The Earlier the Better: Surgical Stabilization of Rib Fractures Associated With Improved Outcomes.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) has been associated with lower rates of mortality and fewer respiratory complications. This study sought to evaluate the association between SSRF timing and patient outcomes. METHODS: This retrospective analysis included patients aged ≥45 y who underwent SSRF in the Trauma Quality Improvement Program database from 2016 to 2020. Primary outcome was incidence of ventilator-assisted pneumonia (VAP). Secondary outcomes included acute respiratory distress syndrome (ARDS), unplanned endotracheal intubation, in-hospital mortality, failure to rescue (FTR) after all major complications, and FTR after severe respiratory complications. Logistic regression models of outcomes on timing to SSRF were fit while controlling for age, gender, body mass index, injury severity score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS: Among 4667 patients who received SSRF, average time to SSRF was 4.6 ± 3.2 d. Each additional day to SSRF was associated with increased odds of VAP (odds ratio [OR] 1.07, confidence interval [CI] 1.03-1.11) and intubation (OR 1.10, CI 1.08-1.13). A longer time to SSRF was associated with increased odds of ARDS (OR 1.10, CI 1.05-1.15), while no significant association was observed for in-hospital mortality (OR 0.99, CI 0.93-1.04). A longer time to SSRF was associated with decreased odds of FTR after a major complication (OR 0.90, CI 0.83-0.97) and respiratory complications (OR 0.87, CI 0.78-0.96). CONCLUSIONS: For each day that SSRF is delayed, increased odds of VAP, intubation, and ARDS were observed. Prompt intervention is crucial for preventing these complications and improving our ability to rescue patients.

Predictive Energy Equations Inaccurately Estimate Metabolic Demands of Older Adult Trauma Patients.

INTRODUCTION: Suboptimal nutrition promotes unfavorable outcomes in trauma patients, particularly among those aged 60 and over. While many institutions employ predictive energy equations to determine patients' energy requirements, mounting evidence shows these equations inaccurately estimate caloric needs. In this pilot randomized controlled trial, we sought to quantify the discrepancy between predictive equations and indirect calorimetry (IC)-the gold standard for determining energy requirements-in the older adult trauma population. METHODS: This is a nested cohort study within a pilot randomized control trial in which 32 older adult trauma patients were randomized 3:1 to receive IC-guided nutrition delivery versus standard of care. IC requirements of patients in the intervention arm were compared to Mifflin St. Jeor (MSJ), Harris-Benedict (HB), and the American Society for Parenteral and Enteral Nutrition-Society of Critical Care Medicine (ASPEN-SCCM) predictive energy equations. RESULTS: Twenty patients underwent IC to assess measured resting energy expenditure (mREE), yielding a mean (standard deviation) mREE of 23.1 ± 4.8 kcal/kg/d. MSJ and HB gave mean predictive resting energy expenditures of 17.5 ± 2.0 and 18.5 ± 2.0 kcal/kg/d in these patients, demonstrating that IC-derived values were 32.1% and 25.0% higher, respectively. When patients were stratified by body mass index (BMI), MSJ, and HB more severely underestimated caloric requirements in individuals with BMI <30 versus BMI 30-50. While the mean mREE fell within the mean predictive resting energy expenditure range prescribed by ASPEN-SCCM equations (21.4 ± 4.1 to 26.2 ± 4.3 kcal/kg/d), individuals' IC-derived values fell within their personal range in 8 of 20 cases. CONCLUSIONS: The MSJ and HB predictive energy equations consistently and significantly underpredict metabolic demands of older adult trauma patients compared to IC and perform worse in lower BMI individuals. ASPEN-SCCM equations frequently overpredict or underpredict resting energy expenditure. While these findings should be confirmed in a larger randomized control trial, this study suggests that institutions should prioritize IC to accurately identify the metabolic demands of older trauma patients.

