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Frailty is defined as a state of decreased physiologic reserve contributing to functional decline and adverse outcomes. Racial disparities in frail patients have been described sparsely in the literature. We aimed to assess whether race influences frailty status in geriatric patients undergoing revascularization for peripheral artery disease (PAD) with chronic limb-threatening ischemia (CLTI). A 5-year analysis of the National Surgical Quality Improvement Program database included all geriatric (65 years and older) patients who underwent revascularization for lower extremity PAD with CLTI. The frailty index was calculated using a 11-variable modified frailty index and a cutoff of 0.27 indicated frail status. The primary outcome was an association of race or ethnicity with frailty status. We included 7,837 geriatric patients who underwent a surgical procedure (open: 55.2%) for PAD with CLTI. Mean age of patients was 75.4 years, 63.8% were male, 24.1% (n = 1,889) were frail, and 21.8% (n = 1,710) were African American (AA). Overall complication rate was 11.2% (n = 909) and overall mortality rate was 1.9% (n = 148). AA patients were more likely to be frail than White patients (29.6% v 23.9%; P =.03). AA and Hispanic patients were more likely to have complications (P =.03 and P =.001) and require readmission (P =.015 and P =.001) compared with White and non-Hispanic patients, respectively. Frail AA and frail Hispanic patients were more likely to have 30-day complications and readmission compared with frail White and frail non-Hispanic patients, respectively. Race and ethnicity influence frailty status in geriatric patients with PAD and CLTI. These disparities exist regardless of age, sex, comorbid conditions, and type of operative procedure. Additional studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors to improve outcomes. [ABSTRACT FROM AUTHOR]

Hf and Zr contamination during immersion in process solutions is most likely to occur in neutral and caustic solutions. Both Hf and Zr contamination are introduced onto the wafer surface if they are present in an ammonium hydroxide peroxide mixture solution (which is caustic), but such contamination is removed using existing acid cleans. Large mounts of wafer-to-wafer cross contamination occurs in plasma etch tools. Particles can cause cross contamination in a thermal reactor during high-temperature anneals of high-k dielectric layers. Residual surface cross contamination does not diffuse into the wafers during thermal processing. If contamination remains on a wafer, gate oxide integrity degradation is only observed at high concentrations. Near surface minority carrier lifetime is also affected, but bulk lifetime is not. Index Terms--Cleaning, cross contamination, hafnium dioxide (Hf[O.sub.2]), high-k dielectric, zirconium dioxide (Zr[O.sub.2]).

Frailty syndrome is an established predictor of adverse outcomes after surgical procedures. Our study aimed to compare the simplified National Surgical Quality Improvement Program 5-factor–modified frailty index (mFI-5) to its prior 11-factor–modified frailty index (mFI-11) with respect to the predictive ability for mortality, postoperative complications, and unplanned 30-d readmission in patients undergoing lower limb amputation. The National Surgical Quality Improvement Program (2005-2012) databank was queried for all geriatric patients (>65 y) who underwent above-knee and below-knee amputations. We calculated each mFI by dividing the number of factors present for a patient by the total number of available factors. To assess the correlation between the mFI-5 and mFI-11, we used Spearman's rho rank coefficient. We then compared the two indices for each outcome (30-d complication, 30-d mortality, and 30-d readmission) and C-Statistic using predictive models. A total of 8681 patients were included with mean age of 76 ± 9 y, complication rate 35.8%, mortality rate 10.2%, and readmission rate 15.9%. There was no difference in type of amputation in frail and nonfrail. Correlation between the mFI-5 and mFI-11 was above 0.9 for all outcome measures. Both mFI-5 and mFI-11 indexes had strong predictive ability for mortality, postoperative complications, and 30-d readmissions. In patients undergoing major lower limb amputation, we found mFI-5 and the mFI-11 were equally effective in predicting postoperative outcomes. Frailty remained a strong predictor of postoperative complications, mortality, and 30-d readmission. [ABSTRACT FROM AUTHOR]

