Discharge to Skilled Nursing Facility Is a Risk Factor for Readmission: A Nationwide Propensity-Matched Study.

INTRODUCTION: General surgery procedures place stress on geriatric patients, and postdischarge care options should be evaluated. We compared the association of discharge to a skilled nursing facility (SNF) versus home on patient readmission. METHODS: We retrospectively reviewed the Nationwide Readmission Database (2016-2019) and included patients ≥65 y who underwent a general surgery procedure between January and September. Our primary outcome was 30-d readmissions. Our secondary outcome was predictors of readmission after discharge to an SNF. We performed a 1:1 propensity-matched analysis adjusting for patient demographics and hospital course to compare patients discharged to an SNF with patients discharged home. We performed a sensitivity analysis on patients undergoing emergency procedures and a stepwise regression to identify predictors of readmission. RESULTS: Among 140,056 included patients, 33,916 (24.2%) were discharged to an SNF. In the matched population of 19,763 pairs, 30-d readmission was higher in patients discharged to an SNF. The most common diagnosis at readmission was sepsis, and a greater proportion of patients discharged to an SNF were readmitted for sepsis. In the sensitivity analysis, emergency surgery patients discharged to an SNF had higher 30-d readmission. Higher illness severity during the index admission and living in a small or fringe county of a large metropolitan area were among the predictors of readmission in patients discharged to an SNF, while high household income was protective. CONCLUSIONS: Discharge to an SNF compared to patients discharged home was associated with a higher readmission. Future studies need to identify the patient and facility factors responsible for this disparity.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery.

INTRODUCTION: Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. METHODS: This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. RESULTS: We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). CONCLUSIONS: In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

The interaction of personal, contextual, and study characteristics and their effect on recruitment and participation of pregnant women in research: a qualitative study in Lebanon.

BACKGROUND: Declining participation rates are impeding health research. Little is known about factors influencing the decision to participate in low- and middle-income countries (LMIC). Therefore, this paper reports on the various individual factors and their with contextual factors in influencing participation in research among pregnant women and the recommendations to enhance their recruitment in Lebanon. METHODS: This study used a qualitative research design drawing on focus groups and in-depth interviews. The Theoretical Domain Framework guided data collection and analysis. The three participant groups included: Group 1-Pregnant women (n = 25) attending public pre-natal events and antenatal clinics in Beirut; Group 2-Pregnant women (n = 6) already enrolled in the ongoing Mother and Infant Nutritional Assessment birth cohort study; Group 3-Key informants (n = 13) including health care workers involved in recruiting pregnant women. Conversations were audio recorded, transcribed, translated into English, and thematically analyzed. RESULTS: Three main factors influencing participation were revealed, with each factor encompassing several sub-themes: (1) personal factors (altruism, self-confidence, personal interest in the topic, previous understanding of the nature and purpose of research, education level, and previous research experience), (2) contextual factors (societal factors, family and friends), and (3) study characteristics (burden of the study, ethical considerations, incentives, and research interpersonal skills and physician endorsement to participate). The results suggested a dynamic interaction among the identified factors, forming two intersecting axes, with a four-quadrant configuration. The y- and x-axes represented personal factors and contextual factors, respectively. Individuals positioned on the lower-left quadrant were the least likely to participate; those on the upper-right quadrant were the most likely to participate; while those on the upper-left and lower-right quadrants were indecisive. Study characteristics seemed to affect the decision of pregnant women to participate situated in any of the four quadrants. Specific recommendations to improve participation were also identified. CONCLUSIONS: Our findings suggested an interaction of personal factors, contextual factors, and study characteristics affecting subjects' participation. This interaction integrates factors into a novel dynamic framework that could be used in future studies. The recommendations identified may help improve participation of pregnant women in health research hence enhancing the quality and generalizability of research findings in LMIC.

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures.

BACKGROUND: There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. METHODS: We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). RESULTS: The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. CONCLUSION: We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study.

BACKGROUND: Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure. METHODS: We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition. RESULTS: We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 â€‹% vs. 11.9 â€‹%; p â€‹= â€‹0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 â€‹% vs. 4.4 â€‹%; p â€‹= â€‹0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group. CONCLUSION: The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.

