Common Injuries Associated with Falls from Tree Stands in Iowa.

INTRODUCTION: Tree stand falls are a common injury among hunters. This study was designed to identify specific injury patterns and local and regional factors affecting access to and care for this unique trauma cohort in Iowa. METHODS: The University of Iowa trauma registry was retrospectively queried from 2004 to 2014 for patients with a mechanism of injury of fall from tree stands. Data are presented as mean±SD, median, and range, or raw number and percentages as appropriate. Correlation analyses were performed using the Spearman coefficient. RESULTS: Fifty-three patients were identified. Age was 44±14 (17-78) y. Median fall height was 4.6 m (15 ft), ranging from 1.5 to 12 m (5 to 40 ft). Transport times varied from <1 h to >7 h. Hypothermia was observed in 6 patients (11%). Two patients (4%) tested positive for alcohol. Three patients (6%) tested positive for drugs. Soft tissue injuries (32 [60%]; ie, lacerations and abrasions) were the most common, followed by 30 spine fractures (57%, including 11 lumbar and 10 thoracic fractures), 16 other bone fractures (30%), and 11 rib fractures (21%). Twenty-two patients underwent surgery. Median hospital length of stay was 4 d, ranging from 0 to 20 d. CONCLUSIONS: Tree stand falls lead to significant injuries. Hypothermia represents a significant risk for these patients, and remote location resulted in long transportation time. Improper use or poor condition of safety equipment contributed to falls and injuries in a few of our patients.

Entertainment education for breast cancer surgery decisions: a randomized trial among patients with low health literacy.

OBJECTIVE: To evaluate an entertainment-based patient decision aid for early stage breast cancer surgery in low health literacy patients. METHODS: Newly diagnosed female patients with early stage breast cancer from two public hospitals were randomized to receive an entertainment-based decision aid for breast cancer treatment along with usual care (intervention arm) or to receive usual care only (control arm). Pre-decision (baseline), pre-surgery, and 1-year follow-up assessments were conducted. RESULTS: Patients assigned to the intervention arm of the study were more likely than the controls to choose mastectomy rather than breast-conserving surgery; however, they appeared better informed and clearer about their surgical options than women assigned to the control group. No differences in satisfaction with the surgical decision or the decision-making process were observed between the patients who viewed the intervention and those assigned to the control group. CONCLUSIONS: Entertainment education may be a desirable strategy for informing lower health literate women about breast cancer surgery options. PRACTICE IMPLICATIONS: Incorporating patient decision aids, particularly computer-based decision aids, into standard clinical practice remains a challenge; however, patients may be directed to view programs at home or at public locations (e.g., libraries, community centers).

Preliminary testing of a just-in-time, user-defined values clarification exercise to aid lower literate women in making informed breast cancer treatment decisions.

OBJECTIVE: To report on the initial testing of a values clarification exercise utilizing a jewellery box within a computerized patient decision aid (CPtDA) designed to assist women in making a surgical breast cancer treatment decision. DESIGN: Pre-post design, with patients interviewed after diagnosis, and then after completing the CPtDA sometime later at their preoperative visit. SAMPLE: Fifty-one female patients, who are low literate and naïve computer users, newly diagnosed with early stage breast cancer from two urban public hospitals. INTERVENTION: A computerized decision aid that combines entertainment-education (edutainment) with enhanced (factual) content. An interactive jewellery box is featured to assist women in: (1) recording and reflecting over issues of concern with possible treatments, (2) deliberating over surgery decision, and (3) communicating with physician and significant others. OUTCOMES: Patients' use of the jewellery box to store issues during completion of the CPtDA, and perceived clarity of values in making a treatment decision, as measured by a low literacy version of the Decisional Conflict Scale (DCS). RESULTS: Over half of the participants utilized the jewellery box to store issues they found concerning about the treatments. On average, users flagged over 13 issues of concern with the treatments. Scores on the DCS Uncertainty and Feeling Unclear about Values subscales were lower after the intervention compared to before the decision was made. CONCLUSIONS: A values clarification exercise using an interactive jewellery box may be a promising method for promoting informed treatment decision making by low literacy breast cancer patients.

