Admission Triage With Pain, Inspiratory Effort, Cough Score can Predict Critical Care Utilization and Length of Stay in Isolated Chest Wall Injury.

INTRODUCTION: Damage to the thoracic cage is common in the injured patient, both when the injuries are confined to this single cavity and as part of the overall injury burden of a polytraumatized patient. In a subset of these patients, the severity of injury to the intrathoracic viscera is either underappreciated at admission or blossom over the following 48-72 h. The ability to promptly identify these patients and abrogate complications therefore requires triage of such at-risk patients to close monitoring in a critical care environment. At our institution, this triage hinges on the Pain, Inspiratory effort, Cough (PIC) score, which generates a composite unitless score from a nomogram which aggregates several variables-patient-reported Pain visual analog scale, Incentive spirometry effort, and the perceived adequacy of Cough. We thus sought to audit PIC's discriminant power in predicting intensive care unit (ICU) need. METHODS: This retrospective cohort study was performed at an urban, academic, level 1 trauma center. All isolated chest wall injuries (excluded any Abbreviated Injury Score >2 in head or abdomen) from January 2020 to June 2021 were identified in the local trauma registry. The electronic medical record was queried for standard demographics, admission PIC score, postadmission destination, ICU and hospital length of stay (LOS), and any unplanned admissions to the ICU. Chi-squared tests were used to determine differences between PIC score outcomes and the recursive partitioning method correlated admission PIC score to ICU LOS. RESULTS: Two hundred and thirty six isolated chest wall injury patients were identified, of whom 194 were included in the final analysis. The median age was 60 (interquartile range [IQR] 50-74) years, 63.1% were male, and the median (IQR) number of rib fractures was 3.0 (2.0-5.0). A cutoff PIC score of 7 or lower was associated with ICU admission (odds ratio [OR] 95% CI: 8.19 [3.39-22.55], P < 0.001 with a PPV = 41.4%, NPV = 91%), and with ICU admission for greater than 48 h [OR (95% CI): 26.86 (5.5-43.96), P < 0.001, with a PPV = 25.9%, NPV = 98.7%] but not anatomic injury severity score, hospital LOS or ICU, or the requirement for mechanical ventilation. The association between PIC score 7 or below and the presence of bilateral fractures, flail chest, or sternal fracture did not meet statistical significance. The accurate cut point of the PIC score to predict ICU admission over 48 h in our retrospective cohort was calculated as PIC ≤ 7 for P = 0.013 and PIC ≤ 6 for P = 0.001. CONCLUSIONS: Patients with isolated chest wall injuries require effective reproducible triage for ICU-level care. The PIC score appears to be a moderate discriminator of critical care need, per se, as judged by our recorded complication rate requiring critical care intervention. This vigilance may pay dividends in early detection and abrogation of respiratory failure emergencies. Furthermore, PIC score delineation for ICU need appears to be appropriate at 7 or less; this threshold can be used during admission triage to guide care.

Practice patterns and clinical outcomes in acute appendicitis differ in the elderly patient.

BACKGROUND: Appendicitis is the most frequent global abdominal surgical emergency. An ageing population, who often exhibit atypical symptoms and delayed presentations, challenge conventional diagnostic and treatment paradigms. OBJECTIVES: This study aims to delineate disparities in presentation, management, and outcomes between elderly patients and younger adults suffering from acute appendicitis. METHODS: This subgroup analysis forms part of ESTES SnapAppy, a time-bound multi-center prospective, observational cohort study. It includes patients aged 15 years and above who underwent laparoscopic appendectomy during a defined 90-day observational period across multiple centers. Statistical comparisons were performed using appropriate tests with significance set at p < 0.05. RESULTS: The study cohort comprised 521 elderly patients (≥65 years) and 4,092 younger adults (18-64 years). Elderly patients presented later (mean duration of symptoms: 7.88 vs. 3.56 days; p < 0.001) and frequently required computed tomography (CT) scans for diagnosis (86.1% vs. 54.0%; p < 0.001). The incidence of complicated appendicitis was higher in the elderly (46.7% vs. 20.7%; p < 0.001). Delays in surgical intervention were notable in the elderly (85.0% operated within 24 h vs. 88.7%; p = 0.018), with longer operative times (71.1 vs. 60.3 min; p < 0.001). Postoperative complications were significantly higher in the elderly (27.9% vs. 12.9%; p < 0.001), including severe complications (6.9% vs. 2.4%; p < 0.001) and prolonged hospital stays (7.9 vs. 3.6 days; p < 0.001). CONCLUSIONS: Our findings highlight significant differences in the clinical course and outcomes of acute appendicitis in the elderly compared to younger patients, suggesting a need for age-adapted diagnostic pathways and treatment strategies to improve outcomes in this vulnerable population.

