The malnutrition in polytrauma patients (MaPP) study: Research protocol.

BACKGROUND: Polytrauma patients are at risk of considerable harm from malnutrition due to the metabolic response to trauma. However, there is little knowledge of (the risk of) malnutrition and its consequences in these patients. Recognition of sub-optimally nourished polytrauma patients and their nutritional needs is crucial to prevent complications and optimize their clinical outcomes. AIM: The primary objective is to investigate whether polytrauma patients admitted to the Intensive Care Unit (ICU) who have or develop malnutrition have a higher complication rate than patients who are and remain well nourished. Secondary objectives are to determine the prevalence of pre-existent and in-hospital acquired malnutrition in these patients, to assess the association between malnutrition and long-term outcomes, and to determine the association between serum biomarkers (albumin and pre-albumin) and malnutrition. METHODS: This international observational prospective cohort study will be performed at three Level-1 trauma centers in the United States and two Level-1 centers in the Netherlands. Adult polytrauma patients (Injury Severity Score ≥16) admitted to the ICU of one of the participating centers directly from the Emergency Department are eligible for inclusion. Nutritional status and risk of malnutrition will be assessed using the Subjective Global Assessment (SGA) scale and Nutritional Risk in Critically Ill (NUTRIC) score, respectively. Nutritional intake, biomarkers and complications will be collected daily. Patients will be followed up to one year after discharge for long-term outcomes. CONCLUSIONS: This international prospective cohort study aims to gain more insight into the effect and consequences of malnutrition in polytrauma patients admitted to the ICU.

Gene-Environment Interplay in the Development of Overweight.

PURPOSE: Overweight in youth is influenced by genes and environment. Gene-environment interaction (G×E) has been demonstrated in twin studies and recent developments in genetics allow for studying G×E using individual genetic predispositions for overweight. We examine genetic influence on trajectories of overweight during adolescence and early adulthood and determine whether genetic predisposition is attenuated by higher socioeconomic status and having physically active parents. METHODS: Latent class growth models of overweight were fitted using data from the TRacking Adolescents' Individual Lives Survey (n = 2720). A polygenic score for body mass index (BMI) was derived using summary statistics from a genome-wide association study of adult BMI (N = ∼700,000) and tested as predictor of developmental pathways of overweight. Multinomial logistic regression models were used to examine effects of interactions of genetic predisposition with socioeconomic status and parental physical activity (n = 1675). RESULTS: A three-class model of developmental pathways of overweight fitted the data best ("non-overweight", "adolescent-onset overweight", and "persistent overweight"). The polygenic score for BMI and socioeconomic status distinguished the persistent overweight and adolescent-onset overweight trajectories from the non-overweight trajectory. Only genetic predisposition differentiated the adolescent-onset from the persistent overweight trajectory. There was no evidence for G×E. DISCUSSION: Higher genetic predisposition increased the risk of developing overweight during adolescence and young adulthood and was associated with an earlier age at onset. We did not find that genetic predisposition was offset by higher socioeconomic status or having physically active parents. Instead, lower socioeconomic status and higher genetic predisposition acted as additive risk factors for developing overweight.

Review of the unprecedented impact of the COVID-19 pandemic on the occurrence of eating disorders.

PURPOSE OF REVIEW: To review the recent literature on the impact of the coronavirus disease-2019 (COVID-19) pandemic on incidence and severity of symptoms of eating disorders (EDs). RECENT FINDINGS: A worrying increase of EDs in- and outpatients has been reported since the COVID-19 pandemic began in 2019/2020. Restrictions implemented during the pandemic to protect populations against COVID-19 increased the risk for onset and for worsening of EDs by disrupting eating and exercise routines, social isolation, lack of support, and limited access to healthcare. Substantial increases since the start of the pandemic have been reported for overall incidence (15%), hospital admissions (48%) and emergency department visits (11%) for EDs, with even higher increases among women and children or adolescents with an ED. During the pandemic, ED patients reported increased severity of ED-specific symptoms and increased anxiety, depression and suicidal ideations and -attempts. Treatments shifted largely toward online methods for continuity of care, despite concerns about the quality of care provided and difficulties in self-monitoring. Our review provides preliminary evidence for a similar effectiveness of online treatment to prepandemic face-to-face treatment. In-person assessment remains essential for detecting EDs and for those requiring medical admission. SUMMARY: Although the ongoing COVID-2019 pandemic affected mental health globally, research shows that it particularly affected individuals with an ED diagnosis or at risk for an ED, especially women, children and adolescents, and those with anorexia nervosa.

Treatment and outcomes of anticoagulated geriatric trauma patients with traumatic intracranial hemorrhage after falls.

