Epidemiology and risk factors for fat embolism in isolated lower extremity long bone fractures.

PURPOSE: Fat embolism syndrome (FES) is a serious complication after orthopedic trauma. The aim of this study was to identify risk factors for FES in isolated lower extremity long bone fractures. METHODS: The National Trauma Data Bank "NTDB" study included patients with isolated femoral and tibial fractures. A total of 344 patients with FES were propensity score matched with 981 patients without FES. Multivariate logistical regression was used to identify independent risk factors for FES. RESULTS: FES was diagnosed in 344 (0.03%) out of the 1,251,143 patients in the study populations. In the two matched groups, the mortality was 7% in the FES group and 1% in the No FES group (p < 0.001). FES was associated with an increased risk of ARDS, VTE, pneumonia, AKI, and stroke. Younger age, femur fractures, obesity, and diabetes mellitus were independent predictors of FES. Early operative fixation (≤ 48 h) was protective against FES. CONCLUSION: FES increases mortality by seven times. Young age, obesity, and diabetes mellitus are significant independent risk factors for FES. Early fixation is independently associated with a reduced risk of FES. LEVEL OF EVIDENCE: Level III. STUDY TYPE: Prognostic study.

Injury Patterns and Treatment Strategies in Civilian and Military Isolated Abdominal Gunshot Wounds.

BACKGROUND: Combat-related gunshot wounds (GSW) may differ from those found in civilian trauma centers. Missile velocity, resources, logistics, and body armor may affect injury patterns and management strategies. This study compares injury patterns, management, and outcomes in isolated abdominal GSW between military (MIL) and civilian (CIV) populations. METHODS: The Department of Defense Trauma Registry (DoDTR) and TQIP databases were queried for patients with isolated abdominal GSW from 2013 to 2016. MIL patients were propensity score matched 1:3 based on age, sex, and extraabdominal AIS. Injury patterns and in-hospital outcomes were compared. Initial operative management strategies, including selective nonoperative management (SNOM) for isolated solid organ injuries, were also compared. RESULTS: Of the 6435 patients with isolated abdominal GSW, 183 (3%) MIL were identified and matched with 549 CIV patients. The MIL group had more hollow viscus injuries (84% vs. 66%) while the CIV group had more vascular injuries (10% vs. 21%) (p < .05 for both). Operative strategy differed, with more MIL patients undergoing exploratory laparotomy (95% vs. 82%) and colectomy (72% vs. 52%) (p < .05 for both). However, no difference in ostomy creation was appreciated. More SNOM for isolated solid organ injuries was performed in the CIV group (34.1% vs. 12.5%; p < 0.05). In-hospital outcomes, including mortality, were similar between groups. CONCLUSIONS: MIL abdominal GSW lead to higher rates of hollow viscus injuries compared to CIV GSW. MIL GSW are more frequently treated with resection but with similar ostomy creation compared to civilian GSW. SNOM of solid organ injuries is infrequently performed following MIL GSW.

Predicting the Future in Trauma: Trauma and Injury Severity Score Loses Accuracy and Validity for Late Deaths After Injury.

BACKGROUND: The Trauma and Injury Severity Score (TRISS) is widely used to predict mortality in trauma patients, but its performance metrics have not been analyzed for early vs later deaths. Therefore, we aimed to investigate the impact of time to death on the accuracy of TRISS. METHODS: Patients from 2013 to 2018 American College of Surgeons Trauma Quality Improvement Program database were included. We compared predicted survival by TRISS using the areas under receiver operating characteristic curves (AUCs) and calibration curves between different cut-off times and subgroups. We further compared early (≤72 hr) and late (>72 hr) deaths based on mechanisms and severity. RESULTS: Among the 1,180,745 patients, the total mortality rate was 6.4%, with 59% early deaths and 41% late deaths. The AUC of TRISS for all patients was .919 (95% CI: .918-.921) for ≤72 hr survival and .845 (95% CI: .843-.848) for >72 hr survival. Significant discrepancies in AUCs between the early and late death groups existed in all cohorts based on blunt/penetrating mechanisms and severity. TRISS predicted well in early survival of penetrating injury but was less reliable in late survival of penetrating injury and all blunt injury. TRISS tended to underestimate survival, particularly for patients with lower probability of survival, with increased discrepancies seen for predicting late deaths. CONCLUSIONS: The predictive ability of TRISS varies significantly based on the timing of deaths and key injury factors. TRISS may be best utilized in predicting early survival in penetrating injury, but its reliability and accuracy diminish when predicting late deaths for all kinds of injury.