European society for trauma and emergency surgery member-identified research priorities in emergency surgery: a roadmap for future clinical research opportunities.

BACKGROUND: European Society for Trauma and Emergency Surgery (ESTES) is the European community of clinicians providing care to the injured and critically ill surgical patient. ESTES has several interlinked missions - (1) the promotion of optimal emergency surgical care through networked advocacy, (2) promulgation of relevant clinical cognitive and technical skills, and (3) the advancement of scientific inquiry that closes knowledge gaps, iteratively improves upon surgical and perioperative practice, and guides decision-making rooted in scientific evidence. Faced with multitudinous opportunities for clinical research, ESTES undertook an exercise to determine member priorities for surgical research in the short-to-medium term; these research priorities were presented to a panel of experts to inform a 'road map' narrative review which anchored these research priorities in the contemporary surgical literature. METHODS: Individual ESTES members in active emergency surgery practice were polled as a representative sample of end-users and were asked to rank potential areas of future research according to their personal perceptions of priority. Using the modified eDelphi method, an invited panel of ESTES-associated experts in academic emergency surgery then crafted a narrative review highlighting potential research priorities for the Society. RESULTS: Seventy-two responding ESTES members from 23 countries provided feedback to guide the modified eDelphi expert consensus narrative review. Experts then crafted evidence-based mini-reviews highlighting knowledge gaps and areas of interest for future clinical research in emergency surgery: timing of surgery, inter-hospital transfer, diagnostic imaging in emergency surgery, the role of minimally-invasive surgical techniques and Enhanced Recovery After Surgery (ERAS) protocols, patient-reported outcome measures, risk-stratification methods, disparities in access to care, geriatric outcomes, data registry and snapshot audit evaluations, emerging technologies interrogation, and the delivery and benchmarking of emergency surgical training. CONCLUSIONS: This manuscript presents the priorities for future clinical research in academic emergency surgery as determined by a sample of the membership of ESTES. While the precise basis for prioritization was not evident, it may be anchored in disease prevalence, controversy around aspects of current patient care, or indeed the identification of a knowledge gap. These expert-crafted evidence-based mini-reviews provide useful insights that may guide the direction of future academic emergency surgery research efforts.

Gamification in Critical Care Education and Practice.

OBJECTIVES: To explore gamification as an alternative approach to healthcare education and its potential applications to critical care. DATA SOURCES: English language manuscripts addressing: 1) gamification theory and application in healthcare and critical care and 2) implementation science focused on the knowledge-to-practice gap were identified in Medline and PubMed databases (inception to 2023). STUDY SELECTION: Studies delineating gamification underpinnings, application in education or procedural mentoring, utilization for healthcare or critical care education and practice, and analyses of benefits or pitfalls in comparison to other educational or behavioral modification approaches. DATA EXTRACTION: Data indicated the key gamification tenets and the venues within which they were used to enhance knowledge, support continuing medical education, teach procedural skills, enhance decision-making, or modify behavior. DATA SYNTHESIS: Gamification engages learners in a visual and cognitive fashion using competitive approaches to enhance acquiring new knowledge or skills. While gamification may be used in a variety of settings, specific design elements may relate to the learning environment or learner styles. Additionally, solo and group gamification approaches demonstrate success and leverage adult learning theory elements in a low-stress and low-risk setting. The potential for gamification-driven behavioral modification to close the knowledge-to-practice gap and enable guideline and protocol compliance remains underutilized. CONCLUSIONS: Gamification offers the potential to substantially enhance how critical care professionals acquire and then implement new knowledge in a fashion that is more engaging and rewarding than traditional approaches. Accordingly, educational undertakings from courses to offerings at medical professional meetings may benefit from being gamified.

Identifying and addressing mentorship gaps in European trauma and emergency surgical training. Results from the Young European Society of Trauma and Emergency Surgery (yESTES) mentorship survey.

