Bone Anchor Fixation in the Repair of Blunt Traumatic Abdominal Wall Hernias: A Western Trauma Association Multicenter Study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWHs) are rare but require a variety of operative techniques to repair including bone anchor fixation (BAF) when tissue tears off bony structures. This study aimed to provide a descriptive analysis of BAF technique for blunt TAWH repair. Bone anchor fixation and no BAF repairs were compared, hypothesizing increased hernia recurrence with BAF repair. METHODS: A secondary analysis of the WTA blunt TAWH multicenter study was performed including all patients who underwent repair of their TAWH. Patients with BAF were compared to those with no BAF with bivariate analyses. RESULTS: 176 patients underwent repair of their TAWH with 41 (23.3%) undergoing BAF. 26 (63.4%) patients had tissue fixed to bone, with 7 of those reinforced with mesh. The remaining 15 (36.6%) patients had bridging mesh anchored to bone. The BAF group had a similar age, sex, body mass index, and injury severity score compared to the no BAF group. The time to repair (1 vs 1 days, P = .158), rate of hernia recurrence (9.8% vs 12.7%, P = .786), and surgical site infection (SSI) (12.5% vs 15.6%, P = .823) were all similar between cohorts. CONCLUSIONS: This largest series to date found nearly one-quarter of TAWH repairs required BAF. Bone anchor fixation repairs had a similar rate of hernia recurrence and SSI compared to no BAF repairs, suggesting this is a reasonable option for repair of TAWH. However, future prospective studies are needed to compare specific BAF techniques and evaluate long-term outcomes including patient-centered outcomes such as pain and quality of life.

Surgeon Implicit Association of Women With Supportive Roles in Medicine.

BACKGROUND: In a previous study, we documented patient implicit bias that surgeons are men. As a next step, we tested the implicit bias of surgeons that women in medicine have leading (chair, surgeon) or supporting roles (medical assistant, physician assistant). QUESTIONS/PURPOSE: (1) What is the relationship between the implicit associations and expressed beliefs of surgeons regarding women as leaders in medicine? (2) Are there factors associated with surgeon implicit association and explicit preference regarding the roles of women in medicine? METHODS: A total of 102 musculoskeletal surgeon members of the Science of Variation Group (88 men and 12 women) completed an implicit association test (IAT) of implicit bias regarding sex and lead/support roles in medicine and a questionnaire that addressed respondent demographics and explicit preference regarding women's roles. The IAT consisted of seven rounds with five rounds used for teaching and two rounds for evaluation. RESULTS: On average, there was an implicit association of women with supportive roles (D-score: -48; SD 4.7; P < 0.001). The mean explicit preference was for women in leadership roles (median: 73; interquartile ranges: 23 to 128; P < 0.001). There was a correlation between greater explicit preference for women in a leading role and greater implicit bias toward women in a supporting role (ρ = 0.40; P < 0.001). Women surgeons and shoulder and elbow specialists had less implicit bias that women have supporting roles. CONCLUSION: The observation that musculoskeletal surgeons have an explicit preference for women in leading roles in medicine but an implicit bias that they have supporting roles-more so among men surgeons-documents the gap between expressed opinions and ingrained mental processing that is the legacy of the traditional "roles" of women in medicine and surgery. To resolve this gap, we will need to be intentional about promotion of and emersion in experiences where the leader is a woman. LEVEL OF EVIDENCE: III.

A western trauma association multicenter comparison of mesh versus non-mesh repair of blunt traumatic abdominal wall hernias.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in <1 % of trauma patients. Optimal repair techniques, such as mesh reinforcement, have not been studied in detail. We hypothesize that mesh use will be associated with increased surgical site infections (SSI) and not improve hernia recurrence. MATERIALS AND METHODS: A secondary analysis of the Western Trauma Association blunt TAWH multicenter study was performed. Patients who underwent TAWH repair during initial hospitalization (1/2012-12/2018) were included. Mesh repair patients were compared to primary repair patients (non-mesh). A logistic regression was conducted to assess risk factors for SSI. RESULTS: 157 patients underwent TAWH repair during index hospitalization with 51 (32.5 %) having mesh repair: 24 (45.3 %) synthetic and 29 (54.7 %) biologic. Mesh patients were more commonly smokers (43.1 % vs. 22.9 %, p = 0.016) and had a larger defect size (10 vs. 6 cm, p = 0.003). Mesh patients had a higher rate of SSI (25.5 % vs. 9.5 %, p = 0.016) compared to non-mesh patients, but a similar rate of recurrence (13.7 % vs. 10.5%, p = 0.742), hospital length of stay (LOS), and mortality. Mesh use (OR 3.66) and higher ISS (OR 1.06) were significant risk factors for SSI in a multivariable model. CONCLUSION: Mesh was used more frequently in flank TAWH and those with a larger defect size. Mesh use was associated with a higher incidence and risk of SSI but did not reduce the risk of hernia recurrence. When repairing TAWH mesh should be employed judiciously, and prospective randomized studies are needed to identify clear indications for mesh use in TAWH.

