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The Journal of Trauma Injury Infection and Critical Care
Number of Followers: 24  Subscription journalISSN (Print) 1079-6061 Published by LWW Wolters Kluwer  [297 journals]
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- Go big and go home
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Authors: Claridge; Jeffrey A.
Abstract:
No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Traumatic brain injury provokes low fibrinolytic activity in severely
injured patients-
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Authors: Meizoso; Jonathan P.; Moore, Hunter B.; Moore, Ernest E.; Gilna, Gareth P.; Ghasabyan, Arsen; Chandler, James; Pieracci, Fredric M.; Sauaia, Angela
Abstract:
Background Traumatic brain injury (TBI) in combination with shock has been associated with hypocoagulability. However, recent data suggest that TBI itself can promote a systemic procoagulant state via the release of brain-derived extracellular vesicles. The objective of our study was to identify if TBI was associated with differences in thrombelastography indices when controlling for other variables associated with coagulopathy following trauma. We hypothesized that TBI is independently associated with a less coagulopathic state.Methods Prospective study includes all highest-level trauma activations at an urban Level I trauma center, from 2014 to 2020. Traumatic brain injury was defined as Abbreviated Injury Scale head score greater than 3. Blood samples were drawn at emergency department admission. Linear regression was used to assess the role of independent predictors on trauma induced coagulopathy. Models adjusted for Injury Severity Score (ISS), shock (defined as ED SBP10), and prehospital Glasgow Coma Scale score.Results Of the 1,023 patients included, 291 (28%) suffered a TBI. Traumatic brain injury patients more often were female (26% vs. 19%, p = 0.01), had blunt trauma (83% vs. 43%, p < 0.0001), shock (33% vs. 25%, p = 0.009), and higher median ISS (29 vs. 10, p < 0.0001). Fibrinolysis shutdown (25% vs. 18%) was more common in the TBI group (p < 0.0001). When controlled for the confounding effects of ISS and shock, the presence of TBI independently decreases lysis at 30 minutes (LY30) (beta estimate: −0.16 ± 0.06, p = 0.004). This effect of TBI on LY30 persisted when controlling for sex and mechanism of injury in addition to ISS and shock (beta estimate: −0.13 ± 0.06, p = 0.022).Conclusion Traumatic brain injury is associated with lower LY30 independent of shock, tissue injury, sex, and mechanism of injury. These findings suggest a propensity toward a hypercoagulable state in patients with TBI, possibly due to fibrinolysis shutdown.LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Dimethyl malonate slows succinate accumulation and preserves cardiac
function in a swine model of hemorrhagic shock-
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Authors: Taghavi; Sharven; Abdullah, Sarah; Toraih, Eman; Packer, Jacob; Drury, Robert H.; Aras, Oguz A.Z.; Kosowski, Emma M.; Cotton-Betteridge, Aaron; Karim, Mardeen; Bitonti, Nicholas; Shaheen, Farhana; Duchesne, Juan; Jackson-Weaver, Olan
Abstract:
BACKGROUND Succinate (SI) is a citric acid cycle metabolite that accumulates in tissues during hemorrhagic shock (HS) due to electron transport chain uncoupling. Dimethyl malonate (DMM) is a competitive inhibitor of SI dehydrogenase, which has been shown to reduce SI accumulation and protect against reperfusion injury. Whether DMM can be therapeutic after severe HS is unknown. We hypothesized that DMM would prevent SI buildup during resuscitation (RES) in a swine model of HS, leading to better physiological recovery after RES.METHODS The carotid arteries of Yorkshire pigs were cannulated with a 5-Fr catheter. After placement of a Swan-Ganz catheter and femoral arterial line, the carotid catheters were opened and the animals were exsanguinated to a mean arterial pressure (MAP) of 45 mm. After 30 minutes in the shock state, the animals were resuscitated to a MAP of 60 mm using lactated ringers. A MAP above 60 mm was maintained throughout RES. One group received 10 mg/kg of DMM (n = 6), while the control received sham injections (n = 6). The primary end-point was SI levels. Secondary end-points included cardiac function and lactate.RESULTS Succinate levels increased from baseline to the 20-minute RES point in control, while the DMM cohort remained unchanged. The DMM group required less intravenous fluid to maintain a MAP above 60 (450.0 vs. 229.0 mL; p = 0.01). The DMM group had higher pulmonary capillary wedge pressure at the 20-minute and 40-minute RES points. The DMM group had better recovery of cardiac output and index during RES, while the control had no improvement. While lactate levels were similar, DMM may lead to increased ionized calcium levels.DISCUSSION Dimethyl malonate slows SI accumulation during HS and helps preserve cardiac filling pressures and function during RES. In addition, DMM may protect against depletion of ionized calcium. Dimethyl malonate may have therapeutic potential during HS.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Do not forget the platelets: The independent impact of red blood cell to
platelet ratio on mortality in massively transfused trauma patients-
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Authors: Dorken Gallastegi; Ander; Naar, Leon; Gaitanidis, Apostolos; Gebran, Anthony; Nederpelt, Charlie J.; Parks, Jonathan J.; Hwabejire, John O.; Fawley, Jason; Mendoza, April E.; Saillant, Noelle N.; Fagenholz, Peter J.; Velmahos, George C.; Kaafarani, Haytham M.A.
