Angioembolization for splenic injuries: does it help? Retrospective evaluation of grade III-V splenic injuries at two level I trauma centers.

Background: Splenic angioembolization (SAE) has increased in utilization for blunt splenic injuries. We hypothesized lower SAE usage would not correlate with higher rates of additional intervention or mortality when choosing initial non-operative management (NOM) or surgery. Study design: Trauma registries from two level I trauma centers from 2010 to 2020 were used to identify patients aged >18 years with grade III-V blunt splenic injuries. Results were compared with the National Trauma Data Bank (NTDB) for 2018 for level I and II centers. Additional intervention or failure was defined as any subsequent SAE or surgery. Mortality was defined as death during admission. Results: There were 266 vs 5943 patients who met inclusion/exclusion criteria at Stanford/Santa Clara Valley Medical Center (SCVMC) versus the NTDB. Initial intervention differed significantly between cohorts with the use of SAE (6% vs 17%, p=0.000). Failure differed significantly between cohorts (1.5% vs 6.5%, p=0.005). On multivariate analysis, failure in NOM was significantly associated with NTDB cohort status, age 65+ years, more than one comorbidity, mechanism of injury, grade V spleen injury, and Injury Severity Score (ISS) 25+. On multivariate analysis, failure in SAE was significantly associated with Shock Index >0.9 and 10+ units blood in 24 hours. On multivariate analysis, a higher risk of mortality was significantly associated with NTDB cohort status, age 65+ years, no private insurance, more than one comorbidity, mechanism of injury, ISS 25+, 10+ units blood in 24 hours, NOM, more than one hospital complications, anticoagulant use, other Abbreviated Injury Scale ≥3 abdominal injuries. Conclusions: Compared with national data, our cohort had less SAE, lower rates of additional intervention, and had lower risk-adjusted mortality. Shock Index >0.9, grade V splenic injuries, and increased transfusion requirements in the first 24 hours may signal a need for surgical intervention rather than SAE or NOM and may reduce mortality in appropriately selected patients. Level of evidence: Level II/III.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study.

Objectives: The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap. Methods: This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R. Results: Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves. Conclusion: Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity. Level of evidence: III.

The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures.

BACKGROUND: Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery. METHODS: All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models. RESULTS: An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)]. CONCLUSION: Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.

Anastomotic leak rates after repair of mesenteric bucket-handle injuries: A multi-center retrospective cohort study.

BACKGROUND: Primary aim was to assess the relative risk (RR) of anastomotic leak (AL) in intestinal bucket-handle (BH) compared to non-BH injury. METHODS: Multi-center study comparing AL in BH from blunt trauma 2010-2021 compared to non-BH intestinal injuries. RR was calculated for small bowel and colonic injury using R. RESULTS: AL occurred in 20/385 (5.2%) of BH vs. 4/225 (1.8%) of non-BH small intestine injury. AL was diagnosed 11.6 ± 5.6 days from index operation in small intestine BH and 9.7 ± 4.3 days in colonic BH. Adjusted RR for AL was 2.32 [0.77-6.95] for small intestinal and 4.83 [1.47-15.89] for colonic injuries. AL increased infections, ventilator days, ICU & total length of stay, reoperation, and readmission rates, although mortality was unchanged. CONCLUSION: BH carries a significantly higher risk of AL, particularly in the colon, than other blunt intestinal injuries.

Validation of the orthopedic frailty score for measuring frailty in hip fracture patients: a cohort study based on the United States National inpatient sample.

