Evaluation of Posttraumatic Stress Disorder Screening Measures of Emergency Medical Services Clinicians in Urban and Suburban New York During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: The objective of this study was to assess the psychological impact of the coronavirus disease 2019 (COVID-19) pandemic on the self-reported rates of posttraumatic stress disorder (PTSD) among emergency medical services (EMS) clinicians in urban and suburban settings that were one of the primary epicenters during the first wave of the COVID-19 pandemic. METHODS: Anonymous surveys containing the PTSD Checklist-Specific (PCL-S) were sent electronically between November 2020 and April 2021 to EMS clinicians working in 2 EMS agencies. A threshold score ≥ 36 was considered a positive screen for PTSD symptomology; a score ≥ 44 was considered a presumptive PTSD diagnosis. RESULTS: Of the 214 surveys sent, 107 responses were returned. The total PCL-S scores suggested PTSD symptoms were present in 33% of responding EMS clinicians (95% confidence interval [CI], 24.1%-42.5%), and 25% (95% CI, 17.6%-34.7%) met the criteria for a presumptive diagnosis of PTSD. Regression revealed increasing PCL-S scores were associated with thoughts of job resignation (+3.8; 95% CI, 1.1-6.4; P = .006), whereas lower PCL-S scores were related to the degree that respondents believed emotional support was available at their institution (-3.6; 95% CI, -6.8 to -0.4; P = .03). CONCLUSION: Sixth months after the first wave of the COVID-19 pandemic, one third of participating EMS clinicians screened positive for PTSD symptoms. Pandemic planning must address the mental health of EMS clinicians to reduce subsequent burnout and maintain a healthy workforce.

Thigh compartment syndrome: Outcomes in an urban level 1 trauma center.

INTRODUCTION: Thigh compartment syndrome (TCS) is a rare surgical emergency associated with a high risk of morbidity with mortality rates as high as 47 %. There is sparse literature discussing the management as well as outcomes of these injuries. The purpose of this study is to review a consecutive series of patients presenting to a single urban Level 1 trauma center with TCS to identify injury characteristics, clinical presentation, and outcomes associated with this injury. METHODS: A trauma database was queried for all patients with a diagnosis of TCS at a single level 1 urban trauma center between January 1, 2011 and December 31, 2021. Demographic and injury variables collected included age, sex, BMI, mechanism of injury, and creatine phosphokinase levels (CPK). Hospital quality measures including time from admission to surgery, length of both hospital and ICU stay, complications, and cost of care were collected. Descriptive statistics are reported as median [interquartile range] or N (percent). RESULTS: There were 14 patients identified with a diagnosis of TCS. All were men with an average age 33.5 [23.5 - 38] years and an average BMI of 26 [22.9-28.1]. The most common cause of injury was blunt trauma (71.4 %), and the remaining 28.6 % were gunshot wound injuries. Within the cohort, 6 (42.9 %) patients sustained a femoral shaft fracture, and 4 (28.6 %) patients sustained a vascular injury. The median initial CPK of patients within this cohort was 3405 [1232-5339] and reached a peak of 5271 [3013-13,266]. The median time from admission to diagnosis was 6.8 [0-236.9] hours. The median time from admission to the operating room was 8.2 [0.6-236.9] hours, and the median number of operating room visits was 3 [2 - 6]. Five patients (35.7 %) wounds were closed with split thickness skin grafting. There were 12 (85.7 %) patients who required ICU care. The median ICU length of stay was 7.5 days [4-15]. The median hospital length of stay was 16.5 days [13.25-38.0]. The median total charges for a patient with thigh compartment syndrome was $129,159.00 [$24,768.00 - $587,152.00]. The median direct variable cost for these patients was $86,106.00 For comparison, the median direct variable cost for patients with femur fractures without TCS at this institution was $8,497.28 [$1,903.52-$21,893.13]. No patients required readmission within 60 days. There were no mortalities. CONCLUSION: TCS is a rare and life-threatening injury associated with significant morbidity. Despite rapid diagnosis and fasciotomy, the majority of the patients have prolonged hospital courses, ICU lengths of stay, and significant costs of treatment. Providers can reference the outcomes reported in this study when caring for TCS patients.