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BACKGROUND Balanced blood component administration during massive transfusion is standard of care. Most literature focuses on the impact of red blood cell (RBC)/fresh frozen plasma (FFP) ratio, while the value of balanced RBC:platelet (PLT) administration is less established. The aim of this study was to evaluate and quantify the independent impact of RBC:PLT on 24-hour mortality in trauma patients receiving massive transfusion.METHODS Using the 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database, adult patients who received massive transfusion (≥10 U of RBC/24 hours) and ≥1 U of RBC, FFP, and PLT within 4 hours of arrival were retrospectively included. To mitigate survival bias, only patients with consistent RBC:PLT and RBC:FFP ratios between 4 and 24 hours were analyzed. Balanced FFP or PLT transfusions were defined as having RBC:PLT and RBC:FFP of ≤2, respectively. Multivariable logistic regression was used to compare the independent relationship between RBC:FFP, RBC:PLT, balanced transfusion, and 24-hour mortality.RESULTS A total of 9,215 massive transfusion patients were included. The number of patients who received transfusion with RBC:PLT>2 (1,942 [21.1%]) was significantly higher than those with RBC:FFP>2 (1,160 [12.6%]) (p < 0.001). Compared with an RBC:PLT ratio of 1:1, a gradual and consistent risk increase was observed for 24-hour mortality as the RBC:PLT ratio increased (p < 0.001). Patients with both FFP and PLT balanced transfusion had the lowest adjusted risk for 24-hour mortality. Mortality increased as resuscitation became more unbalanced, with higher odds of death for unbalanced PLT (odds ratio, 2.48 [2.18–2.83]) than unbalanced FFP (odds ratio, 1.66 [1.37–1.98]), while patients who received both FFP and PLT unbalanced transfusion had the highest risk of 24-hour mortality (odds ratio, 3.41 [2.74–4.24]).CONCLUSION Trauma patients receiving massive transfusion significantly more often have unbalanced PLT rather than unbalanced FFP transfusion. The impact of unbalanced PLT transfusion on 24-hour mortality is independent and potentially more pronounced than unbalanced FFP transfusion, warranting serious system-level efforts for improvement.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Effects of antifibrinolytics on systemic and cerebral inflammation after
traumatic brain injury-
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Authors: Wallen; Taylor E.; Singer, Kathleen E.; Baucom, Matthew R.; England, Lisa G.; Schuster, Rebecca M.; Pritts, Timothy A.; Goodman, Michael D.
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BACKGROUND Administration of antifibrinolytic medications, including tranexamic acid (TXA), may reduce head injury–related mortality. The effect of these medications on post–traumatic brain injury (TBI) inflammatory response is unknown. The goal of this study was to investigate the role of available antifibrinolytic medications on both systemic and cerebral inflammation after TBI.METHODS An established murine weight drop model was used to induce a moderate TBI. Mice were administered 1, 10, or 100 mg/kg of TXA, 400 mg/kg of aminocaproic acid (Amicar, Hospira, Lake Forest, IL), 100 kIU/kg of aprotonin, or equivalent volume of normal saline (NS) 10 minutes after recovery. Mice were euthanized at 1, 6, or 24 hours. Serum and cerebral tissue were analyzed for neuron-specific enolase and inflammatory cytokines. Hippocampal histology was evaluated at 30 days for phosphorylated tau accumulation.RESULTS One hour after TBI, mice given TXA displayed decreased cerebral cytokine concentrations of tumor necrosis factor α (TNF-α) and, by 24 hours, displayed decreased concentrations of cerebral TNF-α, interleukin (IL)-6, and monocyte chemoattractant protein 1 compared with TBI-NS. However, serum concentrations of TNF-α and macrophage inflammatory protein 1α (MIP-1α) were significantly elevated from 1 to 24 hours in TBI-TXA groups compared with TBI-NS. The concentration of phosphorylated tau was significantly decreased in a dose-dependent manner in TBI-TXA groups compared with TBI-NS. By contrast, Amicar administration increased cerebral cytokine levels of IL-6 1 hour after TBI, with serum elevations noted in TNF-α, MIP-1α, and monocyte chemoattractant protein 1 at 24 hours compared with TBI-NS. Aprotonin administration increased serum TNF-α, IL-6, and MIP-1α from 1 to 24 hours without differences in cerebral cytokines compared with TBI-NS.CONCLUSION Tranexamic acid administration may provide acute neuroinflammatory protection in a dose-dependent manner. Amicar administration may be detrimental after TBI with increased cerebral and systemic inflammatory effects. Aprotonin administration may increase systemic inflammation without significant contributions to neuroinflammation. While no antifibrinolytic medication improved systemic inflammation, these data suggest that TXA may provide the most beneficial inflammatory modulation after TBI.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Fluoxetine reduces organ injury and improves motor function after
traumatic brain injury in mice-
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Authors: Weaver; Jessica L.; Eliceiri, Brian; Costantini, Todd W.
