Applying the antecedent, behaviour, and consequence taxonomy to unintentional firearm injury as determined by a collaborative firearm injury database.

BACKGROUND: Unintentional firearm injury (UFI) remains a significant problem in the USA with respect to preventable injury and death. The antecedent, behaviour and consequence (ABC) taxonomy has been used by law enforcement agencies to evaluate unintentional firearm discharge. Using an adapted ABC taxonomy, we sought to categorise civilian UFI in our community to identify modifiable behaviours. METHODS: Using a collaborative firearm injury database (containing both a university-based level 1 trauma registry and a metropolitan law enforcement database), all UFIs from August 2008 through December 2021 were identified. Perceived threat (antecedent), behaviour and injured party (consequence) were identified for each incident. RESULTS: During the study period, 937 incidents of UFI were identified with 64.2% of incidents occurring during routine firearm tasks. 30.4% of UFI occurred during neglectful firearm behaviour such as inappropriate storage. Most injuries occurred under situations of low perceived threat. UFI involving children was most often due to inappropriate storage of weapons, while cleaning a firearm was the most common behaviour in adults. Overall, 16.5% of UFI involved injury to persons other than the one handling the weapon and approximately 1.3% of UFI resulted in mortality. CONCLUSIONS: The majority of UFI occurred during routine and expected firearm tasks such as firearm cleaning. Prevention programmes should not overlook these modifiable behaviours in an effort to reduce UFIs, complications and deaths.

Comparing patterns of care and outcomes after operative management of complications after bariatric surgery at MBSAQIP accredited bariatric centers and non-bariatric facilities.

BACKGROUND: Many operations for complications after bariatric surgery are performed by surgeons without bariatric expertise at centers without teams who routinely care for bariatric patients. This study sought to evaluate whether bariatric expertise affects patterns of care and perioperative outcomes among patients undergoing operative intervention for complications after bariatric surgery. METHODS: Administrative claims data from the Kentucky Office of Health Policy were queried for inpatients undergoing operative intervention for complications related to bariatric surgery between 2015 and 2018. Patients were stratified with respect to whether or not they underwent surgery at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited bariatric surgery center (BCE) or not (non-BCE). Groups were compared with respect to demographic, procedural, and outcome variables. RESULTS: BCE patients were more often Caucasian than non-BCE patients (p < 0.001) and have either private insurance or Medicare coverage (p = 0.02). Regarding operative approach, operations were more likely to be performed laparoscopically in BCE (88.5% BCE vs. 80.9% non-BCE, p = 0.007). Length of stay was significantly shorter for BCE patients (median 2 days BCE vs. 3 days non-BCE, p < 0.001), and BCE patients were more likely to be discharged home (85.4% BCE vs. 78.5% non-BCE, p = 0.02). Inpatient mortality and average total charges per patient did not differ significantly between the two groups CONCLUSIONS: Surgical management of complications after bariatric surgery at BCE is associated with greater utilization of minimally invasive techniques, shorter hospital stay, and increased likelihood of routine home discharge. These findings should prompt a review and standardization of care patterns for patients with complications after bariatric surgery aimed at optimizing outcomes and improving value.

The gut in trauma.

PURPOSE OF REVIEW: The purpose of this review is to describe established and emerging mechanisms of gut injury and dysfunction in trauma, describe emerging strategies to improve gut dysfunction, detail the effect of trauma on the gut microbiome, and describe the gut-brain connection in traumatic brain injury. RECENT FINDINGS: Newer data suggest intraluminal contents, pancreatic enzymes, and hepatobiliary factors disrupt the intestinal mucosal layer. These mechanisms serve to perpetuate the inflammatory response leading to multiple organ dysfunction syndrome (MODS). To date, therapies to mitigate acute gut dysfunction have included enteral nutrition and immunonutrition; emerging therapies aimed to intestinal mucosal layer disruption, however, include protease inhibitors such as tranexamic acid, parenteral nutrition-supplemented bombesin, and hypothermia. Clinical trials to demonstrate benefit in humans are needed before widespread applications can be recommended. SUMMARY: Despite resuscitation, gut dysfunction promotes distant organ injury. In addition, postresuscitation nosocomial and iatrogenic 'hits' exaggerate the immune response, contributing to MODS. This was a provocative concept, suggesting infectious and noninfectious causes of inflammation may trigger, heighten, and perpetuate an inflammatory response culminating in MODS and death. Emerging evidence suggests posttraumatic injury mechanisms, such as intestinal mucosal disruption and shifting of the gut microbiome to a pathobiome. In addition, traumatic brain injury activates the gut-brain axis and increases intestinal permeability.

