Levetiracetam or Phenytoin as Prophylaxis for Status Epilepticus: Secondary Analysis of the "Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial" Dataset, 2014-2017.

OBJECTIVES: To compare levetiracetam and phenytoin as prophylaxis for the short-term development of status epilepticus (SE) during care of pediatric patients with acute severe traumatic brain injury (TBI). DESIGN: Nonprespecified secondary analysis using propensity score matching. SETTING: We used the Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT NCT04077411) dataset (2014-2017). SUBJECTS: Patients less than 18 years old with Glasgow Coma Scale Score less than or equal to 8 who received levetiracetam or phenytoin as a prophylactic anticonvulsant therapy. INTERVENTION: None. MEASUREMENT AND MAIN RESULTS: Of the 516 total patients who qualified for the case-control study, 372 (72.1%) patients received levetiracetam, and 144 (27.9%) received phenytoin. After propensity score matching, the pair-matched analysis with 133 in each group failed to identify an association between levetiracetam versus phenytoin use and occurrent of SE (3.8% vs. 0.8%, p = 0.22), or mortality (i.e., in-hospital, 30-d and 60-d). However, on closer inspection of the statistical testing, we cannot exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with the following: up to a mean difference of 7.3% greater prevalence of SE; up to a mean difference of 13.9%, 12.1%, and 13.9% greater mortality during the hospital stay, and 30-, and 60-days after hospital arrival, respectively. Last, analysis of 6 months Glasgow Outcome Scale Extended score in those without premorbid comorbidities, there was an association between favorable outcomes and use of phenytoin rather than levetiracetam prophylaxis. CONCLUSIONS: In ADAPT, the decision to use prophylactic levetiracetam versus phenytoin failed to show an association with occurrence of subsequent SE, or mortality. However, we are unable to exclude the possibility that selecting levetiracetam rather than phenytoin for prophylaxis was associated with greater prevalence of SE and mortality. We are unable to make any recommendation about one prophylactic anticonvulsant medication over the other, but recommend that further larger, contemporary studies in severe pediatric TBI are carried out.

Factors associated with pediatric trauma patients leaving against medical advice.

BACKGROUND: Discharge against medical advice (AMA) leads to worse patient outcomes, increased readmission rates, and higher cost. However, AMA discharge has received limited study, particularly in pediatric trauma patients. Our objective was to explore the risk factors associated with leaving AMA in pediatric trauma patients. METHODS: We performed a retrospective analysis on pediatric trauma patients from 2017 to 2019 using the National Trauma Data Bank. We examined patient characteristics including age (<18 years), race, sex, Glasgow Coma Scale, trauma type, primary payment methods, and Abbreviated Injury Scale. Multiple Logistic Regression models were utilized to determine characteristics associated with leaving AMA. RESULTS: Of the 224,196 pediatric patients included in the study, 238 left AMA (0.1%). Our study showed black pediatric trauma patients were more likely to leave AMA compared to nonblack patients (OR 1.987, 95% CI 1.501 to 2.631). Patients with self-pay coverage were more likely to leave AMA than those with other insurance coverages (OR 1.759, 95% CI 1.183 to 2.614). Blunt trauma patients were more likely to leave AMA than those with penetrating trauma (OR 1.683, 95% CI 1.216 to 2.330). Every one-year increase in age led to 15% increase in odds of AMA discharge (OR 1.150, 95% CI 1.115 to 1.186). Pediatric patients with severe abdominal injuries were less likely to leave AMA compared to those with mild abdominal injuries (OR 0.271, 95% CI 0.111 to 0.657). Patients with severe lower extremity injury were less likely to leave AMA compared to those with mild lower extremity injuries (OR 0.258, 95% CI 0.127 to 0.522). CONCLUSION: Race, insurance, injury type, and age play a role in AMA discharge of pediatric trauma patients. Black pediatric trauma patients have ∼ double the AMA discharge rate of nonblack patients. AMA discharge remains relevant, and addressing racial and socioeconomic factors provide opportunities for future interventions in pediatric trauma care. LEVEL OF EVIDENCE: III, retrospective study.

Outcomes of Repeat Surgery in Pediatric Severe Traumatic Brain Injury: An Analysis from Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial.