Age-Neutral Surgical Stabilization of Rib Fractures: Breaking the Ageism Barrier.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) is associated with lower rates of mortality and fewer complications. This study evaluates whether the decision to undergo SSRF is associated with age, race, ethnicity, and insurance status and assesses associated clinical outcomes. METHODS: This retrospective analysis included patients ≥45 y old with rib fractures who underwent SSRF in the Trauma Quality Improvement Program from 2016 to 2020. Race, ethnicity, and insurance statuses were collected. Age in years was dichotomized into two groups: 45-64 and 65+. Outcomes included ventilator-associated pneumonia, unplanned endotracheal intubation, acute respiratory distress syndrome, in-hospital mortality, failure to rescue (FTR) after major complications, and FTR after respiratory complications. Logistic regression models were fit to evaluate outcomes, controlling for gender, body mass index, Injury Severity Score, flail chest, chronic obstructive pulmonary disease, congestive heart failure, and smoking. RESULTS: Two thousand eight hundred thirty-nine patients aged 45-64 and 1828 patients aged 65+ underwent SSRF. No significant difference in clinical outcomes was noted between these groups. Analysis showed that the association of SSRF with ventilator-associated pneumonia, unplanned intubation, acute respiratory distress syndrome, in-hospital mortality, FTR after a major complication, or FTR after a respiratory complication did not vary by age (P > 0.05). Black (odds ratio [OR] 0.67; 95% confidence interval [CI]: 0.59-0.77; P < 0.001), Hispanic (OR 0.80; 95% CI: 0.71-0.91; P < 0.001), and Medicaid (OR = 0.85; 95% CI = 0.76-0.95; P = 0.005) patients were less likely to receive SSRF. CONCLUSIONS: No differences in clinical outcomes were measured between adults aged 45-64 and ≥65 who underwent SSRF. Older age should not preclude patients from receiving SSRF. Further work is needed to improve underutilization in Black, Hispanic and Medicaid patients.

The Ethical Obligation to Treat Infectious Patients: A Systematic Review of Reasons.

During pandemics, healthcare providers struggle with balancing obligations to self, family, and patients. While HIV/AIDS seemed to settle this issue, coronavirus disease 2019 (COVID-19) rekindled debates regarding treatment refusal. We searched MEDLINE, Embase, CINAHL Complete, and Web of Science using terms including obligation, refusal, HIV/AIDS, COVID-19, and pandemics. After duplicate removal and dual, independent screening, we analyzed 156 articles for quality, ethical position, reasons, and concepts. Diseases in our sample included HIV/AIDS (72.2%), severe acute respiratory syndrome (SARS) (10.2%), COVID-19 (10.2%), Ebola (7.0%), and influenza (7.0%). Most articles (81.9%, n = 128) indicated an obligation to treat. COVID-19 had the highest number of papers indicating ethical acceptability of refusal (60%, P < .001), while HIV had the least (13.3%, P = .026). Several reason domains were significantly different during COVID-19, including unreasonable risks to self/family (26.7%, P < .001) and labor rights/workers' protection (40%, P < .001). A surge in ethics literature during COVID-19 has advocated for permissibility of treatment refusal. Balancing healthcare provision with workforce protection is crucial in effectively responding to a global pandemic.

Can We Actually Predict Long-Term Patient Satisfaction After Traumatic Brain Injury?

INTRODUCTION: The Traumatic Brain Injury - Patient Reported Outcome (TBI-PRO) model was previously derived to predict long-term patient satisfaction as assessed by the Quality of Life After Brain Injury (QOLIBRI) score. The aim of this study is to externally and prospectively validate the TBI-PRO model to predict long-term patient-reported outcomes and to derive a new model using a larger dataset of older adults with TBI. METHODS: Patients admitted to a Level I trauma center with TBI were prospectively followed for 1 y after injury. Outcomes predicted by the TBI-PRO model based on admission findings were compared to actual QOLIBRI scores reported by patients at 3,6, and 12 mo. When deriving a new model, Collaborative European NeuroTrauma Effectiveness Research in TBI and the Transforming Research and Clinical Knowledge in Traumatic Brain Injury databases were used to identify older adults (≥50 y) with TBI from 2014 to 2018. Bayesian additive regression trees were used to identify predictive admission covariates. The coefficient of determination was used to identify the fitness of the model. RESULTS: For prospective validation, a total of 140 patients were assessed at 3 mo, with follow-up from 69 patients at 6 mo and 13 patients at 12 mo postinjury. The area under receiver operating curve of the TBI-PRO model for predicting favorable outcomes at 3, 6, and 12 mo were 0.65, 0.57, and 0.62, respectively. When attempting to derive a novel predictive model, a total of 1521 patients (80%) was used in the derivation dataset while 384 (20%) were used in the validation dataset. A past medical history of heart conditions, initial hospital length of stay, admission systolic blood pressure, age, number of reactive pupils on admission, and the need for craniectomy were most predictive of long-term QOLIBRI-Overall Scale. The coefficient of determination for the validation model including only the most predictive variables were 0.28, 0.19, and 0.27 at 3, 6, and 12 mo, respectively. CONCLUSIONS: In the present study, the prospective validation of a previously derived TBI-PRO model failed to accurately predict a long-term patient reported outcome measures in TBI. Additionally, the derivation of a novel model in older adults using a larger database showed poor accuracy in predicting long-term health-related quality of life. This study demonstrates limitations to current targeted approaches in TBI care. This study provides a framework for future studies and more targeted datasets looking to assess long-term quality of life based upon early hospital variables and can serve as a starting point for future predictive analysis.

