A narrative review of pulsed radiofrequency for the treatment of carpal tunnel syndrome.

OBJECTIVE: Carpal tunnel syndrome (CTS), which is the most common peripheral nerve entrapment syndrome, can commonly persist despite conservative treatment modalities such as wrist splinting or medications. Pulsed radiofrequency represents a minimally invasive pain intervention technique to alleviate pain. The literature was reviewed to establish the effectiveness of PRF therapy for CTS. STUDY DESIGN: This is a narrative review of relevant articles on the effectiveness of PRF for CTS. METHOD: Four databases, MEDLINE, Cochrane Central Register of Controlled Trials, Embase, OVID Emcare, and Web of Science, were systematically searched. 804 records were screened, and the reference lists of eligible articles were examined. For this review, eight extracted studies were narratively explored. RESULTS: One case report, three retrospective cohorts, one observational prospective study, and three randomized-controlled trials were included. PRF likely provides both an analgesic and functional benefit in patients with mild to severe CTS, and it also shows benefit as an adjunct to carpal tunnel release surgery. Long-term data is limited. It also appears likely that steroid injection may represent a comparable treatment modality to PRF, and there have been positive results when these modalities are used together. Notably, all studies differed in their methodology, making direct comparisons between studies challenging. CONCLUSIONS: The evidence for PRF in the treatment of CTS, across the range of spectrum of severity or peri-operative to CTS surgery, appears favorable and avoids known side effects of steroid injections. Potential mechanisms for PRF and future directions for research are explored.

Septic arthritis of the cervical facet joint: Clinical report and review of the literature.

BACKGROUND: Facet joint septic arthritis (FJSA) is an uncommon cause of neck pain, most frequently occurring in the lumbosacral spine. Cervical facet joint septic arthritis is particularly rare. Symptoms typically include spinal or paraspinal pain and tenderness, with severe infections potentially causing neurological impairments. This condition can progress to discitis and osteomyelitis. High clinical suspicion is required for accurate diagnosis and timely treatment. OBJECTIVE: To present the first known case of cervical spine FJSA caused by Moraxella species and provide an updated narrative review of cervical spine FJSA. METHODS: A case study of a 66-year-old male with cervical spine FJSA caused by Moraxella osloensis is detailed. Additionally, a librarian-assisted literature search was conducted on MEDLINE Pubmed, filtering for adult human trials and including various study types, resulting in the inclusion of 9 relevant manuscripts. RESULTS: The patient's symptoms included neck, right upper thoracic, and periscapular pain, with episodes of numbness and tingling. MRI revealed septic arthritis at the C7-T1 facet joint and associated osteomyelitis. Cultures identified Moraxella osloensis as the causative agent. The patient was successfully treated with antibiotics and experienced significant symptom improvement. Literature review highlights that Staphylococcus aureus is the most common causative agent of cervical FJSA, with diagnosis typically involving MRI and culture tests. Treatment generally includes long-term antibiotics, with some cases requiring surgical intervention. CONCLUSIONS: This report underscores the need for high clinical suspicion in diagnosing FJSA and highlights the importance of early intervention. It documents the first known case of cervical spine FJSA caused by Moraxella osloensis, contributing valuable information to the limited literature on this rare condition.

Hypoxic pulmonary vascular response can screen subclinical lifestyle disease in healthy population.

OBJECTIVE: Subclinical life style disease can cause endothelial dysfunction associated with perfusion abnormalities and reduced vascular compliance. Subclinical elevated beta type natriuretic peptide (BNP) has been associated with altered fluid shift from extra to intracellular space during acute hypoxia. Therefore we measured vascular response and BNP levels during acute hypoxia to study endothelial functions among healthy individuals. METHODS: Individuals were exposed to acute normobaric hypoxia of FiO2 = 0.15 for one hour in supine position and their pulmonary and systemic vascular response to hypoxia was compared. Individuals were divided into two groups based on either no response (Group 1) or rise in systolic pulmonary artery pressure to hypoxia (Group 2) and their BNP levels were compared. RESULTS: BNP was raised after hypoxia exposure in group 2 only from 18.52 ± 7 to 21.56 ± 10.82 picogram/ml, p < 0.05. Group 2 also showed an increase in mean arterial pressure and no fall in total body water in response to acute hypoxia indicating decreased endothelial function compared to Group 1. CONCLUSION: Rise in pulmonary artery pressure and BNP level in response to acute normobaric hypoxia indicates reduced endothelial function and can be used to screen subclinical lifestyle disease among healthy population.

