Computed tomography benefits and cost in hemodynamically stable patients with blunt abdominal trauma at an Egyptian University Hospital.

Background: Trauma is a significant cause of mortality, especially among individuals aged between 15 and 44 years, with a substantial burden falling on economically active populations. Low- and middle-income countries (LMICs) bear the burden of trauma-related deaths, accounting for over 90 % globally. In Egypt, trauma rates are increasing, primarily due to road traffic crashes (RTC), affecting males disproportionately. Blunt abdominal trauma, often caused by RTC, can lead to missed intra-abdominal injuries (IAIs) due to atypical symptoms. Computed Tomography (CT) offers high sensitivity and specificity in detecting IAIs, but concerns about cost and radiation exposure exist. Methodology: This study investigates the roles of Focused Assessment with Sonography for Trauma (FAST) and CT in managing blunt abdominal trauma. A retrospective cohort study was conducted on hemodynamically stable patients. Data included patient demographics, trauma details, healthcare decisions, costs, and outcomes. Results: Computed tomography significantly reduced unnecessary laparotomies (12.3% vs. 24.8 %, p = 0.001), shortened hospital stays (4.83±0.71 days vs. 6.15±1.28 days, p = 0.005), and reduced ICU admissions (8 vs. 32, p = 0.023) compared to FAST alone. Overall costs were lower in the CT & FAST Group ($2055.95 vs. $3488.7, p = 0.0001), with no significant difference in missed IAIs. Conclusion: This study highlights the limitations of relying solely on FAST for IAIs and underscores the value of CT in guiding healthcare decisions. Incorporating CT led to reduced negative laparotomies, shorter hospital stays, and fewer ICU admissions. While CT incurs initial costs, its long-term benefits outweigh expenditures, particularly in LMICs. This study provides insights into optimizing diagnostic approaches for blunt abdominal trauma in low-resource settings.

Combination of Focused Assessment With Sonography for Trauma (FAST) Scan and Detection of Hematuria to Exclude Intra-abdominal Injuries Following Blunt Abdominal Trauma.

Background Blunt abdominal trauma (BAT) is the most common pattern of abdominal traumas. It may be associated with intra-abdominal injuries (IAIs). Exploratory laparotomies are only needed in a minority of patients after BAT. Methodology All BAT patients who presented to the El Demerdash Hospital of Ain Shams University, Cairo, Egypt during the study period were traced. Parameters including demographic data, focused assessment with sonography for trauma (FAST) scan, CT scan results, and hematuria were collected. The cohort was divided according to the CT scan results into two groups: patients with IAIs and patients without IAIs. Results Males represented 78.2% of the patients, and the mean age of the recruited patients was 32.1 ± 18 years. Road traffic accidents represented the main cause of trauma (58%). Patients with IAIs detected by CT scan represented 1.62%, and hematuria was detected in 88.9% of them. The specificity of FAST was 97.1%, and that of hematuria was 84.1%, and for the combination of both tests, the specificity was 99.3%. Conclusion IAIs after BAT can usually be excluded if both FAST and hematuria are negative, provided that the patient is stable.

Psychiatric Disorders and Genotoxicity Following Primary Metal on Polyethylene Total Hip Arthroplasty and Their Correlation to Cobalt/Chromium Levels.

