Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator.

BACKGROUND: The presence of a cardiovascular implantable electronic device has long been a contraindication for the performance of magnetic resonance imaging (MRI). We established a prospective registry to determine the risks associated with MRI at a magnetic field strength of 1.5 tesla for patients who had a pacemaker or implantable cardioverter-defibrillator (ICD) that was "non-MRI-conditional" (i.e., not approved by the Food and Drug Administration for MRI scanning). METHODS: Patients in the registry were referred for clinically indicated nonthoracic MRI at a field strength of 1.5 tesla. Devices were interrogated before and after MRI with the use of a standardized protocol and were appropriately reprogrammed before the scanning. The primary end points were death, generator or lead failure, induced arrhythmia, loss of capture, or electrical reset during the scanning. The secondary end points were changes in device settings. RESULTS: MRI was performed in 1000 cases in which patients had a pacemaker and in 500 cases in which patients had an ICD. No deaths, lead failures, losses of capture, or ventricular arrhythmias occurred during MRI. One ICD generator could not be interrogated after MRI and required immediate replacement; the device had not been appropriately programmed per protocol before the MRI. We observed six cases of self-terminating atrial fibrillation or flutter and six cases of partial electrical reset. Changes in lead impedance, pacing threshold, battery voltage, and P-wave and R-wave amplitude exceeded prespecified thresholds in a small number of cases. Repeat MRI was not associated with an increase in adverse events. CONCLUSIONS: In this study, device or lead failure did not occur in any patient with a non-MRI-conditional pacemaker or ICD who underwent clinically indicated nonthoracic MRI at 1.5 tesla, was appropriately screened, and had the device reprogrammed in accordance with the prespecified protocol. (Funded by St. Jude Medical and others; MagnaSafe ClinicalTrials.gov number, NCT00907361 .).

Head injuries in hospital-admitted adolescents and adults with skateboard-related trauma.

OBJECTIVE: To provide new information on properties of skateboarders who were hospital admitted with head injuries with details of the injuries including region of head impact. METHODS: Hospital records of patients aged 15 and older with a skateboard injury admitted to one Level II Trauma Centre during a 10-year period were reviewed. Data on demographic, exposure, severity, diagnostic and clinical factors for patients with head injury (HI) and without HI (N-HI) were compared analytically. RESULTS: While there were no differences for patients with HI and N-HI by age, gender, mechanism of injury or alcohol use, patients with HI were more severely injured. Although significantly more head impacts occurred to the occipital region of the head, haematomas and/or contusions were much more likely to occur in the frontal region of the brain. Acute neurosurgical intervention was needed in 14% of HI skateboarders. CONCLUSION: Skateboarding is not an innocuous recreational activity, with head injury present in 75% of patients who were hospital-admitted. Pre-hospital treatment protocols should be aware of this growing injured population. Falls while on a skateboard lead to impacts to the back of head with a contra-coup brain injury resulting in severe and sometimes fatal outcomes. The very low prevalence of helmet use among skateboarders with head injuries indicates that greater efforts should be directed toward incentives for their use.

American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

Imaging acute cholecystitis, one test is enough.

BACKGROUND: Patients with right upper quadrant pain are often imaged using multiple modalities with no established gold standard. A single imaging study should provide adequate information for diagnosis. METHODS: A multicenter study of patients with acute cholecystitis was queried for patients who underwent multiple imaging studies on admission. Parameters were compared across studies including wall thickness (WT), common bile duct diameter (CBDD), pericholecystic fluid and signs of inflammation. Cutoff for abnormal values were 3 mm for WT and 6 mm for CBDD. Parameters were compared using chi-square tests and Intra-class correlation coefficients (ICC). RESULTS: Of 861 patients with acute cholecystitis, 759 had ultrasounds, 353 had CT and 74 had MRIs. There was excellent agreement for wall thickness (ICC = 0.733) and bile duct diameter (ICC = 0.848) between imaging studies. Differences between wall thickness and bile duct diameters were small with nearly all <1 mm. Large differences (>2 mm) were rare (<5%) for WT and CBDD. CONCLUSIONS: Imaging studies in acute cholecystitis generate equivalent results for typically measured parameters.

Contemporary management and outcomes of penetrating colon injuries: Validation of the 2020 AAST Colon Organ Injury Scale.

