Stop the Bleed-Wait for the Ambulance or Get in the Car and Drive? A Post Hoc Analysis of an EAST Multicenter Trial.

Background: The Stop the Bleed campaign gives bystanders an active role in prehospital hemorrhage control. Whether extending bystanders' role to private vehicle transport (PVT) for urban penetrating trauma improves survival is unknown, but past research has found benefit to police and PVT. We hypothesized that for penetrating trauma in an urban environment, where prehospital procedures have been proven harmful, PVT improves outcomes compared to any EMS or advanced life support (ALS) transport.Methods: Post-hoc analysis of an EAST multicenter trial was performed on adult patients with penetrating torso/proximal extremity trauma at 25 urban trauma centers from 5/2019-5/2020. Patients were allocated to PVT and any EMS or ALS transport using nearest neighbor propensity score matching. Univariate analyses included Wilcoxon signed rank or McNemar's Test and logistic regression.Results: Of 1999 penetrating trauma patients in urban settings, 397 (19.9%) had PVT, 1433 (71.7%) ALS transport, and 169 (8.5%) basic life support (BLS) transport. Propensity matching yielded 778 patients, distributed equally into balanced groups. PVT patients were primarily male (90.5%), Black (71.2%), and sustained gunshot wounds (68.9%). ALS transport had significantly higher ED mortality (3.9% vs 1.9%, P = 0.03). There was no difference in in-hospital mortality rate, hospital LOS, or complications for all EMS or ALS only transport patients.Conclusion: Compared to PVT, ALS, which provides more prehospital procedures than BLS, provided no survival benefit for penetrating trauma patients in urban settings. Bystander education incorporating PVT for early arrival of penetrating trauma patients in urban settings to definitive care merits further investigation.

Tranexamic Acid and Pulmonary Complications: A Secondary Analysis of an EAST Multicenter Trial.

BACKGROUND: Anti-inflammatory effects of tranexamic acid (TXA) in reducing trauma endotheliopathy may protect from acute lung injury. Clinical data showing this benefit in trauma patients is lacking. We hypothesized that TXA administration mitigates pulmonary complications in penetrating trauma patients. MATERIALS AND METHODS: This is a post-hoc analysis of a multicenter, prospective, observational study of adults (18+ years) with penetrating torso and/or proximal extremity injury presenting at 25 urban trauma centers. Tranexamic acid administration in the prehospital setting or within three hours of admission was examined. Participants were propensity matched to compare similarly injured patients. The primary outcome was development of pulmonary complication (ARDS and/or pneumonia). RESULTS: A total of 2382 patients were included, and 206 (8.6%) received TXA. Of the 206, 93 (45%) received TXA prehospital and 113 (55%) received it within three hours of hospital admission. Age, sex, and incidence of massive transfusion did not differ. The TXA group was more severely injured, more frequently presented in shock (SBP < 90 mmHg), developed more pulmonary complications, and had lower survival (P < 0.01 for all). After propensity matching, 410 patients remained (205 in each cohort) with no difference in age, sex, or rate of shock. On logistic regression, increased emergency department heart rate was associated with pulmonary complications. Tranexamic acid was not associated with different rate of pulmonary complications or survival on logistic regression. Survival was not different between the groups on logistic regression or propensity score-matched analysis. CONCLUSIONS: Tranexamic acid administration is not protective against pulmonary complications in penetrating trauma patients.

Association of High BMI With Morbidity and Mortality in Common Emergency General Surgery Procedures.