Trends in Management of Index Adhesive Small Bowel Obstruction in Children.

INTRODUCTION: To examine practice patterns and surgical outcomes of nonoperative versus operative management (OPM) of children presenting with an index adhesive small bowel obstruction (ASBO). METHODS: A California statewide health discharge database was used to identify children (<18 y old) with an index ASBO from 2007 to 2020. The primary study outcome was evaluating initial management patterns (nonoperative versus OPM and early [≤3 d] versus late surgery [>3 d]) of ASBO. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. RESULTS: Of the 2297 patients identified, 1948 (85%) underwent OPM for ASBO during the index admission. Of these, 14.7% underwent early surgery within 3 d. Teaching hospitals had higher operative intervention than nonteaching centers (87.1% versus 83.7%, P = 0.034). OPM was the highest in 0-5-year-olds compared to other ages (89% versus 82%, P < 0.001). In comparison to early surgery, late surgery was associated with longer length of stay (early 7[interquartile range 5-10], late 9[interquartile range 6-17], P < 0.001), increased infectious complications (16.4% versus 9.8%, P = 0.004), and greater use of total parenteral nutrition (28.0% versus 14.3%, P = 0.001); there was no difference in bowel resection (21% versus 18%, P = 0.102) or mortality (P = 0.423). CONCLUSIONS: Our pediatric study demonstrated a high rate of OPM for index ASBO, especially in newborns and toddlers. Although operative intervention, especially late surgery, was associated with increased length of stay, increased infectious complications, and increased total parenteral nutrition use, the rates of bowel resection and mortality did not differ by management strategy. These trends need to be further evaluated to optimize outcomes.

Buprenorphine for Chronic Pain Management: a Narrative Review.

PURPOSE OF REVIEW: The aim of this review is to educate healthcare professionals regarding buprenorphine for the use of opioid use disorder (OUD) as well as for chronic pain management. This review provides physicians and practitioners with updated information regarding the distinct characteristics and intricacies of prescribing buprenorphine. RECENT FINDINGS: Buprenorphine is approved by the US Food and Drug Administration (FDA) for acute pain, chronic pain, opioid use disorder (OUD), and opioid dependence. When compared to most other opioids, buprenorphine offers superior patient tolerability, an excellent half-life, and minimal respiratory depression. Buprenorphine does have notable side effects as well as pharmacokinetic properties that require special attention, especially if patients require future surgical interventions. Many physicians are not trained to initiate or manage patients on buprenorphine. However, buprenorphine offers a potentially safer alternative for medication management for patients who require chronic opioid therapy for pain or have OUD. This review provides updated information on buprenorphine for both chronic pain and OUD.

Bike Helmet Usage in the Most Disadvantaged Neighborhoods: A Focused Area for Trauma Prevention.

INTRODUCTION: There is a paucity of data to describe how neighborhood socioeconomic disadvantage (NSD) correlates with childhood injuries and outcomes. This study assesses the relationship of NSD to bicycle safety and trauma outcomes among pediatric bicycle versus automobile injuries. METHODS: Between 2008 and 2018, patients ≤18 y old with bicycle versus automobile injuries from a Level I pediatric trauma center were evaluated. Area Deprivation Index (ADI) was used to measure NSD. Patient demographics, injury, clinical data characteristics, and bike safety were analyzed. Traffic scene data from the Statewide Integrated Traffic Records System were matched to clinical records. Multivariate logistic regression was used to assess demographic characteristics related to helmet usage. RESULTS: Among 321 patients, 84% were male with a median age of 12 y [interquartile range 9-13], and 44% were of Hispanic ethnicity. Hispanic ethnicity was greater in the most disadvantaged ADI groups (P < 0.001). Mortality occurred in two patients, and most (96%) were discharged home. Of Statewide Integrated Traffic Records System matched traffic records, 81% were at locations without a bike lane. No differences were found in GCS, intensive care unit admission, or length of stay by ADI. Hispanic ethnicity and the highest deprivation group were independently associated with lower odds of wearing a helmet (AOR 0.35, 95% confidence interval 0.1-0.9, P = 0.03; AOR 0.33 95% confidence interval 0.17-0.62; P = 0.001), while patient age and sex were unrelated to helmet usage. CONCLUSIONS: Outcomes for bike versus auto trauma remains similar across ADI groups. However, bike helmet usage is significantly lower among Hispanic children and those from neighborhoods with greater socioeconomic disadvantage.

