Applied denitrifying bioreactor cost efficiencies based on empirical construction costs and nitrate removal.

Adoption of edge-of-field conservation practices, such as denitrifying bioreactors, may be intrinsically linked to barriers associated with cost. However, most previous bioreactor cost efficiency assessments assumed values for either costs and/or nitrate removal. The objective of this work was to use actual construction costs as well as monitored nitrate removal to develop empirical cost efficiencies for eight full-size bioreactors in Illinois, USA. Capital construction costs were obtained via invoices or personal communications. A cash-flow discounting procedure was used to develop an equal annualized cost for each bioreactor assuming two media recharges over a 24-y planning horizon. These costs were combined with monitored nitrate removal based on one to six years of monitoring per site. Construction costs averaged $12,250 ± $7520 across the eight sites (or, $16,020 ± $9960 in 2023 price levels) but considering one of the sites was a paired bioreactor system, costs averaged $10,890 per bioreactor unit. Drainage treatment area-based cost averaged $132/ha-y and treatment area was strongly correlated with capital costs (R2 = 0.90; p = 0.001). The bioreactors averaged $108/m3 of woodchips and available federal government conservation programs could have offset an average of 70% of this cost. Monitored nitrate removal across 27 site-years resulted in a median of $33/kg N-y removed. This mass-based cost efficiency was higher than most previous assessments because the monitored nitrate removal for the study sites was lower than has been previously assumed or modeled. Future reporting about bioreactor recharge timing and cost will help guide assessment and planning. Water quality planning efforts should also consider the increasingly important engineering design costs, which were not included here. Suggested research and outreach to improve bioreactor cost efficiencies involves scaling the physical capacity of this technology for larger treatment areas, revisiting the use of low-cost non-standard fill media, and providing practical construction training.

Paired denitrifying bioreactors with wide orientation for increased drainage flow capacity.

Denitrifying bioreactors are a conservation drainage practice for reducing nitrate loads in subsurface agricultural drainage. Bioreactor hydraulic capacity is limited by cross-sectional area perpendicular to flow through the woodchip bed, with excess bypass flow untreated. Paired bioreactors with wide orientations were built in 2017 in Illinois, USA, to treat drainage from a relatively large 29 ha field. The paired design consisted of: a larger, Main bioreactor (LWD: 6.1 × 18.3 × 0.9 m) for treating base flow, and 2) a smaller, Booster bioreactor (7.8 × 13.1 × 0.9 m) receiving bypass flow from the Main bioreactor during periods of high flow. Over three years of monitoring, the paired bioreactor captured 84-92% of the annual drainage discharge which demonstrated an expanded cross-sectional area could improve bioreactor flow capture, even for a large drainage area. However, the paired bioreactors removed 6-28% of the annual N load leaving the field (1.8-5.6 kg N ha-1 removed; 52-161 kg N), which was not a notable improvement compared to bioreactors treating smaller drainage areas. The design operated as intended at low annual flow-weighted hydraulic retention times (HRTs) of usually ≤2 h, but these short HRTs ultimately limited bioreactor nitrate removal efficiency. Daily HRTs of <2 h often resulted in nitrate flushing. The Main bioreactor had higher hydraulic loading as intended and was responsible for the majority of flow captured in each year although not always the most nitrate mass removal. The Booster bioreactor provided better nitrate removal than the Main at HRTs of 3.0-11.9 h, possibly due to its drying cycles which may have liberated more available carbon. This new design approach tested at the field-scale illustrated tradeoffs between greater flow capacity (via increased bioreactor width) and longer HRT (via increased length), given a consistent bioreactor surface footprint.

Kids grow up so fast: national patterns of positive drug/alcohol screens among pediatric trauma patients.

