Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers.

BACKGROUND: Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients. MATERIALS AND METHODS: Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports. RESULTS: Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children's physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers. DISCUSSION: Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.

Assessing Risk for Mortality in Trauma: The Value of Admission Hemoglobin A1c.

BACKGROUND: Recent efforts have been made to identify admission characteristics of trauma patients that are associated with increased risk of mortality. Contemporary literature has established an increased risk of mortality with admission hyperglycemia. However, the effects of longstanding hyperglycemia, as surrogated by hemoglobin A1c (HbA1c), has not been studied. METHODS: A prospective trauma database was retrospectively reviewed identifying patients with collected HbA1c at admission. Three cohorts were defined by HbA1c: normal (N), <5.7; prediabetic (PD) 5.7-6.5; and diabetic (D) >6.5. Regression models were used to evaluate the risk of increased hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and mortality. Relative risk (RR) and 95% CI are provided as measures of significance. RESULTS: A total of 2978 patients were included in the analysis (N: n = 1895, PD: n = 744, and D: n = 339). The D cohort was more likely to be older, female, obese, suffered blunt trauma, and triaged at the highest activation acuity level (P < .0001). Mean injury severity score (ISS) was similar between groups. The D group was more likely to have longer ICU-LOS (RR 1.5; 95% CI 1.10-2.07) and ventilator days (RR 1.52; 95% CI 1.03-2.26) than the N group. Relative to the N group, the risk of mortality was 50% higher in the PD (RR 1.49; 95% CI 1.17-1.90) and in the D cohorts (RR 1.50; 95% CI 1.03-2.18). DISCUSSION: Trauma patients with an elevated admission HbA1c have a significantly higher risk of mortality regardless of their history of diabetes. These data add to the body of literature that documents the untoward effect of hyperglycemia on the trauma patient.

Gunshot wound incidence as a persistent, tragic symptom of area deprivation.

BACKGROUND: More than 30,000 Americans die every year of firearm-related injuries. Gun violence is frequently addressed by law enforcement and policing, as opposed to public health interventions that might address poverty or deprivation. Our goal was to evaluate the past 20 years of gunshot wound injury demographics seen at our level I academic trauma center and create a risk map model correlating gunshot wound incidence with area deprivation. METHODS: Patients admitted for gunshot wound-related injuries between 1996 and 2017 were identified using our trauma registry. Demographic and injury data were extracted and analyzed. Multivariable logistic regression models were created to identify predictors of mortality. Geographic information system mapping of incident location and home address was completed to identify zip code hot spots of high gunshot wound incidence. Area Deprivation Indices, which reflect local income or poverty, housing, education, and employment were used as a marker of relative economic disadvantage. Spearman rank correlation was used to determine the relationship between Area Deprivation Indices score and gunshot wound rate. RESULTS: A total of 2,413 patients with gunshot wounds were evaluated. The cohort had a mean age of 28.8 ± 11.5 and was 89.6% male. Mean Injury Severity Score was 11 ± 12.5. gunshot wounds were most frequently a result of assault (91.1%), followed by unintentional injury (3.4%). Geographic information systems mapping revealed significant clustering of gunshot wounds. The areas with highest per capita incidence of gunshot wounds was strongly correlated with Area Deprivation Indices (0.594, P < .001). CONCLUSION: Geographic regions of known lower socioeconomic resources have higher incidence of gunshot wounds in our community. Both Area Deprivation Indices and gunshot wound incidents in these distressed communities remained unchanged throughout the past 20 years, despite law enforcement crime suppression efforts. Gunshot wounds appear to be a symptom of area deprivation, similar to failing schools and poor health outcomes. Efforts to decrease poverty and community capacity-building may help alleviate this area deprivation.

Rural General Surgery Experience as a Valuable Adjunct to an Academic Based General Surgery Residency.

OBJECTIVE: Few general surgery residencies offer rural rotations. We aim to evaluate the contribution of our institution's rural rotation to meeting the Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements for graduation, and residents' perceptions of the educational value of this rotation. DESIGN: ACGME case log data were obtained from categorical general surgery residents who had completed at least 1 month-long rural surgery rotation and 1 month-long general surgery rotation at our academic medical center within the same clinical year. Cases were classified per ACGME defined categories. For each category, the number of cases per month per resident was calculated, and the means for each educational setting were compared using the paired t-test. Residents also completed a 10-question Likert scale survey regarding their perceptions of the rotation. SETTING: Residents rotated at Vidant Medical Center, a tertiary AMC1 affiliated with East Carolina University in Greenville, NC, and at Vidant Chowan, a critical access hospital within the Vidant Health hospital system located in Edenton, NC. PARTICIPANTS: Categorical general surgery residents eligible to rotate through the rural surgery rotation and the general surgery rotation at the AMC. RESULTS: Eleven total residents completed 23 months of rural surgery (mean 2.1 months per resident) and 39 months at the AMC (mean 3.5 months per resident). Significantly more endoscopic cases, hernia repairs, breast cases, and vascular cases were performed on the rural surgery rotation. More abdominal and alimentary tract cases in addition to endocrine, thoracic, and head/neck cases were performed at the AMC. Frequencies of biliary and soft tissue cases were not significantly different. Survey responses regarding the rural rotation were universally positive including more hands-on experience, increased satisfaction with patient care and continuity, and operative confidence and competence. CONCLUSIONS: At our institution, residents benefit from an enriching rural surgery rotation that provides case numbers different from the comparative AMC general surgery rotation.

