Utility of the Healthy Aging Brain Care Monitor as a Patient-Reported Symptom Monitoring Tool in Older Injury Survivors.

INTRODUCTION: The objective of this study was to evaluate the performance of the Healthy Aging Brain Care Monitor (HABC-M) as a patient-reported outcome tool to measure cognitive, functional, and psychological symptoms among older adults who sustained non-neurologic injuries requiring hospital admission. METHODS: We used data from a multicenter randomized controlled trial to evaluate the utility of the HABC-M Self-Report version in older patients recovering from traumatic injuries. A total of 143 patients without cognitive impairment were included in the analysis. Cronbach's alpha was used to measure the internal consistency, and Spearman's rank correlation test was used to evaluate the relationship of the HABC-M with standard measures of cognitive, functional, and psychological outcomes. RESULTS: The HABC-M subscales and the total scale showed satisfactory internal consistency (Cronbach's alpha = 0.64 to 0.77). The HABC-M cognitive subscale did not correlate with the Mini-Mental State Examination. The HABC-M functional and psychological subscales correlated with corresponding standard reference measures (|rs| = 0.24-0.59). CONCLUSIONS: The HABC-M Self-Report version is a practical alternative to administering multiple surveys to monitor functional and psychological sequelae in older patients recovering from recent non-neurologic injuries. Its clinical application may facilitate personalized, multidisciplinary care coordination among older trauma survivors without cognitive impairment.

Angioembolization for Isolated Severe Blunt Splenic Injuries with Hemodynamic Instability: A Propensity Score Matched Analysis.

BACKGROUND: This study aimed to compare patient outcomes after splenic angioembolization (SAE) or splenectomy for isolated severe blunt splenic injury (BSI) with hemodynamic instability, and to identify potential candidates for SAE. METHODS: Adult patients with isolated severe BSI (Abbreviated Injury Scale [AIS] 3-5) and hemodynamic instability between 2013 and 2019 were identified from the American College of Surgeons Trauma Quality Improvement (ACS TQIP) database. Hemodynamic instability was defined as an initial systolic blood pressure (SBP) <90 mmHg, heart rate (HR) >120 bpm, or lowest SBP <90 mmHg within 1 h after admission, with ≥1 unit of blood transfused within 4 h after admission. In-hospital mortality was compared between splenectomy and SAE groups using 2:1 propensity-score matching. The characteristics of unmatched and matched splenectomy patients were also compared. RESULTS: A total of 478 patients met our inclusion criteria (332 splenectomy, 146 SAE). After propensity-score matching, 166 splenectomy and 83 SAE patients were compared. Approximately 85% of propensity-score matched patients sustained AIS 3/4 injuries, and 50% presented with normal SBP and HR before becoming hemodynamically unstable. The median time to intervention (splenectomy or SAE) was 137 min (interquartile range 94-183). In-hospital mortality between splenectomy and SAE groups was not significantly different (5.4% vs. 4.8%, p = 1.000). More than half of unmatched patients in the splenectomy group sustained AIS 5 injuries and presented with initially unstable hemodynamics. The median time to splenectomy in such patients was significantly shorter than in matched splenectomy patients (67 vs. 132 min, p < 0.001). CONCLUSION: Splenectomy remains the mainstay of treatment for patients with AIS 5 BSI who present to hospital with hemodynamic instability. However, SAE might be a feasible alternative for patients with AIS 3/4 injuries.

Patients Follow Different Financial Hardship Trajectories in the Year after Injury.