COVID Stressed, but Not due to the Virus.

INTRODUCTION: Acute care surgeons can experience posttraumatic stress disorder (PTSD) due to the cumulative stress of practice. This study sought to document the potential impact of the COVID-19 pandemic on PTSD in acute care surgeons and to identify potential contributing factors. METHODS: The six-item brief version of the PTSD Checklist-Civilian Version (PCL-6), a validated instrument capturing PTSD symptomology, was used to screen Eastern Association for the Surgery of Trauma members. Added questions gauged pandemic effects on professional and hospital systems-level factors. Regression modeling used responses from attending surgeons that fully completed the PCL-6. RESULTS: Complete responses from 334 of 360 attending surgeons were obtained, with 58 of 334 (17%) screening positive for PTSD symptoms. Factors significantly contributing to both higher PCL-6 scores and meeting criteria for PTSD symptomology included decreasing age, increased administrative duties, reduced research productivity, nonurban practice setting, and loss of annual bonuses. Increasing PCL-6 score was also affected by perceived illness risk and higher odds of PTSD symptomology with elective case cancellation. For most respondents, fear of death and concerns of illness from COVID-19 were not associated with increased odds of PTSD symptomology. CONCLUSIONS: The prevalence of PTSD symptomology in this sample was similar to previous reports using surgeon samples (15%-22%). In the face of the COVID-19 pandemic, stress was not directly related to infectious concerns but rather to the collateral challenges caused by the pandemic and unrelated demographic factors. Understanding factors increasing stress in acute care surgeons is critical as part of pandemic planning and management to reduce burnout and maintain a healthy workforce.

Improving Compliance to Follow-Up Care After Primary Emergency Department Ophthalmic Consultation.

PURPOSE: To identify factors that affect the likelihood of follow-up after emergency department (ED) visit for ophthalmic complaints and to evaluate a protocol to improve compliance. DESIGN: Prospective interventional study with historical controls. METHODS: This study was conducted at Jamaica Hospital Medical Center in Jamaica, New York. The study population included 962 patients who presented to the ED and who required ophthalmology consultation. Participants in the control group were given only verbal follow-up instructions. Participants in the intervention group were given verbal instructions, written instructions, telephone calls, and, if not responding to calls, a mailed letter. The primary outcome was the overall follow-up rate. Secondary outcomes were follow-up rate by demographic subgroup. RESULTS: Patients in the intervention group were significantly more likely to follow up (68.8% vs 42.9%, P < .001). Nearly all subgroups exhibited significantly improved follow-up with the intervention, with the exception of patients 18 to 29 years of age, patients with diagnosis severity class III, patients with no insurance, patients with hospital financial aid, patients paying with workers' compensation, and patients with an unknown employment status. CONCLUSIONS: Before the intervention, most patients receiving ophthalmology consultation in the ED did not return for follow-up care. These patients tended to be young, unemployed, uninsured or use hospital financial aid, were in the control group, had good visual acuity, reported no change in vision, and had a condition that was not vision-threatening. Follow-up rates were improved in nearly all subgroups by providing written instructions, telephone calls, and mailed letters. Such instructions should be considered in similar populations.

Metagenomic Sequencing of the Gallbladder Microbiome: Bacterial Diversity Does Not Vary by Surgical Pathology.

INTRODUCTION: Alterations in the microbiome contribute to the pathogenesis of many gastrointestinal diseases. However, the composition of the microbiome in gallbladder disease is not well described. METHODS: We aimed to characterize the biliary microbiome in cholecystectomy patients. Bile and biliary stones were collected at cholecystectomy for a variety of surgical indications between 2017 and 2019. DNA was extracted and metagenomic sequencing was performed with subsequent taxonomic classification using Kraken2. The fraction of bacterial to total DNA reads, relative abundance of bacterial species, and overall species diversity were compared between pathologies and demographics. RESULTS: A total of 74 samples were obtained from 49 patients: 46 bile and 28 stones, with matched pairs from 25 patients. The mean age was 48 years, 76% were female, 29% were Hispanic, and 29% of patients had acute cholecystitis. The most abundant species were Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus pasteurianus. The bacterial fraction in bile and stone samples was higher in acute cholecystitis compared to other non-infectious pathologies (p < 0.05). Neither the diversity nor differential prevalence of specific bacterial species varied significantly between infectious and other non-infectious gallbladder pathologies. Multivariate analysis of the non-infectious group revealed that patients over 40 years of age had increased bacterial fractions (p < 0.05). CONCLUSIONS: Metagenomic sequencing permits characterization of the gallbladder microbiome in cholecystectomy patients. Although a higher prevalence of bacteria was seen in acute cholecystitis, species and diversity were similar regardless of surgical indication. Additional study is required to determine how the microbiome can contribute to the development of symptomatic gallbladder disease.