Common Medications Which Lead to Unintended Alterations in Weight Gain or Organ Lipotoxicity.

Obesity is one of the most common chronic conditions in the world. Its management is difficult, partly due to the multiple associated comorbidities including fatty liver, diabetes, hypertension, and hyperlipidemia. As a result, the choice of prescription medications in overweight and obese patients has important implications as some of them can actually worsen the fat accumulation and its associated metabolic complications. Several prescription medications are associated with weight gain with mechanisms that are often poorly understood and under-recognized. Even less data are available on the distribution of fat and lipotoxicity (the organ damage related to fat accumulation). The present review will discuss the drugs associated with weight gain, their mechanism of action, and the magnitude and timing of their effect.

Vitamin D Status and Supplementation in the Critically Ill.

Vitamin D deficiency has recently been recognized as a widespread global disorder. Generally considered a direct extension of malnutrition, even subclinical hypovitaminosis D is now recognized in adequately nourished populations. Compared to the general population, the prevalence of hypovitaminosis D is greater in the critically ill population. In fact, several studies have shown poorer outcomes in critically ill patients discovered to be vitamin D deficient or insufficient. Controversy persists regarding vitamin D measurements, quantity of supplementation, and appropriate target level in various populations. Vitamin D has a vital role in calcium homeostasis and extra-skeletal health, such as immune function. Therefore, vitamin D supplementation may have a role for improving outcomes in critically ill patients. In this review, we will first discuss the metabolism and function of vitamin D under normal physiologic conditions. We will then explore the prevalence and prognostic value of vitamin D deficiency in critical illness. Finally, we will examine recent trials focusing on appropriate dosing, route of administration, and outcomes associated with vitamin D supplementation in the ICU.

The Critical Care Obesity Paradox and Implications for Nutrition Support.

Obesity is a leading cause of preventable death worldwide. The prevalence of obesity has been increasing and is associated with an increased risk for other co-morbidities. In the critical care setting, nearly one third of patients are obese. Obese critically ill patients pose significant physical and on-physical challenges to providers, including optimization of nutrition therapy. Intuitively, obese patients would have worse critical care-related outcome. On the contrary, emerging data suggests that critically ill obese patients have improved outcomes, and this phenomenon has been coined "the obesity paradox." The purposes of this review will be to outline the historical views and pathophysiology of obesity and epidemiology of obesity, describe the challenges associated with obesity in the intensive care unit setting, review critical care outcomes in the obese, define the obesity-critical care paradox, and identify the challenges and role of nutrition support in the critically ill obese patient.

When can nutritional therapy impact liver disease?

This article reviews the current literature regarding nutritional therapy in liver disease, with an emphasis on patients progressing to liver failure as well as surgical patients. Mechanisms of malnutrition and sarcopenia in liver failure patients as well as nutritional assessment, nutritional requirements of this patient population, and goals and methods of therapy are discussed. Additionally, recommendations for feeding, micronutrient, branched chain amino acid supplementation, and the use of pre- and probiotics are included. The impact of these methods can have on patients with advanced disease and those undergoing surgical procedures will be emphasized.

Management of contained penetrating cardiac injury in a patient with prior cardiac surgery.

