Cluster-based analysis of PTSD-Checklist for DSM-5 (PCL-5) in civilians with post-concussive cognitive changes.

OBJECTIVE: This study explores the relationship between PTSD symptoms and cognition in patients with persistent post-concussive symptoms (PPCS). METHODS: Adults with PPCS presenting to a specialized brain injury clinic provided demographic and injury information and completed the PTSD checklist for DSM-5, Generalized Anxiety Disorder Scale-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9). The Montreal Cognitive Assessment (MoCA) was used to screen for possible cognitive concerns. Multiple regression analysis (MLR) adjusting for age, sex, mechanism of injury, psychiatric history, number of previous concussions, months since most recent injury, and mental health questionnaire scores was used to determine associations between PTSD and cognition. Binomial logistic regression explored the relationship between domains of the MoCA and PCL-5 scores. RESULTS: We found a negative correlation between MoCA scores, PCL-5 (ρ=-0.211, p = 0.009) and PHQ-9 (ρ=-0.187, p = 0.021) in patients with PPCS and collinearity of PCL-5 and PHQ-9 scores. Significantly higher Arousal and Reactivity cluster scores within the PCL-5 were associated with poorer scores on naming and abstract tasks on the MoCA. CONCLUSION: The association between specific PCL-5 clusters and lower MoCA scores may represent a viable target for psychotherapeutic and psychopharmacologic intervention in patients with cognitive changes associated with PPCS.

Design of a treatment satisfaction measure for patients undergoing varicose vein treatment: Venous Treatment Satisfaction Questionnaire (VenousTSQ).

BACKGROUND: Established condition-specific patient-reported outcome measures for varicose veins are limited to the measurement of health status and function. A treatment satisfaction measure is needed to understand patient satisfaction with different treatment options. The aim of this study was to design a Venous Treatment Satisfaction Questionnaire (VenousTSQ) that would be ready for large-scale data collection and psychometric evaluation. METHODS: Relevant items were selected from the -TSQ Item Library and new items were designed where necessary. A draft VenousTSQ was prepared using the existing AneurysmTSQ as a template. Fifteen interviews were conducted from 4 days to 16 months after the procedure. The interviews were designed to elicit important sources of satisfaction or dissatisfaction before completion of draft questionnaires. The VenousTSQ drafts were modified between sets of interviews until no further changes were required. RESULTS: The final VenousTSQ consists of two questionnaires: VenousTSQ early (VenousTSQe) and VenousTSQ status (VenousTSQs). Items that need be asked only once are in the VenousTSQe, whereas those that can usefully be asked more than once are in the VenousTSQs. Of the 16 unique items forming the VenousTSQ, 12 were from the -TSQ Item Library. Only 1 of these 12 required significant modification. CONCLUSIONS: The VenousTSQ represents a condition-specific psychological outcome measure for varicose veins, enabling patient satisfaction or dissatisfaction with such treatments to be measured. Large-scale data collection is under way to establish optimal scoring, quantitative validity, and reliability of the VenousTSQ.

Biofilm Formation on Central Venous Catheters: A Pilot Study.

INTRODUCTION: Central line-associated bloodstream infection is a complication with serious consequences and biofilm development is thought to play a role. This study evaluated the impact of sterilization technique on central venous catheter (CVC) biofilm formation. MATERIALS AND METHODS: This pilot study was conducted in the surgical intensive care unit of a tertiary care facility. All CVCs were inserted with chlorhexidine preparation (CHG). CHG-only CVCs were compared to the use of CHG with chlorhexidine gluconate-impregnated sponge (CHGIS). After removal, a punch biopsy of the CVC was taken at the noted skin level. Scanning electron microscopy identified the stage of biofilm. Confocal laser scanning microscopy with SYPRO stain confirmed the presence of glycocalyx and a volumetric analysis was completed. RESULTS: Twenty four CVCs were collected. Indications for line placement were similar, with 42% placed for sepsis in the CHGIS group and 33% in the CHG group. There were no positive line cultures or bacteremia and 2/12 CHGIS patients had candidemia. CHGIS lines were in place for a mean of 91 h, compared to 60 h with CHG alone (P = 0.19). The interior of CVCs had lower stage biofilms than the exterior and lacked stage 4 biofilms. Stage 4 biofilms were present externally on 50% of CVCs (8/12 CHG and 4/12 CHGIS). Stage 3 biofilms were present on 7/12 CHG and 6/12 CHGIS interior samples. Volume analysis found an increase in biofilm and glycocalyx in CHGIS compared to CHG samples. CONCLUSIONS: This study identified biofilms on both surfaces of CVCs. No significant difference in biofilm formation was found based on a sterilization technique.

