus death or persistent neurologic deficit were higher for patients transported directly to pediatric trauma centers (odds ratio [OR]= 1.89, 95% confidence interval [CI]=1.03 to 3.47). EMS transport times to first hospital did not differ and did not affect outcomes. Prehospital analgesia was very infrequent. Initial destination from scene (pediatric trauma center vs. local hospital) appears to be associated with neurologic outcome of children with cervical spine injuries. Markers of injury severity (altered mental status and focal neurologic findings) are important predictors of poor outcome in children with cervical spine injuries and should remain the primary guide for prehospital triage to designated trauma centers.

A review on the evidence of transgenerational transmission of posttraumatic stress disorder vulnerability.

To understand the risks of posttraumatic stress disorder (PTSD) development in the next generation of PTSD patients, we conducted a review on the biological, but not genetic, evidence of transgenerational transmission of PTSD vulnerability. Pertinent articles published from 1985 to September 2011 were searched using online academic search engines, including MEDLINE, EMBASE, ScienceDirect, OVID, PsycLIT, and SCOPUS, and a non-systematic review was conducted. There is paradoxical evidence that hypothalamic-pituitary-adrenal axis changes in PTSD patients may also be evident in their offspring. This effect and biological vulnerability to PTSD may be transmitted across generations through maternal epigenetic programming during pregnancy. The samples of most studies, which were not large enough and represented the outcome of few research groups, consisted of a specific type of patients with a particular trauma. There is still a need to conduct studies in other geographical areas with different genetic background and larger samples considering different types of trauma other than those specified in the current literature, so as to strengthen the evidence of transgenerational transmission of PTSD vulnerability.