Risk factors and outcomes in pediatric blunt cardiac injuries.

PURPOSE: Unlike adults, less is known of the etiology and risk factors for blunt cardiac injury (BCI) in children. Identifying risk factors for BCI in pediatric patients will allow for more specific screening practices following blunt trauma. METHODS: A retrospective review was performed using the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019. All patients ≤ 16 years injured following blunt trauma were included. Demographics, mechanism, associated injuries, injury severity, and outcomes were collected. Univariate and multivariate regression was used to determine specific risk factors for BCI. RESULTS: Of 266,045 pediatric patients included in the analysis, the incidence of BCI was less than 0.2%. The all-cause mortality seen in patients with BCI was 26%. Motor-vehicle collisions (MVCs) were the most common mechanism, although no association with seatbelt use was seen in adolescents (p = 0.158). The strongest independent risk factors for BCI were pulmonary contusions (OR 15.4, p < 0.001) and hemothorax (OR 8.9, p < 0.001). CONCLUSIONS: Following trauma, the presence of pulmonary contusions or hemothorax should trigger additional screening investigations specific for BCI in pediatric patients.

Intraoperative bile spillage as a risk factor for surgical site infection: a propensity score-matched NSQIP analysis.

BACKGROUND: Laparoscopic cholecystectomy is one of the most commonly performed operations in the USA. Surgical site infection complicates 1-2% of these operations and can be associated with significant morbidity. Bile spillage (bile spillage) occurs in many of these operations. The associated risk of surgical site infection (SSI) is an ongoing area of research. METHODS: NSQIP registries between 2005 and 2018 were queried using Current Procedural Terminology codes 47,562 and 47,563 to identify patients undergoing elective laparoscopic cholecystectomy. Patients were considered to have bile spillage if the wound classification was annotated 3 or 4. Acute cholecystitis was excluded by ICD code. Patients were propensity scored for bile spillage and matched for preoperative risk factors. The rates of surgical site infections, morbidity, and mortality and length of stay were analyzed. RESULTS: 47,919 (31,946 with no spillage and 15,973 with spillage) patients were matched and included in the analysis. After matching, no significant difference was found in superficial or deep SSI regardless of bile spillage. An absolute increase in organ-space SSI of 0.32% was detected. The group with bile spillage had small increases in both minor (1.41% vs. 2.12%) and major (0.67% vs. 1.01%) complications. There was no difference in mortality. CONCLUSIONS: This database analysis demonstrates no clinically relevant difference in surgical site infection rates after intraoperative bile spillage.

Venous thromboembolism chemoprophylaxis in geriatric trauma patients with isolated severe traumatic brain injury.

PURPOSE: Low-molecular-weight-heparin (LMWH) has been shown to be associated with a decreased risk of venous thromboembolism (VTE) and mortality compared to unfractionated heparin (UH) in severe traumatic brain injury (TBI). The aim of this study was to see if this association persists among a subset of patients, namely elderly patients with isolated TBI. METHODS: This Trauma Quality Improvement Project (TQIP) database study included patients ≥ 65 years old with severe TBI (Abbreviated injury score [AIS] ≥ 3) that received either LMWH or UH for VTE prophylaxis. Patients with associated severe injuries (extracranial AIS ≥ 3), transferals, deaths < 72-h, hospitalization < 2 days, VTE chemoprophylaxis other than UH or LMWH, or with a history of bleeding diathesis were excluded. The association between VTE, deep vein thrombosis (DVT), and pulmonary embolism (PE) with VTE chemoprophylaxis was analyzed with multivariable analysis, subset analyses of different grades of AIS-head injury, and a 1:1 matched LWMH:UH cohort of patients. RESULTS: Out of 14,926 patients, 11,036 (73.9%) received LMWH. Multivariate analysis showed that patients receiving LMWH had a decreased risk of mortality (OR 0.81, 95% CI 0.67-0.97, p < 0.001) but a similar risk of VTE (OR 0.83, 95% CI 0.63-1.08). Analysis according to head-AIS showed that LMWH was associated with a decreased risk of PE in patients AIS-3 but not in AIS 4 or 5. In a 1:1 matched cohort of LMWH:UH patients, the risk of PE, DVT and VTE were all similar but LMWH continued to be associated with a decreased risk of mortality (OR 0.81, CI 0.67-0.97, p = 0.023). CONCLUSION: LMWH was associated with a decreased risk of overall mortality and reduced risk of PE compared to UH among geriatric patients with a severe head injury.