Objective: To assess the safety and efficacy of retrograde arterial recanalization of infrainguinal CTOs in the OBL setting. Methods: Consecutive patients who underwent interventions for lower extremity CTOs in the OBL setting by a single vascular surgeon were evaluated (January 2013-November 2017). If antegrade crossing was not possible, then a retrograde distal approach was used. Patient characteristics, CTO location, procedural time, contrast, anticoagulation and radiation doses and costs were recorded. Post-procedural complications were documented on post-procedure day 1 and 10-14 days post procedure. Three groups were compared: group 1 —antegrade approach for femoropopliteal CTOs; group 2 —antegrade approach for tibial CTOs, and; group 3 —retrograde approach for femoropopliteal and tibial CTOs. Results: Two hundred and thirty-seven patients were studied. In 39 (16.5%), the lesions could not be crossed. A successful antegrade approach was used in 185 of them, of which 69% (group 1, n = 128) patients had femoropopliteal CTOs and 31% (group 2, n = 57) had tibial CTOs. Fourteen patients (5.9%, group 3) were treated by retrograde distal approach. Group 3 patients received higher contrast doses than groups 1 and 2 (p = 0.01). However, patients in groups 1 and 2 received similar contrast doses. Group 3 patients had the highest operative time and treatment costs followed by group 1 and then group 2 (p = 0.01). Three femoral pseudoaneurysms were noted in group 1, and 2 in group 2. No complications were seen in group 3. Conclusions: Although the operative times, costs, radiation and contrast dose are higher with retrograde arterial access, it represents a safe and effective method for the crossing of CTO infrainguinal lesions in an ambulatory venue. [ABSTRACT FROM AUTHOR]

In this article, Forte Genescà and colleagues aimed to determine the relationship between sarcopenia based on several psoas computed tomography (CT)-derived measurements and the 5-year survival after AAA repair [[4]]. After elaborate statistical analysis, they were able to demonstrate that all CT-derived psoas muscle sarcopenia markers were associated with survival after AAA surgery and there was no benefit by combining them with anthropometric measurements rather than using simple quantification of TPA. Comparison between several CT-derived psoas muscle sarcopenia markers for predicting survival after abdominal aortic aneurysm repair. [Extracted from the article]

Abstract Background Failure to rescue (FTR) is an important measure of quality of care. The aim of this study was to assess FTR in patients with colon cancer (CC) who underwent surgical resection. We hypothesized that patient managed in urban centers had lower FTR. Methods We performed a 1-y (2011) retrospective analysis of the National Inpatient Sample database and identified all patients with CC who underwent surgical management. Patients were stratified based on the location of treatment: urban versus rural. Outcome measure was FTR, which was defined as death after major complications. Regression analysis was performed to evaluate the independent predictors of FTR. Results A total of 49,789 patients with CC who underwent surgery were analyzed. The mean age was 71 ± 20.2 y and 59% were males. About 21.5% patients developed in-hospital complications. The overall rates of complications, mortality, and FTR were 21.5%, 3.0%, and 33.8% respectively. Patient managed in rural centers had higher FTR compared with urban centers (39.5% versus 30.1%, P = 0.01). On regression analysis after controlling for age, gender, type of procedure, Charlson Comorbidity Index, and insurance status, management in rural center was independently associated with FTR (odds ratio: 1.9 [1.4-3.7]). On subanalysis of urban centers, management in teaching urban hospital was independently associated with higher FTR (odds ratio: 1.4 [1.2-3.8]). Conclusions Disparities exist among centers managing patients with CC undergoing surgical intervention. Rural centers have higher FTR compared with similar cohort of patients managed in urban centers. Teaching urban hospital performed worse than nonteaching urban centers. Understanding the reason for these differences may help standardize care across centers and help improve patient outcomes. [ABSTRACT FROM AUTHOR]

Frailty has been noted as a powerful predictive preoperative tool for 30-day postoperative complications. We sought to evaluate the association between frailty and postoperative outcomes after colectomy for Clostridium difficile colitis. The National Surgical Quality and Improvement Program cross-institutional database was used for this study. Data from 470 patients with a diagnosis of C. difficile colitis were used in the study. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used with the National Surgical Quality and Improvement Program to assess frailty. Outcome measures included serious morbidity, overall morbidity, and Clavien IV (requiring ICU) and Clavien V (mortality) complications. The median age was 70 years and body mass index was 26.9 kg/m2. 55.6 per cent of patients were females. 98.5 per cent of patients were assigned American Society of Anesthesiologists Class III or higher. The median mFI was 0.27 (0-0.63). Because mFI increased from 0 (non-frail) to 0.55 and above, the overall morbidity increased from 53.3 per cent to 84.4 per cent and serious morbidity increased from 43.3 per cent to 78.1 per cent. The Clavien IV complication rate increased from 30.0 per cent to 75.0 per cent. The mortality rate increased from 6.7 per cent to 56.2 per cent. On a multivariate analysis, mFI was an independent predictor of overall morbidity (AOR: 13.0; P < 0.05), mortality (AOR: 8.8; P = 0.018), cardiopulmonary complications (AOR: 6.8; P = 0.026), and prolonged length of hospital stay (AOR: 6.6; P = 0.045). Frailty is associated with increased risk of complications in C. difficile colitis patients undergoing colectomy. mFI is an easy-to-use tool and can play an important role in the risk stratification of these patients who generally have significant morbidity and mortality to begin with. [ABSTRACT FROM AUTHOR]

