Chances of Mortality Are 3.5-Times Greater in Elderly Patients with Umbilical Hernia Than in Adult Patients: An Analysis of 21,242 Patients.

The goal of this study was to identify risk factors that are associated with mortality in adult and elderly patients who were hospitalized for umbilical hernia. A total of 14,752 adult patients (ages 18−64 years) and 6490 elderly patients (ages 65+), who were admitted emergently for umbilical hernia, were included in this retrospective cohort study. The data were gathered from the National Inpatient Sample (NIS) 2005−2014 database. Predictors of mortality were identified via a multivariable logistic regression, in patients who underwent surgery and those who did not for adult and elderly age groups. The mean (SD) ages for adult males and females were 48.95 (9.61) and 46.59 (11.35) years, respectively. The mean (SD) ages for elderly males and females were 73.62 (6.83) and 77.31 (7.98) years, respectively. The overall mortality was low (113 or 0.8%) in the adult group and in the elderly group (179 or 2.8%). In adult patients who underwent operation, age (OR = 1.066, 95% CI: 1.040−1.093, p < 0.001) and gangrene (OR = 5.635, 95% CI: 2.288−13.874, p < 0.001) were the main risk factors associated with mortality. Within the same population, female sex was found to be a protective factor (OR = 0.547, 95% CI: 0.351−0.854, p = 0.008). Of the total adult sample, 43% used private insurance, while only 18% of patients in the deceased population used private insurance. Conversely, within the entire adult population, only about 48% of patients used Medicare, Medicaid, or self-pay, while these patients made up 75% of the deceased group. In the elderly surgical group, the main risk factors significantly associated with mortality were frailty (OR = 1.284, 95% CI: 1.105−1.491, p = 0.001), gangrene (OR = 13.914, 95% CI: 5.074−38.154, p < 0.001), and age (OR = 1.034, 95% CI: 1.011−1.057, p = 0.003). In the adult non-operation group, hospital length of stay (HLOS) was a significant risk factor associated with mortality (OR = 1.077, 95% CI: 1.004−1.155, p = 0.038). In the elderly non-operation group, obstruction was the main risk factor (OR = 4.534, 95% CI: 1.387−14.819, p = 0.012). Elderly patients experienced a 3.5-fold higher mortality than adult patients who were emergently admitted with umbilical hernia. Increasing age was a significant risk factor of mortality within all patient populations. In the adult surgical group, gangrene, Medicare, Medicaid, and self-pay were significant risk factors of mortality and female sex was a significant protective factor. In the adult non-surgical group, HLOS was the main risk factor of mortality. In the elderly population, frailty and gangrene were the main risk factors of mortality within the surgical group, and obstruction was the main risk factor for the non-surgical group.

Disparate access to breast cancer screening and treatment.

BACKGROUND: Barriers to breast cancer screening remain despite Medicaid expansion for preventive screening tests and implementation of patient navigation programs under the Affordable Care Act. Women from underserved communities experience disproportionately low rates of screening mammography. This study compares barriers to breast cancer screening among women at an inner-city safety-net center (City) and those at a suburban county medical center (County). Inner city and suburban county medical centers' initiatives were studied to compare outcomes of breast cancer screening and factors that influence access to care. METHODS: Women 40 years of age or older delinquent in breast cancer screening were offered patient navigation services between October 2014 and September 2019. Four different screening time-to-event intervals were investigated: time from patient navigation acceptance to screening mammography, to diagnostic mammography, to biopsy, and overall screening completion time. Barriers to complete breast cancer screening between the two centers were compared. RESULTS: Women from lowest income quartiles took significantly longer to complete breast cancer screening when compared to women from higher income quartiles when a barrier was present, regardless of barrier type and center. Transportation was a major barrier to screening mammography completion, while fear was the major barrier to abnormal screening work up. CONCLUSION: Disparity in breast cancer screening and management persists despite implementation of a patient navigation program. In the presence of a barrier, women from the lowest income quartiles have prolonged breast cancer screening completion time regardless of center or barrier type. Women who experience fear have longest screening time completion. Future directions aim to increase resource allocation to ameliorate wait times in overburdened safety-net hospitals as well as advanced training for patient navigators to alleviate women's fears.

A Cost-Benefit Analysis of an Overseas Volunteer Mission to the Local Healthcare System.

