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ImportanceVarious surgical approaches for hidradenitis suppurativa (HS) have been described in the literature, but the nomenclature is inconsistent. Excisions have been described as wide, local, radical, and regional with variable descriptions of margins. Deroofing procedures have been described with various approaches though descriptions of the approach are generally more uniform. No international consensus has been formed to globally standardize terminology for HS surgical procedures. Lack of such agreement may contribute to misunderstanding or misclassification in HS procedural research studies and impair clear communication among clinicians or between clinicians and patients.ObjectiveTo create a set of standard definitions for HS surgical procedures.Design, Setting, and ParticipantsThis consensus agreement study was conducted from January to May 2021 using the modified Delphi consensus method to reach agreement among a group of international HS experts regarding standardized definitions for an initial set of HS surgical terms, including “incision and drainage,” “deroofing/unroofing,” “excision,” “lesional excision,” and “regional excision,” ultimately expanded to 10 terms. Provisional definitions were drafted based on existing literature and discussion among an expert 8-member steering committee. Online surveys were disseminated to members of the HS Foundation, direct contacts of the expert panel, and the HSPlace listserv to reach physicians with considerable experience with HS surgery. Consensus was defined as greater than 70% agreement to accept a definition.ResultsIn the first and second modified Delphi round, 50 and 33 experts participated, respectively. Ten surgical procedural terms and definitions reached consensus with greater than 80% agreement. Overall, the term “local” excision was abandoned and replaced with the descriptors “lesional” or “regional” excision. Of note, “regional” replaced the terms “wide” and “radical” excision. Furthermore, modifiers such as “partial” vs “complete” should also be included when describing surgical procedures. A combination of these terms helped formulate the final glossary of HS surgical procedural definitions.Conclusion and RelevanceAn international group of HS experts agreed on a set of definitions describing surgical procedures frequently used by clinicians and in the literature. The standardization and application of such definitions are vital to allow for accurate communication, reporting consistency, and uniform data collection and study design in the future.

Objective Identify the frequency and types of mistreatment experienced by residents from patients and their families (P&F) and determine whether the types and frequency varied based on resident gender. Design An anonymous survey was distributed to residents to assess the types of P&F mistreatment toward residents and the association with resident gender. Setting The survey was distributed to the general surgery and urology programs at a large academic medical center in the mid-Atlantic. Participants: 23 of 53 residents (43% response rate) participated in the anonymous survey. Residents: 15 male residents (65%), 8 female residents (35%). Results: 12 of 23 responding residents (52%) indicated they experienced at least one form of mistreatment from P&F. Women were more likely to experience mistreatment (88% vs. 33%), with verbal assault was the most frequent (50% for female residents, 33% for male residents). Patients were more often the source than families (52% vs. 41%); verbal assault or threats of physical harm were the most common (50% for female residents, 33% for male residents). Conclusions Residents experience mistreatment from multiple sources. This paper provides insight into the experiences of surgical residents with mistreatment from their P&F, with differences in frequency of behaviors dependent upon the perpetrator group and resident gender. Patients and their family mistreatments are likely underreported and may be more difficult to prevent. It is important to identify mitigation strategies and ensure resources are available for those residents experiencing mistreatment. A strong culture against mistreatment and providing specific resources may minimize the experience and negative effects of mistreatment.

Creating a Core Entrustable Professional Activities (Core EPA) curriculum requires a longitudinal approach. Current curricular efforts have focused primarily on the pre-clerkship and clerkship phases of training; however, the role of the Acting Internship (AI) has not been explored. The AI experience offers opportunities for students to have enhanced clinical responsibility, demonstrate proficiency, and allows for assessment of Core EPAs that are beyond the focus of clerkships. We share our experience developing an interdepartmental AI experience designed to assess designated Core EPAs and highlight tensions that should be considered when incorporating an AI experience into a longitudinal Core EPA-oriented curriculum.

