Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury

Background

This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population.

Materials and methods

A retrospective review included patients admitted to a level I trauma center with HVI from 2000–2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity.

Results

A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036).

Conclusions

Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.     

Cortisol modifies extinction learning of recently acquired fear in men

Exposure therapy builds on the mechanism of fear extinction leading to decreased fear responses. How the stress hormone cortisol affects brain regions involved in fear extinction in humans is unknown. For this reason, we tested 32 men randomly assigned to receive either 30 mg hydrocortisone or placebo 45 min before fear extinction. In fear acquisition, a picture of a geometrical figure was either partially paired (conditioned stimulus; CS+) or not paired (CS−) with an electrical stimulation (unconditioned stimulus; UCS). In fear extinction, each CS was presented again, but no UCS occurred. Cortisol increased conditioned skin conductance responses in early and late extinction. In early extinction, higher activation towards the CS− than to the CS+ was found in the amygdala, hippocampus and posterior parahippocampal gyrus. This pattern might be associated with the establishment of a new memory trace. In late extinction, the placebo compared with the cortisol group displayed enhanced CS+/CS− differentiation in the amygdala, medial frontal cortex and nucleus accumbens. A change from early deactivation to late activation of the extinction circuit as seen in the placebo group seems to be needed to enhance extinction and to reduce fear. Cortisol appears to interfere with this process thereby impairing extinction of recently acquired conditioned fear.     

Side effects of proton beam therapy of choroidal melanoma in dependence of the dose to the optic disc and the irradiated length of the optic nerve

Graefe's Archive for Clinical and Experimental Ophthalmology - To analyze the impact of the dose to the optic disc and the irradiated length of the optic nerve on radiation-induced optic...     

Excluding infections in arthroplasty using leucocyte esterase test

Purpose

Periprosthetic joint infections remain a major challenge for the surgeon in modern arthroplasty. The decision on how to handle a case is often difficult due to the variety of clinical presentations. The aim of this study was to establish the leucocyte esterase test as an intra-operative rapid diagnostic tool in an unclear infected or aseptic situation.

Methods

In the setting of 364 endoprosthetic joint procedures on knee, hip and shoulder, we aspirated synovial fluid before performing capsulotomy. We performed a leucocyte esterase test. The results were correlated with the pre-operative synovial fluid aspirations, the laboratory blood sample parameters (C-reactive protein, white blood cells) and the intra-operative histopathological and microbiological findings.

Results

The leucocyte esterase test has a sensitivity of 100 % and a specificity of 96.5 %. The positive predictive value was 82 % and the negative predictive value was 100 %. Correlation with conventional methods such as serum C-reactive protein and serum white blood cells is given. The histopathological evaluation confirmed the microbiological results in all but three cases.

Conclusions

Based on our results and the current literature, we recommend the leucocyte esterase test as a useful tool in the diagnosis of periprosthetic joint infection.     

The Integral Theory System Questionnaire: an anatomically directed questionnaire to determine pelvic floor dysfunctions in women

Purpose

Anatomical damage to pelvic floor structures may cause multiple symptoms. The Integral Theory System Questionnaire (ITSQ) is a holistic questionnaire that uses symptoms to help locate damage in specific connective tissue structures as a guide to reconstructive surgery. It is based on the integral theory, which states that pelvic floor symptoms and prolapse are both caused by lax suspensory ligaments. The aim of the present study was to psychometrically validate the ITSQ.

Materials and methods

Established psychometric properties including validity, reliability, and responsiveness were considered for evaluation. Criterion validity was assessed in a cohort of 110 women with pelvic floor dysfunctions by analyzing the correlation of questionnaire responses with objective clinical data. Test–retest was performed with questionnaires from 47 patients. Cronbach’s alpha and “split-half” reliability coefficients were calculated for inner consistency analysis.

Results

Psychometric properties of ITSQ were comparable to the ones of previously validated Pelvic Floor Questionnaires. Face validity and content validity were approved by an expert group of the International Collaboration of Pelvic Floor surgeons. Convergent validity assessed using Bayesian method was at least as accurate as the expert assessment of anatomical defects. Objective data measurement in patients demonstrated significant correlations with ITSQ domains fulfilling criterion validity. Internal consistency values ranked from 0.85 to 0.89 in different scenarios.

Conclusions

The ITSQ proofed accurate and is able to serve as a holistic Pelvic Floor Questionnaire directing symptoms to site-specific pelvic floor reconstructive surgery.