When all computers shut down: the clinical impact of a major cyber-attack on a general hospital

Importance

Healthcare organizations operate in a data-rich environment and depend on digital computerized systems; thus, they may be exposed to cyber threats. Indeed, one of the most vulnerable sectors to hacks and malware is healthcare. However, the impact of cyberattacks on healthcare organizations remains under-investigated.

Objective

This study aims to describe a major attack on an entire medical center that resulted in a complete shutdown of all computer systems and to identify the critical actions required to resume regular operations.

Setting

This study was conducted on a public, general, and acute care referral university teaching hospital.

Methods

We report the different recovery measures on various hospital clinical activities and their impact on clinical work.

Results

The system malfunction of hospital computers did not reduce the number of heart catheterizations, births, or outpatient clinic visits. However, a sharp drop in surgical activities, emergency room visits, and total hospital occupancy was observed immediately and during the first postattack week. A gradual increase in all clinical activities was detected starting in the second week after the attack, with a significant increase of 30% associated with the restoration of the electronic medical records (EMR) and laboratory module and a 50% increase associated with the return of the imaging module archiving. One limitation of the present study is that, due to its retrospective design, there were no data regarding the number of elective internal care hospitalizations that were considered crucial.

Conclusions and relevance

The risk of ransomware cyberattacks is growing. Healthcare systems at all levels of the hospital should be aware of this threat and implement protocols should this catastrophic event occur. Careful evaluation of steady computer system recovery weekly enables vital hospital function, even under a major cyberattack. The restoration of EMR, laboratory systems, and imaging archiving modules was found to be the most significant factor that allowed the return to normal clinical hospital work.

International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy.

METHODS

This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database.

RESULTS

One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta.

CONCLUSIONS

Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.

Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA

BACKGROUND

Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients.

METHODS

We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours.

RESULTS

A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001).

DISCUSSION

In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Consensus on resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian (pre-hospital) trauma care: a Delphi study

BACKGROUND

REBOA could prevent lethal exsanguination and support cardiopulmonary resuscitation. In pre-hospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. Aim of this study was to establish consensus on the use and implementation of REBOA in civilian pre-hospital settings for non-compressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings.

METHODS

A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA-experts with different medical specialties, backgrounds and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject.

RESULTS

Panel members reached consensus on potential (contra-)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and pre-hospital REBOA.

CONCLUSION

The international expert panel agreed that REBOA can be used in civilian pre-hospital settings for temporary control of non-compressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For pre-hospital REBOA and early femoral artery access, consensus was reached on (contra-) indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of pre-hospital REBOA for non-compressible truncal hemorrhage.

LEVEL OF EVIDENCE

Delphi study (original research, care management), level 5.

When the lights go down in the delivery room: Lessons from a ransomware attack

OBJECTIVE

To describe the challenges facing the obstetric division following a cyberattack and discuss ways of preparing for and overcoming another one.

METHODS

A retrospective descriptive study conducted in a mid-sized medical center. Division activities, including the number of deliveries, cesarean sections, emergency room visits, admissions, maternal-fetal medicine department occupancy, and ambulatory encounters, from 2 weeks before the attack to 8 weeks following it (a total of 11 weeks), were compared with the retrospective period in 2019 (pre-COVID-19). In addition, we present the challenges and adaptation measures taken at the division and hospital levels leading up to the resumption of full division activity.

RESULTS

On the day of the cyberattack, critical decisions were made. The media announced the event, calling on patients not to come to our hospital. Also, all elective activities other than cesarean deliveries were stopped. The number of deliveries, admissions, and both emergency room and ambulatory clinic visits decreased by 5%-10% overall for 11 weeks, reflecting the decrease in division activity. Nevertheless, in all stations, there were sufficient activities and adaptation measures to ensure patient safety, decision-making, and workflow of patients were accounted for.

CONCLUSIONS

The risk of ransomware cyberattacks is growing. Healthcare systems at all levels should recognize this threat and have protocols for dealing with them once they occur.

Comparison of Sense of Humor and Burnout in Surgeons and Internal Medicine Physicians

OBJECTIVES

We aimed to evaluate humor styles in surgeons and internists and investigate the association between humor and burnout.

METHODS

A cross-sectional survey of physicians in surgical and medicine departments was conducted, assessing sense of humor and burnout using the Humor Styles Questionnaire and the Emotional Exhaustion subscale of the Maslach Burnout Inventory-Human Services Survey for Medical Personnel.

RESULTS

For 131 surgeons and 72 internists, no differences in humor styles were found. A sense of personal accomplishment was more common among surgeons (P = 0.03) and rates of burnout were lower for surgeons (P = 0.02). Physicians with a higher-than-average score in affiliative and self-enhancing humor were less likely to suffer from burnout (P < 0.0001 and P = 0.03, respectively).

