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While recent advancements of Deep Learning (DL) in solving complex real-world tasks have spurred their popularity, the usage of privacy-rich data for their training in varied applications has made them an overly-exposed threat surface for privacy violations. Moreover, the rapid adoption of cloud-based Machine-Learning-asa-Service (MLaaS) has broadened the threat surface to various remote side-channel attacks. In this paper, for the first time, we show one such privacy violation by observing a data-dependent timing side-channel (naming this to be Class-Leakage) originating from non-constant time branching operation in a widely popular DL framework, namely PyTorch. We further escalate this timing variability to a practical inference-time attack where an adversary with user level privileges and having hard-label black-box access to an MLaaS can exploit Class-Leakage to compromise the privacy of MLaaS users. DL models have also been shown to be vulnerable to Membership Inference Attack (MIA), where the primary objective of an adversary is to deduce whether any particular data has been used while training the model. Differential Privacy (DP) has been proposed in recent literature as a popular countermeasure against MIA, where inclusivity and exclusivity of a data-point in a dataset cannot be ascertained by definition. In this paper, we also demonstrate that the existence of a data-point within the training dataset of a DL model secured with DP can still be distinguished using the identified timing side-channel. In addition, we propose an efficient countermeasure to the problem by introducing constant-time branching operation that alleviates the Class-Leakage. We validate the approach using five pre-trained DL models trained on two standard benchmarking image classification datasets, CIFAR-10 and CIFAR-100, over two different computing environments having Intel Xeon and Intel i7 processors.

Microarchitectural attacks on computing systems often stem from simple artefacts in the underlying architecture. In this paper, we focus on the Return Address Stack (RAS), a small hardware stack present in modern processors to reduce the branch miss penalty by storing the return addresses of each function call. The RAS is useful to handle specifically the branch predictions for the RET instructions which are not accurately predicted by the typical branch prediction units. In particular, we envisage a spy process who crafts an overflow condition in the RAS by filling it with arbitrary return addresses, and wrestles with a concurrent process to establish a timing side channel between them. We call this attack principle, RASSLE 1 (Return Address Stack based Side-channel Leakage), which an adversary can launch on modern processors by first reverse engineering the RAS using a generic methodology exploiting the established timing channel. Subsequently, we show three concrete attack scenarios: i) How a spy can establish a covert channel with another co-residing process? ii) How RASSLE can be utilized to determine the secret key of the P-384 curves in OpenSSL (v1.1.1 library)? iii) How an Elliptic Curve Digital Signature Algorithm (ECDSA) secret key on P-256 curve of OpenSSL can be revealed using Lattice Attack on partially leaked nonces with the aid of RASSLE? In this attack, we show that the OpenSSL implementation of scalar multiplication on this curve has varying number of add-and-sub function calls, which depends on the secret scalar bits. We demonstrate through several experiments that the number of add-and-sub function calls can be used to template the secret bit, which can be picked up by the spy using the principles of RASSLE. Finally, we demonstrate a full end-to-end attack on OpenSSL ECDSA using curve parameters of curve P-256. In this part of our experiments with RASSLE, we abuse the deadline scheduler policy to attain perfect synchronization between the spy and victim, without any aid of induced synchronization from the victim code. This synchronization and timing leakage through RASSLE is sufficient to retrieve the Most Significant Bits (MSB) of the ephemeral nonces used while signature generation, from which we subsequently retrieve the secret signing key of the sender applying the Hidden Number Problem. 1RASSLE is a non-standard spelling for wrestle.