Isolated Intracranial Hemorrhage in Elderly Patients With Pre-Injury Anticoagulation: Is Full Trauma Team Activation Necessary?

BACKGROUND: Traumatic intracranial hemorrhage (ICH) is a highly morbid injury, particularly among elderly patients on preinjury anticoagulants (AC). Many trauma centers initiate full trauma team activation (FTTA) for these high-risk patients. We sought to determine if FTTA was superior compared with those who were evaluated as a trauma consultation (CON). METHODS: Patients aged ≥55 on preinjury AC who presented from January 2015 to December 2019 with blunt isolated head injury (non-head AIS ≤2) and confirmed ICH were identified. CON patients and FTTA patients were matched by age and head AIS. Cox proportional hazard model was used to assess patient and injury characteristics with mortality and survivor discharge disposition. REASULTS: There were 45 CON patients and 45 FTTA patients. Mean age was 80 years in both groups. Fall was the most common mechanism (98% CON vs. 92% FTTA). Glasgow Coma Score (GCS) was lower in FTTA (14 vs. 15, p<0.01). CON had a significantly longer time from arrival to CT scan (1.3 vs. 0.4 hrs, p<0.01). Hospital days were similar (CON: 3.9 vs. FTTA: 3.7 days). However, CON had increased ventilator use (p=0.03). Lower admission GCS was the only factor associated with increased risk of death. Among survivors, only head AIS increased the risk of discharge to a level of care higher than that of preinjury (p=0.01). CONCLUSION: There was no difference in mortality or adverse discharge disposition between FTTA and CON, although FTTA was associated with a more rapid evaluation and diagnosis. Any alteration in GCS was strongly associated with mortality and should prompt evaluation by FTTA.

Association of Trauma Center Level and Patient Volume with Outcomes for Penetrating Thoracic Trauma.

BACKGROUND: We investigated the potential link between trauma center American College of Surgeons verification level and institutional volume of penetrating thoracic trauma with outcomes for patients with penetrating thoracic trauma. METHODS: Penetrating thoracic injuries were identified in the National Trauma Data Bank from 2013 to 2016. Primary exposures were trauma center American College of Surgeons verification level and annual penetrating trauma caseload by center. Cox models were used to evaluate the association between primary exposures and mortality. Poisson regression was used to evaluate admission and outcome rate differences by trauma center status. RESULTS: Of 68,727 patients identified, 38% were treated at level I centers, 18% at level II centers, and 44% at other centers. Only 3.1% required major surgery for thoracic injury (3.1% at level I, 2.6% at level II, and 3.2% at other). Overall, annual volume of penetrating thoracic trauma was not associated with mortality. For specific injuries, level I centers had superior outcomes for injuries to the thoracic aorta and vena cava compared with other centers. Level I centers also showed improved outcomes for lung/bronchus injuries compared with level II centers. Level I centers had less sepsis/acute respiratory distress syndrome, but more surgical site infection, venous thromboembolism, and unplanned operation compared with non-level I centers. CONCLUSIONS: There was no identified impact of penetrating thoracic trauma volume or trauma center verification level on overall mortality. However, level I verification did correlate with improved outcomes for some specific injuries. Further study to identify factors that improve outcomes in patients with high-risk penetrating thoracic mechanisms is warranted.

Quantifying the burden of pre-existing conditions in older trauma patients: A novel metric based on mortality risk.

INTRODUCTION: Pre-existing medical conditions (PEC) represent a unique domain of risk among older trauma patients. The study objective was to develop a metric to quantify PEC burden for trauma patients. METHODS: A cohort of 4526 non-severe blunt-injured trauma patients aged 55 years and older admitted to a Level I trauma center between January 2006 and December 2012 were divided into development (80%) and test (20%) sets. Cox regression was used to develop the model based on in-hospital and 90-day mortality. Regression coefficients were converted into a point-based PEC Risk Score. Performance of the PEC Risk Score was compared in the test set with two other PEC-based metrics and three injury-based metrics. An external cohort of 2284 trauma patients admitted in 2013 was used to evaluate combined metric performance. RESULTS: Total mortality was 9.4% and 9.1% in the development and test set, respectively. The final model included 12 PEC. In the test set, the PEC Risk Score (c-statistic: 79.7) was superior for predicting in-hospital and 90-day mortality compared with all other metrics. For in-hospital mortality alone, the PEC Risk Score similarly outperformed all other metrics. Combination of the PEC Risk Score and any injury-based metric significantly improved prediction compared with any injury-based metric alone. CONCLUSION: Our 12-item PEC Risk Score performed well compared with other metrics, suggesting that the classification of trauma-related mortality risk may be improved through its use. Among non-severely injured older trauma patients, the utility of prognostic metrics may be enhanced through the incorporation of comorbidities.

