Injury Hospital Research Articles

An audit of the adherence to dosing and therapeutic monitoring of intravenous vancomycin in accordance with the trust’s antimicrobial guidelines

Abstract Introduction Inappropriate vancomycin dosing and monitoring have compromised patient safety, causing acute kidney injury and prolonged hospital stays. Misuse of antibiotics, like vancomycin, accelerates resistance, a global health threat. Following guidelines can prevent harm and curb the emergence of vancomycin-resistant enterococci and resistant Staphylococcus aureus1. Aim To assess the level of adherence to trust guidelines for the dosing and monitoring of intravenous vancomycin. Audit Standards Standard 1: Patients prescribed intravenous vancomycin should have documented indication Standard 2: Patients prescribed intravenous vancomycin should have correct loading dose Standard 3: Patients prescribed intravenous vancomycin should have correct maintenance dose Standard 4: Patients prescribed intravenous vancomycin should have trough levels taken at the right time Standard 5: Patients prescribed intravenous vancomycin should have doses accurately adjusted against trough level Results: Standard 6: Patients prescribed intravenous vancomycin should have all prescribed doses administered (i.e. no missed doses). Standard 7: Vancomycin prescriptions should be screened by a pharmacist. Methods This audit was approved by both the Trust Clinical Audit Committee and the Antimicrobial Stewardship Group. A retrospective audit using data extracted from EPMA. The data collected included: indication documented (Yes/No), correct loading dose? (Yes/No), missed doses? (Yes/No), correct maintenance dose? (Yes/No), correct first sampling? (Yes/No), correct subsequent sampling? (Yes/No), correct dose adjustments based on levels? (Yes/No) and prescription screened by a pharmacist? (Yes/No). Data was input into Microsoft Excel for analysis. The period covered was 01/12/2022 to 31/05/2023. Ethics approval was not required, as clinical audits do not require ethical review. The inclusion criterion was adult patients prescribed intravenous vancomycin. The exclusion criteria were patients in maternity, labour, and renal wards, due to different guidelines and ITU due to no EPMA. The population size was 243; sample size (n) =150 ensuring a 95% confidence level. Results In total, 150 patient drug charts were analysed, of which 96 % had their vancomycin indication documented. 65.3% of patients had the correct loading dose, 64.7% had the correct maintenance dose. 32.23% had the initial trough level done at the right time and 35% had correct subsequent trough levels measured. 44% had correct dose adjustments based on their trough levels and 57.33% had their prescriptions screened by a pharmacist. Discussion and conclusion None of the target compliance rates were met, highlighting significant issues with vancomycin dosing and therapeutic monitoring within the trust. Therapeutic drug monitoring (TDM) is crucial to ensure optimal patient outcomes2. Audit findings have been shared with the wider multidisciplinary team, education on TDM has taken place with junior pharmacists and digital prompts on EPMA have been included to help improve adherence. A limitation of this audit is its retrospective nature, useful for trend analysis but not for identifying causes. A prospective audit was not feasible due to staffing pressures. Conducting clinical audits are an important tool for assessing and ensuring safe clinical practice.

Risk factors for unintentional injury hospitalisation among Aboriginal and non-Aboriginal children in Australia's Northern Territory: A data linkage study.

Unintentional injuries are a leading cause of hospitalisation for children. This study investigated the incidence and associated risk factors for unintentional injury hospitalisation (UIH) among Aboriginal and non-Aboriginal children aged under 5 years in Australia's Northern Territory. This was a retrospective cohort study using linked data from a perinatal register, hospital admissions, school enrolment and child protection services. The outcome variable was a first UIH. Potential risk factors included gender, pregnancy and birth outcomes, maternal education level, child protection service contact and geographic remoteness. Modified Poisson regression was used for multivariate modelling. A cohort of 21,189 children (54.0% Aboriginal) born between 2000 and 2010 were followed to the age of 5 years. The overall incidence of first UIH was 25.8 per 1,000 person-years, which was 28.6% higher among Aboriginal than non-Aboriginal children (28.8 and 22.4 per 1000 person-years, respectively). Risk factors identified in the full model included: being male (incidence rate ratio (IRR) 1.26, 95%CI: 1.17-1.36); living in a remote (IRR 1.26, 95%CI: 1.14-1.40) or very remote area (IRR 1.44, 95%CI: 1.29-1.59); having a notification or substantiated notification for abuse (IRR 1.42, 95%CI: 1.27-1.58 and IRR 1.60, 95%CI: 1.41-1.82, respectively); or neglect (IRR 1.32, 95%CI: 1.17-1.48 and IRR 1.28, 95%CI: 1.11-1.47, respectively). After adjustment, there was no difference in UIH rates between Aboriginal and non-Aboriginal children. In both stratified models, being male, living in remote or very remote areas and having a notification or substantiated notification for child maltreatment were identified as risk factors. Our study found high UIH incidence rates and evidence for an association between UIH and child maltreatment. This suggests child maltreatment and UIH have shared determinants and points to the need for clinicians to be aware of the overlap between these conditions and the importance of cross-agency collaboration in prevention and management.