Objective:To demonstrate that patients who have been intubated for prolonged periods of time will have an increased likelihood of developing bacterial biofilm on their endotracheal tubes.Methods:We collected endotracheal tubes from patients at the time of extubation, and analysed representative sections with scanning electron microscopy for morphologic evidence of biofilms.Results:From September 2007 to September 2008, 32 endotracheal tubes were analysed with electron microscopy. Patients who had been intubated for 6 days or longer had a significantly higher percentage of endotracheal tubes that exhibited bacterial biofilms, compared with patients intubated for less than 6 days (88.9 versus 57.1 per cent, p = 0.0439).Conclusions:Longer duration of intubation is associated with a higher incidence of bacterial biofilm. Further research is needed to link the presence of bacterial biofilms to acquired laryngotracheal damage. [ABSTRACT FROM PUBLISHER]

Objective: To assess the perceptions of residents and RNs about the effects of a medical emergency team on patient safety and their own educational experiences.Design: Survey-based study.Setting: A single academic medical center.Participants: In 2007, 1 yr after the introduction of a medical emergency team, a Web-based survey was administered to 141 internal medicine and general surgery residents and 497 RNs in a single academic medical center. Residents' and RNs' beliefs about the effects of the medical emergency team on patient safety and education were measured using 12 Likert scale items. Group differences were assessed using Mann-Whitney U test and Kruskal-Wallis test.Results: The overall response rate was 79% (67% for residents and 83% for RNs). Residents and RNs agreed that the medical emergency team improved patient safety, but RNs held this belief more strongly than did residents. Residents neither agreed nor disagreed with the notion that the creation of the medical emergency team decreased their opportunities to obtain critical care skills or education, whereas RNs disagreed with this statement. Relative to surgical residents, medical residents were more involved in activation of the medical emergency team and believed more strongly that the team improved patient safety. Residents and RNs who perceived that they were involved in the call activation had more positive attitudes toward the team.Conclusion: Residents and RNs believe that a medical emergency team improves patient safety in the hospital without compromising educational experiences or skills. Frequency of involvement in the events and the decision to activate the team correlated with more positive attitudes. [ABSTRACT FROM AUTHOR]

Despite advances in ventilator management, 31% to 38% of patients with adult respiratory distress syndrome (ARDS) will die, some from progressive respiratory failure. Inability to adequately oxygenate patients with severe ARDS has prompted extensive efforts to identify what are now known as alternative modes of ventilation including high-frequency oscillatory ventilation and airway pressure release ventilation. Both modalities are based on the principles of the open-lung concept and aim to improve oxygenation by keeping the lung uniformly inflated for an extended period of time. Although a mortality benefit has not been proven, some patients may benefit from these alternative modes of ventilation as rescue measures while the underlying process resolves. The purpose of this article is to review the evidence and mechanisms underlying each modality and to describe the fundamental steps in initiating, adjusting, and terminating these modes of ventilation. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine whether there is an association between transfusion of fresh frozen plasma and infection in critically ill surgical patients. DESIGN: Retrospective study. SETTING: A 24-bed surgical intensive care unit in a university hospital. PATIENTS: A total of 380 non-trauma patients who received fresh frozen plasma from 2004 to 2005 were compared with 2,058 nontrauma patients who did not receive fresh frozen plasma. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We calculated the relative risk of infectious complication for patients receiving and not receiving fresh frozen plasma. T-test allowed comparison of average units of fresh frozen plasma transfused to patients with and without infectious complications to describe a dose-response relationship. We used multivariate logistic regression analysis to evaluate the association between fresh frozen plasma and infectious complication, controlling for the effect of red blood cell transfusion, Acute Physiology and Chronic Health Evaluation II, and patient age. A significant association was found between transfusion of fresh frozen plasma and ventilator-associated pneumonia with shock (relative risk 5.42, 2.73-10.74), ventilator-associated pneumonia without shock (relative risk 1.97, 1.03-3.78), bloodstream infection with shock (relative risk 3.35, 1.69-6.64), and undifferentiated septic shock (relative risk 3.22, 1.84-5.61). The relative risk for transfusion of fresh frozen plasma and all infections was 2.99 (2.28-3.93). The t-test revealed a significant dose-response relationship between fresh frozen plasma and infectious complications (p = .02). Chi-square analysis showed a significant association between infection and transfusion of fresh frozen plasma in patients who did not receive concomitant red blood cell transfusion (p < .01), but this association was not significant in those who did receive red blood cells in addition to fresh frozen plasma. The association between fresh frozen plasma and infectious complications remained significant in the multivariate model, with an odds ratio of infection per unit of fresh frozen plasma transfused equal to 1.039 (1.013-1.067). This odds ratio resembled that noted for each unit of packed red blood cells, 1.074 (1.043-1.106). CONCLUSIONS: Transfusion of fresh frozen plasma is associated with an increased risk of infection in critically ill patients. [ABSTRACT FROM AUTHOR]

