A Retrospective Cohort Study on Health Insurance: Related Disparities in Trauma Patients After Penetrating Injuries: 2000-2014.

OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.

Value of clinical examination in the assessment of penetrating neck injuries: a retrospective study of diagnostic accuracy test.

BACKGROUND: There are many high-volume trauma centers in limited resource environments where a thorough clinical examination of patients may contribute to a more economical, accurate, and widely applicable method of determining the proper management of patients with penetrating neck injuries. The purpose of this study was to validate thorough physical examination as a reliable diagnostic tool in these patients. METHODS: We performed an observational retrospective study of a diagnostic accuracy test where we compared clinical findings (symptoms and soft signs on admission of the patient) with the definitive findings according to the gold standard test for each particular situation (selective studies, clinical observation and surgical exploration). The study was conducted at Hospital Occidente Kennedy (HOK) between August 2009 and June 2010. RESULTS: The sample consisted of the clinical records of 207 (n = 207) patients who went to the emergency room for penetrating neck wounds at Hospital Occidente Kennedy (HOK). Of the total sample, 36.2% (n = 75) of patients were considered "asymptomatic" as they didn't present with any soft signs of injury. Vascular soft signs were present in 57% (n = 118) of the patients, soft signs of the airway and the upper gastrointestinal tract were present in 15.9% (n = 33) and 21.3% (n = 44) of the patients respectively. The sensitivity and negative predictive value (NPV) of any soft sign to determine injuries which require surgical repair was 97.4% [CI] [86.5-99.5%] and 98.7% [CI] [92.8-99.8%] respectively, with a range of confidence [CI] of 95%. CONCLUSIONS: Our study's main findings suggest that patients with neck injuries and no vascular, airway, or gastrointestinal soft sign can be safely managed with a conservative approach. It is important to emphasize the value of the clinical examination since there are many contexts in the modern world where a considerable amount of the population is afflicted by neck trauma and treated under conditions where technological resources are limited.

Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma.

OBJECTIVE: Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. METHODS: We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. RESULTS: We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). CONCLUSIONS: Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.

Assessment and treatment of hypopharyngeal and cervical esophagus injury: Literature review.

Wounds and perforations of the upper gastrointestinal tract are serious and life-threatening. The hypopharynx and cervical esophagus, by their respective anatomical positions, are exposed to traumatic wounds, most often during diagnostic tests, but management such wounds remains a subject of discussion. The present article analyzes the current state of knowledge on epidemiology, etiologies, risk factors, diagnostic management, prognostic factors and available treatments.

Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma.

BACKGROUND: Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals. METHODS: The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury. RESULTS: There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05). CONCLUSIONS: This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.

The medico-legal assessment of asylum seeker victims in Italy.

INTRODUCTION: Changing patterns of migration has required states and governments to respond to the specific medical and legal needs of asylum seekers. Based on medical assessments undertaken at the University Institute of Legal Medicine, the present study aims to describe the cases of asylum applicants who have suffered from physical violence, including torture, and the variables involved. METHODS: Over a 10-year period, 225 survivors were examined by clinical forensic professionals from the University Institute of Legal Medicine. RESULTS: 85% of asylum applicants came from Africa, 87% were male, and the most common age group was 26-40 years old. 46% of applicants fled their country for political reasons. Blunt force injuries were reported in 45% of cases, the trunk was the most affected area of the body (40%), and applicants presented with an average of two different mechanisms of lesions and an average of four lesions each. DISCUSSION/CONCLUSION: Assessment of physical violence on asylum seekers requires the cooperation of professionals with different skillsets and training.

A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting.

