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Introduction The Brain Injury Guidelines (BIG) direct surgeons to implement risk-stratified treatment plans for patients with traumatic brain injury (TBI). BIG categorize patients into one of three severity categories, from lowest to highest risk (BIG 1, BIG 2, and BIG 3). BIG empowers physicians to implement standardized treatment plans that limit unnecessary hospitalizations, repeat imaging, and neurosurgical consultation. These guidelines have been studied in Level I trauma centers, but their clinical application has never been studied in a Level III trauma center. In this pilot study, we sought to determine if the BIG can be implemented in a regional trauma center where patients with less severe brain injuries are locally evaluated and treated. Methods All TBI patients at a Level III trauma center were stratified using the BIG criteria, where BIG 1 and BIG 2 patients were managed locally and BIG 3 patients were transferred to a Level I trauma center. We conducted a retrospective review using the local trauma database and electronic medical records over a 1-year period when BIG were first protocolized. The primary endpoint included deaths, complications, readmissions, and length of stay. Results There were 6 (12.2%) BIG 1, 5 (10.2%) BIG 2, and 38 (77.6%) BIG 3 patients evaluated at the Level III trauma center. All BIG 1 and BIG 2 patients remained at the Level III trauma center, and 33 of the 38 BIG 3 patients were transferred. There were no complications, readmissions, or unexpected transfers within the BIG 1 or BIG 2 patient cohorts. Conclusion The BIG criteria can be successfully implemented in a Level III trauma center. A collaborative transfer agreement with a Level I trauma center reduces unnecessary transfers without negatively affecting patient care. The BIG criteria should be considered for well-developed regional trauma systems.

Ultrasound is the gold standard for workup of cholecystitis in the emergency department, and findings heavily influence clinical decision-making. Patients with negative imaging for acute cholecystitis may be inappropriately sent home. The purpose of our study was to review the pathology and outcomes of patients presenting with biliary pain and negative ultrasound findings of acute cholecystitis.Emergency department patients who underwent laparoscopic cholecystectomy between January 2015 and February 2019 were reviewed retrospectively. Only patients with negative or equivocal imaging were included. The primary outcome was the incidence of cholecystitis on final pathology.Two hundred fifty-seven patients underwent laparoscopic cholecystectomy. Pathology demonstrated cholecystitis in 84% of patients. Only 15% of patients had cholelithiasis without cholecystitis on pathology. The incidence of cholecystitis was similar in negative and equivocal imaging groups (84% versus 83%; P = 0.960). The median time from admission to the operating room was 12.1 h (interquartile range 7.1-18.3 h), and hospital length of stay was 1.2 d (interquartile range 0.8-1.7 d).This study found that patients with negative or equivocal imaging had cholecystitis on pathology. On review of patient outcomes, those patients who underwent surgical intervention had a low rate of complications and short hospital stay.

Background Sarcopenia is associated with increased morbidity and mortality in the trauma patient. The primary objective of this study was to determine the relationship of psoas cross sectional area with hospital mortality in patients with rib fractures over the age of 55 years. Materials and Methods We retrospectively reviewed 1223 patients presenting to a Level 1 Trauma Center between 1/1/2002 and 1/31/2019. Psoas cross sectional area was measured using a polygonal tracing tool. Patients were stratified into four quartiles based on sex-specific values. Results There was increased in-hospital mortality for patients with a lower psoas cross sectional area (10 %, 8%, 6%, and 4%, Q1-Q4 respectively; P=0.021). The logistic regression model determined for every increase in psoas cross sectional area by 1 cm2 the odds of in-hospital mortality decreased by 4%. Conclusions In-hospital mortality is multifactorial; however, psoas cross sectional area may provide a clue in predicting adverse outcomes after traumatic rib fractures.

