Artificial Intelligence for Clinically Meaningful Outcome Prediction in Orthopedic Research: Current Applications and Limitations.

PURPOSE OF REVIEW: Patient-reported outcome measures (PROM) play a critical role in evaluating the success of treatment interventions for musculoskeletal conditions. However, predicting which patients will benefit from treatment interventions is complex and influenced by a multitude of factors. Artificial intelligence (AI) may better anticipate the propensity to achieve clinically meaningful outcomes through leveraging complex predictive analytics that allow for personalized medicine. This article provides a contemporary review of current applications of AI developed to predict clinically significant outcome (CSO) achievement after musculoskeletal treatment interventions. RECENT FINDINGS: The highest volume of literature exists in the subspecialties of total joint arthroplasty, spine, and sports medicine, with only three studies identified in the remaining orthopedic subspecialties combined. Performance is widely variable across models, with most studies only reporting discrimination as a performance metric. Given the complexity inherent in predictive modeling for this task, including data availability, data handling, model architecture, and outcome selection, studies vary widely in their methodology and results. Importantly, the majority of studies have not been externally validated or demonstrate important methodological limitations, precluding their implementation into clinical settings. A substantial body of literature has accumulated demonstrating variable internal validity, limited scope, and low potential for clinical deployment. The majority of studies attempt to predict the MCID-the lowest bar of clinical achievement. Though a small proportion of models demonstrate promise and highlight the utility of AI, important methodological limitations need to be addressed moving forward to leverage AI-based applications for clinical deployment.

The Portrayal of Premium Cigar Selling Propositions in Lifestyle Magazines: A Content Analysis.

INTRODUCTION: Although lifestyle magazines are an important marketing tool for premium cigars, little is known about their recent portrayal of the products. We expand on research conducted for the National Academies of Sciences, Engineering, and Medicine's Committee on Patterns of Use and Health Effects of "Premium Cigars" and Priority Research. AIMS AND METHODS: A content analysis of magazine covers, articles, and advertisements published in 2021 from Cigar Aficionado and Cigar Snob (five issues each) and Cigar Journal (three issues) assessed magazine themes and mentions of lower harm. Magazine covers (n = 14), advertisements (n = 105), and every fifth article (n = 45) were coded. RESULTS: In total, 92% of the magazine covers, 72.4% of advertisements, and 62.2% of articles had premium cigar content. Celebrities (e.g. musicians and actors) appeared on 92.9% of covers. The most common themes in the advertisements and articles were "high quality." Regarding article content, 80% portrayed the premium cigars' quality (e.g. superior materials), and the taste of featured products (e.g. "tones," "aromas," and "notes") was portrayed in 42.4%. While no articles described their health risks, 6.7% described the positive health effects of premium cigar use (e.g. stress relief and clear cognition). Additionally, a digital search of Cigar Snob and Cigar Aficionado for terms related to lower harm (e.g. "organic," "healthy," "clean," "pure," and "natural") found 7.7 mentions of lower-harm words per issue. CONCLUSIONS: Our findings indicate that lifestyle magazines are an important marketing strategy that promotes and normalizes premium cigar use as a high-quality product that can have positive health effects for users. IMPLICATIONS: Our manuscript characterized the premium cigar companies' use of selling propositions, including promoting the products' features, safety, taste, and flavors, as a part of their advertising promotion practices. Premium cigar companies used digital and print lifestyle magazines as marketing tools to promote and normalize the use of their products by emphasizing their high quality and positive health benefits (e.g. reducing stress). Premium cigars were promoted as a symbol of power and success, featured in advertisements of upscale social events (e.g. exclusive trade shows, social clubs, and lounges), and often juxtaposed with expensive alcohol, food, and other luxurious goods. Future research should assess if exposure to premium cigar content increases consumer appeal and detracts from the products' potential adverse health outcomes.

3D Bioprinting for Vascularization.

In the world of clinic treatments, 3D-printed tissue constructs have emerged as a less invasive treatment method for various ailments. Printing processes, scaffold and scaffold free materials, cells used, and imaging for analysis are all factors that must be observed in order to develop successful 3D tissue constructs for clinical applications. However, current research in 3D bioprinting model development lacks diverse methods of successful vascularization as a result of issues with scaling, size, and variations in printing method. This study analyzes the methods of printing, bioinks used, and analysis techniques in 3D bioprinting for vascularization. These methods are discussed and evaluated to determine the most optimal strategies of 3D bioprinting for successful vascularization. Integrating stem and endothelial cells in prints, selecting the type of bioink according to its physical properties, and choosing a printing method according to physical properties of the desired printed tissue are steps that will aid in the successful development of a bioprinted tissue and its vascularization.

