Rising incidence of interpersonal violence in Pennsylvania during COVID-19 stay-at home order.

BACKGROUND: The coronavirus disease 2019 pandemic and associated policies have had important downstream consequences for individuals, communities, and the healthcare system, and they appear to have been accompanied by rising interpersonal violence. The objective of this study was to evaluate the incidence of injuries owing to interpersonal violence after implementation of a statewide stay-at-home order in Pennsylvania in March 2020. METHODS: Using the Pennsylvania Trauma Outcome Study registry, we conducted a retrospective cohort study of patients with gunshot wounds, stab wounds, and blunt assault-related injuries attributable to interpersonal violence treated at Pennsylvania trauma centers from March 16 to July 31 of 2018, 2019, and 2020. RESULTS: There were fewer total trauma admissions in 2020 (17,489) vs 2018 (19,290) and 2019 (19,561). Gunshot wounds increased in 2020 to 737 vs 647 for 2019 and 565 for 2018 (P = .028), whereas blunt assault injuries decreased (P = .03). In all time periods, interpersonal violence primarily impacted urban counties. African American men were predominantly affected by gunshot wounds and stab wounds, whereas Caucasian men were predominantly affected by blunt assault injuries. There were more patients with substance abuse disorders and positive drug screens during coronavirus disease than in comparison periods: (stab wound population 52.3% vs 33.9% vs 45.9%, coronavirus disease era vs 2018 vs 2019, respectively P = .0001), (blunt assault injury population 41.4% vs 33.1% vs 33.5%, coronavirus disease era vs 2018 vs 2019, respectively P < .0001). There was no correlation between the incidence of interpersonal violence and coronavirus disease 2019 rates at the county level. CONCLUSION: The implementation of a stay-at-home order was accompanied by rising incidence of gunshot and stab wound injuries in Pennsylvania. Preparedness for future resurgences of coronavirus disease 2019 and other pandemics calls for plans to address injury prevention, recidivism, and access to mental health and substance abuse prevention services.

The impact of COVID-19 infection on outcomes after injury in a state trauma system.

BACKGROUND: The COVID-19 pandemic reshaped the health care system in 2020. COVID-19 infection has been associated with poor outcomes after orthopedic surgery and elective, general surgery, but the impact of COVID-19 on outcomes after trauma is unknown. METHODS: We conducted a retrospective cohort study of patients admitted to Pennsylvania trauma centers from March 21 to July 31, 2020. The exposure of interest was COVID-19 (COV+) and the primary outcome was inpatient mortality. Secondary outcomes were length of stay and complications. We compared demographic and injury characteristics between positive, negative, and not-tested patients. We used multivariable regression with coarsened exact matching to estimate the impact of COV+ on outcomes. RESULTS: Of 15,550 included patients, 8,170 (52.5%) were tested for COVID-19 and 219 (2.7%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in terms of age and sex, but were less often white (53.5% vs. 74.7%, p < 0.0001), and more often uninsured (10.1 vs. 5.6%, p = 0.002). Injury severity was similar, but firearm injuries accounted for 11.9% of COV+ patients versus 5.1% of COV- patients (p < 0.001). Unadjusted mortality for COV+ was double that of COV- patients (9.1% vs. 4.7%, p < 0.0001) and length of stay was longer (median, 5 vs. 4 days; p < 0.001). Using coarsened exact matching, COV+ patients had an increased risk of death (odds ratio [OR], 6.05; 95% confidence interval [CI], 2.29-15.99), any complication (OR, 1.85; 95% CI, 1.08-3.16), and pulmonary complications (OR, 5.79; 95% CI, 2.02-16.54) compared with COV- patients. CONCLUSION: Patients with concomitant traumatic injury and COVID-19 infection have elevated risks of morbidity and mortality. Trauma centers must incorporate an understanding of these risks into patient and family counseling and resource allocation during this pandemic. LEVEL OF EVIDENCE: Level II, Prognostic Study.

The impact of comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study.

