Failure to Rescue in Emergency General Surgery: Impact of Fragmentation of Care.

OBJECTIVE: Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission. BACKGROUND: Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established. METHODS: The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS: A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001]. CONCLUSION: One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE: Level III Prognostic. STUDY TYPE: Prognostic.

Reliability of online pregnancy-related information and associated feelings of worry among expectant women in Qatar.

BACKGROUND: Although the internet can be a source of reassurance and clarification for expectant women, it could cause concerns or feelings of worry when reading about pregnancy-related information. This research study sought to assess feelings of worry and perceived reliability of online pregnancy-related information and the associated factors among expectant women attending antenatal clinics at primary healthcare centers in Qatar. METHODS: A cross-sectional study design was used. The participants were recruited through a systematic random sampling technique. A self-administered questionnaire was used to collect data from the participants. Descriptive and analytic statistics were used as appropriate. RESULTS: A total of 327 expectant women completed the questionnaire. Most were aged between 26-34 years (74.1%), held a college/university degree (76.4%), and were multigravidas (73.1%). About one-third of the women (31.2%) reported feeling worried due to information they read online. They coped with these feelings by consulting their antenatal care provider at their next appointment (51.0%) or by talking with relatives and friends (47.0%). Most participants (79.2%) considered online pregnancy-related information to be reliable or highly reliable. Holding a college/university degree and being primigravidae were factors significantly associated with a high perception of reliability of online pregnancy information. CONCLUSION: Although online pregnancy information caused feelings of worry for some expectant women, most perceived such information to be reliable. Thus, antenatal care providers should guide expectant women on how to access high-quality web-based information.

Whole truths but half the blood: Addressing the gap between the evidence and practice of pre-hospital and in-hospital blood product use for trauma resuscitation.

BACKGROUND: In recent years, several studies have demonstrated the efficacy of using pre-hospital blood product and in-hospital whole blood for trauma resuscitation. While some observations suggest an encouraging uptake of this evidence by emergency medical service (EMS) agencies and trauma centers, a nationwide characterization of blood product utilization for bleeding trauma patients remains unknown. The objective of this study is to determine nationwide estimates of pre-hospital blood product and in-hospital whole blood utilization for trauma resuscitation. STUDY DESIGN AND METHODS: All adult trauma patients reported to the National Emergency Medical Services Information System (NEMSIS) dataset 2019 were included. Proportions of patients who received any pre-hospital blood product were calculated. The American College of Surgeons (ACS) Trauma Quality Programs (TQP) databases 2015-2017 and first quarter of 2020 were used to calculate the proportion of ACS-verified trauma centers that transfused whole blood. RESULTS: Among a total of 3,058,804 pre-hospital trauma patients, only 313 (0.01%) received any blood transfusion; 208 (0.21%) patients with systolic blood pressure (SBP) ≤90 mmHg and 121 (0.67%) patients with SBP ≤90 mmHg and heart rate ≥120 beats per minute received any blood product. The proportion of ACS-verified trauma centers transfusing whole blood increased from 16.7% (45/269) in 2015 to 24.5% (123/502) in first quarter of 2020. DISCUSSION: Despite strong evidence and recommendations, pre-hospital utilization of blood products for trauma resuscitation remains low. Additionally, while the overall in-hospital whole blood use also remains low, its use has increased at ACS-verified trauma centers over the past 5 years.

The Emergency Department Systolic Blood Pressure Relationship After Traumatic Brain Injury.

