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Traumatic falls among the elderly (≥ 65 years old) are the leading cause of injury, morbidity and mortality are increasing with rising medical costs.This is a retrospective medical record review of elderly mechanical fall patients (288 patients) admitted to an American College of Surgeons level II trauma center from January 2016 to January 2021. Demographics and comorbidities were determined, and physical/occupational therapy used to predict subsequent fall readmissions.Out of 288 patients, 243 received therapy with 45 readmissions for subsequent falls. Age (P = .016), body mass index (P = .035), previous falls (P = .003), walker/cane use (P = .039), and dementia (P = .038) were predictive of readmission. Therapy was shown to benefit patients, but deferred therapy sessions were shown to be associated with prolonged hospitalization.Directed therapy may improve functionality and return autonomy to elderly mechanical fall patients admitted to trauma services.

Metabolic causes such as altered bioenergetics and amino acid metabolism may play a major role in Long COVID. Renal-metabolic regulation is an integral part of these pathways but has not been systematically or routinely investigated in Long COVID. Here we discuss the biochemistry of renal tubular injury as it may contribute to Long COVID symptoms. We propose three potential mechanisms that could be involved in Long COVID namely creatine phosphate metabolism, un-reclaimed glomerular filtrate and COVID specific proximal tubule cells (PTC) injury-a tryptophan paradigm. This approach is intended to allow for improved diagnostics and therapy for the long-haul sufferers.

Objectives Intracranial pressure (ICP) monitoring is recommended for severe traumatic brain injuries (TBI) but some data suggests it may not improve outcomes. The objective was to investigate the effect of ICP monitoring among TBI. Methods This retrospective observational cohort study (1/1/2015–6/1/2020) included severe TBI patients. Outcomes [discharge destination, length of stay (LOS)] were compared by ICP monitoring and were stratified by GCS (3 vs. 4–8), α Results Of the123 patients who met inclusion criteria, 47% received ICP monitoring. There were baseline differences in the two groups characteristics, ICP monitored patients were younger (p = 0.02), had a subarachnoid hemorrhage less often (p = 0.04), and a subdural hematoma more often (p = 0.04) than those without ICP monitors. ICP monitored patients had a significantly longer median LOS (12 vs. 3, p p = 0.06). Among patients with GCS = 3, ICP monitored patients had a longer LOS (p p = 0.01), but fewer were discharged to a skilled nursing facility or long-term care (p = 0.01). Conclusions For TBI patients, ICP monitoring was associated with an increased LOS, with no significant differences in discharge destinations when compared to those without ICP monitoring. However, among only those with a GCS of 4–8, ICP monitoring was associated with a decreased proportion of patients discharged to a skilled nursing facility or long-term acute care .

Background Apprehensions of undocumented immigrants in the Rio Grande Valley sector of the U.S.-Mexico border have grown to account for nearly half of all apprehensions at the border. The purpose of this study is to report the prevalence, mechanism, and pattern of traumatic injuries sustained by undocumented immigrants who crossed the U.S.-Mexico border at the Rio Grande Valley sector over a span of 5 years and were treated at a local American College of Surgeons verified Level II trauma center. Methods A retrospective chart review was conducted from January 2014 to December 2019. Demographics, comorbidities, injury severity score (ISS), mechanism of injury, anatomical part of the body affected, hospital and ICU length of stay (LOS), and treatment costs were analyzed. Descriptive statistics for demographics, injury location and cause, and temporal trends are reported. The impact of ISS or surgical intervention on hospital LOS was analyzed using an analysis of covariance (ANCOVA). Results Of 178 patients, 65.2% were male with an average age of 31 (range 0–67) years old and few comorbidities (88.8%) or social risk factors (86%). Patients most commonly sustained injuries secondary to a border fence-related incident (33.7%), fleeing (22.5%), or motor vehicle accident (16.9%). There were no clear temporal trends in the total number of patients injured, or in causes of injury, between 2014 and 2019. The majority of patients (60.7%) sustained extremity injuries, followed by spine injuries (20.2%). Border fence-related incidents and fleeing increased risk of extremity injuries (Odds ratio (OR) > 3; p < 0.005), whereas motor vehicle accidents increased risk of head and chest injuries (OR > 4; p < 0.004). Extremity injuries increased the odds (OR: 9.4, p p Conclusion In addition to border fence related injuries, undocumented immigrants also sustained injuries while fleeing and in motor vehicle accidents, among others. Extremity injuries, which were more likely with border fence-related incidents, were the most common type. This type of injury often requires surgical intervention and, therefore, a longer hospital stay for severe injuries.