The association of disability conditions with access to minimally invasive general surgery.

BACKGROUND: Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized. OBJECTIVE: To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions. METHODS: We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis. RESULTS: In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS. CONCLUSIONS: This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Traumatic lower extremity amputation as a risk factor for venous thromboembolism.

BACKGROUND: This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS: All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS: A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p â€‹< â€‹0.001) and DVT (6.5% vs. 3.4%, p â€‹< â€‹0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p â€‹= â€‹0.015) and DVT (4.7% vs. 2.6%, p â€‹< â€‹0.001). CONCLUSIONS: In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

Two big bones, one big decision: When to fix bilateral femur fractures.

PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures.

BACKGROUND: Despite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. METHODS: We performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. RESULTS: Among our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. CONCLUSION: Severe intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

Lost in transition: Impact of interhospital transfer on outcomes after emergency general surgery in the older adult population.

BACKGROUND: Emergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients. METHODS: Emergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort. RESULTS: Among the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients. CONCLUSION: Interhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes.

First do no harm: Predicting futility of intervention in geriatric emergency general surgery.

BACKGROUND: Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care. METHODS: We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors. RESULTS: Of 41,029 patients, 5589 (13.6 â€‹%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 â€‹% CI,3.5-26.8, p â€‹< â€‹0.001), septic shock (aOR 4.9, 95 â€‹% CI,4.5-5.4, p â€‹< â€‹0.001), and dialysis (aOR 2.1, 95 â€‹% CI,1.8-2.4, p â€‹< â€‹0.001). Without risk factors, mortality rates were 11.9 â€‹% after colectomy and 10.2 â€‹% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 â€‹% and 100 â€‹% following colectomy and small bowel resection, respectively. CONCLUSIONS: In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making.

Development of a two-hit lethal liver injury model in swine.

PURPOSE: Noncompressible truncal hemorrhage remains a leading cause of preventable death in the prehospital setting. Standardized and reproducible large animal models are essential to test new therapeutic strategies. However, existing injury models vary significantly in consistency and clinical accuracy. This study aims to develop a lethal porcine model to test hemostatic agents targeting noncompressible abdominal hemorrhages. METHODS: We developed a two-hit injury model in Yorkshire swine, consisting of a grade IV liver injury combined with hemodilution. The hemodilution was induced by controlled exsanguination of 30% of the total blood volume and a 3:1 resuscitation with crystalloids. Subsequently, a grade IV liver injury was performed by sharp transection of both median lobes of the liver, resulting in major bleeding and severe hypotension. The abdominal incision was closed within 60 s from the injury. The endpoints included mortality, survival time, serum lab values, and blood loss within the abdomen. RESULTS: This model was lethal in all animals (5/5), with a mean survival time of 24.4 ± 3.8 min. The standardized liver resection was uniform at 14.4 ± 2.1% of the total liver weight. Following the injury, the MAP dropped by 27 ± 8mmHg within the first 10 min. The use of a mixed injury model (i.e., open injury, closed hemorrhage) was instrumental in creating a standardized injury while allowing for a clinically significant hemorrhage. CONCLUSION: This novel highly lethal, consistent, and clinically relevant translational model can be used to test and develop life-saving interventions for massive noncompressible abdominal hemorrhage.

Analyzing the Impact of Concomitant COVID-19 Infection on Outcomes in Trauma Patients.