A population-based analysis of outcomes after repair of thoracic aortic emergencies in trauma.

BACKGROUND: Large-scale assessments of outcomes in thoracic endovascular repair (TEVAR) for thoracic aortic emergencies are lacking. We evaluated perioperative outcomes of TEVAR compared with open surgery among trauma patients in a large statewide database. MATERIALS AND METHODS: We evaluated the California Office of Statewide Health Planning and Development 2007-2014 patient discharge database. Blunt-injured trauma patients with thoracic aortic emergencies were identified by International Classification for Diseases, Ninth Revision, Clinical Modification diagnosis codes and external cause-of-injury codes. Procedure codes were evaluated for TEVAR or open repair. Outcomes included mortality or complications during the index admission and readmission within 30 d. The association between both operative methods and each outcome was evaluated by two-level logistic regression adjusting for age, length of stay, admission year, trauma-related mortality probability, and comorbidity status. RESULTS: Among over 31 million hospitalizations, we identified 48,357 cases (0.2%) of thoracic aortic disease. Of these, 2159 (4.5%) were unique blunt-injured trauma patients of whom 336 (15.6%) underwent operative repair: 256 TEVAR (76.2%) and 80 (23.8%) open repair. Patients with open repair were older than TEVAR patients (mean age 52.0 versus 46.8, P = 0.038). There were no significant differences in race, sex, injury mechanism, mortality, or 30-d readmission by operative method. However, open repair was associated with greater odds for cardiac, spinal cord, and neurological complications. CONCLUSIONS: Although mortality in trauma patients who underwent TEVAR was similar to that in patients with open repair, TEVAR was associated with fewer complications. This suggests that TEVAR offers clinical benefit over open repair in treating trauma patients with aortic disease.

Cardiac Sympathetic Dominance and Systemic Inflammation in COPD.

Cardiac autonomic dysfunction is an independent determinant of adverse outcomes in many diseases. The available literature on the relative changes in sympathetic and parasympathetic components in chronic obstructive pulmonary disease (COPD) is equivocal, the clinical and physiological correlates are poorly defined and association with markers of systemic inflammation has not been explored. As both autonomic dysfunction and systemic inflammation may contribute to cardiovascular morbidity in COPD, we hypothesized that these may be associated. Sixty three stable patients of COPD and 36 controls underwent spirometry, estimation of diffusion capacity, six-minute walk test and measurements of serum interleukin-6 (IL-6) and high-sensitivity C-Reactive protein. Cardiac autonomic activity was evaluated by standard five-minute heart rate variability (HRV) recordings to obtain time- and frequency-domain indices and the averaged heart rate. We observed that HRV indices of overall autonomic modulation, the standard deviation of time intervals between consecutive normal beats (SDNN) and total power, were greater in patients with higher levels of indices of both parasympathetic and sympathetic activity. The heart rate was significantly higher in patients indicating an overall sympathetic dominance and was inversely correlated with diffusion capacity. Serum IL-6 was inversely correlated with pNN50, an index of parasympathetic activity, and positively with LF/HF ratio, a measure of sympathetic: parasympathetic balance. None of the HRV indices was significantly correlated with physiological measures of severity. It was concluded that patients with COPD have increased cardiac autonomic modulation with sympathetic dominance. This is associated with decreased lung diffusion capacity and systemic inflammation.

Correlating surgical clerkship evaluations with performance on the National Board of Medical Examiners examination.