Operative management and outcomes of colorectal injuries after gunshot wounds in the deployed military setting versus civilian trauma centers.

INTRODUCTION: Colon and rectal injuries have been diverted at higher rates in military trauma compared with civilian injuries. However, in the last few years, there has been a shift to more liberal primary anastomosis in wartime injuries. The purpose of this study was to compare the management and outcomes in colorectal gunshot wounds (GSWs) between military and civilian settings. METHODS: The study included Department of Defense Trauma Registry and Trauma Quality Improvement Program database patients who sustained colorectal GSWs, during the period 2013 to 2016. Department of Defense Trauma Registry patients were propensity score matched 1:3 based on age, sex, grade of colorectal injury, and extra-abdominal Abbreviated Injury Scale. Patients without signs of life, transfers from an outside hospital, and nonspecific colorectal Organ Injury Scale were excluded. Operative management and outcomes were compared between the two groups. Subanalysis was performed on the military cohort to identify any differences in the use primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. RESULTS: Overall, there were 2,693 patients with colorectal GSWs; 60 patients in the military group were propensity score matched with 180 patients in the civilian group. Overall, colectomy was the most common procedure performed (72.1%) and was used more frequently in the military group (83.3% vs. 68.3%; p < 0.05). However, the rate of fecal diversion was similar in the two groups (23.3% vs. 27.8%; p = 0.500). Among those in the military group, no difference was seen in primary repair, colectomy, or fecal diversion based upon military affiliation or North Atlantic Treaty Organization status. The rates of in-hospital compilations and mortality were similar between the military and civilian groups. CONCLUSION: The severity of GSW colorectal injuries in military and civilian trauma was comparable. There was no significant difference in terms of fecal diversion, mortality, and complications between groups. Military personnel are treated similarly regardless of affiliation. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The impact of deontological and teleological variables on the intention to visit green hotel: The moderating role of trust.

Green hotels have grown in popularity due to customers' increased awareness of environmental issues. This study aims to construct and evaluate a model that combines the theory of Planned Behavior (TPB) and the theory of ethics to explain green hotel visitors' intentions and behavior. The study also considers the role of trust & subjective norms as a moderator. The framework of the study was evaluated using a quantitative method. Most of the respondents to the study, which was carried out in Noakhali, Bangladesh, were students at Noakhali Science and Technology University and their family members. The data was collected from 414 respondents and analyzed using the structural equation modeling (SEM) technique. The data collection took around two weeks, starting from December 3, 2021. According to the study's findings, the deontological (Moral obligation and justice) and teleological variables (perceived benefit and perceived risk) significantly influence green hotel visitors' intentions and actual behavior. Moreover, trust noticeably influences the relationship between subjective norm (SN) and Intention, and subjective norm affects the connection between attitude and intention. Therefore, hotel management can utilize this research to examine and understand visitors' intention and actual behavior to visit green hotels, which will assist them in attracting guests by portraying their services as eco-friendly. Furthermore, the findings may help hotel management formulate competitive marketing strategies, design effective promotional tools, and help generate an eco-conscious customer base.

Bacteriophage antidefense genes that neutralize TIR and STING immune responses.

Programmed cell suicide of infected bacteria, known as abortive infection (Abi), serves as an immune defense strategy to prevent the propagation of bacteriophage viruses. Many Abi systems utilize bespoke cyclic nucleotide immune messengers generated upon infection to mobilize cognate death effectors. Here, we identify a family of bacteriophage nucleotidyltransferases (NTases) that synthesize competitor cyclic dinucleotide (CDN) ligands and inhibit TIR NADase effectors activated via a linked STING CDN sensor domain (TIR-STING). Through a functional screen of NTase-adjacent phage genes, we uncover candidate inhibitors of cell suicide induced by heterologous expression of tonically active TIR-STING. Among these, we demonstrate that a virus MazG-like nucleotide pyrophosphohydrolase, Atd1, depletes the starvation alarmone (p)ppGpp, revealing a potential role for the alarmone-activated host toxin MazF as an executioner of TIR-driven Abi. Phage NTases and counterdefenses like Atd1 preserve host viability to ensure virus propagation and represent tools to modulate TIR and STING immune responses.