Background: All-terrain vehicle (ATV) crashes result in severe morbidity in trauma. Limited data on these injury patterns come from large urban academic centers, but studies show increased use of ATVs in small rural communities with fewer resources, where these injuries are more likely to be treated. This study uses injury patterns to determine impact on community trauma systems based on length of stay. Methods: The trauma registry of a level II trauma center was reviewed for ATV crash patients from January 2015 to December 2020. Injury type and frequency were grouped by proportion and 95% confidence interval based on ‘score’ method, and co-incidences were first screened with Fisher’s exact test, with significant p-value18) and 65 pediatric patients. Injuries to skin/soft tissue and extremities were most common in both adult (68% and 42%, p

Background Intracranial pressure (ICP) monitoring has been recommended as a guiding tool for ICP treatment; however, data suggests invasive ICP monitoring had no better outcomes than those patients without it. We hypothesized that there is no difference in short term outcomes in patients with severe traumatic brain injury (TBI) who received invasive ICP monitoring compared to those who did not.Methods The trauma registry of a community Level II trauma center was queried from January 2015 to June 2020. Patients with severe TBI identified as Glasgow Coma Scale (GCS) ≤8 upon admission with an abnormal computed tomography (CT) scan, and those meeting Brain Injury Guideline (BIG) 3 (severe) were included. The data was analyzed in a logistic regression model to predict mortality, and a linear model to predict (log-transformed) hospital and ICU length of stay (LOS). Analyses were done in Rv4.0.2software.Results A total of 7,787 trauma patients were admitted during the study period, 592 were found to have GCS≤8 and of those, 118 met inclusion criteria. Forty-seven percent (n=55) received invasive ICP monitoring and 53 percent (n=63) did not. The majority (n=78, 66%) of patients were male. Median age was 35 for the ICP monitored group and 54 for the group with no ICP monitoring. The median GCS was 3 (IQR= 3,6) and the median ISS was 25 (IQR=17,26 or 27) for both groups. The ICU LOS was 5.3 days and hospital LOS 6.2 days longer for patients with ICP monitor compared to those without ICP monitor (p=0.001). The mortality rate of patients who received an ICP monitor was 19 in 55 (35%) compared to 27 of 63 (42%) for those who did not (p=0.84).Conclusions Patients with severe traumatic brain injury who received invasive ICP monitors had an increased ICU and hospital length of stay and no mortality difference when compared to those who did not. The use of an ICP monitor did not improve outcomes in this population of severe TBI patients, particularly for those who did not require neurosurgery.Level of Evidence: Level IV

Background:Odontoid fractures are common and projected to increase. Comorbidities compound risk of surgery and balancing the risk of non-operative management is controversial. Stable fractures are managed based on patient comorbidity with suspected clinical prognosis. Type I and III fractures are typically managed safely with cervical orthoses. Management decisions of type II fractures however, come under frequent debate. This paper evaluates overall morbidity and mortality, and outcomes of operative and non-operative management. Methods:We performed national database review of C2 fractures from January 2014 to December 2019. Patients were divided into categories based on Glasgow Coma Scale (GCS) and Injury Severity Score (ISS). Outcomes data considered hospital admission, Intensive Care Unit (ICU) admission, hospital length of stay (LOS), ICU LOS, and mortality. Logistic regression was used for mortality, hospital admission, and ICU admission. Odds ratios (OR) and 95% confidence intervals (CI) were calculated from the logistic regression models. The Kruskal-Wallis test was used to compare the hospital and ICU LOS based on surgery overall, and by GCS and ISS.Results:42,003 patients were identified, 9,187 had surgery with overall mortality rate of 0.7%. There was a younger operative median age (67) and interquartile range (IQR: 47, 78) than non-operative group (73, IQR: 56, 83). Both had the same median ISS score (10). Surgery was associated with lower rates of mortality, from 0.1% to 0.9% mortality for non-operative. Mild or moderate GCS mortality improved operative (0.07%) to non-operative (0.23%). Severe GCS patients with surgery had significantly improved mortality rates patients without (0.29% vs 7.69%, respectively). Surgery increased ICU admissions for every ISS category. Severe GCS had higher chances of ICU admission, but no interaction with surgery. Operative patients had longer hospital and ICU stays. For all GCS and ISS categories, hospital and ICU LOS was longer for operative patients.Conclusions:This review demonstrates significant improvement in mortality with operative management. Standard non-operative management of type I and III C2 fractures is appropriate. Surgeons should consider operating on type II odontoid fractures unless patient cannot undertake the surgical risks of induction with general anesthesia.Level of evidence: Level IV

