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Background Geriatric patients are at higher risk for adverse outcomes after injury because of their altered physiological reserve. Mortality after trauma laparotomy remains high; however, outcomes in geriatric patients after trauma laparotomy have not been well established. The aim of our study was to identify factors predicting mortality in geriatric trauma patients undergoing laparotomy. Methods A retrospective study was performed of all trauma patients undergoing a laparotomy at our level 1 trauma center over a 6-y period (2006-2012). Patients with age ≥55 y who underwent a trauma laparotomy were included. Patients with head abbreviated injury scale (AIS) score ≥ 3 or thorax AIS ≥ 3 were excluded. Our primary outcome measure was mortality. Significant factors in univariate regression model were used in multivariate regression analysis to evaluate the factors predicting mortality. Results A total of 1150 patients underwent a trauma laparotomy. Of which 90 patients met inclusion criteria. The mean age was 67 ± 10 y, 63% were male, and median abdominal AIS was 3 (2-4). Overall mortality rate was 23.3% (21/90) and progressively increased with age (P = 0.013). Age (P = 0.02) and lactate (P = 0.02) were the independent predictors of mortality in geriatric patients undergoing laparotomy. Conclusions Mortality rate after trauma laparotomy increases with increasing age. Age and admission lactate were the predictors of mortality in geriatric population undergoing trauma laparotomies. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patients with fatal gunshot wounds (GSWs) to the head often have poor outcomes but are ideal candidates for organ donation. The purpose of this study was to evaluate the effects of aggressive management on organ donation in patient with fatal GSWs to the head. METHODS: A 5-year review of all patients at a trauma center with GSWs to the head was performed. The primary outcome was organ donation after fatal GSW to the head. RESULTS: A total of 98 patients with fatal GSWs to the head were identified. The rate of potential organ donation was 70%, of whom 49% eventually donated 72 solid organs. Twenty-five percent of patients were not considered eligible for donation as a result of disseminated intravascular coagulopathy. The T4 protocol lead to significant organ procurement rates (odds ratio, 3.6; 95% confidence interval, 1.3 to 9.6; P = .01). Failures to organ donation in eligible patients were due to lack of family consent and cardiac arrest. CONCLUSIONS: Organ donation after fatal GSW to the head is a legitimate goal. Management goals should focus on early aggressive resuscitation and correction of coagulopathy. [ABSTRACT FROM AUTHOR]

Abstract: Background: The gap between demand of transplantable organs and their supply continues to widen. Trauma patients constitute a significant proportion of organ donors. The incidence of organ donation after traumatic cardiopulmonary arrest (TCPA), however, is not clear. The goals of this study were to determine the success rate of organ donation in patients undergoing cardiopulmonary resuscitation (CPR) after trauma and to determine if there are variables that may predict successful organ donation. Methods: All trauma patients who sustained TCPA from April 2007 to March 2010 were reviewed. We identified all patients who required CPR in the field or the trauma center. Patients were classified as donors if the heart, lung, kidney, small bowel, pancreas, or liver was harvested. Primary outcome was organ donation after CPR. Results: A total of 252 patients required CPR for TCPA in the field or in the trauma center. There were 39 (15.5%) survivors and 213 (84.5%) fatalities. Only 19 of 213 (8.9%) patients who died after TCPA became organ donors. A total of 26 organs were harvested including 15 kidneys, 6 livers, 4 hearts, and 1 pancreas. Of those who failed to donate organs, 64.7% had a cardiac arrest after the donor network had been contacted but before their arrival. Conclusions: Survival rate after TCPA is low but organ donation is an important secondary outcome. Patients with predominant head injuries, without thoracic and minimal extremity injuries, should be identified as having a higher chance of going on to organ donation. The greatest barrier to organ donation in TCPA patients is cardiac arrest before donor network arrival. [Copyright &y& Elsevier]

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]

