Surgical Management of Upper Gastrointestinal Bleeding.

The use of surgery in managing upper gastrointestinal (GI) bleeding has rapidly diminished secondary to advances in our understanding of the pathologies that underlie upper GI bleeding, pharmaceutical treatments for peptic ulcer disease, and endoscopic procedures used to gain hemostasis. A surgeon must work collaboratively with gastroenterologist and interventional radiologist to determine when, and what kind of, surgery is appropriate for the patient with upper GI bleeding.

Emergency general surgery verification: Quality improvement and the case for optimal resources and process standards.

ABSTRACT: Patients with emergency general surgery (EGS) diagnoses comprise over 10% of all hospital admissions, resulting in a projected number of 4.2 million admissions for 2023. Approximately 25% will require emergency surgical intervention, half will sustain a postoperative complication, and 15% will have a readmission within the first 30 days of surgery. In the face of this growing public health burden and to better meet the needs of these acutely ill patients, it was recognized that a formal quality improvement program, including standardization of data collection and the development of systems of care specifically for EGS have been lacking. Establishing standardized processes for quality improvement, including a national databank, and maintaining adherence to these processes as ensured by a robust verification process has improved outcomes research and patient care in the field of trauma, another time-sensitive specialty. In response to this perceived deficit, the "Optimal Resources for Emergency General Surgery" was developed. An extension of the current National Surgical Quality Improvement Program platform, specifically for operative and non-operative EGS cases, was developed and implemented. A robust set of standards were outlined to verify EGS programs/services. Defining the elements of an effective EGS program and developing hospital and practice standards consolidated EGS as an integral component of Acute Care Surgery. The verification program addresses a societal need and allows hospitals to better organize EGS care delivery and benchmark their results nationally.

Management of blunt splenic injury: down the rabbit hole and into the bucket.

Management of splenic trauma has changed dramatically over the past 30 years. Many of these advances were driven by the Memphis team under the leadership of Dr. Timothy Fabian. This review article summarizes some of those changes in clinical care, especially related to nonoperative management and angioembolization.

Empiric tranexamic acid use provides no benefit in urgent orthopedic surgery following injury.

Background: Orthopedic literature has demonstrated a significant decrease in postoperative transfusion requirements when tranexamic acid (TXA) was given during elective joint arthroplasty. The purpose of this study was to evaluate the empiric use of TXA in semi-urgent orthopedic procedures following injury. We hypothesized that TXA would be associated with increased rates of venous thromboembolic events (VTE) and have no effect on transfusion requirements. Methods: Patients who empirically received TXA during a semi-urgent orthopedic surgery following injury (TXA+) were matched using propensity scoring to historical controls (CONTROL) who did not receive TXA. Outcomes included VTE within 6 months of injury and packed red blood cell utilization. Multivariable logistic regression and generalized linear modeling were used to determine odds of VTE and transfusion. Results: 200 patients were included in each group. There was no difference in mortality between groups. TXA+ patients did not have an increase in VTE events (OR 0.680, 95% CI 0.206 to 2.248). TXA+ patients had a significantly higher odds of being transfused during their hospital stay (OR 2.175, 95% CI 1.246 to 3.797) and during the index surgery (increased 0.95 units (SD 0.16), p<0.0001). Overall transfusion was also significantly higher in the TXA+ group (p=0.0021). Conclusion: Empiric use of TXA in semi-urgent orthopedic surgeries did not increase the odds of VTE. Despite the elective literature, TXA administration did not associate with less transfusion requirements. A properly powered, prospective, randomized trial should be designed to elucidate the risks and benefits associated with TXA use in this setting. Level of evidence: Level IV.

Admission Thromboelastography at the Intersection of Traumatic Coagulopathy and Inflammation: A Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) Study Subanalysis.