Background:Firearm related mortality in the USA surpassed all other developed countries. This study hypothesizes that injury patterns, weapon type, and mortality differ between suicide groups as opposed to homicide. Methods:The American College of Surgeons National Trauma Database was queried from January 2017 to December 2019. All firearm related injuries were included, and weapon type was abstracted. Differences between homicide and suicide groups by sex, age, race, and injury severity were compared using a Mann-Whitney test for numerical data and Fisher’s exact test for categorical data. The association between weapon type and mortality relative to suicide as opposed to homicide was assessed in Fisher’s exact tests. Significance was defined as p < 0.05.Results:There were 100,031 homicide and 11,714 suicide subjects that met inclusion criteria. Homicides were mostly assault victims (97.6%), male (88%), African-American (62%), had less severe injury (mean ISS 12.07) and a median age of 20 years old (IQR: 14, 30, p < 0.01). Suicides were mostly male (83%), white (79%), had more severe injury (mean ISS 20.73), and a median age of 36 years old (IQR: 19, 54, p < 0.01). Suicide group had higher odds of head/neck (OR=13.6) or face (OR=5.7) injuries, with lower odds of injury to chest (OR=0.55), abdominal or pelvic contents (OR=0.25), extremities or pelvic girdle (OR=0.15), or superficial soft tissue (OR=0.32). Mortality rate was higher for suicide group (44.8%; 95% confidence interval (CI): 43.9%, 45.7%) compared to the homicide group (11.5%; 95% CI: 11.3%, 11.7%). Conclusions:Suicide had higher mortality, more severe injuries, and more head/neck/facial injuries than homicide. Majority of suicides were with handguns. Level of Evidence: Level IV

ObjectivesFalling from height may lead to significant injuries and time hospitalized; however, there are few studies comparing the specific mechanism of fall. The purpose of this study was to compare injuries from falls after attempting to cross the USA-Mexico border fence (intentional) with injuries from domestic falls (unintentional) of comparable height.MethodsThis retrospective cohort study included all patients admitted after a fall from a height of 15–30 ft to a level II trauma center between April 2014 and November 2019. Patient characteristics were compared by falls from the border fence with those who fell domestically. Fisher’s exact test, χ2test and Wilcoxon Mann-Whitney U test were used as appropriate. A significance level of αResultsOf the 124 patients included, 64 (52%) were falls from the border fence while 60 (48%) were domestic falls. Patients sustaining injuries from border falls were on average younger than patients who had domestic falls (32.6 (10) vs 40.0 (16), p=0.002), more likely males (58% vs 41%, pConclusionPatients sustaining injuries from border crossing falls were slightly younger, and although fell from higher, had a lower ISS, more extremity injuries, and fewer were admitted to the ICU compared with patients sustaining falls domestically. There was no difference in mortality between groups.Level of evidenceLevel III, retrospective study.

Highlights • Colon is a potential site for solitary metastasis from renal cell carcinoma (RCC). • Recurrent disease after curative nephrectomy usually occurs within three years. • Metastatic RCC should be considered in RCC patients with bowel obstruction., Introduction Renal cell carcinoma (RCC) is the most common renal malignancy in adults. Metastatic disease is relatively common at presentation and frequently involves the lung, bone, brain, liver and adrenal glands. After curative resection, there is a 30–40% risk of recurrence, and a 10% risk of developing metastatic disease after 5 years. The gastrointestinal tract, particularly the colon, represents a very uncommon site of late metastatic disease. Presentation of Case We present a case of a 67 year-old-male who underwent a left radical nephrectomy for RCC 9 years before presenting with a metastatic large bowel obstruction. He was later found to have a near-completely obstructing mass in the rectosigmoid colon and underwent a sigmoidectomy with anterior resection of the upper rectum. Histopathology confirmed metastatic RCC confined to the colonic wall with negative microscopic margins. Discussion The tendency of RCC to metastasize to unusual sites such as the pancreas or thyroid gland has been widely reported. However, cases of colon metastasis from RCC are extremely rare. Despite the absence of randomized prospective data, widespread consensus supports the surgical treatment of solitary and oligometastatic disease in light of the poor patient outcomes in non-surgically treated disease (Milovic et al., 2013) [3]. Multiple groups have reported favorable outcomes for surgically resected solitary metastatic disease with long disease-free intervals and good performance status. Conclusion The colon is a potential, though uncommon, site for solitary metastasis from RCC. The clinical presentation is frequently several years after initial curative resection. Oncologic resection with negative margins may result in long-term survival in patients with isolated metastatic disease.

