Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado.

OBJECTIVES: To evaluate motor vehicle crash fatality rates in the first 2 states with recreational marijuana legalization and compare them with motor vehicle crash fatality rates in similar states without recreational marijuana legalization. METHODS: We used the US Fatality Analysis Reporting System to determine the annual numbers of motor vehicle crash fatalities between 2009 and 2015 in Washington, Colorado, and 8 control states. We compared year-over-year changes in motor vehicle crash fatality rates (per billion vehicle miles traveled) before and after recreational marijuana legalization with a difference-in-differences approach that controlled for underlying time trends and state-specific population, economic, and traffic characteristics. RESULTS: Pre-recreational marijuana legalization annual changes in motor vehicle crash fatality rates for Washington and Colorado were similar to those for the control states. Post-recreational marijuana legalization changes in motor vehicle crash fatality rates for Washington and Colorado also did not significantly differ from those for the control states (adjusted difference-in-differences coefficient = +0.2 fatalities/billion vehicle miles traveled; 95% confidence interval = -0.4, +0.9). CONCLUSIONS: Three years after recreational marijuana legalization, changes in motor vehicle crash fatality rates for Washington and Colorado were not statistically different from those in similar states without recreational marijuana legalization. Future studies over a longer time remain warranted.

The impact of exposure technique on perioperative complications in patients undergoing elective open abdominal aortic aneurysm repair.

OBJECTIVE: The objective of this study was to evaluate the impact of exposure technique on perioperative complications in patients undergoing elective open abdominal aortic aneurysm (AAA) repair. METHODS: Using the Society for Vascular Surgery Vascular Quality Initiative database, the study identified patients subjected to open AAA repair from January 2003 to July 2014 and divided them into two aortic exposure groups, retroperitoneal (RP) and transperitoneal (TP). Multivariable analysis was performed to compare the incidence of cardiac events (myocardial infarction, dysrhythmia, heart failure), prolonged intubation, renal dysfunction, and mortality, adjusting for between-group differences identified on univariate analysis. RESULTS: Open AAA repair was performed in 3530 patients, using RP in 26% and TP in 74%. The RP group had a higher rate of suprarenal aortic clamp (60.9% vs 30.2%; P < .001), higher proportion of high-risk patients as stratified by the Vascular Study Group of New England Cardiac Risk Index (25.6% vs 22.2%; P = .038), and lower rate of iliac aneurysms (18.0% vs 31.2%; P < .001). After multivariable analysis, RP was associated with a lower incidence of cardiac events (12.2% vs 16.0%; adjusted odds ratio, 0.60; 95% confidence interval, 0.41-0.88; P = .009) and renal dysfunction (13.3% vs 16.5%; adjusted odds ratio, 0.65; 95% confidence interval, 0.46-0.97; P = .011). No difference in respiratory complications or mortality was identified. CONCLUSIONS: Despite increased utilization of suprarenal aortic clamp during elective open AAA repair, the RP technique was associated with a lower risk-adjusted incidence of cardiac and renal complications compared with the TP technique.

Vein harvesting technique for infrainguinal arterial bypass with great saphenous vein and its association with surgical site infection and graft patency.

OBJECTIVE: The objective of this study was to investigate the association of vein harvesting technique (VHT) with surgical site infection (SSI) and graft patency after infrainguinal arterial bypass. METHODS: The Vascular Quality Initiative database was used to review VHT of all patients undergoing single-segment great saphenous vein graft infrainguinal arterial bypass from 2003 to 2013. Patients were divided into three groups according to the VHT used (continuous incision, skip incision, and endoscopic). Multinomial logistic regression was performed to estimate propensity scores for each treatment group. Propensity score adjustment was included in multivariable analysis of the primary outcomes: SSI and graft primary patency. RESULTS: From 2003 to 2013, 5066 patients underwent single-segment great saphenous vein graft infrainguinal bypass. The VHT was continuous incision in 48.6%, skip incision in 39.7%, and endoscopic in 12.7%. SSI rates did not differ significantly among the groups (continuous, 4.7%; skip, 4.0%; endoscopic, 3.4%; P = .278). On multivariable analysis, there was no difference in discharge primary patency between the three groups. At 1 year, primary patency rates were 69.5% for continuous, 73.0% for skip, and 58.6% for endoscopic (P < .001). After multivariable analysis, endoscopic vein harvest was independently associated with higher 1-year primary patency loss compared with both continuous (hazard ratio [HR], 1.35; 95% confidence interval [CI], 1.05-1.74; P = .020) and skip (HR, 1.53; 95% CI, 1.18-2.00; P = .002). There was no significant difference in 1-year primary patency loss between continuous and skip techniques (HR, 0.88; 95% CI, 0.73-1.05; P = .170). CONCLUSIONS: No association between the choice of VHT and the development of SSI after infrainguinal arterial bypass was identified in the Vascular Quality Initiative population. Endoscopic VHT was associated with significantly reduced 1-year primary patency rate compared with both continuous and skip techniques.

