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Introduction: The Rothman Index (RI) is an objective measurement of a patient's overall condition, automatically generated from 26 variables including vital signs, laboratory data, cardiac rhythms, and nursing assessments. The purpose of this study was to assess the validity of RI scores in predicting surgical ICU (SICU) readmission rates and mortality., Methods: We conducted a single-center retrospective analysis of surgical patients who were transferred from the SICU to the surgical floor from December 2014 to December 2016. Data included demographics, length of stay (LOS), mortality, and RI at multiple pretransfer and post-transfer time points., Results: A total of 1,445 SICU patients were transferred to the surgical floor; 79 patients (5.5%) were readmitted within 48 hours of transfer. Mean age was 52 years, and 67% were male. Compared to controls, patients readmitted to the SICU within 48 hours experienced higher LOS (29 vs. 11 days, p < 0.05) as well as higher mortality (2.5% vs. 0.6%, p < 0.05). Patients requiring readmission also had a lower RI at 72, 48, and 24 hours before transfer as well as at 24 and 48 hours after transfer (p < 0.05 for all). Rothman Index scores were categorized into higher-risk (<40), medium-risk (40-65), and lower-risk groups (>65); RI scores at 24 hours before transfer were inversely proportional to overall mortality (RI < 40 = 2.5%, RI 40-65 = 0.3%, and RI > 65 = 0%; p < 0.05) and SICU readmission rates (RI < 40 = 9%, RI 40-65 = 5.2%, and RI > 65 = 2.8%; p < 0.05). Patients transferred with RI scores greater than 83 did not require SICU readmission within 48 hours., Conclusion: Surgical ICU patients requiring readmission within 48 hours of transfer have a significantly higher mortality and longer LOS compared to those who do not. Patients requiring readmission also have significantly lower pretransfer and post-transfer RI scores compared to those who do not. Rothman Index scores may be used as a clinical tool for evaluating patients before transfer from the SICU. Prospective studies are warranted to further validate use of this technology., Level of Evidence: Retrospective database review, level III.

Smoke inhalation injury is a serious medical problem that increases morbidity and mortality after severe burns. However, relatively little attention has been paid to this devastating condition, and the bulk of research is limited to preclinical basic science studies. Moreover, no worldwide consensus criteria exist for its diagnosis, severity grading, and prognosis. Therapeutic approaches are highly variable depending on the country and burn centre or hospital. In this Series paper, we discuss understanding of the pathophysiology of smoke inhalation injury, the best evidence-based treatments, and challenges and future directions in diagnostics and management., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: To increase trauma-related research and elevate trauma on the national research agenda, the National Trauma Institute (NTI) issued calls for proposals, selected funding recipients, and coordinated 16 federally funded (Department of Defense) trauma research awards over a 4-year period. We sought to collect and describe the lessons learned from this activity to inform future researchers of barriers and facilitators., Methods: Fifteen principal investigators participated in semistructured interviews focused on study management issues such as securing institutional approvals, screening and enrollment, multisite trials management, project funding, staffing, and institutional support. NTI Science Committee meeting minutes and study management data were included in the analysis. Simple descriptive statistics were generated and textual data were analyzed for common themes., Results: Principal investigators reported challenges in obtaining institutional approvals, delays in study initiation, screening and enrollment, multisite management, and study funding. Most were able to successfully resolve challenges and have been productive in terms of scholarly publications, securing additional research funding, and training future trauma investigators., Conclusion: Lessons learned in the conduct of the first two funding rounds managed by NTI are instructive in four key areas: regulatory processes, multisite coordination, adequate funding, and the importance of an established research infrastructure to ensure study success. Recommendations for addressing institution-related and investigator-related challenges are discussed along with ongoing advocacy efforts to secure sustained federal funding of a national trauma research program commensurate with the burden of injury.