Penetrating cardiac injuries usually require emergent surgical intervention. Our patient presented to the trauma centre with multiple stab wounds to the neck, chest, epigastric region and abdomen. She arrived haemodynamically stable, and her initial Focused Assessment with Sonography for Trauma exam was negative. Her chest X-ray did not show any evident pneumothorax or haemothorax. Due to her injury pattern, she was taken to the operating room for exploratory laparotomy and neck exploration. Postoperatively, she was taken for CT and found to have a contained cardiac rupture. The injury was contained within previous scar tissue from her prior cardiac surgery. Further evaluation revealed that the injury included a penetrating stab wound to the right ventricle and a traumatic ventricular septal defect (VSD). She subsequently underwent a redo sternotomy with the repair of the penetrating stab wound and the VSD. Cardiology, intensive care, trauma surgery and cardiothoracic surgery coordinated her care from diagnosis, management and recovery. This case highlights the challenges in the management of cardiac injuries and the benefits of a multidisciplinary approach to care for complex cardiac injuries.

Persistent long-term opioid use after trauma: Incidence and risk factors.

BACKGROUND: The opioid epidemic in the United States continues to lead to a substantial number of preventable deaths and disability. The development of opioid dependence has been strongly linked to previous opioid exposure. Trauma patients are at particular risk since opioids are frequently required to control pain after injury. The purpose to this study was to examine the prevalence of opioid use before and after injury and to identify risk factors for persistent long-term opioid use after trauma. METHODS: Records for all patients admitted to a Level 1 trauma center over a 1-year period were analyzed. Demographics, injury characteristics, and hospital course were recorded. A multistate Prescription Drug Monitoring Program database was queried to obtain records of all controlled substances prescribed from 6 months before the date of injury to 12 months after hospital discharge. Patients still receiving narcotics at 1 year were defined as persistent long-term users and were compared against those who were not. RESULTS: A total of 2,992 patients were analyzed. Of all patients, 20.4% had filled a narcotic prescription within the 6 months before injury, 53.5% received opioids at hospital discharge, and 12.5% had persistent long-term use after trauma with the majority demonstrating preinjury use. Univariate risk factors for long-term use included female sex, longer length of stay, higher Injury Severity Score, anxiety, depression, orthopedic surgeries, spine injuries, multiple surgical locations, discharge to acute inpatient rehab, and preinjury opioid use. On multivariate analysis, the only significant predictors of persistent long-term prescription opioid use were preinjury use and a much smaller effect associated with use at discharge. CONCLUSION: During a sustained opioid epidemic, concerns and caution are warranted in the use of prescription narcotics for trauma patients. However, persistent long-term opioid use among opioid-naive patients is rare and difficult to predict after trauma. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Predictors of oliguria in post-traumatic acute kidney injury.

BACKGROUND: Acute kidney injury is classified by urine output into non-oliguric and oliguric variants. Non-oliguric acute kidney injury has lower morbidity and mortality and accounts for up to 64% of acute kidney injury in hospitalized patients. However, the incidence of non-oliguric acute kidney injury in the trauma population and whether the 2 variants of acute kidney injury share the same risk factors is unknown. We hypothesized that oliguria would be present in the majority of acute kidney injury in severely injured trauma patients and that unique risk factors would predispose patients to the development of oliguria. METHODS: Patients admitted to the trauma intensive care unit and diagnosed with an acute kidney injury between 2016 to 2021 were identified. Cases were categorized based on urine output into oliguric (<400 mL per day) and non-oliguric (>400 mL per day) disease. Risk factors, management, and outcomes were compared. Logistic regression was used to identify risk factors associated with oliguria. RESULTS: A total of 227 patients met inclusion criteria. Non-oliguric acute kidney injury accounted for 74% of all cases and was associated with greater survival (78% vs 35.6%, P < .001). Using logistic regression, female sex, vasopressor use, and a greater net fluid balance at 48 hours were all predictive of oliguria (while controlling for age, race, shock index, massive transfusion, operative intervention, cardiac arrest, and nephrotoxic medication exposure). CONCLUSION: Non-oliguria accounts for the majority of post-traumatic acute kidney injury and is associated with improved survival. Specific risk factors for the development of oliguric acute kidney injury include female sex, vasopressor use, and a higher net fluid balance at 48 hours.

