Multisystem Inflammatory Syndrome in Children in New York State.

BACKGROUND: A multisystem inflammatory syndrome in children (MIS-C) is associated with coronavirus disease 2019. The New York State Department of Health (NYSDOH) established active, statewide surveillance to describe hospitalized patients with the syndrome. METHODS: Hospitals in New York State reported cases of Kawasaki's disease, toxic shock syndrome, myocarditis, and potential MIS-C in hospitalized patients younger than 21 years of age and sent medical records to the NYSDOH. We carried out descriptive analyses that summarized the clinical presentation, complications, and outcomes of patients who met the NYSDOH case definition for MIS-C between March 1 and May 10, 2020. RESULTS: As of May 10, 2020, a total of 191 potential cases were reported to the NYSDOH. Of 95 patients with confirmed MIS-C (laboratory-confirmed acute or recent severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and 4 with suspected MIS-C (met clinical and epidemiologic criteria), 53 (54%) were male; 31 of 78 (40%) were black, and 31 of 85 (36%) were Hispanic. A total of 31 patients (31%) were 0 to 5 years of age, 42 (42%) were 6 to 12 years of age, and 26 (26%) were 13 to 20 years of age. All presented with subjective fever or chills; 97% had tachycardia, 80% had gastrointestinal symptoms, 60% had rash, 56% had conjunctival injection, and 27% had mucosal changes. Elevated levels of C-reactive protein, d-dimer, and troponin were found in 100%, 91%, and 71% of the patients, respectively; 62% received vasopressor support, 53% had evidence of myocarditis, 80% were admitted to an intensive care unit, and 2 died. The median length of hospital stay was 6 days. CONCLUSIONS: The emergence of multisystem inflammatory syndrome in children in New York State coincided with widespread SARS-CoV-2 transmission; this hyperinflammatory syndrome with dermatologic, mucocutaneous, and gastrointestinal manifestations was associated with cardiac dysfunction.

Enhanced Notification of Radiographic Incidental Findings in Trauma Does Not Guarantee Follow-Up Compliance.

OBJECTIVES: Follow-up care for incidental findings (IFs) on trauma computed tomography scans is a component of comprehensive healthcare. Our objective was to assess the effectiveness of our IF predischarge disclosure practice guideline and identify factors contributing to follow-up failure. METHODS: This was a secondary analysis of a prospective observational database: 615 patients with IFs from November 2019 to February 2020. Follow-up compliance was determined by electronic medical record review and/or a telephone call after a mail-out request for voluntary participation. Volunteers answered a predetermined questionnaire regarding follow-up care. RESULTS: A total of 115 patients (19%) had computed tomography-based IFs recommending additional imaging or other follow-ups. Seventy-four (64%) patients were lost to inclusion as a result of death (12.1%), inability to contact (51.3%), or noninterest (5.2%). Of the remaining 36 patients, 19 received follow-up care (52.7%) and 17 did not (47.2%). No statistical differences existed among groups in age, sex, mechanism of injury, Glasgow Coma Scale score, whether informed by physicians or midlevel providers, or type of IF. A total of 15 (88%) nonfollow-up patients did not recall the disclosure or discharge paperwork instructions. Of 19 compliant patients: 9 had additional imaging only, 5 had biopsies and/or surgical intervention (n = 3 cancer, n = 2 benign), 3 had primary care advice against additional studies and 2 were referred to specialists. CONCLUSIONS: Predischarge disclosure of IFs can contribute significantly to overall patient health. Nonetheless, fewer than half of patients do not pursue follow-up recommendations, most often citing failure to recall verbal/written instructions. More effective communication with attention to health literacy, follow-up telephone calls, and postdischarge appointments are potential catalysts for improved patient compliance.

SARS-CoV-2 Infections among Recent Organ Recipients, March-May 2020, United States.

We conducted public health investigations of 8 organ transplant recipients who tested positive for severe acute respiratory syndrome coronavirus 2 infection. Findings suggest the most likely source of transmission was community or healthcare exposure, not the organ donor. Transplant centers should educate transplant candidates and recipients about infection prevention recommendations.

