Obesity is associated with improved early survival but increased late mortality in surgical patients with Sepsis: A propensity matched analysis.

BACKGROUND: While obesity is a risk factor for postoperative complications, its impact following sepsis is unclear. The primary objective of this study was to evaluate the association between obesity and mortality following admission to the surgical intensive care unit (SICU) with sepsis. METHODS: We conducted a single center retrospective review of SICU patients grouped into obese (n = 766, body mass index ≥30 kg/m 2 ) and nonobese (n = 574; body mass index, 18-29.9 kg/m 2 ) cohorts. Applying 1:1 propensity matching for age, sex, comorbidities, sequential organ failure assessment, and transfer status, demographic data, comorbidities, and sepsis presentation were compared between groups. Primary outcomes included in-hospital and 90-day mortality, ICU length of stay, need for mechanical ventilation (IMV) and renal replacement therapy (RRT). p < 0.05 was considered significant. RESULTS: Obesity associates with higher median ICU length of stay (8.2 vs. 5.6, p < 0.001), need for IMV (76% vs. 67%, p = 0.001), ventilator days (5 vs. 4, p < 0.004), and RRT (23% vs. 12%, p < 0.001). In-hospital (29% vs. 18%, p < 0.0001) and 90-day mortality (34% vs. 24%, p = 0.0006) was higher for obese compared with nonobese groups. Obesity independently predicted need for IMV (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.2-2.1), RRT (OR, 2.2; 95% CI, 1.5-3.1), in-hospital (OR, 2.1; 95% CI, 1.5-2.8), and 90-day mortality (HR, 1.4; 95% CI, 1.1-1.8), after adjusting for sequential organ failure assessment, age, sex, and comorbidities. Comparative survival analyses demonstrate a paradoxical early survival benefit for obese patients followed by a rapid decline after 7 days (logrank p = 0.0009). CONCLUSION: Obesity is an independent risk factor for 90-day mortality for surgical patients with sepsis, but its impact appeared later in hospitalization. Understanding differences in systemic responses between these cohorts may be important for optimizing critical care management. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Formal ultrasound curriculum for surgical critical care fellows leads to improvement in comfort and skills in the intensive care unit.

BACKGROUND: Despite its importance, there are no official guidelines for point of care ultrasound training during surgical critical care fellowship. The primary objective of this study was to evaluate the comfort and competency of fellows after implementation of a point of care ultrasound program. METHODS: Surgical critical care fellows (n = 7) participated in an ultrasound rotation (2021-2022), including dedicated lectures and training with interventional and echocardiography technicians. Pre and post self-assessments were administered evaluating comfort in point of care ultrasound for focused assessment with sonography for trauma, vascular access, drainage procedures, volume status, cardiac activity during arrest, and global cardiac function. Technicians assessed fellow skill in probe orientation, location, image manipulation, machine adjustment, and image quality. All questions were answered on a 7-point Likert scale (1, not-at-all; 7, yes/very much). Pre and post cohorts were compared using Wilcoxon signed-rank tests. RESULTS: After the rotation, fellows reported improvement in comfort level for ultrasound-guided technique for focused assessment with sonography for trauma, drainage procedures, volume status, and cardiac assessment. Technician evaluations demonstrated improvement in probe orientation (5 [4-6] vs 7 [7-7], P = .02) and location (5 [3-6] vs 7 [7-7], P = .02), image manipulation (5 [4-5] vs 7 [7-7], P = .02), machine adjustment (5 [4-5] vs 7 [7-7], P = .02), and overall image quality (4 [4-6] vs 7 [7-7], P = .02) after the rotation. All fellows reported the course significantly improved their skill, comfort level, and was worthwhile. CONCLUSION: All fellows exhibited significant improvement in skill and comfort with point of care ultrasound after this rotation. This is the first study to describe a dedicated ultrasound curriculum for surgical critical care with significant skill acquisition.

The effect of amantadine on acute cognitive disability after severe traumatic brain injury: An institutional pilot study.