Injuries from border wall falls after 2018 are more severe: a retrospective cohort study

BackgroundThe U.S.-Mexico “border wall” between El Paso, Texas and Ciudad Juárez, Mexico was raised and extended beginning in 2018 in accordance with Presidential Executive Order 13,767. We hypothesized that these changes resulted in increased incidence and severity of injuries of individuals attempting to cross the border wall in the El Paso region.MethodsA retrospective cohort review was conducted of University Medical Center of El Paso Trauma Registry charts from 2001 to 2022. Year of injury, gender, age, Injury Severity Score, hospital length-of-stay, ICU length-of-stay, ventilator days, and survival were analyzed by Chi-square analysis with Fisher’s exact test for categorical variables and Independent Samples T-test for continuous variables. An independent samples Mann Whitney U Test was used to compare border wall fall injuries before and after 2018.ResultsOf the 842 patients reviewed, 69 patients presented before 2018 and 773 presented from 2018 to 2022. Statistically significant differences were identified in the mean Injury Severity Score which increased from 6.3 (SD ± 3.8) to 8.3 (SD ± 5.5, p < .001) and the mean hospital length-of-stay which increased from 6.7 days (SD ± 5.5) to 9.5 days (SD ± 8.0, p < .005).ConclusionThe incidence, severity, and hospital length-of-stay related to injuries crossing the U.S.-Mexico border have increased with changes in height of the border wall since 2018. Additional resources should be allocated to Emergency Departments and Trauma Centers along the Southwest Border to serve this unique patient population. Additional consideration should be given to the cost of the border wall.

Injury Characteristics and Risk Factors of Sport-Related Concussion Among High School Athletes in School-Sponsored Sports.

Over a million sport-related concussions (SRC) affect children annually in the United States, posing a significant public health concern. Limited data exist on the premorbid risk factors and injury characteristics of SRCs in high school athletes. This study aims to understand acute SRC injury characteristics and describe premorbid risk factors in high school athletes. Athletes (aged 14-19 years) from 19 central Illinois high schools participating in school-sponsored sports from 2009 to 2023 were included. Sports Concussion Assessment Tool evaluations were performed as part of preseason and postinjury evaluations. Injury characteristics, such as mechanism, setting, and symptoms, were described using all SRCs in the study period. Odds ratios (OR) were computed to determine risk factors using athletes with a baseline Sports Concussion Assessment Tool before SRC and nonconcussed athletes. In total, 4360 athletes were included (3953 without SRC; 407 with ≥1 SRC of whom 168 had a previous baseline). Overall, 24.2% of SRCs occurred in female athletes, and most SRCs occurred in competitions while playing American football (52.3%), soccer (20.4%), and basketball (7.6%). Blow/hit to the head was the most common mechanism. Headache was the most severe symptom (2.55 ± 1.51 [SD]), and symptoms of emotionality and nervousness/anxiety were significantly more severe in female athletes (P < .05). Students with previous concussions (OR 2.64 95% CI [1.81, 3.78]), previous hospitalization for head injury (OR 3.19 95% CI [1.9, 5.14]), headache/migraine disorders (OR 2.23 95% CI [1.29, 3.66]), and learning disabilities (OR 2.69 95% CI [1.47, 4.61]) had greater odds of SRC (P < .05). Lower odds of SRC were seen in athletes identifying as Black or African American (vs White) (OR 0.54 95% CI [0.32, 0.86]) and those attending larger (vs smaller) schools (OR 0.64 95% CI [0.46, 0.88]). Understanding SRC risk factors and characteristics in high school athletes is critical for developing prevention and management programs, guiding neurosurgeons in mitigating SRC risk, and informing return-to-play decisions.