BACKGROUND: Acute traumatic coagulopathy (ATC) has many phenotypes and varying morbidity and mortality. The MA-R ratio, calculated from the admission thromboelastogram, serves as a biomarker to identify 1 phenotype of ATC and has previously been associated with significant derangements in the inflammatory response. This study evaluates outcomes related to abnormal MA-R ratios, including inflammatory responses, in a heterogeneous patient population. STUDY DESIGN: Patients from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) dataset were included. The MA-R ratio was calculated from admission thromboelastography, with a CRITICAL ratio defined as 11 or less. Key inflammatory mediators were identified as a priori. Cytokine expression was assessed during 24 hours using multivariable logistic regression. RESULTS: Significant elevations in the proinflammatory cytokines IL-1b, IL-6, and IL-8, as well as in the chemokines eotaxin, IFN-γ-induced protein 10, monocyte chemoattractant protein-1, and macrophage inflammatory protein-1ß, persisted during the first 24 hours. CRITICAL patients had significantly lower survival at 1, 3, 6, 12, and 18 hours and demonstrated significantly increased ARDS (odds ratio [OR] 1.817, 95% CI 1.082 to 3.051, p = 0.0239). CRITICAL patients had fewer ICU-free days (CRITICAL, 10 days, interquartile range [IQR] 0 to 25; vs NORMAL, 22 days, IQR 4 to 26, p < 0.0001) and fewer ventilator-free days (CRITICAL, 15 days, IQR 0 to 28; vs NORMAL, 26 days, IQR 9 to 28, p < 0.0001). CRITICAL patients were protected against systemic inflammatory response (OR 0.521, 95% CI 0.322 to 0.816, p = 0.0044). CONCLUSIONS: The subtype of ATC identified by the low MA-R ratio is associated with significant elevations in multiple proinflammatory cytokines at admission. Early mortality remains elevated in the CRITICAL group, in part due to coagulopathy. The MA-R ratio at admission is associated with a particularly morbid type of coagulopathy, associated with significant alterations in the inflammatory response after severe injury in heterogeneous patient populations.

Patients Follow Different Financial Hardship Trajectories in the Year after Injury.

OBJECTIVE: To determine if distinct financial trajectories exist and if they are associated with quality-of-life outcomes. SUMMARY OF BACKGROUND DATA: Financial hardship after injury measurably impacts Health-Related Quality of Life outcomes. Financial hardship, encompassing material losses, financial worry, and poor coping mechanisms, is associated with lower quality of life and increased psychological distress. However, recovery is dynamic and financial hardship may change over time. METHODS: This is a secondary analysis of a cohort of 500 moderate-to-severe nonneurologic injured patients in which financial hardship and Health-related Quality of Life outcomes were measured at 1, 2, 4, and 12 months after injury using survey instruments (Short Form-36). Enrollment occurred at an urban, academic, Level 1 trauma center in Memphis, Tennessee during January 2009 to December 2011 and follow-up completed by December 2012. RESULTS: Four hundred seventy-four patients had sufficient data for Group- Based Trajectory Analysis. Four distinct financial hardship trajectories were identified: Financially Secure patients (8.6%) had consistently low hardship over time; Financially Devastated patients had a high degree of hardship immediately after injury and never recovered (51.6%); Financially Frail patients had increasing hardship over time (33.6%); and Financially Resilient patients started with a high degree of hardship but recovered by year end (6.2%). At 12-months, all trajectories had poor Short Form-36 physical component scores and the Financial Frail and Financially Devastated trajectories had poor mental health scores compared to US population norms. CONCLUSIONS AND RELEVANCE: The Financially Resilient trajectory demonstrates financial hardship after injury can be overcome. Further research into understanding why and how this occurs is needed.

Which hospital-acquired conditions matter the most in trauma? An evidence-based approach for prioritizing trauma program improvement.