Despite being the leading cause of death in the United States for individuals 46 years and younger and the primary cause of death among military service members, trauma care research has been underfunded for the last 50 years. Sustained federal funding for a coordinated national trauma clinical research program is required to advance the science of caring for the injured. The Department of Defense is committed to funding studies with military relevance; therefore, it cannot fund pediatric or geriatric trauma clinical trials. Currently, trauma clinical trials are often performed within a single site or a small group of trauma hospitals, and research data are not available for secondary analysis or sharing across studies. Data-sharing platforms encourage transfer of research data and knowledge between civilian and military researchers, reduce redundancy, and maximize limited research funding. In collaboration with the Department of Defense, trauma researchers formed the Coalition for National Trauma Research (CNTR) in 2014 to advance trauma research in a coordinated effort. CNTR's member organizations are the American Association for the Surgery of Trauma (AAST), the American College of Surgeons Committee on Trauma (ACS COT), the Eastern Association for the Surgery of Trauma (EAST), the Western Trauma Association (WTA), and the National Trauma Institute (NTI). CNTR advocates for sustained federal funding for a multidisciplinary national trauma research program to be conducted through a large clinical trials network and a national trauma research repository. The initial advocacy and research activities underway to accomplish these goals are presented.

Marked expansion of physiologic understanding and the improvement of burn patient outcomes have resulted from multidisciplinary clinical/laboratory research programs at burn centers in the United States and elsewhere., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Rising medical malpractice premiums have reached a crisis point in many areas of the United States. In 2003 the Texas legislature passed a comprehensive package of tort reform laws that included a cap at $250,000 on noneconomic damages in most medical malpractice cases. We hypothesized that tort reform laws significantly reduce the risk of malpractice lawsuit in an academic medical center. We compared malpractice prevalence, incidence, and liability costs before and after comprehensive state tort reform measures were implemented., Study Design: Two prospectively maintained institutional databases were used to calculate and characterize malpractice risk: a surgical operation database and a risk management and malpractice database. Risk groups were divided into pretort reform (1992 to 2004) and post-tort reform groups (2004 to the present). Operative procedures were included for elective, urgent, and emergency general surgery procedures., Results: During the study period, 98,513 general surgical procedures were performed. A total of 28 lawsuits (25 pre-reform, 3 postreform) were filed, naming general surgery faculty or residents. The prevalence of lawsuits filed/100,000 procedures performed is as follows: before reform, 40 lawsuits/100,000 procedures, and after reform, 8 lawsuits/100,000 procedures (p < 0.01, relative risk 0.21 [95% CI 0.063 to 0.62]). Virtually all of the liability and defense cost was in the pretort reform period: $595,000/year versus $515/year in the postreform group (p < 0.01)., Conclusions: Implementation of comprehensive tort reform in Texas was associated with a significant decrease in the prevalence and cost of surgical malpractice lawsuits at one academic medical center., (Copyright © 2011. Published by Elsevier Inc.)

The accelerated pace of clinical and laboratory research over the past century and application of the research findings to patient care have resulted in unprecedented survival of burned patients in all age groups. Resuscitation based on an understanding of the nature and magnitude of the multisystem response to injury now prevents burn shock; effective topical antimicrobial chemotherapy and early excision prevent wound toxemia and sepsis; biologic and bioengineered dressings compensate for the missing skin; and broad spectrum metabolic support regimens prevent exhaustion and accelerate convalescence. Rehabilitation programs have also been developed to restore physical function and permit the burn patient to reenter society as a productive individual.

Less than 50 per cent of surgical critical care (SCC) fellowship positions are filled each year. We surveyed senior surgical residents to determine their opinions regarding a career in SCC and acute care surgery. A survey was sent to 1348 postgraduate year 3, 4, and 5 residents in the United States. Two hundred fifty-one surveys were returned (19% response rate). Whereas 78 per cent were planning to complete a fellowship, 21 per cent expressed interest in SCC. Fifty-six per cent plan to handle SCC problems only for their own patients, whereas 39 per cent plan to turn this management over to a critical care provider. SCC fellowships were considered to be potentially more appealing if the following changes could be made to the existing structure: adding more general surgery (70% of respondents); adding more trauma experience (50%); adding emergency neurosurgery (44%); adding more emergency orthopedics (42%); or decreasing months of critical care (36%). Increasing salary enhanced appeal for 82 per cent. SCC has limited appeal for most senior surgical residents. Theoretical expansion of surgical critical fellowships to include more general or trauma surgery (acute care surgery) increased the level of interest among senior surgical residents.

