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There is concern regarding the competency of today's general surgery graduates as a large proportion defer independent practice in favor of additional fellowship training. Little is known about the graduates who directly enter general surgery practice and if their operative experiences during residency differ from graduates who pursue fellowship.Nineteen Accreditation Council for Graduate Medical Education-accredited general surgery programs from the US Resident OPerative Experience Consortium were included. Demographics, career choice, and case logs from graduates between 2010 to 2020 were analyzed.There were 1,264 general surgery residents who graduated over the 11-year period. A total of 248 (19.6%) went directly into practice and 1,016 (80.4%) pursued fellowship. Graduates directly entering practice were more likely to be a high-volume resident (43.1% vs 30.5%, P.01) and graduate from a high-volume program (49.2% vs 33.0%, P.01). Direct-to-practice graduates performed 53 more cases compared with fellowship-bound graduates (1,203 vs 1,150, P.01). On multivariable analysis, entering directly into practice was positively associated with total surgeon chief case volume (odds ratio = 1.47, 95% confidence interval 1.18-1.84, P.01) and graduating from a US medical school (odds ratio = 2.54, 95% confidence interval 1.45-4.44, P.01) while negatively associated with completing a dedicated research experience (odds ratio = 0.31, 95% confidence interval 0.22-0.45, P.01).This is the first multi-institutional study exploring resident operative experience and career choice. These data suggest residents who desire immediate practice can tailor their experience with less research time and increased operative volume. These data may be helpful for programs when designing their experience for residents with different career goals.

Malnutrition is associated with increased morbidity and mortality after trauma. The Geriatric Nutritional Risk Index (GNRI) is a validated scoring system used to predict the risk of complications related to malnutrition in nontrauma patients. We hypothesized that GNRI is predictive of worse outcomes in geriatric trauma patients.This was a single-center retrospective study of trauma patients 65 years or older admitted in 2019. Geriatric Nutritional Risk Index was calculated based on admission albumin level and ratio of actual body weight to ideal body weight. Groups were defined as major risk (GNRI82), moderate risk (GNRI 82-91), low risk (GNRI 92-98), and no risk (GNRI98). The primary outcome was mortality. Secondary outcomes included ventilator days, intensive care unit length of stay (LOS), hospital LOS, discharge home, sepsis, pneumonia, and acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed to determine the association between GNRI risk category and outcomes.A total of 513 patients were identified for analysis. Median age was 78 years (71-86 years); 24 patients (4.7%) were identified as major risk, 66 (12.9%) as moderate risk, 72 (14%) as low risk, and 351 (68.4%) as no risk. Injury Severity Scores and Charlson Comorbidity Indexes were similar between all groups. Patients in the no risk group had decreased rates of death, and after adjusting for Injury Severity Score, age, and Charlson Comorbidity Index, the no risk group had decreased odds of death (odds ratio, 0.13; 95% confidence interval, 0.04-0.41) compared with the major risk group. The no risk group also had fewer infectious complications including sepsis and pneumonia, and shorter hospital LOS and were more likely to be discharged home.Major GNRI risk is associated with increased mortality and infectious complications in geriatric trauma patients. Further studies should target interventional strategies for those at highest risk based on GNRI.Prognostic and Epidemiologic; Level III.

Background Psychiatric illness is an independent risk factor for trauma and recidivism and is often comorbid in the trauma population. There is no current standard for the delivery of mental health services in trauma care. The purpose of this study was to gauge trauma surgeon perceptions of needed and currently available resources for this patient population at level 1 trauma centers in the United States. Materials and methods A 10-question survey was developed to capture the estimated volume of psychiatric patients admitted to level 1 trauma centers, their available psychiatric services, and perceived need for resources. It was sent to 27 trauma surgery colleagues at different level 1 trauma centers across the United States using a public survey tool. Descriptive analyses were performed. Results Twenty-two of 27 trauma surgeons responded (81% response rate). Ten centers (48%) estimated admitting 1-5 patients with preexisting serious mental illness weekly, whereas others admitted more. Eight (36%) reported not having acute situational support services available. Ten respondents (46%) did not know how many psychiatric consultants were available at their institution. Twelve surgeons (55%) reported no designated outpatient follow-up for psychiatric issues. Sixteen trauma surgeons (73%) stated that expanded psychiatric services are needed at their trauma center. Conclusions Trauma patients frequently present with preexisting serious mental illness and many struggle with psychological sequelae of trauma. Over half of the surveyed surgeons reported no outpatient follow-up for these patients, and almost three quarters perceived the need for expansion of psychiatric services. In addition to a lack of resources, these findings highlight an overlooked gap in high-quality patient-centered trauma care.