BACKGROUND: Prevention of hospital-acquired conditions (HACs) is a focus of trauma center quality improvement. The relative contributions of various HACs to postinjury hospital outcomes are unclear. We sought to quantify and compare the impacts of six HACs on early clinical outcomes and resource utilization in hospitalized trauma patients. METHODS: Adult patients from the 2013 to 2016 American College of Surgeons Trauma Quality Improvement Program Participant Use Data Files who required 5 days or longer of hospitalization and had an Injury Severity Score of 9 or greater were included. Multiple imputation with chained equations was used for observations with missing data. The frequencies of six HACs and five adverse outcomes were determined. Multivariable Poisson regression with log link and robust error variance was used to produce relative risk estimates, adjusting for patient-, hospital-, and injury-related factors. Risk-adjusted population attributable fractions estimates were derived for each HAC-outcome pair, with the adjusted population attributable fraction estimate for a given HAC-outcome pair representing the estimated percentage decrease in adverse outcome that would be expected if exposure to the HAC had been prevented. RESULTS: A total of 529,856 patients requiring 5 days or longer of hospitalization were included. The incidences of HACs were as follows: pneumonia, 5.2%; urinary tract infection, 3.4%; venous thromboembolism, 3.3%; surgical site infection, 1.3%; pressure ulcer, 1.3%; and central line-associated blood stream infection, 0.2%. Pneumonia demonstrated the strongest association with in-hospital outcomes and resource utilization. Prevention of pneumonia in our cohort would have resulted in estimated reductions of the following: 22.1% for end organ dysfunction, 7.8% for mortality, 8.7% for prolonged hospitalization, 7.1% for prolonged intensive care unit stay, and 6.8% for need for mechanical ventilation. The impact of other HACs was comparatively small. CONCLUSION: We describe a method for comparing the contributions of HACs to outcomes of hospitalized trauma patients. Our findings suggest that trauma program improvement efforts should prioritize pneumonia prevention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Variations in clot phenotype following injury: The MA-R ratio and fragile clots.

INTRODUCTION: Trauma-induced coagulopathy is a continuum ranging from hypercoagulable to hypercoagulable phenotypes. In single-center studies, the maximum amplitude (MA) to r-time (R) (MA-R) ratio has identified a phenotype of injured patients with high mortality risk. The purpose of this study was to determine the relationship between MA-R and mortality using multicenter data and to investigate fibrinogen consumption in the development of this specific coagulopathy phenotype. METHODS: Using the Pragmatic Randomized Optimal Platelet and Plasma Ratios data set, patients were divided into blunt and penetrating injury cohorts. MA was divided by R time from admission thromboelastogram to calculate MA-R. MA-R was used to assess odds of early and late mortality using multivariable models. Multivariable models were used to assess thrombogram values in both cohorts. Refinement of the MA-R cut point was performed with Youden index. Repeat multivariable analysis was performed with a binary CRITICAL and NORMAL MA-R. RESULTS: In initial analysis, MA-R quartiles were not associated with mortality in the penetrating cohort. In the blunt cohort, there was an association between low MA-R and early and late mortality. A refined cut point of 11 was identified (CRITICAL: MA-R, ≤11; NORMAL: MA-R, >11). CRITICAL MA-R was associated with mortality in both penetrating and blunt subgroups. In further injury subgroup analysis, CRITICAL patients had significantly decreased fibrinogen levels in the blunt subgroup only. In both blunt and penetrating injury, there was no difference in time to initiation of thrombin burst (lagtime). However, both endogenous thrombin potential and peak thrombin levels were significantly lower in CRITICAL patients. CONCLUSIONS: MA-R identifies a trauma-induced coagulopathy phenotype characterized in blunt injury by impaired thrombin generation that is associated with early and late mortality. The endotheliopathy and tissue factor release likely plays a role in the cascade of impaired thrombin burst, possible early fibrinogen consumption and the weaker clot identified by MA-R. LEVEL OF EVIDENCE: Therapeutic/care management, level II.

Treatment of asymptomatic blunt cerebrovascular injury (BCVI): a systematic review.

