Trauma and COVID-Induced Severe Rhabdomyolysis.

The novel coronavirus COVID-19 has been implicated in a number of extra-pulmonary manifestations including rhabdomyolysis. It is hypothesized to be secondary to direct muscle damage from the virus. The usual treatment of rhabdomyolysis is resuscitation with aggressive fluid management to prevent acute renal failure. However, the combination of blunt thoracic trauma and COVID pneumonia has posed additional challenges for critical care management. A 68-year-old male presented to our institution after being found down for an unknown duration of time. He was diagnosed symptomatic COVID pneumonia. His traumatic injuries included 4 rib fractures, a rectus sheath hematoma, and rhabdomyolysis with a creatinine kinase (CK) level of 16,716 U/L. He was initially treated with steroids, prone positioning, and aggressive fluid administration. Despite treatment his CK level peaked at 146,328 U/L. Here we present the case of trauma and COVID-induced rhabdomyolysis with an extremely elevated CK level.

Platelet dysfunction in patients with traumatic intracranial hemorrhage: Do desmopressin and platelet therapy help or harm?

BACKGROUND: Pre-injury anti-platelet use has been associated with increased risk of progression of traumatic intracranial hemorrhage (TICH) and worse outcomes. VerifyNow® assays assess platelet inhibition due to aspirin/clopidogrel. This study assesses the outcomes of patients with TICH and platelet dysfunction treated with desmopressin and/or platelets. METHODS: We performed a retrospective chart review of patients with mild TICH at a level 1 trauma center 1/1/2013-6/1/2016. Patients with documented platelet dysfunction who received desmopressin and/or platelets were compared to those who were untreated. Primary outcomes were progression of TICH and neurologic outcomes at discharge. RESULTS: Of 565 patients with a mild TICH, 200 patients had evidence of platelet dysfunction (a positive VerifyNow® assay). Patients had similar baseline demographics, injury characteristics, and rate of TICH progression; but patients who received desmopressin and/or platelets had worse Glasgow Outcomes Score at discharge. CONCLUSION: Treatment of patients with mild TICH and platelet dysfunction with desmopressin and/or platelets did not affect TICH progression but correlated with worse neurologic status at discharge.

A Pilot Study of Surgical Trainee Participation in Humanitarian Surgeries.

BACKGROUND: The impact of general surgery resident participation on operative case time and postoperative complications has been broadly studied in the United States. Although surgical trainee involvement in international humanitarian surgical care is escalating, there is limited information as to how this participation affects care rendered. This study examines the impact of trainee involvement on case length and immediate postoperative complications with regard to operations in low- and middle-income settings. METHODS: A retrospective chart review was conducted of humanitarian surgeries completed during annual short-term surgical missions performed by the International Surgical Health Initiative to Ghana and Peru. Between 2017 and 2019, procedures included inguinal hernia repairs and total abdominal hysterectomies (TAHs). Operative records were reviewed for case type, duration, and immediate postoperative complications. Cases were categorized as involving two attending co-surgeons (AA) or one attending and resident assistant (RA). RESULTS: There were 135 operative cases between 2017 and 2019; the majority (82%) involved a resident assistant. There were no statistically significant differences in case times between the attending assistant (AA) and resident assistant (RA) cohorts in both case types. All 23 postoperative complications were classified as Clavien-Dindo Grade I. In addition, resident assistance did not lead to a statistically significant increase in complication rate; 26% in the AA cohort versus 74% in the RA cohort (P = 0.3). CONCLUSIONS: This pilot study examining 135 operative cases over 2 y of humanitarian surgeries demonstrates that there were no differences in operative duration or complication rates between the AA and RA cohorts. We propose that surgical trainee involvement in low- and middle-income settings do not adversely impact operative case times or postoperative complications.

Uncovering Disparities in Scholarly Productivity among Junior Surgical Society Grant Recipients.