INTRODUCTION: An assessment of physiological status is a key step in the early assessment of trauma patients with implications for triage, investigation and management. This has traditionally been done using vital signs. Previous work from large European trauma datasets has suggested that base deficit (BD) predicts clinically important outcomes better than vital signs (VS). A BD derived classification of haemorrhagic shock appeared superior to one based on VS derived from ATLS criteria in a population of predominantly blunt trauma patients. The initial aim of this study was to see if this observation would be reproduced in penetrating trauma patients. The power of each individual variable (BD, heart rate (HR), systolic blood pressure (SBP), shock index(SI) (HR/SBP) and Glasgow Coma Score (GCS)) to predict mortality was then also compared. METHODS: A retrospective analysis of adult trauma patients presenting to the Pietermaritzburg Metropolitan Trauma Service was performed. Patients were classified into four "shock" groups using VS or BD and the outcomes compared. Receiver Operator Characteristic (ROC) curves were then generated to compare the predictive power for mortality of each individual variable. RESULTS: 1863 patients were identified. The overall mortality rate was 2.1%. When classified by BD, HR rose and SBP fell as the "shock class" increased but not to the degree suggested by the ATLS classification. The BD classification of haemorrhagic shock appeared to predict mortality better than that based on the ATLS criteria. Mortality increased from 0.2% (Class 1) to 19.7% (Class 4) based on the 4 level BD classification. Mortality increased from 0.3% (Class 1) to 12.6% (Class 4) when classified based by VS. Area under the receiver operator characteristic (AUROC) curve analysis of the individual variables demonstrated that BD predicted mortality significantly better than HR, GCS, SBP and SI. AUROC curve (95% Confidence Interval (CI)) for BD was 0.90 (0.85-0.95) compared to HR 0.67(0.56-0.77), GCS 0.70(0.62-0.79), SBP 0.75(0.65-0.85) and SI 0.77(0.68-0.86). CONCLUSION: BD appears superior to vital signs in the immediate physiological assessment of penetrating trauma patients. The use of BD to assess physiological status may help refine their early triage, investigation and management.

Feasibility of selective non-operative management for penetrating abdominal trauma in France.

INTRODUCTION: In France, non-operative management (NOM) is not the widely accepted treatment for penetrating wounds. The aim of our study was to evaluate the feasibility of NOM for the treatment of penetrating abdominal traumas at 3 hospitals in the Southeast of France. METHODOLOGY: Our study was multicentric and retroprospective from January, 2010 to September, 2013. Patients presenting with a penetrating abdominal stab wound (SW) or gunshot wound (GSW) were included in the study. Those with signs of acute abdomen or hemodynamic instability had immediate surgery. Patients who were hemodynamically stable had a CT scan with contrast. If no intra-abdominal injury requiring surgery was evident, patients were observed. Criteria evaluated were failed NOM and its morbidity, rate of non-therapeutic procedures (NTP) and their morbidity, length of hospital stay and cost analysis. RESULTS: One hundred patients were included in the study. One patient died at admission. Twenty-seven were selected for NOM (20 SW and 7 GSW). Morbidity rate was 18%. Failure rate was 7.4% (2 patients) and there were no mortality. Seventy-two patients required operation of which 22 were NTP. In this sub-group, the morbidity rate was 9%. There were no mortality. Median length of hospital stay was 4 days for the NOM group and 5.5 days for group requiring surgery. Cost analysis showed an economic advantage to NOM. CONCLUSION: Implementation of NOM of penetrating trauma is feasible and safe in France. Indications may be extended even for some GSW. Clinical criteria are clearly defined but CT scan criteria should be better described to improve patient selection. NOM reduced costs and length of hospital stay.

Resource use in pediatric blunt and penetrating trauma.