OBJECTIVE: To determine if distinct financial trajectories exist and if they are associated with quality-of-life outcomes. SUMMARY OF BACKGROUND DATA: Financial hardship after injury measurably impacts Health-Related Quality of Life outcomes. Financial hardship, encompassing material losses, financial worry, and poor coping mechanisms, is associated with lower quality of life and increased psychological distress. However, recovery is dynamic and financial hardship may change over time. METHODS: This is a secondary analysis of a cohort of 500 moderate-to-severe nonneurologic injured patients in which financial hardship and Health-related Quality of Life outcomes were measured at 1, 2, 4, and 12 months after injury using survey instruments (Short Form-36). Enrollment occurred at an urban, academic, Level 1 trauma center in Memphis, Tennessee during January 2009 to December 2011 and follow-up completed by December 2012. RESULTS: Four hundred seventy-four patients had sufficient data for Group- Based Trajectory Analysis. Four distinct financial hardship trajectories were identified: Financially Secure patients (8.6%) had consistently low hardship over time; Financially Devastated patients had a high degree of hardship immediately after injury and never recovered (51.6%); Financially Frail patients had increasing hardship over time (33.6%); and Financially Resilient patients started with a high degree of hardship but recovered by year end (6.2%). At 12-months, all trajectories had poor Short Form-36 physical component scores and the Financial Frail and Financially Devastated trajectories had poor mental health scores compared to US population norms. CONCLUSIONS AND RELEVANCE: The Financially Resilient trajectory demonstrates financial hardship after injury can be overcome. Further research into understanding why and how this occurs is needed.

Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults.

Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications. BACKGROUND: Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance. METHODS: Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort. RESULTS: There were 274 patients included (71.2% male). Mean age was 50.56  ±â€Š19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001). CONCLUSIONS: There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.

Perceptions of Equity and Inclusion in Acute Care Surgery: From the #EAST4ALL Survey.

OBJECTIVES AND BACKGROUND: The aim of this study was to characterize equity and inclusion in acute care surgery (ACS) with a survey to examine the demographics of ACS surgeons, the exclusionary or biased behaviors they witnessed and experienced, and where those behaviors happen. A major initiative of the Equity, Quality, and Inclusion in Trauma Surgery Practice Ad Hoc Task Force of the Eastern Association for the Surgery of Trauma was to characterize equity and inclusion in ACS. To do so, a survey was created with the above objectives. METHODS: A cross-sectional, mixed-methods anonymous online survey was sent to all EAST members. Closed-ended questions are reported as percentages with a cutoff of α = 0.05 for significance. Quantitative results were analyzed focusing on mistreatment and bias. RESULTS: Most respondents identified as white, non-Hispanic and male. In the past 12 months, 57.5% of females witnessed or experienced sexual harassment, whereas 48.6% of surgeons of color witnessed or experienced racial/ethnic discrimination. Sexual harassment, racial/ethnic prejudice, or discrimination based on sexual orientation/sex identity was more frequent in the workplace than at academic conferences or in ACS. Females were more likely than males to report unfair treatment due to age, appearance or sex in the workplace and ACS (P ≤ 0.002). Surgeons of color were more likely than white, non-Hispanics to report unfair treatment in the workplace and ACS due to race/ethnicity (P < 0.001). CONCLUSIONS: This is the first survey of ACS surgeons on equity and inclusion. Perceptions of bias are prevalent. Minorities reported more inequity than their white male counterparts. Behavior in the workplace was worse than at academic conferences or ACS. Ensuring equity and inclusion may help ACS attract and retain the best and brightest without fear of unfair treatment.

Impact of Patient Frailty on Morbidity and Mortality after Common Emergency General Surgery Operations.

BACKGROUND: Frailty has been increasingly recognized as a modifiable risk factor prior to elective general surgery. There is limited evidence regarding the association of frailty with perioperative outcomes after specific emergency general surgery procedures. MATERIAL AND METHODS: A retrospective cohort study of 57,173 patients older than 40 y of age from 2010 to 2014 American College of Surgeons National Surgical Quality Improvement Program underwent appendectomy, cholecystectomy, large bowel resection, small bowel resection, or nonbowel resection (lysis of adhesion, ileostomy creation) on an emergent basis. Preoperative modified frailty index (mFI) was determined for each patient and was used in a multivariable logistic regression to determine the association with perioperative morbidity, mortality, and discharge destination. RESULTS: A total of 57,173 patients (46% men, mean [SD] age 60 [13] y) underwent an emergency appendectomy (n = 26,067), cholecystectomy (n = 8138), large bowel resection (n = 12,107), small bowel resection (n = 6503), or nonbowel resection (n = 4358). Among them, 14,300 (25.0%) experienced any perioperative complication, and 12,668 (22.2%) experienced a serious complication with an overall 30-d mortality of 5.1%. Highly frail patients had a 30-d mortality of 19.0% across all five operations. In multivariable analysis, mFI was associated with any complication and 30-d mortality in a step-wise fashion for each emergency operation. Intermediate and high mFI were also inversely associated with discharge home for each operation. CONCLUSIONS: Frailty is associated with increased perioperative morbidity and mortality in common emergency general surgery operations. Frailty should be assessed by surgeons to inform decisions on operative intervention and to inform patients/families on expected outcomes.