BACKGROUND: Early operative intervention, craniotomy, and/or craniectomy are occasionally warranted in severe traumatic brain injury (TBI). Persistent increased intracranial pressure or accumulation of intracranial hematoma postsurgery can result in higher mortality and morbidity. There is a gap in information regarding the outcome of repeat surgery (RS) in pediatric patients with severe TBI. METHODS: An observational cohort study titled Approaches and Decisions in Acute Pediatric TBI Trial data was obtained from the Federal Interagency Traumatic Brain Injury Research Informatics System. All pediatric patients who underwent craniotomy or decompressive craniectomy, survived more than 44 hours and were found to have persistent elevated intracranial pressure >20 mmHg for 2 consecutive hours were included in the study. The purpose of the study was to find the outcomes of RS in pediatric severe TBI. Propensity based matching was used to find the outcomes. The primary outcome was 60-day mortality. RESULTS: Out of 1000 total patients enrolled in the Approaches and Decisions in Acute Pediatric Trial, 160 patients qualified for this study. Propensity score matching created 13 pairs of patients. There were no significant differences found between the groups who had RS versus those who did not have repeat surgery on baseline characteristics. There were no significant differences found between the groups regarding 60-day mortality, median hospital days, median intensive care unit days, and 6-month favorable outcome on Glasgow Outcome Scale Extended score. CONCLUSIONS: There was no difference in mortality between patients who underwent a second surgery and patients who did not have to undergo a second surgery.

Association of Designated Pediatric Trauma Center and Outcomes of Severely Injured Children Who Were Mechanically Ventilated and Underwent Tracheostomy: A Propensity-Matched Analysis.

OBJECTIVES: The purpose of the study is to examine the outcomes of care delivered at the pediatric trauma center (PTC) in severely injured children who were intubated, mechanically ventilated, and underwent tracheostomy. METHODS: The study data were obtained from the Trauma Quality Improvement Program database for the calendar years 2017 to 2019. All children aged ≤17 years who sustained severe injury, required intubation and mechanical ventilation for more than 96 hours, and underwent tracheostomy were included in the study. Patients' characteristics, injury severity, and outcomes were compared between the care provided at the PTCs (level I or level II) and nonpediatric trauma centers (NPTCs). The propensity score matching methodology was used to perform the analysis. All P values are 2-sided, and a P value of <0.0.5 is considered statistically significant. RESULTS: Of 2164 patients who were qualified for the study, 1288 (59%) of the patients were treated at PTCs, and 876 (40.5%) of the patients were treated at NPTCs. Propensity matching created 876 pairs of patients. There were no significant differences found between the 2 groups on patients' characteristics except for age. Patients who were treated at PTCs had a median age of 14 (10-16) versus 15 (11-17) years ( P < 0.001) when compared with care provided at NPTCs. A longer hospital stay was found in the PTC group when compared with the NPTC group (24 [23, 25] vs 22 [21, 24], P = 0.008). Patients who were treated at PTC were found to have significantly less sepsis occurrence (0.9% vs 2.2%), and a higher proportion of patients were discharged home without needing additional support (26.2% vs 18.5%). CONCLUSIONS: Care at the PTC was associated with a lower occurrence of sepsis complications. A higher number of patients were discharged home without additional services when the care was provided at PTC.

Factors Associated With Tracheostomy in Ventilated Pediatric Trauma Patients. A National Trauma Database Study.

PURPOSE: The purpose of the study was to find the factors that were associated with tracheostomy procedures in ventilated pediatric trauma patients. METHODS: The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017 through 2019 was accessed for the study. All patients <18 years old and who were on mechanical ventilation for more than 96 hours were included in the study. Multiple logistic regression analysis was performed to find the factors that were associated with a tracheostomy. RESULTS: Out of 2653 patients, 1907 (71.88%) patients underwent tracheostomy. The patients who underwent tracheostomy had a lower median [IQR] of Glasgow Coma Scale (GCS) (3 [3-8] vs 5 [3-10], P < .001) and had a higher proportion of severe spine injury (On Abbreviated Injury Scale [AIS]≥3) (11.6% vs 8.8%, P = .044) when compared with patients who did not have tracheostomy. Lower GCS scores and severe spine injury were associated with higher odds of tracheostomy, with all P values <.05. Higher proportion of tracheostomy procedures were performed at level I pediatric trauma centers as compared to non-designated pediatric centers (odds ratio [95% CI]: 1.848 [1.524-2.242], P < .001). CONCLUSION: A lower GCS score, severe spine injury and highest level trauma centers were associated with a tracheostomy.