Background With the increasing use of the robotic platform in general surgery, whether 8-mm ports should be closed comes into question. We sought to characterize the incidence of port-site hernias (PSHs) among patients undergoing robotic-assisted general surgery. Methods A retrospective chart review of a single institutional database identified patients who underwent robotic-assisted general surgery from July 2010 to December 2016. For each patient, the number, type, location, and size of all ports were collected. Twelve-millimeter port sites were routinely closed, whereas 5-mm and 8-mm port sites were not. PSH was detected on review of documented physical examination and of postoperative cross-sectional imaging, when available, in which case it was defined as a disruption of the fascia with or without eventration of tissue at a site of prior port placement. Results One hundred and seventy-eight patients underwent robotic-assisted general surgery, with 725 total ports: 433 8-mm working ports, 72 12-mm working ports, 178 12-mm camera ports, and 42 5-mm assistant ports. Ninety-four percent of the patients were men, the mean age was 63 ± 12, body mass index was 29 ± 7 kg/m2, and the median American Society of Anesthesiologists score was 3. Types of cases included 68 rectal (38.2%), 36 colon (20.2%), 25 hepatopancreatobiliary (14.0%), 21 inguinal hernia (11.8%), and 28 “other” (15.7%) operations. At a median follow-up of 193 d, there were three PSHs through 8-mm port sites (0.7%), two PSHs through 12-mm port sites (0.8%), and no PSH through 5-mm port sites. Two of the three 8-mm PSHs occurred in the early postoperative period and required emergent repair due to small bowel incarceration. Conclusions PSHs through 8-mm robotic port sites occur infrequently but can cause significant morbidity. Further investigation with longer follow-up is warranted to better understand the true incidence of robotic PSH.

Objective Damage-control laparotomy, initially developed for trauma patients, has expanded into the general surgery arena. Little evidence exists regarding the utility of damage-control celiotomy (DCCT) in elderly nontrauma patients. Our objective was to review the management and outcomes of DCCT in elderly patients with intra-abdominal catastrophes. Methods Retrospective chart review from 1998 to 2008 identified cases of DCCT. Demographics, comorbidities, surgical techniques, morbidity, long-term disposition, and mortality were analyzed. Results From 210 patients with emergency surgeries, 88 (42%) patients with DCCT were identified, 33 (38%) were greater than 65 years old and 55 (63%) were ≤65 years old. The average APACHE IV score for the elderly was 84 ± 2 versus 68 ± 2 for the younger group ( p Conclusions Age is not an independent predictor of worse outcomes in patients managed by the DCCT technique after intra-abdominal catastrophes. This management technique should be considered for elderly patients who require DCCT.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs) increase morbidity and mortality. We examined the impact of the MRSA bundle on SSIs. METHODS: Data regarding the implementation of the MRSA bundle from 2007 to 2008 were obtained, including admission and discharge MRSA screenings, overall MRSA infections, and cardiac and orthopedic SSIs. Chi-square was used for all comparisons. RESULTS: A significant decrease in MRSA transmission from a 5.8 to 3.0 per 1,000 bed-days (P .05) was found after implementation of the MRSA bundle. Overall MRSA nosocomial infections decreased from 2.0 to 1.0 per 1,000 bed-days (P .016). There was a statistically significant decrease in overall SSIs (P .05), with a 65% decrease in orthopaedic MRSA SSIs and 1% decrease in cardiac MRSA SSIs. CONCLUSION: Our data demonstrate that successful implementation of the MRSA bundle significantly decreases MRSA transmission between patients, the overall number of nosocomial MRSA infections, and MRSA SSIs. Published by Elsevier Inc.