Evaluation of Placental and Fetal Tissue Specimens for Zika Virus Infection - 50 States and District of Columbia, January-December, 2016.

Zika virus infection during pregnancy can cause congenital microcephaly and brain abnormalities (1), and detection of Zika virus RNA in clinical and tissue specimens can provide definitive laboratory evidence of recent Zika virus infection. Whereas duration of viremia is typically short, prolonged detection of Zika virus RNA in placental, fetal, and neonatal brain tissue has been reported and can provide key diagnostic information by confirming recent Zika virus infection (2). In accordance with recent guidance (3,4), CDC provides Zika virus testing of placental and fetal tissues in clinical situations where this information could add diagnostic value. This report describes the evaluation of formalin-fixed paraffin-embedded (FFPE) tissue specimens tested for Zika virus infection in 2016 and the contribution of this testing to the public health response. Among 546 live births with possible maternal Zika virus exposure, for which placental tissues were submitted by the 50 states and District of Columbia (DC), 60 (11%) were positive by Zika virus reverse transcription-polymerase chain reaction (RT-PCR). Among 81 pregnancy losses for which placental and/or fetal tissues were submitted, 18 (22%) were positive by Zika virus RT-PCR. Zika virus RT-PCR was positive on placental tissues from 38/363 (10%) live births with maternal serologic evidence of recent unspecified flavivirus infection and from 9/86 (10%) with negative maternal Zika virus immunoglobulin M (IgM) where possible maternal exposure occurred >12 weeks before serum collection. These results demonstrate that Zika virus RT-PCR testing of tissue specimens can provide a confirmed diagnosis of recent maternal Zika virus infection.

Consistent Estimates of Very Low HIV Incidence Among People Who Inject Drugs: New York City, 2005-2014.

OBJECTIVES: To compare methods for estimating low HIV incidence among persons who inject drugs. METHODS: We examined 4 methods in New York City, 2005 to 2014: (1) HIV seroconversions among repeat participants, (2) increase of HIV prevalence by additional years of injection among new injectors, (3) the New York State and Centers for Disease Control and Prevention stratified extrapolation algorithm, and (4) newly diagnosed HIV cases reported to the New York City Department of Health and Mental Hygiene. RESULTS: The 4 estimates were consistent: (1) repeat participants: 0.37 per 100 person-years (PY; 95% confidence interval [CI] = 0.05/100 PY, 1.33/100 PY); (2) regression of prevalence by years injecting: 0.61 per 100 PY (95% CI = 0.36/100 PY, 0.87/100 PY); (3) stratified extrapolation algorithm: 0.32 per 100 PY (95% CI = 0.18/100 PY, 0.46/100 PY); and (4) newly diagnosed cases of HIV: 0.14 per 100 PY (95% CI = 0.11/100 PY, 0.16/100 PY). CONCLUSIONS: All methods appear to capture the same phenomenon of very low and decreasing HIV transmission among persons who inject drugs. Public Health Implications. If resources are available, the use of multiple methods would provide better information for public health purposes.

Modeling the Declining Positivity Rates for Human Immunodeficiency Virus Testing in New York State.

OBJECTIVE: New York health care providers have experienced declining percentages of positive human immunodeficiency virus (HIV) tests among patients. Furthermore, observed positivity rates are lower than expected on the basis of the national estimate that one-fifth of HIV-infected residents are unaware of their infection. We used mathematical modeling to evaluate whether this decline could be a result of declining numbers of HIV-infected persons who are unaware of their infection, a measure that is impossible to measure directly. DESIGN AND SETTING: A stock-and-flow mathematical model of HIV incidence, testing, and diagnosis was developed. The model includes stocks for uninfected, infected and unaware (in 4 disease stages), and diagnosed individuals. Inputs came from published literature and time series (2006-2009) for estimated new infections, newly diagnosed HIV cases, living diagnosed cases, mortality, and diagnosis rates in New York. MAIN OUTCOME MEASURES: Primary model outcomes were the percentage of HIV-infected persons unaware of their infection and the percentage of HIV tests with a positive result (HIV positivity rate). RESULTS: In the base case, the estimated percentage of unaware HIV-infected persons declined from 14.2% in 2006 (range, 11.9%-16.5%) to 11.8% in 2010 (range, 9.9%-13.1%). The HIV positivity rate, assuming testing occurred independent of risk, was 0.12% in 2006 (range, 0.11%-0.15%) and 0.11% in 2010 (range, 0.10%-0.13%). The observed HIV positivity rate was more than 4 times the expected positivity rate based on the model. CONCLUSIONS: HIV test positivity is a readily available indicator, but it cannot distinguish causes of underlying changes. Findings suggest that the percentage of unaware HIV-infected New Yorkers is lower than the national estimate and that the observed HIV test positivity rate is greater than expected if infected and uninfected individuals tested at the same rate, indicating that testing efforts are appropriately targeting undiagnosed cases.