CONCLUSIONS

Surgeons and internists have similar styles of humor. Surgeons suffer less from burnout. Affiliative and self-enhancing humor styles are associated with reduced burnout.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

QRS duration as an independent risk factor for appropriate shocks and mortality in patients with prophylactic implantable cardioverter-defibrillator

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community’s 7th Framework Programme FP7/2007-2013

Background

The implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death (SCD) in high-risk heart failure patients. However, improvements in risk stratification are necessary to increase the efficiency of ICD use. We performed an analysis of the retrospective EU-CERT-ICD registry with respect to QRS duration and effects of cardiac resynchronisation therapy (CRT) on outcomes.

Methods/Results

A total of 5033 patients (81% males) from 14 European centres had an ICD implanted for primary prophylaxis. Mean age at the time of ICD implantation was 64±11 years and ischemic cardiomyopathy was the underlying pathology in 65% of patients. CRT was used in 43% of the patients. The median follow-up was 2.7 years (IQR 1.4-4.6 years). Predefined primary endpoints were all-cause mortality, first appropriate and first inappropriate shocks. The effect of covariates on the cumulative primary endpoints were assessed through hazard ratios in the Fine and Gray subdistributional hazard models (accounting for the competing risks) stratified by centres.

Because of resynchronization by the device, the analysis considered a different influence of QRS on outcomes in the CRT-D and the ICD groups. We observed an increase in the cumulative incidence of the first appropriate shock with increasing QRS values for patients implanted with only an ICD (HR 1.12 per 10ms increase, p&lt;0.001). In patients with CRT-D, increasing QRS values related to a (statistically non-significant) decrease in the cumulative incidence of the first appropriate shocks (HR 0.96 per 10ms, p=0.299).

Since a wide QRS is an indication for CRT-D therapy, high QRS values cluster among those patients with implanted CRT-D, while among patients with QRS under 130ms standard ICD implantations are more frequent. This can explain the observed increase in the cumulative incidence of the first appropriate shocks for increasing QRS values up to 130ms in the ICD-group and its decrease for increasing QRS values over 130ms in the CRT-D group.

Regarding all-cause mortality, hazard ratios for age, LVEF, NYHA, ICM, AF, diabetes and sex category agreed with the results obtained in previously published meta-analyses.

Increased QRS values are associated with higher mortality in the ICD group (HR 1.09 per 10ms increase, p&lt;0.001), but not in the CRT-D group (HR 0.99 per 10ms increase, p=0.695).

Conclusion

In our study, we confirmed QRS duration as an independent risk factor for appropriate ICD shocks and all-cause mortality in patients with ICD for primary prophylaxis. However, this was only observed in patients with single- or dual-chamber ICD, while there was no correlation in CRT-D patients. The findings suggest that CRT-D exerts a protective effect regarding the occurrence of first appropriate shock and all-cause mortality for patients with QRS values higher than 130 ms and indication for resynchronization.

Synchronous Malignancies Identified by PET-CT Scan in Breast Cancer Patients

Breast cancer is a common malignancy and a common cause of cancer-related mortality in women. Pre-treatment workup of breast cancer does not routinely include positron emission tomography scans. We aimed to review cases of women with breast cancer and a synchronous second primary malignancy. We present three cases of women with non-metastatic cancer in whom a synchronous second primary malignancy was found. Synchronous, second primary malignancies which were identified included rectal cancer, gastrointestinal stromal tumor, and non-small cell lung cancer. All second primary malignancies were identified by a PET-CT scan. In conclusion, PET-CT may be used for detection of secondary primary malignancies in select breast cancer patients.

Is Diffuse Axonal Injury Different in Adults and Children? An Analysis of National Trauma Database

BACKGROUND

Diffuse axonal injury (DAI) is typically associated with significant mechanisms of injury and the effects of acceleration-deceleration forces on brain tissues. The prognosis of DAI remains a matter of active investigation, but little is known about outcome differences between adult and pediatric populations with DAI.

METHODS

We performed a retrospective cohort study involving blunt trauma patients with DAI between the years 1997 and 2018 from the Israeli National Trauma Registry. The patients were divided to pediatric (age <15 years) and adult (age >15 years) groups, with subsequent comparison of demographics and outcomes.

RESULTS

Diffuse axonal injury was identified in 1983 patients, including 469 pediatric victims (23.6%) and 1514 adults (76.4%). Adults had higher Injury Severity Score (20.5% vs 13.2%, P = 0.0004), increased mortality (17.7% vs 13.4%, P < 0.0001), longer hospitalizations (58.4% vs 44.4%, P < 0.001), and higher rehabilitation need rates (56.4% vs 41.8%, P < 0.0001). Associated extracranial injuries were also more common in adults, particularly to the chest.