BACKGROUND: The impact of COVID-19 infection at the time of traumatic injury remains understudied. Previous studies demonstrate that the rate of COVID-19 vaccination among trauma patients remains lower than in the general population. This study aims to understand the impact of concomitant COVID-19 infection on outcomes in trauma patients. METHODS: We conducted a retrospective cohort study of patients ≥18 years old admitted to a level I trauma center from March 2020 to December 2022. Patients tested for COVID-19 infection using a rapid antigen/PCR test were included. We matched patients using 2:1 propensity accounting for age, gender, race, comorbidities, vaccination status, injury severity score (ISS), type and mechanism of injury, and GCS at arrival. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, 30-day readmission, and major complications. RESULTS: Of the 4448 patients included, 168 (3.8%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in age, sex, BMI, ISS, type of injury, and regional AIS. The proportion of White and non-Hispanic patients was higher in COV- patients. Following matching, 154 COV+ and 308 COV- patients were identified. COVID-19-positive patients had a higher rate of mortality (7.8% vs 2.6%; P = .010), major complications (15.6% vs 8.4%; P = .020), and thrombotic complications (3.9% vs .6%; P = .012). Patients also had a longer hospital LOS (median, 9 vs 5 days; P < .001) and ICU LOS (median, 5 vs 3 days; P = .025). CONCLUSIONS: Trauma patients with concomitant COVID-19 infection have higher mortality and morbidity in the matched population. Focused interventions aimed at recognizing this high-risk group and preventing COVID-19 infection within it should be undertaken.

The impact of frailty on long-term functional outcomes in severely injured geriatric patients.

BACKGROUND: The incidence of severe injury in the geriatric population is increasing. However, the impact of frailty on long-term outcomes after injury in this population remains understudied. Therefore, we aimed to understand the impact of frailty on long-term functional outcomes of severely injured geriatric patients. METHODS: We conducted a retrospective cohort study, including patients ≥65 years old with an Injury Severity Score ≥15, who were admitted between December 2015 and April 2022 at one of 3 level 1 trauma centers in our region. Patients were contacted between 6 and 12 months postinjury and administered a trauma quality of life survey, which assessed for the presence of new functional limitations in their activities of daily living. We defined frailty using the mFI-5 validated frailty tool: patients with a score ≥2 out of 5 were considered frail. The impact of frailty on long-term functional outcomes was assessed using 1:1 propensity matching adjusting for patient characteristics, injury characteristics, and hospital site. RESULTS: We included 580 patients, of whom 146 (25.2%) were frail. In a propensity-matched sample of 125 pairs, frail patients reported significantly higher functional limitations than nonfrail patients (69.6% vs 47.2%; P < .001). This difference was most prominent in the following activities: climbing stairs, walking on flat surfaces, going to the bathroom, bathing, and cooking meals. In a subgroup analysis, frail patients with traumatic brain injuries experienced significantly higher long-term functional limitations. CONCLUSION: Frail geriatric patients with severe injury are more likely to have new long-term functional outcomes and may benefit from screening and postdischarge monitoring and rehabilitation services.

From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients.

BACKGROUND: COVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates. METHODS: We conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination. RESULTS: The rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated. CONCLUSION: Hospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.

Timing matters: Early versus late rib fixation in patients with multiple rib fractures and pulmonary contusion.

BACKGROUND: Recent literature has shown that surgical stabilization of rib fractures benefits patients with rib fractures accompanied by pulmonary contusion; however, the impact of timing on surgical stabilization of rib fractures in this patient population remains unexplored. We aimed to compare early versus late surgical stabilization of rib fractures in patients with traumatic rib fractures and concurrent pulmonary contusion. METHODS: We selected all adult patients with isolated blunt chest trauma, multiple rib fractures, and pulmonary contusion undergoing early (<72 hours) versus late surgical stabilization of rib fractures (≥72 hours) using the American College of Surgeons Trauma Quality Improvement Program 2016 to 2020. Propensity score matching was performed to adjust for patient, injury, and hospital characteristics. Our outcomes were hospital length of stay, acute respiratory distress syndrome, unplanned intubation, ventilator days, unplanned intensive care unit admission, intensive care unit length of stay, tracheostomy rates, and mortality. We then performed sub-group analyses for patients with major or minor pulmonary contusion. RESULTS: We included 2,839 patients, of whom 1,520 (53.5%) underwent early surgical stabilization of rib fractures. After propensity score matching, 1,096 well-balanced pairs were formed. Early surgical stabilization of rib fractures was associated with a decrease in hospital length of stay (9 vs 13 days; P < .001), decreased intensive care unit length of stay (5 vs 7 days; P < .001), and lower rates of unplanned intubation (7.4% vs 11.4%; P = .001), unplanned intensive care unit admission (4.2% vs 105%, P < .001), and tracheostomy (8.4% vs 12.4%; P = .002). Similar results were also found in the subgroup analyses for patients with major or minor pulmonary contusion. CONCLUSION: These findings suggest that in patients with multiple rib fractures and pulmonary contusion, the early implementation of surgical stabilization of rib fractures could be beneficial regardless of the severity of pulmonary contusion.

