A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health?

INTRODUCTION: Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic. METHODS: A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests. RESULTS: There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts. CONCLUSIONS: During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.

Answering the Challenge of COVID-19 Pandemic Through Innovation and Ingenuity.

The novel coronavirus disease 2019 (COVID-19) pandemic has created a maelstrom of challenges affecting virtually every aspect of global healthcare system. Critical hospital capacity issues, depleted ventilator and personal protective equipment stockpiles, severely strained supply chains, profound economic slowdown, and the tremendous human cost all culminated in what is questionably one of the most profound challenges that humanity faced in decades, if not centuries. Effective global response to the current pandemic will require innovation and ingenuity. This chapter discusses various creative approaches and ideas that arose in response to COVID-19, as well as some of the most impactful future trends that emerged as a result. Among the many topics discussed herein are telemedicine, blockchain technology, artificial intelligence, stereolithography, and distance learning.

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.

Ethics of Outbreaks Position Statement. Part 2: Family-Centered Care.

OBJECTIVES: Continue the dialogue presented in Ethics of Outbreaks Position Statement. Part 1, with a focus on strategies for provision of family-centered care in critical illness during Pubic Health Emergency of International Concern. DESIGN: Development of a Society of Critical Care Medicine position statement using literature review, expert consensus from the Society of Critical Care Medicine Ethics Committee. A family member of a patient who was critically ill during a natural disaster served on the writing panel and provided validation from a family perspective to the recommendations. SETTING: Provision of family-centered care and support for patients who are critically ill or who have the potential of becoming critically ill, and their families, during a Pubic Health Emergency of International Concern. INTERVENTIONS: Communication; family support. MEASUREMENTS AND MAIN RESULTS: Family-centered interventions during a Pubic Health Emergency of International Concern include understanding how crisis standards may affect regional and local traditions. Transparently communicate changes in decision-making authority and uncertainty regarding treatments and outcomes to the family and community. Assess family coping, increase family communication and support, and guide families regarding possible engagement strategies during crisis. Prepare the public to accept survivors returning to the community.

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.

Injury and fatality risks in aeromedical transport: focus on prevention.

BACKGROUND: Aeromedical transport (AMT) is a reliable and well-established life-saving option for rapid patient transfers to health care delivery hubs. However, owing to the very nature of AMT, fatal and nonfatal events may occur. This study reviews aeromedical incidents reported since the publication of the last definitive review in 2003, aiming to provide additional insight into a wide range of factors potentially associated with fatal and nonfatal AMT incidents (AMTIs). We hypothesized that weather and/or visual conditions, postcrash fire, aircraft make and/or type, and time of day all correlate with the risk of AMTI with injury or fatality. METHODS: Specialty databases were queried for AMTI between January 1, 2003 and July 31, 2015. Additional Internet-based resources were also used to find any additional AMTI (including non-US occurrences) to augment the event sample size available for analysis. Univariate analyses of the collected sample were then performed for association between "fatal crash or injury" (FCOI) and weather/visual conditions, aircraft type and/or make, pilot error, equipment failure, post-incident fire, time of day (6 am-7 pm versus 7 pm-6 am), weekend (Friday-Sunday) versus weekday (Monday-Thursday), season of the year, and presence of patient on board. Variables reaching significance level of P < 0.20 were included in multivariate analysis. RESULTS: A total of 59 AMTIs were identified. Helicopters were involved in 52 of 59 AMTIs, with 7 of 59 fixed-wing incidents. Comparing pre-2003 data with post-2003 data, we noted a significant decrease in AMTIs per month (0.70 versus 0.39, respectively, P = 0.048), whereas the number of fatalities per year increased slightly (7.20 versus 8.26, p = n/s). In univariate analyses, abnormal weather conditions, impaired visibility, time of incident (7 pm-6 am), aircraft model/make, and post-incident fire all reached statistical significance sufficient for inclusion in multivariate analysis (P < 0.20). Factors independently associated with FCOI included post-incident fire (odds ratio, 19.0; 95% confidence interval, 1.41-255.5) and time of incident between 7 pm and 6 am (odds ratio, 11.2; 95% confidence interval, 1.29-97.2). Weather conditions, impaired visibility, and aircraft model/make were not independently associated with FCOI. CONCLUSIONS: The present study supports previous observation that post-crash fire is independently associated with FCOI. However, our data do not support previous observations that weather conditions, impaired visibility, or aircraft model/make are independently predictive of fatal AMTI. In addition, this report demonstrates that flights between the hours of 7 pm-6 am may be associated with greater odds of FCOI. Efforts directed at identification, remediation, and active prevention of factors associated with AMTI and FCOI are warranted given the global increase in aeromedical transport.

