Exploring changes in violence across two waves of the COVID-19 pandemic in Richmond, VA.

The first wave of the COVID-19 pandemic carried with it an increase in violence in the United States and abroad. The proportion of violence cases involving firearms also increased during this time, yet little research has examined these effects using data from the second wave of COVID infections. Explanations for these documented increases in gun violence put forward by scholars include increased firearm purchases, alcohol consumption, unemployment, and organized crime activity. The current work examined these trends in Richmond, VA. We collected data on patients (N = 1744) presenting with violent injuries from 2018 to 2022 from the emergency department of a Level-1 Trauma Center in Richmond, VA. Data were coded on the basis of whether they presented before the pandemic, during the first wave, or during the second wave. Logistic binomial regressions revealed that the risk of gunshot wounds increased by 32% during the first wave and 44% during the second wave, relative to the pre-COVID period, but that the increase between the first and second wave was not significant. These findings held after controlling for victim age, race, sex, and injury severity. Further analyses revealed that these effects were specific to violent injury, as we found no increase in firearm use among self-injury cases. The heightened violence reported during the COVID-19 pandemic was also observed in Richmond, VA. Gun violence in particular increased over time as other forms of violence (i.e., assaults, stabbings, and self-harm) decreased.

Superior Survival Outcomes of a Polyethylene Glycol-20k Based Resuscitation Solution in a Preclinical Porcine Model of Lethal Hemorrhagic Shock.

OBJECTIVE: To compare early outcomes and 24-hour survival after LVR with the novel polyethylene glycol-20k-based crystalloid (PEG-20k), WB, or hextend in a preclinical model of lethal HS. BACKGROUND: Posttraumatic HS is a major cause of preventable death. current resuscitation strategies focus on restoring oxygen-carrying capacity (OCC) and coagulation with blood products. Our lab shows that PEG-20k is an effective non-sanguineous, LVR solution in acute models of HS through mechanisms targeting cell swelling-induced microcirculatory failure. METHODS: Male pigs underwent splenectomy followed by controlled hemorrhage until lactate reached 7.5-8.5 mmol/L. They were randomized to receive LVR with PEG-20k, WB, or Hextend. Surviving animals were recovered 4 hours post-LVR. Outcomes included 24-hour survival rates, mean arterial pressure, lactate, hemoglobin, and estimated intravascular volume changes. RESULTS: Twenty-four-hour survival rates were 100%, 16.7%, and 0% in the PEG-20k, WB, and Hextend groups, respectively (P= 0.001). PEG-20k significantly restored mean arterial press, intravascular volume, and capillary perfusion to baseline, compared to other groups. This caused complete lactate clearance despite decreased OCC. Neurological function was normal after next-day recovery in PEG-20k resuscitated pigs. CONCLUSION: Superior early and 24-hour outcomes were observed with PEG-20k LVR compared to WB and Hextend in a preclinical porcine model of lethal HS, despite decreased OCC from substantial volume-expansion. These findings demonstrate the importance of enhancing microcirculatory perfusion in early resuscitation strategies.

Medication Reconciliation and Patient Safety in Trauma: Applicability of Existing Strategies.

The Joint Commission has established medication reconciliation as a National Patient Safety Goal, but it has not been studied much in trauma even though it is integral to safe patient care. This article reviews the existing medication reconciliation strategies and their applicability to the trauma setting. To perform medication reconciliation, hospitals use a variety of strategies including pharmacists or pharmacy technicians, electronic medical record tools, and patient-centered strategies. All of these strategies are limited in trauma. Subpopulations such as injured children, the elderly, and those with brain trauma are particularly challenging and are at risk for suboptimal care from inaccurate medication reconciliation. Further research is necessary to create a safe and efficient system for trauma patients.

Image-Guided Resuscitation With Limited Transthoracic Echocardiogram in Pediatric Trauma Patients.

