Helmet Usage Reduces Serious Head Injury Without Decreasing Concussion After Bicycle Riders Crash.

BACKGROUND: The importance of bicycle helmets in reducing injuries is unclear. Our center receives a disproportionate number of bicycle crash victims. We sought to evaluate the types of injuries observed and the role of helmets in reducing head injuries. MATERIALS AND METHODS: We evaluated demographic data and compared injuries between bicycle riders that crashed with and without helmets over a 9-year period. Categorical variables were compared using linear regression methods and nominal variables using ANOVA. Differences were considered significant for P ≤ 0.05. RESULTS: There were 906 patients evaluated, 701 with helmets (77%) and 205 (23%) without helmets. The mean Injury Severity Score was 9.3 ± 6.4. The most common injuries were concussion (n = 385), rib fractures (n = 154), clavicle fractures (n = 139), facial fractures (n = 102), and cervical spine fractures (n = 89). There was no significant difference in the number of patients with a concussion in riders with or without helmets, [299/701, 42.6% versus 86/205, 42.0%, respectively, (P = NS)]. In helmet versus no helmet riders, there were significantly fewer patients with facial fractures, [67/701, 9.5%, versus 35/205, 17.0%, respectively, (P = 0.003)], skull fractures [8/701, 1.1% versus 9/205, 4.4%, respectively, (P = 0.003)], and serious head injuries [6/701, 0.85% versus 8/205, 3.9%, respectively, (P = 0.002)]. CONCLUSIONS: Helmeted patients involved in bicycle crashes are less likely to sustain a serious head injury, a skull fracture, or facial fractures compared to riders without helmets. The most common injury in patients with a bicycle crash is a concussion. Helmets did not prevent concussion after bicycle rider's crash in our patient population.

New and Emerging Tobacco Products and the Nicotine Endgame: The Role of Robust Regulation and Comprehensive Tobacco Control and Prevention: A Presidential Advisory From the American Heart Association.

The advent of new tobacco products such as electronic cigarettes and the dramatic rise in their use, especially by adolescents and young adults, are significant public health concerns. Electronic cigarettes have become the most popular tobacco products for youth and adolescents in the United States and are attracting youth to new avenues for nicotine addiction. Although these products may have benefit by helping some smokers quit or to move to a less harmful product, the long-term health effects of these products and the net public health effect associated with their use remain unclear and widely debated. There is increasing concern that the use of newer tobacco products may catalyze transition to the use of other tobacco products or recreational drugs, particularly in young adults. Therefore, there is urgent need for robust US Food and Drug Administration regulation of all tobacco products to avoid the significant economic and population health consequences of continued tobacco use. Although the American Heart Association acknowledges that the ultimate endgame would be an end to all tobacco and nicotine addiction in the United States, it supports first minimizing the use of all combustible tobacco products while ensuring that other products do not addict the next generation of youth and adolescents. The endgame strategy needs to be coordinated with the long-standing, evidence-based tobacco control strategies that have significantly reduced tobacco use and initiation in the United States.

Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation.

Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.

Prevent the Bleed: How Surgeons Can Lead the National Conversation About Firearm Safety Forward.

: In the 5 years since the Sandy Hook elementary school shooting that claimed the lives of 20 children and 6 of their teachers, we have witnessed intolerably more mass shooting events. In the intervening years, over 150,000 Americans have died because of firearm violence, 3 times the number who lost their lives during the Revolutionary war. In the last 2 months, we have been left reflecting on 2 more tragedies. The first came on October 1 in Las Vegas, at the Route 91 music festival where 58 were killed and over 500 injured by a single gunman. The second, on November 5, took place in Sutherland Springs, Texas (population 600) near San Antonio and claimed the lives of 26 men women and children while they prayed. As was witnessed in Orlando and San Bernardino, these most recent mass casualty incidents strained first responders, law enforcement, and the state's trauma systems to their breaking point.Once again, we were left searching for the reasons behind these tragedies asking predictable questions: who did this and why? Was it part of a terrorist plot or a lone psychopath with a grudge? Were the weapons obtained legally, and why would anyone need so many? How can we stop this from happening again?

Taxing Soda: Strategies for Dealing with the Obesity and Diabetes Epidemic.

Over the past several decades, the United States has been experiencing a twin epidemic of obesity and type 2 diabetes. Recently, advocacy efforts to tax sugary drinks, place warning labels on soda, improve nutritional labeling, and reduce sugar overconsumption have swept across the nation to address public health concerns from sugary drinks that strain our nation's health-care resources. In this article, the historical and scientific framework of this public health policy and valuable lessons learned from implementation efforts thus far will be examined to shape the next steps forward for the movement. Additional goals of this article are to share a surgeon's perspective about trends in bariatric surgery and the link between obesity and type 2 diabetes as a result of peripheral insulin resistance.

Patients recovering from abdominal surgery who walked with volunteers had improved postoperative recovery profiles during their hospitalization.