Ten-Year Trends of Persistent Mortality With Gallstone Disease: A Retrospective Cohort Study in New Jersey.

BACKGROUND AND AIMS: Recent trends in mortality with gallstone disease remain scarce in the United States. Yet multiple changes in clinical management, such as rates of endoscopy, cholecystectomy, and cholecystostomy, and insurance access at the state level, may have occurred. Thus, we evaluated recent secular trends of mortality with gallstone disease in New Jersey. METHODS: We performed a retrospective, cohort study of mortality from 2009 to 2018 using the National Center for Health Statistics, Restricted Mortality Files. The primary outcome was any death with an International Classifications of Disease, 10th Revision, Clinical Modification diagnosis code of gallstone disease in New Jersey. Simple linear regression was used to model trends of incidence of death. RESULTS: 1580 deaths with diagnosed gallstone disease (dGD) occurred from 2009 to 2018. The annual trend of incidence of death was flat over 10 years. The incidence of death with dGD relative to all death changed only from 0.21% to 0.20% over 10 years. These findings were consistent also in 18 of 20 subgroup combinations, although the trend of death with dGD in Latinos 65 years or older increased [slope estimate 0.93, 95% confidence limit 0.42-1.43, P = .003]. CONCLUSION: The rate of death with dGD showed little change over the recent 10 years in New Jersey. This needs to be reproduced in other states and nationally. A closer examination of the changes in clinical care and insurance access is needed to help understand why they did not result in a positive change in this avoidable cause of death.

Factors associated with compartment syndrome after a tibial fracture in children.

Objectives: Compartment syndrome (CS) after a tibial fracture in children is one of the orthopedic emergencies. Identifying high-risk patients in a timely fashion minimizes morbidities. This study aimed to find the risk factors of CS after a tibial fracture. Methods: The study data was retrieved from the Trauma Quality Improvement Program database of the calendar year 2017-2019. All patients aged <18 years old who were admitted to the hospital with tibial fractures were included in the study. Patients' characteristics, including demography, injury, injury severity, and associated crushed and vascular injuries were analyzed between the groups who developed CS versus those who did not develop CS after a tibial fracture. Multiple logistic regression analyses were performed to find the association of CS. All p values are two-sided and a p value<0.05 is considered statistically significant. Results: Of 4492 patients who qualified for the study, 49 (1.1%) patients developed CS. The patients who developed CS sustained more crush injuries and were associated with a higher rate of vascular injury (2% vs 0.1%, p=0.043% & 10.2% vs 2.2%, p=0.005). Multivariable analysis showed that for every increase in 1 year of age, the odds of occurrence of CS increased by 15.7% (adjusted OR (AOR)=1.157, 95% CI: 1.032 to 1.297, p=0.013). Non-African American race was associated with more than double the risk of developing CS when compared with the African American race, AOR was 2.238, (95% CI: (1.08 to 4.638)). The associated crush injury had an approximately 19-fold higher risk of CS when compared with patients presented with no crush injury, AOR was 18.812, (95% CI: (1.513 to 233.931)). Associated vascular injury was found to have significantly higher AOR, 3.509, 95% CI: (1.287 to 9.563) of CS. Conclusion: Increased age, non-African American race, vascular injury, and crushed injury were associated with a risk of developing CS after a tibial fracture. Level of evidence IV: Study type: Observational cohort study.

Impact of cannabis on outcome in patients following traumatic injury.