INTRODUCTION: Limited transthoracic echocardiogram (LTTE) has been shown to be a useful tool in guiding resuscitation in adult trauma patients. Our hypothesis is that image-guided resuscitation in pediatric trauma patients with LTTE is feasible. METHODS: A retrospective chart review was performed on highest level pediatric trauma alerts (age 18 years or younger) at our level I trauma center during a 6-month period. Patients were divided into 2 groups as follows: those who had LTTE performed (LTTE group) and those who did not have LTTE performed (non-LTTE group). RESULTS: A total of 31 charts were reviewed; 4 patients were excluded because they died on arrival to the emergency department. Fourteen patients had LTTE performed (LTTE group); 13 patients did not have LTTE performed (non-LTTE group). There was no difference in mechanism of injury, age, injury severity score, weight, or intensive care unit admission between the groups. The LTTE group received significantly less intravenous fluid than the non-LTTE group (1.2 vs 2.3 L, P = 0.0013).Within the LTTE group, 8 patients had "full" inferior vena cava (IVC) and 6 patients had "empty" IVC. There was no difference in injury severity score between these subgroups (P = 0.1018). Less fluid was given in the group labeled with full IVC [1.1 L (0.8-1.2)] than the group with empty IVC [2.4 L (1.7-2.6)], P = 0.0005. Four of the 6 patients with "empty" IVC had a confirmed source of bleeding. CONCLUSIONS: Limited transthoracic echocardiogram can limit the amount of unnecessary crystalloid resuscitation given to pediatric trauma patients who are not hypovolemic.

Low-Volume Resuscitation for Hemorrhagic Shock: Understanding the Mechanism of PEG-20k.

Hemorrhagic shock leads to cell and tissue swelling and no reflow from compressed capillaries. Cell impermeants, including polyethylene glycol-20,000 (PEG-20k), reverse ischemia-induced cell swelling, extend low-volume resuscitation (LVR) time after shock, and increase tolerance to the low-volume state. The purpose of this study was to explore the mechanisms of action of PEG-20k containing LVR solutions. We hypothesized that PEG-20k acts as both an oncotic agent and an impermeant in the microcirculation, which moves water out of the space and into the capillaries to affect peripheral capillary filling and enhanced perfusion during the low-volume state. Rats were hemorrhaged until arterial lactate reached 9-10 mM/liter. Then, saline-based LVR solutions containing various impermeant materials were administered (10% blood volume). The LVR times for these solutions were determined by measuring the amount of time required for plasma lactate to climb back to 9 to 10 mM after LVR administration (low-volume tolerance). Capillary blood flow was measured by colored microspheres, and blood volume was measured by fluorescein isothiocyanate-labeled albumin dilution. Gluconate (impermeant), albumin (colloid), and PEG-20k (hybrid) increased LVR time over saline by 4-, 3-, and 8-fold, respectively. The combination of impermeant + albumin produced a biologic effect that was similar to PEG-20k alone. Capillary blood flow and plasma volume were decreased after shock with saline LVR but increased with PEG-20k, relative to saline. These data are consistent with the hypothesis that PEG-20k may act by establishing multiple osmotic gradients in the microcirculation to drive cell-to-capillary water transfer during hypovolemic shock.

Cell Impermeant-based Low-volume Resuscitation in Hemorrhagic Shock: A Biological Basis for Injury Involving Cell Swelling.