COVID-19 induced PTSD: Stressors for trauma and acute care surgeons.

BACKGROUND: At the peak of the pandemic, acute care surgeons at many hospitals were reassigned to treat COVID-19 patients. However, the effect of the pandemic on this population who are well versed in stressful practice has not been fully explored. METHODS: A web-based survey was distributed to the members of the Eastern Association for the Surgery of Trauma (EAST). PTSD and the personal and professional impact of the pandemic were assessed. A positive screen was defined as a severity score of ≥14 or a symptomatic response to at least 5 of the 6 questions on the screen. RESULTS: A total of 393 (17.8%) participants responded to the survey. The median age was 43 (IQR: 38-52) and 238 (60.6%) were male. The majority of participants were surgeons (351, 89.3%), specializing in general surgery/trauma (379, 96.4%). The main practice type and setting were hospital-based (350, 89%) and university hospital (238, 60.6%), respectively. The incidence of PTSD was 16.3% when a threshold severity score of ≥14 was used and 5.6% when symptomatic responses were assessed. Risk factors for a positive PTSD screen included being single/unmarried (p = 0.02), having others close to you contract COVID-19 (p = 0.02), having family issues due to COVID-19 (p = 0.0004), rural (p = 0.005) and suburban (p = 0.047) practice settings, a fear of going to work (p = 0.001), and not having mental health resources provided at work (p = 0.03). CONCLUSION: The COVID-19 pandemic had a psychological impact on surgeons. Although acute care surgeons are well versed in stressful practice, the pandemic nevertheless induced PTSD symptoms in this population, suggesting the need for mental health resources.

Prodromal dysfunction of α5GABA-A receptor modulated hippocampal ripples occurs prior to neurodegeneration in the TgF344-AD rat model of Alzheimer's disease.

Decades of research attempting to slow the onset of Alzheimer's disease (AD) indicates that a better understanding of memory will be key to the discovery of effective therapeutic approaches. Here, we ask whether prodromal neural network dysfunction might occur in the hippocampal trisynaptic circuit by using α5IA (an established memory enhancer and selective negative allosteric modulator of extrasynaptic tonically active α5GABA-A receptors) as a probe drug in TgF344-AD transgenic rats, a model for ß-amyloid induced early onset AD. The results demonstrate that orally bioavailable α5IA increases CA1 pyramidal cell mean firing rates during foraging and peak ripple amplitude during wakeful immobility in wild type F344 rats in a familiar environment. We further demonstrate that CA1 ripples in TgF344-AD rats are nonresponsive to α5IA by 9 months of age, prior to the onset of AD-like pathology and memory dysfunction. TgF344-AD rats express human ß-amyloid precursor protein (with the Swedish mutation) and human presenilin-1 (with a Δ exon 9 mutation) and we found high serum Aß42 and Aß40 levels by 3 months of age. When taken together, this demonstrates, to the best of our knowledge, the first evidence for prodromal α5GABA-A receptor dysfunction in the ripple-generating hippocampal trisynaptic circuit of AD-like transgenic rats. As α5GABA-A receptors are found at extrasynaptic and synaptic contacts, we posit that negative modulation of α5GABA-A receptor mediated tonic as well as phasic inhibition augments CA1 ripples and memory consolidation but that this modulatory mechanism is lost at an early stage of AD onset.

Trauma Risk Score Also Predicts Blood Transfusion Requirements in Hip Fracture Patients.