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.

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.

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 as Predictor of Outcomes in Older Trauma Patients: A Retrospective Validation Study.

INTRODUCTION: Traditional injury severity assessment is insufficient in estimating the morbidity and mortality risk for older (≥45 years) trauma patients. Commonly used tools involve complex calculations or tables, do not consider all comorbidities, and often rely on data that are not available early in the trauma patient's hospitalization. The comorbidity-polypharmacy score (CPS), a sum of all pre-injury medications and comorbidities, was found in previous studies to independently predict morbidity and mortality in this older patient population. However, these studies are limited by relatively small sample sizes. Consequently, we sought to validate previous research findings in a large, administrative dataset. METHODS: A retrospective study of patients ages≥45 years was performed using an administrative trauma database from St. Luke's University Hospital's Level I Trauma Center. The study period was from 1 January 2008 to 31 December 2013. Abstracted data included patient demographics, injury mechanism and severity [injury characteristics and severity score (ISS)], Glasgow coma scale (GCS), hospital and intensive care unit lengths of stay (HLOS and ILOS, respectively), morbidity, post-discharge destination, and in-hospital mortality. Univariate analyses were conducted with mortality, all-cause morbidity, and discharge destination as primary end-points. Variables reaching statistical significance (p≤0.20) were included in a multivariate logistic regression model. Data are presented as adjusted odds ratios (AORs), with p<0.05 denoting statistical significance. RESULTS: A total of 5863 patient records were analyzed. Average patient age was 68.5±15.3 years (52% male, 89% blunt mechanism, mean GCS 14.3). Mean HLOS and ILOS increased significantly with increasing CPS (p<0.01). Independent predictors of mortality included age (AOR 1.05, p<0.01), CPS (per-unit AOR 1.08, p<0.02), GCS (AOR 1.43 per-unit decrease, p<0.01), and ISS (per-unit 1.08, p<0.01). Independent predictors of all-cause morbidity included age (AOR 1.02, p<0.01), GCS (AOR per-unit decrease 1.08, p<0.01), ISS (per-unit AOR 1.09, p<0.01), and CPS (per-unit AOR 1.04, p<0.01). CPS did not independently predict need for discharge to a facility. CONCLUSIONS: This study confirms that CPS is an independent predictor of all-cause morbidity and mortality in older trauma patients. However, CPS was not independently associated with need for discharge to a facility. Prospective multicenter studies are needed to evaluate the use of CPS as a predictive and interventional tool, with special focus on correlations between specific pre-existing conditions, pharmacologic interactions, and morbidity/mortality patterns.

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.

