Early thromboprophylaxis with low-molecular-weight heparin is safe in patients with pelvic fracture managed nonoperatively.

INTRODUCTION: Early initiation of thromboprophylaxis is highly desired in pelvic fracture patients, but it is often delayed due to the fear of hemorrhage. Aim of our study was to assess the safety of early initiation of venous thromboprophylaxis in patients with pelvic trauma managed nonoperatively. METHODS: Three-year (2010-2012) retrospective study of trauma patients with pelvic fractures who were managed nonoperatively and received thromboprophylaxis with low-molecular-weight heparin (LMWH). Patients were stratified in two groups based on the timing of initiation of prophylaxis; early (initiation within first 24 h) and late (after 24 h). Primary outcome measures included decrease in hemoglobin (Hb) levels, number of packed red blood cell (pRBC) units transfused, and the need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Regression analysis was performed. RESULTS: 255 patients were included (158 in early and 97 in late group). Mean ± standard deviation age was 48.2 ± 23.3 y, and 50.6% were male. After adjusting for confounders, there was no difference between the two groups in the decrease in Hb levels (b = 0.087, 95% confidence interval [CI] = -0.253 to 1.025; P = 0.23) or pRBC units transfused (b = -0.005, 95% CI = -0.366 to 0.364; P = 0.75).One patient required hemorrhage control postprophylaxis and belonged to the late group. Subanalysis of patients with signs of bleeding (n = 52) showed no difference between the two groups in the decrease in Hb levels or pRBC units transfused. Patients who received LMWH after 24 h had a higher incidence of symptomatic deep venous thrombosis and a longer hospital length of stay. CONCLUSIONS: Early initiation of thromboprophylaxis with LMWH in patients with pelvic fractures managed nonoperatively is safe and decreases the risk of symptomatic deep venous thrombosis.

US emergency department visits for fireworks injuries, 2006-2010.

BACKGROUND: Most literature regarding fireworks injuries are from outside the United States, whereas US-based reports focus primarily on children and are based on datasets which cannot provide accurate estimates for subgroups of the US population. METHODS: The 2006-2010 Nationwide Emergency Department Sample was used to identify patients with fireworks injury using International Classification of Diseases, Ninth Revision, Clinical Modification external cause of injury code E923.0. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were examined to determine the mechanism, type, and location of injury. Sampling weights were applied during analysis to obtain US population estimates. RESULTS: There were 25,691 emergency department visits for fireworks-related injuries between 2006 and 2010. There was no consistent trend in annual injury rates during the 5-y period. The majority of visits (50.1%) were in patients aged <20 y. Most injuries were among males (76.4%) and were treated in hospitals in the Midwest and South (42.0% and 36.4%, respectively) than in the West and Northeast (13.3% and 8.3%, respectively) census regions. Fireworks-related injuries were most common in July (68.1%), followed by June (8.3%), January (6.6%), December (3.4%), and August (3.1%). The most common injuries (26.7%) were burns of the wrist, hand, and finger, followed by contusion or superficial injuries to the eye (10.3%), open wounds of the wrist, hand, and finger (6.5%), and burns of the eye (4.6%). CONCLUSIONS: Emergency department visits for fireworks injuries are concentrated around major national holidays and are more prevalent in certain parts of the country and among young males. This suggests that targeted interventions may be effective in combating this public health problem.

Addressing the variation of post-surgical inpatient census with computer simulation.

OBJECTIVE: This study describes the development of a Discrete Event Simulation (DES) of a large pediatric perioperative department, and its use to compare the effectiveness of increasing the number of post-surgical inpatient beds vs. implementing a new discharge strategy on the proportion of patients admitted to the surgical unit to recover. MATERIALS AND METHODS: A DES of the system was developed and simulated data were compared with 1 year of inpatient data to establish baseline validity. Ten years of simulated data generated by the baseline simulation (control) was compared to 10 years of simulated data generated by the simulation for the experimental scenarios. Outcome and validation measures include percentage of patients recovering in post-surgical beds vs. "off floor" in medical beds, and daily census of inpatient volumes. RESULTS: The proportion of patients admitted to the surgical inpatient unit rose from 79.0% (95% CI, 77.9-80.1%) to 89.4% (95% CI, 88.7-90.0%) in the discharge strategy scenario, and to 94.2% (95% CI, 93.5-95.0%) in the additional bed scenario. The daily mean number of patients admitted to medical beds fell from 9.3 ± 5.9 (mean ± SD) to 4.9 ± 4.5 in the discharge scenario, and to 2.4 ± 3.2 in the additional bed scenario. DISCUSSION: Every hospital is tasked with placing the right patient in the right bed at the right time. Appropriately validated DES models can provide important insight into system dynamics. No significant variation was found between the baseline simulation and real-world data. This allows us to draw conclusions about the ramifications of changes to system capacity or discharge policy, thus meeting desired system performance measures.