BACKGROUND: Infectious airborne and surface pathogens constitute a substantial and poorly explored source of patient subclinical illness and infections. With that in mind, a system of advanced air purification technology was designed to destroy the DNA and RNA of all bacteria, fungi, and viruses. This study compares the effects of advanced air purification technology versus high efficiency particulate air filtration with respect to certain metrics of health care economics and resource utilization at a large, community-based, urban hospital. Our hypothesis was that the use of the advanced air purification technology would decrease health care durations of stay, lead to fewer nonhome discharges, and decrease hospital charges. METHODS: After the installation of advanced air purification technology, 3 resultant air purification "zones" were established: zone C, a control floor with high efficiency particulate air filtration; zone B, a mixed high efficiency particulate air and advanced air purification technology floor; and zone A, a comprehensive advanced air purification technology remediation. This study included nonbariatric surgical patients admitted to any zone between December 2017 and December 2018, with reported case mix index on discharge. We analyzed hospital duration of stays, discharge destination, and hospital charges with adjustment for severity of illness using the case mix index. The likelihood of mortality, health care-associated infection, and readmission for each study zone was examined using logistic regression adjusting for case mix index, age, sex, and source of admission. RESULTS: The study included 1,002 patients across the 3 zones, with mean age of 55.8 years (53.7% female), average case mix index of 1.98, and mortality of 1.7%. Compared with zone C, patients in zones A and B demonstrated decreased hospital stays, a greater percentage of home discharges (86.5-87.8% vs 64.7%), and less hospital charges. In addition, logistic regression modeling performed on 999 study patients showed that the likelihood of mortality, hospital-acquired infections, and readmissions did not differ among the 3 zones. A trend toward a lesser incidence of hospital-acquired infections was noted in zones A and B (0.40% and 0.48%, respectively) when compared with zone C (0.63%). CONCLUSION: Patients in the advanced air purification technology zones demonstrated statistically significant improvements in durations of stay, discharge to home, and costs after adjusting for case mix index. In addition, a trend toward fewer hospital-acquired infections in advanced air purification technology zones was noted. These findings suggest that environmental factors may affect key clinical and economic outcomes, supporting further research in this important and largely unexplored area.

Emergency Trauma Providers as Equal Partners: From "Proof of Concept" to "Outcome Parity".

Enmeshment of emergency trauma providers (ETPs) into the United States health-care fabric resulted in the establishment of a formalized surgical critical care fellowship and certification for emergency medicine trainees. The aim of this study was to compare trauma outcomes for surgery-trained providers (STPs) and ETPs at our institution, hypothesizing patient outcome equivalency. We performed an institutional review board-exempt institutional registry review (January 1, 2004 to August 1, 2018), comparing 74 STPs and 6 ETPs. Comparator variables included all-cause mortality, all-cause morbidity, CT imaging studies per provider, time in ED (min), hospital/ICU lengths of stay, ICU admissions, and functional outcomes on discharge. Statistical comparisons included chi-square test for categorical data and analysis of covariance for continuous data (adjustments made for patient age, Injury Severity Score, and trauma mechanism; all P < 0.20). Statistical significance was set at P < 0.05, with an equivalence study design. A total of 33,577 trauma resuscitations were reviewed (32,299 STP-led and 1,278 ETP-led). Except for patient age (STP 50.2 ± 25.9 vs ETP 54.9 ± 25.3 years), Injury Severity Score (8.47 ± 8.14 vs 9.22 ± 8.40), and ICU admissions (16.1% vs 18.8%), we noted no significant intergroup differences. ETPs' performance was equivalent to that of STPs for all primary comparator variables (mortality, morbidity, CT utilization, time in the ED, lengths of stay, and functional outcomes). Incorporation of ETPs into our trauma center resulted in outcome parity between ETPs and STPs, while simultaneously expanding the expertise and experiential diversity within our multidisciplinary team. This study provides support for further incorporation of ETPs as equal partners across the growing network of United States regional trauma centers.

A seven-center examination of the relationship between monthly volume and mortality in trauma: a hypothesis-generating study.