Substance abuse treatment utilization, HIV risk behaviors, and recruitment among suburban injection drug users in Long Island, New York.

Prevention and treatment of injection drug use remains a public health concern. We used data from the 2005 Centers for Disease Control and prevention National HIV Behavioral Surveillance system to assess substance abuse treatment utilization, risk behaviors, and recruitment processes in a respondent driven sample of suburban injectors. Twelve service utilization and injection risk variables were analyzed using latent class analysis. Three latent classes were identified: low use, low risk; low use, high risk; and high use, moderate/high risk. In multivariate analysis, annual income <$15,000 (adjusted odds ratio (aOR) = 8.19 [95 % confidence interval (CI), 3.83-17.51]) and self-reported hepatitis C virus infection (aOR = 4.32, 95 % CI (1.84-10.17)) were significantly associated with class membership. Homophily, a measure of preferential recruitment showed that injectors with recent treatment utilization appear a more cohesive group than out-of-treatment injectors. Preferentially reaching injection drug users with high risk behaviors and no recent drug treatment history via respondent driven sampling will require future research.

Thoracotomy Resuscitation of a Patient Who Sustained Blunt Force Trauma with a pH of 6.7 on Admission and Ultra Massive Transfusion of 42 Units of Blood.

Extreme acidosis is a life-threatening physiological state that thwarts resuscitative actions and most frequently ends in mortality. This report describes a case of a successful resuscitation in a patient who presented without vital signs, agonal respirations, dilated, unresponsive pupils, and an initial pH of 6.7. The patient is a 37-year-old man who was ejected from his package delivery vehicle after it was struck by a loaded dump truck. Resuscitative thoracotomy and other ATLS measures were performed to restore spontaneous circulation at 13 minutes after arrival. He underwent subsequent emergent operative interventions for severe chest, lower extremity, and intra-abdominal injuries. He was transfused 15, 27, and 42 total units of packed red blood cells (U-pRBCs) at resuscitation hours 2, 4, and 24. This case reinforces that resuscitative measures should be undertaken on a case-specific basis despite generalized guidelines suggesting futility at pH below 7.0 and at 23 units pRBCs balanced transfusion.

Ingested Foreign Bodies in the Sigmoid Colon Requiring Earlier Intervention in Patients With Prior Hysterectomy.

The use of dentures and dental plates is widespread in the adult population. Accidental ingestion of these foreign objects is not uncommon, with the majority of patients having an uneventful passage of the object through the gastrointestinal tract. Of those patients requiring intervention, endoscopy is the most common, followed by surgical removal. We discuss a case of a patient with prior pelvic surgery and diverticulosis causing severe angulation of the bowel, resulting in non-passage of the foreign object requiring surgical intervention.

Operative Management and Outcome of Idiopathic Rectal Necrosis in an Octogenarian.

Idiopathic acute rectal necrosis (IARN) is a rare condition due to a robust rectal blood supply. This report describes an 83-year-old man presenting with septic shock due to distal sigmoid and complete rectal necrosis with perforation. He underwent emergent exploratory laparotomy, sigmoid and proximal rectum resection, and end sigmoid colostomy creation with delayed distal rectal evaluation. Bedside proctoscopy revealed pale, viable-appearing distal rectal mucosa on postoperative day 3. The patient had a protracted, complicated hospital stay but required no further operative intervention. Subsequent colostomy reversal was done 8 months postoperatively, and the patient did well and has been discharged with normal gastrointestinal function. Our successful conservative operative management of IARN deviates from previously described management in the literature which is emergent abdominoperineal resection. This conservative surgical strategy appears to have contributed to the patient's positive outcomes, highlighting the importance of considering a similar approach for future IARN cases.

