AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma.

BACKGROUND: Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock. METHODS: Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group. RESULTS: A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs (p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group (p > 0.05). CONCLUSION: This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Predictive Value of the Methicillin-Resistant Staphylococcus aureus Nasal Swab for Methicillin-Resistant Staphylococcus aureus Ventilator-Associated Pneumonia in the Trauma Patient.

Background: Many trauma centers have empiric treatment algorithms for ventilator-associated pneumonia (VAP) treatment prior to culture results that include antibiotic agents for methicillin-resistant Staphylococcus aureus (MRSA) coverage that can have adverse effects. This is the only study to evaluate risk factors and MRSA nasal swabs to risk-stratify trauma patients for MRSA VAP, thereby potentially limiting the need for empiric vancomycin. Patients and Methods: This was a single institution retrospective cohort study. Adult patients admitted to the trauma intensive care unit (ICU) between January 2013 and December 2017 who had a MRSA nasal swab and subsequently met criteria for VAP were included. Demographics, risk factors for MRSA pneumonia, and culture results were collected. Results: A total of 140 patients met inclusion criteria. The negative predictive value (NPV) of MRSA nasal swab at predicting subsequent MRSA pneumonia was 97%. The sensitivity, specificity, and positive predictive value were 50.0%, 96.2%, and 44.4%, respectively. Smokers were more likely to develop MRSA pneumonia, odds ratio: 7.0 (p = 0.02). When considering non-smokers with a negative MRSA nasal swab, NPV was 100%. Conclusions: This is the only study to date that assesses the utility of MRSA nasal swab and risk factor data to guide empiric VAP antibiotic therapy in trauma patients. Smoking was found to be a risk factor for MRSA pneumonia. The use of MRSA nasal swabs in combination with smoking status to guide empiric use of MRSA coverage antibiotic agents is recommended because of a 100% NPV. When utilized, as many as 68% of patients may safely be spared MRSA coverage antibiotic agents and the related adverse effects.

Family Survey of Understanding and Communication of Patient Prognosis in the Intensive Care Unit: Identifying Training Opportunities.

OBJECTIVE: Family members making medical decisions for critically ill patients depend on surgeons' high-quality communication. We aimed to assess family experience of communication in the trauma intensive care unit (TICU), identify opportunities for improvement, and tailor resident communication training to address deficiencies. DESIGN: We designed surveys based on our Conceptual Model of Surgeon Communication and Family Understanding, using items from previously validated tools to assess (1) family well-being, experiences of care, access to information, and assessment of patient condition and prognosis; and (2) surgeon and nursing assessment of patient condition and prognosis. SETTING: Level I TICU in an independent academic medical center. PARTICIPANTS: Adult family members of patients hospitalized in the TICU > 24 hours; 88 families, 22 residents, 9 attendings, 81 nurses completed surveys on 78 unique patients. RESULTS: Family indicated: (1) they had easy access to medical information (91%); (2) the doctors (89%) and nurses (99%) listened carefully (p = 0.013); (3) they were included in morning rounds (80%); and (4) the doctors (91%) and nurses (98%) explained things well (p = 0.041). Family-surgeon agreement regarding the patient's condition and chance of cure was poor (28%) and fair (58%) respectively; families were typically more pessimistic than the surgeon regarding the patient's condition (65%), and more optimistic regarding chance of cure (26%). Residents cited mentors and skills practice with simulated patients as most influential training elements on communication style. CONCLUSIONS: Although families reported high-quality communication with the surgical team and rated physicians well in attributes related to trust, significant discordance in surgeon-family understanding of the patient's condition and prognosis persisted. This may be related to physician difficulty communicating complex information, or a family member's distress resulting in cognitive compromise, coupled with coping through hope and optimism. We recommend ongoing communication training for residents, skills practice for mentors, and open communication between nursing and physicians to optimize family information access.

Patient Perspectives of Surgical Residents' Communication: Do Skills Improve Over Time With a Communication Curriculum?

OBJECTIVE: We aimed to assess surgical residents' communication confidence and skills, analyze resident feedback on our ongoing communication curriculum, and report feedback-driven updates. DESIGN: Surgical residents care for patients in the clinic and hospital and participate in a communication curriculum. We measure patient perception of resident communication using the Communication Assessment Tool (CAT). We assess resident skills confidence and collect curriculum feedback after each quarterly session. SETTING: 900-bed tertiary care hospital with surgical residency program and simulation center. PARTICIPANTS: General surgery residents (PGY 1-5). RESULTS: We collected 353 CAT forms from patients in the clinic and hospital on 27 residents. Overall percent "excellent" scores (primary outcome) was 84%. In multivariate analysis we found a statistically significant increase in individuals' CAT scores over time at a rate of 1% improvement per month (p = 0.02). We observed significant improvement of skill confidence in 9 out of 10 training modules. Resident perception of the curriculum has improved over time with 90% of learners rating the course "A" or "A+" across all years. We updated the curriculum to be more learner-centered by: 1) providing differential scenarios for learner level; 2) engaging chief residents as co-faculty; 3) using both professional and volunteer (former patient) actors as SPs; and 4) refining the flow and timing of module practice. CONCLUSIONS: We assessed and analyzed surgical residents' communication skills and confidence over 17 months; both showed significant increase over the course of the communication curriculum. We adapted our curriculum using resident feedback and engagement. Our results suggest that communication training can be an effective tool to improve non-technical skills.