Pediatric trauma center vs. adult trauma center: which is better?

PURPOSE OF REVIEW: Pediatric trauma centers (PTCs) have been championed as multidisciplinary facilities specializing in the care of pediatric trauma, the leading cause of childhood mortality in the United States. 1 However, the vast majority of pediatric trauma is still seen in trauma centers focused on treating adults. This article reviews the latest evidence comparing the relative strengths of PTCs and adult trauma centers (ATCs) in treating childhood injury. RECENT FINDINGS: Recent multicenter studies comparing outcomes of pediatric injury in PTCs and ATCs have found no differences in mortality or hospital length of stay, contradicting earlier findings. However, fewer invasive procedures and CT scans were performed at PTCs, and more children were discharged back to their homes. SUMMARY: It is difficult to demonstrate a difference in outcomes for children treated at PTCs vs. ATCs. However, PTCs do offer a multidisciplinary, nuanced approach to pediatric trauma care, which may result in long term benefits and offer opportunities for regional collaboration.

Exploring the Role of Short Chain Acids as Surface Ligands in Photoinduced Charge Transfer Dynamics from CsPbBr3 Perovskite Nanocrystals.

The most commonly used surface capping ligands, like oleic acid and oleylamine, passivate the surface of perovskite nanocrystals (PNCs) to enhance their stability and optical properties. However, due to their inherent insulating nature, charge transport across the surface of the PNCs is hindered, limiting their application in devices. In this study, we have post-treatment CsPbBr3 PNCs with short chain ligands benzoic acid (BA) and ascorbic acid (AA) and observed that both acid-treated PNCs show enhanced stability and optical properties. Still, BA-treated PNCs show the highest charge transport rate due to their conjugating nature. The photoelectrochemical measurements also show the most efficient electron flow across the surface of the PNC with BA-treated PNCs. A longer carrier lifetime and fast charge transfer make BA-treated PNCs ideal candidates for application in real-life devices.

The impact of rounds with a psychiatry team in the intensive care unit: A prospective observational pilot study evaluating the effects on delirium incidence and outcomes.

BACKGROUND: Delirium in the intensive care unit (ICU) is a common but serious condition that has been associated with in-hospital mortality and post-discharge psychological dysfunction. The aim of this before and after study is to determine the effect of a multidisciplinary care model entailing daily ICU rounds with a psychiatrist on the incidence of delirium and clinical outcomes. OBJECTIVE: To assess the impact of a proactive psychiatry consultation model in the surgical ICU on the incidence and duration of delirium. METHODS: This was a prospective, single institution, observational controlled cohort pilot study of adult patients admitted to a surgical ICU. A control group that received standard of care (SOC) with daily delirium prevention care bundles in the pre-intervention period was compared to an intervention group, which had a psychiatrist participate in daily ICU rounds (post-intervention period). The primary outcome was delirium incidence. The secondary outcomes were: delirium duration, ventilator days, hospital and ICU length of stay, and in-hospital mortality. RESULTS: A total of 104 patients were enrolled and equally split between SOC and intervention groups; 95 contributed to analysis. The overall incidence of ICU delirium was 19%. SOC and intervention groups had similar rates of delirium (21% vs 18%, p = 0.72). None of the secondary outcomes statistically significantly differed between the two groups. CONCLUSION: Delirium in ICU patients is a potentially preventable condition with serious sequelae. There was no difference in delirium incidence or duration between patients receiving SOC or patients who had multidisciplinary rounds with a psychiatrist.

Therapeutic Interventions and Outcomes in Civilian and Military Isolated Gunshot Wounds to the Head: A Department of Defense Trauma Registry and ACS TQIP-matched Study.