BACKGROUND: The aim of this study was to comparatively evaluate the sustainability and cost-benefit of the Operation Giving Back Bohol surgical volunteerism mission (SVM) carried out in Bohol Province, Philippines, over twelve consecutive missions. METHODS: This was a cost-benefit analysis of prospectively collected financial data from twelve consecutive surgical volunteerism missions held between 2006 and 2018. The overall cost of an SVM and cost per patient were the endpoints of interest. Disability-adjusted life years (DALYs) and costs thereof were calculated for each patient undergoing surgery in the twelve SVMs. RESULTS: A mean of 112 ± 22 patients were included per year of the SVM. A statistically significant increasing trend in the overall cost of SVMs over time was found (R2 = .469; P = .014). A nonsignificant decreasing trend in the cost per patient over time was found (R2 = .007; P = .795). A total of 8811.71 DALYs were averted in the twelve SVMs. DALYs averted per year ranged between 474.02 (2009) and 969.16 (2012). Cost per a DALY averted ranged between $466.9 (2006) and $865.6 (2009). Comparison of the latter with GDP per capita showed that this SVM was "very cost-effective." CONCLUSION: The SVM contributes substantially to the health care system both clinically and financially. A total of 8812 DALYs were averted in these twelve SVMs. Costs per a DALY averted did not significantly change over the mission years. Increasing the number of patients served has increased the total cost of the mission with no impact on the cost per patient.

Telemedicine Consultation as an Indicator of Local Telemedicine Champions' Contributions, Health Care System Needs or Both: Tales from Two Continents.

Background: Telemedicine systems increase access to care, particularly in remote and developing countries. Nationwide telemedicine programs in Cabo Verde and Albania have been built by the International Virtual e-Hospital Foundation (IVeH) and based on the effective Initiate-Build-Operate-Transfer (IBOT) strategy. The aim of this study was to compare the clinical results between the two programs and examine the relationship between the clinical teleconsultations as an indicator of health care system needs and the contribution of local telemedicine champions. Methods: Data were prospectively collected between 2014 and 2018 from Albania and Cabo Verde. Telemedicine champions were defined as programs, physicians, or hospitals who have contributed at least 100 telemedicine consultations during the study periods. Chi-squared test was utilized to analyze the data. Results: There were 2,442 teleconsultations in Cabo Verde and 2,724 teleconsultations in Albania during the study periods. Using the 100-consultation benchmark as the indicator of telemedicine champion, we identified radiology (n = 1,061), neurotrauma (n = 742), and general neurology or stroke (n = 489) as champion clinical disciplines in Albania. With the same method of 100 consultations, we identified eight champion clinical disciplines in Cabo Verde, including neurology (n = 720), cardiology (n = 313), orthopedics (n = 190), surgery (143), endocrinology (141), otolaryngology (n = 139), urology (n = 139), and dermatology (126). The patient transfer/nontransfer ratio was 0.5 in Cabo Verde and 0.3 in Albania (p < 0.001). Three hospitals in Albania and eight community hospitals/health care centers in Cabo Verde requested the majority of teleconsultations. Two main hospitals in Cabo Verde and Albania responded to the consultations. Conclusion: The successful implementation of a telemedicine program depends on many factors. However, physician champions, who eventually create clinical discipline champions, and represent the hospital champions, are the backbone of the sustainability and progress of any telemedicine program. The number of consultations reflects the lack of local specialty expertise to provide health care service and thus can be used for future planning and investment.

Predicting the need for tracheostomy in trauma patients without severe head injury.

BACKGROUND: Early tracheostomy is recommended in patients with severe traumatic brain injury (TBI); however, predicting the timing of tracheostomy in trauma patients without severe TBI can be challenging. METHODS: A one year retrospective analysis of all trauma patients who were admitted to intensive Care Unit for > 7 days was performed, using the ACS-TQIP database. Univariate and Multivariate regression analyses were performed to assess the appropriate weight of each factor in determining the eventual need for early tracheostomy. RESULTS: A total of 21,663 trauma patients who met inclusion and exclusion criteria were identified. Overall, tracheostomy was performed in 18.3% of patients. On multivariate regression analysis age >70, flail chest, major operative intervention, ventilator days >5 days and underlying COPD were independently associated with need of tracheostomy. Based on these data, we developed a scoring system to predict risk for requiring tracheostomy. CONCLUSION: Age >70, presence of flail chest, need for major operative intervention, ventilator days >5 and underlying COPD are independent predictors of need for tracheostomy in trauma patients without severe TBI.