BACKGROUND: Blood pressure alterations in patients with traumatic brain injury (TBI) have been shown to be associated with increased mortality. However, there is paucity of data describing the optimal emergency department (ED) systolic blood pressure (SBP) target during the initial evaluation. The aim of our study was to assess the association between SBP on presentation and mortality in patients with TBI. METHODS: We performed a retrospective (2015-2016) review of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age ≥18y) trauma patients who had TBI on presentation. The outcome measure was in-hospital mortality at different ED-SBP values. A subanalysis by age and TBI severity in accordance with the Glasgow Coma Scale (GCS) was performed (mild (GCS ≥13), moderate (GCS 9-12), and severe (≤8)). Multivariate logistic regression analysis was performed. RESULTS: A total of 94,411 adult trauma patients with TBI were included. Mean age was 59 ± 21y, 62% were male, and median GCS was 15 [14-15]. Mean SBP was 147 ± 28 mmHg, and overall mortality was 8.6%. The lowest rate of mortality was noticed at ED SBP between 110 and 149 mmHg, whereas the highest mortality was at admission SBP <90 mmHg and SBP >190 mmHg. On regression analysis, SBP between 130 and 149 mmHg (odds ratio = 0.92; P = 0.68) was not associated with increased odds of mortality relative to SBP between 110 and 129 mmHg. On subanalysis based on severity of TBI (mild 80.9%, moderate 5.3%, and severe 13.8%), patients with SBP between 110 and 149 mmHg were less likely to die across all TBI groups. CONCLUSIONS: The optimal ED-SBP range for patients with TBI seems to be age and severity dependent. The optimum range might guide clinicians in developing resuscitation protocols for managing patients with TBI. LEVEL OF EVIDENCE: Level III Prognostic.

Trends in Geriatric Ground-Level Falls: Report from the National Trauma Data Bank.

INTRODUCTION: Ground-level falls (GLF) are typically reported as a minor mechanism of injury; however, they represent a significant portion of hospitalized geriatric trauma patients as they can result in multisystem injury in this subset of the population. Our study aimed to analyze trends in geriatric trauma falls on the national level. METHODS: We performed a 5-y (2011-2015) analysis of the American College of Surgeons National Trauma Data Bank (ACS-NTDB) and included all geriatric trauma patients (age ≥ 65 y) who presented with GLF. GLF was identified using ICD-9 E CODES. Our outcome measures were national incidence of GLF, and overall discharge disposition and trauma center level discharge disposition following GLF. We used Cochran Armitage test and multivariate regression analysis. RESULTS: We analyzed a total of 1,017,326 geriatric trauma patients, of which 39% had had a fall as a mechanism of injury. Among those who fell, mean age was 78 ± 7, 63% were females, and 85% were whites. The incidence of falls significantly increased over the study period, and was noted to be proportional to age, with a plateau beyond age 85 y old. The rate of discharge to SNF and/or Rehab significantly increased over the study period; however, discharge to home and mortality rates trended downwards over the study period. Discharge to SNF and/or Rehab was significantly lower among level I trauma centers compared to other level trauma centers. Conversely, discharge to home was higher in level I trauma centers compared to other level trauma centers. CONCLUSION: Around one in three elderly trauma patients were admitted following a GLF with an overall increased incidence of falls over time. Although overall mortality rates decreased, there was an increase in adverse discharge disposition and loss of functional independence over the study period, mostly among those admitted to non-level I trauma centers.

Traumatic Femoral Artery Injuries and Predictors of Compartment Syndrome: A Nationwide Analysis.

BACKGROUND: The femoral artery is commonly injured following lower extremity trauma. If not identified early and addressed properly, it can lead to compartment syndrome (CS) and limb amputation. The aim of this study is to examine traumatic femoral artery injuries and identify risk factors for the development of lower extremity CS. METHODS: Adult (≥18 years) patients who presented with traumatic femoral artery injuries were identified in the Trauma Quality Improvement Program 2017. Patients were stratified into two groups, those with evidence of lower extremity compartment syndrome (CS) and those without CS (NCS), for comparison. Multivariate regression analysis was performed. RESULTS: A total of 1,297 adult trauma patients with femoral artery injury were identified. Mean age was 36 ± 15 y, 86% were male, and 68% had penetrating injuries. Median extremity abbreviated injury scale (AIS) was 3 [3,4], and median injury severity score (ISS) was 27 [22-41]. 68 (5.2%) patients were diagnosed with CS of the lower extremity, 66 (97.1%) of those patients underwent fasciotomy and one (1.5%) patient eventually had an amputation. On multivariate regression analysis, concomitant femoral vein, femoral nerve, and popliteal artery injuries and early need for blood transfusions were independent risk factors for the development of CS (OR 3.1, 3.8, 4.3, and 2.5 respectively). CONCLUSIONS: CS following traumatic femoral artery injury is a relatively common finding. Physicians must maintain a high index of suspicion and should consider prophylactic fasciotomy in the setting of combined femoral vein and nerve injuries, combined popliteal artery injury, and multiple blood transfusions.