Background: Intensive insulin therapy to maintain serum glucose levels between 80 and 110 mg/dL has previously been shown to reduce mortality in the critically ill; recent data, however, have called this benefit into question. In addition, maintaining uniform, tight glucose control is challenging and resource demanding. We hypothesized that, by use of a protocol, tight glucose control could be achieved in the surgical trauma intensive care unit (STICU), and that improved glucose control would be beneficial., Study Design: During the study period, a progressively more rigorous approach to glucose control was used, culminating in an implemented protocol in 2005. We reviewed STICU patients' blood glucose levels, measured by point-of-care testing, from 2003 to 2006. Mortality was tracked over the course of the study, and patient charts were retrospectively reviewed to measure illness and injury severity., Results: Mean blood glucose levels steadily improved (p < 0.01). In addition to absolute improvements in glucose control, total variability of glucose ranges in the STICU steadily diminished. A reduction in STICU mortality was temporally associated with implementation of the protocol (p < 0.01). There were fewer intraabdominal abscesses and fewer postinjury ventilator days after implementation of the protocol. There was a small increase in the incidence of clinically relevant hypoglycemia., Conclusions: Improvements in glucose control in the ICU can be achieved by using a protocol for intensive insulin therapy. In our ICU, this was temporally associated with a significant reduction in mortality.

Background: To determine the opinions of neurosurgeons regarding the care of the injured and to assess the impact of these attitudes on the care of the patients with brain injuries., Methods: A survey was sent to the 2,465 active members of the American Association of Neurologic Surgeons. A manpower assessment of neurosurgical coverage of South Texas was also performed., Results: In total, 872 surveys were returned (35%). Seventy-one percent of the respondents were over the age of 44. Eighty-seven percent of neurosurgeons stated that they currently provide trauma care: 74% at Level I or II trauma centers. The majority of neurosurgeons treated <5 trauma patients per week, 80% placed 2 or fewer intracranial pressure (ICP) monitors per month. Fifty-nine percent of the respondents preferred not to treat trauma patients because of (1) perceived increased medicolegal risk (80%), (2) conflict with elective practice (75%), (3) time required (70%), and (4) inadequate compensation (65%). Fifty-six percent received no compensation for trauma call. The majority of neurosurgeons indicated that no personnel other than neurosurgeons should be allowed to perform trauma craniotomies (90%) or insert ICP monitors (76%). However, 61% thought that non-neurosurgeons should be able to perform neuro-critical care. A maldistribution of neurosurgeons was identified in South Texas, with much of the population uncovered for trauma care. Significant delays in definitive neurosurgical care were identified as a result of this maldistribution., Conclusions: One-half of neurosurgeons prefer not to care for trauma patients because of perceived added time commitment, conflicts with elective practice, lack of compensation, and perceived medicolegal risk. But, they thought that only neurosurgeons should provide emergency neurosurgical procedures. These attitudes appear to impinge on the care of the patients with brain injuries in South Texas.

