Mortality in hypotensive combat casualties who require emergent laparotomy in the forward deployed environment.

INTRODUCTION: Mortality rates among hypotensive civilian patients requiring emergent laparotomy exceed 40%. Damage control (DCR) principles were incorporated into the military's Clinical Practice Guidelines (CPG) in 2008. We examined combat casualties requiring emergent laparotomy to characterize how mortality rates compare to hypotensive civilian trauma patients. METHODS: The DoD Trauma Registry (2004-2020) was queried for adults who underwent combat laparotomy. Patients who were hypotensive were compared to normotensive patients. Mortality was the outcome of interest. Mortality rates before (2004-2007) and after (2009-2020) DCR CPG implementation were analyzed. RESULTS: 1051 patients were studied. Overall mortality was 6.5% for normotensive casualties and 28.7% for hypotensive casualties. Mortality decreased in normotensive patients but remained unchanged in hypotensive patients following the implementation of the DCR CPG. CONCLUSION: Hypotensive combat casualties undergoing emergent laparotomy demonstrated a mortality rate of 29.5%. Despite many advances, mortality rates remain high in hypotensive patients requiring emergent laparotomy.

Outcomes of patients enrolled in a prospective and randomized trial on basis of gestalt assessment or ABC score.

BACKGROUND: The Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial rapidly enrolled patients based on an Assessment of Blood Consumption (ABC) ≥ 2 score, or physician gestalt (PG) when ABC score was <2. The objective of this study was to describe what patients were enrolled by the two methods and whether patient outcomes differed based on these enrollments. We hypothesized that there would be no differences in outcomes based on whether patients were enrolled via ABC score or PG. METHODS: Patients were enrolled with an ABC ≥ 2 or by PG when ABC was <2 by the attending trauma surgeon. We compared 1-hour, 3-hour, 6-hour, 12-hour, 18-hour, and 24-hour mortality, 30-day mortality, time to hemostasis, emergent surgical or interventional radiology procedure and the proportion of patients who required either >10 units of blood in 24 hours or >3 units in 1 hour. RESULTS: Of 680 patients, 438 (64%) were enrolled on the basis of an ABC score ≥2 and 242 (36% by PG when the ABC score was <2). Patients enrolled by PG were older (median, 44; interquartile range [IQR], 28-59; p < 0.001), more likely to be White (70.3% vs. 60.3%, p = 0.014), and more likely to have been injured by blunt mechanisms (77.3% vs. 37.2%, p < 0.001). They were also less hypotensive and less tachycardic than patients enrolled by ABC score (both p < 0.001). The groups had similar Injury Severity Scores in the ABC ≥ 2 and PG groups (26 and 27, respectively) and were equally represented (49.1% and 50.8%, respectively) in the 1:1:1 treatment arm. There were no significant differences between the ABC score and PG groups for mortality at any point. Time to hemostasis (108 for patients enrolled on basis of Gestalt, vs. 100 minutes for patients enrolled on basis of ABC score), and the proportion of patients requiring a massive transfusion (>10 units/24 hours) (44.2% vs. 47.3%), or meeting the critical administration threshold (>3 unit/1 hour) (84.7% vs. 89.5%) were similar ( p = 0.071). CONCLUSION: Early identification of trauma patients likely to require a massive transfusion is important for clinical care, resource use, and selection of patients for clinical trials. Patients enrolled in the PROPPR trial based on PG when the ABC score was <2 represented 36% of the patients and had identical outcomes to those enrolled on the basis of an ABC score of ≥2. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education.

Introduction: Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs. Methods: We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum". Results: We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs. Conclusion: We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.

Engineering Human Cells Expressing CRISPR/Cas9-Synergistic Activation Mediators for Recombinant Protein Production.

Recombinant engineering for protein production commonly employs plasmid-based gene templates for introduction and expression of genes in a candidate cell system in vitro. Challenges to this approach include identifying cell types that can facilitate proper post-translational modifications and difficulty expressing large multimeric proteins. We hypothesized that integration of the CRISPR/Cas9-synergistic activator mediator (SAM) system into the human genome would be a powerful tool capable of robust gene expression and protein production. SAMs are comprised of a "dead" Cas9 (dCas9) linked to transcriptional activators viral particle 64 (VP64), nuclear factor-kappa-B p65 subunit (p65), and heat shock factor 1 (HSF1) and are programmable to single or multiple gene targets. We integrated the components of the SAM system into human HEK293, HKB11, SK-HEP1, and HEP-g2 cells using coagulation factor X (FX) and fibrinogen (FBN) as proof of concept. We observed upregulation of mRNA in each cell type with concomitant protein expression. Our findings demonstrate the capability of human cells stably expressing SAM for user-defined singleplex and multiplex gene targeting and highlight their broad potential utility for recombinant engineering as well as transcriptional modulation across networks for basic, translational, and clinical modeling and applications.