Insights into retroperitoneal hemorrhage management: result from a tertiary cardiovascular center prospective cohort

Abstract Background Although rare, retroperitoneal hemorrhage (RPH) during percutaneous cardiovascular interventions is still potentially fatal, poses a critical challenge, often necessitating swift and precise management strategies. Its management is still controversial, and available recommendations are mostly based on expert opinion, and not updated according to recent advancement in the field of interventional cardiology. Purpose To present the rate, clinical characteristics and modern management of patients complicating with RPH in a large tertiary cardiovascular center Method We collected prospectively all consecutive RPH events encountered in the catheterization laboratories of a large tertiary cardiovascular center during 2014-2022. Procedural data from all the diagnostic and therapeutic procedures performed in the same time period, were retrieved from electronic hospital records (EHR). Results Among 89,361 percutaneous cardiovascular diagnostic or therapeutic procedures performed on 69596 patients, 52 (0.058%) episodes (patients) of RPH, (mean age of 56.37±16.84 years with female sex predominance of 36 (69.23%)). Also 2 (3.8%) patients died due to RPH. Non-contrast abdominopelvic CT scan was the most common primary imaging modality for RPH diagnosis, followed by DSA angiography. Of note, 13 (25 %) of patients returned directly to catheterization laboratory for RPH evaluation. Thirty-one (59.6%) patients were ultimately treated conservatively and no patient treated surgically. Structural and peripheral procedures were more prone to RPH. Still a median time of 7.5 hours was needed for RPH diagnosis. Contralateral access was the dominant approach for treating RPH, and although balloon tamponade was used in 11 (52.4 %) patients, 17 (80.9 %) patients were treated ultimately with covered stents; deep femoral and internal iliac arteries were covered in 1 (5.9%) and 2 (11.8%) patients, respectively. Patients treated endovascularly for RPH had higher acute kidney injury and longer hospital stays. Further comprehensive analysis regarding the potential risk factors of RPH are pending. Conclusion Our preliminary analysis from a large tertiary cardiovascular center database, showed RPH is still rare, with acceptable mortality rate of 3.83%. Our data showed the necessity of more precise probability assessment tools to improve the diagnostic time.

Advancing Community Care and Access to Follow-Up after Acute Kidney Injury Hospitalization: A Randomized Clinical Trial.

Key Points A risk-guided intervention improved adherence to processes of care for AKI survivors.Further supports are necessary to improve uptake of processes of care for AKI survivors in primary care. Background AKI is associated with development and progression of CKD. Gaps in recommended care for CKD are common after AKI. Methods In this randomized controlled trial conducted in Alberta, Canada, we allocated adults hospitalized with Kidney Disease Improving Global Outcomes (KDIGO) stage 2 or greater AKI to a risk-guided, transition of care intervention versus usual practices at the time of hospital discharge. For people in the intervention group, we used a validated risk index to predict risk of severe CKD after AKI. People at low risk (&lt;1%) received patient education alone. People at medium risk received additional clinical guidance, provided to their primary care physician. People at high risk (&gt;10%) were referred to nephrology. The primary outcome was the proportion of patients who received treatment with an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB), statin, and nephrology specialist follow-up within 90 days of discharge. Results One hundred fifty-five patients were recruited; the mean (SD) age was 60 (15) years, 91 (60%) were male, and 96 (62%) had eGFR &lt;60 ml/min per 1.73 m2 or urine albumin-creatinine ratio &gt;30 mg/g at discharge. The proportion of participants who received ACE-I/ARB, statin treatment, and nephrologist follow-up was 28% in the intervention group versus 3% in the usual care group (absolute risk difference [RD], 25%; 95% confidence interval [CI], 15% to 36%). The use of ACE-I or ARB in participants with urine albumin-creatinine ratio &gt;300 mg/g or diabetes was greater in the high-risk group with the intervention versus usual care (RD, 37%; 95% CI, 6% to 67%), as was statin use among those with CKD (RD, 30%; 95% CI, 5% to 56%) and nephrologist follow-up for those with sustained eGFR &lt;30 ml/min per 1.73 m2 at discharge (RD, 78%; 95% CI, 56% to 100%). Hyperkalemia was more frequent in the intervention group (RD, 10%; 95% CI, 9% to 19%). Conclusions A risk-guided intervention for patients hospitalized with AKI increased recommended processes of care for CKD for high-risk patients after hospital discharge. Clinical Trial registry name and registration number: Improving Post Discharge Care after Acute Kidney Injury (AFTER AKI), NCT02915575.

Identifying Child Abuse in Patients With Femur Fractures Through Pathway Compliance: A Pilot Study.