PURPOSE: European training pathways for surgeons dedicated to treating severely injured and critically ill surgical patients lack a standardized approach and are significantly influenced by diverse organizational and cultural backgrounds. This variation extends into the realm of mentorship, a vital component for the holistic development of surgeons beyond mere technical proficiency. Currently, a comprehensive understanding of the mentorship landscape within the European trauma care (visceral or skeletal) and emergency general surgery (EGS) communities is lacking. This study aims to identify within the current mentorship environment prevalent practices, discern existing gaps, and propose structured interventions to enhance mentorship quality and accessibility led by the European Society for Trauma and Emergency Surgery (ESTES). METHODS: Utilizing a structured survey conceived and promoted by the Young section of the European Society of Trauma and Emergency Surgery (yESTES), we collected and analyzed responses from 123 ESTES members (both surgeons in practice and in training) across 20 European countries. The survey focused on mentorship experiences, challenges faced by early-career and female surgeons, the integration of non-technical skills (NTS) in mentorship, and the perceived role of surgical societies in facilitating mentorship. RESULTS: Findings highlighted a substantial mentorship experience gap, with 74% of respondents engaging in mostly informal mentorship, predominantly centered on surgical training. Notably, mentorship among early-career surgeons and trainees was less reported, uncovering a significant early-career gap. Female surgeons, representing a minority within respondents, reported a disproportionately poorer access to mentorship. Moreover, while respondents recognized the importance of NTS, these were inadequately addressed in current mentorship practices. The current mentorship input of surgical societies, like ESTES, is viewed as insufficient, with a call for structured programs and initiatives such as traveling fellowships and remote mentoring. CONCLUSIONS: Our survey underscores critical gaps in the current mentorship landscape for trauma and EGS in Europe, particularly for early-career and female surgeons. A clear need exists for more formalized, inclusive mentorship programs that adequately cover both technical and non-technical skills. ESTES could play a pivotal role in addressing these gaps through structured interventions, fostering a more supportive, inclusive, and well-rounded surgical community.

To close or not to close? Wound management in emergent colorectal surgery, an EAST multicenter prospective cohort study.

BACKGROUND: This study aimed to determine the clinical impact of wound management technique on surgical site infection (SSI), hospital length of stay (LOS), and mortality in emergent colorectal surgery. METHODS: A prospective observational study (2021-2023) of urgent or emergent colorectal surgery patients at 15 institutions was conducted. Pediatric patients and traumatic colorectal injuries were excluded. Patients were classified by wound closure technique: skin closed (SC), skin loosely closed (SLC), or skin open (SO). Primary outcomes were SSI, hospital LOS, and in-hospital mortality rates. Multivariable regression was used to assess the effect of wound closure on outcomes after controlling for demographics, patient characteristics, intensive care unit admission, vasopressor use, procedure details, and wound class. A priori power analysis indicated that 138 patients per group were required to detect a 10% difference in mortality rates. RESULTS: In total, 557 patients were included (SC, n = 262; SLC, n = 124; SO, n = 171). Statistically significant differences in body mass index, race/ethnicity, American Society of Anesthesiologist scores, EBL, intensive care unit admission, vasopressor therapy, procedure details, and wound class were observed across groups. Overall, average LOS was 16.9 ± 16.4 days, and rates of in-hospital mortality and SSI were 7.9% and 18.5%, respectively, with the lowest rates observed in the SC group. After risk adjustment, SO was associated with increased risk of mortality (OR, 3.003; p = 0.028) in comparison with the SC group. Skin loosely closed was associated with increased risk of superficial SSI (OR, 3.439; p = 0.014), after risk adjustment. CONCLUSION: When compared with the SC group, the SO group was associated with mortality but comparable when considering all other outcomes, while the SLC was associated with increased superficial SSI. Complete skin closure may be a viable wound management technique in emergent colorectal surgery. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Crosstalk in the Abdomen: The Interface of the Omentum and the Microbiome in Sepsis.

Previously considered inert, the greater omentum is now thought to play a central role in intra-peritoneal immune defense. The intestinal microbiome has recently become a target for potential therapeutic interventions. A narrative review of the immune functions of the omentum was generated using the Scale for the Assessment of Narrative Review Articles (SANRA) guideline. Articles were selected from domains including surgical history, immunology, microbiology, and abdominal sepsis. Evidence suggests the intestinal microbiome may be responsible for some maladaptive physiologic responses in disease states, particularly intra-peritoneal sepsis. Elaborate crosstalk exists between the gut microbiome and the omentum, given its innate and adaptive immune capabilities. We summarize current knowledge, provide examples of how normal and abnormal microbiomes interface with the omentum, and illustrate their impact on surgical disease and its management.

