Stroke Prevention in Blunt Cerebrovascular Injury: Role of Aspirin 81 mg.

BACKGROUND: The stroke rate in blunt cerebrovascular injury (BCVI) varies from 25% without treatment to less than 8% with antithrombotic therapy. There is no consensus on the optimal management to prevent stroke BCVI. We investigated the efficacy and safety of oral Aspirin (ASA) 81 mg to prevent BCVI-related stroke compared to historically reported stroke rates with ASA 325 mg and heparin. METHODS: A single-center retrospective study included adult trauma patients who received oral ASA 81 mg for BCVI management between 2013 and 2022. Medical records were reviewed for demographic and injury characteristics, imaging findings, treatment-related complications, and outcomes. RESULTS: Eighty-four patients treated with ASA 81 mg for BCVI were identified. The mean age was 41.50 years, and 61.9% were male. The mean Injury Severity Score and Glasgow Coma Scale were 19.82 and 12.12, respectively. A total of 101 vessel injuries were identified, including vertebral artery injuries in 56.4% and carotid artery injuries in 44.6%. Traumatic brain injury was found in 42.9%, and 16.7% of patients had a solid organ injur. Biffl grade I (52.4%) injury was the most common, followed by grade II (37.6%) and grade III (4.9%). ASA 81 mg was started in the first 24 hours in 67.9% of patients, including 20 patients with traumatic brain injury and 8 with solid organ injuries. BCVI-related stroke occurred in 3 (3.5%) patients with Biffl grade II (n = 2) and III (n = 1). ASA-related complications were not identified in any patient. The mean length of stay in the hospital was 10.94 days, and 8 patients died during hospitalization due to complications of polytrauma. Follow-up with computed tomography angiography was performed in 8 (9.5%) patients, which showed improvement in 5 and a stable lesion in 3 at a mean time of 58 days after discharge. CONCLUSIONS: In the absence of clear guidelines regarding appropriate medication, BCVI management should be individualized case-by-case through a multidisciplinary approach. ASA 81 mg is a viable option for BCVI-related stroke prevention compared to the reported stroke rates (2%-8%) with commonly used antithrombotics like heparin and ASA 325 mg. Future prospective studies are needed to provide insight into the safety and efficacy of the current commonly used agent in managing BCVI.

Prevention of Firearm Violence Through Specific Types of Community-based Programming: An Eastern Association for the Surgery of Trauma Evidence-based Review.

OBJECTIVE: The purpose of this review was to provide an evidence-based recommendation for community-based programs to mitigate gun violence, from the Eastern Association for the Surgery of Trauma (EAST). SUMMARY BACKGROUND DATA: Firearm Injury leads to >40,000 annual deaths and >115,000 injuries annually in the United States. Communities have adopted culturally relevant strategies to mitigate gun related injury and death. Two such strategies are gun buyback programs and community-based violence prevention programs. METHODS: The Injury Control and Violence Prevention Committee of EAST developed Population, Intervention, Comparator, Outcomes (PICO) questions and performed a comprehensive literature and gray web literature search. Using GRADE methodology, they reviewed and graded the literature and provided consensus recommendations informed by the literature. RESULTS: A total of 19 studies were included for analysis of gun buyback programs. Twenty-six studies were reviewed for analysis for community-based violence prevention programs. Gray literature was added to the discussion of PICO questions from selected websites. A conditional recommendation is made for the implementation of community-based gun buyback programs and a conditional recommendation for community-based violence prevention programs, with special emphasis on cultural appropriateness and community input. CONCLUSIONS: Gun violence may be mitigated by community-based efforts, such as gun buybacks or violence prevention programs. These programs come with caveats, notably community cultural relevance and proper support and funding from local leadership.Level of Evidence: Review, Decision, level III.

The postoperative use of Impella as a ventricular assist device in high-risk patients undergoing coronary artery bypass surgery: A case series and comparison.

