Rib Fractures and Mortality: Breaking the Causal Relationship.

Rib fractures have long been considered as a major contributor to mortality in the blunt trauma patient. We hypothesized that rib fractures can be an excellent predictor of mortality, but rarely contribute to cause death. We performed a retrospective study (2008-2015) of blunt trauma patients admitted to our urban, Level I trauma center with one or more rib fractures. Medical records were reviewed in detail. Rib fracture deaths were those from any respiratory sequelae or hemorrhage from rib fractures. There were 4413 blunt trauma patients who sustained one or more rib fractures and 295 (6.8%) died. Rib fracture patients who died had a mean Injury Severity Score = 38 and chest Abbreviated Injury Score = 3.4. Rib fractures were the cause of death in only 21 patients (0.5%). After excluding patients who were dead on arrival, patients dying as a result of their rib fractures were found to be older (P < 0.0001) and had a higher admission respiratory rate (P = 0.02). Multivariable logistic regression found that age ≥65 was the only variable independently associated with mortality directly related to rib fractures (odds ratio 4.1, 95% confidence interval = 1.3-13.3, P value < .0001). Mortality in patients with rib fractures is uncommon (7%), and mortality directly related to rib fractures is rare (0.5%). Older patients are four times more likely to die as a direct result of rib fractures and may require additional resources to avoid mortality.

Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado.

OBJECTIVES: To evaluate motor vehicle crash fatality rates in the first 2 states with recreational marijuana legalization and compare them with motor vehicle crash fatality rates in similar states without recreational marijuana legalization. METHODS: We used the US Fatality Analysis Reporting System to determine the annual numbers of motor vehicle crash fatalities between 2009 and 2015 in Washington, Colorado, and 8 control states. We compared year-over-year changes in motor vehicle crash fatality rates (per billion vehicle miles traveled) before and after recreational marijuana legalization with a difference-in-differences approach that controlled for underlying time trends and state-specific population, economic, and traffic characteristics. RESULTS: Pre-recreational marijuana legalization annual changes in motor vehicle crash fatality rates for Washington and Colorado were similar to those for the control states. Post-recreational marijuana legalization changes in motor vehicle crash fatality rates for Washington and Colorado also did not significantly differ from those for the control states (adjusted difference-in-differences coefficient = +0.2 fatalities/billion vehicle miles traveled; 95% confidence interval = -0.4, +0.9). CONCLUSIONS: Three years after recreational marijuana legalization, changes in motor vehicle crash fatality rates for Washington and Colorado were not statistically different from those in similar states without recreational marijuana legalization. Future studies over a longer time remain warranted.

PTSD in those who care for the injured.

BACKGROUND: Post Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD. METHODS: A system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession. RESULTS: 546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P<0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD. CONCLUSION: The results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results.

Thromboelastography Does Not Detect Preinjury Antiplatelet Therapy in Acute Trauma Patients.

Thromboelastography (TEG) with platelet mapping has been proposed as an assay to detect the presence of antiplatelet agents (APA), yet no study has evaluated TEG markers of platelet dysfunction in acute trauma patients stratified by the use of preinjury APA. We hypothesized that patients on preinjury APA would demonstrate prolonged TEG markers of platelet dysfunction compared with those not on preinjury APA. This retrospective review evaluated all trauma patients admitted to a Level I trauma center from February 2011 to April 2013 who received a TEG within the first 24 hours of admission. Patients were classified as receiving preinjury APA or no APA if their documented medications included either aspirin or adenosine diphosphate (ADP) antagonists, including clopidogrel, prasugrel, and ticagrelor. A total of 129 patients were included (APA, n = 35; no APA n = 94) in the study. The time from admission to the first TEG was similar (APA 175 ± 289 minutes versus no APA 216 ± 321 minutes, P = 0.5). There was no significant difference in TEG markers of platelet dysfunction, including per cent ADP inhibition (APA 61.7 ± 25.8% versus no APA 62.3 ± 28.8%; P = 0.91) or per cent arachidonic acid inhibition (APA 58.2 ± 31% versus no APA 53.8 ± 34%; P = 0.54). Both groups had similar proportion of severe platelet dysfunction, defined as ADP inhibition greater than 70 per cent (APA 40% versus no APA 40%; P = 0.8) and arachidonic acid inhibition greater than 70 per cent (APA 40% versus no APA 39%; P = 0.89). In conclusion, platelet dysfunction after major trauma is common. Therefore, TEG alone should not be used to evaluate for the presence of APA due to apparent lack of specificity.

Comparable operative times with and without surgery resident participation.

BACKGROUND: Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes. OBJECTIVE: To evaluate the effect of general surgery resident participation in surgical procedures on operative times and postoperative patient outcomes. DESIGN: Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality. SETTING: Academic general surgery residency program. RESULTS: There were 2280 operative procedures performed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p = 0.14) and male gender (46% vs 45%, p = 0.68), and there was no difference in overall operative time (68min vs 66min, p = 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p = 0.8), thyroidectomy (125 vs 109, p = 0.16), breast procedure (38 vs 26, p = 0.79), hernia repair (61 vs 60, p = 0.74), lower extremity amputation (65 vs 77, p = 0.16), tunneled venous catheter (49 vs 47, p = 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p = 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group (71 vs 66, p = 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p = 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p = 0.45). CONCLUSIONS: There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing surgical procedures.

Silencing of VAMP3 inhibits cell migration and integrin-mediated adhesion.

Integrins are transmembrane receptors for cell adhesion to the extracellular matrix. In cell migration, integrins are endocytosed from the plasma membrane or the cell surface, transported in vesicles and exocytosed actively at the cell front. In the present study, we examined the roles of VAMP3, a SNARE protein that mediates exocytosis, in cell migration and integrin trafficking. Small interfering RNA (siRNA)-induced silencing of VAMP3 inhibited chemotactic cell migration by more than 60% without affecting cell proliferation. VAMP3 silencing reduced the levels of beta1 integrin at the cell surface but had no effect on total cellular beta1 integrin, indicating that VAMP3 is required for trafficking of beta1 integrin to the plasma membrane. Furthermore, VAMP3 silencing diminished cell adhesion to laminin but not to fibronectin or collagen. Taken together, these data suggest that VAMP3-dependent integrin trafficking is crucial in cell migration and cell adhesion to laminin.