What's in a Name? Provider Perception of Injured John Doe Patients.

BACKGROUND: We previously demonstrated that unidentified aliased patients, John Doe's (DOEs), are one of the highest risk and most medically fragile populations of injured patients. Aliasing can result in misplaced information and confusion that must be overcome by health care professionals. DOE alias use is institutionally dependent and not uniform, which may lead to significant variation in perception of confusion and error. We sought to determine if health care practitioners experience confusion that may result in compromised care when caring for injured DOE patients. METHODS: After obtaining institutional review board approval, we surveyed critical care nurses, nurse practitioners, resident physicians, and surgeons who care for DOE patients at two academic level I trauma centers with separate DOE alias practices. Surveys asked whether caring for DOE patients created possible or actual confusion and possible or actual patient care errors. In one institution (Selective DOE), only unidentified patients were given an alias that was reconciled when information became available. At the other institution (All DOE), all trauma patients were admitted with an alias that was reconciled within 24 h. Respondents were invited to complete an anonymous questionnaire regarding the care for DOE patients. Results were analyzed with Wilcoxon rank-sum tests, and significance was assessed at a level of 0.05. RESULTS: Of 176 total respondents, 120 (68.2%) reported from Selective DOE and 56 (31.8%) from All DOE. Overall 53.1% reported that DOE use can cause serious confusion. Specifically, 31.3% reported experiencing actual confusion, although only 4% reported actual errors. Nurses had significantly higher perceived risk of confusion in the system of All DOE versus Selective DOE assignment (17.9% versus 4.2%, P < 0.01). Resident physicians reported significantly more frequent actual mistakes within the All DOE versus Selective DOE (24.1% versus 6.6%, P < 0.01), despite finding no significant difference in resident perception of confusion (21.4% versus 12.5%, respectively, P = 0.18). CONCLUSIONS: Our study sheds light on clinical consequences of EMR use and aliases for end users. We show that nurses perceive that there are greater potential complications associated with DOE aliases use, and this varies depending on the system used for managing unidentified patients. Minimizing DOE alias use may help to minimize provider confusion, risk for error, and patient safety.

Overall Splenectomy Rates Stable Despite Increasing Usage of Angiography in the Management of High-grade Blunt Splenic Injury.

OBJECTIVE: The purpose of this study was to understand the contemporary trends of splenectomy in blunt splenic injury (BSI) and to determine if angiography and embolization (ANGIO) may be impacting the splenectomy rate. BACKGROUND: The approach to BSI has shifted to increasing use of nonoperative management, with a greater reliance on ANGIO. However, the impact ANGIO has on splenic salvage remains unclear with little contemporary data. METHODS: The National Trauma Data Bank was used to identify patients 18 years and older with high-grade BSI (Abbreviated Injury Scale >II) treated at Level I or II trauma centers between 2008 and 2014. Primary outcomes included yearly rates of splenectomy, which was defined as early if performed within 6 hours of ED admission and delayed if greater than 6 hours, ANGIO, and mortality. Trends were studied over time with hierarchical regression models. RESULTS: There were 53,689 patients who had high-grade BSI over the study period. There was no significant difference in the adjusted rate of overall splenectomy over time (24.3% in 2008, 24.3% in 2014, P value = 0.20). The use of ANGIO rapidly increased from 5.3% in 2008 to 13.5% in 2014 (P value < 0.001). Mortality was similar overtime (8.7% in 2008, 9.0% in 2014, P value = 0.33). CONCLUSION: Over the last 7 years, the rate of angiography has been steadily rising while the overall rate of splenectomy has been stable. The lack of improved overall splenic salvage, despite increased ANGIO, calls into question the role of ANGIO in splenic salvage on high-grade BSI at a national level.