OBJECTIVE: Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS), pupil non-reactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH. METHODS: A prospectively collected multi-center database of 3,279 TBI admissions to 45 different U.S. trauma centers between 2017–2019 was queried to identify patients >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables. RESULTS: A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n=150) and the rate of withdrawal of life-sustaining measures was 10% (n=66). A multivariate logistic regression model identified GCS 80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

INTRODUCTION: In 2013, we implemented a pill-based, multi-modal pain regimen (MMPR) in order to decrease in-hospital opioid exposure after injury at our trauma center. We hypothesized that the MMPR would decrease inpatient oral morphine milligram equivalents (MME), decrease opioid prescriptions at discharge, and result in similar Numerical Rating Scale (NRS) pain scores. METHODS: Adult patients admitted to a level-1 trauma center with ≥1 rib fracture from 2010–2017 were included – spanning 3 years before and 4 years after MMPR implementation. MME were summarized as medians and interquartile range (IQR) by year of admission. The effect of the MMPR on daily total MME was estimated using Bayesian generalized linear model. RESULTS: Over the 8 year study period, 6,933 patients who met study inclusion criteria were included. No significant differences between years were observed in Abbreviated Injury Scale (AIS) Chest or Injury Severity Scores (ISS). After introduction of the MMPR, there was a significant reduction in median total MME administered per patient day from 60 MME/ patient day (IQR 36–91 MME/patient day) pre-MMPR implementation to 37 MME/patient day (IQR 18–61 MME/patient day) in 2017, p

BackgroundOlder patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program’s best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification.MethodsWe discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions.ResultsWe describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen.DiscussionSpecialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes.Level of evidence V

BackgroundAlthough widely used in treating severe abdominal trauma, damage control laparotomy (DCL) has not been assessed in any randomized controlled trial. We conducted a pilot trial among patients for whom our surgeons had equipoise and hypothesized that definitive laparotomy (DEF) would reduce major abdominal complications (MAC) or death within 30 days compared with DCL.MethodsEligible patients undergoing emergency laparotomy were randomized during surgery to DCL or DEF from July 2016 to May 2019. The primary outcome was MAC or death within 30 days. Prespecified frequentist and Bayesian analyses were performed.ResultsOf 489 eligible patients, 39 patients were randomized (DCL 18, DEF 21) and included. Groups were similar in demographics and mechanism of injury. The DEF group had a higher Injury Severity Score (DEF median 34 (IQR 20, 43) vs DCL 29 (IQR 22, 41)) and received more prerandomization blood products (DEF median red blood cells 8 units (IQR 6, 11) vs DCL 6 units (IQR 2, 11)). In unadjusted analyses, the DEF group had more MAC or death within 30 days (1.71, 95% CI 0.81 to 3.63, p=0.159) due to more deaths within 30 days (DEF 33% vs DCL 0%, p=0.010). Adjustment for Injury Severity Score and prerandomization blood products reduced the risk ratio for MAC or death within 30 days to 1.54 (95% CI 0.71 to 3.32, p=0.274). The Bayesian probability that DEF increased MAC or death within 30 days was 85% in unadjusted analyses and 66% in adjusted analyses.ConclusionThe findings of our single center pilot trial were inconclusive. Outcomes were not worse with DCL and, in fact, may have been better. A randomized clinical trial of DCL is feasible and a larger, multicenter trial is needed to compare DCL and DEF for patients with severe abdominal trauma.Level of evidenceLevel II.

In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre-group (from January 1, 2018 to July 31, 2019) and Post-group (from January 1, 2020 to June 30, 2020) from before and after the implementation of the protocols (from August 1, 2019 to December 31, 2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MMEs). Secondary outcomes included MMEs/day, pain domain-specific MMEs, and pain scores. Pain was estimated by creating a normalized pain score (range 0–1), which incorporated three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon rank-sum and chi-square tests. Treatment effects were estimated using Bayesian generalized linear models. There were no differences in demographics or burn characteristics between the Pre-group (n = 495) and Post-group (n = 174). The Post-group had significantly lower total MMEs (Post-group 110 MMEs [32, 325] vs Pre-group 230 [60, 840], P < .001), MMEs/day (Post-group 33 MMEs/day [15, 54] vs Pre-group 52 [27, 80], P < .001), and domain-specific total MMEs. No difference in average normalized pain scores was seen. Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.

OBJECTIVE Evaluate the effect of age on opioid consumption after traumatic injury. SUMMARY BACKGROUND DATA Older trauma patients receive fewer opioids due to decreased metabolism and increased complications, but adequacy of pain control is unknown. We hypothesized that older trauma patients require fewer opioids to achieve adequate pain control. METHODS A secondary analysis of the multimodal analgesia strategies for trauma Trial evaluating the effectiveness of 2 multimodal pain regimens in 1561 trauma patients aged 16 to 96 was performed. Older patients (≥55 years) were compared to younger patients. Median daily oral morphine milligram equivalents (MME) consumption, average numeric rating scale pain scores, complications, and death were assessed. Multivariable analyses were performed. RESULTS Older patients (n = 562) had a median age of 68 years (interquartile range 61-78) compared to 33 (24-43) in younger patients. Older patients had lower injury severity scores (13 [9-20] vs 14 [9-22], P = 0.004), lower average pain scores (numeric rating scale 3 [1-4] vs 4 [2-5], P < 0.001), and consumed fewer MME/day (22 [10-45] vs 52 [28-78], P < 0.001). The multimodal analgesia strategies for trauma multi-modal pain regimen was effective at reducing opioid consumption at all ages. Additionally, on multivariable analysis including pain score adjustment, each decade age increase after 55 years was associated with a 23% reduction in MME/day consumed. CONCLUSIONS Older trauma patients required fewer opioids than younger patients with similar characteristics and pain scores. Opioid dosing for post-traumatic pain should consider age. A 20 to 25% dose reduction per decade after age 55 may reduce opioid exposure without altering pain control.