Falling Again? Falls in Geriatric Adults-Risk Factors and Outcomes Associated With Recidivism.

BACKGROUND: The elderly population is at increased risk of fall-related readmissions (FRRs). This study is aimed to identify the factors predictive of repeat falls and to analyze the associated outcomes. METHODS: We studied the Nationwide Readmission Database for the year 2010 and identified the patients (≥65 years) who were admitted after falls, and from that subset, further analyzed patients with ≥1 FRRs. Descriptive statistics were used to analyze continuous and categorical variables. Multivariable logistic regression was used to identify predictors of readmission in geriatric patients after controlling for covariates. RESULTS: A total of 358,581 initial fall-related admissions in geriatric adults were identified, and of these, 21,713 experienced ≥1 FRRs (6.06% risk of repeat fall-related admission). Females outnumbered males, and female gender was identified as an independent predictor of FRR (OR 1.10 95% CI 1.07-1.14 P = 0.000). The other independent predictors significantly associated with FRR were age (OR 1.007, 95% CI 1.005-1.009), depression (OR 1.25, 95% CI 1.21-1.30), drug abuse (OR 1.37, 95% CI 1.15-1.63), liver disease (OR 1.25, 95% CI 1.15-1.43, P < 0.001), psychosis (OR 1.16, 95% CI 1.09-1.23), valvular heart disease (OR 1.07, 95% CI 1.02-1.12), chronic pulmonary disease (OR 1.10, 95% CI 1.06-1.13), and number of chronic conditions (OR 1.022, 95% CI 1.016-1.29). Patients admitted emergently or urgently had higher odds of FRR (OR 1.44, 95% CI 1.36-1.52). Hospital demographic was a significant predictor of FRR, as hospitals with bed number >500 was associated with lower odds (OR 0.95, 95% CI 0.92-0.98, P < 0.001). Geriatric patients admitted at nonteaching hospitals and hospitals in large metro areas (population > 1 million) had higher odds of FRR (OR 1.10, 95% CI 1.03 - 1.16) and (OR 1.10, 95% C1 1.07-1.14), respectively. With respect to discharge disposition, patients in the FRR group were less likely to go home (5.9% versus 21.0%) or with home health care (12.6% versus 18.5%), but more likely to be discharged to skilled nursing or intermediate-care facilities (64.1% versus 54.9%) and short-term hospitals (2.8% versus 1.4%). The mortality rate was higher in the FRR group but was not statistically significant (OR 1.06, 95% CI 0.99-1.14). CONCLUSIONS: Given the high burden of fall-related injuries and FRRs to patients and the health care system, it is essential to identify those who are at risk. This study provides a comprehensive list of high-risk predictors as well as the impact on patient outcomes, and hence a chance to intervene for patients with FRRs.

Increased Access to Care through Telemedicine in Albania: An Analysis of 2,724 Patients.

Introduction: The Integrated Telemedicine and e-Health program (ITeHP) of Albania, built by the International Virtual e-Hospital Foundation (IVeH), has improved access to high-quality health care, particularly in high demanding specialty disciplines. We aimed to test the hypothesis that the majority of patients in remote and regional hospitals can be managed using telemedicine and will prevent unnecessary transfers. Methods: A retrospective analysis of prospectively collected data of patients seen between January 2014 and September 2018 was conducted. Patient demographics, type of teleconsultation modality used, and patient disposition were analyzed. The comparison of continuous data was performed with t-test or Mann-Whitney test. The categorical data were tested with chi-squared test and analysis of variance. Results: There were 2,842 patients seen in all the clinical disciplines during the study period. We excluded tele-autism and incomplete data. There were 2,724 records eligible for study. The most frequent consulting clinical programs (82.9%) were teleradiology (39.0%), teleneurotrauma (27.2%), and teletestroke (16.7%). The majority of patients (77.9%) were kept at regional centers and did not require transfer (p < 0.001) to a tertiary center. Of those transferred, 70.3% were male (p < 0.001), of which 81.6% were for transferred due to neurotrauma. Conclusion: The telemedicine program in Albania has improved access to specialized care in a number of specialty clinical disciplines, particularly in potentially life-threatening and time-sensitive conditions such as neurotrauma. Almost 80% of patients did not require transfer to tertiary centers and were kept for further treatment at the regional centers.

Racial Disparities in the Cardiac Computed Tomography Assessment of Coronary Artery Disease: Does Gender Matter.

