Marijuana Legalization and Rates of Crashing Under the Influence of Tetrahydrocannabinol and Alcohol.

OBJECTIVE: To determine if statewide marijuana laws impact upon the detection of drugs and alcohol in victims of motor vehicle collisions (MVC). METHODS: A retrospective analysis of data collected at trauma centers in Arizona, California, Ohio, Oregon, New Jersey, and Texas between 2006 and 2018 was performed. The percentage of patients testing positive for marijuana tetrahydrocannabinol (THC) was compared to the percentage of patients driving under the influence of alcohol (blood alcohol level >0.08 g/dL) that were involved in an MVC. RESULTS: The data were analyzed to evaluate the trends in THC and alcohol use in victims of MVC, related to marijuana legalization. The change in incidence of THC detection (percentage) over the time period where data were available are as follows: Arizona 9.5% (0.4 to 9.9), California 5.4% (20.8 to 26.2), Ohio 5.9% (6.7 to 12.6), Oregon 3% (3.0 to 6.0), New Jersey 2.3% (2.7 to 5.0), and Texas 15.3% (3.0 to 18.3). Alcohol use did not change over time in most states. There did not appear to be a relationship between the legalization of marijuana and the likelihood of finding THC in patients admitted after MVC. In fact, in Texas, where marijuana remains illegal, there was the largest change in detection of THC. CONCLUSIONS: There was no apparent increase in the incidence of driving under the influence of marijuana after legalization. In addition, the changes in marijuana legislation did not appear to impact alcohol use.

Umbilical Fascial Defects are Common and Predict Trocar Site Hernias After Laparoscopic Appendectomy.

INTRODUCTION: Investigations have demonstrated that trocar site hernia (TSH) is an under-appreciated complication of laparoscopic surgery, occurring in as many as 31%. We determined the incidence of fascial defects prior to laparoscopic appendectomy and its impact relative to other risk factors upon the development of TSH. METHODS: TSH was defined as a fascial separation of ≥ 1 cm in the abdominal wall umbilical region on abdominal computerized tomography scan (CT) following laparoscopic appendectomy. Patients admitted to our medical center who had both a preoperative CT and postoperative CT for any reason (greater than 30 days after surgery) were reviewed for the presence of TSH from May 2010 to December 2018. CT scans were measured for fascial defects, while investigators were blinded to film timing (preoperative or postoperative) and patient identity. Demographic information was collected. RESULTS: 241 patients undergoing laparoscopic appendectomy had both preoperative and late postoperative CT. TSH was identified in 49 (20.3%) patients. Mean preoperative fascial gap was 3.3 ± 4.3 mm in those not developing a postoperative hernia versus 14.8 ± 7.3 mm in those with a postoperative hernia (P < .0001). Preoperative fascial defect on CT was predictive of TSH (P < .001, OR = 1.44), with an Area Under the Curve (AUC) of .921 (95%CI: .88-.92). Other major risk factors for TSH were: age greater than 59 years (P < .031, OR = 2.48); and obesity, BMI > 30 (P < .012, OR = 2.14). CONCLUSIONS: The incidence of trocar site hernia was one in five following laparoscopic appendectomy. The presence of a pre-existing fascial defect, advanced age, and obesity were strong predictors for the development of trocar site hernia.

A CT-Derived Measurement of Sarcopenia Fails to Predict Falls.

Sarcopenia and frailty have both emerged as risk factors for elderly falls. We investigated whether radiologic sarcopenia or frailty are associated with falls in a high-risk geriatric outpatient population. We reviewed 114 patients followed at the Center for Healthy Senior Living who had undergone a computerized tomography (CT) of the abdomen and pelvis for any reason from 2013 to 2019. Sarcopenia was determined by psoas muscle cross-sectional area at L3 on CT scan. Their individual frailty score was calculated. The primary outcome was admission to hospital for falls. There were no statistical differences in frailty score or sarcopenia between the 2 groups (left/right psoas muscle: no hospital admission = 6.8 ± 2.4/6.4 ± 2.5 vs falls requiring hospital admission 6.5 ± 2.3/6.5 ± 2.3 cm2). We concluded that neither frailty score nor sarcopenia predicted the occurrence of falls in our high-risk geriatric outpatient population.

Review of Intravenous Acetaminophen for Analgesia in the Postoperative Setting.