BACKGROUND: Despite increasing the number of women and ethnic minority groups in surgery, the academic advancement of such individuals within surgical fields lags behind Caucasian men. We sought to identify gender and ethnic inequalities in the receipt of surgical society research grants for young faculty investigators and compare the scholarly productivity of these groups. MATERIALS AND METHODS: In this cross-sectional and retrospective study, the gender and race of surgical society grant recipients were determined from surgical society Web sites. Surgical society grants aimed at providing research grants for junior faculty investigators were analyzed. Using the Scopus database, each recipient's scholarly productivity was determined by means of h-index, a standardized measure of the quantity and impact of an individual's published articles. We generated descriptive statistics to compare the gender, race, and h-index of grant recipients in the years 2006-2008 and 2016-2018. RESULTS: Between 2006 and 2008, there were 68 research grant recipients. Of these recipients, 79% were men and 21% were women. The racial breakdown was 54% Caucasian men, 22% Asian men, 1.4% African American men, 1.4% Hispanic men, 12% Caucasian women, 7% Asian Women, and 1.4% African American women. The average h-index of the male and female recipients is 25 (±14) and 24 (±14), respectively (P = 0.81). Between 2016 and 2018, there were 113 research grant recipients. Of these recipients, 66% were men and 34% were women. The racial breakdown was 47% Caucasian men, 16% Asian men, 3.5% African American men, 1% Hispanic men, 26% Caucasian women, 3.5% Asian women, and 3.5% African American women. The average h-index of the male and female recipients is 12 (±8) and 9 (±6), respectively (P = 0.046). Caucasian women had the only statistically significant change in the proportion of grant recipients from 2006-2008 to 2016-2018, with an increase from 12% to 26% (P = 0.02). CONCLUSIONS: Most surgical society research grants for young investigators continue to be awarded to Caucasian men, with Caucasian women earning a distant second in the 2016-2018 cohort. Ethnic minorities continue to be awarded less research grants than Caucasian recipients. Overall, the average h-index of women was less than men. This study highlights the persistent need for surgical societies to consider gender and ethnic disparities when awarding junior investigator grants, including barriers minority groups may face in achieving the same h-index as Caucasian men.

Disproportionally low funding for trauma research by the National Institutes of Health: A call for a National Institute of Trauma.

BACKGROUND: Trauma is a major cause of death and disability in all ages. Previous reviews have suggested that National Institutes of Health (NIH) funding for trauma is not commensurate with its burden of disease, but a detailed analysis has been lacking. We postulated that NIH spending on trauma research was lower than previously thought and was distributed widely, preventing a comprehensive research strategy that could decrease trauma morbidity and mortality. METHODS: The NIH Research Portfolio Online Reporting Tool was initially screened using a search of over 20 terms including "trauma," "injury," "shock," "MVC," and excluding clearly unrelated conditions, for example, "cancer." The details of all grants that screened positive underwent manual review to identify true trauma-related grants. An expert panel was used to adjudicate any ambiguity. RESULTS: In FY2016, NIH awarded 50,137 grants, of which 6,401 (13%) were captured by our initial screen. Following review, 1,888 (28%) were identified as trauma-related; 3.7% of all NIH grants. These grants (US $720 million) represent only 2.9% of the NIH extramural budget. In addition, the grants were funded and administered by 24 of the institutes and centers across the NIH ranging from 0.01% (National Cancer Institute) to 11% (National Institute of Neurological Disorders and Stroke and National Institute of Arthritis and Musculoskeletal and Skin Diseases) of their extramural portfolios. CONCLUSION: Given the extreme burden of trauma-related disability and years of life lost, this review of extramural NIH funding definitively demonstrates that trauma is severely underfunded. The lack of a dedicated home for trauma research at NIH leads to a diffusion of grants across many institutes and makes it impossible to direct a focused and effective national research endeavor to improve outcomes. These data demonstrate the need for a National Institute of Trauma at the NIH to help set an agenda to reach the national goal of Zero Preventable Deaths.

Impact of palliative treatment on survival in sinonasal malignancies.

BACKGROUND: Although palliative care treatment modalities have been shown to improve functional outcomes and provide symptom alleviation in sinonasal cancer, its impact on survival still remains unclear. In this study we aimed to elicit the impact of different palliative therapy options on survival in a nationally representative sample of sinonasal cancer patients. METHODS: National Cancer Database 2004-2015 data sets were queried for cases of primary sinonasal cancer (N = 380). Kaplan-Meier analysis was utilized to determine median overall survival (M-OS) and overall survival (OS) among the different treatment cohorts (pain management, palliative radiation therapy, palliative chemotherapy, palliative surgery, and combination therapy). Prognostic factors were elicited by comparing OS by log-rank tests and subsequent multivariate Cox regression analysis. RESULTS: Of the total patients of sinonasal malignancy treated with palliative therapy, most were <70 years old, had stage 4 cancer, and histology indicating squamous cell carcinoma (p < 0.05). On Kaplan-Meier survival analysis, the 1-year OS (1Y-OS) and M-OS were 43.6% and 10.1 months, respectively. The 1Y-OS and M-OS for pain management alone were 35.3% and 4.56 months, respectively. Surgery had the highest 1Y-OS and M-OS, at 74.7% and 22.8 months, respectively (p = 0.002). All treatment modalities had increased 1Y-OS compared with pain management alone. Multivariant analysis demonstrated palliative surgery to be associated with decreased risk of death (hazard ratio, 0.33; 95% confidence interval, 0.17-0.63). CONCLUSION: In this study we identify the impact of palliative treatment modalities on survival in sinonasal cancer. Palliative surgery was shown to have the highest 1Y-OS and M-OS compared with other palliative treatment modalities.