OBJECTIVE: To determine the role of cell swelling in severe hemorrhagic shock and resuscitation injury. BACKGROUND: Circulatory shock induces the loss of energy-dependent volume control mechanisms. As water enters ischemic cells, they swell, die, and compress nearby vascular structures, which further aggravates ischemia by reducing local microcirculatory flow and oxygenation. Loading the interstitial space with cell impermeant molecules prevents water movement into the cell by passive biophysical osmotic effects, which prevents swelling injury and no-reflow. METHODS: Adult rats were hemorrhaged to a pressure of 30 to 35  mm Hg, held there until the plasma lactate reached 10  mM, and given a low-volume resuscitation (LVR) (10%-20% blood volume) with saline or various cell impermeants (sorbitol, raffinose, trehalose, gluconate, and polyethylene glycol-20k (PEG-20k). When lactate again reached 10  mM after LVR, full resuscitation was started with crystalloid and red cells. One hour after full resuscitation, the rats were euthanized. Capillary blood flow was measured by the colored microsphere technique. RESULTS: Impermeants prevented ischemia-induced cell swelling in liver tissue and dramatically improved LVR outcomes in shocked rats. Small cell impermeants and PEG-20k in LVR solutions increased tolerance to the low flow state by two and fivefold, respectively, normalized arterial pressure during LVR, and lowered plasma lactate after full resuscitation, relative to saline. This was accompanied by higher capillary blood flow with cell impermeants. CONCLUSIONS: Ischemia-induced lethal cell swelling during hemorrhagic shock is a key mediator of resuscitation injury, which can be prevented by cell impermeants in low-volume resuscitation solutions.

Catheter-based endovascular damage-control (CDET): current status and future directions.

INTRODUCTION: Endovascular technology during the past decade has introduced innovative strategies to manage vascular trauma. The purpose of this study was to evaluate the current use catheter-based endovascular damage-control techniques (CDET) in North, Central, and South America. METHODS: A survey was sent to the presidents of local societies in Latin America, members of the board, and past presidents of the Pan-American Trauma Society. The survey was sent using the Research Electronic Data Capture collection tool. RESULTS: A total of 67 surveys were sent with an 85 % response rate. Surgeons from 15 countries participated in the survey. All of the centers in North America had capabilities to perform these procedures. In none of these centers, however, were they performed by trauma and acute care surgeons. In Central and South America, 64 % of the surgeons responded that they have an interventional radiology service, and in 56 % of the cases, trauma and acute care surgeons were already performing CDET. Eight-eight percent of those surveyed thought that the addition of CDET to trauma would improve patient care; 86 % would be interested in further training in this technique if such programs were available. Finally, 68 % thought that the addition of CDET would help the field of acute care surgery and trauma financially. CONCLUSIONS: CDET is being performed already by trauma and acute care surgeons in Latin American countries. More research is necessary to evaluate the role of the trauma surgeon in the endovascular suite as well as training requirements.

Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs.

OBJECTIVES: Limited transthoracic echocardiography (LTTE) has been introduced as a hemodynamic tool for trauma patients. The aim of this study was to evaluate the utility of LTTE during the evaluation of nonsurviving patients who presented to the trauma bay with traumatic cardiac arrest. METHODS: Approval by the Institutional Review Board was obtained. All nonsurviving patients with traumatic cardiac arrest who reached the trauma bay were evaluated retrospectively for 1 year. Comparisons between groups of patients in whom LTTE was performed as part of the resuscitation effort and those in whom it was not performed were conducted. RESULTS: From January 2012 to January 2013, 37 patients did not survive traumatic cardiac arrest while in the trauma bay: 14 in the LTTE group and 23 in the non-LTTE group. When comparing the LTTE and non-LTTE groups, both were similar in sex distribution (LTTE, 86% male; non-LTTE, 74% male; P = .68), age (34.8 versus 24.1 years; P= .55), Injury Severity Score (41.0 versus 38.2; P= .48), and percentage of penetrating trauma (21.6% versus 21.7%; P = .29). Compared with the non-LTTE group, the LTTE group spent significantly less time in the trauma bay (13.7 versus 37.9 minutes; P = .01), received fewer blood products (7.1% versus 31.2%; P = .789), and were less likely to undergo nontherapeutic thoracotomy in the emergency department (7.14% versus 39.1%; P < .05). The non-LTTE group had a mean of $3040.50 in hospital costs, compared with the mean for the LTTE group of $1871.60 (P = .0054). CONCLUSIONS: In this study, image-guided resuscitation with LTTE decreased the time in the trauma bay and avoided nontherapeutic thoracotomy in nonsurviving trauma patients. Limited TTE could improve the use of health care resources in patients with traumatic cardiac arrest.