INTRODUCTION: Prophylactic placement of intra-aortic balloon pumps (IABPs) for hemodynamic support has been used in high-risk patients undergoing coronary artery bypass grafting (CABG) surgery. The use of the Impella CP (ICP) heart pump in high-risk patients undergoing CABG has not been reported. In this study, we report our experience using ICP and IABP devices in high-risk patients during the postoperative period. METHODS: This is a case series and retrospective comparison of ICP vs IABP at a single institution using data from 2017. Twenty-eight patients underwent postoperative placement of either the ICP or an IABP. Nineteen patients received IABP and nine received the ICP heart pump. Patient characteristics, comorbidities, and complications were compared using bivariate analysis. Exact logistic regression was used to compare risk-adjusted mortality. RESULTS: There were no statistically significant differences in epidemiologic characteristics, risk factors, or outcomes between both groups, except the ICP group had a lower preoperative left ventricular ejection fraction (22.5 vs 35; P = .028). Exact logistic regression analysis did not show a difference in 30-day mortality between both groups (P = .086). CONCLUSION: The postoperative use of the ICP heart pump, to support high-risk patients undergoing CABG, is a safe option. This practice has allowed us to perform CABG on sicker patients, specifically with depressed ejection fractions, with comparable results to the IABP. Further studies with larger patient populations are needed to draw definitive conclusions, but this pilot study demonstrates a possible expanded use of the Impella device.

Recurrent violent injury: magnitude, risk factors, and opportunities for intervention from a statewide analysis.

INTRODUCTION: Although preventing recurrent violent injury is an important component of a public health approach to interpersonal violence and a common focus of violence intervention programs, the true incidence of recurrent violent injury is unknown. Prior studies have reported recurrence rates from 0.8% to 44%, and risk factors for recurrence are not well established. METHODS: We used a statewide, all-payer database to perform a retrospective cohort study of emergency department visits for injury due to interpersonal violence in Florida, following up patients injured in 2010 for recurrence through 2012. We assessed risk factors for recurrence with multivariable logistic regression and estimated time to recurrence with the Kaplan-Meier method. We tabulated hospital charges and costs for index and recurrent visits. RESULTS: Of 53 908 patients presenting for violent injury in 2010, 11.1% had a recurrent violent injury during the study period. Trauma centers treated 31.8%, including 55.9% of severe injuries. Among recurrers, 58.9% went to a different hospital for their second injury. Low income, homelessness, Medicaid or uninsurance, and black race were associated with increased odds of recurrence. Patients with visits for mental and behavioral health and unintentional injury also had increased odds of recurrence. Index injuries accounted for $105 million in costs, and recurrent injuries accounted for another $25.3 million. CONCLUSIONS: Recurrent violent injury is a common and costly phenomenon, and effective violence prevention programs are needed. Prevention must include the nontrauma centers where many patients seek care.

Validating a new grading scale for emergency general surgery diseases.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) recently developed a grading scale for measuring anatomic severity of emergency general surgery (EGS) diseases. Grades were developed by expert consensus and have not been validated. The study purpose was to measure inter-rater reliability of the grading scale using colonic diverticulitis and to measure the association between disease grade and patient outcomes. METHODS: All charts were reviewed and independently assigned AAST grades based on specific disease criteria. Inter-rater reliability was measured using a kappa coefficient. Multivariate regression models were used to determine the relationship between AAST disease grade and patient outcomes adjusted for age, comorbidities, and patient physiology. RESULTS: Over 70% of patients demonstrated mild disease (grades I and II). No deaths were encountered. Inter-rater reliability for grade assignment was moderate (kappa coefficient, 0.43; 95% confidence interval, 0.31-0.56), with 67% concordance in grades. Compared to grade I, complications were similar in grade II but increased significantly with higher grades (grade III odds ratio [OR], 3.13 [1.32-7.41]; grade IV OR, 8.18 [2.09-32.0]; and grade V OR, 10.2 [2.68-38.90]). Compared to grade I, length of stay increased with higher grades (grade II incidence rate ratio [IRR], 1.30 [1.07-1.60]; grade III IRR, 2.4 [1.93-2.98]; grade IV IRR, 3.2 [2.27-4.60]; and grade V IRR, 2.6 [1.82-3.60]). CONCLUSIONS: The EGS grading scale for diverticulitis demonstrated moderate inter-rater reliability. Higher grades were independently associated with complications and length of stay. The findings provide a positive validation that the EGS scale is easily used and effective.