High-Transhumeral Amputation: Targeted Muscle Reinnervation and Soft Tissue Coverage With Pedicled Latissimus Dorsi Flap.

The introduction of targeted muscle reinnervation has improved amputation pain outcomes and the control of upper-extremity myoelectric prostheses. However, patients with proximal transhumeral amputation levels and soft tissue deficits present a unique challenge. Existing described targeted muscle reinnervation techniques in transhumeral amputees rely on recipient motor nerves from the biceps and triceps; however, these may be absent in patients with more proximal injuries. Here, we describe the use of the pedicled latissimus dorsi flap for both soft tissue coverage and additional motor targets in patients with high-transhumeral amputation with complex soft tissue deficits.

Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program.

OBJECTIVE: The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN: A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING: Single-center, major university hospital. PATIENTS: The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS: The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS: An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

Safety and efficiency of interventional pulmonologists performing percutaneous tracheostomy.

BACKGROUND: The steady rise in the number of critically ill patients in the USA has led to an increase in the need for tracheostomies in patients requiring chronic ventilatory support. There is a matched need for experienced operators to safely and efficiently perform these procedures. OBJECTIVES: We evaluated the effects on procedural outcomes and efficiency of percutaneous dilatational tracheostomy (PDT) placement in the medical intensive care unit (MICU) by the surgical team (ST) or interventional pulmonologists (IP). The IP team joined the PDT team in September 2007 and became primarily responsible for all PDT in the MICU. METHODS: A retrospective analysis of prospectively collected data of patients who received PDT in the MICU by ST and IP from September 2007 to August 2010 was made. Outcomes including safety, efficacy, and procedural efficiency were compared. RESULTS: One hundred seven patients underwent bedside PDT in the MICU during this period. Forty-three procedures (40.2%) were performed by the ST and 64 procedures (59.8%) were performed by IP. There was no statistical difference between the incidence of airway injury and infection between the two procedural groups. There were no deaths related to the performance of PDT in our series. PDT was completed within 48 h of request in 100% of IP patients and 95% of ST patients (p = 0.08). CONCLUSIONS: There were no statistical differences in PDT between the ST and IP groups when comparing complications. There was a trend towards an increased efficiency in time to PDT after consultation within the IP PDT group. Trained IP can safely and effectively perform PDT.

Using an electrical potential to reversibly switch surfaces between two states for dynamically controlling cell adhesion.

Smart surfaces presenting both antifouling molecules with a charged functional group at their distal end, and molecules that are terminated by RGD peptides for cell adhesion, were fabricated and characterized (see picture). By applying potentials of +300 or -300 mV, the surfaces could be dynamically switched to make the peptide accessible or inaccessible to cells.

CRISIS ventilator: A 3D printed option for ventilator surge in mass respiratory pandemics.

BACKGROUND: The COVID-19 pandemic revealed flaws in the stockpiling and distribution of ventilators. In this study, we assessed the durability, sterilizability, and performance of a 3D-printed ventilator. METHODS: SLS-printed devices were dropped from 1.83 m and autoclaved before evaluation on a COVID-19 simulated patient. The respiratory performance of an extrusion-printed device was studied using a variable compliance model. Ranges of sustainable respiratory rates were evaluated as a function of tidal volume. RESULTS: Autoclaving and dropping the device did not negatively impact minute ventilation or PIP for sustained ventilation. Equivalence was significant across all measures except for comparing the autoclaved and dropped with p = 0.06. Extrusion produced ventilators achieved minute ventilation ranging from 4.1 to 12.2 L/min for all simulated compliances; there was an inverse correlation between tidal volume and respiratory rate. CONCLUSION: The CRISIS ventilator is a durable, sterilizable, and reusable 3D-printed ventilator using off-the-shelf materials which could be employed variety of adult lung diseases. Further in-vivo testing is needed.

Extended home use of an advanced osseointegrated prosthetic arm improves function, performance, and control efficiency.