BACKGROUND: The management of asymptomatic blunt cerebrovascular injury (BCVI) with respect to stroke prevention and vessel healing is challenging. OBJECTIVES: The aim of this systematic review was to determine if a specific treatment results in lower stroke rates and/or improved vessel healing in asymptomatic BCVI. DATA SOURCES: An electronic literature search of MEDLINE, EMBASE, Cochrane Library, CINAHL, SCOPUS, Web of Science, and ClinicalTrials.gov performed from inception to March 2020. STUDY ELIGIBILITY CRITERIA: Studies were included if they reported on a comparison of any treatment for BCVI and stroke and/or vessel healing rates. PARTICIPANTS AND INTERVENTIONS: Adult patients diagnosed with asymptomatic BCVI(s) who were treated with any preventive medication or procedure. STUDY APPRAISAL AND SYNTHESIS METHODS: All studies were systematically reviewed and bias was evaluated by the Newcastle-Ottawa Scale. No meta-analysis was performed secondary to significant heterogeneity across studies in patient population, screening protocols, and treatment selection. The main outcomes were stroke and healing rate. RESULTS: Of 8781 studies reviewed, 19 reported on treatment effects for asymptomatic BCVI and were included for review. Any choice of medical management was better than no treatment, but no specific differences between choice of medical management and stroke outcomes were found. Vessel healing was rare and the majority of healed vessels were following low-grade injuries. LIMITATIONS: Majority of the included studies were retrospective and at high risk of bias. CONCLUSIONS OR IMPLICATIONS OF KEY FINDINGS: Asymptomatic BCVI should be treated medically using a consistent, local protocol. High-quality studies on the effect of individual antithrombotic agents on stroke rates and vessel healing for asymptomatic BCVI are required.

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry.

BACKGROUND: Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS: Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS: Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION: Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE: Epidemiological III; Therapeutic IV.

Comparison of a trauma comorbidity index with other measures of comorbidities to estimate risk of trauma mortality.

BACKGROUND: Comorbidities influence the outcomes of injured patients, yet a lack of consensus exists regarding how to quantify that association. This study details the development and internal validation of a trauma comorbidity index (TCI) designed for use with trauma registry data and compares its performance to other existing measures to estimate the association between comorbidities and mortality. METHODS: Indiana state trauma registry data (2013-2015) were used to compare the TCI with the Charlson and Elixhauser comorbidity indices, a count of comorbidities, and comorbidities as separate variables. The TCI approach utilized a randomly selected training cohort and was internally validated in a distinct testing cohort. The C-statistic of the adjusted models was tested using each comorbidity measure in the testing cohort to assess model discrimination. C-statistics were compared using a Wald test, and stratified analyses were performed based on predicted risk of mortality. Multiple imputation was used to address missing data. RESULTS: The study included 84,903 patients (50% each in training and testing cohorts). The Indiana TCI model demonstrated no significant difference between testing and training cohorts (p = 0.33). It produced a C-statistic of 0.924 in the testing cohort, which was significantly greater than that of models using the other indices (p < 0.05). The C-statistics of models using the Indiana TCI and the inclusion of comorbidities as separate variables-the method used by the American College of Surgeons Trauma Quality Improvement Program-were comparable (p = 0.11) but use of the TCI approach reduced the number of comorbidity-related variables in the mortality model from 19 to one. CONCLUSIONS: When examining trauma mortality, the TCI approach using Indiana state trauma registry data demonstrated superior model discrimination and/or parsimony compared to other measures of comorbidities.

Blueprint for Restructuring a Department of Surgery in Concert With the Health Care System During a Pandemic: The University of Wisconsin Experience.