INTRODUCTION: Outcomes of trauma patients who tested positive for cannabis at the time of admission showed variable results. Sample size and research methodology that was used in prior studies may have resulted in the conflict. The purpose of the study was to evaluate the impact of cannabis use on outcomes in trauma patients using national data. Our hypothesis was that the use of cannabis will impact outcomes. METHODS: The trauma quality improvement program (TQIP) Participant Use File (PUF) database of the calendar years 2017 and 2018 were accessed for the study. All trauma patients aged 12 years old and above who were tested for cannabis at the time of initial evaluation were included in the study. Variables included in the study were: race, sex, injury severity score (ISS), Glasgow Coma Scale (GCS) Score, Abbreviated Injury Scale (AIS) score of different body regions and comorbidities. Excluded from the study were all patients who were not tested for cannabis or tested for cannabis but were also tested positive for alcohol and other drugs and those suffering from mental conditions. Propensity matched analysis was performed. The outcome of interest was overall in-hospital mortality and complications. RESULTS: Propensity matched analysis created 28,028 pairs. The analysis showed no significant difference in-hospital mortality between cannabis positive and cannabis negative groups (3.2% vs. 3.2%). The median length of hospital stay in both groups was not significantly different (4 [IQR: 3-8] vs. 4 [IQR: 2-8] days). No significant difference was found between the two groups regarding hospital complications except in pulmonary embolism (PE) with 0.1% less incidence of PE in the cannabis positive group compared to the cannabis negative group (0.4 vs. 0.5%). The incidence of DVT was identical in both groups (0.9% vs. 0.9%). CONCLUSION: Cannabis was not associated with overall in-hospital mortality or morbidity. There was a slight decrease in the incidence of PE in the cannabis positive group.

Outcomes of Severe Acute Kidney Injury in Pediatric Trauma Patients; The Trauma Quality Improvement Program Database Study.

INTRODUCTION: Acute kidney injury (AKI) has been associated with higher mortality and morbidity in trauma victims. There is a paucity of information regarding the outcomes of severe AKI (sAKI) in pediatric trauma patients. Therefore, the trauma quality improvement program database (TQIP) was used to assess that hypothesis sAKI will be associated with higher mortality among pediatric trauma patients. METHODS: The TQIP database was accessed for the study. Patients aged <18 years old admitted to the hospital after sustaining injury were included in the study. Demographics, injury severity score (ISS) and Glasgow coma scale (GCS) score, other body regions injuries, and available comorbidities were included in the study. Propensity score matching analysis was performed to compare the two groups, sAKI vs. no sAKI on patients' characteristics and outcomes. All p values are two-sided. A p-value <0.05 is considered statistically significant. RESULTS: Out of 139,832 patients who qualified for the study, 106 (0.1%) patients suffered from sAKI. Pair-matched analysis showed no significant difference between the groups, sAKI, and no sAKI, regarding the in-hospital mortality (14.3% vs. 12.4%, P = 0.838). There was a prolonged hospital length of stay in the sAKI group when compared to the no sAKI group, (27 days [21-33] vs. 10 [9-14], P < 0.001). There was a higher incidence of deep vein thrombosis (DVT) (12.4% vs. 2.9%, P = 0.024) in the sAKI group as well. CONCLUSION: The sAKI patients stayed in the hospital approximately three times longer and had a 4-fold increase in the occurrence of DVT. No significant difference was found between the groups in in-hospital mortality. TYPE OF STUDY: Retrospective cohort study.

Outcomes of care at higher-level trauma centers in octogenarians with a history of anticoagulant use who fall from ground level.

BACKGROUND: The appropriate care of octogenarian trauma patients after a fall from ground level (FFGL) is a key factor for better outcomes. The purpose of this study is to use data from a national database to evaluate the outcomes of patients who are 80-89 years old with a history of anticoagulant use, sustained a FFGL, and were treated at a higher-level care institution. METHODS: The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017-2018 was accessed for the study. All hospitalized trauma patients between the ages of 80-89 years old with a history of anticoagulant use and sustaining an injury after FFGL were included in the study. Other variables included in the study are sex [male], race [white], initial systolic blood pressure (SBP mmHg), Injury Severity Score (ISS), Glasgow Coma Scale (GCS), hypotension with an SBP<110 mmHg and other comorbidities. The outcomes of the patients were compared with the care at higher-level trauma centers (Level I & Level II) and lower-level trauma centers (Level III) using propensity matched analysis. RESULTS: After propensity matching, 2348 patients were identified in each group. There was no clinically significant difference between the patients' characteristics who were treated at higher-level and lower-level care centers. A paired matched analysis showed greater mortality in patients who were treated at higher-level care centers compared to lower-level care centers (3.7% vs 2.6%, P = 0.03). The absolute difference in mortality was 1.1%[95% CI: 0.001, 0.022] which may not have any clinical relevance. A greater number of patients were discharged to home and a lesser number of patients were discharged to a skilled nursing facility (SNF) when they were treated at higher-level trauma centers. CONCLUSION & RELEVANCE: The care at higher-level trauma centers did not show any benefit in-hospital mortality in the short term. A higher number of patients was discharged to home without assistance.