Recency measures matter: Variability in reported last use of tobacco and marijuana products among a nationally representative study of U.S. young adults.

INTRODUCTION: Current use of tobacco and marijuana products is largely defined as use within the past 30-days or more recently. These products are not used in the same manner, frequency, or context especially among young adults who are increasingly at risk for poly-product use. The purpose of this study was to examine patterns of most recent product use across select tobacco and marijuana products. MATERIALS AND METHODS: Data used in this study come from a cross-sectional survey conducted among a nationally representative sample of young adults ages 18-34 (n = 1,189) in the U.S. from October-November 2020. Respondents were asked about past product and most recent use of select tobacco/nicotine products (cigarettes, little filtered cigars and cigarillos, large cigars, e-cigarettes, hookah/water pipes) and marijuana products (blunts, e-cigarettes with marijuana, and other products with marijuana). RESULTS: A high proportion of young adults reported having used at least one tobacco (79.6%) or marijuana (68.6%) products. There is variability in the distribution of most recent use across different tobacco and marijuana users even within the past 3 to past 6 months where nearly one in five users of any product report last use. The average number of tobacco/nicotine products used as well as concurrent marijuana use were lowest when looking at those whose most recent use was within the past 30-days. As the measures of most recent use became more broad, the number of tobacco/nicotine products used increased as did the prevalence of concurrent marijuana use which extended through the past 6-months. CONCLUSION: Measures of current use may need to be expanded beyond the past 30-days to include through the past 6-months to better encapsulate usage patterns when considering poly-tobacco and marijuana co-use.

Surgical Outcomes, Trends, and Risk Factors of Distal Triceps Repairs.

BACKGROUND: Distal triceps ruptures are rare, and complete ruptures are commonly treated with surgery. Studies of patients in small cohorts with distal triceps tear have reported outcomes and risk factors; however, large-scale data are scant. This study seeks to determine current trends, outcomes, and risk factors of distal triceps tears. METHODS: Within a large insurance claims database, distal triceps repair patients were identified through Current Procedural Terminology coding with concomitant distal triceps International Classification of Diseases, 9th Revision/10th Revision diagnosis codes and 1-year active status before and after surgery. Demographics, total costs, 90-day complications, and revision rates within 1 year of index surgery were analyzed. Logistic regression was performed for revision and complication rates using sex, age, and comorbidities (anabolic steroid use, diabetes, ischemic heart disease, tobacco use, rheumatoid arthritis, and chronic kidney disease). RESULTS: A total of 8143 patients were included in the cohort. Male patients and patients aged 40 to 59 years comprised most of the study population. The postoperative complication rate was 5.8%, and the 1-year revision rate was 2.6%. Male sex, age >60 years, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease were statistically significant risk factors for higher 90-day complication rates. Anabolic steroid use significantly increased the risk of surgical revision. CONCLUSIONS: Distal triceps repairs in this large cohort study occur most frequently in men aged 40 to 59 years. Complications are generally low, with age >60 years, male sex, ischemic heart disease, rheumatoid arthritis, and chronic kidney disease as risk factors for 90-day complications and prior anabolic steroid use as a risk factor for 1-year revision surgery. This information can help to improve education and expectations of this procedure.

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds.

BACKGROUND: Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW. METHODS: This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed. RESULTS: Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99). CONCLUSION: While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level II.

Sleep in the intensive care unit.

PURPOSE OF REVIEW: Sleep is particularly important for critically ill patients. Here, we review the latest evidence on how sleep and circadian disruption in the intensive care unit (ICU) affects physiology and clinical outcomes, as well as the most recent advances in sleep and circadian rhythm promoting interventions including therapeutics. RECENT FINDINGS: On a molecular level, clock genes dysrhythmia and altered immunity are clearly linked, particularly in sepsis. Melatonin may also be associated with insulin sensitivity in ICU patients. Clinically, changes in sleep architecture are associated with delirium, and sleep-promoting interventions in the form of multifaceted care bundles may reduce its incidence. Regarding medications, one recent randomized controlled trial (RCT) on melatonin showed no difference in sleep quality or incidence of delirium. SUMMARY: Further investigation is needed to establish the clinical relevance of sleep and circadian disruption in the ICU. For interventions, standardized protocols of sleep promotion bundles require validation by larger multicenter trials. Administratively, such protocols should be individualized to both organizational and independent patient needs. Incorporating pharmacotherapy such as melatonin and nocturnal dexmedetomidine requires further evaluation in large RCTs.

