Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA.

BACKGROUND: Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients. METHODS: We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours. RESULTS: A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001). DISCUSSION: In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Workforce Attrition Among Male and Female Physicians Working in US Academic Hospitals, 2014-2019.

Importance: Retaining female physicians in the academic health care workforce is necessary to serve the needs of sociodemographically diverse patient populations. Objective: To investigate differences in rates of leaving academia between male and female physicians. Design, Setting, and Participants: This cohort study used Care Compare data from the Centers for Medicare & Medicaid Services for all physicians who billed Medicare from teaching hospitals from March 2014 to December 2019, excluding physicians who retired during the study period. Data were analyzed from November 11, 2021, to May 24, 2022. Exposure: Physician gender. Main Outcome and Measures: The primary outcome was leaving academia, which was defined as not billing Medicare from a teaching hospital for more than 1 year. Multivariable logistic regression was conducted adjusting for physician characteristics and region of the country. Results: There were 294 963 physicians analyzed (69.5% male). The overall attrition rate from academia was 34.2% after 5 years (38.3% for female physicians and 32.4% for male physicians). Female physicians had higher attrition rates than their male counterparts across every career stage (time since medical school graduation: <15 years, 40.5% vs 34.8%; 15-29 years, 36.4% vs 30.3%; ≥30 years, 38.5% vs 33.3%). On adjusted analysis, female physicians were more likely to leave academia than were their male counterparts (odds ratio, 1.25; 95% CI, 1.23-1.28). Conclusions and Relevance: In this cohort study, female physicians were more likely to leave academia than were male physicians at all career stages. The findings suggest that diversity, equity, and inclusion efforts should address attrition issues in addition to recruiting more female physicians into academic medicine.

Injury-related emergency department visits and unplanned readmissions are associated with worse long-term mental and physical health.

BACKGROUND: The risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for injury-related ED visits and unplanned readmissions following injury and, 2) explore the relationship between these unplanned visits and mental and physical health outcomes 6-12 months post-injury. METHODS: Trauma patients with moderate-to-severe injury admitted to one of three Level-I trauma centers were asked to complete a phone survey to assess mental and physical health outcomes at 6-12 months. Patient reported data on injury-related ED visits and readmissions was collected. Multivariable regression analyses were performed controlling for sociodemographic and clinical variables to compare subgroups. RESULTS: Of 7,781 eligible patients, 4675 were contacted and 3,147 completed the survey and were included in the analysis. 194 (6.2%) reported an unplanned injury-related ED visit and 239 (7.6%) reported an injury-related readmission. Risk factors for injury-related ED visits included: younger age, Black race, a lower level of education, Medicaid insurance, baseline psychiatric or substance abuse disorder and penetrating mechanism. Risk factors for unplanned injury-related readmission included younger age, male sex, Medicaid insurance, substance abuse disorder, greater injury severity and penetrating mechanism of injury. Injury-related ED visits and readmissions were associated with significantly higher rates of PTSD, chronic pain and new injury-related functional limitations in addition to lower SF-12 mental and physical composite scores. CONCLUSIONS: Injury-related ED visits and unplanned readmissions are common after hospital discharge following treatment of moderate-severe injury and are associated with worse mental and physical health outcomes.

Gender Homophily in Interphysician Referrals to Surgeons.

INTRODUCTION: The literature on gender homophily has mostly been focused on patient-physician relationship but not on interprofessional referrals. The goal of this study is to quantify interphysician gender homophily of referring physicians in surgical referrals. METHODS: An observational study of the referral data at a large academic center was performed. Patients referred through Epic to the department of general surgery from January 2016 to October 2019 were included. The primary end point was gender homophily and the primary independent variable was referring physician gender. Gender homophily was defined as greater than expected rates of gender concordance. Gender concordance was defined when referring physicians have the same gender as receiving surgeons. The expected concordance rate was defined as the availability of gender-concordant surgeons in the population. Absolute homophily is the difference between observed and expected concordance rates, whereas relative homophily is the ratio between observed and expected concordance rates. RESULTS: A total of 25,271 patient referrals from 2625 referring physicians to 91 surgeons were analyzed. The overall observed concordance rate for the entire study population was 55.3% and was 31.7% among female physicians and 82.4% among male physicians. Compared to the expected concordance rate, the absolute gender homophily among all female physicians was +7.2% or a relative homophily of 1.29%. In contrast, the absolute gender homophily among all male physicians was +6.9% or a relative homophily of 1.09%. CONCLUSIONS: Gender homophily exists in interprofessional referrals. Although referral decisions are presumably based solely on clinical factors, referrals can be affected by subjective biases.