Decreased Emergency Cholecystectomy and Case Fatality Rate, Not Explained by Expansion of Medicaid.

INTRODUCTION: Population data on longitudinal trends for cholecystectomies and their outcomes are scarce. We evaluated the incidence and case fatality rate of emergency and ambulatory cholecystectomies in New Jersey (NJ) and whether the Medicaid expansion changed trends. MATERIALS AND METHODS: A retrospective population cohort design was used to study the incidence of cholecystectomies and their case fatality rate from 2009 to 2018. Using linear and logistic regression we explored the trends of incidence and the odds of case fatality after versus before the January 1, 2014 Medicaid expansion. RESULTS: Overall, 93,423 emergency cholecystectomies were performed, with 644 fatalities; 87,239 ambulatory cholecystectomies were performed, with fewer than 10 fatalities. The 2009 to 2018 annual incidence of emergency cholecystectomies dropped markedly from 114.8 to 77.5 per 100,000 NJ population (P < 0.0001); ambulatory cholecystectomies increased from 93.5 to 95.6 per 100,000 (P = 0.053). The incidence of emergency cholecystectomies dropped more after than before Medicaid expansion (P < 0.0001). The odds ratio for case fatality among those undergoing emergency cholecystectomies after versus before expansion was 0.85 (95% CI, 0.72-0.99). This decrease in case fatality, apparent only in those over age 65, was not explained by the addition of Medicaid. CONCLUSIONS: A marked decrease in the incidence of emergency cholecystectomies occurred after Medicaid expansion, which was not accounted for by a minimal increase in the incidence of ambulatory cholecystectomies. Case fatality from emergency cholecystectomy decreased over time due to factors other than Medicaid. Further work is needed to reconcile these findings with the previously reported lack of decrease in overall gallstone disease mortality in NJ.

Minor injury turns into major problem in severe acute kidney injury: a propensity matched analysis.

Objective: Severe acute kidney injury (sAKI) has been associated with a higher mortality in trauma patients, and severity of trauma often correlates with risk of sAKI. Whether minor to moderate trauma is associated with sAKI is less clear. The purpose of the study was to examine the outcomes of minor to moderate trauma patients who developed sAKI. Methods: The National Trauma Database participant use files of 2017 and 2018 were accessed for the study. All patients aged 18 years old and above who sustained an Injury Severity Score (ISS) of <16 and who were brought to a level I or level II trauma center were included in the study. sAKI was defined as an abrupt decrease in kidney function either three times increase in serum creatinine (SCr) level from the baseline or increase in SCr to ≥4.0 mg/dL (≥353.6 µmol/L), initiation of renal replacement therapy, or anuria for ≥12 hours. Propensity matching analysis was performed between the groups who developed sAKI and without sAKI. Outcome of interest was in-hospital mortality. Results: A total of 655 872 patients fulfilled the inclusion criteria with complete information, of which 1896 patients were found to have sAKI. There were significant differences between the two groups on baseline characteristics. The propensity score matching eliminated all the differences and created 1896 pairs of patients. The median hospital length of stay was longer in patients with sAKI when compared with patients who did not develop sAKI (14 (13 to 15) vs. 5 (5 to 5), days p<0.001). The overall in-hospital mortality was 20.6% in patients with sAKI compared with 2.1% without sAKI (p<0.001). Conclusion: The occurrence of sAKI in minor to moderate trauma patients was less than 0.5%. There was a three times longer hospital stay in patients with sAKI and 10-fold increase in mortality when compared with patients who did not develop sAKI. Level of evidence: IV. Study type: Observational cohort study.

Early Tracheostomy and Outcomes in Ventilated Pediatric Trauma Patients.