INTRODUCTION: Emergency physicians and trauma surgeons are increasingly confronted with pre-injury direct oral anticoagulants (DOACs). The objective of this study was to assess if pre-injury DOACs, compared to vitamin K antagonists (VKA), or no oral anticoagulants is independently associated with differences in treatment, mortality and inpatient rehabilitation requirement. METHODS: We performed a review of the prospectively maintained institutional trauma registry at an urban academic level 1 trauma center. We included all geriatric patients (aged ≥ 65 years) with tICH after a fall, admitted between January 2011 and December 2018. Multivariable logistic regression analysis controlling for demographics, comorbidities, vital signs, and tICH types were performed to identify the association between pre-injury anticoagulants and reversal agent use, neurosurgical interventions, inhospital mortality, 3-day mortality, and discharge to inpatient rehabilitation. RESULTS: A total of 1453 tICH patients were included (52 DOAC, 376 VKA, 1025 control). DOAC use was independently associated with lower odds of receiving specific reversal agents [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.15-0.54] than VKA patients. DOAC use was independently associated with requiring neurosurgical intervention (OR 3.14, 95% CI 1.36-7.28). VKA use, but not DOAC use, was independently associated with inhospital mortality, or discharge to hospice care (OR 1.62, 95% CI 1.15-2.27) compared to controls. VKA use was independently associated with higher odds of discharge to inpatient rehabilitation (OR 1.41, 95% CI 1.06-1.87) compared to controls. CONCLUSION: Despite the higher neurosurgical intervention rates, patients with pre-injury DOAC use were associated with comparable rates of mortality and discharge to inpatient rehabilitation as patients without anticoagulation exposure. Future research should focus on risk assessment and stratification of DOAC-exposed trauma patients.

A Paradigm Shift in Critical Care Infrastructure in Complex Settings: Evaluating an Ultraportable Operating Room to Improve Field Surgical Safety.

INTRODUCTION: Scarcity of operating rooms and personal protective equipment in far-forward field settings make surgical infections a potential concern for combat mortality and morbidity. Surgical and transport personnel also face infectious risks from bodily fluid exposures. Our study aimed to describe the serial, proof-of-concept testing of the SurgiBox technology: an inflatable sterile environment that addresses the aforementioned problems, fits on gurneys and backpacks, and drapes over incisions. MATERIALS AND METHODS: The SurgiBox environmental control unit and inflatable enclosure were optimized over five generations based on iterative feedback from stakeholders experienced in surgery in austere settings. The airflow system was developed by analytic modeling, verified through in silico modeling in SOLIDWORKS, and confirmed with prototype smoke-trail checking. Particulate counts evaluated the enclosure's ability to control and mitigate users' exposures to potentially infectious contaminants from the surgical field in various settings. SurgiBox enclosures were setup over a mannequin's torso, in a configuration and position for either thoracic or abdominal surgery. A particle counter was serially positioned in sternotomy and laparotomy positions, as well as bilateral flank positions. This setup was repeated with open ports exposing the enclosure to the external environment. To simulate stress scenarios, sampling was repeated with enclosure measurements during an increase in external particulate concentration. RESULTS: The airflow technology effectively kept contaminants away from the incision and maintained a pressure differential to reduce particle entry. Benchtop testing demonstrated that even when ports were opened or the external environment had high contaminant burden, the enclosed surgical field consistently registered 0 particle count in all positions. Time from kit opening to incision averaged 54.5 seconds, with the rate-limiting step being connecting the environmental control unit to the enclosure. The portable kit weighted 5.9 lbs. CONCLUSIONS: Analytic, in silico, and mechanical airflow modeling and benchtop testing have helped to quantify the SurgiBox system's reliability in creating and maintaining an operating room-quality surgical field within the enclosure as well as protecting the surgical team outside the enclosure. More recent and ongoing work has focused on specifying optimal use settings in the casualty chain of care, expanding support for circumferential procedures, automating airflow control, and accelerating system setup. SurgiBox's ultimate goal is to take timely, safe surgery to patients in even the most austere of settings.

Malnutrition and its effects in severely injured trauma patients.

PURPOSE: In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients. METHODS: A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines. RESULTS: Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7-62.5% were malnourished at admission and 35.6-60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life. CONCLUSIONS: Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.

Public perspectives on protective measures during the COVID-19 pandemic in the Netherlands, Germany and Italy: A survey study.

