Pooled Analysis of Trauma Centers Better Predicts Risk Factors for Firearm Violence Reinjury.

INTRODUCTION: Many trauma centers use the first firearm injury admission as a reachable moment to mitigate reinjury. Understanding repeat firearm violence can be difficult in metropolitan areas with multiple trauma centers and laws that prohibit sharing private health information across health systems. We hypothesized that risk factors for repeat firearm violence could be better understood using pooled data from two major metropolitan trauma centers. METHODS: Two level I trauma center registries were queried (2007-2017) for firearm injury admissions using International Classification of Diseases, Ninth and Tenth Revision (ICD9/10) Ecodes. A pseudo encryption tool allowed sharing of deidentified firearm injury and repeat firearm injury data without disclosing private health information. Factors associated with firearm reinjury admissions including, age, sex, race, payor, injury severity, intent, and discharge, were assessed by multivariable logistic regression. RESULTS: We identified 2145 patients with firearm injury admissions, 89 of whom had a subsequent repeat firearm injury admission. Majority of repeat firearm admissions were assaulted (91%), male (97.8%), and non-Hispanic Black (86.5%). 31.5% of repeat firearm injury admissions were admitted to a different trauma center from their initial admission. Independent predictors of repeat firearm injuries were age (adjusted odds ratio [aOR] 0.94, P < 0.001), male sex (aOR 6.18, P = 0.013), non-Hispanic Black race (aOR 5.14, P = 0.007), or discharge against medical advice (aOR 6.64, P=<0.001). CONCLUSIONS: Nearly a third of repeat firearm injury admissions would have been missed in the current study without pooled metropolitan trauma center data. The incidence of repeat firearm violence is increasing and those at the highest risk for reinjury need to be targeted for mitigating interventions.

A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Comparing Firearm and Stabbing Injuries in the Pediatric Trauma Population Using Propensity Matching.

OBJECTIVES: The objective of this study was to compare differences in mortality and nonhome discharge in pediatric patients with firearm and stab injuries, while minimizing bias. Our secondary objective was to assess the influence of insurance on these same outcomes. METHODS: Patients aged 0 to 17 years included in the National Trauma Data Bank (2007-2015) with firearm and stabbing injury were matched by propensity score. Logistic regression was used to assess associations of injury type and insurance with long-term care discharge and death. RESULTS: The average age was 14.8 years, 19.2% were female, 48% were African American, 58.4% had an injury severity score ≤8, and assaults accounted for 73.1% of cases. Firearm injuries were associated with a higher risk of discharge to long-term care (adjusted odds ratio [aOR], 2.07) compared with propensity-matched patients who were stabbed. Similarly, we found a higher risk of mortality in those with firearm injuries compared with stabbing injuries (aOR, 1.85). Regardless of mechanism, self-pay insurance status was associated with a higher risk of mortality (aOR, 2.41). When compared with stab wound patients with commercial insurance, self-pay firearm-injured patients were found to have an increased risk of mortality (aOR, 5.25). CONCLUSIONS: Pediatric victims of firearm violence were more likely to die or need additional care outside the home than victims of other types of penetrating injury when accounting for confounding characteristics to minimize bias.

Treatment of Hypothermic Cardiac Arrest in the Pediatric Drowning Victim, a Case Report, and Systematic Review.

OBJECTIVES: Drowning is the second leading cause of death in children. Extracorporeal membrane oxygenation (ECMO) has become the criterion standard therapy to resuscitate the hypothermic drowning victim in cardiac arrest. We present our own experience treating 5 children with hypothermic cardiac arrest in conjunction with a systematic review to analyze clinical features predictive of survival. METHODS: Our search resulted in 55 articles. Inclusion criteria were as follows: (1) younger than 18 years, (2) ECMO therapy, and (3) drowning. Ten articles met our inclusion criteria. We included studies using both central and peripheral ECMO and salt or fresh water submersions. We compared clinical features of survivors to nonsurvivors. RESULTS: A total of 29 patients from the 10 different studies met our criteria. Data analyzed included presenting cardiac rhythm, time to initiation of ECMO, submersion time, pH, potassium, lactate, duration of chest compressions, and survival. There was a significant increase in mortality for presenting rhythm of asystole and with hyperkalemia (P < 0.05). CONCLUSIONS: Extracorporeal membrane oxygenation is an important resuscitation tool for the hypothermic drowning victim. Hyperkalemia and presenting cardiac rhythm correlate with survival although they are not reasons to end resuscitation. More studies are needed to compare the outcomes in using ECMO for the hypothermic drowning victim.