BACKGROUND: The Orthopedic Frailty Score (OFS) has been proposed as a tool for measuring frailty in order to predict short-term postoperative mortality in hip fracture patients. This study aims to validate the OFS using a large national patient register to determine its relationship with adverse outcomes as well as length of stay and cost of hospital stay. METHODS: All adult patients (18 years or older) registered in the 2019 National Inpatient Sample Database who underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. The association between the OFS and mortality, complications, and failure-to-rescue (FTR) was determined using Poisson regression models adjusted for potential confounders. The relationship between the OFS and length of stay and cost of hospital stay was instead determined using a quantile regression model. RESULTS: An estimated 227,850 cases met the study inclusion criteria. There was a stepwise increase in the rate of complications, mortality, and FTR for each additional point on the OFS. After adjusting for potential confounding, OFS 4 was associated with an almost ten-fold increase in the risk of in-hospital mortality [adjusted IRR (95% CI): 10.6 (4.02-27.7), p < 0.001], a 38% increased risk of complications [adjusted IRR (95% CI): 1.38 (1.03-1.85), p = 0.032], and an almost 11-fold increase in the risk of FTR [adjusted IRR (95% CI): 11.6 (4.36-30.9), p < 0.001], compared to OFS 0. Patients with OFS 4 also required a day and a half additional care [change in median length of stay (95% CI): 1.52 (0.97-2.08), p < 0.001] as well as cost approximately $5,200 more to manage [change in median cost of stay (95% CI): 5166 (1921-8411), p = 0.002], compared to those with OFS 0. CONCLUSION: Patients with an elevated OFS display a substantially increased risk of mortality, complications, and failure-to-rescue as well as a prolonged and more costly hospital stay.

A National Evaluation of Emergency General Surgery Outcomes Among Hospitalized Cardiac Patients.

INTRODUCTION: Emergency general surgery among cardiac surgery patients is increasingly common and consequential. We sought to characterize the true burden of emergency general surgery among hospitalized complex cardiac patients. METHODS: We performed a retrospective analysis of the 2016-2017 National Inpatient Sample. We included adult patients with a primary diagnosis of complex cardiac disease. We then compared patients who underwent emergency general surgery (GS-OR) with those who did not (non-GS-OR). The primary outcome was mortality; secondary outcomes included length of stay and hospitalization costs. RESULTS: We identified 10.2 million patients with a primary diagnosis of complex cardiac disease, of which 148,309 (1.4%) underwent GS-OR. Mortality rates were significantly higher in the GS-OR group (11.0% versus 5.0%, P < 0.001). Among all cardiac patients, GS-OR was associated with 2.2 times increased odds of death (aOR: 2.2, P < 0.001). GS-OR patients also had longer length of stays (14.1 versus 5.8 d, P < 0.001). Among all cardiac patients, GS-OR was associated with an 8.1-day longer length of stay (P < 0.001). GS-OR patients were less often routinely discharged home (31.7% versus 45.3%, P < 0.001) and incurred higher inpatient costs ($46,136 versus $16,303, P < 0.001). Among all cardiac patients, GS-OR patients incurred $30,102 higher hospitalization costs (P < 0.001). CONCLUSIONS: Emergency general surgery among cardiac surgery patients is associated with a greater than two-fold increase in mortality, longer length of stays, higher rates of nonroutine discharge, and higher hospitalization costs. Emergency general surgery complications account for 4.0% of total inpatient costs of cardiac surgery patients and merit further study.

Disparities in detection of suspected child abuse.

BACKGROUND: Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse. METHODS: The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race. RESULTS: Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type. CONCLUSIONS: Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: III.

Explainable Machine Learning to Bring Database to the Bedside: Development and Validation of the TROUT (Trauma fRailty OUTcomes) Index, a Point-of-Care Tool to Prognosticate Outcomes After Traumatic Injury Based on Frailty.