BACKGROUND: Amantadine is used in the post-acute care setting to improve cognitive function after a traumatic brain injury. Its utility in the acute postinjury period is unknown. In this pilot study, we sought to examine the effect of amantadine on short-term cognitive disability among patients with a severe traumatic brain injury and hypothesized that patients receiving amantadine would have a greater improvement in disability throughout their acute hospitalization. METHODS: We performed a prospective, observational study of patients ≥18 years with severe traumatic brain injury (Glasgow Coma Scale ≤8) at a level I trauma center between 2020 and 2022. Patients with penetrating trauma, death within 48 hours of admission, and no radiographic evidence of intracranial pathology were excluded. Patients were grouped according to whether they received amantadine. Our primary outcome was the change in cognitive disability, measured by the Disability Rating Scale (DRS), over the index hospitalization. RESULTS: There were 55 patients in the cohort: 41.8% (n = 23) received amantadine and 58.2% (n = 32) did not. There were higher rates of motor vehicle collisions (65.2% vs 46.9%, P = .02), diffuse axonal injury (47.8% vs 18.8%, P = .02), intracranial pressure monitor use (73.9% vs 21.9%, P = .0001), and propranolol use (73.9% vs 21.9%, P = .0001) in the amantadine. There was a larger improvement in DRS scores among patients receiving amantadine (7.8 vs 3.6, P = .001), and amantadine independently predicted improvement in DRS scores (ß, 1.61; 95% confidence interval, 0.20-3.02, P = .03). Rates of discharge to traumatic brain injury rehabilitation were significantly higher in the amantadine group (73.9% vs 21.9%, P = .0002). CONCLUSION: Among patients with severe traumatic brain injury, amantadine use in the acute postinjury period may be associated with an improvement in cognitive disability and discharge to traumatic brain injury rehabilitation.

Distressed Communities Index Is Not Associated with Mortality for Critically Ill Surgical Patients with Sepsis.

Background: The impact of socioeconomic metrics on outcomes after sepsis is unclear. The Distressed Communities Index (DCI) is a composite score quantifying socioeconomic well-being by zip code. The primary objective of this study was to evaluate the association between DCI and mortality in patients with sepsis admitted to the surgical intensive care unit (SICU). Patients and Methods: All patients with sepsis admitted to the SICU (Sequential Organ Failure Assessment [SOFA] score ≥2) were reviewed retrospectively. Composite DCI scores were obtained for each patient and classified into high-distress (DCI ≥75th percentile; n = 331) and control distress (DCI <50th percentile; n = 666) groups. Baseline demographic and clinical characteristics were compared between groups. The primary outcomes were in-hospital and 90-day mortality. Results: The high-distress cohort was younger and more likely to be African American (19.6% vs. 6.2%), transferred from an outside facility (52% vs. 42%), have chronic obstructive pulmonary disease (25.1% vs. 18.8%), and baseline liver disease (8.2% vs. 4.2%). Sepsis presentation was comparable between groups. Compared with the control cohort, high-distress patients had similar in-house (23% vs. 24%) and 90-day mortality (30% vs. 28%) but were associated with longer hospital stay (23 vs. 19 days). High DCI failed to predict in-hospital or 90-day mortality but was an independent risk factor for longer hospital length of stay (odds ratio [OR], 2.83 ± 1.42; p = 0.047). Conclusions: High DCI was not associated with mortality but did independently predict longer length of stay. This may reflect limitations of DCI score in evaluating mortality for patients with sepsis. Future studies should elucidate its association with length of stay, re-admissions, and follow-up.

The Effect of Antiplatelet Agents on Thromboelastography.

BACKGROUND: Thomboelastography (TEG) is a point of care viscoelastic test that provides an assessment of clot formation and kinetics. Antiplatelet agents are commonly used but there is limited literature evaluating their possible effects on overall clot kinetics. We aimed to evaluate the relationship between antiplatelet agents and clot kinetics as defined by TEG. METHODS: This is a retrospective study of adult patients who underwent TEG from February 2018 to July 2020. Patients who received anticoagulants or blood transfusions within 72 hours, had an incomplete TEG, were diagnosed with COVID-19, or had liver failure were excluded. Patients were stratified based on antiplatelet status. RESULTS: Of 1060 patients, 119 were included (50 controls, 69 antiplatelet agents-37 aspirin monotherapy, 26 dual antiplatelet therapy). Between the control and antiplatelet therapy groups, there was no significant difference in clot time, maximal clot strength, or fibrinogen level. When compared to control patients, patients on dual antiplatelets had significantly higher fibrinogen levels (408.1 mg/dL vs 481.5 mg/dL, P = .013) but no significant differences in clot time or maximal clot strength. In our subgroup analysis, patients on dual antiplatelets had increased maximal clot strength (58.8° vs 63°, P = .005) and fibrinogen levels (384.1 mg/dL vs 481.5 mg/dL, P = .005) compared to those on aspirin alone. DISCUSSION: Compared to control patients and those on aspirin alone, patients on dual antiplatelets have increased maximal clot strength and increased fibrinogen levels. These results can help physicians better target product resuscitation in patients who are on antiplatelet agents.