Background: The American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database is one of the most widely used databases for trauma research. We aimed to critically appraise the quality of the methodological reporting of ACS-TQIP studies.Study Design: The ACS-TQIP bibliography was queried for all studies published between January 2018 and January 2021. The quality of data reporting was assessed using the Strengthening the Reporting of Observational studies in Epidemiology-Reporting of Studies Conducted Using Observational Routinely Collected Health Data (STROBE-RECORD) statement and the JAMA Surgery checklist. Three items from each tool were not applicable and thus excluded. The quality of reporting was compared between high- and low-impact factor (IF) journals (cutoff for high IF is >90th percentile of all surgical journals).Results: A total of 118 eligible studies were included; 12 (10%) were published in high-IF journals. The median (interquartile range) number of criteria fulfilled was 5 (4-6) for the STROBE-RECORD statement (of 10 items) and 5 (5-6) for the JAMA Surgery checklist (of 7 items). Specifically, 73% of studies did not describe the patient population selection process, 61% did not address data cleaning or the implications of missing values, and 76% did not properly state inclusion/exclusion criteria and/or outcome variables. Studies published in high-IF journals had remarkably higher quality of reporting than those in low-IF journals.Conclusion: The methodological reporting quality of ACS-TQIP studies remains suboptimal. Future efforts should focus on improving adherence to standard reporting guidelines to mitigate potential bias and improve the reproducibility of published studies. [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]

Abstract: There has been a spike in interest and use of telehealth, catalyzed recently by the anticipated implementation of the Affordable Care Act, which rewards efficiency in healthcare delivery. Advances in telehealth services are in many areas, including gap service coverage (eg, night-time radiology coverage), urgent services (eg, telestroke services and teleburn services), mandated services (eg, the delivery of health care services to prison inmates), and the proliferation of video-enabled multisite group chart rounds (eg, Extension for Community Healthcare Outcomes programs). Progress has been made in confronting traditional barriers to the proliferation of telehealth. Reimbursement by third-party payers has been addressed in 19 states that passed parity legislation to guarantee payment for telehealth services. Medicare lags behind Medicaid, in some states, in reimbursement. Interstate medical licensure rules remain problematic. Mobile health is currently undergoing explosive growth and could be a disruptive innovation that will change the face of healthcare in the future. [Copyright &y& Elsevier]

Abstract: Background: B-type natriuretic peptide (BNP) is a neurohormone released from cardiomyocytes in response to volume expansion and increased ventricular wall distension. Increased plasma BNP levels are associated with mortality in critically ill patients cared for in medical intensive care units (ICUs). Additionally, plasma BNP levels may serve as a biomarker for excessive fluid resuscitation after injury. The utility of plasma BNP levels as a prognosticator of outcomes after injury has not been previously described. The purpose of this study was to describe the change in plasma BNP levels over the first 48 hours after injury and determine if there was a correlation between plasma BNP levels and clinical outcomes. Methods: In this prospective observational cohort trial, plasma BNP levels were followed in injured patients admitted to a surgical ICU. Levels were obtained at admission to the emergency room (baseline) and at 12, 24, and 48 hours. Change in plasma BNP levels from baseline were calculated for each time point (ΔBNP). Demographic information was collected, including age, gender, injury severity score, ventilator days, ICU length of stay (LOS), hospital LOS, net fluid balance at 24 hours, and in-hospital mortality. Spearman''s rank-order correlation coefficients were determined for plasma ΔBNP levels and outcome measures (days ventilated, ICU LOS, hospital LOS, and mortality). Results: Forty-four ICU patients were prospectively enrolled. Thirty-six patients (82%) were male, and 30 patients (68%) required mechanical ventilation. The mean age was 40.3 years. The median injury severity score was 19.5 (range, 9–29), and overall mortality was 14%. The mean baseline BNP level was 48 ± 66 pg/mL (range, 10–274 pg/mL). Mean ΔBNP at 24 hours was 74 ± 147 pg/mL. Net fluid balance at 48 hours after admission ranged from −1.6 to 15.6 L. Plasma ΔBNP levels at 24 and 48 hours did not correlate with net resuscitation volume at their respective time points of 24 and 48 hours. ΔBNP at 24 hours correlated with the number of days on mechanical ventilation (Spearman''s ρ = .428, P = .007). ΔBNP at 24 hours also correlated with Acute Physiology and Chronic Health Evaluation II scores (Spearman''s ρ = .430, P = .046). Patients with increases in plasma BNP of ≥75 pg/mL at 24 hours were nearly 3 times more likely to be ventilated for >3 days (relative risk, 2.9; 95% confidence interval, 1.1–7.7). Conclusions: Changes in plasma BNP levels over the first 24 hours after ICU admission may have prognostic value in determining the need for mechanical ventilation in patients admitted to ICUs after injury. Additionally, the correlation between plasma BNP levels at 24 hours and mechanical ventilation requirements is not due solely to resuscitation volume. Further studies examining the prognostic value of plasma BNP levels after injury are warranted. [Copyright &y& Elsevier]