Introduction: Falls are the leading cause of accidental death in older adults. Each year, 28.7% of US adults over 65 years experience a fall resulting in over 300,000 hip fractures and $50 billion in medical costs. Annual fall risk assessments have become part of the standard care plan for older adults. However, the effectiveness of these assessments in identifying at-risk individuals remains limited. This study characterizes the performance of a commercially available, automated method, for assessing fall risk using machine learning.Methods: Participants (N = 209) were recruited from eight senior living facilities and from adults living in the community (five local community centers in Houston, TX) to participate in a 12-month retrospective and a 12-month prospective cohort study. Upon enrollment, each participant stood for 60 s, with eyes open, on a commercial balance measurement platform which uses force-plate technology to capture center-of-pressure (60 Hz frequency). Linear and non-linear components of the center-of-pressure were analyzed using a machine-learning algorithm resulting in a postural stability (PS) score (range 1–10). A higher PS score indicated greater stability. Participants were contacted monthly for a year to track fall events and determine fall circumstances. Reliability among repeated trials, past and future fall prediction, as well as survival analyses, were assessed.Results: Measurement reliability was found to be high (ICC(2,1) [95% CI]=0.78 [0.76–0.81]). Individuals in the high-risk range (1-3) were three times more likely to fall within a year than those in low-risk (7–10). They were also an order of magnitude more likely (12/104 vs. 1/105) to suffer a spontaneous fall i.e., a fall where no cause was self-reported. Survival analyses suggests a fall event within 9 months (median) for high risk individuals.Conclusions: We demonstrate that an easy-to-use, automated method for assessing fall risk can reliably predict falls a year in advance. Objective identification of at-risk patients will aid clinicians in providing individualized fall prevention care.

An effective strategy to manage acute pain and minimize opioid exposure is needed for injured patients. In this trial, we aimed to compare 2 multimodal pain regimens (MMPRs) for minimizing opioid exposure and relieving acute pain in a busy, urban trauma center.This was an unblinded, pragmatic, randomized, comparative effectiveness trial of all adult trauma admissions except vulnerable patient populations and readmissions. The original MMPR (IV administration, followed by oral, acetaminophen, 48 hours of celecoxib and pregabalin, followed by naproxen and gabapentin, scheduled tramadol, and as-needed oxycodone) was compared with an MMPR of generic medications, termed the Multi-Modal Analgesic Strategies for Trauma (MAST) MMPR (ie oral acetaminophen, naproxen, gabapentin, lidocaine patches, and as-needed opioids). The primary endpoint was oral morphine milligram equivalents (MMEs) per day and secondary outcomes included total MMEs during hospitalization, opioid prescribing at discharge, and pain scores.During the trial, 1,561 patients were randomized, 787 to receive the original MMPR and 774 to receive the MAST MMPR. There were no differences in demographic characteristics, injury characteristics, or operations performed. Patients randomized to receive the MAST MMPR had lower MMEs per day (34 MMEs/d; interquartile range 15 to 61 MMEs/d vs 48 MMEs/d; interquartile range 22 to 74 MMEs/d; p0.001) and fewer were prescribed opioids at discharge (62% vs 67%; p = 0.029; relative risk 0.92; 95% credible interval, 0.86 to 0.99; posterior probability relative risk1 = 0.99). No clinically significant difference in pain scores were seen.The MAST MMPR was a generalizable and widely available approach that reduced opioid exposure after trauma and achieved adequate acute pain control.

Uncontrolled bleeding is a leading cause of preventable death from trauma. With the rise in mass casualty events, training of laypersons can be life-saving. "Stop the Bleed" is a campaign to teach the public techniques of bleeding control. We believe that training in these techniques will increase participants' willingness and preparedness to intervene and increase knowledge of trauma/hemorrhage control.We created a "Stop the Bleed" training program. School nurses, medical students, researchers, and community members participated in the program. Pre- and post-training questionnaires assessed participants' willingness/preparedness to intervene in a casualty event and knowledge of trauma/hemorrhage control.There was a significant change in attitudes after receiving training (p 0.05). There was also an improvement in knowledge regarding bleeding control techniques."Stop the Bleed" training empowers participants with the confidence and knowledge to aid others in preventable hemorrhagic death.

