Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures.

Facial fractures are commonly managed nonoperatively. Patients with facial fractures involving sinus cavities commonly receive 7 to 10 days of prophylactic antibiotics, yet no literature exists to support or refute this practice. The aim of this study was to compare the administration and duration of antibiotic prophylaxis on the incidence of soft tissue infection in nonoperative facial fractures. A total number of 289 patients who were admitted to our level I trauma center with nonoperative facial fractures from the beginning of 2012 to the end of 2014 were studied. Patients were categorized into 3 groups: no antibiotic prophylaxis, short-term antibiotic prophylaxis (1-5 days), and long-term antibiotic prophylaxis (>5 days). The primary outcome was the incidence of facial soft tissue infection and Clostridium difficile colitis. Fifty patients received no antibiotic prophylaxis. Sixty-three patients completed a short course of antibiotic prophylaxis and 176 patients received long-term antibiotics. Ampicillin/sulbactam, amoxicillin/clavulanic acid, or a combination of both were used in 216 patients. Twenty-three patients received clindamycin due to penicillin allergy. Short and long courses of antibiotic prophylaxis were administered more commonly in patients with concomitant maxillary and orbital fractures (P <0.0001). No mortality was found in any group. Soft tissue infection was not identified in any patient. C. difficile colitis was identified in 1 patient who had received a long course of antibiotic prophylaxis (P = 0.7246). There was no difference in the outcome of patients receiving short-term, long-term, and no antibiotic prophylaxis. Prospective randomized studies are needed to provide further clinical recommendations.

Sex influences how attendings evaluate surgical residents in the operating room.

BACKGROUND: The aim of this study was to evaluate the influence of sex on facultys' perception of resident autonomy and performance. METHODS: Autonomy/performance/complexity evaluations performed by faculty of categorical general surgery residents (2015-2021) were analyzed. Comparisons of scores by faculty and resident sex were performed. RESULTS: A total of 10967 paper/electronic evaluations were collected. Female attendings rated female residents significantly lower in autonomy when compared to males (2.75 vs 2.91, p â€‹= â€‹0.0037). There was no significant difference in autonomy ratings for male versus female residents when evaluated by a male attending (2.93 vs 2.96, p â€‹= â€‹0.054) but male attendings did rate female residents significantly lower in autonomy at the highest complexities (2.37 vs 2.50, p â€‹= â€‹0.012). CONCLUSION: The data suggests a unique interaction between attending and resident sex. A periodic evaluation of evaluations within one's program may provide invaluable implicit bias insight and should be considered.

Fewer Levels of Dedicated Trauma Care Leads to Better Outcomes.

BACKGROUND: Dedicated trauma intensive care units (ICUs) staffed by surgical intensivists lead to better patient outcomes. Increased length of stay (LOS) leads to worse outcomes. Little research has focused on the effect of dedicated trauma medical-surgical units or ICU/medicalsurgical systems. In 2018, our Level 1 trauma center transitioned from 3 non-dedicated levels of care (ICU/stepdown unit/medical-surgical) to 2 dedicated levels of care (ICU/medical-surgical). Our objective was to look at patient outcomes pre- and post-intervention. METHODS: Retrospective analysis of trauma registry data was performed on patients (age ≥18) admitted to the trauma service at a Level 1 rural trauma center over 46-months. In the pre-intervention group, step down and medical-surgical patients were combined as "Non-ICU" for analysis. Standard statistical analysis was performed. RESULTS: Analysis included 6103 patients. The group demographics were similar, except pre-intervention patients had higher ISS and fewer comorbidities. Emergency department LOS decreased from 30 versus 13.9% (P < .0001) and 15.9 versus 5.8% (P < .0001) for greater than 3 and 6 hours, respectively. Median LOS decreased for all patients (P < .0001). Mortality dropped from 9.0 versus 5.5% (P = .0009) for ICU and 1.7 versus 0.26% (P = .0013) for non-ICU patients. Overall patient mortality was level at 3.7%. Inpatient complications dropped from 9.9 versus 8.5% (P = .07). Unplanned ICU readmissions were unchanged (P = .4169). For patients with 3+ comorbidities, overall LOS dropped by 2 days (P < .0001) and home discharge increased from 42.8 versus 51% (P < .0001). CONCLUSION: Implementation of 2 levels of dedicated care has decreased ED and hospital LOS for all trauma patients without increasing mortality or complications. Patients with extensive comorbidities saw the most improvements.

The Effect of Interhospital Transfers on the Outcome of Rural Trauma.