Six Square Miles of Urban America: Association Between Firearm Discharge, Injury, and Fatality.

BACKGROUND: Despite the increase in firearm injury observed across the country, significant gaps remain relevant to our understanding of how firearm exposure translates to injury. Using acoustic gunshot detection and a collaborative hospital and law enforcement firearm injury database, we sought to identify the relationship between firearm discharge and injury over time. STUDY DESIGN: From 2018 to 2021, instances of firearm discharge captured via acoustic detection in 6 square miles of Louisville, KY, were merged with data from the collaborative firearm injury database. Key outcomes included the total number of rounds fired, injury and fatality rates per round, and the percentage of rounds discharged from automatic weapons and high-capacity magazines. RESULTS: During the study period, 54,397 rounds of ammunition were discharged resulting in 914 injuries, 435 hospital admissions, 2,442 hospital days, 155 emergent operations, and 180 fatalities. For each round of ammunition fired, the risk of injury and fatality was 1.7% and 0.3%, respectively. The total number of rounds fired per month nearly tripled (614 vs 1,623, p < 0.001) leading to increased injury (15 vs 37, p < 0.001) and fatality (3 vs 7, p < 0.001). The percentage of rounds fired from automatic weapons (0 vs 6.8%, p < 0.001) and high-capacity magazines (7.6 vs 28.9%, p < 0.001) increased over time. CONCLUSIONS: The increased burden of firearm injury is related to an overall increase in firearm exposure as measured by the total number of rounds discharged. High-capacity magazines and automatic weaponry are being used with increasing frequency in urban America.

A Decade of Analysis of Unplanned Extubation Etiology in Trauma Patients Including the Impact of the COVID Pandemic.

BACKGROUND: Unplanned extubations (UEs) in injured patients are potentially fatal, but etiology and patient characteristics are not well described. We have been prospectively characterizing the etiology of UEs after we identified a high rate of UEs and implemented an educational program to address it. This period of monitoring included the years of the COVID-19 pandemic that produced high rates of workforce turnover in many hospitals, dramatically affecting nursing and respiratory therapy services. We hypothesized that frequency of UEs would depend on the etiology and that the workforce changes produced by the COVID-19 pandemic would increase UEs. METHODS: This study was a prospective tracking and retrospective review of trauma registry and performance improvement data from 2012-2021. RESULTS: UE subjects were younger, were more frequently male, were diagnosed more frequently with pneumonia (38% vs 27%), and had longer hospital (19 d vs 15 d) and ICU length of stay (LOS) (12 d vs 10 d) (all P < .05). Most UEs were due to patient factors (self-extubation) that decreased after education, while UEs from other etiologies (mechanical, provider) were stable. Subjects with UEs from mechanical or provider etiologies had longer ICU LOS, higher mortality, and were less likely to be discharged home. The COVID-19 pandemic was associated with more total patient admissions and more days of ventilator use, but the rate of UEs was not changed. CONCLUSIONS: UEs were decreased by education with ongoing tracking, and UEs from patient factors were associated with better outcome than other etiologies. Workforce changes produced by the COVID-19 pandemic did not change the rate of UEs.

Nutrition therapy issues in esophageal cancer.

Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.

A new pandemic and an old epidemic: The impact of COVID-19 and gun violence as measured by years of potential life lost in a US city.

BACKGROUND: The COVID-19 pandemic has altered daily life on a global scale and has resulted in significant mortality with >985,000 lives lost in the United States alone. Superimposed on the COVID-19 pandemic has been a concurrent worsening of longstanding urban gun violence. We sought to evaluate the impact attributable to these 2 major public health issues on the greater Louisville region as determined by years of potential life lost. METHODS: Using the Collaborative Jefferson County Firearm Injury Database, all firearm injuries from January 1, 2011 to December 31, 2021 were examined. The COVID-19 data was compiled from the Louisville Metro Department of Public Health and Wellness. Pre-COVID (March 1, 2019-February 29, 2020) and COVID (March 1, 2020-February 28, 2021) time intervals were examined. The demographics, outcomes data, and years of potential life lost were determined for the groups, and injury locations were geocoded. RESULTS: From 2011 to 2021, there were 6,043 firearm injuries in Jefferson County, Kentucky. During the COVID time interval, there were 4,574 years of potential life lost due to the SARS-CoV-2 virus and 9,722 years of potential life lost due to all-cause gun violence. In the pre-COVID time interval, there were 5,723 years of potential life lost due to all-cause gun violence. CONCLUSION: In Louisville, greater years of potential life lost were attributable to firearm fatalities than the SARS-CoV-2 virus. Given the impact of COVID-19, the robust response has been proportionate and appropriate. The lack of response to firearm injury and fatality is striking in comparison. Additional resources to combat the sequelae of gun violence are needed.