The Impact of Demographics and Comorbidities on Fall Incidence and Prevalence in Older Adults.

INTRODUCTION: Falls among older adults are more than mere accidents; they are a silent epidemic, profoundly impacting the health and well-being of millions of older adults worldwide. This study examines the incidence and prevalence of falls among individuals aged 65 and above, focusing on the influence of demographic factors and comorbid conditions such as hypertension, diabetes mellitus, cancer, and obesity. METHODS: A retrospective cohort study was conducted using data from the TriNetX network at Virginia Commonwealth University Health System (VCUHS) from 2019 to 2023. The study population included 16,400 individuals aged 65 and above who presented with fall-related trauma. Data on demographics, clinical diagnoses, procedures, and comorbid conditions were analyzed using descriptive statistics to evaluate the incidence and prevalence of falls. RESULTS: The mean age of the study population was 77.3 years, with a higher proportion of females (60.97%) compared to males (39.02%). Despite the larger number of female participants, incidence and prevalence of falls were highest among individuals aged 65-69 years, and fall rates were notably higher among males compared to females. This suggests that while fewer in number, males in our study experienced falls more frequently. Patients with hypertension had the highest incidence proportion (56.67%) and prevalence (75.75%) among comorbid conditions. CONCLUSIONS: Falls among older adults are significantly influenced by demographic factors and comorbid conditions. Hypertension, in particular, is associated with the highest fall risk. These findings highlight the need for targeted interventions to manage comorbidities and reduce fall risks among older adult patients.

Propensity weighted analysis of chemical venous thromboembolism prophylaxis agents in isolated severe traumatic brain injury: An EAST sponsored multicenter study.

BACKGROUND: In patients with severe traumatic brain injury (TBI), clinicians must balance preventing venous thromboembolism (VTE) with the risk of intracranial hemorrhagic expansion (ICHE). We hypothesized that low molecular weight heparin (LMWH) would not increase risk of ICHE or VTE as compared to unfractionated heparin (UH) in patients with severe TBI. METHODS: Patients ≥ 18 years of age with isolated severe TBI (AIS ≥ 3), admitted to 24 level I and II trauma centers between January 1, 2014 to December 31, 2020 and who received subcutaneous UH and LMWH injections for chemical venous thromboembolism prophylaxis (VTEP) were included. Primary outcomes were VTE and ICHE after VTEP initiation. Secondary outcomes were mortality and neurosurgical interventions. Entropy balancing (EBAL) weighted competing risk or logistic regression models were estimated for all outcomes with chemical VTEP agent as the predictor of interest. RESULTS: 984 patients received chemical VTEP, 482 UH and 502 LMWH. Patients on LMWH more often had pre-existing conditions such as liver disease (UH vs LMWH 1.7 % vs. 4.4 %, p = 0.01), and coagulopathy (UH vs LMWH 0.4 % vs. 4.2 %, p < 0.001). There were no differences in VTE or ICHE after VTEP initiation. There were no differences in neurosurgical interventions performed. There were a total of 29 VTE events (3 %) in the cohort who received VTEP. A Cox proportional hazards model with a random effect for facility demonstrated no statistically significant differences in time to VTE across the two agents (p = 0.44). The LMWH group had a 43 % lower risk of overall ICHE compared to the UH group (HR = 0.57: 95 % CI = 0.32-1.03, p = 0.062), however was not statistically significant. CONCLUSION: In this multi-center analysis, patients who received LMWH had a decreased risk of ICHE, with no differences in VTE, ICHE after VTEP initiation and neurosurgical interventions compared to those who received UH. There were no safety concerns when using LMWH compared to UH. LEVEL OF EVIDENCE: Level III, Therapeutic Care Management.