BACKGROUND: Evaluation of medical students during the surgical clerkship is controversial. Performance is often based on subjective scoring, whereas objective knowledge is based on written examinations. Whether these measures correspond or are relevant to assess student performance is unknown. We hypothesized that student evaluations correlate with performance on the National Board Of Medical Examiners (NBME) examination. METHODS: Data were collected from the 2011-2012 academic year. Medical students underwent a ward evaluation using a seven-point Likert scale assessing six educational competencies. Students also undertook the NBME examination, where performance was recorded as a percentile score adjusted to national standards. RESULTS: A total of 129 medical students were studied. Scores on the NBME ranged from the 52nd to the 96th percentile with an average in the 75th percentile (±9). Clerkship scores ranged from 3.2-7.0 with a mean of 5.7 (±0.8). There was a strong positive association between higher NBME scores and higher clerkship evaluations shown by a Pearson correlation coefficient of 0.47 (P<0.001). Students clustered with below average ward evaluations (3.0-4.0) were in the 69.5th percentile of NBME scores, whereas students clustered with above average ward evaluations (6.0-7.0) were in the 79.2th percentile (P<0.001). CONCLUSIONS: A strong positive relationship exists between subjective ward evaluations and NBME performance. These data may afford some confidence to surgical faculty and surgical resident ability to accurately evaluate medical students during clinical clerkships. Understanding factors in student performance may help in improving the surgical clerkship experience.

The vagus nerve alters the pulmonary dendritic cell response to injury.

BACKGROUND: We have shown previously that vagal nerve stimulation (VNS) protects against burn-induced acute lung injury (ALI). Although the mobilization and activation of immune cells is central to tissue injury caused by the systemic inflammatory response, the specific inflammatory cell populations that are modulated by VNS have yet to be fully defined. The purpose of this study was to assess whether VNS alters inflammatory cell recruitment to the lung after severe burn injury. MATERIALS AND METHODS: Male C57BL/6 mice were subjected to 30% total body surface area steam burn with and without electrical stimulation of the right cervical vagus nerve. The relative levels of pulmonary dendritic cells (DC) and macrophages were compared at 4 h versus 24 h after burn injury. Lung tissue injury was characterized by histology to assess changes in lung architecture, and measure the protein levels of interleukin 6 and transforming growth factor-ß1. RESULTS: Severe burn caused an increase in pulmonary DC recruitment at 4 h after injury that persisted at 24 h after severe burn, whereas there was no change in the number of pulmonary macrophages. In contrast, VNS limited the burn-induced recruitment of pulmonary DC. VNS prevented histologic lung injury and attenuated the release of interleukin 6 and transforming growth factor-ß1 in the lung after burn injury. CONCLUSIONS: VNS is an effective method to limit pulmonary DC recruitment to the lung and prevent ALI after burn injury. Identifying strategies to limit inflammatory cell recruitment to the lung may have clinical utility in preventing ALI in severely burned patients.

Ghrelin decreases motor deficits after traumatic brain injury.

BACKGROUND: Pharmacologic therapy for traumatic brain injury (TBI) has remained relatively unchanged for decades. Ghrelin, an endogenously produced peptide, has been shown to prevent apoptosis and blood-brain barrier dysfunction after TBI. We hypothesize that ghrelin treatment will prevent neuronal degeneration and improve motor coordination after TBI. MATERIALS AND METHODS: A weight drop model created severe TBI in three groups of BALB/c mice: Sham, TBI, and TBI + ghrelin (20 µg intraperitoneal ghrelin). Brain tissue was examined by hematoxylin and eosin and Fluoro-Jade B (FJB) staining to evaluate histologic signs of injury, cortical volume loss, and neuronal degeneration. Additionally, motor coordination was assessed. RESULTS: Ghrelin treatment prevented volume loss after TBI (19.4 ± 9.8 mm(3)versus 71.4 ± 31.4 mm(3); P < 0.05). Similarly, although TBI increased FJB-positive neuronal degeneration, ghrelin treatment decreased FJB staining in TBI resulting in immunohistologic patterns similar to sham. Compared with sham, TBI animals had a significant increase in foot faults at d 1, 3, and 7 (2.75 ± 0.42; 2.67 ± 0.94; 3.33 ± 0.69 versus 0.0 ± 0.0; 0.17 ± 0.19; 0.0 ± 0.0; P < 0.001). TBI + ghrelin animals had significantly decreased foot faults compared with TBI at d 1, 3, and 7 (0.42 ± 0.63; 0.5 ± 0.43; 1.33 ± 0.58; P versus TBI <0.001; P versus sham = NS). CONCLUSIONS: Ghrelin treatment prevented post-TBI cortical volume loss and neurodegeneration. Furthermore, ghrelin improved post-TBI motor deficits. The mechanisms of these effects are unclear; however, a combination of the anti-apoptotic and inflammatory modulatory effects of ghrelin may play a role. Further studies delineating the mechanism of these observed effects are warranted.

