University Trauma Center Research Articles

Bedside electromyography for clinical assessment of sacral motor and reflex activity adapted for patients hospitalized with acute neurological conditions: a pilot study.

Pilot cohort study. To develop and implement a sacral electromyographic (sEMG) technique at bedside to ascertain sparing of sacral motor activity and reflexes in patients hospitalized for acute neurological conditions. Hôpital du Sacré-Coeur de Montréal a Canadian Level-1 university trauma center specialized in SCI care. Nine patients underwent digital rectal examination (DRE) and sEMG, assessing voluntary anal contraction and sacral spinal reflexes (bulbocavernosus reflex and the anal wink). Our sEMG technique utilized surface recording electrodes and tactile elicitation of reflexes. EMG signal was acquired at bedside through the Noraxon MR3 system. It was quick, well accepted and did no harm. We found that contrary to the DRE, sEMG detected subclinical sacral motor activity and reflexes in 20% of cases for voluntary anal contraction and 40% of cases for the anal wink. We believe our sEMG technique is a powerful tool able to enhance management of patients suffering from acute neurological impairments and requiring sacral function assessment.

Chronic anticoagulation therapy and acute hip trauma

Regardless of the association between hip fracture surgery and mortality, morbidity and bleeding risks, there are still significant contradictions in various published articles concerning hip fracture surgery outcomes when patients are prescribed anticoagulant medication. The primary objective of this study was to investigate if patients prescribed anticoagulants experienced delayed surgery when compared to non-users. The secondary goal was to investigate if patients prescribed anticoagulants underwent an extended hospital stay and complications such as increased bleeding, mortality and a higher rate of comorbidities when compared to non-users. Data from proximal hip fracture patients were prospectively collected at a level I university trauma center. From 1 January, 2020, through 1 January, 2021, 519 eligible patients were identified. Anticoagulant medication upon admission, time prior to surgery, hospitalized days, 30-day mortality rates, 1-year mortality, blood transfusion requirement and various comorbidities were noted. 222 of the 519 hip fracture patients were prescribed anticoagulants. Of the 222 patients, 75% were females and 25% were males. In total, 46% required a blood transfusion, with no significant differences between the anticoagulated and non-anticoagulated patients. 50% of the anticoagulated group and 42% of the control group required perioperative blood transfusion. Neither the 30-day nor the 1-year mortality rate showed statistically significant differences between the groups. However, the time to surgery and the length of hospital stay was significantly longer in the anticoagulated group. Comorbidities were found in 87% of the patients: in 95% of the anticoagulated group and in 81% of the non-anticoagulated group. Patients prescribed anticoagulants at the time of hip fracture experienced delayed surgery, longer hospital stays and more comorbidities when compared to patients not on anticoagulants. Neither a blood transfusion requirement, 30-day mortality rate nor a 1-year mortality rate showed no significant difference between the two cohorts.

Do upright radiograph findings affect treatment plans for patients with thoracic and lumbar spine injuries?

Background After spinal trauma, upright radiographs are commonly used to evaluate spinal stability. However, the benefits and risks of upright films have not yet been thoroughly studied. This study aimed to elucidate the effect that upright imaging has on patients with thoracic and/or lumbar spinal injuries by evaluating the impact on treatment decisions. Methods A retrospective review of all adult patients who suffered traumatic spine injuries and received thoracic and/or lumbar spine imaging between April 2019 and March 2021 in a Level 1 University Trauma Center. Patients’ charts were reviewed, and those patients who received upright films as a final dynamic evaluation of their spine before clearance for standing were identified. Fractures due to infection or malignancy were excluded as were 17 patients who only received post-operative upright films. We examined whether upright films modified the treatment strategy. Results Of the 353 upright radiographs conducted on patients without prior surgical intervention, 27 (7.6%) of these studies provided information not known from prior imaging; the remaining 92.4% of upright films were considered “unchanged” or “stable.” Of the 27 patients who had changes in uprights, in only 7 cases (2.0%) did the new findings affect the treatment plans. In 6/7 cases, upright films showed increased vertebral body height loss and/or worsening fractures—suggestive of instability—in previously known T12-L1 fractures. Conclusions We studied 353 patients who received T and/or L uprights after suffering a traumatic spine injury and before receiving any surgical interventions. Of these patients, 98.0% did not gain substantial benefit from the additional imaging as the upright radiographs did not affect the treatment strategy. In 2% of cases a significant change in management was indicated following the upright films; virtually all of these were in T11-L2 fractures. The utility of upright films should be re-evaluated and more studies directed to potentially clarify which subgroups of patients will benefit from these radiographs.

