A Prospective Multicenter Comparison of Trauma and Injury Severity Score, American Society of Anesthesiologists Physical Status, and National Surgical Quality Improvement Program Calculator's Ability to Predict Operative Trauma Outcomes.

BACKGROUND: Trauma outcome prediction models have traditionally relied upon patient injury and physiologic data (eg, Trauma and Injury Severity Score [TRISS]) without accounting for comorbidities. We sought to prospectively evaluate the role of the American Society of Anesthesiologists physical status (ASA-PS) score and the National Surgical Quality Improvement Program Surgical Risk-Calculator (NSQIP-SRC), which are measurements of comorbidities, in the prediction of trauma outcomes, hypothesizing that they will improve the predictive ability for mortality, hospital length of stay (LOS), and complications compared to TRISS alone in trauma patients undergoing surgery within 24 hours. METHODS: A prospective, observational multicenter study (9/2018-2/2020) of trauma patients ≥18 years undergoing operation within 24 hours of admission was performed. Multiple logistic regression was used to create models predicting mortality utilizing the variables within TRISS, ASA-PS, and NSQIP-SRC, respectively. Linear regression was used to create models predicting LOS and negative binomial regression to create models predicting complications. RESULTS: From 4 level I trauma centers, 1213 patients were included. The Brier Score for each model predicting mortality was found to improve accuracy in the following order: 0.0370 for ASA-PS, 0.0355 for NSQIP-SRC, 0.0301 for TRISS, 0.0291 for TRISS+ASA-PS, and 0.0234 for TRISS+NSQIP-SRC. However, when comparing TRISS alone to TRISS+ASA-PS (P = .082) and TRISS+NSQIP-SRC (P = .394), there was no significant improvement in mortality prediction. NSQIP-SRC more accurately predicted both LOS and complications compared to TRISS and ASA-PS. CONCLUSIONS: TRISS predicts mortality better than ASA-PS and NSQIP-SRC in trauma patients undergoing surgery within 24 hours. The TRISS mortality predictive ability is not improved when combined with ASA-PS or NSQIP-SRC. However, NSQIP-SRC was the most accurate predictor of LOS and complications.

Defining the "Tipping Point" to Success as a Surgeon-scientist: An Analysis of Applicants and Awardees of the American College of Surgeons Jacobson Promising Investigator Award.

BACKGROUND: Since 2005, the American College of Surgeons has administered the Jacobson Promising Investigator Award (JPIA), which recognizes surgeon-scientists at the "tipping point" of their research careers. OBJECTIVE: We retrospectively reviewed JPIA applicants to identify factors associated with selection for the award and future research success. METHODS: Profiles were reviewed for all applicants between 2008 and 2018, at the time of application and as of 2019. Web of Science and NIH Reporter metrics were also reviewed for each applicant. RESULTS: Eleven of 97 applicants were selected for the JPIA. At the time of application, awardees were more likely to have extramural (NIH K-award) versus intramural (KL2) or other career development award funding (55% vs 33%, P = 0.03) and more publications [median 70 (interquartile range, IQR 55-100) vs 40 (IQR 22-67), P = 0.03]. Post-application, JPIA awardees were more likely to achieve a higher h-Index and m-quotient compared to nonawardees (P < 0.001 for both). All JPIA recipients received new NIH funding post-award, including 82% with R01 funding, compared to 23% of nonselected applicants (P < 0.0001). Over $48 million from NIH was awarded to JPIA recipients since 2008, representing a 147-fold return on investment. CONCLUSIONS: Selection for the JPIA is associated with previous extramural NIH K award and, on average, 70 peer-reviewed publications at the time of application. Receipt of the JPIA is associated with a high rate of subsequent NIH R01 funding and publication metrics. The JPIA is an excellent indicator of "tipping point" success in academic surgery and demonstrates the huge potential impact of philanthropic support on early career surgeon-investigators.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds.

BACKGROUND: Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW. METHODS: This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed. RESULTS: Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99). CONCLUSION: While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level II.

Comparison of National Surgical Quality Improvement Program Surgical Risk Calculator and Trauma and Injury Severity Score Risk Assessment Tools in Predicting Outcomes in High-Risk Operative Trauma Patients.

BACKGROUND: The Trauma and Injury Severity Score (TRISS) uses anatomic/physiologic variables to predict outcomes. The National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC) includes functional status and comorbidities. It is unclear which of these tools is superior for high-risk trauma patients (American Society of Anesthesiologists Physical Status (ASA-PS) class IV or V). This study compares risk prediction of TRISS and NSQIP-SRC for mortality, length of stay (LOS), and complications for high-risk operative trauma patients. METHODS: This is a prospective study of high-risk (ASA-PS IV or V) trauma patients (≥18 years-old) undergoing surgery at 4 trauma centers. We compared TRISS vs NSQIP-SRC vs NSQIP-SRC + TRISS for ability to predict mortality, LOS, and complications using linear, logistic, and negative binomial regression. RESULTS: Of 284 patients, 48 (16.9%) died. The median LOS was 16 days and number of complications was 1. TRISS + NSQIP-SRC best predicted mortality (AUROC: .877 vs .723 vs .843, P = .0018) and number of complications (pseudo-R2/median error (ME) 5.26%/1.15 vs 3.39%/1.33 vs 2.07%/1.41, P < .001) compared to NSQIP-SRC or TRISS, but there was no difference between TRISS + NSQIP-SRC and NSQIP-SRC with LOS prediction (P = .43). DISCUSSION: For high-risk operative trauma patients, TRISS + NSQIP-SRC performed better at predicting mortality and number of complications compared to NSQIP-SRC or TRISS alone but similar to NSQIP-SRC alone for LOS. Thus, future risk prediction and comparisons across trauma centers for high-risk operative trauma patients should include a combination of anatomic/physiologic data, comorbidities, and functional status.