CONCLUSIONS

Pediatric patients with DAI have improved outcomes and fewer associated injuries than adult counterparts.

Hemoperitoneum Due to Penetrating Intercostal Artery Injury: A Case Report of a Rare and Still Understudied Entity

Intercostal artery injury may be life-threatening and usually presents as hemothorax. We report a unique case of penetrating injury, causing hemoperitoneum due to intercostal artery injury, without thoracic involvement. During urgent laparotomy, no intra-abdominal organ injury was found. Hemostasis was successfully achieved via suturing through an additional lateral 10cm incision through the left thorax.

REBOA for Inter-Hospital Transfer: Are We Walking in the Dark?

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Biliary Tract Instrumentations Prior to Elective Cholecystectomy: Effect on Biliary Microbiome

Background: Calculus biliary disease is a common condition that requires invasive procedures in complicated cases. The effect of biliary instrumentation on the biliary microbiome and its impact on surgical complications after elective cholecystectomy remains unclear. This study aimed to assess the impact of prior biliary instrumentation on the biliary microbiome, as well as on the clinical outcomes of cholecystectomy. Patients and Methods: This retrospective study included all patients who underwent elective cholecystectomy for calculus biliary disease between 2015 and 2020 in a single medical center. Data regarding biliary instrumentation prior to cholecystectomy, biliary cultures obtained during cholecystectomy, and clinical outcomes were collected. A comparison between patients with and without prior instrumentation was performed with regard to biliary cultures and clinical outcomes. Results: Of the 508 patients studied, 109 patients underwent biliary instrumentation prior to cholecystectomy. Patients with prior instrumentation were older and more likely to be men (p < 0.0001). Prior instrumentation was also associated with higher rates of conversion to open surgery (p < 0.0001). Positive biliary cultures and polymicrobial growth were both more common among patients with prior instrumentation (p < 0.0001). Prior instrumentation was associated with longer length of hospital stay, as well as higher rates of perioperative complications and surgical site infection (p < 0.0001). Conclusions: Prior instrumentation was associated with poorer clinical outcomes and affected the biliary microbiome. The different results of biliary cultures in these patients may suggest that an alternative empiric antibiotic regimen should be considered when treating patients with biliary instrumentation.

Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of  the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1). Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3). The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control. The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4).     The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided.  Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury.    

REBOA or Preperitoneal Packing in Patients with Pelvic Fractures: Why Not Both?

Editorial

Hybrid Trauma Management: Is It the Way We Are Heading?

Background: Hybrid trauma management, namely, the combination of open and endovascular techniques and/or the application of endovascular methods in the OR/ER is a quickly growing concept worldwide. However, its implications are not well established. We aimed to review the current data regarding hybrid trauma management in medical literature. Methods: A review of the medical literature published between 2000 and 2020 using PubMed and OVID Medline databases was performed in search for clinical studies regarding hybrid trauma treatments. Case reports were excluded from this review. The manuscripts were analyzed regarding the mechanism, location and type of injury, endovascular and surgical techniques utilized and outcomes. Results: Fourteen studies reporting hybrid trauma management of a total of 1049 patients met the inclusion criteria and were analyzed. Blunt trauma was the leading trauma mechanism (87.13%) and the most common procedure was transcatheter arterial embolization (TAE), performed in 29.74% of patients. The overall mortality was 15.16%. Regarding case control studies, 85.71% have shown hybrid trauma management to be associated with a shorter time from arrival to intervention, 42.86% reported lower rates of unfavorable outcome 28.57% reported reduced requirement for red blood cell transfusion as compared with conventional management. Conclusions: This review did not find strong evidence supporting hybrid trauma management as a standard care. However, accumulating data suggests that hybrid management may be associated with a shorter time from arrival to intervention, lower rates of unfavorable outcome and reduced requirement for red blood cell transfusion as compared with conventional management of trauma patients.

Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of  the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1). Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3). The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control. The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4).     The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided.  Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury.    

ECMO in trauma patients requiring total pulmonectomy: Could this be a new approach in the era of hybrid management?

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Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry

BACKGROUND

Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival.

METHODS

Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected.

RESULTS

Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room.

CONCLUSION

Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.

Multiple rib fractures: does flail chest matter?

BACKGROUND

Recent studies have reported significant morbidity and mortality in patients with multiple rib fractures, even without flail chest. The aim of this study was to compare the clinical outcome and incidence of associated chest injuries between patients with and without flail chest, with three or more rib fractures.

METHODS

This study included patients with blunt trauma with at least three rib fractures, hospitalised during 2010-2019 in the Hillel Yaffe Medical Center in central Israel (level II trauma centre). Patients with and without radiologically defined flail chest were compared with regard to demographics, Injury Severity Score (ISS), GCS, systolic blood pressure (SBP) on admission, radiological evidence of flail chest, associated chest injuries, length of stay in intensive care unit, length of hospitalisation and mortality.