The 16-year evolution of a military-civilian partnership: The University of Alabama at Birmingham experience.

BACKGROUND: At the University of Alabama at Birmingham (UAB), a multi-tiered military-civilian partnership (MCP) has evolved since 2006. We aimed to outline this model to facilitate potential replication nationally. METHODS: We performed a comprehensive review of the partnership between UAB, the United States Air Force Special Operations Command, and the Department of Defense (DoD) reviewing key documents and conducting interviews with providers. As a purely descriptive study, this project did not involve any patient data acquisition or analysis and therefore was exempt from institutional review board approval per institutional policy. RESULTS: At the time of this review, six core programs existed targeting training, clinical proficiency, and research. Training: (1) The Special Operations Center for Medical Integration and Development trains up to 144 combat medics yearly. (2) UAB trains one integrated military Surgery resident yearly with two additional civilian-sponsored military residents in Emergency Medicine. (3) UAB's Surgical Critical Care Fellowship had one National Guard member with two incoming Active-Duty, one Reservist and one prior service member in August 2022. Clinical Proficiency: (4) UAB hosts four permanently assigned United States Air Force Special Operations Command Special Operations Surgical Teams composed of general surgeons, anesthesiologists, certified registered nurse anesthetists, surgical technologists, emergency physicians, critical care registered nurses, and respiratory therapists totaling 24 permanently assigned active-duty health care professionals. (5) In addition, two fellowship-trained Air Force Trauma Critical Care Surgeons, one Active-Duty and one Reservist, are permanently assigned to UAB. These clinicians participate fully and independently in the routine care of patients alongside their civilian counterparts. Research: (6) UAB's Division of Trauma and Acute Care Surgery is currently conducting nine DoD-funded research projects totaling $6,482,790, and four research projects with military relevance funded by other agencies totaling $15,357,191. CONCLUSION: The collaboration between UAB and various elements within the DoD illustrates a comprehensive approach to MCP. Replicating appropriate components of this model nationally may aid in the development of a truly integrated trauma system best prepared for the challenges of the future. LEVEL OF EVIDENCE: Economic and Value-based Evaluations; Level IV.

Airborne! UAV delivery of blood products and medical logistics for combat zones.

BACKGROUND: Innovative solutions to resupply critical medical logistics and blood products may be required in future near-peer conflicts. Unmanned aerial vehicles (UAVs) are increasingly being used in austere environments and may be a viable platform for medical resupply and the transport of blood products. METHODS: A literature review on PubMed and Google Scholar up to March of 2022 yielded a total of 27 articles that were included in this narrative review. The objectives of this article are to discuss the current limitations of prehospital blood transfusion in military settings, discuss the current uses of UAVs for medical logistics, and highlight the ongoing research surrounding UAVs for blood product delivery. DISCUSSION: UAVs allow for the timely delivery of medical supplies in numerous settings and have been utilized for both military and civilian purposes. Investigations into the effects of aeromedical transportation on blood products have found minimal blood product degradation when appropriately thermoregulated and delivered in a manner that minimizes trauma. UAV delivery of blood products is now actively being explored by numerous entities around the globe. Current limitations surrounding the lack of high-quality safety data, engineering constraints over carrying capacity, storage capability, and distance traveled, as well as air space regulations persist. CONCLUSION: UAVs may offer a novel solution for the transport of medical supplies and blood products in a safe and timely manner for the forward-deployed setting. Further research on optimal UAV design, optimal delivery techniques, and blood product safety following transport should be explored prior to implementation.

Engineering CRISPR/Cas9 for Multiplexed Recombinant Coagulation Factor Production.