An intersectional examination of the opportunity gap in science: A critical quantitative approach to latent class analysis.

This study employs a critical quantitative lens to model intersectionality in quantitative analysis and examine how inequities are perpetuated in U.S. schools. Using the U.S. sample from nationally representative PISA 2015 data, Latent Class Analysis was used to identify intersectional student background groups based on indicators of race/ethnicity, social class, immigration background, language spoken at home, and measures of cultural capital associated with cultural reproduction theory. A regression auxiliary model combined with latent class regression was then used to determine if intersectional group membership moderated the relationship between a covariate, gender, and two distal outcomes: sense of belonging to school and opportunity to learn (OTL) inquiry-based science. Differences between intersectional background groups on the two distal outcomes were also examined. The findings from this study reinforced the use of LCA as a promising method for incorporating intersectionality frameworks in quantitative research designs. Six distinct intersectional background classes were identified and findings revealed evidence of a wealth gap between classes of similar affluency based on parent occupational status and education. In addition to this evidence of systemic inequality, significant gender disparities within classes were found for OTL and sense of belonging.

Helping survivors of abuse to cope with anxieties triggered during the pandemic.

Alison Welfare-Wilson, Senior Research Nurse, Kent and Medway NHS and Social Care Partnership Trust (alison.welfare-wilson@nhs.net), runner-up in the Mental Health Nurse of the Year category of the BJN Awards 2021.

Analysis of the genetic diversity and mRNA expression level in porcine reproductive and respiratory syndrome virus vaccinated pigs that developed short or long viremias after challenge.

Porcine reproductive and respiratory syndrome virus (PRRSv) infection alters the host's cellular and humoral immune response. Immunity against PRRSv is multigenic and vary between individuals. The aim of the present study was to compare several genes that encode for molecules involved in the immune response between two groups of vaccinated pigs that experienced short or long viremic periods after PRRSv challenge. These analyses include the sequencing of four SLA Class I, two Class II allele groups, and CD163, plus the analysis by quantitative realtime qRT-PCR of the constitutive expression of TLR2, TLR3, TLR4, TLR7, TLR8 and TLR9 mRNA and other molecules in peripheral blood mononuclear cells.

A team approach to effectively discharge trauma patients.

BACKGROUND: Trauma patients represent a high-volume and high-acuity population. This makes discharge planning difficult. Discharged by noon is a metric shown to correlate with hospital throughput. Improvements in efficiency will be needed to improve resource utilization and increase discharge by noon rate. This study aimed to evaluate the impact of a standardized discharge team on length of stay and discharge by noon. MATERIALS AND METHODS: A university level I trauma center implemented a discharge team composed of a trauma attending and an advanced practice provider. This team is tasked with evaluating patients on the discharge list daily. This allowed patients ready for discharge to be evaluated and discharged before noon. A retrospective review was performed to analyze discharge by noon rates before and after implementation of the discharge team. RESULTS: A total of 3053 patients were discharged before the implementation of the discharge team and 3801 after. Discharges by noon increased from 25.5% to 51.2% in the post. For patients with an injury severity score >15, this same improvement was seen, 22.5% to 51.9%. Similar improvements were seen when controlling for final discharge disposition and primary payer status. CONCLUSIONS: By establishing a separate discharge team, large improvements can be seen in the discharge by noon rate. These improvements were maintained when controlling for injury severity score, final discharge disposition, and insurance status. Significant savings are possible in both charges to the patient and direct costs to the facility. The utilization of a discharge team should be considered at similar facilities.

Quasispecies evolution of the prototypical genotype 1 porcine reproductive and respiratory syndrome virus early during in vivo infection is rapid and tissue specific.

Porcine reproductive and respiratory syndrome virus (PRRSV) is a major infectious threat to the pig industry worldwide. Increasing evidence suggests that microevolution within a quasispecies population can give rise to high sequence heterogeneity in PRRSV; potentially impacting the pathogenicity of the virus. Here, we report on micro-evolutionary events taking place within the viral quasispecies population in lung and lymph node 3 days post infection (dpi) following experimental in vivo infection with the prototypical Lelystad PRRSV (LV). Sequence analysis revealed 16 high frequency single nucleotide variants (SNV) or differences from the reference LV genome which are assumed to be representative of the consensus inoculum genome. Additionally, 49 other low frequency SNVs were also found in the inoculum population. At 3 dpi, a total of 9 and 10 SNVs of varying frequencies could already be detected in the LV population infecting the lung and lymph nodes, respectively. Interestingly, of these, three and four novel SNVs emerged independently in the two respective tissues when compared to the inoculum. The remaining variants, though already present at lower frequencies in the inoculum, were positively selected and their frequency increased within the quasispecies population. Hence, we were able to determine directly from tissues infected with PRRSV the repertoire of genetic variants within the viral quasispecies population. Our data also suggest that microevolution of these variants is rapid and some may be tissue-specific.