Delta Shock Index Predicts Outcomes in Pediatric Trauma Patients Regardless of Age.

INTRODUCTION: Changes in the shock index (ΔSI) can be a predictive tool but is not established among pediatric trauma patients. The aim of our study was to assess the impact of ΔSI on mortality in pediatric trauma patients. METHODS: We performed a 2017 analysis of all pediatric trauma patients (age 0-16 y) from the ACS-TQIP. SI was defined as heart rate(HR)/systolic blood pressure(SBP). We abstracted the SI in the field (EMS), SI in the emergency department (ED) and calculated the change in SI (ΔSI = ED SI-EMS SI). Patients were divided into four age groups: 0-3 y, 4-6 y, 7-12 y, and 13-16 y and substratified into two groups based on the value of the age-group-specific ΔSI cutoff obtained with receiver operating characteristic ROC analysis; +ΔSI and -ΔSI. Our outcome measure was mortality. Multivariable logistic and Cox regression analyses were performed. RESULTS: We included 31,490 patients. Mean age was 10.6 ± 4.6 y, and 65.8% were male. The overall mortality rate was 1.4%. In the age group 0-3 y the cutoff point for ΔSI was 0.29 with an area under the curve (AUC) 0.70 [0.62-0.79], ΔSI cutoff 4-6 y was 0.41 AUC 0.81 [0.70-0.92], ΔSI cutoff 7-12 y was 0.05 AUC 0.83 [0.76-0.90], and ΔSI cutoff 13-16 y was 0.13 AUC 0.75 [0.69-0.81]. On the Cox regression analysis, +ΔSI was independently associated with increased in-hospital mortality and 24-h mortality (P ≤ 0.01). CONCLUSIONS: Vital signs vary by age group in children, but ΔSI inherently accounts for this variation. ΔSI predicts mortality and may be utilized as a predictor to help guide triage of pediatric trauma patients. LEVEL OF EVIDENCE: Level III Prognostic.

Readmission With Major Abdominal Complications After Penetrating Abdominal Trauma.

BACKGROUND: Despite improvements in operative techniques, major abdominal complications (MACs) continue to occur after penetrating abdominal trauma (PAT). This study aimed to evaluate the burden of MAC after PAT. METHODS: The (2012-2015) National Readmission Database was queried for all adult (age ≥18 y) trauma patients with penetrating injuries who underwent exploratory laparotomy and were readmitted within 6 mo of index hospitalization discharge. Patients were stratified by firearm injuries (FIs) and stab injuries (SIs). Primary outcomes were rates of MAC: intra-abdominal abscesses (IAAs), superficial surgical site infection (SSI), and fascial dehiscence within 6 mo after discharge. Secondary outcomes were both nonabdominal complications and mortality, postdischarge, and 6-mo readmission. Regression analysis was performed. RESULTS: A total of 4473 patients (FI, 2326; SI, 2147) were included in the study; the mean age was 32 ± 14 y, the Injury Severity Score was 19 (15-25), and 23% underwent damage control laparotomy (DCL). The rate of MAC within 6 mo was 22% (IAA 19%, SSI 7%, and fascial dehiscence 4%). Patients with FIs had a higher rate of IAA (27% versus 10%; P < 0.01), SSI (11% versus 3%; P < 0.01), fascial dehiscence (5% versus 3%; P = 0.03), nonabdominal complications (54% versus 24%; P < 0.01), and postdischarge mortality (8% versus 6%; P < 0.01) compared with patients with SIs . On regression analysis, DCL (P < 0.01), large bowel perforation (P < 0.01), biliary-pancreatic injury (P < 0.01), hepatic injury (P < 0.01), and blood transfusion (P = 0.02) were predictors of MAC. CONCLUSIONS: MAC developed in one in five patients after PAT. FIs have a higher potential for hollow viscus injury and peritoneal contamination, and are more predictive of MAC and nonabdominal complications, especially after DCL. LEVEL OF EVIDENCE: Level III Prognostic.