INTRODUCTION: The Core Entrustable Professional Activities for Entering Residency (Core EPAs) are clinical activities all interns should be able to perform on the first day of residency with indirect supervision. The acting (sub) internship (AI) rotation provides medical students the opportunity to be assessed on advanced Core EPAs. MATERIALS AND METHODS: All fourth-year AI students were taught Core EPA skills and performed these clinical skills under direct supervision. Formative feedback and direct observation data were provided via required workplace-based assessments (WBAs). Supervising physicians rated learner performance using the Ottawa Clinic Assessment Tool (OCAT). WBA and pre-post student self-assessment data were analyzed to assess student performance and gauge curriculum efficacy. RESULTS: In the 2017–2018 academic year, 167 students completed two AI rotations at our institution. By their last WBA, 91.2% of students achieved a target OCAT supervisory scale rating for both patient handoffs and calling consults. Paired sample t tests of the student pre-post surveys showed statistically significant improvement in self-efficacy on key clinical functions of the EPAs. DISCUSSION: This study demonstrates that the AI rotation can be structured to include a Core EPA curriculum that can assess student performance utilizing WBAs of directly observed clinical skills. CONCLUSIONS: Our clinical outcomes data demonstrates that the majority of fourth-year medical students are capable of performing advanced Core EPAs at a level acceptable for intern year by the conclusion of their AI rotations. WBA data collected can also aid in ad hoc and longitudinal summative Core EPA entrustment decisions. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01208-y.

Reflective writing is used by medical educators to identify challenges and promote inter-professional skills. These non-medical skills are central to leadership and career development, and are clinically relevant and vital to a trainees success as a practicing physician. However, identification of actionable feedback from reflective writings can be chal- lenging. In this work, we utilize a Natural Language Processing pipeline that incorporates a seeded Term Frequency- Inverse Document Frequency matrix along with sentence-level summarization, sentiment analysis, and clustering to organize sentences into groups, which can aid educators in assessing common challenges experienced by Acting In- terns. Automated analysis of reflective writing is difficult due to its subjective nature; however, our method is able to identify known and new challenges such as issues accessing the electronic health system and adjusting to specialty differences. Medical educators can utilize these topics to identify areas needing attention in the medical curriculum and help students through this transitional time.

BACKGROUND: Medication management, a complex yet essential part of patient care, requires that clinicians and patients understand indication, dosage, frequency, and adverse effects in order to maximize benefits and minimize errors, as well as to transition patients from hospital to home. Clinical pharmacists improve care transitions and safety by interacting with patients, prescribers, and nurses on medication management and self-care. However, little is known on the use of clinical pharmacists on interdisciplinary teams at the unit level within orthopedics. QUESTIONS/PURPOSES: This study sought to measure the impact of unit-based clinical pharmacists on patient perceptions of communication specific to medication during hospitalization at an orthopedic specialty hospital and on the frequency of medication errors. METHODS: A retrospective, quasi-experimental, two-group evaluative design with nonequivalent controls was used. Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data on six inpatient units was analyzed 6 months before and 6 months after assignment of clinical pharmacists to half these units. Data specific to questions that measure quality of communication as well as medication understanding were analyzed. Additionally, data on medication error frequency were collected and compared between units with and without clinical pharmacists. RESULTS: A total of 2022 surveys were analyzed. The percentage of patients who reported receipt of medication information and medication understanding increased significantly after the implementation of unit-based clinical pharmacists. Comparison of intervention and non-intervention groups showed no statistically significant difference in the frequency of medication errors. CONCLUSION: Results suggest that a clinical pharmacist assigned to an inpatient unit in orthopedics significantly influences patient perceptions of communication about and understanding of their medications. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11420-019-09739-2) contains supplementary material, which is available to authorized users.

The Magnet Model for Nursing Excellence® provides a conceptual framework to guide orthopedic nursing practice. Patient assessment is the cornerstone of patient care delivery and nursing practice communication is a key factor for effective care coordination. Nurses coach and support patients and families through multiple care transitions. Knowledge and self-care competency is achieved through patient and family education.

