Utility of Routine Blood Cultures for Upper Extremity Abscesses.

BACKGROUND: Patients with skin and soft tissue infections (SSTIs) are often admitted by the emergency department for intravenous antibiotic therapy and surgical drainage of abscesses if necessary. As part of the initial diagnostic workup, blood cultures are routinely drawn at our institution in patients with SSTIs. This study seeks to identify the utility of performing blood cultures in patients with upper extremity abscesses as it relates to the number of incision and drainage (I&D) procedures performed, patient readmission rates, and length of hospital stay. METHODS: A retrospective chart review of 314 patients aged 18 to 89 years who underwent 1 or more I&D procedures of upper extremity abscesses were included in the study. Patient demographic data, comorbidities, laboratory values, wound and blood culture results, number of I&D procedures performed, length of stay, and readmission rates were evaluated. RESULTS: Increasing age and white blood count were associated with an increased number of I&Ds performed. Obtaining blood cultures, whether positive or negative, was associated with increased length of stay. There was no association between obtaining blood cultures and number of procedures performed on multivariable analysis. Positive blood cultures were associated with increased readmission rates. CONCLUSIONS: Routinely obtaining blood cultures in patients with upper extremity abscesses may not be beneficial. Obtaining blood cultures is not associated with an increased number of I&D procedures or readmission rates. Furthermore, obtaining blood cultures, regardless of positivity, is associated with increased lengths of hospital stay.

Six months after Maria: A post-hurricane examination of mental health and associated risk factors in older Puerto Ricans.

Following Hurricanes Irma and Maria in September 2017, there were elevated rates of depression and suicide in Puerto Rico. This study evaluates mental health in older and elderly Puerto Ricans 6 months after the hurricanes and suggests strategies for improving future psychosocial responses. Patients attending clinics were evaluated for depression (Patient Health Questionnaire [PHQ-9]) and suicide risk (Ask Suicide-Screening Questions [ASQ]) and were surveyed about their perceived safety, designated as a proxy for anxiety. Used in conjunction, PHQ-9 and ASQ were found to identify a greater proportion of individuals experiencing adverse mental health effects than if each instrument was used in isolation. Patients were also surveyed about time to water and electricity restoration, and it was found that prolonged time to water restoration was associated with increased prevalence and severity of depression and decreased perceived safety. Based on collected patient data (n = 523), using multiple mental health screening tools for diagnosis, improving perceptions of home safety or anxiety, and prioritizing water restoration may reduce mental health sequelae in the elderly and enhance the effect of psychosocial responses following disasters.

Patterns in the Pandemic: Disproportionate Patient Burdens Among Regional Hospitals.

STUDY OBJECTIVE: To examine the distribution of hospitalized COVID-19 patients among adult acute care facilities in the Greater Philadelphia area and identify factors associated with hospitals carrying higher burdens of COVID-19 patients. METHODS: In this observational descriptive study, we obtained self-reported daily COVID-19 inpatient censuses from 28 large (>100 beds) adult acute care hospitals in the Greater Philadelphia region during the initial wave of the COVID-19 pandemic (March 23, 2020, to July 28, 2020). We examined hospitals based on their size, location, trauma certification, median household income, and reliance on public insurance. COVID-19 inpatient burdens (ie, beds occupied by COVID-19 patients), relative to overall facility capacity (ie, total beds), were reported and assessed using thresholds established by the Institute of Health Metrics and Evaluation to approximate the stress induced by different COVID-19 levels. RESULTS: Maximum (ie, peak) daily COVID-19 occupancy averaged 27.5% (SD 11.2%) across the 28 hospitals. However, there was dramatic variation between hospitals, with maximum daily COVID-19 occupancy ranging from 5.7% to 50.0%. Smaller hospitals remained above 20% COVID-19 capacity for longer (small hospital median 27.5 days [interquartile range {IQR}: 4 to 32]; medium hospital median 18.5 days [IQR: 0.5 to 37]; large hospital median 13 days [IQR: 6 to 32]). Trauma centers reached 20% capacity sooner (median 19 days [IQR: 16-25] versus nontrauma median 30 days [IQR: 20 to 128]), remained above 20% capacity for longer (median 31 days [IQR: 11 to 38]; nontrauma median 8 days [IQR: 0 to 30]), and had higher observed burdens relative to their total capacity (median 5.8% [IQR: 2.4% to 8.3%]; nontrauma median 2.5% [IQR: 1.6% to 2.8%]). Urban location was also predictive of higher COVID-19 patient burden (urban median 3.8% [IQR: 2.6% to 6.7%]; suburban median 2.2% [IQR: 1.5% to 2.8%]). Heat map analyses demonstrated that hospitals in lower-income areas and hospitals in areas of higher reliance on public insurance also exhibited substantially higher COVID-19 occupancy and longer periods of higher COVID-19 occupancy. CONCLUSION: Substantial discrepancies in COVID-19 inpatient burdens existed among Philadelphia-region adult acute care facilities during the initial COVID-19 surge. Trauma center status, urban location, low household income, and high reliance on public insurance were associated with both higher COVID-19 burdens and longer periods of high occupancy. Improved data collection and centralized sharing of pandemic-specific data between health care facilities may improve resource balancing and patient care during current and future response efforts.