Appendicitis: changing perspectives.

Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.

Discrepancies between capillary glucose measurements and traditional laboratory assessments in both shock and non-shock states after trauma.

INTRODUCTION: The purpose of this study was to analyze the accuracy of capillary blood glucose (CBG) against laboratory blood glucose (LBG) in critically ill trauma patients during the shock state. METHODS: All critically ill trauma patients admitted to the Surgical Intensive Care Unit at the Los Angeles County + University of Southern California Medical Center requiring blood glucose monitoring from January 2007 to December 2008 were included. Accuracy of CBG was compared against LBG during shock and non-shock states. Shock was defined as either systolic blood pressure <90 mm Hg or mean arterial pressure <70 mm Hg and the need for vasopressor therapy. The Bland-Altman method was used to determine the agreement between CBG and LBG during shock and non-shock states. CBG values were considered to disagree significantly with LBG values when the difference exceeded 15%. RESULTS: During the 2-y study period, a total of 1215 patients were admitted to the Surgical Intensive Care Unit. Overall, the mean age was 38.4 ± 20.9 y, 79.6% (967) were male, and 75.0% (911) sustained blunt trauma. A total of 1935 paired samples of CBG and LBG were included in this analysis (367 during shock and 1568 during non-shock). During shock, the mean difference between CBG and LBG levels was 13.4 mg/dL (95% CI, -15.4 to 42.2 mg/dL), and the limits of agreement were -27.1 and 53.9 mg/dL. A total of 136 CBG values (37.1%) differed from the LBG values by more than 15%. During non-shock, the mean difference between CBG and LBG levels was 12.6 mg/dL (95% CI, -19.9 to 32.5 mg/dL), and the limits of agreement were -20.6 and 45.8 mg/dL. A total of 639 CGB values (40.8%) differed from the LBG values by more than 15%. Agreement was lowest among hypoglycemic readings in both shock and non-shock states. CONCLUSION: There is poor correlation between the capillary and laboratory glucose values in both shock and non-shock states.

Reference accuracy in the general surgery literature.

BACKGROUND: Reference inaccuracy in scientific articles brings the scientific validity of the research into question and may create difficulty when accessing the cited background data. The objective of this study was to examine the reference accuracy in the general surgery literature and its correlation with the journal impact factor. METHODS: Five general surgery journals were chosen with varying impact factors. From the year 2007, one issue was randomly chosen from each journal, and from each issue 180 citations were randomly chosen for review. Three investigators evaluated the chosen references for primary, citational, and quotational errors. The impact factor of each journal was compared to the percentage of errors detected. RESULTS: The total number of errors per journal ranged from 31.3 to 39.3%, with a total of 35.4% of all citations reviewed containing some type of error. The most common error type detected was incorrect citation of the primary source supporting a statement, the incidence of which ranged from 13.8 to 25.2%, depending on the journal, and accounting for 53.6% of the total errors found. Citational errors, which included incorrect author names, pagination, dates, and issue and volume numbers, ranged from 1.8 to 18.1% and accounted for 20.4% of the total errors detected. Qualitative errors, which occurred when the author misquoted another author's written assertions or conclusions, ranged from 7.4 to 16.0% and accounted for 34.7% of the total errors detected. Quantitative errors (misquoted numerical data) ranged from 3.1 to 8.6% and accounted for 17.9% of the total errors detected. No association between impact factor and error rate was demonstrated. CONCLUSIONS: Reference inaccuracy is common in the general surgery literature. The impact factor has no clear association with the error rate, demonstrating that journal quality does not necessarily correlate with reference quality. Further investigation into potential methods for improving reference accuracy in the general surgery literature is warranted.

Donor conversion and procurement failure: the fate of our potential organ donors.

