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Adult polycystic kidney disease has been found in association with pathological distribution of the seminal vesicles in six patients. These men appeared normal on clinical examination, but had azoospermia or sever oligozoospermia. They were investigated by scrotal exploration with vasography, renal and transrectal ultrasound scans (TRUS), and percutaneous puncture of the seminal vesicles in one case, before and after resection of the ejaculatory ducts. This revealed that the gross dilatation of the seminal vesicles was not caused by obstruction, but appeared to be due to atonicity (megavesicles). These ultrasonic appearances, when described previously, were incorrectly thought to be due to seminal vesicle cysts. [ABSTRACT FROM PUBLISHER]

Background: Though the US civilian trauma care system plays a critical role in disaster response, there is currently no systems-based strategy that enables hospital emergency management and local and regional emergency planners to quantify, and potentially prepare for, surges in trauma care demand that accompany mass-casualty disasters., Objective: A proof-of-concept model that estimates the geographic distributions of patients, trauma center resource usage, and mortality rates for varying disaster sizes, in and around the 25 largest US cities, is presented. The model was designed to be scalable, and its inputs can be modified depending on the planning assumptions of different locales and for different types of mass-casualty events., Methods: To demonstrate the model's potential application to real-life planning scenarios, sample disaster responses for 25 major US cities were investigated using a hybrid of geographic information systems and dynamic simulation-optimization. In each city, a simulated, fast-onset disaster epicenter, such as might occur with a bombing, was located randomly within one mile of its population center. Patients then were assigned and transported, in simulation, via the new model to Level 1, 2, and 3 trauma centers, in and around each city, over a 48-hour period for disaster scenario sizes of 100, 500, 5000, and 10,000 casualties., Results: Across all 25 cities, total mean mortality rates ranged from 26.3% in the smallest disaster scenario to 41.9% in the largest. Out-of-hospital mortality rates increased (from 21.3% to 38.5%) while in-hospital mortality rates decreased (from 5.0% to 3.4%) as disaster scenario sizes increased. The mean number of trauma centers involved ranged from 3.0 in the smallest disaster scenario to 63.4 in the largest. Cities that were less geographically isolated with more concentrated trauma centers in their surrounding regions had lower total and out-of-hospital mortality rates. The nine US cities listed as being the most likely targets of terrorist attacks involved, on average, more trauma centers and had lower mortality rates compared with the remaining 16 cities., Conclusions: The disaster response simulation model discussed here may offer insights to emergency planners and health systems in more realistically planning for mass-casualty events. Longer wait and transport times needed to distribute high numbers of patients to distant trauma centers in fast-onset disasters may create predictable increases in mortality and trauma center resource consumption. The results of the modeled scenarios indicate the need for a systems-based approach to trauma care management during disasters, since the local trauma center network was often too small to provide adequate care for the projected patient surge. Simulation of out-of-hospital resources that might be called upon during disasters, as well as guidance in the appropriate execution of mutual aid agreements and prevention of over-response, could be of value to preparedness planners and emergency response leaders. Study assumptions and limitations are discussed. Carr BG , Walsh L , Williams JC , Pryor JP , Branas CC . A geographic simulation model for the treatment of trauma patients in disasters. Prehosp Disaster Med. 2016;31(4):413-421.

Purpose: The impact of a pharmacy-managed program for providing education and discharge instructions for patients with heart failure (HF) was evaluated., Methods: A before-and-after quasiexperimental design was used to quantify the effect of a pharmacist-managed HF medication education and discharge instruction program on the incidence of 30-day readmission rates and adherence to targeted Joint Commission core measures for HF (the provision of discharge instructions and the prescribing of an angiotensin-converting-enzyme inhibitor [ACEI]/angiotensin II receptor blocker [ARB] at discharge or documentation of the reason if therapy was not prescribed). Adult patients admitted to Oregon Health and Science University's cardiology unit with systolic HF exacerbation as their primary diagnosis between December 2010 and March 2011 were included. Throughout patients' hospitalization, the pharmacist collaborated with the multidisciplinary team to make treatment and monitoring recommendations; provided discharge medication reconciliation, discharge medication recommendations, and discharge instructions; answered patient-specific questions; and gave the patient a complete discharge medication list., Results: The study enrolled 35 patients and compared results against a historical control group of 115 patients. The frequency of discharge counseling increased significantly (p = 0.007), as did the rate of ACEI/ARB prescribing at discharge (p = 0.02). Both 30-day all-cause and HF-related readmissions were reduced compared with baseline (p = 0.02 and p = 0.11, respectively)., Conclusion: Pharmacist involvement in medication reconciliation and discharge counseling for HF patients was associated with a significant increase in adherence with the Joint Commission's core measures, a significant reduction in 30-day all-cause readmissions, and a positive effect on patient satisfaction.

Background: More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients., Objectives:   The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma., Methods: The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome., Results: Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159)., Conclusions: Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued., (© 2010 by the Society for Academic Emergency Medicine.)