OBJECTIVE: Exemplify an explainable machine learning framework to bring database to the bedside; develop and validate a point-of-care frailty assessment tool to prognosticate outcomes after injury. BACKGROUND: A geriatric trauma frailty index that captures only baseline conditions, is readily-implementable, and validated nationwide remains underexplored. We hypothesized Trauma fRailty OUTcomes (TROUT) Index could prognosticate major adverse outcomes with minimal implementation barriers. METHODS: We developed TROUT index according to Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis guidelines. Using nationwide US admission encounters of patients aged ≥65 years (2016-2017; 10% development, 90% validation cohorts), unsupervised and supervised machine learning algorithms identified baseline conditions that contribute most to adverse outcomes. These conditions were aggregated into TROUT Index scores (0-100) that delineate 3 frailty risk strata. After associative [between frailty risk strata and outcomes, adjusted for age, sex, and injury severity (as effect modifier)] and calibration analysis, we designed a mobile application to facilitate point-of-care implementation. RESULTS: Our study population comprised 1.6 million survey-weighted admission encounters. Fourteen baseline conditions and 1 mechanism of injury constituted the TROUT Index. Among the validation cohort, increasing frailty risk (low=reference group, moderate, high) was associated with stepwise increased adjusted odds of mortality {odds ratio [OR] [95% confidence interval (CI)]: 2.6 [2.4-2.8], 4.3 [4.0-4.7]}, prolonged hospitalization [OR (95% CI)]: 1.4 (1.4-1.5), 1.8 (1.8-1.9)], disposition to a facility [OR (95% CI): 1.49 (1.4-1.5), 1.8 (1.7-1.8)], and mechanical ventilation [OR (95% CI): 2.3 (1.9-2.7), 3.6 (3.0-4.5)]. Calibration analysis found positive correlations between higher TROUT Index scores and all adverse outcomes. We built a mobile application ("TROUT Index") and shared code publicly. CONCLUSION: The TROUT Index is an interpretable, point-of-care tool to quantify and integrate frailty within clinical decision-making among injured patients. The TROUT Index is not a stand-alone tool to predict outcomes after injury; our tool should be considered in conjunction with injury pattern, clinical management, and within institution-specific workflows. A practical mobile application and publicly available code can facilitate future implementation and external validation studies.

DeepBackRib: Deep learning to understand factors associated with readmissions after rib fractures.

BACKGROUND: Deep neural networks yield high predictive performance, yet obscure interpretability limits clinical applicability. We aimed to build an explainable deep neural network that elucidates factors associated with readmissions after rib fractures among nonelderly adults, termed DeepBackRib . We hypothesized that DeepBackRib could accurately predict readmissions and a game theoretic approach to elucidate how predictions are made would facilitate model explainability. METHODS: We queried the 2017 National Readmissions Database for index hospitalization encounters of adults aged 18 to 64 years hospitalized with multiple rib fractures. The primary outcome was 3-month readmission(s). Study cohort was split 60-20-20 into training-validation-test sets. Model input features included demographic/injury/index hospitalization characteristics and index hospitalization International Classification of Diseases, Tenth Revision , diagnosis codes. The seven-layer DeepBackRib comprised multipronged strategies to mitigate overfitting and was trained to optimize recall. Shapley additive explanation analysis identified the marginal contribution of each input feature for predicting readmissions. RESULTS: A total of 20,260 patients met the inclusion criteria, among whom 11% (n = 2,185) experienced 3-month readmissions. Feature selection narrowed 3,164 candidate input features to 61, and DeepBackRib yielded 91%, 85%, and 82% recall on the training, validation, and test sets, respectively. Shapley additive explanation analysis quantified the marginal contribution of each input feature in determining DeepBackRib's predictions: underlying chronic obstructive pulmonary disease and long index hospitalization length of stay had positive associations with 3-month readmissions, while private primary payer and diagnosis of pneumothorax during index admission had negative associations. CONCLUSION: We developed and internally validated a high-performing deep learning algorithm that elucidates factors associated with readmissions after rib fractures. Despite promising predictive performance, standalone deep learning algorithms are insufficient for clinical prediction tasks: a concerted effort is needed to ensure that clinical prediction algorithms remain explainable. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

A decade of hospital costs for firearm injuries in the United States by region, 2005-2015: government healthcare costs and firearm policies.

