Objective: Many patients with severe traumatic brain injury (TBI) require a tracheostomy after decompressive craniectomy. Determining which patients will require tracheostomy is often challenging. The existing methods for predicting which patients will require tracheostomy are more applicable to stroke and spontaneous intracranial hemorrhage. The aim of this study was to investigate whether the Glasgow Coma Scale (GCS) motor score can be used as a screening method for predicting which patients who undergo decompressive craniectomy for severe TBI are likely to require tracheostomy. Methods: The neurosurgery census at the University of Kansas Medical Center was retrospectively reviewed to identify adult patients aged over 18 years who underwent decompressive craniectomy for TBI. Eighty patients met the inclusion criteria for the study. There were no exclusion criteria. The primary outcome of interest was the need for tracheostomy. The secondary outcome was the comparison of the total length of stay (LOS) and intensive care unit LOS between the early and late tracheostomy patient groups. Results: All patients (100%) with a GCS motor score of 4 or less on post operative (POD) 5 required tracheostomy. Setting the threshold at GCS motor score of 5 on POD 5 for recommending tracheostomy resulted in 86.7% sensitivity, 91.7% specificity, and 90.5% positive predictive value, with an area under the receiver operator curve of 0.9101. Conclusion GCS motor score of 5 or less on POD 5 of decompressive craniectomy is a useful screening threshold for selecting patients who may benefit from tracheostomy, or may be potential candidates for extubation.

Pulmonary emboli (PE) are increasingly recognized as an adverse effect of clozapine. However, little is known about the characteristics or mechanisms of clozapine-associated PE. We present a case of a 34-year-old with treatment-refractory schizophrenia who developed rhabdomyolysis during his first clozapine trial. During re-trial on a lower dose than his initial trial, the patient developed chest pain that he attributed to “pacemakers.” The pleuritic description and associated tachycardia prompted medical workup and the patient was ultimately diagnosed with a clozapine-associated PE. The patient’s only risk factors for PE were obesity and tobacco use, while his hypercoagulability workup was unrevealing.Clozapine use was continued at a lower dose following these adverse effects given inefficacy of other agents in managing the patient’s psychotic symptoms. The patient experienced significant relief of psychotic symptoms with continued clozapine therapy and a course of electroconvulsive therapy. The patient’s presentation was unusual in that it occurred during a retrial of clozapine, after the initial trial was stopped when he developed rhabdomyolysis. This case demonstrates the importance of maintaining vigilance for PE in patients on clozapine as well as not dismissing somatic complaints in patients experiencing psychosis. Additionally, given his history rhabdomyolysis, an uncommon adverse effect of clozapine, the development of a second uncommon adverse effect (PE) raises the question of whether these events may be associated.

Problem: From December 2016 to February 2017, two cases of invasive meningococcal disease and one case of meningococcal conjunctivitis, all serogroup W, occurred in Aboriginal children in the Ceduna region of South Australia. The clustering of cases in time and place met the threshold for a community outbreak. Context: The Ceduna region is a remote part of South Australia, with more than 25% of the population identifying as Aboriginal or Torres Strait Islander. Action: As part of the outbreak response, a community-wide meningococcal vaccination programme against serogroups A, C, W and Y was implemented in a collaboration among different agencies of the South Australia Department for Health and Well-being, Aboriginal health and community services providers, and other local service providers and government agencies. The programme comprised an outbreak vaccination schedule, targeting all people aged 3 2 months residing in the cases’ places of residence or in towns with close links. Outcome: Between March and June 2017, 3383 persons were vaccinated, achieving an estimated coverage of 71–85% of the target population, with 31% (n = 1034) of those vaccinated identifying as Aboriginal or Torres Strait Islander. No local cases of serogroup W occurred during the vaccination programme, but two further cases were notified by the end of 2018. Discussion: The participation of a large number of local and non-health-sector stakeholders in programme planning and implementation, a clear response management structure and high community acceptability were identified as key factors that contributed to the programme achieving high vaccination coverage. The need to develop standard operating procedures for community-based outbreak response interventions to ease logistical challenges was considered an important lesson learnt.