Ultrasonography used by practicing clinicians has been shown to be of utility in the evaluation of time-sensitive and critical illnesses in a range of environments, including pre-hospital triage, emergency department, and critical care settings. The increasing availability of light-weight, robust, user-friendly, and low-cost portable ultrasound equipment is particularly suited for use in the physically and temporally challenging environment of a multiple casualty incident (MCI). Currently established ultrasound applications used to identify potentially lethal thoracic or abdominal conditions offer a base upon which rapid, focused protocols using hand-carried emergency ultrasonography could be developed. Following a detailed review of the current use of portable ultrasonography in military and civilian MCI settings, we propose a protocol for sonographic evaluation of the chest, abdomen, vena cava, and extremities for acute triage. The protocol is two-tiered, based on the urgency and technical difficulty of the sonographic examination. In addition to utilization of well-established bedside abdominal and thoracic sonography applications, this protocol incorporates extremity assessment for long-bone fractures. Studies of the proposed protocol will need to be conducted to determine its utility in simulated and actual MCI settings.

Objectives: To collect and analyze data from deaths and injuries, and from evaluation of the responses by medical services and by fire, rescue, and police services 1 year after the terror attack on World Trade Center., Methodology: Epidemiologic data were collected from all involved agencies and analyzed. The authors personal experience from working at the scene during the event and several other personal testimonies were also included in this analysis., Results: Totally 2,762 death certificates were issued by the state of New York for victims of the terror attack. 1,361 (49.9%) of these were issued for victims whose remains could not be identified. All but nine of these victims died at the day of the attack. 77% of the victims were male, medium age 39 years. Of the dead were 342 fire fighters and paramedics and 60 police officers. A total of 1,103 patients were treated during the first 48 days in five key hospitals receiving the majority of the injured. 29% of these were rescue workers. 66% of the injured were male, average age 39 years. The most common injuries were respiratory impairment (49%) and ocular affection (26%), many severe. The most common trauma was lacerations (14%) and sprains (14%). Of those administered to hospital, 19% had trauma and 19% burns. Head injuries were registered in 6% and crush injuries in 4%. With regard to response from involved agencies, communication failure was the most common and difficulties in command operations and scene control were also prevalent., Conclusions: The difficulties encountered were very similar to those commonly seen in major accidents or disasters, although on a great scale. Response plans have to be critically reviewed based on the experiences from this and other events, in order to pre-empt difficulties such as those described here in future responses to major urban accidents and disasters.

Objectives: The Food and Drug Administration (FDA) requires researchers to consult with the community prior to conducting research with exception from informed consent, but little is known about whether people support this and, if they do, who researchers should consult. We sought to determine if people could identify communities and leaders of those communities who researchers should consult with to represent their views about research that requires an exception from informed consent., Methods: We conducted a cross-sectional interview study using a convenience sample of patients seeking care in an urban emergency department (ED) to determine if people belonged to specific communities and, if they did, if they could identify communities and leaders appropriate for consultation. Descriptive statistics were used to represent our findings., Results: Most of the 262 participants approached for the study completed the interview (199; 76%). Of those interviewed, 122 (61%) were African American, 54 (27%) were white, 83 (42%) were male, and the mean (+/-standard deviation [SD]) age was 36.2 +/- 14.4 years. Most, (194; 97%), identified that they belonged to a community and most (177; 89%), said that researchers could consult at least one of their communities for consultation about an exception from informed consent study. Participants typically named geographic and religious-affiliated communities and leaders as appropriate for consultation., Conclusion: Most participants identified a community and a leader of that community who researchers could consult about research with exception from informed consent. Geographic and faith-based organizations could play an important role in consultation.

Background: Decisions regarding admissions/discharges in the surgical intensive care unit (SICU) can potentially strain the relationship between the critical care team and the primary surgery service. We hypothesized that a multidisciplinary system of arbitration, led by an intensivist, is a safe and workable solution to SICU patient triage, which leads to consensus between critical care team and primary services., Methods: Demographic, illness severity, readmission, and outcome data were collected prospectively on consecutive patients in a large academic center SICU. Arbitration was directed by an intensivist and a charge nurse, with regular meetings. Representation from various hospital departments (admissions, operating room, nursing, and housekeeping) was included. Decisions on patient discharge from the SICU were compared between the primary service (represented by the Chief resident) and the SICU arbitrator., Results: A total of 289 patients were admitted to SICU during the 2-month study period, with 952 arbitration decisions. Good agreement exists between the primary service and the arbitrator regarding SICU patient suitability for discharge (Kappa = 0.85). Seventeen patients (5.9%) were readmitted, with 14 (82%) surviving to hospital discharge. None of the readmitted patients was originally discharged over the primary service objection. Day of discharge APACHE II scores of readmitted patients did not differ from those not readmitted (8.2 vs 7.7). Readmissions had longer hospital stays, equivalent SICU stays, and higher mortality (18%) than for patients overall (2.8%)., Conclusions: A dedicated intensivist, supported by a multidisciplinary team, can make arbitration decisions in the SICU that seem to be safe and generally concordant with the primary surgical team of the patient. Additional larger-scale investigation of arbitration in the SICU is warranted.

Aim: To study the effect of yohimbine in the treatment of men with orgasmic dysfunction., Methods: A 20-mg dose of yohimbine was first given to 29 men with orgasmic dysfunction of different aetiology in the clinic. Patients were then allowed to increase the dose at home (titration) under more favourable circumstances. The outcome and side effects were subsequently assessed., Results: The patients were classified into three groups of orgasmic dysfunction: primary complete (13), primary incomplete (8) and secondary (8). Nocturnal emissions were present in 75%, 40% and 50% of patients in the above groups, respectively (overall average 62%). The men presented because of fertility problems (52%) or because they wanted to experience the pleasure of orgasm (48%). Of the 29 patients who completed the treatment, 16 managed to reach orgasm and were able to ejaculate either during masturbation or sexual intercourse. A further three achieved orgasm, but only with the additional stimulation of a vibrator. A history of preceding nocturnal emissions was present in 69% of the men in whom orgasm was induced but only 50% who failed treatment. Of the patients, two have subsequently fathered children (one set of twins) and another 3 men were also cured. Side effects were not sufficient to cause the men to cease treatment., Conclusion: Yohimbine is a useful treatment option in orgasmic dysfunction.