INTRODUCTION: Emergency general surgery (EGS) patients are at increased risk for postoperative morbidity and mortality. Obesity is a risk factor for poor outcomes in this population. Our study aimed to explore the association of body mass index (BMI) with postoperative outcomes in patients requiring common EGS procedures. METHODS: A retrospective review of the 2018-2020 National Surgical Quality Improvement Program database identified patients undergoing four common EGS procedures: large bowel resection, small bowel resection, cholecystectomy, and appendectomy. Patients were classified by BMI: normal weight (18.5-24.9 kg/m2), obesity classes I (30-34.9 kg/m2), II (35-39.9 kg/m2), III (40-49.9 kg/m2), and IV (≥50 kg/m2). Main outcomes of interest were major adverse event (MAE) and mortality. RESULTS: From 2018 to 2020, a total of 82,540 patients underwent one of four common EGS procedures. On unadjusted analysis, obesity class IV had higher mortality rates compared to classes I-III (6.2% vs 3.1%, P < 0.001). Patients in obesity classes I-III had lower odds of MAE and death relative to those of normal weight. Compared to other patients with obesity, those in obesity class IV were at increased risk of MAE (odds ratio 1.27; 95% confidence interval 1.13-1.44) and death (odds ratio 1.69; 95% confidence interval 1.34-2.13). CONCLUSIONS: Patients with varying degrees of obesity have different risk profiles following common EGS procedures. While patients in lower obesity classes had reduced odds of adverse outcomes, those with BMI ≥50 kg/m2 were particularly at greater risk for postoperative morbidity and mortality. This vulnerable population warrants further investigation and increased vigilance to ensure high-quality care.

Evolving Medical Student Experiences in the Surgery Clerkship: A New Generation.

BACKGROUND: The surgery clerkship has a powerful impact on medical students' attitudes toward surgery. The primary aim of this study was to identify factors that influence current medical student experiences during the surgery clerkship and discern if they have shifted following the COVID pandemic and with a new generation of "Zillennial" students. MATERIALS AND METHODS: We conducted a qualitative content analysis of medical student surgery clerkship evaluations from 2018 to 2022 at three clinical training sites of our medical school (n = 596). The codes and themes that emerged from the data were then compared between the pre-COVID cohort (pre-March 2020) and post-COVID (post June 2020) cohorts. RESULTS: Our analysis revealed four themes: clerkship factors, educator qualities, surgical culture, and student expectations. Clerkship factors included the overall clerkship organization, preparatory sessions, and having schedule flexibility. The clinical educators had a significant impact on medical student experience by setting expectations and providing actionable feedback. Surgical culture included the team dynamic and professionalism or diversity issues. Students were expected to have clear guidance for their roles, opportunities to shine, and sought meaningful learning. While the themes were consistent between both cohorts, the frequency of codes varied, with more students commenting on flexibility, neglect, and long work hours in the post-COVID cohort. CONCLUSIONS: Numerous previously unreported factors impact surgical clerkship experiences, revealing a generational shift in medical student attitudes. These results suggest that educators and their institutions must be proactive in tracking student evaluations to adapt their clerkship curriculum for an optimal educational experience and evolving student expectations.

Proposed revision of the American Association for Surgery of Trauma Renal Organ Injury Scale: Secondary analysis of the Multi-institutional Genitourinary Trauma Study.

BACKGROUND: This study updates the American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) for renal trauma using evidence-based criteria for bleeding control intervention. METHODS: This was a secondary analysis of a multicenter retrospective study including patients with high-grade renal trauma from seven level 1 trauma centers from 2013 to 2018. All eligible patients were assigned new renal trauma grades based on revised criteria. The primary outcome used to measure injury severity was intervention for renal bleeding. Secondary outcomes included intervention for urinary extravasation, units of packed red blood cells transfused within 24 hours, and mortality. To test the revised grading system, we performed mixed-effect logistic regression adjusted for multiple baseline demographic and trauma covariates. We determined the area under the curve (AUC) to assess accuracy of predicting bleeding interventions from the revised grading system and compared this to 2018 AAST OIS. RESULTS: Based on the 2018 OIS grading system, we included 549 patients with AAST grades III to V injuries and computed tomography scans (III, 52% [n = 284]; IV, 45% [n = 249]; and V, 3% [n = 16]). Among these patients, 89% experienced blunt injury (n = 491), and 12% (n = 64) underwent intervention for bleeding. After applying the revised grading criteria, 60% (n = 329) of patients were downgraded, and 4% (n = 23) were upgraded; 2.8% (n = 7) downgraded from grade V to IV, and 69.5% (n = 173) downgraded from grade IV to III. The revised renal trauma grading system demonstrated improved predictive ability for bleeding interventions (2018 AUC, 0.805; revised AUC, 0.883; p = 0.001) and number of units of packed red blood cells transfused. When we removed urinary injury from the revised system, there was no difference in its predictive ability for renal hemorrhage intervention. CONCLUSION: A revised renal trauma grading system better delineates the need for hemostatic interventions than the current AAST OIS renal trauma grading system. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Differences in Prevalence of Transfusion Protocols between Critically Ill Neurologic and Non-Neurologic Patient Populations.