Mind the Difference: Characterizing the Impact of Behavioral Health Disorders on Facial Trauma.

BACKGROUND: Patients with psychiatric diagnoses are at greater risk for traumatic injury than the general population. Current literature fails to characterize how premorbid behavioral health disorders (BHDs) complicate craniofacial trauma. This study aimed to describe the characteristics and outcomes of patients with premorbid BHD sustaining facial fractures. METHODS: All adults in the 2013-2016 Trauma Quality Improvement Program datasets with facial fractures were identified. Demographics, injury characteristics, fracture patterns, and in-hospital outcomes were compared in patients with and without premorbid BHDs. BHDs included major psychiatric illnesses, alcohol or drug use disorders, attention deficit hyperactivity disorder, or dementia. RESULTS: Twenty-five percent of the 240,104 subjects with facial fractures had at least one premorbid BHD. Assault (29.9% versus 23.9%, P< 0.001), self-inflicted injury (2.9% versus 1.2%, P< 0.001), and multiple facial fractures (40.2% versus 38.7%, P< 0.001) were more common among the BHD group. The BHD group displayed significantly higher rates of nearly all in-hospital complications, including pneumonia (4.3% versus 3.3%, P< 0.001), substance withdrawal (3.9% versus 0.3%, P< 0.001), unplanned intubation (1.5% versus 0.9%, P< 0.001) and unplanned transfer to the intensive care unit (ICU, 1.3% versus 0.8%, P< 0.001). BHD was strongly predictive of pneumonia, unplanned intubation, and unplanned ICU admission in multivariate analyses. CONCLUSIONS: Patients with BHD represent a subset of facial trauma characterized by different mechanisms and patterns of injury and premorbid health status. BHDs are associated with higher in-hospital complication rates and resource utilization. Understanding the relationship between craniofacial trauma and premorbid BHD creates opportunities to improve morbidity and resource utilization in this group.

Outcomes of Implant Removal and Capsulectomy for Breast Implant Illness in 248 Patients.

BACKGROUND: Breast implant illness (BII) is a term popularized by social media to describe systemic symptoms that patients ascribe to their breast implants. Though the concept of implants as an underlying cause for a systemic illness remains controversial, few studies have delineated the implant characteristics, capsular histology, and outcomes of patients who undergo explantation for BII. METHODS: We retrospectively reviewed the demographics, presenting symptoms, outcomes, capsular histology, and culture results of all women who presented to the senior author with symptoms attributed to BII and underwent breast implant removal with capsulectomy from August 2016 to February 2020. Chi-square and logistic regression analyses were performed to evaluate association between implant type, composition, and findings of inflammation on capsule pathology. RESULTS: Among 248 patients, 111 (23%) capsules demonstrated inflammatory changes on permanent pathology. Capsular inflammation was independently associated with silicone versus saline (right odds ratio [OR] = 2.18 [1.16-4.11], P = 0.016, left OR = 2.35 [1.08-5.12], P = 0.03) and textured versus smooth implants (right OR = 2.18 [1.16-4.11], P = 0.016, left OR = 2.25 [1.17-4.31], P = 0.01). Silicone material was present in the capsules of 12 patients (4.8%). Fourteen patients had positive cultures. There was one pneumothorax (0.4%), three hematomas requiring evacuation (1%), and two DVTs (0.8%). Of 228 patients, 206 (90.4%) reported high satisfaction with the outcome of the procedure. CONCLUSIONS: In a large cohort of BII patients, we found that capsular inflammation is significantly associated with silicone and textured implants. Implant removal with capsulectomy can be safely performed in patients with BII with a low complication rate and high patient satisfaction.

Risk Stratification Algorithm for Orthopedic Trauma Patients at Risk for Fat Embolism Syndrome.