Laparoscopic versus robotic colectomy: a national surgical quality improvement project analysis.

INTRODUCTION: Robotic colorectal surgery is being increasingly adopted. Our objective was to compare early postoperative outcomes between robotic and laparoscopic colectomy in a nationally representative sample. METHODS: The American College of Surgeons National Surgical Quality Improvement Project Colectomy Targeted Dataset from 2012 to 2014 was used for this study. Adult patients undergoing elective colectomy with an anastomosis were included. Patients were stratified based on location of colorectal resection (low anterior resection (LAR), left-sided resection, or right-sided resection). Bivariate data analysis was performed, and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS: There were a total of 25,998 laparoscopic colectomies (30 % LAR's, 45 % left-sided, and 25 % right-sided) and 1484 robotic colectomies (54 % LAR's, 28 % left-sided, and 18 % right-sided). The risk-adjusted overall morbidity, serious morbidity, and mortality were similar between laparoscopic and robotic approaches in all anastomotic groups. Patients undergoing robotic LAR had a lower conversion rate (OR 0.47, 95 % CI 1.20-1.76) and postoperative sepsis rate (OR 0.49, 95 % CI 0.29-0.85) but a higher rate of diverting ostomies (OR 1.45, 95 % CI 1.20-1.76). Robotic right-sided colectomies had significantly lower conversion rates (OR 0.58, 95 % CI 0.34-0.96). Robotic colectomy in all groups was associated with a longer operative time (by 40 min) and a decreased length of stay (by 0.5 days). CONCLUSIONS: In a nationally representative sample comparing laparoscopic and robotic colectomies, the overall morbidity, serious morbidity, and mortality between groups are similar while length of stay was shorter by 0.5 days in the robotic colectomy group. Robotic LAR was associated with lower conversion rates and lower septic complications. However, robotic LAR is also associated with a significantly higher rate of diverting ostomy. The reason for this relationship is unclear. Surgeon factors, patient factors, and technical factors should be considered in future studies.

The model for end-stage liver disease predicts outcomes in patients undergoing cholecystectomy.

BACKGROUND: The magnitude of risk for patients undergoing cholecystectomy with high model for end-stage liver disease (MELD) scores is poorly understood. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2013 was used to study patients undergoing cholecystectomy. Patients were excluded if they had choledocholithiasis or preoperative dialysis. Bivariate data analysis was performed and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. RESULTS: A total of 63,464 patients were included in the study. Unadjusted mortality significantly increased as the MELD score increased in the laparoscopic (MELD = 6-10, 0.2%; 11-15, 1.1%; 16-20, 3.2%; >20, 5.8%) and open groups (MELD = 6-10, 1.5%; 11-15, 3.7%; 16-20, 8.6%; >20, 17.9%) (p-value <0.001 for both). Unadjusted morbidity also increased with MELD score increases in the laparoscopic (MELD = 6-10, 3.8%; 11-15, 9.9%; 16-20, 16.3%; >20, 22.8%) and open groups (MELD = 6-10, 18.7%; 11-15, 28.2%; 16-20, 40.7%; >20, 57.8%) (p-value <0.001 for both). Patients with ascites and high MELD scores had higher rates of mortality (laparoscopic, MELD > 20, 33.3%; open, MELD > 20, 48.5%) and morbidity (laparoscopic, MELD > 20, 66.7%; open, MELD > 20, 75.8%) across all MELD scores. After adjustment, MELD score acted as a progressive and independent predictor of morbidity and mortality. CONCLUSIONS: The MELD score is an objective and easy to calculate scoring system that independently predicts postoperative morbidity and mortality in patients undergoing cholecystectomy. Patients with ascites have substantially worse outcomes across all MELD scores. Open cholecystectomy is associated with significantly more morbidity and mortality than laparoscopic cholecystectomy across all MELD groups.