Background: Increasing firearm violence has resulted in a strong drive for stricter firearm legislations. Aim of this study was to determine the relationship between firearm legislations and firearm-related injuries across states in the United States. Methods: We performed a retrospective analysis of all patients with trauma related hospitalization using the 2011 Nationwide Inpatient Sample database. Patients with firearm-related injury were identified using E-codes. States were dichotomized into strict firearm laws [SFL] or non-strict firearm laws [Non-SFL] states based on Brady Center score. Outcome measures were the rate of firearm injury and firearm mortality. Linear Regression and correlation analysis were used to assess outcomes among states. Results: 1,277,250 patients with trauma related hospitalization across 44 states were included of which, 2,583 patients had firearm-related injuries. Ten states were categorized as SFL and 34 states as Non-SFL. Mean rate of firearm related injury per 1000 trauma patients was lower in SFL states (1.3±0.5 vs. 2.1±1.4; p=0.006) and negatively correlated with Brady score (R2 linear=-0.07; p=0.04). SFL states had a 28% lower incidence of firearm related injuries compared to Non-SFL states (Beta coefficient, -0.28; 95% CI, -1.7- -0.06; p=0.04). Firearm related mortalities resulted in overall 9,722 potential life years lost and more so in the non-SFL states (p=0.001). Conclusions: States without SFL have higher firearm related injury rates, higher firearm related mortality rate, and significant potential years of life lost compared to SFL states. Further analysis of differences in the legislation between SFL and non-SFL states may help reduce firearm related injury rate. [ABSTRACT FROM AUTHOR]

Disparities in the management of patients with various medical conditions are well established. Colorectal diseases continue to remain one of the most common causes for surgical intervention. The aim of this study was to assess disparities (rural versus urban) in the surgical management of patients with noncancerous benign colorectal diseases. We hypothesized that there is no difference among rural versus urban centers (UC) in the surgical management for noncancerous benign colorectal diseases. The national estimates of surgical procedures for benign colorectal diseases from the National Inpatient Sample database 2011 representing 20 per cent of all in-patient admissions were abstracted. Patients undergoing procedures (abscess drainage, hemmoroidectomy, fistulectomy, and bowel resections) were included. Patients with colon cancer and those who underwent emergency surgery were excluded. The population was divided into two groups: urban and rural, based on the location of treatment. Outcome measures were in-hospital complications, mortality, and hospital costs. Subanalysis of UC was preformed: centers with colorectal surgeons and centers without colorectal surgeons. Regression analysis was performed. A total of 20,617 patients who underwent surgical intervention for benign colorectal diseases across 496 (urban: 342, rural: 154) centers, were included. Of the UC, 38.3 per cent centers had colorectal surgeons. Patients managed in UC had lower complication rate (7.6% vs 10.2%, P < 0.001), shorter hospital length of stay (4.7 ± 3.1 vs 5.9 ± 3.6 days, P < 0.001), and higher hospital costs ($56,820 ± $27,691 vs $49,341 ± $2,598, P < 0.001) compared with rural centers. On subanalysis, patients managed in UC with colorectal surgeons had 11 per cent lower incidence of in-hospital complications [odds ratio: 0.89 (95% confidence interval: 0.76-0.94)] and a shorter hospital length of stay [Beta: -0.72 (95% confidence interval: -0.81 to -0.65)] when compared with patients managed in UC without colorectal specialization. Disparities exit in outcomes of the patients with noncancerous benign colorectal diseases managed surgically in urban versus rural centers. Specialized care with colorectal surgeons at UC helps reduce adverse patient outcomes. Steps to provide effective and safe surgical care in a cost-effective manner across rural as well as UC are warranted.Level Of Evidence: Level III, retrospective cohort analysis. [ABSTRACT FROM AUTHOR]