Child Firearm-Related Homicide and Suicide by State Legislation in the US (2009-2020).

BACKGROUND: Firearms are the leading cause of death among U.S. children and adolescents. This study evaluates whether state gun laws are associated with firearm suicides and homicides in children. STUDY DESIGN: This is a cross-sectional database study comparing childhood firearm mortality with 36 state firearm laws using data from CDC WONDER and the RAND state firearm law database. Primary outcomes were firearm-related suicide and homicide mortalities per 100,000 persons. We examined suicide deaths by all firearms, including intentional self-harm by handguns only, intentional self-harm by rifles, shotguns, or large firearms only, and intentional self-harm by other or unspecified firearms, as well as homicide deaths for the same firearm types in each state. Welch's t-tests compared mean rates of suicide and homicide mortalities between states with and without these laws. States that either enacted or rescinded firearm legislation during this period were excluded. RESULTS: From 2009-2020, there were 6,735 suicides and 10,278 homicides by firearm totaling 17,013 child deaths (<18) by firearm. States with "child access prevention- negligent storage" laws demonstrated lower suicide mortality rates across all firearm types (handguns) N=13, M (mean per 100,000)=0.68, SD=0.27, p<0.001; (long guns) N=12, M=0.65, SD=0.25, p<0.001). There were no significant differences in mean suicide death rates across all firearm types when comparing states with or without firearm laws related to "minimum age youth possession", "minimum age youth purchase and sale", or "child access prevention - intentional." Comparing homicide mortality rates for all firearm types revealed no notable distinctions between states with and without the identified laws. CONCLUSIONS: Firearm legislation is associated with decreased suicide rates for individuals under 18, but its influence on homicides is less certain. Comprehensive research and thoughtful policy formulation are essential for addressing this pressing public health concern.

Firearm Ownership: A Key Factor to Consider in Firearm Suicide Deaths in Children, Despite State Gun Laws.

INTRODUCTION: Firearm-related suicides among children present a significant public health concern and a tragic loss of young lives. This study explores the relationship between firearm-related suicides, gun ownership, and state-specific gun laws. METHODS: This retrospective cohort study collected data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research on children under 18 who died by firearm-related suicides between 2009 and 2016 in all 50 states and D.C. It also utilized data from the RAND State-Level Estimates of Household Firearm Ownership. The study focused on the rate of child firearm suicide deaths per 100,000 individuals. The key variable of interest was the percentage of guns owned per household in each state. Univariable analysis was conducted to examine the association between individual gun laws and child firearm suicide mortalities, while multivariable regression, adjusting for household gun ownership and significant firearm legislation, was employed to assess connection to child firearm suicide mortality. RESULTS: From 2009 to 2016, 3903 children died from firearm-related suicides in the United States. In our analysis, 15 out of 44 firearm laws were found to be associated with reducing the rates of firearm suicides among children (P < 0.05). However, multivariable regression showed that higher state gun ownership rates were the primary predictor of increased child fatalities from firearms, with children in such states being 325% more likely to die when analyzing handgun laws and 337% more likely when analyzing long gun laws, as indicated by coefficients of 4.25 and 4.37, respectively. No state laws alone notably improved death rates. CONCLUSIONS: Gun ownership has a stronger association with child suicide rates than state-specific gun laws. Given the weight of gun ownership, future research should prioritize comprehensive public health initiatives to prevent child firearm-related suicides.