Early surgical stabilization of rib fractures for flail chest is associated with improved patient outcomes: An ACS-TQIP review.

BACKGROUND: Rib fractures are a common in thoracic trauma. Increasingly, patients with flail chest are being treated with surgical stabilization of rib fractures (SSRF). We performed a retrospective review of the Trauma Quality Improvement Program database to determine if there was a difference in outcomes between patients undergoing early SSRF (≤3 days) versus late SSRF (>3 days). METHODS: Patients with flail chest in Trauma Quality Improvement Program were identified by CPT code, assessing those who underwent SSRF between 2017 and 2019. We excluded those younger than 18 years and Abbreviated Injury Scale head severity scores greater than 3. Patients were grouped based on SSRF before and after hospital Day 3. These patients were case matched based on age, Injury Severity Score, Abbreviated Injury Scale head and chest, body mass index, Glasgow Coma Scale, and five modified frailty index. All data were examined using χ2, one-way analysis of variance, and Fisher's exact test within SPSS version 28.0. RESULTS: For 3 years, 20,324 patients were noted to have flail chest, and 3,345 (16.46%) of these patients underwent SSRF. After case matching, 209 patients were found in each group. There were no significant differences between reported major comorbidities. Patients with early SSRF had fewer unplanned intubations (6.2% vs. 12.0%; p = 0.04), fewer median ventilator days (6 days Q1: 3 to Q3: 10.5 vs. 9 Q1: 4.25 to Q3: 14; p = 0.01), shorter intensive care unit length of stay (6 days Q1: 4 to Q3: 11 vs. 11 Q1: 6 to Q3: 17; p < 0.01), and hospital length of stay (15 days Q1: 11.75 to Q3: 22.25 vs. 20 Q1: 15.25 - Q3: 27, p < 0.01. Early plating was associated with lower rates of deep vein thrombosis and ventilator-acquired pneumonia. CONCLUSION: In trauma-accredited centers, patients with flail chest who underwent early SSRF (<3 days) had better outcomes, including fewer unplanned intubations, decreased ventilator days, shorter intensive care unit LOS and HLOS, and fewer DVTs, and ventilator-associated pneumonia. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study.

OBJECTIVE: Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS: The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Early VTE prophylaxis in severe traumatic brain injury: A propensity score weighted EAST multicenter study.

BACKGROUND: Patients with traumatic brain injury (TBI) are at high risk of venous thromboembolism events (VTE). We hypothesized that early chemical VTE prophylaxis initiation (≤24 hours of a stable head CT) in severe TBI would reduce VTE without increasing risk of intracranial hemorrhage expansion (ICHE). METHODS: A retrospective review of adult patients 18 years or older with isolated severe TBI (Abbreviated Injury Scale score, ≥ 3) who were admitted to 24 Level I and Level II trauma centers from January 1, 2014 to December 31 2020 was conducted. Patients were divided into those who did not receive any VTE prophylaxis (NO VTEP), who received VTE prophylaxis ≤24 hours after stable head CT (VTEP ≤24) and who received VTE prophylaxis >24 hours after stable head CT (VTEP>24). Primary outcomes were VTE and ICHE. Covariate balancing propensity score weighting was utilized to balance demographic and clinical characteristics across three groups. Weighted univariate logistic regression models were estimated for VTE and ICHE with patient group as predictor of interest. RESULTS: Of 3,936 patients, 1,784 met inclusion criteria. Incidences of VTE was significantly higher in the VTEP>24 group, with higher incidences of DVT in the group. Higher incidences of ICHE were observed in the VTEP≤24 and VTEP>24 groups. After propensity score weighting, there was a higher risk of VTE in patients in VTEP >24 compared with those in VTEP≤24 (odds ratio, 1.51; 95% confidence interval, 0.69-3.30; p = 0.307), however was not significant. Although, the No VTEP group had decreased odds of having ICHE compared with VTEP≤24 (odds ratio, 0.75; 95% confidence interval, 0.55-1.02, p = 0.070), the result was not statistically significant. CONCLUSION: In this large multi-center analysis, there were no significant differences in VTE based on timing of initiation of VTE prophylaxis. Patients who never received VTE prophylaxis had decreased odds of ICHE. Further evaluation of VTE prophylaxis in larger randomized studies will be necessary for definitive conclusions. LEVEL OF EVIDENCE: Therapeutic Care Management; Level III.