Abstract:
BACKGROUND Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in trauma patients worldwide. Brain injury is associated with significant inflammation, both within the brain and in the peripheral organs. This inflammatory response in TBI leads to a secondary injury, worsening the effects of the original brain injury. Serotonin is also linked to inflammation in the intestine and inflammatory bowel disease, but its role in the gut-brain axis is not known. We hypothesized that using fluoxetine to block serotonin reuptake would reduce organ inflammation and improve outcomes after TBI.METHODS C57/B6 mice were given a severe TBI using a controlled cortical impact. To measure intestinal permeability, a piece of terminal ileum was resected, the lumen was filled with 4-kDa fluorescein isothiocyanate (FITC)-dextran, and the ends were tied. The intestinal segment was submerged in buffer and fluorescence in the buffer measured over time. To measure lung permeability, 70-kDa FITC-dextran is injected retro-orbitally. Thirty minutes later, the left lung was homogenized and the fluorescence was measured. To measure performance on the rota-rod, mice were placed on a spinning rod, and the time to fall off was measured. Those treated with fluoxetine received a single dose of 5 mg/kg via intraperitoneal injection immediately after injury.RESULTS Traumatic brain injury was associated with an increase in intestinal permeability to FITC-dextran, increased lung vascular permeability, and worse performance on the rota-rod. Fluoxetine significantly reduced lung and intestinal permeability after TBI and improved performance on the rota-rod after TBI.CONCLUSION Use of fluoxetine has the potential to reduce lung injury and improve motor coordination in severe TBI patients. Further study will be needed to elucidate the mechanism behind this effect.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Cresting mortality: Defining a plateau in ongoing massive transfusion
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Authors: Quintana; Megan T.; Zebley, James A.; Vincent, Anita; Chang, Parker; Estroff, Jordan; Sarani, Babak; Forssten, Maximilian Peter; Cao, Yang; Chen, Michelle; Corrado, Colleen; Mohseni, Shahin
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BACKGROUND Blood-based balanced resuscitation is a standard of care in massively bleeding trauma patients. No data exist as to when this therapy no longer significantly affects mortality. We sought to determine if there is a threshold beyond which further massive transfusion will not affect in-hospital mortality.METHODS The Trauma Quality Improvement database was queried for all adult patients registered between 2013 and 2017 who received at least one unit of blood (packed red blood cell) within 4 hours of arrival. In-hospital mortality was evaluated based on the total transfusion volume (TTV) at 4 hours and 24 hours in the overall cohort (OC) and in a balanced transfusion cohort, composed of patients who received transfusion at a ratio of 1:1 to 2:1 packed red blood cell to plasma. A bootstrapping method in combination with multivariable Poisson regression was used to find a cutoff after which additional transfusion no longer affected in-hospital mortality. Multivariable Poisson regression was used to control for age, sex, race, highest Abbreviated Injury Scale score in each body region, comorbidities, advanced directives limiting care, and the primary surgery performed for hemorrhage control.RESULTS The OC consisted of 99,042 patients, of which 28,891 and 30,768 received a balanced transfusion during the first 4 hours and 24 hours, respectively. The mortality rate plateaued after a TTV of 40.5 units (95% confidence interval [CI], 40–41) in the OC at 4 hours and after a TTV of 52.8 units (95% CI, 52–53) at 24 hours following admission. In the balanced transfusion cohort, mortality plateaued at a TTV of 39 units (95% CI, 39–39) and 53 units (95% CI, 53–53) at 4 hours and 24 hours following admission, respectively.CONCLUSION Transfusion thresholds exist beyond which ongoing transfusion is not associated with any clinically significant change in mortality. These TTVs can be used as markers for resuscitation timeouts to assess the plan of care moving forward.LEVEL OF EVIDENCE Prognostic and epidemiological, Level III.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Prehospital synergy: Tranexamic acid and blood transfusion in patients at
risk for hemorrhage-
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Authors: Deeb; Andrew-Paul; Hoteit, Lara; Li, Shimena; Guyette, Francis X.; Eastridge, Brian J.; Nirula, Raminder; Vercruysse, Gary A.; O’Keeffe, Terence; Joseph, Bellal; Neal, Matthew D.; Sperry, Jason L.; Brown, Joshua B.
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BACKGROUND Growing evidence supports improved survival with prehospital blood products. Recent trials show a benefit of prehospital tranexamic acid (TXA) administration in select subgroups. Our objective was to determine if receiving prehospital packed red blood cells (pRBC) in addition to TXA improved survival in injured patients at risk of hemorrhage.METHODS We performed a secondary analysis of all scene patients from the Study of Tranexamic Acid during Air and ground Medical Prehospital transport trial. Patients were randomized to prehospital TXA or placebo. Some participating EMS services utilized pRBC. Four resuscitation groups resulted: TXA, pRBC, pRBC+TXA, and neither. Our primary outcome was 30-day mortality and secondary outcome was 24-hour mortality. Cox regression tested the association between resuscitation group and mortality while adjusting for confounders.RESULTS A total of 763 patients were included. Patients receiving prehospital blood had higher Injury Severity Scores in the pRBC (22 [10, 34]) and pRBC+TXA (22 [17, 36]) groups than the TXA (12 [5, 21]) and neither (10 [4, 20]) groups (p < 0.01). Mortality at 30 days was greatest in the pRBC+TXA and pRBC groups at 18.2% and 28.6% compared with the TXA only and neither groups at 6.6% and 7.4%, respectively. Resuscitation with pRBC+TXA was associated with a 35% reduction in relative hazards of 30-day mortality compared with neither (hazard ratio, 0.65; 95% confidence interval, 0.45–0.94; p = 0.02). No survival benefit was observed in 24-hour mortality for pRBC+TXA, but pRBC alone was associated with a 61% reduction in relative hazards of 24-hour mortality compared with neither (hazard ratio, 0.39; 95% confidence interval, 0.17–0.88; p = 0.02).CONCLUSION For injured patients at risk of hemorrhage, prehospital pRBC+TXA is associated with reduced 30-day mortality. Use of pRBC transfusion alone was associated with a reduction in early mortality. Potential synergy appeared only in longer-term mortality and further work to investigate mechanisms of this therapeutic benefit is needed to optimize the prehospital resuscitation of trauma patients.