Enterothecal fistula as a rare cause of adult pneumocephalus and meningitis: a case report.

Background: Enterothecal fistulas are pathological connections between the gastrointestinal system and subarachnoid space. These rare fistulas occur mostly in pediatric patients with sacral developmental anomalies. They have yet to be characterized in an adult born without congenital developmental anomaly yet must remain on the differential diagnosis when all other causes of meningitis and pneumocephalus have been ruled out. Good outcomes rely on aggressive multidisciplinary medical and surgical care, which are reviewed in this manuscript. Case Description: A 25-year-old female with history of a sacral giant cell tumor resected via anterior transperitoneal approach followed by posterior L4-pelvis fusion presented with headaches and altered mental status. Imaging revealed that a portion of small bowel had migrated into her resection cavity and created an enterothecal fistula resulting in fecalith within the subarachnoid space and florid meningitis. The patient underwent a small bowel resection for fistula obliteration, and subsequently developed hydrocephalus requiring shunt placement and two suboccipital craniectomies for foramen magnum crowding. Ultimately, her wounds became infected requiring washouts and instrumentation removal. Despite a prolonged hospital course, she made significant recovery and at 10-month following presentation, she is awake, oriented, and able to participate in activities of daily living. Conclusions: This is the first case of meningitis secondary to enterothecal fistula in a patient without a previous congenital sacral anomaly. Operative intervention for fistula obliteration is the primary treatment and should be performed at a tertiary hospital with multidisciplinary capabilities. If recognized quickly and appropriately treated, there is a possibility of good neurological outcome.

When Death Hits You in Your Face, You Have to Listen": A Qualitative Investigation of Peer Bereavement Support Volunteers in Black American Communities.

Efforts to support grief in Black American communities are often under-recognized despite their potential to address negative mental health outcomes in this population. The aim of the current study was to qualitatively assess the community-level influence of bereavement support programs on predominantly Black communities in Baltimore, Maryland. Five focus groups (n = 23) were conducted with volunteers from a non-profit bereavement organization. Participants were queried about how their training may be sustainably applied as a community resource in Baltimore City. Thematic analysis from focus groups revealed three main themes: (1) enhancing feelings of belongingness fosters a sense of community cohesion, (2) use of bereavement support tools as a source of personal healing, and (3) applications of bereavement support in the community. Implications of our study support the widespread influence of peer-led bereavement support training to reduce the reverberating impact of personal and collective grief in Black American communities.

Acute Respiratory Distress Syndrome (ARDS) after trauma: Improving incidence, but increasing mortality.

PURPOSE: Acute Respiratory Distress Syndrome (ARDS) is an infrequent, yet morbid inflammatory complication in injury victims. With the current project we sought to estimate trends in incidence, determine outcomes, and identify risk factors for ARDS and related mortality. MATERIALS & METHODS: The national Trauma Quality Improvement Program dataset (2010-2014) was queried. Demographics, injury characteristics and outcomes were compared between patients who developed ARDS and those who did not. Logistic regression models were fitted for the development of ARDS and mortality respectively, adjusting for relevant confounders. RESULTS: In the studied 808,195 TQIP patients, incidence of ARDS decreased over the study years (3-1.1%, p < 0.001), but related mortality increased (18.-21%, p = 0.001). ARDS patients spent an additional 14.7 ± 10.3 days in the hospital, 9.7 ± 7.9 in the ICU, and 6.6 ± 9.4 on mechanical ventilation (all p < 0.001). Older age, male gender, African American race increased risk for ARDS. Age, male gender, lower GCS and higher ISS also increased mortality risk among ARDS patients. Several pre-existing comorbidities including chronic alcohol use, diabetes, smoking, and respiratory disease also increased risk. CONCLUSION: Although the incidence of ARDS after trauma appears to be declining, mortality is on the rise.

Pigtail Catheter Insertion Error: Root Cause Analysis and Recommendations for Patient Safety.