Clinician Interruptions and Patient-Rated Clinician Empathy in Specialty Visits.

INTRODUCTION: Clinicians tend to interrupt patients when they are describing their problem, which may contribute to feeling unheard or misunderstood. Using transcripts of audio and video recordings from musculoskeletal (MSK) specialty visits, we asked what factors are associated with (1) Perceived clinician empathy, including the time a patient spends describing the problem and time to the first interruption, (2) duration of patient symptom description, and (3) duration between the end of greeting and first nonactive listening interruption. METHODS: We analyzed transcripts of 194 adult patients seeking MSK specialty care with a median age (Interquartile range [IQR]) of 47 (33 to 59) years. Participants completed postvisit measures of perceived clinician empathy, symptoms of depression, accommodation of pain, and health anxiety. A nonactive listening interruption was defined as the clinician unilaterally redirecting the topic of conversation. Factors associated with patient-rated clinician empathy, patient problem description duration, and time until the first nonactive listening interruption were sought in bivariate and multivariable analyses. RESULTS: The patient's narrative was interrupted at least one time in 144 visits (74%). The duration of each visit was a median of 12 minutes (IQR 9 to 16 minutes). The median time patients spent describing their symptoms was 139 seconds before the first interruption (IQR 84 to 225 seconds). The median duration between the end of the initial greeting and the first interruption was 60 seconds (IQR 30 to 103 seconds). Clinician interruption was associated with shorter duration of symptom description. Greater perceived clinician empathy was associated with greater accommodation of pain (regression coefficient [95% confidence interval] = 0.015 [0.0005-0.30]; P = 0.04). DISCUSSION: Clinician interruption was associated with shorter symptom presentation, but not with diminished perception of clinician empathy. Although active listening and avoidance of interruption are important communication tactics, other aspects of the patient-clinician relationship may have more effect on patient experience.

Magnitude of Incapability and Pain Intensity are Associated More with Unhelpful Thoughts Than Stressful Life Events.

Prior studies show that stressful life events are associated with greater magnitude of incapability and symptom intensity. We sought to understand the association of such events (i.e., both adverse childhood experiences and recent difficult life events [DLEs]) alongside feelings of worry or despair and unhelpful, on the magnitude of incapability and symptom intensity in musculoskeletal patients. One hundred and thirty-six patients presenting for musculoskeletal specialty care completed measures of incapability, pain intensity, adverse childhood experiences, DLEs in the last year, unhelpful thoughts, symptoms of anxiety and depression, and sociodemographic factors. Factors associated with the magnitude of incapability and pain intensity were sought in multivariable analysis. Accounting for potential confounders, greater incapability was associated with greater unhelpful thoughts (RC = -0.81; 95% CI = -1.2 to -0.42; P ≤ .001), but not with stressful life events (either during childhood or more recently). Greater pain intensity was associated with greater unhelpful thoughts(RC = 0.25; 95% CI = 0.16 to 0.35; P ≤ .001) and being divorced or widowed (RC = 1.8; 96% CI = 0.43 to 3.2; P = .011), but again, not with stressful life events. The strong association of unhelpful thoughts with magnitude of incapability and pain intensity can motivate musculoskeletal specialists to anticipate patients expressing negative pain thoughts and behaviors. Future studies might account for social and environmental context behind stressful life events and the influence of resiliency and pain-coping strategies on these interactions. Level of Evidence: Level III, prognostic study.

Does Addressing Mental Health During a Musculoskeletal Specialty Care Visit Affect Patient-rated Clinician Empathy?