Surgical outcomes of segmental diaphyseal forearm fractures in adults: a small case series on plate osteosynthesis, intramedullary nailing, and other surgical methods

BackgroundSegmental fractures often result from high-energy or indirect trauma that causes bending or torsional forces with axial loading. We evaluated surgical outcomes of patients with forearm segmental diaphyseal fractures.MethodsWe retrospectively analyzed data from patients with forearm segmental fractures for which they underwent surgery at the Pusan National University Trauma Center from March 2013 to March 2022. We also analyzed accompanying injuries, injury severity score (ISS), injury mechanism, occurrence of open fracture, surgical technique, and treatment results.ResultsFifteen patients were identified, one with bilateral segmental diaphyseal forearm bone fracture, for a total of 16 cases. Nine of the patients were male. The overall mean age was 50 years, and the mean follow-up period was 16.2 months. Six cases who underwent surgery using plate osteosynthesis achieved bone union without length deformity at final follow-up. Three of seven patients who underwent intramedullary nailing alone underwent reoperation due to nonunion. Six cases achieved bone union at final follow-up, three of which showed length deformity. Three patients underwent surgery using a hybrid method of IM nailing, plates, and mini cables. One patient who underwent surgery with a plate and one patient who underwent surgery with IM nailing alone showed nonunion and were lost to follow-up.ConclusionPlate osteosynthesis is considered the gold standard for treatment of adult forearm diaphyseal segmental fractures. In this study, IM nailing was associated with high rates of non-union and length deformity. However, the combination of IM nailing and a plate-cable system may be an acceptable alternative in segmental diaphyseal forearm fracture, achieving a union rate similar to that provided by plate fixation.

Epidemiology of Pediatric Musculoskeletal Trauma Patients Admitted to a Trauma Center in Northern India: A Prospective Cohort Study.

Background Pediatricinjuries are the leading cause of death and disability worldwide and place a considerable burden on nations with limited resources. A careful investigation of the epidemiology ofpediatricmusculoskeletal trauma can provide insight into its causation and the demography of the affected children and help us devise preventive strategies to reduce the burden of pediatric musculoskeletal trauma. Methodology Musculoskeletal trauma patients up to the age of 18 years were included in this prospective cohort study. Information about age, sex, time since the injury to presentation to a trauma center, mode of injury, the site where the injury was suffered, and the exact injurywererecorded. Age was further recorded as 0 to 3 years, >3 to 6 years, >6 to 12 years, and >12 to 18 years. A subgroup analysis of the mode of injury was done using age group and sex. Results A total of 201 patients were enrolled in the study. The age (mean ± standard deviation [SD]) of the enrolled patients was12.48 ± 4.71 years. Of the 201 patients enrolled, 146 (72.63%) were males. The mean time since the injury to the receptionin the emergency department of theKing George'sMedical University trauma center (a tertiary care center) was 19.13 ± 33.86 hours. The common mechanisms of injury observed were road traffic accidents(RTAs, 55.22%), falls from height (29.35%), and falls at ground level. There was a significant difference in the mode of injury in the age groups (P= 0.0297) and among males and females (P= 0.0034). Injuries to the lower limbs were most common in all age groups. Conclusions Our study presents the baseline epidemiological data onpediatricmusculoskeletal injuries distributed by age groups, gender, mode of injury, site of injury, and region-wise distribution of injuries. The data may be used by policymakers in planning apediatrictrauma care system in India.

Epidemiological Situation of Hip Replacement Surgery: Gender Difference Responding

In some papers, differences in gender regarding the total hip arthroplasty (THA) replacement surgery response are reported. This study evaluated gender differences in response to patients undergoing total hip arthroplasty replacement surgery in our country. It is a cross-sectional and descriptive study that analyzed 401 patients admitted and undergoing THA at the University Trauma Center, Tirana, for five years. SPSS software 20.0 is used to analyze patient outcome measures. The logistic regression compared outcomes between genders. A p-value less than 0.05 was considered significant. The average age in this study was 67.1 +/- 5.4 years, with the range of min to max ranging from 22 to 89 years old.Women were the most predominant Gender, at 51.6% (207/401), compared to men, at 48.4% (194/401). The age group 60–70 years old had the most patients, accounting for 29.7% (119/401). In addition, women were more likely than men to be older, to have arthritis, and to have metabolic syndrome (P=0.001). The preoperative health of men was weaker despite being younger than women. Based on the logistic regression of the data, the length of hospital stay was significantly higher in women versus men. Still, on the other side, mobility after the replacement was much slower in men. Also, the men were less likely to return to their homes or mobilize independently during the 90-day follow-up. The findings of this study show a significant association between the gender effect and the outcomes of the replacement response. The total amount of arthroplasty used is more than four times as great in women as in men. We recommend future studies to clear up the underlying causes of gender differences in joint arthroplasty.

