A novel preoperative score to predict severe acute cholecystitis.

BACKGROUND: In a large multicenter trial, The Parkland Grading Scale(PGS) for acute cholecystitis outperformed other grading scales and has a positive correlation with complications but is limited in its inability to preoperatively predict high-grade cholecystitis. We sought to identify preoperative variables predictive of high-grade cholecystitis(PGS 4 or 5). METHODS: In a six-month period, patients undergoing cholecystectomy at a single institution with prospectively graded PGS were analyzed. Stepwise logistic regression models were constructed to predict high-grade cholecystitis. The relative weight of the variables was used to derive a novel score, the Severe Acute Cholecystitis Score(SACS). This score was compared to the Emergency Surgery Acuity Score(ESS), American Association for the Surgery of Trauma(AAST) preoperative score and Tokyo Guidelines(TG) for their ability to predict high-grade cholecystitis. SACS was then validated using the database from the AAST multicenter validation of the grading scale for acute cholecystitis. RESULTS: Of the 575 patients that underwent cholecystectomy, 172(29.9%) were classified as high-grade. The stepwise logistic regression modeling identified 7 independent predictors of high-grade cholecystitis. From these variable the SACS was derived. Scores ranged from 0 to 9 points with a C statistic of 0.76, outperforming the ESS(C statistic of 0.60), AAST(0.53), and TG(0.70)(p-value <0.001). Using a cutoff of 4 or more on the SACS correctly identifies 76.2% of cases with a specificity of 91.3% and a sensitivity of 40.7%.In the multicenter database, there were 464 patients with a prospectively collected PGS. The C statistic for SACS was 0.74. Using the same cutoff of 4, SACS correctly identifies 71.6% of cases with a specificity of 83.8% and a sensitivity of 52.2%. CONCLUSIONS: The Severe Acute Cholecystitis Score can preoperatively predict high-grade cholecystitis and may be useful for counseling patients and assisting in surgical decision making. LEVEL OF EVIDENCE: Prognostic Level III.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures.

BACKGROUND: Despite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. METHODS: We performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. RESULTS: Among our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. CONCLUSION: Severe intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

Traumatic lower extremity amputation as a risk factor for venous thromboembolism.

BACKGROUND: This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism. METHODS: All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT). RESULTS: A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p â€‹< â€‹0.001) and DVT (6.5% vs. 3.4%, p â€‹< â€‹0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p â€‹= â€‹0.015) and DVT (4.7% vs. 2.6%, p â€‹< â€‹0.001). CONCLUSIONS: In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

Patients Lost to Follow-up After Injury: Who are They and What are Their Long-Term Outcomes?

INTRODUCTION: Trauma patients are at high risk for loss to follow-up (LTFU) after hospital discharge. We sought to identify risk factors for LTFU and investigate associations between LTFU and long-term health outcomes in the trauma population. METHODS: Trauma patients with an Injury Severity Score ≥9 admitted to one of three Level-I trauma centers, 2015-2020, were surveyed via telephone 6 mo after injury. Univariate and multivariate analyses were performed to assess factors associated with LTFU and several long-term outcomes. RESULTS: Of 3609 patients analyzed, 808 (22.4%) were LTFU. Patients LTFU were more likely to be male (71% versus 61%, P = 0.001), Black (22% versus 14%, P = 0.003), have high school or lower education (50% versus 42%, P = 0.003), be publicly insured (23% versus 13%, P < 0.001), have a penetrating injury (13% versus 8%, P = 0.006), have a shorter length of stay (3.64 d ± 4.09 versus 5.06 ± 5.99, P < 0.001), and be discharged home without assistance (79% versus 50%, P < 0.001). In multivariate analyses, patients who followed up were more likely to require assistance at home (6% versus 11%; odds ratio [OR] 2.23, 1.26-3.92, P = 0.005), have new functional limitations (11% versus 26%; OR 2.91, 1.97-4.31, P = < 0.001), have daily pain (30% versus 48%; OR 2.11, 1.54-2.88, P = < 0.001), and have more injury-related emergency department visits (7% versus 10%; OR 1.93, 1.15-3.22, P = 0.012). CONCLUSIONS: Vulnerable populations are more likely to be LTFU after injury. Clinicians should be aware of potential racial and socioeconomic disparities in follow-up care after traumatic injury. Future studies investigating improvement strategies in follow-up care should be considered.

Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors.

INTRODUCTION: Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury. METHODS: Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission â€‹≥ â€‹3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors. RESULTS: 2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR â€‹= â€‹1.57; 95% CI â€‹= â€‹1.21, 2.03), and worse SF-12 mental (mean Δ â€‹= â€‹-1.43; 95% CI â€‹= â€‹-2.79, -0.09) and physical scores (mean Δ â€‹= â€‹-2.61; 95% CI â€‹= â€‹-3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group. CONCLUSIONS: Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.

