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Volume 7, Problème 2 (2018)


America's Dilemma: Reconciling Cultural Norms with 21st Century Education - Part I

Julian D Owens

I am deeply disturbed by the culture of violence, flagrant disrespect, and incivility (FDI) that has become the norm in America. I am especially concerned that violence, aggressive behaviors and trauma (VABT) is increasingly paired with FDI and is being distributed globally by the news, information, and media entertainment industries, or the NIME. Children spend a great deal of time with the NIME via social and digital media (SDM).

article de recherche

Effects of Prehospital Wound Prophylaxis in Iraq and Afghanistan on Mortality

Jason F Naylor*, Kimberly Burbank, Michael D April, Joseph C Wenke, Joseph K Maddry and Steven G Schauer

Introduction: A significant proportion of traumatic injuries sustained during the recent conflicts in Afghanistan and Iraq developed subsequent wound infections. Previous studies demonstrate lower infectious rates with timely administration of antibiotics, but do not evaluate impact on mortality. We compare demographics, injury characteristics, and survival rates among adult combat casualties receiving prehospital wound prophylaxis versus casualties not receiving antibiotic prophylaxis.
Methods: We used a series of emergency department (ED) procedure codes to identify subjects within the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We included subjects that sustained a gunshot wound (GSW), traumatic amputation, or open-fracture proximal to the digits. We stratified our comparisons of characteristics between casualties receiving antibiotic prophylaxis to those not receiving antibiotic prophylaxis by specific injury pattern.
Results: During the study period, our predefined ED search codes captured 28222 of the total 38769 subjects encountered in the DODTR. We identified 6662 subjects with a GSW, 1899 subjects with an amputation, and 6553 subjects with an open fracture. Among subjects with these injuries, 9.8% (1483 of 15114) received prehospital wound prophylaxis. There was no difference in survival to discharge rates between casualties that received prehospital wound prophylaxis and those that did not among subjects who sustained amputations (93.9% vs. 90.7%, p=0.271) or open fractures (96.8% versus 95.9%, p=0.368). In the GSW group, subjects that received antibiotics had a significantly higher survival rate compared to subjects that did not receive prehospital wound prophylaxis (96.2% versus 92.8%, p<0.001). This association persisted on multivariable regression analysis (OR 1.61, 95% CI 1.09-2.38).
Conclusion: Military prehospital providers infrequently administered wound prophylaxis during the recent conflicts in Afghanistan and Iraq. There is an association between prehospital administration of antibiotics and increased survival among casualties suffering gunshot wounds.

Rapport de cas

Intrathecal Bupivacaine as Monotherapy for Non-Malignant Chronic Pain: A Case Series

Jason Hale, Elizabeth Casserly and Jianguo Cheng

Chronic, non-malignant pain can be particularly challenging to treat. Patients who are resistant to medications, nerve blocks, and spinal cord stimulators may eventually receive intrathecal therapy. Opioids are often first line medications for intrathecal therapy, but they frequently cause unacceptable side effects or become ineffective due to tolerance. This is particularly problematic in non-cancer pain, as these patients often require ongoing pain management for decades. Fortunately, combining opioids with other intrathecal medications, such as bupivacaine, clonidine, or ziconotide is very common and often produces improved analgesia. Some patients, however, have persistent pain despite first line or combination therapy, and these patients can be particularly difficult to manage. Bupivacaine is well documented as an excellent adjunct medication in intrathecal therapy, but there is little evidence supporting its use as monotherapy. We reviewed four non-cancer chronic pain patients who failed opioid or ziconotide intrathecal therapy and ultimately were placed on intrathecal bupivacaine as monotherapy. Their clinical courses and pain control are presented based on thorough review of their medical records. Three of our four patients have, at present, achieved effective analgesia with intrathecal bupivacaine monotherapy. This report is limited by the small number of patients as well as the known limitations of retrospective study. However, these data suggest that that pain physicians may consider intrathecal bupivacaine as monotherapy in patients who have failed to respond to other treatment regimens.

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