RESULTS

The study included 407 patients, of which 79 (19.4%) had flail chest. Overall, pneumothorax and haemothorax were more common among patients with flail chest (p<0.05). When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest.

CONCLUSION

In patients with three to five rib fractures, pneumothorax is more common among patients with flail chest. Clinical significance of flail chest in patients with more than six rib fractures is questionable and flail chest may not be a reliable marker for severity of chest injury in patients with more than six fractures.

Spinal cord injury in the setting of traumatic thoracolumbar fracture is not reliably associated with increased risk of associated intra-abdominal injury following blunt trauma: An analysis of a National Trauma Registry database

PURPOSE

There is a common opinion that spinal fractures usually reflect the substantial impact of injuries and therefore may be used as a marker of significant associated injuries, specifically for intra-abdominal injury (IAI). The impact of concomitant spinal cord injury (SCI) with the risk of associated IAI has not been well clarified. The aim of this study was to evaluate the incidence and severity of IAIs in patients suffering from spinal fractures with or without SCI.

METHODS

A retrospective cohort study using the Israeli National Trauma Registry was conducted. Patients with thoracic, lumbar and thoracolumbar fractures resulting from blunt mechanisms of injury from January 1, 1997 to December 31, 2018 were examined, comparing the incidence, severity and mortality of IAIs in patients with or without SCI. The collected variables included age, gender, mechanism of injury, incidence and severity of the concomitant IAIs and pelvic fractures, abbreviated injury scale, injury severity score, and mortality. Statistical analysis was performed using GraphPad InStat ® Version 3.10, with Chi-square test for independence and two sided Fisher's exact probability test.

RESULTS

Review of the Israeli National Trauma Database revealed a total of 16,878 patients with spinal fractures. Combined thoracic and lumbar fractures were observed in 1272 patients (7.5%), isolated thoracic fractures in 4967 patients (29.4%) and isolated lumbar fractures in 10,639 patients (63.0%). The incidence of concomitant SCI was found in 4.95% (63/1272), 7.65% (380/4967) and 2.50% (266/10639) of these patients, respectively. The overall mortality was 2.5%, proving higher among isolated thoracic fracture patient than among isolated lumbar fracture counterparts (11.3% vs. 4.6%, p < 0.001). Isolated thoracic fractures with SCI were significantly more likely to die than non-SCI counterparts (8.2% vs. 3.1%, p < 0.001). There were no differences in the incidence of IAIs between patients with or without SCI following thoracolumbar fractures overall or in isolated thoracic fractures; although isolated lumbar fractures patients with SCI were more likely to have renal (3.4% vs. 1.6%, p = 0.02) or bowel injuries (2.3% vs. 1.0%, p = 0.04) than the non-SCI counterparts.

CONCLUSION

SCI in the setting of thoracolumbar fracture does not appear to be a marker for associated IAI. However, in a subset of isolated lumbar fractures, SCI patient is associated with increased risks for renal and bowel injury.

The Cyclicity of coronavirus cases: "Waves" and the "weekend effect"

INTRODUCTION

Medical statistics is one of the "milestones" of current medical systems. It is the foundation for many protocols, including medical care systems, government recommendations, epidemic planning, etc. At this time of global COVID-19, credible data on epidemic spread can help governments make better decisions. This study's aim is to evaluate the cyclicity in the number of daily diagnosed coronavirus patients, thus allowing governments to plan how to allocate their resources more effectively.

METHODS

To assess this cycle, we consider the time series of the first and second differences in the number of registered patients in different countries. The spectral densities of the time series are calculated, and the frequencies and amplitudes of the maximum spectral peaks are estimated.

RESULTS

It is shown that two types of cycles can be distinguished in the time series of the case numbers. Cyclical fluctuations of the first type are characterized by periods from 100 to 300 days. Cyclical fluctuations of the second type are characterized by a period of about seven days. For different countries, the phases of the seven-day fluctuations coincide. It is assumed that cyclical fluctuations of the second type are associated with the weekly cycle of population activity.

CONCLUSIONS

These characteristics of cyclical fluctuations in cases can be used to predict the incidence rate.

A new modelling of the COVID 19 pandemic

А model of coronavirus incidence is proposed. Process of disease development is represented as analogue of first- and second order phase transition in physical systems. The model is very simple in terms of the data necessary for the calculations. To verify the proposed model, only data on the current incidence rate are required. However, the determination coefficient of model R2 is very high and exceeds 0.95 for most countries. The model permits the accurate prediction of the pandemics dynamics at intervals of up to 10 days. The ADL(autoregressive distributed lag)-model was introduced in addition to the phase transition model to describe the development of the disease at the exponential phase.The ADL-model allows describing nonmonotonic changes in relative infection over the time, and providing to governments and health care decision makers the possibility to predict the outcomes of their decisions on public health.