Coronary heart disease (CHD) represents a significant healthcare burden in terms of hospital resources, morbidity, and mortality. Primary prevention and early detection of risk factors for the development of CHD are pivotal to successful intervention programs and prognostication. Yet, there remains a paucity of evidence regarding differences in the assessment of these risk factors and the tools of assessment among different ethnicities. We conducted a narrative review to assess the utility of cardiac computed tomography, particularly coronary artery calcification (CAC), in different ethnicities. We also looked to see whether age, sex, comorbidities, and genetic background have peculiar influences on CAC. In this review, we highlight some of the pivotal studies regarding the question of CAC in relation to the development of CHD among different ethnicities. We identify several key trends in the literature showing that although African Americans have high rates of CHD, their risk of CAC may be relatively lower compared with other ethnicities. Similarly, South Asian patients may be at a high risk for adverse cardiac events due to elevated CAC. We also note that several studies are limited by small sample size and were based on 1 large cohort study. Future studies should include a large international prospective cohort to truly evaluate the effects of ethnicity on CAC and CHD risk. To appropriately apply CAC in the clinical practice, the variations in its scoring based on a subject's age, sex, comorbidity, and ethnicity should be addressed and interpreted beforehand.

Stress among surgical attending physicians and trainees: A quantitative assessment during trauma activation and emergency surgeries.

BACKGROUND: The adverse effects of stress on the wellness of trauma team members are well established; however, the level of stress has never been quantitatively assessed. The aim of our study was to assess the level of stress using subjective data and objective heart rate variability (HRV) among attending surgeons (ASs), junior residents (JRs) (PGY2/PGY3), and senior residents (SRs) (PGY5/PGY6) during trauma activation and emergency surgery. METHODS: We preformed a prospective study enrolling participants over eight 24-hour calls in our Level I trauma center. Stress was assessed based on decrease in HRV, which was recorded using body worn sensors. Stress was defined as HRV of less than 85% of baseline HRV. We collected subjective data on stress for each participant during calls. Three groups (ASs, JRs, SRs) were compared for duration of different stress levels through trauma activation and emergency surgery. RESULTS: A total of 22 participants (ASs: n = 8, JRs: n = 7, SRs: n = 7) were evaluated over 192 hours, which included 33 trauma activations and 50 emergency surgeries. Stress level increased during trauma activations and operations regardless of level of training. The ASs had significantly lower stress when compared with SRs and JRs during trauma activation (21.9 ± 10.7 vs. 51.9 ± 17.2 vs. 64.5 ± 11.6; p < 0.001) and emergency surgery (30.8 ± 7.0 vs. 53.33 ± 6.9 vs. 56.1 ± 3.8; p < 0.001). The level of stress was similar between JRs and SRs during trauma activation (p = 0.37) and emergency surgery (p = 0.19). There was no correlation between objectively measured stress level and subjectively measured stress using State-Trait Anxiety Inventory (R = 0.16; p = 0.01) among surgeons or residents. CONCLUSIONS: Surgeon wellness is a significant concern, and this study provides empirical evidence that trauma and acute care surgeons encounter mental strain and fail to recognize it. Stress management and burnout are very important in this high-intensity field, and this research may provide some insight in finding those practitioners who are at risk. LEVEL OF EVIDENCE: Epidemiologic study, level II.

The impact of patient protection and Affordable Care Act on trauma care: A step in the right direction.

INTRODUCTION: The Patient Protection and Affordable Care Act (ACA) was implemented to guarantee financial coverage for health care for all Americans. The implementation of ACA is likely to influence the insurance status of Americans and reimbursement rates of trauma centers. The aim of this study was to assess the impact of ACA on the patient insurance status, hospital reimbursements, and clinical outcomes at a Level I trauma center. We hypothesized that there would be a significant decrease in the proportion of uninsured trauma patients visiting our Level I trauma center following the ACA, and this is associated with improved reimbursement. METHODS: We performed a retrospective analysis of the trauma registry and financial database at our Level I trauma center for a 27-month (July 2012 to September 2014) period by quarters. Our outcome measures were change in insurance status, hospital reimbursement rates (total payments/expected payments), and clinical outcomes before and after ACA (March 31, 2014). Trend analysis was performed to assess trends in outcomes over each quarter (3 months). RESULTS: A total of 9,892 patients were included in the study. The overall uninsured rate during the study period was 20.3%. Post-ACA period was associated with significantly lower uninsured rate (p < 0.001). During the same time, there was as a significant increase in the Medicaid patients (p = 0.009). This was associated with significantly improved hospital reimbursements (p < 0.001).On assessing clinical outcomes, there was no change in hospitalization (p = 0.07), operating room procedures (p = 0.99), mortality (p = 0.88), or complications (p = 0.20). Post-ACA period was also not associated with any change in the hospital (p = 0.28) or length of stay at intensive care unit (p = 0.66). CONCLUSION: The implementation of ACA has led to a decrease in the number of uninsured trauma patients. There was a significant increase in Medicaid trauma patients. This was associated with an increase in hospital reimbursements that substantially improved the financial revenues. Despite the controversies, implementation of ACA has the potential to substantially improve the financial outcomes of trauma centers through Medicaid expansion. LEVEL OF EVIDENCE: Economic and value-based evaluation, level III.