Introduction: Hip arthroplasty (HA) using implantable metal components is among the commonest orthopedic interventions. However, it can be followed by several complications following corrosion and the release of metal ions. Several studies proved that damaged genomic DNA may contribute to the pathophysiology of mental disorders. Aim: The current work aims to evaluate the psychiatric disorders in metal on polyethylene hip arthroplasty (MOP-HA) patients and its correlation to cobalt/chromium (Co/Cr) levels and genotoxicity. Methods: The work was a longitudinal follow-up study including 34 adults with unilateral primary MOP-HA meeting the inclusion and exclusion criteria. Preoperatively, 6, 12-months-postoperatively, patients were examined for cognitive impairment using mini-mental-state-examination (MMSE), depression using major-depressive-inventory (MDI), and blood samples were collected for estimation of Co/Cr, detection of genotoxicity by single-cell-gel-electrophoresis (comet assay) and serum 8-hydroxy-2'-deoxyguanosine (8-OHdG). Results: Cognitive impairment was reported in 18.5% and 14.8% at 6-months, and 12-months postoperative, respectively. Depressive disorder was recorded in 22.2% at 6-months and 14.8% at 12-months postoperative. The marginal homogeneity tests proved a non-significant difference. There was a non-significant difference in preoperative, 6-months, 12-months postoperative MMSE, and MDI scores. There were significantly increased Co/Cr levels at 6-months postoperative. The levels decreased at 12-months postoperative, however, still significantly higher than preoperative values. There was a significant increase in serum 8-OHdG and the levels were positively correlated to cobalt levels at both 6 and 12-months-postoperative. There was a non-significant difference among preoperative, 6-months, and 12-months postoperative comet assay measurements. Conclusion: From previous findings, we can conclude that will-functioning MOP hip arthroplasty can induce increased ion levels and positively correlated increase in biochemical markers of genotoxicity (8-OHdG).

Impact of Health Policy Changes on Emergency Medicine in Maryland Stratified by Socioeconomic Status.

INTRODUCTION: On January 1, 2014, the financing and delivery of healthcare in the state of Maryland (MD) profoundly changed. The insurance provisions of the Patient Protection and Affordable Care Act (ACA) began implementation and a major revision of MD's Medicare waiver ushered in a Global Budget Revenue (GBR) structure for hospital reimbursement. Our objective was to analyze the impact of these policy changes on emergency department (ED) utilization, hospitalization practices, insurance profiles, and professional revenue. We stratified our analysis by the socioeconomic status (SES) of the ED patient population. METHODS: We collected monthly mean data including patient volume, hospitalization percentages, payer mix, and professional revenue from January 2013 through December 2015 from a convenience sample of 11 EDs in Maryland. Using regression models, we compared each of the variables 18 months after the policy changes and a six-month washout period to the year prior to ACA/GBR implementation. We included the median income of each ED's patient population as an explanatory variable and stratified our results by SES. RESULTS: Our 11 EDs saw an annualized volume of 399,310 patient visits during the study period. This ranged from a mean of 41 daily visits in the lowest volume rural ED to 171 in the highest volume suburban ED. After ACA/GBR, ED volumes were unchanged (95% confidence interval [CI] [-1.58-1.24], p=.817). Hospitalization percentages decreased significantly by 1.9% from 17.2% to 15.3% (95% CI [-2.47%-1.38%], p<.001). The percentage of uninsured patients decreased from 20.4% to 11.9%. This 8.5% change was significant (95% CI [-9.20%-7.80%], p<.001). The professional revenue per relative value unit increased significantly by $3.97 (95% CI [3.20-4.74], p<.001). When stratified by the median patient income of each ED, changes in each outcome were significantly more pronounced in EDs of lower SES. CONCLUSION: Health policy changes at the federal and state levels have resulted in significant changes to emergency medicine practice and finances in MD. Admission and observation percentages have been reduced, fewer patients are uninsured, and professional revenue has increased. All changes are significantly more pronounced in EDs with patients of lower SES.

Helicopter emergency medical services for adults with major trauma.