BACKGROUND: Acetaminophen is a non-opioid analgesic commonly utilized for pain control after several types of surgical procedures. METHODS: This scoping primary literature review provides recommendations for intravenous (IV) acetaminophen use based on type of surgery. RESULTS: Intravenous acetaminophen has been widely studied for postoperative pain control and has been compared to other agents such as NSAIDs, opioids, oral/rectal acetaminophen, and placebo. Some of the procedures studied include abdominal, gynecologic, orthopedic, neurosurgical, cardiac, renal, and genitourinary surgeries. Results of these studies have been conflicting and largely have not shown consistent clinical benefit. CONCLUSION: Overall, findings from this review did not support the notion that IV acetaminophen has significant efficacy for postoperative analgesia. Given the limited clinical benefit of IV acetaminophen, especially when compared to the oral or rectal formulations, use is generally not justifiable.

Are NSAIDs Safe? Assessing the Risk-Benefit Profile of Nonsteroidal Anti-inflammatory Drug Use in Postoperative Pain Management.

In this article, we review controversies in assessing the risk of serious adverse effects caused by administration of nonsteroidal anti-inflammatory drugs (NSAIDs). Our focus is upon NSAIDs used in short courses for the management of acute postoperative pain. In our review of the literature, we found that the risks of short-term NSAID use may be overemphasized. Specifically, that the likelihood of renal dysfunction, bleeding, nonunion of bone, gastric complications, and finally, cardiac dysfunction do not appear to be significantly increased when NSAIDs are used appropriately after surgery. The importance of this finding is that in light of the opioid epidemic, it is crucial to be aware of alternative analgesic options that are safe for postoperative pain control.

Inability to Reverse Aspirin and Clopidogrel-induced Platelet Dysfunction with Platelet Infusion.

Background Platelets are commonly administered to trauma patients to reverse the effects of pre-injury anti-platelet drugs if these individuals are judged to be at risk for ongoing bleeding (i.e., traumatic brain injury). In the U.S. blood banks, platelets are maintained at room temperature and are not infused prior to 72 hours storage due to rigorous screening methods. Recent work suggested that cold refrigerated platelets may be effective at restoring platelet function. We hypothesized that refrigerated platelets might be superior to room temperature platelets in reversing aspirin and clopidogrel-induced platelet dysfunction. Methods Using a cross-over design, 10 healthy, adult subjects underwent platelet removal by apheresis, received anti-platelet drugs (aspirin 325 mg and clopidogrel 75 mg) daily for three days, and then had return of their own platelets (about 3 x 1011 platelets). Five subjects were randomly assigned to receive platelets stored at 4°C, and five received platelets stored at room temperature. One month later, this entire process was repeated with each subject receiving platelets stored by the alternative method. Thus, subjects served as their own controls. At multiple time points during the study in vivo platelet function was assessed by bleeding times, which were measured by a single observer blinded to patient group. Results Bleeding times rose dramatically after anti-platelet drugs were given, but remained well above the normal range (seven minutes) despite reinfusion of platelets. There were no differences in platelet function according to the method of storage. Conclusions Transfusion with autologous platelets appears to be ineffective in reversing the anti-platelet effects of aspirin and clopidogrel. Cold refrigerated platelets were no more effective than room temperature stored platelets in restoring platelet function. This abstract was presented at American College of Surgeons-clinical congress, Boston 10-22-2018. (Khoury L, Cohn S, Panzo M. Inability to Reverse Aspirin and Clopidogrel-Induced Platelet Dysfunction with Platelet Infusion. Journal of the American College of Surgeons. 2018. 227. S265. DOI: 10.1016/j.jamcollsurg.2018.07.546).

Impact of time to repair on outcomes in patients with lower extremity arterial injuries.

BACKGROUND: Six hours has long been considered the threshold of ischemia after peripheral artery injury. However, there is a paucity of evidence regarding the impact of operative delays on morbidity and mortality in patients with lower extremity arterial injuries. METHODS: We analyzed the records of 3,441,259 injured patients entered into the National Trauma Data Bank Research Dataset from 2012 to 2015. Patients (≥16 years) with lower extremity arterial injuries were identified by International Classification of Diseases, Ninth Revision injury and procedure codes. Patients with crush injuries, patients with prehospital or emergency department cardiac arrest, those not transferred directly from point of injury, and patients in whom a nonoperative management strategy was attempted were excluded from analysis. RESULTS: We examined the data from 4406 patients with lower extremity arterial injuries; 85% of the patients were male, with a mean age of 35 years. The overall mortality in this cohort was 3.2% (143/4406); the amputation rate was 11.3% (499/4406). Using a multivariate logistic regression model, blunt mechanisms of injury, increased time from injury to operating room arrival, nerve injury, associated lower extremity fractures, increased age, and Injury Severity Score were associated with increased amputation risk. The amputation rate in those undergoing repair within 60 minutes was 6% compared with 11.7% and 13.4% in those undergoing repair after 1 to 3 hours and 3 to 6 hours, respectively. CONCLUSIONS: Optimal limb salvage is achieved when revascularization of lower extremity arterial injury occurs within 1 hour of injury. To improve survival and recovery after extremity arterial injury, efforts should be focused on strategies to expedite reperfusion of the injured limb.

