Mental Health Care Resource Utilization of Victims of Interpersonal Violence in the Novel Coronavirus Era.

INTRODUCTION: Higher incidences of interpersonal violence were reported throughout the country during the coronavirus (COVID) time period. We aimed to compare health-care encounters and resource utilization related to interpersonal violence with mental health (MH) disorders before and during the pandemic within a year of the index visit for interpersonal violence. METHODS: A retrospective analysis of the Delaware Healthcare Claims data of all patients aged ≥16 y who suffered interpersonal violence was performed. Patients were followed up for 1 y pre and post their index visit of interpersonal violence episode during the pre-COVID (March 2018 through December 2018) and the COVID (March 2020 through December 2020) period. Census tract information was used to assess social determinants of health. RESULTS: There were 431 patients in the COVID period and 527 patients in the pre-COVID period with index violence claim encounters. African American patients were more likely to have a violence encounter during COVID (60.3% versus 47.2%, P < 0.001). Patients in the COVID period were more likely to live in a census tract with public assistance households (median 3.3% versus 2.2%, P = 0.005) and higher unemployment (7.5% versus 7.1%, P = 0.01). In the following year of index violence claim, the mean numbers of MH claim-days for COVID and pre-COVID patients were 19.5 (53.3) and 26.2 (66.2), (P = 0.51). The COVID group had fewer MH claim-days mostly in the second half of the year after the index encounter with an incidence rate ratio of 0.61, 95% CI (0.45-0.83). CONCLUSIONS: Racial and socioeconomic disparities were amplified and MH resource utilization was lower during COVID. Further injury prevention efforts should be focused on MH in future pandemics or disasters.

Outcomes of Traumatic Brain Injury Patients Managed in a Non-Intensive Care Unit Setting.

INTRODUCTION: The management of traumatic brain injury (TBI) requires significant health-care resources. The modified Brain Injury Guidelines (mBIG) stratifies TBI patients by severity to help guide disposition and management. We sought to analyze the outcomes of TBI patients managed in a non-intensive care unit (ICU) setting after stratifying them using the mBIG criteria. METHODS: A retrospective single-center study was performed on all adult patients who sustained blunt TBI from 2021 to 2022 and were managed in a non-ICU setting. Primary outcome was unplanned upgrade to the ICU. Secondary outcomes were need for neurosurgical intervention, unplanned intubation, mortality, and hospital length of stay. Patients were divided into cohorts of mBIG 1 & 2 versus mBIG 3. RESULTS: Of the 274 patients managed in a non-ICU setting, 119 (43.4%) met mBIG 3 criteria. The majority (76.5%) were managed in a step-down level of care. Nine patients required upgrade to the ICU, with only two upgraded for acute progression of their intracranial hemorrhage. Eight patients in mBIG 3 cohort required neurosurgical interventions, with only two related to progression of their intracranial hemorrhage and both over 24 h after admission. The remaining six patients had planned delayed neurosurgical intervention. Unplanned intubation occurred in three patients with only one related to a delayed progression of their TBI. Longer hospitalization and decreased survival were noted in mBIG 3 group. No differences in 30-d readmissions, stroke, venous thromboembolism events or seizures were found between the two groups. CONCLUSIONS: Select patients with severe TBI may be considered for admission to step-down units with frequent neurologic exams in lieu of ICU level of care.

A Statewide Analysis of Self-Inflicted Injuries During COVID-19 Pandemic: Is There Adequate Access to Mental Health?