The problem of the pillion rider: India's helmet law and New Delhi's exemption.

BACKGROUND: In India, motorized two-wheeler (MTW) road traffic accidents injure or kill 72,000 women annually. Before the Motor Vehicle Act of 1988, which required mandatory helmet use for MTW riders, a study found 0.6% of all MTW pillions (backseat passengers) were helmeted. Citing religious protests to the legislation, Delhi's high court exempted the city's 12 million women from the law. We hypothesize that currently male pillions use helmets more frequently than females, and that overall pillion helmet usage has increased over the last 20 y. METHODS: Continuous video was recorded in half-hour blocks at four locations in Delhi on separate days, totaling 8 hours of high- and low-volume traffic. Videos were reviewed with at least two reviewers extracting the number of MTW pillions, as well as their gender, approximate age, and helmet usage. RESULTS: Of 4010 pillions identified, 63.8% were male, 32.4% female, and 3.3% children. Among males, there were significantly more helmeted pillions (88.4%, P < 0.001); among females, there were significantly more unhelmeted pillions (99.4%, P < 0.001). Among unhelmeted pillions, significantly more were female (81.4%) than male (P < 0.001). Current overall pillion helmet use is significantly higher than historical rate (P < 0.001). CONCLUSIONS: The significantly higher male pillion helmet usage compared with females indicates Delhi's helmet law is associated with increased compliance among those who fall under its jurisdiction. This augments the growing body of evidence that mandatory helmet laws are efficacious, thus repealing the exemption of women is an important step in increasing female pillion helmet usage.

Outcomes for older trauma patients in the emergency department screening positive for alcohol, cocaine, or marijuana use.

BACKGROUND: Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients. OBJECTIVES: To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older. METHODS: This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80 mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens. RESULTS: 21 320 patients were included in the alcohol analysis and 17 077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p < 0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative. CONCLUSION: Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.

Colorectal Malignancy Complicated by Arterioenteric Fistula.

Arterioenteric fistulas (AEF) are rare and devastating complications of colorectal/pelvic malignancies. These fistulas can be seen following neoadjuvant or adjuvant therapy but are exceptionally rare de novo. The reported incidence of AEF is less than 1% and iliac artery-enteric fistulas make up less than .1% of all AEF. Here we present a patient in hemorrhagic shock secondary to an advanced colorectal malignancy without adjuvant therapies with local invasion of the right external iliac artery. Following initial resuscitation and hemorrhage control with coil embolization, definitive control with ligation and excision of the involved artery, end colostomy, and ureteral stent placement was achieved. It is important to consider malignancy as the source of lower gastrointestinal bleeds, especially in elderly patients without current colonoscopy studies. The management of this unfortunate diagnosis often involves a multidisciplinary approach with early and frequent goals of care discussions.

Trauma of abortion restrictions and forced pregnancy: urgent implications for acute care surgeons.

In the aftermath of the Supreme Court's Dobbs vs. Jackson Women's Health decision, acute care surgeons face an increased likelihood of seeing patients with complications from both self-managed abortions and forced pregnancy in underserved areas of reproductive and maternity care throughout the USA. Acute care surgeons have an ethical and legal duty to provide care to these patients, especially in obstetrics and gynecology deserts, which already exist in much of the country and are likely to be exacerbated by legislation banning abortion. Structural inequities lead to an over-representation of poor individuals and people of color among patients seeking abortion care, and it is imperative to make central the fact that people of color who can become pregnant will be disproportionately affected by this legislation in every respect. Acute care surgeons must take action to become aware of and trained to treat both the direct clinical complications and the extragestational consequences of reproductive injustice, while also using their collective voices to reaffirm the right to abortion as essential healthcare in the USA.