Graft survival of fourth-time renal transplant recipients is similar to third-time recipients: A SRTR database analysis.

BACKGROUND: Candidates for repeat kidney transplant (KT) have increased. While graft and patient survival are inferior to primary KT, second and third KTs improve patient survival over dialysis. Little is known about the outcomes after fourth KTs. METHODS: We retrospectively compared characteristics of third and fourth KTs in the SRTR. Factors associated with graft survival in third vs fourth KT and patient survival of fourth KT vs patients waitlisted for a 4th KT were assessed by Cox regression and multivariable linear regression analysis. RESULTS: There were 3055 third- and fourth-time KTs performed in the United States. Fourth-time graft survival was not significantly different from third-time transplants (HR 1.06, P = .653). Patients who received a fourth KT have a significant survival advantage compared with patients who remained on the waitlist for a fourth KT (HR = 0.53, P = .006). CONCLUSIONS: Graft and patient survival of fourth KTs are comparable to third KTs, but inferior to first and second KTs in terms of graft and patient survival. Recipients of fourth KT have had an increased life expectancy compared with patients waitlisted for a fourth KT.

Incidence and Profile of Severe Cycling Injuries After Bikeway Infrastructure Changes.

The objective of this study was to evaluate whether bicycling infrastructure changes in the city of Minneapolis effectively reduced the incidence or severity of traumatic bicycling related injuries sustained by patients admitted to our Level 1 Trauma Center. Data for this retrospective cohort study was obtained from the trauma database at our institution and retrospective chart review. The total number of miles of bikeway in the city on a yearly basis was used to demonstrate the change in cycling infrastructure. Adjusted regression analysis demonstrated a significant reduction in ISS when total bike lane miles increased (Coef. - 0.04, P < 0.001). Increasing bike lane miles was also associated with a significant reduction in severe head injury (OR 0.99, P < 0.001) and ICU LOS (Coef. - 0.17, P = 0.013). The miles of bike lanes were not associated with any significant changes in mortality or mechanical ventilation days when adjusted for other factors. We were able to demonstrate a reduction in the severity of injuries incurred by cyclists in the setting of a significant increase in the total number of bicycle lane miles. Our data lends credence to the existing evidence that the addition of bicycle lane miles increases cyclist safety.

Use of Chest Computed Tomography for Blunt Pediatric Chest Trauma: Does It Change Clinical Course?

INTRODUCTION: Given the concern for radiation-induced malignancy in children and the fact that risk of severe chest injury in children is low, the risk/benefit ratio must be considered in each child when ordering a computed tomography (CT) scan after blunt chest trauma. METHODS: The study included pediatric blunt trauma patients (age, <15 years) with chest radiograph (CR) before chest CT on admission to our adult and pediatric level I trauma center. Surgeons were asked to view the blinded images and reads and indicate if they felt CT was warranted based on CR findings, if their clinical management change based on additional findings on chest CT, and how they might change management. RESULTS: Of the 127 patients identified, 64.6% had no discrepancy between their initial CR and chest CT and 35.4% of the children's imaging contained a discrepancy. The majority of the pediatric and general trauma surgeons felt CT was indicated in 6 of 45 patients based on CR. In 87% of patients with a discrepancy in findings on CR and CT, the majority of surgeons agreed that their management would not change based on the additional information. In the 6 patients in which the CT was considered indicated, 4 of the 6 would have triggered a management change. CONCLUSIONS: Our study suggests that chest CT scans frequently serve as confirmatory diagnostic tools and in the pediatric blunt chest trauma patient and can be withheld in many cases without hindering the management of an injured child.

Marijuana use should not preclude consideration for kidney transplantation.