Impact of Ingudi (Balanites aegyptiaca Linn. Delile) Seed oil on Prameha Pidika (Diabetic Carbuncle): A Case Study

Background: We gone a thorough the literature the use of medicinal plants and plant-based products for topical ulcers and discovered the natural products and its derivatives account for more than half of all medications taken globally today.
 Case Presentation: A fifty-eight-year-old gentleman of middle socioeconomic status developed a carbuncle on right side of the nape of the neck with firm edge and a necrotic fowl smelling slough on the floor. Despite his attempts to treat the carbuncle at home and nearby allopathic physicians "it continued to enlarge and fester" (became inflamed and suppurated). The patient was visited the Trauma Surgery Out Patient Department (OPD), Banaras Hindu University (BHU) Trauma center & Super specialty Hospital, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India, and, following surgical incision and drainage. ET nurse consultation for regular dressing but wound did not show the progressive healing, patient was referred to the Ayurvedic OPD wing of Banaras Hindu University for Ayurvedic management. Sushruta used Ingudi oil for the management of vitiated/chronic wounds. This case study aims to anticipate the clinical efficacy of Ingudi seed oil in the treatment of chronic diabetic wounds without causing any side effect, which is a complex type of Diabetic carbuncle (Prameha pidika).
 Conclusion: Ingudi seed oil has prompt healing properties against diabetic wounds. Ingudi seed oil is natural, safe, and cost-effective material used in chronic diabetic wounds (Prameha pidika).

Influence of patella height after patella fracture on clinical outcome: a 13-year period

IntroductionThe incidence of patella fracture is statistically low (0.5–1.5%) compared to other fractures of the extremities [Patella fractures 76(10):987–997, 2005]. In the latter research, patella fractures if treated surgically present an overall inferior functional outcome. Little is known about the influence of the postoperative patella height on the clinical outcome. Therefore, the aim of our study was to analyse the influence of the patella height on the patients’ functional outcome after surgery.MethodsIn this retrospective study the in-house trauma register of our level I University trauma center was screened for patients suffering patella fractures treated surgically. Patella height of the same patients was evaluated on lateral X-rays using the Insall–Salvati Ratio (ISR). The patients’ X-rays were analyzed at two time points for the ISR, whereas group A presents ISR data right after surgery and group B data at the latest follow up (minimum 6 weeks). The change of mean ISR at both time points was tested for significance. The functional outcome was measured by the “Munich Knee Questionaire” (MKQ). These MKQ results of different patella heights and fracture types were compared.ResultsThe screening of our in-house trauma register revealed 375 patients between the years 2003 and 2016. Out of these 54 patients (34f, 20 m) were enrolled. In detail the follow-up time for ISR between group A and B accounted for a mean of 503.8 ± 655.7 days. The MKQ was assessed at a mean of 1367.0 ± 1042.8 days after surgery. According to the AO-classification 10% AO.34 type B and 90% AO.34 type C fractures were found. Group A showed in 9.1% a patella baja and in 27.3% a patella alta compared to group B presenting 20.0% patella baja and 14.5% patella alta. There was no significant difference in functional outcome referring to the MKQ in patella alta (MKQ 69.0% ± 18.2) or baja (MKQ 67.1% ± 17.9) (p = 0.9). No significant functional difference between AO34.type B (MKQ 74.5% ± 11.0) and AO34.type C fractures (MKQ 64.0% ± 15.0) resulted (p = 0.1).ConclusionOur results demonstrate that different postoperative patella heights apparently do not influence the functional outcome in the short follow-up.

Does implementation of a tailored intervention increase adherence to a National Safety and Quality Standard? A study to improve delirium care.