This study describes the prevalence of blood transfusion protocols in ICUs caring for neurologically vs. non-neurologically injured patients across a sample of US ICUs. This prospective, observational multi-center cohort study is a subgroup analysis of the USCIITG-CIOS, comprising 69 ICUs across the US (25 medical, 24 surgical, 20 mixed ICUs). Sixty-four ICUs were in teaching hospitals. A total of 6179 patients were enrolled, with 1266 (20.4%) having central nervous system (CNS) primary diagnoses. We evaluated whether CNS versus non-CNS diagnosis was associated with care in ICUs with restrictive transfusion protocols (RTPs) or massive transfusion protocols (MTPs) and whether CNS versus non-CNS diagnosis was associated with receiving blood products or colloids during the initial 24 h of care. Protocol utilization in CNS vs. non-CNS patients was as follows: RTPs-36.9% vs. 42.9% (p < 0.001); MTPs-48.3% vs. 47.4% (p = 0.57). Blood product transfusions in the first 24 h of ICU care (comparing CNS vs. non-CNS patients) were as follows: packed red blood cells-4.3% vs. 14.6% (p < 0.001); fresh frozen plasma-2.9% vs. 5.1% (p < 0.001); colloid blood products-3.2% vs. 9.2% (p < 0.001). In this cohort, we found differences in ICU utilization of RTPs, but not MTPs, when comparing where critically ill patients with neurologic versus non-neurologic primary diagnoses received ICU care.

Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study.

PURPOSE: To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management. METHODS: We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery). RESULTS: Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found. CONCLUSION: Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Prospective, multicenter study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (XenMatrix™ AB Surgical Graft) for hernia repair in all centers for disease control and prevention wound classes: 24-month follow-up cohort.

Prospective, multicenter, single-arm study of antimicrobial-coated, noncrosslinked, acellular porcine dermal matrix (AC-PDM) in a cohort involving all centers for disease control and prevention wound classes in ventral/incisional midline hernia repair (VIHR). Materials and methods: Seventy-five patients (mean age 58.6±12.7 years; BMI 31.3±4.9 kg/m2) underwent ventral/incisional midline hernia repair with AC-PDM. Surgical site occurrence (SSO) was assessed in the first 45 days post-implantation. Length of stay, return to work, hernia recurrence, reoperation, quality of life, and SSO were assessed at 1, 3, 6, 12, 18, and 24 months. Results: 14.7% of patients experienced SSO requiring intervention within 45 days post-implantation, and 20.0% thereafter (>45 d post-implantation). Recurrence (5.8%), definitely device-related adverse events (4.0%), and reoperation (10.7%) were low at 24 months; all quality-of-life indicators were significantly improved compared to baseline. Conclusion: AC-PDM exhibited favourable results, including infrequent hernia recurrence and definitely device-related adverse events, with reoperation and SSO comparable to other studies, and significantly improved quality of life.

Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess?

BACKGROUND: Perforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis. METHODS: We used the 2016-2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI). RESULTS: 132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06-6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38-8.89) were associated with higher likelihoods of SSIs. CONCLUSIONS: Upfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.

Real-Time Student Feedback on the Surgical Learning Environment: Use of a Mobile Application.