INTRODUCTION: Many social and behavioral changes occurred during the COVID-19 pandemic. Our objective was to identify changes in incidence of self-inflicted injuries during COVID-19 compared to prepandemic years. Further, we aimed to identify risk factors associated with self-inflicted injuries before and during the pandemic. METHODS: A retrospective cohort study of patients aged ≥18 y with self-inflicted injuries from 2018 to 2021 was performed using the Pennsylvania Trauma Outcome Study registry. Patients were grouped into pre-COVID Era (pre-CE, 2018-2019) and COVID Era (CE, 2020-2021). Statistical comparisons were accomplished using Wilcoxon rank-sum tests and chi-square or Fisher's exact tests. RESULTS: There were a total of 1075 self-inflicted injuries in the pre-CE cohort and 482 during the CE. There were no differences in age, gender, race or ethnicity between the two cohorts. Among preexisting conditions, those within the pre-CE cohort had a higher incidence of mental/personality disorder (59.2% versus 52.3%, P = 0.01). There were no significant differences in the mechanism of self-inflicted injuries or place of injury between the two periods. Additionally, there were no differences in discharge destinations or mortality between the two cohorts. CONCLUSIONS: During the height of social isolation in Pennsylvania, there were no associated increases in self-inflicted injuries. However, there were increased incidences of self-inflicted injuries among those with a prior diagnosis of mental or personality disorder in the pre-CE group. Further investigations are required to study the access to mental health services in future pandemics or public health disasters.

Evaluating the Accuracy, Comprehensiveness, and Validity of ChatGPT Compared to Evidence-Based Sources Regarding Common Surgical Conditions: Surgeons' Perspectives.

BACKGROUND: This study aims to assess the accuracy, comprehensiveness, and validity of ChatGPT compared to evidence-based sources regarding the diagnosis and management of common surgical conditions by surveying the perceptions of U.S. board-certified practicing surgeons. METHODS: An anonymous cross-sectional survey was distributed to U.S. practicing surgeons from June 2023 to March 2024. The survey comprised 94 multiple-choice questions evaluating diagnostic and management information for five common surgical conditions from evidence-based sources or generated by ChatGPT. Statistical analysis included descriptive statistics and paired-sample t-tests. RESULTS: Participating surgeons were primarily aged 40-50 years (43%), male (86%), White (57%), and had 5-10 years or >15 years of experience (86%). The majority of surgeons had no prior experience with ChatGPT in surgical practice (86%). For material discussing both acute cholecystitis and upper gastrointestinal hemorrhage, evidence-based sources were rated as significantly more comprehensive (3.57 (±.535) vs 2.00 (±1.16), P = .025) (4.14 (±.69) vs 2.43 (±.98), P < .001) and valid (3.71 (±.488) vs 2.86 (±1.07), P = .045) (3.71 (±.76) vs 2.71 (±.95) P = .038) than ChatGPT. However, there was no significant difference in accuracy between the two sources (3.71 vs 3.29, P = .289) (3.57 vs 2.71, P = .111). CONCLUSION: Surveyed U.S. board-certified practicing surgeons rated evidence-based sources as significantly more comprehensive and valid compared to ChatGPT across the majority of surveyed surgical conditions. However, there was no significant difference in accuracy between the sources across the majority of surveyed conditions. While ChatGPT may offer potential benefits in surgical practice, further refinement and validation are necessary to enhance its utility and acceptance among surgeons.

Thromboprophylaxis in hospitalized trauma patients: a systematic review and meta-analysis of implementation strategies.

Introduction: Venous thromboembolism (VTE) prophylaxis implementation strategies are well-studied in some hospitalized medical and surgical patients. Although VTE is associated with substantial mortality and morbidity in trauma patients, implementation strategies for the prevention of VTE in trauma appear to be based on limited evidence. Therefore, we conducted a systematic review and meta-analysis of published literature on active implementation strategies for VTE prophylaxis administration in hospitalized trauma patients and the impact on VTE events. Methods: A systematic review and meta-analysis was performed in adult hospitalized trauma patients to assess if active VTE prevention implementation strategies change the proportion of patients who received VTE prophylaxis, VTE events, and adverse effects such as bleeding or heparin-induced thrombocytopenia as well as hospital length of stay and the cost of care. An academic medical librarian searched Medline, Scopus, and Web of Science until December 2022. Results: Four studies with a total of 1723 patients in the active implementation strategy group (strategies included education, reminders, human and computer alerts, audit and feedback, preprinted orders, and/or root cause analysis) and 1324 in the no active implementation strategy group (guideline creation and dissemination) were included in the analysis. A higher proportion of patients received VTE prophylaxis with an active implementation strategy (OR=2.94, 95% CI (1.68 to 5.15), p<0.01). No significant difference was found in VTE events. Quality was deemed to be low due to bias and inconsistency of studies. Conclusions: Active implementation strategies appeared to improve the proportion of major trauma patients who received VTE prophylaxis. Further implementation studies are needed in trauma to determine effective, sustainable strategies for VTE prevention and to assess secondary outcomes such as bleeding and costs. Level of evidence: Systematic review/meta-analysis, level III. PROSPERO registration number: CRD42023390538.

