The Utility of Lower Extremity Screening Duplex for the Detection of Deep Vein Thrombosis in Trauma.

BACKGROUND: Trauma patients are high-risk for venous thromboembolism (VTE). Lower extremity screening duplex ultrasonography (LESDUS) is controversial and not standardized for early VTE diagnosis. By implementing risk stratification and selective screening, we aim to optimize resource utilization. MATERIALS AND METHODS: A retrospective review were conducted at a Level-1 Trauma Center, January 2015-October 2019. LESDUS was performed within 72-h of presentation, then weekly. Demographics, VTE data, and outcomes were collected from the trauma registry. Risk assessment profile (RAP) score was calculated based on collected data. RESULTS: Of 5,645 patients included, 2,813 (49.8%) were screened for lower extremity deep vein thrombosis (LEDVT). Of 187 patients with LEDVT, 154 were diagnosed on LESDUS, 18 after negative LESDUS, and 15 in unscreened patients. Patients with VTE were older (61y versus 55, P < 0.01), more often male (70.9% versus 29.1%, P = 0.03), had higher ISS (16 versus 10, P < 0.01), longer hospital length of stay (LOS) (11.5 d versus 3, P < 0.01), longer ICU LOS (4.5 d versus 1, P < 0.01), and increased mortality (9.1% versus 4.3%, P = 0.01). RAP was higher in VTE patients versus those without (nine versus three, P < 0.01). RAP ≥8 was 62.5% sensitive and 70.4% specific for VTE. Chemoprophylaxis delay also correlated with increased VTE (OR = 1.48, 95% CI = 1.03-2.12). CONCLUSIONS: VTE remains a significant complication in trauma patients. Despite a universal LESDUS protocol, only 50% of patients underwent screening and 20% of all LE DVTs were not identified on LESDUS. To optimize resource utilization and protocol adherence, LESDUS should only be performed if RAP ≥8 or if unable to administer timely chemoprophylaxis.

Age is But a Number: Damage Control Surgery Outcomes in Geriatric Emergency General Surgery.

BACKGROUND: Damage control surgery (DCS) with temporary abdominal closure (TAC) is increasingly utilized in emergency general surgery (EGS). As the population ages, more geriatric patients (GP) are undergoing EGS operations. Concern exists for GP's ability to tolerate DCS. We hypothesize that DCS in GP does not increase morbidity or mortality and has similar rates of primary closure compared to non-geriatric patients (NGP). METHODS: A retrospective chart review from 2014-2020 was conducted on all non-trauma EGS patients who underwent DCS with TAC. Demographics, admission lab values, fluid amounts, length of stay (LOS), timing of closure, post-operative complications and mortality were collected. GP were compared to NGP and results were analyzed using Chi square and Wilcox signed rank test. RESULTS: Ninety-eight patients (n = 50, <65 y; n = 48, ≥65 y) met inclusion criteria. There was no significant difference in median number of operations (3 versus 2), time to primary closure (2.5 versus 3 d), hospital LOS (19 versus 17.5 d), ICU LOS (11 versus 8 d), rate of primary closure (66% versus 56%), post op ileus (44% versus 48%), abscess (14% versus 10%), need for surgery after closure (32% versus 19%), anastomotic dehiscence (16% versus 6%), or mortality (34% versus 42%). Average time until take back after index procedure did not vary significantly between young and elderly group (45.8 versus 38.5 h; P = 0.89). GP were more likely to have hypertension (83% versus 50%; P ≤ 0.05), atrial fibrillation (25% versus 4%; P ≤ 0.05) and lower median heart rate compared to NGP (90 versus 103; P ≤ 0.05). CONCLUSIONS: DCS with TAC in geriatric EGS patients achieves similar outcomes and mortality to younger patients. Indication, not age, should factor into the decision to perform DCS.

Fever in the ICU: A Predictor of Mortality in Mechanically Ventilated COVID-19 Patients.

PURPOSE: While fever may be a presenting symptom of COVID-19, fever at hospital admission has not been identified as a predictor of mortality. However, hyperthermia during critical illness among ventilated COVID-19 patients in the ICU has not yet been studied. We sought to determine mortality predictors among ventilated COVID-19 ICU patients and we hypothesized that fever in the ICU is predictive of mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study of 103 ventilated COVID-19 patients admitted to the ICU between March 14 and May 27, 2020. Final follow-up was June 5, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: 103 patients were included, 40 survived and 63(61.1%) died. Deceased patients were older {66 years[IQR18] vs 62.5[IQR10], (p = 0.0237)}, more often male {48(68%) vs 22(55%), (p = 0.0247)}, had lower initial oxygen saturation {86.0%[IQR18] vs 91.5%[IQR11.5], (p = 0.0060)}, and had lower pH nadir than survivors {7.10[IQR0.2] vs 7.30[IQR0.2] (p < 0.0001)}. Patients had higher peak temperatures during ICU stay as compared to hospital presentation {103.3°F[IQR1.7] vs 100.0°F[IQR3.5], (p < 0.0001)}. Deceased patients had higher peak ICU temperatures than survivors {103.6°F[IQR2.0] vs 102.9°F[IQR1.4], (p = 0.0008)}. Increasing peak temperatures were linearly associated with mortality. Febrile patients who underwent targeted temperature management to achieve normothermia did not have different outcomes than those not actively cooled. Multivariable analysis revealed 60% and 75% higher risk of mortality with peak temperature greater than 103°F and 104°F respectively; it also confirmed hyperthermia, age, male sex, and acidosis to be predictors of mortality. CONCLUSIONS: This is one of the first studies to identify ICU hyperthermia as predictive of mortality in ventilated COVID-19 patients. Additional predictors included male sex, age, and acidosis. With COVID-19 cases increasing, identification of ICU mortality predictors is crucial to improve risk stratification, resource management, and patient outcomes.