BACKGROUND: The extent to which people implement government-issued protective measures is critical in preventing further spread of coronavirus disease 2019 (COVID-19) caused by coronavirus SARS-CoV-2. Our study aimed to describe the public belief in the effectiveness of protective measures, the reported implementation of these measures, and to identify communication channels used to acquire information on COVID-19 in European countries during the early stage of the pandemic. METHODS AND FINDINGS: An online survey available in multiple languages was disseminated starting on March 19th, 2020. After five days, we computed descriptive statistics for countries with more than 500 respondents. Each day, we assessed enacted community containment measures by stage of stringency (I-IV). In total, 9,796 adults responded, of whom 8,611 resided in the Netherlands (stage III), 604 in Germany (stage III), and 581 in Italy (stage IV). To explore possible dynamics as containment strategies intensified, we also included 1,365 responses submitted during the following week. Participants indicated support for governmental measures related to avoiding social gatherings, selective closure of public places, and hand hygiene and respiratory measures (range for all measures: 95.0%-99.7%). Respondents from the Netherlands less frequently considered a complete social lockdown effective (59.2%), compared to respondents in Germany (76.6%) or Italy (87.2%). Italian residents applied enforced social distancing measures more frequently (range: 90.2%-99.3%, German and Dutch residents: 67.5%-97.0%) and self-initiated hygienic and social distancing behaviors (range: 36.3%-96.6%, German and Dutch residents: 28.3%-95.7%). Respondents reported being sufficiently informed about the outbreak and behaviors to avoid infection (range: 90.2%-91.1%). Information channels most commonly reported included television newspapers, official health websites, and social media. One week later, we observed no major differences in submitted responses. CONCLUSIONS: During the early stage of the COVID-19 pandemic, belief in the effectiveness of protective measures among survey respondents from three European countries was high and participants reported feeling sufficiently informed. In March 2020, implementation of measures differed between countries and were highest among respondents from Italy, who were subjected to the most stringent lockdown measures and greatest COVID-19 burden in Europe during this period.

Gallbladder wall thickness as a predictor of intraoperative events during laparoscopic cholecystectomy: A prospective study of 1089 patients.

BACKGROUND: Laparoscopic cholecystectomy (LC) has a wide range of technical difficulty. Preoperative risk stratification is essential for adequate planning and patient counseling. We hypothesized that gallbladder wall thickness (GWT) is more objective marker than symptom duration in predicting complexity, as determined by operative time (OT), intraoperative events (IE), and postoperative complications. METHODS: All adult patients who underwent LC during 2010-2018 were included. GWT, measured on imaging and on the histopathologic exam, was divided into three groups: <3 mm (normal), 3-7 mm and >7 mm. Univariate and multivariable analyses were performed to determine the association between GWT and 1) operative time, 2) the incidence of IE and 3) postoperative outcomes. RESULTS: A total of 1089 patients, subjects to LC, were included in the study. GWT was positively correlated with median OT (p < 0.001), the incidence of IE (p < 0.001) and median length of hospital stay (p < 0.001). GWT independently predicted IE (OR = 2.1 95% CI: 1.3-3.4) and outperformed symptom duration, which was not significantly associated with any of the outcomes (p = 0.7). CONCLUSIONS: GWT independently predicted IE and may serve as an objective marker of LC complexity.

Necrotizing Soft Tissue Infection: Time is Crucial, and the Admitting Service Matters.

Background: Early diagnosis and prompt debridement of necrotizing soft tissue infection (NSTI) improves the outcome. We sought to determine whether failure to admit NSTI patients to acute care surgery (ACS) departments delays treatment and increases the mortality rate. Methods: Patients with NSTI were identified using the 2007-2018 institutional emergency surgery database at a tertiary care hospital. The diagnosis was confirmed by the operative/pathology reports. Patients who developed NSTI during hospitalization or underwent initial debridement at an outside hospital were excluded. Patients admitted to a non-ACS service (e.g., medicine, gynecology) were compared with those admitted to the ACS service with respect to co-morbidities, clinical presentation, time to surgery, and mortality rate. Multi-variable linear and logistic analyses were performed to determine whether admission to a non-ACS service predicts a delay in surgery or an increase in the mortality rate. Results: Of 132 patients, 91 met the inclusion criteria. The mean age was 53 years; 56% were male. Twenty patients (22%) were admitted to a non-ACS service, two thirds of them with an initial misdiagnosis (e.g., cellulitis). The demographics, co-morbidities, and clinical presentation were similar in the two groups except that the non-ACS group more often had human immunodeficiency virus infection (15.0% versus 2.8%; p = 0.04) and less often presented with erythema (70% versus 94.4%; p = 0.01). The median time to incision in non-ACS patients was significantly longer (24.8 versus 3.9 hours; p < 0.001). The mortality rates were 20.0% for the non-ACS group and 7.0% for the ACS group (p = 0.086). Multi-variable analyses revealed that absence of erythema is independently associated with a non-ACS admission (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.3-25.6; p = 0.02), and non-ACS admissions correlated independently with delayed surgery (OR 35.20; 95% CI 3.86-321.20; p = 0.002). Conclusions: Admission of patients with NSTI to a non-ACS service often occurs because of initial misdiagnosis, especially in the absence of skin erythema; correlates with significantly delayed surgery; and might lead to more deaths.