BACKGROUND: Early walking as part of a perioperative care program benefits patients who have had surgery. However, the impact of early walking by itself on the mental and physical recovery of postoperative patients has not been examined. METHODS: We established a program called walking to recovery (WTR) in which college volunteers provided walking assistance to patients recovering after abdominal surgery. Patients who participated in the program were compared with patients who did not. The postoperative recovery profile survey (PRP-17) was administered on day of discharge to 15 participants and 15 non-participants. Medical records were reviewed to obtain indication for surgery, type of surgery, length of hospital stay, and postoperative complications. At 1 month post-discharge, a short form (SF)-12v2 questionnaire was administered by telephone to assess postoperative quality of life as defined by mental and physical level of function and measured with the mental component score (MCS) and the physical component score (PCS). RESULTS: The average age of participants and non-participants was similar (48.9 ± 9.8 vs. 51.4 ± 8.7 years; p = 0.28). When the two groups were approximately matched by type and severity of surgery, participants had lower PRP-17 composite scores (9.9 vs. 12.5, p = 0.003) and higher indicator sums (9.8 vs. 8.4, p = 0.04) than non-participants, both of which indicate better postoperative recovery in participants. The mean immobilization score was significantly lower in participants (0.3 vs. 0.8, p = 0.04). Postoperative length of stay and MCS did not differ between the two groups, but in participants there was a trend for higher scores in the PCS. CONCLUSIONS: Walking with volunteers was associated with a better PRP during the hospitalization period but not at 1 month follow-up. The WTR program is a sustainable, cost-effective model program for other hospitals to emulate as part of the standard of care of postoperative patients.

Increase in trauma volume as compared to emergency department volume during the COVID-19 pandemic.

BACKGROUND: During the months between April through June 2020 when we experienced the largest number of COVID-19 patients in our hospital, the volume of patients in the Emergency Department (ED) was decreased by more than 30%. In contrast to most early reports we did not notice a decrease in trauma volume during this time period. MATERIALS AND METHODS: We compared trauma patients presenting to our Level III Trauma Center, between April 2019 through June 2019 to those presenting from April 2020 through June 2020, the initial surge in COVID-19 patients. We compared ground level falls (GLF), motor vehicle crashes (MVC), bicycle and skateboard crashes, assault, and other. RESULTS: There was a 13% increase in trauma patients presenting during the study period in 2020 as compared to 2019, and the total number of trauma patients as a percentage of total ED patients also increased 269/9235 (2.9%) to 308/6216 (5.0%), P < 0.0001. There was no significant difference in demographics or outcome data between the trauma patients presenting during the two time periods. Although traffic decreased by more than 40%, the number of MVC's was similar. CONCLUSION: The volume of patients presenting to our Trauma Center as compared to the total ED volume increased during the time period from April through June 2020 versus the year just prior to the COVID-19 pandemic. Despite the fact that the total traffic volume decreased more than 40 percent between these two time periods, the actual number of motor vehicle crashes remained similar.

A 22-year history of treating intentional falls from the Golden Gate Bridge at Marin Health Medical Center.

Background: The historical mortality rate after falling from the Golden Gate Bridge has been approximately 98%. We report on 14 recent survivors treated at Marin Health Medical Center. Methods: We retrospectively reviewed the 22-year experience of treating patients after Golden Gate Bridge falls. Patients with signs of life when recovered by the Coast Guard were included. Results: Marin General Hospital treated 26 patients with an average age of 28.2 years. The mortality rate was 46.2% with an increased survival over the past decade compared to the first 12 years, 61% vs 37%, P = not significant. The average injury severity score was 29.3 and was significantly lower over the past decade (43.9 vs 22.8, P = .004). The leading injuries were hemothorax/pneumothorax (73%), spine fractures (65%), lung contusions (50%), rib fractures (50%), and solid organ injury (46%). Patients with major cardiovascular injuries were significantly more likely to expire, 88% vs 28%, P = .009. Conclusion: The pattern of injury leading to death after an intentional fall from the Golden Gate Bridge has not changed significantly over the decades.

Health technology assessment at the University of California-San Francisco.

Over the past thirty years, various efforts have been made to align the incentives of hospitals and physicians to control healthcare costs while assuring the provision of high-quality patient care. One innovative strategy used by some hospitals involves the creation of technology assessment programs to develop a more thorough and objective review process for new clinical technology. The University of California-San Francisco Medical Center has been a pioneer in this area. Its physician-led healthcare technology assessment program has been successful in changing the culture of how innovative technology is evaluated and adopted by the hospital and fostering an increased awareness among physicians of the clinical, financial, and programmatic implications of their technology decisions. We explore the operational characteristics and various effects of this program and highlight the key components to its success and opportunities for improvement in the context of its reproduction at other medical centers.

Integrating surgical skills education into the anatomy laboratory.