BACKGROUND: Donor availability remains the primary limiting factor for organ transplantation today. The purpose of this study was to examine the causes of procurement failure amongst potential organ donors. METHODS: After Institutional Review Board approval, all surgical intensive care unit (SICU) patients admitted to the LAC+USC Medical Center from 01/2006 to 12/2008 who became potential organ donors were identified. Demographics, clinical data, and procurement data were abstracted. In non-donors, the causes of procurement failure were documented. RESULTS: During the 3-year study period, a total of 254 patients were evaluated for organ donation. Mean age was 44.8±18.7 years; 191 (75.2%) were male, 136 (53.5%) were Hispanic, and 148 (58.3%) were trauma patients. Of the 254 patients, 116 (45.7%) were not eligible for donation: 34 had multi-system organ failure, 24 did not progress to brain death and had support withdrawn, 18 had uncontrolled sepsis, 15 had malignancy, 6 had human immunodeficiency virus or hepatitis B or C, and 19 patients had other contraindications to organ donation. Of the remaining 138 eligible patients, 83 (60.2%) did not donate: 56 because the family denied consent, 9 by their own choice. In six, next of kin could not be located, five died because of hemodynamic instability before organ procurement was possible, four had organs that could not be placed, and three had their organs declined by the organ procurement organization. The overall consent rate was 57.5% (n=67). From the 55 donors, 255 organs were procured (yield 4.6 organs/donor). CONCLUSIONS: Of all patients screened for organ donation, only a fifth actually donated. Denial of consent was the major potentially preventable cause of procurement failure, whereas hemodynamic instability accounted for only a small percentage of donor losses. With such low conversion rates, the preventable causes of procurement failure warrant further study.

The increasing burden of radiation exposure in the management of trauma patients.

BACKGROUND: As trauma care evolves, there has been increased reliance on imaging. The purpose of this study was to examine changes in trauma imaging and radiation exposure over time. Our hypothesis was that there has been an increased usage of imaging in the management of trauma patients without measurable improvements in outcomes. METHODS: A continuous series of injured patients admitted to a Level I trauma center during a 2-month period in 2002 was compared with the same period in 2007. All computed tomography (CT)s and plain radiographs performed for each patient were tabulated. Effective radiation dose estimates for each patient were then calculated. The outcome measures were length of stay, mortality, and missed injuries. RESULTS: The 495 patients in 2007 and 497 patients in 2002 demonstrated no significant differences in demographics, clinical data, or outcomes between groups. However, from 2002 to 2007, for blunt trauma, the mean CTs per patient increased significantly (2.1 ± 1.6 vs. 3.2 ± 2.0, p < 0.001), as did plain radiographs (8.8 ± 12.9 vs. 14.9 ± 17.0, p < 0.001). For penetrating trauma, roentgenogram usage increased significantly (4.2 ± 5.3 vs. 9.1 ± 14.4, p = 0.01) with a trend toward increased CTs (0.7 ± 1.1 vs.1.0 ± 1.6, p = 0.11). Total radiation dose estimates demonstrated significantly increased radiation exposure in 2007; blunt (11.5 ± 11.3 mSv vs. 20.7 ± 14.9 mSv, p < 0.05) and penetrating (2.9 ± 4.9 mSv vs. 5.4 ± 7.9 mSv, p < 0.05). CONCLUSION: From 2002 to 2007, there was a significant increase in the use of CT and plain radiographs in the management of trauma patients, leading to significantly higher radiation exposure with no demonstrable improvements in the diagnosis of missed injuries, mortality, or length of stay.

Blunt thoracic aortic injuries: an autopsy study.

OBJECTIVE: The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries. METHODS: All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries. RESULTS: During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002). CONCLUSION: Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.

Epidemiology of post-traumatic limb amputation: a National Trauma Databank analysis.

The purpose of this study was to examine the epidemiology and outcomes of posttraumatic upper (UEA) and lower extremity amputations (LEA). The National Trauma Databank version 5 was used to identify all posttraumatic amputations. From 2000 to 2004 there were 8910 amputated patients (1.0% of all trauma patients). Of these, 6855 (76.9%) had digit and 2055 (23.1%) had limb amputation. Of those with limb amputation, 92.7 per cent (1904/2055) had a single limb amputation. LEA were more frequent than UEA among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt in 83 per cent; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%, P < 0.001), whereas motorcyclists (86.2% vs 13.8%, P < 0.001) and pedestrians (91.9% vs 8.1%, P < 0.001) had more LEA. Patients with LEA were more likely to require discharge to a skilled nursing facility; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. Although single limb amputation did not impact mortality, the need for multiple limb amputation was an independent risk factor for death.