BACKGROUND: Small-caliber chest tubes are used to treat pneumothorax and pleural fluid collections. Although commonly considered a less invasive alternative to large-caliber thoracostomy tubes, small-caliber tubes have a high complication rate. Emergency physicians must be familiar with common and dangerous procedure complications associated with these devices and have a systematic and rapid approach to identify and solve malfunctions. Structured root cause analysis can facilitate identification of problems. METHODS: We reviewed the medical literature for complications of small-caliber chest tubes and searched the U.S. Food and Drug Administration (FDA) database for complications of a specific pigtail catheter kit. Using a structured root cause analysis (RCA), we examined two cases of retained pigtail catheter obturators resulting in catheter malfunction and unresolved pneumothorax. RESULTS: We identified common complications of pigtail catheters from the medical literature, as well as 28 reports to FDA of complications with the kit used in the analyzed cases; ours were the only reports of the obturator error. RCA identified multiple contributing factors, including unrecognized and novel radiographic clues, human errors, communication breakdown, device design, and opportunities for improved systematic procedural approach. DISCUSSION: We discuss factors identified in RCA and regulatory considerations relevant to emergency physicians, including FDA reporting mechanisms. CONCLUSIONS: A structured review of complications of pigtail catheter insertion revealed opportunities for improved patient safety. We highlight a preventable error in insertion of a percutaneous catheter and describe radiographic features to enhance error detection. Improved design, systematic processes for device insertion and troubleshooting, and enhanced provider education could reduce the risk of medical device errors. An end-of-procedure time-out including instrument counts and systematic assessment of device function is a generalizable patient safety measure for bedside procedures.

The Impact of Race and Socioeconomic Status on Treatment and Outcomes of Blunt Splenic Injury.

BACKGROUND: Racial, ethnic, and socioeconomic disparities have been shown to exist in trauma patients. Management of blunt splenic injuries (BSIs) can include splenectomy, embolization, or nonoperative management. This study assesses the effect of race and insurance status on outcomes in patients after blunt splenic trauma. METHODS: The National Trauma Data Bank was used to study patients aged 15-89 y with BSIs from 2013 to 2015. Patients with abbreviated injury scores greater than two in nonabdominal areas, excluding extremities, were eliminated, as were patients with other concomitant abdominal injuries requiring repair. Variables of interest were compared across groups using chi-square tests, and those with significant associations were used in multivariate regression models for each outcome. RESULTS: We analyzed 13,537 BSI patients. Uninsured patients had increased odds of mortality, more splenic operations, and were less likely to have nonoperative management (P < 0.001). Uninsured patients were also twice as likely to be discharged home and three times as likely to leave against medical advice (P < 0.001). African Americans and Hispanics had higher mortality (odds ratio [OR] 2.03, CI 1.34-3.08; OR 1.58, CI 1.03-2.44, respectively). African Americans had more splenic operations (OR 1.33, CI 1.08-1.64) and were 60% less likely to receive angioembolization (CI 0.41-0.84). Hispanics had fewer splenic operations (OR 0.79, CI 0.63-0.98). CONCLUSIONS: Noteworthy differences exist in the management of splenic trauma patients based on race/ethnicity and socioeconomic status, despite controlling for demographics and injury characteristics. Insurance status and race likely affect surgical treatment plans and mortality, particularly for uninsured, black, and Hispanic patients, but further research is needed to identify the root cause of these disparities.

Socioeconomic Status Affects Outcomes After Severity-Stratified Traumatic Brain Injury.

BACKGROUND: Socioeconomic status (SES) and race have been shown to increase the incidence of being afflicted by a traumatic brain injury (TBI) resulting in worse posthospitalization outcomes. The goal of this study was to determine the effect disparities have on in-hospital mortality, discharge to inpatient rehabilitation, hospital length of stay (LOS), and TBI procedures performed stratified by severity of TBI. METHODS: This was a retrospective cohort study of patients with closed head injuries using the National Trauma Data Bank (2012-2015). Multivariate logistic/linear regression models were created to determine the impact of race and insurance status in groups graded by head Abbreviated Injury Scale (AIS). RESULTS: We analyzed 131,461 TBI patients from NTDB. Uninsured patients experienced greater mortality at an AIS of 5 (odds ratio [OR] = 1.052, P = 0.001). Uninsured patients had a decreased likelihood of being discharged to inpatient rehabilitation with an increasing AIS beginning from an AIS of 2 (OR = 0.987, P = 0.008) to an AIS of 5 (OR = 0.879, P < 0.001). Black patients had an increased LOS as their AIS increased from an AIS of 2 (0.153 d, P < 0.001) to 5 (0.984 d, P < 0.001) with the largest discrepancy in LOS occurring at an AIS of 5. CONCLUSIONS: Disparities in race and SES are associated with differences in mortality, LOS, and discharge to inpatient rehabilitation. Patients with more severe TBI have the greatest divergence in treatment and outcome when stratified by race and ethnicity as well as SES.