Reduced morbidity with minimally invasive distal pancreatectomy for pancreatic adenocarcinoma.

BACKGROUND: Minimally invasive distal pancreatectomy (MISDP) has been shown to be safe relative to open distal pancreatectomy (ODP). However, MISDP has been slow to adopt for pancreatic adenocarcinoma (PDAC). This study sought to compare outcomes following MISDP vs. ODP for PDAC. METHODS: Data were prospectively collected from 2011 to 2014 for DP by the American College of Surgeons-National Surgical Quality Improvement Program. Patients without PDAC on surgical pathology were excluded. Impact of minimally invasive approach on morbidity and mortality was analyzed using two-way statistical analyses. RESULTS: Of 6198 patients undergoing DP, 501 (7.5%) had a pathologic diagnosis of PDAC. MISDP was undertaken in 166 (33.1%) patients, ODP was performed in 335 (66.9%). MISDP and ODP were not different in preoperative comorbidities or pathologic stage. Overall morbidity (MISDP 31%, ODP 42%; p = 0.024), transfusion (MISDP 6%, ODP 23%; p = 0.0001), pneumonia (MISDP 1%, ODP 7%; p = 0.004), surgical site infections (MISDP 8%, OPD 17%; p = 0.013), sepsis (MISDP 2%, ODP 8%; p = 0.007), and length of stay (MISDP 5.0 days, ODP 7.0 days; p = 0.009) were lower in the MIS group. Mortality (MISDP 0%, ODP 1%; p = 0.307), pancreatic fistula (MISDP 12%, ODP 19%; p = 0.073), and delayed gastric emptying (MISDP 3%, ODP 7%; p = 0.140) were similar. CONCLUSIONS: This analysis of a large multi-institution North American experience of DP for treatment of pancreatic adenocarcinoma suggests that short-term postoperative outcomes are improved with MISDP.

Utilizing Group-based Trajectory Modeling to Understand Patterns of Hemorrhage and Resuscitation.

OBJECTIVE: The purpose of this study was to describe variations in blood-based resuscitation in an injured cohort. We hypothesize that distinct transfusion trajectories are present. BACKGROUND: Retrospective studies of hemorrhage utilize the concept of massive transfusion, where a set volume of blood is required. Patterns of hemorrhage vary and massive transfusion does little to describe these differences. METHODS: Patients were prospectively included from June 2012 to 2013. Time of transfusion for each packed red blood cell (PRBC) transfused was recorded, in minutes, for all patients. Additional measures included demographic and injury data, admission laboratory values, and vital signs and outcomes including mortality, tempo of transfusion, and operative requirements. Group-based trajectory modeling was utilized to describe transfusion trajectories throughout the cohort. RESULTS: Three hundred sixteen patients met the inclusion criteria. Among them, 72% were men and median age was 35 years (interquartile range [IQR] 24-50), median injury severity score was 13 (IQR 9-22), median 24-hour transfusion volume was 4 units of PRBCs (IQR 2-8), and mortality was 14%. Six transfusion trajectories were identified. Among the patients, 35% received negligible transfusions (group 1). Groups 2 and 3 received greater than 15 units PRBCs-the former as early resuscitation, whereas the latter intermittently throughout the day. Groups 4 and 5 had similar small resuscitations with distinct demographic differences. Group 6 suffered blunt injuries and required rapid resuscitation. CONCLUSIONS: Traditional definitions of massive transfusion are broad and imprecise. In cohorts of severely injured patients, there are distinct, identifiable transfusion trajectories. Identification of subgroups is important in understanding clinical course and to anticipate resuscitative and therapeutic needs.

Trajectory subtypes after injury and patient-centered outcomes.

