Patients Transferred for Upper Extremity Amputation: Participation of Regional Trauma Centers.

PURPOSE: Level-I trauma centers are required to provide hand and microsurgery capability at all times. We examined transfers to our center to better understand distant patient referrals and, indirectly, study referrals in our region. METHODS: Records were reviewed from 2010 to 2015 to evaluate patients transferred to our level-I institution for upper extremity amputation. Patients were referred from 6 states to our institution over this period. We measured the straight-line distance from each patient's transferring facility to our facility and compared this distance with the straight-line distances from the zip code of the transferring facility to the zip code of each level-I trauma center. RESULTS: We had data for 250 transferred patients (91% male, 9% female). For 110 patients (44%), our hospital was the nearest level-I trauma center; however, for the remaining 140 patients (56%), other level-I trauma facilities were located closer to the referring hospital. Among these 140 patients, the mean distance of the referring facility to the nearest level-I trauma center (30 miles; SD, 27) was significantly different from the mean distance of the referring facility to our facility (71 miles; SD, 60). A median of 4 (range, 1-10) level-I trauma centers were bypassed before patients arrived at our center. Medicaid and "self-pay" patients were more likely to be transferred to our facility. CONCLUSIONS: Fifty-six percent of patients transferred to our hospital for upper extremity amputation had a level-I trauma center closer to their injury. Patients with upper extremity amputation are referred to our regional center despite the proximity of closer level-I trauma centers. This suggests that regional microsurgery expertise does not correlate with level-I trauma designation, and establishment of designated microsurgery centers and formal referral guidelines may be beneficial for management of these difficult injuries. CLINICAL RELEVANCE: We believe that this study further supports the need for formal designation of regional centers of expertise for microsurgical hand trauma.

Delayed Carotid Dissection Following Lower Lip Revascularization in the Setting of Hyoid Fracture--A Case Report and Review of the Literature.

Traumatic injuries to the lip are common, but injuries that require revascularization of the lower lip are infrequent and pose a major challenge to the reconstructive surgeon. This report describes the case of a 53-year-old woman who sustained a lower lip avulsion injury, a comminuted mandibular parasymphyseal fracture, and a hyoid bone fracture secondary to a bicycle accident. Trauma workup included computed tomographic angiography of the head and neck, which did not show vascular injury. Despite successful revascularization of the lower lip, on postoperative day 11 the patient developed a large internal carotid artery dissection and middle cerebral artery stroke. This case highlights the importance of careful postoperative monitoring after high-energy facial trauma, particularly in the setting of vascular and bony injuries.

Relative Blood Volume Profiles Hours After Loop Diuretic Administration: A Systematic Review and Meta-analysis.

Background: Plasma refill rates can be estimated by combining measurements of urine output with relative blood volume profiles. Change in plasma refill rates could guide decongestive loop diuretic therapy in acute heart failure. The objective of the study was to assess average relative blood volume profiles generated from 2 or 3 follow-up measurements obtained hours after loop diuretic administration in subjects with vs without baseline congestion. Methods: A systematic review was conducted of articles written in English, French, Spanish, and German, using MEDLINE (1964 to 2019), Cochrane Reviews (1996 to 2019), and Embase (1974 to 2019). Search terms included the following: diuretics, hemoconcentration, plasma volume, and blood volume. We included studies of adults given a loop diuretic with at least one baseline and one follow-up measurement. A single author extracted subject- or group-level blood volume measurements, aggregated them when needed, and converted them to relative changes. Results: Across all 16 studies that met the prespecified inclusion criteria, relative blood volume maximally decreased 9.2% (6.6% to 12.0%) and returned to baseline after 3 or more hours. Compared to subjects without congestion, those with congestion experienced smaller decreases in relative blood volume across all follow-up periods (P = 0.001) and returned to baseline within the final follow-up period. Conclusions: Single doses of loop diuretics produce measurable changes in relative blood volume that follow distinct profiles for subjects with vs without congestion. Measured alongside urine output, these profiles may be used to estimate plasma refill rates-potential patient-specific targets for decongestive therapy across serial diuretic doses.