BACKGROUND: Retained surgical items (RSI) are designated as completely preventable "never events". Despite numerous case reports, clinical series, and expert opinions few studies provide quantitative insight into RSI risk factors and their relative contributions to the overall RSI risk profile. Existing case-control studies lack the ability to reliably detect clinically important differences within the long list of proposed risks. This meta-analysis examines the best available data for RSI risk factors, seeking to provide a clinically relevant risk stratification system. METHODS: Nineteen candidate studies were considered for this meta-analysis. Three retrospective, case-control studies of RSI-related risk factors contained suitable group comparisons between patients with and without RSI, thus qualifying for further analysis. Comprehensive Meta-Analysis 2.0 (BioStat, Inc, Englewood, NJ) software was used to analyze the following "common factor" variables compiled from the above studies: body-mass index, emergency procedure, estimated operative blood loss >500 mL, incorrect surgical count, lack of surgical count, >1 subprocedure, >1 surgical team, nursing staff shift change, operation "afterhours" (i.e., between 5 PM and 7 AM), operative time, trainee presence, and unexpected intraoperative factors. We further stratified resulting RSI risk factors into low, intermediate, and high risk. RESULTS: Despite the fact that only between three and six risk factors were associated with increased RSI risk across the three studies, our analysis of pooled data demonstrates that seven risk factors are significantly associated with increased RSI risk. Variables found to elevate the RSI risk include intraoperative blood loss >500 mL (odds ratio [OR] 1.6); duration of operation (OR 1.7); >1 subprocedure (OR 2.1); lack of surgical counts (OR 2.5); >1 surgical team (OR 3.0); unexpected intraoperative factors (OR 3.4); and incorrect surgical count (OR 6.1). Changes in nursing staff, emergency surgery, body-mass index, and operation "afterhours" were not significantly associated with increased RSI risk. CONCLUSIONS: Among the "common risk factors" reported by all three case-control studies, seven synergistically show elevated RSI risk across the pooled data. Based on these results, we propose a risk stratification scheme and issue a call to arms for large, prospective, and multicenter studies evaluating effects of specific changes at the institutional level (i.e., universal surgical counts, radiographic verification of the absence of RSI, and radiofrequency labeling of surgical instruments and sponges) on the risk of RSI. Overall, our findings provide a meaningful foundation for future patient safety initiatives and clinical studies of RSI occurrence and prevention.

Veno-venous ECMO: a synopsis of nine key potential challenges, considerations, and controversies.

BACKGROUND: Following the 2009 H1N1 Influenza pandemic, extracorporeal membrane oxygenation (ECMO) emerged as a viable alternative in selected, severe cases of ARDS. Acute Respiratory Distress Syndrome (ARDS) is a major public health problem. Average medical costs for ARDS survivors on an annual basis are multiple times those dedicated to a healthy individual. Advances in medical and ventilatory management of severe lung injury and ARDS have improved outcomes in some patients, but these advances fail to consistently "rescue" a significant proportion of those affected. DISCUSSION: Here we present a synopsis of the challenges, considerations, and potential controversies regarding veno-venous ECMO that will be of benefit to anesthesiologists, surgeons, and intensivists, especially those newly confronted with care of the ECMO patient. We outline a number of points related to ECMO, particularly regarding cannulation, pump/oxygenator design, anticoagulation, and intravascular fluid management of patients. We then address these challenges/considerations/controversies in the context of their potential future implications on clinical approaches to ECMO patients, focusing on the development and advancement of standardized ECMO clinical practices. SUMMARY: Since the 2009 H1N1 pandemic ECMO has gained a wider acceptance. There are challenges that still must be overcome. Further investigations of the benefits and effects of ECMO need to be undertaken in order to facilitate the implementation of this technology on a larger scale.

Comorbidity-polypharmacy score: a novel adjunct in post-emergency department trauma triage.

OBJECTIVE: Post-emergency department triage of older trauma patients continues to be challenging, as morbidity and mortality for any given level of injury severity tend to increase with age. The comorbidity-polypharmacy score (CPS) combines the number of pre-injury medications with the number of comorbidities to estimate the severity of comorbid conditions. This retrospective study examines the relationship between CPS and triage accuracy for older (≥45y) patients admitted for traumatic injury. METHODS: Patients aged 45y and older presenting to level 1 trauma center from 2005 to 2008 were included. Basic data included patient demographics, injury severity score, morbidity and mortality, and functional outcome measures. CPS was calculated by adding total numbers of comorbid conditions and pre-injury medications. Patients were divided into three triage groups: undertriage (UT), appropriate triage (AT), and overtriage (OT). UT criteria included initial admission to the floor or step-down unit followed by an unplanned transfer to intensive care unit (ICU) within 24h of admission. OT was defined as initial ICU admission for <1d without stated need for ICU level of care (i.e., lack of evidence for tracheal intubation or mechanical ventilation, injury-related hemorrhage, or other traditional ICU indications, such as intracranial bleeding). All other patients were presumed to be correctly triaged. The three triage groups were then analyzed looking for contributors to mistriage. RESULTS: Charts for 711 patients were evaluated (mean age, 63.5y; 55.7% male; mean ISS, 9.02). Of those, 11 (1.55%) met criteria for UT and 14 (1.97%) for OT. The remaining 686 patients had no evidence of mistriage. The three groups were similar in terms of injury severity and GCS. The groups were significantly different with respect to CPS, with UT CPSs (14.9±6.80) being nearly three times higher than OT CPSs (5.14±3.48). There were more similarities between AT and OT groups, with the UT group being characterized by greater number of complications and lower functional outcomes at discharge (all, P<0.05). The UT group had significantly higher mortality (27%) than the AT and OT groups (6% and 0%, respectively). CONCLUSIONS: In the era of medication reconciliation, CPS is easy to obtain and calculate in patients who are not critically injured. This study suggests that CPS may be a promising adjunct in identifying older trauma patients who are more likely to be undertriaged. The significance of our findings is especially important when considering that injury severity in the UT group was similar to that in the other groups. Further evaluation of CPS as a triage tool in acute trauma is warranted.