Performance of Artificial Intelligence Content Detectors Using Human and Artificial Intelligence-Generated Scientific Writing.

BACKGROUND: Few studies have examined the performance of artificial intelligence (AI) content detection in scientific writing. This study evaluates the performance of publicly available AI content detectors when applied to both human-written and AI-generated scientific articles. METHODS: Articles published in Annals of Surgical Oncology (ASO) during the year 2022, as well as AI-generated articles using OpenAI's ChatGPT, were analyzed by three AI content detectors to assess the probability of AI-generated content. Full manuscripts and their individual sections were evaluated. Group comparisons and trend analyses were conducted by using ANOVA and linear regression. Classification performance was determined using area under the curve (AUC). RESULTS: A total of 449 original articles met inclusion criteria and were evaluated to determine the likelihood of being generated by AI. Each detector also evaluated 47 AI-generated articles by using titles from ASO articles. Human-written articles had an average probability of being AI-generated of 9.4% with significant differences between the detectors. Only two (0.4%) human-written manuscripts were detected as having a 0% probability of being AI-generated by all three detectors. Completely AI-generated articles were evaluated to have a higher average probability of being AI-generated (43.5%) with a range from 12.0 to 99.9%. CONCLUSIONS: This study demonstrates differences in the performance of various AI content detectors with the potential to label human-written articles as AI-generated. Any effort toward implementing AI detectors must include a strategy for continuous evaluation and validation as AI models and detectors rapidly evolve.

Systematic Literature Review of Health-Related Quality-of-Life Measures for Caregivers of Older Adult Trauma Patients.

INTRODUCTION: As the older adult population increases, hospitals treat more older adults with injuries. After leaving, these patients suffer from decreased mobility and independence, relying on care from others. Family members often assume this responsibility, mostly informally and unpaid. Caregivers of other older adult populations have increased stress and decreased caregiver-related quality of life (CRQoL). Validated CRQoL measures are essential to capture their unique experiences. Our objective was to review existing CRQoL measures and their validity in caregivers of older adult trauma patients. METHODS: A professional librarian searched published literature from the inception of databases through August 12, 2022 in MEDLINE (via PubMed), Embase (via Elsevier), and CINAHL Complete (via EBSCO). We identified 1063 unique studies of CRQoL in caregivers for adults with injury and performed a systematic review following COnsensus-based Standards for the selection of health Measurement Instruments guidelines for CRQoL measures. RESULTS: From the 66 studies included, we identified 54 health-related quality-of-life measures and 60 domains capturing caregiver-centered concerns. The majority (83%) of measures included six or fewer CRQoL content domains. Six measures were used in caregivers of older adults with single-system injuries. There were no validated CRQoL measures among caregivers of older adult trauma patients with multisystem injuries. CONCLUSIONS: While many measures exist to assess healthcare-related quality of life, few, if any, adequately assess concerns among caregivers of older adult trauma patients. We found that CRQoL domains, including mental health, emotional health, social functioning, and relationships, are most commonly assessed among caregivers. Future measures should focus on reliability and validity in this specific population to guide interventions.

Outcomes by time-to-OR for penetrating abdominal trauma patients.

INTRODUCTION: Time-To-OR is a critical process measure for trauma performance. However, this measure has not consistently demonstrated improvement in outcome. STUDY DESIGN: Using TQIP, we identified facilities by 75th percentile time-to-OR to categorize slow, average, and fast hospitals. Using a GEE model, we calculated odds of mortality for all penetrating abdominal trauma patients, firearm injuries only, and patients with major complication by facility speed. We additionally estimated odds of mortality at the patient level. RESULTS: Odds of mortality for patients at slow facilities was 1.095; 95% CI: 0.746, 1.608; p = 0.64 compared to average. Fast facility OR = 0.941; 95% CI: 0.780, 1.133; p = 0.52. At the patient-level each additional minute of time-to-OR was associated with 1.5% decreased odds of in-hospital mortality (OR 0.985; 95% CI:0.981, 0.989; p < 0.001). For firearm-only patients, facility speed was not associated with odds of in-hospital mortality (p-value = 0.61). Person-level time-to-OR was associated with 1.8% decreased odds of in-hospital mortality (OR 0.982; 95% CI: 0.977, 0.987; p < 0.001) with each additional minute of time-to-OR. Similarly, failure-to-rescue analysis showed no difference in in-hospital mortality at the patient level (p = 0.62) and 0.4% decreased odds of in-hospital mortality with each additional minute of time-to-OR at the patient level (OR 0.996; 95% CI: 0.993, 0.999; p = 0.004). CONCLUSION: Despite the use of time-to-OR as a metric of trauma performance, there is little evidence for improvement in mortality or complication rate with improved time-to-OR at the facility or patient level. Performance metrics for trauma should be developed that more appropriately approximate patient outcome.