OBJECTIVE: The purpose of this study was to compare therapeutic strategies and outcomes, following isolated gunshot wounds of the head, between military and civilian populations. BACKGROUND: Recent military conflicts introduced new concepts in trauma care, including aggressive surgical intervention in severe head trauma. METHODS: This was a cohort-matched study, using the civilian Trauma Quality Improvement Program (TQIP) database of the American College of Surgeons (ACS) and the Department of Defense Trauma Registry (DoDTR), during the period 2013 to 2016. Included in the study were patients with isolated gunshots to the head. Exclusion criteria were dead on arrival, civilians transferred from other hospitals, and patients with major extracranial associated injuries (body area Abbreviated Injury Scale >3). Patients in the military database were propensity score-matched 1:3 with patients in the civilian database. RESULTS: A total of 136 patients in the DoDTR database were matched for age, sex, year of injury, and head Abbreviated Injury Scale with 408 patients from TQIP. Utilization of blood products was significantly higher in the military population ( P <0.001). In the military group, patients were significantly more likely to have intracranial pressure monitoring (17% vs 6%, P <0.001) and more likely to undergo craniotomy or craniectomy (34% vs 13%, P <0.001) than in the civilian group. Mortality in the military population was significantly lower (27% vs 38%, P =0.013). CONCLUSIONS: Military patients are more likely to receive blood products, have intracranial pressure monitoring and undergo craniectomy or craniotomy than their civilian counterparts after isolated head gunshot wounds. Mortality is significantly lower in the military population. LEVEL OF EVIDENCE: Level III-therapeutic.

Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study.

BACKGROUND: Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS: Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS: 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS: REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.

Effect of Genetic and Dietary Perturbation of Glycine Metabolism on Atherosclerosis in Humans and Mice.

Objective: Epidemiological and genetic studies have reported inverse associations between circulating glycine levels and risk of coronary artery disease (CAD). However, these findings have not been consistently observed in all studies. We sought to evaluate the causal relationship between circulating glycine levels and atherosclerosis using large-scale genetic analyses in humans and dietary supplementation experiments in mice. Methods: Serum glycine levels were evaluated for association with prevalent and incident CAD in the UK Biobank. A multi-ancestry genome-wide association study (GWAS) meta-analysis was carried out to identify genetic determinants for circulating glycine levels, which were then used to evaluate the causal relationship between glycine and risk of CAD by Mendelian randomization (MR). A glycine feeding study was carried out with atherosclerosis-prone apolipoprotein E deficient (ApoE-/-) mice to determine the effects of increased circulating glycine levels on amino acid metabolism, metabolic traits, and aortic lesion formation. Results: Among 105,718 subjects from the UK Biobank, elevated serum glycine levels were associated with significantly reduced risk of prevalent CAD (Quintile 5 vs. Quintile 1 OR=0.76, 95% CI 0.67-0.87; P<0.0001) and incident CAD (Quintile 5 vs. Quintile 1 HR=0.70, 95% CI 0.65-0.77; P<0.0001) in models adjusted for age, sex, ethnicity, anti-hypertensive and lipid-lowering medications, blood pressure, kidney function, and diabetes. A meta-analysis of 13 GWAS datasets (total n=230,947) identified 61 loci for circulating glycine levels, of which 26 were novel. MR analyses provided modest evidence that genetically elevated glycine levels were causally associated with reduced systolic blood pressure and risk of type 2 diabetes, but did provide evidence for an association with risk of CAD. Furthermore, glycine-supplementation in ApoE-/- mice did not alter cardiometabolic traits, inflammatory biomarkers, or development of atherosclerotic lesions. Conclusions: Circulating glycine levels were inversely associated with risk of prevalent and incident CAD in a large population-based cohort. While substantially expanding the genetic architecture of circulating glycine levels, MR analyses and in vivo feeding studies in humans and mice, respectively, did not provide evidence that the clinical association of this amino acid with CAD represents a causal relationship, despite being associated with two correlated risk factors.

Amine-Free Synthetic Route: An Emerging Approach to Making High-Quality Perovskite Nanocrystals for Futuristic Applications.