Objective: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model., Summary Background Data: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model., Methods: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means., Results: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001)., Conclusions: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.

Background: Time to definitive care is a major determinant of trauma patient outcomes yet little is empirically known about prehospital times at the national level. We sought to determine national averages for prehospital times based on a systematic review of published literature., Methods: We performed a systematic literature search for all articles reporting prehospital times for trauma patients transported by helicopter and ground ambulance over a 30-year period. Forty-nine articles were included in a final meta-analysis. Activation time, response time, on-scene time, and transport time were abstracted from these articles. Prehospital times were also divided into urban, suburban, rural, and air transports. Statistical tests were computed using weighted arithmetic means and standard deviations., Results: The data were drawn from 20 states in all four U.S. Census Regions and represent the prehospital experience of 155,179 patients. Average duration in minutes for urban, suburban, and rural ground ambulances for the total prehospital interval were 30.96, 30.97, and 43.17; for the response interval were 5.25, 5.21, and 7.72; for the on-scene interval were 13.40, 13.39, and 14.59; and for the transport interval were 10.77, 10.86, and 17.28. Average helicopter ambulance times were response 23.25, on-scene 20.43, and transport 29.80 minutes., Conclusions: Despite the emphasis on time in the prehospital and trauma literature there has been no national effort to empirically define average prehospital time intervals for trauma patients. We provide points of reference for prehospital intervals so that policymakers can compare individual emergency medical systems to national norms.

Background: The case-management team (CMT) has been an effective tool to decrease denied days and improve hospital throughput on a trauma service. With the addition of emergency general surgery (EGS) to our practice, we reviewed the ability of the case management team to absorb EGS patients on the inpatient trauma service while maintaining the improvements initially realized., Methods: An interdisciplinary CMT was implemented in January 1999. CRNPs were added in August 2003 to address the Accreditation Council for Graduate Medical Education resident work-hour restrictions. "Key communications" for each CMT member are reported three times per week as defined by a hospital-approved policy. Beginning in August 2001, the trauma service was expanded to include EGS patients. Data from the trauma registry, hospital utilization review, and finance office were analyzed before (1998 and 1999) and after (2003 and 2004) the addition of EGS. Tests of proportion were used to evaluate questions of interest., Results: The number of injured patients admitted to the trauma service remained relatively constant during the study periods, ranging from a high of 1,365 in 1999 to a low of 1,116 in 2003. Beginning in 2003, the influx of emergency surgery patients to the service was marked. By 2004, there were 561 emergency surgery admissions, representing more than 30% of the total service admissions. As a result, the total number of service admissions has dramatically increased, reaching 1,833 in CY 2004, a 56% increase from CY 1998 levels. Hospital length of stay data varied from a low of 5.5 days in CY 1999 to a high of 6.9 days in CY 2003. Length of stay appeared to be associated with injury severity (mean Injury Severity Score 11.8 in 1999 and 13.1 in 2003) and case mix, but not associated with denied days. The percent of denied days decreased over the study periods, from 4.6% in 1998 (before the implementation of the CMT) to 0.5% in 2004 (p<0.01). The percent of readmissions also fell significantly over the study periods (4.0% in 1998 to 1.8% in 2004; p<0.01)., Conclusions: The initial improvements in patient throughput noted after the introduction of a CMT in January 1999 have been maintained in recent years despite the addition of an EGS component to the trauma service. Percent denied days and readmissions have continued to decrease. The length of stay for these patients remains, in part, dependent on other factors. The CMT plays an integral role in maintaining the efficiency of a trauma/emergency surgery service.

Background: Pain relief can often be overlooked during a busy trauma resuscitation, especially in patients who are intubated. We sought to investigate qualitative and quantitative aspects of analgesic use in intubated patients during the acute phase of resuscitation., Methods: We evaluated a retrospective cohort of consecutive adult patients who were intubated during the acute trauma resuscitation (first 6 hours) from January 2001 to May 2002 at a Level I trauma center in the United States. Patient demographics, injuries, vital signs, medications, trauma bay procedures, and disposition status were analyzed. Analgesia was recorded as the type of analgesic, route of administration, elapsed time to receive the first analgesic, total dosage, and time intervals between two successive doses. Fisher's exact test, chi test, and ANOVA were used to analyze data., Results: A total of 120 patients were included. Sixty-one (51%) patients received analgesia during their stay in the emergency department. Using logistic regression analysis, patients who more likely to receive analgesia were those who did not require immediate surgical operation and were transferred to the intensive care unit (odds ratio [OR]=3.91; 95% CI=1.75-8.76) and those who were admitted during the hours of 8 am to 6 pm (OR=3.17; CI=1.40-7.16). Among those patients receiving analgesia, 30 (25%) patients received analgesia within 30 minutes upon arrival. The mean time of receiving the first analgesia dose was 57 minutes. The average morphine equivalent dose given to the patients was 15.7 mg. The most frequently given single dose was 100 mug of intravenous fentanyl. Most of the analgesics (37%) were given between 30 to 60 minutes apart., Conclusion: Our findings suggest that patients who are intubated during the acute resuscitation probably receive inadequate analgesia. The inadequacy appears to be in the timing and repetition of administration, rather than the dose. Patients who were transferred early to the intensive care unit were more likely to receive analgesics.