BACKGROUND: Trauma is one of the leading causes of pediatric morbidity and mortality with significant patient and economic impacts that necessitate constant study. Significant differences in outcomes and resource use exist between blunt and penetrating mechanisms. METHODS: The National Trauma Data Bank was analyzed for patients aged 0-18 y with International Classification of Diseases, 9th Revision injury codes for blunt and penetrating trauma from 2007-2012. Demographic information, causes, treatments, complications, and outcomes were assessed. RESULTS: A total of 748,347 pediatric trauma patients were assessed. Blunt trauma was identified as the cause in 601,898 (80.43%) patients compared with 55,597 (7.4%) patients with penetrating trauma. Blunt trauma patients were younger on average and more likely to be female. Despite having a slightly higher mean injury severity scores, blunt trauma patients had shorter length of stay in the hospital (2.9 versus 4.3 d, P < 0.001), fewer complications (34.8% versus 38.6%, P < 0.001), and a much lower mortality rate (1.3% versus 7.1%, P < 0.001). Blunt trauma patients were more likely to undergo computed tomography scanning but less likely to receive transfusions (1.79% versus 5.5%, P < 0.001) and to undergo exploratory laparotomy (0.9% versus 9.4%, P < 0.001) and thoracotomy (0.07% versus 1.7%, P < 0.001). Variations in outcome and resource use were also noted by age. CONCLUSIONS: Compared with penetrating trauma, blunt trauma is more common and patients have shorter length of stay, less complications, lower mortality, and are less likely to need operative intervention or blood transfusion. Resource use also varied by age.

Racial disparities after vascular trauma are age-dependent.

OBJECTIVE: Different racial disparities exist between white and black all-cause trauma patients depending on their age group; however, the effects of race and age on outcomes after vascular trauma are unknown. We assessed whether the previously described age-dependent racial disparities after all-cause trauma persist in the vascular trauma population. METHODS: Vascular trauma patients were identified from the Nationwide Inpatient Sample (January 2005 to December 2012) using International Classification of Diseases-Ninth Edition codes. Univariable and multivariable analyses were used to compare in-hospital mortality and amputation for blacks vs whites for younger (16-64 years) and older (≥65 years) age groups. RESULTS: Black patients (n = 937) were younger, more frequently male, without insurance, and suffered from more penetrating and nonaccidental injuries than white patients (n = 1486; P < .001). On univariable analysis, blacks had a significantly higher risk of death (odds ratio, [OR], 1.78; 95% confidence interval [CI], 1.16-2.74) and a significantly lower risk of amputation (OR, 0.54; 95% CI, 0.38-0.77), but these differences were not sustained after adjusting for baseline differences between groups. When stratified by age, there were significant racial disparities in mortality and amputation on univariable analysis. After risk adjustment, these differences persisted in the older group (mortality: OR, 5.95; 95% CI, 1.42-25.0; amputation: OR, 4.21; 95% CI, 1.28-13.6; P < .001) but not the younger group (mortality: OR, 1.31; 95% CI, 0.71-2.42; amputation: OR, 0.92; 95% CI, 0.58-1.46; P = not significant). Differences in survival and amputation after vascular trauma appear to be related to a higher prevalence of nonaccidental penetrating injuries in the younger black population. Race was the single greatest predictor of poor outcomes in the older population (P ≤ .008). CONCLUSIONS: Older black patients are nearly five-times more likely to experience death or amputation after vascular trauma than their white counterparts. Contrary to reports suggesting that younger white patients have better outcomes after all-cause trauma than younger black patients, racial disparities among patients with traumatic vascular injuries appear to be confined to the older age group after risk adjustment.

Penetrating and blunt trauma to the neck: clinical presentation, assessment and emergency management.