Background: Firearm injuries are a costly, national public health emergency, and government-sponsored programs frequently pay these hospital costs. Understanding regional differences in firearm injury burden may be useful for crafting appropriate policies, especially with widely varying state gun laws. Objective: To estimate the volume of, and hospital costs for, fatal and non-fatal firearm injuries from 2005 to 2015 for each region of the United States and analyze the proportionate cost by payer status. Methods: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2005 to 2015. We converted hospitalization charges to costs, which were inflation-adjusted to 2015 dollars. We used survey weights to create regional estimates. We used the Brady Gun Law to determine significance between firearm restrictiveness and firearm hospitalizations by region. Results: There were a total of 317 479 firearm related admissions over the study period: 52 829 (16.66%), 66 671 (21.0%), 134 008 (42.2%), and 63 972 (20.2%) for the Northeast, Midwest, South, and West respectively, demonstrating high regional variability. In the Northeast, hospital costs were $1.98 billion (13.9% of total), of which 56.0% was covered by government payers; for the Midwest, costs were $153 billion (19.7% of total), 40.4% of which was covered by government payers; in the South costs were highest at $3.2 billion (41.4% of total), but government payers only covered 34.3%; and costs for the West were $1.94 billion (25.0% of total), with government programs covering 41.6% of the cost burden. Conclusions: Hospital admissions and costs for firearm injuries demonstrated wide variation by region, suggesting opportunities for financial savings. As government insurance programs cover 41.5% of costs, tax dollars heavily subsidize the financial burden of firearm injuries and cost recovery options for treating residents injured by firearms should be considered. Injury control strategies have not been well applied to this national public health crisis. Level of evidence: Level II, Economic and Value Based Evaluation.

Concomitant Sternal Fractures: Harbinger of Worse Pulmonary Complications and Mortality in Patients With Rib Fractures.

BACKGROUND: Sternal and rib fractures are common concomitant injuries. However, the impact of concurrent sternal fractures on clinical outcomes of patients with rib fractures is unclear. We aimed to unveil the pulmonary morbidity and mortality impact of concomitant sternal fractures among patients with rib fractures. METHODS: We identified adult patients admitted with traumatic rib fractures with vs. without concomitant sternal fractures using the 2012-2014 National Inpatient Sample (NIS). After 2:1 propensity score matching and adjustment for residual imbalances, we compared risk of pulmonary morbidity and mortality between patients with vs. without concomitant sternal fractures. Subgroup analysis in patients with flail chest assessed whether sternal fractures modify the association between undergoing surgical stabilization of rib fractures (SSRF) and pulmonary morbidity or mortality. RESULTS: Of 475 710 encounters of adults admitted with rib fractures, 24 594 (5%) had concomitant sternal fractures. After 2:1 propensity score matching, patients with concomitant sternal fractures had 70% higher risk (95% CI: 50-90% higher, P < 0.001) of undergoing tracheostomy, 40% higher risk (30-50% higher, P <.001) of undergoing intubation, and 20% higher risk of respiratory failure (10-30% higher, P <.001) and mortality (10-40% higher, P =.007). Subgroup analysis of 8600 patients with flail chest showed concomitant sternal fractures did not impact the association between undergoing SSRF and any pulmonary morbidity or mortality. CONCLUSION: Concomitant sternal fractures are associated with increased risk for pulmonary morbidity and mortality among patients with rib fractures. However, our findings are limited by a binary definition of sternal fractures, which encompasses heterogeneous injury patterns with likely variable clinical relevance.

Factors associated with postoperative complications and costs for adrenalectomy in benign adrenal disorders.