Role of preoperative CT imaging in penetrating thoraco-abdominal injuries: A multicenter study of urban trauma centers.

INTRODUCTION: Management of penetrating thoracoabdominal (PTA) injuries with signs of hemorrhage have warranted operative intervention but improved imaging capabilities have redefined interventions required. We examined outcomes of hemodynamically stable patients undergoing preoperative CT imaging with the hypothesis that CT imaging would decrease OR time without delaying OR arrival. METHODS: A retrospective multicenter study was performed amongst four urban trauma centers examining hemodynamically stable patients with PTA injuries requiring operative intervention from January 2017-December 2021. The primary outcome was OR time. Secondary outcomes included length of stay (LOS), ICU LOS, and mortality. A multivariable logistic regression with random intercept for trauma center was fit to assess whether preoperative CT affected time in the OR. RESULTS: Of 534 hemodynamically stable patients with penetrating injuries, 322 (60.3 â€‹%) received preoperative CT. The median time in OR were 130 (IQR: 84,180) and 140 (IQR: 100, 180) minutes for patients with and without preoperative CT, respectively. Median time to OR was 68 (IQR: 47, 110) and 26 (IQR 17,38) minutes in patients with and without preop CT, respectively. Median ICU LOS were 0 vs 1 day, the median hospital LOS were 7 vs 8 days for patients with and without pre-op imaging respectively. The multivariable model showed that obtaining a pre-op CT scanning was not independently associated with time spent in OR. (Adjusted OR:0.94; 95 â€‹% CI: 0.85, 1.04). CONCLUSION: In patients with PTA injuries and hemodynamic stability, preoperative CT scanning was not associated with decreased OR time, postoperative complications, or mortality.

Geriatric trauma triage: optimizing systems for older adults-a publication of the American Association for the Surgery of Trauma Geriatric Trauma Committee.

Background: Geriatric trauma patients are an increasing population of the United States (US), sustaining a high incidence of falls, and suffer greater morbidity and mortality to their younger counterparts. Significant variation and challenges exist to optimize outcomes for this cohort, while being mindful of available resources. This manuscript provides concise summary of locoregional and national practices, including relevant updates in the triage of geriatric trauma in an effort to synthesize the results and provide guidance for further investigation. Methods: We conducted a review of geriatric triage in the United States (US) at multiple stages in the care of the older patient, evaluating existing literature and guidelines. Opportunities for improvement or standardization were identified. Results: Opportunities for improved geriatric trauma triage exist in the pre-hospital setting, in the trauma bay, and continue after admission. They may include physiologic criteria, biochemical markers, radiologic criteria and even age. Recent Trauma Quality Improvement Program (TQIP) Best Practices Guidelines for Geriatric Trauma Management published in 2024 support these findings. Conclusion: Trauma systems must adjust to provide optimal care for older adults. Further investigation is required to provide pertinent guidance.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

BACKGROUND: This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION: When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Scanning the aged to minimize missed injury: An EAST multicenter study.

