Double Trouble: Exploring Bilateral Acetabular Fractures in a Trauma Patient

Bilateral acetabular fractures, though rare, pose significant challenges in both diagnosis and management due to their association with high-energy trauma and the potential for long-term disability. This case report presents the clinical course of a 27-year-old female who presented to our department after a motorcycle accident with bilateral acetabular fractures. Initial assessment revealed nondisplaced bilateral acetabular fractures, along with associated injuries including a right ulnar styloid fracture. Further evaluation via 3D CT scan delineated associated column fractures on the right and posterior + anterior wall fractures on the left, classified according to the Letournel and Judet system. Notably, this specific combination of acetabular fractures has not been documented in existing literature as per our investigation. The surgical intervention involved an anterior intrapelvic approach for open reduction and internal fixation (ORIF) of the right acetabulum, while the left acetabulum was managed conservatively. Postoperatively, the patient is scheduled for non-weightbearing activity until radiographic evidence of fracture healing is observed. This case underscores the importance of tailored surgical approaches and comprehensive management strategies in optimizing outcomes for patients with bilateral acetabular fractures.

Defining Ultra-Massive Transfusion through a Systematic Review

Background

Despite the widespread use of ultra-massive transfusion (UMT) as an intervention for trauma patients in hemorrhagic shock, no standard definition exists. We performed a systematic review to determine a consensus definition for UMT.

Methods

A search was performed from 1979-2022. The authors screened studies defining UMT and associated outcomes as defined by our prespecified PICO questions. The PRISMA guidelines were used.

Results

1662 articles met criteria for eligibility assessment, 17 for full-text review and eight for data extraction. Only two studies demonstrated a consensus definition of UMT, which used ≥20 units of red blood cell product within 24hrs. Parameters associated with increased mortality included lower blood pressure, lower pulse and lower Glasgow Coma Score at the time of presentation and a higher injury severity score and undergoing a resuscitative thoracotomy.

Conclusions

The absence of a consensus definition for UMT raises challenges from clinical, research and ethical perspectives. Based on our findings, the authors advocate for the feasibility of standardizing the definition of UMT as ≥20 units of red blood cell product within 24hrs.

Early Psychiatric Consultation Is Associated With Decreased Cost and Length of Stay in the Patient Population at a Level I Trauma Center

Introduction

Psychiatric illness impacts nearly one-quarter of the US population. Few studies have evaluated the impact of psychiatric illness on in-hospital trauma patient care. In this study, we conducted a retrospective cohort study to evaluate hospital resource utilization for trauma patients with comorbid psychiatric illnesses.

Methodology

Trauma patients admitted to a level I center over a one-year period were included in the study. Patients were categorized into one of three groups: (1) no psychiatric history or in-hospital psychiatric service consultation; (2) psychiatric history but no psychiatric service consultation; and (3) psychiatric service consultation. Time to psychiatric service consultation was calculated and considered early if occurring on the day of or the day following admission. Patient demographics, outcomes, and resource utilization were compared between the three groups.

Results

A total of 1,807 patients were included in the study (n = 1,204, 66.6% no psychiatric condition; n = 508, 28.1% psychiatric condition without in-hospital psychiatric service consultation; and n = 95, 5.3% in-hospital psychiatric service consultation). Patients requiring psychiatric service consultation were the youngest (P < .001), with the highest injury severity (P = .024), the longest hospital length of stay (P < .001), and the highest median hospital cost (P < .001). Early psychiatric service consultation was associated with an average saving in-hospital length of stay of 2.9 days (P = .021) and an average hospital cost saving of $7,525 (P = .046).

Conclusion

One-third of our trauma population had an existing psychiatric diagnosis or required psychiatric service consultation. Resource utilization was higher for patients requiring consultation. Early consultation was associated with a savings of hospital length of stay and cost.

Predictive Value of the Methicillin-Resistant Staphylococcus aureus Nasal Swab for Methicillin-Resistant Staphylococcus aureus Ventilator-Associated Pneumonia in the Trauma Patient