Twenty years of pediatric gunshot wounds in our community: Have we made a difference?

BACKGROUND/PURPOSE: Pediatric gunshot wounds (GSWs) carry significant incidence, mortality, and cost. We evaluated 20 years of GSW demographics at this level 1 trauma center and constructed a risk map triangulating areas of high incidence with risk factors. METHODS: Children 0-18 years suffering a GSW between 1996 and 2016 were identified via our trauma registry. Hospital charges, demographic, socioeconomic, and institutional variables were retrospectively reviewed. Multivariable logistic regression identified predictors of mortality. Geographic information system (GIS) mapping of incident location and residence identified areas of higher incidence. RESULTS: The cohort (n = 898) was 86.4% male. Mean age was 15.6 ±â€¯3.4 years. Median Injury Severity Score (ISS) was 9 (1-75). Procedural and/or operative intervention occurred in 52.9%. Intent included assault (81.5%) and unintentional injury (12.8%). Hospital charges showed significant annual increase. Annual incidence varied without trend (p = 0.89). Mapping revealed significant clustering of GSWs in known lower socioeconomic areas. Yearly and total GSWs were highest in one particular zip code. ISS was a significant predictor of mortality (n = 18) (OR 1.19, 95% CI 1.15-1.22, p < 0.001). CONCLUSIONS: Our impoverished neighborhoods have higher pediatric GSW incidence, unchanged over 20 years. Alternative community-based prevention efforts should involve neighborhood capacity building and economic strengthening. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: Level IV.

Prospective Assessment of Postoperative Nausea Early After Bariatric Surgery.

BACKGROUND: The most common reason for readmission after bariatric surgery is postoperative nausea and vomiting (PONV). The aim of this study was to compare the incidence and severity of PONV between patients undergoing laparoscopic sleeve gastrectomy (SG) and gastric bypass (GB). METHODS: This was a prospective observational cohort study that evaluated all patients who underwent non-revisional isolated SG or GB at a tertiary care center. Patients were asked to grade their nausea on a 10-point Likert scale at 2 h postoperatively and the morning of each postoperative day (POD). RESULTS: There were 65 patients that matched the inclusion criteria, of which 29 underwent SG and 36 underwent GB. There were no significant differences in age (p = 0.198), BMI (p = 0.294), American Society of Anesthesiology classification (p = 0.380), or male gender (p = 0.164) when comparing SG and GB patients. Perioperative PONV prophylaxis was similar. There were no differences in LOS (2.6 ± 1.3 vs 2.3 ± 0.5 days, p = 0.919) or readmission/visit to the emergency department due to PONV (10.3% vs 13.9%, p = 0.665) between the two groups. Prolonged LOS due to PONV occurred in 20.7% of SG patients and 19.4% of GB patients (p = 0.901). CONCLUSIONS: The severity and incidence of PONV are similar following SG and GB. Importantly, there was no difference in hospital utilization due to PONV between SG and GB.

An in-situ simulation-based educational outreach project for pediatric trauma care in a rural trauma system.

BACKGROUND: Outcome disparities between urban and rural pediatric trauma patients persist, despite regionalization of trauma systems. Rural patients are initially transported to the nearest emergency department (ED), where pediatric care is infrequent. We aim to identify educational intervention targets and increase provider experience via pediatric trauma simulation. METHODS: Prospective study of simulation-based pediatric trauma resuscitation was performed at three community EDs. Level one trauma center providers facilitated simulations, providing educational feedback. Provider performance comfort and skill with tasks essential to initial trauma care were assessed, comparing pre-/postsimulations. Primary outcomes were: 1) improved comfort performing skills, and 2) team performance during resuscitation. RESULTS: Provider comfort with the following improved (p-values <0.05): infant airway, infant IV access, blood administration, infant C-spine immobilization, chest tube placement, obtaining radiographic images, initiating transport, and Broselow tape use. The proportion of tasks needing improvement decreased: 42% to 27% (p-value=0.001). Most common deficiencies were: failure to obtain additional history (75%), beginning secondary survey (58.33%), log rolling/examining the back (66.67%), calling for transport (50%), calculating medication dosages (50%). CONCLUSIONS: Simulation-based education improves provider comfort and performance. Comparison of patient outcomes to evaluate improvement in pediatric trauma care is warranted. LEVEL OF EVIDENCE RATING: IV.