Objective.Full restoration of arm function using a prosthesis remains a grand challenge; however, advances in robotic hardware, surgical interventions, and machine learning are bringing seamless human-machine interfacing closer to reality.Approach.Through extensive data logging over 1 year, we monitored at-home use of the dexterous Modular Prosthetic Limb controlled through pattern recognition of electromyography (EMG) by an individual with a transhumeral amputation, targeted muscle reinnervation, and osseointegration (OI).Main results.Throughout the study, continuous prosthesis usage increased (1% per week,p< 0.001) and functional metrics improved up to 26% on control assessments and 76% on perceived workload evaluations. We observed increases in torque loading on the OI implant (up to 12.5% every month,p< 0.001) and prosthesis control performance (0.5% every month,p< 0.005), indicating enhanced user integration, acceptance, and proficiency. More importantly, the EMG signal magnitude necessary for prosthesis control decreased, up to 34.7% (p< 0.001), over time without degrading performance, demonstrating improved control efficiency with a machine learning-based myoelectric pattern recognition algorithm. The participant controlled the prosthesis up to one month without updating the pattern recognition algorithm. The participant customized prosthesis movements to perform specific tasks, such as individual finger control for piano playing and hand gestures for communication, which likely contributed to continued usage.Significance.This work demonstrates, in a single participant, the functional benefit of unconstrained use of a highly anthropomorphic prosthetic limb over an extended period. While hurdles remain for widespread use, including device reliability, results replication, and technical maturity beyond a prototype, this study offers insight as an example of the impact of advanced prosthesis technology for rehabilitation outside the laboratory.

Leveraging 3D Printing Capacity in Times of Crisis: Recommendations for COVID-19 Distributed Manufacturing for Medical Equipment Rapid Response.

The SARS-CoV-2 (COVID-19) pandemic has provided a unique set of global supply chain limitations with an exponentially growing surge of patients requiring care. The needs for Personal Protective Equipment (PPE) for hospital staff and doctors have been overwhelming, even just to rule out patients not infected. High demand for traditionally manufactured devices, challenged by global demand and limited production, has resulted in a call for additive manufactured (3D printed) equipment to fill the gap between traditional manufacturing cycles. This method has the unique ability to pivot in real time, while traditional manufacturing may take months to change production runs. 3D printing has been used to produce a variety of equipment for hospitals including face shields, masks, and even ventilator components to handle the surge. This type of rapid, crowd sourced, design and production resulted in new challenges for regulation, liability, and distribution. This manuscript reviews these challenges and successes of additive manufacturing and provides a forward plan for hospitals to consider for future surge events. Recommendations: To accommodate future surges, hospitals and municipalities should develop capacity for short-run custom production, enabling them to validate new designs. This will rapidly increase access to vetted equipment and critical network sharing with community distributed manufacturers and partners. Clear guidance and reviewed design repositories by regulatory authorities will streamline efforts to combat future pandemic waives or other surge events.

Three-Dimensional Printed Ventilators: A Rapid Solution to Coronavirus Disease 2019-Induced Supply-Chain Shortages.

OBJECTIVE: To examine rapidly emerging ventilator technologies during coronavirus disease 2019 and highlight the role of CRISIS, a novel 3D printed solution. DATA SOURCES: Published articles, literature, and government guidelines that describe and review emergency use ventilator technologies. STUDY SELECTION: Literature was chosen from peer-reviewed journals and articles were limited to recent publications. DATA EXTRACTION: All information regarding ventilator technology was extracted from primary sources. DATA SYNTHESIS: Analysis of technology and relevance to coronavirus disease 2019 physiology was collectively synthesized by all authors. CONCLUSIONS: The coronavirus disease 2019 pandemic has placed massive stress on global supply chains for ventilators due to the critical damage the virus causes to lung function. There is an urgent need to increase supply, as hospitals become inundated with patients requiring intensive respiratory support. Coalitions across the United States have formed in order to create new devices that can be manufactured quickly, with minimal resources, and provide consistent and safe respiratory support. Due to threats to public health and the vulnerability of the U.S. population, the Food and Drug Administration released Emergency Use Authorizations for new or repurposed devices, shortening the approval timeline from years to weeks. The list of authorized devices varies widely in complexity, from automated bagging techniques to repurposed sleep apnea machines. Three-dimensional printed ventilators, such as "CRISIS," propose a potential solution to increase the available number of vents for the United States and abroad, one that is dynamic and able to absorb the massive influx of hospitalized patients for the foreseeable future.

Implementation of 3D Printing Technology in the Field of Prosthetics: Past, Present, and Future.