Access to Specialized Care Through Telemedicine in Limited-Resource Country: Initial 1,065 Teleconsultations in Albania.

OBJECTIVE: To analyze the initial experience of the nationwide clinical telemedicine program of Albania, as a model of implementation of telemedicine using "Initiate-Build-Operate-Transfer" strategy. METHODS: This was a retrospective study of prospectively collected data from teleconsultations in Albania between January 1, 2014 and August 26, 2015, delivered synchronously, asynchronously, or a combination of both methods. Patient's demographics, mode of consultation, clinical specialty, hospitals providing referral and consultation, time from initial call to completion of consultation, and patient disposition following teleconsultation were analyzed. Challenges of the newly created program have been identified and analyzed as well. RESULTS: There were 1,065 teleconsultations performed altogether during the study period. Ninety-one patients with autism managed via telemedicine were not included in this analysis and will be reported separately. Of 974 teleconsults, the majority were for radiology, neurotrauma, and stroke (55%, 16%, and 10% respectively). Asynchronous technology accounted for nearly two-thirds of all teleconsultations (63.7%), followed by combined (24.3%), and then synchronous (12.0%). Of 974 cases, only 20.0% of patients in 2014 and 22.72% of patients in 2015 were transferred to a tertiary hospital. A majority (98.5%) of all teleconsultations were conducted within the country itself. CONCLUSIONS: The Integrated Telemedicine and e-Health program of Albania has become a useful tool to improve access to high-quality healthcare, particularly in high demanding specialty disciplines. A number of challenges were identified and these should serve as lessons for other countries in their quest to establish nationwide telemedicine programs.

Antibiotics for appendicitis! Not so fast.

BACKGROUND: Emerging literature in acute appendicitis favors the nonoperative management of acute appendicitis. However, the actual use of this practice on a national level is not assessed. The aim of this study was to assess the changing trends in nonoperative management of acute appendicitis and its effects on patient outcomes. METHODS: We did an 8-year (2004-2011) retrospective analysis of the National Inpatient Sample database. We included all inpatients with the diagnosis of acute appendicitis. Patients with a diagnosis of appendiceal abscess or patients who underwent surgery for any other pathology were excluded from the analysis. Jonckheere-Terpstra trend analysis was performed for operative versus nonoperative management and outcomes. RESULTS: A total of 436,400 cases of acute appendicitis were identified. Mean age of the population was 33 ± 19.5 years, and 54.5% were male. There was no significant change in the number of acute appendicitis diagnosed over the study period (p = 0.2). During the study period, nonoperative management of acute appendicitis increased significantly from 4.5% in 2004 to 6% in 2011 (p < 0.001). When compared with operatively managed patients, conservatively managed patients had a significantly longer hospital length of stay (3 [2-6] vs. 2 [1-3] days, p < 0.001), and in-hospital complications (27.8% vs. 7%, p < 0.001). On comparison of open and laparoscopic appendectomy, both had shorter hospital length of stay and rate of in-hospital complications. Overall hospital charges were lower in patients managed conservatively (15,441 [8,070-31,688] vs. 20,062 [13,672-29,928] USD, p < 0.001). CONCLUSIONS: Nonoperative management of appendicitis has increased over time; however, outcomes of nonoperative management did not improve over the study period. A more in-depth analysis of patient and system demographics may reveal this disparity in trends. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Cabo Verde telemedicine program: initial results of nationwide implementation.