BACKGROUND: National guidelines recommend screening all trauma patients for drug and alcohol use beginning at age 12, but no national data have examined rates of screening or positive results in this population. METHODS: We examined national testing rates and results among all trauma patients under 21 years old in the 2017 American College of Surgeons Trauma Quality Programs (TQP) database. RESULTS: Of a cohort of n = 157,450 pediatric and adolescent trauma patients, n = 45,443 (28.9%) were screened, and n = 16,662 (36.7%) of those had a positive result. While both testing and positive results increased with age, testing rates were only 61.7% by age 20 and the prevalence of positive results was significant even at younger ages. Cannabinoids were the most commonly detected substance, followed by alcohol, and then opioids. CONCLUSIONS: These national data support the need for further efforts to increase screening rates and provide structured interventions to mitigate the consequences of substance abuse. IMPACT: These data provide the first national evidence of underutilization of drug and alcohol screening in pediatric and adolescent trauma patients, with substantial rates of positive screens among those tested. Cannabinoids were the most commonly detected substance, followed by alcohol and then opioids. These data should guide physicians' and policymakers' efforts to improve screening in this high-risk population, which will amplify the potential benefits of using the trauma admission as a critical opportunity to intervene with structured programs to mitigate the consequences of substance abuse.

Woodchip bioreactors provide sustained denitrification of brine from groundwater desalination plants.

Woodchip bioreactors are widely known as a best management practice to reduce excess nitrate loads that are discharged with agricultural leachates. The aim of this study was to evaluate the performance of citrus woodchip bioreactors for denitrification of brine (electrical conductivity ≈ 17 mS cm-1) from groundwater desalination plants with high nitrate content (NO3--N ≈ 48 mg L-1) in the Campo de Cartagena agricultural watershed, one of the main providers of horticultural products in Europe. The performance was evaluated relative to seasonal changes in temperature, dissolved organic carbon (DOC) provided by woodchips, hydraulic residence time (HRT) and woodchip aging. Bioreactors (capacity 1 m3) operated for 2.5 years (121 weeks) in batch mode (24 h HRT) with three batches per week. Denitrification efficiency was modulated by DOC concentration, temperature, hydraulic residence time and the drying-rewetting cycles. High salinity of brine did not prevent nitrate removal from occurring. The high DOC availability (>25 mg C L-1) during the first ≈48 weeks resulted in high nitrate removal rate (>75%) and nitrate removal efficiency (until ≈ 25 g N m-3 d-1) regardless of temperature. Moreover, the high DOC contents in the effluents during this period may present environmental drawbacks. Denitrification was still high after 2.5 years (reaching ≈9.3 g N m-3 d-1 in week 121), but dependence on warm temperature became more apparent with woodchips aging from week ≈49 onwards. Nitrate removal efficiency was highest on the first weekly batch, immediately after woodchips had been unsaturated for four days. It was attributable to a flush of DOC produced by aerobic microbial metabolism during drying that stimulated denitrification following re-saturation. Hence, alternance of drying-rewetting cycles is an operation practice that increase bioreactors nitrate removal performance.

High-frequency, in situ sampling of field woodchip bioreactors reveals sources of sampling error and hydraulic inefficiencies.

Woodchip bioreactors are a practical, low-cost technology for reducing nitrate (NO3) loads discharged from agriculture. Traditional methods of quantifying their performance in the field mostly rely on low-frequency, time-based (weekly to monthly sampling interval) or flow-weighted sample collection at the inlet and outlet, creating uncertainty in their performance and design by providing incomplete information on flow and water chemistry. To address this uncertainty, two field bioreactors were monitored in the US and New Zealand using high-frequency, multipoint sampling for in situ monitoring of NO3-N concentrations. High-frequency monitoring (sub hourly interval) at the inlet and outlet of both bioreactors revealed significant variability in volumetric removal rates and percent reduction, with percent reduction varying by up to 25 percentage points within a single flow event. Time series of inlet and outlet NO3 showed significant lag in peak concentrations of 1-3 days due to high hydraulic residence time, where calculations from instantaneous measurements produced erroneous estimates of performance and misleading relationships between residence time and removal. Internal porewater sampling wells showed differences in NO3 concentration between shallow and deep zones, and "hot spot" zones where peak NO3 removal co-occurred with dissolved oxygen depletion and dissolved organic carbon production. Tracking NO3 movement through the profile showed preferential flow occurring with slower flow in deeper woodchips, and slower flow further from the most direct flowpath from inlet to outlet. High-frequency, in situ data on inlet and outlet time series and internal porewater solute profiles of this initial work highlight several key areas for future research.