Background: Nasogastric tube placement is widely taught, and tube maintenance relies on astute nursing care with adherence to both institutional and evidence-based recommendations. However, precise adherence to current recommendations relies on knowledge base regarding the identification of malfunctioning gastric drainage tubes. Troubleshooting skills are crucial in maintaining patient safety and recognizing malfunction. Method: Educational sessions on nasogastric and orogastric decompression tube management, led by a surgical intensive care fellow at a level 1 trauma center, were offered to critical care nurses. A presession and postsession survey evaluated the nurses' subjective and objective knowledge and comfort with naso/orogastric decompression tube management. Results: Ninety-seven critical care RNs participated. For all questions, the proportion of correct answers significantly increased from presession survey to postsession survey ( p < .001). Ninety-seven percent of all participants found the session to be very helpful. Conclusion: Physician-led educational sessions on naso/orogastric decompression tube management were well-received and improved subjective and objective measurements of nurses' knowledge and comfort level with gastric decompression tubes. [ J Contin Educ Nurs . 2020;51(10):484–488.]

Introduction: Motorcycles are colloquially referred to as “donorcycles” among medical staff. However, the actual impact of helmet laws and helmet use on organ donation is unknown. Michigan’s 35-year-old universal helmet law (UHL) was repealed in April 2012 and replaced by a partial-helmet law. We hypothesized that there would be an increase in organ donation rates from unhelmeted motorcyclist fatalities. Methods: Michigan's Gift of Life Michigan organ donation database was queried from April 2008 through May 2015 in conjunction with the Michigan Trauma Quality Improvement Program database from the same time period. All in-hospital motorcycle crash fatalities were examined. Results: A three-fold increase was found in the rate of organ donation for unhelmeted motorcyclists compared to helmeted motorcyclists (p = 0.006). Motorcycle crash fatalities tended to be younger in age after the UHL repeal with an average age of 32.8 years versus 40.8, however, this finding was not statistically significant (p = 0.071). Additionally, there was no significant difference in organ donation rates pre-UHL repeal (2008–2012) versus post-repeal (2012–2015). Conclusions: This is the first study to demonstrate an increased rate of organ donation among unhelmeted motorcyclist fatalities compared to helmeted rider fatalities. There was no significant increase in the rate of organ donation following the Michigan UHL repeal. However, we identified that some motorcycle crash fatalities were from illegally unhelmeted riders in the past, prior to the repeal. Practical Application: Unhelmeted motorcyclists are three times more likely than helmeted riders to become organ donors, possibly due to the well documented increase in severe traumatic brain injuries in this population. From a public health perspective, helmets should be required for all motorcyclists and efforts to advocate in favor of helmet legislation should be supported by trauma systems and health professionals.

Background Immediately fatal motorcycle crashes have not been well characterized. This study catalogues injuries sustained in fatal motorcycle crashes and assesses the impact of crash conditions on injury patterns. Methods Autopsy records from the office of the medical examiner of Kent County, MI and publicly available traffic reports were queried for information pertaining to motorcyclists declared dead on-scene between January 1, 2007, and December 31, 2016. Results A total of 71 autopsies of on-scene motorcycle crash fatalities were identified. The two most prevalent injuries were traumatic brain injury (TBI) (85%) and rib fractures (79%). The majority of fatalities occurred in daylight hours (54.3%) and in a 55 mph speed limit zone (63.8%). Conclusions This study provides a catalogue of the injuries sustained in immediately fatal motorcycle crashes and the associated conditions. Advocacy efforts that highlight the risks associated with motorcycle riding and that promote safe riding practices are warranted.

Wildlife-human interactions are increasing in prevalence as urban sprawl continues to encroach into rural areas. Once considered to be unsuitable habitat for most wildlife species, urban/suburban areas now host an array of wildlife populations, many of which were previously restricted to rural or pristine habitats. The presence of some wildlife species in close proximity to dense human populations can create conflict, forcing resource managers to address issues relating to urban wildlife. However, evidence suggests that wildlife residing in urban areas may not exhibit the same life history traits as their rural counterparts because of adaptation to human-induced stresses. This creates difficulty for biologists or managers that must address problems associated with urban wildlife. Population control or mitigation efforts aimed at urban wildlife require detailed knowledge of the habits of wildlife populations in urban areas. This paper describes the history of wildlife in urban areas, provides examples of wildlife populations that have modified their behavior as an adaptation to urban stresses, and discusses the challenges that resource managers face when dealing with urban wildlife.