IMPORTANCE: Resident operative autonomy has been steadily decreasing. Whether this reduction in autonomy has been associated with changes in patient outcomes is unclear. OBJECTIVE: To assess whether surgical procedures performed by residents without an attending surgeon scrubbed are associated with differences in patient outcomes compared with procedures performed by attending surgeons alone or by residents with the assistance of attending surgeons. DESIGN, SETTING, AND PARTICIPANTS: This retrospective propensity score–matched cohort study analyzed 30-day outcomes among patients who received operations at US Veterans Affairs (VA) medical centers and were recorded within the VA Surgical Quality Improvement Program (VASQIP) database from July 1, 2004, to September 30, 2019. Among 1 797 056 operations recorded in the VASQIP during that period, 1 319 020 were eligible for inclusion. Operations performed by a surgical resident without an attending surgeon scrubbed (resident primary) were propensity score matched on a 1:1 ratio (based on year of procedure and patient age, race, sex, American Society of Anesthesiologists physical status classification, functional status, emergency status, inpatient status, presence of multiple comorbidities, and Current Procedural Terminology code) to operations performed by an attending surgeon only (surgeon primary) and operations performed by a resident with assistance from an attending surgeon (resident plus surgeon). EXPOSURES: Level of resident involvement. MAIN OUTCOMES AND MEASURES: Thirty-day adjusted all-cause mortality. RESULTS: Among 1 319 020 surgical procedures included, 138 750 were performed by residents only, 308 724 were performed by surgeons only, and 871 546 were performed by residents and surgeons. For the 1 319 020 total cases, patients’ mean (SD) age was 61.6 (12.9) years; 1 223 051 patients (92.7%) were male; and 212 315 (16.1%) were Black or African American, 63 817 (4.9%) were Hispanic, 830 704 (63.0%) were White, and 212 814 (16.1%) were of other or unknown race and ethnicity. Propensity score matching produced 101 130 pairs of resident-primary and surgeon-primary procedures and 137 749 pairs of resident-primary and resident plus surgeon procedures. Patient all-cause mortality and morbidity were no different among those who received surgeon-primary procedures (mortality: odds ratio [OR], 1.03 [95% CI, 0.95-1.12]; morbidity: OR, 1.01 [95% CI, 0.97-1.05]) vs resident plus surgeon procedures (mortality: OR, 1.03 [95% CI, 0.97-1.11]; all-cause morbidity: OR, 0.97 [95% CI, 0.95-1.00]). Resident-primary procedures had longer operative times than surgeon-primary procedures (median, 80 minutes [IQR, 50-123 minutes] vs 70 minutes [IQR, 41-114 minutes], respectively; P

Introduction Concomitant traumatic injury in the burn patient complicates care coordination and increases morbidity and mortality. The incidence of concomitant injury, however, is uncommon and reported to range from 5–7%. In May 2020, our level 1 trauma center began seeing 40% more patients per month that the 12 months prior. We sought to determine the incidence of concomitant injury in burn patients during this time of increased trauma volume and to examine the associated traumatic injuries in this group. Methods The burn registry at a single ABA-verified burn center was examined from 5/20–9/20. Patients with concomitant burn and traumatic injury were examined with respect to: %TBSA burn, mechanism of injury, operative interventions, associated traumatic injuries, and length of hospital stay. Continuous data was presented as mean (standard deviation). Results Eighty-nine burn patients were admitted during this period, of whom 24 (26.9%) had concomitant traumatic injuries. The cohort was young and mostly male; the mean TBSA was 16% () (Table 1). The most common mechanism of injury was motor vehicle collision (12 or 50%), followed by fall after high voltage electrical injury (6 or 25%) and motorcycle collisions (5 or 21%). The most common associated injuries were: pulmonary contusions 29.1% (7/24); long bone fractures 25% (6/24); pelvic/acetabular fractures 20.8% (5/24); femur fractures 16.6% (4/24); and solid organ injury: 16.6% (4/24). Twenty patients (83.3%) required burn or trauma operative intervention during hospital stay. Of the 20 patients who required operative intervention, 85% underwent burn surgery and 55% underwent trauma surgery (solid organ or orthopedic). Forty percent of these patients required operation for both burn and traumatic injury. In looking specifically at the electric injury group, all six patients required operative intervention for burn injuries, and four required extremity fasciotomy. Patients with electrical injury had a significantly longer hospital stay relative to their TBSA (p< 0.04). Conclusions Concomitant trauma and burn injuries are infrequent yet present a major clinical challenge. Our recent increase in overall trauma volume was paralleled by an increase in patients with concomitant burn injuries. The associated traumatic injuries require a multi-disciplinary approach to minimize morbidity and restore function.

Introduction Traditionally, opioids have been the mainstay of treatment for background, breakthrough, procedural, and postoperative pain after burns. However, in addition to an impetus to reduce provider-driven opioid exposure, there is increasing evidence that opioids can worsen acute pain through induction of hyperalgesia. In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes. We hypothesized that these protocols would reduce inpatient opioid exposure without increasing acute pain scores. Methods Two groups of consecutive patients admitted to the burn service were compared: Pre (01/2018 to 07/2019) and Post (01/2020 to 06/2020) implementation of the protocols (08/2019 to 12/2019). Patient demographics, burn characteristics, and lengths of stay were abstracted from the burn registry. Opioid exposure and pain scale scores were obtained from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain specific MME, pain scores, and lengths of stay. Pain was estimated by creating a normalized pain score (range 0–1) from three different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effect was estimated using Bayesian generalized linear models. Results There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174), including TBSA burn (Pre 4% [2, 10] versus Post 5% [2, 10], p=0.898). The Post group had significantly lower total MME (IRR 0.72, 95% CrI 0.57–0.93, posterior probability 99%), MME/day (IRR 0.76, 95% CrI 0.65–0.90, posterior probability 99%), and domain-specific total MME (Table). No difference in average normalized pain scores was seen. The Pre group were hospitalized longer than the Post group (5 days [2, 14] versus 4 days [1, 9], p=0.012). Conclusions Implementation of opioid-minimizing protocols for acute burn pain were associated with a significant reduction in inpatient opioid exposure without increased pain scores. More information is needed to understand the association with reduced hospital days.