Sonographic evaluation of intravascular volume status in the surgical intensive care unit: a prospective comparison of subclavian vein and inferior vena cava collapsibility index.

BACKGROUND: Traditional methods for intravascular volume status assessment are invasive and are associated significant complications. While focused bedside sonography of the inferior vena cava (IVC) has been shown to be useful in estimating intravascular volume status, it may be technically difficult and limited by patient factors such as obesity, bowel gas, or postoperative surgical dressings. The goal of this investigation is to determine the feasibility of subclavian vein (SCV) collapsibility as an adjunct to IVC collapsibility in intravascular volume status assessment. METHODS: A prospective study was conducted on a convenience sample of surgical intensive care unit patients to evaluate interchangeability of IVC collapsibility index (IVC-CI) and SCV-CI. After demographic and acuity of illness information was collected, all patients underwent serial, paired assessments of IVC-CI and SCV-CI using portable ultrasound device (M-Turbo; Sonosite, Bothell, WA). Vein collapsibility was calculated using the formula [collapsibility (%) = (max diameter - min diameter)/max diameter × 100%]. Paired measurements from each method were compared using correlation coefficient and Bland-Altman measurement bias analysis. RESULTS: Thirty-four patients (mean age 56 y, 38% female) underwent a total of 94 paired SCV-CI and IVC-CI sonographic measurements. Mean acute physiology and chronic health evaluation II score was 12. Paired SCV- and IVC-CI showed acceptable correlation (R(2) = 0.61, P < 0.01) with acceptable overall measurement bias [Bland-Altman mean collapsibility difference (IVC-CI minus SCV-CI) of -3.2%]. In addition, time needed to acquire and measure venous diameters was shorter for the SCV-CI (70 s) when compared to IVC-CI (99 s, P < 0.02). CONCLUSIONS: SCV collapsibility assessment appears to be a reasonable adjunct to IVC-CI in the surgical intensive care unit patient population. The correlation between the two techniques is acceptable and the overall measurement bias is low. In addition, SCV-CI measurements took less time to acquire than IVC-CI measurements, although the clinical relevance of the measured time difference is unclear.

Intentional foreign object ingestions: need for endoscopy and surgery.

BACKGROUND: Intentional ingestion of foreign objects (IIFO) is common in the incarcerated population. This study was undertaken in order to better define clinical patterns of IIFO among prisoners. We sought to determine factors associated with the need for endoscopic and surgical therapy for IIFO. METHODS: After obtaining permission to conduct IIFO research in incarcerated populations, study patients were identified by ICD-9 codes. Patient charts were reviewed for demographics; past medical history; IIFO characteristics; and diagnostic, endoscopic, and surgical findings. Univariate and multivariate analyses were performed using statistical software. RESULTS: Thirty patients with 141 episodes of IIFO were identified. The mean number of ingested items per episode was 4.60. Endoscopy was performed in 97 of 141 IIFO instances, with failure to retrieve the ingested object in 21 of 97 cases (22%). Eleven instances (7.8%) required surgical intervention. On multivariate analyses, hospital admission was associated with elevated white blood cell count (odds ratio [OR] 1.4, P < 0.05) and number of items ingested (OR 1.3, P < 0.05). The need for endoscopy was independently associated with ingestion of multiple objects (OR 3.3, P < 0.05) and elevated white blood cell count (OR 1.3, P < 0.05). Surgical therapy was significantly associated with elevated white blood cell count (OR 1.6, P < 0.01) and with increasing number of ingested items (OR 1.07 per item, P < 0.05). Endoscopy is associated with significantly lower odds of surgery (OR 0.13, P < 0.01). CONCLUSIONS: Intentional ingestion of foreign objects continues to pose a significant human and economic burden. The need for admission or therapy is frequently associated with leukocytosis. Further investigation is warranted into resource-appropriate triage of patients who present with IIFO.