Techniques for mesoappendix transection and appendix resection: insights from the ESTES SnapAppy study.

INTRODUCTION: Surgically managed appendicitis exhibits great heterogeneity in techniques for mesoappendix transection and appendix amputation from its base. It is unclear whether a particular surgical technique provides outcome benefit or reduces complications. MATERIAL AND METHODS: We undertook a pre-specified subgroup analysis of all patients who underwent laparoscopic appendectomy at index admission during SnapAppy (ClinicalTrials.gov Registration: NCT04365491). We collected routine, anonymized observational data regarding surgical technique, patient demographics and indices of disease severity, without change to clinical care pathway or usual surgeon preference. Outcome measures of interest were the incidence of complications, unplanned reoperation, readmission, admission to the ICU, death, hospital length of stay, and procedure duration. We used Poisson regression models with robust standard errors to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: Three-thousand seven hundred sixty-eight consecutive adult patients, included from 71 centers in 14 countries, were followed up from date of admission for 90 days. The mesoappendix was divided hemostatically using electrocautery in 1564(69.4%) and an energy device in 688(30.5%). The appendix was amputated by division of its base between looped ligatures in 1379(37.0%), with a stapler in 1421(38.1%) and between clips in 929(24.9%). The technique for securely dividing the appendix at its base in acutely inflamed (AAST Grade 1) appendicitis was equally divided between division between looped ligatures, clips and stapled transection. However, the technique used differed in complicated appendicitis (AAST Grade 2 +) compared with uncomplicated (Grade 1), with a shift toward transection of the appendix base by stapler (58% vs. 38%; p < 0.001). While no statistical difference in outcomes could be detected between different techniques for division of appendix base, decreased risk of any [adjusted IRR (95% CI): 0.58 (0.41-0.82), p = 0.002] and severe [adjusted IRR (95% CI): 0.33 (0.11-0.96), p = 0.045] complications could be detected when using energy devices. CONCLUSIONS: Safe mesoappendix transection and appendix resection are accomplished using heterogeneous techniques. Technique selection for both mesoappendix transection and appendix resection correlates with AAST grade. Higher grade led to more ultrasonic tissue transection and stapled appendix resection. Higher AAST appendicitis grade also correlated with infection-related complication occurrence. Despite the overall well-tolerated heterogeneity of approaches to acute appendicitis, increasing disease acuity or complexity appears to encourage homogeneity of intraoperative surgical technique toward advanced adjuncts.

Surgical management of acute appendicitis during the European COVID-19 second wave: safe and effective.

INTRODUCTION: The COVID-19 (SARS-CoV-2) pandemic drove acute care surgeons to pivot from long established practice patterns. Early safety concerns regarding increased postoperative complication risk in those with active COVID infection promoted antibiotic-driven non-operative therapy for select conditions ahead of an evidence-base. Our study assesses whether active or recent SARS-CoV-2 positivity increases hospital length of stay (LOS) or postoperative complications following appendectomy. METHODS: Data were derived from the prospective multi-institutional observational SnapAppy cohort study. This preplanned data analysis assessed consecutive patients aged ≥ 15 years who underwent appendectomy for appendicitis (November 2020-May 2021). Patients were categorized based on SARS-CoV-2 seropositivity: no infection, active infection, and prior infection. Appendectomy method, LOS, and complications were abstracted. The association between SARS-CoV-2 seropositivity and complications was determined using Poisson regression, while the association with LOS was calculated using a quantile regression model. RESULTS: Appendectomy for acute appendicitis was performed in 4047 patients during the second and third European COVID waves. The majority were SARS-CoV-2 uninfected (3861, 95.4%), while 70 (1.7%) were acutely SARS-CoV-2 positive, and 116 (2.8%) reported prior SARS-CoV-2 infection. After confounder adjustment, there was no statistically significant association between SARS-CoV-2 seropositivity and LOS, any complication, or severe complications. CONCLUSION: During sequential SARS-CoV-2 infection waves, neither active nor prior SARS-CoV-2 infection was associated with prolonged hospital LOS or postoperative complication. Despite early concerns regarding postoperative safety and outcome during active SARS-CoV-2 infection, no such association was noted for those with appendicitis who underwent operative management.