Penetrating and blunt trauma to the neck: clinical presentation, assessment ana emergency management. In Belgium, and even in Western Europe, penetrating and blunt injury to the neck is relatively uncommon in both the civilian and military populations. Pre-hospital and emergency assessment and management will therefore always prove challenging, as individual exposure to this specific type of injury remains low. Historically, the neck has been divided into three anatomical zones with specific landmarks to guide the diagnostic and therapeutic approach to penetrating neck injuries. Most penetrating injuries need to be explored surgically, although with the advent of multi-detector computed tomographic angiography (MDCTA), which yields high diagnostic sensitivity, this inflexible approach has recently changed to a more targeted management, based on clinical, radiographic and, if deemed necessary, endoscopic findings. However, some authors have addressed their concern about this novel, 'no-zone' approach, since the risk of missing less apparent aerodigestive tract injuries may increase. It is recommended, therefore, that all patients with penetrating neck injuries be closely observed, irrespective of the initial findings. The incidence of blunt neck injury is much lower, and this makes risk assessment and management even more difficult in comparison with penetrating injuries. Again, MDCTA is most often the first diagnostic tool if a blunt neck injury is suspected, due to its good sensitivity for blunt cerebrovascular injuries (BCVI) as well as for aerodigestive tract injuries. Specific patterns of injury and unexpected neurological and neuro-radiological findings in trauma patients should always warrant further investigation. Despite ongoing debate, systemic anticoagulation is recommended for most BCVI, sometimes combined with endovascular treatment. Aerodigestive tract injuries may present dramatically, but are often more subtle, making the diagnosis more difficult than other types of neck injuries. Treatment may be conservative if damage is minimal, but surgery is warranted in all other cases.

The use of the anatomic 'zones' of the neck in the assessment of penetrating neck injury.

The traditional classification of neck injuries uses an anatomic description of Zones I through III. The objective of this article was to characterize the association between external wounds and the corresponding internal injuries after penetrating neck trauma to identify the clinical use of the anatomic zones of the neck. Patients who sustained penetrating neck trauma from December 2008 to March 2011 were analyzed. All patients underwent structured clinical examination documenting the external zone where the wound(s) were located. All internal injuries were then correlated with the external wounds. An internal injury was defined as "unexpected" if it was located outside the borders of the neck zone corresponding to the external wound. In total, 146 patients sustaining a penetrating neck injury were analyzed; 126 (86%) male. The mechanism of injury was stab wounds in 74 (51%) and gunshot wounds in 69 (47%). Mean age was 31 years (range, nine to 62 years). Thirty-seven (25%) patients sustained had a total of 50 internal injuries. There was a high incidence of noncorrelation between the location of the external injury and the internal structures that were damaged in patients with hard signs of vascular or aerodigestive injury. The use of the anatomic zones and their role in the workup of penetrating neck injury are questionable.

Benchmarking trauma centers on mortality alone does not reflect quality of care: implications for pay-for-performance.

BACKGROUND: Trauma centers are currently benchmarked on mortality outcomes alone. However, pay-for-performance measures may financially penalize centers based on complications. Our objective was to determine whether the results would be similar to the current standard method of mortality-based benchmarking if trauma centers were profiled on complications. METHODS: We analyzed data from the National Trauma Data Bank from 2007 to 2010. Patients 16 years or older with blunt or penetrating injuries and an Injury Severity Score (ISS) of 9 or higher were included. Risk-adjusted observed-to-expected (O/E) mortality ratios for each center were generated and used to rank each facility as high, average, or low performing. We similarly ranked facilities on O/E morbidity ratios defined as occurrence of any major complication. Concordance between hospital performance rankings was evaluated using a weighted κ statistic. Correlation between morbidity- and mortality-based O/E ratios was assessed using Pearson coefficients. Sensitivity analyses were performed to mitigate the competing risk of death for the morbidity analyses. RESULTS: A total of 449,743 patients from 248 facilities were analyzed. The unadjusted morbidity and mortality rates were 10.0% and 6.9%, respectively. No correlation was found between morbidity- and mortality-based O/E ratios (r = -0.01). Only 40% of the centers had similar performance rankings for both mortality and morbidity. Of the 31 high performers for mortality, only 11 centers were also high performers for morbidity. A total of 78 centers were ranked as average, and 11 ranked as low performers on both outcomes. Comparison of hospital performance status using mortality and morbidity outcomes demonstrated poor concordance (weighted κ = 0.03, p = 0.22). CONCLUSION: Mortality-based external benchmarking does not identify centers with high complication rates. This creates a dichotomy between current trauma center profiling standards and measures used for pay-for-performance. A benchmarking mechanism that reflects all measures of quality is needed. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Cost-utility analysis of prehospital spine immobilization recommendations for penetrating trauma.