BACKGROUND: Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured people derive the greatest benefit. OBJECTIVES: To determine if helicopter emergency medical services (HEMS) transport, compared with ground emergency medical services (GEMS) transport, is associated with improved morbidity and mortality for adults with major trauma. SEARCH METHODS: We ran the most recent search on 29 April 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE (OvidSP), EMBASE Classic + EMBASE (OvidSP), CINAHL Plus (EBSCOhost), four other sources, and clinical trials registers. We screened reference lists. SELECTION CRITERIA: Eligible trials included randomized controlled trials (RCTs) and nonrandomized intervention studies. We also evaluated nonrandomized studies (NRS), including controlled trials and cohort studies. Each study was required to have a GEMS comparison group. An Injury Severity Score (ISS) of at least 15 or an equivalent marker for injury severity was required. We included adults age 16 years or older. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and assessed the risk of bias of included studies. We applied the Downs and Black quality assessment tool for NRS. We analyzed the results in a narrative review, and with studies grouped by methodology and injury type. We constructed 'Summary of findings' tables in accordance with the GRADE Working Group criteria. MAIN RESULTS: This review includes 38 studies, of which 34 studies examined survival following transportation by HEMS compared with GEMS for adults with major trauma. Four studies were of inter-facility transfer to a higher level trauma center by HEMS compared with GEMS. All studies were NRS; we found no RCTs. The primary outcome was survival at hospital discharge. We calculated unadjusted mortality using data from 282,258 people from 28 of the 38 studies included in the primary analysis. Overall, there was considerable heterogeneity and we could not determine an accurate estimate of overall effect.Based on the unadjusted mortality data from six trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS. Twenty-one studies used multivariate regression to adjust for confounding. Results varied, some studies found a benefit of HEMS while others did not. Trauma-Related Injury Severity Score (TRISS)-based analysis methods were used in 14 studies; studies showed survival benefits in both the HEMS and GEMS groups as compared with MTOS. We found no studies evaluating the secondary outcome, morbidity, as assessed by quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Four studies suggested a small to moderate benefit when HEMS was used to transfer people to higher level trauma centers. Road traffic and helicopter crashes are adverse effects which can occur with either method of transport. Data regarding safety were not available in any of the included studies. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria. AUTHORS' CONCLUSIONS: Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

Depressive symptoms and hospital readmission in older adults.

OBJECTIVES: To quantify the risk of 30-day unplanned hospital readmission in adults aged 65 and older with depressive symptoms. DESIGN: Prospective cohort study. SETTING: University of Maryland Medical Center. PARTICIPANTS: Individuals aged 65 and older admitted between July 1, 2011, and August 9, 2012, to the general medical and surgical units and followed for 31 days after hospital discharge (N = 750). MEASUREMENTS: Primary exposure was depressive symptoms at admission, defined as a score of 6 or more on the 15-item Geriatric Depression Scale. Primary outcome was unplanned 30-day hospital readmission, defined as an unscheduled overnight stay at any inpatient facility not occurring in the emergency department. RESULTS: Prevalence of depressive symptoms was 19% and incidence of 30-day unplanned hospital readmission was 19%. Depressive symptoms were not significantly associated with hospital readmission (relative risk (RR) = 1.20, 95% confidence interval (CI) = 0.83-1.72). Age, Charlson Comorbidity Index score, and number of hospitalizations within the past 6 months were significant predictors of unplanned 30-day hospital readmission. CONCLUSION: Although not associated with hospital readmission, depressive symptoms were associated with other poor outcomes and may be underdiagnosed in hospitalized older adults. Hospitals interested in reducing readmission should focus on older adults with more comorbid illness and recent hospitalizations.

Propofol for procedural sedation and analgesia reduced dedicated emergency nursing time while maintaining safety in a community emergency department.

INTRODUCTION: Procedural sedation and analgesia is a core competency in emergency medicine. Propofol is replacing midazolam in many emergency departments. Barriers to performing procedural sedation include resource utilization. We hypothesized that emergency nursing time is shorter with propofol than midazolam, without increasing complications. METHODS: Retrospective analysis of a procedural sedation registry for two community emergency departments with combined census of 100,000 patients/year. Demographics, procedure, and ASA physical classification status of adult patients receiving procedural sedation between 2007-2010 with midazolam or propofol were analyzed. Primary outcome was dedicated emergency nursing time. Secondary outcomes were procedural success, ED length of stay, and complication rate. Comparative statistics were performed with Mann-Whitney, Kruskal-Wallis, chi-square, or Fisher's exact test. Linear regression was performed with log-transformed procedural sedation time to define predictors. RESULTS: Of 328 procedural sedation and analgesia, 316 met inclusion criteria, of which 60 received midazolam and 256 propofol. Sex distribution varied between groups (midazolam 3% male; propofol 55% male; P = 0.04). Age, procedure, and ASA status were not significantly different. Propofol had shorter procedural sedation time (propofol 32.5 ± 24.2 minutes; midazolam 78.7 ± 51.5 minutes; P < 0.001) and higher rates of procedural success (propofol 98%; midazolam 92%; P = 0.02). There were no significant differences between complication rates (propofol 14%; midazolam 13%; P = 0.88) or emergency department length of stay (propofol 262.5 ± 132.8 minutes; midazolam 288.6 ± 130.6 minutes; P = 0.09). DISCUSSION: Use of propofol resulted in shorter emergency nursing time and higher procedural success rate than midazolam with a comparable safety profile.