INTRODUCTION: The American Association for the Surgery of Trauma Colon Organ Injury Scale (OIS) was updated in 2020 to include a separate OIS for penetrating colon injuries and included imaging criteria. In this multicenter study, we describe the contemporary management and outcomes of penetrating colon injuries and hypothesize that the 2020 OIS system correlates with operative management, complications, and outcomes. METHODS: This was a retrospective study of patients presenting to 12 Level 1 trauma centers between 2016 and 2020 with penetrating colon injuries and Abbreviated Injury Scale score of <3 in other body regions. We assessed the association of the new OIS with surgical management and clinical outcomes and the association of OIS imaging criteria with operative criteria. Bivariate analysis was done with χ 2 , analysis of variance, and Kruskal-Wallis, where appropriate. Multivariable models were constructed in a stepwise selection fashion. RESULTS: We identified 573 patients with penetrating colon injuries. Patients were young and predominantly male; 79% suffered a gunshot injury, 11% had a grade V destructive injury, 19% required ≥6 U of transfusion, 24% had an Injury Severity Score of >15, and 42% had moderate-to-large contamination. Higher OIS was independently associated with a lower likelihood of primary repair, higher likelihood of resection with anastomosis and/or diversion, need for damage-control laparotomy, and higher incidence of abscess, wound infection, extra-abdominal infections, acute kidney injury, and lung injury. Damage control was independently associated with diversion and intra-abdominal and extra-abdominal infections. Preoperative imaging in 152 (27%) cases had a low correlation with operative findings ( κ coefficient, 0.13). CONCLUSION: This is the largest study to date of penetrating colon injuries and the first multicenter validation of the new OIS specific to these injuries. While imaging criteria alone lacked strong predictive value, operative American Association for the Surgery of Trauma OIS colon grade strongly predicted type of interventions and outcomes, supporting use of this grading scale for research and clinical practice. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Validation of the American Association for the Surgery of Trauma Organ Injury Scale for Penetrating Colon Injuries.

In 2020, the American Association for the Surgery of Trauma (AAST) published a revision of the organ injury scale (OIS) for bowel injuries. The update included for the first time a separate OIS for penetrating colon injuries as well as imaging criteria. To validate the new OIS and its correlation with outcomes, we performed a retrospective review of patients with penetrating colon injuries (AIS<3 in other body regions) between 2016 and 2020 at a single institution. Sixty-six patients met inclusion criteria. Most were young (29 years median) and male (90%). All underwent operative intervention and 23 (34%) had pre-operative imaging. Imaging grade was higher than operative grade in 11 patients (48%). Higher AAST operative grade was associated with a higher likelihood of resection and anastomosis or colostomy, need for damage control laparotomy, and development of intra-abdominal abscess and acute kidney injury. A multicenter study is underway to confirm these findings.

Pain management on a trauma service: a crisis reveals opportunities.

Objectives: The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). Methods: Retrospective analysis of pain management at a level II trauma center for January-November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. Results: 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. Conclusions: Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. Level of evidence: IV.

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients.

BACKGROUND: Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A 'pit stop' (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost. METHODS: We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05. RESULTS: There were 994 TAs and 474 TRs in the first 9 months after implementation. TR's preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%. DISCUSSION: PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources. LEVEL OF EVIDENCE: Level II, economic/decision therapeutic/care management study.

Immunologic function after splenic embolization, is there a difference?

BACKGROUND: To define the immunologic status of patients undergoing splenic embolization (SE) after traumatic injury. This information may lead to the development of immunization protocols based on scientific data. METHODS: Patients with traumatic splenic injury, treated at one level II Trauma Center were eligible for study. SE patients were compared with splenectomy (SP) patients and controls (C = blunt abdominal trauma patients with negative abdominal computed tomography scans). Clinical examination, medical survey, blood sampling, and nuclear medicine spleen scans were performed. IgM, IgG, C3 complement, complement factor B, helper T cells (CD3, CD4), suppressor T-cells (CD8), complete blood counts, and HIV status were tested. Radionuclide spleen scans were analyzed for total spleen volume, splenic defects, abnormal radionuclide uptake, and ectopic sites of tracer uptake. RESULTS: There were no significant differences in age, gender, or injury severity score among groups. Follow-up time was comparable (SP = 2.67 years; SE = 2.88 years). There were no significant differences in all studies measured except for higher CD8 levels in the SP group (730.1 vs. SE 452.1 vs. C 480.6; p = 0.002), although all values were within the normal range. CD3 levels showed a trend of being higher in the SP group (1709.3 vs. SE 1397.2 vs. C 1371.9), but were not statistically significant. CONCLUSION: The data suggest that the immunologic profile of embolized patients is similar to controls. This supports the safe use of SE in managing the traumatically injured spleen. Larger studies examining the immune function after SE will be needed to make definitive vaccination recommendations.