The association of disability conditions with access to minimally invasive general surgery.

BACKGROUND: Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized. OBJECTIVE: To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions. METHODS: We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis. RESULTS: In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS. CONCLUSIONS: This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.

Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter.

BACKGROUND: The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. STUDY DESIGN: Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. RESULTS: Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. CONCLUSIONS: Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.

The Operating Room management for emergency Surgical Activity (ORSA) study: a WSES international survey.

BACKGROUND: Despite advances and improvements in the management of surgical patients, emergency and trauma surgery is associated with high morbidity and mortality. This may be due in part to delays in definitive surgical management in the operating room (OR). There is a lack of studies focused on OR prioritization and resource allocation in emergency surgery. The Operating Room management for emergency Surgical Activity (ORSA) study was conceived to assess the management of operating theatres and resources from a global perspective among expert international acute care surgeons. METHOD: The ORSA study was conceived as an international web survey. The questionnaire was composed of 23 multiple-choice and open questions. Data were collected over 3 months. Participation in the survey was voluntary and anonymous. RESULTS: One hundred forty-seven emergency and acute care surgeons answered the questionnaire; the response rate was 58.8%. The majority of the participants come from Europe. One hundred nineteen surgeons (81%; 119/147) declared to have at least one emergency OR in their hospital; for the other 20/147 surgeons (13.6%), there is not a dedicated emergency operating room. Forty-six (68/147)% of the surgeons use the elective OR to perform emergency procedures during the day. The planning of an emergency surgical procedure is done by phone by 70% (104/147) of the surgeons. CONCLUSIONS: There is no dedicated emergency OR in the majority of hospitals internationally. Elective surgical procedures are usually postponed or even cancelled to perform emergency surgery. It is a priority to validate an effective universal triaging and scheduling system to allocate emergency surgical procedures. The new Timing in Acute Care Surgery (TACS) was recently proposed and validated by a Delphi consensus as a clear and reproducible triage tool to timely perform an emergency surgical procedure according to the clinical severity of the surgical disease. The new TACS needs to be prospectively validated in clinical practice. Logistics have to be assessed using a multi-disciplinary approach to improve patients' safety, optimise the use of resources, and decrease costs.

Patience is key: Association of surgical timing with clinical outcomes in elderly patients with sigmoid volvulus.

BACKGROUND: Current guidelines for sigmoid volvulus recommend endoscopy as a first line of treatment for decompression, followed by colectomy as early as possible. Timing of the latter varies greatly. This study compared early (≤2 days) versus delayed (>2 days) sigmoid colectomy. METHODS: 2016-2019 NRD database was queried to identify patients aged ≥65 years admitted for sigmoid volvulus who underwent sequential endoscopic decompression and sigmoid colectomy. Outcomes included mortality, complications, hospital length of stay, readmissions, and hospital costs. RESULTS: 842 patients were included, of which 409 (48.6 â€‹%) underwent delayed sigmoid colectomy. Delayed sigmoid colectomy was associated with reduced cardiac complications (1.1 â€‹% vs 0.0 â€‹%, p â€‹= â€‹0.045), reduced ostomy rate (38.3 â€‹% vs 29.4 â€‹%, p â€‹= â€‹0.013), an increased overall length of stay (12 days vs 8 days, p â€‹< â€‹0.001) and increased overall costs (27,764 dollar vs. 24,472 dollar, p â€‹< â€‹0.001). CONCLUSION: In geriatric patient with sigmoid volvulus, delayed surgical resection after decompression is associated with reduced cardiac complications and reduced ostomy rate, while increasing overall hospital length of stay and costs.

Are we ready for "green surgery" to promote environmental sustainability in the operating room? Results from the WSES STAR investigation.

BACKGROUND: The importance of environmental sustainability is acknowledged in all sectors, including healthcare. To meet the United Nations Sustainable Development Goals 2030 Agenda, healthcare will need a paradigm shift toward more environmentally sustainable practices that will also impact clinical decision-making. The study investigates trauma and emergency surgeons' perception, acceptance, and employment of environmentally friendly habits. METHODS: An online survey based on the most recent literature regarding environmental sustainability in healthcare and surgery was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was advertised to the 917 WSES members through the society's website and Twitter/X profile. RESULTS: 450 surgeons from 55 countries participated in the survey. Results underline both a generally positive attitude toward environmental sustainability but also a lack of knowledge about several concepts and practices, especially concerning the potential contribution to patient care. DISCUSSION: The topic of environmental sustainability in healthcare and surgery is still in its infancy. There is a clear lack of salient guidance and knowledge, and there is a critical need for governments, institutions, health agencies, and scientific societies to promote, disseminate, and report environmentally friendly initiatives and their potential impacts while employing an interdisciplinary approach.