There is an interesting and long history of prostheses designed for those with upper-limb difference, and yet issues still persist that have not yet been solved. Prosthesis needs for children are particularly complex, due in part to their growth rates. Access to a device can have a significant impact on a child's psychosocial development. Often, devices supporting both cosmetic form and user function are not accessible to children due to high costs, insurance policies, medical availability, and their perceived durability and complexity of control. These challenges have encouraged a grassroots effort globally to offer a viable solution for the millions of people living with limb difference around the world. The innovative application of 3D printing for customizable and user-specific hardware has led to open-source Do It Yourself "DIY" production of assistive devices, having an incredible impact globally for families with little recourse. This paper examines new research and development of prostheses by the maker community and nonprofit organizations, as well as a novel case study exploring the development of technology and the training methods available. These design efforts are discussed further in the context of the medical regulatory framework in the United States and highlight new associated clinical studies designed to measure the quality of life impact of such devices.

Perioperative glycemic control and postoperative complications in patients undergoing emergency general surgery: What is the role of Plasma Hemoglobin A1c?

BACKGROUND: Plasma hemoglobin A1c (HbA1c) reflects quality of glucose control in diabetic patients. Literature reports that patients undergoing surgery with an elevated HbA1c level are associated with increased postoperative morbidity and mortality. The aim of our study was to evaluate the impact of HbA1c level on outcomes after emergency general surgery (EGS). METHODS: We performed a 3-year analysis of our prospectively maintained EGS database. Patients who had HbA1c levels measured within 3 months before surgery were included. Patients were divided into two groups (HbA1c < 6 and HbA1c ≥ 6). Our primary outcome measures included in-hospital complications (major and minor complications), hospital and intensive care unit length of stay, and mortality. Secondary outcomes measures were 30-day complications, readmissions, and mortality. Multivariate and linear regressions were performed. RESULTS: Of the 402 study patients, mean age was 61 ± 12 years, 53% were females, and 63.8% were diabetics. Overall, 49% had an HbA1c ≥ 6%; the mortality rate was 6%. Those with hypertension, history of coronary artery disease, and body mass index of 30 kg/m or greater were more likely to have HbA1c of 6.0% or greater. 7.9% patients experienced major complications. Patients with HbA1c of 6% or greater had a higher complication rate (36% vs 11%, p < 0.001) than those with HbA1c less than 6%. However there was no difference in mortality between two groups (p = 0.09). After controlling for confounders, HbA1c ≥ 6.0% (odds ratio [OR], 2.9; p < 0.01) and a postoperative random blood sugar (RBS) of 200 mg/dL or greater (OR, 2.3; p < 0.01) were independent predictors of major complications. Patients with both HbA1c of 6.0% or greater and postoperative RBS of 200 or greater had higher odds (OR, 4.2; p < 0.01) of developing major complication. After adjusting for confounders, a higher HbA1c was independently correlated with a higher postoperative RBS (b = 0.494, [19.7-28.4], p = 0.02), but there was no correlation with the preoperative RBS. CONCLUSION: Patients with HbA1c of 6.0% or greater and a postoperative RBS of 200 mg/dL or greater have a four times higher risk of developing major complications after EGS. A preoperative HbA1c can stratify patients prone to develop postoperative hyperglycemia, regardless of their preoperative RBS. LEVEL OF EVIDENCE: Prognostic, level III.

A pilot study of eye-tracking devices in intensive care.

BACKGROUND: Eye-tracking devices have been suggested as a means of improving communication and psychosocial status among patients in the intensive care unit (ICU). This study was undertaken to explore the psychosocial impact and communication effects of eye-tracking devices in the ICU. METHODS: A convenience sample of patients in the medical ICU, surgical ICU, and neurosciences critical care unit were enrolled prospectively. Patients participated in 5 guided sessions of 45 minutes each with the eye-tracking computer. After completion of the sessions, the Psychosocial Impact of Assistive Devices Scale (PIADS) was used to evaluate the device from the patient's perspective. RESULTS: All patients who participated in the study were able to communicate basic needs to nursing staff and family. Delirium as assessed by the Confusion Assessment Method for the Intensive Care Unit was present in 4 patients at recruitment and none after training. The device's overall psychosocial impact ranged from neutral (-0.29) to strongly positive (2.76). Compared with the absence of intervention (0 = no change), patients exposed to eye-tracking computers demonstrated a positive mean overall impact score (PIADS = 1.30; P = .004). This finding was present in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all P < .01). CONCLUSION: There is a population of patients in the ICU whose psychosocial status, delirium, and communication ability may be enhanced by eye-tracking devices. These 3 outcomes are intertwined with ICU patient outcomes and indirectly suggest that eye-tracking devices might improve outcomes. A more in-depth exploration of the population to be targeted, the device's limitations, and the benefits of eye-tracking devices in the ICU is warranted.