OBJECTIVE: Improvements to the medical student surgical learning environment are limited by lack of granular data and recall bias on end-of-clerkship evaluations. The purpose of this study was to identify specific areas for intervention using a novel real-time mobile application. DESIGN: An application was designed to obtain real-time feedback from medical students regarding the learning environment on their surgical clerkship. Thematic analysis of student experiences was performed at the conclusion of 4 consecutive 12-week rotation blocks. SETTING: Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts. RESULTS: Fifty-four medical students at a single institution were asked to participate during their primary clerkship experience. Students submitted 365 responses over 48 weeks. Multiple themes emerged which were dichotomized into positive and negative emotions centered on specific student priorities. Approximately half of responses were associated with positive emotions (52.9%) and half with negative emotions (47.1%). Student priorities included the desire to feel included in the surgical team (resulting in feeling engaged/ignored), to have a positive relationship with members of the team (perceiving kind/rude interactions), to witness compassionate patient care (observing empathy/disrespect for patients), to have a well-planned surgical rotation (experiencing organization/disorganization within teams), and to feel that student well-being is prioritized (reporting opportunities/disregard for student wellness). CONCLUSION: A novel, user-friendly mobile application identified several areas to improve the experience and engagement of students on their surgery clerkship. Allowing clerkship directors and other educational leaders to collect longitudinal data in real time may allow for more targeted, timely improvements to the medical student surgical learning environment.

Predictors of care discontinuity in geriatric trauma patients.

BACKGROUND: Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population. METHODS: This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality. RESULTS: We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01). CONCLUSION: More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Accessibility of Level III trauma centers for underserved populations: A cross-sectional study.

BACKGROUND: By providing definitive care for many, and rapid assessment, resuscitation, stabilization, and transfer to Level I/II centers when needed, Level III trauma centers can augment capacity in high resource regions and extend the geographic reach to lower resource regions. We sought to (1) characterize populations served principally by Level III trauma centers, (2) estimate differences in time to care by trauma center level, and (3) update national estimates of trauma center access. METHODS: In a cross-sectional study (United States, 2019), we estimated travel time from census block groups to the nearest Level I/II trauma center and nearest Level III trauma center. Block groups were categorized based on the level of care accessible within 60 minutes, then distributions of population characteristics and differences in time to care were estimated. RESULTS: An estimated 22.8% of the US population (N = 76,119,228) lacked access to any level of trauma center care within 60 minutes, and 8.8% (N = 29,422,523) were principally served by Level III centers. Black and American Indian/Alaska Native (AIAN) populations were disproportionately represented among those principally served by Level III centers (39.1% and 12.2%, respectively). White and AIAN populations were disproportionately represented among those without access to any trauma center care (26.2% and 40.8%, respectively). Time to Level III care was shorter than Level I/II for 27.9% of the population, with a mean reduction in time to care of 28.9 minutes (SD = 31.4). CONCLUSION: Level III trauma centers are a potential source of trauma care for underserved populations. While Black and AIAN disproportionately rely on Level III centers for care, most with access to Level III centers also have access to Level I/II centers. The proportion of the US population with timely access to trauma care has not improved since 2010. LEVEL OF EVIDENCE: Prognostic/Epidemiological; Level IV.

Sarcopenia Is Associated With Increased Mortality in Patients With Necrotizing Soft Tissue Infections.

INTRODUCTION: Necrotizing soft tissue infections (NSTIs) are surgical emergencies associated with high morbidity and mortality. Identifying risk factors for poor outcome is a critical part of preoperative decision-making and counseling. Sarcopenia, the loss of lean muscle mass, has been associated with an increased risk of mortality and can be measured using cross-sectional imaging. Our aim was to determine the impact of sarcopenia on mortality in patients with NSTI. We hypothesized that sarcopenia would be associated with an increased risk of mortality in patients with NSTI. METHODS: This is a retrospective cohort study of NSTI patients admitted from 1995 to 2015 to two academic institutions. Operative and pathology reports were reviewed to confirm the diagnosis in all cases. Average bilateral psoas muscle cross-sectional area at L4, normalized for height (Total Psoas Index [TPI]), was calculated using computed tomography (CT). Sarcopenia was defined as TPI in the lowest sex-specific quartile. Primary outcome was in-hospital mortality. Multivariate logistic regression was performed to assess the association between sarcopenia and in-hospital mortality. RESULTS: There were 115 patients with preoperative imaging, 61% male and a median age of 57 y interquartile range (IQR 46.6-67.0). Overall in-hospital mortality was 12.1%. There was no significant difference in sex, body mass index (BMI), comorbidities and American Society of Anesthesiologists classification (Table 1). After multivariate analysis, sarcopenia was independently associated with increased in-hospital mortality (Odds ratio, 3.5; 95% Confidence Interval [CI], 1.05-11.8). CONCLUSIONS: Sarcopenia is associated with increased risk of in-hospital mortality in patients with NSTIs. Sarcopenia identifies patients with higher likelihood of poor outcomes, which can possibly help surgeons in counseling their patients and families.

