Racial and Ethnic Disparities in Emergency General Surgery Outcomes Among Older Adult Patients.

INTRODUCTION: Racial and ethnic disparities in emergency general surgery (EGS) patients have been well described in the literature. Nonetheless, the burden of these disparities, specifically within the more vulnerable older adult population, is relatively unknown. This study aims to investigate racial and ethnic disparities in clinical outcomes among older adult patients undergoing EGS. METHODS: This retrospective analysis used data from 2013 to 2019 American College of Surgeons National Surgery Quality Improvement Program database. EGS patients aged 65 y or older were included. Patients were categorized based on their self-reported race and ethnicity. The primary outcomes evaluated were in-hospital mortality, 30-d mortality, and overall morbidity. Multivariable logistic regression was performed to examine the relationship between race/ethnicity and postoperative outcomes while adjusting for relevant factors including age, comorbidities, functional status, preoperative conditions, and surgical procedure. RESULTS: A total of 54,132 patients were included, of whom 79.8% identified as non-Hispanic White, 9.5% as non-Hispanic Black (NHB), 5.8% as Hispanic, and 4.2% as non-Hispanic Asian. After risk adjustment, compared to non-Hispanic White patients, NHB, non-Hispanic Asian, and Hispanic patients had decreased odds of 30-d mortality. For 30-d readmission and reoperation, differences among groups were comparable. However, NHB patients had significantly increased odds of overall morbidity (adjusted odds ratio, 1.18; 95% confidence interval: 1.10-1.26; P < 0.001) and postoperative complications including sepsis, venous thromboembolism, and unplanned intubation. Hispanic ethnicity was associated with lower odds of postoperative myocardial infarction and stroke. CONCLUSIONS: Among older adult patients undergoing emergency general surgery, minority patients experienced higher morbidity rates, but paradoxical disparities in mortality were detected. Further research is necessary to identify the cause of these disparities and develop targeted interventions to eliminate them.

The Open Abdomen After Intra-Abdominal Contamination in Emergency General Surgery.

INTRODUCTION: Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. METHODS: This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. RESULTS: We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). CONCLUSIONS: In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Debunking the "Obesity Paradox": Obesity Is Associated With Adverse Outcomes in Emergency General Surgery.

INTRODUCTION: Obesity is increasingly prevalent both nationwide and in the emergency general surgery (EGS) population. While previous studies have shown that obesity may be protective against mortality following EGS procedures, the association between body mass index (BMI) and postoperative outcomes, as well as intraoperative decision-making, remains understudied. METHODS: The National Surgical Quality Improvement Program 2015-2019 database was used to identify all adult patients undergoing an open abdominal or abdominal wall procedure for EGS conditions. Our outcomes included 30-d postoperative mortality, composite 30-d morbidity, delayed fascial closure, reoperation, operative time, and hospital length of stay (LOS). Multivariable logistic regression models were used to explore the association between BMI and each outcome of interest while adjusting for patient demographics, comorbidities, laboratory tests, preoperative and intraoperative variables. RESULTS: We identified 78,578 patients, of which 3121 (4%) were categorized as underweight, 23,661 (30.1%) as normal weight, 22,072 (28.1%) as overweight, 14,287 (18.2%) with class I obesity, 7370 (9.4%) with class II obesity, and 8067 (10.3%) with class III obesity. Class III obesity was identified as a risk factor for 30-d postoperative morbidity (adjusted odds ratio 1.14, 95% CI, 1.03-1.26, P < 0.01). An increase in obesity class was also associated with a stepwise increase in the risk of undergoing delayed fascial closure, experiencing a prolonged operative time, and having an extended LOS. CONCLUSIONS: Obesity class was associated with an increase in delayed fascial closure, longer operative time, higher reoperation rates, and extended hospital LOS. Further studies are needed to explore how a patient's BMI impacts intraoperative factors, influences surgical decision-making, and contributes to hospital costs.

Discharge to Skilled Nursing Facility Is a Risk Factor for Readmission: A Nationwide Propensity-Matched Study.