Complications and death at the start of the new academic year: is there a July phenomenon?

BACKGROUND: The "July Phenomenon" refers to the propensity for increased errors to occur with new housestaff, as they assume new responsibilities at the beginning of the academic year. The purpose of this study was to examine the impact of the new residents presenting in July at a high volume Level I Academic Trauma Center. METHODS: The trauma registry at the Los Angeles County + University of Southern California Medical center was retrospectively reviewed to identify all injured patients admitted over a 5-year period ending in December 2006. All Morbidity and Mortality reports for the study period were reviewed to extract deaths and any complications classified as preventable or potentially preventable. Patients admitted in the first 2 months (July to August) of the academic year were compared with those treated at the end of the academic year (May to June). Baseline clinical and demographic characteristics were compared, and the rates of preventable and potentially preventable deaths and complications were determined for each of these groups. RESULTS: During the 5-year study period, 24,302 injured patients were admitted. Of those, 8,151 were admitted during the period from May to August with 4,030 (49.4%) at the beginning of the academic year (July to August) and 4,121 (50.6%) at the end of the academic year (May to June). Overall, the average age was 35.1 +/- 17.7 years, 77% were men with an Injury Severity Score of 8.4 +/- 9.7 and 24.2% penetrating injury rate. When examining mortality, after adjustment for differences between the two groups, there was no difference between patients admitted at the beginning or at the end of the academic year (adjusted odds ratio [95% confidence interval]: 1.1 [0.8, 1.5], p = 0.52). However, when compared with the patients treated for their injuries in May to June, those treated at the beginning of the academic year had a significantly higher rate of preventable and potentially preventable complications (adjusted odds ratio [95% confidence interval]: 1.9 [1.1, 3.2], p = 0.013). CONCLUSIONS: At an academic Level I trauma center, admission at the beginning of the academic year was associated with an increased risk of errors resulting in preventable and potentially preventable complications; however, these errors did not impact mortality. Specific errors associated with this increased rate of preventable complications warrant further investigation.

Motorcycle-related injuries: effect of age on type and severity of injuries and mortality.

BACKGROUND: The aim of this study was to evaluate the relationship of age to the injury types, distribution, and severity in motorcycle crash (MCC) victims admitted to Los Angeles County emergency hospitals in California. METHODS: This Los Angeles countywide trauma registry study included all MCC victims admitted to the 13 trauma centers of the Los Angeles County between January 1995 and December 2007. Besides demographical data collected, the Injury Severity Score, body area (head, chest, abdomen, and extremities), Abbreviated Injury Scale score >or=3, specific organ injuries, and mortality were calculated according to age groups (55 years). A stepwise logistic regression model was used to identify independent risk factors for death. RESULTS: Among 6,530 admissions due to MCCs, there were 493 patients (7.5%) aged 18 years or younger, 5,627 patients (86%) aged 19 years to 55 years, and 398 patients (6.5%) older than 55 years. The incidences of severe injury (Injury Severity Score >15) in the three ascending age groups were 23.5%, 30.3%, and 36.2%, respectively (p < 0.05), and critical injuries (Injury Severity Score >25) occurred in 6.5%, 12.3%, and 13.8%, respectively (p < 0.05). Severe head injuries were significantly more likely in the population older than 55 year (odds ratio [OR] {95% confidence interval [CI] } = 1.45 {1.03-2.03}, p = 0.04). The risk of sustaining a severe chest injury (Abbreviated Injury Scale Chest Score >or=3) increased in a stepwise fashion with increasing age, with an OR (95% CI) = 1.86 (1.44-2.39) in the age group 19 years to 55 years and 2.81 (2.03-3.88) in the older than 55 years group, p < 0.001. Mortality was twofold higher in the 19-year- to 55-year-old group [OR (95% CI) = 2.30 (1.08-4.93), p = 0.03] and threefold higher in the older than 55 years group [OR (95% CI) = 3.28 (1.36-7.93), p = 0.05] compared with the

Measurable outcomes of quality improvement using a daily quality rounds checklist: one-year analysis in a trauma intensive care unit with sustained ventilator-associated pneumonia reduction.