Current hemostatic agents are obtained from pooled plasma from multiple donors requiring costly pathogen screening and processing. Recombinant DNA-based production represents an engineering solution that could improve supply, uniformity, and safety. Current approaches are typically for single gene candidate peptides and often employ non-human cells. We devised an approach where multiple gene products could be produced from a single population of cells. We identified gene specific Synergistic Activation Mediators (SAM) from the CRISPR/Cas9 system for targeted overexpression of coagulation factors II, VII, IX, X, and fibrinogen. The components of the CRISPR-SAM system were expressed in Human Embryonic Kidney Cells (HEK293), and single (singleplex) or multi-gene (multiplex) upregulation was assessed by quantitative RT-PCR (qRT-PCR) and protein expression by ELISA analysis. Factor II, VII, IX, and X singleplex and multiplex activation resulted in 120-4700-fold and 60-680-fold increases in gene expression, respectively. Fibrinogen sub-unit gene activation resulted in a 1700-92,000-fold increases and 80-5500-fold increases in singleplex or multiplex approaches, respectively. ELISA analysis showed a concomitant upregulation of candidate gene products. Our findings demonstrate the capability of CRISPR/Cas9 SAMs for single or multi-agent production in human cells and represent an engineering advance that augments current recombinant peptide production techniques.

Adenosine, lidocaine, and magnesium for attenuating ischemia reperfusion injury from resuscitative endovascular balloon occlusion of the aorta in a porcine model.

BACKGROUND: Minimally invasive resuscitative endovascular balloon occlusion of the aorta (REBOA) following noncompressible hemorrhage results in significant ischemia reperfusion injury (IRI). Adverse outcomes from IRI include organ dysfunction and can result in profound hemodynamic and molecular compromise. We hypothesized that adenosine, lidocaine, and magnesium (ALM) attenuates organ injury and inflammation responses following REBOA IRI in a porcine model of hemorrhage. METHODS: Animals underwent a 20% controlled hemorrhage followed by 45 minutes of supraceliac balloon occlusion. They were randomized into two groups: control (n = 9) and ALM intervention (n = 9) to include a posthemorrhage, pre-REBOA bolus (200 mL of 3% NaCl ALM) followed by a continuous drip (2 mL/kg per hour of 0.9% NaCl ALM) during the 4-hour resuscitative period. Primary outcomes included hemodynamic parameters, gene expression of inflammatory signaling molecules, and plasma concentrations of select cytokines and chemokines. RESULTS: The ALM cohort demonstrated a significant reduction in cardiac output and cardiac index. Plasma concentrations of interleukin 2 and interleukin 10 were significantly lower 3 hours post-REBOA in animals treated with ALM versus vehicle. Interleukin 4 levels in plasma were also lower with ALM at 3 and 4 hours post-REBOA (p < 0.05). Liver expression of IL1RN, MTOR, and LAMP3 messenger RNA was significantly lower with ALM as compared with the vehicle. No significant difference in large bowel gene expression was observed between treatments. CONCLUSION: In a porcine model of hemorrhage, ALM treatment mitigated inflammatory responses early during post-REBOA resuscitation. Our findings suggest that ALM use with trauma may reduce inflammatory injury and improve outcomes related to REBOA utilization.

Addition of neurological status to pediatric adjusted shock index to predict early mortality in trauma: A pediatric Trauma Quality Improvement Program analysis.

INTRODUCTION: Pediatric adjusted shock index (SIPA) has demonstrated the ability to prospectively identify children at the highest risk for early mortality. The addition of neurological status to shock index has shown promise as a reliable triage tool in adult trauma populations. This study sought to assess the utility of combining SIPA with Glasgow Coma Scale (GCS) for predicting early trauma-related outcomes. METHODS: Retrospective review of the 2017 Trauma Quality Improvement Program Database was performed for all severely injured patients younger than 18 years old. Pediatric adjusted shock index and reverse SIPA × GCS (rSIG) were calculated. Age-specific cutoff values were derived for reverse shock index multiplied by GCS (rSIG) and compared with their SIPA counterparts for early mortality assessment using area under the receiver operating characteristic curve analyses. RESULTS: A total of 10,389 pediatric patients with an average age of 11.4 years, 67% male, average Injury Severity Score of 24.1, and 4% sustaining a major penetrating injury were included in the analysis. The overall mortality was 9.3%. Furthermore, 32.1% of patients displayed an elevated SIPA score, while only 27.5% displayed a positive rSIG. On area under the receiver operating characteristic curve analysis, rSIG was found to be superior to SIPA as a predictor for in hospital mortality with values of 0.854 versus 0.628, respectively. CONCLUSION: Reverse shock index multiplied by GCS more readily predicted in hospital mortality for pediatric trauma patients when compared with SIPA. These findings suggest that neurological status should be an important factor during initial patient assessment. Further study to assess the applicability of rSIG for expanded trauma-related outcomes in pediatric trauma is necessary. LEVEL OF EVIDENCE: Prognostic study, level IV.