BackgroundAccurate medication reconciliation in trauma patients is essential but difficult. Currently there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS) based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.MethodsPlasma samples were collected from 356 patients who provided informed consent including-10 healthy controls, 19 known positive or negative controls and 327 trauma patients over 65 years of age who were evaluated at our large, urban Level 1 Trauma Center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage was compared with LCMS results to determine overall accuracy, sensitivity, specificity and positive and negative predictive values (PPV, NPV) of the assay.ResultsOf 356 patients, 39 were on DOACs (10.96%): 21 were on Apixaban, 14 on rivaroxaban and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.06%, (PPV 92.50% and NPV 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.11% (PPV 86.36% and NPV 99.40%). There were three false positive results and two false negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.ConclusionsThis LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.Study type: diagnostic testBasic Science paper: therefore does not require a level of evidence.

Mistreatment has been correlated with burnout and poor well-being in medical students, but data regarding residents and faculty are limited. The objective was to investigate the prevalence of mistreatment towards surgical housestaff and faculty and characterize such experiences.In 2018, the Department of Surgery surveyed housestaff and faculty on incidents of mistreatment.Clinical faculty (63%) and residents (72%) completed the mistreatment survey. Excluding public embarrassment, 48% of residents and 29% of clinical faculty experienced mistreatment. Residents experienced public embarrassment and public humiliation more frequently than faculty, however faculty were subjected to racially or ethnically offensive remarks/names more frequently than residents (p .05). Faculty within and external to their department were most cited as instigators of mistreatment. Residents experienced mistreatment most often by faculty, co-residents, and nurses. Reporting of the behaviors was low.Incidents of mistreatment are frequently occurring for surgical residents and faculty.

The management of penetrating colon injuries in civilians has evolved over the last four decades. The objectives of this meta-analysis are to evaluate the current treatment regimens available for penetrating colon injuries and assess the role of anastomosis in damage control surgery to develop a practice management guideline for surgeons.Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines section of EAST conducted a systematic review using MEDLINE and EMBASE articles from 1980 through 2017. We developed three relevant problem, intervention, comparison, and outcome (PICO) questions regarding penetrating colon injuries. Outcomes of interest included mortality and infectious abdominal complications.Thirty-seven studies were identified for analysis, of which 16 met criteria for quantitative meta-analysis and included 705 patients considered low-risk in six prospective randomized studies. Seven hundred thirty-eight patients in 10 studies undergoing damage control laparotomy and repair or resection and anastomosis (RA) were included in a separate meta-analysis. Meta-analysis of high-risk patients undergoing repair or RA was not feasible due to inadequate data.In adult civilian patients sustaining penetrating colon injury without signs of shock, significant hemorrhage, severe contamination, or delay to surgical intervention we recommend that colon repair or RA be performed rather than routine colostomy. In adult high-risk civilian trauma patients sustaining penetrating colon injury, we conditionally recommend that colon repair or RA be performed rather than routine colostomy. In adult civilian trauma patients sustaining penetrating colon injury who had damage control laparotomy, we conditionally recommend that routine colostomy not be performed; instead, definitive repair or delayed RA or anastomosis at initial operation should be performed rather than routine colostomy.Systematic review/meta-analysis, level III.

Background Over 50,000 homicides and suicides occur each year. An estimated half of all US households are believed to have a firearm present, making them one of the most ubiquitous consumer products. Our goal was to determine if the manner of storage of a firearm in a home could potentially make a difference in the outcomes of intentional and unintentional injuries involving a firearm; specifically addressing the use of gun safes and devices that block/disable firearm function (trigger locks, cable locks, etc.). Methods A comprehensive review of the literature was performed. We used Grading of Recommendations Assessment, Development, and Evaluation methodology to assess the breadth and quality of the data specific to our Population, Intervention, Comparator, Outcomes (PICO) questions. Results A total of 176 studies were initially identified, then, 120 more added after a subsequent literature review, with 97 removed as duplicates. One hundred ninety-one case reports, case series, and reviews were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of two studies which merited inclusion for PICO 1, should gun locks be used to prevent firearm injuries and six studies which merited inclusion for PICO 2, should safe storage for guns be used to prevent firearm injuries. Conclusion PICO 1: We conditionally recommend that gun locks be used to prevent unintentional firearm injury. PICO 2: Because of the large effect size and the reasonable quality of available evidence with safe storage of firearms, we recommend safe storage prevent firearm-related injuries. Level of evidence Systematic review, level III.