Adjunctive aerosolized colistin for multi-drug resistant gram-negative pneumonia in the critically ill: a retrospective study.

BACKGROUND: The incidence of multi-drug resistant (MDR) gram-negative (GN) organisms including Pseudomonas and Acinetobacter spp has increased in the last decade, prompting re-evaluation of colistin for the management of these infections. Aerosolized colistin as an adjunct to intravenous therapy is a current option for the management of MDR-GN pneumonia, although data supporting this practice is limited. This study evaluates the efficacy of adjunctive aerosolized colistin in combination with intravenous colistin in critically ill patients with MDR-GN pneumonia. METHODS: A retrospective multi-center cohort analysis comparing critically ill patients with MDR-GN pneumonia who received intravenous colistin (IV) alone or in combination with adjunctive aerosolized colistin (IV/AER) with a primary endpoint of clinical cure at the end of colistin therapy. Secondary endpoints included microbiologic cure, duration of mechanical ventilation, length of stay, and hospital mortality. A post-hoc subgroup analysis was performed for patients with high quality cultures used for diagnosis of MDR-GN pneumonia. Dichotomous data were compared using Fisher's exact test while the student's t-test or Mann-Whitney U test were used for continuous variables. RESULTS: Ninety-five patients met criteria for evaluation with 51 patients receiving IV and 44 receiving IV/AER. Baseline characteristics were similar between the two groups. Twenty patients (39.2%) receiving IV and 24 (54.5%) receiving IV/AER achieved clinical cure (p = 0.135). There was no difference in microbiologic cure rates between the IV and IV/AER colistin groups (40.7vs. 44.4%, p = 0.805). The IV group demonstrated a trend towards higher pneumonia attributable mortality (70.4 vs. 40%, p = 0.055). In the subgroup analysis of patients with high quality respiratory cultures, there was a significantly lower clinical cure rate for those in the IV group as compared to the IV/AER group (31.3 vs. 57.1%, p = 0.033). CONCLUSIONS: Addition of aerosolized colistin to IV colistin may improve clinical cure and mortality for patients with MDR-GN pneumonia. Larger, prospective trials are warranted to confirm the benefit of adjunctive aerosolized colistin in critically ill patients with MDR-GN pneumonia.

Increase in Motor Vehicle Crash Severity: An Unforeseen Consequence of COVID-19.

INTRODUCTION: The 2019 coronavirus (COVID-19) pandemic led to stay-at-home (SAH) orders in Pennsylvania targeted at reducing viral transmission. Limitations in population mobility under SAH have been associated with decreased motor vehicle collisions (MVC) and related injuries, but the impact of these measures on severity of injury remains unknown. The goal of this study is to measure the incidence, severity, and outcomes of MVC-related injuries associated with SAH in Pennsylvania. MATERIALS & METHODS: We conducted a retrospective geospatial analysis of MVCs during the early COVID-19 pandemic using a state-wide trauma registry. We compared characteristics of patients with MVC-related injuries admitted to Pennsylvania trauma centers during SAH measures (March 21-July 31, 2020) with those from the corresponding periods in 2018 and 2019. We also compared incidence of MVCs for each zip code tabulation area (ZCTA) in Pennsylvania for the same time periods using geospatial mapping. RESULTS: Of 15,550 trauma patients treated during the SAH measures, 3486 (22.4%) resulted from MVCs. Compared to preceding years, MVC incidence decreased 10% under SAH measures with no change in mortality rate. However, in ZCTA where MVC incidence decreased, there was a 16% increase in MVC injury severity. CONCLUSIONS: Stay-at-home orders issued in response to the COVID-19 pandemic in Pennsylvania were associated with significant changes in MVC incidence and severity. Identifying such changes may inform resource allocation decisions during future pandemics or SAH events.