Contexte: Le taux de remplissage plasmatique peut être estimé en combinant les mesures de la diurèse et les profils volémiques relatifs. Chez les personnes atteintes d'insuffisance cardiaque aiguë, une variation du taux de remplissage plasmatique pourrait guider un traitement décongestif par un diurétique de l'anse. L'étude avait pour objectif d'évaluer les profils volémiques relatifs moyens obtenus dans le cadre de deux ou trois mesures de suivi réalisées quelques heures après l'administration d'un diurétique de l'anse à des sujets présentant ou non une congestion initiale. Méthodologie: Une revue systématique d'articles rédigés en anglais, en français, en espagnol et en allemand a été effectuée au moyen des bases de données MEDLINE (1964 à 2019), Cochrane Reviews (1996 à 2019) et Embase (1974 à 2019). Les termes de recherche comprenaient : diurétiques, hémoconcentration, volume plasmatique et volume sanguin. Nous avons inclus des études portant sur des adultes ayant reçu un diurétique de l'anse chez qui au moins une mesure initiale et une mesure de suivi avaient été effectuées. Un seul auteur a recueilli des mesures du volume sanguin individuelles ou de groupe, les a regroupées, au besoin, et converties en variations relatives. Résultats: Parmi les 16 études qui répondaient aux critères d'inclusion prédéfinis, le volume sanguin relatif a diminué de 9,2 % (de 6,6 % à 12,0 %) et est revenu aux valeurs initiales après trois heures ou plus. Les sujets qui présentaient une congestion ont connu des diminutions du volume sanguin relatif inférieures à celles de ceux n'en présentant pas lors de toutes les périodes de suivi (p = 0,001); le volume sanguin relatif est revenu aux valeurs initiales durant la période finale de suivi. Conclusions: Des doses uniques de diurétique de l'anse produisent des changements mesurables du volume sanguin relatif selon des profils distincts chez les sujets présentant une congestion, comparativement à ceux n'en présentant pas. Utilisés en association avec les mesures de la diurèse, ces profils peuvent servir à estimer le taux de remplissage plasmatique, qui constitue potentiellement une cible particulière au patient qui reçoit une série de doses d'un diurétique comme traitement décongestif.

Incidence, Treatment, and Outcomes of Symptomatic Device Lead-Related Venous Obstruction.

BACKGROUND: The incidence and clinical impact of lead-related venous obstruction (LRVO) among patients with cardiovascular implantable electronic devices (CIEDs) is poorly defined. OBJECTIVES: The objectives of this study were to determine the incidence of symptomatic LRVO after CIED implant; describe patterns in CIED extraction and revascularization; and quantify LRVO-related health care utilization based on each type of intervention. METHODS: LRVO status was defined among Medicare beneficiaries after CIED implant from October 1, 2015, to December 31, 2020. Cumulative incidence functions of LRVO were estimated by Fine-Gray methods. LRVO predictors were identified using Cox regression. Incidence rates for LRVO-related health care visits were calculated with Poisson models. RESULTS: Among 649,524 patients who underwent CIED implant, 28,214 developed LRVO, with 5.0% cumulative incidence at maximum follow-up of 5.2 years. Independent predictors of LRVO included CIEDs with >1 lead (HR: 1.09; 95% CI: 1.07-1.15), chronic kidney disease (HR: 1.17; 95% CI: 1.14-1.20), and malignancies (HR: 1.23; 95% CI: 1.20-1.27). Most patients with LRVO (85.2%) were managed conservatively. Among 4,186 (14.8%) patients undergoing intervention, 74.0% underwent CIED extraction and 26.0% percutaneous revascularization. Notably, 90% of the patients did not receive another CIED after extraction, with low use (2.2%) of leadless pacemakers. In adjusted models, extraction was associated with significant reductions in LRVO-related health care utilization (adjusted rate ratio: 0.58; 95% CI: 0.52-0.66) compared with conservative management. CONCLUSIONS: In a large nationwide sample, the incidence of LRVO was substantial, affecting 1 of every 20 patients with CIEDs. Device extraction was the most common intervention and was associated with long-term reduction in recurrent health care utilization.

Thoracic Aortic Aneurysm: A Clinical Review.

Thoracic aortic aneurysms are common. Most thoracic aortic aneurysms are degenerative. However, some are associated with connective tissue disorders, bicuspid aortic valves, or familial/genetic predisposition. Most are asymptomatic, discovered incidentally on imaging. Aortic diameter is the best predictor of the natural history and risk of complications. Treating hypertension and smoking cessation can slow their growth. Surveillance imaging and referral for prophylactic aortic repair based on absolute aneurysm diameter is the primary means to decrease mortality from thoracic aortic aneurysm. We provide a practical evidence-based summary of the pathophysiology, risk factors, associated genetic syndromes, and clinical management of thoracic aortic aneurysms.

Culturally tailored health camps and cardiovascular risk among South Asian immigrants.

INTRODUCTION: South Asians have a high prevalence and early age of onset of diabetes, metabolic syndrome, and cardiovascular disease (CVD). We assess the potential of a culturally responsive intervention, health camps, to identify and inform U.S. South Asian community members at risk for CVD. METHODS: We held four culturally and linguistically tailored health camps between October 2009 and November 2010 to educate participants about and screen for CVD risk factors, including diabetes, hypertension, and hypercholesterolemia. Data analysis was conducted in December 2010. RESULTS: Nearly 300 (289) South Asians registered at the health camps: 20% reported a previous diagnosis of diabetes, 34% elevated blood pressure, and 22% hypercholesterolemia. Most (240) participants had their blood glucose measured; 13% had values >200 mg/dl. Most (265) had their blood pressure measured; 32% had elevated values. Over half (57%) of LDLs were <100 mg/dl. DISCUSSION: Health camps are a potentially important component in addressing increased CVD risk in this vulnerable population.