BACKGROUND: The incidence of adrenal incidentaloma has been increasing, and indications of and approaches to adrenalectomy are diverse. Drivers of complications and costs are not well identified. METHODS: The 2016 National Inpatient Sample data were used to identify patients who underwent adrenalectomy for benign adrenal disorders, such as Cushing syndrome, primary hyperaldosteronism, pheochromocytoma, and other benign neoplasms defined using the 10th Revision of the International Classification of Diseases. The primary outcome was determining the factors associated with clinical outcomes, perioperative complications, and hospitalization costs. RESULTS: Using weighted estimates of the national sample data, 5,140 patients were identified. The mean age was 55 years. The majority of adrenalectomies were performed laparoscopically (48.5%) followed by a robotic approach (32.7%). The postoperative complication rate was 7.6%. In adjusted multivariable analyses, independent risk factors for perioperative complications included Hispanic race (odds ratio, 2.5; P = .01), and perioperative comorbid heart failure (odds ratio, 6.3; P < .001) and respiratory failure (odds ratio, 9.9; P < .001). The mean cost was $18,122. Independent risk factors associated with decrease of cost were female sex and primary hyperaldosteronism; factors associated with increased cost were pheochromocytoma, intraoperative complications, perioperative underlying comorbid respiratory failure and heart failure, and postoperative complications (P < .001). CONCLUSION: Among patients undergoing adrenalectomy for benign adrenal disorders, underlying comorbidities, including heart and respiratory failure, should be considered when recommending adrenalectomy, as these may increase the postoperative complication rates and hospitalization costs.

Rib Fracture Frailty Index: A risk stratification tool for geriatric patients with multiple rib fractures.

BACKGROUND: Rib fractures are consequential injuries for geriatric patients (age, ≥65 years). Although age and injury patterns drive many rib fracture management decisions, the impact of frailty-which baseline conditions affect rib fracture-specific outcomes-remains unclear for geriatric patients. We aimed to develop and validate the Rib Fracture Frailty (RFF) Index, a practical risk stratification tool specific for geriatric patients with rib fractures. We hypothesized that a compact list of frailty markers can accurately risk stratify clinical outcomes after rib fractures. METHODS: We queried nationwide US admission encounters of geriatric patients admitted with multiple rib fractures from 2016 to 2017. Partitioning around medoids clustering identified a development subcohort with previously validated frailty characteristics. Ridge regression with penalty for multicollinearity aggregated baseline conditions most prevalent in this frail subcohort into RFF scores. Regression models with adjustment for injury severity, sex, and age assessed associations between frailty risk categories (low, medium, and high) and inpatient outcomes among validation cohorts (odds ratio [95% confidence interval]). We report results according to Transparent Reporting of Multivariable Prediction Model for Individual Prognosis guidelines. RESULTS: Development cohort (n = 55,540) cluster analysis delineated 13 baseline conditions constituting the RFF Index. Among external validation cohort (n = 77,710), increasing frailty risk (low [reference group], moderate, high) was associated with stepwise worsening adjusted odds of mortality (1.5 [1.2-1.7], 3.5 [3.0-4.0]), intubation (2.4 [1.5-3.9], 4.7 [3.1-7.5]), hospitalization ≥5 days (1.4 [1.3-1.5], 1.8 [1.7-2.0]), and disposition to home (0.6 [0.5-0.6], 0.4 [0.3-0.4]). Locally weighted scatterplot smoothing showed correlations between increasing RFF scores and worse outcomes. CONCLUSION: The RFF Index is a practical frailty risk stratification tool for geriatric patients with multiple rib fractures. The mobile app we developed may facilitate rapid implementation and further validation of RFF Index at the bedside. LEVEL OF EVIDENCE: Prognostic study, level III.

Nationwide cost-effectiveness analysis of surgical stabilization of rib fractures by flail chest status and age groups.