INTRODUCTION: The relationship between trauma volumes and patient outcomes continues to be controversial, with limited data available regarding the effect of month-to-month trauma volume variability on clinical results. This study examines the relationship between monthly trauma volume variations and patient mortality at seven Level I Trauma Centers located in the Eastern United States. We hypothesized that higher monthly trauma volumes may be associated with lower corresponding mortality. METHODS: Monthly patient volume data were collected from seven Level I Trauma Centers. Additional information retrieved included monthly mortality, demographics, mean monthly injury severity (ISS), and trauma mechanism (blunt versus penetrating). Mortality was utilized as the primary study outcome. Statistical corrections for mean age, gender distribution, ISS, and mechanism of injury were made using analysis of co-variance (ANCOVA). Center-specific, annually-adjusted median monthly volumes (CSAA-MMV) were calculated to standardize patient volume differences across participating institutions. Statistical significance was set at α < 0.05. RESULTS: A total of 604 months of trauma admissions, encompassing 122,197 patients, were analyzed. Controlling for patient age, gender, ISS, and mechanism of injury, aggregate data suggested that monthly trauma volumes < 100 were associated with significantly greater mortality (3.9%) than months with volumes > 400 (mortality 2.9%, p < 0.01). To account for differences in monthly volumes between centers, as well as for temporal bias associated with potential differences over the entire study duration period, data were normalized using CSAA-MMV as a standardized reference point. Monthly volumes ≤ 33% of the CSAA-MMV were associated with adjusted mortality of 5.0% whereas monthly volumes ≥ 134% CSAA-MMV were associated with adjusted mortality of 2.7% (p < 0.01). CONCLUSIONS: This hypothesis-generating study suggests that greater monthly trauma volumes appear to be associated with lower mortality. In addition, our data also suggest that across all participating centers mortality may be a function of relative month-to-month volume variation. When normalized to institution-specific, annually-adjusted "median" monthly trauma contacts, we show that months with patient volumes ≤ 33% median may be associated with subtly but not negligibly (1.4-2.3%) higher mortality than months with patient volumes ≥ 134% median.

Ethics of Outbreaks Position Statement. Part 1: Therapies, Treatment Limitations, and Duty to Treat.

OBJECTIVES: Outbreaks of disease, especially those that are declared a Public Health Emergency of International Concern, present substantial ethical challenges. Here we start a discourse (with a continuation of the dialogue in Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care) concerning the ethics of the provision of medical care, research challenges and behaviors during a Public Health Emergency of International Concern with a focus on the proper conduct of clinical or epidemiologic research, clinical trial designs, unregistered medical interventions (including vaccine introduction, devices, pharmaceuticals, who gets treated, vulnerable populations, and methods of data collection), economic losses, and whether there is a duty of health care providers to provide care in such emergencies, and highlighting the need to understand cultural diversity and local communities in these efforts. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review and expert consensus from the Society of Critical Care Medicine Ethics committee. The committee had representation from ethics, medical philosophy, critical care, nursing, internal medicine, emergency medicine, pediatrics, anesthesiology, surgery, and members with international health and military experience. SETTING: Provision of therapies for patients who are critically ill or who have the potential of becoming critically ill, and their families, regarding medical therapies and the extent of treatments. POPULATION: Critically ill patients and their families affected by a Public Health Emergency of International Concern that need provision of medical therapies. INTERVENTIONS: Not applicable. MAIN RESULTS: Interventions by high income countries in a Public Health Emergency of International Concern must always be cognizant of avoiding a paternalistic stance and must understand how families and communities are structured and the regional/local traditions that affect public discourse. Additionally, the obligations, or the lack of obligations, of healthcare providers regarding the treatment of affected individuals and communities must also be acknowledged. Herein, we review such matters and suggest recommendations regarding the ethics of engagement in an outbreak that is a Public Health Emergency of International Concern.

Portal vein thrombosis: What surgeons need to know.

KEY POINTS: (a) The lifetime risk of portal vein thrombosis (PVT) is approximately 1%; (b) The portal vein is formed by the union of the splenic and superior mesenteric veins posterior to the pancreas; (c) Imaging modalities most frequently used to diagnose PVT include sonography, computed tomography, and magnetic resonance imaging; (d) Malignancy, hepatic cirrhosis, surgical trauma, and hypercoagulable conditions are the most common risk factors for the development of PVT; (e) PVT eventually leads to the formation of numerous collateral vessels around the thrombosed portal vein; (f) First-line treatment for PVT is therapeutic anticoagulation-it helps prevent the progression of the thrombotic process; (g) Other therapeutic options include surgery and interventional radiographic procedures including mechanical thrombectomy and thrombolysis; (h) Portal biliopathy is a clinicopathologic entity characterized by biliary abnormalities due to portal hypertension secondary to PVT and appears to be more common in cases of extrahepatic PVT. REPUBLISHED WITH PERMISSION FROM: Quarrie R, Stawicki SP. Portal vein thrombosis: What surgeons need to know. OPUS 12 Scientist 2008;2(3):30-33.

