Review of Statutory Obligations for Reporting Ballistic Injuries.

Traumatic ballistic injury is an unfortunate and commonly encountered problem seen by surgeons. An estimated 85,694 nonfatal ballistic injuries occur annually, and in 2020 there were 45,222 firearm-related deaths in the United States. Surgeons of all subspecialties may provide necessary care. Acute care injuries are generally reported to authorities immediately; however, delayed presentation of ballistic injuries may go unreported despite regulations to do so. We present a case of a delayed ballistic injury and a comparative review of individual states' reporting requirements to highlight statutory obligations and penalties as an educational reference for surgeons treating ballistic injuries. Methods: Google and PubMed searches were performed utilizing keywords "ballistic," "gunshot," "physician," and "reporting" as terms. Inclusion criteria included the English language, official state statute sites, legal and scientific articles, and websites. Exclusion criteria included nongovernmental sites and information sources. Data collected were analyzed to include statute numbers, time to report, infraction consequences, and monetary fines. The resultant data are reported by state and region. Results: All but two state jurisdictions mandate healthcare providers to report knowledge and/or treatment of ballistic injuries, regardless of the timeline of injury. Violations of mandatory reporting may lead to fines or imprisonment, depending on the specific state. The timeline for reporting, fines, and subsequent legal action varies by state and region. Conclusions: Requirements for reporting injuries exist in 48 of 50 states. The treating physician/surgeon should thoughtfully question patients with a chronic ballistic injury history and provide reports to local law enforcement.

An Analysis of Inhalation Injury Diagnostic Methods and Patient Outcomes.

The purpose of this study was to compare patient outcomes according to the method of diagnosing burn inhalation injury. After approval from the American Burn Association, the National Burn Repository Dataset Version 8.0 was queried for patients with a diagnosis of burn inhalation injury. Subgroups were analyzed by diagnostic method as defined by the National Burn Repository. All diagnostic methods listed for each patient were included, comparing mortality, hospital days, intensive care unit (ICU) days, and ventilator days (VDs). Z-tests, t-tests, and linear regression were used with a statistical significance of P value of less than .05. The database query yielded 9775 patients diagnosed with inhalation injury. The greatest increase in mortality was associated with diagnosis by bronchoscopy or carbon monoxide poisoning. A relative increase in hospital days was noted with diagnosis by bronchoscopy (9 days) or history (2 days). A relative increase in ICU days was associated with diagnosis according to bronchoscopy (8 days), clinical findings (2 days), or history (2 days). A relative increase in VDs was associated with diagnosis by bronchoscopy (6 days) or carbon monoxide poisoning (3 days). The combination of diagnosis by bronchoscopy and clinical findings increased the relative difference across all comparison measures. The combination of diagnosis by bronchoscopy and carbon monoxide poisoning exhibited decreased relative differences when compared with bronchoscopy alone. Diagnosis by laryngoscopy showed no mortality or association with poor outcomes. Bronchoscopic evidence of inhalation injury proved most useful, predicting increased mortality, hospital, ICU, and VDs. A combined diagnosis determined by clinical findings and bronchoscopy should be considered for clinical practice.

The evaluation of physical exam findings in patients assessed for suspected burn inhalation injury.

The purpose of this investigation was to evaluate the utility of singed nasal hair (SN), carbonaceous sputum (CS), and facial burns (FB) as indicators of burn inhalation injury, when compared to the accepted standard of bronchoscopic diagnosis of inhalation injury. An institutional review board approved, retrospective review was conducted. All patients were suspected to have burn inhalation injury and subsequently underwent bronchoscopic evaluation. Data collected included: percent burn TBSA, burn injury mechanism, admission physical exam findings (SN, CS, FB), and bronchoscopy findings. Thirty-five males and twelve females met inclusion criteria (n = 47). Bronchoscopy was normal in 31 patients (66%). Data were analyzed as all patients and in subgroups according to burn TBSA and an enclosed space mechanism of injury. Physical exam findings (SN, CS, FB) were evaluated individually and in combination. Overall, the sensitivities, specificities, positive predictive values, and negative predictive values calculated were poor and inconsistent, and they did not improve within subgroup analysis or when physical findings were combined. Further statistical analysis suggested the physical findings, whether in isolation or in combination, have poor discrimination between patients that have and do not have inhalation injury (AUC < 0.7, P > .05) and poor agreement with the diagnosis made by bronchoscopy (κ < 0.4, P > .05). This remained true in the subgroup analysis as well. Our data demonstrated the findings of SN, CS, and FB are unreliable evidence for inhalation injury, even in the context of an enclosed space mechanism of injury. Thus, these physical findings are not absolute indicators for intubation and should be interpreted as one component of the history and physical.