Transplant eligibility for tobacco and/or marijuana using candidates varies among transplant centers. This study compared the impact of marijuana use and tobacco use on kidney transplant recipient outcomes. Kidney transplant recipients at a single center from 2001 to 2015 were reviewed for outcomes of all-cause graft loss, infection, biopsy-proven acute rejection, and estimated glomerular filtration rate between four groups: marijuana-only users, marijuana and tobacco users, tobacco-only users, and nonusers. The cohort (N = 919) included 48 (5.2%) marijuana users, 45 (4.8%) marijuana and tobacco users, 136 (14.7%) tobacco users, and 75% nonusers. Smoking status was not significantly associated with acute rejection, estimated glomerular filtration rate or pneumonia within one-year post-transplant in an adjusted model. Compared to nonuse, marijuana and tobacco use and tobacco-only use was significantly associated with increased risk of graft loss (aHR 1.68, P = .034 and 1.52, P = .006, respectively). Patients with isolated marijuana use had similar overall graft survival compared to nonusers (aHR 1.00, P = .994). Marijuana use should not be an absolute contraindication to kidney transplant.

Prediction of discharge destination after traumatic brain injury in children using the head abbreviated injury scale.

INTRODUCTION: Traumatic brain injury (TBI) is a major public health problem, particularly in children. Prognostication of injury severity at the time of presentation is difficult. The Abbreviated Injury Scale (AIS) is a commonly used anatomical-based coding system created to classify and describe injury severity after initial presentation, once test results are able to better define the anatomical characteristics of the injury. We hypothesize that the Head AIS can predict discharge destination in children after TBI. METHODS: The trauma registry database for a Pediatric Level 1 Trauma center was queried for patients age ≤14 years from 2006 to 2015 with a Head AIS>2. All diagnoses with head AIS>2 were retrieved. Since one patient can have multiple diagnoses with an AIS>2, we selected the diagnosis with highest Head AIS associated with each patient. The demographics, length of stay, and the discharge disposition of patients were retrieved. Descriptive statistics were performed and association of Head AIS with the length of stay and discharge disposition was determined using logistic regression. RESULTS: 393 pediatric patients (age≤14 years) with an Head AIS ≥3, (64.0% males, mean age = 6.2 S.D. 4.58) presented over 10 years. Head AIS was strongly associated with mortality; with 0.8%, 1.1% and 42.0% of patients with Head AIS of 3, 4 and 5, respectively, dying - odds ratio for Head AIS 5 over Head AIS 3 = 89 (logistic regression, p-value<0.001). 80.0% of deaths (23 patients) in this cohort occurred within 24-h of presentation. Head AIS was associated with an increase likelihood of discharge to rehabilitation with 1.2%, 7.7% and 47.0% of survivors discharging to rehabilitation for Head AIS of 3, 4 and 5. CONCLUSION: Head AIS can reliably predict discharge disposition to home, rehab or death. Calculation of Head AIS prior to discharge could lead to accurate prediction of discharge destination.

The association between objectively-measured activity, sleep, call responsibilities, and burnout in a resident cohort.

BACKGROUND: When compared to the general US working population, physicians are more likely to experience burnout and dissatisfaction with work-life balance. Our aim was to examine the association of objectively-measured sleep, activity, call load, and gender with reported resident burnout and wellness factors. METHODS: Residents were recruited to wear activity tracker bands and complete interval blinded surveys. RESULTS: Of the 30 residents recruited, 28 (93%) completed the study. Based on survey results, residents who reported high amounts of call reported equivalent levels of wellness factors to those who reported low call loads. There was no association between amount of call on training satisfaction, emotional exhaustion, self-reported burnout, or sleep quality. Analysis of sleep tracker data showed that there was no significant association with time in bed, time asleep, times awakened or sleep latency and call load or self-reported burnout. Female gender, however, was found to be associated with self-reported burnout. No significant associations were found between objectively-measured activity and burnout. CONCLUSIONS: Based on the results of our study, there was no association with burnout and objectively-measured sleep, call volume, or activity. Increased call demands had no negative association with training satisfaction or professional fulfillment. This would suggest that more hours worked does not necessarily equate to increased burnout.

A clinical tool to risk stratify potential kidney transplant recipients and predict severe adverse events.