The influence of vehicle damage on injury severity of drivers in head-on motor vehicle crashes.

Data from crashes investigated through the Crash Injury Research and Engineering Network (CIREN) Program were used to assess differences in injury patterns, severity, and sources for drivers, protected by safety belts and deploying steering wheel air bags, in head-on frontal impacts. We studied whether exterior vehicle damage with a different distribution (wide vs. narrow) across the front vehicle plane influenced injury characteristics. Drivers from both impact types were similar on the basis of demographic characteristics (except age), restraint use, and vehicle characteristics. There were significant differences in the type of object contacted and intrusion into the passenger compartment at the driver's seat location. The mean delta V (based on the kilometers per hour change in velocity during the impact) was similar for drivers in both (wide vs. narrow) impact types. There were no significant differences in injury patterns and sources except that drivers in wide impacts were almost 4 times more likely (odds ratio (OR)=3.81, 95% confidence limits (CL) 1.26, 11.5) to have an abbreviated injury scale (AIS) 3 serious or greater severity head injury. Adjusted odds ratios showed that drivers in wide impacts were less likely (OR=0.54, 95% CI 0.37, 0.79) to have severe injury (based on injury severity score (ISS)>25) when controlling for intrusion, vehicle body type, vehicle curb weight, age, proper safety belt use, and delta V. Drivers with intrusion into their position or who were driving a passenger vehicle were almost twice more likely to have severe injury, regardless of whether the frontal plane damage distribution was wide or narrow. Our study supports that the type of damage distribution across the frontal plane may be an important crash characteristic to consider when studying drivers injured in head-on motor vehicle crashes.

Risk stratification tools in emergency general surgery.

The use of risk stratification tools (RST) aids in clinical triage, decision making and quality assessment in a wide variety of medical fields. Although emergency general surgery (EGS) is characterized by a comorbid, physiologically acute patient population with disparately high rates of perioperative morbidity and mortality, few RST have been explicitly examined in this setting. We examined the available RST with the intent of identifying a tool that comprehensively reflects an EGS patients perioperative risk for death or complication. The ideal tool would combine individualized assessment with relative ease of use. Trauma Scoring Systems, Critical Care Scoring Systems, Surgical Scoring Systems and Track and Trigger Models are reviewed here, with the conclusion that Emergency Surgery Acuity Score and the American College of Surgeons National Surgical Quality Improvement Programme Universal Surgical Risk Calculator are the most applicable and appropriate for EGS.

Trauma resource designation: an innovative approach to improving trauma system overtriage.

BACKGROUND: Effective triage of injured patients is often a balancing act for trauma systems. As healthcare reimbursements continue to decline,1 innovative programs to effectively use hospital resources are essential in maintaining a viable trauma system. The objective of this pilot intervention was to evaluate a new triage model using 'trauma resource' (TR) as a new category in our existing Tiered Trauma Team Activation (TA) approach with hopes of decreasing charges without adversely affecting patient outcome. METHODS: Patients at one Level II Trauma Center (TC) over seven months were studied. Patients not meeting American College of Surgeons criteria for TA were assigned as TR and transported to a designated TC for expedited emergency department (ED) evaluation. Such patients were immediately assessed by a trauma nurse, ED nurse, and board-certified ED physician. Diagnostic studies were ordered, and the trauma surgeon (TS) was consulted as needed. Demographics, injury mechanism, time to physician evaluation, time to CT scan, time to disposition, hospital length of stay (LOS), and in-hospital mortality were analyzed. RESULTS: Fifty-two of the 318 TR patients were admitted by the TS and were similar to TA patients (N=684) with regard to gender, mean Injury Severity Score, mean LOS and in-hospital mortality, but were older (60.4 vs 47.2 years, p<0.0001) and often involved in a fall injury (52% vs 35%, p=0.0170). TR patients had increased door to physician evaluation times (11.5 vs 0.4 minutes, p<0.0001) and increased door to CT times (76.2 vs 25.9 minutes, p<0.0001). Of the 313 TR patients, 52 incurred charges totaling US$253 708 compared with US$1 041 612 if patients had been classified as TA. CONCLUSIONS: Designating patients as TR prehospital with expedited evaluation by an ED physician and early TS consultation resulted in reduced use of resources and lower hospital charges without increase in LOS, time to disposition or in-hospital mortality. LEVEL OF EVIDENCE: Level II.

