Traumatic Brain Injury Patients Admitted on High-Census Days Receive Less Critical Care and Have an Increased Risk for Delirium.

INTRODUCTION: The utilization of healthcare services in a growing population has raised concerns about its impact on clinical outcomes. Studies have shown that increased hospital census is associated with higher admission rates and unnecessary consults, tests, and procedures in various areas of healthcare. Traumatic brain injuries (TBIs), a significant concern due to their potential for long-term disabilities, are commonly encountered in intensive care units (ICUs) and are a leading cause of patient mortality. Despite extensive research on various aspects of TBI, the effect of the patient census on TBI outcomes remains unexplored. This study aims to investigate the relationship between healthcare provider patient census and clinical outcomes in TBI patients at a level I trauma center. METHODS: A retrospective review was conducted from 2017 to 2022. The mean number of patients per day in the trauma service was determined, with patients below this average considered to be present on low-census days and those above it on high-census days. Patient demographics, mechanisms of injury, vital signs, TBI severity, and associated injuries were analyzed. Adjusted regression analyses were conducted. RESULTS: Over the study period, 1,527 TBI patients were identified. Demographics were similar between patients admitted on high- and low-census days. Patients with moderate TBI were 30% less likely to be admitted to the ICU on high-census days, whereas there was no difference in ICU admission for patients with mild or severe TBI. Delirium was significantly higher in patients admitted on high-census days compared to those on low-census days. This was further identified to be predominantly driven by patients with mild TBI admitted on high-census days. CONCLUSION: While most outcomes remained consistent, significant rates of delirium were found in our mild TBI patients admitted on high-census days suggesting the need for additional factors in the evaluation of these patients on admission. This study also reveals potential under-triage in moderate TBI patients on high-census days as they had significantly lower rates of ICU admission. These findings emphasize the need for further investigations to optimize patient care strategies within the context of fluctuating healthcare system demands.

Surgical Management of an Intentionally Ingested Vape Device Chronically Impacted within the Duodenum of an Adult Male.

Most foreign body ingestion cases are accidental in the adult population. Intentional ingestion of foreign bodies in adults is typically associated with psychiatric disorders or developmental delay. In most cases, foreign bodies pass spontaneously through the gastrointestinal tract or can be managed endoscopically. Rarely, surgical intervention is indicated. We present a unique case of surgical management of an intentionally ingested vape device that was chronically impacted within the duodenum of an adult male present for six weeks before intervention without associated perforation. The foreign object was removed via exploratory laparotomy with duodenotomy and primary duodenorrhaphy with an uncomplicated postoperative course. There are only two previously reported cases of an ingested vape device. One was managed by observation, and the other was removed endoscopically. There are no previously reported cases of an ingested vape device that required surgical management.

Recurrent Idiopathic Spontaneous Pneumoperitoneum: A Case Report.

The most common cause of pneumoperitoneum is perforated hollow viscus, which generally necessitates emergent surgical intervention. Idiopathic spontaneous pneumoperitoneum (ISP) is a rare condition less commonly described. This report outlines the case of a 79-year-old male with recurrent idiopathic spontaneous pneumoperitoneum managed by repeated laparotomy. Knowledge of this rare phenomenon and appropriate workup may allow for the avoidance of unnecessary laparotomies. Despite this, definitively ruling out perforated hollow viscus is difficult outside of the operating room, and many patients will ultimately be taken for surgical exploration and definitive diagnosis.

The History of Hemorrhagic Shock and Damage Control Resuscitation.

The understanding and management of hemorrhagic shock have evolved significantly over the last 400 years. Injured patients in shock mandate immediate surgeon involvement. Every graduating surgical resident and every surgeon taking trauma call should thoroughly understand the concepts of damage control resuscitation and be prepared to care for these patients. This review seeks to revisit the history of hemorrhagic shock and the evolution of damage control resuscitation.

Prospective Factors that Predict American Board of Surgery In-Training Examination Performance: A Systematic Review.

INTRODUCTION: American Board of Surgery In-Training Examination (ABSITE) performance has become an important factor when monitoring resident progress. Understanding which prospective factors predict performance can help identify residents at risk. METHODS: A literature search was conducted searching PubMed, EMBASE, and JAMA Network from June 2011 to June 2021, in accordance with the PRISMA guidelines. Searches were performed for the terms "ABSITE" and "American Board of Surgery In-Training Examination." Prospective factors such as prior examination performance, clinical evaluations, and demographics were evaluated. RESULTS: A final 35 studies were included. The prospective factor most consistently found to predict ABSITE performance is performance on prior knowledge-based examinations such as the USMLE step exams. The ACGME Medical Knowledge 1 milestone evaluation also appears to correlate to ABSITE performance, although clinical evaluations, in general, do not. Demographics have no significant correlation to ABSITE performance. DISCUSSION: Using performance on prior knowledge-based examinations programs may be able to identify residents at risk for failing ABSITE. It may be possible to initiate early intervention before rather than only remediation after poor performance.

Clostridioides difficile Enteritis Induced Anastomotic Rupture: A Case Report and Literature Review.

Background. A 76-year-old male patient who suffered small bowel anastomotic dehiscence believed to be a complication provoked by Clostridioides difficile enteritis. Case Presentation. The patient was a 76-year-old male who underwent small bowel resection with primary anastomosis for a small bowel obstruction. On postoperative day #7, he rapidly decompensated and upon return to the operating room was found to have complete anastomotic dehiscence with copious enteric spillage. The presentation appeared as if the staple line had burst open. Enteric contents confirmed the diagnosis of Clostridioides difficile enteritis. Subsequent hospital course was complicated by ventilatory-dependent respiratory failure, hemodynamic instability, and persistent anemia secondary to gastric ulcer requiring endoscopic cauterization. After a prolonged hospital course, he eventually progressed and was transferred to a skilled nursing facility on hospital day #42. Discussion. Clostridioides difficile causes inflammation and copious large volume secretions that would theoretically increase intraluminal pressures creating an internal tension. This tension along with other factors from the infection itself would likely be inhibitory of anastomotic healing. Although it is rare, Clostridioides difficile enteritis is being reported with increasing frequency, and in the setting of recent small bowel anastomosis, it should be considered a possible risk factor for anastomotic leak.