Background: Many trauma centers have empiric treatment algorithms for ventilator-associated pneumonia (VAP) treatment prior to culture results that include antibiotic agents for methicillin-resistant Staphylococcus aureus (MRSA) coverage that can have adverse effects. This is the only study to evaluate risk factors and MRSA nasal swabs to risk-stratify trauma patients for MRSA VAP, thereby potentially limiting the need for empiric vancomycin. Patients and Methods: This was a single institution retrospective cohort study. Adult patients admitted to the trauma intensive care unit (ICU) between January 2013 and December 2017 who had a MRSA nasal swab and subsequently met criteria for VAP were included. Demographics, risk factors for MRSA pneumonia, and culture results were collected. Results: A total of 140 patients met inclusion criteria. The negative predictive value (NPV) of MRSA nasal swab at predicting subsequent MRSA pneumonia was 97%. The sensitivity, specificity, and positive predictive value were 50.0%, 96.2%, and 44.4%, respectively. Smokers were more likely to develop MRSA pneumonia, odds ratio: 7.0 (p = 0.02). When considering non-smokers with a negative MRSA nasal swab, NPV was 100%. Conclusions: This is the only study to date that assesses the utility of MRSA nasal swab and risk factor data to guide empiric VAP antibiotic therapy in trauma patients. Smoking was found to be a risk factor for MRSA pneumonia. The use of MRSA nasal swabs in combination with smoking status to guide empiric use of MRSA coverage antibiotic agents is recommended because of a 100% NPV. When utilized, as many as 68% of patients may safely be spared MRSA coverage antibiotic agents and the related adverse effects.

Relationship between a High-inspired Oxygen Concentration and Dorsal Atelectasis in High-energy Trauma Patients

We performed a retrospective cohort study of 911 high-energy trauma patients who underwent chest CT scans at least twice after admission. We hypothesized that in high-energy trauma patients, a high-inspired oxygen concentration delivered after admission results in dorsal atelectasis. The study's primary outcome was dorsal atelectasis formation diagnosed based on CT images. We defined dorsal atelectasis as the presence of atelectasis at ≥ 10 mm thick on CT images. We defined high-inspired oxygen concentration as >60% oxygen delivered between two CT scans. Four hundred sixty-five patients (51.0%) developed atelectasis according to the second CT scan, and 338 (37.1%) received a high-inspired oxygen concentration. A univariate analysis showed that the rate of the high-inspired oxygen concentration in the atelectasis group was significantly higher than that in the non-atelectasis group (43.4% vs. 30.1%, p<0.001). However, a logistic regression analysis showed that there was no significant relationship between the oxygen concentration and the formation of dorsal atelectasis (OR: 1.197, 95%CI: 0.852-1.683, p=0.30). Age, the Injury Severity Score, BMI, and smoking were found to be risk factors of dorsal atelectasis formation in high-energy trauma patients. There was no relationship between the oxygen concentration and atelectasis formation in our series of high-energy trauma patients.

Feasibility and validity of ambulant biofeedback devices to improve weight-bearing compliance in trauma patients with lower extremity fractures: A narrative review

BACKGROUND

Ambulant biofeedback devices can be used to provide real-time feedback for trauma patients on weight-bearing regimes. The devices also enable prescribing clinicians to monitor and train patients' level of weight-bearing. However, there is limited evidence regarding the feasibility of use of such devices in controlling weight-bearing, and their full potential remains to be elucidated.

OBJECTIVE

To investigate the feasibility of using ambulant biofeedback training devices to improve compliance with weight-bearing regimes in trauma patients with lower extremity fractures.

METHODS

A literature review of the feasibility and clinical validity of ambulant biofeedback devices.

RESULTS

Three clinically validated biofeedback devices were found feasible for use in monitoring the compliance of patients who have lower extremity fractures with different weight-bearing regimes.

CONCLUSION

Further information about the feasibility and clinical validity of biofeedback training devices is nee-ded in order to optimize weight-bearing instructions for patients.

Nutritional status of trauma patients hospitalized at surgical intensive care unit

Malnutrition results from a decrease or increase or imbalance of energy, protein and other nutrients, leading to measurable negative effects on body tissue, body shape, organ function and clinical status. Research shows that nutritional support is one of the necessary processes for survival of traumatic patient hospitalized at surgical intensive care unit. The purpose of this study is to evaluate the nutritional status of trauma patients hospitalized at surgical intensive care unit of Kowsar Hospital in Semnan, Iran. This cross-sectional descriptive study was performed on patients older than 18 years with head, neck and femur injuries. Initial data were collected using a checklist containing demographic information questions, designed from the Ministry of Health and Medical Education's Nutrition Screening Form, which was available in the Nutrition Assessment Forms and Guidelines for Hospitalized Patients Approved in 2013. The data were analyzed using Chi-square or Fisher's exact tests, paired t-test and Pearson coefficient. The confidence level was 95% and significance level was less than 0.05 in all tests. The amount of energy determined by the intensive care unit for the patients, with a significantly lower relationship than the amount of energy required by the patients for 24 hours, based on the Harris Benedict formula was (918.20±474.80 calories vs. 1535.76±243.73 calories, respectively and P-value˂0.001). The amount of protein determined by the intensive care unit for the patients for 24 hours, with a significantly relationship lower than the protein required for the patients for 24 hours, was (51.68±34.39 vs. 106.57±13.67, respectively, and P-value˂ 0.001). There was a statistically significant relationship between the age of the patients and energy (P˂0.001) and protein (P˂0.001) determined by the intensive care unit for the patients for 24 hours and energy (P˂0.001) and protein (P˂0.001) required for the patients for 24 hours. The results of this study showed that both the amount of energy and the amount of protein determined by the intensive care unit for trauma patients for less than 24 hours were lower than the required level; therefore, dietary modification for these patients is recommended.