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

The purpose of this study was to identify practice patterns associated with the use of antimicrobial agents with damage control laparotomy (DCL) and the relationship with post-operative intra-abdominal infection (IAI) rates.The study was a retrospective review of trauma patients undergoing laparotomy at a Level 1 trauma center in 2010. Patients undergoing DCL versus those primarily closed (PCL) were compared for antimicrobial use (ABX) and its correlation with IAI rates (p 0.05). Deaths with length of stay5 days were excluded.A total of 121 patients were identified (28 DCL, 93 PCL). The DCL group was more severely injured (Injury Severity Score [ISS]: 31.4 ± 15 DCL vs. 18 ± 12.7 PCL, p 0.001) with more small and large bowel injuries (SLBI), although not statistically significant (53.6% DCL vs. 35.5% PCL, p = 0.12). Practice patterns of ABX administration in terms of pre-operative (94.6% PCL vs. 69.2% DCL, p = 0.0012) and post-operative administration (PCL: 50.5% none, 21.5% one day, 28% long term1 d; DCL: 21.4% none, 25.0% one day, 53.6% long term1 day, p = 0.0130) were significant. Regression analyses demonstrated that neither ISS nor DCL was an independent predictor of infection, but pre-operative ABX was a negative predictor (odds ratio [OR] 0.20, 95% confidence interval [CI] 0.05-0.91, p = 0.037), while post-operative ABX (OR 6.7, 95%CI 1.33-33.8, p = 0.044) and SLBI (OR 3.45, CI 1.03-11.5, p = 0.02) were positive predictors of infection with an receiver operating characteristic of 0.81.Significant variations exist in the use of ABX in DCL and PCL. These variations may lead to deleterious results from both lack of initial pre-operative coverage and prolonged ABX use. The decrease in infection rates with pre-operative ABX yet significant increase with continued post-operative use even in the presence of SLBI suggests the need for a more standardized approach. With the increase in DCL and the open abdomen, more research is needed to clearly establish ABX protocols in this patient population.

OBJECTIVES Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool to guide therapy during the initial phase of resuscitation in trauma patients.All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion (present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups.A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03).LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation.Therapeutic study, level II.

BACKGROUND: In the past decade, more than 300,000 people in the United States have died from firearm injuries. Our goal was to assess the effectiveness of two particular prevention strategies, restrictive licensing of firearms and concealed carry laws, on firearm-related injuries in the U.S. Restrictive licensing was defined to include denials of ownership for various offenses, such as performing background checks for domestic violence and felony convictions. Concealed carry laws allow licensed individuals to carry concealed weapons. METHODS: A comprehensive review of the literature was performed. We used GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology to assess the breadth and quality of the data specific to our PICO (Population, Intervention, Comparator, Outcomes) questions. RESULTS: A total of 4673 studies were initially identified, then seven more added after two subsequent, additional literature reviews. Of these, 3623 remained after removing duplicates; 225 case reports, case series, and reviews were excluded, and 3379 studies were removed because they did not focus on prevention or did not address our comparators of interest. This left a total of 14 studies which merited inclusion for PICO 1 and 13 studies which merited inclusion for PICO 2. CONCLUSION: PICO 1: We recommend the use of restrictive licensing to reduce firearm-related injuries.PICO 2: We recommend against the use of concealed carry laws to reduce firearm-related injuries.This committee found an association between more restrictive licensing and lower firearm injury rates. All 14 studies were population-based, longitudinal, used modeling to control for covariates, and 11 of the 14 were multi-state. Twelve of the studies reported reductions in firearm injuries, from 7-40%. We found no consistent effect of concealed carry laws. Of note, the varied quality of the available data demonstrates a significant information gap, and this committee recommends that we as a society foster a nurturing and encouraging environment that can strengthen future evidence based guidelines. LEVEL OF EVIDENCE: Systematic review, level III. Language: en