Intersection of Race, Ethnicity, and Sex in New Functional Limitations after Injury: Black and Hispanic Female Survivors at Greater Risk.

BACKGROUND: The impact of disparities at the intersection of multiple marginalized social identities is poorly understood in trauma. We sought to evaluate the joint effect of race, ethnicity, and sex on new functional limitations 6 to 12 months postinjury. STUDY DESIGN: Moderately to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing functional outcomes 6 to 12 months postinjury. Multivariate adjusted regression analyses were used to compare functional limitations by race and ethnicity alone, sex alone, and the interaction between both race and ethnicity and sex. The joint disparity and its composition were calculated across race and sex strata. RESULTS: Included were 4,020 patients: 1,621 (40.3%) non-Hispanic White male patients, 1,566 (39%) non-Hispanic White female patients, 570 (14.2%) Black or Hispanic/Latinx male patients, and 263 (6.5%) Black or Hispanic/Latinx female patients (BHF). The risk-adjusted incidence of functional limitations was highest among BHF (50.6%) vs non-Hispanic White female patients (39.2%), non-Hispanic White male patients (35.8%), and Black or Hispanic male patients (34.6%; p < 0.001). In adjusted analysis, women (odds ratio 1.35 [95% CI 1.16 to 1.57]; p < 0.001) and Blacks or Hispanic patients (odds ratio 1.28 [95% CI 1.03 to 1.58]; p = 0.02) were more likely to have new functional limitations 6 to 12 months postinjury. When sex and race were analyzed together, BHF were more likely to have new functional limitations compared with non-Hispanic White male patients (odds ratio 2.12 [1.55 to 2.90]; p < 0.001), with 63.5% of this joint disparity being explained by the intersection of race and ethnicity and sex. CONCLUSION: More than half of the race and sex disparity in functional limitations experienced by BHF is explained by the unique experience of being both minority and a woman. Intermediate modifiable factors contributing to this intersectional disparity must be identified.

National evaluation of the association between stay-at-home orders on mechanism of injury and trauma admission volume.

BACKGROUND: The COVID-19 pandemic had numerous negative effects on the US healthcare system. Many states implemented stay-at-home (SAH) orders to slow COVID-19 virus transmission. We measured the association between SAH orders on the injury mechanism type and volume of trauma center admissions during the first wave of the COVID-19 pandemic. METHODS: All trauma patients aged 16 years and older who were treated at the American College of Surgeons Trauma Quality Improvement Program participating centers from January 2018-September 2020. Weekly trauma patient volume, patient demographics, and injury characteristics were compared across the corresponding SAH time periods from each year. Patient volume was modeled using harmonic regression with a random hospital effect. RESULTS: There were 166,773 patients admitted in 2020 after a SAH order and an average of 160,962 patients were treated over the corresponding periods in 2018-2019 in 474 centers. Patients presenting with a pre-existing condition of alcohol misuse increased (13,611 (8.3%) vs. 10,440 (6.6%), p <0.001). Assault injuries increased (19,056 (11.4%) vs. 15,605 (9.8%)) and firearm-related injuries (14,246 (8.5%) vs. 10,316 (6.4%)), p<0.001. Firearm-specific assault injuries increased (10,748 (75.5%) vs. 7,600 (74.0%)) as did firearm-specific unintentional injuries (1,318 (9.3%) vs. 830 (8.1%), p<0.001. In the month preceding the SAH orders, trauma center admissions decreased. Within a week of SAH implementation, hospital admissions increased (p<0.001) until a plateau occurred 10 weeks later above predicted levels. On regional sub-analysis, admission volume remained significantly elevated for the Midwest during weeks 11-25 after SAH order implementation, (p<0.001).

Variability of Pediatric Cervical Spine Clearance Protocols: A Systematic Review.

OBJECTIVE: The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. BACKGROUND DATA: Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. METHODS: A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. CONCLUSIONS: Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

The Social Vulnerability Index and Long-term Outcomes After Traumatic Injury.

