Together is better - RibScore and SCARF in the prediction of pulmonary complications and association with SSRF.

BACKGROUND: Optimal treatment of patients with rib fractures requires identification of those patients at risk of pulmonary complications. It is also important to determine which patients would benefit from Surgical Stabilisation of Rib Fractures (SSRF). This study aims to validate two scoring systems (RibScore and SCARF score) in predicting complications and association with SSRF in an Australian trauma population. Clinical observation suggests that complications and criteria for SSRF is associated with anatomical and physiological factors. Therefore it is hypothesized that utilisation of an anatomical (RibScore) and physiological (SCARF) in conjunction will have improved predictive ability. METHOD: Retrospective cohort study of rib fracture patients admitted to an Australian Level I trauma centre from Jan 2017 to Jan 2021. RibScore and SCARF score were calculated. Multivariate logistic regression was performed to determine risk factors associated with complications and SSRF, as well the scoring systems' ability via ROC AUC. RESULTS: 1157 patients were included. Higher median RibScore (1vs0; p < 0.001) and SCARF score (3vs1, p < 0.001) was associated with development of complications. Similarly for SSRF, RibScore (3vs0; p < 0.001), SCARF score (3vs1; p < 0.001) were higher. On multivariate analysis, increasing RibScore and SCARF score were associated with an increased risk of respiratory failure, pneumonia, death, and SSRF. The sensitivity for a patient with a high risk score in either RibScore or SCARF increased to 96.3 % in identifying pulmonary complications (from 66.7 % in RibScore and 88 % in SCARF, when used individually) and 91.9 % in identifying association with SSRF (from 86.5 % in RibScore and 70.3 % in SCARF). CONCLUSION: RibScore and SCARF score demonstrate predictive ability for complications and SSRF in an Australian trauma rib fracture population. Combining a radiological score with a clinical scoring system demonstrates improved sensitivity over each score individually for identifying patients at risk of complications from rib fractures, those who may require SSRF, and those who are low risk. STUDY TYPE: Retrospective Cohort Study LEVEL OF EVIDENCE: Level III.

Neutrophil-lymphocyte ratio and platelet-lymphocyte ratio use in detecting bowel ischaemia in adhesional small bowel obstruction.

BACKGROUND: Bowel ischaemia significantly increases morbidity and mortality from adhesional small bowel obstruction. Current biomarkers and clinical parameters have poor predictive value for ischaemia. Our study investigated whether neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) could be used to predict bowel ischaemia in adhesional small bowel obstruction. METHODS: This single-centre retrospective study collected clinical, biochemical and radiological data from patients with adhesional small bowel obstruction between 2017 and 2020 who underwent operative management. The presence or absence of bowel ischaemia/infarction was used to distinguish two populations. Biochemical markers on admission and immediately prior to operation were collected to give platelet-lymphocyte ratio (PLR0 and PLRPRE-OP , respectively) and neutrophil-lymphocyte ratio (NLR0 and NLRPRE-OP , respectively). SAS 9.4 (SAS Institute Inc., Cary, NC) software was used for data analysis with Mann-Whitney U testing for continuous variables and Pearson Chi-square test for categorical variables. Sensitivity and specificity for PLR and NLR were calculated by means of receiver operating characteristic (ROC) curve analysis. RESULTS: Twenty-seven patients had intra-operative bowel ischaemia whilst the remaining 73 had no evidence of bowel ischaemia. Both median PLRPRE-OP and NLRPRE-OP were significantly higher in patients with bowel ischaemia compared to those without (PLRPRE-OP 272 [IQR 224-433] and 231 [IQR 146-295] respectively, P = 0.027; NLRPRE-OP 12.5 [IQR 8.6-21.3] v. 5.5 [IQR 3.5-10.2] respectively, P ≤ 0.001). Area under the receiver operator characteristic curve (AUC) was 0.762 for NLRPRE-OP , with a sensitivity of 85.1% and specificity of 63% for NLR 7.4. CONCLUSION: Raised NLR is predictive of bowel ischaemia in patients with adhesional small bowel obstruction.

Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer.

PURPOSE: The tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes. METHODS: Patients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models. RESULTS: Following PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03-1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06-2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19-2.31, p = 0.003). CONCLUSION: Smokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection.

Is excision of testicular nubbin necessary in vanishing testis syndrome?

BACKGROUND/PURPOSE: Vanishing Testes Syndrome1 (VTS) is one of the most common causes of impalpable testes in children. The role of removal of testicular nubbins owing to malignant potential in VTS is unclear. We sought to evaluate whether testicular nubbins need to be excised owing to this potential. METHODS: We conducted a retrospective review of children with a clinical diagnosis of impalpable testes aged 0-18 who presented to our tertiary hospital between 2007 and 2017. VTS was defined as the presence of hypoplastic vas entering a closed internal inguinal ring or remnants of gonadal tissue distally. Data collected included: age at operation, need for laparoscopy, location of nubbin and histopathological findings. RESULTS: We identified 50 consecutive children (mean age 2.4 years, range: 7 months to 12 years) with a clinical diagnosis of impalpable testis. Forty-eight of the 50 underwent laparoscopy with no testicle palpable when examined under anesthesia. Thirty-three children had VTS confirmed at laparoscopy and testicular nubbins identified with three of these being bilateral. Thirty-two children had these nubbins excised with histopathology available for 31 individual testes. Thirty were confirmed testicular nubbins with no viable testicular tissue. No malignancies were identified. CONCLUSION: Results from this study show that testicular nubbins do not have viable germ cells and therefore do not need to be excised on the basis of malignant potential of residual testicular tissue. LEVEL OF EVIDENCE: Level IV treatment study.

The effect of correct cross-chest clip use on injury outcomes in young children during motor vehicle crashes.

OBJECTIVE: Traffic crashes have high mortality and morbidity for young children. Though many specialized child restraint systems improve injury outcomes, no large-scale studies have investigated the cross-chest clip's role during a crash, despite concerns in some jurisdictions about the potential for neck contact injuries from the clips. This study aimed to investigate the relationship between cross-chest clip use and injury outcomes in children between 0 and 4 years of age. METHODS: Child passengers between 0 and 4 years of age were selected from the NASS-CDS data sets (2003-2014). Multiple regression analysis was used to model injury outcomes while controlling for age, crash severity, crash direction, and restraint type. The primary outcomes were overall Abbreviated Injury Score (AIS) 2+ injury, and the presence of any neck injury. RESULTS: Across all children aged 0-4 years, correct chest clip use was associated with decreased Abbreviated Injury Scale (AIS) 2+ injury (odds ratio [OR] = 0.44, 95% confidence interval [CI], 0.21-0.91) and was not associated with neck injury. However, outcomes varied by age. In children <12 months old, chest clip use was associated with decreased AIS 2+ injury (OR = 0.09, 95% CI, 0.02-0.44). Neck injury (n = 7, all AIS 1) for this age group only occurred with correct cross-chest clip use. For 1- to 4-year-old children, cross-chest clip use had no association with AIS 2+ injury, and correct use significantly decreased the odds of neck injury (OR = 0.49; 95% CI, 0.27-0.87) compared to an incorrectly used or absent cross-chest clip. No serious injuries were directly caused by the chest clips. CONCLUSIONS: Correct cross-chest clip use appeared to reduce injury in crashes, and there was no evidence of serious clip-induced injury in children in 5-point harness restraints.