A Narrative Review on Intraoperative Adverse Events: Risks, Prevention, and Mitigation.

INTRODUCTION: Adverse events from surgical interventions are common. They can occur at various stages of surgical care, and they carry a heavy burden on the different parties involved. While extensive research and efforts have been made to better understand the etiologies of postoperative complications, more research on intraoperative adverse events (iAEs) remains to be done. METHODS: In this article, we reviewed the literature looking at iAEs to discuss their risk factors, their implications on surgical care, and the current efforts to mitigate and manage them. RESULTS: Risk factors for iAEs are diverse and are dictated by patient-related risk factors, the nature and complexity of the procedures, the surgeon's experience, and the work environment of the operating room. The implications of iAEs vary according to their severity and include increased rates of 30-day postoperative morbidity and mortality, increased length of hospital stay and readmission, increased care cost, and a second victim emotional toll on the operating surgeon. CONCLUSIONS: While transparent reporting of iAEs remains a challenge, many efforts are using new measures not only to report iAEs but also to provide better surveillance, prevention, and mitigation strategies to reduce their overall adverse impact.

A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology.

BACKGROUND: Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS: A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS: Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION: An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level V.

Optimal dose of cryoprecipitate in massive transfusion following trauma.

BACKGROUND: While cryoprecipitate (Cryo) is commonly included in massive transfusion protocols for hemorrhagic shock, the optimal dose of Cryo transfusion remains unknown. We evaluated the optimal red blood cell (RBC) to RBC to Cryo ratio during resuscitation in massively transfused trauma patients. METHODS: Adult patients in the American College of Surgeon Trauma Quality Improvement Program (2013-2019) receiving massive transfusion (≥4 U of RBCs, ≥1 U of fresh frozen plasma, and ≥1 U of platelets within 4 hours) were included. A unit of Cryo was defined as a pooled unit of 100 mL. The RBC:Cryo ratio was calculated for blood products transfused within 4 hours of presentation. The association between RBC:Cryo and 24-hour mortality was analyzed with multivariable logistic regression adjusting for the volume of RBC, plasma and platelet transfusions, global and regional injury severity, and other relevant variables. RESULTS: The study cohort included 12,916 patients. Among those who received Cryo (n = 5,511 [42.7%]), the median RBC and Cryo transfusion volume within 4 hours was 11 U (interquartile range, 7-19 U) and 2 U (interquartile range, 1-3 U), respectively. Compared with no Cryo administration, only RBC:Cryo ratios ≤8:1 were associated with a significant survival benefit, while lower doses of Cryo (RBC:Cryo >8:1) were not associated with decreased 24-hour mortality. Compared with the maximum dose of Cryo administration (RBC:Cryo, 1:1-2:1), there was no difference in 24-hour mortality up to RBC:Cryo of 7:1 to 8:1, whereas lower doses of Cryo (RBC:Cryo, >8:1) were associated with significantly increased 24-hour mortality. CONCLUSION: One pooled unit of Cryo (100 mL) per 7 to 8 U of RBCs could be the optimal dose of Cryo in trauma resuscitation that provides a significant survival benefit while avoiding unnecessary blood product transfusions. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; Level IV.

Surgical leadership in a culture of safety: An inter-professional study of metrics and tools for improving clinical practice.

BACKGROUND: Leadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aims to identify a framework, metrics and tools to improve surgical leadership and safety outcomes. METHODS: Qualitative interviews were performed with leadership experts from safety-critical professions. Non-probability-based sampling was undertaken in major international airlines. Data underwent thematic analysis and clinical adaptation by multiple surgeon-analysts using the framework method. RESULTS: 583 codes were synthesised into 10 themes. Leaders were identified as 'threat and error managers' who placed safety first. Their core attribute was humble confidence. This allowed them to set the tone for high standards of practice, whilst empowering individuals to speak up about safety issues. Safety-oriented leaders assumed complete responsibility and applied their authority discerningly to obtain optimal outcomes. Finally, effective leaders rallied support for their mission by instilling confidence, building collaborations and managing conflict. CONCLUSIONS: Surgical leadership requires the ability to manage risk, opportunity and people. The study provides an assessment matrix and deliverable tools for improving surgical safety.

Negative pressure wound therapy for emergency laparotomy incisions: A national database propensity matched study.