Level of agreement between three-dimensional volumetric ultrasound and real-time conventional ultrasound in the assessment of synovitis, tenosynovitis and erosions in rheumatoid arthritis patients.

The aim of the study was to assess agreement between three-dimensional volumetric ultrasound (3D US) performed by inexperienced staff and real-time conventional ultrasound (2D US) performed by experienced rheumatologists in detecting and scoring rheumatoid arthritis (RA) lesions. Thirty-one RA patients underwent examination of seven joints by 2D and 3D US for synovitis and tenosynovitis in B and PD modes and erosions in B mode. A global score for synovitis and global counts for synovitis, tenosynovitis and erosions were also calculated for every patient. Agreement between 2D and 3D US was analysed for counts and scores at the patient level with the intraclass correlation coefficient (ICC) and for counts at the joint level with Cohen's kappa coefficient. B-mode synovitis was detected at a median of five joints in each patient, frequently in wrists and hand joints but less frequently in foot joints. PD-mode synovitis, tenosynovitis and erosions were detected less frequently. All ICCs for agreement between 2D and 3D US findings were significant. All kappa coefficients were significant for B- and PD-mode synovitis and for erosions (except PIP3), while those for tenosynovitis were only significant for MCP2 (B and PD modes) and PIP2 (B mode). Although the 3D US volumes were acquired by inexperienced operators, agreement between 2D and 3D US was acceptable in detecting and scoring synovitis. A higher level of agreement was attained for patient-level global scores and counts than for individual joints.

The Effect of Sporting Events on Medical Transport Time at a Level 1 Trauma Center: a Retrospective Cohort Study.

OBJECTIVE: We investigate how West Virginia University football games affect transport to Ruby Memorial Hospital, which shares a parking lot with Milan Puskar Football Stadium. METHODS: A retrospective chart review of a trauma registry from a level 1-trauma center was conducted from 2007 to 2011 for all home and away football games. Home games served as time period of interest and away games served as a control time period. Patient charts were collected for a 36-hour time window surrounding the game. 250 patient charts were complete for home games and 185 patient charts for away games. Data analyzed were time from scene to arrival at hospital, use of air transport, transport time in relation to kick-off, and comparison between demographic and emergency department disposition of patients arriving during home games vs. patients arriving during away games. RESULTS: No statistically significant differences were found for demographic data or emergency department disposition between groups. For ground transport directly from scene, the average time to arrival at the hospital was 44.9 minutes for home games and 45.1 minutes for away games. For air transport directly from the scene, the average time to arrival at the hospital was 44.9 minutes for home games and 44.0 minutes for away games. For ground transfer from another facility, the average time to arrival at the hospital was 76.4 minutes for home games and 52.9 minutes for away games. For air transport from another facility, the average time to arrival at the hospital was 37.4 minutes for home games and 24.0 minutes for away games. Air transportation utilization was increased in inter-facility transfers during home games (5/16, 31.3% vs. 4/20, 22.2%), and helicopters traveled a further distance (avg. 66.6 vs. 50.25 air miles). For patients coming from the scene during a home game, if the start of the game occurred after the trauma but before arrival to the trauma center, the average time of ground transport increased from 44.9 minutes to 120 minutes (p<0.0001). CONCLUSION: A mass gathering in close proximity to a rural trauma center does affect transport patterns and transport times for trauma patients. Further investigation is warranted in order to improve patient care during mass gathering events.

Nationwide secondary overtriage in level 3 and level 4 trauma centers: are these transfers necessary?