Background Child abuse is a significant cause of morbidity and mortality in children. A thorough history and physical exam is critical to identifying abuse. Standardized screening tools as well as clinical pathways can assist with identifying patients who may have an injury secondary to abuse. There are varied recommendations for the upper age in which to routinely evaluate pediatric patients for child abuse. Objectives The primary objective of this study was to describe the outcomes of the implementation of an evidence-based clinical pathway for suspected non-accidental trauma for all pediatric patients aged five years and under presenting with a femur fracture. This pathway includes orders for imaging, labs, and consults. In addition, the characteristics of this population and the findings were described. Methods A retrospective study of patients at a single institution who met the National Trauma Data Standard registry inclusion criteria and had a femur fracture was performed. Variables analyzed included age, demographics, mechanism and location of injury, admission status and service, injury severity, hospital characteristics, and discharge status. Patients with a metabolic bone disease were excluded. Results There were 200 patients who met the inclusion criteria. Thirty-two patients had a diagnosis of confirmed or suspected child abuse. While all 32 patients had a skeletal survey performed, only 23 (71.9%) had the complete workup per the clinical pathway, and 21 (65.6%) had a diagnosis of confirmed child abuse. Conclusion Clinical pathways are established to provide the standardization of clinical assessments and interventions; however, this process relies on a single individual to make a judgment determining whether or not to implement the pathway. Children presenting to an emergency department with confirmed or suspected child abuse are a vulnerable population. A child abuse diagnosis is a clinical judgment; however, clinical pathways aid in the diagnosis in hopes to stop any further abuse. For a pathway to be successful, each step needs to be addressed.

Demographics, management and outcomes of major trauma in older patients at an Irish trauma unit.

Major trauma data in the developed world trends towards increased rates of lower energy mechanism in an older cohort. This study examines how the mechanism of trauma, injury pattern and outcomes differ between a younger and older cohorts in an Irish trauma unit. In this retrospective study, all entries to the Trauma Audit and Research Network (TARN) database from Tallaght University Hospital, between January 1st 2016 and 31st December 2021, were interrogated. Differences between injury severity, 30-day mortality, and hospital length of stay in younger and older patients were also examined. Older patients (≥ 65years) had a similar severity of injury to younger patients (< 65years); however, they had longer stays in hospital (18.8 versus 9.5days, p < 0.001). Older patients (≥ 65years) were more likely to have head (16.1% versus 11.3%, p < 0.05) and cervical spine (21.4% versus 11.2%, p < 0.05) injuries as their primary injury compared with younger patients. Older patients (≥ 65years) are less likely to have limb (33.3% versus 45.6%, p < 0.05). Fall from a height less than 2m was more likely to be the mechanism of injury in the older cohort compared with the younger cohort (77.3% versus 36.3%, p < 0.05). This study highlights the increased mortality and morbidity experienced by older trauma patients compared with a younger cohort. The findings support the development of "silver trauma" care pathways and directing resources to meet the needs of older trauma patients and optimize clinical outcomes.

8418 Association of GLP-1 Receptor Agonists and SGLT-2 Inhibitors with Major Adverse Cardiovascular Events and Serious Liver Events among Patients with Type 2 Diabetes and MASLD

Abstract Disclosure: A. Kutz: None. D.J. Wexler: None. J. Liu: None. J.M. Paik: None. E. Patorno: None. Introduction and study question Little is known about the cardiovascular (CV) and hepatic effectiveness of glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium–glucose cotransporter 2 inhibitors (SGLT-2i) in people with type 2 diabetes (T2D) and known metabolic dysfunction-associated steatotic liver disease (MASLD) in clinical practice. We assessed the comparative CV and hepatic effectiveness and the safety of GLP-1 RA and SGLT-2i in people with T2D and prevalent MASLD. Methodology Using pooled data from Medicare fee-for-service (2013–2020) and a large U.S. health insurance database (2013-June 2022), we conducted two propensity-score fine stratification weighted cohort studies including adults with T2D and a diagnosis of MASLD who initiated GLP-1RA, SGLT-2i, or dipeptidyl peptidase 4 inhibitors (DPP-4i, reference). Using Cox proportional hazards models, we assessed the primary CV effectiveness composite outcome of acute myocardial infarction, ischemic stroke, hospitalization for heart failure, or all-cause mortality. The primary hepatic effectiveness outcome was a composite of serious liver events (hospitalization for ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, bleeding esophageal varices, hepatic encephalopathy, or liver transplantation). The safety outcome was a composite of severe adverse events (lower limb amputation, non-vertebral fracture, emergency admission for hypoglycemia, or hospitalization for acute kidney injury, diabetic ketoacidosis [DKA], severe genital or urinary tract infection, acute pancreatitis, or biliary event). Major results Compared with DPP-4i (n=17,084 initiators), the hazard ratio (HR) for the primary CV outcome associated with GLP-1 RA (n=13,666 initiators) was 0.67 (95% CI, 0.56 to 0.81), corresponding to an incidence rate difference (IRD) per 1,000 person-years of -21.6 (95% CI, -26.7 to -16.6). The HR for the primary hepatic outcome was 0.47 (95% CI, 0.25 to 0.90), the IRD -2.1 (95% CI -3.4 to -0.9). Similar CV benefits were observed for SGLT-2i (n=11,108) vs DPP-4i (n=16,979), with a HR for the primary CV outcome of 0.82 (95% CI 0.70–0.96) and an IRD of -11.0 (95% CI -16.2 to -5.8). For the primary hepatic outcome, the HR was 0.81 (95% CI 0.45 to 1.44) and the IRD -1.1 (95% CI -2.4 to 0.3). Severe adverse events were not more frequent with GLP-1RA or SGLT-2i compared with DPP-4i. Interpretation and conclusion Among people with T2D and MASLD, the use of GLP-1 RA or SGLT-2i was associated with fewer CV events, vs DPP-4i, while GLP-1 RA also reduced serious liver events. Compared with DPP-4i, GLP-1RA or SGLT-2i were not associated with higher safety adverse event rates. Presentation: 6/2/2024