Early Results of Fecal Microbial Transplantation Protocol Implementation at a Community-based University Hospital.

INTRODUCTION: Clostridium difficile (CD) is a serious and increasingly prevalent healthcare-associated infection. The pathogenesis of CD infection (CDI) involves the acquisition of CD with a concurrent disruption of the native gut flora. Antibiotics are a major risk although other contributing factors have also been identified. Clinical management combines discontinuation of the offending antibiotic, initiation of CD-specific antibiotic therapy, probiotic agent use, fecal microbiota transplantation (FMT), and surgery as the "last resort" option. The aim of this study is to review short-term clinical results following the implementation of FMT protocol (FMTP) at our community-based university hospital. METHODS: After obtaining Institutional Review Board and Infection Control Committee approvals, we implemented an institution-wide FMTP for patients diagnosed with CDI. Prospective tracking of all patients receiving FMT between July 1, 2015, and February 1, 2017, was conducted using REDCap™ electronic data capture system. According to the FMTP, indications for FMT included (a) three or more CDI recurrences, (b) two or more hospital admissions with severe CDI, or (c) first episode of complicated CDI (CCDI). Risk factors for initial infection and for treatment failure were assessed. Patients were followed for at least 3 months to monitor for cure/failure, relapse, and side effects. Frozen 250 mL FMT samples were acquired from OpenBiome (Somerville, MA, USA). After 4 h of thawing, the liquid suspension was applied using colonoscopy, beginning with terminal ileum and proceeding distally toward mid-transverse colon. Monitored clinical parameters included disease severity (Hines VA CDI Severity Score or HVCSS), concomitant medications, number of FMT treatments, non-FMT therapies, cure rates, and mortality. Descriptive statistics were utilized to outline the study results. RESULTS: A total of 35 patients (mean age 58.5 years, 69% female) were analyzed, with FMT-attributable primary cure achieved in 30/35 (86%) cases. Within this subgroup, 2/30 (6.7%) patients recurred and were subsequently cured with long-term oral vancomycin. Among five primary FMT failures (14% total sample), 3 (60%) achieved medical cure with long-term oral vancomycin therapy and 2 (40%) required colectomy. For the seven patients who either failed FMT or recurred, long-term vancomycin therapy was curative in all but two cases. For patients with severe CDI (HVCSS ≥3), primary and overall cure rates were 6/10 (60%) and 8/10 (80%), respectively. Patients with CCDI (n = 4) had higher HVCSS (4 vs. 3) and a mortality of 25%. Characteristics of patients who failed initial FMT included older age (70 vs. 57 years), female sex (80% vs. 67%), severe CDI (80% vs. 13%), and active opioid use during the initial infection (60% vs. 37%) and at the time of FMT (60% vs. 27%). The most commonly reported side effect of FMT was loose stools. CONCLUSIONS: This pilot study supports the efficacy and safety of FMT administration for CDI in the setting of a community-based university hospital. Following FMTP implementation, primary (86%) and overall (94%) nonsurgical cure rates were similar to those reported in other studies. The potential role of opioids as a modulator of CDI warrants further clinical investigation.

Exploring the association between initial serum alcohol concentration and polysubstance use: More than a simple "gateway drug" effect?

