Evaluation of levetiracetam for early post-traumatic seizure prophylaxis: A level II trauma center experience.

INTRODUCTION: Traumatic brain injury (TBI) can induce early or late post-traumatic seizures (PTS). While PTS incidence is low, prophylaxis is used despite a lack of consensus on agent or duration. Levetiracetam (LEV) for early PTS prophylaxis is preferred due to its safety and efficacy. The purpose of this study was to evaluate LEV for early PTS prophylaxis. METHODS AND MATERIALS: A single-center, retrospective chart review of TBI patients ≥18 years who received LEV for early PTS prophylaxis between August 2018-July 2019. The primary outcome was LEV duration. Secondary outcomes were incidence of seizure, intensive care unit (ICU) and hospital length of stay (LOS). RESULTS: Of the 137 included, mean age was 59 ± 20 years and 69.3% were male. The mean admission GCS was 13 ± 4 and 77.4% had mild TBI. Median LEV duration was 7 (IQR 4-10) days and 13.9% met recommended 7-day duration. Those prescribed LEV >7 days had more than twice the median LEV duration than those prescribed ≤7 days [10.25 (8.5-15.5) vs 4 (1.5-4.5) days, p < 0.0001]. Electroencephalography-confirmed PTS occurred in 2.2%, with an early PTS incidence of 0.73%. Median ICU and hospital LOS were 2 (IQR 1-7) and 7 (IQR 3-16) days, respectively. CONCLUSIONS: The incidence of PTS was low as most patients in our study had mild or moderate TBI. Early PTS prophylaxis with LEV for 7 days is appropriate, although the majority of patients did not meet the recommended duration. Efforts to standardize and implement PTS prophylaxis protocols are needed.

Opioid Prescribing at Discharge in Opioid-Naïve Trauma Patients.

BACKGROUND: Opioid analgesics remain mainstay of treatment for trauma-related pain despite growing concerns for opioid dependency or misuse. The purpose of this study was to evaluate opioid prescribing at hospital discharge after traumatic injury. METHODS: This is a single-center, retrospective analysis of patients ≥18 years of age admitted for ≥24 hours with a primary diagnosis of traumatic injury. Those with alcohol use disorder, polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. The primary outcome was the incidence of patients prescribed opioids at discharge. Secondary outcomes included percent of patients who received nonopioids, intensive care unit (ICU) admission, and hospital length of stay (LOS). RESULTS: Of the 927 encounters, 471 were included. The mean age was 60 ± 23 years, and 62.0% were male. The majority were blunt trauma, and 49.9% were falls. Mean initial injury severity score (ISS) was 9 ± 7.2. Of the 70.4% of patients prescribed opioids, 39.4% were discharged on opioids. Age ≥30 years, ICU admission, ISS <9, or Charlson Comorbidity Index >1 was less likely to have opioids prescribed at discharge. Most received nonopioids (93.6%) and multimodal analgesia (84.3%). The median hospital and ICU LOS were 5 (3-9) and 2 (0-4) days, respectively. DISCUSSION: Only 39.4% had opioids prescribed at discharge. Opioid-reductive strategies may decrease in-hospital and discharge opioid prescribing. While opioid analgesics remain a mainstay of trauma-associated pain management, institution-wide opioid-sparing strategies can further reduce discharge opioid prescribing after trauma.

Effect of Alternatives to Opiates Program on Discharge Opioid Prescribing in Trauma Patients.

BACKGROUND: Opioid overdose deaths have increased over the last two decades, despite efforts to reduce prescribing. This study aimed to determine if a hospital-wide Alternatives to Opiates (ALTOSM) program reduced opioid prescribing in hospital and upon discharge after trauma. OBJECTIVES: The primary outcome was incidence of opioid prescribing at hospital discharge Pre- and Post-ALTO. Secondary outcomes were the percent of patients with in-hospital opioid, non-opioid and multimodal analgesia, and hospital and intensive care unit (ICU) length of stay (LOS). METHODS: This is a single-center, retrospective analysis of patients >/ = 18 years old admitted for >24 hours with the primary diagnosis of traumatic injury between August 2018 - October 2019. Patients with alcohol or polysubstance abuse, chronic opioid use, or in-hospital mortality were excluded. RESULTS: A total of 703 patients were included, 471 in Pre-ALTO and 232 in Post-ALTO groups. The mean age was 59 ± 22 years and most were male (58.7%). Mean initial Injury Severity Score (ISS) was 9.1 ± 7.7. Opioid prescribing at hospital discharge occurred more in the Post-ALTO group (132/332, 39.4% vs 90/203, 43.8%; P = .1237). Most patients were prescribed in-hospital opioid (332/471, 70.4% vs 203/232, 87.5%, P < .0001) and non-opioid (441/471, 93.6% vs 229/232, 98.7%; P = .0027) analgesics, or multimodal analgesia (397/471, 84.3% vs 203/232, 87.5%; P = .2591). Median hospital and ICU LOS were also similar between groups [5 (3-9) vs 4(3-7), P = .3427] and ICU [2(0-4) vs 3(2-5), P = .3461]. CONCLUSION: Opioids remain mainstay for trauma-related pain treatment. ALTOSM was not associated with less in-hospital or discharge opioid prescribing.