Investigating the relationship between weather and violence in Baltimore, Maryland, USA.

BACKGROUND: It is a common refrain at major urban trauma centers that caseloads increase in the heat of the summer. Several previous studies supported this assertion, finding trauma admissions and crime to correlate positively with temperature. We examined links between weather and violence in Baltimore, MD, through trauma presentation to Johns Hopkins Hospital and crime reports filed with the Baltimore Police Department. METHODS: Crime data were obtained from the Baltimore City Police Department from January 1, 2008 to March 31, 2013. Trauma data were obtained from a prospectively collected registry of all trauma patients presenting to Johns Hopkins Hospital from January 1, 2007 to March 31, 2013. Weather data were obtained from the National Climatic Data Center. Correlation coefficients were calculated and negative binomial regression was used to elucidate the independent associations of weather and temporal variables with the trauma and crime data. RESULTS: When adjusting for temporal and meteorological factors, maximum daily temperature was positively associated with total trauma, intentional injury, and gunshot wounds presenting to Johns Hopkins Hospital along with total crime, violent crime, and homicides in Baltimore City. Associations of average wind speed, daily precipitation, and daily snowfall with trauma and crime were far weaker and, when significant, nearly universally negative. CONCLUSION: Maximum daily temperature is the most important weather factor associated with violence and trauma in our study period and location. Our findings suggest potential implications for hospital staffing to be explored in future studies.

Improving Cardiac Surgical Site Infection Reporting and Prevention By Using Registry Data for Case Ascertainment.

BACKGROUND: The use of administrative data for surgical site infection (SSI) surveillance leads to inaccurate reporting of SSI rates [1]. A quality improvement (QI) initiative was conducted linking clinical registry and administrative databases to improve reporting and reduce the incidence of SSI [2]. METHODS: At our institution, The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and infection surveillance database (ISD) were linked to the enterprise data warehouse containing electronic health record (EHR) billing data. A data visualization tool was created to (1) use the STS-CHSD for case ascertainment, (2) resolve discrepancies between the databases, and (3) assess impact of QI initiatives, including wound alert reports, bedside reviews, prevention bundles, and billing coder education. RESULTS: Over the 24-month study period, 1,715 surgical cases were ascertained according to the STS-CHSD clinical criteria, with 23 SSIs identified through the STS-CHSD, 20 SSIs identified through the ISD, and 32 SSIs identified through the billing database. The rolling 12-month STS-CHSD SSI rate decreased from 2.73% (21 of 769 as of January 2013) to 1.11% (9 of 813 as of December 2014). Thirty reporting discrepancies were reviewed to ensure accuracy. Workflow changes facilitated communication and improved adjudication of suspected SSIs. Billing coder education increased coding accuracy and narrowed variation between the 3 SSI sources. The data visualization tool demonstrated temporal relationships between QI initiatives and SSI rate reductions. CONCLUSIONS: Linkage of registry and infection control surveillance data with the EHR improves SSI surveillance. The visualization tool and workflow changes facilitated communication, SSI adjudication, and assessment of the QI initiatives. Implementation of these initiatives was associated with decreased SSI rates.

Prefilled devices for parenteral applications.

Current parenteral administration of drugs suffers from several drawbacks including the requirement of healthcare personnel to administer the drug, the risk of needle stick injuries that may result in the transmission of blood borne pathogens, and patient discomfort. Prefilled devices have emerged as powerful tools to improve parenteral administration of drugs. There are a number of clinical conditions including treatment of endocrine diseases, neurological disorders, autoimmune diseases and emergency medicine where prefilled devices have made major improvements to patient care. Prefilled devices have become an important set of tools for the medical practitioner due to their ease of use and safety, cost effectiveness and patient convenience. This review provides a comprehensive summary of existing prefilled devices, their current clinical uses and corresponding regulatory processes.

Rapid Reconstitution Packages (RRPs) implemented by integration of computational fluid dynamics (CFD) and 3D printed microfluidics.