Effects of Early Chemoprophylaxis in Traumatic Brain Injury and Risk of Venous Thromboembolism.

BACKGROUND: The optimal timing to initiate venous thromboembolism (VTE) prophylaxis in patients with a traumatic brain injury (TBI) is still unknown. We designed a study to determine the effect that timing of initiation of VTE prophylaxis has on VTE rates in TBI patients. METHODS: Patient records were obtained from 32 level 1 and 2 trauma centers in the Michigan Trauma Quality Improvement Program from 2008 to 2018. Overall, 5589 patients with a TBI were included and split into cohorts based on VTE prophylaxis initiation time. Outcomes included rate of VTE, mortality, and serious in-hospital complications. RESULTS: There were nine patients (1.3%) in the <24 hour group with a VTE as compared to 36 (2.6%) in the 24-48 hour group, 51 (4.1%) in the 48-72 hour group, and 181 (8.1%) in the >72 hour group (P < .001). The adjusted odds of VTE were significantly greater in patients initiated within 48-72 hours (AOR 2.861, 95% CI 1.271-6.439) and >72 hours (AOR 3.963, 95% CI 1.824-8.612) compared to <24 hours. Patients that received VTE prophylaxis within 24 hours had similar rates of serious in-hospital complication as patients initiated within 24-48 hours (AOR .956, 95% CI .637-1.434) and 48-72 hour (AOR 1.132, 95% CI .757-1.692) but less than the >72 hour group (AOR 1.662, 95% CI 1.154-2.393) groups. DISCUSSION: Patients initiated on VTE prophylaxis within 48 hours of presentation had lower incidence of VTE without a significant increase in serious complications.

Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio.

OBJECTIVE: Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels. METHODS: We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level. RESULTS: There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01). CONCLUSION: Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.

Association of timing of initiation of pharmacologic venous thromboembolism prophylaxis with outcomes in trauma patients.

BACKGROUND: Patients are at a high risk for developing venous thromboembolism (VTE) following traumatic injury. We examined the relationship between timing of initiation of pharmacologic prophylaxis with VTE complications. METHODS: Trauma quality collaborative data from 34 American College of Surgeons Committee on Trauma-verified levels I and II trauma centers were analyzed. Patients were excluded if they were on anticoagulant therapy at the time of injury, had hospitalization <48 hours, or received no or nonstandard pharmacologic VTE prophylaxis (heparin drip). Patient comparison groups were based on timing of initiation of VTE prophylaxis relative to hospital presentation (0 to <24 hours, 24 to <48 hours, ≥48 hours). Risk-adjusted rates of VTE events were calculated accounting for patient factors including type of pharmacologic agent in addition to standard trauma patient confounders. A sensitivity analysis was performed excluding patients who received blood in the first 4 hours and/or patients with a significant traumatic brain injury. RESULTS: Within the 79,386 patients analyzed, there were 1,495 (1.9%) who experienced a VTE complication and 1,437 (1.8%) who died. After adjusting for type of prophylaxis and patient factors, the risk of a VTE event was significantly increased in the 24- to <48-hour (odds ratio, 1.26; 95% confidence interval, 1.09-1.47; p = 0.002) and ≥48-hour (odds ratio, 2.35; 95% confidence interval, 2.04-2.70; p < 0.001) cohorts relative to patients initiated at 0 to <24 hours. These VTE event findings remained significant after exclusion of perceived higher-risk patients in a sensitivity analysis. CONCLUSION: Early initiation of pharmacologic VTE prophylaxis in stable trauma patients is associated with lower rates of VTE. LEVEL OF EVIDENCE: Diagnostic, level III.