The current health care environment is complex. Systems often cross US state boundaries to provide care to patients with a wide variety of medical needs. The coronavirus disease 2019 pandemic is challenging health care systems across the globe. Systems face varying levels of complexity as they adapt to the new reality. This pandemic continues to escalate in hot spots nationally and internationally, and the worst strain on health care systems may be yet to come. The purpose of this article is to provide a road map developed from lessons learned from the experience in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health and University of Wisconsin Health, based on past experience with incident command structures in military combat operations and Federal Emergency Management Agency responses. We will discuss administrative restructuring leveraging a team-of-teams approach, provide a framework for deploying the workforce needed to deliver all necessary urgent health care and critical care to patients in the system, and consider implications for the future.

The electric scooter: A surging new mode of transportation that comes with risk to riders.

Objective: The proliferation of electric scooter sharing companies has inundated many municipalities with electric scooters. The primary objective of this study is to characterize the epidemiology of injuries from this new mode of transportation in order to inform injury prevention efforts.Methods: A multicenter, retrospective study was conducted at two level 1 trauma centers in an urban setting. Patients seen in the emergency department from September 4, 2018 to November 4, 2018 were included if injury coding and chart review identified a scooter-related injury. Demographics, injury patterns, and other injury related factors were obtained via chart review.Results: Ninety-two patients were identified over the study period in 2018 with electric scooter-related injuries. Of the patients utilizing an electric scooter; none used protective gear and 33% used alcohol prior to presentation. More than 60% of patients required medical intervention including laceration repair (26%), fracture reduction (17%), operative fixation of a fracture (7%), or arterial embolization for an associated arterial injury (1%). Approximately 10% of patients required inpatient admission and one required an admission to the intensive care unit.Conclusion: We found a substantial increase in the number of scooter-related injuries during the first two months of electric scooter legalization. There was a lack of safety equipment utilization and concomitant alcohol utilization was common. These may offer areas of focus for injury prevention efforts. Additionally, standardization of injury coding for electric scooter related injury is critical to future studies and will help better understand the impact of this new mode of transportation.

Insights into the association between coagulopathy and inflammation: abnormal clot mechanics are a warning of immunologic dysregulation following major injury.

BACKGROUND: Severe injury initiates a complex physiologic response encompassing multiple systems and varies phenotypically between patients. Trauma-induced coagulopathy may be an early warning of a poorly coordinated response at the molecular level, including a deleterious immunologic response and worsening of shock states. The onset of trauma-induced coagulopathy (TIC) may be subtle however. In previous work, we identified an early warning sign of coagulopathy from the admission thromboelastogram, called the MAR ratio. We hypothesized that a low MAR ratio would be associated with specific derangements in the inflammatory response. METHODS: In this prospective, observational study, 88 blunt trauma patients admitted to the intensive care unit (ICU) were identified. Concentrations of inflammatory mediators were recorded serially over the course of a week and the MAR ratio was calculated from the admission thromboelastogram. Correlation analysis was used to assess the relationship between MAR and inflammatory mediators. Dynamic network analysis was used to assess coordination of immunologic response. RESULTS: Seventy-nine percent of patients were male and mean age was 37 years (SD 12). The mean ISS was 30.2 (SD 12) and mortality was 7.2%. CRITICAL patients (MAR ratio ≤14.2) had statistically higher shock volumes at three time points in the first day compared to NORMAL patients (MAR ratio >14.2). CRITICAL patients had significant differences in IL-6 (P=0.0065), IL-8 (P=0.0115), IL-10 (P=0.0316) and MCP-1 (P=0.0039) concentrations compared to NORMAL. Differences in degree of expression and discoordination of immune response continued in CRITICAL patients throughout the first day. CONCLUSIONS: The admission MAR ratio may be the earliest warning signal of a pathologic inflammatory response associated with hypoperfusion and TIC. A low MAR ratio is an early indication of complicated dysfunction of multiple molecular processes following trauma.

Impact of Patient Frailty on Morbidity and Mortality after Common Emergency General Surgery Operations.

