Burns in the Elderly.

Burns in the elderly are a significant cause of morbidity and mortality. Frailty is an important indicator of patient health and physiologic reserve. Comorbidities and typical age-related changes significantly impact the outcomes of elderly burn patients and decisions made during their burn care. It is essential to have early and thorough discussions about the goals of care and rehabilitation plans. Physiologic changes that occur from aging cause slower wound healing and may make operative treatment more challenging, although techniques such as autographing, skin substitutes, and flaps may all play a role in treating this patient population.

Teaching Palliative Care in Surgical Education.

Without training in how to identify and relieve pain and suffering, surgeons miss opportunities to offer palliative services to patients. Despite explicit calls for expanding palliative care education since the 1990s, palliative care training in surgical curricula is often limited to end-of-life discussions. A growing consensus among palliative care experts suggests that formal palliative care education during surgical training should include structured communication and prognostication tools, strategies for symptom management, and an understanding of palliative care specialists' role in treating patients at all disease stages.

Use of regional analgesia and risk of delirium in older adults with multiple rib fractures: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers. METHODS: Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence. RESULTS: Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16). CONCLUSION: In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury. LEVEL OF EVIDENCE: Therapeutic, level IV; Epidemiologic, level III.

Surgical Palliative Care Education.

Surgical palliative care education is in increasing demand to meet the needs of a growing geriatric population. Multiple accrediting agencies for undergraduate and graduate medical education require that students be trained in end-of-life care. These requirements, however, have resulted in didactic curricula that are implemented in various degrees with uncertain levels of success. Reviews of physician communication on palliative care topics find that skilled feedback has the best evidence for generating improvements. Once graduated, there is little to no requirement that practicing providers seek out opportunities to improve their palliative care skills.

10 years of laparoscopic common bile duct exploration: A single tertiary institution experience.

INTRODUCTION: Laparoscopic common bile duct exploration (LCBDE-LC) or ERCP plus laparoscopic cholecystectomy (ERCP-LC) represent minimally invasive choledocholithiasis treatments. We hypothesized that LCBDE-LC has a shorter length of stay (LOS) and lower charges than ERCP-LC. METHODS: Charts were reviewed for all LCBDE-LC or ERCP-LC for choledocholithiasis from 2007 to 2017. Exclusions included cholangitis, concomitant procedures, or history of Roux-en-Y or biliary surgery. Groups were determined via intention-to-treat with LCBDE-LC or ERCP-LC. RESULTS: 281 subjects were identified; 157 met inclusion criteria. 89 (56%) were in the LCBDE-LC group. There were no differences in age, sex, or ASA. LOS was shorter for LCBDE-LC (3.1 vs 4.4 days, p < 0.01) although total anesthesia time was longer (292 vs 262 min, p = 0.01). There was no difference in total charges ($44,412 vs $51,353, p = 0.08). Thirty (33%) LCBDE-LC were aborted due to challenges passing the dilator or scope (33%) or clearing stones (30%). Two ERCP-LC cases required post-procedure LCBDE. CONCLUSION: LCBDE-LC resulted in shorter LOS but had a high failure rate. Further research is needed to predict which cases suit each modality.

Elderly patients presenting to a Level I trauma center with Physician Orders for a Life-Sustaining Treatment form: A propensity-matched analysis.

BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) forms are portable medical orders documenting patient treatment preferences in an acute health decline. It is unclear how these forms are used in the management of elderly trauma patients. METHODS: Patients 65 years and older presenting to a Level I trauma center were identified between 2012 and 2017. Hospital trauma registry and medical records were used to identify a preinjury POLST and its acknowledgment by providers within 24 hours of arrival. A 1:1 propensity score matched sample was used to evaluate clinical outcomes based on the presence of a POLST limiting interventions with p less than 0.05 deemed significant. RESULTS: There were 3,342 elderly trauma patients identified. One hundred ninety-two (6%) had a POLST identified by the institutional trauma registry dated before the injury. Do not attempt resuscitation (DNR) was listed in 154 patients (80%), and 79% desired to avoid the intensive care unit (ICU) with limited (54%) or comfort measures only (CMO, 25%). One hundred seven (76%) of admitted POLST DNR patients had a DNR code status for the majority of their admission. 59 (58%) of the limited and 29 (60%) of the comfort measures only patients were admitted to the ICU. Acknowledgment of a preinjury POLST or code status was explicitly documented in 110 cases (57%). Propensity score analysis yielded a comparison sample of 288 patients. In the matched comparison, an acknowledged POLST with limitations was associated with a shorter ICU stay (1.7 vs. 2.8 days, p = 0.008) but there was no difference in ICU admission (58% vs. 61%, p = 0.69), total length of stay (3.8 days vs. 4.8 days, p = 0.08), or in-hospital mortality (13% vs. 8%, p = 0.2). CONCLUSION: Limited provider acknowledgment of preinjury medical directives necessitates protocol development for the management of frail elderly trauma patients. When acknowledged, patients with a POLST limiting interventions had fewer ICU days without increased in-hospital mortality compared with similarly injured elderly patients. LEVEL OF EVIDENCE: Care Management, level IV.

Palliative Care and Geriatric Surgery.

Although many seniors cite maintaining independence and a desire to die at home as health priorities, admission to the ICU and the use of invasive procedures are common near the end of life. Palliative care aims to relieve pain and other symptoms to maintain the highest quality of life for the longest period of time, but surgical patients are less likely to be referred to palliative care than patients with chronic medical conditions. Meeting the palliative care needs of elderly surgical patients requires early recognition, advance care planning, and multidisciplinary interventions that align patient goals with possible outcomes.

Utilizing spatiotemporal analysis of influenza-like illness and rapid tests to focus swine-origin influenza virus intervention.

In the spring of 2009, a novel strain of H1N1 swine-origin influenza A virus (S-OIV) emerged in Mexico and the United States, and soon after was declared a pandemic by the World Health Organization. This work examined the ability of real-time reports of influenza-like illness (ILI) symptoms and rapid influenza diagnostic tests (RIDTs) to approximate the spatiotemporal distribution of PCR-confirmed S-OIV cases for the purposes of focusing local intervention efforts. Cluster and age adjusted relative risk patterns of ILI, RIDT, and S-OIV were assessed at a fine spatial scale at different time and space extents within Cameron County, Texas on the US-Mexico border. Space-time patterns of ILI and RIDT were found to effectively characterize the areas with highest geographical risk of S-OIV within the first two weeks of the outbreak. Based on these results, ILI and/or RIDT may prove to be acceptable indicators of the location of S-OIV hotspots. Given that S-OIV data is often difficult to obtain real-time during an outbreak; these findings may be of use to public health officials targeting prevention and response efforts during future flu outbreaks.

Response to H1N1 in a U.S.-Mexico border community.

Public health experts from a county health department and a school of public health collaborated to establish a simple, functional surveillance system to monitor swine-origin influenza virus as it crossed from Mexico into a Texas border community during the 2009 pandemic. The draft national and state preparedness plans were found to be cumbersome at the local level, so a simple, more practical real-time surveillance and response system was developed, in part by modifying these documents, and immediately implemented. Daily data analyses, including geographical information system mapping of cases and reports of school and daycare absences, were used for outbreak management. Aggregate reports of influenzalike illness and primary school absences were accurate in predicting influenza activity and were practical for use in local tracking, making decisions, and targeting interventions. These simple methods should be considered for local implementation and for integration into national recommendations for epidemic preparedness and response.