Introduction: Distracted driving (talking and/or texting) is a growing public safety problem, with increasing incidence among adult drivers. The aim of this study was to identify the incidence of distracted driving (DD) among health care providers and to create awareness against DD. We hypothesized that distracted driving is prevalent among health care providers and a preventive campaign against distracted driving would effectively decrease distracted driving among health care providers.Methods: We performed a 4-phase prospective interventional study of all health care providers at our level 1 trauma center. Phase 1: one week of pre-intervention observation; phase 2: one week of intervention; phase 3: one week of postintervention observation; and phase 4: one week of 6 months of postintervention observation. Observations were performed outside employee parking garage at the following time intervals: 6:30-8:30 a.m., 4:40-5:30 p.m., and 6:30-7:30 p.m. Intervention included an e-mail survey, pamphlets and banners in the hospital cafeteria, and a postintervention survey. Hospital employees were identified with badges and scrubs, employees exiting through employee gate, and parking pass on the car. Outcome measure was incidence of DD pre, post, and 6 months postintervention.Results: A total of 15,416 observations (pre: 6,639, post: 4,220, 6 months post: 4,557) and 520 survey responses were collected. The incident of DD was 11.8% among health care providers. There was a significant reduction in DD in each time interval of observation between pre- and postintervention. On subanalysis, there was a significant decrease in talking (P = .0001) and texting (P = .01) while driving postintervention compared to pre-intervention. In the survey, 35.5% of respondents admitted to DD and 4.5% respondents were involved in an accident due to DD. We found that 77% respondents felt more informed after the survey and 91% respondents supported a state legislation against DD. The reduction in the incidence of DD postintervention was sustained even at 6-month follow-up.Conclusion: There was a 32% reduction in the incidence of distracted driving postintervention, which remained low even at 6-month follow-up. Implementation of an effective injury prevention campaign could reduce the incidence of distracted driving nationally. [ABSTRACT FROM AUTHOR]

Introduction Whole body CT (WBCT) scan is known to be associated with significant radiation risk especially in pediatric trauma patients. The aim of this study was to assess the use WBCT scan across trauma centers for the management of pediatric trauma patients. Methods We performed a two year (2011–2012) retrospective analysis of the National Trauma Data Bank. Pediatric (age ≤ 18 years) trauma patients managed in level I or II adult or pediatric trauma centers with a head, neck, thoracic, or abdominal CT scan were included. WBCT scan was defined as CT scan of the head, neck, thorax, and abdomen. Patients were stratified into two groups: patients managed in adult centers and patients managed in designated pediatric centers. Outcome measure was use of WBCT. Multivariate logistic regression analysis was performed. Results A total of 30,667 pediatric trauma patients were included of which; 38.3% (n = 11,748) were managed in designated pediatric centers. 26.1% (n = 8013) patients received a WBCT. The use of WBCT scan was significantly higher in adult trauma centers in comparison to pediatric centers (31.4% vs. 17.6%, p = 0.001). There was no difference in mortality rate between the two groups (2.2% vs. 2.1%, p = 0.37). After adjusting for all confounding factors, pediatric patients managed in adult centers were 1.8 times more likely to receive a WBCT compared to patients managed in pediatric centers (OR [95% CI]: 1.8 [1.3–2.1], p = 0.001). Conclusions Variability exists in the use of WBCT scan across trauma centers with no difference in patient outcomes. Pediatric patients managed in adult trauma centers were more likely to be managed with WBCT, increasing their risk for radiation without a difference in outcomes. Establishing guidelines for minimizing the use of WBCT across centers is warranted. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to assess the seasonal variation in emergency general surgery (EGS) admissions. Background: Seasonal variation in medical conditions is well established; however, its impact on EGS cases remains unclear. Methods: The National Inpatient Sample (NIS) database was queried over an 8-year period (2004-2011) for all patients with diagnosis of acute appendicitis, acute cholecystitis, and diverticulitis. Elective admissions were excluded. The following data for each admission were recorded: age, sex, race, admission month, major operative procedure, hospital region, and mortality. Seasons were defined as follows: Spring (March, April, May), Summer (June, July, August), Fall (September, October, November), and Winter (December, January, February). X11 procedure and spectral analysis were performed to confirm seasonal variation. Results: A total of 63,911,033 admission records were evaluated of which 493,569 were appendicitis, 395,838 were cholecystitis, and 412,163 were diverticulitis. Seasonal variation is confirmed in EGS (F=159.12, P<0.0001) admissions. In the subanalysis, seasonal variation was found in acute appendicitis (F=119.62, P<0.0001), acute cholecystitis (F=37.13, P<0.0001), and diverticulitis (F=69.90, P<0.0001). The average monthly EGS admission in Winter was 11,322±674. The average monthly EGS admission in Summer was higher than that of Winter by 13.6% (n=1542; 95% CI: 1180-1904, P<0.001). Conclusions: Hospitalization due to EGS adheres to a consistent cyclical pattern, with more admissions occurring during the Summer months. Although the reasons for this variability are unknown, this information may be useful for hospital resource reallocation and staffing. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury. METHODS: We performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention. RESULTS: A total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs 16%; P = .10) between the 2 groups. CONCLUSIONS: In a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan. [ABSTRACT FROM AUTHOR]