Background: Drug-related lupus [DRL] especially with hydralazine has been known for 40 years. Signs and symptoms of DRL may be readily mistaken for other disorders such as fibromyalgia. The purpose of the case presentation is to review the pathophysiology and similarities between DRL and fibromyalgia in addition to emphasize the importance of accurate diagnosis in physiatric practice. Findings: This is a case of 57-year-old hypertensive woman on hydralazine for nine years who developed multiple complaints including bilateral chest pain, cough, shortness of breath, joint pain at knees and ankles, muscle pain in thighs and calf, swelling of hands and feet, intermittent skin lesions, depression and anxiety. She was referred to a physiatrist with the mistaken diagnosis of fibromyalgia. The patient's sings and symptoms were not diagnostic of DRL but were suspicious of something other than fibromyalgia. An immunological work-up showed suggestion of DRL and hydralazine was discontinued. Conclusion: Drug-related ...

In this article, the epidemiology of traumatic spinal cord injury is reviewed in terms of basic demographic data and etiology. The increasing importance of nontraumatic causes is also highlighted. Recent studies have provided interesting information on life expectancy, causes of death, and costs of care. These data form the basis for health care planning and can be useful as baseline comparisons for intervention studies.

The development of heterotopic ossification (HO) as a complication of toxic epidermal necrolysis (TEN) has not been previously reported. TEN, also known as Lyell's syndrome, is a rare but serious skin disorder that typically occurs after the administration of drugs, especially sulfonamides, barbiturates, phenytoin, and nonsteroidal anti-inflammatory agents. TEN is characterized by the development of large fluid-filled bullae with separation of large sheets of skin. Complications of TEN can include extensive denudation of skin with dehydration and electrolyte abnormalities, gastrointestinal hemorrhage, acute tubular necrosis, secondary infection of denuded skin, pneumonia, bacterial conjunctivitis, keratitis, and septic infarcts of internal organs. We report a case of HO in a patient with TEN after treatment with trimethoprim-sulfamethoxazole. A 49-year-old man developed an erythematous rash, bullae, fever, and extensive skin loss consistent with a diagnosis of TEN. He was intubated for complications of TEN (pneumonia) and maintained on bed rest for several weeks. In addition, he developed HO that resulted in multiple joint contractures. He was treated with aggressive range of motion by physical therapy, surgical resection of the HO followed by radiation to both elbows, right hip, and right knee. Postoperative outpatient rehabilitation enabled improved function in his mobility and activities of daily living. HO is known to occur after spinal cord and brain injuries and burns. It has not been reported to occur after TEN. Our experience with this case suggests that HO may merit inclusion into the list of complications of TEN.

In order to assess the microbial water quality in canal waters throughout the Florida Keys, a survey was conducted to determine the concentration of microbial fecal indicators and the presence of human pathogenic microorganisms. A total of 19 sites, including 17 canal sites and 2 nearshore water sites, were assayed for total coliforms, fecal coliforms, Escherichia coli , Clostridium perfringens , enterococci, coliphages, F-specific (F + ) RNA coliphages, Giardia lamblia , Cryptosporidium parvum , and human enteric viruses (polioviruses, coxsackie A and B viruses, echoviruses, hepatitis A viruses, Norwalk viruses, and small round-structured viruses). Numbers of coliforms ranged from E. coli organisms from Clostridium spp. from + phages were identified. The sites were ranked according to microbial water quality and compared to various water quality standards and guidelines. Seventy-nine percent of the sites were positive for the presence of enteroviruses by reverse transcriptase PCR (polioviruses, coxsackie A and B viruses, and echoviruses). Sixty-three percent of the sites were positive for the presence of hepatitis A viruses. Ten percent of the sites were positive for the presence of Norwalk viruses. Ninety-five percent of the sites were positive for at least one of the virus groups. These results indicate that the canals and nearshore waters throughout the Florida Keys are being impacted by human fecal material carrying human enteric viruses through current wastewater treatment strategies such as septic tanks. Exposure to canal waters through recreation and work may be contributing to human health risks.

This book is a very nice review of spinal cord injury, including sections on anatomy, pathology, diagnosis, imaging, and treatment. There are 16 chapters representing the work of 35 contributors. In the preface, the authors note that space limitations preclude coverage of some important areas, specifically citing the omission of spasticity and evoked potentials. Interestingly, there is an informative chapter by Dr Aminoff on segmentally specific somatosensory evoked potentials, which he concludes are of little use in the clinical management of spinal cord disorders. Perhaps one of the excluded topics could have been substituted in its place. There are two excellent reviews of nontraumatic spinal cord disorders, and this is material that is often not well covered in textbooks of spinal cord injury. This volume is well illustrated and is recommended for clinicians wishing a current and succinct review of spinal cord disorders.