BACKGROUND: The American College of Surgeons' Committee on Trauma's recent prehospital trauma life support recommendations against prehospital spine immobilization (PHSI) after penetrating trauma are based on a low incidence of unstable spine injuries after penetrating injuries. However, given the chronic and costly nature of devastating spine injuries, the cost-utility of PHSI is unclear. Our hypothesis was that the cost-utility of PHSI in penetrating trauma precludes routine use of this prevention strategy. METHODS: A Markov model based cost-utility analysis was performed from a society perspective of a hypothetical cohort of 20-year-old males presenting with penetrating trauma and transported to a US hospital. The analysis compared PHSI with observation alone. The probabilities of spine injuries, costs (US 2010 dollars), and utility of the two groups were derived from published studies and public data. Incremental effectiveness was measured in quality-adjusted life-years. Subset analyses of isolated head and neck injuries as well as sensitivity analyses were performed to assess the strength of the recommendations. RESULTS: Only 0.2% of penetrating trauma produced unstable spine injury, and only 7.4% of the patients with unstable spine injury who underwent spine stabilization had neurologic improvement. The total lifetime per-patient cost was $930,446 for the PHSI group versus $929,883 for the nonimmobilization group, with no difference in overall quality-adjusted life-years. Subset analysis demonstrated that PHSI for patients with isolated head or neck injuries provided equivocal benefit over nonimmobilization. CONCLUSION: PHSI was not cost-effective for patients with torso or extremity penetrating trauma. Despite increased incidence of unstable spine injures produced by penetrating head or neck injuries, the cost-benefit of PHSI in these patients is equivocal, and further studies may be needed before omitting PHSI in patients with penetrating head and neck injuries. LEVEL OF EVIDENCE: Economic and value-based evaluation, level II.

Systemic administration of fluoro-gold for the histological assessment of vascular structure, integrity and damage.

Fluoro-Gold (F-G) has been used extensively as a fluorescent retrograde neuronal-track tracer in the past. We now report that intraperitoneal administration of 10 to 30 mg/ kg of F-G from 30 min to 7 days prior to sacrifice labels vascular endothelial cells of the brain, choroid plexus and meninges and can be used to assess vascular integrity and damage. F-G vascular labeling co-localized with rat endothelial cell antigen (RECA-1) in the membrane. F-G also intensely labeled the nuclei of the endothelial cells, and co-localized with propidium iodide staining of these nuclei. As well, the administration of F-G during neurotoxic insults produced by amphetamine, kainic acid or "penetrating" wound to the brain can detect where vascular leakage/ hemorrhage has occurred. Histological methods to detect F-G labeled brain vasculature were performed in the same manner as that used for fluorescent visualization of neuronal elements labeled with F-G after perfusion fixation and coronal sectioning (15 to 40 µm) of the brain. This in vivo F-G labeling of endothelial cells and their nuclei yields a clear picture of the integrity of the vasculature and can be used to detect changes in structure. Vascular leaks after "penetrating" wounds through the cortex and striatum, hyperthermic amphetamine exposure or excitotoxic kainate exposure were detected by F-G in the extracellular space and via parenchymal F-G subsequently labeling the terminals and neurons adjacent to the lesioned or damaged vasculature. Further studies are necessary to determine the extent of the leakage necessary to detect vasculature damage. Visualization of the F-G labeling of vasculature structure and leakage is compatible with standard fluorescent immuno-labeling methods used to detect the presence and distribution of a protein in histological sections. This method should be directly applicable to studying brain vascular damage that occurs in the progression of Alzheimer's disease, diabetes and for monitoring the brain vascular changes during development.

Epidemiological features and management of complex neck trauma from an ENT surgeon's perspective.

