Total synthesis of (+)-pilosinine via a stereodivergent conjugate addition strategy.

In recent work, asymmetric conjugate addition reactions to chiral 4-phenyl-N-enoyl-1,3-oxazolidinones have been shown to give different stereochemical outcomes depending on the conditions employed. Through the application of stereodivergent reaction conditions, the total synthesis of (+)-pilosinine and the formal synthesis of (-)-pilosinine has been completed from a single enantiomer of the 1,3-oxazolidi-none auxiliary.

Conscious sedation versus rapid sequence intubation for the reduction of native traumatic hip dislocation.

BACKGROUND: Traumatic hip dislocations (THD) are a medical emergency. There is debate whether the painful reduction of a dislocated hip should be first attempted using primary conscious sedation (PCS) or primary general anesthesia (PGA) METHODS: All cases of native THD from 2006 to 2015 in the trauma registry of a level 1 trauma center were reviewed. The primary outcome was successful reduction of the THD. RESULTS: 67 patients had a native, meaning not a hip prosthesis, THD. 34 (50.7%) patients had successful PCS, 12 (17.9%) failed PCS and underwent reduction following PGA. 21 (31.3%) underwent PGA. Patients in the PGA group were more severely injured. Time to reduction greater than 6 h was associated with PCS failure (Odds ratio (95% confidence interval) 19.75 (2.06,189.10) p = 0.01). CONCLUSION: Clinicians treating patients with a THD can utilize either PCS or PGA with many patients safely reduced under PCS. However, patients whose hip have been dislocated for more than 6 h are at risk for failure with PCS, and are good candidates for PGA.

Major Barbara Stimson: A Historical Perspective on the American Board of Surgery Through the Accomplishments of the First Woman to Achieve Board Certification.

: Dr. Barbara Bartlett Stimson, AB, MD, MedScD, FACS (1898-1986) was a pioneering orthopedic surgeon from a prominent American family who, in 1940, became the first woman certified by the American Board of Surgery (ABS, certificate number 860). It would be another 7 years and approximately 2500 candidates before the next female surgeon would be certified. A member of the third class to admit women to Columbia Medical School and the second female surgical resident to complete training at Columbia-Presbyterian Medical Center, Dr. Stimson was a confident and exceptionally accomplished trailblazer for women in surgery. In this biographical sketch based upon documents from the ABS, and the archives of Vassar College and the College of Physicians and Surgeons at Columbia-Presbyterian Medical Center, Dr. Stimson's motivations, attitudes, and unique accomplishments emerge as testimony to the exceptional career of this driven, self-possessed woman. Stimson was undaunted by the sex-based conventions of her time, and achieved a notable career as a surgeon in the profession she loved; first honing her skills at a busy urban fracture service in New York, then serving with distinction in the Royal Army Medical Corps during World War II, and finally returning to the states to become a respected leader in her field. Her life story and unprecedented ABS certification affirm her conviction that proven skill and ability can be used as a means of overcoming unfounded biases, and helped pave the way for future generations of board certified female surgeons in the United States.

Optimizing physician skill development for medical students: The four-part assessment.

BACKGROUND: Medical student performance has been poorly correlated with residency performance and warrants further investigation. We propose a novel surgical assessment tool to determine correlations with clinical aptitude. METHODS: Retrospective review of medical student assessments from 2013 to 2015. Faculty rating of student performance was evaluated by: 1) case presentation, 2) problem definition, 3) question response and 4) use of literature and correlated to final exam assessment. A Likert scale interrater reliability was evaluated. RESULTS: Sixty student presentations were scored (4.8 assessors/presentation). A student's case presentation, problem definition, and question response was correlated with performance (r = 0.49 to 0.61, p ≤ 0.003). Moderate correlations for either question response or use of literature was demonstrated (0.3 and 0.26, p < 0.05). CONCLUSION: Our four-part assessment tool identified correlations with course and examination grades for medical students. As surgical education evolves, validated performance and reliable testing measures are required.

Bicarbonate and mannitol treatment for traumatic rhabdomyolysis revisited.

