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Abstract Introduction Facial fractures (FFs) occur after high- and low-energy trauma; differences in associated injuries and outcomes have not been well articulated. Objective To compare the epidemiology, management, and outcomes of patients suffering FFs from high-energy and low-energy mechanisms. Methods We conducted a 6-year retrospective local trauma registry analysis of adults aged 18–55 years old that suffered a FF treated at the Santa Barbara Cottage Hospital. Fracture patterns, concomitant injuries, procedures, and outcomes were compared between patients that suffered a high-energy mechanism (HEM: motor vehicle crash, bicycle crash, auto versus pedestrian, falls from height > 20 feet) and those that suffered a low-energy mechanism (LEM: assault, ground-level falls) of injury. Results FFs occurred in 123 patients, 25 from an HEM and 98 from an LEM. Rates of Le Fort (HEM 12% vs. LEM 3%, P = 0.10), mandible (HEM 20% vs. LEM 38%, P = 0.11), midface (HEM 84% vs. LEM 67%, P = 0.14), and upper face (HEM 24% vs. LEM 13%, P = 0.217) fractures did not significantly differ between the HEM and LEM groups, nor did facial operative rates (HEM 28% vs. LEM 40%, P = 0.36). FFs after an HEM event were associated with increased Injury Severity Scores (HEM 16.8 vs. LEM 7.5, P

Abstract Objective: To evaluate oral antibiotic prescribing for common infections at hospital discharge before and after implementation of a pharmacist-driven transitions-of-care (TOC) program. Design: Single-center before-and-after study. Setting: Acute-care, academic, community hospital in Santa Barbara, California. Patients: Eligible adult patients prescribed oral antibiotics at hospital discharge for community-acquired pneumonia, skin and soft-tissue infections, and urinary tract infections between September 2019 and December 2019 (preimplementation period) and between March 2021 and May 2021 (postimplementation period). Intervention: Antimicrobial stewardship–initiated, department-wide, TOC program requiring all clinical pharmacists to review discharge antibiotic prescriptions in real time. Results: In total, 260 antibiotic prescriptions were assessed for appropriateness: 140 before implementation and 120 after implementation. After implementation, the number of prescriptions considered inappropriate significantly decreased by 18% (52% vs 34%; P = .005). Inappropriate rates decreased in all assessment categories: dosing (15% vs 2%; P < .001), treatment duration (42% vs 31%; P = .08), antibiotic selection based on infection type or microbiology (8% vs 4%; P = .33), and antibiotics not indicated (16% vs 10%; P = .18). Median total antibiotic days decreased by 1 day after implementation (10 days vs 9 days; P = .67), and 30-day readmission rates were similar between both phases. Conclusions: A real-time, pharmacist-driven, TOC program for oral antibiotic prescriptions had a significant impact in reducing inappropriate prescribing of antibiotics at hospital discharge for common infections. Incorporating discharge antibiotic prescription review into pharmacist daily workflow may be a sustainable approach to outpatient antimicrobial stewardship in a setting with limited resources.

Summary:. Infected breast implants during lactation present a rare but challenging clinical scenario that may result in early cessation of breastfeeding and unnecessary morbidity to mother and infant. We present the case of a 39-year-old African American primigravid woman with a history of bilateral retropectoral textured implants placed three years prior. Five days after delivering a healthy, full-term infant via cesarean section, she sought evaluation for nipple pain and trauma. She was instructed to use a nipple shield and pump every 2–3 hours in addition to breastfeeding, which resulted in iatrogenic hyperlactation. One week postpartum, the patient was started on antibiotics for presumed mastitis. Ultrasound demonstrated a complex fluid collection at the 12 o’clock periareolar position, as well as peri-implant fluid. She subsequently underwent aspirations of a periareolar complex galactocele and aspirations of peri-implant fluid. She continued on antibiotics without improvement. The patient proceeded to implant removal and definitive drainage of the galactocele at four months postpartum. Throughout her course, the patient provided her infant with exclusive breastmilk, including breastfeeding in the perioperative area of the operating room. This case demonstrates an example of safe surgical removal of infected breast implants and management of an infected galactocele without interruption of breastfeeding.