BACKGROUND: Secondary overtriage (SO) refers to the interfacility transfer of trauma patients who are rapidly discharged home without surgical intervention by the receiving institution. SO imposes a financial hardship on patients and strains trauma center resources. Most studies on SO have been conducted from the perspective of the receiving hospital, which is usually a level 1 trauma center. Having previously studied SO from the referring rural hospital's perspective, we sought to identify variables contributing to SO at the national level. METHODS: Using data from the 2008-2012 National Trauma Data Bank, we isolated patients transferred to level 1 trauma centers who were: (1) discharged home within 48 h and (2) did not undergo any surgical procedure. This population was subsequently compared with similar patients treated at and discharged directly from level 3 and 4 centers. Multivariate logistic regression analysis was used to isolate variables that independently influenced a patient's risk of undergoing SO. Injury patterns were characterized by use of subspecialty consultants. RESULTS: A total of 99,114 patients met inclusion criteria, of which 13.2% were discharged directly from level 3 or 4 trauma centers, and 86.8% of them were transferred to a level 1 trauma center before discharge. The mean Injury Severity Score of the nontransfer and transfer groups was 5.4 ± 4.5 and 7.3 ± 5.7, respectively. Multivariate regression analysis showed that Injury Severity Score > 15, alcoholism, smoking, drug use, and certain injury patterns involving the head, vertebra, and face were associated with being transferred. In this minimally injured population, factors protective against transfers were: age > 65 y, female gender, systolic blood pressure <80, a head computed tomography scan and orthopedic injuries. CONCLUSIONS: SO results from the complex interplay of variables including patient demographics, facility characteristics, and injury type. The inability to exclude a potentially devastating neurologic injury seems to drive SO.

Distinct functional enrichment of transcriptional signatures in pigs with high and low IFN-gamma responses after vaccination with a porcine reproductive and respiratory syndrome virus (PRRSV).

Little is known about the host factor in the response to PRRSV vaccination. For this purpose, piglets were immunized with a commercial PRRSV-live vaccine and classified as high responders (HR) or low responders (LR) as regards to the frequencies of virus-specific IFN-γ-secreting cells. Six weeks post vaccination, PBMCs isolated from three individuals with the most extreme responses in each HR and LR groups and 3 unvaccinated controls, were either stimulated with phytohaemagglutinin, challenged with the vaccine or mock treated for 24 h, prior conducting transcriptional studies, gene ontology and pathway analyses. The LR group had very low neutralizing antibody levels and showed a higher number of down-regulated transcripts compared with the HR group (FDR < 0.2, P < 0.001). Down-regulated genes encoded chemoattractants, proinflammatory cytokines and the interferon-inducible GBP family, and showed enrichment in wounding (FDR < 3.6E-13), inflammation (FDR < 8E-12), defence (FDR < 8.7E-09) and immunity (FDR < 7.6E-08), suggesting immune response impairment. In the HR group, down-regulated genes were involved in protein transport (FDR < 4.77E-03), locomotory behavior (FDR < 5.47E-3), regulation of protein localization (FDR < 1.02E-02), and regulation of TNF superfamily member 15 and miR181. In contrast, the HR group presented up-regulated transcripts associated with wounding (FDR < 4.95). Moreover, IFN-γ was predicted to be an inhibited upstream regulator since IFN-γ pathways were associated with higher number of down-regulated genes in the LR (n = 40) than the HR (n = 10). Divergent responses to PRRSV-vaccination may be the result of the genetic background of the host.

Clinical usefulness and patient satisfaction with a musculoskeletal ultrasound clinic: results of a 6-month pilot service in a Rheumatology Unit.

There is no agreement among the rheumatology community in how to implement the musculoskeletal ultrasound (MSUS) technique in the Rheumatology Divisions. To test the perceived usefulness of the MSUS, under consensus indications, for referring colleagues for the clinical management of their patients with inflammatory arthritis (IA) and to score the satisfaction level of the patients with different aspects of the ultrasound (US) examination, after attend to the MSUS clinic. A written questionnaire-based survey regarding the usefulness and satisfaction with the implementation of a pilot MSUS clinic in a Rheumatology Unit. Over a 6-month period, 43 patients attended 10 MSUS clinics. Referral agreed indications were: US assisting in early/subclinical diagnosis (35 %), decision making with patient treatment (44 %), monitoring of disease activity/treatment response (39 %) and US-guided injection (11 %). Average scores of the referrers regarding usefulness of the information provided for the US for these indications were 8.0, 8.3, 8.7 and 8.6, respectively, with a high score of 9.0 regarding the valuable support of the US for the management of their patients with IA. Patient satisfaction scores in responders (44 %) were averaged 9.5 and higher for receiving an adequate explanation of the US procedure, indications, US findings and their significance, lack of discomfort and length of the appointment. The average score was slightly lower (8.5) for the waiting time frame for the appointment for the MSUS examination. The referrers expressed a perception of usefulness of our pilot US clinic, under previous consensus indications, for the clinical management of their patients with IA. In addition, this MSUS clinic seemed to show a good acceptability and a high satisfaction scores for the patients.