BACKGROUND: Preclinical education plays a pivotal role in improving the quality of patient care and safety. Early exposure to surgical skills training and surgical mentors enhance students' retention and confidence in those skills, and may promote their interest in surgery. METHODS: Based upon a needs assessment survey of surgical education at UCSF, we introduced a curriculum to teach basic surgical techniques in the preclinical years with the intent of emphasizing several important skills and providing students with exposure to surgical mentors in a small group environment. We then surveyed the students to assess satisfaction with the new curriculum and the effect on perceptions regarding a career in surgery. RESULTS: Rising fourth y students at UCSF identified the need for increased exposure to basic surgical skills in preparation for third y clerkships. Collaboration between the Departments of Anatomy and Surgery subsequently produced an integrated suturing curriculum in the anatomy lab as part of the first y medical school coursework. The curriculum offered a focused exposure to skills identified by senior students as important for their clinical rotations. The vast majority of respondents agreed or strongly agreed that the exercise was enjoyable and worth continuing, and that their interactions with the surgeon volunteers were positive. Furthermore, 33% stated that their interest in surgery increased after the exercise. Qualitative comments praised both the experience and surgical faculty participation. CONCLUSION: A needs-based surgical skills curriculum can be integrated into the traditional first-y anatomy course without detracting from didactic instruction in anatomy. Furthermore, students received early exposure to surgical mentors and skills training, which may translate into greater confidence on the wards and increased interest in surgical careers.

A professional development course for the clinical clerkships: developing a student-centered curriculum.

INTRODUCTION: Although professional development is addressed throughout the medical school curriculum, it is particularly salient to third-year students as they become integral members of health care teams. AIM: We present a professional development curriculum for third-year medical students. SETTING: Urban medical school. PROGRAM DESCRIPTION: In 2005, our curriculum consisted of 3 large group panels, each followed by a small group, occurring after the first, third, and last clerkship. Before each small group, students prepared critical incident reports, which led to focused group reflection. The individual topics were, respectively: (1) transition to clerkship learning; (2) challenges to professional behavior; and (3) medical errors. In 2006, based on student feedback, we piloted a revised student-centered panel on professionalism that was based entirely on themes from students' critical incident reports. PROGRAM EVALUATION: Students rated the curriculum well overall. In 2005-2006, the small groups ranged from 3.95 to 3.98 (SD 0.88) on a 5-point Likert scale (1 = poor, 5 = excellent) and the panels ranged from 3.54 to 4.41 (SD 0.9). The pilot panel in 2006 was rated 4.38 (SD 0.80). The most common professionalism themes generated from 185 critical incident reports were communication, compassionate patient care, accountability, and team collaboration. DISCUSSION: A professional development curriculum, consisting of panels, small groups, and critical incident reports, can promote reflection among third-year medical students.

Perforated appendicitis after colonoscopy.

BACKGROUND: Acute appendicitis is a rare complication of colonoscopy that has been reported only 12 times in the English-language literature and is usually associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports have described findings of perforation of the appendix within 24 hours of colonoscopy. METHODS: We present the case report of a patient who underwent urgent laparotomy within 16 hours of colonoscopy for findings of free intraabdominal air and peritonitis from acute perforated appendicitis. RESULTS: Laparoscopy confirmed 2 perforations of the appendix and diffuse peritonitis. Laparotomy was necessary to perform appendectomy, exclude a right colonic injury, and control intraabdominal sepsis. CONCLUSION: In patients with abdominal pain who have had a recent colonoscopy, a high index of suspicion is necessary for accurate diagnosis of perforated appendicitis. Perforation can occur hours after colonoscopy even when a biopsy is not performed.

Harnessing the Affordable Care Act to catalyze delivery system reform and strengthen emergency care in America.

As health care reform in the US evolves beyond insurance reform to encompass delivery system reform, the opportunity arises to harness the Affordable Care Act to strengthen patient care in America. One area for dedicated individuals to lead this effort is by improving transitions in patient care across the continuum of team members, specialties, settings, and systems. This article will describe innovations of the surgicalist and acute care surgeon that have emerged in response to the challenges facing surgery in specialization, geography, and the need to comply with health care reform mandates. Three ways will be described to integrate these innovations with pilot programs in the Affordable Care Act: to promote teamwork, to reduce readmissions, and to strengthen emergency care because the key location where the joint efforts intersect most acutely with patient need is in our nation's Emergency Departments.

Laparoscopic shunt revision avoids many complications of open shunt revision and has outcomes similar to first-time shunt placement.

Open revision of abdominal shunts is associated with increased risk of wound infection, visceral injury, hernia, and shunt complications. We hypothesized that laparoscopic revision mitigates these risks to a level similar to initial (i.e., first-time) shunt placement. This was a single-center, multisurgeon, retrospective cohort study of patients who underwent either laparoscopic initial shunt placement or laparoscopic shunt revision over a 5-year period. Outcomes were operative time, length of stay, and 30-day complication rate. Sixty-nine patients underwent laparoscopic shunt revision and 99 patients underwent laparoscopic initial shunt placement. Operative times were nearly identical (75 vs 73 minutes, P = 0.63). There were no significant differences in blood loss or hospital length of stay. Abdominal complications and total complications did not differ between groups. Laparoscopic shunt revision avoided many of the known complications of open shunt revision and had outcomes similar to initial laparoscopic shunt placement.