Background After traumatic spinal cord injury (SCI), there is increased risk of venous thromboembolism (VTE), but chemoprophylaxis (PPX) may cause expansion of intraspinal hematoma (ISH). Methods Single-center retrospective study of adult trauma patients from 2012 to 2015 with SCI. Exclusion criteria VTE diagnosis, death, or discharge within 48 hours. Patients were dichotomized based on early (≤48 hours) heparinoid and/or aspirin PPX. Intraspinal hematoma expansion was diagnosed intraoperatively or by follow-up radiology. We used multivariable Cox proportional hazards to estimate the effect of PPX on risk of VTE and ISH expansion controlling for age, injury severity score (ISS), complete SCI, and mechanism as static covariates and operative spine procedure as a time-varying covariate. Results Five hundred one patients with SCI were dichotomized into early PPX (n = 260 [52%]) and no early PPX (n = 241 [48%]). Early PPX patients were less likely blunt injured (91% vs 97%) and had fewer operative spine interventions (65% vs 80%), but age (median, 43 vs 49 years), ISS (median 24 vs 21), admission ISH (47% vs 44%), and VTE (5% vs 9%) were similar. Cox analysis found that early heparinoids was associated with reduced VTE (hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.16-0.84) and reduced pulmonary embolism (PE) (HR, 0.20; 95% CI, 0.06-0.69). The estimated number needed to treat with heparinoids was 10 to prevent one VTE and 13 to prevent one PE at 30 days. Early aspirin was not associated with reduced VTE or PE. Seven patients (1%) had ISH expansion, of which four were on PPX at the time of expansion. Using heparinoid and aspirin as time-varying covariates, neither heparinoids (HR, 1.90; 95% CI, 0.32-11.41) nor aspirin (HR, 3.67; 95% CI, 0.64-20.88) was associated with ISH expansion. Conclusion Early heparinoid therapy was associated with decreased VTE and PE risk in SCI patients without concomitant increase in ISH expansion. Level of evidence Therapeutic, level IV.

Our institution has published damage control laparotomy (DCL) rates of 30% and documented the substantial morbidity associated with the open abdomen. The purpose of this quality improvement (QI) project was to decrease the rate of DCL at a busy, Level I trauma center in the US.A prospective cohort of all emergent trauma laparotomies from November 2013 to October 2015 (QI group) was followed. The QI intervention was multifaceted and included audit and feedback for every DCL case. Morbidity and mortality of the QI patients were compared with those from a published control (control group: emergent laparotomy from January 2011 to October 2013).A significant decrease was observed immediately on beginning the QI project, from a 39% DCL rate in the control period to 23% in the QI group (p0.001). This decrease was sustained over the 2-year study period. There were no differences in demographics, Injury Severity Score, or transfusions between the groups. No differences organ/space infection (control 16% vs QI 12%; p = 0.15), fascial dehiscence (6% vs 8%; p = 0.20), unplanned relaparotomy (11% vs 10%; p = 0.58), or mortality (9% vs 10%; p = 0.69) were observed. The reduction in use resulted in a decrease of 68 DCLs over the 2-year period. There was a further reduction in the rate of DCL to 17% after completion of the QI project.A QI initiative rapidly changed the use of DCL and improved quality of care by decreasing resource use without an increase morbidity or mortality. This decrease was sustained during the QI period and further improved upon after its completion.

Clinical scores determining the likelihood of acute appendicitis (AA), including the Alvarado score, were devised using a younger population, and their efficacy in predicting AA in elderly patients is not well documented. This study's purpose is to evaluate the utility of Alvarado scores in this population. A retrospective chart review of patients >65 years old presenting with pathologically diagnosed AA from 2000 to 2010 was performed. Ninety-six patients met inclusion criteria. The average age was 73.7 ± 1.5 years and our cohort was 41.7 per cent male. The average Alvarado score was 6.9 ± 0.33. The distribution of scores was 1 to 4 in 3.7 per cent, 5 to 6 in 37.8 per cent, and 7 to 10 in 58.5 per cent of cases. There was a statistically significant increase in patients scoring 5 or 6 in our cohort versus the original Alvarado cohort (P < 0.01). Right lower quadrant tenderness (97.6%), left shift of neutrophils (91.5%), and leukocytosis (84.1%) were the most common symptoms on presentation. In conclusion, our data suggest that altering our interpretation of the Alvarado score to classify elderly patients presenting with a score of ≥5 as high risk may lead to earlier diagnosis of AA. Physicians should have a higher clinical suspicion of AA in elderly patients presenting with right lower quadrant tenderness, left shift, or leukocytosis.