OBJECTIVE: The aim of this study was to evaluate the Social Vulnerability Index (SVI) as a predictor of long-term outcomes after injury. BACKGROUND: The SVI is a measure used in emergency preparedness to identify need for resources in the event of a disaster or hazardous event, ranking each census tract on 15 demographic/social factors. METHODS: Moderate-severely injured adult patients treated at 1 of 3 level-1 trauma centers were prospectively followed 6 to 14 months post-injury. These data were matched at the census tract level with overall SVI percentile rankings. Patients were stratified based on SVI quartiles, with the lowest quartile designated as low SVI, the middle 2 quartiles as average SVI, and the highest quartile as high SVI. Multivariable adjusted regression models were used to assess whether SVI was associated with long-term outcomes after injury. RESULTS: A total of 3153 patients were included [54% male, mean age 61.6 (SD = 21.6)]. The median overall SVI percentile rank was 35th (IQR: 16th-65th). compared to low SVI patients, high SVI patients were more likely to have new functional limitations [odds ratio (OR), 1.51; 95% confidence interval (CI), 1.19-1.92), to not have returned to work (OR, 2.01; 95% CI, 1.40-2.89), and to screen positive for post-traumatic stress disorder (OR, 1.56; 95% CI, 1.12-2.17). Similar results were obtained when comparing average with low SVI patients, with average SVI patients having significantly worse outcomes. CONCLUSIONS: The SVI has potential utility in predicting individuals at higher risk for adverse long-term outcomes after injury. This measure may be a useful needs assessment tool for clinicians and researchers in identifying communities that may benefit most from targeted prevention and intervention efforts.

The impact of the COVID-19 pandemic on functional and mental health outcomes after trauma.

BACKGROUND: The COVID-19 pandemic has led to decreased access to care and social isolation, which have the potential for negative psychophysical effects. We examine the impact of the pandemic on physical and mental health outcomes after trauma. METHODS: Patients in a prospective study were included. The cohort injured during the pandemic was compared to a cohort injured before the pandemic. We performed regression analyses to evaluate the association between the COVID-19 pandemic and physical and mental health outcomes. RESULTS: 1,398 patients were included. In adjusted analysis, patients injured during the pandemic scored significantly worse on the SF-12 physical composite score (OR 2.21; [95% CI 0.69-3.72]; P = 0.004) and were more likely to screen positive for depression (OR 1.46; [1.02-2.09]; P = 0.03) and anxiety (OR 1.56; [1.08-2.26]; P = 0.02). There was no significant difference in functional outcomes. CONCLUSIONS: Patients injured during the COVID-19 pandemic had worse mental health outcomes but not physical health outcomes.

Perceived Socioeconomic Status: A Strong Predictor of Long-Term Outcomes After Injury.

BACKGROUND: Socioeconomic status (SES) is defined as a total measure of an individual's economic or social position in relation to others. Income and educational level are often used as quantifiable objective measures of SES but are inherently limited. Perceived SES (p-SES), refers to an individual's perception of their own SES. Herein, we assess the correlation between objective SES (o-SES) as defined by income and educational level and p-SES after injury and compare their associations with long-term outcomes after injury. METHODS: Moderate-to-severely injured patients admitted to a Level 1 trauma center were asked to complete a phone-based survey assessing functional and mental health outcomes, social dysfunction, chronic pain, and return to work/school 6-12 mo postinjury. o-SES was determined by income and educational level (low educational level: high school or lower; low income: live in zip code with median income/household lower than the national median). p-SES was determined by asking patients to categorize their SES. The correlation coefficient between o-SES and p-SES was calculated. Multivariate logistic regression models were built to determine the associations between o-SES and p-SES and long-term outcomes. RESULTS: A total of 729 patients were included in this study. Patients who reported a low p-SES were younger, more likely to suffer penetrating injuries, and to have a weak social support network. Twenty-one percent of patients with high income and high educational level classified their p-SES as low or mid-low, and conversely, 46% of patients with low education and low income classified their p-SES as high or mid-high. The correlation coefficient between p-SES and o-SES was 0.2513. After adjusting for confounders, p-SES was a stronger predictor of long-term outcomes, including functional limitations, social dysfunction, mental health outcomes, return to work/school, and chronic pain than was o-SES. CONCLUSIONS: Patient-reported p-SES correlates poorly with o-SES indicating that the commonly used calculation of income and education may not accurately capture an individuals' SES. Furthermore, we found p-SES to be more strongly correlated with long-term outcome measures than o-SES. As we strive to improve long-term outcomes after injury, p-SES may be an important variable in the early identification of individuals who are likely to suffer from worse long-term outcomes after injury.