BACKGROUND: Surgical stabilization of rib fracture (SSRF) is increasingly used to manage patients with rib fractures. Benefits of performing SSRF appear variable, and the procedure is costly, necessitating cost-effectiveness analysis for distinct subgroups. We aimed to assess the cost-effectiveness of SSRF versus nonoperative management among patients with rib fractures younger than 65 years versus 65 years or older, with versus without flail chest. We hypothesized that, compared with nonoperative management, SSRF is cost-effective only for patients with flail chest. METHODS: This economic evaluation used a decision-analytic Markov model with a lifetime time horizon incorporating US population-representative inputs to simulate benefits and risks of SSRF compared with nonoperative management. We report quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios. Deterministic and probabilistic sensitivity analyses accounted for most plausible clinical scenarios. RESULTS: Compared with nonoperative management, SSRF was cost-effective for patients with flail chest at willingness-to-pay threshold of US $150,000/QALY gained. Surgical stabilization of rib fracture costs US $25,338 and US $123,377/QALY gained for those with flail chest younger than 65 years and 65 years or older, respectively. Surgical stabilization of rib fracture was not cost-effective for patients without flail chest, costing US $172,704 and US $243,758/QALY gained for those younger than 65 years and 65 years or older, respectively. One-way sensitivity analyses showed that, under most plausible scenarios, SSRF remained cost-effective for subgroups with flail chest, and nonoperative management remained cost-effective for patients older than 65 years without flail chest. Probability that SSRF is cost-effective ranged from 98% among patients younger than 65 years with flail chest to 35% among patients 65 years or older without flail chest. CONCLUSIONS: Surgical stabilization of rib fracture is cost-effective for patients with flail chest. Surgical stabilization of rib fracture may be cost-effective in some patients without flail chest, but delineating these patients requires further study. LEVEL OF EVIDENCE: Economic/decision, level II.

Early National Landscape of Surgical Stabilization of Sternal Fractures.

BACKGROUND: Operative management of chest wall injuries aims to restore respiratory mechanics and mitigate pulmonary complications. Extensive studies support surgical stabilization of rib fractures (SSRF) for select patients, but role for surgical stabilization of sternal fractures (SSSF) remains unclear. We aimed to understand national prevalence of SSSF and compare outcomes after surgical stabilization and non-operative management of sternal fractures. METHODS: We retrospectively analyzed adult patients (age ≥ 18 years) admitted with sternal fractures after blunt trauma using the 2016 National Trauma Data Bank. We compared odds of inpatient mortality, pneumonia, and respiratory failure for propensity score matched patients (4:1) who underwent non-operative management vs SSSF. We characterized subgroup of patients with concurrent rib and sternal fractures who underwent concomitant SSRF-SSSF. RESULTS: We identified 14,760 encounters of adults admitted with sternal fractures; 270 (1.8%) underwent SSSF. Compared to matched patients who underwent non-operative management, patients who underwent SSSF had lower odds of mortality (OR [95%CI]: 0.19 [0.06-0.62], p = 0.006). Adjusted for trauma center level, Mantel-Haenszel mortality odds remained lower for patients who underwent SSSF. Odds of pneumonia and respiratory failure were similar between matched groups. Among 46% of patients who had concomitant rib fractures, 0.3% (n = 18) underwent concurrent SSRF-SSSF and these patients survived hospitalization without pneumonia or respiratory failure. CONCLUSION: A vast majority of patients who suffer sternal fractures undergo non-operative management. Potential mortality benefit of SSSF and concurrent SSRF-SSSF's role for commonly concomitant rib and sternal fractures deserve further study. Our preliminary findings call for delineating heterogeneity of sternal fractures and establishing consensus SSSF indications.

Heterogeneity in managing rib fractures across non-trauma and level I, II, and III trauma centers.

BACKGROUND: We aimed to elucidate management patterns and outcomes of high-risk patients with rib fractures (elderly or flail chest) across non-trauma and trauma centers. We hypothesized highest-capacity (level I) centers would have best outcomes for high-risk patients. METHODS: We queried the 2016 National Emergency Department Sample to identify adults presenting with rib fractures. Multivariable regression assessed ED and inpatient events across non-trauma and level III/II/I trauma centers. RESULTS: Among 504,085 rib fracture encounters, 46% presented to non-trauma centers. Elderly patients with multiple rib fractures had stepwise increase in inpatient admission odds and stepwise decrease in pneumonia odds at higher-capacity trauma centers compared to non-trauma centers. Among patients with flail chest, odds of undergoing surgical stabilization (SSRF) increased at trauma centers. Undergoing SSRF was associated with reduced mortality but remained underutilized. CONCLUSION: Half of patients with rib fractures present to non-trauma centers. Nationwide care-optimization for high-risk patients requires further effort.

Outcomes after Surgery among Patients Diagnosed with One or More Multi-Drug-Resistant Organisms.

