Screening for osteoporosis after trauma: a new approach using quantitative computed tomography of the skull.

BACKGROUND: The diagnosis of osteoporosis is important in the care of elderly patients at risk of trauma. While pelvis computed tomography (CT) is accurate in the measurement of bone mineral density, axial skull CT has not previously been evaluated for this purpose. This study investigated whether data from axial skull CT scans can screen for osteoporosis. METHODS: Bone density measurements were derived from digital analysis of routine scans of the head and pelvis using quantitative CT. The study took place from October 2010 to November 2011 at a medium-sized community hospital. The first study phase included patients older than 18 years who had both a head and a pelvis CT scan within 30 days. The known diagnostic value for osteoporosis on pelvis CT scans was used to derive a diagnostic value for head CT. The second study phase included adult trauma patients who underwent noncontrast head CT during an initial trauma evaluation. A subgroup analysis was performed during Phase II on patients older than 65 years to identify the incidence of fracture as it is affected by age and bone mineral density. RESULTS: Our data demonstrated that head CT was able to identify osteoporosis with a sensitivity of 0.70, a specificity of 0.81, and an accuracy of 0.76 compared with pelvic CT. Of 261 trauma patients, 54% had bone disease based on axial skull CT criteria. Patients older than 65 years with a positive screen result for osteoporosis on head CT were twice as likely to have a fracture. CONCLUSION: Analysis of data from head CT scans has the potential to provide a useful screen for osteoporosis. Adding this analysis to CT scans performed for elderly trauma patients could result in improved diagnosis and treatment of osteoporosis. LEVEL OF EVIDENCE: Diagnostic study, level II.

Operation PeaceWorks: a community program with the participation of a Level II trauma center to decrease gang-related violence.

BACKGROUND: Gang-related violence is a major public health problem. A gang prevention program (Operation PeaceWorks) was developed in Ventura County, California, to help trauma patients who were gang members quit gang lifestyles. The purpose of this study was to determine the incidence of gang-related violence in the community before and after establishing Operation PeaceWorks. METHODS: In Operation PeaceWorks, participating gang members were mentored, counseled, offered job training, and provided with opportunities to further their education or secure employment. Data about gang-related activity in the community were identified and recorded. The number of gang-related assaults (total), assaults involving firearms, and homicides were determined and compared before and after the start of the program. RESULTS: During the 3 years after starting Operation PeaceWorks (2010-2012), the program had 3,430 interventions with 1,464 gang members (2.3 interventions per gang member). Three years after starting Operation PeaceWorks, there was a significant decrease in mean annual total gang assaults (-16%, p < 0.001), assaults with firearms (-32%, p < 0.001), and homicides (-47%, p = 0.05) compared with the 7 years before Operation PeaceWorks. CONCLUSION: A multidisciplinary community gang prevention program, with the participation of the trauma center, may be effective in decreasing gang-related trauma. The experience with this program may contribute to the development of further evidence-based programs to decrease gang-related trauma. LEVEL OF EVIDENCE: Epidemiologic study, level III. Therapeutic study, level IV.

Renal management in the critically ill patient.

Acute kidney injury is common in the hospital setting and morbidity and mortality outcomes depend on early recognition and early intervention. Identifying patients at risk of acute kidney injury is critical in prevention, early identification, and appropriate treatment.

FAST enough? A validation study for focused assessment with sonography for trauma ultrasounds in a Level II trauma center.

The Focused Assessment with Sonography for Trauma (FAST) is widely used as the initial screening tool for abdominal trauma. Several recent studies have questioned its use. Using the Trauma Registry, 1 year of data at a Level II trauma center were reviewed. All trauma patients with dictated FAST examinations were identified. Disconcordant findings were reviewed. Predictive values for determining intraperitoneal injuries were calculated. Nine hundred seventy-four designated trauma patients were entered into the Trauma Registry. Of these, 633 had dictated FAST examinations. There were 533 true-negatives, 11 true-positives, 77 false-negatives, and six false-positives. Of the 77 false-negatives, 33 had retroperitoneal injuries and 25 had intraperitoneal injuries. No adverse outcomes were identified from diagnostic delay. For predicting intraperitoneal injury, FAST had a negative predictive value of 96 per cent, positive predictive value of 63 per cent, sensitivity of 29 per cent, specificity of 99 per cent, and accuracy of 95 per cent. Our data demonstrate that FAST was useful for the initial assessment of intraperitoneal injuries. FAST was 95 per cent accurate and allowed for rapid triage to operative management when indicated. The data also confirm that a negative FAST does not exclude abdominal injury.