Drying-Rewetting Cycles Affect Nitrate Removal Rates in Woodchip Bioreactors.

Woodchip bioreactors are widely used to control nitrogen export from agriculture using denitrification. There is abundant evidence that drying-rewetting (DRW) cycles can promote enhanced metabolic rates in soils. A 287-d experiment investigated the effects of weekly DRW cycles on nitrate (NO) removal in woodchip columns in the laboratory receiving constant flow of nitrated water. Columns were exposed to continuous saturation (SAT) or to weekly, 8-h drying-rewetting (8 h of aerobiosis followed by saturation) cycles (DRW). Nitrate concentrations were measured at the column outlets every 2 h using novel multiplexed sampling methods coupled to spectrophotometric analysis. Drying-rewetting columns showed greater export of total and dissolved organic carbon and increased NO removal rates. Nitrate removal rates in DRW columns increased by up to 80%, relative to SAT columns, although DRW removal rates decreased quickly within 3 d after rewetting. Increased NO removal in DRW columns continued even after 39 DRW cycles, with ∼33% higher total NO mass removed over each weekly DRW cycle. Data collected in this experiment provide strong evidence that DRW cycles can dramatically improve NO removal in woodchip bioreactors, with carbon availability being a likely driver of improved efficiency. These results have implications for hydraulic management of woodchip bioreactors and other denitrification practices.

Increased resource use in lung transplant admissions in the lung allocation score era.

RATIONALE: In 2005, the lung allocation score (LAS) was implemented to prioritize organ allocation to minimize waiting-list mortality and maximize 1-year survival. It resulted in transplantation of older and sicker patients without changing 1-year survival. Its effect on resource use is unknown. OBJECTIVES: To determine changes in resource use over time in lung transplant admissions. METHODS: Solid organ transplant recipients were identified within the Nationwide Inpatient Sample (NIS) data from 2000 to 2011. Joinpoint regression methodology was performed to identify a time point of change in mean total hospital charges among lung transplant and other solid-organ transplant recipients. Two temporal lung transplant recipient cohorts identified by joinpoint regression were compared for baseline characteristics and resource use, including total charges for index hospitalization, charges per day, length of stay, discharge disposition, tracheostomy, and need for extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS: A significant point of increased total hospital charges occurred for lung transplant recipients in 2005, corresponding to LAS implementation, which was not seen in other solid-organ transplant recipients. Total transplant hospital charges increased by 40% in the post-LAS cohort ($569,942 [$53,229] vs. $407,489 [$28,360]) along with an increased median length of stay, daily charges, and discharge disposition other than to home. Post-LAS recipients also had higher post-transplant use of extracorporeal membrane oxygenation (odds ratio, 2.35; 95% confidence interval, 1.56-3.55) and higher incidence of tracheostomy (odds ratio, 1.52; 95% confidence interval, 1.22-1.89). CONCLUSIONS: LAS implementation is associated with a significant increase in resource use during index hospitalization for lung transplant.

Heart-lung vs. double-lung transplantation for idiopathic pulmonary arterial hypertension.