Machine Learning Differentiates Extracorporeal Membrane Oxygenation Mortality Risk Profiles Among Trauma Patients.

Extracorporeal membrane oxygenation (ECMO) is resource intensive with high mortality. Identifying trauma patients most likely to derive a survival benefit remains elusive despite current ECMO guidelines. Our objective was to identify unique patient risk profiles using the largest database of trauma patients available. ECMO patients ≥16years were identified using Trauma Quality Improvement Program data (2010-2019). Machine learning K-median clustering (ML) utilized 101 variables including injury severity, demographics, comorbidities, and hospital stay information to generate unique patient risk profiles. Mortality and patient and center characteristics were evaluated across profiles. A total of 1037 patients were included with 33% overall mortality, mean age 32years, and median ISS = 26. The ML identified 3 unique patient risk profile groups. Although mortality rates were equivalent across the 3 groups, groups were distinguished by (Group 1) young (median 25years), severely injured (ISS = 34) patients with thoracic and head injuries (99%) via blunt mechanism (93%), and a high prevalence of ARDS (77%); (Group 2) relatively young (median 30years) and moderately injured (ISS = 22) patients with exposure-related injuries (11%); and (Group 3) older (median 46years) patients with a high proportion of comorbidities (69%) and extremity injuries (100%). There were no differences based on center ECMO volume, teaching status, or ACS-Level across all 3 groups. Machine learning compliments traditional analyses by identifying unique mortality risk profiles for trauma patients receiving ECMO. These details can further inform treatment guidelines, clinical decision making, and institutional criteria for ECMO usage.

Association between ambient temperature and economic burden of unintentional injury in Tianjin: a case-crossover study

ObjectiveUnintentional injuries constitute a significant global public health issue with significant social and economic costs. Previous evidence suggests ambient temperatures are associated with unintentional injury occurrences. However, the impacts of...

Drowning Among Children 1-4Years of Age in California, 2017-2021.

Drowning, the leading cause of unintentional injury death among California children less than five years of age, averaged 49 annual fatalities for the years 2010-2021. The California Pool Safety Act aims to reduce fatalities by requiring safety measures around residential pools. This study was designed to analyze annual fatality rates and drowning incidents in California among children 1-4years of age from 2017-2021. We identified fatalities, injury hospitalizations, and emergency department (ED) visits from California state vital statistics death data and state hospital and ED discharge data using the EpiCenter California Injury Data Online website. Over the five-year study period, 4,166 drowning incidents were identified: 234 were fatalities, 846 were hospitalizations, and 3,086 were ED visits. The observed difference in fatality rates from 2017 to 2021 failed to achieve statistical significance (P = 0.88). Location-based analysis of the 234 fatal drowning incidents revealed that pools were the most common injury site, accounting for 65% of the cases. Drowning remains the leading cause of unintentional, injury-related death among California children 1-4years of age, as the annual rate of fatality over the five-year study period did not decline. While the EpiCenter California Injury Data Online website is excellent for analyzing annual rates of drowning incidents among California residents over time, it is limited in providing insight into modifiable risk factors and event circumstances that can further inform prevention. The development of robust integrated fatal and non-fatal local, state, and national systematic data collection systems could aid in moving the needle in decreasing pool fatalities among young children.

Community-Based Exercise Programs Post Spinal Cord Injury Hospitalization: A Pilot Study for a Randomized, Multicenter, Double-Blind Controlled Setting.