INTRODUCTION: General surgery procedures place stress on geriatric patients, and postdischarge care options should be evaluated. We compared the association of discharge to a skilled nursing facility (SNF) versus home on patient readmission. METHODS: We retrospectively reviewed the Nationwide Readmission Database (2016-2019) and included patients ≥65 y who underwent a general surgery procedure between January and September. Our primary outcome was 30-d readmissions. Our secondary outcome was predictors of readmission after discharge to an SNF. We performed a 1:1 propensity-matched analysis adjusting for patient demographics and hospital course to compare patients discharged to an SNF with patients discharged home. We performed a sensitivity analysis on patients undergoing emergency procedures and a stepwise regression to identify predictors of readmission. RESULTS: Among 140,056 included patients, 33,916 (24.2%) were discharged to an SNF. In the matched population of 19,763 pairs, 30-d readmission was higher in patients discharged to an SNF. The most common diagnosis at readmission was sepsis, and a greater proportion of patients discharged to an SNF were readmitted for sepsis. In the sensitivity analysis, emergency surgery patients discharged to an SNF had higher 30-d readmission. Higher illness severity during the index admission and living in a small or fringe county of a large metropolitan area were among the predictors of readmission in patients discharged to an SNF, while high household income was protective. CONCLUSIONS: Discharge to an SNF compared to patients discharged home was associated with a higher readmission. Future studies need to identify the patient and facility factors responsible for this disparity.

General Versus Locoregional Anesthesia in TEVAR: An NSQIP Analysis.

BACKGROUND: Thoracic Endovascular Aortic Repair (TEVAR) is a minimally invasive surgery for repairing thoracic aneurysms and dissections. This study aims to compare postoperative outcomes of TEVAR performed under general versus locoregional anesthesia. METHODS: Utilizing the 2008-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, patients older than the age of 18 years who received TEVAR, were identified using the following current procedural terminology codes: 33,880, 33,881, 33,883, 33,884, or 33,886. Patients who underwent concomitant procedures, those with both thoracoabdominal and abdominal aortic pathologies, and trauma cases were excluded. Standard descriptive statistics, in addition to χ2, Fisher's exact test, and Mann-Whitney U-tests were used to compare patient baseline characteristics and postoperative outcomes between general and locoregional anesthesia groups as appropriate. Univariable and multivariable logistic regression analyses were performed to assess independent predictors of hospital length of stay (LOS) greater than 7 days. RESULTS: Of the 1,028 patients included in the study, 86.5% received general anesthesia, and 13.5% received locoregional anesthesia, such as local anesthesia with monitored anesthesia care or regional anesthesia. No significant differences were found between patients receiving locoregional versus general anesthesia in mortality (3.6% vs. 7.9%, respectively, P = 0.071) and morbidity (18.7% and 24.8%, respectively, P = 0.121) within 30 days post-TEVAR, including any wound, pulmonary, thromboembolic, renal, septic, and cardiac arrest complications. Patients who received general anesthesia had significantly higher median LOS compared to those who received locoregional anesthesia [5 days (interquartile range (IQR): 3-10) versus 4 days (IQR: 2-7), P = 0.002], with 34.3% of the general anesthesia group having an LOS greater than 7 days compared to 21.6% of locoregional anesthesia group, P = 0.003. On multivariable logistic regression analysis, general anesthesia was found to be an independent predictor of prolonged LOS greater than 7 days (odds ratio (OR): 1.72, 95% confidence interval (CI): 1.05-2.81, P = 0.031). CONCLUSIONS: Locoregional anesthesia results in significantly lower postoperative hospital LOS with similar postoperative mortality and morbidity compared to general anesthesia in patients undergoing TEVAR.

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

BACKGROUND: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database. METHODS: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses. RESULTS: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived. CONCLUSIONS: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.

Validation of Artificial Intelligence-Based POTTER Calculator in Emergency General Surgery Patients Undergoing Laparotomy: Prospective, Bi-Institutional Study.

