Goals of Care Discussions for the Imminently Dying Trauma Patient.

BACKGROUND: A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures. MATERIALS AND METHODS: We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams. RESULTS: A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001). CONCLUSIONS: MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.

What drives outcomes in infants of mothers with congenital heart disease? A mediation analysis.

OBJECTIVE: Infants of mothers with adult congenital heart disease (ACHD) are at increased risk for adverse pregnancy and neonatal outcomes. We aim to identify mediators in the relationship between ACHD and pregnancy and infant outcomes. STUDY DESIGN: Case-control study using linked maternal and infant hospital records. Structural equation modeling was performed to assess for potential mediators of pregnancy and infant outcomes. RESULT: We showed an increased risk of multiple adverse infant and pregnancy outcomes among infants born to mothers with ACHD. Maternal placental syndrome and congestive heart failure were mediators of prematurity. Prematurity and critical congenital heart disease in the infant were mediators of infant outcomes. However, the direct effect of ACHD on outcomes beyond that explained by these mediators remained significant. CONCLUSION: While significant mediators of infant and pregnancy outcomes were identified, there was a large direct effect of maternal ACHD. Further studies should aim to identify more factors that explain these infants' vulnerability.

Biomechanical comparison of long head of biceps tenodesis with interference screw and biceps sling soft tissue techniques.

PURPOSE: The purpose of our study was to compare biomechanically a long head biceps tenodesis using an all soft tissue biceps sling technique versus an interference screw technique. METHODS: Six paired fresh frozen shoulder specimens were separated into 2 groups. One group used an all soft tissue biceps sling technique for tenodesis. The other group used the interference screw technique for subpectoral tenodesis of the long head biceps tendon. Specimens in both groups were sequentially loaded for 200 cycles, and the difference between the initial and final displacements were recorded. Specimens were then loaded to failure. Load and mode of failure were recorded. RESULTS: The mean displacement of all specimens undergoing the sling technique was significantly less than that of the interference technique at 3.0 mm (±0.80) versus 5.0 mm (±1.08) (P < .05). The biceps sling technique had a higher mean ultimate failure load (UFL) than did the interference screw tenodesis (216.9 N ± 91.6 v 171.7 N ± 101.4), although this was not statistically significant (P = .63). In the interference screw technique, 4 specimens failed at the tenodesis site by either tearing or complete pullout, whereas 2 failed at the biceps myotendinous junction. In the sling technique, 4 specimens failed at the biceps myotendinous junction, whereas one specimen tore at the tenodesis site and one detached the pectoralis tendon insertion from the humerus. One specimen in the biceps sling technique and 2 specimens in the interference screw technique failed before completing all 200 cycles. CONCLUSIONS: The results of this biomechanical study show that the biceps sling technique has construct stability similar to that of the interference screw technique. CLINICAL RELEVANCE: The biceps sling may be a reasonable alternative for treating symptomatic pathologic conditions of the long head biceps tendon.

Risk Factors for Wound Infection in Outpatients With Lower Extremity Burns.

BACKGROUND: We sought to evaluate risk factors for wound infection in patients with lower extremity (LE) burn. METHODS: Adults presenting with LE burn from January 2014 to July 2015 were included. Data regarding demographics, injury characteristics, and outcomes were obtained. The primary outcome was wound infection. Multivariate logistic regression analysis was performed to identify independent risk factors for wound infection. RESULTS: 317 patients were included with a mean age of 43 years and median total body surface area of .8%; 22 (7%) patients had a component of full-thickness (FT) burn; and 212 (67%) patients had below-the-knee (BTK) burn. The incidence of wound infection was 15%. The median time to infection was 5 days, and majority (61%) of the patients developed wound infection by day 5. Patients who developed wound infection were more likely to have an FT burn (22% vs. 5%, P < .001) and BTK burn (87% vs. 64%, P = .002), without a difference in other variables. Multivariate logistic regression analysis showed age (Odds ratio (OR) 1.02 and CI 1.00-1.04), presence of FT burn (OR 5.33 and CI 2.09-13.62), and BTK burn (OR 3.42 and CI 1.37-8.52) as independent risk factors for wound infection (area under the curve = .72). CONCLUSION: Age, presence of FT burn, and BTK burn are independent risk factors for wound infection in outpatients with LE burns.

Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?

BACKGROUND: Missed documentation for critical care time (CCT) for dying patients may represent a missed opportunity for physicians to account for intensive care unit (ICU) services, including end-of-life care. We hypothesized that CCT would be poorly documented for dying trauma patients. METHODS: Adult trauma ICU patients who died between December 2014 and December 2017 were analyzed retrospectively. Critical care time was not calculated for patients with comfort care code status. Critical care time on the day prior to death and day of death was collected. Logistic regression was used to determine factors associated with documented CCT. RESULTS: Of 147 patients, 43% had no CCT on day prior to death and 55% had no CCT on day of death. 82% had a family meeting within 1 day of death. Family meetings were independently associated with documented CCT (OR 3.69, P = .008); palliative care consultation was associated with decreased documented CCT (OR .24, P < .001). CONCLUSIONS: Critical care time is not documented in half of eligible trauma patients who are near death. Conscious (time spent in family meetings and injury acuity) and unconscious factors (anticipated poor outcomes) likely affect documentation.

Can educational videos reduce opioid consumption in trauma inpatients? A cluster-randomized pilot study.

BACKGROUND: Opioids are often used to treat pain after traumatic injury, but patient education on safe use of opioids is not standard. To address this gap, we created a video-based opioid education program for patients. We hypothesized that video viewing would lead to a decrease in overall opioid use and morphine equivalent doses (MEDs) on their penultimate hospital day. Our secondary aim was to study barriers to video implementation. METHODS: We performed a prospective pragmatic cluster-randomized pilot study of video education for trauma floor patients. One of two equivalent trauma floors was selected as the intervention group; patients were equally likely to be admitted to either floor. Nursing staff were to show videos to English-speaking or Spanish-literate patients within 1 day of floor arrival, excluding patients with Glasgow Coma Scale score less than 15. Opioid use and MEDs taken on the day before discharge were compared. Intention to treat (ITT) (intervention vs. control) and per-protocol groups (video viewers vs. nonviewers) were compared (α = 0.05). Protocol compliance was also assessed. RESULTS: In intention to treat analysis, there was no difference in percent of patients using opioids or MEDs on the day before discharge. In per-protocol analysis, there was no different in percent of patients using opioids on the day before discharge. However, video viewers still on opioids took significantly fewer MEDs than patients who did not see the video (26 vs. 38, p < 0.05). Protocol compliance was poor; only 46% of the intervention group saw the videos. CONCLUSION: Video-based education did not reduce inpatient opioid consumption, although there may be benefits in specific subgroups. Implementation was hindered by staffing and workflow limitations, and staff bias may have limited the effect of randomization. We must continue to establish effective methods to educate patients about safe pain management and translate these into standard practices. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Grade of injury, not initial management, is associated with unplanned interventions in liver injury.

INTRODUCTION: Risk factors for complications after liver injury do not distinguish between patients undergoing selective non-operative management (sNOM) vs operative management (OM) as the initial treatment strategy. Our objective was to identify risk factors for complications requiring an unplanned intervention following sNOM or OM. We hypothesized that patient undergoing sNOM will have fewer unplanned interventions. METHODS: Adults presenting to a level I trauma center with grade III or higher liver injury over a period of 6 years were reviewed. Patient and injury factors, initial management strategy, subsequent complications and interventions were obtained. Bivariate analysis was performed between patients undergoing sNOM vs OM to determine factors associated with unplanned interventions, defined as intervention >48 h after injury. Logistic regression was performed to identify independent risk factors for unplanned interventions. RESULTS: 191 patients were identified: 105 (55%) grade III, 64 (34%) grade IV, and 22 (12%) grade V injury; 136 (71%) underwent sNOM and 55 (29%) underwent OM. 21 (15%) patients required an unplanned intervention: 26 percutaneous drainage, 10 ERCP, and 3 angiography; 12 had multiple procedures. Male gender, younger age, higher ISS, higher grade of injury, firearm mechanism, and initial OM (all p < 0.05) were associated with unplanned interventions. Firearm mechanism and injury grade IV and V, but not initial OM, were independent risk factors for an unplanned intervention. CONCLUSIONS: Grade of liver injury, not the initial mode of treatment, was significantly associated with requiring an unplanned intervention for liver-related complications. Surveillance at 7-10 days, or prior to discharge, in the high-risk group may be able to capture those requiring unplanned intervention and readmission.