Objective: We set out to determine if there is an increased medical malpractice lawsuit rate when trauma patient cases are presented at an open, multidisciplinary morbidity and mortality conference (M&M)., Introduction: Patient safety proponents emphasize the importance of transparency with respect to medical errors. In contrast, the tort system focuses on blame and punishment, which encourages secrecy. Our question: Can the goals of the patient safety movement be met without placing care providers and healthcare institutions at unacceptably high malpractice risk?, Methods: The trauma registry, a risk management database, along with the written minutes of the trauma morbidity and mortality conference (M&M) were used to determine the number and incidence of malpractice suits filed following full discussion at an open M&M conference at an academic level I trauma center., Results: A total of 20,749 trauma patients were admitted. A total of 412 patients were discussed at M&M conference and a total of seven lawsuits were filed. Six of the patients were not discussed at M&M prior to the lawsuit being filed. One patient was discussed at M&M prior to the lawsuit being filed. The incidence of lawsuit was calculated in three groups: all trauma patients, all trauma patients with complications, and all patients presented at trauma M&M conference. The ratio of lawsuits filed to patients admitted and incidence in the three groups is as follows: All Patients, 7 lawsuits/20,479 patients (4.25 lawsuits/100,000 patients/year); M&M Presentation, 1 lawsuit/421 patients (29.6 lawsuits/100,000 patients/year); All Trauma Complications, 7 lawsuits/6,225 patients (14 lawsuits/100,000 patients/year). Patients with a complication were more likely to sue (P < 0.01); otherwise, there were no statistical differences between groups., Conclusions: A transparent discussion of errors, complications, and deaths does not appear to lead to an increased risk of lawsuit.

Objective: We set out to compare the malpractice lawsuit risk and incidence in trauma surgery, emergency surgery, and elective surgery at a single academic medical center., Summary and Background Data: The perceived increased malpractice risk attributed to trauma patients discourages participation in trauma call panels and may influence career choice of surgeons. When questioned, surgeons cite malpractice risk as a rationale for not providing trauma care. Little data substantiate or refute the perceived high trauma malpractice risk. We hypothesized that the malpractice risk was equivalent between an elective surgical practice and a trauma/emergency practice., Methods: Three prospectively maintained institutional databases were used to calculate and characterize malpractice incidence and risk: a surgical operation database, a trauma registry, and a risk management/malpractice database. Risk groups were divided into elective general surgery (ELECTIVE), urgent/emergent, nontrauma general surgery (URGENT), and trauma surgery (TRAUMA). Malpractice claims incidence was calculated by dividing the total number of filed lawsuits by the total number of operative procedures over a 12-year period., Results: Over the study period, 62,350 operations were performed. A total of 21 lawsuits were served. Seven were dismissed. Three were granted summary judgments to the defendants. Ten were settled with payments to the plaintiffs. One went to trial and resulted in a jury verdict in favor of the defendants. Total paid liability was 4.7 million dollars(391,667 dollars/year). Total legal defense costs were 1.3 million dollars(108,333 dollars/year). The ratio of lawsuits filed/operations performed and incidence in the 3 groups is as follows: ELECTIVE 14/39,080 (3.0 lawsuits/100,000 procedures/year), URGENT 5/17,958, (2.3 lawsuits/100,000 procedures/year), and TRAUMA 2/5312 (3.1/100,000 procedures/year). During the study period, there were an estimated 49,435 trauma patients evaluated. The incidence of malpractice lawsuits using this denominator is 0.34 lawsuits/100,000 patients/year., Conclusions: These data demonstrate no increased risk of lawsuit when caring for trauma patients, and the actual risk of a malpractice lawsuit was low.

White male Sprague Dawley rats (200 g.) with 20% full thickness scald burns seeded with 10 Pseudomonas aeruginosa, strain 59-1244, were used as experimental animals. Studies including the following: (1). Control groups. (2). DC pretreatment groups. (3). Treatment groups. P. aeruginosa infected burn wounds were excised, and then treated with either autograft or silver-nylon dressings, with (SNDC) or without (SN) application direct current. Excision and treatment were initiated 1, 2, 3, 4 or 5 days after burning and inoculation. (4). Groups for antimicrobial barrier function study. Mortality of each group was recorded at 21 days PB. With burns alone, there was no mortality. Without treatment 19 of 20 burn inoculated controls died. In the pretreatment study, the mortality of the group pretreated with SN was 95% while that of the group pretreated with SNDC was only 30%. With excision and autografting, PB mortality rose from 5/20 at day 2 PB to 19/20 at day 3 PB. In the excision and SN groups, mortality rose from 5/20 at day 3 PB to 18/20 at day 4 PB. In the excision and SNDC groups, mortality rose from 5/20 at day 3 PB to 18/20 at day 4 PB. In the antimicrobial barrier function study, the 10% mortality in the SN dressing group was significantly less than that of 95% in the plain nylon dressed group. Histologic examination revealed progressively deepening colonization of non-viable wound tissue, progressing to invasion of underlying viable tissue by PB day 4. With wound excision, SN, SNDC, and autografting were equally protective for the first two days, but only SN and SNDC extended this effect to the third PB day. In conclusion, SN and SNDC have a strong local anti-microbial effect on the burn wound when applied within 72 hours of the time of bacterial inoculation, but little effect if applied after the bacteria have invaded unburned vessels and viable tissue adjacent to the burn.