BACKGROUND: Frailty has been increasingly recognized as a modifiable risk factor prior to elective general surgery. There is limited evidence regarding the association of frailty with perioperative outcomes after specific emergency general surgery procedures. MATERIAL AND METHODS: A retrospective cohort study of 57,173 patients older than 40 y of age from 2010 to 2014 American College of Surgeons National Surgical Quality Improvement Program underwent appendectomy, cholecystectomy, large bowel resection, small bowel resection, or nonbowel resection (lysis of adhesion, ileostomy creation) on an emergent basis. Preoperative modified frailty index (mFI) was determined for each patient and was used in a multivariable logistic regression to determine the association with perioperative morbidity, mortality, and discharge destination. RESULTS: A total of 57,173 patients (46% men, mean [SD] age 60 [13] y) underwent an emergency appendectomy (n = 26,067), cholecystectomy (n = 8138), large bowel resection (n = 12,107), small bowel resection (n = 6503), or nonbowel resection (n = 4358). Among them, 14,300 (25.0%) experienced any perioperative complication, and 12,668 (22.2%) experienced a serious complication with an overall 30-d mortality of 5.1%. Highly frail patients had a 30-d mortality of 19.0% across all five operations. In multivariable analysis, mFI was associated with any complication and 30-d mortality in a step-wise fashion for each emergency operation. Intermediate and high mFI were also inversely associated with discharge home for each operation. CONCLUSIONS: Frailty is associated with increased perioperative morbidity and mortality in common emergency general surgery operations. Frailty should be assessed by surgeons to inform decisions on operative intervention and to inform patients/families on expected outcomes.

The Utility of Rivaroxaban as Primary Venous Thromboprophylaxis in an Adult Trauma Population.

BACKGROUND: Venous thromboembolism (VTE) is a frequent and morbid complication after injury. Despite utilization of twice-daily enoxaparin, a significant proportion of patients still develop VTE. The purpose of this study was to compare the safety and efficacy of rivaroxaban to enoxaparin for the prevention of VTE in patients with multisystem injuries. MATERIALS AND METHODS: This retrospective cohort analysis evaluated VTE rate in multiply injured patients at a level I trauma Center. Propensity matching was used to compare patients receiving rivaroxaban or enoxaparin. The primary outcome was incidence of VTE during or up to 6 mo after admission. Secondary outcomes included major and minor bleeding, hospital mortality, and hospital length of stay. RESULTS: A total of 2106 patients were randomly selected from the entire cohort for inclusion. Patients who developed a VTE with no significant difference between groups (14 [1.3%] in the rivaroxaban group and 14 [1.3%] in the enoxaparin group, P = 1) was 1.3%. In addition, there was no difference in deep venous thrombosis (10 [0.9%] in the rivaroxaban group and 12 [1.1%] in the enoxaparin group) or pulmonary embolism (6 [0.6%] in the rivaroxaban group and 2 [0.2%] in the enoxaparin group). Incidence of bleeding, minor or major, was equivalent between groups (P > 0.05). Hospital length of stay and mortality were significantly higher in the enoxaparin group compared with rivaroxaban (11 [1.0%] versus 0 [0%] respectively, P < 0.001). CONCLUSIONS: Rivaroxaban demonstrated a similar incidence of VTE and bleeding complications as enoxaparin. Rivaroxaban may be a safe and effective alternative for VTE prophylaxis in this high-risk population.

NSTI Organisms and Regions: A Multicenter Study From the American Association for the Surgery of Trauma.