BACKGROUND: Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a Pan-Scan (Head/C-spine/Torso) or a Selective Scan (Head/C-spine ± Torso). We hypothesized that a patient's initial history and exam could be used to guide imaging. METHODS: We prospectively studied blunt trauma patients aged 65+ at 18 Level I/II trauma centers. Patients presenting >24 h after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of Head/C-spine or Torso (chest, abdomen/pelvis, and T/L spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our dataset. Our priority was to identify a simple rule which could be applied at the bedside, maximizing sensitivity (Sens) and negative predictive value (NPV) to minimize missed injuries. RESULTS: We enrolled 5,498 patients with 3,082 injuries. Nearly half (47.1%, n = 2,587) had an injury within the defined CT body regions. No rule to guide a Pan-Scan could be identified with suitable Sens/NPV for clinical use. A clinical algorithm to identify patients for Pan-Scan, using a combination of physical exam findings and specific high-risk criteria, was identified and had a Sens of 0.94 and NPV of 0.86 This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT. CONCLUSIONS: Our findings advocate for Head/Cspine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population. LEVEL OF EVIDENCE: Level 2, Diagnostic Tests or Criteria.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study.

BACKGROUND: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE: Level III, Therapeutic Care Management.

Management of the complex duodenal injury.

INTRODUCTION: Complex duodenal trauma is a rare injury with an incidence of 1-4.7% of all abdominal trauma. Historically, varied approaches have been used in the management of these complex injuries and the prevention of complications. This is a review of the current management methodology of complex duodenal injury. METHODS: A review of the medical literature to include the past and current management of duodenal trauma was performed. Google scholar (1970-2022) and PubMed (1970-2022) were searched using the keywords: complex duodenal trauma, surgical management, and duodenal complications. DISCUSSION: Complex duodenal trauma can be classified using the AAST grading scale as those encompassing grades III-V. Multiple studies and review articles characterize the difficulty in managing complex duodenal injuries. The tenets of operative management of duodenal trauma include the decision for damage control, resection of non-viable tissue, restoring gastrointestinal continuity, diversion of gastrointestinal contents, bile and pancreatic enzymes, allowing the repair to heal, and providing feeding access. The variety of both historic and current approaches attempt to address these tenets. The incidence of complications are as high as 65% with the most common complications including abscess formation, suture line dehiscence and fistula formation. The overall mortality ranges from 5 to 30%. CONCLUSIONS: Many different approaches and strategies have been proposed to repair complex duodenal injuries, all of which address important tenets of its management. The risk of complications remains high, therefore, it is vital to have a thoughtful and multidisciplinary approach when treating these injuries.

A Rare Case of Urinothorax as a Result of Penetrating Trauma.

Urinothorax, defined as urine within the pleural space, is an uncommon finding in published trauma literature. To date, there are less than ten recorded cases of non-iatrogenic trauma-induced urinothorax, most resulting from blunt traumatic injuries from motor vehicle collisions. Given the rarity of the condition, the diagnosis is often missed or delayed. Once the diagnosis is suspected, the most reliable finding is a pleural fluid to serum creatinine ratio of >1. A confirmed diagnosis of urinothorax then requires drainage of pleural fluid and management of distal ureteral obstruction. Unfortunately, the added complexity of the poly-trauma patient obscures this difficult diagnosis often leading to a delay in treatment and prolonged hospital stay. No current published literature exists on penetrating trauma as a cause of urinothorax. Here, we describe a unique case of urinothorax in a 32-year-old male as a result of penetrating trauma.

National survey results on effect of COVID-19 pandemic on female surgeons: A new normal work environment.

BACKGROUND: The impact of COVID-19 reaches the overall well-being of women surgeons. We aimed to describe the impact of transitioning to a new challenging environment. METHODS: A survey of 60 quantitative questions using a Likert-like scale was distributed electronically via email across 1200 members of the Association of Women Surgeons in 2021. Family lifestyle factors including care for children, elderly family members, extent of household chores, and impact of COVID-19 pandemic were queried. RESULTS: A total of 139 members responded. Fifty one percent of these respondents had children at home and 31.2% indicated they needed additional help at home during that time. Eighteen percent of those in practice cared for their elderly family members. Of the survey participants, 71.2% felt the COVID pandemic resulted in a worsened clinical practice, with 30.9% noting a decrease in income. CONCLUSIONS: Women surgeons faced crucial challenges during and post pandemic. An awareness of the changing needs of women surgeons is essential.