Surgeons in surge - the versatility of the acute care surgeon: outcomes of COVID-19 ICU patients in a community hospital where all ICU patients are managed by surgical intensivists.

BACKGROUND: Reported characteristics and outcomes of critically ill patients with COVID-19 admitted to the intensive care unit (ICU) are widely disparate with varying mortality rates. No literature describes outcomes in ICU patients with COVID-19 managed by an acute care surgery (ACS) division. Our ACS division manages all ICU patients at a community hospital in New Jersey. When that hospital was overwhelmed and in crisis secondary to COVID-19, we sought to describe outcomes for all patients with COVID-19 admitted to our closed ICU managed by the ACS division. METHODS: This was a prospective case series of the first 120 consecutive patients with COVID-19 admitted on March 14 to May 10, 2020. Final follow-up was May 27, 2020. Patients discharged from the ICU or who died were included. Patients still admitted to the ICU at final follow-up were excluded. RESULTS: One hundred and twenty patients were included (median age 64 years (range 25-89), 66.7% men). The most common comorbidities were hypertension (75; 62.5%), obesity (61; 50.8%), and diabetes (50; 41.7%). One hundred and thirteen (94%) developed acute respiratory distress syndrome, 89 (74.2%) had shock, and 76 (63.3%) experienced acute kidney injury. One hundred (83.3%) required invasive mechanical ventilation (IMV). Median ICU length of stay (LOS) was 8.5 days (IQR 9), hospital LOS was 14.5 days (IQR 13). Mortality for all ICU patients with COVID-19 was 53.3% and 62% for IMV patients. CONCLUSIONS: This is the first report of patients with COVID-19 admitted to a community hospital ICU managed by an ACS division who also provided all surge care. Mortality of critically ill patients with COVID-19 admitted to an overwhelmed hospital in crisis may not be as high as initially thought based on prior reports. While COVID-19 is a non-surgical disease, ACS divisions have the capability of successfully caring for both surgical and medical critically ill patients, thus providing versatility in times of crisis. LEVEL OF EVIDENCE: Level V.

Competition as a Means for Improving Academic Scores and Attendance at Education Conference.

OBJECTIVE: To determine the effectiveness of competition on education conference attendance rate with a secondary goal of increased performance on in-service examination performance within a single academic general surgery residency. DESIGN: By using a competition-based model of learning, we aimed to increase the overall resident attendance to weekly education conference as well as performance on in-service examination. Residents were given weekly reading assignments which were supplemented with lectures from faculty with expert knowledge of a given topic on a weekly basis. The ability of the surgical resident to apply this knowledge in a board-style exam was then tested on a weekly by administering a 10-question quiz. SETTING: The program was implemented at Robert Wood Johnson Medical School, an academic surgical residency program. RESULTS: The competition-based model of learning had improved conference attendance rates from 52% to 90% Overall quiz participation rates were 90.3% (SEM = 6.32%). Of the 5 distinct postgraduate levels performing on the weekly quizzes, the postgraduate year (PGY) 3 class performed best with the highest scores through 8 weeks. The next highest scoring class was the PGY 4 class. Overall average scores were 76% (standard deviation 10%). American Board of Surgery In-Training Examination scores did not significantly change between the observed years. Overall the average percentile for 2016 American Board of Surgery In-Training Examination was 55.3 compared to 2017's 47.4 (p = 0.0906). CONCLUSIONS: After adding competition to our weekly education conference, we were able to improve our overall education conference attendance. Although this change did not have any objective changes measured on in-service examination results, we feel the increase in attendance and participation within education conference can only serve to benefit the surgical trainee. The establishment of this program has increased resident academic expectations, and a formalized guest-attending lecture schedule only drives conference participation higher. The establishment of weekly quizzes for and by residents allows the student to be more involved in their own education, and that of their peers.

The impact of inpatient palliative care on end-of-life care among older trauma patients who die after hospital discharge.