Background As the population ages, increasing number of geriatric patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information is crucial for making informed decisions on behalf of such patients. Therefore, the aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients. Methods We performed a 1-y (2011) retrospective analysis of isolated geriatric TBI patients (age ≥65 y, head abbreviated injury score [AIS] ≥ 3, and other body AIS < 3) in the National Trauma Data Bank. We calculated a Glasgow Coma Scale (GCS)–age prognosis (GAP) score (age/GCS score) for all patients. Outcome measures were in-hospital adverse outcomes (mortality and Rehab/skilled nursing facility discharge disposition). Regression analysis and receiver operator characteristic curve analysis were performed to determine the discriminatory power of GAP score. Results A total of 8750 geriatric patients with TBI were included. Mean age was 77.8 ± 7.1 y, the median (interquartile range) GCS was 15 (13-15), and the median (interquartile range) head AIS was 4 (3-4). The overall in-hospital mortality rate was 12.7%, and 34.2% of the patients were discharged home. As the GAP score increased, the mortality rate increased and discharge to-home decreased. Receiver operator characteristic curve analysis revealed excellent discriminatory power for mortality (area under the curve: 0.826). Above a GAP score of 12, the mortality rate was >50% and more than 45% of the patients were discharged to Rehab/skilled nursing facility. Conclusions For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in a drastic increase in mortality and an adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patients' families. [ABSTRACT FROM AUTHOR]

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010-2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13-15), and median head Abbreviated Injury Scale score was 3 (2-4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay (P = 0.02) and longer intensive care unit length of stay (P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH. [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]

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]

Background Falls from ladders account for a significant number of hospital visits. However, the epidemiology, injury pattern, and how age affects such falls are poorly described in the literature. Materials and methods Patients ≥18 y who suffered falls from ladders over a 51/2-y period were identified in our trauma registry. Dividing patients into three age groups (18-45, 46-65, and >66 y), we compared demographic characteristics, clinical data, and outcomes including injury pattern and mortality. The odds ratios (ORs) were calculated with the group 18-45 y as reference; group means were compared with one-way analysis of variance. Results Of 27,155 trauma patients, 340 (1.3%) had suffered falls from ladders. The average age was 55 y, with a male predominance of 89.3%. Average fall height was 9.8 ft, and mean Injury Severity Score was 10.6. Increasing age was associated with a decrease in the mean fall height (P < 0.001), an increase in the mean Injury Severity Score (P < 0.05), and higher likelihood of admission (>66 y: OR, 5.3; confidence interval [CI], 2.5-11.5). In univariate analysis, patients in the >66-y age group were more likely to sustain traumatic brain injuries (OR, 3.4; CI, 1.5-7.8) and truncal injuries (OR, 3.6; CI, 1.9-7.0) and less likely to sustain hand and/or forearm fractures (OR, 0.3; CI, 0.1-0.9). Conclusions Older people are particularly vulnerable after falling from ladders. Although they fell from lower heights, the elderly sustained different and more severe injury patterns. Ladder safety education should be particularly tailored at the elderly. [ABSTRACT FROM AUTHOR]

Background Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. Methods Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. Results A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI. Conclusions ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification. [ABSTRACT FROM AUTHOR]