Sangre total leucorreducida y filtro ahorrador de plaquetas preserva su función hemostática por 21 días: ¿La resucitación hemostática podría ser una realidad en Colombia? / Leukoreduced whole blood and platelet-sparing filter preserves its hemostatic function for 21 days: Could hemostatic resuscitation become a reality in Colombia?

Introducción. La resucitación hemostática es una estrategia para compensar la pérdida sanguínea y disminuir el impacto de la coagulación inducida por trauma. Debido a que la disponibilidad de transfundir una razón equilibrada de hemocomponentes es difícil de lograr en el entorno clínico, la sangre total ha reaparecido como una estrategia fisiológica, con ventajas logísticas, que le permiten ser accesible para iniciar tempranamente la resucitación hemostática. El objetivo de este estudio fue evaluar las propiedades celulares, coagulantes y viscoelásticas de la sangre total almacenada por 21 días. Métodos. Las unidades de sangre total fueron obtenidas de 20 donantes voluntarios sanos. Se procesaron mediante un sistema de leucorreducción ahorrador de plaquetas y fueron almacenadas en refrigeración (1-6°C) sin agitación. Se analizaron los días 0, 6, 11 y 21. Las bolsas fueron analizadas para evaluar las líneas celulares, niveles de factores de coagulación y propiedades viscoelásticas mediante tromboelastografía. Resultados. El conteo eritrocitario y la hemoglobina se mantuvieron estables. El conteo de plaquetas tuvo una reducción del 50 % al sexto día, pero se mantuvo estable el resto del seguimiento. Los factores de coagulación II-V-VII-X, fibrinógeno y proteína C se mantuvieron dentro del rango normal. La tromboelastografía mostró una prolongación en el tiempo del inicio de la formación del coágulo, pero sin alterar la formación final de un coágulo estable. Conclusiones. La sangre total leucorreducida y con filtro ahorrador de plaquetas conserva sus propiedades hemostáticas por 21 días. Este es el primer paso en Colombia para la evaluación clínica de esta opción, que permita hacer una realidad universal la resucitación hemostática del paciente con trauma severo.

Background. Hemostatic resuscitation is a strategy to compensate blood loss and reduce the impact of trauma-induced coagulopathy. However, balanced resuscitation presents challenges in its application in the clinical setting. Whole blood has re-emerged as a physiologic strategy with logistical advantages that offer the opportunity for early initiation of hemostatic resuscitation. The study aims to evaluate the cellular, coagulation, and viscoelastic properties of whole blood preserved for 21 days. Methods. Whole blood units were donated by 20 healthy volunteers. These units were processed using a platelet-sparing leukoreduction filtration system. Units were stored under refrigeration (1-6°C) without agitation and were sampled on days 0, 6, 11, 16, and 21. The units were tested to assess its cellular properties and coagulation factors levels. In addition, viscoelastic features were tested using tromboelastography.Results. Red blood cells count and hemoglobin levels remained stables. Platelet count had a 50% reduction on day 6, and then remained stable for 21 days. Factors II-V-VII-X, fibrinogen, and protein C remained within normal range. Tromboelastrography test showed that the reaction time of clot formation is prolonged, but the final clot formation is not altered. Conclusion. Whole blood retains its hemostatic properties for 21 days. This is the first step to evaluate the use of whole blood in the resuscitation protocols for Colombia allowing hemostatic resuscitation become a universal reality.

Evolution of damage control surgery in non-traumatic abdominal pathology: a light in the darkness.

Damage control surgery is based on temporal control of the injury, physiologic recovery and posterior deferred definitive management. This strategy began in the 1980s and became a formal concept in 1993. It has proven to be a strategy that reduces mortality in severely injured trauma patients. Nevertheless, the concept of damage control in non-traumatic abdominal pathology remains controversial. This article aims to gather historical experiences in damage control surgery performed in non-traumatic abdominal emergency pathology patients and present a novel management algorithm. This strategy could be a surgical option to treat hemodynamically unstable patients in catastrophic scenarios such as hemorrhagic and septic shock caused by peritonitis, pancreatitis, acute mesenteric ischemia, among others. Therefore, damage control surgery is light amid better short- and long-term results.