Prevalence of abnormal urine drug tests during COVID-19 pandemic in the cancer patient population: retrospective study.

Background: Opioid misuse is a persistent concern, heightened by the COVID-19 pandemic. This study examines the risk factors contributing to elevated rates of abnormal urine drug tests (UDTs) in the cancer pain patient population during COVID-19. Materials & methods: A retrospective chart review of 500 patient encounters involving UDTs at a comprehensive cancer center. Results: Medication adherence rates increase when UDTs are incorporated into a chronic cancer pain management protocol. Higher positive tests for illicit or nonprescribed substances in patients with specific risk factors: current smokers (tobacco), no active cancer and concurrent benzodiazepine use. Conclusion: This research emphasizes the increased risk of opioid misuse during COVID-19 among cancer pain patients with specific risk factors outlined in the results.

This study looked at how the COVID-19 pandemic has affected opioid use among people with cancer-related pain. The researchers checked the records of 500 patients who had had tests to see if they used opioids correctly. They found that when these tests were part of the treatment plan, patients were more likely to take their medicines correctly. However, they also noticed that certain patients, such as those who smoke, do not have active cancer or are taking another type of medication (i.e., benzodiazepines), are more likely to use opioids or other drugs in ways that deviated from the original intention. This study shows that during the pandemic, which continues to exist, it is even more important to watch how these patients use their painkillers and help them avoid misuse.

A Window of Opportunity: Understanding Pediatric Falls Using Area Deprivation Index.

INTRODUCTION: The purpose of our study is to assess neighborhood socioeconomic disadvantage (NSD) as a risk factor for window falls (WF) in children. METHODS: A single institution retrospective review was performed of patients ≤18 years old with fall injuries treated at a Level I trauma center between 2018 and 2021. Demographic, injury, and NSD characteristics which were collected from a trauma registry were analyzed and compared between WF versus non-window falls. Area Deprivation Index (ADI) was used to measure NSD levels based on patients' home address 9-digit zip code, with greater NSD being defined as ADI quintiles 4 and 5. Property type was used to compare falls that took place at single-family homes versus apartment buildings. RESULTS: Among 1545 pediatric fall injuries, 194 were WF, of which 60 % were male and 46 % were Hispanic. WF patients were younger than NWF patients (median age WF 3.2 vs. age 4.3, p<0.047). WF patients were more likely to have a depressed Glasgow Coma Scale (GCS score ≤12, WF 9 % vs. 3 %) and sustain greater head/neck injuries (median AIS 3vs. AIS 2, p<0.001) when compared to NWF. WF patients had longer hospital and ICU lengths of stay than NWF patients (p<0.001 and p<0.001, respectively). WF patients were more likely to live in areas of greater NSD than NWF patients (53 % vs. 35 %, p<0.001), and 73 % of all WF patients lived in apartments or condominiums. CONCLUSIONS: Window fall injuries were associated with lower GCS, greater severity of head/neck injuries, and longer hospital and ICU length of stay than non-window falls. ADI research can provide meaningful data for targeted injury prevention programs in areas where children are at higher risk of window falls. STUDY TYPE: Retrospective review. LEVEL OF EVIDENCE: III.

Machine Learning Differentiates Extracorporeal Membrane Oxygenation Mortality Risk Profiles Among Trauma Patients.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is resource intensive with high mortality. Identifying trauma patients most likely to derive a survival benefit remains elusive despite current ECMO guidelines. Our objective was to identify unique patient risk profiles using the largest database of trauma patients available. METHODS: ECMO patients ≥16 years were identified using Trauma Quality Improvement Program data (2010-2019). Machine learning K-median clustering (ML) utilized 101 variables including injury severity, demographics, comorbidities, and hospital stay information to generate unique patient risk profiles. Mortality and patient and center characteristics were evaluated across profiles. RESULTS: A total of 1037 patients were included with 33% overall mortality, mean age 32 years, and median ISS = 26. The ML identified 3 unique patient risk profile groups. Although mortality rates were equivalent across the 3 groups, groups were distinguished by (Group 1) young (median 25 years), severely injured (ISS = 34) patients with thoracic and head injuries (99%) via blunt mechanism (93%), and a high prevalence of ARDS (77%); (Group 2) relatively young (median 30 years) and moderately injured (ISS = 22) patients with exposure-related injuries (11%); and (Group 3) older (median 46 years) patients with a high proportion of comorbidities (69%) and extremity injuries (100%). There were no differences based on center ECMO volume, teaching status, or ACS-Level across all 3 groups. CONCLUSION: Machine learning compliments traditional analyses by identifying unique mortality risk profiles for trauma patients receiving ECMO. These details can further inform treatment guidelines, clinical decision making, and institutional criteria for ECMO usage.