INTRODUCTION: The purpose of the study was to evaluate the outcomes of pediatric ventilated patients who underwent early tracheostomy. Our hypothesis is early tracheostomy will be associated with less ventilator days, Intensive care (ICU) days and hospital days. METHODS: The Trauma Quality Improvement Program (TQIP) database of the calendar year 2017 through 2019 was used for the study. All pediatric trauma patients ≤17 years who were admitted to the hospital and were placed on mechanical ventilation were included in the study. Other variables included patients' demography, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, types of procedure that were performed for hemorrhage control. Propensity score matching analysis was performed between the early (≤7 days) and late tracheostomy (>7 days) groups. The primary outcome of the study was total hospital length of stay. Other outcomes were ICU days, ventilator days. RESULTS: Propensity score matching created 643 pairs of patients. The median age (years [interquartile range]) of the patient was 14 [8-16]. Most patients suffered from severe injuries with a median ISS 29 [22-38] and GCS score was 3 [3-8]. There was no significant difference identified between the early and the late groups, in hospital stay (24 [23, 26] vs. 24 [23, 26], P = 0.5), ICU days (14 [9-22] vs. 16 [9-23], P = 0.073) and ventilator days (10 [6-17] vs. 11 [7-18], P = 0.068). The incidence of pneumonia between the groups was (8.7% vs. 9.2%, P = 0.347). CONCLUSION: Early tracheostomy failed to show any outcomes benefit in ventilated pediatric trauma patients.

Effect of Smoking History on 30-Day Morbidity Following Bariatric Surgery.

INTRODUCTION: Smoking and postoperative complications are well documented across surgical specialties. Preoperative smoking cessation is frequently recommended by surgeons. In this study, we assessed to what degree documented smoking history increased a patient's risk of postoperative complications. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the years 2015-2018 was used. Patients were included if they underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (LRYGB). Patients with a documented smoking history were assigned to the "SH" cohort and patients without smoking history were assigned to the "NSH" cohort. Patients without documentation regarding smoking history, missing variables, younger than 18, with prior surgery, or lost to follow-up were excluded. 30-day morbidity and mortality data were assessed. Multiple logistic regression analysis was made based on all available patient characteristics and perioperative factors, continuous variables were analyzed using Student's t-test and categorical variables were compared using the chi-square test. RESULTS: After evaluation of 760,076 patients on the MBSAQIP database, 650,930 patients underwent non-revisional bariatric surgery, including 466,270 SG and 184,660 LRYGB. Of the total patients included in the study, 44,606 patients were assigned to the SH cohort and 479,601 were assigned to the NSH cohort. 4628 of patients did not have documented smoking status. Within 30 days SH patients had higher rates of readmission (4.2% vs 3.7%, P < .0001), reoperation (1.3% vs 1.1%, P < .0001), unplanned intubation (.2% vs .1%, P = .0212), and unplanned ICU admission (.7% vs .0.6%, P = .0022). CONCLUSION: SH patients undergoing bariatric surgery were at significantly increased risk of readmission and reoperation within 30 days of procedure. In addition, SH patients were more likely to have unplanned intubation and unplanned ICU admission. Given the higher rates of complications in smoking patients, this study would suggest that preoperative smoking cessation in patients prior to primary bariatric surgery might be beneficial. Further study is warranted to compare short-term cessation vs long-term cessation preoperatively, which was not assessed in our study.

Pulmonary Complications of Alcohol Withdrawal Syndrome in Trauma Patients. A Matched Analysis From a National Trauma Database.

BACKGROUND: Alcohol withdrawal syndrome (AWS) is associated with increased occurrence of pneumonia and longer hospital stay. The purpose of the study is to find a national estimate of pulmonary complications in AWS patients using the National Trauma Quality Improvement Program (TQIP) database. METHODS: We accessed the TQIP database focusing on the calendar years 2013-2016 and included all adult admitted trauma patients. The two groups (AWS and no AWS) were compared on baseline characteristics, injury, comorbidities, and outcomes. We performed univariate analysis followed by propensity matching. RESULTS: Out of 534 880 patients who qualified for the study, 6929 (1.29%) patients had developed AWS. The propensity matching balanced the two groups on all the baseline characteristics, injury severity, and comorbidities and created 6929 pairs. One-to-one pair-matched analysis showed a significantly increased occurrence of pneumonia (12% vs 4.3%), acute respiratory distress syndrome (ARDS) (2.7% vs 1%), and sepsis (2.4% vs 1.1%) in AWS patients when compared with the patients without the AWS. CONCLUSION: The study showed approximately a 3-fold increase in ARDS and pneumonia and a more than two-fold increase in sepsis in AWS patients. Early intervention in high-risk AWS patients may reduce the complications.

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.

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.