La cirugía de control de daños es una estrategia de control temporal del daño tisular y recuperación fisiológica para un manejo definitivo diferido. Esta estrategia tiene antecedentes en el mundo del trauma desde la década de 1980, hasta su formalización conceptual en 1993. Hasta el momento ha demostrado ser una estrategia factible y que reduce la mortalidad en los pacientes críticamente enfermos. Sin embargo, el manejo de patologías abdominales no traumáticas aun es tema de discusión sobre su factibilidad y seguridad. El presente articulo tiene como objetivo realizar un relato histórico y experiencias en la aplicación de la cirugía de control de daños en emergencias quirúrgicas abdominales no asociadas a trauma y presentar un algoritmo de manejo usando los principios de la cirugía de control de daños. La aplicabilidad del control de daños en no trauma se enfrenta a los contextos de shock hemorrágico y séptico para patologías como peritonitis generalizada, peritonitis postquirúrgica, pancreatitis, isquemia mesentérica aguda, entre otras. Se ha demostrado que el uso de control de daños representa una luz para el cirujano ante la tormenta de la incertidumbre de la descompensación metabólica en el manejo de emergencias abdominales, para crear un puente para su manejo definitivo y permitir anastomosis como estrategia de reconstrucción intestinal y mejorar los resultados a corto y largo plazo.

Long-term Outcomes of Firearm Injury Survivors in the United States: The National Trauma Research Action Plan Scoping Review.

SUMMARY BACKGROUND/OBJECTIVE: To describe the current literature regarding long-term physical, mental, and social outcomes of firearm injury survivors in the United States. METHODS: We systematically searched the PubMed/MEDLINE and Embase databases for articles published from 2013 to 2019 that involved survivors of acute physical traumatic injury aged 18 or older and reported health outcomes between 6 months and 10 years postinjury. Out of 747 articles identified, seven reported outcomes on United States-based civilian patients whose mechanism of injury involved firearms. We extended our publication date criteria from 1995 to 2020 and expanded the search strategy to include medical subject headings terms specific for firearm injury outcomes. Ultimately, ten articles met inclusion criteria. RESULTS: When studied, a significant proportion of patients surviving firearm injury screened positive for posttraumatic stress disorder (49%-60%) or were readmitted (13%-26%) within 6 months postinjury. Most studies reported worse long-term outcomes for firearm injury survivors when compared both to similarly injured motor vehicle collision survivors and to the United States general population, including increased chronic pain, new functional limitations, and reduced physical health composite scores. Studies also reported high rates of posttraumatic stress disorder, reduced mental health composite scores, lower employment and return to work rates, poor social functioning, increased alcohol, and substance abuse. CONCLUSIONS: Research on the long-term health impact of firearm injury is scant, and heterogeneity in available studies limits the ability to fully characterize the outcomes among these patients. A better understanding of the long-term health impact of firearm injury would support systematic change in policy and patient care to improve outcomes.

Impact of the COVID-19 Pandemic on Long-term Recovery From Traumatic Injury.

OBJECTIVE: Determine the proportion and characteristics of traumatic injury survivors who perceive a negative impact of the COVID-19 pandemic on their recovery and to define post-injury outcomes for this cohort. BACKGROUND: The COVID-19 pandemic has precipitated physical, psychological, and social stressors that may create a uniquely difficult recovery and reintegration environment for injured patients. METHODS: Adult (≥18 years) survivors of moderate-to-severe injury completed a survey 6 to 14 months post-injury during the COVID-19 pandemic. This survey queried individuals about the perceived impact of the COVID-19 pandemic on injury recovery and assessed post-injury functional and mental health outcomes. Regression models were built to identify factors associated with a perceived negative impact of the pandemic on injury recovery, and to define the relationship between these perceptions and long-term outcomes. RESULTS: Of 597 eligible trauma survivors who were contacted, 403 (67.5%) completed the survey. Twenty-nine percent reported that the COVID-19 pandemic negatively impacted their recovery and 24% reported difficulty accessing needed healthcare. Younger age, lower perceived-socioeconomic status, extremity injury, and prior psychiatric illness were independently associated with negative perceived impact of the COVID-19 pandemic on injury recovery. In adjusted analyses, patients who reported a negative impact of the pandemic on their recovery were more likely to have new functional limitations, daily pain, lower physical and mental component scores of the Short-Form-12 and to screen positive for PTSD and depression. CONCLUSIONS: The COVID-19 pandemic is negatively impacting the recovery of trauma survivors. It is essential that we recognize the impact of the pandemic on injured patients while focusing on directed efforts to improve the long-term outcomes of this already at-risk population.