Prevalence of Postconcussion Syndrome after Mild Traumatic Brain Injury in Young Adults from a Single Neurosurgical Center in East Coast of Malaysia

Context:

Postconcussion syndrome (PCS) is a set of symptoms occurred after a mild traumatic brain injury (MTBI). Aims: This study aims to determine the prevalence of PCS in a young adult population from a single Neurological Centre in Malaysia's East Coast and to evaluate the factors associated with PCS in MTBI patients.

Settings and Design:

This was a cross-sectional study conducted in a Neurological Centre at Hospital Tengku Ampuan Afzan, Kuantan, Pahang, Malaysia, from January 2016 to December 2016.

Subjects and Methods:

A total of 209 patients; 133 males and 76 females, in the age range of 16–84 years, were randomly recruited for this study. All the selected patients were subjected to the checklist for diagnosis of PCS as per International Statistical Classification of Diseases and Related Health Problems 10^th edition classification at a 2-week interval.

Statistical Analysis Used:

Descriptive statistic and Multivariable Logistic Regression Model were used for frequency and percentage analyses of categorical variables, using SPSS version 23.0.

Results:

Only 20 patients were identified with PCS. There were more female (70%) patients with PCS than the male (30%) patients. The prevalence of PCS for 2 weeks, 3 and 6 months since injuries were 9.6%, 8.1%, and 8.1% respectively. Majority (80%) of the patients were found to have PCS due to road traffic accidents, while the remaining were attributed to assault (15%), and falls (5%). Among the sample population, 25% were smokers, while 10% of them had either skull fracture or premorbidity.

Conclusion:

Less than 10% of patients with MTBI had PCS after 6 months’ following trauma. None of the variables tested were significant factors for the development of PCS symptoms.

Elevated postinjury thrombospondin 1-CD47 triggering aids differentiation of patients' defective inflammatory CD1a+dendritic cells

A subset of Pts develops dysfunctional MO to inflammatory DC differentiation and immunosuppression. MDDC, a newly described DC subset, is pivotal in initiating antibacterial responses. Endogenous proteins are known to alter MO to MDDC differentiation. In particular, trauma-elevated TSP-1, a protein that is known to affect MO functions, could trigger MDDC differentiation defects. We hypothesized that TSP-1-deranged differentiation of inflammatory CD1a(+)MDDC would negatively alter activation of immune functions, thereby increasing the risk of postinjury infections. Post-trauma increased TSP-1 levels in patients' plasma and MO correlated with two distinct MDDC differentiation dysfunctions: the previously described decreased CD1a(+)DC yields but also, development of an immunoincompetent CD1a(+)MDDC. The Pts' development of Dysf DC correlated to increased infectious complications. TSP-1 triggered its inhibitory receptor, CD47, activating an inhibitory phosphatase, SHP-1. Increased pSHP-1, decreased antigen processing, and depressed T cell stimulation characterized Pt Dysf DC. TSP-1 mimics added during Cnt MDDC differentiation depressed CD1a(+)DC yields but more importantly, also induced defective CD1a(+)MDDC, reproducing Pts' MDDC differentiation dysfunctions. CD47 triggering during Cnt MDDC differentiation increased SHP-1 activation, inhibiting IL-4-induced STAT-6 activation (critical for CD1a(+)MDDC differentiation). SHP-1 inhibition during MDDC differentiation in the presence of TSP-1 mimics restored pSTAT-6 levels and CD1a(+)MDDC immunogenicity. Thus, postinjury-elevated TSP-1 can decrease CD1a(+)DC yields but more critically, also induces SHP-1 hyperactivity, deviating MDDC differentiation to defective CD1a(+) inflammatory MDDCs by inhibiting STAT-6.