Delirium is commonly detected in older people after hip fracture. Delirium is considered to be a multifactorial disorder that is often seen post-operatively (incidence ranging from 35% to 65%). Hospitals in Australia are required to meet eight standards including the comprehensive care standard to be able to maintain their accreditation. The standard includes actions related to falls, pressure injuries, nutrition, mental health, cognitive impairment and end-of-life care. Delirium prevention was identified as an area for improvement in our Orthopaedic unit in a Level 1 University Trauma Centre in Australia. This implementation research project aimed to understand the efficacy of a delirium prevention intervention within an existing orthopaedic speciality care system. Implementation of the tailored intervention will increase adherence to National Safety and Quality Health Service Standards, thereby reducing rate of delirium. In this study, we used an interrupted time series design to examine changes in practice over time in people admitted to hospital with a hip fracture. Clinical staff caring for patients with hip fracture in an acute care setting in Adelaide, South Australia, participated in the project. In brief, intervention included education, environmental restructuring, change champions, infographics and audit feedback reports. The primary outcome of interest was rate of delirium. The secondary outcome was compliance with the use of delirium 4AT screening tool, duration of delirium and hospital length of stay. The rate of change per month in patients with delirium decreased significantly by 19.2%. There was no significant change observed in trend for duration of delirium and length of hospital stay between pre-intervention and post-intervention phases. A significant increase in the use of screening tool was observed from 4.7% in the pre-intervention phase to 33.6% in the post-intervention phase. Translation of evidence-based intervention model incorporating well-considered implementation strategies had a mixed impact on decreasing the rate of delirium. The scheduled hospital accreditation enhanced the use of validated screening tool to recognize delirium. This project highlights the importance of aligning implementation goals with the wider goals of the organization as well as making clinicians accountable by consistent auditing.

What constitutes a ‘successful’ recovery? Patient perceptions of the recovery process after a traumatic injury

BackgroundAs the number of patients surviving traumatic injuries has grown, understanding the factors that shape the recovery process has become increasingly important. However, the psychosocial factors affecting recovery from trauma...

The impact of teaching status on trauma center clinical outcomes in the United States.

Teaching status/academic ranking may play a role in the variations in trauma center (TC) outcomes. Our study aimed to determine the relationship between TC teaching status and injury-adjusted, all-cause mortality in a national sampling.Retrospective review of the National Sample Program (NSP) from the National Trauma Data bank (NTDB). TCs were categorized based on teaching status. Adjusted mortality was determined by observed/expected (O/E) mortality ratios, derived using TRauma Injury Severity Score methodology from the Injury Severity Score and Revised Trauma Score. Chi-square and t test analyses were utilized with a statistical significance defined as P <.05.Of the 94 TCs in the NSP, 46 were university, 38 were community teaching, and 10 were community nonteaching. For the University TCs, 62.8% were American College of Surgeons (ACS) level 1 and 81.2% state level 1. Of the community teaching TCs, 39.0% was ACS level 1 and 35.1% was state level 1. Of the community nonteaching TCs, 0% was ACS level 1 and 11.1% was state level 1. University TCs had a significantly higher O/E mortality rate than community teaching (0.75 vs 0.71; P = .04). There were no differences in O/E between community teaching and nonteaching TCs (0.71 vs 0.70; P = .70).Community teaching and nonteaching TCs have lower injury-adjusted, all-cause mortality rates than University Centers. Future studies should further investigate key differences between University TCs and community teaching TC to evaluate possible quality and performance improvement measures.

Critical call for hospital-based domestic violence intervention: The Davis Challenge.

Fifty percent of women killed in intimate partner violence (IPV) were seen by a health care provider within a year of their death. As guest speaker to Virginia Commonwealth University Trauma Center (VCU-TC), Dr. James Davis (Western Trauma Association past president) challenged VCU-TC to develop a hospital-based IPV program. This research examines the development and impact of an integrated hospital/VCU-TC-based IPV program. The IPV survey was carried out to determine need for training and screening. Hospital forensic nurse examiners case logs were evaluated to determine IPV prevalence. An integrated IPV program-Project Empower was developed, consisting of staff education, patient screening, victim crisis fund, and interdisciplinary sexual assault/domestic violence intervention team. Between 2014 and 2018, patients admitted with an IPV consult to Project Empower were entered into a secure database capturing demographics, mechanisms, income data, and social determinants of risk. Program feasibility was evaluated on patient engagement via screening and case management. Program impact was evaluated on crisis intervention, safety planning, and community referral. Forensic nurse examiner data and IPV survey evaluation noted 20% IPV prevalence and lack of IPV screening and training. The IPV patients (N = 799) were women (90%), unmarried (79%) and African-American (60%). Primary mechanisms were firearm (44%) or stabbing (34%). Survivors were perpetrated by a cohabiting (42%) or dating partner (18%). Monthly income averaged US $622. Forty percent had no health insurance. Advocates provided 62% case management. Survivors received victim crisis funds (16%), safety planning (68%), crisis intervention (78%), sexual and domestic violence education (83%), and community referral (83%). Within 5 years, 35 (4%) were reinjured and seen in the emergency department. Thirty-one (4%) were readmitted for IPV-related injuries. Two deaths were attributed to IPV. Critical call for hospital-based IPV intervention programs as a priority for trauma centers to adopt cannot be underestimated but can be answered in a comprehensive integrated model. Therapeutic, level I.