The limitations of hospital and law enforcement databases in characterizing the epidemiology of firearm injury.

BACKGROUND: Current data on the epidemiology of firearm injury in the United States are incomplete. Common sources include hospital, law enforcement, consumer, and public health databases, but each database has limitations that exclude injury subgroups. By integrating hospital (inpatient and outpatient) and law enforcement databases, we hypothesized that a more accurate depiction of the totality of firearm injury in our region could be achieved. METHODS: We constructed a collaborative firearm injury database consisting of all patients admitted as inpatients to the regional level 1 trauma hospital (inpatient registry), patients treated and released from the emergency department (ED), and subjects encountering local law enforcement as a result of firearm injury in Jefferson County, Kentucky. Injuries recorded from January 1, 2016, to December 31, 2020, were analyzed. Outcomes, demographics, and injury detection rates from individual databases were compared with those of the combined collaborative database and compared using χ2 testing across databases. RESULTS: The inpatient registry (n = 1,441) and ED database (n = 1,109) were combined, resulting in 2,550 incidents in the hospital database. The law enforcement database consisted of 2,665 patient incidents, with 2,008 incidents in common with the hospital database and 657 unique incidents. The merged collaborative database consisted of 3,207 incidents. In comparison with the collaborative database, the inpatient, total hospital (inpatient and ED), and law enforcement databases failed to include 55%, 20%, and 17% of all injuries, respectively. The hospital captured nearly 94% of survivors but less than 40% of nonsurvivors. Law enforcement captured 93% of nonsurvivors but missed 20% of survivors. Mortality (11-26%) and injury incidence were markedly different across the databases. DISCUSSION: The utilization of trauma registry or law enforcement databases alone do not accurately reflect the epidemiology of firearm injury and may misrepresent areas in need of greater injury prevention efforts. LEVEL OF EVIDENCE: Epidemiological, level IV.

Direct detection of structurally resolved dynamics in a multiconformation receptor-ligand complex.

Structure-based drug design relies on static protein structures despite significant evidence for the need to include protein dynamics as a serious consideration. In practice, dynamic motions are neglected because they are not understood well enough to model, a situation resulting from a lack of explicit experimental examples of dynamic receptor-ligand complexes. Here, we report high-resolution details of pronounced ~1 ms time scale motions of a receptor-small molecule complex using a combination of NMR and X-ray crystallography. Large conformational dynamics in Escherichia coli dihydrofolate reductase are driven by internal switching motions of the drug-like, nanomolar-affinity inhibitor. Carr-Purcell-Meiboom-Gill relaxation dispersion experiments and NOEs revealed the crystal structure to contain critical elements of the high energy protein-ligand conformation. The availability of accurate, structurally resolved dynamics in a protein-ligand complex should serve as a valuable benchmark for modeling dynamics in other receptor-ligand complexes and prediction of binding affinities.

Carbohydrate provision in the era of tight glucose control.

Glycemic control in the critically ill patient has remained a controversial issue over the last decade. Several large trials, with widely varying results, have generated significant interest in defining the optimal target for blood-glucose control necessary for improving care while minimizing morbidity. Nutritional support has evolved into an additional area of critical care where appropriate practices have been associated with improved patient outcomes. Carbohydrate provision can impact blood-glucose levels, and the relationship between nutrition and glucose levels has become more complex in the era of improved glycemic control. This review discusses the controversy surrounding intensive-insulin therapy in the intensive care unit and explores the relationship with nutritional support, both in the enteral and parenteral form. Achieving realistic goals in both carbohydrate provision and glycemic control may improve patient outcome, and are not mutually exclusive practices.