Background: Advances in medical technology have widened the gaps and exposed disparities in medical treatments. The prevalence of surgical stabilization for rib fractures is rising despite its controversial indications for this treatment modality. In situations of equipoise, surgeons may find themselves choosing patients for surgery, revealing potential implicit biases. We hypothesize that there exists an inequity in surgical stabilization for rib fractures performed based on race., Methods: Data were obtained from the American College of Surgeons 2013-2021 Trauma Quality Improvement Program database. Study participants were divided into race groups according to Trauma Quality Improvement Program data registry. To assess the association between race and surgical stabilization for rib fractures, a Poisson regression model was used. Potential confounding adjusted include race, age, sex, highest abbreviated injury severity score in each region, flail chest, sternum fracture, pneumothorax, hemothorax, pulmonary contusion, and comorbidities., Result: Black patients were more often treated at a level 1 trauma center (74%) (P < .001). Flail chest was most common in White (3.2%) and American Indian (3.4%) patients compared with other races (P = .012). After adjusting for potential confounding in the Poisson regression analyses, Black patients were 26% less likely to undergo surgical stabilization for rib fractures (adjusted incident rate ratio [95% confidence interval]: 0.74 [0.64-0.85], P < .001) and Asian were 40% less likely to undergo surgical stabilization for rib fractures (adjusted incident rate ratio [95% confidence interval]: 0.60 [0.43-0.81], P = .001) than White patients., Conclusion: There is a disparity in the delivery of surgical stabilization for rib fractures in patients with rib fractures. Black and Asian patients undergo surgical stabilization for rib fractures at a significantly lower rate than their White counterparts. This discrepancy in the delivery of care is concerning and requires further study., Competing Interests: Conflict of Interest/Disclosure Babak Sarani is a consultant for Belmont and Medtronic and speaker and consultant for Accumed and Haemonetics. The other authors have indicated that they have no conflicts of interest regarding the content of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: There are no validated and sensitive models that can guide the decision regarding amputation in patients with mangled lower extremities. We sought to describe a simple scoring model, the Mangled Lower Extremity (MangLE) score, which can predict those who are highly unlikely to need an amputation as a means to direct resources to this cohort., Methods: This is a retrospective study using the 2013-2021 American College of Surgeons Trauma Quality Improvement Program data set. Adult patients with a mangled lower extremity, defined as a crush injury or a fracture of the femur or tibia combined with severe soft tissue injury, arterial injury, or nerve injury, were included. Patients who suffered a traumatic lower extremity amputation, underwent amputation within 24 hours of admission, or who died within 24 hours of admission were excluded. Patients were divided into those who did/did not undergo amputation during their hospital stay. Demographics, injury mechanism, Injury Severity Score, and Abbreviated Injury Scale score, initial vital signs, and comorbid conditions were abstracted. A logistic regression model was constructed and the top five most important variables were used to create the score., Results: The study includes 107,620 patients, of whom 2,711 (2.5%) underwent amputation. The five variables with the highest predictive value for amputation were arterial injury, lower-extremity Abbreviated Injury Scale score of ≥3, crush injury, blunt mechanism, and shock index. The lowest possible MangLE score was 0, and the highest was 15. The model demonstrated an excellent predictive ability for lower extremity amputation in both the development and validation data set with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.80-0.82) and 0.82 (95% confidence interval, 0.81-0.84), respectively. The negative predictive value for a score of <8 is 99%., Conclusion: The MangLE score is able to identify patients who are unlikely to require amputation. Resources for limb salvage can be directed to this cohort., Level of Evidence: Prospective and Epidemiologic; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Annually, nearly 3 million individuals in the US are hospitalized after experiencing a traumatic injury (e.g., serious automobile crash, gunshot wound, stab injury). Many traumatically injured patients experience a trajectory of resilience. However, 20-40 % develop mental health problems such as posttraumatic stress disorder and depression; population estimates exceed 600,000 patients annually. Most trauma centers do not provide direct services to address mental health recovery, but the 2022 American College of Surgeons guidelines have established this as a priority. Cost-effective interventions are needed