This study explores the effectiveness of community-based exercise programs for individuals with spinal cord injury (SCI) following hospital discharge. Given the rising incidence of SCI, particularly in South Korea, and the associated long-term disabilities, the necessity for comprehensive post-discharge rehabilitation is paramount. The study focuses on a pilot randomized multicenter double-blind controlled trial, targeting SCI patients who have completed inpatient rehabilitation and are living in the community. The primary aim is to evaluate the impact of structured exercise programs on physical fitness, functional capacity, and overall recovery. The research introduces the SpinalFit program, a community-based intervention designed to enhance muscle strength, cardiopulmonary endurance, and mobility through a combination of aerobic and resistance training. This program addresses the critical need for safe and effective rehabilitation options outside the hospital setting, utilizing circuit training with resistance bands and body-weight exercises tailored to each participant's capacity. The study also investigates barriers to physical activity in the community for SCI patients and the potential role of community exercise centers in bridging this gap. Preliminary findings from this pilot trial are expected to provide valuable insights into optimizing exercise regimens for SCI patients, informing future large-scale studies and contributing to improved post-discharge rehabilitation strategies.

Occurrence of Patellofemoral Joint Osteoarthritis in Long-Term Postoperative Cases of Open-Wedge High Tibial Osteotomy: Differences in Symptoms Based on Patient-Standing Type Evaluation with and Without Patellofemoral Joint Osteoarthritis

PurposeTo examine the frequency of patellofemoral joint (PFJ) osteoarthritis (OA) and its symptoms in the long-term course of open-wedge high tibial osteotomy (OWHTO).MethodsWe analyzed 113 joints of 91 patients. OA and osteonecrosis (ON) developed in 91 and 22 joints, after an average postoperative period of 127.5 ± 19.5 months. For X-ray evaluation, the standing femorotibial angle (FTA), % mechanical axis (%MA), Caton–Deschamps index (CDI), patellar tilt angle (TA), lateral patellar shift (LPS), and PFJ space width (medial [MJS] and lateral [LJS]) were analyzed. PFJ-associated symptoms were evaluated using the hospital for special surgery patellar score (HSS-PS) and knee injury and osteoarthritis outcome score patellofemoral subscale (KOOS-PF). Statistical analysis was performed with paired and unpaired t tests, and a risk rate of less than 1% was significantly judged.ResultsPreoperative FTA and CDI decreased from 180.8° to 170.0° and 0.88 to 0.70 at the final follow-up. Preoperative %MA lateralized from 20.8 to 66.0 at the final follow-up. TA and LPS values decreased significantly compared with before surgery until plate removal. The MJS and LJS significantly decreased, and OA with a joint space < 3 mm occurred in 14 cases. However, HSS-PS and KOOS-PF scores were not significantly different between the groups with and without OA.ConclusionPFJ OA occurred in 12.4% cases in the long-term postoperative course of OWHTO; however, no symptomatic difference was found in the group with or without OA.

Hospital readmission for acute kidney injury is independently associated with de novo end-stage renal disease after liver transplantation.

End-stage renal disease (ESRD) after liver transplantation (LT) is associated with high morbidity and mortality. The consequences of hospitalizations for post-LT acute kidney injury (AKI) are poorly understood. Using linked Medicare claims and transplant registry data, we analyzed adult liver alone recipients not receiving pre-transplant dialysis between 1/1/2007-12/31/2016. Covariate-adjusted Cox proportional hazards models stratified by center evaluated factors associated with AKI readmission during the first post-LT year, and whether AKI readmission was associated with de novo early (<1y) or late (≥1y) ESRD post-LT. The cohort included 10,559 patients and was 64.5% male, 72.5% White, 8.1% Black and 14.0% Hispanic with median age 62 years. Overall, 2,875 (27.2%) patients had ≥1 AKI hospitalization during the first year. eGFR at LT was associated with AKI readmission (aHR 1.16 per 10mL/min/1.73m2 decrease; p<0.001). The aHR for early ESRD in patients with ≥1 AKI readmission <90 days post-LT was 1.90 (p<0.001). The aHRs for late ESRD with 1 and ≥2 prior AKI readmissions were 1.57 and 2.80 respectively (p<0.001). AKI readmissions in the first post-LT year impact over one-quarter of recipients. These increase the risk of subsequent ESRD, but may represent an opportunity to intervene and mitigate further renal dysfunction.

Recurrent acute kidney injury with Fanconi syndrome related to red yeast rice supplement.