The mortality risk from motor vehicle injuries in California has increased during the last decade.

BACKGROUND: Organized trauma systems and trauma centers are thought to improve trauma outcomes. It is clear that injured patients who receive care in trauma centers have survival advantages. However, large regions of California still do not have access to trauma centers. Many injured patients in California continue to receive their care in nontrauma center hospitals. The purpose of this study was to compare outcomes in California counties with and without trauma centers. In addition, we wished to query the efficacy of the current statewide trauma system by asking whether mortality after motor vehicle trauma in California has improved during the last decade. METHODS: We performed a retrospective outcome study. The California highway patrol provided data from all motor vehicle crashes (MVCs) and mortality during the years 1999 to 2008 for the 58 counties in California. Percent fatality was calculated as the number of motor vehicle fatalities divided by the number of injuries. Data were analyzed to compare outcomes in counties with and without trauma centers. Furthermore, demographic data were studied to analyze the relationship of population and hospital density on mortality. RESULTS: Mortality was significantly lower in counties with trauma centers. Low population and hospital density independently correlated with increased mortality. Injury mortality rates after MVCs increased during the decade both in counties with and without trauma centers. CONCLUSION: Overall, the presence of a trauma center improved the chances of survival after an MVC in California counties. However, mortality rates after injuries increased during the decade both in counties with and without trauma centers. Future efforts to improve outcomes for injured patients in California will require new approaches, which must include improving both access to trauma centers and the care provided in nontrauma center hospitals. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Providing endoscopy for underserved patients benefits public health and resident education.

OBJECTIVE: To determine the clinical and educational value of a new model for providing endoscopy for medically indigent patients. HYPOTHESIS: A model can be developed at minimal cost to provide essential endoscopy services for underserved patients while providing resident education. DESIGN: In our community, there was limited access to endoscopy for indigent patients, and surgical resident endoscopy experience was inadequate. To address these problems, a new endoscopy program was developed. Procedures were performed during underused times in a hospital endoscopy clinic. Endoscopies were performed on patients referred from the public health clinics. All procedures were performed by senior surgical residents supervised by attending endoscopists. The data were collected over 30 months. Colonoscopies were performed for both diagnostic and screening purposes. INTERVENTIONS: In all, 205 colonoscopies, 65 upper endoscopies, and 14 combined endoscopies were performed. OUTCOME MEASURES: Positive findings on endoscopy were documented. The cost-effectiveness was calculated. RESULTS: Of 205 colonoscopies, 35% had positive findings. Sixty-six (32%) patients had polyps and 6 (3%) patients had carcinomas. Of 65 upper endoscopies, 34 (55%) patients had positive findings. Thirty (47%) patients had moderate to severe gastritis/esophagitis or ulcers, 2 (3%) patients had esophageal varices, 2 (5%) patients had carcinomas, 10 (15%) patients had positive H. pylori biopsies, and 2 (3%) patients had Barrett's esophagus. The program incurred minimal incremental costs, and large cost savings were realized in prevention and early detection of colon and gastric carcinomas. CONCLUSIONS: Our 30-month experience resulted in clinical benefits to patients at minimal incremental cost while reducing future medical costs by preventing and detecting disease. Surgical residents received essential training.

Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study.

BACKGROUND: We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents. DESIGN: Retrospective review. SETTING: Seventeen general surgery training programs in the western United States. PARTICIPANTS: Six hundred seven residents who graduated in 2000-2007. MAIN OUTCOME MEASURES: First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research. RESULTS: The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]). CONCLUSIONS: Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Management of postoperative ileus.

Postoperative ileus is an abnormal pattern of gastrointestinal motility that is common after both abdominal and nonabdominal surgeries. There are many causes of ileus, including postoperative pain and the use of narcotics for analgesia, electrolyte imbalances, and manipulation of the bowel during surgery. Despite its prevalence, there is still no reliable treatment to prevent ileus or shorten its course. This article discusses the causes of postoperative ileus and the treatment options currently available. The literature on early refeeding, gum chewing, and the use of tube feeds is reviewed. In addition, new and experimental drugs currently in development are discussed.

Predictors of postoperative urinary retention.