In recent years, colloidal cesium lead halide (CsPbX3) perovskite nanocrystals (PNCs) have attracted significant attention from researchers due to their unique optical properties and potential use in optoelectronic applications. In colloidal synthesis, oleic acid and oleylamine are commonly used as surface-capping ligands. Although oleylamine plays a crucial role in maintaining the colloidal stability and surface passivation of PNCs, its dynamic equilibrium with oleic acid leads to the formation of labile oleylammonium, which pulls halides from the surface of PNCs and thus degrades the crystals. In this Perspective, we summarize the various approaches for eliminating the amines to make high-quality, photostable, and amine-free CsPbX3 PNCs. In addition, we look over the prospects of these PNCs regarding stability in different environmental conditions, photoluminescence properties, and optoelectronic device performance. This perspective will give a broad overview of amine-free PNCs starting from their synthesis, challenges, and optoelectronic properties to their future prospects.

When is it safe to resume anticoagulation in traumatic brain injury?

PURPOSE OF REVIEW: When to resume or initiate anticoagulation therapy following traumatic brain injury (TBI) is controversial. This summary describes the latest evidence to guide best practice. RECENT FINDINGS: Following trauma, prophylactic, and therapeutic anticoagulation (TAC) have been widely encouraged to prevent major comorbidities such as pulmonary embolism and deep venous thrombosis. Increased rebleeding risk and potentially catastrophic outcome from initiation of anticoagulation treatment in TBI are mainly influenced by institutional guidelines or physician preference in the absence of level I or II recommendations. In recent years, there has been an increasing number of TBI in the elderly population on anticoagulation for other medical conditions; this complicates the decision and timing to restart anticoagulation after the injury. SUMMARY: Strategies and timing to start prophylactic and TAC differ significantly between institutions and physicians. Each TBI patient should be evaluated on a case-by-case basis on when to start anticoagulation. More investigation is required to guide best practice.

Gene-Environment Interactions for Cardiovascular Disease.

PURPOSE OF REVIEW: We provide an overview of recent findings with respect to gene-environment (GxE) interactions for cardiovascular disease (CVD) risk and discuss future opportunities for advancing the field. RECENT FINDINGS: Over the last several years, GxE interactions for CVD have mostly been identified for smoking and coronary artery disease (CAD) or related risk factors. By comparison, there is more limited evidence for GxE interactions between CVD outcomes and other exposures, such as physical activity, air pollution, diet, and sex. The establishment of large consortia and population-based cohorts, in combination with new computational tools and mouse genetics platforms, can potentially overcome some of the limitations that have hindered human GxE interaction studies and reveal additional association signals for CVD-related traits. The identification of novel GxE interactions is likely to provide a better understanding of the pathogenesis and genetic liability of CVD, with significant implications for healthy lifestyles and therapeutic strategies.

Association of serum HDL-cholesterol and apolipoprotein A1 levels with risk of severe SARS-CoV-2 infection.

Individuals with features of metabolic syndrome are particularly susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus associated with the severe respiratory disease, coronavirus disease 2019 (COVID-19). Despite considerable attention dedicated to COVID-19, the link between metabolic syndrome and SARS-CoV-2 infection remains unclear. Using data from the UK Biobank, we investigated the relationship between severity of COVID-19 and metabolic syndrome-related serum biomarkers measured prior to SARS-CoV-2 infection. Logistic regression analyses were used to test biomarker levels and biomarker-associated genetic variants with SARS-CoV-2-related outcomes. Among SARS-CoV-2-positive cases and negative controls, a 10 mg/dl increase in serum HDL-cholesterol or apolipoprotein A1 levels was associated with ∼10% reduced risk of SARS-CoV-2 infection, after adjustment for age, sex, obesity, hypertension, type 2 diabetes, and coronary artery disease. Evaluation of known genetic variants for HDL-cholesterol revealed that individuals homozygous for apolipoprotein E4 alleles had ∼2- to 3-fold higher risk of SARS-CoV-2 infection or mortality from COVID-19 compared with apolipoprotein E3 homozygotes, even after adjustment for HDL-cholesterol levels. However, cumulative effects of all evaluated HDL-cholesterol-raising alleles and Mendelian randomization analyses did not reveal association of genetically higher HDL-cholesterol levels with decreased risk of SARS-CoV-2 infection. These results implicate serum HDL-cholesterol and apolipoprotein A1 levels measured prior to SAR-CoV-2 exposure as clinical risk factors for severe COVID-19 infection but do not provide evidence that genetically elevated HDL-cholesterol levels are associated with SAR-CoV-2 infection.