BACKGROUND: The recent focus on patient-centered outcomes highlights the need to better describe recovery trajectories after injury. The purpose of this study was to characterize recovery trajectory subtypes that exist after non-neurologic injury. MATERIALS AND METHODS: A prospective, observational cohort of 500 adults with an Injury Severity Score > 10 but without traumatic brain or spinal cord injury from 2009 to 2011 was formed. The Short Form-36 was administered at admission and repeated at 1, 2, 4, and 12 mo after injury. Group-based trajectory modeling was used to determine the number and shape of physical composite score (PCS) and mental composite score (MCS) trajectories. RESULTS: Three PCS trajectories and five MCS trajectories were identified. For PCS, trajectory 1 (10.4%) has low baseline scores, followed by no improvement over time. Trajectory 2 (65.6%) declines 1 mo after injury then improves over time. Trajectory 3 (24.1%) has a sharp decline followed by rapid recovery. For MCS, trajectory 1 (9.4%) is low at baseline and remains low. Trajectory 2 (14.4%) has a large decrease after injury and does not recover over the next 12 mo. Trajectory 3 (22.7%) has an initial decrease in MCS early, followed by continuous recovery. Trajectory 4 (19.1%) has a steady decline over the study period. Trajectory 5 (34.3%) stays consistently high at all time points. CONCLUSIONS: Recovery after injury is complex and results in multiple recovery trajectories. This has implications for patient-centered clinical trial design and in development of patient-specific interventions to improve outcomes.

The effect of pH versus base deficit on organ failure in trauma patients.

BACKGROUND: Base deficit (BD) calculations are affected by trauma-related changes in circulating concentrations of anions after injury. In contrast, pH is a direct measurement that corresponds to hypoperfusion. We hypothesized that changes in pH would more closely correspond to organ dysfunction compared with changes in BD. MATERIALS AND METHODS: BD and pH values were collected for the first 48 h after injury from a retrospective cohort of 74 multiply injured adult patients who were admitted to the surgical intensive care unit for a minimum of 1 wk. Mean and extreme (minimum pH and maximum BD) values of pH and BD were determined for day 1 (0-24 h) and for day 2 (24-48 h) after injury. Organ dysfunction was measured by averaging daily sequential organ failure assessment scores over the entire duration of intensive care unit admission. BD and pH values were compared with mean modified sequential organ failure assessment scores by univariate and multivariate linear regression. RESULTS: Organ dysfunction corresponded more closely with changes in pH compared with those in BD. Minimum pH and maximum BD showed better correspondence to organ dysfunction compared with mean values. Minimum pH values at 24-48 h had the highest univariate (r(2) = 0.43) correspondence to organ dysfunction. In contrast, mean BD values at 24-48 h showed no correspondence (r(2) = 0.07) to organ dysfunction. Multivariate analysis demonstrated that 24-48 h of minimum pH had the highest numerical effect on organ dysfunction. CONCLUSIONS: Correspondence between organ dysfunction and BD deteriorated in contrast to increasing correspondence between organ dysfunction and pH measured within 48 h after injury.

Tissue damage volume predicts organ dysfunction and inflammation after injury.

BACKGROUND: Multiply injured patients (MIPs) are at risk to develop multiple-organ failure (MOF) and prolonged systemic inflammation response syndrome (SIRS). It is difficult to predict which MIPs are at the highest risk to develop these complications. We have developed a novel method that quantifies the distribution and physical magnitude of all injuries identified on admission computed tomography scanning called the Tissue Damage Volume (TDV) score. We explored how individualized TDV scores corresponded to MOF and SIRS. MATERIALS AND METHODS: A retrospective study on 74 MIPs measured mechanical TDV by calculating injury volumes on admission computed tomography scans of all injuries in the head/neck, chest, abdomen, and pelvis. Regional and total TDV scores were compared between patients that did or did not develop MOF or sustained SIRS. The magnitude of organ dysfunction was also stratified by the magnitude of TDV. RESULTS: Mean total and pelvic TDV scores were significantly increased in patients who developed MOF. Mean total, chest, and abdominal TDV scores were increased in patients who developed sustained SIRS. The magnitude of organ dysfunction was significantly higher in patients who sustained large volume injuries in the pelvis or abdomen, and in patients who sustained injuries in at least three anatomic regions. CONCLUSIONS: A novel index that quantifies the magnitude and distribution of mechanical tissue damage volume is a patient-specific index that can be used to identify patients who have sustained injury patterns that predict progression to MOF and SIRS. The preliminary methods will need refinement and prospective validation.