Implementation science approaches to optimizing venous thromboembolism prevention in patients with traumatic injuries: Findings from the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma.

ABSTRACT: Disease burden of venous thromboembolism (VTE) without pharmacologic prophylaxis is high in trauma patients. Although VTE prophylaxis guidelines exist, studies on real-world use of VTE prophylaxis in trauma shows limited uptake of guideline recommendations. Despite existing guidelines, reports indicate that VTE prophylaxis implementation across trauma centers is lagging. Implementation barriers of VTE prophylaxis in trauma are multifactorial, and VTE prescribing practices require further optimization. Implementation science methods can help standardize and improve care; well-established approaches in medical and surgical hospitalized patients and their effects on clinical outcomes such as VTE and bleeding complications must be investigated because they apply to trauma patients. Nonadministration of VTE prophylaxis medications in hospitalized patients is associated with VTE events and remains a barrier to providing optimal defect-free care. Further investigations are required for VTE prophylaxis implementation across all trauma populations.

Papillary muscle rupture of the mitral valve following blunt thoracic trauma.

Blunt cardiac injury is caused by large deceleration forces seen in motor vehicle accidents and can range from non-life-threatening arrhythmias to potentially fatal cardiac conditions such as valve disruption. A 28-year-old man presented following a motor vehicle accident involving direct blunt-force chest trauma. He developed papillary muscle rupture resulting in mitral valve dysfunction. Diagnosis was delayed due to concomitant chest pathology. Diagnosis of cardiac valvular injuries may be difficult due to concomitant injuries in a trauma patient. Though rare, papillary muscle rupture should be included in the differential diagnosis following blunt thoracic trauma, particularly involving persistent hypoxemia.

Increase in Motor Vehicle Crash Severity: An Unforeseen Consequence of COVID-19.

INTRODUCTION: The 2019 coronavirus (COVID-19) pandemic led to stay-at-home (SAH) orders in Pennsylvania targeted at reducing viral transmission. Limitations in population mobility under SAH have been associated with decreased motor vehicle collisions (MVC) and related injuries, but the impact of these measures on severity of injury remains unknown. The goal of this study is to measure the incidence, severity, and outcomes of MVC-related injuries associated with SAH in Pennsylvania. MATERIALS & METHODS: We conducted a retrospective geospatial analysis of MVCs during the early COVID-19 pandemic using a state-wide trauma registry. We compared characteristics of patients with MVC-related injuries admitted to Pennsylvania trauma centers during SAH measures (March 21-July 31, 2020) with those from the corresponding periods in 2018 and 2019. We also compared incidence of MVCs for each zip code tabulation area (ZCTA) in Pennsylvania for the same time periods using geospatial mapping. RESULTS: Of 15,550 trauma patients treated during the SAH measures, 3486 (22.4%) resulted from MVCs. Compared to preceding years, MVC incidence decreased 10% under SAH measures with no change in mortality rate. However, in ZCTA where MVC incidence decreased, there was a 16% increase in MVC injury severity. CONCLUSIONS: Stay-at-home orders issued in response to the COVID-19 pandemic in Pennsylvania were associated with significant changes in MVC incidence and severity. Identifying such changes may inform resource allocation decisions during future pandemics or SAH events.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Cardiac tamponade secondary to iatrogenic needle decompression in blunt force trauma.

The proper treatment for tension pneumothorax is rapid needle decompression. This procedure is frequently performed in the field for trauma patients who have clinical symptoms of pneumothorax. The procedure itself has a high rate of failure due to improper placement, operator inexperience, or chest wall thickness. A 22-year-old unrestrained driver in a high-speed motor vehicle collision was found unconscious and subsequently had needle decompression for decreased breath sounds in the field. The patient was initially stable upon arrival but progressed to cardiac arrest. She had a thoracotomy in the emergency department that showed cardiac tamponade followed by return of spontaneous circulation. On formal thoracotomy, it was discovered that the patient had an iatrogenic cardiac injury from the angiocatheter placed during needle decompression. Needle decompression is a lifesaving procedure, but it is associated with high failure rates and possibility for iatrogenic injury.