Assessing the quality of colorectal cancer staging: documenting the process in improving the staging of node-negative colorectal cancer.

HYPOTHESIS: Examination of 14 or more nodes is the optimal criterion to accurately stage node-negative colorectal cancer and predict outcome. DESIGN: Case series. SETTING: Three university-affiliated community medical centers. PATIENTS: A total of 2149 individuals with apparently localized, invasive colorectal cancer examined between January 1, 1990, and December 31, 2002. INTERVENTION: Study of tumor registry data. MAIN OUTCOME MEASURES: Nodal status and disease-specific survival. RESULTS: The number of nodes examined ranged from 0 to 97 (mean +/- SD, 18 +/- 15 nodes). The mean number of nodes examined in node-positive individuals was 21.0 vs 16.6 in node-negative individuals (P<.001). The mean number of nodes examined at medical center A was 22.3; center B, 17.9; and center C, 14.0. The mean number of nodes examined for T3 and T4 tumors at center A was 26; center B, 20; and center C, 16 (P<.001). The node-positive rate for all T3 and T4 lesions was 49.7% at center A, 57.8% at center B, and 50.0% at center C (P<.001). Despite significant differences in the mean number of nodes examined between medical centers, the overall survival in patients with node-negative colorectal cancer in the 3 medical centers was not statistically different (P = .79). The criterion of examining 14 or more nodes distinguished between individuals at low risk for recurrence and those at increased risk. CONCLUSIONS: Variability exists between medical centers in the pathological analysis of colorectal cancer specimens. However, within an institution, examining a mean of 14 or more nodes accurately stages apparently node-negative colorectal cancer and accurately predicts outcome.

ICD-9-CM and ICD-10-CM mapping of the AAST Emergency General Surgery disease severity grading systems: Conceptual approach, limitations, and recommendations for the future.

The American Association for the Surgery of Trauma (AAST) recently established a grading system for uniform reporting of anatomic severity of several emergency general surgery (EGS) diseases. There are five grades of severity for each disease, ranging from I (lowest severity) to V (highest severity). However, the grading process requires manual chart review. We sought to evaluate whether International Classification of Diseases, 9th and 10th Revisions, Clinical Modification (ICD-9-CM, ICD-10-CM) codes might allow estimation of AAST grades for EGS diseases. The Patient Assessment and Outcomes Committee of the AAST reviewed all available ICD-9-CM and ICD-10-CM diagnosis codes relevant to 16 EGS diseases with available AAST grades. We then matched grades for each EGS disease with one or more ICD codes. We used the Official Coding Guidelines for ICD-9-CM and ICD-10-CM and the American Hospital Association's "Coding Clinic for ICD-9-CM" for coding guidance. The ICD codes did not allow for matching all five AAST grades of severity for each of the 16 diseases. With ICD-9-CM, six diseases mapped into four categories of severity (instead of five), another six diseases into three categories of severity, and four diseases into only two categories of severity. With ICD-10-CM, five diseases mapped into four categories of severity, seven diseases into three categories, and four diseases into two categories. Two diseases mapped into discontinuous categories of grades (two in ICD-9-CM and one in ICD-10-CM). Although resolution is limited, ICD-9-CM and ICD-10-CM diagnosis codes might have some utility in roughly approximating the severity of the AAST grades in the absence of more precise information. These ICD mappings should be validated and refined before widespread use to characterize EGS disease severity. In the long-term, it may be desirable to develop alternatives to ICD-9-CM and ICD-10-CM codes for routine collection of disease severity characteristics.

Toll of methamphetamine on the trauma system.