INTRODUCTION: Polysubstance abuse (PSA) is a significant problem affecting our society. In addition to negatively affecting the health and well-being of substance users, alcohol and/or drug abuse is also associated with heavy injury burden. The goal of this study was to determine if elevated serum alcohol (EtOH) levels on initial trauma evaluation correlate with the simultaneous presence of other substances of abuse (SOAs). We hypothesized that PSA would be more common among patients who present with EtOH levels in excess of the legal blood alcohol content (BAC) (≥0.10%). METHODS: An audit of trauma registry records from January 2009 to June 2015 was performed. Abstracted data included patient demographics, BAC measurements, all available formal determinations of urine/serum "drug screening," Glasgow Coma Scale (GCS) assessments, injury mechanism/severity, and 30-day mortality. Stratification of BAC was based on the 0.10% cutoff. Parametric and nonparametric statistical testing was performed, as appropriate, with significance set at α = 0.05. RESULTS: We analyzed 1550 patients (71% males, mean age: 38.7 years) who had both EtOH and SOA screening. Median GCS was 15 (interquartile range [IQR]: 14-15). Median ISS was 9 (IQR: 5-17). Overall 30-day mortality was 4.25%, with no difference between elevated (≥0.10) and normal (<0.10) EtOH groups. For the overall study sample, the median BAC was 0.10% (IQR: 0-0.13). There were 1265 (81.6%) patients with BAC <0.10% and 285 (18.4%) patients with BAC ≥0.10%. The two groups were similar in terms of mechanism of injury (both, ∼95% blunt). Patients with BAC ≥0.10% on initial trauma evaluation were significantly more likely to have the findings consistent with PSA (e.g., EtOH + additional substance) than patients with BAC <0.10% (377/1265 [29.8%] vs. 141/285 [49.5%], respectively, P < 0.001). Among polysubstance users, BAC ≥0.10% was significantly associated with cocaine, marijuana, and opioid use. CONCLUSIONS: This study confirms that a significant proportion of trauma patients with admission BAC ≥0.10% present with the evidence of additional substance use. Cocaine and opioids were most strongly associated with acute alcohol intoxication. Our findings support the need for further research in this important area of public health concern. In addition, specific efforts should focus on primary identification, remediation of withdrawal symptoms, prevention of drug-drug interactions, and early PSA intervention.

Competitive Advantage of MBA for Physician Executives: A Systematic Literature Review.

In response to systemic challenges facing the US healthcare system, many medical students, residents and practicing physicians are pursuing a Master in Business Administration (MBA) degree. The value of such proposition remains poorly defined. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician executives (PEs). We hypothesized that physicians who supplement their clinical expertise with business education gain a significant competitive advantage. A detailed literature search of four electronic databases (PubMed, SCOPUS, Embase and ERIC) was performed. Included were studies published between Jan 2000 and June 2017, focusing specifically on PEs. Among 1580 non-duplicative titles, we identified 23 relevant articles. Attributes which were found to add value to one's competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication. We found that competitive domains deemed to be most important for PEs in the context of MBA training were leadership (n = 17), career advancement opportunities (n = 12), understanding of financial aspects of medicine (n = 9) and team-building skills (n = 10). Among other prominent factors associated with the desire to engage in an MBA were higher compensation, awareness of public health issues/strategy, increased negotiation skills and enhanced work-life balance. Of interest, the learning of strategies for reducing malpractice litigation was less important than the other drivers. This comprehensive systemic review supports our hypothesis that a business degree confers a competitive advantage for PEs. Physician executives equipped with an MBA degree appear to be better equipped to face the challenge of the dynamically evolving healthcare landscape. This information may be beneficial to medical schools designing or implementing combined dual-degree curricula.

Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost.

BACKGROUND: Approximately 250,000 new cases of breast cancer are diagnosed yearly in the U.S. resulting in more postmastectomy breast reconstructions (PMBRs). The acellular dermal matrix (ADM) expander-implant method became popular in the mid-2000s, but newer techniques such as the inferior deepithelialized flap (IDF) has more recently been described. We hypothesize that ADMs and IDFs provide comparable aesthetic outcomes, with no difference in complication rates and operative characteristics. METHODS: A retrospective, single-institution study was performed between July 1, 2012, and June 30, 2014, examining all PMBR's (ADM and IDF). Outcomes were categorized as clinical (e.g., complications requiring surgical intervention) or aesthetic. RESULTS: A total of 65 patients (41 ADM; 24 IDF; mean age, 53.4 ± 10.7 years) were included, with 101 PMBR's evaluated (63 ADM and 38 IDF). Patients who underwent IDFs had higher body mass index (32 versus 25; P < 0.01) and higher grades of breast ptosis. Major complication rates were similar between ADM and IDF groups (22% versus 31.5%; P = 0.34). There were no differences in aesthetic outcomes between groups (rater intraclass correlation, 0.92). The average IDF breast reconstruction took nearly 30 minutes longer per reconstructed side (192 minutes versus 166 minutes; P = 0.02), but operative costs were more expensive for the ADM breast reconstruction. CONCLUSIONS: The IDF procedure took 30 minutes longer for each reconstructed side, without significant differences in complications or aesthetic outcomes between the 2 PMBRs. IDF reconstructions may be more suitable for patients with grade 3 breast ptosis and higher body mass index. Further studies should focus on long-term outcomes and value-based approaches to PMBR.