BACKGROUND: We have previously demonstrated that the use of a daily "Quality Rounds Checklist" (QRC) can increase compliance with evidence-based prophylactic measures and decrease complications in a busy trauma intensive care unit (ICU) over a 3-month period. This study was designed to determine the sustainability of QRC use over 1 year and examine the relationship between compliance and outcome improvement. METHODS: A prospective before-after design was used to examine the effectiveness of the QRC tool in documenting compliance with 16 prophylactic measures for ventilator-associated pneumonia (VAP), deep venous thrombosis, pulmonary embolism, catheter-related bloodstream infection, and other ICU complications. The QRC was implemented on a daily basis for a 1-year period by the ICU fellow on duty. Monthly compliance rates were assessed by a multidisciplinary team for development of strategies for real-time improvement. Compliance and outcomes were captured over 1 year of QRC use. RESULTS: QRC use was associated with a sustained improvement of VAP bundle and other compliance measures over a year of use. After multivariable analysis adjusting for age (> 55), injury mechanism, Glasgow Coma Scale score (≤ 8), and Injury Severity Score (> 20), the rate of VAP was significantly lower after QRC use, with an adjusted mean difference of -6.65 (per 1,000 device days; 95% confidence interval, -9.27 to -4.04; p = 0.008). During the year of QRC use, 3% of patients developed a VAP if all four daily bundle measures were met for the duration of ICU stay versus 14% in those with partial compliance (p = 0.04). The overall VAP rate with full compliance was 5.29 versus 9.23 (per 1,000 device days) with partial compliance. Compared with the previous year, a 24% decrease in the number of pneumonias was recorded for the year of QRC use, representing an estimated cost savings of approximately $400,000. CONCLUSION: The use of a QRC facilitates sustainable improvement in compliance rates for clinically significant prophylactic measures in a busy Level I trauma ICU. The daily use of the QRC, requiring just a few minutes per patient to complete, equates to cost-effective improvement in patient outcomes.

Traumatic suicide attempts at a level I trauma center.

BACKGROUND: The purpose of this study is to characterize traumatic suicide attempts (TSA) by age, gender, race, and mechanism of injury. METHODS: This is a retrospective review of TSA patients (identified by E-codes) admitted to our urban, level I trauma center from 1992 through 2005. Mechanisms of TSA included jump from height, firearm (gunshot wound [GSW]), cutting or piercing instrument (stab wound [SW]), and motor vehicle (MV)-related. Patients were categorized in groups by age in years (< 18, 18-35, 36-54, 55-69, ≥ 70). RESULTS: A total of 876 TSA patients were identified; 83% were male, with a mean age of 35 years and a mean Injury Severity Score of 10. The most common mechanism was SW (39%), followed by jump (26%), GSW (21%), and MV-related (13%). Primary mechanism of TSA varied by age (p < 0.0001), with GSW most common in those patients aged < 18 years (64%) and ≥ 70 years (44%), and SW most common in all other age groups. Overall, 16% of TSAs were successful. The adjusted odds ratio (AOR) for mortality for age 70+ vs. age 36-54 was 12.4 (95% confidence interval [CI] 2.3-78, p = 0.005), and the AOR for mortality from GSW vs. SW was 9.8 (95% CI 2.6-44, p = 0.001). CONCLUSIONS: The most common mechanism for TSA was SW, although GSW was the most effective. The mechanism of choice for TSA depends on age, with the extremes of age more commonly choosing a firearm. Age and method of TSA are significant contributing factors to success of suicide attempts.

Helicopter evacuation of trauma victims in Los Angeles: does it improve survival?