Patients with idiopathic pulmonary arterial hypertension (IPAH) have improved survival after heart-lung transplantation (HLT) and double-lung transplantation (DLT). However, the optimal procedure for patients with IPAH undergoing transplantation remains unclear. We hypothesized that critically ill IPAH patients, defined by admission to the intensive care units (ICU), would demonstrate improved survival with HLT vs. DLT. All adult IPAH patients (>18 yr) in the Scientific Registry of Transplant Recipients (SRTR) database, who underwent either HLT or DLT between 1987 and 2012, were included. Baseline characteristics, survival, and adjusted survival were compared between the HLT and DLT groups. Similar analyses were performed for the subgroups as defined by the recipients' hospitalization status. A total of 928 IPAH patients (667 DLT, 261 HLT) were included in this analysis. The HLT recipients were younger, more likely to be admitted to the ICU, and have had their transplant in previous eras. Overall, the adjusted survivals after HLT or DLT were similar. For recipients who were hospitalized in the ICU, DLT was associated with worse outcomes (HR 1.827; 95% CI 1.018-3.279). In IPAH patients, the overall survival after HLT or DLT is comparable. HLT may provide improved outcomes in critically ill IPAH patients admitted to the ICU at time of transplantation.

Complications of catheter-based electrophysiology procedures in adults with congenital heart disease: a national analysis.

OBJECTIVE: To determine whether adult congenital heart disease patients (ACHD) undergoing catheter-based electrophysiology (EP) procedures have an increased risk for complications compared with adults without congenital heart disease. DESIGN: Retrospective cohort study of a national administrative database. SETTING: Nationwide Inpatient Sample, 1998 through 2011. PARTICIPANTS: All admission records of patients who underwent a catheter-based electrophysiology procedure, categorized based on the presence or absence of ACHD. INTERVENTIONS: ACHD and non-ACHD cohorts were compared with respect to baseline, procedural, and outcome characteristics. MEASUREMENTS AND MAIN RESULTS: ACHD patients accounted for n=15,133 (1.7%) of n=873,437 EP procedure admissions and comprised a significantly increasing proportion over the study period (from 0.8% in 1998 to 2.4% in 2011, p<0.0001). ACHD patients were younger than non-ACHD patients (52.5±0.3 years v 61.9±0.04 years; p<0.0001), had a longer length of stay (4.6±0.1 days v 4.4±0.01 days, p=0.013), higher total hospital charges ($89,485±$1,543 v $70,456±$175, p<0.0001), and a higher rate of procedure-related complications (odds ratio 1.66, 95% confidence interval 1.49-1.85, p<0.0001). On multivariate analysis, ACHD patients continued to demonstrate an increased risk of procedural complications (odds ratio 1.95, 95% confidence interval 1.75-2.19, p<0.0001). CONCLUSIONS: ACHD patients experienced greater morbidity after catheter-based EP procedures. This finding will be of increasing significance as ACHD patients occupy a growing segment of the population undergoing these procedures. Further investigations are warranted to determine whether this increased risk is modifiable, with the aim of improving patient safety.

Obstructive Sleep Apnea Is an Independent Predictor of Postoperative Atrial Fibrillation in Cardiac Surgery.

OBJECTIVE: To test the hypothesis that obstructive sleep apnea (OSA) is a risk factor for development of postoperative atrial fibrillation (POAF) after cardiac surgery. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: Five hundred forty-five patients in sinus rhythm preoperatively undergoing coronary artery bypass grafting (CABG), aortic valve replacement, mitral valve replacement/repair, or combined valve/CABG surgery from January 2008 to April 2011. INTERVENTIONS: Retrospective review of medical records. MEASUREMENTS AND MAIN RESULTS: Postoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Of 545 cardiac surgical patients, 226 (41%) patients developed POAF. The risk was higher in 72 OSA patients than 473 patients without OSA (67% v 38%, adjusted hazard ratio 1.83 [95% CI: 1.30-2.58], p<0.001). Of the 32 OSA patients who used home positive airway pressure (PAP) therapy, 18 (56%) developed POAF compared with 29 of 38 (76%) patients who did not use PAP at home (unadjusted hazard ratio 0.63 [95% CI: 0.35-1.15], p = 0.13). CONCLUSION: OSA is significantly associated with POAF in cardiac surgery patients. Further investigation is needed to determine whether or not use of positive airway pressure in OSA patients reduces the risk of POAF.

Pulmonary vascular resistance index and mortality after paediatric heart transplant.