Early Chemoprophylaxis in Severely Injured Trauma Patients Reduces Risk of Venous Thromboembolism.

BACKGROUND: Venous thromboembolism (VTE) remains a serious complication for trauma patients. While early VTE prophylaxis has gained traction, the timing of prophylaxis remains uncertain. We hypothesized that VTE prophylaxis within 24 hours of admission would have lower VTE rates and similar rates of adverse events in seriously injured patients. METHODS: Trauma patients were included from 32 American College of Surgeons verified Level 1 and 2 trauma centers over a 10-year period. Patients with injury severity score (ISS) <15, death or discharge within 48 hours of arrival, or who received no prophylaxis were excluded. RESULTS: 14 096 patients received VTE prophylaxis with an ISS of ≥15. Patients given prophylaxis at <24 hours had fewer VTE events and trended toward fewer serious in-hospital complications. Mortality and return to the operating room were similar across groups. Hospital and intensive care unit length of stay in the <24 hours prophylaxis group was significantly shorter when VTE prophylaxis was initiated earlier. CONCLUSIONS: In severely injured trauma patients with ISS >15, early VTE prophylaxis within 24 hours significantly reduced the risk of VTE as compared with delayed prophylaxis. Early chemoprophylaxis was found to be efficacious in reducing the incidence of VTE; however, the safety of this practice should be evaluated by future prospective studies.

Effect of Preinjury Oral Anticoagulants on Outcomes Following Traumatic Brain Injury from Falls in Older Adults.

BACKGROUND: Warfarin has been the oral anticoagulant of choice for the treatment of thromboembolic disease. However, upward of 50% of all new anticoagulant prescriptions are now for direct oral anticoagulants (DOAC). Despite this, outcome data evaluating preinjury anticoagulants remain scarce following traumatic brain injury (TBI). Our study objective is to determine the effects of preinjury anticoagulation on outcomes in older adults with TBI. METHODS: Patient data were obtained from 29 level 1 and 2 trauma centers from 2012 to June 30, 2018. Overall, 8312 patients who were aged 65 years or older, suffering a ground level fall, and with an Abbreviated Injury Scale (AIS) head score of ≥ 3 were identified. Patients were excluded if they presented with no signs of life or a traumatic mechanism besides ground level fall. Statistical comparisons were made using multivariable analyses with anticoagulant/antiplatelet use as the independent variable. RESULTS: Of the total patients with TBI, 3293 were on antiplatelet agents (AP), 669 on warfarin, 414 on warfarin + AP, 188 on DOACs, 116 on DOAC + AP, and 3632 on no anticoagulant. There were 185 (27.7%) patients on warfarin and 43 (22.9%) on a DOAC with a combined outcome of mortality or hospice as compared to 575 (15.8%) in the no anticoagulant group (p<0.001). After adjusting for patient factors, there was an increased risk of mortality or hospice in the warfarin (OR 1.60; 95% CI 1.27-2.01) and DOAC group (OR 1.67; 95% CI 1.07-2.59) as compared to no anticoagulant. Warfarin + AP was associated with an increased risk of mortality or hospice (OR 1.61; 95% CI 1.18-2.21) that was not seen with DOAC + AP (OR 0.93; 95% CI 0.46-1.87) as compared to no anticoagulant. CONCLUSIONS: In older adults with TBI, preinjury treatment with warfarin or DOACs resulted in an increased risk of mortality or hospice whereas preinjury AP therapy did not increase risk. Future studies are needed with larger sample sizes to directly compare TBI outcomes associated with preinjury warfarin versus DOAC use.

Association of mortality among trauma patients taking preinjury direct oral anticoagulants versus vitamin K antagonists.