Rising incidence of interpersonal violence in Pennsylvania during COVID-19 stay-at home order.

BACKGROUND: The coronavirus disease 2019 pandemic and associated policies have had important downstream consequences for individuals, communities, and the healthcare system, and they appear to have been accompanied by rising interpersonal violence. The objective of this study was to evaluate the incidence of injuries owing to interpersonal violence after implementation of a statewide stay-at-home order in Pennsylvania in March 2020. METHODS: Using the Pennsylvania Trauma Outcome Study registry, we conducted a retrospective cohort study of patients with gunshot wounds, stab wounds, and blunt assault-related injuries attributable to interpersonal violence treated at Pennsylvania trauma centers from March 16 to July 31 of 2018, 2019, and 2020. RESULTS: There were fewer total trauma admissions in 2020 (17,489) vs 2018 (19,290) and 2019 (19,561). Gunshot wounds increased in 2020 to 737 vs 647 for 2019 and 565 for 2018 (P = .028), whereas blunt assault injuries decreased (P = .03). In all time periods, interpersonal violence primarily impacted urban counties. African American men were predominantly affected by gunshot wounds and stab wounds, whereas Caucasian men were predominantly affected by blunt assault injuries. There were more patients with substance abuse disorders and positive drug screens during coronavirus disease than in comparison periods: (stab wound population 52.3% vs 33.9% vs 45.9%, coronavirus disease era vs 2018 vs 2019, respectively P = .0001), (blunt assault injury population 41.4% vs 33.1% vs 33.5%, coronavirus disease era vs 2018 vs 2019, respectively P < .0001). There was no correlation between the incidence of interpersonal violence and coronavirus disease 2019 rates at the county level. CONCLUSION: The implementation of a stay-at-home order was accompanied by rising incidence of gunshot and stab wound injuries in Pennsylvania. Preparedness for future resurgences of coronavirus disease 2019 and other pandemics calls for plans to address injury prevention, recidivism, and access to mental health and substance abuse prevention services.

Academic Medical Centers Experienced Higher Rates of Post-Operative Health-Care-Associated Infections during the COVID-19 Pandemic: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Trial.

Background: We sought to examine health-care-associated infections (HAIs) among patients undergoing an appendectomy at academic medical centers (AMCs) and non-AMCs during the coronavirus disease 2019 (COVID-19) peri-pandemic. We hypothesized that AMCs would have higher rates of post-operative HAIs during the first wave of the pandemic. Patients and Methods: We performed a post hoc analysis of a prospective, observational, multi-center study of patients aged >18 years who underwent an appendectomy for acute appendicitis before (pre-CoV), during (CoV), and after pandemic restrictions were lifted (post-CoV). Patients were grouped according to hospital type (AMC vs. non-AMC). Our primary outcome was the incidence of post-operative HAIs. Results: There were 1,003 patients; 69.5% (n = 697) were treated at AMCs and 30.5% (n = 306) at non-AMCs. Patients at AMCs had greater rates of concomitant COVID-19 infections (5.5% vs. 0.7%; p < 0.0001) and worse operative appendicitis severity (p = 0.01). Greater rates of HAIs were seen at AMCs compared with non-AMCs (4.9% vs. 2%; p = 0.03). Surgical site infections were the most common HAI and occurred more often at AMCs (4.3% vs. 1.6%; p = 0.04). Only during CoV were there more HAIs at AMCs (5.1% vs. 0.3%; p = 0.02). Undergoing surgery at an AMC during CoV was a risk factor for HAIs (adjusted odds ratio [aOR], 8.55; 95% confidence interval [CI], 1.03-71.03; p = 0.04). Conclusions: During the COVID-19 pandemic, appendectomies performed at AMCs were an independent risk factor for post-operative HAIs. Our findings stress the importance of adherence to standard infection prevention efforts during future healthcare crises.