Interaction of chlorhexidine with trisEDTA or miconazole in vitro against canine meticillin-resistant and -susceptible Staphylococcus pseudintermedius isolates from two UK regions.

BACKGROUND: Topical therapy is an important alternative to systemic antibacterial therapy for treatment of canine superficial pyoderma in light of the emergence of multidrug-resistant staphylococci. Chlorhexidine is widely used in shampoo products alone or in combination with miconazole or tromethamine-ethylenediaminetetraacetic acid (trisEDTA). Comparisons of these combinations have not been made. HYPOTHESIS/OBJECTIVES: To determine minimum inhibitory concentrations (MICs) of combinations of chlorhexidine/miconazole and chlorhexidine/trisEDTA in vitro in a collection of Staphylococcus pseudintermedius (SP) from northern (NUK) and southeastern (SEUK) United Kingdom (UK) sources. METHODS: MICs of chlorhexidine, miconazole, trisEDTA and combinations of chlorhexidine/miconazole (1:1) or chlorhexidine/trisEDTA (80:16:1 and 80:5:1) were determined for 196 canine SP isolates from NUK [49 meticillin-resistant (MRSP), 50 meticillin-susceptible (MSSP)] and fom SEUK (48 MRSP, 49 MSSP) using agar dilution. RESULTS: TrisEDTA alone did not inhibit growth. Chlorhexidine/miconazole MICs (median = 0.5 mg/L) were lower than those of either drug alone (P < 0.05) and lower than chlorhexidine/trisEDTA MICs (median = 1 mg/L; P < 0.0005) in each bacterial type and from both regions, except for miconazole in NUK MSSP. An additive interaction was noted between chlorhexidine and miconazole or trisEDTA (80:16:1 ratio) in 79 and 43 isolates, respectively, whereas antagonism between chlorhexidine and trisEDTA was noted for three isolates. NUK isolates were more susceptible than SEUK isolates (P < 0.05), except MRSP exposed to chlorhexidine and the chlorhexidine/trisEDTA (80:16:1) combination. CONCLUSIONS AND CLINICAL IMPORTANCE: These low MICs are likely to be exceeded by topical therapy. Evaluation of the mechanisms by which chlorhexidine combinations interact to reduce MICs is warranted, in view of increasing concerns of biocide tolerance in staphylococci.

Secondary overtriage in a statewide rural trauma system.

BACKGROUND: Rural hospitals have variable degrees of involvement within the nationwide trauma system because of differences in resources and operational goals. "Secondary overtriage" refers to the patient who is discharged home shortly after being transferred from another hospital. An analysis of these occurrences is useful to determine the efficiency of the trauma system as a whole. MATERIALS AND METHODS: Data were extracted from a statewide trauma registry from 2007-2012 to include those who were (1) discharged home within 48 h of arrival and (2) did not undergo a surgical procedure. We then identified those who arrived as a transfer before being discharged (secondary overtriage) from those who arrived from the scene. Factors associated with transfers were analyzed using a logistic regression. Injuries were classified based on the need of a specific consultant. Time of arrival to the emergency department was analyzed using 8-h blocks, with the 7 AM-3 PM block as reference. RESULTS: A total of 19,319 patients fit our inclusion criteria of which 1897 (9.8%) arrived as transfers. Descriptive analysis showed a number of differences between transfers and nontransfers because of our large sample size. Thus, we examined variables that had more clinical significance using logistic regression controlling for age, injury severity score, the type of injury, blood products given, the time of arrival to initial emergency room, and whether a computed tomography scan was obtained initially. Factors associated with being transferred were injury severity score >15, transfusion of packed-red-blood-cells, graveyard-shift arrivals, and neurosurgical, spine, and facial injuries. Patients having a computed tomography scan were less likely to be transferred. CONCLUSIONS: Secondary overtriage may result from the hospital's limited resources. Some of these limitations are the availability of surgical specialists, blood products, and overall coverage during the "graveyard-shift." However, some of these transfers may be appropriate even though patients are ultimately discharged shortly after transfer.

A CBT-based anxiety management workshop in first-episode psychosis.