BACKGROUND: Telemedicine and e-health have been suggested as one solution for closing the health disparity gap between the developed world and the developing world. Yet evidence is lacking from current successful programs in the developing world and, in particular, from sub-Saharan Africa. The primary objective of our study was to present the preliminary results of our efforts in building the Integrated Telemedicine and e-Health Program for Cabo Verde (ITeHP-CV), with an emphasis on initial utilization and results. MATERIALS AND METHODS: This is a prospective study of data collected while we worked to establish a fully functional, integrated national telemedicine network and virtual education network in Cabo Verde. We used the International Virtual e-Hospital Foundation strategic approach known as "initiate-build-operate-transfer" over a 26-month period (November 2011-December 2013). We describe herein the five main pillars of this process that have been implemented: (1) capacity building; (2) network development and deployment of equipment; (3) implementation of clinical telemedicine; (4) implementation of activities related to continuing medical education, delivered from within the country and from abroad; and (5) establishment and use of the electronic virtual library. RESULTS: Based on comprehensive technical and medical assessment of the country's needs, 10 fully functional telemedicine centers in all nine inhabited islands of the Republic of Cabo Verde have been established. RESULTS are presented under the five main pillars of capacity building, network deployment, implementation of clinical telemedicine, implementation of continuing medical education activities, and establishment of the electronic virtual library. CONCLUSIONS: The ITeHP-CV has been successfully launched, and the initial results are encouraging. The continuity of the program and sustainability are primary goals once the program is transferred fully to the Ministry of Health of Cabo Verde. A long-term follow-up study is required in order to ensure sustainability and continuity goals are met.

Telemedicine for disaster management: can it transform chaos into an organized, structured care from the distance?

BACKGROUND: Telemedicine and advanced technologies that ensure telepresence have become common practice and are an effective way of providing healthcare services. MATERIALS AND METHODS: The authors conducted a traditional narrative review of English literature through search engines (Medline, Pub Med, Embase, and Science Direct) using mesh terms "telemedicine," "telepresence," "earthquake," "disaster," "natural disaster," and "man-made disaster" published between January 1, 1980 and September 30, 2013. For our analysis, only published studies were selected when telemedicine or telepresence was reported for disaster management, both in real life and in mock and simulation situations. Original articles, clinical trials, case presentations, and review articles were considered. Books and book chapters were used as well. Data from the International Disaster Database were included in the review to provide a sense of worldwide disaster occurrence. Symposia and other meetings were searched and used when available. RESULTS: Between January 1980 and September 2013, 17,565 disasters recorded. During this study period, 878 articles, chapters, books, and presentations were reported. Of these, only 88 articles and books fulfilled our selection criteria. Six articles described the effectiveness of telemedicine in mock simulations and disaster drills, and 63 presented the need and discussed how telemedicine would be beneficial in disaster response. Only 19 articles provided examples of effective use of telemedicine in disaster response. However, these studies demonstrated telemedicine as a valuable tool for communication between front-line humanitarian aid workers and expert physicians at remote locations. CONCLUSION: Telemedicine has not been used thus in the management of disasters, despite its great potential. There is an acute need for establishing telemedicine programs in high risk areas for disasters, so that when these disasters strike, existing telemedicine networks can be used, rather than attempting to bring solutions into a chaotic situation postevent.

Recreational-related head injuries in Qatar.

BACKGROUND: The incidence of recreation related-injuries (RRI) among the physically active population is increasing. This study aimed to analyse frequency and characteristics of RRI in Qatar. METHODS: A retrospective chart review was conducted for all patients with head injuries who sustained a RRI and were admitted to the trauma unit between 2008-2011. Patients' demographics, injuries, complications and mortality were analysed. RESULTS: Of 1665 cases of head injury, 107 (6.4%) had RRI. The majority of cases were males with mean age of 27 ± 12, injury severity score of 14 ± 8 and head abbreviated injury score of 3.2 ± 0.9. Mechanisms of injury included All-Terrain Vehicle, Jet-skiing, football and water-boat. Patients sustained RRI mainly had contusion followed by subarachnoid haemorrhage, subdural and epidural haematoma. Upper extremities and the chest were the most frequently associated injuries. Severe head injuries were observed in 18% of patients with Glasgow Coma Score <8. Median length of stay was 4 (1-67) days. The incidence of RRI was highest amongst Asians (66%) and nationals (23%). The overall mortality among patients with RRI was 7%. CONCLUSION: RRI causes significant morbidity and mortality. An urgent need is recommended for legislative amendment and public awareness for safety regulations during recreational activities involving potential risk of trauma.