Effects of Ohio's opioid prescribing limit for the geriatric minimally injured trauma patient.

BACKGROUND: Geriatric patients, age ≥65, frequently require no operation and only short observation after injury; yet many are prescribed opioids. We reviewed geriatric opioid prescriptions following a statewide outpatient prescribing limit. METHODS: Discharge and 30-day pain prescriptions were collected for geriatric patients managed without operation and with stays less than two midnights from May and June of 2015 through 2018. Patients were compared pre- and post-limit and with a non-geriatric cohort aged 18-64. Fall risk was also assessed. RESULTS: We included 218 geriatric patients, 57 post-limit. Patients received fewer discharge prescriptions and lower doses following the limit. However, this trend preceded the limit. Geriatric patients received fewer opioid prescriptions but higher doses than non-geriatric patients. Fall risk was not associated with reduced prescription frequency or doses. CONCLUSIONS: Opioid prescribing has decreased for geriatric patients with minor injuries. However, surgeons have not reduced dosage based on age or fall risk.

Current Evaluation of Antibiotic Usage in Complicated Intra-Abdominal Infection after the STOP IT Trial: Did We STOP IT?

BACKGROUND: After publication of the Study to Optimize Peritoneal Infection Therapy (STOP IT) trial, we sought to determine if we were implementing study findings into practice appropriately. We had three objectives: evaluate antibiotic usage; evaluate patient outcomes; and delineate differences in antibiotic usage between general surgeons (GS) and trauma/acute care surgery trained surgeons (TACS). PATIENTS AND METHODS: This was an analysis of patients with complicated intra-abdominal infection admitted via the emergency department from February 2014 through May 2017. Complicated intra-abdominal infection (cIAI) was defined as perforated viscus, complicated appendicitis, or ischemic bowel. Patients were excluded if they had an ICD-9/10 code for diverticular/anorectal disease, did not undergo source control, or if the post-operative antibiotic course was not given or was incomplete because of withdrawal of care, change in code status, or death. Outcomes and antibiotic usage were compared before and after the STOP IT publication date. Short-course antibiotic regimens were defined as four days or less of antibiotics after source control. RESULTS: A total of 133 patients met inclusion criteria, with 47 admitted before STOP IT and 86 admitted after. Demographics and other characteristics were similar between these groups. Total antibiotic days and antibiotic days after source control decreased after STOP IT publication (p = 0.031 and p = 0.047, respectively). There were no differences in hospital length of stay (LOS), intensive care unit (ICU) LOS, surgical site infections, intra-abdominal abscesses, or death between the two groups. Short-course antibiotic compliance increased after publication from 30% to 52% (p = 0.012). Compared with GS, patients managed by TACS had decreased total antibiotic days (p = 0.030) and antibiotic days after source control (p = 0.025). CONCLUSION: We demonstrated decreased antibiotic days and increased use of short-course antibiotic regimens for patients with cIAI after the publication of STOP IT. However, there still appears to be opportunity for improved adherence to short-course regimens, as well as opportunities to educate our colleagues.

Opioid prescribing in minimally injured trauma patients: Effect of a state prescribing limit.