Urban areas house the majority of the population in the United States but trauma deaths occur more commonly in rural areas. In this study, we aimed to investigate if direct patient admission to a Level I trauma center improves outcomes in rural trauma. We retrospectively reviewed data in our trauma database from January 2008 to the end of December 2012 to compare the overall outcomes between direct admissions (DAs) and interhospital transfers (IHTs). Of the 6118 patients who met the inclusion criteria, 59.5 per cent were in the DA group and 40.5 per cent in the IHT group. Injury severity score was similar between the two groups but severe traumatic brain injury was more common (P = 0.001) in the DA group. Hospital length of stay, complication rate, and in-hospital mortality were not different between the two groups (all P> 0.2). In multivariate analysis, there was no difference in survival between the two modes of admission (odds ratio, 95% confidence interval: 0.91, 0.69-1.20, P = 0.51). We concluded that rural trauma IHTs had no detrimental impact on the outcome. Prospective studies would better elucidate factors associated with patient outcomes in rural trauma.

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma.

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01-2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05-1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04-1.40).

Mode of Transport and Clinical Outcome in Rural Trauma: A Helicopter versus Ambulance Comparison.

Helicopter Emergency Medical Services (HEMS) is presumably an effective way of patient transport in rural trauma, yet the literature addressing its effectiveness is scarce. In this study, we compared the clinical outcome of rural trauma patients between Ground Emergency Medical Services (GEMS) and HEMS transportation from the beginning of 2006 to the end of 2012. Focus was placed on identifying factors associated with survival to discharge in these patients. Over the seven-year study period, 4492 patients met the inclusion criteria with 2414 patients (54%) being transferred by GEMS and 2078 patients (46%) being transferred by HEMS. In comparison with GEMS, patients transferred by HEMS were younger men who were admitted with a higher mean Injury Severity Score and a lower mean Glasgow Coma Score (all Ps < 0.0001). HEMS patients were more frequently intubated before arrival at the trauma center (32% vs 9%, P < 0.0001) and were more frequently transferred to the operating room from the emergency department (11% vs 5%, P < 0.0001). In multivariate analysis, transfer by HEMS was associated with a significant increase in survival to discharge (odds ratio: 1.57, 95% confidence interval: 1.03-2.40, P = 0.036). Blunt injury, no intubation, and Glasgow Coma Score >8 were also associated with significantly improved odds of survival to discharge (all P < 0.0001). These findings show that although patients transferred by HEMS arrived in less favorable clinical conditions, HEMS transfer was associated with significantly higher odds of survival in rural trauma.

Changes in rural trauma prehospital times following the Rural Trauma Team Development Course training.

BACKGROUND: The majority of the US population live in urban areas, yet more than half of all trauma deaths occur in rural areas. The Rural Trauma Team Development Course (RTTDC) is developed to improve the outcomes of rural trauma and we aimed to study its effect on patient transfer. METHODS: Trauma referrals 2 years before the RTTDC training were compared with referrals 2 years after the course. RESULTS: Of the 276 studied patients, 97 were referred before the RTTDC training and 179 patients were referred after the course. Transfer acceptance time was significantly shorter after the RTTDC training (139.2 ± 87.1 vs 110 ± 66.3 min, P = .003). The overall transfer time was also significantly reduced following the RTTDC training (257.4 ± 110.8 vs 219.2 ± 86.5 min, P = .002). Patients receiving pretransfer imaging had a significantly higher transfer time both before and after RTTDC training (all Ps < .01). Mortality was nearly halved (6.2% vs 3.4%) after the RTTDC training. CONCLUSION: The RTTDC training was associated with reduced transfer acceptance time and reduced transfer time.

Novel method of stump closure for distal pancreatectomy with a 75% reduction in pancreatic fistula rate.

BACKGROUND: Pancreatic fistula is a significant problem for patients undergoing distal pancreatectomy with fistula rates up to 61%. Fistulas lead to substantial morbidity. The study objective was to compare radiofrequency dissector closure with traditional stump closure for distal pancreatectomy. METHODS: Sixty-two patients underwent distal pancreatectomy at our institution between 2002 and 2011. Thirty-three patients had traditional stump closure compared with 29 patients who had radiofrequency closure. Fistula rates, operative times, and blood loss were compared. The control patients underwent open operation in 20 (60%) cases and laparoscopic operation in the remaining 13 (40%). Of the patients that underwent radiofrequency closure, 10 (35%) underwent open operation, and the remaining 19 (65%) patients underwent laparoscopic operation. RESULTS: Fistula occurred in 12 of 33 (36%) patients with traditional stump closure compared to 3 of 29 (10%) patients with radiofrequency closure (p<0.02). Operative time (307 vs. 231 min [p<0.002]) and blood loss (364-200 mL [p<0.02]) were decreased in the radiofrequency closure group. Length of stay decreased from 7.8 to 6.6 days; however, this was not statistically significant. CONCLUSIONS: The use of radiofrequency dissector in distal pancreatectomy is effective with low rates of fistula formation. Radiofrequency closure should be studied further in prospective trials.