Expecting the unexpected: incidental findings at a level 1 trauma center.

INTRODUCTION: Incidental findings on comprehensive imaging in the adult trauma population occur at rates as high as 54.8%. We sought to determine the incidence of potentially malignant or pre-malignant incidental findings in a high-volume level 1 trauma center and to evaluate follow-up recommendations. METHODS: This was a retrospective review of all patients with incidental findings on imaging who were admitted to the trauma service at our level 1 trauma center between January 1st, 2014, and October 1st, 2019. A multi-disciplinary team characterized findings as potentially malignant or pre-malignant. RESULTS: The study included 495 patients who had incidental findings, 410 of whom had potentially malignant or pre-malignant findings on imaging, resulting in a cumulative incidence of 6.6%. The mean age was 65 and 217 (52.9%) patients were male. The majority of "incidentalomas" were discovered on CT imaging (n=665, 98.1%); over half were solid (n=349, 51.5%), while 27.4% were cystic (n=186) in nature. The lungs (n=199, 29.4%), kidneys (n=154, 22.8%), liver (n=74, 10.9%), thyroid gland (n=58, 8.6%), and adrenal glands (n=53, 7.8%) harbored the most incidentalomas. Less than half of patients with incidental findings received specific follow-up recommendations on the radiologist's report (n=150, 39%). Sixty-one percent of patients (n=250) had their incidentalomas detailed in the discharge paperwork. CONCLUSION: The results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Specific follow-up recommendations were not presented in 61% of the radiology reports, highlighting the need to standardize medical record capture of an incidentaloma to ensure adequate and appropriate follow-up.

Direct to Operating Room for Decompressive Craniotomy/Craniectomy in Patients With Traumatic Brain Injury.

BACKGROUND: Emergent decompressive craniotomy/craniectomy can be a lifesaving surgical intervention for select patients with traumatic brain injury. Prompt management is critical as early decompression can impact traumatic brain injury outcomes. OBJECTIVE: This study aims to describe the feasibility and clinical impact of a new pathway for transporting patients with severe traumatic brain injury directly to the operating room from the trauma bay for decompressive craniotomy/craniectomy. METHODS: This is a retrospective cohort preintervention and postintervention study of severe traumatic brain injury patients undergoing decompressive craniectomy/craniotomy at a Midwestern U.S. Level I trauma center between 2016 and 2022. In the new pathway, the in-house trauma surgeon takes the patient directly to the operating room with the neurosurgery advanced practice provider to drape and prepare the patient for surgery while the neurosurgeon is en route to the hospital. RESULTS: A total of 44 patients were studied, five (5/44, 11.4%) of which were in the preintervention group and 39 (39/44, 88.6%) in the postintervention group. The median arrival-to-operating room time was shorter in the postintervention cohort (1.4 hr) than in the preintervention cohort (1.5 hr). In examining night shifts only, the preintervention cohort had shorter arrival-to-operating room times (1.2 hr) than the postintervention cohort (1.5 hr). CONCLUSION: The study demonstrated that the new pathway is feasible and expedites patient transport to the operating room while awaiting the arrival of the on-call neurosurgeon.

The NOpioid Project: a prospective observational feasibility study examining the implementation of a non-narcotic post-operative pain control regimen.