BACKGROUND: Fat embolism syndrome (FES) is commonly reported in the setting of long bone and pelvic fractures, but the etiology and pathogenesis are unclear. The aim of this study was to identify clinical characteristics and laboratory findings that may place orthopedic trauma patients at a higher risk of developing FES. METHODS: Electronic medical records were reviewed of all patients aged 18-89 years from 2015 to 2020 with a mention of FES in the patient chart who met Gurd and Wilson's criteria for diagnosis after experiencing orthopedic trauma. A 3:1 matched pair analysis was performed between FES patients and those with similar age, gender, and FES-associated fracture (femur, tibia, humerus, or pelvis fracture). RESULTS: 18 patients with FES who met inclusion criteria were identified. Hypomagnesemia (OR = 7.43), hyperphosphatemia (OR = 6.24), hypoalbuminemia (OR = 3.78), blunt traumatic mechanism of injury (OR = 7.16) and a greater number of bones fractured (Avg/SD = 2.89/1.53) were seen more often in FES patients (all p-values < 0.05). CONCLUSION: Findings of this study suggest that patients with hypomagnesemia, hyperphosphatemia, hypoalbuminemia, a blunt trauma mechanism of injury, and an increased number of bones fractured are at increased risk for the development of FES. This may be related to their roles in physiologic oncotic pressure and inflammatory response, and thus further investigation of these variables is necessary for the evaluation of FES prevention. LEVEL OF EVIDENCE: Level 3.

Prevalence of Venous Thromboembolism Following Acute Spinal Cord Injury in an Urban Inner City Hospital.

BACKGROUND: Venous thromboembolism (VTE) is known to occur at high rates in patients who suffer spinal cord injury (SCI). Large population studies in the United States have shown a prevalence of approximately 4-5%, with some studies suggesting higher prevalence. While the specific mechanism behind increased VTE incidence in the SCI population is unknown, it is likely tied to immobility and functional decline. Previous studies have also linked social determinants of health to higher VTE prevalence in certain populations. The purpose of this study is to determine the prevalence of VTE after acute SCI in the inner urban city population and to identify factors that place patients at increased VTE risk. METHODS: Patients who suffered SCI between 2014 and 2019 were identified from one inner city urban hospital. A retrospective chart review was completed to record the development of VTE after SCI. Medical comorbidities, type of thromboprophylaxis used, patient demographics, injury characteristics, and postinjury sequelae were compared between individuals who did and did not develop VTE. RESULTS: A total of 148 patients were included. These patients were from a low socioeconomic demographic when compared with the larger US population. Average household income based on zip code data for included patients was $56 647, $30 315 below the national average. The prevalence of VTE in this patient population was 19.59%. Weight, deep vein thrombosis history, chemoprophylaxis use, mobility impairment postinjury, neurologic level of SCI, malignancy history, and history of smokeless tobacco were associated with VTE (all P < .05). Low molecular weight heparin (LMWH) use was associated with fewer occurrences of VTE (P < .001). CONCLUSION: Patients from our urban inner city hospital have a higher VTE prevalence after SCI than shown in previous US-based studies. These patients may be at increased risk due to increased numbers of medical comorbidities, social factors, or undiagnosed medical conditions. Thromboprophylaxis with LMWH appears to lower the risk of VTE after SCI. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Patients with the previously mentioned risk factors are at increased risk for VTE development during their acute recovery process. These patients should have a much lower screening threshold for VTE evaluation and likely would benefit from more routine screening to prevent complications related to VTE development or progression. Furthermore, these patients should, when medically appropriate, be treated with low molecular weight heparin for VTE prophylaxis as previously recommended by the Consortium for Spinal Cord Medicine.

Outcomes of Premature Ventricular Contraction-Cardiomyopathy in the Veteran Population: A Secondary Analysis of the CHF-STAT Study.

