How Did the COVID-19 Pandemic Affect Trauma Volume at an Urban Level I Trauma Center?

Introduction The COVID-19 pandemic changed the face of health care worldwide. While the impacts from this catastrophe are still being measured, it is important to understand how this pandemic impacted existing health care systems. As such, the objective of this study was to quantify its effects on trauma volume at an urban Level 1 trauma center in one of the earliest and most significantly affected US cities. Methods A retrospective chart review of consecutive trauma patients admitted to a Level 1 trauma center from January 1, 2017 to December 31, 2020 was completed. The total trauma volume in the years prior to the pandemic (2017-2019) was compared to the volume in 2020. These data were then further stratified to compare quarterly volume across all 4 years. Results A total of 4138 trauma patients were treated in the emergency room throughout 2020 with 4124 seen during 2019, 3774 during 2018, and 3505 during 2017 in the pre-COVID-19 time period. No significant difference in the volume of minor trauma or trauma transfers was observed ( P < .05). However, there was a significant increase in the number of major traumas in 2020 as compared to prior years (38.5% vs 35.6%, P < .01) and in the volume of penetrating trauma (29.1% vs 24.0%, P < .01). Discussion During the COVID-19 outbreak, trauma remained a significant health care concern. This study found an increase in volume of penetrating trauma, specifically gunshot wounds throughout 2020. It remains important to continue to devote resources to trauma patients during the ongoing COVID-19 pandemic.

Operative Management Considerations in a Patient With Multiple Occult Penetrating Cardiac Injuries

Penetrating cardiac injury remains one of the deadliest traumatic injuries. Early identification and definitive operative management are critical tenets for patient survival; however, variable clinical presentations can obscure the diagnosis. Here, we present the case of a 58-year-old obese man who presented to an urban level 1 trauma center with multiple stab wounds to the epigastrium and lateral left chest in the axillary line with an unknown weapon. The patient was taken emergently to the operating room for exploratory laparotomy, median sternotomy, and attempted repair of multiple full-thickness lacerations of the right ventricle and left and right atrium. This case demonstrates several instructive points. First, a high index of suspicion for penetrating cardiac injury is needed, especially during triage of multiple injuries. Second, careful release of cardiac tamponade is critical. Finally, there are several indications for cardiopulmonary bypass, which include multichambered injuries, uncontrollable hemorrhage, and concern for intracardiac injury.

A new operational approach for understanding water-related interactions to achieve water sustainability in growing cities

About 56 percent of the world’s population currently lives in cities. Anthropogenic activities have both directly and indirectly modified their environment. Therefore, management actions at the urban level determine whether or not cities are heading toward sustainability. Consequently, water management is in need of a clear insight of the social and ecological water-related interactions. Thus, a new operational approach is proposed for a better understanding of the interactions between the water cycle, cities and the society. In our approach, eleven key issues and their interactions emerge from an analysis of 371 documents published between 2012 and 2018. The interactions between different key issues were examined through four main foci of analysis: water resources, urban throughput, water equity, and water governance and financing. Those main foci help to comprehend water as a holistic element intertwined in urban areas. In addition, our approach provides six challenges to guide the stakeholders in decision-making processes: how to recognize, integrate, and/or restore water-related ecosystem services, how to maintain and improve the supporting green and blue spaces, how to guarantee the quality and quantity of water resources and the water supplied and used, how to ensure public and social health and well-being of the citizens, how to prevent and manage water-related conflicts, and how to make informed and equitable decisions on water management at urban level?

Cultural Jugaad in historic city transformations: India

Several historic Indian cities have managed to retain the original urban character by using readily available materials, craftspeople, and cultural traditions despite increasing urban transformations. This notion of sustaining/preserving/continuing certain cultural elements and rituals has survived in various forms in the last two centuries. Historic cities showcase their living heritage at the global level and are exemplars for studying the strong linkages within traditions and indigenous modes of preservation. In such situations where stakeholders have centuries of association with the site, it is essential that professionals look beyond conventional solutions to better understand local perceptions and thereby establish the appropriateness of any urban level interventions. This article draws from various urban conservation works carried out in the historic cities of Rajasthan over the last two decades. It illustrates the discoveries and challenges in understanding the traditional local mindset for working in such areas. The indigenous methods practiced in these historic living cores are often at variance with the norms and logics of Western city planning being followed in post-colonial India. Examples in the cities and settlements of Jaipur, Udaipur and Ajmer, feature in this article, highlighting the urgent need to understand the local community mindset and the Indian approach to solutions for rapidly modernizing historic urban centres