Prospective Evaluation of Health Literacy and Its Impact on Outcomes in Emergency General Surgery.

BACKGROUND: Health literacy (HL) is an important component of national health policy. The aim of our study was to assess the prevalence of low HL (LHL) and determine its impact on outcomes after emergency general surgery (EGS). METHODS: We performed a (2016-2017) prospective cohort analysis of adult EGS patients. HL was assessed using the Short Assessment of HL score. LHL was defined as Short Assessment of HL score <14. Outcomes were the prevalence of LHL, compliance with medications, wound/drain care, 30-d complications, 30-d readmission, and time to resuming activities of daily living. RESULTS: We enrolled 900 patients. The mean age was 43 ± 11 y. Overall, 22% of the patients had LHL. LHL patients were more likely to be Hispanics (59% versus 15%, P < 0.01), uninsured (50% versus 20%, P < 0.01), have lower socioeconomic status (80% versus 40%, P < 0.02), and are less likely to have completed college (5% versus 60%, P < 0.01) compared with HL patients. On regression analysis, LHL was associated with lower medication compliance (OR: 0.81, [0.4-0.9], P = 0.02), inadequate wound/drain care (OR: 0.75, [0.5-0.8], P = 0.01), 30-d complications (OR: 1.95, [1.3-2.5], P < 0.01), and 30-d readmission (OR: 1.51, [1.2-2.6], P = 0.02). The median time of resuming activities of daily living was longer in patients with LHL than HL patients (4 d versus 7 d, P < 0.01). CONCLUSIONS: One in five patients undergoing EGS has LHL. LHL is associated with decreased compliance with discharge instructions, medications, and wound/drain care. Health literacy must be taken into account when discussing the postoperative plan and better instruction is needed for patients with LHL. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Prognostic.

Platelet Transfusion After Traumatic Intracranial Hemorrhage in Patients on Antiplatelet Agents.

BACKGROUND: With an aging population, the number of patients on antiplatelet medications and traumatic brain injury (TBI) is increasing. Our study aimed to evaluate the role of platelet transfusion on outcomes after traumatic intracranial bleeding (IB) in these patients. METHODS: We analyzed our prospectively maintained TBI database from 2014 to 2016. We included all isolated TBI patients with an IB, who were on preinjury antiplatelet agents and excluded patients taking anticoagulants. Outcome measures included the progression of IB, neurosurgical intervention, and mortality. Regression analysis was performed. RESULTS: A total of 343 patients met the inclusion criteria. Mean age was 58 ± 11 y, 58% were men, and median injury severity score was 15 (10-24). Distribution of antiplatelet agents was as follows: aspirin (60%) and clopidogrel (35%). Overall, 74% patients received platelet transfusion after admission with a median number of two platelet units. After controlling for confounders, patients who received one unit of pooled platelets had no difference in progression of IB (odds ratio [OR]: 0.98, [0.6-1.9], P = 0.41), need for neurosurgical intervention (OR: 1.09, [0.7-2.5], P = 0.53), and mortality (OR: 0.84, [0.6-1.8], P = 0.51). However, patients who received two units of pooled platelets had lower rate of progression of IB (OR: 0.69, [0.4-0.8], P = 0.02), the need for neurosurgical intervention (OR: 0.81, [0.3-0.9], P = 0.03), and mortality (OR: 0.84, [0.5-0.9], P = 0.04). Both groups were compared with those who did not receive platelet transfusion. CONCLUSIONS: The use of two units of platelet may decrease the risk of IB progression, neurosurgical intervention, and mortality in patients on preinjury antiplatelet agents and TBI. Further studies should focus on developing protocols for platelet transfusion to improve outcomes in these patients. LEVEL OF EVIDENCE: Level III prognostic.

Racial and Ethnic Disparities in Frail Geriatric Trauma Patients.