How To Be a Leader: A Course for Residents.

BACKGROUND: Physicians are required to assume a leadership role as part of their career. For most, this is not an innate characteristic and must be developed throughout their medical training. There are few residency courses designed to assist in the enhancement of these leadership skills. We created and implemented a novel course on leadership, utilizing weekly presentations designed to stimulate discussions and improve the leadership qualities of trainees. METHODS: Senior residents provided leadership lectures stimulated by assigned readings from the book "The Founding Fathers on Leadership." The traits and characteristics demonstrated throughout course readings and discussions were subsequently incorporated into everyday resident activities. Baseline and post-course survey responses were evaluated to assess changes in leadership qualities. RESULTS: Seven senior (postgraduate year (PGY) 3-5) participated as course leaders. All seven filled out pre- and post-course surveys. Seventeen junior residents (PGY 1-2) were involved as audience members. Significant pre- and post-course differences were noted in the following areas: feelings of increased encouragement of personal development (4.86 vs. 5.43, p=0.03); increased team participation in decision-making (4.00 vs. 4.57, p=0.03); increased ease of obtaining answers to difficult questions (4.57 vs. 5.23, p=0.047); increased team member work (4.86 vs. 5.71, p=0.047), and a sense of leading a more balanced life (3.86 vs. 4.43, p=0.03). CONCLUSION: The initiation of a novel leadership course for senior surgical residents led to an enjoyable experience, resulting in enhanced leadership skills for all participants. We believe this process resulted in a more cohesive, efficient, communicative, and supportive residency program.

Natural History of Isolated Skull Fractures in Children.

Head injury is the most common cause of neurologic disability and mortality in children. We had hypothesized that in children with isolated skull fractures (SFs) and a normal neurological examination on presentation, the risk of neurosurgical intervention is very low. We retrospectively reviewed the medical records of all children aged six to sixteen years presenting to our Level 1 trauma center with traumatic brain injuries between January 1, 2006 and December 31, 2014. We also analyzed the National Trauma Data Bank (NTDB) research data set for the years 2012-2014 using the same metrics. During this study period, our center admitted 575 children with skull fractures, 197 of which were isolated (no associated intracranial lesions (ICLs)). Of the 197 patients with isolated SFs, 155 had a normal neurological examination at presentation. In these patients, there were no fatalities and only three (1.9%) required surgery, all for the elevation of the depressed skull fracture. Analyzing the NTDB yielded similar results. In 5,194 children with isolated SFs and a normal neurological examination on presentation, there were no fatalities and 249 (4.8%) required neurosurgical intervention, almost all involving craniotomy/craniectomy and/or elevation of the SF segments. In conclusion, children with non-depressed isolated skull fractures and a normal Glasgow coma scale (GCS) at the time of initial presentation are at extremely low risk of death or needing neurosurgical intervention.

Cirrhosis, Operative Trauma, Transfusion, and Mortality: A Multicenter Retrospective Observational Study.

BACKGROUND: In trauma patients with cirrhosis who require laparotomy, little data exists to establish clinical predictors of the outcome. We sought to determine the prognosticators of mortality in this population. METHODS: We performed a 10-year review at four, busy Level I trauma centers of patients with cirrhosis identified during trauma laparotomy. We compared vital signs, laboratory values, and transfusion requirements for those who survived versus those who died. A linear regression was then conducted to determine the variables associated with death in this population. RESULTS: A total of 66 patients were included and 47% (31/66) died. The model for end-stage liver disease (MELD) score was low (7.8 in Lived, 10.2 in Died). Packed red blood cell (PRBC) transfusion at six hours was greater in those who died; those receiving > 6 units of PRBCs at 6 hours had an increased likelihood of death (odds ratio OR 5.8 (95% CI 1.9, 17.4)). All patients receiving ≥ 17 units of PRBCs died. We found an association between lower preoperative platelets (PLTs), higher preoperative international normalized ratio (INR) and partial thromboplastin time (PTT), lower preoperative pH (presence of profound acidemia), increased intraoperative crystalloid use, and increased intraoperative blood product administration to be associated with death (p < 0.05). CONCLUSIONS: Cirrhotic trauma patients requiring laparotomy should be considered to have a high chance of mortality if they receive six or more PRBCs, are acidotic (pH ≤ 7.25) at the time of hospital arrival, or have coagulopathy at the time of admission (INR > 1.2, PTT > 40).