Non-surgical Management of a Malecot Tube Migrating From a Small Bowel Fistula.

Foreign bodies are encountered relatively often within the practice of general surgery. We present a unique case of a rubber, self-retaining, radiopaque "mushroom-tip" Malecot tube placed for fistula drainage control due to an enterocutaneous fistula (ECF) that became a gastrointestinal foreign body.  A 24-year-old male presented in shock with gunshot wounds to his right chest and right upper abdomen to a Level I trauma center. He required a prolonged hospital stay with additional urological and thoracic procedures and an interventional radiology procedure for hepatic pseudoaneurysm and subsequently developed an ECF. The patient was discharged to a rehabilitation facility with a wound management system (WMS) for ECF drainage but returned to the clinic with chemical burns and skin excoriation due to poorly controlled output and suboptimal WMS fit. A better fitting WMS was employed and a 20-French Malecot catheter was placed to assist with drainage control. The patient later returned with abdominal pain reporting the Malecot advanced forward spontaneously and was not externally visible. CT scan revealed the Malecot across the prior ileocolic anastomosis. After considering potential treatment options, we initially proceeded with aggressive bowel stimulation, and saline enemas hoping the tube would pass through his colostomy. He was discharged and the catheter passed at home a few days later via the stoma. Gastroenterological literature recommends invasive management for sharp, corrosive, or elongated foreign bodies exceeding 6cm in length. This unusual case demonstrates a 30-centimeter (cm) blunt object passing through the small bowel and colon in the absence of an ileocecal valve.

Delayed vs Early Admission to Intensive Care: A Retrospective Review of Outcomes and Clinical Indicators of Deterioration Following Trauma.

Unplanned admission to an intensive care unit (ICU) is a trauma quality improvement indicator associated with increased morbidity, mortality, and hospital resource usage. We identified demographics, injuries, and other clinical factors between early ICU admission, <72 hrs after admission (EAd), and delayed admission, >72 hrs (DelAd) from a medical/surgical floor. 146 trauma patients admitted to ICU at a level 1 trauma center from January 2020 to March 2023 met inclusion criteria and were divided into EAd and DelAd. No statistical differences in injury mechanism or severity were observed. Delayed admission demonstrated higher mortality (P = .001), more frequent decline in GCS (P = .045), and initiation of anticoagulation (P = .002). Abnormal EKG, orthopedic surgery during admission, and home anticoagulant and antidepressant use were statistically significant in identifying patients requiring early ICU admission.

Comparing Chest Tube Thoracostomy in East Tennessee Trauma Centers: A Prospective Study Highlighting Differences in Urban vs Rural Locations.

Chest tube thoracostomy (CTT) is essential for lung expansion, but protocol discrepancies exist across trauma centers. This prospective study compared CTT protocols between an urban (center 1) and rural (center 2) level 1 trauma center in East Tennessee from June to August 2023. 66 trauma patients required CTT (51 from center 1 and 15 from center 2). Diagnostic practices and post-pull chest X-rays (CXR) differed significantly. Center 1 favored CXR for diagnosis (P = 0.012), while center 2 relied more on clinical presentation (P = 0.012). Post-pull CXR was less common at center 2 (P = 0.012). Center 2 had lower Glasgow Coma Scale scores (P = 0.028), shorter tube duration (P = 0.044), and more needle thoracostomy use (P = 0.393). These findings underscore the need for regional protocols considering pre-arrival factors, hospital practices, and injury patterns. Protocol adjustments aim to improve adherence and patient outcomes, with ongoing data collection exploring factors influencing protocol evolution.

Surgical Resident Education and Performance in Extended Focused Abdominal Sonography for Trauma.