Comparison of National Surgical Quality Improvement Program Surgical Risk Calculator, Trauma and Injury Severity Score, and American Society of Anesthesiologists Physical Status to predict operative trauma mortality in elderly patients.

BACKGROUND: The Trauma and Injury Severity Score (TRISS) uses anatomical and physiologic variables to predict mortality. Elderly (65 years or older) trauma patients have increased mortality and morbidity for a given TRISS, in part because of functional status and comorbidities. These factors are incorporated into the American Society of Anesthesiologists Physical Status (ASA-PS) and National Surgical Quality Improvement Program Surgical Risk Calculator (NSQIP-SRC). We hypothesized scoring tools using comorbidities and functional status to be superior at predicting mortality, hospital length of stay (LOS), and complications in elderly trauma patients undergoing operation. METHODS: Four level I trauma centers prospectively collected data on elderly trauma patients undergoing surgery within 24 hours of admission. Using logistic regression, five scoring models were compared: ASA-PS, NSQIP-SRC, TRISS, TRISS-ASA-PS, and TRISS-NSQIP-SRC.Brier scores and area under the receiver operator characteristics curve were calculated to compare mortality prediction. Adjusted R2 and root mean squared error were used to compare LOS and predictive ability for number of complications. RESULTS: From 122 subjects, 9 (7.4%) died, and the average LOS was 12.9 days (range, 1-110 days). National Surgical Quality Improvement Program Surgical Risk Calculator was superior to ASA-PS and TRISS at predicting mortality (area under the receiver operator characteristics curve, 0.978 vs. 0.768 vs. 0.903; p = 0.007). Furthermore, NSQIP-SRC was more accurate predicting LOS (R2, 25.9% vs. 13.3% vs. 20.5%) and complications (R2, 34.0% vs. 22.6% vs. 29.4%) compared with TRISS and ASA-PS. Adding TRISS to NSQIP-SRC improved predictive ability compared with NSQIP-SRC alone for complications (R2, 35.5% vs. 34.0%; p = 0.046). However, adding ASA-PS or TRISS to NSQIP-SRC did not improve the predictive ability for mortality or LOS. CONCLUSION: The NSQIP-SRC, which includes comorbidities and functional status, had superior ability to predict mortality, LOS, and complications compared with TRISS alone in elderly trauma patients undergoing surgery. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level III.

Impact of Morbid Obesity on Liver Transplant Candidacy and Outcomes: National and Regional Trends.

BACKGROUND: Body mass index (BMI) limits for liver transplant (LT) candidacy are controversial. In this study, we evaluate waitlist and post-LT outcomes, and prognostic factors and examine regional patterns of LT waitlist registration in patients with BMI ≥40 versus BMI 18-39. METHODS: United Network for Organ Sharing (UNOS) data were analyzed to assess waitlist dropout, post-LT survival, and prognostic factors for patient survival. The distribution of waitlisted patients with BMI ≥40 was compared with the Centers for Disease Control Behavioral Risk Factors Surveillance System data to explore the rates of morbid obesity in the general population of each UNOS region. RESULTS: Post-LT outcomes demonstrate a small but significantly lower 1- and 3-y overall survival for patients with BMI ≥45. Risk factors for post-LT mortality for patients with BMI ≥40 included age >60 y, prior surgery, and diabetes on multivariable analysis. Model for End-Stage Liver Disease >30 was significant on univariable analysis only, likely due to the limited number of patients with BMI ≥40; however, median Model for End-Stage Liver Disease scores in this BMI group were higher than those in patients with lower BMI across all UNOS regions. Patients with BMI ≥40 had a higher waitlist dropout in 4 regions. Comparison with BRFSS data illustrated that the proportion of waitlisted patients with BMI ≥40 was significantly lower than the observed rates of morbid obesity in the general population in 3 regions. CONCLUSIONS: While BMI ≥45 is associated with modestly lower patient survival, careful selection may equalize these numbers.

Structural Connection between Activation Microswitch and Allosteric Sodium Site in GPCR Signaling.

Sodium ions are endogenous allosteric modulators of many G-protein-coupled receptors (GPCRs). Mutation of key residues in the sodium binding motif causes a striking effect on G-protein signaling. We report the crystal structures of agonist complexes for two variants in the first sodium coordination shell of the human A2A adenosine receptor, D522.50N and S913.39A. Both structures present an overall active-like conformation; however, the variants show key changes in the activation motif NPxxY. Changes in the hydrogen bonding network in this microswitch suggest a possible mechanism for modified G-protein signaling and enhanced thermal stability. These structures, signaling data, and thermal stability analysis with a panel of pharmacological ligands provide a basis for understanding the role of the sodium-coordinating residues on stability and G-protein signaling. Utilizing the D2.50N variant is a promising method for stabilizing class A GPCRs to accelerate structural efforts and drug discovery.