Appropriate protein and specific amino acid delivery can improve patient outcome: fact or fantasy?

Protein utilization and requirements in critical illness are much researched and debated topics. The enhanced turnover and catabolism of protein in the setting of critical illness is well described and multifactorial in nature. The need to preserve lean body mass and enhance nitrogen retention in this state to improve immunologic function and reduce morbidity is well described. Debates as to the optimum amount of protein to provide in such states still exist, and a significant amount of research has contributed to our understanding of not only how much protein to supply to these patients, but how best to do so. Small peptide formulations, intact protein formulations, branched chain amino acids, and specialty formulas all exist, and their benefits, drawbacks, and potential uses have been investigated. Specific amino acid therapy has become part of the concept of immunonutrition, or the modification and enhancement of the immune response with specific nutrients. In this article, we describe the changes in outcomes demonstrated through the provision of protein, both as a macronutrient and as specific amino acids.

Food Access, Food Insecurity, and Gun Violence: Examining a Complex Relationship.

PURPOSE OF REVIEW: Food insecurity and gun violence are timely and relevant public health issues impacting many regions within the USA with a potential association. Terminology surrounding food access and food security can be confusing, which is important to understand when examining the relationship between these issues and gun violence. RECENT FINDINGS: Food insecurity is an individual level risk factor that appears to correlate with an increased rate of exposure and future involvement in violence. Food deserts represent geographic regions with limited access to food but do not necessarily represent regions with high prevalence of food insecurity. Although both food insecurity and food deserts in urban regions have been linked with increased incidence of gun violence, a high prevalence of food insecurity was found to be more predictive. A high prevalence of food insecurity in urban regions likely serves as a marker for socioeconomic disadvantage and intentional disinvestment. These regions are predictably associated with a higher incidence of interpersonal gun violence. Food deserts in rural areas have not, to date, been shown to correlate with interpersonal gun violence. Urban food insecurity and gun violence are both likely the byproduct of structural violence. Despite the significant overlap and similar contributors, the application of the public health framework in addressing these two issues has historically been quite different.

An evaluation of emergency general surgery transfers and a call for standardization of practices.

BACKGROUND: There is an increasing trend toward regionalization of emergency general surgery, which burdens patients. The absence of a standardized, emergency general surgery transfer algorithm creates the potential for unnecessary transfers. The aim of this study was to evaluate clinical reasoning prompting emergency general surgery transfers and to initiate a discussion for optimal emergency general surgery use. METHODS: Consecutive emergency general surgery transfers (December 2018 to May 2019) to 2 tertiary centers were prospectively enrolled in an institutional review board-approved protocol. Clinical reasoning prompting transfer was obtained prospectively from the accepting/consulting surgeon. Patient outcomes were used to create an algorithm for emergency general surgery transfer. RESULTS: Two hundred emergency general surgery transfers (49% admissions, 51% consults) occurred with a median age of 59 (18 to 100) and body mass index of 30 (15 to 75). Insurance status was 25% private, 45% Medicare, 21% Medicaid, and 9% uninsured. Weekend transfers (Friday to Sunday) occurred in 45%, and 57% occurred overnight (6:00 pm to 6:00 am). Surgeon-to-surgeon communication occurred with 22% of admissions. Pretransfer notification occurred with 10% of consults. Common transfer reasons included no surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). A minority (36%) underwent surgery within 24 hours; 54% did not require surgery during the admission. Median length of stay was 6 (1 to 44) days. CONCLUSION: Conditions prompting emergency general surgery transfers are heterogeneous in this rural state review. There remains an unmet need to standardize emergency general surgery transfer criteria, incorporating patient and hospital factors and surgeon availability. Well-defined requirements for communication with the accepting surgeon may prevent unnecessary transfers and maximize resource allocation.