A Surgeon's Guide to Machine Learning.

Machine learning (ML) represents a collection of advanced data modeling techniques beyond the traditional statistical models and tests with which most clinicians are familiar. While a subset of artificial intelligence, ML is far from the science fiction impression frequently associated with AI. At its most basic, ML is about pattern finding, sometimes with complex algorithms. The advanced mathematical modeling of ML is seeing expanding use throughout healthcare and increasingly in the day-to-day practice of surgeons. As with any new technique or technology, a basic understanding of principles, applications, and limitations are essential for appropriate implementation. This primer is intended to provide the surgical reader an accelerated introduction to applied ML and considerations in potential research applications or the review of publications, including ML techniques.

Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma.

INTRODUCTION: Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries. METHODS: Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality. RESULTS: A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality. CONCLUSION: Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population. LEVEL OF EVIDENCE: Prognostic study, level IV.

Safety code blue! Assessing the use of blue surgical sterilization wrap for homemade respirator masks during the COVID-19 crisis.

The use of surgical sterilization wrap for respirator masks during the COVID-19 crisis has become a popularized personal protective equipment alternative option due to claims supporting its ability to meet N95 standards. This study sought to assess these claims using standardized filter testing. The tested material failed to meet N95 standards and suggests its use may place medical personnel at increased risk of harm when managing COVID-19 patients.

Dynamic trend or static variable: Shock Index Pediatric-Adjusted (SIPA) in warzone trauma.

BACKGROUND: Civilian studies suggest that trending Shock-Index Pediatric Adjusted(SIPA) values can prove useful in the prediction of trauma outcomes. The purpose of this study was to evaluate the relationship between trends in SIPA and outcomes in pediatric warzone trauma. METHODS: Retrospective review of the Department of Defense Trauma Registry from 2008 to 2015, including all patients age ≤17years. SIPA was calculated both pre-hospital and upon arrival, then classified as "normal" or "abnormal" based upon previously validated thresholds. Patients were stratified into groups based on the trend of their SIPA (1-normal to normal, 2-normal to abnormal, 3-abnormal to normal, 4-abnormal to abnormal). Key outcomes including ICU admission, severe injury, mechanical ventilation, and mortality were then compared between groups. RESULTS: 669 patients were included, mean ISS 12 ± 10. The most common mechanism of injury was blast (46.5%). Overall, 43% were stratified into Group 1, 13.9% into Group 2, 14.8% into Group 3, and 28.0% into Group 4. Those patients with a persistently abnormal SIPA (Group 4) had significantly increased incidence of severe injury, ICU admission, need for mechanical ventilation, and mortality. CONCLUSION: Trends in SIPA may be used to predict trauma outcomes for children injured in warzones, with persistently abnormal values associated with worse outcomes overall.

Quality Assurance During a Global Pandemic: An Evaluation of Improvised Filter Materials for Healthcare Workers.

OBJECTIVE: The proliferation of improvised masks during the COVID-19 pandemic has raised questions regarding filter effectiveness and safety. We sought to compare the effectiveness of commonly used improvised filter materials against N95 industry standards. METHODS: Six different filter materials commonly used in the community were tested using both single- and multi-layer configurations with the TSI 8130 automated filter tester in accordance with National Institute for Occupational Safety and Health (NIOSH) standards for N95 respirators. RESULTS: Only three of the tested filter material configurations met N95 parameters with regard to filtration efficiency and pressure drop across the filter material-the: True-high-efficiency particulate air (HEPA) filter, four-layer MERV 13 and 14 HVAC filters. CONCLUSIONS: Many proposed filter materials for improvised masks do not meet current industry standards and may pose safety and efficacy concerns. Care should be taken when selecting materials for this critical respirator component, particularly for health care workers or others at high risk for pathogen exposure.