Diagnostic performance of thromboelastometry in trauma-induced coagulopathy: a comparison between two level I trauma centres using two different devices.

The implementation of a ROTEM®-based algorithm requires reliable thresholds to mirror a prothrombin time (PT) ratio > 1.2 and/or a fibrinogen concentration < 1.5gl-1. Our goal was to compare the diagnostic performances of two devices (ROTEM® Sigma and Delta, IL Werfen, Munich, Germany) in two level-I trauma centres for the diagnostic of post-traumatic coagulopathy. We conducted a retrospective analysis of two registries across two periods of time: from September 2014 to December 2015 in Lyon-Sud university trauma centre and from April 2016 to January 2018 in the Grenoble Alps Trauma Centre. Accuracies of EXTEM and FIBTEM assays to detect patients with coagulation disorders were tested for each device using receiver operating characteristic (ROC) analyses. Within the study period, 74 trauma patients in the Grenoble cohort and 75 trauma patients in the Lyon cohort had concomitant ROTEM® and standard coagulation testing on admission. No statistically significant difference was found between the two ROC curves for FIBTEM amplitude at 5min (A5), FIBTEM maximum clot firmness, EXTEM clotting time (CT) and EXTEM A5 for ROTEM® Sigma and Delta to diagnose post-traumatic coagulation disorders. The best threshold for FIBTEM A5 to predict low fibrinogen concentration was 7mm for each device. EXTEM CT thresholds to diagnose PT ratio > 1.2 were 78s and 74s for ROTEM® Sigma and Delta, respectively. These results suggest that ROTEM®-based algorithms may be transposed from one trauma centre to another independently of the setting and the ROTEM® device in use.

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The purpose of this study was to improve the treatment results of multicomminued fractures of the distal humerus metaepiphysis through the development of a compression device that provides stable osteosynthesis of small fragments. Materials and methods Clinical testing of the device developed for osteosynthesis of small fragments in multicomminuted fractures of the distal humerus metaepiphysis (patent of Ukraine for useful model #12560) was conducted. Treatment sample included 104 persons with multicomminued fractures of the distal humerus metaepiphysis admitted to the Donetsk national medical university and national trauma center of Donetsk. Results Osteosynthesis of small fragments in multicomminuted metaepiphyseal fractures of the distal humerus with the help of the developed by us compression device enabled to reduce and stabilize small bone fragments, provided the possibility of early movements in the joint and resulted in good outcomes. Conclusions Osteosynthesis of small fragments with application of the developed by us compression device in patients with multicomminued fractures of the distal humerus metaepiphysis showed high efficiency. The mean score was 82.67 ± 5.59 points, which corresponds to good results of treatment.

Thoracoscopic anterior stabilization for thoracolumbar fractures in patients without spinal cord injury: quality of life and long-term results

PurposeTo determine the health-related quality of life (QOL), safety and radiologic parameters after thoracoscopic treatment of traumatic thoracolumbar fractures using a distractible cage in patients without spinal cord injury (SCI).MethodsRetrospective cohort study of patients treated between 2004 and 2012 in a university level-one trauma center. Patient and treatment characteristics were collected from the hospital information system. All available radiographic material was assessed for fracture characteristics and Cobb angle at consecutive times. Patients completed the SF-36 and EQ-5D QOL questionnaires at follow-up.Results105 patients were treated with a distractible cage, which was performed thoracoscopically in 86 cases, including 16 patients with SCI. Of 70 eligible patients, 46 were available for follow-up and completed the questionnaires at median 49 months after surgery. QOL was lower on most domains compared to the general population. Compared to patients who underwent solely posterior fixation for less severe fractures, QOL did not differ significantly. The complication rate was low (10%) with one re-operation. Mean loss of correction was 6.8° and bony fusion on CT scan was present in 98% of patients. Maintenance of kyphosis correction was significantly better for two segments anterior fixation compared to one segment.ConclusionsThoracoscopic anterior stabilization leads to a high percentage of bony fusion in highly unstable thoracic and thoracolumbar fractures with limited post-operative loss of correction and no hardware failure. QOL of these patients does not return to normal population values but is comparable to that of patients with less severe fractures treated with solely posterior instrumentation.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