BACKGROUND: Surgical site infections (SSI) are a common complication of laparotomy incisions. The role of Negative Pressure Wound Therapy (NPWT) in preventing SSIs has not yet been explored in a nationwide analysis. We aimed to evaluate the association of the prophylactic use of NPWT with SSIs in patients undergoing an emergency laparotomy procedure. METHODS: We conducted a retrospective cohort study using the National Surgery Quality Initiative Program (NSQIP) database from 2013 to 2020. We included patients ≥18 years undergoing an emergency laparotomy. We performed a 1:1 propensity matching adjusting for patient age, sex, race, ethnicity, BMI, comorbid conditions, ASA status, diagnosis, preoperative factors and laboratory variables, procedure type, wound class, and intraoperative variables. We compared NPWT with standard dressings in two patient populations: 1. patients with completely closed (skin and fascia) laparotomy incisions and 2. patients with partially closed (fascia only) laparotomy incisions. Our primary outcome was the rate of incisional SSI. Secondary outcomes included the type of SSI, postoperative 30-day complications, postoperative hospital length of stay, and discharge disposition. RESULTS: We included 65,803 patients with completely closed incisions of whom 387 patients received NPWT. There was no significant difference in the rate of total SSIs (13.4 â€‹% vs. 11.9 â€‹%; p â€‹= â€‹0.52) in the matched population of 387 pairs. We included 7285 patients with partially closed incisions of whom 477 patients received NPWT. There was no significant difference in the rate of total SSIs (3.6 â€‹% vs. 4.4 â€‹%; p â€‹= â€‹0.51) in the matched population of 477 pairs. Secondary outcomes did not differ significantly in either group. CONCLUSION: The rate of SSIs was not significantly different when prophylactic NPWT was used compared to standard dressings for patients with a closed or partially closed laparotomy incision.

From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients.

BACKGROUND: COVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates. METHODS: We conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination. RESULTS: The rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated. CONCLUSION: Hospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.

The use of POTTER (Predictive Optimal Trees in Emergency Surgery Risk) calculator to predict mortality and complications in patients submitted to Emergency Surgery.

INTRODUCTION: the ability of the care team to reliably predict postoperative risk is essential for improvements in surgical decision-making, patient and family counseling, and resource allocation in hospitals. The Artificial Intelligence (AI)-powered POTTER (Predictive Optimal Trees in Emergency Surgery Risk) calculator represents a user-friendly interface and has since been downloaded in its iPhone and Android format by thousands of surgeons worldwide. It was originally developed to be used in non-traumatic emergency surgery patients. However, Potter has not been validated outside the US yet. In this study, we aimed to validate the POTTER calculator in a Brazilian academic hospital. METHODS: mortality and morbidity were analyzed using the POTTER calculator in both trauma and non-trauma emergency surgery patients submitted to surgical treatment between November 2020 and July 2021. A total of 194 patients were prospectively included in this analysis. RESULTS: regarding the presence of comorbidities, about 20% of the population were diabetics and 30% were smokers. A total of 47.4% of the patients had hypertensive prednisone. After the analysis of the results, we identified an adequate capability to predict 30-day mortality and morbidity for this group of patients. CONCLUSION: the POTTER calculator presented excellent performance in predicting both morbidity and mortality in the studied population, representing an important tool for surgical teams to define risks, benefits, and outcomes for the emergency surgery population.

Missing Narrative: Examining the Impact of Disability on Post-Operative Infectious Complications.

Background: More than 20% of the population in the United States suffers from a disability, yet the impact of disability on post-operative outcomes remains understudied. This analysis aims to characterize post-operative infectious complications in patients with disability. Patients and Methods: This was a retrospective review of the National Readmission Database (2019) among patients undergoing common general surgery procedures. As per the U.S. Centers for Disease Control and Prevention (CDC), disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. A propensity-matched analysis comparing patients with and without a disability was performed to compare outcomes, including post-operative septic shock, sepsis, bacteremia, pneumonia, catheter-associated urinary tract infection (CAUTI), urinary tract infection (UTI), catheter-associated blood stream infection, Clostridioides Difficile infection, and superficial, deep, and organ/space surgical site infections during index hospitalization. Patients were matched using age, gender, comorbidities, illness severity, income, neighborhood, insurance, elective procedure, and the hospital's bed size and type. Results: A total of 710,548 patients were analysed, of whom 9,451(1.3%) had at least one disability. Motor disability was the most common (3,762; 40.5%), followed by visual, intellectual, and hearing impairment. Patients with disability were older (64 vs. 57 years; p < 0.001), more often insured under Medicare (65.2% vs. 37.3% p < 0.001) and had more medical comorbidities (Elixhauser comorbidity score ≥3; 69.2% vs. 41.9%; p < 0.001). After matching, 9,292 pairs were formed. Patients with a disability had a higher incidence of pneumonia (10.1% vs. 6.5%; p < 0.001), aspiration pneumonia (5.2% vs. 1.4%; p < 0.001), CAUTI (1.0% vs. 0.4%; p < 0.001), UTI (10.4% vs. 6.2%; p < 0.001), and overall infectious complications (21.8% vs. 14.5%; p < 0.001). Conclusions: Severe intellectual, hearing, visual, or motor impairments were associated with a higher incidence of infectious complications. Further investigation is needed to develop interventions to reduce disparities among this high-risk population.