Fluid Intelligence Moderates the Link Between Psychopathy and Aggression Differently for Men and Women.

Research on sex differences in the association of psychopathy with fluid intelligence is limited, and it remains unknown if fluid intelligence plays a meaningful role in explaining the psychopathy-aggression link for men and women. The present study aimed to test for sex differences in the relation between the four-facet model of psychopathy and intelligence, and to assess whether fluid intelligence moderates the link between psychopathy and aggression. In a community sample of men (n = 356) and women (n = 196), we assessed psychopathy using the Psychopathy Checklist: Screening Version (PCL:SV), fluid intelligence using the Raven's Progressive Matrices, and types of aggression using the Aggression Questionnaire (AQ). Hierarchical regressions showed that the psychopathy lifestyle facet was negatively associated with intelligence and there were no sex differences. Our analyses for types of aggression revealed sex differences and similarities. For both men and women, total AQ scores were predicted by higher antisocial facet scores. Lower intelligence moderated the link between higher antisocial facet scores and aggression in men, but not for women. Physical aggression in women was associated with higher interpersonal, affective, and antisocial facet scores, whereas for men, it was only associated with higher antisocial facet scores. Verbal and indirect aggression were associated with higher intelligence in both men and women. For men only, higher antisocial facet scores were associated with verbal and indirect aggression. Higher intelligence moderated the link between the lifestyle facet and indirect aggression for women, whereas for men, it moderated the link between the affective facet and indirect aggression. This study further highlights sex differences in mechanisms of psychopathy-related aggression, which need to be considered in the development of violence interventions and risk assessment.

Minimal Aortic Injury Detected on Computed Tomography Angiography during Initial Trauma Imaging: Single Academic Level 1 Trauma Center Experience.

BACKGROUND: Minimal aortic injury (MAI), a subtype of acute traumatic aortic injury, is being increasingly recognized with better imaging techniques. Given conservative management, the role of follow-up imaging albeit important yet has to be defined. METHODS: All trauma chest computed tomography angiographies (CTAs) at our center between January 2012 and January 2019 were retrospectively reviewed for presence of MAI. MAIs were generally reimaged at 24 to 72 hours and then at a 7- and 30-day interval. Follow-up CTAs were reviewed for stability, progression, or resolution of MAI, along with assessment of injury severity scores (ISS) and concomitant injuries, respectively. RESULTS: A total of 17,569 chest CTAs were performed over this period. Incidence of MAI on the initial chest CTA was 113 (0.65%), with 105 patients receiving follow-up CTAs. The first, second, third, and fourth follow-up CTAs were performed at a median of 2, 10, 28, and 261 days, respectively. Forty five (42.9%), 22 (21%), 5 (4.8%), and 1 (1%) of the MAIs were resolved by first, second, third, and fourth follow-up CTAs. Altogether, 21 patients showed stability (mean ISS of 16.6), and 11 demonstrated improvement (mean ISS 25.8) of MAIs. Eight patients had no follow-up CTA (mean ISS 21). No progression to higher-grade injury was observed. Advancing age decreased the odds of MAI resolution on follow-up. A possible trend (p-value 0.22) between increasing ISS and time to resolution of MAIs was noted. CONCLUSION: In our series of acute traumatic MAIs diagnosed on CTA imaging, there was no progression of injuries with conservative management, questioning the necessity of sequential follow-up imaging.