BACKGROUND: Although some prior studies have provided evidence to question the historical belief that pulmonary vascular resistance index ⩾6 Wood Units×m2 should be a contraindication to heart transplantation in children, no national analyses specific to the modern area have addressed this question. METHODS: Data were analysed for paediatric heart transplant recipients from 1 January, 2002 to 1 September, 2012 (n=699). The relationship between pulmonary vascular resistance and all-cause 30-day mortality was evaluated using univariate and multivariate analyses. RESULTS: The 30-day mortality included 10 patients (1.43%), which is lower than in the previous analyses. Receiver operating curve analysis of pulmonary vascular resistance index as a predictor of mortality yielded a cut-off value of 3.37 Wood Units×m2, but the area under the curve and specificity of this threshold was weaker than in previous analyses. Whereas pulmonary vascular resistance index treated as a dichotomised variable was a significant predictor of mortality in univariate (odds ratio 4.92, 95% confidence interval 1.04-23.33, p=0.045) and multivariate (odds ratio 5.26, 95% confidence interval 1.07-25.80, p=0.041) analyses, pulmonary vascular resistance index treated as a continuous variable was not a significant predictor of mortality in univariate (p=0.12) or multivariate (p=0.11) analyses. CONCLUSIONS: The relationship between pulmonary vascular resistance and post-heart transplant mortality in children is less convincing in this analysis of a comprehensive, contemporary database than in previous series. This suggests the possibility that modern improvements in the management of post-transplant right ventricular dysfunction have mitigated the contribution of pulmonary hypertension to early mortality.

Percutaneous tracheostomy at the bedside: 13 tips for improving safety and success.

We have developed a set of routines and practices in the course of performing a large series (n = 70) of percutaneous dilational tracheostomy (PDT). The 13 tips discussed in this review fall into 4 categories. System factors that facilitate training, patient safety, and avoidance of crises including the use of appropriate personnel, importance of timing, use of premedication, and the utility and content of a preprocedure briefing. Suggestions to prevent loss of the airway include tips on airway assessment, preparation of airway equipment, and use of exchange catheter techniques. Strategies to avoid and manage both microvascular and large-vessel bleeding are discussed. We also discuss the management of common postprocedure problems including tracheostomy tube obstruction, malposition requiring tube exchange or replacement, and air leak. The practical considerations for successful execution of PDT involve common sense, thorough planning, and structured approaches to prevent adverse effects if the procedure does not go as smoothly as expected. These strategies will aid anesthesiologists and intensivists in improving their comfort level, safety, and competence in performing this beside procedure.

Congenital anomalies of the aortic arch in acute type-a aortic dissection: implications for monitoring, perfusion strategy, and surgical repair.

OBJECTIVE: To assess whether management of acute Stanford type-A aortic dissection differs in patients with congenital anomalies of the aortic arch compared with standard institutional practice. DESIGN: Retrospective analysis of all consecutive patients from 2001 through 2011. SETTING: Quaternary referral center for surgical management of thoracic aortic disease. PARTICIPANTS: All patients with arch anomalies who underwent surgery for acute Stanford type-A aortic dissection during the study period (n = 43). INTERVENTIONS: Surgical management, anesthetic monitoring, and perfusion strategy were analyzed in a retrospective fashion. No new interventions were undertaken as part of this study. MEASUREMENTS AND MAIN RESULTS: Management differed most in patients with an aberrant right subclavian artery (n = 5), because the institutional standard of right axillary artery cannulation with left upper extremity arterial pressure monitoring was not possible. In patients with one of two "bovine" arch patterns (n = 32), management differed in the conduct of selective antegrade cerebral perfusion, which could include clamping above or below the takeoff of the left common carotid artery (and, therefore, produced unilateral or bilateral antegrade cerebral perfusion). All patients with a connective tissue disorder exhibited a bovine arch pattern. Management of patients with a right arch (n = 3) reflected the opposite of management for normal anatomy (for patients with traditional mirror-image branching) or opposite that of the aberrant right subclavian group (for patients who had a corresponding aberrant left subclavian artery). CONCLUSIONS: Rational management reflected the anatomic variations observed. These results support the importance of interdisciplinary planning, especially in an emergency, to optimize outcome.