Preoperative risk assessment of potential kidney transplant recipients often fails to adequately balance risk related to underlying comorbidities with the beneficial impact of kidney transplantation. We sought to develop a simple scoring system based on factors known at the time of patient assessment for placement on the waitlist to predict likelihood of severe adverse events 1 year post-transplant. The tool includes four components: age, cardiopulmonary factors, functional status, and metabolic factors. Pre-transplant factors strongly associated with severe adverse events include diabetic (OR: 3.76, P<.001), coronary artery disease (OR: 3.45, P<.001), history of CABG/PCI (OR 3.1, P=.001), and peripheral vascular disease (OR 2.74, P=.008).The score was evaluated by calculation of concordance index. The C statistic of 0.74 for the risk stratification group was considered good discrimination in the validation cohort (N=127) compared to the development cohort (N=368). The pre-transplant risk group was highly predictive of severe adverse events (OR 2.36, P<.001). Patients stratified into the above average-risk group were four times more likely to experience severe adverse events compared to average-risk patients, while patients in the high-risk group were nearly 11 times more likely to experience severe adverse events. The pre-transplant risk stratification tool is a simple scoring scheme using easily obtained preoperative characteristics that can meaningfully stratify patients in terms of post-transplant risk and may ultimately guide patient selection and inform the counseling of potential kidney transplant recipients.

The ligation of the intersphincteric fistula tract procedure for anal fistula: a mixed bag of results.

BACKGROUND: The ligation of the intersphincteric fistula tract procedure, a sphincter-preserving technique, aims to obtain complete, durable healing, while preserving fecal continence in the treatment of transsphincteric anal fistulas. OBJECTIVE: This was a systematic review to evaluate the outcomes of the originally described (classic) ligation of the intersphincteric fistula tract procedure and the identified technical variations of the procedure. DATA SOURCES: PubMed, Web of Science, and the archive of Diseases of the Colon & Rectum were searched with the terms "ligation of intersphincteric fistula" and "ligation of intersphincteric fistula tract." STUDY SELECTION: Original, English-language studies reporting the primary healing rate for each technical variation of the ligation of the intersphincteric fistula tract procedure were included. Studies were excluded when the technique used was unclear or when primary healing rate was reported in a pooled manner including outcomes from multiple technical variations of the ligation of the intersphincteric fistula tract procedure. INTERVENTION: Outcomes associated with all of the technical variations of the ligation of the intersphincteric fistula tract procedure were investigated. MAIN OUTCOME MEASURES: The main outcome measured was primary healing rate. Secondary outcome measures included time to healing, changes in continence, and risk factors for failure. RESULTS: In all, 26 studies met criteria for review, including 1 randomized controlled trial and 25 cohort/case series. Seven technical variations of the ligation of the intersphincteric fistula tract procedure were identified and classified according to the surgical technique. Primary healing rates ranged from 47% to 95%. LIMITATIONS: The levels of evidence available in the published works are relatively low, as indicated by the Oxford Center for Evidence-Based Medicine evidence levels. CONCLUSIONS: The ligation of the intersphincteric fistula tract procedure is a promising treatment option for transsphincteric fistulas, with reasonable success rates and minimal impact on continence. The true efficacy of the procedure is unknown because of the number of technical variations and the pooled results reported in the literature.

Impact of personality, sex, and generation on resident operative role.

BACKGROUND: The aim of this study was to determine if gender, generation, or personality traits influence resident perception of their operative role. MATERIALS AND METHODS: Over a 4-wk period, daily surveys were sent to residents and staff to assess the Accreditation Council for Graduate Medical Education (ACGME) role of residents on operative cases. Personality was assessed on completion of the survey period using the big five inventory (BFI). RESULTS: In 184 paired responses, resident perception of their operative role and staff reported resident role coincided in 82.1% surveys. In instances when resident perception differed from staff assessment, neither gender nor generation correlated with discrepancy between resident and staff assessment. High BFI agreeableness of staff was associated with more disparity, and high BFI neuroticism scores of staff translated to less disparity between resident-perceived and staff-assessed operative roles (odds ratio 2.63, P = 0.003 and odds ratio 0.44, P = 0.002, respectively). CONCLUSIONS: This study demonstrates agreement between resident and staff reports of ACGME resident operative role in most cases; however, staff personality traits influenced resident's perception of their operative role. Perceived underparticipation in operative cases may influence a resident's experience during training, which may impact their reporting of operative experience to the ACGME.