FRIEND or FOE: A prospective evaluation of risk factors for reintubation in surgical and trauma patients.

BACKGROUND: A Form for Re-Intubation Evaluation by Nurses and Doctors (FRIEND) was used to prospectively collect pre-extubation data, to determine failure of extubation (FOE) risk. METHODS: FRIENDs, including airway, breathing, and neurologic variables, were completed before extubation on trauma & surgical patients in one ICU from 1/1/16 to 5/31/17. Those with failed vs. successful extubation were compared. We excluded those with tracheostomy, comfort measures, or death before extubation. RESULTS: There were 464 eligible extubations in 436 patients. Thirty five reintubations (7.9% FOE rate) occurred in 32 patients within 96 h of extubation. FOE patients had higher ICU days (6 d vs. 2 d), ventilator days (6 d vs. 2 d), and mortality (15.6% vs. 2.7%) [all p < 0.001] compared to those without FOE. Odds of FOE (OR [CI]) increased with age (1.03, [1, 1.06]), delirium (3, [1.16, 7.76]), moderate/copious secretions (3.95, [1.46, 10.66]), and enteral opioid use (4.23, [1.28, 14.02]). CONCLUSIONS: Several characteristics present at the time of extubation were risk factors for FOE in trauma and surgical patients. Patients with FOE had higher mortality.

Evaluating Surgical Residents' Patient-Centered Communication Skills: Practical Alternatives to the "Apprenticeship Model".

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to assess communication skills and provide feedback to residents. We aimed to develop a feasible data collection process that generates objective clinical performance information to guide training activities, inform ACGME milestone evaluations, and validate assessment instruments. DESIGN: Residents care for patients in the surgical clinic and in the hospital, and participate in a communication curriculum providing practice with standardized patients (SPs). We measured perception of resident communication using the 14-item Communication Assessment Tool (CAT), collecting data from patients at the surgery clinic and surgical wards in the hospital, and from SP encounters during simulated training scenarios. We developed a handout of CAT example behaviors to guide patients completing the communication assessment. SETTING: Independent academic medical center. PARTICIPANTS: General surgery residents. RESULTS: The primary outcome is the percentage of total items patients rated "excellent;" we collected data on 24 of 25 residents. Outpatient evaluations resulted in significantly higher scores (mean 84.5% vs. 68.6%, p < 0.001), and female patients provided nearly statistically significantly higher ratings (mean 85.2% vs. 76.7%, p = 0.084). In multivariate analysis, after controlling for patient gender, visit reason, and race, (1) residents' CAT scores from SPs in simulation were independently associated with communication assessments in their concurrent patient population (p = 0.017), and (2) receiving CAT example instructions was associated with a lower percentage of excellent ratings by 9.3% (p = 0.047). CONCLUSIONS: Our data collection process provides a model for obtaining meaningful information about resident communication proficiency. CAT evaluations of surgical residents by the inpatient population had not previously been described in the literature; our results provide important insight into relationships between the evaluations provided by inpatients, clinic patients, and SPs in simulation. Our example behaviors guide shows promise for addressing a common concern, minimizing ceiling effects when measuring physician-patient communication.

Reducing transfusions in critically injured patients using a restricted-criteria order set.