A 51-year-old woman was admitted to our hospital for acute kidney injury (AKI) with an elevated serum creatinine level of 5.07mg/dL and Fanconi syndrome. The patient was discharged after partial recovery of kidney dysfunction with conservative treatment but was readmitted approximately three months later due to a recurrence of AKI with Fanconi syndrome. A kidney biopsy revealed findings consistent with acute tubular necrosis and localized tubulointerstitial nephritis, with no specific vascular or glomerular lesions. The patient's medical history revealed that prior to both AKI episodes, the patient had been taking "Red Yeast Cholestehelp", a lipid-lowering supplement for a period of time. Her kidney dysfunction and Fanconi syndrome improved with the discontinuation of the supplement and correction with oral medications. In Japan, a series of similar health hazards related to the red yeast rice supplement has been reported, but the causative toxin and its causal relationship with AKI have not been established. The present case provides firm evidence that clinically supports this relationship.

Firearm injury hospitalizations and handgun purchaser licensing laws: longitudinal evaluation of state-level purchaser licensure requirements on firearm violence, 2000–2016

BackgroundHandgun purchaser licensing (HPL) laws mandate individuals to obtain a license from law enforcement before buying a firearm. Research indicates these laws effectively reduce various forms of fatal firearm violence, including homicides, suicides, and mass shootings. Our study sought to assess the impact of HPL laws on non-fatal firearm violence.MethodsUtilizing the augmented synthetic control method (ASCM), we estimated the average treatment effect on the treated (ATT) resulting from a full repeal of an HPL law in Missouri (2007), a partial repeal in Michigan (2012), and an adoption on HPL law in Maryland (2013) on firearm injury hospitalizations. We utilized RAND's healthcare cost and utilization project-based dataset from 2000 to 2016 for our outcome variable. We conducted in-time placebo testing and leave-one-out donor pool testing as sensitivity analyses.ResultsMaryland’s adoption was associated with a statistically significant 32.3% reduction in firearm-related injury hospitalization (FIH) rates (ATT = − 0.497, standard error (SE) = 0.123); Missouri’s repeal was associated with a statistically significant 35.7% increase in FIH rates (ASCM = 0.456, SE = 0.155); and Michigan’s partial repeal showed no statistically significant associations with FIH rates (ATT = − 0.074, SE = 0.129). Sensitivity analyses confirm the robustness of the estimated HPL effects.DiscussionHPL laws appear to be protective against hospitalizations for nonfatal firearm injuries. These findings align with prior research indicating that HPL laws are effective in reducing fatal firearm violence. States without such licensing systems ought to consider these robust policies as a means to address firearm violence.

Firearm injuries in Edmonton: A decade of experience

Background: Firearms cause severe injuries that require a large amount of healthcare resources. In Canada, few studies describe the incidence and outcomes of gun violence treated in our trauma centers. Objective: From trauma registry data, we describe the demographic, social, and medical characteristics of patients presenting to the hospital with gunshot wounds. In particular, we describe their injury severity, resuscitative interventions, hospitalizations, and outcomes. Results: From 2012 to 2022, Edmonton’s two trauma centers saw 367 patients injured by firearms, predominately young males. Assault was a more common intent for injury (76%) than self-harm, accident, or law enforcement (16%, 6%, and 2%, respectively). Handguns were the most common weapon identified. Resuscitative procedures for these patients were common, including endotracheal intubation, chest decompression, and blood administration. Overall mortality was 24% with most deaths occurring on the first day. In those who survived beyond that, hospitalization duration averaged 21 days. Only 53% were discharged to routine self-care. Conclusion: Gun violence is an uncommon presentation in Edmonton’s trauma centers. Healthcare resource utilization is expected to be high, especially on the first day.

Electric Scooter-related Injuries Are Becoming More Frequent and Costly in Denver, CO.