Objective: To evaluate the outcome of penile prosthesis surgery for different types of prosthesis., Patients and Methods: The notes of 447 men who had 504 penile prosthesis implanted between August 1975 and December 2000 were evaluated. Of the prostheses inserted, 393 were malleable, 81 were three-piece inflatable and 30 were self-contained hydraulic prostheses. The mean (range) age of the men was 52 (21-78) years; 404 men had primary implants and 43 had revision surgery after operations at other institutions. The mean follow-up was 50 (1-297) months., Results: Of the 447 men, 22 were lost to follow-up immediately after surgery. The most serious postoperative complications were infection (8%) and erosion (5%), which was more common in diabetic patients (10%) and after pelvic trauma with a urethral injury (21%). Of 482 prostheses, 21 failed mechanically (4%) and revision surgery was needed for 5% of the prostheses inserted (24/482). Overall, 89% (377/425) of men could have sexual intercourse and 344 (81%) were satisfied with the results., Conclusions: Of the men implanted with a penile prosthesis, 81% were satisfied with the outcome and an even higher proportion were satisfied with the inflatable prostheses. Dissatisfaction was mainly due to complications that resulted in removal of the prosthesis.

Background: Cervical spinal cord injury (SCI) has a well-established association with a high risk of respiratory complications. We sought to determine whether high-thoracic (HT) SCI was associated with a similar increased risk of respiratory complications and death., Methods: This was a retrospective cohort study of all adult patients with thoracolumbar injuries entered into the Pennsylvania Trauma System Foundation registry between January 1993 and December 2002. Records were reviewed for the documentation of respiratory complications (intubation, tracheostomy, bronchoscopy, pneumonia) and mortality. The data were then evaluated controlling for age, sex, Glasgow Coma Scale, and Injury Severity Score., Results: In all, 11,080 patients met inclusion criteria: 4,258 patients had thoracic spine fractures and 6,226 patients had lumbar spine fractures, all without SCI; and 596 patients had thoracic SCI (T1 to T6, 231; T7 to T12, 365). Respiratory complications occurred in 51.1% of patients with T1 to T6 SCI (versus 34.5% in T7 to T12 SCI and 27.5% in thoracic fractures). The need for intubation, the risk of pneumonia, and risk of death were significantly greater for patients with T1- to T6-level spinal cord injuries. Among patients with an Injury Severity Score less than 17 (n = 6427), the relative mortality risk was 26.7 times higher among those who developed respiratory complications (9.9% versus 0.4%)., Conclusion: Compared with patients with low thoracic SCI or thoracolumbar fractures, patients with HT-SCI have an increased risk of pneumonia and death. Respiratory complications significantly increase the mortality risk in less severely injured patients. The current findings suggest that HT-SCI patients warrant intensive monitoring and aggressive pulmonary care and attention, similar to that given for patients with cervical SCI.

Background: Although the traditional role of radiology in trauma care has been diagnostic, therapeutic interventional radiology (IR) techniques have now become essential in the management of many injuries. We hypothesized that IR has evolved at our institution over the last decade from a largely diagnostic to a more therapeutic role in the care of the injured patient., Methods: Demographic information, computed tomographic scans of the chest and abdomen, and angiographic procedures (APs) performed within 48 hours of admission were reviewed in all patients evaluated at a Level I trauma center for the periods 1993 to 1995 and 2000 to 2002. All APs performed with the intent to embolize, stent, or insert a device into a vessel were designated as therapeutic. Analysis by means of chi provided between-group comparisons for questions of interest and the Student's t test was used for comparison of means., Results: A total of 4,750 patients were reviewed, 1,677 from the time period 1993 to 1995 and 3,073 from the period 2000 to 2002. Overall injury severity as measured by the Injury Severity Score (ISS) was similar in both groups (9.6 vs. 9.9, p = not significant). The number of angiograms obtained decreased significantly from 7.1% to 4.0% of all patients (p < 0.01). Concurrently, the fraction of all angiograms that were considered therapeutic rose from 10% to 22% (p < 0.05). The overall number of aortic arch angiograms decreased over time (from 3.6% to 0.9%, p < 0.01), and the percentage of positive examinations increased from 5.0% to 21.4%. In comparison, the number of computed tomographic scans of the chest increased from 1.6% of all patients to 10.8% (p < 0.01)., Conclusion: Axial imaging studies are being used more frequently to screen trauma patients for injury. Concurrently, diagnostic APs are less frequently performed but are more frequently positive. In addition, IR studies are increasingly focused on therapeutic intervention. IR program development and support is an integral aspect of modern trauma care. These findings have prompted our institution to equip the IR suite to function as an active resuscitation area similar to the trauma bay and intensive care unit.