Incidental discovery of goblet cell carcinoid, a rare appendiceal malignancy case report.

Goblet cell carcinoid (GCC) tumor is a rare appendiceal carcinoma that has had several names throughout its history. Often found incidentally on pathology following an appendectomy, treatment includes a right hemicolectomy and possible adjuvant chemotherapy. Survival rate has been shown to be correlated with the histological features. Here, we report a 45-year-old African American male who presented with signs and symptoms consistent with acute appendicitis, but was ultimately diagnosed with GCC. After undergoing a right hemicolectomy, he continues to undergo long-term surveillance with his oncologist. Due to the rarity of this tumor, we describe the history of GCC and our recommendations for surgical and long-term management.

Surgical residents' interpretation of diagnostic radiologic imaging in the traumatically injured patient.

BACKGROUND: Senior surgical residents are of paramount importance in directing further therapeutic modalities based on their interpretation of critical diagnostic imaging. We propose that senior surgical residents are proficient with interpreting radiologic imaging studies in the trauma patient. METHODS: A prospective cohort study was performed comparing surgery resident interpretations of computed tomography (CT) scans of the head, maxillofacial bones, spine (cervical, thoracic, lumbar), chest, abdomen, pelvis, and chest X-rays versus final radiologists' reports at a Level II trauma center from September 2014 to May 2015. A Cohen κ coefficient and a statistical analysis of variance testing were used to make multiple comparisons of the data. RESULTS: There were 951 trauma alerts activated in the period stated. Of these, 860 met our age inclusion criteria (age, > 18 years). There were 204 images included with an overall accuracy of 81.3%. Residents were more than 70% successful interpreting seven of nine categories. They achieved an accuracy of 84.6%, 62.5%, and 75% in the cervical, thoracic, and lumbar spine categories, respectively. Forty-one of 50 CT scans of the head were interpreted correctly. Maxillofacial CT scans proved to be the weakest category, with only 50% read accurately. In regard to CT scans of the abdomen and pelvis, 80% proficiency was achieved. Abdominal x-rays were read correctly in all instances and chest x-rays 83.3%. On κ analysis, there was an overall moderate agreement between the two groups with K = 0.449, and an overall p less than 0.0005 (Table 1). A perfect agreement existed with abdominal x-rays. CONCLUSION: Senior surgical residents are capable of interpreting critical images obtained in the trauma setting. When discordance existed with attending radiologists' interpretation, it did not change the clinical outcome or result in any critically missed findings. LEVEL OF EVIDENCE: Therapeutic/Care Management study, Level IV.

Prospective Analysis of Laparoscopic Cholecystectomies Based on Postgraduate Resident Level.

BACKGROUND: Few studies have attempted to ascertain the safety of laparoscopic cholecystectomies (LC) based on resident postgraduate year. We hypothesize that there is no difference in complications based on resident level in LC. METHODS: We prospectively gathered data from 200 LC. Residents were classified as surgeon chief (SC), surgeon junior (SJ), or teaching assistant (TA/SJ). Outcomes included surgical complications and operative time based on resident level or ambulatory status. RESULTS: Average operating time was 65.17, 69.38, and 63.91 minutes for SC, SJ, and TA/SJ, respectively. Average operative time in the elective group was 62 versus 70.67 minutes in the emergent group (P=0.037). Five, 2, and 6 major complications occurred in the TA/SJ, and SC groups, respectively, (P=0.937). Major complications occurred in 9 of 97 emergent and 4 of 70 elective cases (P=0.396). CONCLUSION: With respect to time and morbidity in LC, we found all level of residents to be safe.