Background Trauma centers are resource-intensive environments, and pediatric-specific personnel are often limited resources. Identifying the temporal patterns of pediatric traumas can help guide resource allocation strategies to optimize patient care.Methods We conducted a retrospective, single-institution analysis of 575 injured patients less than 18 years old that triggered a trauma team activation (TTA). TTA volume according to time of day and day of the week was analyzed using a mixed Poisson regression model and monthly patterns were analyzed using an analysis of variance. Subset analyses were conducted for children and teenagers.Results Across all days, the 6-hour time frame between 15:00 and 21:00 had significantly more activations than average, encompassing nearly half (47.2%) of all pediatric TTAs (p=0.01). Saturdays had significantly more activations than the daily average (Saturdays: 26.0/year, Other: 14.8/year, p

Background The efficacy of prothrombin complex concentrate (PCC) compared with fresh frozen plasma (FFP) for reversal of oral anticoagulants has not been investigated in geriatric patients suffering intracranial hemorrhage (ICH) due to a ground-level fall (GLF).Methods Patients 65 years and older who were treated at Santa Barbara Cottage Hospital between January 2011 and March 2018 with ICH after a GLF while taking warfarin were reviewed. Patients were reversed with either FFP (n=25) or PCC (n=27) and patient outcomes were compared. Separate analyses were conducted for patients who received adjuvant vitamin K administration and those who did not.Results Mortality rates, hospital length of stay, intensive care unit admission and length of stay were similar for both FFP and PCC intervention. There was no difference in radiological progression of hemorrhage within the first 24 hours of admission (FFP: 36%, PCC: 43%, p=0.365). In patients who had international normalized ratio (INR) values measured prior to intervention, 81% (17 out of 21) of the PCC group reached an INR value below 1.5 within an 8-hour period, whereas only 29% (4 out of 14) of the FFP group did (p=0.002). Vitamin K was concomitantly given to 28% of the patients receiving FFP, and 81% of those patients receiving PCC. No significant differences in outcomes were found whether adjunctive vitamin K was administered or not, in either FFP or PCC group. However, when vitamin K was not administered, the PCC group had a higher rate of INR reversal (80% vs. 10% for FFP, p=0.006).Conclusion Administration of PCC is as effective in short-term outcomes as FFP in treating geriatric patients on warfarin sustaining an ICH after a GLF. INR reversal was more successful, significantly faster, and required lower infusion volumes in patients receiving PCC.Level of evidence Level III.

Background Traumatic brain injury (TBI) is a significant source of morbidity and mortality. In patients with TBI, racial disparities have been shown to exist in patient outcomes. Identifying where disparities occur along the patient continuum of care will allow for targeted interventions. This study evaluated if racial disparity exists for neuromonitoring and neurointervention rates in patients with severe TBI due to blunt injury.Methods The National Trauma Data Bank was used to identify patients aged 18 to 55 years old from 2007 through 2016 with a blunt injury, an initial Glasgow Coma Scale score of 3 to 8, a head Abbreviated Injury Scale score of 3 to 5, and all other anatomic Abbreviated Injury Scale scores less than 3. Coarsened exact matching (CEM) was used to balance covariates between white and non-white patients. Rates of neuromonitoring and neurosurgical interventions were compared between groups. Secondary outcomes were days spent in the intensive care unit (ICU), total hospital length of stay (LOS), and mortality.Results A total of 3692 patients with severe isolated TBI due to blunt injury were identified. After applying CEM, 1064 patients were analyzed (644 white, 420 non-white). No differences were observed between white and non-white patient groups for neuromonitoring, neurointervention, mortality, or ICU LOS. White patients had a shorter hospital LOS (8 days vs. 9 days, p

The anatomical connectivity of the human brain supports diverse patterns of correlated neural activity that are thought to underlie cognitive function. In a manner sensitive to underlying structural brain architecture, we examine the extent to which such patterns of correlated activity systematically vary across cognitive states. Anatomical white matter connectivity is compared with functional correlations in neural activity measured via blood oxygen level dependent (BOLD) signals. Functional connectivity is separately measured at rest, during an attention task, and during a memory task. We assess these structural and functional measures within previously-identified resting-state functional networks, denoted task-positive and task-negative networks, that have been independently shown to be strongly anticorrelated at rest but also involve regions of the brain that routinely increase and decrease in activity during task-driven processes. We find that the density of anatomical connections within and between task-positive and task-negative networks is differentially related to strong, task-dependent correlations in neural activity. The space mapped out by the observed structure-function relationships is used to define a quantitative measure of separation between resting, attention, and memory states. We find that the degree of separation between states is related to both general measures of behavioral performance and relative differences in task-specific measures of attention versus memory performance. These findings suggest that the observed separation between cognitive states reflects underlying organizational principles of human brain structure and function.