Rapid Reconstitution Packages (RRPs) are portable platforms that integrate microfluidics for rapid reconstitution of lyophilized drugs. Rapid reconstitution of lyophilized drugs using standard vials and syringes is an error-prone process. RRPs were designed using computational fluid dynamics (CFD) techniques to optimize fluidic structures for rapid mixing and integrating physical properties of targeted drugs and diluents. Devices were manufactured using stereo lithography 3D printing for micrometer structural precision and rapid prototyping. Tissue plasminogen activator (tPA) was selected as the initial model drug to test the RRPs as it is unstable in solution. tPA is a thrombolytic drug, stored in lyophilized form, required in emergency settings for which rapid reconstitution is of critical importance. RRP performance and drug stability were evaluated by high-performance liquid chromatography (HPLC) to characterize release kinetics. In addition, enzyme-linked immunosorbent assays (ELISAs) were performed to test for drug activity after the RRPs were exposed to various controlled temperature conditions. Experimental results showed that RRPs provided effective reconstitution of tPA that strongly correlated with CFD results. Simulation and experimental results show that release kinetics can be adjusted by tuning the device structural dimensions and diluent drug physical parameters. The design of RRPs can be tailored for a number of applications by taking into account physical parameters of the active pharmaceutical ingredients (APIs), excipients, and diluents. RRPs are portable platforms that can be utilized for reconstitution of emergency drugs in time-critical therapies.

Increased mortality associated with EMS transport of gunshot wound victims when compared to private vehicle transport.

BACKGROUND: Recent studies suggest that mode of transport affects survival in penetrating trauma patients. We hypothesised that there is wide variation in transport mode for patients with gunshot wounds (GSW) and there may be a mortality difference for GSW patients transported by emergency medical services (EMS) vs. private vehicle (PV). STUDY DESIGN: We studied adult (≥16 years) GSW patients in the National Trauma Data Bank (2007-2010). Level 1 and 2 trauma centres (TC) receiving ≥50 GSW patients per year were included. Proportions of patients arriving by each transport mode for each TC were examined. In-hospital mortality was compared between the two groups, PV and EMS, using multivariable regression analyses. Models were adjusted for patient demographics, injury severity, and were adjusted for clustering by facility. RESULTS: 74,187 GSW patients were treated at 182 TCs. The majority (76%) were transported by EMS while 12.6% were transported by PV. By individual TC, the proportion of patients transported by each category varied widely: EMS (median 78%, interquartile range (IQR) 66-85%), PV (median 11%, IQR 7-17%), or others (median 7%, IQR 2-18%). Unadjusted mortality was significantly different between PV and EMS (2.1% vs. 9.7%, p<0.001). Multivariable analysis demonstrated that EMS transported patients had a greater than twofold odds of dying when compared to PV (OR=2.0, 95% CI 1.73-2.35). CONCLUSIONS: Wide variation exists in transport mode for GSW patients across the United States. Mortality may be higher for GSW patients transported by EMS when compared to private vehicle transport. Further studies should be performed to examine this question.

Post-traumatic empyema: aetiology, surgery and outcome in 125 consecutive patients.

INTRODUCTION: Empyema remains a potentially serious condition with multiple etiologies including post-pneumonic, post-resection, and post-traumatic. There are few studies describing the latter. We reviewed our experience at a high volume trauma centre in injured patients with empyema, examining pre-operative status, surgical procedures, pathogens and outcome. METHODS: Retrospective trauma registry review, from 9/01 to 4/10. Empyema was defined as culture positive pleural fluid or purulence at operation. Data collected included demographics, injury mechanism, thoracic injuries, organ dysfunction, pathogens isolated, surgical procedures, outcomes and follow up. RESULTS: One hundred twenty-five consecutive patients with empyema were identified. Average injury severity score and age were 27.3 and 37.2 years respectively; 89.6% were male, 63.2% sustained blunt chest trauma. Time from injury to diagnosis averaged 12.1 days. All underwent decortication; 80% by thoracotomy, the remainder thoracoscopically. At operation over half were mechanically ventilated and 13.6% required vasoactive infusions. Monomicrobial cultures with Gram positive cocci predominating were obtained in 44%, 48% had polymicrobial cultures and 18.4% had a ruptured lung abscess. There were five deaths (4%); two occurring after a ruptured lung abscess. Recurrent empyema occurred in 6.4%, all successfully treated by re-operation or catheter drainage. Intensive care and hospital stays were 18.1 and 30.6 days respectively. All survivors achieved resolution of empyema. CONCLUSIONS: Trauma patients with empyema represent a subset of severely injured critically ill patients with diverse pathogens and polymicrobial flora. Appropriate surgical management and specific antibiotic therapy yields excellent results with acceptable risk. A ruptured lung abscess may be the aetiology of the post-traumatic empyema in a subset of patients and may represent an increased operative risk.