BACKGROUND: A rhabdomyolysis protocol (RP) with mannitol and bicarbonate to prevent acute renal dysfunction (ARD, creatinine >2.0 mg/dL) remains controversial. METHODS: Patients with creatine kinase (CK) greater than 2,000 U/L over a 10-year period were identified. Shock, Injury Severity Score, massive transfusion, intravenous contrast exposure, and RP use were evaluated. RP was initiated for a CK greater than 10,000 U/L (first half of the study) or greater than 20,000 U/L (second half). Multivariable analyses were used to identify predictors of ARD and the independent effect of the RP. RESULTS: Seventy-seven patients were identified, 24 (31%) developed ARD, and 4 (5%) required hemodialysis. After controlling for other risk factors, peak CK greater than 10,000 U/L (odds ratio 8.6, P = .016) and failure to implement RP (odds ratio 5.7, P = .030) were independent predictors of ARD. Among patients with CK greater than 10,000, ARD developed in 26% of patients with the RP versus 70% without it (P = .008). CONCLUSION: Reduced ARD was noted with RP. A prospective controlled study is still warranted.

Is futile care in the injured elderly an important target for cost savings?

BACKGROUND: This study proposes a definition of futile care and quantifies its cost in injured elders. METHODS: This was a retrospective study of Medicare patients with an International Classification of Diseases-9 injury diagnosis admitted to 171 Oregon and Washington facilities from January 1, 2001, through December 31, 2002, who died within 6 months of admission. Futile care was defined as death within 7 days of discharge from a hospitalization of at least 14 days. We compared health care costs in the last 6 months of life with those who did and did not meet our definition of futility. To simulate predicting and preventing futility early in the hospital course, we examined the effect of reducing spending on the futile care cohort to the level of those who survived 7 to 10 days after injury. RESULTS: There were 6,832 elders who died within 6 months of injury, of whom 230 (3.4%) met our definition of futility. The median cost of care in the last 6 months of life was $33,373 for those not meeting our definition of futility and $87,391 for the futile care group (p < 0.001). The 3.4% receiving futile care incurred 8.9% of total costs. Reducing expenditures in the futile care group to the level of those who died from 7 to 10 days after injury (median, $25,633) would result in an overall cost savings of 6.5%. CONCLUSION: End-of-life health care costs were significantly higher for those who received futile care. However, even aggressive reductions in futile care would result in small savings overall. LEVEL OF EVIDENCE: Economic analysis, level III.

Using hospital outcomes to predict 30-day mortality among injured patients insured by Medicare.

HYPOTHESIS: Survival until a fixed time after injury is a more useful outcome variable than survival until hospital discharge. DESIGN: We sought to determine whether 30-day survival could be accurately predicted by hospital discharge status. SETTING: Academic research. PATIENTS: We analyzed Medicare fee-for-service records for patients 65 years or older admitted with a principal diagnosis of injury (International Classification of Diseases, Ninth Revision, Clinical Modification codes 800-959, excluding 905-909, 930-939, and 958). MAIN OUTCOME MEASURES: Patients were classified by maximum Abbreviated Injury Score (range, 1-5) and Charlson comorbidity score (0, 1, 2, or ≥ 3). We modeled the conditional probability of survival at 30 days given hospitalization survival (P[S30SH]) as a function of census region, age, sex, maximum Abbreviated Injury Score, Charlson comorbidity score, length of stay, and discharge home or not. RESULTS: A total of 436 104 patients met inclusion criteria, and a model was created using half the sample. For northeastern women aged 65 to 69 years with a maximum Abbreviated Injury Score of less than 3, Charlson comorbidity score of 0, and discharge home with length of stay less than 3 days, the model predicted P (S30SH) to be 0.998. The P (S30SH) was lower for other census regions, male sex, older age, more severe injury, and greater comorbidity. The equation had modest predictive ability when applied to individuals in the other half of the sample (area under the receiver operating characteristic curve, 0.75) and closely predicted P (S30SH) within numerous subpopulations. CONCLUSION: For injured patients insured by Medicare, P (S30SH) can be estimated using administrative data known at the time of hospital discharge.

The optimum follow-up period for assessing mortality outcomes in injured older adults.