Damage control in penetrating duodenal trauma: less is better - the sequel.

The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

El trauma de duodeno comúnmente se produce por un trauma penetrante que puede asociarse a lesiones vasculares y de órganos adyacentes. En el manejo quirúrgico se recomienda realizar un reparo primario o el empleo de técnicas quirúrgicas simples. Sin embargo, el abordaje de lesiones severas del duodeno es un tema controversial. Anteriormente, se han descrito técnicas como la exclusión pilórica o la pancreatoduodenectomía con resultados no concluyentes. El presente artículo presenta una propuesta del manejo de control de daños del trauma penetrante de duodeno, a través, de un algoritmo de cinco pasos. Este algoritmo plantea una solución para el cirujano cuando no es posible realizar el reparo primario. El control de daños del duodeno y su reconstrucción depende de una toma de decisiones respecto a la porción del duodeno lesionada y el compromiso sobre el complejo pancreatoduodenal. Se recomiendan medidas rápidas para contener el daño y se proponen vías de reconstrucción duodenal diferente a las clásicamente descritas. Igualmente, la probabilidad de complicaciones como fistula duodenales es considerable, por lo que proponemos, que el manejo de este tipo de fistulas de alto gasto se aborde por medio de una laparostomía retroperitoneal (lumbotomía). El abordaje del trauma penetrante de duodeno se puede realizar a través del principio "menos es mejor".

Perceived social support is strongly associated with recovery after injury.

BACKGROUND: The strength of one's social support network is a potentially modifiable factor that may have a significant impact on recovery after injury. We sought to assess the association between one's perceived social support (PSS) and physical and mental health outcomes 6 months to 12 months postinjury. METHODS: Moderate to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing physical and mental health outcomes in addition to return to work and chronic pain 6 months to 12 months postinjury. Patients were also asked to rate the strength of their PSS on a 5-point Likert scale. Multivariate linear and logistic regression models were built to determine the association between PSS and postdischarge outcome metrics. RESULTS: Of 907 patients included in this study, 653 (72.0%) identified themselves as having very strong/strong, 182 (20.1%) as average, and 72 (7.9%) as weak/nonexistent PSS. Patients who reported a weak/nonexistent PSS were younger and were more likely to be male, Black, and to have a lower level of education than those who reported a very strong/strong PSS. After adjusting for potential confounders, patients with a weak/nonexistent PSS were more likely to have new functional limitations and chronic pain in addition to being less likely to be back at work/school and being more likely to screen positive for symptoms of posttraumatic stress disorder, depression and anxiety at 6 months to 12 months postinjury than those with a strong/very strong PSS. CONCLUSION: Lower PSS is strongly correlated with worse functional and mental health outcome metrics postdischarge. The strength of one's social support network should be considered when trying to identify patients who are at greatest risk for poor postdischarge outcomes after injury. Our data also lend support to creating a system wherein we strive to build a stronger support network for these high-risk individuals. LEVEL OF EVIDENCE: Prognostic/epidemiologic, level III.

Evolution of damage control surgery in non-traumatic abdominal pathology: a light in the darkness / Evolución de la cirugía de control de daños en patología no traumática abdominal: un faro en medio de la tormenta

Abstract Damage control surgery is based on temporal control of the injury, physiologic recovery and posterior deferred definitive management. This strategy began in the 1980s and became a formal concept in 1993. It has proven to be a strategy that reduces mortality in severely injured trauma patients. Nevertheless, the concept of damage control in non-traumatic abdominal pathology remains controversial. This article aims to gather historical experiences in damage control surgery performed in non-traumatic abdominal emergency pathology patients and present a novel management algorithm. This strategy could be a surgical option to treat hemodynamically unstable patients in catastrophic scenarios such as hemorrhagic and septic shock caused by peritonitis, pancreatitis, acute mesenteric ischemia, among others. Therefore, damage control surgery is light amid better short- and long-term results.