Intravascular retained surgical items: a multicenter study of risk factors.

INTRODUCTION: Retained surgical items (RSIs) have been previously studied in patients undergoing major surgical procedures. This is the first study that specifically examines potential risk factors for intravascular RSI (ivRSI). METHODS: Multicenter retrospective review of 83 RSIs was performed. Among these, 13 cases involved ivRSI. Cases in the ivRSI group were compared with a group of similar control cases to determine potential risk factors for ivRSI, including procedural factors (urgency and complicating factors), patient factors (body mass index), equipment failure (structural or functional), and safety variances. Fisher's exact testing was performed. RESULTS: Thirteen ivRSI cases and 14 controls were examined. There were no differences between the two groups with regard to age, gender, or body mass index. ivRSI items included guide wires (8/13), catheter/catheter fragments (4/13), and a coil (1/13). The incidence of unexpected procedural factors was significantly higher among ivRSI cases (10/13) than among controls (3/14) (P < 0.007). Equipment failure occurred in five ivRSI cases, with none among controls (P < 0.016). There were no differences between the two groups with regard to number of urgent procedures, bleeding >500 mL, evening procedures, or trainee involvement. Both groups had a very high proportion of safety variances (8 in ivRSI and 11 in control group, P = not significant). In addition, seven of 13 ivRSIs were missed on initial confirmatory postprocedural imaging. DISCUSSION: Unexpected procedural factors and equipment failure are significantly associated with ivRSI. Of concern, over half of all ivRSIs were missed on confirmatory postprocedural imaging. Strict adherence to established protocols and stringent radiographic review for intravascular procedures is required to prevent ivRSI.

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.

Identification of Seniors at Risk Scoring in Geriatric Trauma: Exploring Clinical Outcome Correlations.

Introduction: Geriatric trauma patients (GTP) make up an increasing percentage of the overall trauma population. Due to frailty, GTP are at an increased risk of morbidity and readmission. Therefore, it is becoming increasingly important to prognosticate outcomes to assist with resource utilization. We hypothesized that the "Identification of Seniors at Risk" (ISAR) score may correlate with both clinical outcomes and resource utilization for geriatric trauma patients. Methods: Patients older than 65 years who were admitted to the trauma service were screened using an ISAR scoring algorithm. Outcomes, including 30-day mortality, all-cause morbidity, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional independence measures (FIM) at discharge, and percent discharged to a facility, were analyzed. Both descriptive and data-appropriate parametric and non-parametric statistical approaches were utilized, with significance set at α = 0.05. Results: One thousand and two hundred seventeen GTP were included in this study. The average age was 81, median injury severity score was 9, and 99% had a blunt trauma mechanism. ISAR scores were generally associated with increasing 30-day mortality (0%, 1.9%, 2.4%, and 2.1% for ISAR 0, ISAR 1-2, ISAR 3-4, and ISAR 5-6, respectively), morbidity (2.6%, 7.6%, 14.7%, and 7.3% for respective categories), longer hospital (3.1, 4.6, 5.1, and 4.3 days, respectively) and ICU stays (0.37, 0.64, 0.81, and 0.67, respectively), lower FIM score at discharge (18.5, 17.1, 15.8, and 14.4, for respective categories), as well as increasing percentage of patients discharged to a facility (29.8%, 58.9%, 72.1%, and 78.8% for respective categories). Conclusions: This exploratory study provides important early insight into potential relationships between ISAR and geriatric trauma outcomes. ISAR screening is a quick and easy-to-use tool that may be useful in GTP triage, level-of-care determination, and disposition planning. Understanding populations at risk, especially those with more intricate discharge needs, is an important step in mitigating those risks and implementing appropriate care plans.