OBJECTIVES: To compare mortality rates of hospitalized injured aged 67 and older across commonly used follow-up periods (e.g., in-hospital, 30-day, 1-year) and to determine the postinjury time after which mortality rates stabilize. DESIGN: Retrospective analysis of Medicare claims. SETTING: Oregon and Washington Medicare patients. PARTICIPANTS: Patients admitted to 171 Oregon and Washington facilities during 2001/02 with injuries identified according to International Classification of Diseases, Ninth Revision, code and followed for 1 year. MEASUREMENTS: The primary outcome was in-hospital mortality and mortality at 30, 60, 90, 180, and 365 days. Kaplan-Meier survival curves and daily postadmission mortality rates were also evaluated. The rate of change (slope) of the survival curves and daily mortality rates were analyzed to select the point after which mortality rates were no longer decreasing. RESULTS: There were 32,135 injured older adults hospitalized over the 2-year period, with a median age of 82 (interquartile range 77-88). Cumulative in-hospital mortality and at 30, 60, 90, 180, and 365 days was 4.1%, 9.7%, 13.6%, 16.1%, 21.3%, and 28.4%, respectively. Mortality rates stabilized by 6 months after injury, with 89% of the change occurring within 60 days. Although serious injuries, medical comorbidities, and preinjury nursing facility residence were all associated with higher mortality, they did not affect the pattern of mortality after injury. CONCLUSION: In-hospital mortality is much lower than postdischarge mortality in injured older adults, with a substantial portion of persons dying shortly after discharge from the hospital. Mortality appears to stabilize by 6 months after injury, although 60-day postadmission follow-up captures most of the excess daily mortality rate.

A population-based survival assessment of categorizing level III and IV rural hospitals as trauma centers.

CONTEXT: Patients injured in rural areas are hypothesized to have improved outcomes if statewide trauma systems categorize rural hospitals as Level III and IV trauma centers, though evidence to support this belief is sparse. PURPOSE: To determine if there is improved survival among injured patients hospitalized in states that categorize rural hospitals as trauma centers. METHODS: We analyzed a retrospective cohort of injured patients included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 1997 to 1999. We used generalized estimating equations to compare survival among injured patients hospitalized in states that categorize rural hospitals as Level III and IV trauma centers versus those that do not. Multivariable models adjusted for important confounders, including patient demographics, co-morbid conditions, injury severity, and hospital-level factors. FINDINGS: There were 257,044 admitted patients from 7 states with a primary injury diagnosis, of whom 64,190 (25%) had a "serious" index injury, 32,763 (13%) were seriously injured (by ICD-9 codes), and 12,435 (5%) were very seriously injured (by ICD-9 codes). There was no survival benefit associated with rural hospital categorization among all patients with a primary injury diagnosis or for those with specific index injuries. However, seriously injured patients (by ICD-9 codes) had improved survival when hospitalized in a categorizing state (OR for mortality 0.72, 95% confidence interval [CI] 0.53-0.97; OR for very seriously injured 0.68, 95% CI 0.52-0.90). CONCLUSIONS: There was no survival benefit to categorizing rural hospitals among a broad, heterogeneous group of hospitalized patients with a primary injury diagnosis; however the most seriously injured patients did have increased survival in such states.

Long-term morbidity, pain, and disability after repair of severe chest wall injuries.

Long-term morbidity after severe chest wall injuries is common. We report our experience with acute chest wall injury repair, focusing on long-term outcomes and comparing our patients' health status with the general population. We performed a retrospective medical record review supplemented with a postal survey of long-term outcomes including the McGill Pain Questionnaire (MPQ) and RAND-36 Health Survey. RAND-36 outcomes were compared with reference values from the Medical Outcomes Study and from the general population. Forty-six patients underwent acute chest wall repair between September 1996 and September 2005. Indications included flail chest with failure to wean from the ventilator (18 patients), acute, intractable pain associated with severely displaced rib fractures (15 patients), acute chest wall defect/deformity (5 patients), acute pulmonary herniation (3 patients), and thoracotomy for other traumatic indications (5 patients). Three patients had a concomitant sternal fracture repair. Fifteen patients with a current mean age of 60.6 years (range 30-91) responded to our surveys a mean of 48.5 +/- 22.3 months (range 19-96) postinjury. Mean long-term MPQ Pain Rating Index was 6.7 +/- 2.1. RAND-36 indices indicated equivalent or better health status compared with references with the exception of role limitations due to physical problems when compared with the general population. The operative repair of severe chest wall injuries is associated with low long-term morbidity and pain, as well as health status nearly equivalent to the general population. Both the MPQ and the RAND-36 surveys were useful tools for determining chest wall pain and disability outcomes.

Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair.

INTRODUCTION: Rib and sternal fracture repair are controversial. The opinion of surgeons regarding those patients who would benefit from repair is unknown. METHODS: Members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons (THS) affiliated with teaching hospitals in the United States were recruited to complete an electronic survey regarding rib and sternal fracture repair. RESULTS: Two hundred thirty-eight trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS), and 70 THS completed the survey. Eighty-two percent of TRS, 66% of OTS, and 71% of THS thought that rib fracture repair was indicated in selected patients. A greater proportion of surgeons thought that sternal fracture repair was indicated in selected patients (89% of TRS, 85% of OTS, and 95% of THS). Chest wall defect/pulmonary hernia (58%) and sternal fracture nonunion (>6 weeks) (68%) were the only two indications accepted by a majority of respondents. Twenty-six percent of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22% of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Of surgeons who thought rib fracture or sternal fracture repair was rarely, if ever, indicated, 91% and 95%, respectively, specified that a randomized trial confirming efficacy would be necessary to change their negative opinion. CONCLUSIONS: A majority of surveyed surgeons reported that rib and sternal fracture repair is indicated in selected patients; however, a much smaller proportion indicated that they had performed the procedures. The published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.

Early neurosurgical procedures enhance survival in blunt head injury: propensity score analysis.

BACKGROUND: Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions. OBJECTIVE: We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury. METHODS: We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >or= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure. RESULTS: The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48). CONCLUSIONS: Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted.

Establishing the need for trauma center care: anatomic injury or resource use?

OBJECTIVE: It remains unclear whether the "need" for care at a trauma center should be based on anatomic injury (the current standard) or specialized resource use. We investigated whether anatomic injury severity scores adequately explain hospital resource use. METHODS: This was a retrospective cohort study including children and adults meeting statewide trauma criteria and transported to 48 hospitals from 1998 to 2003. The injury severity score (ISS) was considered as both continuous (range 0-75) and categorical (0-8, 9-15, and >or= 16) terms. Specialized resource use was defined as: major surgery (with and without orthopedic intervention), mechanical ventilation > 96 hours, blood transfusion, intensive care unit (ICU) stay >or= 2 days, or in-hospital mortality. Resource use was assessed as both a binary variable and a continuous term. Descriptive statistics and simple and multivariable linear regressions were used to compare ISS and resource use. RESULTS: 33,699 injured persons were included in the analysis. Within mild, moderate, and serious anatomic injury categories, 8%, 26%, and 69%, respectively, had specialized resource use. When the resource use definition included orthopedic surgery, 12%, 49%, and 76%, respectively, had specialized resource use. Whereas there was fair correlation between ISS and additive resource use (rho = 0.61), ISS explained only 37% of the variability in resource use (adjusted R-squared = 0.37). Resource use within anatomic injury categories differed by age group. CONCLUSIONS: The standard anatomic injury criterion for trauma center "need" (i.e., ISS >or= 16) misclassifies a substantial number of injured persons requiring critical trauma resources. Out-of-hospital trauma triage guidelines based on anatomic injury may need revision to account for patients with resource need.

Regional variation in hospital mortality and 30-day mortality for injured Medicare patients.

BACKGROUND: We sought to evaluate how survival of older patients with injuries differs by geographic region within the United States. METHODS: We analyzed Medicare fee-for-service records for patients aged 65 years and older with principal injury diagnoses (ICD-9 800-959, excluding 905, 930-939, 958). Cases were classified by Maximum Abbreviated Injury Score (AISmax) and Charlson Comorbidity score (0, 1, 2, >or=3). Hospital mortality and 30-day mortality were modeled as functions of age, sex, AISmax, comorbidity, and geographic region (northeast, midwest, south, west). RESULTS: Hospital and 30-day mortality were both higher with male sex and increased age, AISmax, or Charlson score. Adjusted hospital mortality was highest in the northeast and south, but 30-day adjusted mortality was lowest in the same two regions. CONCLUSIONS: Regional differences in risk-adjusted hospital survival for older patients with injuries are different from regional differences in 30-day survival. Hospital mortality as an outcome for older injured patients should be interpreted cautiously.