BACKGROUND: The population of patients on anticoagulant or antiplatelet therapy for medical conditions is increasing. The objective of this study was to investigate the effects of preinjury anticoagulation or antiplatelet therapy on outcomes after trauma. METHODS: This cohort study analyzed data from the Michigan Trauma Quality Improvement Program from 2012 to 2017 and included trauma patients age ≥16 years with an Injury Severity Score ≥5 treated at 29 hospitals. The primary outcome was in-hospital mortality. RESULTS: Of 115,042 trauma patients, 44.2% were women and 78.2% were white with a mean age (standard deviation) of 59.1 (23.2) years. A total of 23,196 patients were on antiplatelet therapy, 3,855 on warfarin, 1,893 on warfarin + antiplatelet agent, 1,306 on a direct oral anticoagulant, and 717 patients on direct oral anticoagulant + antiplatelet therapy. We observed an increased risk of mortality in patients on preinjury antiplatelet (odds ratio [OR] 1.17; 95% confidence interval [CI] 1.02-1.33), warfarin (OR 1.32; 95% CI 1.05-1.65), or warfarin + antiplatelet therapy (OR 1.59; 95% CI 1.18-2.14). Patients on a direct oral anticoagulant only were not at statistically increased risk for mortality. CONCLUSION: Preinjury antiplatelet and/or warfarin use was associated with an increased risk of mortality after traumatic injury. Preinjury direct oral anticoagulant use was not associated with a statistically increased risk of adverse outcomes.

Direct oral anticoagulants do not worsen traumatic brain injury after low-level falls in the elderly.

BACKGROUND: Falls are now the leading cause of trauma and represent the most common type of trauma in the elderly. The use of anticoagulants is increasing in older patients, but there are little data on outcomes after traumatic brain injury while anticoagulated with direct oral anticoagulants compared with warfarin. We hypothesized that anticoagulated patients would have a greater mortality and complications than nonanticoagulated patients, and patients on direct oral anticoagulants would have more fatal outcomes after low-level falls because of lack of reversal agents. METHODS: Patients 65 years or older admitted to level 1-3 trauma centers with 24-hour neurosurgical care were identified through the administrative database of 19 Trinity Health hospitals. Patients with International Classification of Diseases, Ninth Revision, codes consistent with low-level fall and traumatic brain injury from May 2013 through October 2015 were included. Preadmission warfarin or direct oral anticoagulant use was extracted from admission reconciliation of medications in the database. RESULTS: A total of 700 patients met inclusion criteria with 177 on anticoagulants before admission. Anticoagulated patients had more cardiac (P < .001), pulmonary (P < .001), and clotting (P < .02) comorbidities. Warfarin patients had the greatest neurosurgical intervention rate at 18% compared with direct oral anticoagulants (2.8%, P < .02) or nonanticoagulation (11%, P < .02). No difference was identified in overall mortality and mortality after neurosurgical intervention between the nonanticoagulated, warfarin, or direct oral anticoagulant groups. Warfarin patients received more plasma (P < .001) and red cell transfusions (P = .035) with greater intensive care unit stays (P < .001) compared with direct oral anticoagulant or nonanticoagulated patients. With logistic regression, only advancing age (P < .05) and a lesser Glasgow Coma Scale score (P < .01) were associated with greater mortality. CONCLUSION: Older direct oral anticoagulant patients with traumatic brain injury after low-level fall did not have increased morbidity or mortality compared with those treated with warfarin or who were not treated with anticoagulants. Concerns over the use of direct oral anticoagulant agents in this population may be overstated and deserve more scrutiny.

The Michigan Trauma Quality Improvement Program: Results from a collaborative quality initiative.

BACKGROUND: American College of Surgeons verified trauma centers and a third-party payer within the state of Michigan built a regional collaborative quality initiative (CQI). The Michigan Trauma Quality Improvement Program began as a pilot in 2008 and expanded to a formal program in 2011. Here, we examine the performance of the collaborative over time with regard to patient outcomes, resource utilization, and process measures. METHODS: Data from the initial 23 hospitals that joined the CQI in 2011 were analyzed. Performance trends from 2011 to 2015 were evaluated for outcomes, resource utilization, and process measures using univariate analysis. Risk-adjustment was performed to confirm results observed in the unadjusted data. To calculate the potential number of patients impacted by the CQI program, the maximum absolute change was multiplied by the number of trauma patients treated in the 23 hospitals during 2015. RESULTS: Membership in a CQI program significantly reduced serious complications (8.5 vs. 7.3%, p = 0.002), decreased resource utilization, and improved process measure execution in trauma patients over 5 years time. Similar results were obtained in unadjusted and risk-adjusted analyses. The CQI program potentially avoided inferior vena cava filter placement in 167 patients annually. Decreased venous thromboembolism rates mirrored increased compliance with venous thromboembolism pharmacologic prophylaxis. CONCLUSION: This study confirms our hypothesis that participation in a regional CQI improves patient outcomes and decreases resource utilization while promoting compliance with processes of care. LEVEL OF EVIDENCE: Economic/therapeutic care, level V.

