Faculty Bibliography

UNLABELLED:This case highlights a rare and complex occurrence of an open chest wound with a pathologic sternal fracture. This resulted from a combination of remote chest trauma, chronic chest wall infection, malignancy, and ultimately, sternal osteomyelitis. A 69-year-old male presented with a large, open anterior chest wound, chronic ulceration, and weight loss. Thirty years earlier, the patient had sustained trauma from a firecracker, which led to a chronic wound for which he did not seek medical attention. Physical exam revealed a large open chest wound with an open sternal fracture and exposed pericardium. The patient underwent surgical resection, followed by chest wall reconstruction using a rectus myocutaneous flap. Tissue pathology confirmed squamous cell carcinoma and osteomyelitis of the sternum. The case demonstrates the complexity of managing a large chronic chest wound and pathologic sternal fracture secondary to malignancy and osteomyelitis. The key lesson is the importance of early medical evaluation and a multidisciplinary approach to improve outcomes in similar scenarios. The rarity of this case emphasizes the need for heightened awareness among clinicians who may encounter earlier presentations of this disease process in order to prevent complications, such as osteomyelitis, pathological fractures and structural instability of the chest wall. TOPICS/UNASSIGNED:Open sternal fracture, open chest wound, chest wall malignancy, squamous cell carcinoma, sternal osteomyelitis, chronic chest wall infection.

A review of the uses and evidence for the Injury Severity Score, which standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems.

The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems.

OBJECTIVES/OBJECTIVE:Septic shock is associated with increased long-term morbidity and mortality. However, little is known about the use of hospital-based acute care in survivors after hospital discharge. The objectives of the study were to examine the frequency, timing, causes, and risk factors associated with emergency department visits and hospital readmissions within 30 days of discharge. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Tertiary, academic hospital in the United States. PATIENTS/METHODS:Patients admitted with septic shock (serum lactate≥4 mmol/L or refractory hypotension) and discharged alive to a nonhospice setting between 2007 and 2010. INTERVENTIONS/METHODS:None. MEASUREMENTS AND MAIN RESULTS/RESULTS:The coprimary outcomes were all-cause hospital readmission and emergency department visits (treat-and-release encounters) within 30 days to any of the three health system hospitals. Of 269 at-risk survivors, 63 (23.4%; 95% CI, 18.2-28.5) were readmitted within 30 days of discharge and another 12 (4.5%; 95% CI, 2.3-7.7) returned to the emergency department for a treat-and-release visit. Readmissions occurred within 15 days of discharge in 75% of cases and were more likely in oncology patients (p=0.001) and patients with a longer hospital length of stay (p=0.04). Readmissions were frequently due to another life-threatening condition and resulted in death or discharge to hospice in 16% of cases. The reasons for readmission were deemed potentially related to the index septic shock hospitalization in 78% (49 of 63) of cases. The most common cause was infection related, accounting for 46% of all 30-day readmissions, followed by cardiovascular or thromboembolic events (18%). CONCLUSIONS:The use of hospital-based acute care appeared to be common in septic shock survivors. Encounters often led to readmission within 15 days of discharge, were frequently due to another acute condition, and appeared to result in substantial morbidity and mortality. Given the potential public health implications of these findings, validation studies are needed.