C-spine injury and mandibular fractures: lifesaver broken in two spots.

BACKGROUND: Trauma is a leading cause of injury and mortality and may involve mandibular fractures and cervical spine injuries. Manipulation of the spine during trauma protocols and operative treatment has the potential to cause serious spinal cord injuries. The purpose of this study was to identify risk factors associated with cervical spine injury (CSI) in patients with mandibular fractures. METHODS: The National Trauma Databank (2007-2010) was used to identify patients with mandibular fractures. RESULTS: A total of 59,028 patients were identified and separated into adult and pediatric cohorts. There were 50,711 adults (86%) and 8317 children (14%). There were statistically significant lower rates of associated CSI in pediatric patients than adults (3.5% versus 7.3%, P < 0.01). Predictors of associated CSI in mandible fractures for both adults and children were older age, lower Glasgow Coma Scale, thoracic injuries, firearm or motor vehicle accident mechanisms, and symphyseal fractures. In the pediatric cohort, body, ramus, and subcondylar fractures were significantly associated with CSI. In adults, female gender, and upper extremity, abdominopelvic, and head injuries were also significantly associated with CSI. CONCLUSIONS: Multiple mandibular fractures were inversely correlated with CSI. One possibility is that energy dissipation in the mandible with multiple fractures is protective of the C-spine leading to fewer fractures. Children and adults had different associations in the pattern of mandible fractures concomitant with CSI. This has implications in management, imaging, and workup of trauma patients.

Emergency general surgery outcomes at safety net hospitals.

BACKGROUND: The United States hospital safety net is defined by the Agency for Healthcare Research and Quality as the top decile of hospitals, which see the greatest proportion of uninsured patients. These hospitals provide important access to health care for uninsured patients but are commonly believed to have worse outcomes. The aim of this study was to compare the outcomes of emergency general surgery procedures performed at safety net and nonsafety net hospitals. MATERIAL AND METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2008-2010 was used to create a cohort of inpatients who underwent emergency appendectomy, cholecystectomy, or herniorrhaphy. Outcomes measured included length of stay, charge, cost, death in hospital, complications, and failure to rescue (FTR). Univariate and logistic regression analysis was performed to associate variables with outcomes. RESULTS: A total of 187,913 emergency general surgery cases were identified, 11.5% of which were performed at safety net hospitals. The safety net cohort had increased length of stay but lower mean charge and cost. Age, comorbidity score, black race, male gender, and Medicaid and Medicare insurance were associated with mortality, complication, and FTR. Lower socioeconomic status was associated with mortality and complication. Safety net status was positively associated with complication but not mortality or FTR. CONCLUSIONS: Safety net hospitals had higher complication rates but no difference in FTR or mortality. This may mean that the hospitals are able to effectively recognize and treat patient complications and do so without increased cost.

The relationship between trauma center volume and in-hospital outcomes.