Background Health care-associated infections (HAI) result in 100,000 deaths/year. Alcohol use disorders (AUD) increase the risk of community-acquired infections and HAI. Small studies have shown that AUD increase the risk of HAI and surgical site infections (SSI). We sought to determine the risk of HAI and SSI in surgical patients undergoing elective inpatient joint replacement, coronary artery bypass grafting, laparoscopic cholecystectomy, colectomy, and hernia repair. Study Design The Nationwide Inpatient Sample was analyzed (years 2007 and 2008). HAI were defined as health care-associated pneumonia, sepsis, SSI, and urinary tract infection. Primary outcomes were risk of HAI and SSI in patients with AUD. Secondary outcomes were mortality and hospital length of stay in patients with HAI and SSI, alpha=10 −6 . Results There were 1,275,034 inpatient admissions analyzed; 38,335 (3.0%) cases of HAI were documented, and 5,756 (0.5%) cases of SSI were identified. AUD was diagnosed in 11,640 (0.9%) of cases. Multivariable analysis demonstrated that AUD was an independent predictor of developing HAI: odds ratio (OR) 1.70, p −6 , and this risk was independent of type of surgery. By multivariable analysis, the risk of SSI in patients with AUD was also higher: OR 2.73, p −6 . Hospital mortality in patients with HAI or SSI was not affected by AUD. However, hospital length of stay was longer in patients with HAI who had AUD (multivariable analysis 2.4 days longer, p −6 ). Among patients with SSI, those with AUD did not have longer hospital length of stay. Conclusions Patients with AUD who undergo a variety of elective operations have an increased risk of infectious postoperative morbidity.

This article was migrated. The article was not marked as recommended. The General Surgery residency application process has grown competitive, requiring medical students to apply to a greater number of programs. While there has been much discussion of how programs can select the best applicants, there are few resources to help applicants. Person-organization fit is an important determinant of job satisfaction, which itself is an important determinant of physician performance. Using a validated method from the field Organizational Psychology, we developed a formal tool to assist residency applicants in assessing person-organization fit in prospective programs.

Many patients have difficulty with pain control after transition from patient-controlled analgesia modalities to oral analgesics. The creation of a Recuperative Pain Medicine (RPM) service was intended to bridge this gap in pain management at the Hospital for Special Surgery. Specific goals were to improve patient and staff satisfaction with management of postoperative oral analgesics by improving clinical care, administrative policies, and patient and staff education. Primary outcome measures for improved satisfaction were Press Ganey surveys and staff surveys. From inception in Aug 2007 to Dec 2008, RPM has seen 6,305 patients for discharge planning and education and 997 patients for pain management consultation. Administrative and educational accomplishments have included creation of a patient "Helpline" for emergent phone questions regarding postdischarge home pain medications, a policy for prescribing pain medications for home discharge, patient education booklets, a pain management webpage on the Hospital for Special Surgery website, and direct education of staff. Press Ganey measurements of patient satisfaction increased from 87th percentile up to the 99th percentile among peer institutions since the implementation of RPM. Staff satisfaction was 92% positive regarding the RPM service's function and patient management. An RPM appears to be an effective means to optimize postoperative pain management after transition off patient-controlled analgesia devices. Further research is needed to ascertain the exact cost-benefit and potential impact on postoperative quality-of-life measurements.