Background: As the malpractice and financial environment has changed, injured patients evaluated by the trauma team and discharged from the emergency department (ED) are now commonplace. The evaluation, care, and disposition of this population has become a significant workload component but is not reported to accrediting organizations and is relatively invisible to hospital administrators. Our objective was to quantify and begin to qualify the evolving picture of the trauma ED discharge population as a work component of trauma service function in an urban, Level I trauma center with an aeromedical program., Methods: Trauma registry (contacts, mechanism, transport, injuries, and disposition) and hospital databases (ED closure, occupancy rates) were queried for a 5-year period (1999-2003). Trend analysis provided statistical comparisons for questions of interest., Results: During the 5-year study period, the total number of trauma contacts rose by 18.1% (2,220 in 1999 vs. 2,622 in 2003; trend p < 0.05). This increase in total contacts was not a manifestation of an increase in admissions (1,672 in 1999 vs. 1,544 in 2003) but rather a reflection of a marked increase in patients seen primarily by the trauma team and discharged from the ED (473 in 1999 vs. 1,000 in 2003; trend p < 0.05). These ED discharge patients were increasingly transported by helicopter (12.3% in 1999 vs. 29.2% in 2003; trend p < 0.05) and less frequently from urban areas (57.1% in 1999 vs. 48.1% in 2003; trend p < 0.05) over the course of the study period. Average injury severity of this group increased over the study period (Injury Severity Score of 2.7 +/- 0.1 in 1999 vs. 3.3 +/- 0.1 in 2003; trend p < 0.05). ED length of stay for this group increased 19.8% over the study period (trend p < 0.05), averaging nearly 5 hours in 2003., Conclusion: The total number, relative percentage, and injury severity of patients evaluated by the trauma team and discharged from the ED has significantly increased over the last 5 years, representing nearly 5,000 patient care hours in 2003. Systems to care for these patients in a cost- and resource-efficient fashion should be put in place. The impact of this growing population of patients on the workload of the trauma center should be recognized by accrediting agencies, hospital administration, and Emergency Medical Services.

Objective: To describe a novel phalloplasty technique and to study the results and complications in female patients with gender dysphoria., Patients and Methods: Between 1989 and 2000, 85 female-to-male transsexual patients had a phalloplasty fashioned from suprapubic abdominal wall flap that was tubed to form the phallus, and which incorporated the neourethra made from a pedicled tube of labial skin. The complete neourethral reconstruction was in one stage in 32 patients and in two in 48; five patients did not wish to have the neourethra fashioned., Results: The cosmetic appearance of the phallus was considered good in 68% of the patients. The major complications (in 60 patients) were related to the neourethra (75%) with stricture formation (64%) and/or fistulae (55%) predominating. This complication rate was significantly less (P < 0.001) when the neourethra was created in two stages. Once the neourethra was completed, patients were then offered both penile and testicular prostheses. Sexual intercourse was possible with no prosthesis in 16 patients., Conclusions: The pubic phalloplasty offers an acceptable neophallus without disfiguring the donor skin site. The main complications stem from creating the neourethra and these may be reduced by a two-stage procedure.

Background: There has been considerable discussion on the national level on the future of trauma surgery as a specialty. One of the leading directions for the field is the integration of emergency general surgery as a wider and more attractive scope of practice. However, there is currently no information on how the addition of an emergency general surgery practice will affect the care of injured patients. We hypothesized that the care of trauma patients would be negatively affected by adding emergency general surgery responsibilities to a trauma service., Methods: Our institution underwent a system change in August 2001, where an emergency general surgery (ES) practice was added to an established trauma service. The ES practice included emergency department and in-house consultations for all urgent surgical problems except thoracic and vascular diseases. There were no trauma staff changes during the study period. Trauma registry data (demographics, injuries, injury severity, and procedures) and performance improvement data (peer-review judgments for all identified errors, denied days, audit filters, and deaths) were abstracted for two 15-month periods surrounding this system change. Chi-square, Fisher's exact, and t tests provided between-group comparisons., Results: The trauma staff evaluated a total of 5,874 patients during the 30-month study. There were 1,400 (51%) trauma admissions in the pre-ES group and 1,504 (48%) in the post-ES group, of which 1,278 and 1,434, respectively, met severity criteria for report to our statewide database (Pennsylvania Trauma Outcome Study [PTOS]). There were 163 (12.7% of PTOS) deaths in the pre-ES group compared with 171 (11.9% PTOS) deaths in the post-ES group (p = not significant [NS]). There was one death determined to be preventable by the peer review process for the pre-ES group, and none in the post-ES group. Both groups had 10 potentially preventable deaths, with the remaining mortalities being categorized as nonpreventable (p = NS). Unexpected deaths by TRISS methodology were 36 (2.8%) and 41 (2.9%) for the two groups, respectively (p = NS). There was no difference in the number of provider-specific complications between the groups (23, [1.8%] vs. 19 [1.3%], p = NS). The addition of emergency surgery has resulted in an additional average daily workload of 1.3 cases and 1.2 admissions., Conclusion: Despite an increase in trauma volume over the study period, the addition of emergency surgery to a trauma service did not affect the care of injured patients. The concept of adding emergency surgery responsibilities to trauma surgeons appears to be a valid way to increase operative experience without compromising care of the injured patient.

The initial care of the patient with blunt polytrauma involves a systematic search for causes of hemodynamic instability. Bleeding most often occurs in the pleural space, peritoneal cavity, and retroperitoneum. Orthopaedic injuries also can contribute to instability after blunt trauma. Blood loss from open fractures may be substantial, and exposure with direct vessel control should be performed early. Pelvic fractures can be associated with severe retroperitoneal bleeding. The treatment of patients with complex pelvic fractures includes closing the pelvic space with a binding device, and early pelvic angiography with embolization. Care of patients with multiple organ and bone injuries requires coordination by one trauma team leader. This physician oversees the resuscitation and sets treatment priorities, including the type and amount of time allowed for fracture stabilization. In many cases, nonorthopaedic injuries will need to be addressed before definitive fracture care. However, optimal care typically involves a coordinated multispeciality approach that sometimes includes concurrent operative procedures. Patients with severe physiologic derangements may require damage control techniques to decrease blood loss and operative time. Understanding the overall care of patients who are injured critically will facilitate the integration of the orthopaedic surgeon into the trauma team.