BACKGROUND: Post-operative prescription of opioids has fueled an increase in opioid-associated morbidity and mortality. Alternative post-operative pain control with non-opioid pharmaceuticals can help counteract this effect. We investigated a non-opioid pain management protocol following emergent laparoscopic appendectomy and laparoscopic cholecystectomy. METHODS: Our tertiary referral center performed a prospective observational feasibility study of patients from October 2019 to 2020 who underwent emergent laparoscopic appendectomies and cholecystectomies. Patients aged 18-65 with no prior history of chronic pain or opioid abuse, no contraindications to taking acetaminophen and ibuprofen, and Glomerular Filtration Rate > 60 ml/min were included. Counseling was provided about non-narcotic pain control. Patients were not prescribed narcotics at discharge and were instead prescribed ibuprofen and acetaminophen. Patients were surveyed at their 2-week post-operative appointment to assess pain control and other patient-reported outcomes, including quality of life (QOL). RESULTS: Fifty-one patients met the inclusion criteria and completed the postoperative survey. Thirty-two were female (63%), average age 38, and BMI 30.4. 30 (59%) underwent laparoscopic appendectomy for acute non-perforated appendicitis and 21 (41%) underwent laparoscopic cholecystectomy for acute cholecystitis or symptomatic cholelithiasis. 88% of patients felt satisfied or neutral with their post-operative pain control at discharge. After 2 weeks, 34 patients (66.7%) rated QOL as high, 17 (33.3%) rated QOL as moderate, and none rated QOL as poor. Fascial suture was not associated with poor outcomes. Anxiety, depression, alcohol use, and prior abdominal surgery were not associated with increased need for post-operative narcotics. There were no significant differences between appendectomy and cholecystectomy in satisfaction with pain control or QOL (p > 0.05). CONCLUSION: Patients undergoing surgery have an increased risk of developing an opioid disorder. The NOpioid Project demonstrated a non-narcotic multimodal pain regimen can be effectively adopted in the post-operative period after an emergent laparoscopic appendectomy or emergent laparoscopic cholecystectomy.

To Tranexamic Acid or Not to Tranexamic Acid? Accuracy of Antifibrinolytic Administration at Altitude.

OBJECTIVE: Tranexamic acid (TXA) has demonstrated a reduction in all-cause mortality in trauma patients with hemorrhage. Administering TXA in the prehospital setting presents unique challenges because the identification of bleeding is based on clinical suspicion without advanced imaging or diagnostic tools. The objective of this study was to examine whether prehospital suspicion of bleeding is validated by in-hospital computed tomographic imaging and examination and to determine if patients received TXA in the absence of hemorrhage. The study was conducted at a level 1 trauma center supported by air medical transport services. METHODS: This is a retrospective cohort study examining 88 trauma patients receiving prehospital TXA to treat suspected hemorrhage. Adult trauma patients who received TXA during the study period and were transported to our level 1 trauma center were included. A panel of trauma surgeons reviewed CT imaging and examination findings to retrospectively identify significant hemorrhage. RESULTS: Forty-three percent of patients who received TXA during air medical transport did not have confirmed hemorrhage upon arrival. CONCLUSION: TXA was given to a significant number of patients who did not have confirmed hemorrhage upon arrival. We recommend that institutions using TXA perform this internal validation to ensure they are accurately identifying hemorrhage in the prehospital setting.

Mouse long-chain acyl-CoA synthetase 1 is active as a monomer.

Fatty acids are essential cellular building blocks and a major energy source. Regardless of their metabolic fate, fatty acids first need to be activated by forming a thioester with a coenzyme A group. This reaction is carried out by acyl-CoA synthetases (ACSs), of which ACSL1 (long-chain acyl-CoA synthetase 1) is an important member. Two bacterial homologues of ACSL1 crystal structures have been solved previously. One is a soluble dimeric protein, and the other is a monomeric peripheral membrane protein. The mammalian ACSL1 is a membrane protein with an N-terminal transmembrane helix. To characterize the mammalian ACSL1, we purified the full-length mouse ACSL1 and reconstituted it into lipid nanodiscs. Using enzymatic assays, mutational analysis, and cryo-electron microscopy, we show that mouse ACSL1 is active as a monomer.

Protect the neck: Devastating outcomes of cervical spine fractures in the elderly.