Early (8 hours) operative debridement and irrigation (DI) of open fractures are considered essential to reduce the risk of deep infection. With the advent of powerful antimicrobials, this axiom has been challenged. The current study evaluates the rates of deep infections of open fractures in relation to the time to the first DI.A list of all blunt open fractures during a 6-year period was obtained from the trauma registry. Patients were evaluated for age, Injury Severity Score (ISS), physiologic derangement (systolic blood pressure, lactate, Revised Trauma Score [RTS]), and fracture type (Gustilo). Time to the first DI was calculated. All patients received appropriate prophylactic antimicrobials. Infection rates were calculated and correlated to the time to the first DI (8 hours vs.8 hours). Regression analysis was performed to identify independent predictors of infection.During the 72-month study period, 404 patients met entry criteria, with 415 open extremity fractures (upper, 129; lower, 287). Early (8 hours) and delayed (8 hours) groups were well matched, although the age was lower and ISS was higher in the group with greater than 8 hours. The rates of infection were 35 (11%) of 328 (8 hour) and 17 (19%) of 87 (8 hours) (p0.05). When fractures were subgrouped by extremity, for the lower extremity, both a delay of greater than 8 hours and higher Gustilo type correlated with the development of infection. In the upper extremity, only higher Gustilo type correlated, and a delay to the first DI did not increase the incidence of infection. Regression analysis revealed that higher ISS (odd ratio [OR], 1.052; 95% confidence interval [CI], 1.019-1.086), Gustilo grade, and a delay of greater than 8 hours (OR, 2.035; 95% CI, 1.022-4.054) were independent predictors of infection for the all-extremity model. Separate models for upper and lower extremities showed that the same three parameters were independent predictors for the lower extremity (ISS: OR, 1.045; 95% CI, 1.004-1.087; Gustilo type and8-hour delay: OR, 3.006; 95% CI, 1.280-7.059), but none for the upper extremity.Delay of greater than 8 hours to the first DI for open fractures of the lower extremity increases the likelihood of infection but not for the upper extremity. Higher Gustilo type open fractures have a higher incidence of infection for both upper and lower extremities. The results have important implications in an era of decreasing surgeon availability, especially in off hours.Therapeutic study, level IV.

Background: Venous Thrombo-embolism (VTE – Deep venous thrombosis (DVT) and/or pulmonary embolism (PE) – in traumatized patients causes significant morbidity and mortality. The current study evaluates the effectiveness of DVT surveillance in reducing PE, and performs a cost-effectiveness analysis. Methods: All traumatized patients admitted to the adult ICU underwent twice weekly DVT surveillance by bilateral lower extremity venous Duplex examination (48-month surveillance period – SP). The rates of DVT and PE were recorded and compared to the rates observed in the 36-month pre-surveillance period (PSP). All patients in both periods received mechanical and pharmacologic prophylaxis unless contraindicated. Total costs – diagnostic, therapeutic and surveillance – for both periods were recorded and the incremental cost for each Quality Adjusted Life Year (QALY) gained was calculated. Results: 4234 patients were eligible (PSP – 1422 and SP – 2812). Rate of DVT in SP (2.8%) was significantly higher than in PSP (1.3%) – p,0.05, and rate of PE in SP (0.7%) was significantly lower than that in PSP (1.5%) – p,0.05. Logistic regression demonstrated that surveillance was an independent predictor of increased DVT detection (OR: 2.53 – CI: 1.462–4.378) and decreased PE incidence (OR: 0.487 – CI: 0.262–0.904). The incremental cost was $509,091/life saved in the base case, translating to $29,102/QALY gained. A sensitivity analysis over four of the parameters used in the model indicated that the incremental cost ranged from $18,661 to $48,821/QALY gained. Conclusions: Surveillance of traumatized ICU patients increases DVT detection and reduces PE incidence. Costs in terms of QALY gained compares favorably with other interventions accepted by society.

Let me make this clear. I do not look for "mission impossible" cases, but they always find me! A nurse case manager on a busy pediatric floor, I was trying to think through a challenging case one day when a new nurse working with me said in frustration, "Stephanie, how do you keep from giving up on cases like this?"My mind flashed back to three situations that stand out as mission impossible. I have seen so many struggles and disappointments in the quest to solve the impossible. However, I have painfully learned a fundamental truth in the past 20 years. In my practice, some of the most hopeless cases stand out as pivotal in drawing from that truth, which gives me strength.