INTRODUCTION: The purpose of this study is to determine if the risk of receiving a blood transfusion during hip fracture hospitalization can be predicted by a validated risk profiling score (Score for Trauma Triage in Geriatric and Middle Aged (STTGMA)). MATERIALS AND METHODS: A consecutive series of 1449 patients 55 years and older admitted for a hip fracture at one academic medical center were identified from a trauma database. The STTGMA risk score was calculated for each patient. Patients were stratified into risk groups based on their STTGMA score quantile: minimal risk (0-50%), low risk (50-80%), moderate risk (80-95%), and high risk (95-100%). Incidence and volume of blood transfusions were compared between risk groups. RESULTS: There were 562 (38.8%) patients who received a transfusion during their admission. 58.3% of patients in the high risk group received a transfusion during admission compared to 31.2% of minimal risk group patients, 42.6% of low risk group patients, and 50.0% of moderate risk group patients (p < 0.001). STTGMA was predictive of first transfusion incidence in both the preoperative and postoperative periods. There was no difference in mean total transfusion volume between the four risk groups. CONCLUSION: The STTGMA model is capable of risk stratifying hip fracture patients more likely to receive blood transfusions during hospitalization. Surgeons can use this tool to anticipate transfusion requirements.

Clinical and non-clinical factors that predict discharge disposition after a fall.

BACKGROUND: Falls can result in injuries that require rehabilitation and long-term care after hospital discharge. Identifying factors that contribute to prediction of discharge disposition is crucial for efficient resource utilization and reducing cost. Several factors may influence discharge location after hospitalization for a fall. The aim of this study was to examine clinical and non-clinical factors that may predict discharge disposition after a fall. We hypothesized that age, injury type, insurance type, and functional status would affect discharge location. METHODS: This two-year retrospective study was performed at an urban, adult level-1 trauma center. Fall patients who were discharged home or to a facility after hospital admission were included in the study. Data was obtained from the trauma registry and electronic medical records. Logistic regression modeling was used to assess independent predictors. RESULTS: A total of 1,121 fallers were included in the study. 621 (55.4%) were discharged home and 500 (44.6%) to inpatient rehabilitation (IRF)/skilled nursing facility (SNF). The median age was 64 years (IQR: 49-79) and 48.4% (543) were male. The median length of hospital stay was 5 days (IQR: 2.5-8). Increasing age (p < 0.001), length of stay in the ICU (p < 0.001), injury severity (p < 0.001), number of comorbidities (p = 0.038), having Medicare insurance (p = 0.025), having a fracture at any body region (p < 0.001), and ambulation status (p = 0.025) significantly increased the odds of being discharged to IRF/SNF compared to home. The removal of injury severity score and ICU length of stay from the "late/regular discharge" model, to create an "early discharge" model, decreased the accuracy of the prediction rate from 78.5% to 74.9% (p < 0.001). CONCLUSION: A combination of demographic, clinical, social, economic, and functional factors can together predict discharge disposition after a fall. The majority of these factors can be assessed early in the hospital stay, which may facilitate a timely discharge plan and shorter stays in the hospital.

Variability in CT imaging of blunt trauma among ED physicians, surgical residents, and trauma surgeons.

BACKGROUND: Trauma triage decisions can be influenced by both knowledge and experience. Consequently, there may be substantial variability in computed tomography (CT) scans desired by emergency medicine physicians, surgical chief residents, and attending trauma surgeons. We quantified this difference and studied the effects of each group's decisions on missed injuries, cost, and radiation exposure. METHODS: All blunt trauma activations at an urban level 1 trauma center were studied over a 6-mo period. Three months into the study, a pan-scan protocol was introduced. Prior to CT imaging, providers separately completed a survey that asked which CT scans were desired for each patient. Based on the completed surveys, hypothetical missed injuries, radiation exposure, and cost were determined. RESULTS: The variability in the number of CT scans desired by each of the three providers and the resulting cost and radiation exposure were not statistically significant. Substantial variability was predominantly seen in the indications for the desired scans, with the difference between proportions ranging from 3.1%-68.7%. Agreement among the three providers was highest for head and c-spine scans (80%-100%) and lowest for maxillary face (57%-80%) and chest scans (52%-74%). Overall, the missed injury rate was similar for all the providers; chief residents missed significantly more major injuries than trauma attendings during the pan-scan period (P = 0.03). CONCLUSIONS: Trauma training and level of training did not have a substantial effect on radiological decisions during the initial trauma assessment. This study sheds light on the growing uniformity among providers with regard to medical decision-making in the initial work-up of trauma.