BACKGROUND: Unhelpful thoughts and feelings of worry or despair about symptoms account for a notable amount of the variation in musculoskeletal symptom intensity. Specialists may be best positioned to diagnose these treatable aspects of musculoskeletal illness. Musculoskeletal specialists might be concerned that addressing mental health could offend the patient, and avoidance might delay mental health diagnosis and treatment. Evidence that conversations about mental health are not associated with diminished patient experience might increase specialist confidence in the timely diagnosis and initial motivation to treat unhelpful thoughts and feelings of worry or despair. QUESTIONS/PURPOSES: Using transcripts of videotaped and audiotaped specialty care visits in which at least one instance of patient language indicating an unhelpful thought about symptoms or feelings of worry or despair surfaced, we asked: (1) Is clinician discussion of mental health associated with lower patient-rated clinician empathy, accounting for other factors? (2) Are clinician discussions of mental health associated with patient demographics, patient mental health measures, or specific clinicians? METHODS: Using a database of transcripts of 212 patients that were audio or video recorded for prior studies, we identified 144 transcripts in which language reflecting either an unhelpful thought or feelings of distress (worry or despair) about symptoms was detected. These were labeled mental health opportunities. Patients were invited on days when the researcher making video or audio records was available, and people were invited based on the researcher's availability, the patient's cognitive ability, and whether the patient spoke English. Exclusions were not tracked in those original studies, but few patients declined. There were 80 women and 64 men, with a mean age of 45 ± 15 years. Participants completed measures of health anxiety, catastrophic thinking, symptoms of depression, and perceived clinician empathy. Factors associated with perceived clinician empathy and clinician discussion of mental health were sought in bivariate and multivariable analyses. RESULTS: Greater patient-rated clinician empathy was not associated with clinician initiation of a mental health discussion (regression coefficient 0.98 [95% confidence interval 0.89 to 1.1]; p = 0.65). A clinician-initiated mental health discussion was not associated with any factors. CONCLUSION: The observation that a clinician-initiated mental health discussion was not associated with diminished patient ratings of clinician empathy and was independent from other factors indicates that generally, discussion of mental health does not harm patient-clinician relationship. Musculoskeletal clinicians could be the first to notice disproportionate symptoms or misconceptions and distress about symptoms, and based on the evidence from this study, they can be confident about initiating a discussion about these mental health priorities to avoid delays in diagnosis and treatment. Future studies can address the impact of training clinicians to notice unhelpful thoughts and signs of distress and discuss them with compassion in a specialty care visit; other studies might evaluate the impact of timely diagnosis of opportunities for improvement in mental health on comfort, capability, and optimal stewardship of resources.

When Musculoskeletal Clinicians Respond to Empathetic Opportunities, do Patients Perceive Greater Empathy?

BACKGROUND: Patient use of verbal and nonverbal communication to signal what is most important to them can be considered empathetic opportunities. Orthopaedic surgeons may have mixed feelings toward empathetic opportunities, on one hand wanting the patient to know that they care, and on the other hand fearing offense, prolonged visit duration, or discussions for which they feel ill prepared. Evidence that action about empathetic opportunities does not harm the patient's experience or appreciably prolong the visit could increase the use of these communication tactics with potential for improved experience and outcomes of care. QUESTIONS/PURPOSES: Using transcripts from musculoskeletal specialty care visits in prior studies, we asked: (1) Are there factors, including clinician attentiveness to empathetic opportunities, associated with patient perception of clinician empathy? (2) Are there factors associated with the number of patient-initiated empathetic opportunities? (3) Are there factors associated with clinician acknowledgment of empathetic opportunities? (4) Are there factors associated with the frequency with which clinicians elicited empathetic opportunities? METHODS: This study was a retrospective, secondary analysis of transcripts from prior studies of audio and video recordings of patient visits with musculoskeletal specialists. Three trained observers identified empathetic opportunities in 80% (209 of 261) of transcripts of adult patient musculoskeletal specialty care visits, with any uncertainties or disagreements resolved by discussion and a final decision by the senior author. Patient statements considered consistent with empathetic opportunities included relation of emotion, expression of worries or concerns, description of loss of valued activities or loss of important roles or identities, relation of a troubling psychologic or social event, and elaboration on daily life. Clinician-initiated empathetic opportunities were considered clinician inquiries about these factors. Clinician acknowledgment of empathetic opportunities included encouragement, affirmation or reassurance, or supportive statements. Participants completed post-visit surveys of perceived clinician empathy, symptoms of depression, and health anxiety. Factors associated with perceived clinician empathy, number of empathetic opportunities, clinician responses to these opportunities, and the frequency with which clinicians elicited empathetic opportunities were sought in bivariate and multivariable analyses. RESULTS: After controlling for potentially confounding variables such as working status and pain self-efficacy scores in the multivariable analysis, no factors were associated with patient perception of clinician empathy, including attentiveness to empathetic opportunities. Patient-initiated empathetic opportunities were modestly associated with longer visit duration (correlation coefficient 0.037 [95% confidence interval 0.023 to 0.050]; p < 0.001). Clinician acknowledgment of empathetic opportunities was modestly associated with longer visit duration (correlation coefficient 0.06 [95% CI 0.03 to 0.09]; p < 0.001). Clinician-initiated empathetic opportunities were modestly associated with younger patient age (correlation coefficient -0.025 [95% CI -0.037 to -0.014]; p < 0.001) and strongly associated with one specific interviewing clinician as well as other clinicians (correlation coefficient -1.3 [95% CI -2.2 to -0.42]; p = 0.004 and -0.53 [95% CI -0.95 to -0.12]; p = 0.01). CONCLUSION: Musculoskeletal specialists can respond to empathic opportunities without harming efficiency, throughput, or patient experience. CLINICAL RELEVANCE: Given the evidence that patients prioritize feeling heard and understood, and evidence that a trusting patient-clinician relationship is protective and healthful, the results of this study can motivate specialists to train and practice effective communication tactics.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study.