Genome-wide analysis identifies novel susceptibility loci for myocardial infarction.

AIMS: While most patients with myocardial infarction (MI) have underlying coronary atherosclerosis, not all patients with coronary artery disease (CAD) develop MI. We sought to address the hypothesis that some of the genetic factors which establish atherosclerosis may be distinct from those that predispose to vulnerable plaques and thrombus formation. METHODS AND RESULTS: We carried out a genome-wide association study for MI in the UK Biobank (n∼472 000), followed by a meta-analysis with summary statistics from the CARDIoGRAMplusC4D Consortium (n∼167 000). Multiple independent replication analyses and functional approaches were used to prioritize loci and evaluate positional candidate genes. Eight novel regions were identified for MI at the genome wide significance level, of which effect sizes at six loci were more robust for MI than for CAD without the presence of MI. Confirmatory evidence for association of a locus on chromosome 1p21.3 harbouring choline-like transporter 3 (SLC44A3) with MI in the context of CAD, but not with coronary atherosclerosis itself, was obtained in Biobank Japan (n∼165 000) and 16 independent angiography-based cohorts (n∼27 000). Follow-up analyses did not reveal association of the SLC44A3 locus with CAD risk factors, biomarkers of coagulation, other thrombotic diseases, or plasma levels of a broad array of metabolites, including choline, trimethylamine N-oxide, and betaine. However, aortic expression of SLC44A3 was increased in carriers of the MI risk allele at chromosome 1p21.3, increased in ischaemic (vs. non-diseased) coronary arteries, up-regulated in human aortic endothelial cells treated with interleukin-1ß (vs. vehicle), and associated with smooth muscle cell migration in vitro. CONCLUSIONS: A large-scale analysis comprising ∼831 000 subjects revealed novel genetic determinants of MI and implicated SLC44A3 in the pathophysiology of vulnerable plaques.

Impact of obesity on outcomes after abdominal gunshot injury.

BACKGROUND: The impact of obesity, on outcomes after a gunshot wound, remains unclear. We hypothesized that patients with obesity have a higher burden of intraabdominal injuries after gunshot injury when compared with the nonobese population. METHODS: The Trauma Quality Improvement Program database (2013-2017) was queried for all patients age ≥16 with abdominal gunshot injuries. Patients who died in the emergency department (ED), arrived without signs of life, had Abbreviated Injury Scale score ≥ 3 in any other region, or transferred from an outside hospital were excluded. The patient with obesity was defined by a body mass index ≥ 30. Demographics, injury data, and outcomes were abstracted and analyzed. Patients with obesity were compared to those with a body mass index < 30. Multivariate logistical regression was used to compare mortality between groups. RESULTS: Of 34,138 patients with gunshot injuries, there were 2,616 (7.7%) with isolated abdominal injuries. Median age is 29 years (22-39 years), 86.7% men. Eight hundred twenty-seven (31.6%) were obese. The obese group was significantly older (32 [25-42] vs. 27 [22-37]; p < 0.001) with a higher incidence of hypertension (16.8% vs. 6.3%, p < 0.001) and diabetes mellitus (7.1% vs. 2.3%, p < 0.001). There was no difference in presenting vital signs, abdominal Abbreviated Injury Scale or Injury Severity Score between groups. The rate of superficial injuries and intraabdominal organ injuries were comparable between groups. Patients with obesity had significantly higher mortality (6.5% vs. 4.2%, p = 0.010), hospital length of stay (9 [7-16] vs. 9[6-14], p < 0.001), ventilator days (3 [2-5] vs. 3 [2-4], p = 0.015), and hospital-acquired pneumonia (3.5% vs. 1.7%, p = 0.005). On multivariate analysis, in addition to older age (odds ratio [OR], 1.050; p < 0.001), ED hypotension (OR, 3.192; p < 0.001), and ED tachycardia (OR, 3.714; p < 0.001), obesity was significantly associated with mortality (OR, 1.636; p = 0.021). CONCLUSION: Patients with obesity are at a high risk of mortality after abdominal gunshot injury. Further prospective evaluation is warranted. LEVEL OF EVIDENCE: Prognostic study, Level III.