Graded operative autonomy in emergency appendectomy mirrors case-complexity: surgical training insights from the SnapAppy prospective observational study.

INTRODUCTION: Surgical skill, a summation of acquired wisdom, deliberate practice and experience, has been linked to improved patient outcomes. Graded mentored exposure to pathologies and operative techniques is a cornerstone of surgical training. Appendectomy is one of the first procedures surgical trainees perform independently. We hypothesize that, given the embedded training ethos in surgery, coupled with the steep learning curve required to achieve trainer-recognition of independent competency, 'real-world' clinical outcomes following appendectomy for the treatment of acute appendicitis are operator agnostic. The principle of graded autonomy matches trainees with clinical conditions that they can manage independently, and increased complexity drives attending input or assumption of the technical aspects of care, and therefore, one cannot detect an impact of operator experience on outcomes. MATERIALS AND METHODS: This study is a subgroup analysis of the SnapAppy international time-bound prospective observational cohort study (ClinicalTrials.gov Trial #NCT04365491), including all consecutive patients aged ≥ 15 who underwent appendectomy for appendicitis during a three-month period in 2020-2021. Patient- and surgeon-specific variables, as well as 90-day postoperative outcomes, were collected. Patients were grouped based on operating surgeon experience (trainee only, trainee with direct attending supervision, attending only). Poisson and quantile regression models were used to (adjusted for patient-associated confounders) assess the relationship between surgical experience and postoperative complications or hospital length of stay (hLOS), respectively, adjusted for patient-associated confounders. The primary outcome of interest was any complications within 90 days. RESULTS: A total of 4,347 patients from 71 centers in 14 countries were included. Patients operated on by trainees were younger (Median (IQR) 33 [24-46] vs 38 [26-55] years, p < 0.001), had lower ASA classifications (ASA ≥ 3: 6.6% vs 11.6%, p < 0.001) and fewer comorbidities compared to those operated on by attendings. Additionally, trainees operated alone on fewer patients with appendiceal perforation (AAST severity grade ≥ 3: 8.7% vs 15.6%, p < 0.001). Regression analyses revealed no association between operator experience and complications (IRR 1.03 95%CI 0.83-1.28 for trainee vs attending; IRR 1.13 95%CI 0.89-1.42 for supervised trainee vs attending) or hLOS. CONCLUSION: The linkage of case complexity with operator experience within the context of graduated autonomy is a central tenet of surgical training. Either subconsciously, or by design, patients operated on by trainees were younger, fitter and with earlier stage disease. At least in part, these explain why clinical outcomes following appendectomy do not differ depending on the experience of the operating surgeon.

Racial Disparity in Placement of Intracranial Pressure Monitoring: A TQIP Analysis.

BACKGROUND: The Brain Trauma Foundation recommends intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Race is associated with worse outcomes after TBI. The reasons for racial disparities in clinical decision-making around ICP monitor placement remain unclear. STUDY DESIGN: We queried the TQIP database from 2017 to 2019 and included patients 16 years or older, with blunt severe TBI, defined as a head abbreviated injury score 3 or greater. Exclusion criteria were missing race, those without signs of life on admission, length of stay 1 day or less, and AIS of 6 in any body region. The primary outcome was ICP monitor placement, which was calculated using a Poisson regression model with robust SEs while adjusting for confounders. RESULTS: A total of 260,814 patients were included: 218,939 White, 29,873 Black, 8,322 Asian, 2,884 American Indian, and 796 Native Hawaiian or Other Pacific Islander. Asian and American Indian patients had the highest rates of midline shift (16.5% and 16.9%). Native Hawaiian or Other Pacific Islanders had the highest rates of neurosurgical intervention (19.3%) and ICP monitor placement (6.5%). Asian patients were found to be 19% more likely to receive ICP monitoring (adjusted incident rate ratio 1.19; 95% CI 1.06 to 1.33; p = 0.003], and American Indian patients were 38% less likely (adjusted incident rate ratio 0.62; 95% CI 0.49 to 0.79; p < 0.001), compared with White patients, respectively. No differences were detected between White and Black patients. CONCLUSIONS: ICP monitoring use differs by race. Further work is needed to elucidate modifiable causes of this difference in the management of severe TBI.