BACKGROUND: The purpose of this study was to investigate the relationship between the method of transport after injury and survival among trauma patients admitted to a Level 1 trauma facility in Los Angeles, California. METHODS: The trauma registry of LAC+USC Medical Center was reviewed to identify all injured patients evacuated by emergency medical service (EMS) from the injury scene from 1998 to 2007. The study population was divided into those who were airlifted (HEMS) and those who were transported by ground emergency medical service (GEMS) with transportation time that exceeded 30 minutes (GEMS > 30 minutes). RESULTS: During the 10-year study period, 1,836 patients were airlifted (helicopters for emergency medical service (HEMS)) and 1,537 patients were ground transported (GEMS > 30 minutes). HEMS patients suffered more frequently a penetrating injury (19% vs. 11%, p < 0.001), presented more often hypotensive to the emergency department (4% vs. 1%, p < 0.001), had more frequently a Glasgow Coma Scale (GCS) < or = 8 (9% vs. 3%, p < 0.001) and required more often an intubation at the injury scene (1.6% vs. 0.4%, p < 0.001). However, the transportation time and the total prehospital time were significantly shorter for airlifted patients. After multivariable analysis, the difference in mortality between the two transport modalities was not significant (adjusted odds ratio (95% confidence interval, 0.72 (0.22, 2.35); p = 0.596). CONCLUSIONS: In a metropolitan Los Angeles trauma system, EMS helicopter transportation of injured patients does not appear to improve overall adjusted survival after injury. There is however a potential benefit for severely injured subgroups of patients due to the shorter prehospital times.

Enterocutaneous fistula complicating trauma laparotomy: a major resource burden.

Enterocutaneous fistula (ECF) is an uncommon and poorly studied postoperative complication. The objective of this study was to analyze the incidence and resource utilization of patients who developed an ECF after trauma laparotomy. All patients with an ECF occurring after trauma laparotomy at a Level I trauma center were identified through a review of both the Trauma Registry and the Morbidity and Mortality reports for a 9-year period ending in December 2006. Each ECF case was matched with a control (non-ECF) that did not develop this complication after laparotomy. The matching criteria were: age, gender, mechanism of injury, Injury Severity Score, Abbreviated Injury Score, and damage control laparotomy requiring an open abdomen. Outcomes analyzed were intensive care unit (ICU) and hospital length of stay, mortality, and total hospital charges. During the 9-year period, of 2373 acute trauma laparotomies performed, 36 (1.5%) patients developed an enterocutaneous fistula, and were matched to 36 controls. Patients with an ECF were 31 +/- 12 years of age, were 97 per cent male, had a mean Injury Severity Score of 21 +/- 10, and 75 per cent were penetrating. Eighty-nine per cent of the ECF patients had a hollow viscus injury. The most common was colon (69%), followed by small bowel (53%), duodenum (36%), and stomach (19%). Fifty-six per cent of the ECF patients had multiple hollow viscus injuries. The development of an ECF was associated with significantly increased ICU length of stay (28.5 +/- 30.5 vs 7.6 +/- 9.3 days, P = 0.004), hospital length of stay (82.1 +/- 100.8 vs 16.2 +/- 17.3 days, P < 0.001), and hospital charges ($539,309 vs $126,996, P < 0.001). In conclusion, the development of an enterocutaneous fistula after laparotomy for trauma resulted in a significant impact on resource utilization including longer ICU and hospital length of stay and higher hospital charges. Further investigation into the prevention and treatment of this costly complication is warranted.

An international fellowship in trauma research and the potential benefits for fellows, sponsoring institution, and the global trauma community.

For over a decade, the Los Angeles County/University of Southern California Hospital has supported an international fellowship in trauma that provides research experience, education, and opportunity for clinical observation at a high-volume American College of Surgeons (ACS) designated Level I trauma center. We performed a descriptive study of the design, implementation, and results of an international fellowship in trauma and critical care. Fellows from 27 countries throughout the world have actively engaged in trauma research at Los Angeles County/University of Southern California Hospital. Our program involves intensive education and clinical observation components designed to facilitate dissemination of evidence-based trauma practices throughout the world by graduates. The majority of alumni responding to a survey returned to their countries of origin, remaining active in trauma care and research. Motivation for participation varied, but former fellows universally rated their experience highly and stated they would recommend the program to their colleagues. An international research fellowship in trauma and critical care provides foreign medical trainees opportunities for exposure to research and evidence-based practices at a high-volume trauma center. The program is designed to be beneficial to both the participating fellow and sponsoring institution; and is constructed to effectively promote improved trauma education and the dissemination of quality trauma practices internationally.

Epidemiology of sternal fractures.