Changes in Little Cigar and Cigarillo Use during the COVID-19 Pandemic: A Cross-Sectional Analysis of a Nationally Representative Sample of Young Adult Users.

We examined the smoking behaviors of U.S. young adults ages 18-36 regarding little cigars and cigarillos (LCCs) during the COVID-19 pandemic. Survey data were collected from a nationally representative sample of young adults between October and November 2020. Respondents who reported using LCCs with tobacco (CAI) and/or with marijuana (CAB) within the past 6 months prior to the survey (n = 399) were included in the study. Logistic regression analyses assessed the association between their perceived risk of having COVID when smoking LCCs and pandemic-related behavioral changes in CAI and CAB use (e.g., worrying, quit attempts, smoking more, smoking less). Findings showed that users with a higher perceived risk of getting COVID-19 when smoking LCCs were more likely to endorse trying to quit CAI and CAB during the pandemic. Compared to the non-Hispanic White population, the non-Hispanic Black population were less likely to endorse smoking less CAI and trying to quit CAB during the pandemic. Dual users of CAI and CAB and females were more likely to endorse smoking more CAB compared to CAB-only users and males, respectively. Tailored cessation strategies are needed for dual users, non-Hispanic Black young adults, and young women. Raising awareness about the risks of LCC use can be an effective strategy for LCC smoking cessation.

Combining Machine Learning, Patient-Reported Outcomes, and Value-Based Health Care: Protocol for Scoping Reviews.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are self-reporting tools that can measure important information about patients, such as health priorities, experience, and perception of outcome. The use of traditional objective measures such as vital signs and lab values can be supplemented with these self-reported patient measures to provide a more complete picture of a patient's health status. Machine learning, the use of computer algorithms that improve automatically through experience, is a powerful tool in health care that often does not use subjective information shared by patients. However, machine learning has largely been based on objective measures and has been developed without patient or public input. Algorithms often do not have access to critical information from patients and may be missing priorities and measures that matter to patients. Combining objective measures with patient-reported measures can improve the ability of machine learning algorithms to assess patients' health status and improve the delivery of health care. OBJECTIVE: The objective of this scoping review is to identify gaps and benefits in the way machine learning is integrated with patient-reported outcomes for the development of improved public and patient partnerships in research and health care. METHODS: We reviewed the following 3 questions to learn from existing literature about the reported gaps and best methods for combining machine learning and patient-reported outcomes: (1) How are the public engaged as involved partners in the development of artificial intelligence in medicine? (2) What examples of good practice can we identify for the integration of PROMs into machine learning algorithms? (3) How has value-based health care influenced the development of artificial intelligence in health care? We searched Ovid MEDLINE(R), Embase, PsycINFO, Science Citation Index, Cochrane Library, and Database of Abstracts of Reviews of Effects in addition to PROSPERO and the ClinicalTrials website. The authors will use Covidence to screen titles and abstracts and to conduct the review. We will include systematic reviews and overviews published in any language and may explore additional study types. Quantitative, qualitative, and mixed methods studies are included in the reviews. RESULTS: The search is completed, and Covidence software will be used to work collaboratively. We will report the review using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and Critical Appraisal Skills Programme for systematic reviews. CONCLUSIONS: Findings from our review will help us identify examples of good practice for how to involve the public in the development of machine learning systems as well as interventions and outcomes that have used PROMs and PREMs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36395.

Breastfeeding Patterns in Mothers with Inflammatory Bowel Disease: A Pilot Prospective Longitudinal Study.