Primary Pure Squamous Cell Carcinoma of the Gallbladder Locally Invading the Liver, Duodenum, and Stomach: A Case Report and Literature Review.

Primary pure squamous cell carcinoma (SCC) of the gallbladder is an exceptionally rare type of tumor that comprises only 1% of all gallbladder cancer. SCC of the gallbladder portends a worse prognosis than the more common adenocarcinoma variant because of its aggressive invasion to local structures and because it is often diagnosed at an advanced stage. Owing to its rarity, diagnosis and management can be challenging. Herein, we present the case of a 75-year-old female complaining of abdominal pain, nausea, and vomiting. Computed tomography and ultrasonography results of the abdomen were consistent with acute cholecystitis and cholelithiasis. Histologic evaluation of the resected mass revealed a malignant tumor with prominent keratinization, confirming the diagnosis of an invasive primary pure SCC of the gallbladder. Microscopic examination showed direct infiltration to the liver, duodenum, and stomach. This case report describes the hospital course of a patient with SCC of the gallbladder and suggests that gallbladder cancer should be considered as part of the differential diagnosis in elderly patients presenting with acute cholecystitis. In addition, this article will review existing literature to examine the utility of different diagnostic techniques and treatment modalities available in the management of gallbladder cancer.

Cervical spine immobilization may be of value following firearm injury to the head and neck.

BACKGROUND: Penetrating injuries to the head and neck may not be able to cause unstable fractures without concomitant spinal cord injury, rendering prehospital spinal immobilization (PHSI) ineffectual, and possibly harmful. However, this premise is based on reports including predominantly chest and abdominal injuries, which are unlikely to cause cervical spine (CS) injuries. METHODS: We performed a retrospective review of all patients presenting with a penetrating wound to the head or neck over a 4-year period at an urban, level 1 trauma center to determine if there was a benefit of PHSI. RESULTS: One hundred seventy-two patients were identified, of which 16 (9.3%) died prior to CS evaluation. Of 156 surviving patients, mechanism was gunshot wound (GSW) in 36 (28%) and stab wound (SW) in 120 (72%). Fifty-eight patients had PHSI placed (37%), and GSW patients' odds of having PHSI were greater than SW patients (OR 2.3; CI 1.08-4.9). Eight of 156 surviving patients eventually died (5.1%), and the odds of mortality were greater among those that had PHSI than those without (OR 5.54; CI 1.08-28.4). Six (3.8%; 5 GSW, 1 SW) patients had a CS fracture. Two GSW patients (5.6%) had unstable CS fractures with a normal neurological exam at initial evaluation. CONCLUSIONS: Of patients with a GSW to the head or neck that survived to be evaluated, 5.6% had unstable fractures without an initial neurologic deficit. PHSI may be appropriate in this population. Further studies are warranted prior to a determination that PHSI is unnecessary in penetrating head and neck injuries.

Massive Hemothorax Caused by a Single Intercostal Artery Bleed Ten Days after Solitary Minimally Displaced Rib Fracture.

Delayed hemothorax (DHX) following blunt thoracic trauma is a rare occurrence with an extremely variable incidence and time to diagnosis that is generally associated with clinically insignificant blood loss. In this report, we present a case of acute onset DHX ten days after a relatively mild traumatic event that resulted in a single minimally displaced rib fracture. The patient awoke from sleep suddenly with acute onset dyspnea and chest pain and reported to the emergency department (ED). The patient lost over six and a half liters of blood during the first 9 hours of his admission, the largest volume yet reported in the literature for DHX, which was eventually found to be due to a single intercostal artery bleed. Successful management in this case entailed two emergent thoracotomies and placement of multiple thoracostomy tubes to control blood loss. The patient was discharged home on postoperative day 5.

Blunt trauma resulting in pneumothorax with progression to pneumoperitoneum: a unique diagnosis with predicament in management.