Implications of atypical antipsychotic prescribing in the intensive care unit.

PURPOSE: The purpose of the study was to determine the downstream implications of atypical antipsychotic (AAP) prescribing in the intensive care unit (ICU), including discharge prescribing practices, monitoring, and attributable adverse drug events. MATERIALS AND METHODS: This retrospective cohort study included patients at least 18 years of age admitted to an ICU that received at least 2 doses of an AAP for documented delirium or avoidance of a deliriogenic medication. Exclusion criteria were documentation of an AAP as a home medication or initiation for a psychiatric indication unrelated to delirium (eg, schizophrenia). RESULTS: During the 8-month study period, 156 patients were included and 133 (85.2%) patients survived to hospital discharge. Of the survivors, AAP therapy was continued for 112 (84.2%) patients upon ICU transfer and for 38 (28.6%) patients upon hospital discharge. A majority of these patients had evidence of delirium resolution or no indication for continuation documented at discharge. Of the 127 patients with an electrocardiogram ordered during AAP therapy, QTc prolongation occurred in 49 (31.4%) patients. An adverse drug event leading to drug discontinuation was documented in 16 (10.2%) patients. CONCLUSIONS: Because of significant patient-centered implications, AAPs initiated in the ICU require continued evaluation for indication to avoid prolonged and possibly unnecessary use.

No need to wait: an analysis of the timing of cholecystectomy during admission for acute cholecystitis using the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: The objective of our analysis was to determine the optimal timing of cholecystectomy during admission for acute cholecystitis. METHODS: All patients from the American College of Surgeons National Surgical Quality Improvement Program Participant User Files from 2005 through 2010 who underwent emergency cholecystectomy within 7 days of hospital admission for acute cholecystitis were included for analysis. The association between timing of cholecystectomy and postoperative outcomes was determined using multivariate logistic regression analyses after adjustment for patient demographics, acute and chronic comorbid medical conditions, preoperative sepsis classification, American Society of Anesthesiologists physical status classification, and preoperative liver function tests. RESULTS: A total of 5,268 patients were included for analysis. The timing of operation was day of admission for 49.7% of these patients, 1 day after admission for 33.4%, 2 days after admission for 9.5%, 3 days after admission for 3.9%, and 4 days to 7 days after admission for 3.6%. Multivariate logistic regression analyses revealed no significant association between timing of operation and 30-day postoperative mortality or overall morbidity. Patients who underwent operation later in the course of admission were more likely to require an open procedure and sustained significantly longer postoperative and overall lengths of hospitalization. Similar findings were demonstrated for a subgroup of patients who exhibited characteristics that placed them at higher risk for surgical intervention. CONCLUSION: Immediate cholecystectomy is preferred for patients who require hospitalization for acute cholecystitis. LEVEL OF EVIDENCE: Economic/decision analysis, level III.

Does intent matter? The medical and societal burden of self-inflicted injury.

BACKGROUND: The objective of our study was to assess the impact of injury intentionality on the outcomes and healthcare resource utilization of severely injured patients in the United States. METHODS: The National Trauma Data Bank for the years 2001 through 2006 was used for our analysis. Adult patients with an injury severity score >or=15 were divided into three groups based on injury intentionality: unintentional, assault, and self-inflicted. Demographic and injury characteristics, unadjusted and risk-adjusted mortality rates, and healthcare resource utilization variables were compared for these three groups using t tests, analysis of variance, and multivariable regression analyses where appropriate. Stata/SE version 9.2 was used for all statistical analyses. p values <0.05 were considered significant. RESULTS: A total of 138,589 patients were included for analysis. After adjustment for potentially confounding variables, self-inflicted injury remained a significant predictor of increased mortality (mortality 42.3%, adjusted odds ratio for death = 2.31, 95% confidence interval 1.97-2.71), and injury by assault a significant predictor of decreased mortality (mortality 18.3%, adjusted odds ratio for death = 0.83, 95% confidence interval 0.74-0.92), when compared with unintentional injury (mortality 15.1%). Patients surviving self-inflicted injury required longer intensive care unit stays and overall hospital stays than survivors of unintentional injury. CONCLUSIONS: Patients who are treated for self-inflicted injury have higher risk-adjusted mortality and utilize comparatively higher levels of healthcare resources than victims of assault or patients sustaining unintentional injury. The findings of our study emphasize the need for trauma center participation in the development and maintenance of aggressive primary and secondary suicide prevention programs.