BACKGROUND: Breastfeeding practices in patients with inflammatory bowel disease (IBD) remain unknown. We aimed to characterize these practices and describe factors that may lead to early discontinuation. METHODS: This was a pilot, prospective, longitudinal study enrolling mothers with IBD from 2014 to 2017. Patients completed surveys on breastfeeding at time of delivery and up to 12 months postpartum. Breastfeeding discontinuation rates were reported for all patients with IBD and compared between patients with ulcerative colitis and Crohn's disease. Reproductive knowledge was defined using the Crohn's and Colitis Pregnancy Knowledge score. The Mann-Whitney U test assessed for differences between continuous variables, whereas categorical variables were compared using the chi-square test. RESULTS: A total of 74 mothers with IBD were included, 47 with ulcerative colitis and 27 with Crohn's disease. Breastfeeding rates in mothers with IBD was 94.6% at delivery, 73.9% at 3 months postpartum, 55.2% at 6 months postpartum, and 30.1% at 12 months postpartum. The most common reasons for discontinuing breastfeeding before 6 months postpartum included perceived insufficient milk production and concerns of infant medication exposure through breast milk. Compared with those who continued breastfeeding beyond 6 months postpartum, those who discontinued had lower median Crohn's and Colitis Pregnancy Knowledge scores (14.0 vs 9.0; P = .04). CONCLUSIONS: Though most mothers with IBD initiate breastfeeding at time of delivery, about half continue beyond 6 months postpartum. Common reasons for this include perceived insufficient milk production and medication concerns. Larger studies are required to validate our findings in more generalizable settings such as primary and secondary care.

Early hypermetabolism is uncommon in trauma intensive care unit patients.

BACKGROUND: Classic experiments demonstrating hypermetabolism after major trauma were performed in a different era of critical care. We aim to describe the modern posttraumatic metabolic response in the trauma intensive care unit (TICU). METHODS: This prospective observational study enrolled TICU mechanically ventilated adults (aged ≥18) from 3/2018-2/2019. Multiple, daily resting energy expenditure (REE) measurements were recorded. Basal energy expenditure (BEE) was calculated by the Harris-Benedict equation. Hypometabolism was defined as average daily REE < 0.85*BEE and hypermetabolism defined as average daily REE > 1.15*BEE. Demographics, interventions, and clinical outcomes were abstracted. Descriptive statistics and multivariable logistical regression models evaluating demographics with the outcome variable of hypermetabolism for the first 3 days ("sustained hypermetabolism") were performed, along with group-based trajectory modeling (GBTM). RESULTS: Fifty-five patients were analyzed: median age was 38 (28-56) years; 38 (69%) were male; body mass index (kg/m2 ) was 28 (26-32); and Injury Severity Score was 27 (19-34), with (38 [71%] blunt, 8 [15%] penetrating, 7 [13%] burn) injury mechanism. Overall, 19 (35%) had hypermetabolism on day 1 ("immediate hypermetabolism"), and 11 (21%) had sustained hypermetabolism for the first 3 days. Logistic regression analysis identified penetrating mechanism (adjusted odds ratio [AOR], 16.4; 95% CI, 1.9-199.6; p = .015), burn mechanism (AOR, 11.1; 95% CI, 1.3-116.8; p =.029), and maximum temperature (AOR, 4.2; 95% CI, 1.3-20.3; p= .041) as independent predictors of sustained hypermetabolism. GBTM identified 4 nutrition phenotypes, with 2 hyperconsumptive phenotypes associated with increased risk of malnutrition at discharge. CONCLUSION: Only a minority of injured patients is hypermetabolic in the first week after injury. Elevated temperature, penetrating mechanism, and burn mechanism are independently associated with sustained hypermetabolism. Hyperconsumptive phenotype patients are more likely to develop malnutrition during hospitalization.

A Systematic Review and Meta-Analysis of Ligation Versus Repair of Inferior Vena Cava Injuries.