HYPOTHESIS: Methamphetamine use affects length of hospital stay in the minimally injured patient. DESIGN: Case series. SETTING: The only tertiary trauma center serving Hawaii. PATIENTS: Trauma patients examined during a 12-month period with an Injury Severity Score of 1 to 5 and an age of 18 to 55 years undergoing urine toxicology screen for suspected suicide attempt or altered sensorium. MAIN OUTCOME MEASURES: Presence or absence of amphetamine or methamphetamine on urine toxicology screen, intention of injury, hospital admission rate, length of stay, and hospital charges. RESULTS: During the study period, 1650 trauma patients were examined, with 544 meeting study criteria. Urine toxicology screens were performed in 212 patients, with 57 positive and 155 negative for amphetamine or methamphetamine. There was no difference in sex (77% vs 73% male; P =.53), Injury Severity Score (3.2 for both groups), or total number of computed tomographic scans performed (mean +/- SEM, 3.0 +/- 0.3 vs 4.0 +/- 0.3; P =.07). Patients in the positive group were more likely to have intentional self-inflicted injury or intentional assaults than patients in the negative group (37% vs 22%; P =.04). The positive group was older than the negative group (33.6 +/- 1.3 vs 29.9 +/- 0.8 years; P =.02), had a significantly longer hospital stay (2.7 +/- 0.4 vs 1.7 +/- 0.1 days; P =.003), had significantly higher hospital charges (15 617 dollars +/- 1866 dollars vs 11 600 dollars +/- 648 dollars; P =.01), and was more likely admitted to the hospital (91% vs 70%; P =.001) despite the low Injury Severity Score. CONCLUSION: Methamphetamine use results in trauma center resource utilization out of proportion to injury severity.

Cutaneous melanoma in a multiethnic population: is this a different disease?

HYPOTHESIS: Cutaneous melanoma in nonwhite persons has a manifestation and a prognosis that are different than those of cutaneous melanoma in white persons. DESIGN: Case series. SETTING: Tertiary care university-affiliated community medical center located in a multiethnic state in which white persons are a minority of the population. PATIENTS: Consecutive series of 357 patients with melanoma seen between January 1994 and August 2003. MAIN OUTCOME MEASURES: Ethnicity, age, sex, primary site, tumor thickness, nodal status, stage at diagnosis, and survival. RESULTS: There were 208 men and 149 women who ranged in age from 15 to 93 years (mean, 58 years). Twenty-two patients initially had unknown primary sites. Of these 357 patients, 67 (18.7%) were nonwhite. There was no statistically significant difference in the age (P =.10) or sex (P =.57) distribution of these 2 populations. Nonwhite patients at initial diagnosis had thicker tumors (P =.002), more frequently had ulcerated primary tumors (P<.001), more frequently had positive nodes (P =.004), and were at a more advanced stage (P =.002) than their white counterparts. The anatomic distribution between the 2 populations was significantly different (P<.001), with a high incidence of melanoma on the sole and subungual locations and a substantially less frequent occurrence on the head and neck, trunk, and extremities in the nonwhite population when compared with the white population. The overall survival rate of the nonwhite patients was significantly worse than that of the white patients, but when stratified by stage at initial diagnosis, there was no difference in outcome. CONCLUSIONS: In a multiethnic population, cutaneous melanoma in nonwhite persons is unusual but not rare. Although the diagnoses are distinctly different at initial examinations, suggesting a potential biological component, stage-for-stage outcomes are similar between white and nonwhite persons and suggest a need for early diagnostic interventions with unusual pigmented lesions in nonwhite persons.

Eliminating catheter-associated urinary tract infections in the intensive care unit: is it an attainable goal?

BACKGROUND: Purpose of this study is to determine strategies to decrease catheter-associated urinary tract infection (CAUTI) in intensive care unit (ICU) patients. METHODS: ICU patients with an indwelling urinary catheter (UC) in one tertiary hospital were monitored for CAUTI. Interventions were implemented sequentially with quarterly data collection. Outcome measures were infection ratio (IR = number of infections/catheter days [CD] × 1000) and device utilization rate (DUR = catheter days/patient days). RESULTS: CDs and DUR decreased (fiscal year 2008: CD, 11,414; DUR, .85 vs fiscal year 2013: CD, 8,144; DUR, .70). IR increased with suspension of prepackaged baths (IR, 3.2 to 3.5 to 4.9 to 5.0), twice daily UC care (IR, 4.8 to 6.7), emptying UC bags at 400 mL (IR, 6.7 to 9.2). Two-person UC placement (IR, 5.6 to 4.8), physician notification of CAUTI (IR, 6.1 to 4.8), and reinstitution of prepackaged baths and daily UC care (IR, 4.8 to 3.7) decreased CAUTI rates. CONCLUSIONS: Decreasing CAUTI in the ICU requires diligent monitoring and constant practice re-evaluation. Elimination of CAUTI in the ICU may not be possible.