Extended focused assessment with sonography for trauma (eFAST) is a rapid triage tool aiding the detection of life-threatening injuries. In academic settings, residents perform most eFAST; however, the ACGME has no recommendations for eFAST training standards. We surveyed general surgery programs (GSPs) regarding eFAST training and established a baseline for sensitivity, specificity, and positive and negative predictive values for resident-performed eFAST. US GSP eFAST surveys were conducted by email and phone. We prospectively collected patient variables and evaluated resident performance from May to September 2022 and 2023 at an academic level I trauma center. A total of 60/339 general surgery residency programs (GSRPs) responded: Ten use Advanced Trauma Life Support (ATLS) only, n = 7 group training, n = 8 on-the-job only, and n = 33 several methods. Resident-performed eFAST had accuracy = 85.6%, sensitivity = 35.6%, specificity = 97.2%, PPV = 75%, and NPV = 87%. General surgery residency program training in eFAST is non-standardized. Sensitivity was considerably lower than the literature suggests. Positive resident-performed eFAST is generally accurate. We recommend a standardized approach to resident training in eFAST.

Incidence and Risk Factors for ICU-Associated Delirium in the Alert Geriatric Trauma Population.

BACKGROUND: This study analyzed the overall incidence of delirium, comorbid conditions, injury patterns, and pharmacological risk factors for the development of delirium in an alert, geriatric trauma population. METHODS: IRB-approved, prospective, consecutive cohort series at two Southeastern Level 1 trauma centers from June 11 to August 15, 2023. Delirium was assessed using the Confusion Assessment Method (CAM) score. Comorbidities and medications were detailed from electronic medical records. Inclusion criteria: age ≥55, GCS ≥14, and ICU admission for trauma. Patients on a ventilator were excluded. Data was analyzed using SPSS version 28 (Armonk, NY: IBM Corp). RESULTS: In total, 196 patients met inclusion criteria. Incidences of delirium for Hospital 1 (n = 103) and Hospital 2 (n = 93) were 15.5% and 12.9%, respectively, with an overall incidence of 14.3% and with no statistical differences between hospitals (P = .599). CAD, CKD, dementia, stroke history, and depression were statistically significant risk factors for developing delirium during ICU admission. Inpatient SSRI/SNRIs, epinephrine/norepinephrine, and lorazepam were significant risk factors. Injury patterns, operative intervention, and use of lidocaine infusions and gabapentin were not statistically significant in delirium development. Using binary linear regression (BLR) analysis, independent risk factors for delirium were dementia, any stage CKD, home SSRI/SRNI prescription, any spine injury and cerebrovascular disease, or injury. DISCUSSION: Comorbidities of CAD, CHF, CKD, and depression, and these medications: home lorazepam and ICU epinephrine/norepinephrine statistically are more common in patients developing delirium. Dementia, CKD, home SSRI/SRNI and stroke/cerebrovascular disease/injury, and spine injuries are independent predictors by BLR.

Coronary Artery Calcification and Risk of Cardiac Complication in Geriatric Trauma Population.

BACKGROUND: Better means of identifying patients with increased cardiac complication (CC) risk is needed. Coronary artery calcification (CAC) is reported on routine chest CT scans. We assessed the correlation of CAC and CCs in the geriatric trauma population. STUDY DESIGN: A prospective, observational study of patients 55 years and older who had chest CT scan from May to September 2022 at a level 1 trauma center. Radiologists scored CAC as none, mild, moderate, or severe. None-to-mild CAC (NM-CAC) and moderate-to-severe CAC (MS-CAC) were grouped and in-hospital CCs assessed (arrhythmia, ST elevation myocardial infarction [STEMI], non-STEMI, congestive heart failure, pulmonary edema, cardiac arrest, cardiogenic shock, and cardiac mortality). Univariate and bivariate analyses were performed. RESULTS: Five hundred sixty-nine patients had a chest CT, of them 12 were excluded due to missing CAC severity. Of 557 patients, 442 (79.3%) had none-to-mild CAC and 115 (20.7%) has MS-CAC; the MS-CAC group was older (73.3 vs 67.4 years) with fewer male patients (48.7% vs 54.5%), had higher cardiac-related comorbidities, and had higher abbreviated injury scale chest injury scores. The MS-CAC group had an increased rate of CC (odds ratio [OR] 1.81, p = 0.016). Cardiac complications statistically more common in MS-CAC were congestive heart failure (OR 3.41, p = 0.003); cardiogenic shock (OR 3.3, p = 0.006); non-STEMI I or II (OR 2.8, p = 0.017); STEMI (OR 5.9, p = 0.029); and cardiac-caused mortality (OR 5.27, p = 0.036). No statistical significance between pulmonary edema (p = 0.6), new-onset arrhythmia (p = 0.74), or cardiac arrest (p = 0.193). CONCLUSIONS: CAC as reported on chest CT scans demonstrates a significant correlation with CC and should warrant additional cardiac monitoring.