OBJECTIVE: Inferior vena cava (IVC) injuries have a high mortality rate that may be related to the location of injury and type of repair. Previous studies have been either single center series or database studies lacking granular detail. These have reported conflicting results. We aimed to perform a systematic review and meta-analysis of published literature evaluating ligation versus repair. METHODS: Studies published in English on MEDLINE or EMBASE from 1946 through October 2018 were examined to evaluate mortality among patients treated with ligation versus repair of IVC injuries. Studies were included if they provided mortality associated with ligation versus repair and reported IVC injury by level. Risk of bias was assessed regarding incomplete and selective outcome reporting with Newcastle-Ottawa score of 7 or higher to evaluate study quality. We used a random-effects model with restricted maximum likelihood estimation method in R using the Metafor package to evaluate outcomes. RESULTS: Our systematic review identified 26 studies, of which 14 studies, including 855 patients, met our inclusion criteria for meta-analysis. IVC ligation was associated with higher mortality than IVC repair (OR: 3.12, P < 0.01, I2 = 49%). Ligation of infrarenal IVC injuries was not statistically associated with mortality (OR: 3.13, P = 0.09). Suprarenal injury location compared to infrarenal (OR 3.11, P < 0.01, I2 = 28%) and blunt mechanism compared to penetrating (OR: 1.91, P = 0.02, I2 = 0%) were also associated with higher mortality. CONCLUSIONS: In this meta-analysis, ligation of IVC injuries was associated with increased mortality compared to repair, but not specifically for infrarenal IVC injuries. Suprarenal IVC injury, and blunt mechanism was associated with increased mortality compared to infrarenal IVC injury and penetrating mechanism, respectively. Data are limited regarding acute renal injury and venous thromboembolic events after IVC ligation and may warrant multicenter studies. Standardized reporting of IVC injury data has not been well established and is needed in order to enable comparison of outcomes across institutions. In particular, reporting of injury location, severity, and repair type should be standardized. A contemporary prospective, multicenter study is needed in order to definitively compare surgical technique.

Rapid Diagnosis of Altered Mental Status in Home Parenteral Nutrition Patient.

This report describes the application of a routine lab test to confirm a diagnosis of hypernatremia suspected to be secondary to an error in parenteral nutrition compounding. The novel aspect of this case is the use of the "urine electrolytes" laboratory test to verify that the electrolyte concentration of the mixture is consistent with what was printed on the bag label.

Fecal Calprotectin May Predict Adverse Pregnancy-Related Outcomes in Patients with Inflammatory Bowel Disease.

BACKGROUND: The role of fecal calprotectin in predicting pregnancy-related outcomes in inflammatory bowel disease (IBD) remains unknown. AIM: To determine whether increased fecal calprotectin during pregnancy is associated with adverse pregnancy outcomes in IBD. METHODS: This is a multicenter cohort study of women with IBD who underwent fecal calprotectin monitoring during pregnancy. Fecal calprotectin levels were stratified by trimester, and adverse pregnancy-related outcomes were recorded. The Mann-Whitney U test assessed differences between continuous variables, whereas categorical variables were compared using the Chi-squared test. RESULTS: Eighty-five women with IBD were included. First trimester fecal calprotectin was higher in patients who underwent emergency Cesarean birth compared to those who had a vaginal delivery (503 ug/g, IQR 1554.3 ug/g vs. 130 ug/g, IQR 482 ug/g, p = .030, respectively) and in those who delivered infants with low birth weight compared to normal birth weight (1511 ug/g, IQR 579 ug/g vs. 168 ug/g, IQR 413 ug/g, p = .049, respectively). Third trimester fecal calprotectin was higher in those with non-elective induction of labor (334.5 ug/g, IQR 1411.0 ug/g) compared to those with spontaneous delivery (116.5 ug/g, IQR 227.1 ug/g) (p = .025). Those with a fecal calprotectin ≥ 250 ug/g in the second trimester had an increased incidence of infants with low birth weight (35.3% vs. 3.8%) (p = .049), whereas those with a fecal calprotectin ≥ 250 ug/g in the third trimester had an increased incidence of non-elective induction of labor (43.8% vs. 10.3%, p = .030). CONCLUSIONS: Fecal calprotectin may be a useful noninvasive marker to predict adverse pregnancy-related outcomes in patients with IBD.

Ibuprofen Increases the Hepatotoxicity of Ethanol through Potentiating Oxidative Stress.

Over 30 million prescriptions of NSAIDs (non-steroidal anti-inflammatory drugs) are issued every year. Considering that these drugs are available without a prescription as over the counter (OTC) drugs, their use will be astronomical. With the increasing use of NSAIDs, their adverse effects are drawing attention. Especially, stomach bleeding, kidney toxicity, liver toxicity, and neurological toxicity are reported as common. Ibuprofen, one of the extensively used NSAIDs along with aspirin, can also induce liver toxicity, but few studies are addressing this point. Here we examined the liver toxicity of ibuprofen and investigated whether co-exposure to ethanol can manifest synergistic effects. We employed 2D and 3D cultured human hepatoma cells, HepG2 to examine the synergistic hepatotoxicity of ibuprofen and alcohol concerning cell viability, morphology, and histology of 3D spheroids. As a result, ibuprofen and alcohol provoked synergistic hepatotoxicity against hepatocytes, and their toxicity increased prominently in 3D culture upon extended exposure. Oxidative stress appeared to be the mechanisms underlying the synergistic toxicity of ibuprofen and alcohol as evidenced by increased production of ROS and expression of the endogenous antioxidant system. Collectively, this study has demonstrated that ibuprofen and EtOH can induce synergistic hepatotoxicity, providing a line of evidence for caution against the use of ibuprofen in combination with alcohol.