Introduction. Familial hypercholesterolemia (FH) is caused by nonfunctioning low-density lipoprotein (LDL) receptors, resulting in high serum cholesterol. Two types of FH are described: the heterozygous form is diagnosed in adults and responds well to medical therapy; the homozygous form is rare, diagnosed in children, and often requires multiple treatments to prevent complications. Cholesterol accumulation in tissues produces common clinical manifestations including cutaneous xanthomas, coronary artery disease, and aortic stenosis. Treatment options consist of lifestyle modifications, lipid-lowering medications, LDL aphaeresis, and orthotopic liver transplantation (OLT).Case Presentation. Two patients with FH presented at young ages due to characteristic cutaneous xanthomas. The patients underwent cardiac testing that revealed atherosclerotic changes. The patients received maximal medical therapy, but only experienced a small decrease in serum cholesterol and LDL levels. After several years of medical treatment without improvement of symptoms, the patients were listed for OLT. The transplantations were successful, and only one patient had a postoperative complication of acute rejection, treated successfully. Currently, both patients are doing well with regression of the cutaneous xanthomas and atherosclerotic changes.Conclusion. OLT is a safe and effective option for patients with homozygous FH refractory to maximal medical therapy and may represent the optimal treatment for these patients.

Background Perioperative atrial arrhythmias (PAAs) in noncardiothoracic patients have poorly defined risk factors and management. Methods The surgical intensive care unit database was queried for patients who developed PAAs from 2008 to 2009. Demographics, comorbidities, preoperative data (electrocardiography, chest x-rays, laboratory results), medications, intraoperative variables, management, and outcomes of atrial arrhythmias were collected. Controls were randomly chosen in a 3:1 ratio. Comparisons were performed using χ2 tests, Student's t tests, or nonparametric comparisons as appropriate. Multivariate logistic regression was performed. Results Five hundred sixty-one patients were admitted to the surgical intensive care unit. Three hundred fifty-four (63%) had noncardiothoracic surgery, and 30 (8.5%) developed PAAs. The mean age of patients with PAAs was 66 ± 7.3 years, compared with 64 ± 11 years for controls (P = NS), with most patients undergoing general (60%) and vascular (33%) surgery. PAA patients were more likely to have coronary artery disease (P = .029), cardiomegaly (P = .011), and premature atrial contractions (P = .016) and to take aspirin (P = .010). On multivariate logistic regression, predictors of atrial arrhythmias were premature atrial contractions, preoperative hypokalemia, intraoperative adverse events, and cardiomegaly. Most PAA patients received amiodarone (63%). Ten percent required electrical cardioversion, and 26% received anticoagulation. PAA patients had significantly longer intensive care unit lengths of stay (P = .032). Conclusion Coronary artery disease, cardiomegaly, hypokalemia, and premature atrial contractions were significantly associated with PAAs in noncardiothoracic patients. Prospective studies are needed to define treatment guidelines.

Damage-control laparotomy, initially developed for trauma patients, has expanded into the general surgery arena. Little evidence exists regarding the utility of damage-control celiotomy (DCCT) in elderly nontrauma patients. Our objective was to review the management and outcomes of DCCT in elderly patients with intra-abdominal catastrophes.Retrospective chart review from 1998 to 2008 identified cases of DCCT. Demographics, comorbidities, surgical techniques, morbidity, long-term disposition, and mortality were analyzed.From 210 patients with emergency surgeries, 88 (42%) patients with DCCT were identified, 33 (38%) were greater than 65 years old and 55 (63%) were ≤ 65 years old. The average APACHE IV score for the elderly was 84 ± 2 versus 68 ± 2 for the younger group (p.001). Elderly patients had significantly higher comorbidites with respect to cardiovascular, pulmonary, and renal disease. When comparing the 2 groups, there were no significant differences in-hospital or intensive care unit lengths of stay or ventilator days. There were also no significant differences in complications and disposition. Using Cox proportional hazards analysis, age was not an independent predictor of 30-day mortality.Age is not an independent predictor of worse outcomes in patients managed by the DCCT technique after intra-abdominal catastrophes. This management technique should be considered for elderly patients who require DCCT.

Background Little is known regarding the morbidity and mortality of the open abdomen technique in older nontrauma patients. Methods A retrospective chart review identified cases of emergency laparotomy in which open abdomens were used. Results Eighty-eight patients with open Acute Physiology and Chronic Health Evaluation (APACHE) abdomens were identified. An overall mortality rate of 34%, consistent with mortality predicted by APACHE IV score, was seen. Common complications included ventilator-associated pneumonia (30%) and acute renal failure (22%). A perioperative APACHE IV score of greater than 65 and an albumin level less than 2.5 g/dL were found to predict an increased likelihood of long-term assisted care placement after discharge from the acute care setting. Conclusions The use of the open abdomen technique in older nontrauma patients carries acceptable morbidity and mortality given the acuity of disease. Focus on ventilator-associated pneumonia prevention and aggressive fluid resuscitation to avoid acute renal failure may improve outcomes. Need for long-term assisted care placement can be predicted early after admission based on the APACHE IV score or albumin level.