Reduction in Venous Thromboembolism Events: Trauma Performance Improvement and Loop Closure Through Participation in a State-Wide Quality Collaborative.

BACKGROUND: The Michigan Trauma Quality Improvement Program (MTQIP) is a collaborative quality initiative sponsored by Blue Cross Blue Shield of Michigan and Blue Care Network (BCBSM/BCN). The MTQIP benchmark reports identified our trauma center as a high outlier for venous thromboembolism (VTE) episodes. This study outlines the performance improvement (PI) process used to reduce the rate of VTE using MTQIP infrastructure. STUDY DESIGN: Trauma patients admitted for > 24 hours, with an Injury Severity Score (ISS) ≥ 5, were included in this study. We performed a preliminary analysis examining prophylaxis drug type to VTE, adjusted by patient confounders and timing of first dose, using MTQIP data abstracted for our hospital. It showed that patients receiving enoxaparin had a VTE rate that was half that of those receiving unfractionated heparin (odds ratio 0.46, 95% CI 0.25 to 0.85). Guided by these results, we produced the following plan: consolidation to single VTE prophylaxis agent and dose, focused education of providers, initiation of VTE prophylaxis for all patients-with clear exception rules-and dose withholding minimization. Results were monitored using the MTQIP platform. RESULTS: After implementation of our focused PI plan, the VTE rate decreased from 6.2% (n = 36/year) to 2.6% (n = 14/year). Our trauma center returned to average performance status within MTQIP. CONCLUSIONS: Participation in MTQIP provided identification of trauma center outlier status for the outcome of VTE. Analysis of MTQIP data allowed creation of a local action plan. The MTQIP infrastructure supported execution and monitoring of the action plan consistent with loop-closure practices, as advocated by the American College of Surgeons Committee on Trauma, and a positive performance improvement result was achieved with VTE reduction.

Regional collaborative quality improvement for trauma reduces complications and costs.

BACKGROUND: Although evidence suggests that quality improvement to reduce complications for trauma patients should decrease costs, studies have not addressed this question directly. In Michigan, trauma centers and a private payer have created a regional collaborative quality initiative (CQI). This CQI program began as a pilot in 2008 and expanded to a formal statewide program in 2010. We examined the relationship between outcomes and expenditures for trauma patients treated in collaborative participant and nonparticipant hospitals. METHODS: Payer claims and collaborative registry data were analyzed for 30-day episode payments and serious complications in patients admitted with trauma diagnoses. Patients were categorized as treated in hospitals that had different CQI status: (1) never participated (Never-CQI); (2) collaborative participant, but patient treated before CQI initiation (Pre-CQI); or (3) active collaborative participant (Post-CQI). DRG International Classification of Diseases--9th Rev. codes were crosswalked to Abbreviated Injury Scale (AIS) 2005 codes. Episode payment data were risk adjusted (age, sex, comorbidities, type/severity of injury, and year of treatment), and price was standardized. Outcome data were risk adjusted. A serious complication consisted of one or more of the following occurrences: acute lung injury/adult respiratory distress syndrome, acute kidney injury, cardiac arrest with cardiopulmonary resuscitation, decubitus ulcer, deep vein thrombosis, enterocutaneous fistula, extremity compartment syndrome, mortality, myocardial infarction, pneumonia, pulmonary embolism, severe sepsis, stroke/cerebral vascular accident, unplanned intubation, or unplanned return to operating room. RESULTS: The risk-adjusted rate of serious complications declined from 14.9% to 9.1% (p < 0.001) in participating hospitals (Post-CQI, n = 26). Average episode payments decreased by $2,720 (from $36,043 to $33,323, p = 0.08) among patients treated in Post-CQI centers, whereas patients treated at Never-CQI institutions had a significant year-to-year increase in payments (from $23,547 to $28,446, p < 0.001). A savings of $6.5 million in total episode payments from 2010 to 2011 was achieved for payer-covered Post-CQI treated patients. CONCLUSION: This study confirms our hypothesis that participation in a regional CQI program improves outcomes and reduces costs for trauma patients. Support of a regional CQI for trauma represents an effective investment to achieve health care value. LEVEL OF EVIDENCE: Economic/value-based evaluation, level III.