Operation versus antibiotics--The "appendicitis conundrum" continues: A meta-analysis.

BACKGROUND: Acute appendicitis continues to constitute a diagnostic and therapeutic challenge. The aim of this study was to synthesize evidence from randomized controlled trials (RCTs) comparing nonoperative versus surgical management of uncomplicated acute appendicitis in adult patients. METHODS: A systematic literature search of the PubMed, Cochrane, and Scopus databases was performed with respect to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement (end-of-search date: January 29, 2017). Data on the study design, interventions, participants, and outcomes were extracted by two independent reviewers. The random-effects model (DerSimonian-Laird) was used to calculate pooled effect estimates when substantial heterogeneity was encountered; otherwise, the fixed-effects (Mantel-Haenszel) model was implemented. Quality assessment of included RCTs was performed using the modified Jadad scale. RESULTS: Five RCTs were included in this review. Overall, 1,430 adult patients with uncomplicated acute appendicitis underwent either nonoperative (n = 727) or operative management (n = 703). Treatment efficacy at 1-year follow-up was significantly lower (63.8%) for antibiotics compared with the surgery group (93%) (risk ratio [RR], 0.68; 95% confidence interval [CI], 0.60-0.77; p < 0.001). Overall complications were significantly higher in the surgery group (166/703 [23.6%]) compared with the antibiotics group (56/727 [7.7%]) (RR, 0.32; 95% CI, 0.24-0.43; p < 0.001). No difference was found between the two treatment modalities in terms of perforated appendicitis rates (RR, 0.52; 95% CI, 0.14-1.92), length of hospital stay (weighted mean difference [WMD], 0.20; 95% CI, -0.16 to 0.56), duration of pain (WMD, 0.22; 95% CI, -5.30 to -5.73), and sick leave (WMD, -2; 95% CI, -5.2 to 1.1). CONCLUSIONS: Conservative management of uncomplicated appendicitis in adults warrants further study. Addressing patients' expectations via a shared decision-making process is a crucial step in optimizing nonoperative outcomes. LEVEL OF EVIDENCE: Systematic review, level II.

Predictors of dexmedetomidine-associated hypotension in critically ill patients.

BACKGROUND: Dexmedetomidine is commonly used for sedation in the Intensive Care Unit (ICU), and its use may be associated with hypotension. We sought to determine predictors of dexmedetomidine-associated hypotension. METHODS: Retrospective, single-center study of 283 ICU patients in four adults ICUs over a 12 month period. Univariate analyses were performed to determine factors associated with dexmedetomidine-related hypotension. Risk factors significant at the 0.20 level in the univariate analysis were considered for inclusion into a step-wise multiple logistical regression model. RESULTS: Hypotension occurred in 121 (42.8%) patients with a median mean arterial pressure (MAP) nadir of 54 mmHg. Univariate analyses showed an association between hypotension and age (P = 0.03), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (P = 0.02), baseline MAP (<0.001), admission to the cardiothoracic ICU (P = 0.05), history of coronary artery disease (P = 0.02), and postcardiac surgery (P = 0.0009). Admission to the medical ICU was associated with a decrease in development in hypotension (P = 0.03). There was a trend for hypotension with weight (P = 0.09) and history of congestive heart failure (P = 0.12) Only MAP prior to initiation (odds ratio [OR] 0.97, 95% confidence interval [95% CI] 0.95-0.99; P < 0.0001), APACHE II scores (OR 1.06, 95% CI 1.01-1.12; P = 0.017), and history of coronary artery disease (OR 0.48, 95% CI 0.26-0.90, P = 0.022) were independently associated with hypotension by multivariable analysis. CONCLUSIONS: Dexmedetomidine-associated hypotension is common. Preexisting low blood pressure, history of coronary artery disease, and higher acuity were identified as independent risk factors for dexmedetomidine-associated hypotension.