Age-related diminution in function is felt the earliest in the respiratory system. Additionally, injury to and the reserve of the system has a disproportionately high impact on outcomes after trauma, especially in the elderly. Principals of management of the respiratory system, whether injured or not, relate to preventing alveolar collapse and maximizing gas exchange. Detecting deterioration and/or infection early with aggressive therapy forms the other pillars of management. If mechanical ventilation is required, utilizing lung protective strategies will optimize outcomes.

IL-1β contributes to connective tissue destruction in part by up-regulating stromelysin-1 (MMP-3), which in fibroblasts is a focal adhesion-dependent process. Protein tyrosine phosphatase-α (PTPα) is enriched in and regulates the formation of focal adhesions, but the role of PTPα in connective tissue destruction is not defined. We first examined destruction of periodontal connective tissues in adult PTPα(+/+) and PTPα(-/-) mice subjected to ligature-induced periodontitis, which increases the levels of multiple cytokines, including IL-1β. Three weeks after ligation, maxillae were processed for morphometry, micro-computed tomography and histomorphometry. Compared with unligated controls, there was ∼1.5-3 times greater bone loss as well as 3-fold reduction of the thickness of the gingival lamina propria and 20-fold reduction of the amount of collagen fibers in WT than PTPα(-/-) mice. Immunohistochemical staining of periodontal tissue showed elevated expression of MMP-3 at ligated sites. Second, to examine mechanisms by which PTPα may regulate matrix degradation, human MMP arrays were used to screen conditioned media from human gingival fibroblasts treated with vehicle, IL-1β or TNFα. Although MMP-3 was upregulated by both cytokines, only IL-1β stimulated ERK activation in human gingival fibroblasts plated on fibronectin. TIRF microscopy and immunoblotting analyses of cells depleted of PTPα activity with the use of various mutated constructs or with siRNA or PTPα(KO) and matched wild type fibroblasts were plated on fibronectin to enable focal adhesion formation and stimulated with IL-1β. These data showed that the catalytic and adaptor functions of PTPα were required for IL-1β-induced focal adhesion formation, ERK activation and MMP-3 release. We conclude that inflammation-induced connective tissue degradation involving fibroblasts requires functionally active PTPα and in part is mediated by IL-1β signaling through focal adhesions.

Modulation of Rho GTPases Rac1 and Rac2 impacts bone development, remodeling, and disease. In addition, GTPases are considered treatment targets for dysplastic and erosive bone diseases including Neurofibromatosis type 1. While it is important to understand the effects of Rac modulation on osteoclast function, two-dimensional resorption pit area measurements fall short in elucidating the volume aspect of bone resorption activity. Bone marrow from wild-type, Rac1 and Rac2 null mice was isolated from femora. Osteoclastogenesis was induced by adding M-CSF and RANKL in culture plates containing dentin slices and later stained with Picro Sirius Red to image resorption lacunae. Osteoclasts were also plated on glass cover slips and stained with phalloidin and DAPI to measure their surface area and the number of nuclei. Volumetric images were collected on a laser-scanning confocal system. Sirius Red confocal imaging provided an unambiguous, continuous definition of the pit boundary compared to reflected and transmitted light imaging. Rac1- and Rac2-deficient osteoclasts had fewer nuclei in comparison to wild-type counterparts. Rac1-deficient osteoclasts showed reduced resorption pit volume and surface area. Lacunae made by single Rac2 null osteoclasts had reduced volume but surprisingly surface area was unaffected. Surface area measures are deceiving since volume changed independently in resorption pits made by individual Rac2 null osteoclasts. Our innovative confocal imaging technique allows us to derive novel conclusions about Rac1 and Rac2 in osteoclast function. The data and method can be applied to study effects of genes and drugs including Rho GTPase modulators on osteoclast function and to develop pharmacotherapeutics to treat bone lytic disorders.

1. Der Einflu\ der Temperatur auf die Koagulation des kolloiden Goldes entspricht dem Verlangen der Theorie von Smoluchowski. 2. Die Empfindlichkeit gegen TemperaturAnderungen ist bei der Koagulation des kolloiden Goldes (Koagulationsgeschwindigkeit) bedeutend viel kleiner als bei chemischen Reaktionen (Reaktionsgeschwindigkeit).