An analysis of police transport in an Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients.

BACKGROUND: Police transport (PT) of penetrating trauma patients in urban locations has become routine in certain metropolitan areas; however, whether it results in improved outcomes over prehospital Advanced life support (ALS) transport has not been determined in a multicenter study. We hypothesized that PT would not result in improved outcomes. METHODS: This was a multicenter, prospective, observational study of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. Police transport and ALS patients were allocated via nearest neighbor, propensity matching. Transport mode also examined by Cox regression. RESULTS: Of 1,618 total patients, 294 (18.2%) had PT and 1,324 (81.8%) were by ALS. After matching, 588 (294/cohort) remained. The patients were primarily Black (n = 497, 84.5%), males (n = 525, 89.3%, injured by gunshot wound (n = 494, 84.0%) with 34.5% (n = 203) having Injury Severity Score of 16 or higher. Overall mortality by propensity matching was not different between cohorts (15.6% ALS vs. 15.0% PT, p = 0.82). In severely injured patients (Injury Severity Score ≥16), mortality did not differ between PT and ALS transport (38.8% vs. 36.0%, respectively; p = 0.68). Cox regression analysis controlled for relevant factors revealed no association with a mortality benefit in patients transported by ALS. CONCLUSION: Police transport of penetrating trauma patients in urban locations results in similar outcomes compared with ALS. Immediate transport to definitive trauma care should be emphasized in this patient population. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Point-of-care ultrasound-first for the evaluation of small bowel obstruction: National cost savings, length of stay reduction, and preventable radiation exposure.

OBJECTIVES: Computed tomography (CT) has long been the gold standard in diagnosing patients with suspected small bowel obstruction (SBO). Recently, point-of-care ultrasound (POCUS) has demonstrated comparable test characteristics to CT imaging for the diagnosis of SBO. Our primary objective was to estimate the annual national cost saving impact of a POCUS-first approach for the evaluation of SBO. Our secondary objectives were to estimate the reduction in radiation exposure and emergency department (ED) length of stay (LOS). METHODS: We created and ran 1000 trials of a Monte Carlo simulation. The study population included all patients presenting to the ED with abdominal pain who were diagnosed with SBO. Using this simulation, we modeled the national annual cost savings in averted advanced imaging from a POCUS-first approach for SBO. The model assumes that all patients who require surgery or have non-diagnostic POCUS exams undergo CT imaging. The model also conservatively assumes that a subset of patients with diagnostic POCUS exams undergo additional confirmatory CT imaging. We used the same Monte Carlo model to estimate the reduction in radiation exposure and total ED bed hours saved. RESULTS: A POCUS-first approach for diagnosing SBO was estimated to save a mean (±SD) of $30.1 million (±8.9 million) by avoiding 143,000 (±31,000) CT scans. This resulted in a national cumulative decrease of 507,000 bed hours (±268,000) in ED LOS. The reduction in radiation exposure to patients could potentially prevent 195 (±56) excess annual cancer cases and 98 (±28) excess annual cancer deaths. CONCLUSIONS: If adopted widely and used consistently, a POCUS-first algorithm for SBO could yield substantial national cost savings by averting advanced imaging, decreasing ED LOS, and reducing unnecessary radiation exposure in patients. Clinical decision tools are needed to better identify which patients would most benefit from CT imaging for SBO in the ED.

A multisite study of medical student perspectives on the core surgical clerkship.