Genetic determinants of reovirus pathogenesis in a murine model of respiratory infection.

Many viruses invade mucosal surfaces to establish infection in the host. Some viruses are restricted to mucosal surfaces, whereas others disseminate to sites of secondary replication. Studies of strain-specific differences in reovirus mucosal infection and systemic dissemination have enhanced an understanding of viral determinants and molecular mechanisms that regulate viral pathogenesis. After peroral inoculation, reovirus strain type 1 Lang replicates to high titers in the intestine and spreads systemically, whereas strain type 3 Dearing (T3D) does not. These differences segregate with the viral S1 gene segment, which encodes attachment protein σ1 and nonstructural protein σ1s. In this study, we define genetic determinants that regulate reovirus-induced pathology following intranasal inoculation and respiratory infection. We report that two laboratory isolates of T3D, T3D(C) and T3D(F), differ in the capacity to replicate in the respiratory tract and spread systemically; the T3D(C) isolate replicates to higher titers in the lungs and disseminates, while T3D(F) does not. Two nucleotide polymorphisms in the S1 gene influence these differences, and both S1 gene products are involved. T3D(C) amino acid polymorphisms in the tail and head domains of σ1 protein influence the sensitivity of virions to protease-mediated loss of infectivity. The T3D(C) polymorphism at nucleotide 77, which leads to coding changes in both S1 gene products, promotes systemic dissemination from the respiratory tract. A σ1s-null virus produces lower titers in the lung after intranasal inoculation and disseminates less efficiently to sites of secondary replication. These findings provide new insights into mechanisms underlying reovirus replication in the respiratory tract and systemic spread from the lung.

Safety of percutaneous endoscopic gastrostomy after trauma laparotomy.

BACKGROUND: Trauma patients frequently require long-term enteral access because of injuries to the head, neck, or gastrointestinal tract. Noninvasive methods for gastrostomy placement include percutaneous endoscopic gastrostomy (PEG) and percutaneous radiographic gastrostomy (PRG). In patients with recent trauma laparotomy, PEG placement is felt to be relatively contraindicated because of the concerns about altered anatomy. We hypothesize that there is no increased rate of complications related to PEG placement in patients with trauma laparotomy compared with those without laparotomy provided that basic safety principles are followed. MATERIALS AND METHODS: This retrospective study evaluates all percutaneous gastrostomies (both PEG and PRG) placed in trauma patients admitted at a level I trauma center between January 1, 2007 and March 30, 2010. The electronic medical records of the 354 patients were reviewed through 30 days after procedure, and patients were further subdivided by the history of laparotomy. Statistical analysis was performed using Fisher exact test or two-tailed t-test, as appropriate. RESULTS: In patients with no prior trauma laparotomy, successful PEG placement occurred in 92.2% of patients, the remainder underwent PRG placement. Of patients with prior trauma laparotomy, 82.4% had successful PEG placement. Two percent of attempted PEG placements failed in patients with no previous trauma laparotomy, whereas 11.8% failed in patients with recent trauma laparotomy. The overall complication rate was 2.0%, with no recorded complications in patients with trauma laparotomy before PEG placement. CONCLUSIONS: These data suggest that surgeons should not consider recent trauma laparotomy a contraindication to PEG placement.

Characterizing long-term outcomes following AMA discharges after assault-related penetrating trauma.