Shock Index as a Predictor of Massive Transfusion and Emergency Surgery on the Modern Battlefield.

BACKGROUND: Shock Index (SI) has been used to predict the need for massive transfusion (MT) and emergency surgical procedures (ESP) in civilian trauma. We hypothesize that SI can reliably identify combat trauma patients that will require MT and ESP when applied to the resource-constrained, combat environment. METHODS: A retrospective review was performed within the Department of Defense Trauma Registry (2008-2016). SI was calculated using heart rate and systolic blood pressure on arrival to the initial facility with surgical capabilities. A threshold value of 0.8 was used to stratify patients into two groups (Group I, SI < 0.8; and Group II, SI ≥ 0.8). The need for MT, ESP, and mortality was compared. Regression analyses were conducted to determine the independent association of SI with MT and ESP. RESULTS: A total of 4008 patients were included. The mean age of the patients was 25.5 y, and the majority were predominately male (98%). Mechanisms of injury were blunt and blast injury (62%), penetrating injury (36.7%), and burn injury (0.5%). Overall, 77% of patients (n = 3070) were stratified to Group I, and 23% of patients (n = 938) were stratified to Group II, by SI. Group II patients had a significantly greater need for MT (8.4% versus 0.4%) and ESP (30.7% versus 6.5%), both P < 0.001. Regression analysis controlling for age, gender, Injury Severity Score, and Glasgow Coma Score confirmed that SI ≥ 0.8 was an independent risk factor for both MT and need for ESPs (P < 0.001). CONCLUSIONS: SI is a significant predictor of the need for MT and ESPs in the military trauma population, representing a simple and potentially potent tool for triage and prediction of resource consumption in the resource-limited, austere setting.

All trauma is not created equal: Redefining severe trauma for combat injuries.

Injury severity scores (ISS) and shock index (SI) are popular trauma scoring systems. We assessed ISS and SI in combat trauma to determine the optimal cut-off values for mortality and trauma outcomes. Retrospective analysis of the Department of Defense Trauma Registry, 2008-2016, was performed. Areas under receiver operating characteristic curves (AUROCs) were calculated for ISS and SI on mortality, massive volume transfusion (MVT), and emergent surgical procedure (ESP). Optimal cut-off values were defined using the Youden index (YI). 22,218 patients (97.1% male), median ages 25-29 years, ISS 9.4 ± 0.07, with 58.1% penetrating injury were studied. Overall mortality was 3.4%. AUROCs for ISS on mortality, MVT, and ESP were 0.882, 0.898, and 0.846, while AUROCs for SI were 0.727, 0.864, and 0.711 respectively. The optimal cut-off values for ISS on mortality, MVT, and ESP were 12.5 (YI = 0.634), 12.5 (YI = 0.666), and 12.5 (YI = 0.819), with optimal values for SI being 0.94 (YI = 0.402), 0.88 (YI = 0.608), and 0.81 (YI = 0.345) respectively. Classic values for severe ISS underrepresent combat injury while the SI values defined in this study are consistent with civilian data.

Viscoelastic testing in combat resuscitation: Is it time for a new standard?

BACKGROUND: Traumatic hemorrhage and coagulopathy represent major sources of morbidity and mortality on the modern battlefield. Viscoelastic testing (VET) offers a potentially more personalized approach to resuscitation. We sought to evaluate outcomes of combat trauma patients who received VET-guided resuscitation compared with standard balanced blood product resuscitation. METHODS: Retrospective analysis of the Department of Defense Trauma Registry, 2008 to 2016 was performed. Multivariate logistic regression analyses of all adult patients initially presenting to NATO Role III facilities who required blood products were performed to identify factors associated with VET-guided resuscitation and mortality. A propensity score matched comparison of outcomes in patient cohorts treated at VET versus non-VET Role III facilities was performed. RESULTS: There are 3,320 patients, predominately male (98%), median age ranges from 25 years to 29 years, Injury Severity Score of 18.8, with a penetrating injury (84%) were studied. Overall mortality was 9.7%. Five hundred ninety-four patients had VET during their initial resuscitation. After adjusting for confounders, VET during initial resuscitation was independently associated with decreased mortality (odds ratio, 0.63; p = 0.04). Propensity analysis confirmed this survival advantage with a 57% reduction in overall mortality (7.3% vs. 13.1%; p = 0.001) for all patients requiring blood products. CONCLUSION: Viscoelastic testing offers the possibility of a product-specific resuscitation for critically injured patients requiring transfusion in combat settings. Routine VET may be superior to non-VET-guided resuscitation for combat trauma victims. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Validation of Shock Index Pediatric-Adjusted for children injured in warzones.