OBJECTIVES: This study sought to assess the rate and outcomes of premature ventricular contractions (PVC)-cardiomyopathy from the CHF-STAT (Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure) trial, a population with cardiomyopathy (left ventricular [LV] ejection fraction of <40%) and frequent PVCs (>10 PVCs per hour). BACKGROUND: PVCs are associated with heart failure and PVC-cardiomyopathy. The prevalence of PVC-cardiomyopathy and outcome benefits of PVC suppression are not clear. METHODS: A secondary analysis of the CHF-STAT study was performed to compare the rate of successful PVC suppression (≥80% PVC reduction), LV recovery (defined as improvement in LV ejection fraction of ≥10% points), and PVC-cardiomyopathy between amiodarone and placebo groups at 6 months. PVC-cardiomyopathy was defined if both PVC reduction of ≥80% and LV ejection fraction improvement of ≥10% were present at 6 months. Cardiac events (death or resuscitated cardiac arrest) were compared between PVC-cardiomyopathy versus non-PVC-cardiomyopathy during a 5-year follow-up. RESULTS: The rates of successful PVC suppression and LV recovery were significantly higher in the amiodarone (72% and 39%, respectively) when compared to the placebo group (12% and 16%, respectively; p < 0.001), regardless of cardiomyopathy etiology. PVC-cardiomyopathy was present in 29% and 1.8% of patients in the amiodarone and placebo groups, respectively (p < 0.001). Similar PVC-cardiomyopathy rates were found in ischemic (24% amiodarone vs. 2% placebo; p < 0.001) and nonischemic populations (41% amiodarone vs. 1.5% placebo; p < 0.001). Death and resuscitated cardiac arrest were significantly lower in patients with PVC-cardiomyopathy and those treated with amiodarone. CONCLUSIONS: The overall prevalence of PVC-cardiomyopathy in the CHF-STAT study was significant regardless of ischemic substrate (29%, overall population; 41%, nonischemic cardiomyopathy). Treatment of PVC-cardiomyopathy with amiodarone is likely to improve survival in this high-risk population.

The Effect of Discrimination on Likelihood of Participation in a Clinical Trial.

OBJECTIVES: Despite efforts to increase minority enrollment in research, racial disparities still exist, and a belief persists that minorities are inherently less likely to enroll in medical research. This lingering view may impact the manner in which studies are presented to minority patients. This study aimed to assess racial differences in reported discrimination while seeking medical care and likelihood to participate in a medical research study. METHODS: 844 residents were enrolled via convenience sampling, and asked to complete a survey designed to examine perceived discrimination while seeking healthcare and likelihood to participate (LoP) in a medical research study. RESULTS: Participants who reported worse treatment than other races had lower mean LoP scores (53.7 ± 17.6) than participants who reported being treated the same as (61.1 ± 16.1) or better than (64.0 ± 15.0) other races (p < .001). There were no significant differences in mean LoP score by race/ethnicity. The interaction of race with discrimination had no significant effect on mean LoP (p = 0.8). There was a statistically significant association between race and discrimination (X2 = 11.32, p = 0.023), although the majority of participants reported no discrimination. CONCLUSION: Patient experiences in the medical arena may have an impact on their willingness to join a medical study. An effective strategy to increase minority participation in research may be to work with investigators and staff on implicit bias with regard to minority patients. Further research should focus on the impact of research staff interactions on an individual's decision-making process.

Increasing Multidrug Antibiotic Resistance in MRSA Infections of the Hand: A 10-Year Analysis of Risk Factors.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen isolated from hand abscesses. The purpose of this study was to understand trends and changes in longitudinal antibiotic resistance profiles and risk factors for these infections to better guide empiric treatment of hand infections. Methods: We performed a retrospective review of culture-positive hand infections over a 10-year period at an urban academic institution from 2005 to 2014. A subset of MRSA hand infections from 2013 to 2014 was then subanalyzed for risk factors for antibiotic resistance for antibiotics with increasing antibiotic resistance during this period. Results: MRSA grew in 46% of hand infections, with a decreasing incidence over the 10-year study period. However, in the same time period clindamycin and levofloxacin resistance increased from 7% to 31% and 12% to 56%, respectively. Risk factors for clindamycin resistance included nosocomial infections and a history of intravenous drug use and hepatitis C. Risk factors for levofloxacin resistance included a history of diabetes and a fever upon initial presentation. Conclusions: The incidence of multidrug resistance remains high, with growing resistance to clindamycin and levofloxacin. There remains a trend for increased clindamycin resistance for patients with history of intravenous drug use and nosocomial infections. Our findings indicate that clindamycin and levofloxacin should be avoided for empiric treatment for hand infections in patients with these risk factors.

Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia.

Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

Philadelphia glaucoma detection and treatment project: ocular outcomes and adherence to follow-up at a single health centre.