Whole blood resuscitation for injured patients requiring transfusion: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

INTRODUCTION: Whole blood (WB) resuscitation has reemerged as a resuscitation strategy for injured patients. However, the effect of WB-based resuscitation on outcomes has not been established. The primary objective of this guideline was to develop evidence-based recommendations on whether WB should be considered in civilian trauma patients receiving blood transfusions. METHODS: An Eastern Association for the Surgery of Trauma working group performed a systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation methodology. One Population, Intervention, Comparison, and Outcomes question was developed to analyze the effect of WB resuscitation in the acute phase on mortality, transfusion requirements, infectious complications, and intensive care unit length of stay. English language studies including adult civilian trauma patients comparing in-hospital WB to component therapy were included. Medline, Embase, Cochrane CENTRAL, CINAHL Plus, and Web of Science were queried. GRADEpro (McMaster University; Evidence Prime, Inc.; Ontario) was used to assess quality of evidence and risk of bias. The study was registered on International Prospective Register of Systematic Reviews (CRD42023451143). RESULTS: A total of 21 studies were included. Most patients were severely injured and required blood transfusion, massive transfusion protocol activation, and/or a hemorrhage control procedure in the early phase of resuscitation. Mortality was assessed separately at the following intervals: early (i.e., emergency department, 3 hours, or 6 hours), 24 hours, late (i.e., 28 days or 30 days), and in-hospital. On meta-analysis, WB was not associated with decreased mortality. Whole blood was associated with decreased 4-hour red blood cell (mean difference, -1.82; 95% confidence interval [CI], -3.12 to -0.52), 4-hour plasma (mean difference, -1.47; 95% CI, -2.94 to 0), and 24-hour red blood cell transfusions (mean difference, -1.22; 95% CI, -2.24 to -0.19) compared with component therapy. There were no differences in infectious complications or intensive care unit length of stay between groups. CONCLUSION: We conditionally recommend WB resuscitation in adult civilian trauma patients receiving blood transfusions, recognizing that data are limited for certain populations, including women of childbearing age, and therefore this guideline may not apply to these populations. LEVEL OF EVIDENCE: Systematic Review/Meta-Analysis; Level III.

Racial and ethnic demographics in malnutrition related deaths.

BACKGROUND AND AIMS: Currently, 40 million Americans are food insecure. They are forced to skip meals and buy non-nutritious food, leading to health disparities for those of low socioeconomic status. This study aims to investigate relationships between malnutrition deaths and sociodemographic groups. METHODS: This cross-sectional study from 2009 to 2018 used aggregate data from the CDC Wide-ranging Online Data for Epidemiologic Research (CDC Wonder). Patients with known race, gender, and Hispanic origin age ≥18 who died from malnutrition (E40-E46) were included. Place of death was grouped into home, inpatient medical facility, hospice facility, nursing facility/long-term care, other (including outpatient, ED, and DOA), and unknown. Crude rates of malnutrition deaths per 100,000 persons for race, gender, and Hispanic origin were calculated using US census estimates. Gross proportions of total deaths were calculated for each place of death. RESULTS: Between 2009 and 2018, there were 46,517 malnutrition deaths in the US. Death rates for Black (1.8) and White Americans (2) were twice as high compared to Native Americans (1.1) and Asians or Pacific Islanders (0.7). Death rates among females (2.3) were higher than males (1.5). Death rates among non-Hispanics (2.1) were twice as high compared to Hispanics (0.7). Most people who died of malnutrition died in hospitals (37 %). CONCLUSION: Malnutrition deaths occur at greater rates among White, Black, non-Hispanic Americans, and females. Despite reported disparities in food access, Black and White Americans have similar malnutrition mortality rates, raising concerns that malnutrition is under-diagnosed among Black patients. Given the existing nutrition literature, this finding requires further investigation.