that meet the needs of patients at each stage of the recovery process while achieving sustainability at the level of implementation. This protocol paper describes a study that rigorously tests the Trauma Resilience and Recovery Program (TRRP), a scalable, sustainable technology-enhanced intervention to support the mental health recovery of patients who have experienced a traumatic injury., Methods: We describe a randomized controlled trial with 1-year follow up of TRRP vs. enhanced usual care with 350 traumatically injured patients, including recruitment and retention procedures, assessment, implementation and fidelity monitoring, and statistical plans., Conclusion: Novel components of our design include integration of technology-based elements, use of a stepped-care model, and implementation in a trauma center that did not previously have a mental health program. Data collected address the impact of TRRP and inform improvements to the model and its implementation in preparation for large-scale testing and implementation initiatives. This body of work is critical to informing the field as it continues to move toward national standards and recommendations., Trial Registration: NCT05497115Clinicaltrials.gov., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Andexanet alfa (AA) is the only FDA-approved reversal agent for apixaban and rivaroxaban (DOAC). There are no studies comparing its efficacy with four-factor prothrombin complex concentrate (PCC). This study aimed to compare PCC to AA for DOAC reversal, hypothesizing noninferiority of PCC., Methods: We performed a retrospective, noninferiority multicenter study of adult patients admitted from July 1, 2018, to December 31, 2019, who had taken a DOAC within 12 hours of injury, were transfused red blood cells (RBCs) or had traumatic brain injury, and received AA or PCC. Primary outcome was PRBC unit transfusion. Secondary outcome with intensive care unit length of stay. MICE imputation was used to account for missing data and zero-inflated Poisson regression was used to account for an excess of zero units of RBC transfused. Two units difference in RBC transfusion was selected as noninferior., Results: Results: From 263 patients at 10 centers, 77 (29%) received PCC and 186 (71%) AA. Patients had similar transfusion rates across reversal treatment groups (23.7% AA vs. 19.5% PCC) with median transfusion in both groups of 0 RBC. According to the Poisson component, PCC increases the amount of RBC transfusion by 1.02 times (95% confidence interval, 0.79-1.33) compared with AA after adjusting for other covariates. The average amount of RBC transfusion (nonzero group) is 6.13. Multiplying this number by the estimated rate ratio, PCC is estimated to have an increase RBC transfusion by 0.123 (95% confidence interval, 0.53-2.02) units compared with AA., Conclusion: PCC appears noninferior to AA for reversal of DOACs for RBC transfusion in traumatically injured patients. Additional prospective, randomized trials are necessary to compare PCC and AA for the treatment of hemorrhage in injured patients on DOACs., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Small bowel obstruction (SBO) frequently necessitates emergency surgical intervention. The impact of frailty and age on operative outcomes is uncertain. This study evaluated postoperative outcomes of SBO surgery based on patient's age and frailty and explore the optimal timing to operation in elderly and/or frail patients., Methods: Patients who underwent SBO surgery were identified in American College of Surgeons National Surgical Quality Improvement Program database 2005 to 2021. Patients aged ≥65 years were defined as elderly. Patients with 5-Factor Modified Frailty Index≥2 were defined as frail. Multivariable logistic regression was used to compare 30-day postoperative outcomes between elderly frail versus nonfrail patients, as well as between nonfrail young versus elderly patients., Results: There were 49,344 patients who had SBO surgery, with 7,089 (14.37%) patients classified as elderly frail, 17,821 (36.12%) as elderly nonfrail, and 21,849 (44.28%) as young nonfrail. Elderly frail patients had higher mortality (adjusted odds ratio, 1.541; p < 0.01) and postoperative complications compared with their elderly nonfrail counterparts; these patients also had longer wait until definitive operation ( p < 0.01). Among nonfrail patients, when compared with young patients, the elderly had higher mortality (adjusted odds ratio, 2.388; p < 0.01) and complications, and longer time to operation ( p < 0.01). In elderly nonfrail patients, a higher mortality was observed when surgery was postponed after 2 days. Mortality risk for frail elderly patients is heightened from their already higher baseline when surgery is delayed after 4 days., Conclusion: When SBO surgery is postponed for more than 2 days, elderly nonfrail patients have an increased mortality risk. Consequently, upon admission, these patients should be placed under a nasogastric tube and undergo an initial gastrograffin challenge. If there is no contrast in colon, they should be operated on within 2 days. Conversely, elderly frail patients with SBO have a higher mortality risk when surgery is delayed beyond 4 days. Thus, following the same scheme, they should be operated on before 4 days if gastrograffin challenge fails., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Tourniquet use for hemorrhage control is a core skill for many law enforcement officers (LEOs) and all emergency medical services (EMS) providers. However, LEO tourniquet training is not as