Mandatory surgical exploration for gunshot wounds to the abdomen has been a surgical dictum for the greater part of this past century. Although nonoperative management of blunt solid organ injuries and low-energy penetrating injuries such as stab wounds is well established, the same is not true for gunshot wounds. The vast majority of patients who sustain a gunshot injury to the abdomen require immediate laparotomy to control bleeding and contain contamination. Nonoperative treatment of patients with a gunshot injury is gaining acceptance in only a highly selected subset of hemodynamically stable adult patients without peritonitis. Although the physical examination remains the cornerstone in the evaluation of patients with gunshot injury, other techniques such as computed tomography, diagnostic peritoneal lavage, and laparoscopy allow accurate determination of intra-abdominal injury. The ability to exclude internal organ injury nonoperatively avoids the potential complications of unnecessary laparotomy. Clinical data to support selective nonoperative management of certain gunshot injuries to the abdomen are accumulating, but the approach has risks and requires careful collaborative management by emergency physicians and surgeons experienced in the care of penetrating injury.

Background: Cerebral hypoxia (cerebral cortical oxygenation [Pbro2] < 20 mm Hg) monitored by direct measurement has been shown in animal and small clinical studies to be associated with poor outcome. We present our preliminary results observing Pbro2 in patients with traumatic brain injury (TBI)., Methods: A prospective observational cohort study was performed. Institutional review board approval was obtained. All patients with TBI who required measurement of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Pbro2 because of a Glasgow Coma Scale score < 8 were enrolled. Data sets (ICP, CPP, Pbro2, positive end-expiratory pressure (PEEP), Pao2, and Paco2) were recorded during routine manipulation. Episodes of cerebral hypoxia were compared with episodes without. Results are displayed as mean +/- SEM; t test, chi2, and Fisher's exact test were used to answer questions of interest., Results: One hundred eighty-one data sets were abstracted from 20 patients. Thirty-five episodes of regional cerebral hypoxia were identified in 14 patients. Compared with episodes of acceptable cerebral oxygenation, episodes of cerebral hypoxia were noted to be associated with a significantly lower mean Pao2 (144 +/- 14 vs. 165 +/- 8; p < 0.01) and higher mean PEEP (8.8 +/- 0.7 vs. 7.1 +/- 0.3; p < 0.01). Mean ICP and CPP measurements were similar between groups. In a univariate analysis, cerebral hypoxic episodes were associated with Pao2 < or = 100 mm Hg (p < 0.01) and PEEP > 5 cm H2O (p < 0.01), but not ICP > 20 mm Hg, CPP < or = 65 mm Hg, or Pac2 < or = 35 mm Hg., Conclusion: Cerebral oxymetry is confirmed safe in the patient with multiple injuries with TBI. Occult cerebral hypoxia is present in the traumatic brain injured patient despite normal traditional measurements of cerebral perfusion. Further research is necessary to determine whether management protocols aimed at the prevention of cerebral cortical hypoxia will affect outcome.

Background: An important objective of organized trauma care is to minimize delayed diagnoses and missed injuries. Discrepant interpretations of radiographs initially read by trauma surgeons represent a unique source of delayed diagnoses. The purpose of this study was to evaluate the efficacy of formalized radiology rounds as a component of the tertiary survey., Methods: Over an 18-month period, 432 consecutive patients admitted to the trauma service at a Level II trauma center were studied prospectively. Radiographs obtained as part of the initial evaluation were initially interpreted by an attending trauma surgeon. All radiographs from the previous 24-hour admissions were reviewed by the trauma team with an attending radiologist at radiology rounds. New diagnoses (NDx) were defined as radiographic findings identified at radiology rounds that were not recorded by the trauma surgeon at the time of initial evaluation. The clinical significance of any NDx was described as follows: level 1, NDx resulted in significant morbidity/mortality; level 2, NDx resulted in alteration in care/no morbidity; level 3, NDx resulted in no alteration in care; level 4, NDx was an incidental finding by the radiologist; level 5, NDx by radiologist not definite., Results: Forty-seven NDx were identified in 42 patients (9.7%). Of the 47 NDx, 19 (40.4%) were level 3 and 28 (59.6%) were level 2. No level 1 NDx were identified. Forty-four changes in clinical management were documented in the level 2 group. Eight new consults were ordered in seven patients (16.7%): orthopedic surgery (n = 6), neurosurgery (n = 1), and physical therapy (n = 1). Seventeen additional diagnostic procedures were required in 16 patients (38.1%): plain radiographs (n = 11) and computed tomographic scans (n = 6). Nineteen therapeutic changes were required in 16 patients (38.1%): splint/immobilization device (n = 7), modified level of activity (n = 6), surgical procedures (n = 4), transfer (n = 1), and home equipment (n = 1)., Conclusion: A small number of radiographic findings are not detected by trauma surgeons during the initial evaluation. Although these findings are not of major clinical significance, the majority required some alteration in care plan. Formalized radiology rounds promotes clinical efficiency through early identification of these injuries, which facilitates any necessary alteration in the care plan.

