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Background: We hypothesized that the number of rib fractures independently impacted patient pulmonary morbidity and mortality. Methods: The National Trauma Data Bank (NTDB, v. 3.0 American College of Surgeons, Chicago, IL) was queried for patients sustaining 1 or more rib fractures. Data abstracted included the number of rib fractures by International Classification of Diseases-9 code, Injury Severity Score, the occurrence of pneumonia, acute respiratory distress syndrome, pulmonary embolus, pneumothorax, aspiration pneumonia, empyema, and associated injuries by abbreviated injury score, the need for mechanical ventilation, number of ventilator days, intensive care unit (ICU) length of stay (LOS), hospital LOS, mortality, and use of epidural analgesia. Statistical analysis was performed using the Student t test and linear regression analysis. Statistical significance was defined as a P value of less than .05. Results: The NTDB included 731,823 patients. Of these, 64,750 (9%) had a diagnosis of 1 or more fractured ribs. Thirteen percent (n = 8,473) of those with rib fractures developed 13,086 complications, of which 6,292 (48%) were related to a chest-wall injury. Mechanical ventilation was required in 60% of patients for an average of 13 days. Hospital LOS averaged 7 days and ICU LOS averaged 4 days. The overall mortality rate for patients with rib fractures was 10%. The mortality rate increased (P < .02) for each additional rib fracture. The same pattern was seen for the following morbidities: pneumonia (P < .01), acute respiratory distress syndrome (P < .01), pneumothorax (P < .01), aspiration pneumonia (P < .01), empyema (P < .04), ICU LOS (P < .01), and hospital LOS for up to 7 rib fractures (P < .01). An association between increasing hospital LOS and number of rib fractures was not shown (P = .19). Pulmonary embolism also was not related to the number of rib fractures (P = .06). Epidural analgesia was used in 2.2% (n = 1,295) of patients with rib fractures. A reduction in mortality with epidural analgesia was shown at 2, 4, and 6 through 8 rib fractures. The use of epidural analgesia had no impact on the frequency of pulmonary complications. When stratifying data by Injury Severity Score and the presence or absence of rib fractures the mortality rates were similar. Conclusions: Increasing the number of rib fractures correlated directly with increasing pulmonary morbidity and mortality. Patients sustaining fractures of 6 or more ribs are at significant risk for death from causes unrelated to the rib fractures. Epidural analgesia was associated with a reduction in mortality for all patients sustaining rib fractures, particularly those with more than 4 fractures, but this modality of treatment appears to be underused. [Copyright &y& Elsevier]

BACKGROUND: Esophagectomy in locally advanced esophageal adenocarcinoma is challenging and carries risk. The value of esophagectomy in locally advanced esophageal adenocarcinoma is not well-defined. STUDY DESIGN: The National Cancer Database was used to identify patients with cT4 esophageal adenocarcinoma from 2004 to 2020. Multivariable regression was used to identify factors associated with use of esophagectomy. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing esophagectomy were 1:1 propensity score--matched to patients treated nonsurgically. Kaplan--Meier analysis was used to compare 5-year overall survival (OS). RESULTS: A total of 3,703 patients met inclusion criteria. Of those, 541 (15%) underwent esophagectomy, and 3,162 (85%) did not. Age 65 years or less (adjusted odds ratio [aOR] 1.69, 95% CI 1.33 to 2.14), White race (aOR 2.98, 95% CI 2.24 to 3.96), treatment in academic centers (aOR 1.64, 95% CI 1.33 to 2.02), private insurance (aOR 1.88, 95% CI 1.50 to 2.36), and tumors less than 6 cm (aOR 1.86, 95% CI 1.44 to 2.40) were associated with use of esophagectomy. Government of lack of insurance (hazard ratio [HR] 1.23, 95% CI 1.12 to 1.35), income <$46,000 (HR 1.11, 95% CI 1.03 to 1.20), treatment in nonacademic centers (HR 1.16, 95% CI 1.07 to 1.25), Charlson-Deyo Comorbidity Index 1 or more (HR 1.22, 95% CI 1.12 to 1.32), and tumors 6 cm or more (HR 1.20, 95% CI 1.09 to 1.32) were associated with risk of all-cause mortality. Esophagectomy (HR 0.50, 95% CI 0.44 to 0.56) and systemic therapy (HR 0.40, 95% CI 0.37 to 0.43) were associated with decreased risk of all-cause mortality. Patients undergoing esophagectomy had higher rates of 5-year OS (27.4% vs 13.2%, p < 0.0001) and longer median OS (24.71 vs 10.09 months, p < 0.0001). Among cT4b patients, those who underwent esophagectomy had higher rates of 5-year OS (24.5% vs 12.3%, p < 0.0001) and longer median OS (25.53 vs 11.01 months, p < 0.0001). CONCLUSIONS: In cT4 esophageal adenocarcinoma, esophagectomy is associated with improved rates of 5-year OS compared with nonsurgical treatment. [ABSTRACT FROM AUTHOR]

Abstract: Background: The relative impact of rib fractures on mortality risk is unclear. This study examined the respective relationships between mortality and the number of fractured ribs, patient age, and severity of intrathoracic and extrathoracic injuries. Methods: The National Trauma Data Bank was queried, abstracting mortality, age, number of ribs fractured, associated intrathoracic and extrathoracic injury, and Abbreviated Injury Score codes. Results: Multivariate logistic regression indicated the strongest influence on mortality was severity of intrathoracic injury, followed by severity of extrathoracic injury, age 65 years or older, more than 5 ribs fractured, and age 46 to 65 years. The mortality rate for isolated rib fractures ranged from 1.8% to 3.2%. Conclusions: Mortality related to rib fractures is affected independently by severe intrathoracic injury, presence of extrathoracic injury, advanced age, and more than 5 fractured ribs. Patients with these conditions may benefit from a higher level of care. [Copyright &y& Elsevier]

Background Atrial fibrillation (AF) with rapid ventricular rate (RVR; heart rate >100) in noncardiac postoperative surgical patients is associated with poor outcomes. The objective of this study was to evaluate the practice patterns of AF management in a surgical intensive care unit to determine practices associated with rate and rhythm control and additional outcomes. Materials and methods Adult patients (≥18 y) admitted to the surgical intensive care unit (SICU) from June 2014 to June 2015 were retrospectively screened for the development of new-onset AF with RVR. Demographics, hospital course, evaluation and treatment of AF with RVR, and outcome were evaluated and analyzed. Results Thousand seventy patients were admitted to the SICU during the study period; 33 met inclusion criteria (3.1%). Twenty-six patients (79%) had rate and rhythm control within 48 h of AF with RVR onset. β-Blockers were the most commonly used initial medication (67%) but were successful at rate and rhythm control in only 27% of patients (6/22). Amiodarone had the highest rate of success if used initially (5/6, 83%) and secondarily (11/13, 85%). Failure to control rate and rhythm was associated with a greater likelihood of comorbidities (100% versus 57%; P = 0.06). Conclusions New-onset AF with RVR in the noncardiac postoperative patient is associated with a high mortality (21%). Amiodarone is the most effective treatment for rate and rhythm control. Failure to establish rate and rhythm control was associated with cardiac comorbidities. These results will help to form future algorithms for the treatment of AF with RVR in the SICU. [ABSTRACT FROM AUTHOR]