BACKGROUND: Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients. METHODS: We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay. RESULTS: We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2-2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1-1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1-1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1-1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics. CONCLUSION: Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.

Pattern of internet use for pregnancy-related information and its predictors among women visiting primary healthcare in Qatar: a cross-sectional study.

BACKGROUND: Internet usage has been steadily increasing and the available online information for pregnant women today is immense. OBJECTIVE: This study aimed to investigate the prevalence of women who search for information relating to pregnancy on the internet and to identify predictors of this behavior among expecting women visiting primary health care (PHC) centers in Qatar. METHODS: A cross-sectional study was conducted at the antenatal clinics of six PHC centers in Qatar from June 1 to December 31, 2019. Pregnant women were recruited through a systematic random sampling technique. Participants were interviewed using a structured questionnaire. Descriptive and analytic statistics were used when appropriate. A multivariable logistic regression analysis was constructed to identify the predictors of internet use for pregnancy-related information. RESULTS: The study included 403 pregnant women (response rate: 87.9%). Most of them were in the 26-35 years age category (71.5%), in the second trimester (55.5%), and had 1-2 children at home (51.5%). The internet was the most common source (81.1%) of pregnancy-related information. The access to online information was mainly through websites (67.3%), mobile applications (48.3%), and social media platforms (39.7%). The most frequently searched topics online were fetal development (74.3%), diet during pregnancy (53.6%), and management of health problems (39.6%). The multivariable regression model identified the age group 26-35 years (AOR: 4.93; 95% CI: 2.14, 11.38), Arabs (AOR: 4.12; 95% CI: 2.03, 8.36), tertiary education (AOR: 5.22; 95% CI: 1.78, 15.33), being a housewife (AOR: 6.37; 95% CI: 1.44, 28.19), or employed (AOR: 5.56 95% CI: 1.31, 23.63), and having up to 2 children as independent predictors of internet use for pregnancy-related information. CONCLUSION: The internet was a commonly used source of health information among pregnant women in Qatar. Internet use was significantly associated with the age group of 26-35 years, Arabs, higher level of education, being employed or a housewife, and having up to two children.

Pediatric Firearm Injuries and Fatalities: Do Racial Disparities Exist?

OBJECTIVE: To evaluate racial disparities among White and Black pediatric firearm injury patients on a national level. BACKGROUND: Pediatric firearm-related morbidity and mortality are rising in the United States. There is a paucity of data examining racial disparities in those patients. METHODS: The Pediatric Trauma Quality Improvement Program (2017) was queried for pediatric (age ≤17 years) patients admitted with firearm injuries. Patients were stratified by race: White and Black. Injury characteristics were assessed. Outcomes were mortality, hospital length of stay, and discharge disposition. Hierarchical regression models were performed to determine predictors of mortality and longer hospital stays. RESULTS: A total of 3717 pediatric firearm injury patients were identified: Blacks (67.0%) and Whites (33.0%). The majority of patients were male (84.2%). The most common injury intent in both groups was assault (77.3% in Blacks vs in 45.4% Whites; P<0.001), followed by unintentional (21.1% vs 35.4%; P<0.001), and suicide (1.0% vs 14.0%; P<0.001). The highest fatality rate was in suicide injuries (62.6%). On univariate analysis, White children had higher mortality (17.5% vs 9.8%; P<0.001), longer hospital stay [3 (1-7) vs 2 (1-5) days; P = 0.021], and more psychiatric hospital admissions (1.3% vs 0.1%; P<0.001). On multivariate analysis, suicide intent was found to be an independent predictor of mortality (aOR 2.67; 95% CI 1.35-5.29) and longer hospital stay (ß + 4.13; P<0.001), while White race was not. CONCLUSION: Assault is the leading intent of injury in both Black and White children, but White children suffer more from suicide injuries that are associated with worse outcomes. LEVEL OF EVIDENCE: Level III Prognostic.

The Evolution of Nonoperative Management of Abdominal Gunshot Wounds in the United States.