Mobile Application-Based Communication Facilitation Platform for Family Members of Critically Ill Patients: A Randomized Clinical Trial.

Importance: Unmet and racially disparate palliative care needs are common in intensive care unit (ICU) settings. Objective: To test the effect of a primary palliative care intervention vs usual care control both overall and by family member race. Design, Setting, and Participants: This cluster randomized clinical trial was conducted at 6 adult medical and surgical ICUs in 2 academic and community hospitals in North Carolina between April 2019 and May 2022 with physician-level randomization and sequential clusters of 2 Black patient-family member dyads and 2 White patient-family member dyads enrolled under each physician. Eligible participants included consecutive patients receiving mechanical ventilation, their family members, and their attending ICU physicians. Data analysis was conducted from June 2022 to May 2023. Intervention: A mobile application (ICUconnect) that displayed family-reported needs over time and provided ICU attending physicians with automated timeline-driven communication advice on how to address individual needs. Main Outcomes and Measures: The primary outcome was change in the family-reported Needs at the End-of-Life Screening Tool (NEST; range 0-130, with higher scores reflecting greater need) score between study days 1 and 3. Secondary outcomes included family-reported quality of communication and symptoms of depression, anxiety, and posttraumatic stress disorder at 3 months. Results: A total of 111 (51% of those approached) family members (mean [SD] age, 51 [15] years; 96 women [86%]; 15 men [14%]; 47 Black family members [42%]; 64 White family members [58%]) and 111 patients (mean [SD] age, 55 [16] years; 66 male patients [59%]; 45 Black patients [41%]; 65 White patients [59%]; 1 American Indian or Alaska Native patient [1%]) were enrolled under 37 physicians randomized to intervention (19 physicians and 55 patient-family member dyads) or control (18 physicians and 56 patient-family member dyads). Compared with control, there was greater improvement in NEST scores among intervention recipients between baseline and both day 3 (estimated mean difference, -6.6 points; 95% CI, -11.9 to -1.3 points; P = .01) and day 7 (estimated mean difference, -5.4 points; 95% CI, -10.7 to 0.0 points; P = .05). There were no treatment group differences at 3 months in psychological distress symptoms. White family members experienced a greater reduction in NEST scores compared with Black family members at day 3 (estimated mean difference, -12.5 points; 95% CI, -18.9 to -6.1 points; P < .001 vs estimated mean difference, -0.3 points; 95% CI, -9.3 to 8.8 points; P = .96) and day 7 (estimated mean difference, -9.5 points; 95% CI, -16.1 to -3.0 points; P = .005 vs estimated mean difference, -1.4 points; 95% CI, -10.7 to 7.8; P = .76). Conclusions and Relevance: In this study of ICU patients and family members, a primary palliative care intervention using a mobile application reduced unmet palliative care needs compared with usual care without an effect on psychological distress symptoms at 3 months; there was a greater intervention effect among White family members compared with Black family members. These findings suggest that a mobile application-based intervention is a promising primary palliative care intervention for ICU clinicians that directly addresses the limited supply of palliative care specialists. Trial Registration: ClinicalTrials.gov Identifier: NCT03506438.

Where Are the Children? A Thematic Analysis of State, Territory, and Tribal Organization Comprehensive Cancer Control Plans.

