Legal Firearm Sales at State Level and Rates of Violent Crime, Property Crime, and Homicides.

INTRODUCTION: The effects of firearm sales and legislation on crime and violence are intensely debated, with multiple studies yielding differing results. We hypothesized that increased lawful firearm sales would not be associated with the rates of crime and homicide when studied using a robust statistical method. METHODS: National and state rates of crime and homicide during 1999-2015 were obtained from the United States Department of Justice and the Centers for Disease Control and Prevention. National Instant Criminal Background Check System background checks were used as a surrogate for lawful firearm sales. A general multiple linear regression model using log event rates was used to assess the effect of firearm sales on crime and homicide rates. Additional modeling was then performed on a state basis using an autoregressive correlation structure with generalized estimating equation estimates for standard errors to adjust for the interdependence of variables year to year within a particular state. RESULTS: Nationally, all crime rates except the Centers for Disease Control and Prevention-designated firearm homicides decreased as firearm sales increased over the study period. Using a naive national model, increases in firearm sales were associated with significant decreases in multiple crime categories. However, a more robust analysis using generalized estimating equation estimates on state-level data demonstrated increases in firearms sales were not associated with changes in any crime variables examined. CONCLUSIONS: Robust analysis does not identify an association between increased lawful firearm sales and rates of crime or homicide. Based on this, it is unclear if efforts to limit lawful firearm sales would have any effect on rates of crime, homicide, or injuries from violence committed with firearms.

Early Resumption of ß Blockers Is Associated with Decreased Atrial Fibrillation after Noncardiothoracic and Nonvascular Surgery: A Cohort Analysis.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Beta (ß) blockers reduce the risk of postoperative atrial fibrillation and should be restarted after surgery, but it remains unclear when best to resume ß blockers postoperatively. The authors thus evaluated the relationship between timing of resumption of ß blockers and atrial fibrillation in patients recovering from noncardiothoracic and nonvascular surgery. METHODS: The authors evaluated 8,201 adult ß-blocker users with no previous history of atrial fibrillation who stayed at least two nights after noncardiothoracic and nonvascular surgery as a retrospective observational cohort. After propensity score matching on baseline and intraoperative variables, 1,924 patients who did resume ß blockers by the end of postoperative day 1 were compared with 973 patients who had not resumed by that time on postoperative atrial fibrillation using logistic regression. A secondary matched analysis compared 3,198 patients who resumed ß blockers on the day of surgery with 3,198 who resumed thereafter. RESULTS: Of propensity score-matched patients who resumed ß blockers by end of postoperative day 1, 4.9% (94 of 1,924) developed atrial fibrillation, compared with 7.0% (68 of 973) of those who resumed thereafter (adjusted odds ratio, 0.69; 95% CI, 0.50-0.95; P = 0.026). Patients who resumed ß blockers on day of surgery had an atrial fibrillation incidence of 4.9% versus 5.8% for those who started thereafter (odds ratio, 0.84; 95% CI, 0.67-1.04; P = 0.104). CONCLUSIONS: Resuming ß blockers in chronic users by the end of the first postoperative day may be associated with lower odds of in-hospital atrial fibrillation. However, there seems to be little advantage to restarting on the day of surgery itself.

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care.

OBJECTIVES: To describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level. PARTICIPANTS: A multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM). DATA SOURCES AND SYNTHESIS: Relevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria. CONCLUSIONS: Guidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.

Critical care obstetrics and gynecology.

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.

The changing face of trauma management and its impact on surgical resident training.

BACKGROUND: The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. METHODS: A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. RESULTS: There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. CONCLUSION: Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.