When co-occurring with psychosis, anxiety can adversely affect social and occupational functioning and can cause debilitating levels of distress. This article describes a single-centre three-phase service development project culminating in the introduction of 1-day anxiety management workshops for service users of an Early Intervention for Psychosis Service (EIPS). The workshops, which were run by a mental health nurse and an assistant psychologist, attracted 12 participants with a first episode of psychosis and co-morbid anxiety. Quantitative and qualitative measures demonstrated a statistically significant reduction (p<0.0005) in subjective anxiety levels following the intervention, and that participants felt they were likely to make use of the skills in the future. It can be concluded that such workshops are not only time-and cost-effective, but also valuable in delivering brief interventions based on cognitive behavioural therapy (CBT) to service users with a first episode of psychosis.

Genomic variation in macrophage-cultured European porcine reproductive and respiratory syndrome virus Olot/91 revealed using ultra-deep next generation sequencing.

BACKGROUND: Porcine Reproductive and Respiratory Syndrome (PRRS) is a disease of major economic impact worldwide. The etiologic agent of this disease is the PRRS virus (PRRSV). Increasing evidence suggest that microevolution within a coexisting quasispecies population can give rise to high sequence heterogeneity in PRRSV. FINDINGS: We developed a pipeline based on the ultra-deep next generation sequencing approach to first construct the complete genome of a European PRRSV, strain Olot/9, cultured on macrophages and then capture the rare variants representative of the mixed quasispecies population. Olot/91 differs from the reference Lelystad strain by about 5% and a total of 88 variants, with frequencies as low as 1%, were detected in the mixed population. These variants included 16 non-synonymous variants concentrated in the genes encoding structural and nonstructural proteins; including Glycoprotein 2a and 5. CONCLUSION: Using an ultra-deep sequencing methodology, the complete genome of Olot/91 was constructed without any prior knowledge of the sequence. Rare variants that constitute minor fractions of the heterogeneous PRRSV population could successfully be detected to allow further exploration of microevolutionary events.

Down-regulation of mechanisms involved in cell transport and maintenance of mucosal integrity in pigs infected with Lawsonia intracellularis.

Lawsonia intracellularis is an obligate intracellular bacterium, responsible for the disease complex known as proliferative enteropathy (PE). L. intracellularis is associated with intestinal crypt epithelial cell proliferation but the mechanisms responsible are yet to be defined. Microarray analysis was used to investigate the host-pathogen interaction in experimentally infected pigs to identify pathways that may be involved. Ileal samples originating from twenty-eight weaner pigs experimentally challenged with a pure culture of L. intracellularis (strain LR189/5/83) were subjected to microarray analysis. Microarray transcriptional signatures were validated using immunohistochemistry and quantitative real time PCR of selected genes at various time points post challenge. At peak of infection (14 days post challenge) 86% of altered transcripts were down regulated, particularly those involved in maintenance of mucosal integrity and regulation of cell transport. Among the up-regulated transcripts, CD163 and CDK1 were novel findings and considered to be important, due to their respective roles in innate immunity and cellular proliferation. Overall, targeted cellular mechanisms included those that are important in epithelial restitution, migration and protection; maintenance of stable inter-epithelial cell relationships; cell transport of nutrients and electrolytes; innate immunity; and cell cycle.

Benefits of standardizing additional airway clearance in the trauma patient population.

The objective of this project was the development of a systematic preventative approach toward the treatment of respiratory complications among the trauma population. The team used and documented existing treatment regimens within specific study groups, to determine an effective structure to combat respiratory complications. The project included retrospective data collected from the Trauma Registry of an American College of Surgeons verified Level 1, adult rural, academic facility. Review data indicated significant inconsistencies in the pulmonary treatment among the trauma population. Pulmonary hygiene orders lacked consistency, and the patient-focused standards of care led to the creation of nonspecific or omitted orders. The results of the analysis revealed that the overall rate of unplanned upgrades to the higher level of care and intubations due to respiratory compromise were significantly impacted by the design of a collaborative pulmonary care regimen defining role delineation, timelines, and education. This project provided support to the credence of the designated pathway.

Backed into a corner: damage control surgery in the rural or austere setting.

Damage control surgery has evolved during the past 40 years. The initial cases and studies were performed at level 1 trauma centers but has now shifted to damage control at smaller hospitals. This buys time for definitive care at higher-level centers. There is a role for damage control surgery in both general surgery and trauma patients at community trauma centers. The successful implementation and completion of damage control surgery require thorough planning and a full understanding of resource limitation. Additional training or practice for infrequently performed procedures may be necessary. A systems-based approach with postoperative transfer to a higher level of care is acceptable and expected.