P-wave characteristics on routine preoperative electrocardiogram improve prediction of new-onset postoperative atrial fibrillation in cardiac surgery.

OBJECTIVE: To test the hypothesis that including preoperative electrocardiogram (ECG) characteristics with clinical variables significantly improves the new-onset postoperative atrial fibrillation prediction model. DESIGN: Retrospective analysis. SETTING: Single-center university hospital. PARTICIPANTS: Five hundred twenty-six patients, ≥ 18 years of age, who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement/repair, or a combination of valve surgery and coronary artery bypass grafting requiring cardiopulmonary bypass. INTERVENTIONS: Retrospective review of medical records. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics and cardiopulmonary bypass times were collected. Digitally-measured timing and voltages from preoperative electrocardiograms were extracted. Postoperative atrial fibrillation was defined as atrial fibrillation requiring therapeutic intervention. Two hundred eight (39.5%) patients developed postoperative atrial fibrillation. Clinical predictors were age, ejection fraction<55%, history of atrial fibrillation, history of cerebral vascular event, and valvular surgery. Three ECG parameters associated with postoperative atrial fibrillation were observed: Premature atrial contraction, p-wave index, and p-frontal axis. Adding electrocardiogram variables to the prediction model with only clinical predictors significantly improved the area under the receiver operating characteristic curve, from 0.71 to 0.78 (p<0.01). Overall net reclassification improvement was 0.059 (p = 0.09). Among those who developed postoperative atrial fibrillation, the net reclassification improvement was 0.063 (p = 0.03). CONCLUSION: Several p-wave characteristics are independently associated with postoperative atrial fibrillation. Addition of these parameters improves the postoperative atrial fibrillation prediction model.

Perioperative outcomes of major noncardiac surgery in adults with congenital heart disease.

BACKGROUND: An increasing number of patients with congenital heart disease are surviving to adulthood. Consensus guidelines and expert opinion suggest that noncardiac surgery is a high-risk event, but few data describe perioperative outcomes in this population. METHODS: By using the Nationwide Inpatient Sample database (years 2002 through 2009), the authors compared patients with adult congenital heart disease (ACHD) who underwent noncardiac surgery with a non-ACHD comparison cohort matched on age, sex, race, year, elective or urgent or emergency procedure, van Walraven comborbidity score, and primary procedure code. Mortality and morbidity were compared between the two cohorts. RESULTS: A study cohort consisting of 10,004 ACHD patients was compared with a matched comparison cohort of 37,581 patients. Inpatient mortality was greater in the ACHD cohort (407 of 10,004 [4.1%] vs. 1,355 of 37,581 [3.6%]; unadjusted odds ratio, 1.13; P = 0.031; adjusted odds ratio, 1.29; P < 0.001). The composite endpoint of perioperative morbidity was also more commonly observed in the ACHD cohort (2,145 of 10.004 [21.4%] vs. 6,003 of 37,581 [16.0%]; odds ratio, 1.44; P < 0.001). ACHD patients comprised an increasing proportion of all noncardiac surgical admissions over the study period (P value for trend is <0.001), and noncardiac surgery represented an increasing proportion of all ACHD admissions (P value for trend is <0.001). CONCLUSIONS: Compared with a matched control cohort, ACHD patients undergoing noncardiac surgery experienced increased perioperative morbidity and mortality. Within the limitations of a retrospective analysis of a large administrative dataset, this finding demonstrates that this is a vulnerable population and suggests that better efforts are needed to understand and improve the perioperative care they receive.

Improving bioenergy recovery from municipal wastewater with a novel cloth-filter anaerobic membrane bioreactor.