BACKGROUND: Cervical spine fractures are associated with high mortality in elderly patients. This study aims to identify patient-related and in-hospital factors contributing to this mortality. METHODS: A 3-year retrospective study of 235 patients aged 65+ presenting with cervical spine fractures was performed. Age cohorts were 65-74, 75-84, and 85+ years. Mortality was measured at 30, 90, 180 and 365-days post-discharge. RESULTS: Mortality was 11 â€‹%, 15 â€‹%, 19 â€‹%, and 22 â€‹% at 30-, 90-, 180- and 365-days respectively. Surgery and fracture pattern was not associated with mortality (p â€‹= â€‹0.37; p â€‹= â€‹0.28). Charlson Comorbidity Index (p â€‹< â€‹0.001; hazard ratio [HR] â€‹= â€‹1.3), functional dependency (p â€‹< â€‹0.001; HR â€‹= â€‹2.5) and delirium (p â€‹< â€‹0.001; HR â€‹= â€‹8.9) were associated with mortality between 0 and 365 days post-discharge. CONCLUSIONS: Mortality in cervical spine fractures is associated with CCI and delirium, but not associated with operative management or fracture pattern. This suggests the need for careful consideration in patient selection for cervical spine procedures and aggressive inpatient delirium management.

Evaluation of the Michigan Clinical Consultation and Care Program: An Evidence-Based Approach to Perinatal Mental Healthcare.

Mood and anxiety disorders affect pregnant individuals and their families at increased rates throughout the perinatal period. Geographic, financial, and social barriers often preclude adequate diagnosis and treatment. The aim of this manuscript is to describe the consultation and care arms of the Michigan Clinical Consultation and Care (MC3) program, a statewide program designed to facilitate access to perinatal mental healthcare for OB/Gyn patients, and to describe the participants engaged in the program, examine the predictors of participant retention, and provide preliminary data regarding participants' mental health outcomes. We enrolled 209 participants to the clinical care arm, of which 48 were lost to follow-up, while 107 remained enrolled at the time of data analysis. A total of 54 participants met their treatment goals. A total of 97% of participants asserted they were satisfied with the services they received. Black race and public insurance predicted faster attrition from the care arm treatment; risks for interpersonal violence exposure and substance use were unrelated to attrition. Preliminary mental health outcomes showed significant decreases in anxiety and depression, with the most dramatic decreases in the first month of treatment. Overall, the MC3 clinical care arm shows promising rates of adherence, excellent program satisfaction, and a positive impact on perinatal mental health, supporting continued program implementation and ongoing evaluation.

Out of sight, out of mind? The impact on trauma patient opioid use when the medicine administration schedule is not displayed.

INTRODUCTION: The impact of a visual pain medication schedule on opioid use among hospitalized trauma patients is unknown. We examined whether removal of this displayed schedule would decrease oral morphine equivalent (OME) use. METHODS: This retrospective cohort study compared OME use in trauma patients in the inpatient setting before and after removing the patient-facing pain medication schedule that is typically displayed on the patient's white board for all trauma admissions. RESULTS: 707 patients were included. The control (n = 308, 43.6%) and intervention (n = 399, 56.4%) groups were similar in age (p = 0.06). There was no difference in total inpatient OME use between the control and intervention groups, median 50 (IQR: 22.5-118) vs 60 (IQR: 22.5-126), p = 0.79, respectively. No difference in total OME use was observed when patients were stratified by age, sex, race, ISS, and length of hospital stay. CONCLUSION: Removing a visual display of the pain medication schedule did not decrease OME use in inpatient trauma patients.

Outcomes of simultaneous versus staged intramedullary nailing fixation of multiple long bone lower extremity fractures.