BACKGROUND: Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH). METHODS: Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence. RESULTS: TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model. CONCLUSION: Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Agitation in the Trauma Bay Is an Early Indicator of Hemorrhagic Shock.

INTRODUCTION: Agitation on arrival in trauma patients is known as a sign of impending demise. The aim of this study is to determine outcomes for trauma patients who present in an agitated state. We hypothesized that agitation in the trauma bay is an early indicator for hemorrhage in trauma patients. METHODS: We performed a single-institution prospective observational study from September 2018 to December 2020 that included any trauma patient who arrived agitated, defined as a Richmond Agitation-Sedation Scale of +1 to +4. Variables collected included demographics, mechanism of injury, admission physiology, blood alcohol level, toxicity screen, and injury severity. The primary outcomes were need for massive transfusion (≥ 10 units) and need for emergent therapeutic intervention for hemorrhage control (laparotomy, preperitoneal pelvic packing, sternotomy, thoracotomy, or angioembolization). RESULTS: Of 4657 trauma admissions, 77 (2%) patients arrived agitated. Agitated patients were younger (40 versus 46, P = 0.03), predominantly male (94% versus 66%, P < 0.0001) sustained more penetrating trauma (31% versus 12%, P < 0.0001), had a lower systolic blood pressure (127 versus 137, P < 0.0001), and a higher Injury Severity Score (17 versus 9, P < 0.0001). On multivariable logistic regression, agitation was independently associated with massive transfusion (odds ratio: 2.63 [1.20-5.77], P = 0.02) and emergent therapeutic intervention for hemorrhage control (odds ratio: 2.60 [1.35-5.03], P = 0.005). CONCLUSIONS: Agitation in trauma patients may serve as an early indicator of hemorrhagic shock, as agitation is independently associated with a two-fold increase in the need for massive transfusion and emergent therapeutic intervention for hemorrhage control.

If at First You Do Not Succeed: Consideration of Attempts in Patients With Trauma.

INTRODUCTION: Failed extubation in critically ill patients is associated with poor outcomes. In critically ill trauma patients who have failed extubation, providers must decide whether to proceed with tracheostomy or attempt extubation again. The aim of this study was to describe the natural history of failed extubation in trauma patients and determine whether tracheostomy or a second attempt at extubation is more appropriate. METHODS: Trauma patients admitted to our level I trauma center from 2013 to 2019 were identified. Patients who failed extubation, defined as an unplanned reintubation within 48 h of extubation, were included. Patients who immediately underwent tracheostomy were compared with those who had subsequent attempts at extubation. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) length of stay (LOS), ventilator days, and hospital LOS. RESULTS: The population included 93 patients who failed extubation and met inclusion criteria. A total of 53 patients were ultimately successfully extubated, whereas 40 patients underwent a tracheostomy. There was no statistically significant difference in demographics or injury patterns. Patients who underwent tracheostomy had a longer ICU LOS and more ventilator days. There was no difference in mortality or hospital LOS between the two groups. CONCLUSIONS: In trauma patients, those who underwent subsequent attempts at extubation did not experience higher rates of mortality than those who received a tracheostomy. Tracheostomy was associated with longer ICU LOS and ventilator days. In certain situations, it is appropriate to consider subsequent attempts at extubation in trauma patients who fail extubation rather than proceeding directly to tracheostomy.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

BACKGROUND: Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. METHODS: A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. RESULTS: Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). CONCLUSION: This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.