BACKGROUND: Conflicting data on the microbiology and epidemiology of necrotizing soft tissue infections (NSTIs) appear to stem from the heterogeneity in microbiology observed in regions across the United States. Our goal was to determine current differences in organism prevalence and outcomes for NSTI and non-necrotizing severe soft tissue infections across the United States. We hypothesized that there were geographical differences in organism prevalence that would lead to differences in outcomes. MATERIALS AND METHODS: This study was a retrospective multi-institutional trial from centers across the United States and Canada. Demographic, clinical, and outcomes data were collected. Bivariate and multivariable analyses were performed to determine the effects of region and microbiology on outcomes. RESULTS: A total of 622 patients were included in this study. Polymicrobial infections (45%) were the most prevalent infections in all regions. On bivariate analysis, Clostridium and polymicrobial infections had higher mean Laboratory Risk Indicator for Necrotizing Fasciitis scores and American Association for the Surgery of Trauma grades (P < 0.001 for both) than other organisms. Patients in the South were more likely to be uninsured and had worse unadjusted outcomes. In a risk-adjusted model, increasing American Association for the Surgery of Trauma grade was predictive of mortality (OR, 2.3; 95% CI, 1.6-3.1; P < 0.001), as was age ≥ 55 y (OR 2.7, 95% CI 1.3-5.3, P = 0.006), but region and organism type were not associated with mortality. CONCLUSIONS: We found important regional differences with respect to organism type and demographics. However, on risk-adjusted models, neither region nor organism type predicted mortality.

Financial toxicity is associated with worse physical and emotional long-term outcomes after traumatic injury.

BACKGROUND: Increasing health care costs and high deductible insurance plans have shifted more responsibility for medical costs to patients. After serious illnesses, financial responsibilities may result in lost wages, forced unemployment, and other financial burdens, collectively described as financial toxicity. Following cancer treatments, financial toxicity is associated with worse long-term health-related quality of life (HRQoL) outcomes. The purpose of this study was to determine the incidence of financial toxicity following injury, factors associated with financial toxicity, and the impact of financial toxicity on long-term HRQoL. METHODS: Adult patients with an Injury Severity Score of 10 or greater and without head or spinal cord injury were prospectively followed for 1 year. The Short-Form-36 was used to determine overall quality of life at 1 month, 2 months, 4 months, and 12 months. Screens for depression and posttraumatic stress syndrome were administered. The primary outcome was any financial toxicity. A multivariable generalized estimating equation was used to account for variability over time. RESULTS: Five hundred patients were enrolled, and 88% suffered financial toxicity during the year following injury (64% reduced income, 58% unemployment, 85% experienced stress due to financial burden). Financial toxicity remained stable over follow-up (80-85%). Factors independently associated with financial toxicity were lower age (odds ratio [OR], 0.96 [0.94-0.98]), lack of health insurance (OR, 0.28 [0.14-0.56]), and larger household size (OR, 1.37 [1.06-1.77]). After risk adjustment, patients with financial toxicity had worse HRQoL, and more depression and posttraumatic stress syndrome in a stepwise fashion based on severity of financial toxicity. CONCLUSION: Financial toxicity following injury is extremely common and is associated with worse psychological and physical outcomes. Age, lack of insurance, and large household size are associated with financial toxicity. Patients at risk for financial toxicity can be identified, and interventions to counteract the negative effects should be developed to improve long-term outcomes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction.

In April 2017, the American Association for the Surgery of Trauma (AAST) asked the AAST Patient Assessment Committee to undertake a gap analysis for published clinical practice guidelines in emergency general surgery (EGS). Committee members performed literature searches to catalogue published guidelines for common EGS diseases and also to identify gaps in the literature where guidelines could be created. For five of the most common EGS conditions, acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstruction, we found multiple well-referenced guidelines published by leading professional organizations. We have summarized guideline recommendations for each of these disease states stratified by the AAST EGS anatomic severity score based on these published consensus guidelines. These summaries could be used to help inform evidence-based clinical decision-making, but are intended to be flexible and updatable in real time as further research emerges. Comprehensive guidelines were available for all of the diseases queried and identified gaps most commonly represented areas lacking a solid evidence base. These are therefore areas where further research is needed.

The EGS grading scale for skin and soft-tissue infections is predictive of poor outcomes: a multicenter validation study.

INTRODUCTION: Over the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs). METHODS: This multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability. RESULTS: 1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well. CONCLUSION: This validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes. LEVEL OF EVIDENCE: Prognostic/Epidemiologic retrospective multicenter trial, level III.