BACKGROUND: Surgical exploration for gunshot wounds to the abdomen has been a surgical standard for the greater part of the past century. Recently, nonoperative management (NOM) has been deemed as a safe option for abdominal gunshot wounds (AGWs). The aim of this analysis was to review the utilization of NOM and mortality after AGWs. METHODS: We performed a 2010-2014 retrospective analysis of the American College of Surgeons Trauma Quality and Improvement Program. We included all adult (aged 18 and older) patients with AGWs. NOM was defined as nonsurgical intervention within the first 6 h. Outcome measures were trends of utilization of NOM and mortality. Cochrane-Armitage trend analysis was performed. RESULTS: A total of 808,272 trauma patients were identified, and 16,866 patients with AGWs were included. During the study period, the incidence of AGWs increased, whereas the proportion of bowel injury (P = 0.75) and solid organ injury (P = 0.44) did not change. The NOM rate of AGW increased (2010: 19.5% versus 2014: 27%, P < 0.001). This was accompanied by a decrease in mortality rate (11% versus 9.4%, P = 0.01). Likewise, there was an increase in the use of angiography (7.5% versus 27%, P < 0.001) and laparoscopy (0.9% versus 2.6%, P < 0.001). Overall, 9.8% of the patients had failed NOM. There was no difference in mortality in patients who were managed successfully or failed NOM (5% versus 4.6%, P = 0.45). CONCLUSIONS: NOM of AGW is more prevalent and is associated with a decrease in mortality rate. Selective NOM may be practiced safely after AGWs.

Alcohol Use Disorder Is Bad for Broken Ribs: A Nationwide Analysis of 19,638 Patients With Rib Fractures.

BACKGROUND: Alcohol use disorder (AUD) has deleterious effects on many organ systems. The aim of our study was to assess the impact of AUD on outcomes in patients with rib fractures. We hypothesized that AUD is associated with increased risk adverse outcomes. METHODS: We performed a 2013-2014 retrospective analysis of all adult trauma patients diagnosed with rib fractures from the American College of Surgeons-Trauma Quality Improvement Program database. We excluded patients who were acutely intoxicated with alcohol. Patients were stratified into two groups: AUD + and AUD -. A 1:1 ratio propensity score matching for demographics, admission vitals, injury severity, smoking status, operative intervention, and number of rib fractures was performed. Outcome measures were in-hospital complications, mortality, hospital and intensive care unit length of stay, and ventilator days. RESULTS: We matched 19,638 patients (AUD +:9,819, AUD -:9819). Mean age was 53 ± 22y, and median injury severity score was 15[10-20]. Matched groups were similar in age (P = 0.18), smoking status (P = 0.82), injury severity score (P = 0.28), chest Abbreviated Injury Scale (P = 0.24), and number of rib fractures (2[1-4] versus 2[1-4], P = 0.86). Alcoholic patients had higher rates of pneumonia (18.1% versus 9.2%, P < 0.01), unplanned intubation (18.5% versus 9.7, P < 0.001), sepsis (10.8% versus 6.3%, P < 0.001), acute respiratory distress syndrome (12.2% versus 7.4%, P < 0.001), and mortality (8.0 versus 5.7%, P < 0.001). Patients with AUD spent more days in the hospital and intensive care unit . There was no difference in ventilator days between the two groups. CONCLUSIONS: Patients with AUD and rib fractures had higher rates of adverse events than patients without AUD. Early identification of patients with rib fractures with AUD may allow better resource allocation and help improve outcomes. LEVEL OF EVIDENCE: Level III prognostic.

Epidemiology of herpes zoster in the State of Qatar, 2012-2017.

Purpose: This study aimed to determine the epidemiological features of herpes zoster (HZ) in Qatar. Methods: This study was a retrospective review of all reported HZ cases received by the surveillance unit at the Ministry of Public Health, between January 2012 and December 2017. Results: A total of 2815 cases were reported during the study period. The mean incidence of HZ was estimated to be 19/100,000 population, which increased from 9.8/100,000 in 2012 to 36.2/100,000 in 2017. The ratio of male/female was about 4:1. HZ incidence overall was found to be highest in those aged ≥ 50 years. According to nationality, the mean incidence of HZ was estimated to be 79/100,000 among Qataris and 101/100,000 among expatriates. Additionally, more HZ cases were notified during the hot months. Conclusion: Such epidemiological data will contribute to the baseline information, which is necessary for effective preventive and control measures to be implemented in the country.