BACKGROUND: The surgical clerkship is the primary surgical learning experience for medical students. This study aims to understand student perspectives on the surgery clerkship both before and after the core surgical rotation. METHODS: Medical students at 4 academic hospitals completed pre and postclerkship surveys that included open-ended questions regarding (1) student learning goals and concerns and (2) how surgical clerkship learning could be enhanced. Thematic analysis was performed, and interrater reliability was calculated. RESULTS: Ninety-one percent of students completed both a pre and postclerkship survey (n =162 of 179), generating 320 preclerkship and 270 postclerkship responses. Mean kappa coefficients were 0.83 and 0.82 for pre and postclerkship primary themes, respectively. Thematic analysis identified 5 broad themes: (1) core learning expectations, (2) understanding surgical careers, culture, and work, (3) inhabiting the role of a surgeon, (4) inclusion in the surgical team, and (5) the unique role of the medical student on clinical clerkships. Based on these themes, we propose a learner-centered model of a successful surgical clerkship that satisfies discrete student learning and goals and career objectives while ameliorating the challenges of high-stakes clinical surgical environments such as the operating room. CONCLUSION: Understanding student perspectives on the surgery clerkship, including preclerkship motivations and concerns and postclerkship reflections on surgical learning, revealed potential targets of intervention to improve the surgery clerkship. Future investigation may elucidate whether the proposed model of the elements of a successful surgery clerkship learning facilitates improvement of the surgical learning environment and enhanced surgical learning.

Plasma metagenomic sequencing to detect and quantify bacterial DNA in ICU patients suspected of sepsis: A proof-of-principle study.

BACKGROUND: Timely recognition of sepsis and identification of pathogens can improve outcomes in critical care patients but microbial cultures have low accuracy and long turnaround times. In this proof-of-principle study, we describe metagenomic sequencing and analysis of nonhuman DNA in plasma. We hypothesized that quantitative analysis of bacterial DNA (bDNA) levels in plasma can enable detection and monitoring of pathogens. METHODS: We enrolled 30 patients suspected of sepsis in the surgical trauma intensive care unit and collected plasma samples at the time of diagnostic workup for sepsis (baseline), and 7 days and 14 days later. We performed metagenomic sequencing of plasma DNA and used computational classification of sequencing reads to detect and quantify total and pathogen-specific bDNA fraction. To improve assay sensitivity, we developed an enrichment method for bDNA based on size selection for shorter fragment lengths. Differences in bDNA fractions between samples were evaluated using t test and linear mixed-effects model, following log transformation. RESULTS: We analyzed 72 plasma samples from 30 patients. Twenty-seven samples (37.5%) were collected at the time of infection. Median total bDNA fraction was 1.6 times higher in these samples compared with samples with no infection (0.011% and 0.0068%, respectively, p < 0.001). In 17 patients who had active infection at enrollment and at least one follow-up sample collected, total bDNA fractions were higher at baseline compared with the next sample (p < 0.001). Following enrichment, bDNA fractions increased in paired samples by a mean of 16.9-fold. Of 17 samples collected at the time when bacterial pathogens were identified, we detected pathogen-specific DNA in 13 plasma samples (76.5%). CONCLUSION: Bacterial DNA levels in plasma are elevated in critically ill patients with active infection. Pathogen-specific DNA is detectable in plasma, particularly after enrichment using selection for shorter fragments. Serial changes in bDNA levels may be informative of treatment response. LEVEL OF EVIDENCE: Epidemiologic/Prognostic, Level V.

Nephrectomy After High-Grade Renal Trauma is Associated With Higher Mortality: Results From the Multi-Institutional Genitourinary Trauma Study (MiGUTS).

OBJECTIVE: To test the hypothesis that undergoing nephrectomy after high-grade renal trauma is associated with higher mortality rates. METHODS: We gathered data from 21 Level-1 trauma centers through the Multi-institutional Genito-Urinary Trauma Study. Patients with high-grade renal trauma were included. We assessed the association between nephrectomy and mortality in all patients and in subgroups of patients after excluding those who died within 24 hours of hospital arrival and those with GCS≤8. We controlled for age, injury severity score (ISS), shock (systolic blood pressure <90 mmHg), and Glasgow Coma Scale (GCS). RESULTS: A total of 1181 high-grade renal trauma patients were included. Median age was 31 and trauma mechanism was blunt in 78%. Injuries were graded as III, IV, and V in 55%, 34%, and 11%, respectively. There were 96 (8%) mortalities and 129 (11%) nephrectomies. Mortality was higher in the nephrectomy group (21.7% vs 6.5%, P <.001). Those who died were older, had higher ISS, lower GCS, and higher rates of shock. After adjusting for patient and injury characteristics nephrectomy was still associated with higher risk of death (RR: 2.12, 95% CI: 1.26-2.55). CONCLUSION: Nephrectomy was associated with higher mortality in the acute trauma setting even when controlling for shock, overall injury severity, and head injury. These results may have implications in decision making in acute trauma management for patients not in extremis from renal hemorrhage.