Objective: To describe outcomes from a clinical trauma surgical education program that places the board-eligible/board-certified fellow in the role of the attending surgeon (fellow-in-exception [FIE]) during the latter half of a 2-year trauma/surgical critical care fellowship., Summary Background Data: National discussions have begun to explore the question of optimal methods for postresidency training in surgery. Few objective studies are available to evaluate current training models., Methods: We analyzed provider-specific data from both our trauma registry and performance improvement (PI) databases. In addition, we performed TRISS analysis when all data were available. Registry and PI data were analyzed as 2 groups (faculty trauma surgeons and FIEs) to determine experience, safety, and trends in errors. We also surveyed graduate fellows using a questionnaire that evaluated perceptions of training and experience on a 6-point Likert scale., Results: During a 4-year period 7,769 trauma patients were evaluated, of which 46.3% met criteria to be submitted to the PA Trauma Outcome Study (PTOS, ie, more severe injury). The faculty group saw 5,885 patients (2,720 PTOS); the FIE group saw 1,884 patients (879 PTOS). The groups were similar in respect to mechanism of injury (74% blunt; 26% penetrating both groups) and injury severity (mean ISS faculty 10.0; FIEs 9.5). When indexed to patient contacts, FIEs did more operations than the faculty group (28.4% versus 25.6%; P < 0.05). Death rates were similar between groups (faculty 10.5%; FIEs 10.0%). Analysis of deaths using PI and TRISS data failed to demonstrate differences between the groups. Analysis of provider-specific errors demonstrated a slightly higher rate for FIEs when compared with faculty when indexed to PTOS cases (4.1% versus 2.1%; P < 0.01). For both groups, errors in management were more common than errors in technique. Twenty-one (91%) of twenty-three surveys were returned. Fellows' feelings of preparedness to manage complex trauma patients improved during the fellowship (mean 3.2 prior to fellowship versus 4.5 after first year versus 5.8 after FIE year; P < 0.05 by ANOVA). Eighty percent rated the FIE educational experience "great -5" or "exceptional- 6." Eighty-five percent consider the current structure of the fellowship (with FIE year) as ideal. Ninety percent would repeat the fellowship., Conclusion: The educational experience and training improvement offered by the inclusion of a FIE period during a trauma fellowship is exceptional. Patient outcomes are unchanged. The potential for an increased error rate is present during this period of clinical autonomy and must be addressed when designing the methods of supervision of care to assure concurrent senior staff review.

Background: Venous thromboembolic disease remains a difficult problem in the trauma patient population. The purpose of this study was to delineate the incidence and natural history of below-knee deep venous thrombosis (BKDVT) in high-risk trauma patients., Methods: Patients were stratified into risk categories (low, high, or very high) for deep venous thrombosis on the basis of an institutional practice management guideline and known risk factors. All at-risk patients received either sequential compression devices (SCDs) or subcutaneous heparin (SQH) compounds, and high-risk patients also underwent weekly surveillance by duplex scanning. Very-high-risk patients had prophylactic inferior vena cava (IVC) filter placement. This prospective, observational study examines the duplex results on all high-risk patients. Data regarding method of prophylaxis, the incidence of proximal propagation on serial duplex examinations, and changes in management (anticoagulation or IVC filter placement) were collected on the high-risk patients who developed a BKDVT., Results: Between March 1997 and June 2001, 601 patients were stratified into the high-risk category and underwent a total of 1,109 duplex examinations. Eighty-five patients (14.1%) had 113 BKDVTs. These patients underwent a total of 212 duplex examinations; all patients developed their BKDVTs within 34 days. Weekly incidence was 40 (47.1%), 25 (29.4%), 15 (17.6%), 1 (1.2%), and 4 (4.7%) for weeks 1 through 5, respectively. SCDs, SQH compounds, and SCDs with SQH compounds were used on 73, 3, and 9 patients, respectively. In 4 of 85 (4.7%) patients, the BKDVT propagated proximally to an above-knee location in 4 to 8 days. Two of these patients were anticoagulated, and two underwent placement of an IVC filter. One patient (1.2%) with a BKDVT that had not propagated on duplex study developed a pulmonary embolus., Conclusion: Patients identified as high-risk by our practice management guideline had a 14.1% incidence of a BKDVT; 94.1% were diagnosed within the first 3 weeks of hospitalization. Proximal propagation occurred in 4.7% and led to changes in management. Serial duplex examination of the BKDVT alone, rather than systemic anticoagulation or IVC filter placement, appears to be a reasonable treatment alternative.

