A Core Outcome Set for Acute Necrotizing Pancreatitis: an Eastern Association for the Surgery of Trauma Modified Delphi Method Consensus Study.

BACKGROUND: The management of acute necrotizing pancreatitis (ANP) has changed dramatically over the past 20 years including the use of less invasive techniques, the timing of interventions, nutritional management, and anti-microbial management. This study sought to create a core outcome set (COS) to help shape future research by establishing a minimal set of essential outcomes that will facilitate future comparisons and pooling of data, while minimizing reporting bias. METHODS: A modified Delphi process was performed though involvement of ANP content experts. Each expert proposed a list of outcomes for consideration and the panel anonymously scored the outcomes on a 9-point Likert scale. Core outcome consensus defined a priori as >70% of scores receiving 7-9 points and < 15% of scores receiving 1-3 points. Feedback and aggregate data were shared between rounds with inter-class correlation trends used to determine the end of the study. RESULTS: A total of 19 experts agreed to participate in the study with 16 (84%) participating through study completion. Forty-three outcomes were initially considered with 16 reaching consensuses after four rounds of the modified Delphi process. The final COS included outcomes related to mortality, organ failure, complications, interventions/management, and social factors. CONCLUSION: Through an iterative consensus process, content experts agreed on a COS for the management of ANP. This will help shape future research to generate data suitable for pooling and other statistical analyses that may guide clinical practice. STUDY TYPE: Diagnostic Tests or Criteria. LEVEL OF EVIDENCE: Diagnostic test or criteria, V.

Operative rates in acute diverticulitis with concurrent small bowel obstruction.

Background: The prevalence of diverticulitis has steadily increased during the past century. One possible complication of large bowel diverticulitis (LBD) is the concurrent development of a small bowel obstruction (SBO). The literature regarding these joint diagnoses is primarily limited to small case series from the 1950s. Consequently, no official recommendations or recent literature exists to guide decision making. Methods: This is a retrospective case-control study with 5:1 matching by demographics, comorbidities, and Hinchey classification of patients presenting with concomitant LBD and SBO and patients with LBD alone. The primary outcome assessed was the need for same admission surgical intervention. Results: Patients with concurrent LBD and SBO were more likely to require surgical intervention (OR 4.2, p<0.001) and more likely to receive an open operation than patients with only LBD (p<0.001). The length of stay (LOS) was longer for LBD with SBO (mean LOS +3.2 days, p=0.003). Discussion: Patients with concurrent LBD and SBO are more likely to fail non-operative management. Given this, along with their longer LOS and higher rate of open surgery, earlier surgical intervention may improve outcomes and reduce hospital LOS. Level of evidence: 4.

Clinical outcomes in men with prostate cancer who selected active surveillance using a clinical cell cycle risk score.

Aim: To evaluate active surveillance (AS) selection, safety and durability among men with low-risk prostate cancer assessed using the clinical cell cycle risk (CCR) score, a combined clinical and molecular score. Patients & methods: Initial treatment selection (AS vs treatment) and duration of AS were evaluated for men with low-risk prostate cancer according to the CCR score and National Comprehensive Cancer Network guidelines. Adverse events included biochemical recurrence and metastasis. Results: 82.4% (547/664) of men initially selected AS (median follow-up: 2.2 years), 0.4% (2/547) of whom experienced an adverse event. Two-thirds of patients remained on AS for more than 3 years; patient choice was the most common reason for leaving AS. Conclusion: The CCR score may aid in the identification of men who can safely defer prostate cancer treatment.

Bedside Ultrasonography in the Management of Penetrating Cardiac Injury Caused by a Nail Gun.

BACKGROUND: Injuries from nail guns are a unique type of penetrating trauma seen in emergency departments (EDs), rising in prevalence in the United States. These devices can lead to life-threatening injuries that require rapid diagnosis to help guide management. CASE REPORT: An elderly man was brought to the ED having sustained a nail gun injury to the chest. After loss of pulses, brief closed chest compressions and rapid blood product administration led to a return of spontaneous circulation. Using bedside ultrasound, a metallic foreign body was identified tracking through the right ventricle with associated pericardial fluid and pericardial clot. This rapid diagnosis with bedside ultrasound helped facilitate timely transport to the operating room for median sternotomy, foreign body removal, and pledgeted cardiac repair. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With continued developments in image quality and acquisition, and improvements of physician operator performance, ultrasonography has continued to make significant impacts in traumatically injured patients in new ways. We present this case report to highlight precordial nail gun injuries and to emphasize the diagnostic capabilities of bedside ultrasound for these patients.

Admission ASIA motor score predicting the need for tracheostomy after cervical spinal cord injury.

BACKGROUND: Respiratory compromise and the need for tracheostomy are common after cervical spinal cord injury (cSCI). The purpose of the study was to evaluate if admission American Spinal Injury Association (ASIA) motor score is associated with the need for tracheostomy following cSCI. METHODS: The trauma registry identified patients with isolated cSCI during a 3-year period. Patients with an Abbreviated Injury Scale score greater than 3 in other body regions were excluded. Medical records were reviewed for demographics, admission ASIA motor score, ASIA Impairment Scale (AIS), anatomic level of injury, need for a tracheostomy, and length of stay (LOS). Logistic regression models were constructed to examine the effect of admission ASIA motor scores on the outcome of tracheostomy. Cox proportional hazards models were fit to determine risk factors for time to tracheostomy. RESULTS: A total of 128 patients were identified. Seventy-four patients had a tracheostomy performed on mean (SD) hospital Day 9 (4). Median admission ASIA motor score was 22.0 (interquartile range [IQR], 8-54). Median anatomic level of injury was 5 (IQR, 4-6). Patients requiring tracheostomy had significantly lower median admission ASIA motor score (9 [IQR, 3-17] vs. 57 [IQR, 30-77], p < 0.001) and were more likely to be an AIS A. There was no difference in median anatomic level of injury (5 [IQR, 4-5.8] vs. 5 [IQR, 4-6], p = nonsignificant). ASIA motor scores less than 10 had an unadjusted odds ratio for requiring tracheostomy of 56 (95 confidence interval, 7-426). Following adjustment for independent risk factors, the odds ratio for ASIA motor score less than 10 remained statistically significant at 22 (confidence interval, 3-180). Among patients with incomplete cSCI, ASIA motor scores increased significantly from AIS B to AIS D, while Injury Severity Score (ISS), LOS and intensive care unit LOS declined significantly. Of those patients without a tracheostomy, 100% had an ASIA motor score greater than 10, 98% had an ASIA motor score greater than 20, and 86% had an ASIA motor score greater than 25. Among patients with an ASIA motor score less than 10, 100% had a tracheostomy; among patients with an ASIA motor score less than 20, 96% had a tracheostomy. Among patients with a tracheostomy, 91% were an AIS B or C, while 85% of patients classified as AIS D did not have a tracheostomy. CONCLUSION: Tracheostomy after cSCI is common. Lower admission ASIA motor score and "complete" cSCI are significantly associated with the need for tracheostomy. Anatomic level of injury was not associated with tracheostomy after cSCI. Classification of incomplete patients by AIS indicates that ASIA motor score may be used as a surrogate for grade of injury. When looking only at patients with an "incomplete" cSCI, those with an admission ASIA score of less than 10 should have an early tracheostomy. Those with an AIS D scale should not be considered for early tracheostomy. LEVEL OF EVIDENCE: Therapeutic/care management, level II.