PICC versus midlines: Comparison of peripherally inserted central catheters and midline catheters with respect to incidence of thromboembolic and infectious complications.

INTRODUCTION: To decrease the complications related to central catheters there has been an increasing utilization of peripherally inserted central catheters (PICC) and ultrasound-guided long peripheral intravenous catheters (i.e. midlines). While the complications of PICC lines are well described there is less reported data on complications related to midline catheters. Our study aims are to compare the incidences of infectious and deep venous thrombosis (DVT) and sepsis related to PICCs and Midlines. METHODS: We performed a single-center retrospective review at an academic hospital. Data were collected on patients admitted between 1/1/2014-5/31/2016. Patient demographics, hospital length of stay (LOS), and ventilator days were collected. Outcomes of interest were line-related infections and thromboembolic events after the placement of these catheters. Endpoints were compared between three groups (PICC group, midline group and PICC placement followed by midline placement group). Univariate and multivariable analyses were used to compare across the three groups. RESULTS: The study included 3560 unique patients with 5058 catheters. There was an increase in use of midlines over the observed study period (245% increase from the end of 2015 to the middle of 2016). We found no significant differences in the rates of DVT among the three groups (PICC 4%, midline 3% and PICC-midline 4%; p = 0.12). There were no differences across the groups for sepsis (PICC 29%, midline 27%, and PICC-midline 32%; p = 0.14) or septic shock (PICC 7%, midline 8%, and PICC-midline 6%; p = 0.39). Adjusted means LOS were higher for patients with PICC lines compared to midlines, in both females and males. PICC group stayed longer, on average, on the ventilator compared to the midline group. No other significant differences were seen among groups. CONCLUSION: Increased utilization of midline catheters were not associated with decreased risk of DVT or sepsis when compared to peripherally inserted central catheters.

National Surgical Quality Improvement Program Adverse Events Combined With Clavien-Dindo Scores Can Direct Quality Improvement Processes in Surgical Patients.

OBJECTIVE: The burden of postoperative adverse events (AE) weighs immediately on the patient as unanticipated stress and on the healthcare system as unreimbursed cost. Applying the Clavien-Dindo (C-D) system of AE gradation as a surrogate of cost, we analyzed 4 years' data from a single-state National Surgical Quality Improvement Program (NSQIP) collaboration, hypothesizing that trends of AE were consistent over time and that more frequently performed cases would be associated with less and more minor AE. METHODS: The NSQIP defined AEs, consisting of 21 listed postoperative occurrences, which were analyzed using deidentified 30-day postoperative data for 2015 to 2018. Each AE was graded using (C-D) severity (1, lowest; 4, highest with survival). The C-D severity weight, as defined in previous multi-institutional studies, was used as a surrogate for cost and unplanned patient burden. Adverse event incidence was calculated as sum AE/case volume, and population burden as total AE burden/case volume. RESULTS: There were 12,567 surgical cases recorded by members of the state collaborative. The overall data demonstrated no significant difference in AE incidence; however, the burden of AE increased by 18.8%. The 8 most common Current Procedural Terminology codes had approximately 50% lower AE incidence compared with overall cases; however, the incidence increased by 56.0% and the AE burden/case increased by 48.0%. CONCLUSIONS: Although the 8 most common Current Procedural Terminology codes showed a 50% lower AE incidence compared with overall cases, the incidence increased over the study period. Surgical quality initiatives should be patient centered and focus on high burden AE.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death. METHODS: We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929). RESULTS: Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]). CONCLUSION: Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

Antibiotic prophylaxis for tube thoracostomy placement in trauma: a practice management guideline from the Eastern Association for the Surgery of Trauma.

Background: Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. Methods: Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results: Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. Discussion: In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO registration number: CRD42018088759.

Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study.