BACKGROUND: Opioid-prescribing practices for minimally injured trauma patients are unknown. We hypothesized that opioid-prescribing frequency and morphine-equivalent doses prescribed have decreased in recent years, specifically surrounding an acute prescribing limit implemented in August 2017 mandating opioid prescriptions not exceed 210 morphine-equivalent doses. METHODS: A single-center retrospective study was performed in the month of May during the years 2015 to 2018 on minimally injured trauma patients in a level I trauma center. Minimally injured trauma patients included patients discharged within 2 midnights of trauma evaluation without surgical intervention. Primary outcomes were discharge opioid-prescribing frequency and dosing in morphine-equivalent doses. Secondary outcomes were occurrence and timing of postdischarge follow-up. RESULTS: For 673 minimally injured trauma patients, opioid-prescribing frequency and morphine-equivalent doses prescribed decreased between 2015 and 2017 (49.3% to 31.5%, P = .006, mean 229 to 146 morphine-equivalent doses, P = .007). Decreases between 2017 and 2018 were not statistically significant. Acute prescribing limit compliance was 97% in 2018. After the acute prescribing limit was implemented, outpatient opioid prescribing did not increase and time to earliest follow-up did not decrease. CONCLUSION: Opioid-prescribing frequency and morphine-equivalent doses prescribed to minimally injured trauma patients decreased dramatically between 2015 and 2018. These changes occurred primarily before the implementation of an acute prescribing limit; however, incremental improvement and high compliance since implementation are demonstrated. Patients did not have significantly earlier follow-up encounters for pain or additional opioid prescriptions. Prospective research on pain control for minimally injured trauma patients is needed.

The GAAA tetraloop-receptor interaction contributes differentially to folding thermodynamics and kinetics for the P4-P6 RNA domain.

Tetraloops with the generic sequence GNRA are commonly found in RNA secondary structure, and interactions of such tetraloops with "receptors" elsewhere in RNA play important roles in RNA structure and folding. However, the contributions of tetraloop-receptor interactions specifically to the kinetics of RNA tertiary folding, rather than the thermodynamics of maintaining tertiary structure once folded, have not been reported. Here we investigate the role of the key GAAA tetraloop-receptor motif in folding of the P4-P6 domain of the Tetrahymena group I intron RNA. Insertions of one or more nucleotides into the tetraloop significantly disrupt the thermodynamics of tertiary folding; single-nucleotide insertions shift the folding free energy by 2-4 kcal/mol (DeltaDeltaG(o)'). The folding kinetics of several modified P4-P6 domains were determined by stopped-flow fluorescence spectroscopy, using an internally incorporated pyrene residue as the chromophore. In contrast to the thermodynamic results, the kinetics of Mg(2+)-induced folding were barely affected by the tetraloop modifications, with a DeltaDeltaG(++) of 0.2-0.4 kcal/mol and a Phi value (ratio of the kinetic and thermodynamic contributions) of <0.1. These data indicate an early transition state for folding of P4-P6 with respect to forming the tetraloop-receptor contact, consistent with previous results for modifications elsewhere in P4-P6. We conclude that the GAAA tetraloop-receptor motif contributes little to the stabilization of the transition state for Mg(2+)-induced P4-P6 folding. Rather, the tetraloop-receptor motif acts to clamp the RNA once folding has occurred. This is the first report to correlate the kinetic and thermodynamic contributions of an important RNA tertiary motif, the GNRA tetraloop-receptor. The results are related to possible models for the Mg(2+)-induced folding of the P4-P6 RNA, including a model invoking rapid nonspecific electrostatic collapse.

Mechanistic investigation of a novel vitamin B(12)-catalyzed carbon [bond] carbon bond forming reaction, the reductive dimerization of arylalkenes.

In the presence of catalytic vitamin B(12) and a reducing agent such as Ti(III)citrate or Zn, arylalkenes are dimerized with unusual regioselectivity forming a carbon [bond] carbon bond between the benzylic carbons of each coupling partner. Dimerization products were obtained in good to excellent yields for mono- and 1,1-disubstituted alkenes. Dienes containing one aryl alkene underwent intramolecular cyclization in good yields. However, 1,2-disubstituted and trisubstituted alkenes were unreactive. Mechanistic investigations using radical traps suggest the involvement of benzylic radicals, and the lack of diastereoselectivity in the product distribution is consistent with dimerization of two such reactive intermediates. A strong reducing agent is required for the reaction and fulfills two roles. It returns the Co(II) form of the catalyst generated after the reaction to the active Co(I) state, and by removing Co(II) it also prevents the nonproductive recombination of alkyl radicals with cob(II)alamin. The mechanism of the formation of benzylic radicals from arylalkenes and cob(I)alamin poses an interesting problem. The results with a one-electron transfer probe indicate that radical generation is not likely to involve an electron transfer. Several alternative mechanisms are discussed.