Hypotension on admission in patients with isolated traumatic brain injury: contemporary examination of the incidence and outcomes using a national registry

PURPOSE

This study was primarily aimed at establishing the incidence and impact of hypotension in patients with blunt traumatic brain injury based on National Trauma Registry Database.

METHODS

A retrospective cohort study using the National Trauma Registry was conducted. Patients with TBI following blunt mechanisms of injury were examined, comparing those with and without hypotension (SBP < 90 mm Hg) on arrival.

RESULTS

During the period from 1998 to 2017, the registry included 437.354 blunt trauma patients. Of them, 7818 patients were hemodynamically unstable (SBP < 90 mm Hg) on admission. 513 met the inclusion criteria. Significant percentages of patients with high grade injures (ISS≥16) and low admission's GCS 3-12 (46% vs 16.4%), were found in the group of hypotensive TBI patients (p<0.0001). 323 (62.9%) patients had head AIS score 3-4 and only 190 (37.1%) patients AIS 5-6 (p<0.0001). Mortality in the hypotensive TBI group was 32.3%, whereas 6.1% patients died in the TBI hemodynamically stable group (p<0.0001).

CONCLUSION

TBI patients presenting with hypotension represent an appreciable portion blunt trauma patients. Prompt brain CT, expedient efforts at optimal resuscitation and possibly early inotropic and vasopressors agents use may have an impact on final outcome in these patients.

Is computed tomography cystography indicated in children with pelvic fractures?

PURPOSE

Pelvic fracture evaluation with abdominopelvic computed tomography (CT) and formal CT cystography for rule out of urine bladder injury have been commonly employed in pediatric trauma patients. The additional delayed imaging required to obtain optimal CT cystography is, however, associated with increased doses of ionizing radiation to pelvic organs and represent a significant risk in the pediatric population for future carcinogenic risk. We hypothesized that avoidance of routine CT cystography among pediatric pelvic fracture victims would not result in an appreciable rate of missed bladder injuries and would aid in mitigating the radiation exposure risk associated with these additional images.

METHODS

A retrospective cohort study involving blunt trauma pelvic fractures among pediatric trauma patients (age<14) between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry. Statistical analysis was performed using SAS statistical software version 9.4 via the tests of Chi-square test and two-sided Fisher's exact test. A p value of less than 0.05 was considered statistically significant.

RESULTS

A total of 1072 children were identified from the registry for inclusion. Mean age of patients was 7.7 years (range 0-14) and 713 (66.5%) were male. Overall mortality in this population was 4.1% (44/1072). Only 2.1% (23) of pediatric patients with pelvic fractures had bladder injury identified, with just 9 children having intraperitoneal bladder rupture (0.8% of all the patients).

CONCLUSION

The vast majority of blunt pediatric trauma victims with pelvic fractures do not have urine bladder injuries. Based on our study results we do not recommend the routine utilization of CT cystography in this unique population.

Tolerability of non-ergot oral and transdermal dopamine agonists in younger and older Parkinson's disease patients: an European multicentre survey

In older patients with Parkinson’s disease (PD), the use of dopamine agonists (DA) has been limited due to uncertainties related to their tolerability in spite of potential gains with the advent of longer acting or transdermal therapies. Comparative real-life data addressing the tolerability of DA therapy across age ranges are currently sparse. This study addressed the tolerability (Shulman criteria, continued intake of DA therapy for at least 6 months) in PD patients across several European centres treated with long-acting and transdermal DA (Rotigotine skin patch, Ropinirole extended release, or Pramipexole prolonged release) as part of routine clinical care in younger and older PD patients. A medical record-based retrospective data capture and clinical interview-based follow-up survey of patients initiating or initiated on DA treatment (short and long acting) in a real-life setting. 425 cases were included [mean age 68.3 years (range 37–90), mean duration of disease 7.5 years (range 0–37), 31.5% older age (≥ 75 years of age)]. Tolerability was above 90% irrespective of age, with no significant differences between younger and older patients. Based on our findings, we suggest that long-acting/transdermal DA are tolerated in non-demented older patients, as well as in younger patients, however, with lower daily dose in older patients.

Commentary: Trauma Management During and After COVID-19

Editorial Commentary to: Trauma management during and after COVID-19.