Clinical practice selectively follows acute appendicitis guidelines.

INTRODUCTION: Acute appendicitis is a common surgical emergency, and the standard approach to diagnosis and management has been codified in several practice guidelines. Adherence to these guidelines provides insight into independent surgical practice patterns and institutional resource constraints as impediments to best practice. We explored data from the recent ESTES SnapAppy observational cohort study to determine guideline compliance in contemporary practice to identify opportunities to close evidence-to-practice gaps. METHODS: We undertook a preplanned analysis of the ESTES SnapAppy observational cohort study, identifying, at a patient level, congruence with, or deviation from WSES Jerusalem guidelines for the diagnosis and management of acute appendicitis and the Surviving Sepsis Campaign in our cohort. Compliance was then correlated with the incidence of postoperative complications. RESULTS: Four thousand six hundred and thirteen (4613) consecutive adult and adolescent patients with acute appendicitis were followed from date of admission (November 1, 2020, and May 28, 2021) for 90 days. Patient-level compliance with guideline elements allowed patients to be grouped into those with full compliance (all 5 elements: 13%), partial compliance (1-4 elements: 87%) or noncompliance (0 elements: 0.2%). We identified an excess postoperative complication rate in patients who received noncompliant and partially compliant care, compared with those who received fully guideline-compliant care (36% and 16%, versus 7.3%, p < 0.001). CONCLUSIONS: The observed diagnostic and treatment practices of the participating institutions displayed variability in compliance with key recommendations from existing guidelines. In general, practice was congruent with recommendations for preoperative antibiotic surgical site infection prophylaxis administration, time to surgery, and operative approach. However, there remains opportunities for improvement in the choice of diagnostic imaging modality, postoperative antibiotic stewardship to timely discontinue prophylactic antibiotics, and the implementation of ambulatory treatment pathways for uncomplicated appendicitis in the healthy young adult.

Racial Disparities in Administration of Venous Thromboembolism Prophylaxis After Severe Traumatic Injuries.

BACKGROUND: Race is associated with differences in quality of care process measures and incidence of venous thromboembolism (VTE) in trauma patients. We aimed to investigate if racial disparities exist in the administration of VTE prophylaxis in trauma patients. METHODS: We queried the Trauma Quality Improvement Project database from 2017 to 2019. Patients ages ≥16 years old with ISS ≥15 were included. Patients with no signs of life on arrival, any AIS ≥6, hospital length of stay <1 day, anticoagulant use before admission, or without recorded race were excluded. Patients were grouped by race: white, black, Asian, American Indian, and Native Hawaiian or Pacific Islander. The association between VTE prophylaxis administration and race was determined using a Poisson regression model with robust standard errors to adjust for confounders. RESULTS: A total of 285,341 patients were included. Black patients had the highest rates of VTE prophylaxis exposure (73.8%), shortest time to administration (1.6 days), and highest use of low molecular weight heparin (56%). Black patients also had the highest incidence of deep vein thrombosis (2.8%) and pulmonary embolism (1.4%). Black patients were 4% more likely to receive VTE prophylaxis than white patients [adj. IRR (95% CI): 1.04 (1.03-1.05), P < .001]. American Indians were 8% less likely to receive VTE prophylaxis [adj. IRR (95% CI): .92 (.88-.97), P < .001] than white patients. No differences between white and Asian or Native Hawaiian or Pacific Islander patients existed. DISCUSSION: While black patients had the highest incidence of DVT and PE, they had higher administration rates and earlier initiation of VTE prophylaxis. Further work can elucidate modifiable causes of these differences.

The revised cardiac risk index is associated with morbidity and mortality independent of injury severity in elderly patients with rib fractures.