BACKGROUND: Increases in hospital volume are positively associated with improved surgical outcomes. However, in the trauma setting, studies have reported conflicting findings in regard to volume's effect on in-hospital mortality. This study investigates whether complications, failure-to-rescue (FTR), and mortality are influenced by trauma centers' average annual volume. METHODS: We performed a retrospective cohort study that analyzed patient records included in the National Trauma Data Bank from years 2008-2010. We calculated risk-adjusted complication, FTR, and mortality rates for centers treating different volumes of patients. We also performed multilevel logistic regression modeling to examine the probability that patients treated at trauma centers with higher annual volumes would experience complication, FTR, and mortality while controlling for injury severity, type of injury, mechanism of trauma, age, gender, race, number of comorbidities, head injury, hypotension, and hospital clustering. Hospital characteristics including designation level, academic status, nonprofit status, safety-net status, and region were incorporated into the model. RESULTS: Risk-adjusted complication, FTR, and mortality rates differed significantly across hospital volume quintiles. Regression analyses indicated that higher hospital volumes were significantly associated with a decreased likelihood of mortality for individual patient but not for complication or FTR. CONCLUSIONS: Our findings suggest that higher trauma center volume is associated with improved mortality outcomes. However, the relationship between volume and FTR is more complex. Future research should address the question of determining optimal volume levels that lead to high provider experience, efficient resource usage, and low unintended consequences or outcomes.

"Smoker's Paradox" in Patients Treated for Severe Injuries: Lower Risk of Mortality After Trauma Observed in Current Smokers.

BACKGROUND: Studies evaluating the effect of smoking status on mortality outcomes in trauma patients have been limited, despite the fact that survival benefits of smoking have been reported in other critical care settings. The phenomenon "smoker's paradox" refers to the observation that following acute cardiovascular events, such as acute myocardial infarction and cardiac arrest, smokers often experience decreased mortality in the hospital setting. The objective of our study was to determine whether smoking imparts a survival benefit in patients with traumatic injuries. METHODS: We performed a retrospective cohort study that analyzed cases included in the National Trauma Data Bank research dataset. Hierarchical logistic regression analyses were used to determine whether smoking alters the risk of mortality and complications in patients who smoke. RESULTS: The percentage of patients experiencing mortality differed significantly between smokers (n = 38,564) and nonsmokers (n = 319,249) (1.8% vs. 4.3%, P < .001); however, the percentage experiencing a major complication did not (9.7% vs. 9.6%, P = .763). Regression analyses indicated that smokers were significantly less likely to die during the hospital stay compared to nonsmokers after adjusting for individual and hospital factors (OR = 0.15; CI = 0.10, 0.22). Additionally, smokers were also less likely to develop a major complication than nonsmokers (OR = 0.73, CI = 0.59-0.91). CONCLUSIONS: Patients who smoke appear to have a much lower risk of in-hospital mortality than nonsmokers. Further investigation into biological mechanisms responsible for this effect should be carried out in order to potentially develop therapeutic applications.

Pain management in trauma: the need for trauma-informed opioid prescribing guidelines.

Background/objectives: Surgical populations and particularly injury survivors often present with complex trauma that elevates their risk for prolonged opioid use and misuse. Changes in opioid prescribing guidelines during the past several years have yielded mixed results for pain management after trauma, with a limiting factor being the heterogeneity of clinical populations and treatment needs in individuals receiving opioids. The present analysis illuminates this gap between clinical guidelines and clinical practice through qualitative feedback from hospital trauma providers and unit staff members regarding current opioid prescribing guidelines and practices in the setting of traumatic injury. Methods: The parent study aimed to implement a pilot screening tool for opioid misuse in four level I and II trauma hospitals throughout Wisconsin. As part of the parent study, focus groups were conducted at each study site to explore the facilitators and barriers of implementing a novel screening tool, as well as to examine the current opioid prescribing guidelines, trainings, and resources available for trauma and acute care providers. Focus group transcripts were independently coded and analyzed using a modified grounded theory approach to identify themes related to the facilitators and barriers of opioid prescribing guidelines in trauma and acute care. Results: Three major themes were identified as impactful to opioid-related prescribing and care provided in the setting of traumatic injury; these include (1) acute treatment strategies; (2) patient interactions surrounding pain management; and (3) the multifactorial nature of trauma on pain management approaches. Conclusion: Providers and staff at four Wisconsin trauma centers called for trauma-specific opioid prescribing guidelines in the setting of trauma and acute care. The ubiquitous prescription of opioids and challenges in long-term pain management in these settings necessitate additional community-integrated research to inform development of federal guidelines. Level of evidence: Therapeutic/care management, level V.