A seven-center examination of the relationship between monthly volume and mortality in trauma: a hypothesis-generating study.

INTRODUCTION: The relationship between trauma volumes and patient outcomes continues to be controversial, with limited data available regarding the effect of month-to-month trauma volume variability on clinical results. This study examines the relationship between monthly trauma volume variations and patient mortality at seven Level I Trauma Centers located in the Eastern United States. We hypothesized that higher monthly trauma volumes may be associated with lower corresponding mortality. METHODS: Monthly patient volume data were collected from seven Level I Trauma Centers. Additional information retrieved included monthly mortality, demographics, mean monthly injury severity (ISS), and trauma mechanism (blunt versus penetrating). Mortality was utilized as the primary study outcome. Statistical corrections for mean age, gender distribution, ISS, and mechanism of injury were made using analysis of co-variance (ANCOVA). Center-specific, annually-adjusted median monthly volumes (CSAA-MMV) were calculated to standardize patient volume differences across participating institutions. Statistical significance was set at α < 0.05. RESULTS: A total of 604 months of trauma admissions, encompassing 122,197 patients, were analyzed. Controlling for patient age, gender, ISS, and mechanism of injury, aggregate data suggested that monthly trauma volumes < 100 were associated with significantly greater mortality (3.9%) than months with volumes > 400 (mortality 2.9%, p < 0.01). To account for differences in monthly volumes between centers, as well as for temporal bias associated with potential differences over the entire study duration period, data were normalized using CSAA-MMV as a standardized reference point. Monthly volumes ≤ 33% of the CSAA-MMV were associated with adjusted mortality of 5.0% whereas monthly volumes ≥ 134% CSAA-MMV were associated with adjusted mortality of 2.7% (p < 0.01). CONCLUSIONS: This hypothesis-generating study suggests that greater monthly trauma volumes appear to be associated with lower mortality. In addition, our data also suggest that across all participating centers mortality may be a function of relative month-to-month volume variation. When normalized to institution-specific, annually-adjusted "median" monthly trauma contacts, we show that months with patient volumes ≤ 33% median may be associated with subtly but not negligibly (1.4-2.3%) higher mortality than months with patient volumes ≥ 134% median.

An observational study of patients' attitudes to tattoos and piercings on their physicians: the ART study.

INTRODUCTION: Perceptions regarding body art change over time as societal norms change. Previous research regarding patients' perceptions of physicians with exposed body art have been hampered by flaws in design methodology that incorporate biases into patient responses. This study was performed to determine whether emergency department (ED) patients perceived a difference in physician competence, professionalism, caring, approachability, trustworthiness and reliability in the setting of exposed body art. METHODS: Standardised surveys about physician competence, professionalism, caring, approachability, trustworthiness and reliability rating providers on a five point Likert scale were administered to patients in an ED after an encounter with a physician provider who demonstrated no body art modification, non-traditional piercings, tattoos, or both piercings and tattoos. Each provider served as their own control. Patients were blinded to the purpose of the survey. RESULTS: Patients did not perceive a difference in physician competence, professionalism, caring, approachability, trustworthiness or reliability in the setting of exposed body art. Patients assigned top box performance in all domains >75% of the time, regardless of physician appearance. CONCLUSION: In the clinical setting, having exposed body art does not significantly change patients' perception of the physician.

The infected heart: ventriculoseptal abscess and intracardiac fistulization.

Infective endocarditis is a rare but potentially deadly infection of the endocardial layer, which can involve the valves of the heart among other structures. The extraordinarily rare complication seen in this case involves extensive damage manifesting in an aortic root abscess resulting in an abnormal communication between the aorta and the atrium known as an aortocavitary fistula (Eur Heart J 2005;26:288-297; Pediatr Cardiol 2011;32:1057-1059; J Am Coll Cardiol 1991;18:663-667). As the disease progresses, wading through the complex symptoms, which may seem unrelated, represents a key challenge in diagnosis. This case describes both early and late findings of endocarditis and highlights a rare complication in which rapid diagnosis and early surgical intervention before the development of hemodynamic sequelae are paramount. In this case, infective endocarditis, a great masquerader in this case, provided a challenging diagnostic situation, a very rare complication, and commonalities of disease characteristics that health care provider should appreciate.

Extensive retroperitoneal air, pneumomediastinum, and subcutaneous air secondary to stercoral perforation.

Stercoral perforation is an uncommon cause of large intestinal perforation that is typically the result of chronic constipation. Historically, this disease process has a devastatingly high mortality rate, and recent evidence questions the incidence of the disease, once thought to be scarce. We report the case of an elderly woman presenting with symptoms related to mediastinal and soft tissue air in the neck from dissection of air retroperitoneally from stercoral perforation. She had minimal abdominal complaints and no history of chronic constipation. The emergency provider should be aware that this disease entity exists and should be cognizant that retroperitoneal pathology may present with complaints referable to the chest or even neck with a paucity of abdominal findings.