BACKGROUND: Palliative care (PC) is associated with lower-intensity treatment and better outcomes at the end of life. Trauma surgeons play a critical role in end-of-life (EOL) care; however, the impact of PC on health care utilization at the end of life has yet to be characterized in older trauma patients. METHODS: This retrospective cohort study using 2006 to 2011 national Medicare claims included trauma patients 65 years or older who died within 180 days after discharge. The exposure of interest was inpatient PC during the trauma admission. A non-PC control group was developed by exact matching for age, comorbidity, admission year, injury severity, length of stay, and post-discharge survival. We used logistic regression to evaluate six EOL care outcomes: discharge to hospice, rehospitalization, skilled nursing facility or long-term acute care hospital admission, death in an institutional setting, and intensive care unit admission or receipt of life-sustaining treatments during a subsequent hospitalization. RESULTS: Of 294,665 patients who died within 180 days after discharge, 2.1% received inpatient PC. Among 5,693 matched pairs, inpatient PC was associated with increased odds of discharge to hospice (odds ratio [OR], 3.80; 95% confidence interval [CI], 3.54-4.09) and reduced odds of rehospitalization (OR, 0.17; 95% CI, 0.15-0.20), skilled nursing facility/long-term acute care hospital admission (OR, 0.43; 95% CI, 0.39-0.47), death in an institutional setting (OR, 0.34; 95% CI, 0.30-0.39), subsequent intensive care unit admission (OR, 0.51; 95% CI, 0.36-0.72), or receiving life-sustaining treatments (OR, 0.56; 95% CI, 0.39-0.80). CONCLUSION: Inpatient PC is associated with lower-intensity and less burdensome EOL care in the geriatric trauma population. Nonetheless, it remains underused among those who die within 6 months after discharge. LEVEL OF EVIDENCE: Therapeutic/Care management, level III.

Glycation inactivation of the complement regulatory protein CD59: a possible role in the pathogenesis of the vascular complications of human diabetes.

Micro- and macrovascular diseases are major causes of morbidity and mortality in the diabetic population, but the cellular and molecular mechanisms that link hyperglycemia to these complications remain incompletely understood. We proposed that in human diabetes, inhibition by glycation of the complement regulatory protein CD59 increases deposition of the membrane attack complex (MAC) of complement, contributing to the higher vascular risk. We report here 1) the generation and characterization of an anti-glycated human CD59 (hCD59) specific antibody, 2) the detection with this antibody of glycated hCD59 colocalized with MAC in kidneys and nerves from diabetic but not from nondiabetic subjects, and 3) a significantly reduced activity of hCD59 in erythrocytes from diabetic subjects, a finding consistent with glycation inactivation of hCD59 in vivo. Because hCD59 acts as a specific inhibitor of MAC formation, these findings provide a molecular explanation for the increased MAC deposition reportedly found in the target organs of diabetic complications. We conclude that glycation inactivation of hCD59 that leads to increased MAC deposition may contribute to the extensive vascular pathology that complicates human diabetes.

Comparison of massive blood transfusion predictive models in the rural setting.

BACKGROUND: Hemorrhage is the leading cause of preventable death in trauma patients, of which 3% require massive transfusion (MT). MT predictive models such as the Assessment of Blood Consumption (ABC), Trauma-Associated Severe Hemorrhage (TASH), and McLaughlin scores have been developed, but only included patients requiring blood transfusion during their hospital stay, excluding a large percentage of trauma patients. Our purpose was to validate these MT predictive models in our rural Level I trauma center patient population, using all major trauma victims, regardless of blood product requirements. METHODS: Review of all Level I trauma patients admitted in 2008 to 2009 was performed. ABC, TASH, and McLaughlin scores were calculated using 80% probability for the need for MT. RESULTS: Three hundred seventy-three patients were admitted; 13% had a penetrating mechanism and 52% were scene transports. MT patients had higher Injury Severity Score (median, 43 vs. 13; p < 0.001) and lower Trauma-Injury Severity Score (0.310 vs. 0.983; p < 0.001). Mortality was higher in MT patients (18.4% vs. 5.4%; p < 0.009). Thirty-eight (10%) required MT; 34 were predicted by ABC, one by TASH, and six by McLaughlin. ABC (area under the receiver operating characteristic [AUROC] = 0.86) was predictive of MT, whereas TASH (AUROC = 0.51) and McLaughlin (AUROC = 0.56) were not. CONCLUSIONS: The ABC score correctly identified 89% of MT patients and was predictive of MT in major trauma patients at our rural Level I trauma center; the TASH and McLaughlin scores were not. The ABC score is simpler, faster, and more accurate. Based on this work, we strongly recommend adoption of the ABC score for MT prediction.

Deficiency of the mouse complement regulatory protein mCd59b results in spontaneous hemolytic anemia with platelet activation and progressive male infertility.

Basal complement activity presents a potential danger for "self" cells that are tightly protected by complement regulators including CD59. Mice express two Cd59 genes (mCd59a and mCd59b); mCd59b has approximately a 6-fold higher specific activity than mCd59a. Consistently, mCd59b knockout mice present a strong phenotype characterized by hemolytic anemia with increased reticulocytes, anisopoikilocytosis, echinocytosis, schistocytosis, free hemoglobin in plasma, hemoglobinuria with hemosiderinuria, and platelet activation. Remarkably, mCd59b(-/-) males express a progressive loss of fertility associated with immobile dysmorphic and fewer sperm cells after 5 months of age. This work indicates that mCd59b is a key complement regulator in mice and that CD59 is critical in protecting self cells; it also provides a novel model to study complement regulation in human diseases.