The epidemiology of sternal fractures has been poorly described. The objective of this study was to examine the demographics, outcomes and injuries associated with sternal fractures. The trauma registry at a level I trauma center was retrospectively reviewed to identify all patients with sternal fractures over a 10 year period. Demographic data collected included age, gender, mechanism of injury and injury severity score. Patients were analyzed according to age < or = 55 or > 55 years. During the 10-year study period, a total of 37,087 patients were admitted to the emergency department. Of these, 125 (0.33%) had a sternal fracture. The average age was 44 +/- 17 years, with 76.0 per cent being male. The most common mechanism of injury was motor vehicle collision (68%) followed by auto vs. pedestrian (18%). Associated rib fractures occurred in 49.6% of the population, cardiac contusions in 8.0%, thoracic aortic injuries in 4.0 per cent and heart lacerations in 2.4 per cent of patients. Associated rib fractures were more likely to occur in patients over the age of 55 (66.7% vs 44.2%, P = 0.032) as well as a traumatic hemothorax (15.8% vs 40.0%, P = 0.005). However, no significant difference in mortality was observed between the two age groups (16.8% vs. 26.7%, OR: 0.56, 95% CI, 0.21 to 1.47; P = 0.234). Sternal fractures are a rare sequela of blunt trauma. Associated injuries are common, including rib fractures and soft tissue contusions. Associated cardiac and aortic injuries are rare but highly lethal and should be screened for on the initial chest CT scan. After appropriate exclusion of associated injuries, the majority of patients diagnosed with a sternal fracture following blunt trauma can be safely discharged to home.

Methicillin-resistant Staphylococcus aureus in a surgical intensive care unit.

The rate of methicillin-resistant Staphylococcus aureus (MRSA) infections has increased significantly over the last years, especially from community-associated MRSA (CA-MRSA) sources. The true prevalence of these multidrug-resistant infections among the trauma patient population, however, is not well defined. A retrospective review of our surgical intensive care unit (SICU) database from April 2003 to April 2007 was performed to identify all trauma patients surviving 48 hours or more that had a positive culture result during their SICU stay. The results of the cultures were examined. A total of 582 SICU patients with 2,860 cultures were assessed for MRSA infection. Among these, 368 cultures (12.9%) in 36 patients were reported as MRSA positive. Thirteen of these patients fulfilled the criteria for a CA-MRSA infection. When outcomes were analyzed, no significant difference in mortality (8.7% vs 15.4%, P = 0.540) or hospital related charges ($364,231 +/- 323,719 vs $242,458 +/- 276,630, P = 0.091) was noted. Patients with a hospital-acquired MRSA infection, however, had longer hospital lengths of stay (42.7 +/- 47.1 vs 25.3 +/- 31.1, P = 0.037) than their community-associated counterparts. MRSA constitutes an important source of infection among critically ill trauma patients. CA-MRSA organisms may play an increasing pathogenic role in this population.

Perineal injuries at a large urban trauma center: injury patterns and outcomes.

The purpose of this study was to describe the characteristics of this unique patient population, their clinical presentations, and outcomes. The Los Angeles County and University of Southern California Medical Center Trauma Registry was used to retrospectively identify patients who sustained perineal injuries. Information included gender, age, vital signs, trauma scores, mechanisms of injury, studies performed, surgeries performed, and outcomes. Pediatric patients and injuries related to obstetric trauma were not included. Sixty-nine patients were identified between February 1, 1992 and October 31, 2005. One patient died on arrival; 85 per cent (58 of 68) were males, mean age was 30 +/- 12 years, and there was a penetrating mechanism in 56 per cent. Vital signs on admission were systolic blood pressure 119 +/- 33 mmHg, heart rate 94 +/- 27 beats/minute, and respiratory rate 20 +/- 6 breaths/min. Glasgow Coma Scale (GCS) was 13 +/- 3, Revised Trauma Score (RTS) was 7.2 +/- 1.5, and Injury Severity Score (ISS) was 11 +/- 12. CT scan was obtained for 23 (33%) patients. Lower extremity fractures were 35 per cent and pelvic fractures 32 per cent. The most common surgery was débridement and drainage, diversion with colostomy in five patients (7%). Overall mortality was 10 per cent. Mortality group mean scores were: GCS, 6; RTS, 5.74; and ISS, 34. The survival group mean scores were: GCS, 14; RTS, 7.7; and ISS, 8. There was a statistically significant association between mortality and GCS, RTS, and ISS scores (P < 0.001). Most patients with perineal injuries (93%) can be managed without colostomy. Associated injuries are not uncommon, particularly bony fractures. Mortality is mostly the result of exsanguination related to associated injuries.