Vitamin C and thiamine are associated with lower mortality in sepsis.

BACKGROUND: The efficacy of vitamin C (VitC) and thiamine (THMN) in patients admitted to the intensive care unit (ICU) with sepsis is unclear. The purpose of this study was to evaluate the effect of VitC and THMN on mortality and lactate clearance in ICU patients. We hypothesized that survival and lactate clearance would be improved when treated with thiamine and/or VitC. METHODS: The Philips eICU database version 2.0 was queried for patients admitted to the ICU in 2014 to 2015 for 48 hours or longer and patients with sepsis and an elevated lactate of 2.0 mmol/L or greater. Subjects were categorized according to the receipt of VitC, THMN, both, or neither. The primary outcome was in-hospital mortality. Secondary outcome was lactate clearance defined as lactate less than 2.0 mmol/L achieved after maximum lactate. Univariable comparisons included age, sex, race, Acute Physiology Score III, Acute Physiology and Chronic Health Evaluation (APACHE) IVa score, Sequential Organ Failure Assessment, surgical ICU admission status, intubation status, hospital region, liver disease, vasopressors, steroids, VitC and THMN orders. Kaplan-Meier curves, logistic regression, propensity score matching, and competing risks modeling were constructed. RESULTS: Of 146,687 patients from 186 hospitals, 7.7% (n = 11,330) were included. Overall mortality was 25.9% (n = 2,930). Evidence in favor of an association between VitC and/or THMN administration, and survival was found on log rank test (all p < 0.001). After controlling for confounding factors, VitC (adjusted odds ratio [AOR], 0.69 [0.50-0.95]) and THMN (AOR, 0.71 [0.55-0.93]) were independently associated with survival and THMN was associated with lactate clearance (AOR, 1.50 [1.22-1.96]). On competing risk model VitC (AOR, 0.675 [0.463-0.983]), THMN (AOR, 0.744 [0.569-0.974]), and VitC+THMN (AOR, 0.335 [0.13-0.865]) were associated with survival but not lactate clearance. For subgroup analysis of patients on vasopressors, VitC+THMN were associated with lactate clearance (AOR, 1.85 [1.05-3.24]) and survival (AOR, 0.223 [0.0678-0.735]). CONCLUSION: VitC+THMN is associated with increased survival in septic ICU patients. Randomized, multicenter trials are needed to better understand their effects on outcomes. LEVEL OF EVIDENCE: Therapeutic Study, Level IV.

Nationwide Outcomes and Risk Factors for Reinjury After Penetrating Trauma.

BACKGROUND: Previous studies have shown that a notable portion of patients who are readmitted for reinjury after penetrating trauma present to a different hospital. The purpose of this study was to identify the risk factors for reinjury after penetrating trauma including reinjury admissions to different hospitals. METHODS: The 2010-2014 Nationwide Readmissions Database was queried for patients surviving penetrating trauma. E-codes identified patients subsequently admitted with a new diagnosis of blunt or penetrating trauma. Univariable analysis was performed using 44 injury, patient, and hospital characteristics. Multivariable logistic regression using significant variables identified risk factors for the outcomes of reinjury, different hospital readmission, and in-hospital mortality after reinjury. RESULTS: There were 443,113 patients identified. The reinjury rate was 3.5%. Patients presented to a different hospital in 30.0% of reinjuries. Self-inflicted injuries had a higher risk of reinjury (odds ratio [OR]: 2.66, P < 0.05). Readmission to a different hospital increased risk of mortality (OR: 1.62, P < 0.05). Firearm injury on index admission increased risk of mortality after reinjury (OR: 1.94, P < 0.05). CONCLUSIONS: This study represents the first national finding that one in three patients present to a different hospital for reinjury after penetrating trauma and have a higher risk of mortality due to this fragmentation of care. These findings have implications for quality and cost improvements by identifying areas to improve continuity of care and the implementation of penetrating injury prevention programs.