BACKGROUND: Patients discharged against medical advice do not receive adequate treatment and have a greater risk of readmission. This study assessed the rate of discharges against medical advice following assault-related penetrating trauma, with secondary aims to evaluate long term pre/post-injury hospitalizations and mortality. METHODS: Adult assault-related penetrating injuries admitted to a Level 1 Trauma Center were identified in the prospectively maintained database. Chart review was conducted for hospitalizations ± 5 years from index injury and statewide mortality data was used to identify deaths outside of hospital care. RESULTS: Out of a total of 1,744 assault-related penetrated injuries, 3.2% (52/1630) of survivors discharged against medical advice. Reasons for discharge against medical advice included: unknown (38%), home/child/family/pets (25%), unhappy with care/restrictions (23%), and work/money/other (13%). Post-discharge mortality did not differ between routine (6.5%) and against medical advice discharge (3.9%). Against medical advice and routine discharge had similar rates of any hospitalization (38.5 v 28.2%) and trauma hospitalization in prior 5-years (35 v 36%). However, significantly more against medical advice discharges had prior hospitalizations involving drug or alcohol abuse (65 v 38%), but not mental health diagnosis (55 v 55%). Significantly more against medical advice discharges have post-injury hospitalizations compared to routine discharges (48 vs 26.5%); however, include similar rates of repeat traumatic injury (36 v 32%). CONCLUSIONS: Those with against medical advice discharges were significantly more likely to have prior hospitalizations involving drug or alcohol abuse and significantly higher rates of post-injury hospitalizations. However, we did not see an increase in repeat traumatic injury or post-discharge mortality in those with against medical advice discharges when compared to those with routine discharges.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Impact of host proteases on reovirus infection in the respiratory tract.

Virion uncoating is an essential early event in reovirus infection. In natural enteric infections, rapid proteolytic uncoating of virions is mediated by pancreatic serine proteases. The proteases that promote reovirus disassembly and cell entry in the respiratory tract remain unknown. In this report, we show that endogenous respiratory and inflammatory proteases can promote reovirus infection in vitro and that preexisting inflammation augments in vivo infection in the murine respiratory tract.

Management of bloodless surgery in a trauma setting. Balancing patient wishes with safety.

Many patients refuse blood or blood products because of religious beliefs or fear of complications. At Hennepin County Medical Center, a multidisciplinary team developed a Bloodless Surgery Medicine Guideline (BSMG) to help identify those who refuse blood products, guide medical decision-making, improve documentation of informed consent or refusal, and ensure continuity of care for patients. To our knowledge, this is the first documentation of a guideline for managing informed consent for or refusal of blood or blood products in trauma patients. This article discusses the development of and legal rationale for two key components of the BSMG: an informed consent/refusal algorithm and a blueprint for discussing the use of blood or blood components with patients and documenting their decisions.

Firearm injury survival is only the beginning: The impact of socioeconomic factors on unplanned readmission after injury.

BACKGROUND: Firearm trauma remain a national crisis disproportionally impacting minority populations in the United States. Risk factors leading to unplanned readmission after firearm injury remain unclear. We hypothesized that socioeconomic factors have a major impact on unplanned readmission following assault-related firearm injury. METHODS: The 2016-2019 Nationwide Readmission Database of the Healthcare Cost and Utilization Project was used to identify hospital admissions in those aged >14 years with assault-related firearm injury. Multivariable analysis assessed factors associated with unplanned 90-day readmission. RESULTS: Over 4 years, 20,666 assault-related firearm injury admissions were identified that resulted in 2,033 injuries with subsequent 90-day unplanned readmission. Those with readmissions tended to be older (31.9 vs 30.3 years), had a drug or alcohol diagnosis at primary hospitalization (27.1% vs 24.1%), and had longer hospital stays at primary hospitalization (15.5 vs 8.1 days) [all P<0.05]. The mortality rate in the primary hospitalization was 4.5%. Primary readmission diagnoses included: complications (29.6%), infection (14.5%), mental health (4.4%), trauma (15.6%), and chronic disease (30.6%). Over half of the patients readmitted with a trauma diagnosis were coded as new trauma encounters. 10.3% of readmission diagnoses included an additional 'initial' firearm injury diagnosis. Independent predictors of 90-day unplanned readmission were public insurance (aOR 1.21, P = 0.008), lowest income quartile (aOR 1.23, P = 0.048), living in a larger urban region (aOR 1.49, P = 0.01), discharge requiring additional care (aOR 1.61, P < 0.001), and discharge against medical advice (aOR 2.39, P < 0.001). CONCLUSIONS: Here we present socioeconomic risk factors for unplanned readmission after assault-related firearm injury. Better understanding of this population can lead to improved outcomes, decreased readmissions, and decreased financial burden on hospitals and patients. Hospital-based violence intervention programs may use this to target mitigating intervention programs in this population.