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Mortality and pulmonary complications in emergency general surgery
patients with COVID-19: A large international multicenter study-
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Authors: COVIDSurg Collaborative
Abstract:
OBJECTIVES The outcomes of emergency general surgery (EGS) patients with concomitant COVID-19 infection remain unknown. With a multicenter study in 361 hospitals from 52 countries, we sought to study the mortality and pulmonary complications of COVID-19 patients undergoing EGS.METHODS All patients 17 years or older and diagnosed preoperatively with COVID-19 between February and July 2020 were included. Emergency general surgery was defined as the urgent/emergent performance of appendectomy, cholecystectomy, or laparotomy. The main outcomes were 30-day mortality and 30-day pulmonary complications (a composite of acute respiratory distress syndrome, unexpected mechanical ventilation, or pneumonia). Planned subgroup analyses were performed based on presence of preoperative COVID-related respiratory findings (e.g., cough, dyspnea, need for oxygen therapy, chest radiology abnormality).RESULTS A total of 1,045 patients were included, of which 40.1% were female and 50.0% were older than 50 years; 461 (44.1%), 145 (13.9%), and 439 (42.0%) underwent appendectomy, cholecystectomy, and laparotomy, respectively. The overall mortality rate was 15.1% (158 of 1,045 patients), and the overall pulmonary complication rate was 32.9% (344 of 1,045 patients); in the subgroup of laparotomy patients, the rates were 30.6% (134 of 438 patients) and 59.2% (260 of 439 patients), respectively. Subgroup analyses found mortality and pulmonary complication risk to be especially increased in patients with preoperative respiratory findings.CONCLUSION COVID-19 patients undergoing EGS have significantly high rates of mortality and pulmonary complications, but the risk is most pronounced in those with preoperative respiratory findings.LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Not all is lost: Functional recovery in older adults following emergency
general surgery-
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Authors: Guttman; Matthew P.; Tillmann, Bourke W.; Nathens, Avery B.; Bronskill, Susan E.; Saskin, Refik; Huang, Anjie; Haas, Barbara
Abstract:
BACKGROUND Although functional decline and death are common long-term outcomes among older adults following emergency general surgery (EGS), we hypothesized that patients' postdischarge function may wax and wane over time. Periods of fluctuation in function may represent opportunities to intervene to prevent further decline. Our objective was to describe the functional trajectories of older adults following EGS admission.METHODS This was a population-based retrospective cohort study of all independent, community-dwelling older adults (age ≥65 years) in Ontario with an EGS admission (2006–2016). A multistate model was used to examine patients' functional trajectories over the 5 years following discharge. Patients were followed as they transitioned back and forth between functional independence, use of chronic home care (in-home assistance for personal care, homemaking, or medical care for at least 90 days), nursing home admission, and death.RESULTS We identified 78,820 older adults with an EGS admission (mean age, 77 years; 53% female). In the 5 years following admission, 32% (n = 24,928) required new chronic home care, 21% (n = 5,249) of whom had two or more episodes of chronic home care separated by periods of independence. The average time spent in chronic home care was 11 months, and 50% (n = 12,679) of chronic home care episodes ended with a return to independence. For patients requiring chronic home care at any time, the probability of returning to independent living during the subsequent 5 years ranged from 36% to 43% annually.CONCLUSION Not all is lost for older adults who experience functional decline following EGS admission. Half of those who require chronic home care will recover to independence, and one-third will have a durable recovery, remaining independent after 5 years. Fluctuations in function in the years following EGS may represent a unique opportunity for interventions to promote rehabilitation and recovery among older adults.LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Not all is lost: Dynamic functional recovery in older adults following
emergency general surgery-
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Authors: Sharoky; Catherine E.
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Outcomes after emergency general surgery and trauma care in incarcerated
individuals: An EAST multicenter study-
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Authors: Bryant; Mary K.; Tatebe, Leah C.; Siva, Nandini Rajaram; Udekwu, Pascal O.; Wurzelmann, Mary; Crandall, Marie L.; Zuniga, Yohan Diaz; Tran, Virginia; Santos, Ariel; Krause, Cassandra; Turay, David; Nordham, Kristen D.; Taghavi, Sharven; Dreesen, Elizabeth B.; Scarlet, Sara; Snyder, Andrew; Applewhite, Megan; Patel, Pooja; Schroeppel, Thomas J.; Rodriquez, Jennifer; Kornblith, Lucy Z.; Boeck, Marissa A.; Bonne, Stephanie; Tufariello, Ann; Maine, Rebecca G.