CONTEXT/OBJECTIVE: Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN: Cohort study. SETTING: Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS: Adult Acute Cervical SCI Patients, 2011–2018. INTERVENTIONS: HVtV. OUTCOME MEASURES: VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS: Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55–2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS: While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.

BACKGROUND: Financial interactions between industry and healthcare providers are reportable. Substantial discrepancies have been detected between industry and self-report of these conflicts of interest (COIs). OBJECTIVE: Our aim was to determine if authors who fail to disclose reportable COI are more likely to publish findings that are favorable to industry than authors with no COI. DESIGN: In this blinded, observational study of medical and surgical primary research articles in PubMed, 590 articles were reviewed. MAIN MEASURES: Reportable financial relationships between authors and industry were evaluated. COIs were considered to have relevance if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, defined as an impression favorable to the product(s) discussed by an article and determined by 3 independent, blinded clinicians for each article. Primary analysis compared Incomplete Self-Disclosure to No COI. Two-level multivariable mixed-effects ordered logistic regression was used to assess factors associated with favorability. KEY RESULTS: A 69% discordance rate existed between industry and self-report in COI disclosure. When authors failed to disclose COI, their conclusions were more likely to favor industry partners than authors without COI (favorable ratings 73% versus 62%, RR 1.18, p =

Substantial discrepancies exist between industry-reported and self-reported conflicts of interest (COI). Although authors with relevant, self-reported financial COI are more likely to write studies favorable to industry sponsors, it is unknown whether undisclosed COI have the same effect. We hypothesized that surgeons who fail to disclose COI are more likely to publish findings that are favorable to industry than surgeons with no COI. PubMed was searched for articles in multiple surgical specialties. Financial COI reported by surgeons and industry were compared. COI were considered to be relevant if they were associated with the product(s) mentioned by an article. Primary outcome was favorability, which was defined as an impression favorable to the product(s) discussed by an article and was determined by 3 independent, blinded clinicians for each article. Primary analysis compared incomplete self-disclosure to no COI. Ordered logistic multivariable regression modeling was used to assess factors associated with favorability. Overall, 337 articles were reviewed. There was a high rate of discordance in the reporting of COI (70.3%). When surgeons failed to disclose COI, their conclusions were significantly more likely to favor industry than surgeons without COI (RR 1.2, 95% CI 1.1–1.4, p

National health care expenditures constitute a continuously expanding component of the US economy. Health care resources are distributed unequally among the population, and geriatric patients are disproportionately represented. Characterizing this group of individuals that accounts for the largest percentage of US health spending may facilitate the introduction of targeted interventions in key high-impact areas. Changing demographics, an increasing incidence of chronic disease and progressive disability, rapid technological advances, and systemic market failures in the health care sector combine to drive cost. A multidisciplinary approach will become increasingly necessary to balance the delicate relationship between our constrained supply and increasing demand.

Introduction Damage control laparotomy (DCL) for trauma is thought to be associated with increased abdominal complications. The purpose of this study is to determine the effect of DCL on abdominal complications by comparing two groups of trauma patients: DCL patients who were prospectively adjudicated to potentially being closed at the primary laparotomy (potential DEF or pDEF) and those who underwent definitive laparotomy (DEF). Methods The pDEF group was matched to DEF patients according to mechanism of injury, abdominal injury severity, operating room transfusions, and performance of a colon resection. The primary outcome was major abdominal complications (MAC), a composite variable. Results No statistically significant difference in the primary outcome, major abdominal complications, were seen (pDEF 19% versus DEF 56%, p = 0.066). The pDEF group was more likely to have a fascial dehiscence (38% versus 0%, p = 0.018), and to be re-opened after fascial closure (38% versus 0%, p = 0.018). Conclusion Damage control laparotomy was associated with clinically but not statistically significant increase in rates of MAC. Increased numbers of patients to analyze in this fashion is needed.

BACKGROUND: The pathophysiology and time course of coagulopathy after major burns are inadequately understood. Our study objectives were to determine whether acute traumatic coagulopathy (ATC) is seen in burn patients at admission and to determine the changes in international normalized ratio (INR), activated partial thromboplastin time (aPTT), platelet count (PLT), and hemoglobin (Hgb) in the first 7 days after injury. METHODS: We conducted a retrospective study of patients with burn injury of at least 15% total body surface area who presented to the University of North Carolina. Data on patient demographics, injury characteristics, and laboratory data (INR, aPTT, PLT, and Hgb) at admission and within the first 7 days after injury were recorded. We defined ATC as INR of 1.3 or greater, aPTT of 1.5 or greater times the mean normal limit, and normal PLT at admission. RESULTS: We studied the hematologic profile of 102 patients with burn injury of 15% to 100% total body surface area but did not identify a single patient with ATC at admission. The screening hematologic profile at admission was not influenced by burn severity. In the first 7 days after injury, the INR and aPTT were relatively preserved, while the PLT quickly recovered to baseline after an early decline and the Hgb remained stable at around 10 g/dL; all these changes occurred during the time when the burn patients had received large amounts of fluid resuscitation. CONCLUSION: The screening hematologic profile of burn patients at admission is normal, and the standard screening assays do not suggest the existence of ATC at admission. While this is a relatively small study, it provides evidence to suggest that ATC is unique to trauma patients. LEVEL OF EVIDENCE: Prognostic study, level III. Language: en