intensive as EMS. Overuse of tourniquet can result in overtriage. We hypothesize that LEOs are more liberal than EMS with tourniquet placement., Methods: A 7-year retrospective, single-center study of adult patients who had a tourniquet placed in the field was conducted. Data were stratified by provider who placed the tourniquet. Patient demographics, body location where the tourniquet was placed, hospital location where the tourniquet was removed, incidence of recurrent bleeding and need for operative control of bleeding, and name of injured vessel were recorded. Data were analyzed using Student's t and χ 2 tests., Results: A total of 192 patients had 197 tourniquets placed (LEO, 77 [40%]; EMS, 120 [63%]). Most tourniquets were placed on the thigh. There was no difference in body mass index, but the EMS cohort had a higher Injury Severity Score (9.4 vs. 6.5, p = 0.03) and extremity Abbreviated Injury Scale severity score (2.4 vs. 1.9, p = 0.007). The LEO-placed tourniquets were more commonly removed in the trauma bay (83% vs. 73%, p = 0.03). The EMS-placed tourniquets were more likely to require operative control of bleeding (23% vs. 6%, p = 0.003). There were no complications related to tourniquet use in either arm., Conclusion: Law enforcement officers are more likely than EMS to place tourniquets without injury to a named vessel or the presence of severe bleeding. Law enforcement officers need better training to determine when a tourniquet is needed. Emergency medical services should be allowed to remove tourniquet if appropriate. Studies on the impact of overtriage based on tourniquet use are needed., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Trauma Quality Improvement Program (TQIP) database has delineated management strategies and outcomes for adults with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries and suggests that nonoperative management (NOM) is a viable option for these injuries. However, management strategies vary for children following significant pancreatic injuries and outcomes for these intermediate/high-grade injuries have not been sufficiently studied. Our aim was to describe the management and outcomes for grades III and IV pancreatic injuries using TQIP. We hypothesize that pediatric patients with intermediate/high-grade injuries can be safely managed with NOM., Methods: All pediatric patients (younger than 18 years) registered in TQIP between 2013 and 2021 who suffered a grade III or IV pancreatic injury due to blunt trauma were included in the current study. Patient demographics, clinical characteristics, complications, and in-hospital mortality were compared between the different treatment strategies for pancreatic injury: NOM versus drainage and/or pancreatic resection., Results: A total of 580 patients meeting the inclusion criteria were identified. A total of 416 pediatric patients suffered a grade III pancreatic injury; 79% (n = 332) were NOM, 7% (n = 27) received a drain, and 14% (n = 57) underwent a pancreatic resection. A further 164 patients suffered a grade IV pancreatic injury; 77% (n = 126) were NOM, 11% (n = 18) received a drain, and 12% (n = 20) underwent a pancreatic resection. No differences in overall injury severity or demographical data were observed between the treatment groups. No difference in in-hospital mortality was detected between the different management strategies. Patients who received a drain had a longer hospital length of stay., Conclusion: The majority of children with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries are managed nonoperatively. Nonoperative management is a reasonable strategy for these injuries and results in equivalent in-hospital adverse outcome profiles as pancreatic drainage or resection with a shorter hospital length of stay., Level of Evidence: Therapeutic/Care Management; Level IV., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Ten percent of all injured patients and 55% of patients with blunt chest trauma experience rib fractures. The incidence of death due to rib fractures is related to the number of fractured ribs, severity of fractured ribs, and patient age and comorbid conditions. Death due to rib fracture is mostly caused by pneumonia because of inability to expectorate and take deep breaths. Over the last 25 to 30 years, there has been renewed interest in surgical stabilization of rib fractures (SSRF), known colloquially as "rib plating." This review will present what you need to know in regard to triage decisions on whether to admit a patient to the hospital, the location to which they should be admitted, criteria and evidentiary support for SSRF, timing to SSRF, and operative technique. The review also addresses the cost-effectiveness of this operation and stresses nonoperative treatment modalities that should be implemented prior to operation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Rib fractures are common, morbid, and potentially lethal. Intuitively, if interventions to mitigate downstream effects of rib fractures can be implemented early, likelihood of developing these complications should be reduced. Surgical stabilization of rib fractures (SSRF) is one therapeutic intervention shown to be useful for mitigating complications of these common fractures. Our aim was to investigate for association between time to SSRF and complications among patients with isolated rib fractures undergoing SSRF., Methods: The 2016-2019 American College of Surgeons Trauma Quality Improvement Program (TQIP) database was queried to identify patient >18 years with isolated thoracic injury undergoing