An Eastern Association for the Surgery of Trauma multicenter trial examining prehospital procedures in penetrating trauma patients.

BACKGROUND: Prehospital procedures (PHP) by emergency medical services (EMS) are performed regularly in penetrating trauma patients despite previous studies demonstrating no benefit. We sought to examine the influence of PHPs on outcomes in penetrating trauma patients in urban locations where transport to trauma center is not prolonged. We hypothesized that patients without PHPs would have better outcomes than those undergoing PHP. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored, multicenter, prospective, observational trial of adults (18+ years) with penetrating trauma to the torso and/or proximal extremity presenting at 25 urban trauma centers. The impact of PHPs and transport mechanism on in-hospital mortality were examined. RESULTS: Of 2,284 patients included, 1,386 (60.7%) underwent PHP. The patients were primarily Black (n = 1,527, 66.9%) males (n = 1,986, 87.5%) injured by gunshot wound (n = 1,510, 66.0%) with 34.1% (n = 726) having New Injury Severity Score of ≥16. A total of 1,427 patients (62.5%) were transported by Advanced Life Support EMS, 17.2% (n = 392) by private vehicle, 13.7% (n = 312) by police, and 6.7% (n = 153) by Basic Life Support EMS. Of the PHP patients, 69.1% received PHP on scene, 59.9% received PHP in route, and 29.0% received PHP both on scene and in route. Initial scene vitals differed between groups, but initial emergency department vitals did not. Receipt of ≥1 PHP increased mortality odds (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.01-1.83; p = 0.04). Logistic regression showed increased mortality with each PHP, whether on scene or during transport. Subset analysis of specific PHP revealed that intubation (OR, 10.76; 95% CI, 4.02-28.78; p < 0.001), C-spine immobilization (OR, 5.80; 95% CI, 1.85-18.26; p < 0.01), and pleural decompression (OR, 3.70; 95% CI, 1.33-10.28; p = 0.01) had the highest odds of mortality after adjusting for multiple variables. CONCLUSION: Prehospital procedures in penetrating trauma patients impart no survival advantage and may be harmful in urban settings, even when performed during transport. Therefore, PHP should be forgone in lieu of immediate transport to improve patient outcomes. LEVEL OF EVIDENCE: Prognostic, level III.

Efficacy of a multispecies probiotic as adjunctive therapy in generalized anxiety disorder: a double blind, randomized, placebo-controlled trial.

ABSTRACT Objectives: Studies have shown that probiotics may decrease anxiety symptoms, but to our knowledge so far no trial has investigated the effects of probiotics in generalized anxiety disorder (GAD). The aim of the present study was to determine the effects of probiotics as adjunctive therapy on anxiety severity and quality of life (QOL) in patients with GAD. Methods: Forty-eight drug-free patients with a diagnosis of GAD based on DSM-V criteria were randomly assigned to two groups to receive daily either one capsule of probiotics or placebo in addition to 25 mg sertraline for 8 weeks. Probiotic capsules contained 18*109 CFU Bifidobacterium longom, Bifidobacterium bifidum, Bifidobacterium lactis and Lactobacillus acidophilus bacteria. Results: Intention to treat analysis was performed in 39 Patients who completed at least 4 weeks of the intervention. After 8 weeks, the score of Hamilton Rating Scale for anxiety (HAM-A) decreased more in the probiotics + sertraline (PS) group (p = 0.003). Although the reduction of Beck Anxiety Inventory (BAI) was also more in the PS group, it was not significantly different from that of the sertraline alone(S) group. Moreover, despite the greater reduction of State-Anxiety Inventory score in the PS group, the score of Trait-Anxiety Inventory was not statistically different between the two groups at week 8. With regard to QOL, there was no significant difference between the two groups in the change of the score of QOL domains. Conclusions: Probiotics + sertraline combination was superior to sertraline alone in decreasing anxiety symptoms after 8 weeks in patients with GAD, although it did not affect QOL.