BACKGROUND: Risk factors for mortality and in-hospital morbidity among geriatric patients with traumatic rib fractures remain unclear. Such patients are often frail and demonstrate a high comorbidity burden. Moreover, outcomes anticipated by current rubrics may reflect the influence of multisystem injury or surgery, and thus not apply to isolated injuries in geriatric patients. We hypothesized that the Revised Cardiac Risk Index (RCRI) may assist in risk-stratifying geriatric patients following rib fracture. METHODS: All geriatric patients (age ≥65 years) with a conservatively managed rib fracture owing to an isolated thoracic injury (thorax AIS ≥1), in the 2013-2019 TQIP database were assessed including demographics and outcomes. The association between the RCRI and in-hospital morbidity as well as mortality was analyzed using Poisson regression models while adjusting for potential confounders. RESULTS: 96,750 geriatric patients sustained rib fractures. Compared to those with RCRI 0, patients with an RCRI score of 1 had a 16% increased risk of in-hospital mortality [adjusted incidence rate ratio (adj-IRR), 95% confidence interval (CI): 1.16 (1.02-1.32), p=0.020]. An RCRI score of 2 [adj-IRR (95% CI): 1.72 (1.44-2.06), p<0.001] or ≥3 [adj-IRR (95% CI): 3.07 (2.31-4.09), p<0.001] was associated with an even greater mortality risk. Those with an increased RCRI also exhibited a higher incidence of myocardial infarction, cardiac arrest, stroke, and acute respiratory distress syndrome. CONCLUSIONS: Geriatric patients with rib fractures and an RCRI ≥1 represent a vulnerable and high-risk group. This index may inform the decision to admit for inpatient care and can also guide patient and family counseling as well as computer-based decision-support.

The Accuracy of Point-of-Care Ultrasound (POCUS) in Acute Gallbladder Disease.

There is increasing recognition that point-of-care ultrasound (POCUS), performed by the clinician at the bedside, can be a natural extension of the clinical examination-the modern abdominal "stethoscope" and provides an opportunity to expedite the care pathway for patients with acute gallbladder disease. The primary aims of this study were to benchmark the accuracy of surgeon-performed POCUS in suspected acute gallbladder disease against standard radiology or pathology reports and to compare time to POCUS diagnosis with time to definitive imaging. This prospective single-arm observational cohort study was conducted in four hospitals in Ireland, Italy, and Portugal to assess the accuracy of POCUS against standard radiology in patients with suspected acute biliary disease (ClinicalTrials.govIdentifier: NCT02682368). The findings of surgeon-performed POCUS were compared with those on definitive imaging or surgery. Of 100 patients recruited, 89 were suitable for comparative analysis, comparing POCUS with radiological findings in 84 patients and with surgical/histological findings in five. The overall global accuracy of POCUS was 88.7% (95% CI, 80.3-94.4%), with a sensitivity of 94.7% (95% CI, 85.3-98.9%), a specificity of 78.1% (95% CI, 60.03-90.7%), a positive likelihood ratio (LR+) of 4.33 and negative likelihood ratio (LR) of 0.07. The mean time from POCUS to the final radiological report was 11.9 h (range 0.06-54.9). In five patients admitted directly to surgery, the mean time between POCUS and incision was 2.30 h (range 1.5-5), which was significantly shorter than the mean time to formal radiology report. Sixteen patients were discharged from the emergency department, of whom nine did not need follow-up. Our study is one of the very few to demonstrate a high concordance between surgeon-performed POCUS of patients without a priori radiologic diagnosis of gallstone disease and shows that the expedited diagnosis afforded by POCUS can be reliably leveraged to deliver earlier definitive care for patients with acute gallbladder pathology, as the general surgeon skilled in POCUS is uniquely positioned to integrate it into their bedside assessment.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice.

BACKGROUND: Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level. AIM: To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes. METHODS: A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission. ENDPOINTS: A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay. RESULTS: Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low. CONCLUSION: This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich 'real world' insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

Tertiary peritonitis: considerations for complex team-based care.

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key-but not all-elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Developing and validating a scoring system for measuring frailty in patients with hip fracture: a novel model for predicting short-term postoperative mortality.