BACKGROUND: The Center for Disease Control's Comprehensive Cancer Control Program (CCCP) funds initiatives in fifty states, the District of Columbia, seven U.S. territories, and seven tribal organizations to prevent and control cancer. These initiatives influence policy, care, research, and advocacy for cancer treatment. We performed an analysis of CCCP plans for states, U.S. territories, and tribal organizations to understand the extent of inclusion of pediatric cancer care. METHODS: We conducted a thematic and quantitative analysis of CCCP plans for states, U.S. territories, and tribal organizations. Plans were assessed by two reviewers and scored for discussion of cancer prevention, risk factors, early detection and screening, treatment and innovation, access, barriers to care, and survivorship in childhood cancer. RESULTS: Plans from fifty states, the District of Columbia, seven territories, seven tribal organizations, and one Pacific Regional (USAPI) plan were reviewed, for a total of sixty-six plans. Up-to-date CCCP plans were available through the CDC or state websites for 74% of states, 57% of territories, and 71% of tribal organizations; older plans were available for all groups without up-to-date CCCP plans. While all plans referenced children, most did so in the context of childhood exposures influencing adult cancer risks (e.g., sun, tobacco, HPV). Few plans contained a section dedicated to childhood cancer (30% states, 14.3% territories, 14.3% tribes). A minority of plans specifically discussed early detection and screening (14% states, 0% territories, 14.3% tribes), treatment and innovation (32% states, 0% territories, 28.6% tribes), access to cancer care (38% states, 28.6% territories, 28.6% tribes), reducing barriers to cancer care (28% states, 42.9% territories, 28.6% tribes), and pediatric cancer survivorship (42% states, 0% territories, 28.6% tribes). CONCLUSIONS: Promoting inclusion of pediatric cancer in CCPs will help to standardize pediatric cancer care, eliminate treatment disparities across state lines, and allow for comprehensive understanding of pediatric oncology. LEVEL OF EVIDENCE: Level IV.

Unspoken Truths: Mental Health Among Academic Surgeons.

OBJECTIVE: To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND: Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS: Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS: Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS: Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.

Amino acid kinetics in the critically ill.

PURPOSE OF REVIEW: Stable isotope methods have been used for many years to assess whole body protein and amino acid kinetics in critically ill patients. In recent years, new isotope approaches and tracer insights have been developed. The tracer pulse approach has some advantages above the established primed-continuous tracer infusion approach because of the high amount of metabolic information obtained, easy applicability, and low tracer costs. Effects of disease severity and sex on amino acid kinetics in ICU patients will also be addressed. RECENT FINDINGS: Current knowledge was synthesized on specific perturbations in amino acid metabolism in critically ill patients, employing novel methodologies such as the pulse tracer approach and computational modeling. Variations were evaluated in amino acid production and linked to severity of critical illness, as measured by SOFA score, and sex. Production of the branched-chain amino acids (BCAAs), glutamine, tau-methylhistidine and hydroxyproline were elevated in critical illness, likely related to increased transamination of the individual BCAAs or increased breakdown of proteins. Citrulline production was reduced, indicative of impaired gut mucosa function. Sex and disease severity independently influenced amino acid kinetics in ICU patients. SUMMARY: Novel tracer and computational approaches have been developed to simultaneously measure postabsorptive kinetics of multiple amino acids that can be used in critical illness. The collective findings lay the groundwork for targeted individualized nutritional strategies in ICU settings aimed at enhancing patient outcomes taking into account disease severity and sex.

The Use of Parenteral Nutrition and Disparities in Its Allocation Following Traumatic Injury.

INTRODUCTION: Severe traumatic injury requires rapid and extensive deployment of resources to save the lives of the critically injured. The sequelae of traumatic injuries frequently require extensive intervention obligating patients to a complicated recovery process devoid of meaningful nutrition. In this setting, parenteral nutrition (PN) is key in enabling appropriate wound healing, recovery, and rehabilitation. We sought to examine the use of PN in adult trauma management and to highlight any disparities in the utilization of PN in adult trauma patients. METHODS: We queried the 2017-2019 Trauma Quality Improvement Program (TQIP) for adult patients (aged > 18 y) who sustained blunt or penetrating traumatic injuries and received PN as part of their hospitalization. We compared time to PN administration based on demographics. We then used a multivariable logistic regression model to identify factors associated with the use of PN. We hypothesized that PN would be less commonly employed in the uninsured and minority groups. RESULTS: We identified 2,449,498 patients with sufficient data for analysis. Of these, 1831 patients were treated with PN. On univariate analysis, PN patients were more commonly male (74.7% PN versus 60.2% non-PN; P < 0.001). PN use was more frequent in the Black population (24.3% PN versus 15.5% non-PN; P < 0.001) and less frequent in the White population (72.7% PN versus 81.2% non-PN; P < 0.001). PN use was also much more common among patients covered by Medicaid. Penetrating trauma was over twice as common among PN recipients relative to non-PN patients (% PN versus % non-PN). PN patients had higher injury severity scores (ISSs), more intensive care unit days, longer hospitalizations, and increased mortality compared to non-PN patients. PN patients were half as likely to discharge home and twice as likely to discharge to a long-term care facility. Multivariable analysis including age, race, trauma mechanism, primary payer, and ISS, demonstrated an association of PN use with increasing age (OR 1.01, P < 0.001), cases of penetrating trauma (odds ratio [OR], 2.47; P < 0.001), and patients with high ISS (OR, 0.1.06; P < 0.001). There was decreased use in Uninsured patient (OR, 0.54; P < 0.001). CONCLUSIONS: PN use following traumatic injury is rarely required. Patients treated with PN typically have a resource-intense hospital course. More severe injuries, penetrating trauma, and increased age are more likely to result in PN use. Variations in PN use are apparent based on insurance payer, further examination into allocation of hospital and intensive care resources, as it pertains to patient socioeconomic status, is warranted in light of these findings.