BACKGROUND: Shock Index Pediatric-Adjusted (SIPA) has been used to predict injury severity and outcomes after civilian pediatric trauma. We hypothesize that SIPA can predict the need for blood transfusion and emergent surgery among pediatric patients injured in warzones, where resources are limited and accurate triage is essential. METHODS: Retrospective review of the DoD Trauma Registry for all patients 17 years or younger, from 2008 to 2015. Shock Index Pediatric-Adjusted was determined using vital signs recorded upon arrival to the initial level of care. Patients were classified into two groups (normal vs. elevated SIPA) using age-specific threshold values. The need for blood product transfusion (BPT) within 24 hours and emergent surgical procedures (ESP) was compared between groups. Intensive care unit admission, injury severity, and mortality were also compared. Regression analysis was performed to evaluate the relationship between SIPA and primary outcomes. RESULTS: There were 2,121 patients included with a mean Injury Severity Score of 12 ± 10. The mechanism of injury was penetrating (63%), blunt (25%), and burns (12%). Patients with an elevated SIPA (43%) had a significantly greater need for BPT (49.2% vs. 25.0%) and ESP (22.9% vs. 16.0%), as well as mortality (10.3% vs. 4.8%) and intensive care unit admission (49.9% vs. 36.1%), all p less than 0.001. Regression analysis confirmed an elevated SIPA as independently associated with both BPT (odds ratio, 2.36; 95% confidence interval, 1.19-2.94; p < 0.001) and ESP (odds ratio, 1.29; 95% confidence interval, 1.01-1.64; p = 0.044). CONCLUSION: This is the first study of SIPA in pediatric warzone trauma. Elevated SIPA is associated with significantly increased need for BPT and emergent surgery and may therefore serve as a valuable tool for planning and triage in austere settings. LEVEL OF EVIDENCE: Prognostic/epidemiological, Level III.

Big problems in little patients: Nationwide blunt cerebrovascular injury outcomes in the pediatric population.

BACKGROUND: Blunt cerebrovascular injuries (BCVI) are uncommon but potentially devastating. The epidemiology, outcomes, and screening criteria are well described in adults, but data in pediatric patients are extremely limited. The purpose of this study was to characterize pediatric BCVI in a large nationwide sample. We hypothesized that outcomes of BCVI in the pediatric blunt trauma population will vary by age. METHODS: We conducted a retrospective cohort study of the Kids' Inpatient Database for pediatric BCVI from 2000 to 2012. Epidemiology, associated injuries, outcomes (including stroke and mortality), and the utility of standard screening criteria were analyzed. RESULTS: There were 1,182 cases of BCVI identified, yielding an incidence of 0.21%. Patients were predominately male (69%; mean age, 15 ± 5 years). Injuries were 59% carotid, 13% vertebral, and 28% unspecified, with 15% having bilateral or multivessel BCVI. Although younger patients (<11 years) had significantly lower ISS and decreased severe associated injuries (all p < 0.01), they had a similar mortality rate (10%) versus the older cohort. Additionally, the stroke rate was significantly higher among the younger patients versus their older peers (29% mortality for <11 years vs. 15% for ≥11 years, p < 0.01). Only four of seven commonly utilized risk factors were associated with BCVI overall, but none were significantly associated with BCVI in younger children (<11 years). CONCLUSION: This represents the first nationwide assessment of BCVI in the pediatric population. Pediatric BCVI carry considerable mortality and stroke risk. Despite being less severely injured, younger children (<11 years) had similar a mortality rate and a significantly higher stroke rate compared with older pediatric patients. Furthermore, commonly utilized adult screening criteria had limited utility in the younger cohorts. These findings suggest pediatric BCVI may require screening and treatment protocols that are significantly different than currently utilized adult-based programs. LEVEL OF EVIDENCE: Prognostic/Epidemiological Study, level III.

Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs.

INTRODUCTION: The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME. METHODS: Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs. RESULTS: One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047). CONCLUSIONS: Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.