BACKGROUND: We sought to examine the effect on blood usage of a new electronic order set restricting transfusion orders to specific evidence-based criteria for each unit (U) of red blood cells (RBC), plasma, and platelets. METHODS: Prospectively collected transfusion data for Trauma ICU patients were compared for the 12 months before (PRE) and 8 months after (POST) order set implementation. Criteria for RBC transfusion were 1 U only for hemoglobin <7 g/dL in stable patients or <8 g/dL with angina, myocardial infarction, or cardiogenic shock; 2 U for hemoglobin <5 g/dL; and multiple U in the presence of shock, hypotension, or bleeding. Restrictive ordering criteria were also applied to plasma and platelets. Massive transfusion patients were excluded. Differences in demographics and outcomes were assessed with Wilcoxon-Mann-Whitney test or Wilcoxon rank sum test for continuous variables, and χ test for categorical variables. The percentage of patients receiving transfusions over time was compared with trend tests. Severity of illness (SOI) was graded from 1 (minor) to 4 (extreme). RESULTS: Of 1,038 Trauma ICU patients (583 PRE, 455 POST), 228 (22%) were transfused. Median SOI [IQR] (4 [3-4] vs. 4 [3-4]) and mortality (24.3% vs. 22.5%, p = 0.757) were similar for PRE and POST transfused patients, respectively. The percentage of patients getting transfused decreased for all transfusions (25.4% vs. 17.6%, p = 0.003), RBC (19.9% vs. 11.2%, p < 0.001), and plasma (9.3% vs. 5.9%, p = 0.047) in PRE and POST, respectively. After adjusting for age, Injury Severity Score, admission hypotension, and other variables, there was a lower odds of receiving any transfusion (OR 0.67 [0.49-0.92], p = 0.015), and RBCs specifically (OR 0.60 [0.41-0.86], p = 0.006), in the POST period. The frequency of pre-transfusion hemoglobin ≥7 g/dL decreased by 27%, and mean direct costs of transfusion decreased by approximately 28%, after the intervention. CONCLUSIONS: A significant reduction in transfusions was achieved after introduction of an order set restricting orders to predefined evidence-based criteria. LEVEL OF EVIDENCE: Therapeutic study, level III.

Multiparametric magnetic resonance imaging-transrectal ultrasound fusion-assisted biopsy for the diagnosis of local recurrence after radical prostatectomy.

OBJECTIVE: Approximately 15% of patients who undergo radical prostatectomy (RP) for prostate cancer develop local recurrence, which is heralded by a rise in serum prostate-specific antigen (PSA) levels. Early detection and treatment of recurrence improves the outcome of salvage treatment. We investigated the ability of multiparametric magnetic resonance imaging (mpMRI)-transrectal ultrasound (TRUS) fusion-guided biopsy (FGB) combined with "cognitive biopsy" to confirm local recurrence of prostate cancer after RP. MATERIALS AND METHODS: In this retrospective study conducted between January 2010 and December 2014, patients with rising PSA levels after RP who had no known evidence of distant metastases underwent mpMRI including T2-weighted (T2W) imaging, diffusion-weighted imaging, dynamic contrast-enhanced (DCE) MRI at 3 Tesla, and subsequent MRI-ultrasound fusion biopsy with cognitive assistance. The detection rate of locally recurrent disease was determined. RESULTS: A total of 10 patients (mean age = 67y, mean PSA level = 3.44ng/ml) met the inclusion criteria. Of the 10 patients, all had positive findings suspicious for local recurrence on mpMRI per entrance criterion. The most important features on mpMRI were early enhancement on DCE MR images and hypointensity on T2W images. The average lesion diameter on mpMRI was 1.12cm (range: 0.40-2.20cm). All suspicious lesions (16/16, 100%) were positive on T2W MR images, 14 (89%) showed positive features on apparent diffusion coefficient maps of diffusion-weighted images, and 16 (100%) were positive on DCE MR images. MRI-TRUS FGBs were positive in 10/16 lesions (62.5%) and 8/10 (80%) patients. CONCLUSION: MRI-TRUS FGB with cognitive assistance is able to detect and diagnose locally recurrent lesions after RP, even at low PSA levels. This may facilitate early detection of recurrent disease and improve salvage treatment outcomes.

Urinary aHGF, IGFBP3 and OPN as diagnostic and prognostic biomarkers for prostate cancer.

AIM: Serum PSA screening for prostate cancer (PCa) is controversial. Here, we identify three urinary biomarkers - aHGF, IGFBP3 and OPN - for PCa screening and prognostication. METHODS: Urinary aHGF, OPN and IGFBP3 from healthy men (n = 19) and men with localized (n = 65) and metastatic (n = 36) PCa were quantified via ELISA. Mann-Whitney nonparametric t-test and the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) analyses were used to analyze associations. RESULTS: Mean aHGF and IGFBP3 levels were significantly elevated in PCa patients versus controls (p = 0.0006 and p = 0.0012, respectively), and the area under the curve of the receiver operating characteristic curve (indicator of diagnostic accuracy) for aHGF and IGFBP3 was 0.75 and 0.74, respectively. OPN levels were significantly higher in metastatic groups (p = 0.0060) versus localized and controls (area under the curve = 0.68). CONCLUSION: Urinary aHGF and IGFBP3 exhibit the capacity for diagnostic discrimination for PCa, whereas OPN may indicate presence of metastatic disease.