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BACKGROUND The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals.METHODS Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort.RESULTS More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27–47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02–6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07–8.01).CONCLUSION Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated.LEVEL OF EVIDENCE Prognostic and epidemiological, Level III.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- A disturbing trend: An analysis of the decline in surgical critical care
fellowship training of Black and Hispanic surgeons-
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Authors: Hambrecht; Amanda; Berry, Cherisse; DiMaggio, Charles; Chiu, William; Inaba, Kenji; Frangos, Spiros; Krowsoski, Leandra; Ricketts Greene, Wendy; Issa, Nabil; Pugh, Carla; Bukur, Marko
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BACKGROUND Underrepresented minorities in medicine (URiMs) are disproportionally represented in surgery training programs. Rates of URiMs applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiMs disparities would persist into surgical critical care (SCC) fellowship applicants, matriculants, and graduates.METHODS We performed a retrospective analysis of SCC applicants, matriculants, and graduates from 2005 to 2020 using the graduate medical education resident survey and analyzed applicant characteristics using the Surgical Critical Care and Acute Care Surgery Fellowship Application Service from 2018 to 2020. The data were stratified by race/ethnicity and sex. Indicator variables were created for Asian, Hispanic, White, and Black trainees. Yearly proportions for each race/ethnicity and sex categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and sex proportion as the dependent variables and year as the explanatory variable.RESULTS From 2005 to 2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased.CONCLUSION Disparities in URiMs representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiMs in SCC training are warranted.LEVEL OF EVIDENCE Prognostic and Epidemiologic; level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- The association between food insecurity and gun violence in a major
metropolitan city-
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Authors: Ali; Ayman; Broome, Jacob; Tatum, Danielle; Fleckman, Julia; Theall, Katherine; Chaparro, M. Pia; Duchesne, Juan; Taghavi, Sharven
Abstract:
BACKGROUND Food insecurity (FI) is an important social determinant of health that is associated with many forms of violence. We hypothesized that FI would be associated with gun violence.METHODS Firearm injury data was collected from 2016 to 2020 (n = 3115) at a single institution that serves as the only Level I trauma center in a major southern US city. The data were linked with Map the Meal Gap data, a publicly available data set, which estimates rates of county-level FI based on state-level FI and social determinants, including unemployment, poverty, disability, and other factors. Regression analysis was utilized to examine the relationship between FI with rates of overall gun trauma and odds of gun-related violence. Food insecurity by county of patient residence was categorized by rates less than the national average of 11.5% (low), between the national and state average (16.5%) (moderate), and greater than the state average (high). Out of state residents were excluded from the analyses.RESULTS Of the 3,115 patients with firearm injuries identified, 138 (4.4%) resided in counties with low FI rates, 1048 (33.6%) in moderate FI, and 1929 (62.0%) in counties with high FI. Patients in regions of high FI were more likely to be a Level I trauma activation, a victim of assault, and have Medicaid or be self-pay. There was no significant difference in mortality by levels of FI. Food insecurity was significantly associated with firearm injury, with each percent increase in FI being related to approximately 56 additional gun-related injuries per 100,000 people (95% confidence interval, 54–59) and increased odds of the injury classified as assault (odds ratio, 1.13; 95% confidence interval, 1.07–1.19).CONCLUSION Violence prevention initiatives targeting food insecure communities may help alleviate the US gun violence epidemic. Further, trauma center screening for household FI and in-hospital interventions addressing FI may help reduce gun violence recidivism.LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Tranexamic acid is not inferior to placebo with respect to adverse events
in suspected traumatic brain injury patients not in shock with a normal
head computed tomography scan: A retrospective study of a randomized trial
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Authors: Harmer; Jordan W.; Dewey, Elizabeth N.; Meier, Eric N.; Rowell, Susan E.; Schreiber, Martin A.
Abstract:
BACKGROUND A 2-g bolus of tranexamic acid (TXA) has been shown to reduce 28-day mortality in a randomized controlled trial. This study investigates whether out-of-hospital TXA use is associated with adverse events or unfavorable outcomes in suspected traumatic brain injury (TBI) when intracranial hemorrhage (ICH) is absent on initial computed tomography.METHODS This study used data from a 2015 to 2017, multicenter, randomized trial studying the effect of the following TXA doses on moderate to severe TBI: 2-g bolus, 1-g bolus plus 1-g infusion over 8 hours, and a placebo bolus with placebo infusion. Of the 966 participants enrolled, 395 with an initial computed tomography negative for ICH were included in this analysis. Fifteen adverse events (28-day incidence) were studied: myocardial infarction, deep vein thrombosis, seizure, pulmonary embolism, acute respiratory distress syndrome, cardiac failure, liver failure, renal failure, cerebrovascular accident, cardiac arrest, cerebral vasospasm, “any thromboembolism,” hypernatremia, acute kidney injury, and infection. Other unfavorable outcomes analyzed include mortality at 28 days and 6 months, Glasgow Outcome Scale—Extended score of ≤4 at discharge and 6 months, intensive care unit–free days, ventilator-free days, hospital-free days, and combined unfavorable outcomes. In both study drug groups, the incidence of dichotomous outcomes and quantity of ordinal outcomes were compared with placebo.RESULTS No statistically significant increase in adverse events or unfavorable outcomes was found between either TXA dosing regimen and placebo. Demographics and injury scores were not statistically different other than two methods of injury, which were overrepresented in the 1-g TXA bolus plus 1-g TXA infusion.CONCLUSION Administration of either a 2-g TXA bolus or a 1-g TXA bolus plus 1-g TXA 8-hour infusion in suspected TBIs without ICH is not associated with increased adverse events or unfavorable outcomes. Because the out-of-hospital 2-g bolus is associated with a mortality benefit, it should be administered in suspected TBI.LEVEL OF EVIDENCE Therapeutic/Care Management; Level II.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- A multicenter validation of the modified brain injury guidelines: Are they
safe and effective'-
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Authors: Khan; Abid D.; Lee, Janet; Galicia, Kevin; Billings, Joshua D.; Dobaria, Vishal; Patel, Purvi P.; McIntyre, Robert C.; Gonzalez, Richard P.; Schroeppel, Thomas J.