BACKGROUND: The POTTER calculator, a widely used interpretable artificial intelligence (AI) risk calculator, has been validated in population-based studies and shown to predict outcomes in emergency general surgery (EGS) patients better than surgeons. We sought to prospectively validate POTTER. STUDY DESIGN: Patients undergoing an emergency exploratory laparotomy for non-trauma indications at two Academic Medical Centers between June 2020 and March 2022 were included. POTTER preoperative risk calculations and postoperative outcomes were systematically recorded. POTTER's performance in predicting 30-day postoperative mortality, septic shock, respiratory failure, bleeding, and pneumonia was assessed using the c-statistic methodology. RESULTS: A total of 361 patients were included. The median age was 63 years (IQR: 51-72), 45.4% were females, and the overall mortality and morbidity were 24.1% and 51.4%, respectively. POTTER predicted mortality accurately with a c-statistic of 0.90. POTTER also accurately predicted the occurrence of individual postoperative complications, with c-statistics ranging between 0.80 and 0.89. CONCLUSION: This is the first prospective validation of the AI-enabled POTTER calculator. The superior accuracy, user-friendliness, and interpretability of POTTER make it a useful bedside tool for preoperative patient and family counseling.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients.

BACKGROUND: The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients. METHODS: We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site. RESULTS: We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations. CONCLUSION: Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

First do no harm: Predicting futility of intervention in geriatric emergency general surgery.

BACKGROUND: Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care. METHODS: We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors. RESULTS: Of 41,029 patients, 5589 (13.6 â€‹%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 â€‹% CI,3.5-26.8, p â€‹< â€‹0.001), septic shock (aOR 4.9, 95 â€‹% CI,4.5-5.4, p â€‹< â€‹0.001), and dialysis (aOR 2.1, 95 â€‹% CI,1.8-2.4, p â€‹< â€‹0.001). Without risk factors, mortality rates were 11.9 â€‹% after colectomy and 10.2 â€‹% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 â€‹% and 100 â€‹% following colectomy and small bowel resection, respectively. CONCLUSIONS: In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making.

Renal angioembolization vs. surgery for high-grade renal trauma: a nationwide comparative analysis.

PURPOSE: Renal angioembolization (RAE) is widely employed in low-grade renal injuries and associated with improved patient outcomes, while surgery remains the mainstay for managing high-grade injuries. We compared the outcomes following surgery and RAE in high-grade renal trauma (HGRT). METHODS: We used the ACS TQIP 2016-2020 to identify patients ≥ 16 years with HGRT who underwent RAE or surgery. Morbidity was the primary outcome, while mortality and lengths of stay were secondary outcomes. We accounted for clinically relevant characteristics using multilevel logistic regression analyses. RESULTS: We included 591 patients, of whom 279 (47.2%) underwent RAE. After adjusting, there was no difference in morbidity, hospital LOS, or ICU LOS. The surgery cohort had increased odds of mortality (aOR 4.93; [95% CI] 1.53-15.82; p = 0.007) compared to RAE. In the penetrating injury subgroup, no associations between management and outcomes were observed. In the grade V injury subgroup, morbidity was significantly higher after surgery (aOR 4.64; [95% CI] 1.49-14.47; p = 0.008). CONCLUSION: Overall, RAE did not significantly impact morbidity but was associated with improved mortality. RAE could safeguard renal function by augmenting the efficacy of concurrent non-operative interventions. Randomized studies are needed to further validate the utility of RAE in HGRT.

Outcomes of severe isolated blunt chest trauma in young and geriatric patients.

PURPOSE: Our understanding of the growing geriatric population's risk factors for outcomes after traumatic injury remains incomplete. This study aims to compare outcomes of severe isolated blunt chest trauma between young and geriatric patients and assess predictors of mortality. METHODS: The ACS-TQIP 2017-2020 database was used to identify patients with severe isolated blunt chest trauma. Patients having extra-thoracic injuries, no signs of life upon presentation to the emergency department (ED), prehospital cardiac arrest, or who were transferred to or from other hospitals were excluded. The primary outcome was in-hospital mortality. Univariate and multivariable regression analyses were performed to assess independent predictors of mortality. RESULTS: A total of 189,660 patients were included in the study, with a median age of 58 years; 37.5% were aged 65 or older, and 1.9% died by discharge. Patients aged 65 and older had significantly higher mortality (3.4% vs. 1.0%, p < 0.001) and overall complications (7.0% vs. 4.7%, p < 0.001) compared to younger patients. Age ≥ 65 was independently associated with mortality (OR: 5.45, 95%CI: 4.96-5.98, p < 0.001), prolonged hospitalization, and complications. In the geriatric group, age > 75 was an independent predictor of mortality compared to ages 65-75 (OR: 2.62, 95%CI: 2.37-2.89, p < 0.001). Geriatric patients with an MVC, presenting with a GCS ≤ 8, and having an SBP < 90 had the highest mortality of 56.9%. CONCLUSION: The geriatric trauma patient with isolated severe blunt chest injury has significantly higher mortality and morbidity compared to younger patients and warrants special consideration of multiple factors that affect outcomes. Individual predictors of mortality carry a greater impact on mortality in geriatric patients.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Lost in transition: Impact of interhospital transfer on outcomes after emergency general surgery in the older adult population.