A Novel Technique for the Damage Control of Huge Diaphragmatic Injuries

A novel technique for the damage control of big diaphragmatic injuriesPurpose: To evaluate and describe a novel technique for the temporary closure ofmajor diaphragmatic defects not suitable for primary suture in damage control setting.Background: It is an acceptable opinion that all left sided diaphragmatic injuriesshould be repaired, as opposed to right sided where the liver may safely protect thedefect. In most cases the repair of the diaphragm is simple, using non-absorbablesutures. Closure of defects not suitable for primary suture, remains a reallychallenging problem. Up today, there is no adequate solution for prevention of re-protrusion of abdominal contents in a damage control setting.Methods: We report a novel technique suitable for treating diaphragmatic injuries indamage control setting. This method allows a rapid temporary closure of, non-suitablefor primary closure, large diaphragmatic defects and part of the damage controlconcept.Results: Two anesthetized pigs were used in an animal trial to evaluate the feasibilityof the technique. Same size defects were created in both subjects. In the first subject,the defect was closed with a plastic (Bogota) bag. In the second subject, thediaphragmatic defect was covered using a large abdominal pad. In both cases, nochest protrusion was observed after completion of the experiment.Conclusion: We describe a simple new technique for temporary diaphragmatic closurethat might be done as part of damage control. Further investigation will help toinclude it to routine surgical arsenal.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Consensus on resuscitative endovascular balloon occlusion of the Aorta: A first consensus paper using a Delphi method

BACKGROUND

To further strengthen the evidence base on the use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBOA) we performed a Delphi consensus. The aim of this paper is to establish consensus on the indications and contraindications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.

STUDY DESIGN

A literature review facilitated the design of a three-round Delphi questionnaire. Delphi panelists were identified by the investigators. Consensus was reached when at least 70% of the panelists responded to the survey and more than 70% of respondents reached agreement or disagreement.

RESULTS

Panel members reached consensus on potential indications, contra-indications and settings for use of REBOA (excluding the pre hospital environment), physiological parameters for patient selection and indications for early femoral access. Panel members failed to reach consensus on the use of REBOA in patients in extremis (no pulse, no blood pressure) and the use of REBOA in patients with two major bleeding sites.

CONCLUSIONS

Consensus was reached on indications, contra indications, physiological parameters for patient selection for REBOA and early femoral access. The panel did not reach consensus on the use of REBOA in patients in pre-hospital settings, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings, patients in near cardiac arrest and REBOA inflation times.

Selective Management of Multiple Anterior Abdominal Stab Wounds: Is it Safe?

BACKGROUND

Selective management of stable patients with anterior abdomen stab wounds (AASWs) has become a gold standard management approach throughout the world. Evidenced-based options for supporting selective management include clinical follow-up, local wound exploration with or without diagnostic peritoneal lavage, diagnostic laparoscopy, and abdominal computerized tomography. The presence of multiple AASWs might signify a more aggressive attack and limit the safety of a selective management approach.

OBJECTIVES

To evaluate whether multiple AASWs are associated with an increased risk of intra-abdominal injury requiring emergency surgery.

METHODS

We retrospectively reviewed all AASW patients admitted to Assaf Harofeh Medical Center, Zerifin, Israel, and Hillel Yaffe Medical Center in Hadera, Israel, from 2007 to 2015. Patients were divided into two groups based on the number of stab wounds: single or multiple. Data were coded for demographics, severity of injury, presence of intra-abdominal injury, laparotomy rate, length of hospital stay (LOS), length of stay in the intensive care unit (LICU), and survival.

RESULTS

The study included 169 patients. Of these, 143 patients had a single AASW and 26 had multiple AASWs. There were no differences between the groups regarding demographics, severity of injury, intra-abdominal penetration, specific organ injury, LOS, or LICU. There was no difference in the percentage of patients requiring laparotomy. The overall mortality was 2.36% (4/169). There was no significant difference in the mortality rate between the groups (P = 0.11).

CONCLUSIONS

The presence of multiple AASWs is not a risk factor for increased frequency and severity of intra-abdominal injury.

Abdominal stab wound injury in children: Do we need a different approach?

BACKGROUND

Penetrating stab wounds in children are relatively rare and no clear recommendations for the optimal evaluation have been devised. An acceptable traditional approach to the patient with an abdominal stab wound who does not require urgent surgery is selective nonoperative management and serial exams. The use of routine computed tomography remains an actively utilized investigation for these patients at many institutions.

PURPOSE

We hypothesize that the approach to pediatric stab wound victims should be distinctly different than that of adult counterparts in order to minimize radiation exposure.

METHODS

A retrospective cohort study involving abdominal stab wounds among pediatric trauma patients (age < 14) compared with adults between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry.

RESULTS

A total of 92 children and 4444 adults were identified from the registry for inclusion. Among the children 20 (21.7%) patients had intraabdominal injury compared to 1730 (38.9%) among adult counterparts. Four children were hemodynamically unstable, two of them were referred directly to operating room and two others were treated without surgery. Among the remaining 88 children there was no observed mortality.