Improving Oratory Skills: An "American Idol" Presentation Competition for Residents.

Background It is essential for physicians to master the ability to deliver high-quality oral presentations. Despite this, little time is dedicated throughout residency for training and refining this important skill. In order to solve this issue, we set out to design and implement a course which will improve the oratory skills of the resident physicians. Methods Senior surgical residents (postgraduate years three and four) were involved in a single-elimination tournament with the audience voting for the top presenters. Faculty provided feedback on oration, slide layout and overall presentation format throughout the course. Baseline and post-course survey responses were evaluated to assess a change in presentation skills after the "oratory course". Results Seven senior residents participated as competitors. Seventeen other junior and chief residents (postgraduate years 1, 2 and 5) were involved as audience members along with several attending physicians, physician assistants and medical students. Both the presenters and audience appreciated a statistically significant improvement in communication skills and slide layout (p < 0.01). Conclusion The use of a structured course in public speaking and presentation skills proved to be effective in developing oratory skills in surgical residents when used in conjunction with an entertaining format.

The Natural History of Hematemesis in the 21st Century.

OBJECTIVE: Upper gastrointestinal (GI) bleeding occurs at a rate of 40-150 episodes per 100,000 persons per year and is associated with a mortality rate of 6%-10%. We sought to determine the need for therapeutic endoscopy or surgical interventions in patients with hematemesis and the association with blood transfusion requirements. METHODS: We queried the database of our large teaching facility for adult patients presenting with obvious upper GI hemorrhage (hematemesis) between 2014 and 2017. We evaluated the amount of blood transfusions administered and the need for operative, endoscopic or angiographic interventions. RESULTS: Eighty-one patients were admitted with hematemesis: mean age was 63 years old (range 21-103), 60% were male, and mean hemoglobin was 11.3 g/dL (range 3.6-15.6). Forty-one percent received blood transfusions with a mean of one unit transfused per patient (range 0-10); 9% received ≥ 3 units of packed red blood cells. Bleeding stopped spontaneously in 88% of patients and nine died. Forty-seven percent underwent inpatient endoscopy but only 6% underwent a therapeutic endoscopic intervention. No patient had a surgical or interventional radiologic procedure related to their GI bleed. CONCLUSION: Upper GI bleeding rarely requires operative or interventional radiologic intervention. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6% of patients.

The Natural History of Gastrointestinal Bleeding in Patients without an Obvious Source.

With the advent of proton pump inhibitors and H. Pylori treatment, the old dogma "the most common cause of lower GI bleeding is upper GI bleeding" may no longer be valid. We sought to determine the most common causes of GI bleeding in patients without an obvious source and their clinical outcomes. We queried our hospital database for GI hemorrhage during 2015, excluding patients with obvious sources such as hematemesis or anal pathology. We collected data from patients with GI bleeding defined as bright red blood per rectum, melena, or a positive fecal occult blood test. The primary endpoints were etiology of GI bleed, amount of transfusions required, and types of interventions performed. Ninety-three patients were admitted with GI bleeding as defined previously: mean age was 74 years and mean hemoglobin was 8.2. Seventy-four per cent received blood transfusions with an average of 2 units transfused per patient; 22 per cent received 3 or more units of blood. The etiology of bleeding was 17 per cent upper GI source, 15 per cent lower GI source, and in 68 per cent, the source remained unknown. Bleeding stopped spontaneously in 86 per cent of patients and 9 per cent died. Endoscopy was performed in 71 per cent, but only 6 per cent underwent therapeutic endoscopic intervention. No patient had surgical or interventional radiologic procedures related to their GI bleed. Gastrointestinal bleeding, without an obvious source on presentation, rarely requires operative intervention or interventional radiologic procedure. Blood transfusions were not predictive of the need for therapeutic endoscopic intervention which was required in only 6 per cent of patients.