Predicting Unplanned Readmissions to the Intensive Care Unit in the Trauma Population.

Background: Unplanned readmission to intensive care units (UR-ICU) in trauma is associated with increased hospital length of stay and significant morbidity and mortality. We identify independent predictors of UR-ICU and construct a nomogram to estimate readmission probability. Materials and Methods: We performed an IRB-approved retrospective case-control study at a Level I trauma center between January 2019 and December 2021. Patients with UR-ICU (n = 175) were matched with patients who were not readmitted (NR-ICU) (n = 175). Univariate and multivariable binary linear regressionanalyses were performed (SPSS Version 28, IBM Corp), and a nomogram was created (Stata 18.0, StataCorp LLC). Results: Demographics, comorbidities, and injury- and hospital course-related factors were examined as potential prognostic indicators of UR-ICU. The mortality rate of UR-ICU was 22.29% vs 6.29% for NR-ICU (P < .001). Binary linear regression identified seven independent predictors that contributed to UR-ICU: shock (P < .001) or intracranial surgery (P = .015) during ICU admission, low hematocrit (P = .001) or sedation administration in the 24 hours before ICU discharge (P < .001), active infection treatment (P = .192) or leukocytosis on ICU discharge (P = .01), and chronic obstructive pulmonary disease (COPD) (P = .002). A nomogram was generated to estimate the probability of UR-ICU and guide decisions on ICU discharge appropriateness. Discussion: In trauma, UR-ICU is often accompanied by poor outcomes and death. Shock, intracranial surgery, anemia, sedative administration, ongoing infection treatment, leukocytosis, and COPD are significant risk factors for UR-ICU. A predictive nomogram may help better assess readiness for ICU discharge.

Estimating HCV prevalence at the state level: a call to increase and strengthen current surveillance systems.

The degree to which case surveillance captures persons ever infected with HCV is unknown. We determined the discrepancy between HCV seroprevalence, estimated from national survey data, among adults in New York State in 2008 (n = 286 262, or 1.95%) and the number of infected persons reported to the state's surveillance hepatitis registries (n = 144 015). Findings suggest the need to strengthen the existing surveillance system.

"Early Post-operative Mechanical Small Bowel Obstruction Induced by Unidirectional Barbed Suture".

Unidirectional barbed suture is widely used in minimally invasive procedures as a secure alternative to traditional knot tying. In this report, a 44-year-old female with endometriosis and complex gynecological history presented to our emergency department 2 weeks after undergoing minimally invasive gynecological surgery. She had persistent, progressive signs and symptoms typical of intermittent partial small bowel obstruction. On her third admission within 7 days for this pattern, laparoscopic abdominal exploration was performed. She was noted to have small bowel obstruction secondary to ingrowth of the tail of a unidirectional barbed suture kinking the terminal ileum during this procedure. We discuss small bowel obstruction due to unidirectional barbed suture and make recommendations on how to avoid this complication.

Surgical Repair of Idiopathic Mid-Forearm Radial Artery Aneurysm Using a Reversed Greater Saphenous Vein Interposition Graft.

Idiopathic, non-traumatic, radial artery aneurysms are rare in medical literature. This report presents the case of a 56-year-old man who was incidentally found to have a 1.01 cm × 1.31 cm left radial artery aneurysm during a carpal tunnel workup. The patient had no other aneurysms, nor any known predisposing diseases that could explain his condition. We proceeded with surgical intervention to prevent future complications. We describe the use of a greater saphenous vein interposition graft for the repair of an idiopathic mid-forearm radial artery aneurysm. The patient had an uncomplicated recovery course following repair.