Objectives: Frailty is common among patients with hip fracture and may, in part, contribute to the increased risk of mortality and morbidity after hip fracture surgery. This study aimed to develop a novel frailty score for patients with traumatic hip fracture that could be used to predict postoperative mortality as well as facilitate further research into the role of frailty in patients with hip fracture. Methods: The Orthopedic Hip Frailty Score (OFS) was developed using a national dataset, retrieved from the Swedish National Quality Registry for Hip Fractures, that contained all adult patients who underwent surgery for a traumatic hip fracture in Sweden between January 1, 2008 and December 31, 2017. Candidate variables were selected from the Nottingham Hip Fracture Score, Sernbo Score, Charlson Comorbidity Index, 5-factor modified Frailty Index, as well as the Revised Cardiac Risk Index and ranked based on their permutation importance, with the top 5 variables being selected for the score. The OFS was then validated on a local dataset that only included patients from Orebro County, Sweden. Results: The national dataset consisted of 126,065 patients. 2365 patients were present in the local dataset. The most important variables for predicting 30-day mortality were congestive heart failure, institutionalization, non-independent functional status, an age ≥85, and a history of malignancy. In the local dataset, the OFS achieved an area under the receiver-operating characteristic curve (95% CI) of 0.77 (0.74 to 0.80) and 0.76 (0.74 to 0.78) when predicting 30-day and 90-day postoperative mortality, respectively. Conclusions: The OFS is a significant predictor of short-term postoperative mortality in patients with hip fracture that outperforms, or performs on par with, all other investigated indices. Level of evidence: Level III, Prognostic and Epidemiological.

Mortality risk stratification in isolated severe traumatic brain injury using the revised cardiac risk index.

PURPOSE: Traumatic brain injury (TBI) continues to be a significant cause of mortality and morbidity worldwide. As cardiovascular events are among the most common extracranial causes of death after a severe TBI, the Revised Cardiac Risk Index (RCRI) could potentially aid in the risk stratification of this patient population. This investigation aimed to determine the association between the RCRI and in-hospital deaths among isolated severe TBI patients. METHODS: All adult patients registered in the TQIP database between 2013 and 2017 who suffered an isolated severe TBI, defined as a head AIS ≥ 3 with an AIS ≤ 1 in all other body regions, were included. Patients were excluded if they had a head AIS of 6. The association between different RCRI scores (0, 1, 2, 3, ≥ 4) and in-hospital mortality was analyzed using a Poisson regression model with robust standard errors while adjusting for potential confounders, with RCRI 0 as the reference. RESULTS: 259,399 patients met the study's inclusion criteria. RCRI 2 was associated with a 6% increase in mortality risk [adjusted IRR (95% CI) 1.06 (1.01-1.12), p = 0.027], RCRI 3 was associated with a 17% increased risk of mortality [adjusted IRR (95% CI) 1.17 (1.05-1.31), p = 0.004], and RCRI ≥ 4 was associated with a 46% increased risk of in-hospital mortality [adjusted IRR(95% CI) 1.46 (1.11-1.90), p = 0.006], compared to RCRI 0. CONCLUSION: An elevated RCRI ≥ 2 is significantly associated with an increased risk of in-hospital mortality among patients with an isolated severe traumatic brain injury. The simplicity and bedside applicability of the index makes it an attractive choice for risk stratification in this patient population.

Pharmacological differences between beta-blockers and postoperative mortality following colon cancer surgery.

ß-blocker therapy has been positively associated with improved survival in patients undergoing oncologic colorectal resection. This study investigates if the type of ß-blocker used affects 90-day postoperative mortality following colon cancer surgery. The study was designed as a nationwide retrospective cohort study including all adult (≥ 18 years old) patients with ongoing ß-blocker therapy who underwent elective and emergency colon cancer surgery in Sweden between January 1, 2007 and December 31, 2017. Patients were divided into four cohorts: metoprolol, atenolol, bisoprolol, and other beta-blockers. The primary outcome of interest was 90-day postoperative mortality. A Poisson regression model with robust standard errors was used, while adjusting for all clinically relevant variables, to determine the association between different ß-blockers and 90-day postoperative mortality. A total of 9254 patients were included in the study. There was no clinically significant difference in crude 90-day postoperative mortality rate [n (%)] when comparing the four beta-blocker cohorts metoprolol, atenolol, bisoprolol and other beta-blockers. [97 (1.8%) vs. 28 (2.0%) vs. 29 (1.7%) vs. 11 (1.2%), p = 0.670]. This remained unchanged when adjusting for relevant covariates in the Poisson regression model. Compared to metoprolol, there was no statistically significant decrease in the risk of 90-day postoperative mortality with atenolol [adj. IRR (95% CI): 1.45 (0.89-2.37), p = 0.132], bisoprolol [adj. IRR (95% CI): 1.45 (0.89-2.37), p = 0.132], or other beta-blockers [adj. IRR (95% CI): 0.92 (0.46-1.85), p = 0.825]. In patients undergoing colon cancer surgery, the risk of 90-day postoperative mortality does not differ between the investigated types of ß-adrenergic blocking agents.