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Background: Nonoperative management (NOM) of solid abdominal organ injury (SAOI) is increasing. Consequently, training programs are challenged to ensure essential operative trauma experience. We hypothesize that the increasing use and success of NOM for SAOI negatively impacts resident operative experience with these injuries and that curriculum-based simulation might be necessary to augment clinical experience., Materials and Methods: A retrospective cohort analysis of 1198 consecutive adults admitted to a Level I trauma center over 12 y diagnosed with spleen and/or liver injury was performed. Resident case logs were reviewed to determine operative experience (Cohort A: 1996-2001 versus Cohort B: 2002-2007)., Results: Overall, 24% of patients underwent operation for SAOI. Fewer blunt than penetrating injuries required operation (20% versus 50%, P < 0.001). Of those managed operatively, 70% underwent a spleen procedure and 43% had a liver procedure. More patients in Cohort A received an operation compared with Cohort B (34% versus 16%, P < 0.001). Patient outcomes did not vary between cohorts. Over the study period, 55 residency graduates logged on average 27 ± 1 operative trauma cases, 3.4 ± 0.3 spleen procedures, and 2.4 ± 0.2 liver operations for trauma. Cohort A graduates recorded more operations for SAOI than Cohort B graduates (spleen 4.1 ± 0.4 versus 3.0 ± 0.2 cases, P = 0.020 and liver 3.2 ± 0.3 versus 1.8 ± 0.3 cases, P = 0.004)., Conclusions: Successful NOM, especially for blunt mechanisms, diminishes traditional opportunities for residents to garner adequate operative experience with SAOI. Fewer operative occasions may necessitate an increased role for standardized, curriculum-based simulation training., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Suicide is a major, preventable public health issue. Although firearm-related mechanisms commonly result in death, nonfirearm methods cause significant morbidity and healthcare expenditures. The goal of this study is to compare risk factors and outcomes of firearm and nonfirearm traumatic suicide methods. This retrospective cohort study identified 146 patients who attempted traumatic suicide between 2002 and 2007 at a Level I trauma center. Overall, mean age was 40.2 years, 83 per cent were male, 74 per cent were white, and mean Injury Severity Score (ISS) was 12.7. Most individuals (53%) attempted suicide by firearms and 25 per cent died (84% firearm, 16% nonfirearm techniques). Subjects were more likely to die if they were older than 60 years-old, presented with an ISS greater than 16, or used a firearm. On average, patients using a firearm were older and had a higher ISS and mortality rate compared with those using nonfirearm methods. There was no statistical difference between cohorts with regard to gender, ethnicity, positive drug and alcohol screens, requirement for operation, intensive care unit admission, and hospital length of stay. Nonfirearm traumatic suicide prevention strategies aimed at select individuals may decrease overall attempts, reduce mechanism-related mortality, and potentially impact healthcare expenditures.

Purpose: Expanded polytetraflouroethylene (ePTFE) grafts are the most popular prosthetic grafts for hemodialysis patients in whom autogenous fistulas cannot be constructed. Long-term studies to study the durability and complication rate of the different wall configurations of ePTFE grafts have not been carried out. The primary, secondary, and cumulative patency and other complications between standard thickness (STD) and thin wall (THN) 6 mm stretch ePTFE grafts (WL Gore & Assoc, Flagstaff, AZ) was prospectively evaluated., Methods: From September 1993 to August 1995, 108 patients receiving new grafts were randomized into 2 groups: those receiving STD grafts (n = 56) or those receiving THN (n = 52) grafts. Data prospectively collected included day of first access, primary patency, interventions required, and long-term results. Infections, pseudoaneurysms, and mortality were also documented. Student's unpaired t-test was used to compare the 2 groups, and log-rank life tables were constructed and compared., Results: Mean follow-up examination time was 38.1 +/- 0.8 months for STD grafts and 35.1 +/- 1.0 months for THN grafts (P<.03). Longer patency was noted in the STD group of grafts (18.2 months for STD vs. 12.1 months for THN). Biographical data and complications, including pseudoaneurysm (6% vs. 5%), infection (2% vs. 3%), and mortality (22% vs. 19%), between STD and THN groups were not different statistically. Mean primary (18.2 months vs. 12.1 months), secondary (20.9 months vs. 13.7 months), and cumulative patency times (22.2 months vs. 15.2 months) for the STD group were significantly more than those for the THN group (P<.000 by log rank of life tables). Other complications were not different between groups., Conclusion: Standard thickness ePTFE is the graft of choice when placing ePTFE arteriovenous grafts for hemodialysis.

Background: Significant changes occurred over a 4.5-year period in the causes, diagnosis, and treatment of arterial injuries associated with skeletal fractures of the extremities., Study Design: The trauma registry data of 1,091 consecutive patients with fractures, dislocations, or both, were reviewed for the diagnosis of associated arterial injury documented by arteriography or an exploratory operation. The decision to perform a vascular repair was based solely on the presence of definitive signs of arterial injury found during physical examination., Results: Arterial injuries occurred in 41 patients (3.8 percent). Of these, 29 (71 percent) had penetrating injuries, and 12 (29 percent) had blunt trauma. Twenty-six patients (63 percent) had definitive signs of arterial injury and all required arterial repairs. Only three patients (7.3 percent), all with blunt injuries, required amputations because of massive soft tissue trauma. Fifteen patients had intimal flaps, irregularities, or localized narrowings shown on the arteriogram. No patient's condition had deteriorated by the time of a repeat arteriogram (n = 6) or physical examination (n = 9), and no injury required delayed repair (mean follow-up of 6.5 months). No patient without definitive signs of vascular injury at the time of initial examination required surgical repair., Conclusions: Arterial injuries associated with fractures increasingly result from penetrating trauma and carry a much lower risk of amputation than injuries from blunt trauma. Physical examination can accurately detect 100 percent of the arterial injuries requiring repair. Minimal arterial abnormalities seen on arteriograms may be safely followed up by observation.

Background: Optimal management of patients with Zone II penetrating neck trauma for vascular injury remains controversial. Retrospective studies have demonstrated that physical examination alone may be as accurate as arteriography in detecting significant cervical vascular injuries requiring operative repair. This study was undertaken to evaluate prospectively the safety and accuracy of physical examination in determining the management of patients with penetrating Zone II neck trauma., Study Design: During a 22 month period, 66 consecutive patients presented to our Level I trauma center with penetrating neck trauma. Determination of the vascular status of these patients was based on physical examination alone if the injury was located in Zone II and there was no definite sign of vascular injury. Patients were observed for at least 23 hours. Patients admitted during the first year of the study underwent ultrasound examination of the carotid artery within 48 hours to assess for injuries., Results: Thirty-six patients met admission criteria. Two patients had large lacerations requiring operative debridement and closure. Six patients underwent arteriography because of the proximity of the vertebral arteries to the injury tract, the trajectory also included Zone I or III, or there were equivocal signs of vascular injury. Each arteriogram was negative. Of the remaining 28 patients, none had any evidence of a vascular injury during hospitalization or follow-up period (mean of 1.8 months). Eighteen of the 28 patients had carotid ultrasounds, none of which showed injuries requiring operative intervention., Conclusions: Patients with Zone II penetrating neck injuries and no definite signs of vascular injury can be safely and accurately managed on the basis of physical examination alone. Arteriography or ultrasonography are not needed to identify vascular injuries.