OBJECTIVES: The aim of this study is to present a clear picture of the epidemiological aspects pertaining to the cases of neck trauma addressing to the ENT Emergency Room, as well as to display the complexity of the diagnostic and therapeutic management employed in two important Romanian ENTDepartments - "Sfantul Spiridon" Hospital Iasi and SfantaMaria Hospital Bucharest MATERIAL AND METHODS: We conducted a retrospective study on 538 patients with neck trauma that were referred to the abovementioned ENT Departments between March 2009 ­ March 2011, selecting 27 cases with forensic implications. RESULTS: In terms of aetiological mechanism, the most frequentneck injuries in our study were penetrating neck injuries due to assault or self-mutilation with white weapons (knives, razor blades, forks, glass) - 56%, followed by blunt trauma cases due to car accident, strangulation or accidental fall ­ 44%. The most important clinical findings recorded at admission were polytraumas (24.14%), hematomas, fractures, subcutaneous emphysema or skin perforation with visceral damages(representing each 13.8%) and tissue rip (10.34%), important bleedings (6.89%), as well as perforation of neck organs(3.45%). The most frequent postoperative complications were postoperative pharyngo-cutaneous fistula (7.4%) and laryngotrachealstenosis (7.4%). There were also 3 other patients with long-term complications, such as acute mediastinitis (3.4%)recurrential paralysis with Gerhardt's syndrome (3.4%) and dysphagia (3.4%).

Utility of clinical examination and CT scan in assessment of penetrating neck trauma.

Managing penetrating injuries adequately and effectively depends a great deal on proper assessment of the injury. This study carried out was done at The Aga Khan University Hospital to assess the role of clinical examination and CT scan imaging in evaluation of penetrating neck injuries. A total of 68 students were included, with ages ranging from 3 to 74 years. The involved zones and the injured structures were noted. Results showed a high sensitivity of clinical examination in assessing vascular (81%) and airway trauma (77%), with a low sensitivity for esophageal trauma (34%). For CT scan the sensitivity was 90% for vascular trauma, 83% for airway trauma and 53% for esophageal injuries. Clinical findings and CT scan imaging are important assessment tools for evaluation of penetrating neck traumas, with a high sensitivity for vascular and airway injuries.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: an empirical assessment of VHA's experience.

BACKGROUND: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). METHODS: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. RESULTS: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. CONCLUSIONS: VHA's TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.

An evidence based review of the assessment and management of penetrating neck trauma.

BACKGROUND: Although relatively uncommon, penetrating neck trauma has the potential for serious morbidity and an estimated mortality of up to 6%. The assessment and management of patients who have sustained a penetrating neck injury has historically been an issue surrounded by significant controversy. OBJECTIVES OF REVIEW: To assess recent evidence relating to the assessment and management of penetrating neck trauma, highlighting areas of controversy with an overall aim of formulating clinical guidelines according to a care pathway format. TYPE OF REVIEW: Structured, non-systematic review of recent medical literature. SEARCH STRATEGY: An electronic literature search was performed in May 2011. The Medline database was searched using the Medical Subject Headings terms 'neck injuries' and 'wounds, penetrating' in conjunction with the terms 'assessment' or 'management'. Embase was searched with the terms 'penetrating trauma' and 'neck injury', also in conjunction with the terms 'assessment' and 'management'. Results were limited to articles published in English from 1990 to the present day. EVALUATION METHOD: Abstracts were reviewed by the first three authors to select full-text articles for further critical appraisal. The references and citation links of these articles were hand-searched to identify further articles of relevance. RESULTS: 147 relevant articles were identified by the electronic literature search, comprising case series, case reports and reviews. 33 were initially selected for further evaluation. CONCLUSIONS: Although controversy continues to surround the management of penetrating neck trauma, the role of selective non-operative management and the utility of CT angiography to investigate potential vascular injuries appears to be increasingly accepted.

[Diagnostic assessment and treatment concepts for thoracic trauma]. / Diagnostik und Behandlungskonzepte beim Thoraxtrauma.

Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. An appropriate structured network of surgical centers guarantees sufficient and efficient care of patients with severe chest trauma. In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.