Early aggressive closure of the open abdomen.

BACKGROUND: The aim of this series is to describe a new and aggressive approach to definitive closure of the open abdomen. METHODS: A retrospective review of 37 patients who underwent definitive abdominal closure using a combination of vacuum pack, vacuum-assisted wound management and human acellular dermal matrix (HADM). RESULTS: All patients' open abdomens were maintained with vacuum assisted wound management in attempts for primary closure. Once it was determined that the abdomen would not close primarily; it was closed with HADM and skin advancement. The mean duration of the open abdomen was 21.7 days (range 6-45), with an average of 127.78 cm of HADM, the largest number being 800 cm, with decreasing use of product later in the series. No major complications were seen with the repair. Superficial wound infection occurred with two patients that were easily treated with wet to dry dressing changes. No intraabdominal complications such as fistula or graft loss were seen. All patients left the hospital with an intact abdominal wall and skin. All 37 patients survived to discharge and were seen in follow-up within one month. No early hernia formation was seen at the one month follow up with the longest at three years. No abdominal wall complications were seen in subsequent follow up patients. CONCLUSIONS: Early aggressive closure of the open abdomen is possible with a combination of vacuum pack, vacuum-assisted wound management and HADM. Short term results are promising and warrant further study.

Patterns of microbiology in intra-abdominal packing for trauma.

INTRODUCTION: This study tracks the microbiology of packs and infections in damage-control trauma patients to determine whether the packs cause infections. METHODS: The peritoneum and abdominal packs were cultured in patients who survived to re-operation. The study recorded all positive cultures, pack count, packing duration, number of operations, and infections. RESULTS: Thirty-five patients were studied. Twenty-eight patients survived; seven died. Packs were cultured in 29 patients. Data for 291 cultures collected. Pack cultures were positive in 20 patients and negative in nine. Positive pack cultures grew skin and gut flora. Twenty-one patients had infections, 14 did not. Organisms from positive pack cultures did not contribute to subsequent infections or mortality. Microbes and sites of infections were consistent with SICU patients. CONCLUSIONS: Intra-abdominal packs are contaminated with skin and gut flora. These contaminants, however, do not contribute to subsequent infections. Pathogens from subsequent infections were typical for ICU infections.

Intraoperative detection of traumatic coagulopathy using the activated coagulation time.

Traumatic coagulopathy manifests as a hypocoagulable state associated with hypothermia, acidosis, and coagulation factor dilution. The diagnosis must be made clinically because traditional coagulation tests are neither sensitive nor specific and take too long to be used for intraoperative monitoring. We hypothesized that the activated coagulation time (ACT) would reflect the global coagulation status of traumatized patients and would become elevated as coagulation reserves become exhausted. A prospective protocol was used to study 31 victims of major trauma who underwent immediate surgical Intervention. Victims of major head trauma were excluded and patients were selected at random over an 8-month period. At least two serial intraoperative blood samples were obtained at 15-min intervals via indwelling arterial catheters. A Hemochron model 801 coagulation monitor was used to measure the ACT. Of the 31 patients studied, 7 became clinically coagulopathic and 24 did not. The ACT measurements of coagulopathic and noncoagulopathic trauma patients were significantly different by multiple statistical comparisons. Both groups differed from normal, nontraumatized patients. The coagulopathic trauma patients had significantly elevated values when compared with other trauma patients or to normal values. We conclude that a low ACT reflects the initial hypercoagulability associated with major trauma and an elevated ACT is an objective indicator that the coagulation system reserve is near exhaustion. An elevated ACT may represent an indication for considering damage control maneuvers or more aggressive resuscitation.