Helicopter emergency medical services for adults with major trauma.

BACKGROUND: Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured patients derive the greatest benefit. OBJECTIVES: The purpose of this review is to determine if helicopter emergency medical services transport (HEMS) is associated with improved morbidity and mortality, compared to ground emergency medical services transport (GEMS), for adults with major trauma. The primary outcome was survival to hospital discharge. Secondary outcomes were quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). SEARCH METHODS: Searches were run in CENTRAL, MEDLINE, EMBASE, CINAHL (EBSCOhost), SCI-EXPANDED, CPCI-S, and ZETOC in January 2012. Relevant websites were also searched, including controlled trials registers, HSRProj, the World Health Organization (WHO) ICTRP, and OpenSIGLE. Searches were not restricted by date, language, or publication status. Attempts were made to contact authors in the case of missing data. SELECTION CRITERIA: Eligible trials included randomised controlled trials (RCTs) and non-randomised intervention studies. Non-randomised studies (NRS), including controlled trials and cohort studies, were also evaluated. Each study was required to have a GEMS comparison group. An injury severity score (ISS) > 15 or an equivalent marker for injury severity was required. Only adults aged 16 years or older were included. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data and assessed the risk of bias of included studies. The Downs and Black quality assessment tool was applied for NRS. The results were analysed in a narrative review, and with studies grouped by methodology and injury type. A predefined subgroup was comprised of four additional studies that examined the role of HEMS versus GEMS for inter-facility transfer. Summary of findings tables were constructed in accordance with the GRADE Working Group criteria. MAIN RESULTS: Twenty-five studies met the entry criteria for this review. Four additional studies met the criteria for a separate, predefined subgroup analysis of patients transferred to trauma centres by HEMS or GEMS. All studies were non-randomised studies; no RCTs were found. Survival at hospital discharge was the primary outcome. Data from 163,748 people from 21 of the 25 studies included in the primary analysis were available to calculate unadjusted mortality. Overall, considerable heterogeneity was observed and an accurate estimate of overall effect could not be determined. Based on the unadjusted mortality data from five trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS (relative risk (RR) 1.02; 95% CI 0.85 to 1.23). Nine studies used multivariate regression to adjust for confounding, the five largest indicated a statistically significant increased odds of survival associated with HEMS. All Trauma-Related Injury Severity Score (TRISS)-based studies indicated improved survival in the HEMS group as compared to the Major Trauma Outcomes Study (MTOS) cohort; some studies showed survival benefits in both the HEMS and GEMS groups as compared to MTOS. No studies were found to evaluate the secondary outcome of morbidity as assessed by QALYs and DALYs. All four studies suggested a positive benefit when HEMS was used to transfer patients to higher level trauma centres. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria. AUTHORS' CONCLUSIONS: Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, an accurate composite estimate of the benefit of HEMS could not be determined. Although five of the nine multivariate regression studies indicated improved survival associated with HEMS, the remainder did not. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their non-randomised design. Similarly, TRISS-based studies, which all demonstrated improved survival, cannot be considered strong evidence because of their methodology, which did not randomize the use of HEMS. The question of which elements of HEMS may be beneficial for patients has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximise the potential utility of results. Large, multicentre studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.