Benefits and advantages of tracheostomy have been vigorously debated. There is a lack of consensus as to whether perceived clinical improvement is attributable to fundamental changes in respiratory dynamics. We compare the effect of tracheostomy versus endotracheal tube on dead space, airway resistance and other lung parameters in critically ill ventilated patients. Data collected included patients who were admitted to surgical, burn and neurosurgical intensive care units at the University of North Carolina. Twenty-four intubated patients were included in our analysis with various aetiologies of respiratory failure. Tracheostomy was deemed necessary either for severe neurological devastation or failure to wean from the ventilator. The diameter of the endotracheal tubes ranged from 6-8 mm and the tracheostomy tube diameters were from 6.4-8.9 mm. Internal diameters between endotracheal tube and tracheostomy tubes, ventilator settings and sedation were kept consistent throughout the study. Respiratory parameters were measured using the Respironics' non-invasive cardiac output 2 device (Phillips, Andover, MA) immediately prior to tracheostomy and repeated within 24 hours of tracheostomy. Only two (8%) of the patients had slight improvement (>6% decrease in dead space). The average dead space of endotracheal versus tracheostomy tubes was 41±12.6% and 40±14.6%, respectively (P=0.75). The remaining 22 patients (92%) had no significant change in dead space, compliance or other respiratory parameters. This study shows that there is no significant difference in respiratory mechanics and dead space with a tracheostomy versus endotracheal tube.

Introduction Enteral nutrition improves clinical outcomes. The effects of feeding on LPS induced liver injury are unknown. We hypothesized that feeding would attenuate liver injury from LPS. Methods Fasted or fed rats were given LPS (20 mg/kg ip) or saline for 5 h and sacrificed. Serum aminotransferases and cytokines (immunoassay) were measured. Oxidative stress protein (iNOS, COX2, and HO1) assessments (Western immunoblot) were also obtained. Results In fasted rats, LPS significantly increased serum aminotransferase levels, enhanced hepatic COX2, iNOS, and HO1 immunoreactivity, and increased serum cytokine levels when compared to controls. While feeding diminished liver enzymes, attenuated expression of COX2 and iNOS, and blunted production of pro-inflammatory cytokines, it did not modulate LPS-induced expression of the anti-inflammatory markers HO1 and IL-10. Conclusion These data suggest that feeding decreases liver injury by attenuating expression of pro-inflammatory mediators while maintaining expression of anti-inflammatory mediators, both systemically and locally.

The pathophysiology of sepsis is incompletely understood, however alterations in systemic inflammation and serum cytokines are thought to play a central role. In the rat, ketamine, but not isoflurane, prevents hepatic injury from lipopolysaccharide (LPS). The effect of these anesthetics on the systemic inflammatory response and other organs remains to be fully elucidated. We hypothesized that ketamine, but not isoflurane, would blunt the cytokine response to LPS administration.Male rats received no anesthesia, intraperitoneal ketamine (70 mg/kg), or inhalational isoflurane. One hour later, LPS (20 mg/kg, intraperitoneal) or saline was given for 5 hours and rats were killed. Gastric fluid volumes were determined as an index of gastric emptying. Serum was collected and cytokines measured via a multiplexed suspension immunoassay.In nonanesthetized rats, LPS increased gastric luminal fluid accumulation and serum levels of proinflammatory cytokines when compared with saline controls. Anesthesia with either ketamine or isoflurane caused a significant reduction in LPS-induced changes in serum cytokines, although ketamine had a more dramatic reduction in tumor necrosis factor alpha levels than did isoflurane. Both anesthetics reduced the interleukin IL-6/IL-10 ratio in response to LPS when compared with LPS alone. Ketamine, but not isoflurane, prevented LPS-induced gastric luminal fluid accumulation.These data indicate that both ketamine and isoflurane diminish the systemic inflammatory response to LPS in the rat as measured by serum cytokines and a reduced IL-6/IL-10 ratio. However, only ketamine improves LPS-induced gastric dysfunction, perhaps secondary to its ability to reduce serum tumor necrosis factor alpha levels more effectively.

Purpose of review Clostridium difficile is the most common cause of nosocomial infectious diarrhea in adults. The purpose of this review is to increase awareness that infection from C. difficile is not always indolent, but with fulminant colitis, it can be lethal. The epidemiology, pathogenesis and treatment of C. difficile infection are discussed, with special emphasis on management of fulminant colitis. Recent findings Clostridium difficile causes fulminant colitis in 3-8% of patients. Early predictors of disease include immunosuppression, hypotension, hypoalbuminemia, and a pronounced leukocytosis. In patients with fulminant colitis, early colectomy before vasopressor therapy is required and may improve survival. Summary The incidence and virulence of C. difficile infection are increasing. Antibiotic use and length of hospital stay correlate strongly with infection. Oral or intravenous metronidazole is the recommended first-line therapy, with discontinuation of systemic antibiotics if possible. Forty percent of patients may have a prolonged course and 20% will relapse despite adequate therapy. Fulminant colitis develops in 3-8% of patients; diagnosis can be difficult with diarrhea absent in 20% of the subgroup. Once diagnosed, subtotal colectomy with ileostomy is usually required. In patients with a marked leukocytosis or bandemia, surgery is advisable because the leukocytosis frequently precedes hypotension and the requirement for vasopressor therapy, which carries a poor prognosis.

