Incidence, outcomes and costs of severe sepsis and septic shock in geriatric trauma patients: Analysis of 2,563,463 hospitalizations at 3,284 hospitals.

BACKGROUND: Severe sepsis/septic shock (sepsis) is a leading cause of death in hospitalized trauma patients. Geriatric trauma patients are an increasing proportion of trauma care but little recent, large-scale, research exists in this high-risk demographic. The objectives of this study are to identify incidence, outcomes and costs of sepsis in geriatric trauma patients. METHODS: Patients at short-term, nonfederal hospitals 65 years or older with ≥1 injury International Classification of Diseases, Tenth Revision, Clinical Modification code were selected from 2016 to 2019 Centers for Medicare & Medicaid Services Medicare Inpatient Standard Analytical Files. Sepsis was defined as International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes R6520 and R6521. A log-linear model was used to examine the association of Sepsis with mortality, adjusting for age, sex, race, Elixhauser score, and Injury Severity Score. Dominance analysis using logistic regression was used to determine the relative importance of individual variables in predicting Sepsis. Institutional review board exemption was granted for this study. RESULTS: There were 2,563,436 hospitalizations from 3,284 hospitals (62.8% female; 90.4% White; 72.7% falls; median ISS, 6.0). Incidence of Sepsis was 2.1%. Sepsis patients had significantly worse outcomes. Mortality risk was significantly higher in septic patients (adjusted risk ratio, 3.98, 95% confidence interval, 3.92-4.04). Elixhauser score contributed the most to the prediction of Sepsis, followed by ISS (McFadden's R2 = 9.7% and 5.8%, respectively). CONCLUSION: Severe sepsis/septic shock occurs infrequently among geriatric trauma patients but is associated with increased mortality and resource utilization. Pre-existing comorbidities influence Sepsis occurrence more than Injury Severity Score or age in this group, identifying a population at high risk. Clinical management of geriatric trauma patients should focus on rapid identification and prompt aggressive action in high-risk patients to minimize the occurrence of sepsis and maximize survival. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Evaluation of the Georgia trauma system using the American College of Surgeons Needs Based Assessment of Trauma Systems tool.

BACKGROUND: The American College of Surgeons Needs Based Assessment of Trauma Systems (NBATS) tool was developed to help determine the optimal regional distribution of designated trauma centers (DTC). The objectives of our current study were to compare the current distribution of DTCs in Georgia with the recommended allocation as calculated by the NBATS tool and to see if the NBATS tool identified similar areas of need as defined by our previous analysis using the International Classification of Diseases, Ninth Revision, Clinical Modification Injury Severity Score (ICISS). METHODS: Population counts were acquired from US Census publications. Transportation times were estimated using digitized roadmaps and patient zip codes. The number of severely injured patients was obtained from the Georgia Discharge Data System for 2010 to 2014. Severely injured patients were identified using two measures: ICISS<0.85 and Injury Severity Score >15. RESULTS: The Georgia trauma system includes 19 level I, II, or III adult DTCs. The NBATS guidelines recommend 21; however, the distribution differs from what exists in the state. The existing DTCs exactly matched the NBATS recommended number of level I, II, or III DTCs in 2 of 10 trauma service areas (TSAs), exceeded the number recommended in 3 of 10 TSAs, and was below the number recommended in 5 of 10 TSAs. Densely populated, or urban, areas tend to be associated with a higher number of existing centers compared with the NBATS recommendation. Other less densely populated TSAs are characterized by large rural expanses with a single urban core where a DTC is located. The identified areas of need were similar to the ones identified in the previous gap analysis of the state using the ICISS methodology. DISCUSSION: The tool appears to underestimate the number of centers needed in extensive and densely populated areas, but recommends additional centers in geographically expansive rural areas. The tool signifies a preliminary step in assessing the need for state-wide inpatient trauma center services. LEVEL OF EVIDENCE: Economic, level IV.

A Decade Evaluation of a State Trauma System: Has Access to Inpatient Trauma Care at Designated Trauma Centers Improved?