Serum protein expression predicts recurrence in patients with early-stage lung cancer after resection.

BACKGROUND: Patients with early stage nonsmall-cell lung cancer who have undergone complete resection have a recurrence rate of approximately 50%, predominately due to the development of systemic metastases. This study is a prospective analysis of the expression of seven serum protein markers of invasion and metastasis, collected preoperatively (baseline) and serially after resection, to determine the relationship between marker expression and recurrence. METHODS: Serum was collected from 196 patients with clinical stage I nonsmall-cell lung cancer who underwent resection over a 5-year period (1996 to 2000). Samples were drawn before resection and 1, 4, 6, 12, 18, and 24 months postoperatively. All patients were followed for at least 24 months or until death. Serum protein levels of vascular endothelial growth factor, hepatocyte growth factor), E-selectin, CD44, basic fibroblast growth factor, urokinase plasminogen activator, and urokinase plasminogen activator receptor were determined using enzyme-linked immunosorbent assay. RESULTS: To date, 73 patients (37%) have demonstrated recurrence. Baseline levels of only 1 marker (CD44) correlated with pathologic stage (p = 0.02). Analysis of the serial samples demonstrated that recurrence was predicted (before clinical or radiographic determination) by decreasing levels of E-selectin (p = 0.002), increasing levels of CD44 (p = 0.001), and increasing levels of urokinase plasminogen activator receptor (p = 0.03). CONCLUSIONS: This study demonstrates the potential to predict recurrence after resection in patients with early-stage nonsmall-cell lung cancer using a panel of serum protein markers. Early identification of patients with recurrence may improve the efficacy of systemic therapy.

Measurement of chemoresistance markers in patients with stage III non-small cell lung cancer: a novel approach for patient selection.

BACKGROUND: The long-term survival of patients with stage III non-small cell lung cancer treated with a combination of chemotherapy and radiation is 10% to 20%. Survival could potentially be increased and toxicity limited if one could identify patients most likely to respond to a particular treatment regimen. This project prospectively evaluated a panel of potential immunohistochemical markers of chemoresistance in a population of patients with pathology-confirmed stage III non-small cell lung cancer in order to determine the prognostic value of each marker in relation to response to chemotherapy or survival. METHODS: Immunohistochemical staining was performed on histologically positive mediastinal nodal specimens obtained from 59 patients (mean age, 62 years; range, 41 to 79 years) without evidence of distant metastatic disease treated with navelbine-based chemotherapy and external beam radiation therapy between 1996 and 2001. Included were markers for apoptosis (p53, bcl-2), drug efflux/degradation (MDR, GST-pi), growth factors (EGFr, Her2-neu), and mismatch repair (hMLH1, hMSH2). After chemotherapy, patients underwent radiologic evaluation for response measured by standard criteria. RESULTS: After a median 41 months of follow-up (range, 17 to 55 months), 43 patients had recurrent disease and 38 of these patients were dead of cancer (median cancer-free survival of 10 months and overall survival of 18 months). Patients who demonstrated a complete or partial response (n = 38) had a significantly improved survival (p = 0.002) compared with those with stable or progressive cancer (n = 21). Multivariable Cox step-wise regression analysis of marker expression associated overexpression of p53 and low expression of hMSH2 with poor treatment response and cancer death. CONCLUSIONS: These preliminary data suggest that marker expression may allow the separation of patients into low- and high-risk groups with respect to survival after combined navelbine-based chemotherapy and XRT. This could represent a novel method of selecting patients for a particular treatment regimen if these data are reproduced in a larger prospective trial.