Here, we present a case of pneumoperitoneum caused by traumatic pneumothorax after a fall. The patient is an 82-year-old male who was brought into the emergency department after being found at the bottom of a flight of stairs with a bleeding scalp laceration. Upon presentation, the patient underwent emergent intubation followed by tube thoracostomy placement, had necessary imaging and was transferred to the surgical intensive care unit (SICU). Imaging revealed signs of pneumomediastinum and pneumoperitoneum in addition to the partially resolved pneumothorax. In the SICU, the patient became hemodynamically unstable requiring vasopressor support, which in the face of documented pneumoperitoneum without a clear cause mandated exploration. He was taken to the operating room for suspected viscus perforation, though none was found after extensively searching during an exploratory laparotomy. We suspect the patient developed pneumomediastinum and pneumoperitoneum as a result of traumatic pneumothorax, hastened by his subsequent intubation and mechanical ventilation.

Aneurysmal Rupture of a Mesodiverticular Band to a Meckel's Diverticulum.

Aneurysmal rupture of a mesodiverticular band has not previously been reported in the clinical literature. We are reporting a case of hemoperitoneum in a 51-year-old male after an aneurysmal rupture of a mesodiverticular band. This case demonstrates that in rare instances, a rupture of the mesodiverticular band leading to Meckel's diverticulum can lead to significant hemoperitoneum. This is usually caused by a traumatic injury but in our case was apparently caused by an aneurysm of the mesodiverticular artery. Patients with known Meckel's diverticula should be aware of the possibility of rupture, as should clinicians treating those with a history of this usually benign congenital abnormality. Rapid surgical intervention is necessary to repair the source of bleeding, as massive blood loss was encountered in this case.

Place cell activation predicts subsequent memory.

A major quandary in memory research is how hippocampal place cells, widely recognized as elements of a spatial map, contribute to episodic memory, our capacity to remember unique experiences that depends on hippocampal function. Here we recorded from hippocampal neurons as rats performed a T-maze alternation task in which they were required to remember a preceding experience over a delay in order to make a subsequent spatial choice. As it has been reported previously in other variations of this task, we observed differential firing that predicted correct subsequent choices, even as the animal traversed identical locations prior to the choice. Here we also observed that most place cells also fired differently on correct as compared to error trials. Among these cells, a large majority fired strongly before the delay or during the retrieval phase but were less active or failed to activate when the animal subsequently made an error. These findings join the place cell phenomenon with episodic memory performance dependent on the hippocampus, revealing that memory accuracy can be predicted by the activation of single place cells in the hippocampus.

Olfactory memory: a bridge between humans and animals in models of cognitive aging.

Odor-recognition memory in rodents may provide a valuable model of cognitive aging. In a recent study we used signal detection analyses to distinguish odor recognition based on recollection versus that based on familiarity. Aged rats were selectively impaired in recollection, with relative sparing of familiarity, and the deficits in recollection were correlated with spatial memory impairments. These results complement electrophysiological findings indicating age-associated deficits in the ability of hippocampal neurons to differentiate contextual information, and this information-processing impairment may underlie the common age-associated decline in olfactory and spatial memory.

Cognitive aging: a common decline of episodic recollection and spatial memory in rats.

In humans, recognition memory declines with aging, and this impairment is characterized by a selective loss in recollection of previously studied items contrasted with relative sparing of familiarity for items in the study list. Rodent models of cognitive aging have focused on water maze learning and have demonstrated an age-associated loss in spatial, but not cued memory. The current study examined odor recognition memory in young and aged rats and compared performance in recognition with that in water maze learning. In the recognition task, young rats used both recollection and familiarity. In contrast, the aged rats showed a selective loss of recollection and relative sparing of familiarity, similar to the effects of hippocampal damage. Furthermore, performance on the recall component, but not the familiarity component, of recognition was correlated with spatial memory and recollection was poorer in aged rats that were also impaired in spatial memory. These results extend the pattern of impairment in recollection and relative sparing of familiarity observed in human cognitive aging to rats, and suggest a common age-related impairment in both spatial learning and the recollective component of nonspatial recognition memory.