The Clinical Evaluation of Alcohol Intoxication Is Inaccurate in Trauma Patients.

BACKGROUND: Discharging patients from emergency centers based on the clinical features of intoxication alone may be dangerous, as these may poorly correlate with ethanol measurements. OBJECTIVE: We determined the feasibility of utilizing a hand-held breath alcohol analyzer to aid in the disposition of intoxicated trauma patients by comparing serial breathalyzer (Intoximeter, Alco-Sensor FST, St. Louis, Missouri, USA] data with clinical assessments in determining the readiness of trauma patients for discharge. METHODS: A total of 20 legally intoxicated (LI) patients (blood alcohol concentration (BAC) >80 mg/dL) brought to our trauma center were prospectively investigated. Serial breath samples were obtained using a breathalyzer as a surrogate measure of repeated BAC. A clinical exam (nystagmus, one-leg balance, heel-toe walk) was performed prior to each breath sampling. RESULTS: The enrollees were 85% male, age 30±10 (range 19-51), with a body mass index (BMI) of 29±7. The average initial body alcohol level (BAL) was 245±61 (range 162-370) mg/dL. Based on breath samples, the alcohol elimination rates varied from 21.5 mg/dL/hr to 45.7 mg/dL/hr (mean 28.5 mg/dL/hr). There were no significant differences in alcohol elimination rates by gender, age, or BMI. The clinical exam also varied widely among patients; only seven of 16 (44%) LI patients demonstrated horizontal nystagmus (suggesting sobriety when actually LI) and the majority of the LI patients (66%) were able to complete the balance tasks (suggesting sobriety). CONCLUSION: Intoxicated trauma patients have an unreliable clinical sobriety exam and a wide range of alcohol elimination rates. The portable alcohol breath analyzer represents a potential option to easily and inexpensively establish legal sobriety in this population.

Evolution of a Novel Business Leadership Course for General Surgery Chief Residents.

Background General surgery chief residents are typically well equipped for board examinations but poorly trained to deal with the business challenges of surgical practice. We began a business leadership course to better prepare them for their careers. Methods Chief residents were given one-hour lectures with topics that included: Differences between private/academic practice, personal finances, contracts, practice management, legal issues and health law, and time management. Results Initial evaluations revealed that the topics covered and the presentations were well received. Subsequently, the course was moved to earlier in the academic year to prepare them for contract negotiations and then to Sunday nights to decrease interruptions and allow spouse participation. Conclusions The course evolved into a program that the chief residents feel is an important addition to their education. Moving the meetings to a weekend evening improved attendance, decreased interruptions, and allowed participation by spouses and significant others.

The Impact of Marijuana Legalization on Vehicular Trauma.

Background Drugged driving, or driving under the influence of any drug, is a growing public health concern, especially with the recent legislation legalizing marijuana use in certain states in the USA. We sought to gain a better understanding of the surgeons' perspective regarding marijuana (MJ) and alcohol (ETOH) and the relationship of recent laws to identification of MJ and ETOH in trauma victims. Methods Members of a national trauma surgical organization were asked to participate in an Institutional Review Board (IRB)-approved, web-based survey which centered on attitudes, knowledge, and beliefs regarding ETOH and MJ as they related to injury. Two Level I trauma center registries (located in TX and CA) were queried for the incidence of motor vehicular collision (MVC) and the presence of ETOH (defined as > 0.08 g/dL) or MJ from 2006 thru 2012. Results A total of 127 trauma surgeons participated in the survey. The majority were male (84%, n = 107) and with a median age of 52. Most were in surgical practice for greater than 11 years (78%, n = 99) and worked at a Level I trauma center (78%, n = 99) in an academic institution (65%, n = 83). MJ was illegal in the states where most of the participants were in practice (79%, n = 100), but 90% (n = 114) of respondents from states where MJ is legal stated they have not seen an increase in MVC since MJ was legalized. At the TX trauma center, only 4% of patients involved in a vehicular trauma tested positive for MJ, 21% of patients had the presence of ETOH, and 3% had both. For both MJ and also ETOH, the incidence remained the same each year. In CA, there was little yearly variation in the incidence of patients that tested positive for MJ (23%), ETOH (50%), and both (7%). In addition, the incidence of MJ was essentially unchanged after the decriminalization law was passed in 2010. Conclusion The prevalence of cannabis and alcohol varies among the states studied, TX and CA. The impact of decriminalization of marijuana did not seem to affect the incidence of drugged driving with marijuana in CA.