Beyond "Initiate-Build-Operate-Transfer" strategy for creating sustainable telemedicine programs: lesson from the first decade.

BACKGROUND: December 10, 2012 will mark the 10th anniversary of the implementation of telemedicine in the Balkans. This first decade of development and function is due to the passion, creativity, experience, and implementation know-how of the award-winning concept of the International Virtual e-Hospital (IVeH) Foundation. The objective of this article is to analyze the results of the IVeH's core strategy, "Initiate-Build-Operate-Transfer" (IBOT), which has been instrumental in establishing telemedicine in the Balkans and has been adopted by many other countries worldwide, and to describe the lessons learned that go beyond IBOT. MATERIALS AND METHODS: A retrospective review of the results of IVeH engagement in establishing telemedicine in developing countries was conducted. RESULTS: Using IBOT, the IVeH has successfully established two national programs: one in Kosova and one in Albania. Together, they have connected 16 hospitals. Currently IVeH is in the process of creating such programs in many countries around the world. During the analysis of the first decade, we have identified eight factors that should be considered when establishing telemedicine programs. CONCLUSION: IBOT has been successful, but further studies are needed to demonstrate its effectiveness in countries beyond the Balkans.

Cost-benefit analysis on the use of telemedicine program of Kosova for continuous medical education: a sustainable and efficient model to rebuild medical systems in developing countries.

BACKGROUND: The Ministry of Health of Kosova has recently announced the Telemedicine Program of Kosova (TMPK) as the official institution responsible for managing and coordinating the nation's Long-Distance Continuous Medical Education (CME) program. There are a lack of studies on cost-benefit analysis (CBA) and other economic evaluations of telemedicine programs (TMP), in particular the financial value of CME offered through such a service. In addition, there is lack of prospective studies on Monitoring & Evaluation (M&E) of TMP. OBJECTIVE: The goal of this study was to conduct a retrospective CBA of prospective data collected at TMPK over a 5-year period (2005-2010) in order to determine the cost benefit as opposed to the alternative method of delivery of this model for developing countries whose healthcare systems are in disarray. MATERIALS AND METHODS: We reviewed data on the number of participants in virtual lectures both at the Telemedicine Center of Kosova (TCK) as well as the number of participants at six Regional Telemedicine Centers throughout Kosova, the number of lectures broadcasted, the clinical cases reviewed and transmitted for international consultation, and other quantitative data. RESULTS: Only in 2009, approximately 2,000 CME certificates were awarded to physicians and nurses of Kosova, 18 international teleconsultations were conducted, 138 videoconferences, lectures, and seminars were held, and there were over 9,000 visitors at the TCK e-library. Data analysis shows that the TMPK has been an efficient mechanism for CME and sustainable model for rebuilding the medical system. TMPK has been successful in offering physicians, nurses, and other medical professions access to electronic information. CONCLUSIONS: TMP is an efficient mechanism to ensure CME and rebuilding medical systems in developing countries. There is a need for prospective CBA of any TMP and the establishment of M&E programs in any future telemedicine initiatives in developing countries.

Damage control laparotomy: a vital tool once overused.

BACKGROUND: Trauma surgery is in constant evolution as is the use of damage control laparotomy (DCL). The purpose of this study was to report the change in usage of DCL over time and its effect on outcome. METHODS: Trauma patients requiring laparotomies during a 3-year (2006-2008) period were reviewed. DCL was defined as laparotomy when fascia was not closed at the first operation. RESULTS: There were 14,534 trauma patients evaluated, and 843 laparotomies were performed on 532 patients during the study period. The number of patients requiring open laparotomies slightly increased while the demographics and Injury Severity Score were similar during the study period. The number of patient requiring DCL significantly decreased from 36.3% (53 of 146) in 2006 to 8.8% (15 of 170) in 2008 (p < 0.001). During this same time period, the mortality rate for patients requiring open laparotomy significantly decreased from 21.9% in 2006 to 12.9% in 2008 (p = 0.05). The decreased use of DCL resulted in a 33.3% reduction in the number of laparotomies performed. The decrease in average costs and charges is projected to result in savings of $2.2 million and $5.8 million, respectively. CONCLUSIONS: The use of DCL was significantly decreased by 78% during the study with significantly improved outcome. The improved outcome and decreased resource utilization can reduce health care costs and charges. Although DCL may be a vital aspect of trauma surgery, it can be used more selectively with improved outcome.