Pearsonlemming3316

BACKGROUND While there is little debate that pediatric trauma centers (PTC) are uniquely equipped to manage pediatric trauma patients, the extent to which adolescents benefit from treatment there remains controversial. We sought to elucidate differences in management approach and outcome between PTC and adult trauma centers (ATC) for the adolescent penetrating trauma population. We hypothesized that improved mortality would be observed at ATC for this subset of patients. METHODS Adolescent patients (aged 15-18 years) presenting to Pennsylvania-accredited trauma centers between 2003-2017 with penetrating injury were queried from the Pennsylvania Trauma Outcome Study (PTOS) database. Dead on arrival, transfer patients, and those admitted to a Level III or IV trauma center were excluded from analysis. Patient length of stay (LOS), number of complications, surgical intervention, and mortality were compared between ATC and PTC. Multilevel mixed effects logistic regression models with trauma center as the clustering variable were used to assess the impact of center type (ATC/PTC) on management approach and mortality adjusted for appropriate covariates. RESULTS A total of 2,630 adolescent patients met inclusion criteria (PTC n=428 [16.3%]; ATC n=2,202 [83.7%]). PTC's had a lower adjusted odds of mortality ([AOR] 0.35; 95% confidence interval [CI], 0.17-0.74; p=0.006) and a lower adjusted odds of surgery (AOR 0.67; 95% CI, 0.0.48-0.93; p =0.016) than their ATC counterparts. There were no differences in complication rates (AOR 0.94; 95% CI, 0.57-1.55; p=0.793) or LOS > 4 days (AOR 0.95; 95% CI, 0.61-1.48; p=0.812) between the PTC or ATC centers. read more There were also differences in penetrating injury type between PTC and ATC. CONCLUSION The adolescent penetrating trauma patient population treated at PTC had less surgery performed with improved mortality compared to ATC. LEVEL OF EVIDENCE Epidemiologic study, level III.BACKGROUND Anemia in patients who decline transfusion has been associated with increased morbidity and mortality. We hypothesized that the time to death decreases with increasing severity of anemia in patients for whom transfusion is not an option. METHODS With IRB approval, a retrospective review of registered adult blood refusal patients with at least one hemoglobin (Hb) value ≤12.0g/dL during hospital admission at a single institution from January 2004 to September 2015 was performed. The association of nadir Hb category and time to death (all-cause 30-day mortality) was determined using Kaplan-Meier plots, log rank tests, and Cox proportional hazard models. We investigated if there was a nadir Hb level between the values of 5.0 and 6.0g/dL at which mortality risk significantly increased, and then categorized nadir Hb by the traditional cut points, and the newly identified "critical" cut point. RESULTS The study population included 1011 patients. The Cox proportional hazard models showed a more than 50% increase in hazard of death per 1g/dL decrease in Hb (adjusted hazard ratio (HR) 1.55 (1.40, 1.72), p less then 0.001). A Hb value of 5.0g/dL was identified as defining 'critical anemia.' We found a strong association between anemia severity level and mortality (p less then 0.001). Time to death was shorter (median 2 days) in patients with critical anemia than in those having higher Hb (median time to death of 4 or 6 days, in severe or moderate anemia). CONCLUSION In anemic patients unable to be transfused, critical anemia was associated with a significantly and clinically important reduced time to death. LEVEL OF EVIDENCE III (Prognostic).BACKGROUND According to the Joint Theater Trauma Registry, 26-33% of war casualties develop Acute Respiratory Distress Syndrome (ARDS), with high mortality. Here we aimed to describe ARDS incidence and severity among patients evacuated from war zones and admitted to French intensive care units (ICUs). METHODS We performed an observational retrospective multicentric review of all patients evacuated from war zones and admitted to French ICUs between 2003-2018. Our analysis included all medical and trauma patients developing ARDS according to the Berlin definition. We evaluated ARDS incidence, and determined ARDS severity from arterial blood gas analysis. Analyzed parameters included invasive ventilation duration, ARDS treatments, ICU stay length, and 30-day and 90-day mortality. RESULTS Among 141 included patients (84% military; median age, 30 years), 57 (42%) developed ARDS. ARDS was mild in 13 patients (22%), moderate in 24 (42%), and severe in 20 (36%). Evacuation occurred in less then 26 hours for 32 war casualties, 17 non-war-related trauma patients, and 8 medical patients. Among severe trauma patients, median ISS was 34, and AIS thorax was 3. Upon French ICU admission, median PaO2/fiO2 ratio was 241 [144-296]. Administered ARDS treatments included intubation (98%, n = 56), protective ventilation (87%, n = 49), neuromuscular blockade (76%, n = 43), prone position (16%, n = 9), inhaled nitric oxide (10%, n = 6), almitrine (7%, n = 7), and extracorporeal life support (ECLS) (4%, n = 2). Median duration of invasive ventilation was 13 days, ICU stay was 18 days, 30-day mortality was 14%, and 90-day mortality was 21%. CONCLUSIONS ARDS was frequent and severe among French patients evacuated from war theaters. Improved treatment capacities are needed in the forward environment-for example, a specialized US team can provide ECLS for highly hypoxemic war casualties. LEVEL OF EVIDENCE Prognostic and epidemiological study, level III.PRECIS This clinical trial compares a modified trabeculectomy technique (ESST) to conventional trabeculectomy (SST) regarding success rate and bleb morphology. ESST showed comparable results with lower incidence of bleb-related complications and need for postoperative anti-glaucoma medications. BACKGROUND To evaluate the outcome of modified trabeculectomy with extended subscleral tunnel "ESST" versus conventional subscleral trabeculectomy "SST" in the management of uncontrolled primary open-angle glaucoma. METHODS This is a randomized clinical trial including 40 eyes (40 patients) divided into 2 equal groups. In the first group, a conventional SST with adjuvant 0.3% mitomycin-C was performed. In the second group; the ESST group, an additional 1.00▒mm wide longitudinal scleral groove was dissected and excised in the center of the deep scleral bed extending 1.00▒mm beyond the posterior margin of the flap. Patients were examined on days 1, 7, 14, 30, 90, 180 and at 1 year with special emphasis on intraocular pressure (IOP) and bleb morphology.