OBJECTIVES: To determine ocular outcomes and factors associated with adherence to ophthalmic follow-up in a medically underserved population at a single health centre in Philadelphia. DESIGN: Retrospective chart review. PARTICIPANTS: Patients from a community glaucoma screening program. METHODS: Chart review was conducted for participants who received a complete eye examination at the Philadelphia District Health Center 5 between January 1, 2012 and May 31, 2014 within the Philadelphia Glaucoma Detection and Treatment Project. Multivariate logistic regression was used to determine factors related to ophthalmic follow-up adherence. RESULTS: A total of 249 participants completed an eye examination (mean age = 57.7 ± 6.9 years). Most were African American (n = 220; 88.4%); female (n = 129; 51.8%). Forty-seven participants (18.9%) received glaucoma-related diagnoses, 20 (8.0%) were prescribed ocular medication, and 26 (10.4%) underwent laser therapy. Ninety (36.1%) attended their recommended follow-up eye examination at the health centre. Glaucoma-related diagnosis (p ≤ 0.001), recommendation of a 4- to 6-week follow-up period (p < 0.001), prescribed eye drops (p < 0.001), or received laser therapy (p = 0.047) were factors most predictive of ophthalmic follow-up adherence. CONCLUSIONS: The collaborative effort of eye care providers and health centres offers an important opportunity to detect, treat, and manage glaucoma and other ocular pathology in medically underserved communities. Having a glaucoma-related diagnosis, initiating treatment, and scheduling regular follow-up visits are the most important factors influencing adherence to follow-up eye appointments.

Sciatic Nerve Variants in Patients Diagnosed With Sciatica: Is There a Correlation?

PURPOSE: Compression of the sciatic nerve in its path along the piriformis muscle can produce sciatica-like symptoms. There are 6 predominant types of sciatic nerve variations with type 1 being the most common (84.2%), followed by type 2 (13.9%). However, there is scarce literature on the prevalence of sciatic nerve variation in those diagnosed with sciatica. MATERIALS AND METHODS: The charts of 95 patients clinically diagnosed with sciatica who had a magnetic resonance imaging of the pelvis/hip were retrospectively studied. All patients had T1-weighted axial, coronal, and sagittal images. Magnetic resonance imagings were interpreted separately by 2 board-certified fellowship-trained musculoskeletal radiologists to identify the sciatic nerve variant. RESULTS: Seven cases were excluded because of inadequate imaging. Of the remaining 88 patients, 5 had bilateral sciatica resulting in a sample size of 93 limbs. Fifty-two (55.9%) had type 1 sciatic nerve anatomy, 39 (41.9%) had type 2, and 2 (2.2%) had type 3. The proportions of type 1 and 2 variations were significantly different from the normal distribution (P < 0.001), whereas type 3, 4, 5, and 6 variants were not (P = 1.00). CONCLUSIONS: There is strong statistical significance regarding the relationship between sciatic nerve variation and the clinical diagnosis of sciatica. Preoperative magnetic resonance imaging can be considered in sciatica patients to prevent iatrogenic injury in pelvic surgery.

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.

BACKGROUND: Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions. QUESTIONS/PURPOSES: (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints? METHODS: Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient's willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire. RESULTS: Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference [MD], 0.1 ± 0.6; 95% CI, 0.0-0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0-0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon's perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0-0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0-0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1-0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8-1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1-0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7-1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5-0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA. CONCLUSIONS: Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician's attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care. LEVEL OF EVIDENCE: Level II, therapeutic study.

HIV and HCV screening among trauma patients.

The purpose of this study was to develop a hepatitis C virus (HCV) and HIV screening program for patients evaluated by the trauma service and link to care. Patients were offered screening for HCV antibody and HIV. Demographics were collected on gender, race, age, and history of intravenous drug use. A navigator connected patients to treatment. In total, 1160 trauma patients were screened for HCV and/or HIV. There were 162 (14%) patients with HCV antibodies. Patients who inject drugs comprised 39.5% (64) of the HCV antibody positive group. Forty-six (68.7%) patients received linkage to care services and 55 (34%) patients were actively engaged in treatment. There were 155 (10.5%) of all eligible patients screened for HIV. Twenty-one (13.5%) patients were living with HIV (PLWH) and there were two (1.3%) new HIV infections. All new PLWH were linked to care and a total of 14 (73.7%) PLWH were on antiretroviral therapy. This is the first HCV and HIV screening and linkage to care program of trauma surgery patients. In this interim program evaluation, we found high prevalence of HCV antibody and HIV prevalence and high linkage to care rates. Trauma service HCV and HIV screening is an opportunity to diagnose, link, and re-engage a vulnerable population.

Patient Satisfaction in the Preoperative Period: Preparing for Hand Surgery.