AN EVALUATION OF HOUSING FLEXIBILITY AFTER SEVEN YEARS OF HABITATION: IBA HAMBURG 2013

Flexibility in housing has been used for a long time to meet the changing needs of inhabitants. After a century of vicissitude, flexibility became a means for architects to deal with social changes in the new millennium. The International Building Exhibition (IBA) 2013, which took place in Hamburg, Germany, is an example of how the concept of flexibility is being adopted. Housing, in particular, the post-occupancy phase, has not been studied, despite the urban-level aspects of the IBA Hamburg having been extensively written about. Seven years after its construction, nothing is known about what happened regarding these new approaches. The purpose of this study is to investigate the number of households in the IBA Hamburg housing projects that have used the promoted concept of flexibility, particularly in the “Building Exhibition within the Building Exhibition.” As a result, this article aims to shed light on this issue by presenting data from a field survey regarding whether floor plan flexibility was used, and if so, to what extent and what were the reasons. As a result, the author utilized an administered and self-administered open and closed-ended survey questionnaire research approach to collect necessary data for the execution of this investigation. The survey was conducted in twenty-two apartments, with four residential buildings chosen as a case selection for this investigation. The results of this study revealed that, despite being considered during the initial planning phase, flexibility was not commonly applied in the housing projects of IBA Hamburg 2013. Furthermore, the findings reveal that the extent of use of flexibility in these case studies is closely linked with the occupation status of the inhabitants.

A NEW MODEL OF URBAN REGENERATION AND ECONOMIC REVITALISATION: THE I.D.E.A. DISTRICT, SAN DIEGO

In the 21st century globalized economy, innovation is a crucial factor within strategies targeted at growing and sustaining competitiveness of regions and cities. The emerging trend of innovation-led urban planning initiatives provides strong evidence of how cities are implementing strategies to promote innovation mainstreaming. Hence, these innovationoriented policies are currently translated into the creation of innovation districts, becoming part of the urban settlement dynamics towards regeneration processes. This paper intends to explore the new paradigm of urban development initiatives driven by the increasing demand of innovation. Accordingly, innovation districts will be investigated by identifying the role, as well as the influence, of the different actors who nurture and accelerate the innovation process at urban level. The I.D.E.A. District case study will be examined, by pointing out the policies and planning initiatives undertaken in Downtown San Diego. Findings from this research will evaluate the effectiveness of the new generation of urban planning initiatives in supporting urban growth strategies. Additionally, the level of public private partnership effectiveness in supporting the development of innovation districts will be highlighted. Useful lessons can be drawn in encouraging planners and policymakers towards implementing these new innovation-oriented urban regeneration initiatives within urban growth strategies, important for enhancing competitiveness and for improving liveability by providing solutions for a more efficient land use.

Near Disappearance of Splenorrhaphy as an Operative Strategy for Splenic Preservation After Trauma

Background Splenorrhaphy was once used to achieve splenic preservation in up to 40% of splenic injuries. With increasing use of nonoperative management and angioembolization, operative therapy is less common and splenic injuries treated operatively are usually high grade. Patients are often unstable, making splenic salvage unwise. Modern surgeons may no longer possess the knowledge to perform splenorrhaphy. Methods The records of adult trauma patients with splenic injuries from September 2014 to November 2018 at an urban level I trauma center were reviewed retrospectively. Data including American Association for the Surgery of Trauma splenic organ injury scale, type of intervention, splenorrhaphy technique, and need for delayed splenectomy were collected. This contemporary cohort (CC) was compared to a historical cohort (HC) of splenic injuries at a single center from 1980 to 1989 (Ann Surg 1990; 211: 369). Results From 2014 to 2018, 717 adult patients had splenic injuries. Initial management included 157 (21.9%) emergent splenectomy, 158 (22.0%) angiogram ± embolization, 371 (51.7%) observation, and only 10 (1.4%) splenorrhaphy. The HC included a total of 553 splenic injuries, of which 313 (56.6%) underwent splenectomy, while splenorrhaphy was performed in 240 (43.4%). Those who underwent splenorrhaphy in each cohort (CC vs HC) were compared. Conclusion The success rate of splenorrhaphy has not changed. However, splenorrhaphy now involves only electrocautery with topical hemostatic agents and is used primarily in low-grade injuries. Suture repair and partial splenectomy seem to be “lost arts” in modern trauma care.

Toward more accurate documentation in neurosurgical care

OBJECTIVE Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a “system-based” progress note template was changed to a “problem-based” progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.