Factors Associated with Discharge to Skilled Nursing Facility Following Gunshot Wounds.

INTRODUCTION: Firearm injury is a public health crisis. Most victims are minorities in underserved neighborhoods. Measuring firearm injury by mortality underestimates its impact, as most victims survive to discharge. This study was done to determine if race and insurance status are associated with discharge disposition for gunshot wound (GSW)-related trauma. METHODS: Using the 2019 Trauma Quality Improvement Program database, we identified GSW patients with Abbreviated Injury Scale (AIS) = 1-3. Exclusion criteria included patients who died in hospital and routine home discharge. We compared discharge patterns of patients based on demographics (age, gender, race, ethnicity, payor, AIS, hospital designation, and length of stay [LOS]) and injury severity. Multivariable logistic regression models identified factors associated with discharge disposition. RESULTS: Our sample included 2437 patients with GSWs. On univariable analysis, Black patients were more likely to discharge to home with home health (64.1% Black versus 34.7% White; P < 0.001). White patients were more likely to discharge to skilled nursing facility (SNF) (51.4% White versus 44.6% Black; P < 0.001). Controlling for age, race, Latin ethnicity, primary payor, LOS, AIS severity, and injury severity score factors independently associated with discharge to SNF included age (0.0462, P < 0.001), Medicaid (1.136, P < 0.0003), Medicare (1.452, P < 0.001), and LOS (0.03745, P < 0.001). CONCLUSIONS: Postacute care following traumatic injuries is essential to recovery. Black GSW victims are more likely to be discharged to home health than White patients, who are more likely to be discharged to SNF. Targeted programs to reduce barriers to appropriate aftercare are necessary to eliminate this bias and improve the care of underserved populations.

Going beyond the means: Exploring the role of bias from digital determinants of health in technologies.

BACKGROUND: In light of recent retrospective studies revealing evidence of disparities in access to medical technology and of bias in measurements, this narrative review assesses digital determinants of health (DDoH) in both technologies and medical formulae that demonstrate either evidence of bias or suboptimal performance, identifies potential mechanisms behind such bias, and proposes potential methods or avenues that can guide future efforts to address these disparities. APPROACH: Mechanisms are broadly grouped into physical and biological biases (e.g., pulse oximetry, non-contact infrared thermometry [NCIT]), interaction of human factors and cultural practices (e.g., electroencephalography [EEG]), and interpretation bias (e.g, pulmonary function tests [PFT], optical coherence tomography [OCT], and Humphrey visual field [HVF] testing). This review scope specifically excludes technologies incorporating artificial intelligence and machine learning. For each technology, we identify both clinical and research recommendations. CONCLUSIONS: Many of the DDoH mechanisms encountered in medical technologies and formulae result in lower accuracy or lower validity when applied to patients outside the initial scope of development or validation. Our clinical recommendations caution clinical users in completely trusting result validity and suggest correlating with other measurement modalities robust to the DDoH mechanism (e.g., arterial blood gas for pulse oximetry, core temperatures for NCIT). Our research recommendations suggest not only increasing diversity in development and validation, but also awareness in the modalities of diversity required (e.g., skin pigmentation for pulse oximetry but skin pigmentation and sex/hormonal variation for NCIT). By increasing diversity that better reflects patients in all scenarios of use, we can mitigate DDoH mechanisms and increase trust and validity in clinical practice and research.