Lower extremity nontensioned traction pins: is it a benign procedure?

Background: To evaluate our institution’s infection rate with lower extremity traction pins and ascertain any risk factors. Additionally we sought to evaluate if the location of pin placement provided a higher risk of infection. Methods: This was a retrospective case-control study at a level 1 urban university trauma center. Five hundred and fifty six patients had 575 traction pins placed from February 2009 through December 2014. The intervention was bedside application of a centrally threaded 6-mm traction pin in the femur, tibia, or calcaneus. Radiographs were reviewed and zones were denoted. The diaphysis was bisected to determine anterior and posterior margins. The quadrant locations were as follows (1- proximal anterior, 2- proximal posterior, 3- distal anterior, and 4- distal posterior). Results: The total pins placed were 575 pins: 320 tibial, 236 femoral, and 19 calcaneal. There was an average of 9.6 mo of follow-up. There were five pin track infections (0.87%), all of which were treated successfully with oral antibiotics. There were two peroneal nerve injuries both which resolved by last follow-up. There was no septic arthritis of the knee. No correlations were noted between diabetes, body mass index, smoking, hypertension, and pin track infections or peroneal nerve injuries. There were 283 pins placed into zone 1, 166 in zone 2, 87 in zone 3, and 20 in zone 4. The 19 calcaneal pins were not categorized into quadrant systems. No correlation was noted between the bone in which the traction pin was placed and pin track infection or peroneal nerve injuries. Of the five pin track infections, all were placed in an eccentric posterior location. Four were in zone 2 and one in zone 4, which was statistically significant (P&lt;0.05). No correlation was found between location of pins and peroneal nerve injury. The average time of pin placement to definitive surgery and pin removal was 2.83 days (0-28 days). There was no correlations between rates of infection and the amount of time in traction. Conclusions: This study revealed a low infection rate with 6-mm centrally threaded traction pins in our population. These larger, temporary lower extremity traction pins can be safely placed at the bedside and require no additional equipment for their use. Proximal and posteriorly placed pins in the tibia and femur have a correlation to pin track infections and thus should be avoided. These posteriorly placed pins tether more musculotendinous structures and, thus, are at risk for producing more immediate tissue necrosis with insertion and or use. Nontensioned anterior pins can be used with minimal risk of complication and are recommended. Level of Evidence: Prognostic level IV.

Bridging the Gap: Hospital Community-Based Youth Violence Prevention Program—Pitfalls and Lessons Learned

This review focuses on pitfalls and lessons learned during the development, implementation, and sustainability of hospital community-based youth violence prevention program. In the USA, homicide is the third leading cause of death among youth aged 10–24. The re-injury rate seen at Virginia Commonwealth University Trauma center (VCU-TR) is comparable to the nationally observed rate of 10 to 50%. VCU-TR, along with several other Trauma Centers, has taken an active role in the development of hospital community-based youth violence prevention programs. The efforts have been effective in reducing recidivism and the risks of violence. Significant pitfalls can be avoided in the development and sustainability of an evidence-based, collaborative, hospital community-based youth violence prevention programs. This review highlights the effectiveness of hospital community-based violence prevention programs in reducing the risks of re-injury. There are significant pitfalls to avoid both internal within the institution as well as external with the community partners.