Electric scooters (e-scooters) have become a widely adopted form of transportation. Information regarding the timing, conditions, and context associated with increased frequency of e-scooter-related injuries could inform policy that may potentially reduce associated injuries and healthcare costs. However, this information is lacking, as most research to date has focused on the injury patterns sustained while using e-scooters rather than context. We sought to evaluate these factors in an urban setting and describe how these are evolving over time, as such information may help guide future safety initiatives. (1) How has the epidemiology of e-scooter-related injuries in Denver, CO, USA, changed over time? (2) What are the associated hospital charges to treat patients with these injuries? (3) What circumstances are associated with an increased frequency of e-scooter-related injuries and higher accompanying hospital charges? A retrospective study at a Level 1 trauma center in Denver, CO, USA, examined trends in e-scooter-related injuries from January 1, 2020, to November 1, 2023. Patients were identified by the key terms "e-scooter crash" or "scooter" within their emergency department/urgent care visit notes. Patient demographic and injury characteristics and hospital data (admission and hospital charges) were analyzed. Patients who sustained injuries from devices other than stand-up e-scooters or who did not have complete records available for analysis were excluded. The epidemiologic data on e-scooter-related injuries were quantified for each year within the study period, and descriptive analyses were performed to assess patient and injury characteristics, including age, gender, and fracture characteristics. Hospital charges were calculated using the mean annual sum of hospital charges associated with the treatment for e-scooter-related injuries. Circumstances influencing the frequency of injury and magnitude of hospital charges were assessed based on the timing of presentation to the emergency department or urgent care. We recognize that charge may have little or no direct relationship to true cost, but we believe that within one hospital system it represents a reasonable metric for comparative resource utilization. Injury frequency by time of the day and day of the week were compared using chi-square goodness-of-fit analyses. The value of hospital charges associated with e-scooter-related injuries was compared between patients presenting with alcohol intoxication and those who were not intoxicated. In all, 2424 patients were identified as having e-scooter-related injuries (58% [1405] men, 42% [1019] women, median (IQR) age 30 years [25 to 37 years]). The number of annual e-scooter-related injuries during the years 2020 to 2023 were 273 in 2020, 736 in 2021, 758 in 2022, and 657 in 2023 (only 10 months). From 2020 to 2023, the mean annual sum of hospital charges for treatment of e-scooter-related injuries was USD 10.4 million; USD 6.4 million in 2020, USD 11.5 million in 2021, USD 11.9 million in 2022, and USD 10.9 million in 2023 (only 10 months). Hospital charges associated with orthopaedic e-scooter-related injuries amounted to a mean annual sum of USD 3.6 million over the 4-year study period; USD 1.5 million in 2020, USD 3.9 million in 2021, USD 4.5 million in 2022, and USD 4.1 million in 2023 (only 10 months). Forty-five percent (1098) of all e-scooter-related injuries occurred between 7 PM and 3 AM, and 44% (1064) of them occurred over the weekend. The treatment of e-scooter-related injuries incurred higher hospital charges if injuries occurred during night hours (median [IQR] USD 10,459 [4779 to 16,423]) compared with early morning (USD 4973 [1178 to 11,671]) or daytime hours (USD 4871 [1059 to 11,673]; p < 0.001), or while patients were intoxicated (USD 13,404 [10,346 to 22,525]) compared with those who were not intoxicated (USD 6132 [2612 to 13,620]; p < 0.001). E-scooter-related injuries are increasing in frequency and occur most commonly during nighttime and weekend hours. Total hospital charges to treat these injuries are also increasing annually, with the highest charges observed during evening hours and in patients presenting with alcohol intoxication. These results may help inform e-scooter awareness initiatives and policy reform to place restrictions on e-scooter use during periods of highest injury frequency and healthcare charges. Further research related to the efficacy of implementing e-scooter restrictions is needed. Future observational studies evaluating time of injury compared with presentation for treatment could help to provide a more precise understanding of the epidemiology of these injuries. Level IV, prognostic study.

Upper-Extremity Injuries in a Level 1 Trauma Center Following Border Wall Height Increase

PurposeFrom 2018-2019, the height of over 400 miles of southern border wall was raised to 30 feet. Our aim was to evaluate the impact of the increase in border wall height on upper extremity injuries sustained via barrier fall. MethodsA retrospective review of patients admitted with upper extremity injuries sustained via border wall fall between January 2015 and December 2022 at a Level 1 trauma center serving the United States- Mexico border. Patients admitted between 2015-2018 were included in the pre-increase group, and those admitted between 2019-2022 were included in the post-increase group. Demographic data, injury severity metrics, fracture characteristics, operative treatments, hospital charges, and lengths of stay were compared. Results110 patients were identified, with 16 pre-increase and 94 post-increase. Following the barrier height increase, patients had higher injury severity scores. Radial fractures were most common pre- and post-increase and accounted for nearly a third of all fractures. Post-increase upper extremity trauma patients required more operative events (2.15 ± 2.10 vs. 1.44 ± 0.73 pre-increase). The average cost for each patient’s hospital stay also quadrupled after the increase in wall height ($397,632 ± $1,057,574 vs. $98,978 ± $84,169 pre-increase). ConclusionsThe increase in overall injury severity and costly inpatient treatment of upper extremity injuries among patients who fell from the border following construction has placed additional stress on an already strained healthcare system.