Background: The potential impact of the number and type of preoperative encounters on satisfaction rates prior to elective surgical procedures is unclear, specifically scheduling and medical clearance encounters. Methods: Questionnaires investigating satisfaction with the preoperative process were collected for 200 patients presenting for elective hand surgery. The number of telephone, surgeon, and medical clearance encounters were recorded, and satisfaction was determined for each type based on a 4-category Likert scale. All patients 18 years or older were included, while only patients providing incomplete questionnaires were excluded. Outcome data were assessed for associations between different encounter totals or types and satisfaction rates. Results: Among 200 patients, 197 completed the questionnaire and were included. Overall satisfaction with the preoperative process was 92.9%, with only 3% of patients dissatisfied. There was a significant association between satisfaction and the number of telephone and total encounters. Satisfaction fell below 90% after 4 or more telephone calls (66.6%, P = 0.005) and 5 or more total encounters (80%, P = 0.008). When considered individually, there was no significant association between satisfaction and the number of surgeon (P = 0.267) or medical office encounters (P = 0.087), or a patient's perceived health status (P = 0.14). Conclusions: Greater than 3 telephone or 4 total encounters significantly decreases patient satisfaction, while surgeon and medical office visits are not associated with satisfaction rates when considered individually. This suggests the number, not the type, of preoperative encounters impact satisfaction and highlight the importance of efficient communication between patients and providers.

Inflammatory signature in lung tissues in patients with combined pulmonary fibrosis and emphysema.

Background: The aetiology and inflammatory profile of combined pulmonary fibrosis and emphysema (CPFE) remain uncertain currently. Objective: We aimed to examine the levels of inflammatory proteins in lung tissue in a cohort of patients with emphysema, interstitial pulmonary fibrosis (IPF), and CPFE. Materials and methods: Explanted lungs were obtained from subjects with emphysema, IPF, CPFE, (or normal subjects), and tissue extracts were prepared. Thirty-four inflammatory proteins were measured in each tissue section. Results: The levels of all 34 proteins were virtually indistinguishable in IPF compared with CPFE tissues, and collectively, the inflammatory profile in the emphysematous tissues were distinct from IPF and CPFE. Moreover, inflammatory protein levels were independent of the severity of the level of diseased tissue. Conclusions: We find that emphysematous lung tissues have a distinct inflammatory profile compared with either IPF or CPFE. However, the inflammatory profile in CPFE lungs is essentially identical to lungs from patients with IPF. These data suggest that distinct inflammatory processes collectively contribute to the disease processes in patients with emphysema, when compared to IPF and CPFE.

Administration of intravenous antibiotics in patients with open fractures is dependent on emergency room triaging.

BACKGROUND: Recent literature has demonstrated that emergent administration of antibiotics is perhaps more critical than even emergent debridement. Most recent studies recommend patients receive antibiotics no later than 1 hour after injury to prevent infection. The objective of this study is to evaluate the time to antibiotic administration after patients with open fractures arrive to a trauma center depending on triaging team. METHODS: A retrospective study at a level 1 Trauma center from January 2013 to March 2015 where 117 patients with open fractures were evaluated. Patients who presented with open fractures of the extremities or pelvis were considered. Subjects were identified using Current Procedural Terminology (CPT) codes. Patients aged 18 and older were analyzed for Gustilo type, antibiotics administered in the emergency room (ER), presence of an antibiotic allergy, post-operative antibiotic regimen and number of debridements, among others. Additionally, whether a patient was triaged by ER doctors or trauma surgeons (and made a trauma activation) was evaluated. Outcome measurements included time to intravenous (IV) antibiotic administration and time to surgical debridement. RESULTS: Patients received IV cefazolin a median of 17 minutes after arrival. Eighty-five patients who were made trauma activations received cefazolin 14 minutes after arrival while 24 non-trauma patients received cefazolin 53 minutes after arrival (p = <0.0001). The median time to gentamicin administration for all patients was 180 minutes. Patients not upgraded to a trauma received gentamicin 263 minutes after arrival, while patients upgraded received gentamicin 176 minutes after arrival. There was no statistically significant difference between the timing to cefazolin or gentamicin based on Gustilo type. CONCLUSIONS: Overall, patients that arrive at our institution with open fractures receive IV cefazolin significantly faster when trauma surgeons evaluate the patient. Additionally, delays in gentamicin administration are demonstrated in both triaging groups. This is due to the fact that cefazolin is stocked in the hospital ER, while gentamicin is commonly not due to weight-based dosing requirements precluding a standard dose. Improvements can be made to antibiotic administration of non-trauma patients and those requiring gentamicin via improved education and awareness of open fractures.