INTRODUCTION: Repair of multiple lower extremity long bone fractures with intramedullary nail (IMN) fixation is associated with significant cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, Acute Respiratory Distress Syndrome (ARDS), and pneumonia. No standardized guidelines exist to guide treatment of these patients. Further, there is a paucity of data regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that includes both tibial and femoral injuries, as patients with multiple concomitant fractures are often excluded from relevant analyses. Our level one trauma center aimed to identify whether simultaneous fixation, defined by definitive fixation of multiple lower extremity long bone fractures during one operative event, led to increased cardiopulmonary complications as compared to a staged approach, defined as multiple operations to reach definitive fixation. PATIENTS AND METHODS: The Michigan Trauma Quality Improvement Program (MTQIP) database from 35 Level I and II trauma centers was queried to identify patients from January 2016 - December 2019. The primary outcome was incidence of cardiopulmonary complications for staged and simultaneous IMN fixation. RESULTS: We identified 11,427 patients with tibial and/or femoral fractures during the study period. 146 patients met the inclusion criteria of two or more fractures treated with IMN fixation. 118 patients underwent simultaneous IMN fixation, and 28 patients received staged IMN fixation. There were no significant differences in injury severity score (ISS), demographics, pre-existing conditions, and cardiopulmonary complications between the two groups. There was a statistically significant difference in hospital length of stay (LOS) (p = 0.0012). The median hospital LOS for simultaneous fixation was 8.3 days versus 15.8 days for the staged cohort, a difference of 7.5 days. CONCLUSION: This is the largest retrospective study to date examining simultaneous versus staged IMN fixation in patients with multiple long bone lower extremity fractures. In contrast to previous studies, we found no difference in cardiopulmonary complications. Given these findings, patients with multiple long bone lower extremity fractures should be considered for simultaneous IMN, an approach which may decrease hospital LOS.

Fall Risk Identification Throughout the Continuum of Care for Elderly Trauma Patients: An Injury Prevention Initiative.

INTRODUCTION: Falls are the second leading cause of trauma-related deaths worldwide. Identifying fall risk patients and initiating interventions reduces injuries and mortality, particularly in the elderly. The primary aim of this retrospective study was to identify missed opportunities for fall risk identification and intervention for geriatric trauma patients. PATIENTS AND METHODS: In this retrospective observational cohort study, the trauma registry was queried to identify geriatric patients admitted for a fall over 36 months. The electronic medical record (EMR) was reviewed to evaluate patients' fall risk in the 12 months prior to the index fall admission. The EMR was also queried for repeat falls within 12 months after discharge, and to determine if fall prevention education was provided at discharge. RESULTS: 597 patients met inclusion criteria; 68.3% were female. 64.7% were at risk for falling in the year before admission. 2% had documented fall prevention education at discharge. 32% of patients fell again within a year of discharge and 19.4% were readmitted for a repeat fall. Patients at high risk for falls (on the Hester-Davis scale) were significantly more likely to be readmitted (p = 0.005) and expire within six months (p = 0.033) than moderate risk patients. Mortality at 12 months post-admission for all patients was 19.4%. CONCLUSION: This large study demonstrated that geriatric trauma patients admitted for a fall were already at risk for falling in the 12 months prior to admission. This is a novel finding that presents a substantial prevention opportunity for healthcare systems. Education and implementation of proven techniques to prevent falls as soon as at-risk patients are identified has the potential to change the course for a patient who may not only fall, but also fall again. This proactive approach could significantly impact the fall epidemic in our elderly population.

TXNIP interaction with GLUT1 depends on PI(4,5)P2.

GLUT1 is a major glucose facilitator expressed ubiquitously among tissues. Upregulation of its expression plays an important role in the development of many types of cancer and metabolic diseases. Thioredoxin-interacting protein (TXNIP) is an α-arrestin that acts as an adaptor for GLUT1 in clathrin-mediated endocytosis. It regulates cellular glucose uptake in response to both intracellular and extracellular signals via its control on GLUT1-4. In order to understand the interaction between GLUT1 and TXNIP, we generated GLUT1 lipid nanodiscs and carried out isothermal titration calorimetry and single-particle electron microscopy experiments. We found that GLUT1 lipid nanodiscs and TXNIP interact in a 1:1 ratio and that this interaction requires phosphatidylinositol 4,5-bisphosphate (PI(4,5)P2 or PIP2).