National health care expenditures constitute a continuously expanding component of the US economy. Health care resources are distributed unequally among the population, and geriatric patients are disproportionately represented. Characterizing this group of individuals that accounts for the largest percentage of US health spending may facilitate the introduction of targeted interventions in key high-impact areas. Changing demographics, an increasing incidence of chronic disease and progressive disability, rapid technological advances, and systemic market failures in the health care sector combine to drive cost. A multidisciplinary approach will become increasingly necessary to balance the delicate relationship between our constrained supply and increasing demand.

Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery.

The US’ economy is the largest in the world and US health-care costs represent a larger percentage of the gross domestic product than in any other developed nation, resulting in the highest national per capita spending in the world. Economists project that health-care costs will continue to rise, eventually exceeding 50 % of all US economic transactions. The aging “baby boomer” generation is thought to be a major driving force for increased health-care expenditures, but other key issues may have even greater impact on future spending.

Despite a well-described association of age and injury with mortality and decreased functional status, inpatient mortality studies have traditionally not included analysis of do not resuscitate (DNR) status. We hypothesized that the increased likelihood of DNR status in older patients alters age-adjusted mortality rates in trauma.The trauma registry was queried for adult patients admitted to our Level I trauma center (January 2005-December 2008) and divided into eight age groups by decade. Ages 15-44 years were collapsed because of the lack of variation. We compared age, case fatality rate, and DNR status by univariate analysis and trends by χ (p0.05).Of the 15,227 adult patients admitted, 13% were elderly (≥65) and 7% died. DNR status was known in 75% of deaths, and 42% of those had active DNR orders on the chart at time of death. DNR likelihood increased with age (p0.05), from 5% to 18%. With DNRs excluded, mortality variability across all ages was markedly diminished (4-7%).DNR status among trauma patients varies significantly because of inconsistent implementation and meaning between hospitals, and successive decades are more likely to have an active DNR order at time of death. When DNR patients were excluded from mortality analysis, age was minimally associated with an increased risk of death. The inclusion of DNR patients within mortality studies likely skews those analyses, falsely indicating failed resuscitative efforts rather than humane decisions to limit care after injury.

Background Uncontrolled bleeding is an important cause of increased transfusion in burn victims; however, description of blood utilization patterns in the burn population is lacking. Study Design and Methods We conducted a single-institution, retrospective cohort study to measure blood utilization in 89 consecutive burn patients with 15% to 65% total body surface area (TBSA) burn within 60 days of injury. We also evaluated the relationship of blood product utilization with clinical variables including anticoagulant usage and mortality. Results We determined that: 1) the predictors for increased red blood cells (RBCs) and plasma transfusions were high TBSA burn and the use of argatroban anticoagulation (for suspected heparin-induced thrombocytopenia [HIT]); 2) TBSA burn and patient age were independent predictors of mortality, but not RBC or plasma transfusion; and 3) the incidence of symptomatic venous thromboembolic events is not uncommon (11.2%), although HIT is rare (1.1%). Conclusion Despite concerns about adverse correlation between increased number of transfusions and mortality in other clinical settings, we did not find this association in our study. However, we demonstrated that the type and intensity of anticoagulation carries substantial risk for increased RBC as well as plasma usage.

Trauma centers are caring for increased proportions of elderly patients. Although age and Injury Severity Score are independently associated with mortality, trauma centers were originally designed to care for seriously injured patients without age-specific guidelines. We hypothesized that elderly patients would have different complication patterns than their younger counterparts.The trauma registry of an American College of Surgeons -verified Level I trauma center was queried for all patients older than 14 years admitted between January 2005 and December 2008. Mechanism, mortality, and complications were evaluated after dividing patients into eight age groups.Of the 15,223 patients, 13% were elderly (≥65), and 86% were injured via a blunt mechanism. Increasing age correlated with fatality (all Injury Severity Scores), end-organ failure, and thromboembolic complications (deep venous thrombosis and coagulopathy). Analysis revealed a significant breakpoint at 45 years of age for mortality, decubitus ulcer, and renal failure (all p values0.05). Infectious complications (sepsis, wound infection, and abscess) all peaked between 45 years and 65 years and then declined with increasing age.We document that elderly trauma patients suffer the same complications as their younger counterparts, albeit at a different rate. More importantly, we identified a "breakpoint" of increased risk of complications and mortality at greater than 45 years. Although the mechanisms behind these observations remain unknown, understanding their unique patterns may allow appropriate allocation of resources and focus research efforts on interventions that should improve outcomes.