Assessment of rehabilitation practices during hematopoietic stem cell transplantation in the United States: a survey.

Background: Rehabilitation therapy is important to treat physical and functional impairments that may occur in individuals receiving physically taxing, yet potentially curative hematopoietic stem cell transplants (HSCT). However, there is scarce data on how rehabilitation is delivered during HSCT in real-life setting. Our objective is to assess the rehabilitation practices for adult patients hospitalized for HSCT in the United States. Methods: A 48-question online survey with cancer centers with the top 10% HSCT volumes (per American registries). We obtained data on patient characteristics, rehabilitation therapy details (timing, indication, administering providers), physical function objective and subjective outcome measures, and therapy activity precautions. Results: Fourteen (out of 21) institutions were included. Rehabilitation therapy referrals occurred at admission for all patients at 35.7% of the centers for: functional decline (92.9%), fall risk (71.4%), and discharge planning (71.4%). Participating institutions had physical therapists (92.9%), occupational therapists (85.7%), speech language pathologists (64.3%) and therapy aides (35.7%) in their rehabilitation team. Approximately 71% of centers used objective functional measures including sit-to-stand tests (50.0%), balance measures (42.9%), and six-minute walk/gait speed (both 35.7%). Monitoring of blood counts to determine therapy modalities frequently occurred and therapies held for low platelet or hemoglobin values; but absolute neutrophil values were not a barrier to participate in resistance or aerobic therapies (42.9%). Discussion: Rehabilitation practices during HSCT varied among the largest volume cancer centers in the United States, but most centers provided skilled therapy, utilized objective, clinician and patient reported outcomes, and monitored blood counts for safety of therapy administration.

Modified Brain Injury Guidelines for preinjury anticoagulation in traumatic brain injury: An opportunity to reduce health care resource utilization.

INTRODUCTION: The Brain Injury Guidelines (BIG) stratify patients by traumatic brain injury (TBI) severity to provide management recommendations to reduce health care resource burden but mandates that patients on anticoagulation (AC) are allocated to the most severe tertile (BIG 3). We sought to analyze TBI patients on AC therapy using a modified BIG model to determine if this population can offer further opportunity for safe reductions in health care resource utilization. METHODS: Patients 55 years or older on AC with traumatic intracranial hemorrhage (ICH) from two centers were retrospectively stratified into BIG 1 to 3 risk groups using modified BIG criteria excluding AC as a criterion. Intracranial hemorrhage progression, neurosurgical intervention (NSI), death, and worsened discharge status were compared. RESULTS: A total of 221 patients were included, with 23%, 29%, and 48% classified as BIG 1, BIG 2, and BIG 3, respectively. The BIG 3 cohort had a higher rate of AC reversal agents administered (66%) compared with the BIG 1 (40%) and BIG 2 (54%) cohorts ( p < 0.01), as well as ICH progression discovered on repeat head computed tomography (56% vs. 38% vs. 26%, respectively; p < 0.001). No patients in the BIG 1 and 2 cohorts required NSI. No patients in BIG 1 and 3% of patients in BIG 2 died secondary to the ICH. In the BIG 3 cohort, 16% of patients required NSI and 26% died. Brain Injury Guidelines 3 patients had 15 times the odds of mortality compared with BIG 1 patients ( p < 0.01). CONCLUSION: The AC population had higher rates of ICH progression than the BIG literature, but this did not lead to more NSI or mortality in the lower tertiles of our modified BIG protocol. If the modified BIG used the original tertile management on our population, then NS consultation may have been reduced by up to 52%. These modified criteria may be a safe opportunity for further health care resource and cost savings in the TBI population. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.