CONCLUSIONS

The majority of pediatric stab wounds trauma victims have minor abdominal injuries. We do not recommend the routine utilization of abdominal CT scan in the evaluation of abdominal stab wounds. Observation with serial exams and minimization of radiation exposure from CT are warranted in this unique population.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

3.

The Differences in Stabbing-Related Injury Profiles of Men and Women

BACKGROUND

Although women comprise only a minority of patients hospitalized due to violence-related injury, the circumstances of attacks against women may make their injuries more severe.

METHODS

We conducted a retrospective study using data of 9173 patients with stabbing-related injuries from 19 trauma centers participating in the Israeli National Trauma Registry between 1 January 1997 and 31 December 2014. Male and female patients were compared in terms of demographic and circumstantial factors, clinical characteristics, and outcomes.

RESULTS

Women were found to have greater injury severity according to the Injury Severity Scale (ISS) - 18% vs. 11% of severe (ISS 16+) injuries - requiring more hospital resources. Injuries that contributed most to injury severity in the female population were head and severe abdominal trauma. Women also sustained injuries to more body sites than men; however, regression analysis showed that the contribution of this factor to the overall difference in injury severity was less important than the injured sites. Regression analysis among severely injured patients pointed at injury to lower extremities as an independent factor related to female mortality. Different from men, among women the stabbing injuries to the upper extremities were not a protective factor in terms of mortality.

CONCLUSIONS

There are significant differences in the injury profiles of male and female stabbing victims, which can be explained by the different circumstances of the injury event.

[HIGH VOLTAGE ELECTRIC INJURY: MECHANISM OF INJURY, CLINICAL FEATURES AND INITIAL EVALUATION.]

Electrical injury is an infrequent but potentially devastating form of multisystem injury associated with high morbidity and mortality. Despite significant improvement in injury prevention and implementation of safety protocols at work places, electrical injury accounts for more than 500 deaths per year in the United States with a mortality rate of 10-30%. Electrical injuries are traditionally divided into low-voltage electric power injuries (less than 1,000V) and high-voltage )more than 1,000V). In contrast with other types of trauma, high voltage injuries present some rather unique problems that require a high index of suspicion and awareness of all possible manifestations. Electrical injury should be viewed and managed as a multisystem injury, since there is virtually no organ that is protected against it. The most essential concept of successful management of patients who sustain high voltage injury is that there is no relationship between skin burn, vital organs involvement and severity of injuries. This review aims to provide a comprehensive overview of reported high voltage electrical injury manifestations in an attempt to gain a better understanding of the distribution of morbidity and clinical features of the injury. We tried to encompass most of the reported cases of high voltage electrical injuries in order to give the readers a general view of the spectrum of injuries that can be encountered in victims suffering high voltage current, aiming to increase the awareness of emergency care and trauma teams to this rare but dangerous and potentially fatal type of injury.

[CONTRIBUTION OF CONVENTIONAL CHEST/ABDOMINAL PLAIN FILMS FOR THE DECISION-MAKING PROCESS IN PATIENTS WITH PREVIOUS ABDOMINAL SURGERIES, WHO HAVE SUSPECTED GASTROINTESTINAL PERFORATION]

INTRODUCTION

Gastrointestinal perforation is a well-known phenomenon among patients presented to emergency rooms. Common causes for perforation are gastric and duodenal ulcers, colon tumors and trauma. Some patients are operated on immediately due to the clear clinical picture of acute abdomen. The most accurate imaging is the abdominal CT scan. Conventional X-rays remain the first choice in the case of GI tract perforations. Our clinical observation is that in many cases X-ray studies are not sufficient for the decision-making process in patients with previous abdominal surgeries.

AIMS

The purpose of this study was to evaluate the impact of X-rays on the decision-making process in patients with previous abdominal surgery.

METHODS

A retrospective evaluation was conducted of chest/abdominal X-rays, computed tomography findings and the surgeries reports of patients admitted due to GI perforation.

RESULTS

The study population of 69 patients was divided into two groups. In group 1: patients without previous abdominal surgery, X-rays of 27 patients (69.2%) were found positive for free air. In group 2: patients with previous abdominal surgeries, 16 patients demonstrated free air on chest/abdominal X-rays. The sensitivity in group 2 (53.3%) was found significantly lower compared to group 1 (69.2 %). The difference between the groups was not statistically significant; 19 of 30 (63.3%) patients with previous abdominal operations needed abdominal CT scan before final surgical decision in comparison to 38.5% of the patients without previous abdominal operations.

CONCLUSIONS

Based on these results we recommend not routinely performing X-rays in patients with previous abdominal surgery. Urgent computed tomography should be the first imaging modality.

DISCUSSION

In patients with previous abdominal surgeries, free air is visible only in half the patients in routine X-ray imaging. A significant number of those patients needed abdominal CT scan. Our study demonstrated that chest and abdominal plain radiography films are insufficient for the decision-making process in patients with previous abdominal operations. A multi-center prospective study is required in order to validate our findings.