Abstract:
BACKGROUND The modified Brain Injury Guidelines (mBIG) are an algorithm for treating patients with traumatic brain injury and intracranial hemorrhage by which selected patients do not require a repeat head computed tomography, a neurosurgery consult, or even an admission. The mBIG refined the original Brain Injury Guidelines (BIG) to improve safety and reproducibility. The purpose of this study is to assess safety and resource utilization with mBIG implementation.METHODS The mBIG were implemented at three Level I trauma centers in August 2017. A multicenter retrospective review of prospectively collected data was performed on adult mBIG 1 and 2 patients. The post-mBIG implementation period (August 2017 to February 2021) was compared with a previous BIG retrospective evaluation (January 2014 to December 2016).RESULTS There were 764 patients in the two study periods. No differences were identified in demographics, Injury Severity Score, or admission Glasgow Coma Scale score. Fewer computed tomography scans (2 [1,2] vs. 2 [2,3], p < 0.0001) and neurosurgery consults (61.9% vs. 95.9%, p < 0.0001) were obtained post-mBIG implementation. Hospital (2 [1,4] vs. 2 [2,4], p = 0.013) and intensive care unit (0 [0,1] vs. 1 [1,2], p < 0.0001) length of stay were shorter after mBIG implementation. No difference was seen in the rate of clinical or radiographic progression, neurosurgery operations, or mortality between the two groups.After mBIG implementation, eight patients (1.6%) worsened clinically. Six patients that clinically progressed were discharged with Glasgow Coma Scale score of 15 without needing neurosurgery intervention. One patient had clinical and radiographic decompensation and required craniotomy. Another patient worsened clinically and radiographically, but due to metastatic cancer, elected to pursue comfort measures and died.CONCLUSION This prospective validation shows the mBIG are safe, pragmatic, and can dramatically improve resource utilization when implemented.LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Delayed splenic pseudoaneurysm identification with surveillance imaging
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Authors: Wallen; Taylor E.; Clark, Katherine; Baucom, Matthew R.; Pabst, Rebecca; Lemmink, Jennifer; Pritts, Timothy A.; Makley, Amy T.; Goodman, Michael D.
Abstract:
BACKGROUND Recent studies have shown that nonoperative management of patients with splenic injury has up to a 90% success rate. However, delayed hemorrhage secondary to splenic artery pseudoaneurysm occurs in 5% to 10% of patients with up to 27% of patients developing a pseudoaneurysm on delayed imaging. The goal of our study was to evaluate the safety and utility of delayed computed tomography (CT) imaging for blunt splenic injury patients.METHODS A retrospective evaluation of all traumatic splenic injuries from 2018 to 2020 at a single level 1 trauma center was undertaken. Patients were subdivided into four groups based on the extent of splenic injury: grades I and II, grade III, grade IV, and grade V. Patient injury characteristics along with hospital length of stay, imaging, procedures, and presence/absence of pseudoaneurysm were documented.RESULTS A total of 588 trauma patients were initially included for evaluation, with 539 included for final analysis. Two hundred ninety-seven patients sustained grades I and II; 123 patients, grade III; 61 patients, grade IV; and 58 patients, grade V splenic injuries. One hundred twenty-nine patients (24%) underwent either emergent or delayed (>6 hours) splenectomy with an additional six patients having a splenorrhaphy on initial operation. Of the patients who were treated nonoperatively, 98% of grade III, 91% of grade IV, and 100% of grade V splenic injury patients underwent follow-up CT imaging. The mean ± SD time from admission to follow-up abdominal CT scan was 5 ± 4.4 days. Twenty-two pseudoaneurysms were identified including grade III (10 of 84), grade IV (7 of 22), and grade V (2 of 5) patients; of these patients, 33% of grade III and 30% of grade IV required subsequent splenectomy.CONCLUSION Routine follow-up CT imaging after high-grade splenic injury identifies splenic artery pseudoaneurysm in a significant proportion of patients. Standardized surveillance imaging for high-grade splenic trauma promotes prospective identification of pseudoaneurysms, allowing for interventions to minimize delayed splenic injury complications.LEVEL OF EVIDENCE Therapeutic/Care Management; level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Center for Trauma Survivorship improves postdischarge follow-up and
retention-
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Authors: Goldstein; Carma; Gore, Amy; La Bagnara, Susan; Jacniacka-Soto, Ilona E.; Sieck, Derrick; Yonclas, Peter; Livingston, David H.
Abstract:
BACKGROUND Although the need for high-level care persists postdischarge, severely injured trauma survivors have historically poor adherence to follow-up. We hypothesized that a dedicated Center for Trauma Survivorship (CTS) improves follow-up and facilitates postdischarge specialty care.METHODS A retrospective study of “CTS eligible” trauma patients before (January to December 2017) and after (January to December 2019) creation of the CTS was performed. Patients with an intensive care unit stay ≥2 days or a New Injury Severity Score of ≥16 are CTS eligible. The before (PRE) cohort was followed through December 2018 and the after (CTS) cohort through December 2020. Primary outcome was follow-up within the hospital system exclusive of mental health and rehabilitative therapy appointments. Secondary outcomes include postdischarge surgical procedures and specialty-specific follow-up.RESULTS There were no significant differences in demographics or hospital duration in the PRE (n = 177) and CTS (n = 119) cohorts. Of the CTS group, 91% presented for outpatient follow-up within the hospital system, compared with 73% in the PRE group (p < 0.001). In the PRE cohort, only 39% were seen by the trauma service compared with 62% in the CTS cohort (p < 0.001). Center for Trauma Survivorship patients also had increased follow-up with other providers (80% vs. 65%; p = 0.006). Notably, 33% of CTS patients had additional surgery compared with only 20% in the PRE group (p = 0.011). Center for Trauma Survivorship patients had more than 20% more outpatient visits (1,280 vs. 1,006 visits).CONCLUSION Despite the follow-up period for the CTS cohort occurring during the peak of the COVID-19 pandemic, limiting availability of outpatient services, our CTS significantly improved follow-up with trauma providers, as well as with other specialties. The CTS patients also underwent significantly more secondary operations. These data demonstrate that creation of a CTS can improve the postdischarge care of severely injured trauma survivors, allowing for care coordination within the health care system, retaining patients, generating revenue, and providing needed follow-up care.LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- FFP maintains normal coagulation while Kcentra induces a hypercoagulable