BACKGROUND: The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals. METHODS: Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort. RESULTS: More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27-47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02-6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07-8.01). CONCLUSION: Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

Multiple imputation in trauma disparity research.

BACKGROUND: Missing data has remained a major disparity in trauma outcomes research due to missing race and insurance data. Multiple imputation (M.IMP) has been recommended as a solution to deal with this major drawback. STUDY DESIGN: Using the National Data Trauma Bank (NTDB) as an example, a complete dataset was developed by deleting cases with missing data across variables of interest. An incomplete dataset was then created from the complete set using random deletion to simulate the original NTDB, followed by five M.IMP rounds to generate a final imputed dataset. Identical multivariate analyses were performed to investigate the effect of race and insurance on mortality in both datasets. RESULTS: Missing data proportions for known trauma mortality covariates were as follows: age-4%, gender-0.4%, race-8%, insurance-17%, injury severity score-6%, revised trauma score-20%, and trauma type-3%. The M.IMP dataset results were qualitatively similar to the original dataset. CONCLUSION: M.IMP is a feasible tool in NTDB for handling missing race and insurance data.

Level of Comfort With Pediatric Trauma Transports: Survey of Prehospital Providers.

BACKGROUND: Unintentional injury is the leading cause of death in pediatric patients. Despite a heavy burden of pediatric trauma, prehospital transport and triage of pediatric trauma patients are not standardized. Prehospital providers report anxiety and a lack of confidence in transport, triage, and care of pediatric trauma patients. MATERIALS AND METHODS: Prehospital transport providers with 3 organizations across southeast Georgia and northeast Florida were contacted via email (n = 146) and asked to complete 2 Web-based surveys to evaluate their comfort level with performing tasks in the transport of pediatric and adult trauma patients. Bivariate statistics and qualitative thematic analyses were performed to assess comfort with pediatric trauma transports. RESULTS: Survey 1 (N = 35) showed that mean comfort levels of prehospital providers were significantly lower for pediatric patients than adult trauma patients in 7 out of 9 tasks queried, including airway management and interpreting children's physiology. The following themes emerged from survey 2 (N = 14) responses: additional clinical knowledge resources would be beneficial when caring for pediatric trauma patients, pediatric medication administration is a source of uncertainty, prehospital transport teams would benefit from additional pediatric trauma training, infrequent transport of pediatric trauma patients affects provider comfort level, and pediatric trauma generates higher levels of anxiety among providers. DISCUSSION: Prehospital transport of pediatric trauma patients is infrequent and a source of anxiety for prehospital providers. Rigs should be equipped with a reference tool addressing crucial tasks and deficiencies in training.

Acute Care Surgery Billing, Coding and Documentation Series Part 3: Coding of Additional Select Procedures; Modifiers; Telemedicine Coding; Robotic Surgery.

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work "smarter, not harder" and garner the maximum compensation for their work. We hope we have been successful in achieving and that goal that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement. This third section deals with coding of additional select procedures, modifiers, telemedicine coding, and robotic surgery.

Acute Care Surgery Billing, Coding and Documentation Series Part 2: Postoperative Documentation and Coding; Documentation and Coding in Conjunction with Trainees and Advanced Practitioners; Coding Select Procedures.

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work "smarter, not harder" and garner the maximum compensation for their work. We hope we have been successful in achieving that goal and that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement. This second section deals with postoperative documentation and coding, documentation and coding in conjunction with trainees and advanced practitioners, and coding of select procedures.

Acute Care Surgery Billing, Coding and Documentation Series Part 1: Basic Evaluation and Management (E/M), Emergency Department E/M, Prolonged Services, Adult Critical Care Documentation and Coding.

This series of reviews has been produced to assist both the experienced surgeon and coder, as well as those just starting practice that may have little formal training in this area. Understanding this complex system will allow the provider to work 'smarter, not harder' and garner the maximum compensation for their work. We hope we have been successful in achieving that goal and that this series will provide useful information and be worth the time invested in reading it by bringing tangible benefits to the efficiency of practice and its reimbursement.