Divergent and dynamic activity of endogenous retroviruses in burn patients and their inflammatory potential.

Genes constitute ~3% of the human genome, whereas human endogenous retroviruses (HERVs) represent ~8%. We examined post-burn HERV expression in patients' blood cells, and the inflammatory potentials of the burn-associated HERVs were evaluated. Buffy coat cells, collected at various time points from 11 patients, were screened for the expression of eight HERV families, and we identified their divergent expression profiles depending on patient, HERV, and time point. The population of expressed HERV sequences was patient-specific, suggesting HERVs' inherent genomic polymorphisms and/or differential expression potentials depending on characteristics of patients and courses of injury response. Some HERVs were shared among the patients, while the others were divergent. Interestingly, one burn-associated HERV gag gene from a patient's genome induced IL-6, IL-1ß, Ptgs-2, and iNOS. These findings demonstrate that injury stressors initiate divergent HERV responses depending on patient, HERV, and disease course and implicate HERVs as genetic elements contributing to polymorphic injury pathophysiology.

Improved perioperative and short-term outcomes of robotic versus conventional laparoscopic colorectal operations.

BACKGROUND: Robotic assistance may offer unique advantages over conventional laparoscopy in colorectal operations. METHODS: This prospective observational study compared operative measures and postoperative outcomes between laparoscopic and robotic abdominal and pelvic resections for benign and malignant disease. RESULTS: From 2005 through 2012, 200 (58%) laparoscopic and 144 (42%) robotic operations were performed by a single surgeon. After adjustment for differences in demographics and disease processes using propensity score matching, all laparoscopic operations had a significantly shorter operative time (P < .01), laparoscopic left colectomies had a longer length of hospital stay (2009 and 2010: 6.5 vs 3.6 days, P = .01); and laparoscopic right colectomies had a higher risk for overall complications (P = .03) and postoperative ileus (P = .04). There were no significant differences in the outcomes of pelvic operations (P = .15). CONCLUSIONS: Compared with conventional laparoscopy, some types of robotic-assisted colorectal operations may offer advantages regarding postoperative length of stay and perioperative complications.

Early albumin use improves mortality in difficult to resuscitate burn patients.

BACKGROUND: The optimal resuscitation algorithm remains elusive for patients with a large burn injury. Recent reports from the military support that larger burns that do not respond well to ongoing lactated Ringer's solution resuscitation may improve with the use of 5% albumin and vasopressors. We hypothesized that the use of 5% albumin and vasopressors, as needed, would decrease complications of fluid resuscitation and burn mortality. METHODS: Fluid needs during the first 24 hours after burn injury, complications, and demographics were collected from all patients 12 years and older with burn size 20% or more of total body surface area admitted from 2003 to 2010. In March 2007, we changed our resuscitation to include the use of 5% albumin in the first 24 hours if the estimated fluid needs at 12 hours after burn would lead to a fluid volume of 6 mL/kg per percent burn at 24 hours. The patients treated before this change (Preprotocol) were compared with those treated after the guideline change (Postprotocol). RESULTS: The two groups were well matched for age, burn size, and inhalation injury. Ventilator days and mortality were decreased in the Postprotocol group. There was a trend toward less intravenous fluid use in the Postprotocol group where the use of albumin was higher. There was significantly less vasopressor infusion in the Postprotocol group. There was no statistical difference in the number of escharotomies performed or overall incidence of abdominal compartment syndrome, but no patient required open laparotomy in the Postprotocol group. CONCLUSION: An algorithm incorporating albumin use in the first 24 hours after burn injury was associated with the use of less vasopressor agents and lower mortality. Early albumin use was also associated with a shorter duration of mechanical ventilation in burn patients sustaining burns 20% or more total body surface area. LEVEL OF EVIDENCE: Therapeutic study, level IV.