Background: An anteroposterior pelvic radiograph (PXR) continues to be recommended by Advanced Trauma Life Support protocol as an early diagnostic adjunct in the resuscitation of blunt trauma patients. At the same time, computed tomographic (CT) scanning has become a practice standard for diagnosis of most abdominal and pelvic injury. The objective of this study was to determine the necessity of obtaining an early PXR in stable trauma patients who will undergo CT scanning during the initial resuscitation., Methods: A retrospective review of all blunt trauma patients undergoing immediate abdomen and pelvic CT scanning was performed from July 2000 until June 2001 at an urban Level I trauma center. These patients were divided into two groups depending on whether they also received a PXR (group I) or not (group II). At the time of the study, there was no formal protocol to determine which patients underwent pelvic radiography. Radiology reports of all PXRs and CT scans were reviewed. Patient demographics and Injury Severity Scores (ISSs) were abstracted from our trauma registry. The data were analyzed using Student's test., Results: A total of 686 patients with blunt trauma underwent CT scanning of the abdomen and pelvis. Group I consisted of 311 (45%) patients with an average ISS of 12.3 +/- 0.7. In group I, 56 (10%) patients were found to have at least one pelvic fracture on CT scan, 38 of which were also identified on the PXR. Defining CT scanning as the definitive test, the sensitivity and specificity of the PXR in group I was 68% and 98%, respectively. The false-negative rate for pelvic radiography was 32%. In all patients with a positive PXR, the majority (55%) had either additional fractures or an increase in the Young and Burgess grade of fracture diagnosed on CT scan. Group II consisted of 375 patients, with 16 fractures noted in 13 (3%) patients, none of which required treatment. The mean ISS of group II was 8.0 +/- 0.5., Conclusion: The PXR has limited sensitivity for detecting pelvic fractures compared with CT scanning. Selected hemodynamically stable patients who undergo CT scanning during their immediate resuscitation do not need a routine PXR. The PXR may continue to be beneficial in unstable patients, those with positive physical findings, or those who cannot undergo CT scanning because of other clinical priorities.

Two cases of brachial plexus injury after prone position in the intensive care unit are described. Mechanisms of brachial plexus injury are described, as are methods for prevention of this unusual complication.

Patients with Peyronie's disease usually present soon after the onset of the disease with penile pain and deformity when they develop an erection. They are middle-aged men and a palpable plaque is usually present. A good clinical history and examination are all that are necessary to manage most patients with Peyronie's disease. Further investigation is only required in those men with erectile dysfunction or where surgery is indicated.

Introduction: Prone positioning in respiratory failure has been shown to be a useful adjunct in the treatment of severe hypoxia. However, the prone position can result in dislodgment or malfunction of tubes and cannulae. Certain patients receiving extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) may also benefit from positional therapy. The impact of cannula-related complications in these patients is potentially disastrous. The safety and efficacy of prone positioning of these patients has not been previously reported., Materials and Methods: A retrospective chart review evaluated ECMO or CRRT cannula location, and displacement or malfunction during positional change or while prone. The study was set in a General Surgery and Trauma Intensive Care Unit. The subjects were all patients at our institution who simultaneously underwent ECMO or CRRT and prone positioning from July 1996 to July 2001. There were no interventions., Results: Ten patients underwent ECMO and 42 patients underwent CRRT during the study period. Seven patients underwent simultaneous prone positioning and either ECMO (4/10) or CRRT (4/42). A total of 68 turning events (prone to supine or supine to prone) were recorded, with each patient averaging 9.7 (range, 4-16) turning episodes. Turning was performed with sheets and extra nursing personnel; no special mechanical assist devices were used. No patients experienced inadvertent cannula removal during turning. Two patients had poor flow through their cannulae. In one patient, this occurred in the supine position and required repositioning of the cannula. In the second patient, cannulae were changed twice and flow was poor in both the supine and the prone positions. All ECMO and CRRT patients received venous cannulae. Cannula location (seven internal jugular and 11 femoral) did not the affect risk of malfunction., Discussion and Conclusions: Patients with venous cannulae for ECMO or CRRT can be safely placed in the prone position. Flow rates are maintained in this position. Potential cannula complications of ECMO and CRRT are not a contraindication to prone positioning in severely ill patients.

Objective: To assess the Lue procedure (plaque incision and venous grafting) for correcting the penile deformity of Peyronie's disease (which can cause penile shortening and erectile dysfunction) as an alternative to the Nesbit procedure (which can worsen the shortening)., Patients and Methods: Fifty-one patients (mean age 51 years, range 27-68) with Peyronie's disease had their penile deformity corrected by plaque incision and saphenous vein grafting. All patients had stable Peyronie's disease and a mean (range) penile deformity of 57 (20-90). The vein graft was taken from the long saphenous vein at the ankle or groin and several sites grafted in 14 patients. The mean follow-up was 16 months., Results: An excellent or satisfactory result was obtained in 47 patients (92%); the penis was completely straightened in 42 (82%). Four patients (8%) developed postoperative erectile dysfunction. Eighteen men (35%) had some degree of penile shortening (> 1 cm in eight), among whom intercourse was affected to a variable extent in six (12%)., Conclusion: The Lue procedure is an effective option in the surgical management of Peyronie's disease, but penile shortening after surgery remains a risk.

Objectives: Sildenafil citrate (Viagra) is a potent selective inhibitor of phosphodiesterase type 5 proposed for the oral treatment of erectile dysfunction (ED). The aim of this study was to evaluate its efficacy and safety when used in daily practice in patients with ED of various aetiology., Patients and Methods: From September 1998 to April 1999, 380 patients chose sildenafil as treatment for their ED. One hundred and forty-five (38%) of them suffered from psychogenic ED, 125 (33%) organic and 110 (29%) of mixed aetiology. The grade of erection achieved and the occurrence of satisfactory sexual intercourse assessed the efficacy. Safety and tolerance were evaluated recording any side effect or adverse event., Results: The overall efficacy of Viagra was 77%, with a response of 100% among the group of hormonal patients, 88% for psychogenic, 72% for mixed, 69% for diabetes, 65% for vascular and 60% for neurological symptoms. A few and mild to moderate side effects were recorded., Conclusion: These results indicate that the use of sildenafil citrate is an effective and well-tolerated therapy for men with ED of various aetiology with an overall success rate of 77%.