Radiation therapy for the management of patients with HTLV-1-associated adult T-cell leukemia/lymphoma.

Human T-cell leukemia virus type 1-associated adult T-cell leukemia/lymphoma (ATL) typically has survivals measured in months with chemotherapy. One prior published series (1983-1991) assessed local radiotherapy for ATL. Ten consecutive patients with pathologically confirmed ATL treated with radiotherapy were reviewed. Subtypes included acute (n = 7), smoldering (n = 2), and lymphomatous (n = 1). Patients received an average of 2.5 systemic therapy regimens before radiotherapy. Twenty lesions (cutaneous = 10, nodal = 8, extranodal = 2) were treated to a mean of 35.4 Gy/2-3 Gy (range, 12-60 Gy). At 9.0-month mean follow-up (range, 0.1-42.0 months), all lesions symptomatically and radiographically responded, with in-field complete responses in 40.0% (nodal 37.5% vs. cutaneous 50.0%; P = .62). No patient experienced in-field progression. Nine patients developed new/progressive out-of-field disease. Median survival was 17.0 months (3-year survival, 30.0%). No Radiation Therapy Oncology Group acute grade ≥ 3 or any late toxicity was noted. This report is the first to use modern radiotherapy techniques and finds effective local control across ATL subtypes. Radiotherapy should be considered for symptomatic local progression of ATL.

Early Experiences of Image Guided Prostate and Pelvic Nodal Irradiation With Intensity Modulated Radiation Treatment in Localized Prostate Cancer.

BACKGROUND: To present the early findings of a phase I clinical trial studying the use of intensity modulated radiation treatment (IMRT) to treat at risk pelvic and lower para-aortic lymph nodes in patients with high risk prostate cancer while escalating dose. Dose escalation was performed with a technique particularly aiming to limit the dose to surrounding critical structures. METHODS: A total of 12 patients were treated with an IMRT plan that delivered 45 Gy to the pelvic lymph nodes, prostate and proximal seminal vesicles. This was followed by an image guided IMRT plan that delivered 9 Gy to the prostate and seminal vesicles and then an additional 21.6 Gy delivered to the prostate for a total dose of 75.6 Gy to the prostate. Gastrointestinal (GI) and genitourinary (GU) toxicity were recorded weekly throughout treatment and in follow up (range: 20 - 49 months). RESULTS: At diagnosis, median age was 64, median PSA 15.5 (range: 5 - 103) and Gleason score ranged 7 - 9. The median dose to the bladder was 52 Gy, the median dose to the rectum was 53 Gy and the median dose to the small bowel was 26 Gy. During treatment, Grade 2 GU toxicity was noted in 3/12 (25%) patients and Grade 2 GI toxicity was noted in 2/12 patients (16%). At a median follow-up of 28 months, Grade 2 late GI toxicity was seen in 1/12 (8%) and late GU in 3/12 (25%) of patients. There were no acute or late grade 3 and 4 GU or GI toxicities. CONCLUSIONS: Our study shows the feasibility of using IMRT for pelvic and lower para-aortic nodal irradiation as the toxicities are low for the total dose that was delivered. This shows promise for reducing normal tissue doses, improving target control, and potentially allowing for additional dose escalation to the pelvic/lower para-aortic lymph nodes in our successive cohorts.

Twenty-five year results of the national cancer institute randomized breast conservation trial.

Breast conservation therapy (BCT) consisting of lumpectomy and postoperative radiation has become an accepted alternative to mastectomy (MRM) for the treatment of early stage breast cancer. We currently report the 25 year outcomes of a single institution, prospective, randomized clinical trial at the National Cancer Institute. 237 women with pathologically confirmed invasive breast tumors 5 cm or less were accrued between 1979 and 1987 and randomized to receive either BCT or MRM. Overall survival was the primary endpoint. Patients with node positive disease were included and treated with doxorubicin and cyclophosphamide. Both arms received axillary dissection. BCT patients had radiation to the whole breast followed by a boost. At a median follow-up of 25.7 years, overall survival was 43.8% for the MRM group and 37.9% for BCT (P = 0.38). Although the cumulative incidence of a disease-free survival event was higher in BCT patients (29.0% MRM vs. 56.4% BCT, P = 0.0017), the additional treatment failures were primarily isolated ipsilateral breast tumor recurrences (IBTR's) requiring salvage mastectomy. 22.3% of BCT patients experienced an IBTR. Distant disease and second cancers were similar in both arms. After 25 years, long term survival between BCT and MRM continues to be similar in patients treated for early stage breast cancer. Patients receiving BCT may be at risk for additional treatment-related morbidity, which may occur as a late event. Further studies are required to delineate patients at higher risk for these events, and prolonged follow up should be encouraged after treatment for all women.