Repeated Elevation of the Anterolateral Thigh Flap for Lower Extremity Orthopedic Trauma Does Not Affect Flap Viability.

BACKGROUND: The anterolateral thigh (ALT) flap has a key role regarding limb salvage and has facilitated the preservation of function and esthetics in lower extremity reconstruction. The purpose of this study is to review the advantages of the ALT flap when used early in the reconstruction of the trauma patient; specifically, its long-term viability when ALT flap reconstruction is followed by recurrent flap elevation performed to allow a variety of sequential orthopedic operations including washout, antimicrobial disc placement, and reinstrumentation. METHODS: A retrospective analysis was performed to review all ALT flaps performed by the authors from January 2009 to October 2012 at the Orlando Regional Medical Center. A total of 69 patients with an average age of 38 years were included in the study leading to a total of 69 ALT flaps indicated for traumatic orthopedic wounds. Out of these, 29 flaps were elevated at least once leading to a total of 49 flap elevations. RESULTS: The median number of days to flap elevation was 117 with a minimum of 1 day and a maximum of 540 days. A total of 42% flaps were elevated at least once after initial placement for reinstrumentation, washout, or antibiotic disk placement. Overall, 52% of the flaps were lifted once, 34% were lifted twice, and 14% were lifted more than thrice. There is no statistically significant difference in the complication rate between elevating the flap compared with primary ALT placement. CONCLUSION: We conclude, therefore, there is no elevated risk to long-term viability by elevating the ALT flap. This combined with the ease of elevation makes it a safe procedure to be performed as needed for access to the deep tissues.

Early intravenous ibuprofen decreases narcotic requirement and length of stay after traumatic rib fracture.

Pain control after traumatic rib fracture is essential to avoid respiratory complications and prolonged hospitalization. Narcotics are commonly used, but adjunctive medications such as nonsteroidal anti-inflammatory drugs may be beneficial. Twenty-one patients with traumatic rib fractures treated with both narcotics and intravenous ibuprofen (IVIb) (Treatment) were retrospectively compared with 21 age- and rib fracture-matched patients who received narcotics alone (Control). Pain medication requirements over the first 7 hospital days were evaluated. Mean daily IVIb dose was 2070 ± 880 mg. Daily intravenous morphine-equivalent requirement was 19 ± 16 vs 32 ± 24 mg (P < 0.0001). Daily narcotic requirement was significantly decreased in the Treatment group on Days 3 through 7 (P < 0.05). Total weekly narcotic requirement was significantly less among Treatment patients (P = 0.004). Highest and lowest daily pain scores were lower in the Treatment group (P < 0.05). Hospital length of stay was 4.4 ± 3.4 versus 5.4 ± 2.9 days (P = 0.32). There were no significant complications associated with IVIb therapy. Early IVIb therapy in patients with traumatic rib fractures significantly decreases narcotic requirement and results in clinically significant decreases in hospital length of stay. IVIb therapy should be initiated in patients with traumatic rib fractures to improve patient comfort and reduce narcotic requirement.

Characterization of HCV interactions with Toll-like receptors and RIG-I in liver cells.

BACKGROUND AND AIM: The aim of this study was to examine the mechanisms of IFN induction and viral escape. In order to accomplish the goal we compared our new hepatoma cell line LH86, which has intact TLR3 and RIG-I expression and responds to HCV by inducing IFN, with Huh7.5 cells which lack those features. METHODS: The initial interaction of LH86 cells, Huh7.5 cells or their transfected counter parts (LH86 siRIG-I, siTLR3 or siTLR7 and Huh7.5 RIG-I, TLR3 or TLR7) after infection with HCV (strain JFH-1) was studied by measuring the expression levels of IFNß, TRAIL, DR4, DR5 and their correlation to viral replication. RESULTS: HCV replicating RNA induces IFN in LH86 cells. The IFN induction system is functional in LH86, and the expression of the RIG-I and TLR3 in LH86 is comparable to the primary hepatocytes. Both proteins appear to play important roles in suppression of viral replication. We found that innate immunity against HCV is associated with the induction of apoptosis by RIG-I through the TRAIL pathway and the establishment of an antiviral state by TLR3. HCV envelope proteins interfere with the expression of TLR3 and RIG-I. CONCLUSION: These findings correlate with the lower expression level of PRRs in HCV chronic patients and highlight the importance of the PRRs in the initial interaction of the virus and its host cells. This work represents a novel mechanism of viral pathogenesis for HCV and demonstrates the role of PRRs in viral infection.