Postoperative urinary retention (PUR) rates vary greatly depending on the population studied. PUR leads to urinary tract instrumentation, which causes increased hospital costs and morbidity. We sought to determine our PUR rate and the risk factors that associated with it. One hundred seventy-six adult surgical inpatients were included in the study. Excluded were those receiving intraoperative catheterization, epidural anesthesia, and urologic procedures. The study population included 42 per cent spinal, 24 per cent laparoscopic abdominal, 20 per cent neck surgeries excluding the spine, and 14 per cent miscellaneous surgeries. Patient bladder volumes were determined using ultrasound scanning at three different intervals: a postvoid residual just before transfer to the operating suite, immediately on arrival in the recovery unit, and then immediately before transfer to the ward. Our overall rate of PUR was 5.7 per cent (10 of 176), defined as the need for catheterization during the postoperative hospitalization. Associated with PUR were advanced age (P = 0.0292) and postoperative bladder volume (P = 0.0246). Preoperative bladder volume, intraoperative fluid, and operative time did not reach statistical significance as being predictive of urinary retention. Our data suggest that PUR is associated with increased bladder volumes on arrival to the recovery room. A prospective study to determine whether identification of patients at risk will lead to decreased incidence of urinary tract infection is warranted.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma.

BACKGROUND: Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS: The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS: Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS: CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

Bleeding complications with Drotrecogin alfa activated (Xigris): a retrospective review of 31 operative and 68 non-operative patients with severe sepsis.

We reviewed 100 consecutive patients who received Drotrecogin alfa (activated) (DAA) (Xigris, Eli Lilly, Indianapolis, IN) for the treatment of severe sepsis and compared the incidence of bleeding complications in surgical (n = 30) and nonsurgical cohorts (n = 70). Thirty patients who received DAA therapy for severe sepsis underwent one or more contemporaneous surgical procedures. These were compared with 70 DAA patients who did not undergo surgery. During the course of DAA administration, transfusion of greater than three units of blood, an intracranial hemorrhage, or other bleeding serious adverse event were qualified as bleeding complications. Overall, we identified seven patients who fulfilled the designated bleeding complication criteria, four in the surgical cohort, and three in the nonsurgical cohort. There was no significant difference in the rate of bleeding complications between surgical and nonsurgical cohorts (P = 0.1063). Moreover, there were no mortalities ascribed to bleeding and there were no intracranial hemorrhage events. All bleeding complications were due to a drop in hemoglobin or platelets only, and were treated with transfusion. Our experience demonstrates that there is an equivalent risk of bleeding for surgical patients treated with DAA compared with nonsurgical patients. Additionally, all bleeding complications were amenable to simple transfusion.

Management of postoperative ileus.

Postoperative ileus is an abnormal pattern of gastrointestinal motility that is common after both abdominal and nonabdominal surgeries. There are many causes of ileus, including postoperative pain and the use of narcotics for analgesia, electrolyte imbalances, and manipulation of the bowel during surgery. Despite its prevalence, there is still no reliable treatment to prevent ileus or shorten its course. This article discusses the causes of postoperative ileus and the treatment options currently available. The literature on early refeeding, gum chewing, and the use of tube feeds is reviewed. In addition, new and experimental drugs currently in development are discussed.

B-type natriuretic peptide levels may be elevated in the critically injured trauma patient without congestive heart failure.

BACKGROUND: Rapid diagnosis of congestive heart failure (CHF) is essential to treatment. B-type natriuretic peptide (BNP) is a neurohormone secreted by the heart in response to fluid overload and has been shown to be elevated in medical patients with left ventricular dysfunction. However, BNP has not been evaluated in the critically ill patient with trauma. METHODS: Trauma patients of at least 18 years of age with an expected intensive care unit stay of at least 24 hours were studied. Patients had BNP measurements at admission and at 24 hours and 48 hours. Echocardiography was performed within 48 hours of admission. CHF was determined by echocardiographic findings of systolic or diastolic dysfunction. Elevated BNP levels were defined as those greater than 100 pg/mL. A Fisher's exact test was performed to determine whether a relationship between BNP levels and echocardiographic findings existed. Linear correlation was used to determine whether BNP correlated with echocardiographic findings and initial Glasgow Coma Scores. RESULTS: Fifty patients were included in the analysis. There was no relationship between elevated BNP levels and echocardiographic evidence of CHF (p = 0.149). There was no threshold value above which CHF was present. There were 28 patients with head injuries, and no relationship between BNP levels and CHF could be found (p = 0.432) in this group. CONCLUSION: Our data show no association between BNP and CHF in the critically ill patient with trauma. BNP levels may be elevated in patients with head injuries without echocardiographic evidence of CHF.

Ruptured abdominal aortic aneurysm: does trauma center designation affect outcome?