Vaccination coverage in Qatar: Benchmarking with global figures.

Introduction: Vaccination is considered one of the most successful and cost-effective public health interventions of the 20th century. In 2017, Qatar's Expanded Program of Immunization (EPI) provided vaccination services against a comprehensive list of 15 vaccine-preventable diseases. Objectives: To assess the performance of Qatar's national immunization system, identify possible gaps by determining the national vaccination coverage rates, and benchmark these rates against regional and global figures. Methods: The data utilized herein were retrieved from the vaccination coverage estimates generated by the World Health Organization and United Nations International Children's Emergency Fund. Relevant local, regional, and global vaccination coverage figures were manually extracted and then analyzed for six vaccines (DTP3, Pol3, MCV2, HepB, PCV3, and RotaC) in 2017. Percentages and proportions were compared using the Chi-squared test. Results: Vaccination coverage levels in Qatar have surpassed the optimal level of 90% for all vaccines. Compared with international figures, the national coverage exceeds the relevant benchmarks. For DTP3 and Pol3, Qatar achieved 97% coverage compared with 99% coverage in Jordan and 85% coverage globally. For MCV2, Qatar achieved 93% coverage compared with 99% coverage in Jordan and 67% coverage globally. For RotaC, Qatar achieved 97% coverage compared with 96% coverage in Jordan and 28% coverage globally. For HepB, Qatar achieved 97% coverage compared with 43% coverage globally. Conclusions: Compared with the international benchmarks of major vaccines, the vaccination coverage rates in Qatar are high. However, challenges for maintaining high coverage, such as cultural and language barriers, should be addressed.

Epidemiological characteristics of a salmonella outbreak among infants in Qatar, 2017.

Purpose: This study was conducted to investigate the epidemiology behind the increased incidence of infant salmonella cases in Qatar during 2017 and identify the possible risk factors. Methods: This was a cross-sectional study using the notification reports of laboratory-confirmed infant salmonella cases received by the Ministry of Public Health during the year 2017. Furthermore, complementary phone interviews with the infants' mothers using a validated questionnaire were conducted. Results: The infant salmonella attack rate was calculated at approximately 3.23 cases per 1000 infants. Among the 89 confirmed infant salmonella cases, there were more girls (53%) than boys (47%) with a median age of 8 months. The most common type of salmonella species isolated was group B (50.5%). Among the 59 infant cases whose mothers were interviewed, the majority (94.9%) were symptomatic and diarrhea was the main reported symptom (90%), particularly bloody diarrhoea (62%). Regarding their dietary consumption, the majority (69.5%) of the infected infants were formula-fed. Moreover, the majority reported having no pets at home (91.6%) and were not enrolled in a day care center (93.3%). Conclusion: This study revealed a high incidence of salmonella infection among infants in the State of Qatar, which poses a public health concern. Therefore, targeted interventions and health awareness programs are required for outbreak prevention, detection and control.

Pseudogout of the lumbar spine.

Calcium pyrophosphate deposition involves deposition of calcium pyrophosphate dihydrate crystals in various joints throughout the body. The term "pseudogout" refers to an acute attack of calcium pyrophosphate crystal-induced arthritis. Though clinical presentation and joint involvement vary, involvement of the lumbar spine is rare. We present the case of a 61-year-old male who presented with 3 days of worsening lower back pain. He had elevated inflammatory markers, leukocytosis, and spinal tenderness on exam. Magnetic resonance imaging of the lumbar spine showed likely L4-L5 osteomyelitis; however, biopsy of the disk space revealed extensive calcium pyrophosphate crystal deposition. The patient was treated with prednisone taper with alleviation of symptoms. Though pseudogout of the spine is rare, our report supports literature urging clinicians to consider pseudogout when assessing elderly patients with back pain for prompt and appropriate treatment.