The Geriatric Nutritional Risk Index is a powerful predictor of adverse outcome in the elderly emergency surgery patient.

BACKGROUND: The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES. METHODS: Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed. RESULTS: A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES. CONCLUSION: Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively. LEVEL OF EVIDENCE: Prognostic study, Level IV.

Obesity as protective against, rather than a risk factor for, postoperative Clostridium difficile infection: A nationwide retrospective analysis of 1,426,807 surgical patients.

BACKGROUND: Recent studies suggest that obesity is a risk factor for Clostridium difficile infection, possibly due to disruptions in the intestinal microbiome composition. We hypothesized that body mass index (BMI) is associated with increased incidence of C. difficile infection in surgical patients. METHODS: In this nationwide retrospective cohort study in 680 American College of Surgeons National Surgical Quality Improvement Program participating sites across the United States, the occurrence of C. difficile infection within 30 days postoperatively between different BMI groups was compared. All American College of Surgeons National Surgical Quality Improvement Program patients between 2015 and 2016 were classified as underweight, normal-weight, overweight, or obese class I-III if their BMI was less than 18.5, 18.5 to 25, 25 to 30, 30 to 35, 35 to 40 or greater than 40, respectively. RESULTS: A total of 1,426,807 patients were included; median age was 58 years, 43.4% were male, and 82.9% were white. The postoperative incidence of C. difficile infection was 0.42% overall: 1.11%, 0.56%, 0.39%, 0.35%, 0.33% and 0.36% from the lowest to the highest BMI group, respectively (p < 0.001 for trend). In univariate then multivariable logistic regression analyses, adjusting for patient demographics (e.g., age, sex), comorbidities (e.g., diabetes, systemic sepsis, immunosuppression), preoperative laboratory values (e.g., albumin, white blood cell count), procedure complexity (work relative unit as a proxy) and procedure characteristics (e.g., emergency, type of surgery [general, vascular, other]), compared with patients with normal BMI, high BMI was inversely and incrementally correlated with the postoperative occurrence of C. difficile infection. The underweight were at increased risk (odds ratio, 1.15 [1.00-1.32]) while the class III obese were at the lowest risk (odds ratio, 0.73 [0.65-0.81]). CONCLUSION: In this nationwide retrospective cohort study, obesity is independently and in a stepwise fashion associated with a decreased risk of postoperative C. difficile infection. Further studies are warranted to explore the potential and unexpected association. LEVEL OF EVIDENCE: Prognostic/Epidemiologic, Level IV.

Emergency Surgery Score Accurately Predicts the Risk of Post-Operative Infection in Emergency General Surgery.

BACKGROUND: The Emergency Surgery Score (ESS) was validated recently as an accurate and user-friendly post-operative mortality risk calculator specific for Emergency General Surgery (EGS). ESS is calculated by adding one to three integer points for each of 22 pre-operative variables (demographics, co-morbidities, and pre-operative laboratory values); increasing scores accurately and gradually predict higher mortality rates. We sought to evaluate whether ESS can predict the occurrence of post-operative infectious complications in EGS patients. PATIENTS AND METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2007-2015, all EGS patients were identified by using the "emergent" ACS-NSQIP variable and a concomitant surgery Current Procedural Terminology code for "digestive system." Patients with any missing ESS variables or those who died within 72 hours from the surgical procedure were excluded. A composite variable, post-operative infection, was created and defined as the post-operative occurrence of one or more of the following: superficial, deep incisional or organ/space surgical site infection, surgical site disruption, pneumonia, sepsis, septic shock, or urinary tract infection. ESS was calculated for all included patients, and the correlation between ESS and post-operative infection was examined using c-statistics. RESULTS: Of a total of 4,456,809 patients, 90,412 patients were included. The mean age of the population was 56 years, 51% were female, and 70% were white; 22% developed one or more post-operative infections, most commonly sepsis/septic shock (12.2%), surgical site infection (9%), and pneumonia (5.7%). The ESS gradually and consistently predicted infectious complications; post-operative infections developed in 7%, 24%, and 49% of patients with an ESS of 1, 5, and 10, respectively. The c-statistics for overall post-operative infection, post-operative sepsis/septic shock, and pneumonia were 0.73, 0.75, and 0.80, respectively. CONCLUSION: The ESS accurately predicts the occurrence of post-operative infectious complications in EGS patients and could be used for pre-operative clinical decision-making as well as quality benchmarking of infection rates in EGS.