Ruptured abdominal aortic aneurysm (RAAA) continues to be a major cause of mortality in the United States. Rapid diagnosis and uncomplicated surgical repair remain paramount to improving survival in this population. We proposed that the addition of an organized trauma service and subsequent improved management of critically ill patients who present with RAAA would positively impact overall mortality. A retrospective analysis was performed on all patients treated for RAAA at Santa Barbara Cottage Hospital for the years 1985-2004. Patients treated before level II trauma center designation (1985-1999) were compared to those treated after the trauma center was instituted. A total of 76 patients were included in this analysis. The two groups were similar with regard to demographics. However, significant decreases in transport time from the emergency department to the operating room and overall 30-day mortality were seen in patients after the trauma center designation. This designation also led to an increase in the number of cases performed per year, centralizing the treatment for these critically ill patients. Institution of a well-prepared and organized service, such as trauma, improved the outcome for patients treated with RAAA, with a particular benefit in the unstable patient.

The use of tagged white blood cell scans to diagnose appendicitis in pregnant patients.

A prompt and accurate diagnosis of appendicitis in pregnant patients is important in avoiding premature labor and fetal loss. Computed tomography (CT) scans are accurate, but fetal radiation exposure is high. Ultrasound avoids radiation exposure, but is less accurate as the uterus enlarges. A third option involves the use of technetium-99 tagged white blood cell scans (TWBCS), which have less than 5 per cent of the fetal radiation exposure of CT scans. However, in pregnancy, the value of TWBCS has not been studied. Therefore, a retrospective review of all patients who were pregnant and underwent a nuclear medicine study as part of their evaluation was performed. Thirteen patients were identified from 1999 through 2005. Before receiving a TWBCS, each patient had an indeterminate physical examination and an ultrasound or CT. Patients with negative TWBCS were admitted and observed clinically. There was no relationship between the results of TWBCS and the presence of appendicitis (P = 0.538). The sensitivity of the TWBCS was 50 per cent, whereas the specificity was 73 per cent. TWBCS had a false-positive rate of 27 per cent and a false-negative rate of 50 per cent, and its positive predictive value was 25 per cent. The data suggest that TWBCS in pregnancy is not reliable in evaluating for appendicitis.

The use of vacuum-assisted closure therapy for the treatment of a large infected facial wound.

Chronic wounds in difficult locations pose constant challenges to health care providers. Negative-pressure wound therapy is a relatively new treatment to promote wound healing. Laboratory and clinical studies have shown that the vacuum-assisted closure (VAC) therapy increases wound blood flow, granulation tissue formation, and decreases accumulation of fluid and bacteria. VAC therapy has been shown to hasten wound closure and formation of granulation tissue in a variety of settings. Accepted indications for VAC therapy include the infected sternum, open abdomen, chronic, nonhealing extremity wounds and decubitus ulcers. We report the first case of VAC therapy successfully used on a large infected wound to the face to promote healing.

Gum chewing reduces ileus after elective open sigmoid colectomy.

HYPOTHESIS: Gum chewing after elective open colon resection may stimulate bowel motility and decrease duration of postoperative ileus. DESIGN AND SETTING: Prospective, randomized study in a community-based teaching hospital. PATIENTS: Thirty-four patients undergoing elective open sigmoid resections for recurrent diverticulitis or cancer. MAIN OUTCOME MEASURES: First feelings of hunger, time to first flatus, time to first bowel movement, length of hospital stay, and complications. RESULTS: A total of 34 patients were randomized into 2 groups: a gum-chewing group (n = 17) or a control group (n = 17). The patients in the gum-chewing group chewed sugarless gum 3 times daily for 1 hour each time until discharge. Patient demographics, intraoperative, and postoperative care were equivalent between the 2 groups. All gum-chewing patients tolerated the gum. The first passage of flatus occurred on postoperative hour 65.4 in the gum-chewing group and on hour 80.2 in the control group (P = .05). The first bowel movement occurred on postoperative hour 63.2 in the gum-chewing group and on hour 89.4 in the control group (P = .04). The first feelings of hunger were felt on postoperative hour 63.5 in the gum-chewing group and on hour 72.8 in the control group (P = .27). There were no major complications in either group. The total length of hospital stay was shorter in the gum-chewing group (day 4.3) than in the control group (day 6.8), (P = .01). CONCLUSIONS: Gum chewing speeds recovery after elective open sigmoid resection by stimulating bowel motility. Gum chewing is an inexpensive and helpful adjunct to postoperative care after colectomy.