Knowledge & attitudes toward fertility preservation (Medical and social freezing) among Lebanese women between the ages of 18 and 39 years.

Egg freezing is a relatively new and controversial procedure in the Arab region, challenging traditional perceptions of fertility and motherhood. This study aims to assess Lebanese women's awareness and acceptance of egg freezing and how these attitudes differ according to vary with age, socio-demographic characteristics, and educational level. We conducted a cross-sectional survey targeting Lebanese females aged between 18 and 39, involving 402 Lebanese women from six different institutions representing diverse cultural backgrounds. 65% of the respondents had heard of egg freezing. Younger women (18-30 years old) were 2.09 times more likely to consider egg freezing than those aged 31-39. Single women were 4.31 times more likely to consider egg freezing than women in relationships, while childless women were 5.00 times more likely compared to women who already had children. Overall, medical egg freezing was more widely accepted than social egg freezing. The most supported indication for social egg freezing was to enable women who struggled to find the right partner during their peak fertile years to have children in the future (41.5%). The most common concern that affected women's decision to undergo egg freezing was whether the procedure would be proven safe for their future children and whether it would affect their future fertility. Interestingly, in a relatively conservative country, concerns about hymenal disruption were the least prevalent, (19%). The most common concern by far was limited information on the procedure (62%). In conclusion, the study reveals that awareness and acceptance of social egg freezing among Lebanese women were higher than expected. Limited information on the procedure's details was the main impediment to higher acceptance rates, highlighting the importance of physicians and primary healthcare providers in providing reproductive-aged women with the necessary information to safeguard their reproductive potential.

Is severe traumatic brain injury no longer a contraindication for surgical stabilization of rib fractures in patients with multiple rib fractures? A propensity-matched analysis.

BACKGROUND: Traumatic brain injury (TBI) is often considered a contraindication to surgical stabilization of rib fractures (SSRF). In this study, we hypothesized that, compared with nonoperative management, SSRF is associated with improved outcomes in TBI patients. METHODS: Using the American College of Surgeons Trauma Quality Improvement Program 2016-2019, we performed a retrospective analysis of patients with concurrent TBI and multiple rib fractures. Following propensity score matching, we compared patients who underwent SSRF with those who were managed nonoperatively. Our primary outcome was mortality. Secondary outcomes included ventilator-associated pneumonia, hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, tracheostomy rate, and hospital discharge disposition. In a subgroup analysis, we stratified patients into mild and moderate TBI (GCS score >8) and severe TBI (GCS score ≤8). RESULTS: Of 36,088 patients included in this study, 879 (2.4%) underwent SSRF. After propensity-score matching, compared with nonoperative management, SSRF was associated with decreased mortality (5.4% vs. 14.5%, p < 0.001), increased hospital LOS (15 days vs. 9 days, p < 0.001), increased ICU LOS (12 days vs. 8 days, p < 0.001), and increased ventilator days (7 days vs. 4 days, p < 0.001). In the subgroup analyses, in mild and moderate TBI, SSRF was associated with decreased in-hospital mortality (5.0% vs. 9.9%, p = 0.006), increased hospital LOS (13 days vs. 9 days, p < 0.001), ICU LOS (10 days vs. 7 days, p < 0.001), and ventilator days (5 days vs. 2 days, p < 0.001). In patients with severe TBI, SSRF was associated with decreased mortality (6.2% vs. 18%, p < 0.001), increased hospital LOS (20 days vs. 14 days, p = 0.001), and increased ICU LOS (16 days vs. 13 days, p = 0.004). CONCLUSION: In patients with TBI and multiple rib fractures, SSRF is associated with a significant decrease in in-hospital mortality and with longer hospital and ICU LOSs. These findings suggest that SSRF should be considered in patients with TBI and multiple rib fractures. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.