Introduction: Computed Tomography Angiography (CTA) is being used to identify traumatic intracranial aneurysms (TICA) in patients with findings such as skull fracture and intracranial haemorrhage on initial Computed Tomography (CT) scans after blunt traumatic brain injury (TBI). However, the incidence of TICA in patients with blunt TBI is unknown. The aim of this study is to report the incidence of TICA in patients with blunt TBI and to assess the utility of CTA in detecting these lesions. Methods: A 10-year retrospective study (2003-2012) was performed at a Level 1 trauma centre. All patients with blunt TBI who had an initial non-contrasted head CT scan and a follow-up head CTA were included. Head CTAs were then reviewed by a single investigator and TICAs were identified. The primary outcome measure was incidence of TICA in blunt TBI. Results: A total of 10 257 patients with blunt TBI were identified, out of which 459 patients were included in the analysis. Mean age was 47.3 ± 22.5, the majority were male (65.1%) and median ISS was 16 [9-25]. Thirty-six patients (7.8%) had intracranial aneurysm, of which three patients (0.65%) had TICAs. Conclusion: The incidence of traumatic intracranial aneurysm was exceedingly low (0.65%) over 10-years. This study adds to the growing literature questioning the empiric use of CTA for detecting vascular injuries in patients with blunt TBI. [ABSTRACT FROM AUTHOR]

Background Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring for traumatic brain injury (TBI) patients with a Glasgow Coma Scale score of 8 or less with an abnormal head computed tomography, or a normal head computed tomography scan with systolic blood pressure ≤90 mm Hg, posturing, or in patients of age ≥40. The benefits of these guidelines on outcome remain unproven. We hypothesized that adherence to BTF guidelines for ICP monitoring does not improve outcomes in patients with TBI. Methods All TBI patients with an admission Glasgow Coma Scale ≤8 admitted to our level I trauma center over a 3-y period were identified. Adherence to the individual components of our institutional TBI Bundle (ICP monitoring, SpO2 ≥95%, PaCO2 30-39 mm Hg, systolic blood pressure ≥90 mm Hg, cerebral perfusion pressure ≥60 mm Hg, ICP ≤25 mm Hg, and temperature 36°C-37°C) was assessed. Patients were stratified into two groups as follows: patients with ICP monitoring (ICP) and patients without ICP monitoring (no-ICP). Outcome measures were survival and discharge disposition. Multivariate regression analysis was performed. Results We identified 2618 TBI patients, 261 of whom met the BTF criteria for ICP monitoring. After excluding those with nonsurvivable injuries (n = 67), 194 patients were available for analysis. The two groups were similar in demographics and severity of head injury. Survival rate was higher in the no-ICP group compared with that in the ICP group (98% versus 76%, P < 0.004). Non-monitored patients were discharged with higher levels of function per discharge location (28% home versus 4% home; P < 0.001). Patients without ICP monitoring were 1.21 times more likely to survive compared with that of patients with ICP monitoring (odds ratio: 1.21, 95% confidence interval [1.1-1.9], P = 0.01). In the ICP group, the overall compliance rate to the ICP and cerebral perfusion pressure goals as required by the BTF guidelines was poor. Conclusions Our data suggest that there is a subset of patients meeting BTF criteria for ICP monitoring that do well without ICP monitoring. This finding should provoke reevaluation of the indication and utility of ICP monitoring in TBI patients. [ABSTRACT FROM AUTHOR]