Background: This retrospective review tests the hypothesis that including selective splenic arteriography and embolization in the algorithm of a previously existing nonoperative management (NOM) strategy will result in higher rates of successful NOM in patients with blunt splenic injury., Methods: All patients with blunt splenic injuries documented by computed tomographic scan and/or operative findings over a 24-month period at a Level I trauma center were reviewed. A previously published series from this institution of 251 patients with splenic injury (Group 1) was then compared with the patients that constitute this current review (Group 2). Group 2 was then compared with patients described in a previous publication advocating nonselective arteriography in blunt splenic injuries., Results: Thirteen patients with blunt splenic injury in Group 2 underwent 14 splenic embolization procedures, with 12 (93%) being successfully treated without operation. Group 2 had a significantly higher NOM rate (82% vs. 65%, p < 0.01) than Group 1. These results are similar to the series published by Sclafani et al. (82.1% vs. 83.1%) in which every patient with splenic injury that was managed non-operatively underwent arteriography with or without embolization., Conclusion: A high rate of NOM can be achieved with observation and selective use of arteriography with or without embolization in the management of blunt splenic injuries.

The effect of hormone disruptors on human health is an area of recent concern. The authors measured heptachlor epoxide and oxychlordane--the body storage forms of estrogenic insecticides-in the sera of patients with major burns (i.e., 7 survivors and 10 age- and burn-size-matched nonsurvivors) on days 1, 3, 5, 7, and 11 after they had been burned, as well as in 12 age-matched normal controls. During the hypermetabolic phase, serum concentrations of heptachlor epoxide and oxychlordane were greater in nonsurvivors than in controls, and heptachlor epoxide concentrations in nonsurvivors exceeded those in survivors on postburn day 5. The postburn alterations in heptachlor epoxide and oxychlordane concentrations could not be accounted for by changes in concentrations of circulating lipid. These findings, which indicate that xenoestrogens are released from fat depots after thermal injury, suggest a possible contribution to mortality, especially in older patients.

In a climate of limited resources, it is often necessary to prioritize restoration efforts geographically. The synoptic approach is an ecologically based tool for geographic prioritization of wetland protection and restoration efforts. The approach was specifically designed to incorporate best professional judgment in cases where information and resources are otherwise limited. Synoptic assessments calculate indices for functional criteria in subunits (watersheds, counties, etc.) of a region and then rank the subunits. Ranks can be visualized in region-scale maps which enable managers to identify areas where efforts optimize functional performance on a regional scale. In this paper, we develop a conceptual model for prioritizing watersheds whose wetlands can be restored to reduce total sediment yield at the watershed outlet. The conceptual model is designed to rank watersheds but not individual wetlands within a watershed. The synoptic approach is valid for applying the sediment yield reduction model because there is high demand for prioritizing disturbed wetlands for restoration, but there is limited, quantitative, accurate information available with which to make decisions. Furthermore, the cost of creating a comprehensive database is prohibitively high. Finally, because the model will be used for planning purposes, and, specifically, for prioritizing based on multiple decisions rather than optimizing a single decision, the consequence of prioritization errors is low. Model results cannot be treated as scientific findings. The conclusions of an assessment are based on judgement, but this judgement is guided by scientific principles and a general understanding of relevant ecological processes. The conceptual model was developed as the first step towards prioritizing of wetland restoration for sediment yield reduction in US EPA Region 4.