Recently, the trauma center component of the Georgia trauma system was evaluated demonstrating a 10 per cent probability of increased survival for severely injured patients treated at designated trauma centers (DTCs) versus nontrauma centers. The purpose of this study was to determine the effectiveness of a state trauma system to provide access to inpatient trauma care at DTCs for its residents. We reviewed 371,786 patients from the state's discharge database and identified 255,657 treated at either a DTC or a nontrauma center between 2003 and 2012. Injury severity was assigned using the International Classification Injury Severity Score method. Injury was categorized as mild, moderate, or severe. Patients were also categorized by age and injury type. Access improved over time in all severity levels, age groups, and injury types. Although elderly had the largest improvement in access, still only 70 per cent were treated at a DTC. During the study period, increases were noted for all age groups, injury severity levels, and types of injury. A closer examination of the injured elderly population is needed to determine the cause of lower utilization by this age group. Overall, the state's trauma system continues to mature by providing patients with increased access to treatment at DTCs.

Pulse!!: a model for research and development of virtual-reality learning in military medical education and training.

Pulse!! The Virtual Clinical Learning Lab at Texas A&M University-Corpus Christi, in collaboration with the United States Navy, has developed a model for research and technological development that they believe is an essential element in the future of military and civilian medical education. The Pulse!! project models a strategy for providing cross-disciplinary expertise and resources to educational, governmental, and business entities challenged with meeting looming health care crises. It includes a three-dimensional virtual learning platform that provides unlimited, repeatable, immersive clinical experiences without risk to patients, and is available anywhere there is a computer. Pulse!! utilizes expertise in the fields of medicine, medical education, computer science, software engineering, physics, computer animation, art, and architecture. Lab scientists collaborate with the commercial virtual-reality simulation industry to produce research-based learning platforms based on cutting-edge computer technology.

Preoperative anemia in colon cancer: assessment of risk factors.

Anemia is common in cancer patients and is associated with reduced survival. Recent studies document that treatment of anemia with blood transfusion in cancer patients is associated with increased infection risk, tumor recurrence, and mortality. We therefore investigated the incidence of preoperative anemia in colorectal cancer and assessed risk factors for anemia. Prospective data were collected on 311 patients diagnosed with colorectal cancer over a 6-year period from 1994 through 1999. Patients were stratified by age, gender, presenting complaint, preoperative hematocrit, American Joint Committee on Cancer (AJCC) stage, and TNM classification. Discrete variables were compared using Pearson's Chi-square analysis. Continuous variables were compared using Student's t test. Differences were considered significant when P < 0.05. The mean age of the study cohort was 67 +/- 9.2 with 98 per cent of the study population being male. The mean AJCC stage was 2.2 +/- 1.2 and the mean preoperative hematocrit was 35 +/- 7.9 with an incidence of 46.1 per cent. The most common presenting complaints were hematochezia (n = 59), anemia (n = 51), heme-occult-positive stool (n = 33), bowel obstruction (n = 26), abdominal pain (n = 21), and palpable mass (n = 13). Preoperative anemia was most common in patients with right colon cancer with an incidence of 57.6 per cent followed by left colon cancer (42.2%) and rectal cancer (29.8%). Patients with right colon cancer had significantly lower preoperative hematocrits compared with left colon cancer (33 +/- 8.5 vs 36 +/- 7.4; P < 0.01) and rectal cancer (33 +/- 8.5 vs 38 +/- 6.0; P < 0.0001). Patients with right colon cancer also had significantly increased stage at presentation compared with left colon cancer (2.3 +/- 1.3 vs 2.1 +/- 1.2; P < 0.02). Age was not a significant risk factor for preoperative anemia in colorectal cancer. We conclude that there is a high incidence of anemia in patients with colon cancer. Patients with right colon cancer had significantly lower preoperative hematocrits and higher stage of cancer at diagnosis. Complete colon evaluation with colonoscopy is warranted in patients with anemia to improve earlier diagnosis of right colon cancer. A clinical trial of preoperative treatment of anemic colorectal cancer patients with recombinant human erythropoietin is warranted.