Early video-assisted thoracoscopic surgery (VATS) for non-emergent thoracic trauma remains underutilized in trauma accredited centers despite evidence of improved patient outcomes.

PURPOSE: Thoracic injury is a major contributor to morbidity in trauma patients. There is limited data regarding practice patterns of video-assisted thoracoscopic surgery (VATS) across trauma-accredited hospitals in the United States. We hypothesized that early VATS remains underutilized affecting patient outcomes. METHOD: We evaluated a cohort of patients who underwent non-urgent thoracic surgical intervention for trauma from the ACS-TQIP database in 2017 excluding patients who were discharged within 48-h or died within 72-h. We selected patients who underwent partial lung resection and decortication to assess the effect of early (day 2-5) versus late VATS. Univariate followed by multivariate regression analyses were utilized to evaluate the independent impact of timing. RESULTS: Over 12 months, 997,970 patients were admitted to 850 trauma-accredited centers. Thoracic injury occurred in 23.5% of patients, 1% of whom had non-urgent thoracic procedures. A total of 406 patients underwent VATS for pulmonary decortication with/out partial resection, 39% were Early VATS (N = 159) compared to 61% late VATS (N = 247). Both groups had comparable demographics and comorbidities with exception of a higher ISS score in the late surgical group (17.9 ± 9.8 vs 14.9 ± 7.6, p < 0.01). The late VATS patients' group had higher rates of superficial site infection, unplanned intubation, and pneumonia. Early VATS was associated with shorter ICU stay and HLOS. Multivariate analysis confirmed the independent effect of surgical timing on postoperative complications and LOS. The conversion rate from VATS to thoracotomy was 1.9% in early group compared to 6.5%, p = 0.03. There was no difference in surgical pattern among participating facilities. CONCLUSION: Despite established practice guidelines supporting early VATS for thoracic trauma management, there is underutilization with less than half of patients undergoing early VATS. Early VATS is associated with improved patient outcomes.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries.

INTRODUCTION: The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study. MATERIALS AND METHODS: Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study. RESULTS: Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively. CONCLUSION: This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Bronchoalveolar lavage in the diagnosis of ventilator-associated pneumonia: to quantitate or not, that is the question.

Quantitative bronchoalveolar lavage (BAL) is used to diagnose ventilator-associated pneumonia (VAP). We prospectively compared semiquantitative (SQ) and quantitative (Qu) culture of BAL for VAP diagnosis. Ventilated patients suspected of VAP underwent bronchoscopic BAL. BAL fluid was examined by both Qu (colony-forming units [CFUs]/mL) and SQ culture (none, sparse, moderate, or heavy) and results were compared. VAP was defined as 105 CFU/mL or greater on Qu culture. Over 36 months, 319 BALs were performed. Sixty-three of 319 (20%) showed diagnostic growth by Qu culture identifying a total of 81 organisms causing VAP. All 63 specimens showed growth of some organism(s) on SQ culture with 79 of 81 causative organisms identified and two (Pseudomonas, one; Corynebacterium, one) not identified. The remaining 256 specimens did not meet the threshold for VAP by the Qu method. Among these, 79 did not show any growth on SQ culture. Among the 240 specimens showing some growth on SQ culture, a total of 384 organisms were identified. VAP rates in relation to strength of growth on SQ culture were: sparse, 10 of 140 (7%); moderate, 24 of 147 (16%); and heavy, 45 of 97 (46%). Sensitivity (Sn), specificity (Sp), positive (PPV), and negative (NPV) predictive values of SQ culture of BAL fluid for the diagnosis of VAP were 97, 21, 21, and 97 per cent, respectively. Nonquantitative culture of BAL fluid is fairly accurate in ruling out VAP (high Sn and NPV). It however has poor Sp and PPV and using this method will lead to unnecessary antimicrobial use with its attendant complications of toxicity, cost, and resistance.