Background: Infections with multi-drug-resistant organisms (MDROs) may be difficult to treat and prolong patient hospitalization and recovery. Multiple MDRO coinfections may increase the complexity of clinical management. However, association between multiple MDROs and outcomes of patients who undergo surgery is unknown. Patients and Methods: We performed a retrospective, cross-sectional analysis of the 2016 National Inpatient Sample for identified by International Classification of Disease, 10th Revision Clinical Modification (ICD-10-CM) diagnosis codes associated with multi-drug-resistant organisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), multi-drug-resistant gram-negative bacilli, and Clostridioides difficile infection (CDI). Admitted patients with diagnosis codes for MDROs were cross-matched with codes for common general surgery procedures. Outcomes of interest included length of stay and mortality. Weighted univariable and multivariable analyses accounting for the survey methodology were performed. Results: Of 1,550,224 patients undergoing surgery in 2016, 39,065 (3%) admissions were diagnosed with an MDRO and 1,176 (0.1%) were associated with dual MDROs diagnoses. Patients diagnosed with one MDRO were hospitalized three times longer (17.3 days; 95% confidence interval [CI], 16.8-17.7) and patients diagnosed with two MDROs five times longer (31.6 days; 95% CI, 27.0-36.2; p < 0.0001) than undiagnosed patients (6.1 days; 95% CI, 6.1-6.1; all p < 0.0001). On multivariable analysis, the strongest predictor of mortality was a diagnosis of two MDRO infections (odds ratio [OR], 4.8; 95% CI, 3.16-7.21; p < 0.0001). The second strongest predictor was diagnosis of single MDRO infection (OR, 2.9; 95% CI, 2.64-3.20; p < 0.0001). Conclusion: Presence of an MDRO was associated with increased odds of mortality and length of stay in admitted surgical patients. Interventions to reduce MDRO infection among surgical patients may reduce hospital length of stay and mortality.

Pulmonary contusions in patients with rib fractures: The need to better classify a common injury.

BACKGROUND: Pulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion. METHODS: We identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality. RESULTS: Among 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16-33%], respiratory failure 40% [95%CI: 31-50%], and intubation 46% [95%CI: 33-61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications. CONCLUSIONS: There is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.

Mortality After General Surgery Among Hospitalized Patients With Hematologic Malignancy.

BACKGROUND: Hospitalized patients with hematologic malignancies (HMs) may require abdominal operations for complications of malignancy, treatment sequelae, or unrelated abdominal pathology. We determined predictors of mortality after emergency general surgery for patients with HM using national-level data. MATERIALS AND METHODS: We analyzed the 2010-2014 National Inpatient Sample for International Classification of Disease, Ninth Revision, Clinical Modification codes for HM and abdominal operations, comparing adult patient encounters with abdominal operations with HM to those without HM. Multivariate logistic regression was performed to identify predictors of mortality. RESULTS: Of the 7.9 million adult inpatient encounters where abdominal surgery was performed, 82,187 (1%) had concomitant diagnoses of HM. Mortality among patient encounters with HM was significantly higher than without HM (9.0% versus 2.0%; P < 0.0001). Patient encounters with HM and surgery and a diagnosis of acute abdominal pain had mortality rates as high as 41%. The median standardized risk ratio for death after the top 25 general surgery procedures was 2.9 (interquartile range: 2.2-3.8) among patients with HM. In adjusted analyses, odds of mortality among patients with HM undergoing surgery were increased by concomitant acute abdominal pain diagnosis (odds ratio [OR] = 2.6; P < 0.0001), coagulopathy (OR = 2.0; P < 0.0001), aplastic anemia (OR = 1.7; P < 0.0001), peripheral vascular disease (OR = 1.4; P = 0.001), and weight loss (OR = 1.3; P < 0.0001). CONCLUSIONS: Although uncommon, surgery on patients with HM is associated with mortality rates nearly five times higher than the general surgical population. Patients with HM requiring surgical intervention may be at particularly high odds of death and postoperative complications.