state in a porcine model of pulmonary contusion and hemorrhagic shock-
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Authors: Dixon; Alexandra; Beiling, Marissa; Smith, Sawyer; Behrens, Brandon; Appleman, Luisa; Rick, Elizabeth; Murphy, James; Madtson, Brianne; McCully, Belinda; Goodman, Andrew; Kanlerd, Amonpon; Schaller, Traci; Subramanian, Sarayu; Trivedi, Alpa; Pati, Shibani; Schreiber, Martin
Abstract:
BACKGROUND Moderate injury can lead to a coagulopathy. Fresh frozen plasma (FFP) corrects coagulopathy by means of a balanced array of clotting factors. We sought to compare the late effects of FFP and a prothrombin complex concentrate (PCC) on the coagulopathy of trauma using a porcine model of pulmonary contusion (PC) and hemorrhagic shock (HS) designed to evaluate the organ protective effects of these treatments.METHODS Female Yorkshire swine (40–50 kg) were randomized to receive PC + HS or control (instrumented and uninjured). A blunt PC was created using a captive bolt gun. To induce HS, a liver crush injury was performed. Eighty minutes after injury, swine were treated with 25 U·kg−1 PCC, 1 U FFP, or 50 mL lactated Ringer’s vehicle in a blinded manner. Arterial blood samples were drawn every 6 hours. Swine were euthanized 48 hours postinjury. Data were analyzed by Pearson χ2, analysis of variance and Kruskal-Wallis tests with Tukey’s or Mann-Whitney U tests for post hoc analysis.RESULTS Twenty-seven swine received PC + HS, 3 groups of 9 per group received PCC, FFP, or vehicle. Nine were noninjured controls. When compared with control, PC + HS swine had significantly shortened R time at 6 hours, 36 hours, and 42 hours, decreased LY30 at 12 hours, shortened K time at 30 hours and reduced α angle at 42 hours. PC + HS swine showed significant differences between treatment groups in K and α angle at 3 hours, LY30 at 12 hours and 18 hours, and MA at 12 hours, 18 hours, and 30 hours. Post hoc analysis was significant for higher α angle in PCC versus vehicle at 3 hours, higher MA in vehicle versus PCC at 12 hours and 18 hours, and higher LY30 in PCC versus vehicle at 18 hours (p < 0.012) with no significant differences between FFP and vehicle.CONCLUSION Severe injury with HS induced a coagulopathy in swine. While FFP maintained normal coagulation following injury, PCC induced more rapid initial clot propagation in injured animals.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Higher risk of auto versus pedestrian crashes in school-age children on
school days-
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Authors: Morrison; Chad; Olson, Ty; McNickle, Allison G.; Fraser, Douglas R.; Kuhls, Deborah A.; Gryder-Culver, Laura K.; Slinkard-Barnum, Samantha; Saquib, Syed F.; Carroll, Joseph T.; Chestovich, Paul J.
Abstract:
BACKGROUND This study examines the rates of pediatric auto versus pedestrian collision (APCs) and determined ages and periods of greatest risk. We hypothesized that the rate of APC in children would be higher on school days and in the timeframes correlating with travel to and from school.METHODS Retrospective case-control study of APC on school and nonschool days for patients younger than 18 years at an urban Level II pediatric trauma center from January 2011 to November 2019. Frequency of APC by hour of the day was plotted overall, for school versus nonschool days and for age groups: 0 year to 4 years, 5 years to 9 years, 10 years to 13 years, and 14 years to 17 years. t Test was used with a p value less than 0.05, which was considered significant.RESULTS There were 441 pediatric APC in the study period. Frequency of all APC was greater on school days (0.174 vs. 0.101; relative risk [RR], 1.72, p < 0.001), and APC with Injury Severity Score greater than 15 (0.039 vs. 0.024; p = 0.014; RR, 1.67; 95% confidence interval, 1.10–2.56). Comparing school day with nonschool day, the 0-year to 4-year group had no significant difference in APC frequency (0.021 vs. 0.014; p = 0.129), APC frequency was higher on school days in all other age groups: 5 years to 9 years (0.036 vs. 0.019; RR, 1.89; p = 0.0134), 10 years to 13 years (0.055 vs. 0.024; RR, 2.29; p < 0.001), and 14 years to 17 years (0.061 vs. 0.044; RR, 1.39; p = 0.045). The greatest increase in APC on school days was in the 10-year to 13-year age group.DISCUSSION All school age children are at higher risk of APC on school days. The data support our hypothesis that children are at higher risk of APC during transit to and from school. The age 10-year to 13-year group had a 129% increase in APC frequency on school days. This age group should be a focus of injury prevention efforts.LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level IV.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Burnout, shiftwork and suicide: 2022 Scott B. Frame Memorial Lecture
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Authors: Dissanaike; Sharmila
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- A reproducible strategy to solve problems
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Authors: Jacobs; Lenworth
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- The surgical management of complicated peptic ulcer disease: An EAST video
presentation-
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Authors: Hudnall; Aaron; Bardes, James M.; Coleman, Kennith; Stout, Conley; Regier, Daniel; Balise, Stephen; Borgstrom, David; Grabo, Daniel
Abstract:
BACKGROUND Peptic ulcer disease (PUD), once primary a surgical problem, is now medically managed in the majority of patients. The surgical treatment of PUD is now strictly reserved for life-threatening complications. Free perforation, refractory bleeding and gastric outlet obstruction, although rare in the age of medical management of PUD, are several of the indications for surgical intervention. The acute care surgeon caring for patients with PUD should be facile in techniques required for bleeding control, bypass of peptic strictures, and vagotomy with resection and reconstruction. This video procedures and techniques article demonstrates these infrequently encountered, but critical operations.CONTENT (VIDEO DESCRIPTION) A combination of anatomic representations and videos of step-by-step instructions on perfused cadavers will demonstrate the key steps in the following critical operations. Graham patch repair of perforated peptic ulcer is demonstrated in both open and laparoscopic fashion. The choice to perform open versus laparoscopic repair is based on individual surgeon comfort. Oversewing of a bleeding duodenal ulcer via duodenotomy and ligation of the gastroduodenal artery is infrequent in the age of advanced endoscopy and interventional radiology techniques, yet this once familiar procedure can be lifesaving. Repair of giant duodenal or gastric ulcers can present a challenging operative dilemma on how to best repair or exclude the defect. Vagotomy and antrectomy, perhaps the least common of all the aforementioned surgical interventions, may require more complex reconstruction than other techniques making it challenging for inexperienced surgeons. A brief demonstration on reconstruction options will be shown, and it includes Roux-en-Y gastrojejunostomy.CONCLUSION Surgical management of PUD is reserved today for life-threatening complications for which the acute care surgeon must be prepared. This presentation provides demonstration of key surgical principles in management of bleeding and free perforation, as well as gastric resection, vagotomy and reconstruction.LEVEL OF EVIDENCE Video procedure and technique, not applicable.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Data resources for evaluating the economic and financial consequences of
surgical care in the United States-
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Authors: Scott; John W.; Ayoung-Chee, Patricia; Lester, Erica L.W.; Bruns, Brandon R.; Davis, Kimberly A.; Gore, Amy; Knowlton, Lisa Marie; Liu, Charles; Martin, R. Shayn; Oh, Esther Jiin; Ross, Samuel Wade; Wandling, Michael; Minei, Joseph P.; Staudenmayer, Kristan; on behalf of the AAST Healthcare Economics Subcommittee
Abstract:
Evaluating the relationship between health care costs and quality is paramount in the current health care economic climate, as an understanding of value is needed to drive policy decisions. While many policy analyses are focused on the larger health care system, there is a pressing need for surgically focused economic analyses. Surgical care is costly, and innovative technology is constantly introduced into the operating room, and surgical care impacts patients' short- and long-term physical and economic well-being. Unfortunately, significant knowledge gaps exist regarding the relationship between cost, value, and economic impact of surgical interventions. Despite the plethora of health care data available in the forms of claims databases, discharge databases, and national surveys, no single source of data contains all the information needed for every policy-relevant analysis of surgical care. For this reason, it is important to understand which data are available and what can be accomplished with each of the data sets. In this article, we provide an overview of databases commonly used in surgical health services research. We focus our review on the following five categories of data: governmental claims databases, commercial claims databases, hospital-based clinical databases, state and national discharge databases, and national surveys. For each, we present a summary of the database sampling frame, clinically relevant variables, variables relevant to economic analyses, strengths, weaknesses, and examples of surgically relevant analyses. This review is intended to improve understanding of the current landscape of data available, as well as stimulate novel analyses among surgical populations. Ongoing debates over national health policy reforms may shape the delivery of surgical care for decades to come. Appropriate use of available data resources can improve our understanding of the economic impact of surgical care on our health care system and our patients.LEVEL OF EVIDENCE Regular Review, Level V.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Value in acute care surgery, part 2: Defining and measuring quality
outcomes-
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Authors: Ross; Samuel Wade; Wandling, Michael W.; Bruns, Brandon R.; Martin, R. Shayn; Scott, John W.; Doucet, Jay J.; Davis, Kimberly A.; Staudenmayer, Kristan L.; Minei, Joseph P.
Abstract:
The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Not so FAST replacing the “e” in e-FAST with supine
chest-x-ray-
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Authors: Osterwalder; Joseph; Seibel, Armin
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Response to Letter to the Editor: Not so FAST—chest ultrasound
underdiagnoses traumatic pneumothorax-
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Authors: Santorelli; Jarrett E.; Chau, Harrison; Godat, Laura; Casola, Giovanna; Doucet, Jay J.; Costantini, Todd W.
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Technique and timing may influence sensitivity of lung ultrasound for
pneumothorax in trauma patients-
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Authors: Volpicelli; Giovanni; Lamorte, Alessandro
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Author reply: Not so FAST—chest ultrasound underdiagnoses traumatic
pneumothorax-
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Authors: Santorelli; Jarrett E.; Chau, Harrison; Godat, Laura; Casola, Giovanna; Doucet, Jay J.; Costantini, Todd W.
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Ultrasound is superior to supine chest x-ray for the diagnosis of
clinically relevant traumatic pneumothorax-
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Authors: Kim; Daniel J.; Theyyunni, Nik; Liu, Rachel B.
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Response to letter to the editor
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Authors: Santorelli; Jarrett E.; Chau, Harrison; Godat, Laura; Casola, Giovanna; Doucet, Jay J.; Costantini, Todd W.
Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- FEATURED ARTICLES FOR CME CREDIT JULY 2022
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Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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- Meetings/Courses
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Abstract: No abstract available
PubDate: Fri, 01 Jul 2022 00:00:00 GMT-
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