Performance of new adjustments to the TRISS equation model in developed and developing countries

BackgroundThe Trauma and Injury Severity Score (TRISS) has been criticized for being based on data from the USA and Canada—high-income countries—and therefore, it may not be applicable to low-income and middle-income countries. The present study evaluated the accuracy of three adjustments to the TRISS equation model (NTRISS-like; TRISS SpO2; NTRISS-like SpO2) in a high-income and a middle-income country to compare their performance when derived and applied to different groups.MethodsThis was a retrospective study of trauma patients admitted to two institutions: a university medical center in São Paulo, Brazil (a middle-income country), and a level 1 university trauma center in San Diego, USA (a high-income country). Patients were admitted between January 1, 2006, and December 31, 2010. The subjects were 2416 patients from Brazil and 8172 patients from the USA. All equations had adjusted coefficients for São Paulo and San Diego and for blunt and penetrating trauma. Receiver operating characteristic (ROC) curves were used to evaluate performance of the models.ResultsRegardless of the population where the equation was generated, it performed better when applied to patients in the USA (AUC from 0.911 to 0.982) compared to patients in Brazil (AUC from 0.840 to 0.852). When the severity was considered and homogenized, the performance of equations were similar to both application in the USA and Brazil.ConclusionsSurvival probability models showed better performance when applied in data collected in the high-income countries (HIC) regardless the country they were derived. The severity is an important factor to consider when using non-adjusted survival probability models for the local population. Adjusted models for severely traumatized patients better predict survival probability in less severely traumatized populations. Other factors besides physiological and anatomical data may impact final outcomes and should be identified in each environment if they are to be used in the development of the trauma care performance improvement process in middle-income countries.

Perioperative inflammatory response in major fracture: do geriatric patients behave differently?

Interleukin-6 is a mainly proinflammatory interleukin and an indicator for the magnitude of surgery. The IL-6 serum concentration correlates with injury severity, the extent of tissue trauma and has negative impact on prognosis. To date it is unclear whether the immunologic changes assessed are age dependent. The aim of this study is to compare the surgical inflammatory response in different age groups. Data were collected at a level-1 university trauma center in a prospective, consecutive cohort study. IL-6 levels were analyzed via ELISA from venous blood samples of cohorts of injuries with typical peak incidence: patients with unstable fractures of the spine (SP) for a middle-aged group and patients with fractures of the proximal femur (PF) for a geriatric group. Surgical treatment was performed using minimal-invasive instrumentation. 25 patients in group SP (age: 51 years±20) and 16 patients in the group PF (age: 73 years±16) were analysed. Group PF showed higher baseline IL-6 concentrations. Surgical treatment was followed by a significant increase of IL-6 levels in both groups 4 and 24h postoperatively. Concentration profiles were similar, but increase was significantly higher in the PF group 4h after surgery. Both the operative treatment of fractures in a middle-aged (SP) and a geriatric group (PF) lead to significant increasing of IL-6 levels. In view of a comparative surgical burden, these data suggest that age may be a confounding factor for a surgery induced pro-inflammatory response in the early postoperative stage.

Isolated prehospital hypotension correlates with injury severity and outcomes in patients with trauma

ObjectivePatients normotensive in the trauma bay despite documented prehospital hypotension may not be recognized as significantly injured. The purpose of this study was to determine whether isolated prehospital hypotension portends poor outcomes and correlates with injury severity.MethodsProspective cohort study conducted at a level 1 university trauma center. The lowest recorded prehospital systolic blood pressure (SBP) and the first recorded SBP on hospital arrival were used to divide patients into either the normotensive (NP) or hypotensive (HP) group. Patients who failed to achieve normotension on hospital arrival were excluded. Hypotension was defined as SBP≤110 mmHg.ResultsCompared to NP (n=206), HP (n=81) had lower Glasgow Coma Scores both prehospital (12.81±0.44 vs 14.38±0.13) and at hospital admission (12.78±0.47 vs 14.37±0.14). Injury Severity Score positively correlated with prehospital hypotension (HP 12.27±1.12 vs NP 9.22±0.49). Prehospital hypotension positively correlated with intensive care unit (ICU) admission (HP 56.79% vs NP 22.82%), ICU length of stay (LOS) (HP 3.23±0.71 vs NP 0.71±0.17), hospital LOS (HP 8.58±1.39 vs NP 4.86±0.33), ventilator days (HP 3.38±1.20 vs NP 0.27±0.08 days), and repeat hypotensive episodes during their hospital stay (HP 81.71% vs NP 38.16%). HP also required more packed red blood cells in the first 24 hours after admission (22% vs 6%). Significance was set at p<0.05.ConclusionsIsolated prehospital hypotension in patients in the trauma and emergency department correlates with increased injury severity and portends worse outcomes despite a normal blood pressure reading at admission. Prehospital hypotension must be given heavy consideration in triage, as these patients may be transiently hypotensive and appear less critical than their true status.Level of EvidenceLevel II, Prognostic study.