Traditional autopsy versus computed tomography imaging autopsy in trauma: A case of "synergistic disagreement".

BACKGROUND: Decreases in the rates of traditional autopsy (TA) negatively impact traumatology, especially in the areas of quality improvement and medical education. To help enhance the understanding of trauma-related mortality, a number of initiatives in imaging autopsy (IA) were conceived, including the postmortem computed tomography ("CATopsy") project at our institution. Though IA is a promising concept, few studies directly correlate TA and IA findings quantitatively. Here, we set out to increase our understanding of the similarities and differences between key findings on TA and IA in a prospective fashion with blinding of pathologist and radiologist evaluations. METHODS: A prospective study of TA versus IA was conducted at an Academic Level I Trauma Center (June 2001-May 2010). All decedents underwent a postmortem, whole-body, noncontrast computed tomography that was interpreted by an independent, blinded, board-certified radiologist. A blinded, board-certified pathologist then performed a TA. Autopsy results were grouped into predefined categories of pathologic findings. Categorized findings from TA and IA were compared by determining the degree of agreement (kappa). The χ(2) test was used to detect quantitative differences in "potentially fatal" findings (eg, aortic trauma, splenic injury, intracranial bleeding, etc) between TA and IA. RESULTS: Twenty-five trauma victims (19 blunt; 9 female; median age 33 years) had a total of 435 unique findings on either IA or TA grouped into 34 categories. The agreement between IA and TA was worse than what chance would predict (kappa = -0.58). The greatest agreement was seen in injuries involving axial skeleton and intracranial/cranio-facial trauma. Most discrepancies were seen in soft tissue, ectopic air, and "incidental" categories. Findings determined to be "potentially fatal" were seen on both TA/IA in 48/435 (11%) instances with 79 (18%) on TA only and 53 (12%) on IA only. TA identified more "potentially fatal" solid organ and heart/great vessel injuries, while IA revealed more spine injuries, "potentially fatal" procedure-related findings, and the presence of ectopic air/fluid. CONCLUSION: This limited study does not support substitution of noncontrast, computed tomography-based IA for TA. Our quantitative analyses suggest that TA and IA evaluations may be complementary and synergistic when performed concurrently. There are potential benefits to using IA in trauma process/quality improvement and in educational settings. Further research should focus on the value (and limitations) of the information provided by IA in the absence of TA.

Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective.

Modern medical management of comorbid conditions has resulted in escalating use of multiple medications and the emergence of the twin phenomena of multimorbidity and polypharmacy. Current understanding of how the polypharmacy in conjunction with multimorbidity influences trauma outcomes is limited, although it is known that trauma patients are at increased risk for medication-related adverse events. The comorbidity-polypharmacy score (CPS) is a simple clinical tool that quantifies the overall severity of comorbidities using the polypharmacy as a surrogate for the "intensity" of treatment necessary to adequately control chronic medical conditions. Easy to calculate, CPS is derived by counting all known pre-injury comorbid conditions and medications. CPS has been independently associated with mortality, increased risk for complications, lower functional outcomes, readmissions, and longer hospital stays. In addition, CPS may help identify older trauma patients at risk of post-emergency department undertriage. The goal of this article was to review and refine the rationale for CPS and to provide an evidence-based outline of its potential clinical applications.

Laparoscopy in trauma: An overview of complications and related topics.

The introduction of laparoscopy has provided trauma surgeons with a valuable diagnostic and, at times, therapeutic option. The minimally invasive nature of laparoscopic surgery, combined with potentially quicker postoperative recovery, simplified wound care, as well as a growing number of viable intraoperative therapeutic modalities, presents an attractive alternative for many traumatologists when managing hemodynamically stable patients with selected penetrating and blunt traumatic abdominal injuries. At the same time, laparoscopy has its own unique complication profile. This article provides an overview of potential complications associated with diagnostic and therapeutic laparoscopy in trauma, focusing on practical aspects of identification and management of laparoscopy-related adverse events.