Upper extremity deep vein thrombosis with tourniquet use.

INTRODUCTION: Upper extremity deep vein thrombosis is an increasingly important clinical finding with significant morbidity and mortality. The condition may be under-diagnosed in trauma and surgery settings. PRESENTATION OF CASE: We present a case of upper extremity thrombosis with venous congestive symptoms secondary to the use of an operative tourniquet. A literature review and discussion of the causes of upper extremity deep vein thrombosis and the pathophysiological disturbances seen with tourniquet use are presented. DISCUSSION: Upper extremity deep venous thrombosis is uncommon. In this case the likely cause was operative tourniquet use. CONCLUSION: Operative tourniquet may be a risk factor in upper extremity deep vein thrombosis.

Obesity and surgical wound healing: a current review.

Objective. The correlation between obesity and deficient wound healing has long been established. This review examines the current literature on the mechanisms involved in obesity-related perioperative morbidity. Methods. A literature search was performed using Medline, PubMed, Cochrane Library, and Internet searches. Keywords used include obesity, wound healing, adipose healing, and bariatric and surgical complications. Results. Substantial evidence exists demonstrating that obesity is associated with a number of postoperative complications. Specifically in relation to wound healing, explanations include inherent anatomic features of adipose tissue, vascular insufficiencies, cellular and composition modifications, oxidative stress, alterations in immune mediators, and nutritional deficiencies. Most recently, advances made in the field of gene array have allowed researchers to determine a few plausible alterations and deficiencies in obese individuals that contribute to their increased risk of morbidity and mortality, especially wound complications. Conclusion. While the literature discusses how obesity may negatively affect health on various of medical fronts, there is yet to be a comprehensive study detailing all the mechanisms involved in obesity-related morbidities in their entirety. Improved knowledge and understanding of obesity-induced physiological, cellular, molecular, and chemical changes will facilitate better assessments of surgical risks and outcomes and create efficient treatment protocols for improved patient care of the obese patient population.

Implant-associated anaplastic large cell lymphoma: beyond breast prostheses.

OBJECTIVE: Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin T-cell lymphoma potentially associated with silicone-shelled breast implants. The low incidence of ALCL has prevented establishment of causality. Many implantable devices are constructed with biomaterials similar to those used in breast prostheses. The purpose of this paper is to identify reports of ALCL in association with other types of implantable devices. METHODS: A literature review was conducted using PubMed to identify reports of non-Hodgkin lymphoma in association with various implantable devices. RESULTS: One case of ALCL was identified in association with a stainless steel internal fixation plate. Diffuse large B-cell lymphoma was widely reported in association with various implantable biomaterials and chronic inflammation. CONCLUSION: The neoplastic response associated with breast prostheses appears substantively different from other implantable devices. Physicians caring for patients with silicone elastomer-containing implants should have increased suspicion for implant-associated ALCL and report all pertinent cases in the literature.

The Use of EZ Derm® in Partial-Thickness Burns: An Institutional Review of 157 Patients.

OBJECTIVES: To evaluate the use of EZ Derm® (Molnlycke Health Care, US, LLC, Norcross, GA) on partial-thickness burns. METHODS: A retrospective review of medical records from patients presenting to the Tampa General Regional Burn Center from January 1, 2008, through January 1, 2012, was conducted. A hospitalwide list of patients was generated on the basis of the presence of charge codes for EZ Derm®. All encounters that did not pass through the Burn Unit were excluded. Applicable charts were reviewed for basic patient characteristics, burn characteristics, outcomes, and complications. Complications were defined as premature separation of EZ Derm®, deviation from a flat fully epithelized wound at the time of final EZ Derm® separation and hypertrophic/keloid scaring. RESULTS: A total of 157 patients were identified and met the study criteria. Eighteen complications were reported from 16 of the 157 patients. Complications were attributed to positioning (2/133 = 1.5%), infection (4/133 = 3.0%), incomplete epithelialization at time of separation (3/133 = 2.2%), need for additional excision and grafting (6/133 = 4.5%), hypertrophic scaring (2/60 = 3.3), and cryptogenic (1/133 = 0.75). CONCLUSIONS: EZ Derm® has proven to be a robust wound dressing that provides cost-effective, consistent durable wound coverage with minimal complications that resolve without long-term sequela.