Severe venous injury in acute trauma setup – Is there a role for endovascular treatment?

Background The role of endovascular treatment of acute traumatic venous injuries (ATVI) remains controversial. Endovascular Resuscitation and Hybrid Trauma Management (EVTM) concepts, which constitute the combination of conventional and endovascular capabilities in the treatment of vascular injuries continue to evolve, yet published reports of traumatic venous injuries treated by endovascular means remains confined to sporadic case reports. Methods A review of the medical literature from 1990 to 2017 using Pubmed and OVID Medline databases was done in order to search for reports of endovascular treatments of ATVI . No publication was excluded due to the small number of the available publications. Sixteen reports were found. The manuscripts were analyzed regarding the mechanism, location and type of injury, endovascular techniques utilized and both clinical and radiographic outcomes. Results Endovascular treatment was reported in only 16 patients with ATVI during the study period. Most cases (10/16; 62.5%) were secondary to blunt trauma, while the rest (6/16; 37.5%) were secondary to penetrating injuries equally divided between gunshot wounds (GSW) and stab wounds. Endovascular stent or stent graft utilization was employed in 12 of these cases, 2 cases were treated by endovascular embolization and in 2 cases endovascular balloons were used for temporary hemorrhage control to facilitate open surgical exposure and intervention . No mortalities related to described the endovascular interventions were reported. Conclusion The experience with endovascular treatment of ATVI remains very limited. Currently available results, although very limited in numbers, appear promising. Additional study will prove essential in defining the optimal employment of EVTM concepts in the management of venous injures, particularly as technology continues to advance and experience with these modalities increases.

The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry

PURPOSE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes.

METHODS

REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported.

RESULTS

Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion.

CONCLUSIONS

This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

Frequency of intra-abdominal organ injury is higher in patients with concomitant stab wounds to other anatomical areas

Background

Management of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas.

Methods

We performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury.

Results

The study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1–1.6, p < 0.001). These patients also had a higher rate of injury to the solid organs than patients with an isolated abdominal stab wound.

Conclusions

Patients with multi-regional stab wounds have an increased risk of intra-abdominal injury. Worldwide accepted “clinical follow up” protocol may not be appropriate in management of patients with multi-regional stab wounds.

First comprehensive tool for screening pain in Parkinson's disease: the King's Parkinson's Disease Pain Questionnaire

BACKGROUND AND PURPOSE

Pain is highly prevalent in Parkinson's disease (PD), impacting patients' ability, mood and quality of life. Detecting the presence of pain in its multiple modalities is necessary for adequate personalized management of PD. A 14-item, PD-specific, patient-based questionnaire (the King's Parkinson's Disease Pain Questionnaire, KPPQ) was designed corresponding to the rater-based KPP Scale (KPPS). The present multicentre study was aimed at testing the validity of this screening tool.

METHODS

First, a comparison between the KPPQ scores of patients and matched controls was performed. Next, convergent validity, reproducibility (test-retest) and diagnostic performance of the questionnaire were analysed.

RESULTS

Data from 300 patients and 150 controls are reported. PD patients declared significantly more pain symptoms than controls (3.96 ± 2.56 vs. 2.17 ± 1.39; P < 0.0001). The KPPQ convergent validity was high with KPPS total score (r_S  = 0.80) but weak or moderate with other pain assessments. Test-retest reliability was satisfactory with kappa values ≥0.65 except for item 5, Dyskinetic pains (κ = 0.44), and the intraclass correlation coefficient (ICC) for the KPPQ total score was 0.98. After the scores of the KPPS were adapted for screening (0, no symptom; ≥1, symptom present), a good agreement was found between the KPPQ and the KPPS (ICC = 0.88). A strong correlation (r_S  = 0.80) between the two instruments was found. The diagnostic parameters of the KPPQ were very satisfactory as a whole, with a global accuracy of 78.3%-98.3%.

CONCLUSIONS

These results suggest that the KPPQ is a useful, reliable and valid screening instrument for pain in PD to advance patient-related outcomes.

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

PURPOSE

Early diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients.

METHODS

A retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13-15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant.

RESULTS

There were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3-12 that including 6351 (72%) patients with GCS of 3-8 and 2380 (28%) patient with GCS of 9-12. In these 8731 patients with GCS of 3-12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3-12, 1256 (89%) patients with GCS 3-8, 148 (11%) patients with GCS 9-12. In the 5095 stable blunt trauma patients with GCS 3-8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9-12 was 50.1%. In the unstable patients with GCS 3-8, 60.5% of them had TBI, and in subgroup of patients with GCS 9-12, only 37.2% suffered from TBI.

CONCLUSION

The utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.