Longer Prehospital Time Decreases Reliability of Vital Signs in the Field: A Dual Center Study.

BACKGROUND: Field vital signs are integral in the American College of Surgeons (ASA) Committee on Trauma (COT) triage criteria for trauma team activation (TTA). Reliability of field vital signs in predicting first emergency department (ED) vital signs, however, may depend upon prehospital time. The study objective was to define the effect of prehospital time on correlation between field and first ED vital signs. METHODS: All highest level TTAs at two Level I trauma centers (2008-2018) were screened. Exclusions were unrecorded prehospital vital signs and those dead on arrival. Demographics, prehospital time (scene time + transport time), injury data, and vital signs were collected. Differences between field and first ED vitals were determined using the paired Student's t test. Propensity score analysis, adjusting for age, sex, injury severity score (ISS), and mechanism of injury compared outcomes among patients with ISS ≥16. Multivariate linear regression determined impact of prehospital time on vital sign differences between field and ED among propensity-matched patients. RESULTS: After exclusions, 21 499 patients remained. Mean prehospital time was 32 vs. 41 minutes (P < .001). On propensity score analysis, longer prehospital time was associated with significantly greater differences in systolic blood pressure (SBP) (P < .001), pulse pressure (PP) (P = .003), and Glasgow Coma Scale (GCS) (P < .001). On multivariate analysis, linear regression that demonstrated longer prehospital time was associated with greater differences in SBP, heart rate (HR), and PP (P < .001). CONCLUSIONS: Field vital signs are less likely to reflect initial ED vital signs when prehospital times are longer. Given the reliance of trauma triage criteria on prehospital vital signs, medical providers must be cognizant of this pitfall during the prehospital assessment of trauma patients.

When Is It Safe to Start Pharmacologic Venous Thromboembolism Prophylaxis After Pelvic Fractures? A Prospective Study From a Level I Trauma Center.

BACKGROUND: The ideal time for pharmacologic venous thromboembolism (VTE) prophylaxis initiation after pelvic fracture is controversial. This prospective study evaluated the safety and efficacy of early VTE prophylaxis after blunt pelvic trauma. METHODS: Patients presenting to our American College of Surgeons-verified level I trauma center (between December 1, 2016 and November 30, 2017) with blunt pelvic fracture were prospectively screened. Exclusion criteria were emergency department death, immediate operative intervention, transfers, home anticoagulation, pregnancy, and patients receiving no pharmacologic VTE prophylaxis during hospitalization. Patients were dichotomized into study groups based on VTE prophylaxis initiation time ≤48 h (early prophylaxis [EP]) versus >48 h (late prophylaxis [LP]) after emergency department arrival. Demographics, injury data, clinical data, VTE prophylaxis agent and initiation time, and outcomes were compared. RESULTS: After exclusions, 146 patients were identified: 74 (51%) patients in EP group and 72 (49%) patients in LP group. Pelvic fracture severity was comparable between groups (Abbreviated Injury Scale extremity score 2 [2-3] versus 2 [2-3]; P = 0.610). On univariate analysis, deep vein thrombosis rates were higher after LP (n = 5, 7% versus 0, 0%; P = 0.027). Pulmonary embolism rates were similar (n = 2, 3% versus n = 3, 4%; P = 1.000). No patient required delayed intervention for bleeding, and postprophylaxis blood transfusion was comparable between groups (P > 0.05). On multivariate analysis, timing of pharmacologic VTE prophylaxis initiation was not associated with VTE development (odds ratio, 0.647; P = 0.999). Pelvic angioembolization was independently associated with VTE (odds ratio, 1.296; P = 0.044). CONCLUSIONS: Early initiation of pharmacologic VTE prophylaxis after blunt pelvic fracture is safe. Although EP initiation did not reduce the rate of VTE, these data identify angioembolization as an independent risk factor for VTE. Patients with blunt pelvic fracture who undergo angioembolization may therefore represent a high-risk population who may especially benefit from EP.