Proportion of seriously injured patients admitted to hospitals in the US with a high annual injured patient volume: a metric of regionalized trauma care.

BACKGROUND: Multiple regional trauma systems have been implemented over the past 3 decades to achieve the goal of regionalized care for injured patients. The American College of Surgeons Committee on Trauma (ACS-COT) advocates that seriously injured patients should be treated in designated Level I trauma centers that meet criteria including admitting more than 1,200 injured patients annually. Reliable measures are needed to evaluate the implementation of regionalized care nationally. The goal of this study was to measure the proportion of seriously injured patients treated at high injury-volume hospitals. STUDY DESIGN: We performed a retrospective observational study of injured patients hospitalized in the US during the years 1995 to 2003, drawn from the Nationwide Inpatient Sample. Hospitals were ranked in order of annual volume of injured patient admissions. A patient's severity of injury was calculated using ICD-9-based Injury Severity Score (ICISS). The principal measure was the proportion of seriously injured patients (ICISS

Racial disparities in mortality among adults hospitalized after injury.

BACKGROUND: Injury is a major cause of death in adults. Although racial disparities in healthcare access and health outcomes are well documented for medical conditions, the influence of race on access to emergent care after injury has received little scrutiny. OBJECTIVES: We sought to determine whether race was associated with risk of in-hospital death after injury. RESEARCH DESIGN: Data from the Healthcare Cost and Utilization Project (1998-2002) were used to estimate multivariate models of in-hospital mortality, controlling for age, race, gender, comorbid conditions, injury severity, primary payer, median income of zip code of residence, and hospital type. Additional multivariate models were estimated among stratified subsets of patients, including injury severity and hospital type. SUBJECTS: Patients age 18-64 with a primary diagnosis of injury. RESULTS: Relative to injured white patients, black and Asian patients had a higher risk of death [1.5% vs. 2.1% and 2.0%, multivariate odds ratios (OR) = 1.14 and 1.39]. Other racial/ethnic groups showed no significant mortality difference from white patients. In stratified analyses, we found large black-white mortality disparities among mild to moderately injured patients (OR = 1.40, 95% confidence interval: 1.18-1.66), whereas Asian-white disparities were concentrated among more severely injured patients (OR = 1.37, 95% confidence interval: 1.03-1.80). CONCLUSIONS: Black and Asian patients have a higher risk of death after injury than white patients. These data raise important questions about access to quality trauma care for racial minority patients.

The benefit of higher level of care transfer of injured patients from nontertiary hospital emergency departments.

BACKGROUND: Although injured persons presenting to nontertiary hospitals are routinely transferred for further care, it is unknown whether there is an outcome benefit associated with this practice. We sought to assess whether the transfer of injured patients from nontertiary hospital emergency departments (EDs) is associated with improved survival. METHODS: This was a retrospective cohort analysis of all consecutive injured children and adults meeting state trauma criteria, presenting to 1 of 42 nontertiary hospital EDs (primarily rural) and requiring either admission or transfer (n = 10,176) from January 1998 through December 2003. Higher level of care transfer was defined as interhospital transfer from the ED to one of six Level I or II trauma centers. Propensity scores were used to adjust for the known nonrandom selection of patients for higher level of care transfer. The outcome measure was inhospital mortality. RESULTS: There were 10,176 trauma patients who presented to nontertiary hospital EDs and were included in the analysis, of which 3,785 (37%) were transferred to a tertiary hospital from the ED. Transfer patients had higher unadjusted mortality (odds ratio [OR] 2.83, 95% confidence interval [CI] 2.06-3.89). After adjusting for the propensity to be transferred, transfer from the ED to a tertiary hospital was associated with a reduction in mortality (OR 0.67, 95% CI 0.48-0.94), which was strongest among patients transferred to Level I hospitals (OR 0.62, 95% CI 0.40-0.95). There was no measurable benefit for patients transferred to Level II hospitals (OR 0.82, 95% CI 0.47-1.43). CONCLUSIONS: After adjusting for injury severity and the nonrandom selection of patients for transfer, trauma patients transferred from nontertiary EDs to major trauma centers had lower inhospital mortality than patients remaining in nontrauma hospitals. Recognition and early transfer of at-risk rural trauma patients may improve survival in a regionalized trauma system.