Time to weigh in on obesity and associated comorbidities in combat-wounded amputees.

BACKGROUND: The Joint Trauma System database estimates that about 1,200 individuals have sustained a combat-related amputation during the Global War on Terror. Previous retrospective studies have demonstrated that combat-related amputees develop obesity and cardiovascular disease, but the incidence of obesity and associated comorbidities in this population is unknown. The objectives of this study are to determine the prevalence of obesity in the military amputee population and to compare this with the general population. METHODS: This is a retrospective review of 978 patients who sustained a combat-related amputation from 2003 to 2014. Prevalence of obesity and comorbid conditions were determined. A multivariate logistic regression model was performed to identify risk factors for postamputation obesity. Kaplan-Meier curves were constructed using obesity as the event of interest. RESULTS: A total of 1,233 charts were reviewed with 978 patients included for analysis. The median age of injury was 24 years. Median follow-up time was 8.7 years, ranging from 0.5 years to 16.9 years. The average Injury Severity Score was 23.3. The average body mass index preinjury was 25.6 kg/m2, and the average most recent corrected body mass index was found to be 31.4 kg/m2. Prevalence of comorbidities was higher in the amputee population. Fifty percent of patients who progressed to obesity did so within 1.3 years. CONCLUSION: There is a notable prevalence of obesity that develops in the amputee population that is much higher than the general population. We determined that the amputee population is at risk, and these patients should be closely monitored for 1 to 2.5 years following injury. This study provides a targeted period for which monitoring and intervention can be implemented. LEVEL OF EVIDENCE: Retrospective, basic science, outcomes analysis, level III/IV.

Duodenal Adenocarcinoma at the Ligament of Treitz: Management and Outcome.

Primary small bowel neoplasms at the ligament of Treitz are extremely rare and require advanced surgical technique for extirpation. The insidious onset of disease allows for a delayed presentation, often accompanied by moderate-size growth of the neoplasm, causing intestinal bleeding and bowel obstruction. The partial retroperitoneal location of these tumors pose a unique challenge for surgical resection. We present an unusual case of a primary small bowel adenocarcinoma at the Ligament of Treitz, requiring segmental resection of the fourth portion of the duodenum plus the proximal jejunum.

Epidemiology and predictors of failure of the infant car seat challenge.

OBJECTIVES: The American Academy of Pediatrics recommends all neonates born at <37 weeks' gestation receive a predischarge Infant Car Seat Challenge (ICSC), a resource-intensive test with little information on failure rates and risk factors. We sought to determine incidence and predictors of failure to allow more selective testing. METHODS: We conducted a retrospective medical record review of 1173 premature neonates qualifying for the ICSC between 2009 and 2010. We looked at ICSC result and potential risk factors and then performed bivariate and multivariable logistic analyses to evaluate for predictors of failure. RESULTS: Overall incidence of failure was 4.3%. Infants who failed were less premature and had higher birth weights. Late-preterm infants made up 60% of our study population but accounted for 78% of failures (P = .019). Infants who passed had older chronologic ages at time of testing, were more likely to have been exposed to caffeine, and were more likely to have required some type of respiratory support than those that failed. Final multivariable model demonstrated that increasing birth gestational age (GA) increased the odds of failure when corrected for gender, race, and small for GA status. For every 1-day increase in birth GA the odds ratio of failure was 1.03 (95% confidence interval 1.01-1.05). CONCLUSIONS: We found that increasing birth GA was a significant predictor of failure, and that late-preterm infants comprised a significant percentage of infants who failed. This suggests that limiting testing to extremely premature infants would miss most cases of ICSC failure.