BACKGROUND: Emergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients. METHODS: Emergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort. RESULTS: Among the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients. CONCLUSION: Interhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes.

Development of a two-hit lethal liver injury model in swine.

PURPOSE: Noncompressible truncal hemorrhage remains a leading cause of preventable death in the prehospital setting. Standardized and reproducible large animal models are essential to test new therapeutic strategies. However, existing injury models vary significantly in consistency and clinical accuracy. This study aims to develop a lethal porcine model to test hemostatic agents targeting noncompressible abdominal hemorrhages. METHODS: We developed a two-hit injury model in Yorkshire swine, consisting of a grade IV liver injury combined with hemodilution. The hemodilution was induced by controlled exsanguination of 30% of the total blood volume and a 3:1 resuscitation with crystalloids. Subsequently, a grade IV liver injury was performed by sharp transection of both median lobes of the liver, resulting in major bleeding and severe hypotension. The abdominal incision was closed within 60 s from the injury. The endpoints included mortality, survival time, serum lab values, and blood loss within the abdomen. RESULTS: This model was lethal in all animals (5/5), with a mean survival time of 24.4 ± 3.8 min. The standardized liver resection was uniform at 14.4 ± 2.1% of the total liver weight. Following the injury, the MAP dropped by 27 ± 8mmHg within the first 10 min. The use of a mixed injury model (i.e., open injury, closed hemorrhage) was instrumental in creating a standardized injury while allowing for a clinically significant hemorrhage. CONCLUSION: This novel highly lethal, consistent, and clinically relevant translational model can be used to test and develop life-saving interventions for massive noncompressible abdominal hemorrhage.

The impact of comorbidities and functional status on outcomes in the older adult emergency general surgery patient.

BACKGROUND: The aim of this study is to quantify the relative contribution of comorbidities and pre-operative functional status on outcomes in geriatric emergency general surgery (EGS) patients. METHODS: This is a retrospective study of older-adult EGS patients at an academic medical center between 2017 and 2018. Patients ≥65 years were included. The primary outcomes examined were 30-day mortality, 30-day morbidity, and length of stay (LOS). RESULTS: 734 patients were included. The mean age was 76, and 48.9 â€‹% received non-operative management. The median LOS was 6.8 days; 11.8 â€‹% of patients died within 30 days, and 40.6 â€‹% developed morbidities. Lacking capacity to consent on admission was independently associated with 30-day mortality (OR: 2.63, [1.32-5.25], p â€‹= â€‹0.006). Comorbidities associated with developing morbidity were CVA with neurologic deficit (OR: 2.29, [1.20-4.36], p â€‹= â€‹0.012), CHF (OR: 2.60, [1.64-4.11], p â€‹< â€‹0.001), in addition to pre-operative delirium (OR: 3.42, [1.43-8.14], p â€‹= â€‹0.006). CONCLUSIONS: A significant contribution to outcomes is determined by pre-admission comorbidities and cognitive and functional status. Opportunities exist for collaboration between Acute Care Surgery and geriatric medicine teams for the optimization of comorbidities.

Extra-pulmonary applications of procalcitonin: an updated literature review.