Amniotic fluid embolism: despite progress, challenges remain.

PURPOSE OF REVIEW: This article reviews the incidence, pathophysiology, risk factors, diagnosis, and management of amniotic fluid embolism (AFE). RECENT FINDINGS: AFE is a leading cause of maternal morbidity and mortality despite an incidence of approximately 7 to 8 per 100,000 births. Recent reevaluation of AFE suggests that the presence of fetal tissue in maternal circulation alone is not sufficient to cause the clinical syndrome, but rather an individual's response to this fetal tissue. The 'anaphylactoid reaction' associated with AFE shares many clinical and metabolic aspects of septic shock. Acute dyspnea followed by cardiovascular collapse, coagulopathy, and neurological symptoms, such as coma and seizures may all be associated with the clinical AFE syndrome. Specific biochemical markers have been described, but are of limited clinical value because of the rapid progression of the disease process. Treatment is based on an interdisciplinary approach that consists of a combination of prompt, aggressive hemodynamic resuscitation, provision of end-organ support, correction of hemostatic disorders, and delivery. SUMMARY: Although AFE cannot be prevented, early diagnosis and intervention may lead to better outcomes for both the mother and the fetus. Clinical suspicion, traditional laboratory data, or intravascular cellular debris (demonstrated only in 50% of patients) are insufficient to make a definitive diagnosis of AFE. An evolving array of novel biomarkers may help differentiate AFE from other conditions, but none of them currently provide sufficient 'early warning' ability to make real-time impact on diagnosis and/or treatment of AFE.

Comorbidity-polypharmacy score predicts readmission in older trauma patients.

BACKGROUND: Hospital readmissions are considered to be a measure of quality of care, correlate with worse outcomes, and may soon lead to decreased reimbursement. The comorbidity-polypharmacy score (CPS) is the sum of the number of preinjury medications and comorbidities, and may estimate patient frailty more effectively than patient age. This study evaluates the association between CPS and readmission. METHODS: Medical records for trauma patients ≥45 y evaluated between January 1 and December 31, 2008, at our American College of Surgeons-verified level 1 trauma center were reviewed to obtain information on demographics, injuries, preinjury comorbidities, and medications, and occurrences of readmission to our facility within 30 d of discharge. Chi-square and Kruskal-Wallis testing was used to evaluate differences between readmitted and nonreadmitted patients, with multiple logistic regression used to evaluate the contribution of independent risk factors for readmission. RESULTS: A total of 879 patients were included; their ages ranged from 45-103 y (median 58), injury severity scores from 0-50 y (median 5), and CPS from 0-39 y (median 7). A total of 76 patients (8.6%) were readmitted to our facility within 30 d of discharge. The readmitted cohort had higher CPS (median, 9.5, range 0-32, P = 0.031) and injury severity score (median, 9, range 1-38, P = 0.045), but no difference in age (median, 59.5, range 47-99, P = 0.646). Logistic regression demonstrated independent association of higher CPS with increased risk of readmission, with each CPS point increasing readmission likelihood by 3.5% (P = 0.03). CONCLUSIONS: CPS appears to correlate well with readmissions within 30 d. Frailty defined by CPS was a significantly stronger predictor of readmission than was patient age. Early recognition of elevated CPS may improve discharge planning and help guide interventions to decrease readmission rates in older trauma patients.

Complications of chest tubes: a focused clinical synopsis.

PURPOSE OF REVIEW: Chest tube placement, or tube thoracostomy, is an invasive procedure designed to evacuate air and/or fluid from the thorax, whether emergent or elective. In the placement of these devices particular attention and effort must be made to understand safe and reliable anatomic techniques and device maintenance so as to avoid serious injury to the patient. This review focuses on complications of chest tube placement, with the emphasis on patient safety and error prevention. RECENT FINDINGS: There is a paucity of high-quality recent literature on tube thoracostomy complications. With the advent of value-driven healthcare, increasing emphasis is being placed on appropriate procedural indications, procedural safety, and patient satisfaction. Good clinical outcomes are critical to achieve and maintain in this context. SUMMARY: Given the high volume of tube thoracostomies globally, greater awareness of potential complications and preventive strategies is needed. The authors attempt to bridge this important gap.