Intermittent positive pressure ventilation (IPPB) is reported to improve lung compliance and decrease the work of breathing in subjects with kyphoscoliosis. These results suggest that IPPB may improve chest wall and lung compliance in patients with neuromuscular disease. We studied the short-term effects of IPPB on total respiratory system compliance in 14 subjects with neuromuscular disease. Seven were quadriplegics, and seven had muscular dystrophy. Vital capacity was reduced to 38±14 percent of the predicted normal values. Baseline measurements of total respiratory system compliance were 57±18 percent when compared to normal control values. After a 20 minute treatment of IPPB delivered with inspiratory pressures of 20 to 25 cm H 2 O that more than tripled resting tidal volume, there was no significant change in total respiratory system compliance in either group of patients. These findings indicate that patients with quadriplegia or muscular dystrophy do not derive immediate improvement in ventilatory mechanics from IPPB treatments.

SummaryFifty former rehabilitation patients completed the recent life changes questionnaire (RLCQ), an inventory of potentially stressful life events. Subjects indicated those events that had occurred to them during the 6 months prior to onset of illness/injury and during the 6 months following hospital discharge. Certain RLCQ items have associated point values (“life change units” or LCU) indicative of the amount of stress induced by that event. The average number of LCU reported for the post-discharge period exceeded by 3 1/2 times the average for the pre-injury epoch. Ranges for both sets of values were substantial. Forty-five of the fifty-seven events were reported more frequently for the later period, while eight occurred slightly more often before the onset of illness or injury. These findings have implications for the genesis, frequency, magnitude and individual variability of depression following the onset of disabling illness.Resume50 patients ayant termine leur programme de reeducation et readap...

This is a book that truly does fill a void, and it should be welcomed by all who deal with chronic disease in children. The editors are a physiatrist and a neurologist and the topics covered in the book undoubtedly reflect their specialty interests. There are 26 other contributors to the volume, most of whom are affiliated with the College of Physicians and Surgeons of Columbia University, as are the two editors. The book is divided into five sections: (1) four selected chronic medical illnesses (juvenile rheumatoid arthritis, cystic fibrosis, hemoglobinopathies, and asthma); (2) disorders of the neuromuscular system; (3) disorders of the musculoskeletal system and injuries (including burns and cosmetic surgery); (4) dentistry (only one chapter long but highly useful); and (5) psychosocial aspects. This last section contains six chapters ranging from sexuality in the handicapped adolescent to administration of hospitals caring for the chronically ill child. As

The article by Woolsey 1 entitled "Rehabilitation Outcome Following Spinal Cord Injury" is a particularly important work for neurologists who may occasionally see patients with spinal cord injury but who are not closely involved with this subject. The field has changed in many ways during the past two decades, and the results have been impressive. One change has been the frequency of renal failure, which was long known to be a major cause of death in this population. It may come as a surprise to many physicians to learn that renal failure has now become a rarity. Renal failure associated with renal amyloidosis was found to be related to See also p 116. chronic osteomyelitis resulting from pressure sores, but with current concepts of care, including sophisticated surgical techniques, the patient with an indolent pressure sore is seldom encountered. Another area of change has been in the care of patients

This book is intended for physicians and physical therapists who deal with children with developmental disabilities and who are interested in expanding physical therapy services for such children. The title of the book is a bit restrictive, as much of the material would probably be of interest to many occupational therapists. There are 11 contributors to this volume, and they represent a variety of health and educational disciplines, as well as being international. Two of the contributors also serve as editors. Dr. Pearson is the Director of the Meyer Children's Rehabilitation Institute of the University of Nebraska Medical Center, and Miss Williams was formerly a physical therapy consultant to the US Public Health Service. The emphasis in the book is generally on cerebral palsy, but other disabilities are also mentioned. The heart of the book is the three chapters on treatment, which deal with the methods developed by the Bobaths