Resumen La cirugía de control de daños es una estrategia de control temporal del daño tisular y recuperación fisiológica para un manejo definitivo diferido. Esta estrategia tiene antecedentes en el mundo del trauma desde la década de 1980, hasta su formalización conceptual en 1993. Hasta el momento ha demostrado ser una estrategia factible y que reduce la mortalidad en los pacientes críticamente enfermos. Sin embargo, el manejo de patologías abdominales no traumáticas aun es tema de discusión sobre su factibilidad y seguridad. El presente articulo tiene como objetivo realizar un relato histórico y experiencias en la aplicación de la cirugía de control de daños en emergencias quirúrgicas abdominales no asociadas a trauma y presentar un algoritmo de manejo usando los principios de la cirugía de control de daños. La aplicabilidad del control de daños en no trauma se enfrenta a los contextos de shock hemorrágico y séptico para patologías como peritonitis generalizada, peritonitis postquirúrgica, pancreatitis, isquemia mesentérica aguda, entre otras. Se ha demostrado que el uso de control de daños representa una luz para el cirujano ante la tormenta de la incertidumbre de la descompensación metabólica en el manejo de emergencias abdominales, para crear un puente para su manejo definitivo y permitir anastomosis como estrategia de reconstrucción intestinal y mejorar los resultados a corto y largo plazo.

Damage control in penetrating duodenal trauma: less is better - the sequel / El control de daños en trauma penetrante de duodeno: "Menos es Mejor

Abstract The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

Resumen El trauma de duodeno comúnmente se produce por un trauma penetrante que puede asociarse a lesiones vasculares y de órganos adyacentes. En el manejo quirúrgico se recomienda realizar un reparo primario o el empleo de técnicas quirúrgicas simples. Sin embargo, el abordaje de lesiones severas del duodeno es un tema controversial. Anteriormente, se han descrito técnicas como la exclusión pilórica o la pancreatoduodenectomía con resultados no concluyentes. El presente artículo presenta una propuesta del manejo de control de daños del trauma penetrante de duodeno, a través, de un algoritmo de cinco pasos. Este algoritmo plantea una solución para el cirujano cuando no es posible realizar el reparo primario. El control de daños del duodeno y su reconstrucción depende de una toma de decisiones respecto a la porción del duodeno lesionada y el compromiso sobre el complejo pancreatoduodenal. Se recomiendan medidas rápidas para contener el daño y se proponen vías de reconstrucción duodenal diferente a las clásicamente descritas. Igualmente, la probabilidad de complicaciones como fistula duodenales es considerable, por lo que proponemos, que el manejo de este tipo de fistulas de alto gasto se aborde por medio de una laparostomía retroperitoneal (lumbotomía). El abordaje del trauma penetrante de duodeno se puede realizar a través del principio "menos es mejor".

Long-term patient-reported outcomes and patient-reported outcome measures after injury: the National Trauma Research Action Plan (NTRAP) scoping review.

BACKGROUND: The aim of this scoping review is to identify and summarize patient-reported outcome measures (PROMs) that are being used to track long-term patient-reported outcomes (PROs) after injury and can potentially be included in trauma registries. METHODS: Online databases were used to identify studies published between 2013 and 2019, from which we selected 747 articles that involved survivors of acute physical traumatic injury aged 18 years or older at time of injury and used PROMs to evaluate recovery between 6 months and 10 years postinjury. Data were extracted and summarized using descriptive statistics and a narrative synthesis of the results. RESULTS: Most studies were observational, with relatively small sample sizes, and predominantly on traumatic brain injury or orthopedic patients. The number of PROs assessed per study varied from one to 12, for a total of 2052 PROs extracted, yielding 74 unique constructs (physical health, 25 [34%]; mental health, 27 [37%]; social health, 12 [16%]; cognitive health, 7 [10%]; and quality of life, 3 [4%]). These 74 constructs were assessed using 355 different PROMs. Mental health was the most frequently examined outcome domain followed by physical health. Health-related quality of life, which appeared in more than half of the studies (n = 401), was the most common PRO evaluated, followed by depressive symptoms. Physical health was the domain with the highest number of PROMs used (n = 157), and lower-extremity functionality was the PRO that contributed most PROMs (n = 33). CONCLUSION: We identified a wide variety of PROMs available to track long-term PROs after injury in five different health domains: physical, mental, social, cognitive, and quality of life. However, efforts to fully understand the health outcomes of trauma patients remain inconsistent and insufficient. Defining PROs that should be prioritized and standardizing the PROMs to measure them will facilitate the incorporation of long-term outcomes in national registries to improve research and quality of care. LEVEL OF EVIDENCE: Systematic Reviews & Meta-analyses, Level IV.