SSRF. Patients were divided into three groups: SSRF ≤2 days, SSRF >2 days but <3 days, and SSRF >3 days. Poisson regression, and adjusting for demographic and clinical covariates, was used to evaluate the association between time to SSRF and the primary endpoint, in-hospital complications. Quantile regression was used to evaluate the effects of time to SSRF on the secondary endpoints, hospital and intensive care unit (ICU) length of stay (LOS)., Results: Out of 2185 patients, 918 (42%) underwent SSRF <2 days, 432 (20%) underwent SSRF >2 days but <3 days, and 835 (38%) underwent SSRF >3 days. Hemothorax was more common among patients undergoing SSRF >3 days, otherwise all demographic and clinical variables were similar between groups. After adjusting for potential confounding, SSRF >3 days was associated with a threefold risk of composite in-hospital complications (adjusted incidence rate ratio: 3.15, 95% CI 1.76 to 5.62; p<0.001), a 4-day increase in total hospital LOS (change in median LOS: 4.09; 95% CI 3.69 to 4.49, p<0.001), and a nearly 2-day increase in median ICU LOS (change in median LOS: 1.70; 95% CI 1.32 to 2.08, p<0.001), compared with SSRF ≤2 days., Conclusion: Among patients undergoing SSRF in TQIP, earlier SSRF is associated with less in-hospital complications and shorter hospital stays. Standardization of time to SSRF as a trauma quality metric should be considered., Level of Evidence: Level II, retrospective., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: With an aging global population, the prevalence of frailty in patients with traumatic spinal injury (TSI) is steadily increasing. The aim of the current study is to evaluate the utility of the Orthopedic Frailty Score (OFS) in assessing the risk of adverse outcomes in patients with isolated TSI requiring surgery, with the hypothesis that frailer patients suffer from a disproportionately increased risk of these outcomes., Methods: The Trauma Quality Improvement Program database was queried for all adult patients (18 years or older) who suffered an isolated TSI due to blunt force trauma, between 2013 and 2019, and underwent spine surgery. Patients were categorized as non-frail (OFS 0), pre-frail (OFS 1), or frail (OFS ≥2). The association between the OFS and in-hospital mortality, complications, and failure to rescue (FTR) was determined using Poisson regression models, adjusted for potential confounding., Results: A total of 43 768 patients were included in the current investigation. After adjusting for confounding, frailty was associated with a more than doubling in the risk of in-hospital mortality (adjusted incidence rate ratio (IRR) (95% CI): 2.53 (2.04 to 3.12), p<0.001), a 25% higher overall risk of complications (adjusted IRR (95% CI): 1.25 (1.02 to 1.54), p=0.032), a doubling in the risk of FTR (adjusted IRR (95% CI): 2.00 (1.39 to 2.90), p<0.001), and a 10% increase in the risk of intensive care unit admission (adjusted IRR (95% CI): 1.10 (1.04 to 1.15), p=0.004), compared with non-frail patients., Conclusion: The findings indicate that the OFS could be an effective method for identifying frail patients with TSIs who are at a disproportionate risk of adverse events., Level of Evidence: Level III., Competing Interests: None declared., (Copyright © Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Over the last two decades, the acute management of rib fractures has changed significantly. In 2021, the Chest Wall injury Society (CWIS) began recognizing centers that epitomize their mission as CWIS Collaborative Centers. The primary aim of this study was to determine the resources, surgical expertise, access to care, and institutional support that are present among centers., Methods: A survey was performed including all CWIS Collaborative Centers evaluating the resources available at their hospital for the treatment of patients with chest wall injury. Data about each chest wall injury center care process, availability of resources, institutional support, research support, and educational offerings were recorded., Results: Data were collected from 20 trauma centers resulting in an 80% response rate. These trauma centers were made up of 5 international and 15 US-based trauma centers. Eighty percent (16 of 20) have dedicated care team members for the evaluation and management of rib fractures. Twenty-five percent (5 of 20) have a dedicated rib fracture service with a separate call schedule. Staffing for chest wall injury clinics consists of a multidisciplinary team: with attending surgeons in all clinics, 80% (8 of 10) with advanced practice providers and 70% (7 of 10) with care coordinators. Forty percent (8 of 20) of centers have dedicated rib fracture research support, and 35% (7 of 20) have surgical stabilization of rib fracture (SSRF)-related grants. Forty percent (8 of 20) of centers have marketing support, and 30% (8 of 20) have a web page support to bring awareness to their center. At these trauma centers, a median of 4 (1-9) surgeons perform SSRFs. In the majority of trauma centers, the trauma surgeons perform SSRF., Conclusion: Considerable similarities and differences exist within these CWIS collaborative centers. These differences in resources are hypothesis generating in determining the optimal chest wall injury center. These findings may generate several patient care and team process questions to optimize patient care, patient experience, provider satisfaction, research productivity, education, and outreach., Level of Evidence: Therapeutic/Care Management; Level V., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)