INTRODUCTION: Procalcitonin (PCT) is a biomarker with established performance in the differentiation between bacterial and viral infections, predominantly in pulmonary infections, as well as the diagnosis and prognosis of bacterial sepsis. However, the role of PCT in extra-pulmonary infections is not well described. AREAS COVERED: We reviewed the role of PCT in commonly experienced extra-pulmonary infections including meningitis, diabetic foot infection, prosthetic joint infection, osteomyelitis, and skin and soft tissue infection. PubMed and Medline online libraries were searched, from 2013 till 2022, for relevant articles. EXPERT OPINION: For meningitis, PCT could distinguish bacterial from viral meningitis. PCT distinguished septic arthritis from different inflammatory states but had variable performance in discriminating septic arthritis from crystal arthropathy. For periprosthetic joint infections, results were inconclusive. PCT had a potential role in diagnosis of more complex infections such as osteomyelitis and diabetic foot infections, but further studies are needed for a definitive cutoff. In skin and soft tissue infections, PCT performance was variable requiring further investigation to define cutoff for the discrimination of cellulitis from necrotizing fasciitis. We find that PCT performed best for meningitis and helps in the reduction of unnecessary antibiotic treatment, but has variable outcomes with other extra-pulmonary infections.

Mid-regional Proadrenomedullin Biomarker Predicts Coronavirus Disease 2019 Clinical Outcomes: A US-Based Cohort Study.

Background: Mid-regional proadrenomedullin (MR-proADM) is a biomarker released following endothelial damage. Studies have shown a correlation in predicting coronavirus disease 2019 (COVID-19) outcomes with MR-proADM levels. Our study aimed to investigate baseline MR-proADM as a predictor of a wider range of clinical outcomes of varying severity in patients admitted with COVID-19, and to compare to other biomarkers. Methods: Data from the Boston Area COVID-19 Consortium (BACC) Bay Tocilizumab Trial was used in this study. Patients with biomarker determinations, and not admitted to the intensive care unit (ICU) on admission, were included. MR-proADM cutoff of 0.87 nmol/L was assessed in predicting clinical outcomes. Results: Of 182 patients, 11.0% were mechanically ventilated or dead within 28 days. Of patients with MR-proADM >0.87 nmol/L, 21.1% were mechanically ventilated or dead within 28 days, compared with 4.5% of those with MR-proADM ≤0.87 nmol/L (P < .001). The sensitivity, specificity, negative predictive value, and positive predictive value of MR-proADM cutoff of 0.87 nmol/L in predicting mechanical ventilation or death were 75%, 65%, 95%, and 21%, respectively, with an area under the receiver operating characteristic curve of 0.76. On multivariable logistic regression analysis, MR-proADM >0.87 nmol/L was independently associated with mechanical ventilation or death, ICU admission, prolonged hospitalization beyond day 4, and day 4 COVID-19 ordinal scale equal to or worse than day 1. Conclusions: MR-proADM functions as a valuable biomarker for the early risk stratification and detection of severe disease progression of patients with COVID-19. In the prediction of death, MR-proADM performed better compared to many other commonly used biomarkers.

Baseline procalcitonin as a predictor of bacterial infection and clinical outcomes in COVID-19: A case-control study.

PURPOSE: Coronavirus disease-2019 (COVID-19) is associated with a wide spectrum of clinical symptoms including acute respiratory failure. Biomarkers that can predict outcomes in patients with COVID-19 can assist with patient management. The aim of this study is to evaluate whether procalcitonin (PCT) can predict clinical outcome and bacterial superinfection in patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). METHODS: Adult patients diagnosed with SARS-CoV-2 by nasopharyngeal PCR who were admitted to a tertiary care center in Boston, MA with SARS-CoV-2 infection between March 17 and April 30, 2020 with a baseline PCT value were studied. Patients who were presumed positive for SARS-CoV-2, who lacked PCT levels, or who had a positive urinalysis with negative cultures were excluded. Demographics, clinical and laboratory data were extracted from the electronic medical records. RESULTS: 324 patient charts were reviewed and grouped by clinical and microbiologic outcomes by day 28. Baseline PCT levels were significantly higher for patients who were treated for true bacteremia (p = 0.0005) and bacterial pneumonia (p = 0.00077) compared with the non-bacterial infection group. Baseline PCT positively correlated with the NIAID ordinal scale and survival over time. When compared to other inflammatory biomarkers, PCT showed superiority in predicting bacteremia. CONCLUSIONS: Baseline PCT levels are associated with outcome and bacterial superinfection in patients hospitalized with SARS-CoV-2.