Anaerobic membrane bioreactors (AnMBR) have been used for treating high-strength industrial wastewater at full-scale and the potential to use them for mainstream municipal wastewater treatment presents an important opportunity to turn energy-intensive plants into net-energy producers. However, several limitations of the AnMBR technology have prevented their adoption in the municipal wastewater industry, namely, high membrane cleaning energy demand and low membrane flux. This study demonstrated a novel AnMBR configuration that uses a commercially available cloth filter technology to address the key limitations of cleaning energy and membrane flux. The cloth filter anaerobic membrane bioreactor (CFAnMBR) is comprised of an anaerobic fixed-film bioreactor coupled with a cloth filter membrane with nominal pore size of 5 µm. The pilot CFAnMBR was operated for 150 days through the winter at a municipal wastewater plant in central Illinois (minimum/average influent temperature 5/13°C). The CFAnMBR increased membrane flux by more than 2 orders of magnitude (3,649 ± 1,246 L per meter squared per hour) and reduced cleaning energy demand by 78%-92% (0.0085 kWh/m3) relative to previously reported AnMBR configurations. With the CFAnMBR, average chemical oxygen demand and total suspended solids removal were 66% and 91%, respectively, and were shown to be increased up to 88% and 96% by in-line coagulant dosing with ferric chloride. Average headspace methane yield was 154 mL CH4/g CODremoved by the end of the study period with influent temperatures of 11°C± 4°C. The CFAnMBR resolves major limitations of AnMBR technology by employing a commercially-available technology already used for other municipal wastewater treatment applications.

SARS-Co-V-2 positive status is associated with a more seriously injured population of trauma patients but not independently associated with worse outcomes of trauma care.

BACKGROUND: SARS-CoV-2 positive status has been considered a predominantly incidental finding among trauma patients. We sought to examine whether concurrent infection is associated with worse outcomes in a contemporary cohort of injured patients during the COVID-19 pandemic. METHODS: Retrospective cohort analysis of a level I trauma center's institutional registry from May 1, 2020 through June 30, 2021. The prevalence of COVID in the trauma population was compared monthly using prevalence ratios relative to population estimates. Unadjusted cohorts of COVID+ vs COVID- trauma patients were compared. COVID+ patients then were matched on age, mechanism of injury, year, and injury severity score (ISS) with COVID- controls for adjusted analysis with a primary composite outcome of mortality. RESULTS: Out of n=2,783 trauma activations, n=51 (1.8%) were COVID+. Compared to the general population, the trauma population had prevalence ratios for COVID of 5.3 to 79.7 (median=20.8). Compared to COVID- patients, COVID+ patients had worse outcomes, including a higher proportion who were admitted to the ICU, required intubation, underwent a major operation, and had greater total charges and a longer length of stay. However, these differences appeared related to more severe injury patterns in the COVID+ cohort. In the adjusted analysis, no significant differences between groups in any of the outcome variables were observed. CONCLUSIONS: Worse trauma outcomes in COVID+ patients appear to be correlated to the more substantial patterns of injury observed in this group. Trauma patients have substantially higher rates of SARS-CoV-2 positivity than the local population at large. These results reinforce that this population is vulnerable to multiple threats. They will guide the ongoing delivery of care in shaping the needs for testing, PPE for those delivering care, and the capacity and operational needs of trauma systems that must care for a population with such high rates of SARS-CoV-2 infection.

Perioperative management of the morbidly obese adolescent with heart failure undergoing bariatric surgery.

The incidence and prevalence of adolescent obesity and adolescent heart failure are increasing, and anesthesiologists increasingly will encounter patients with both conditions. A greater understanding of the physiologic challenges of adolescent heart failure as they relate to the perioperative stressors of anesthesia and bariatric surgery is necessary to successfully manage the perioperative risks faced by this growing subpopulation. Here, we present a representative case of a morbidly obese adolescent with heart failure who underwent a laparoscopic bariatric operation and review the limited available literature on perioperative management in this age group. Specifically, we review evidence and offer recommendations related to preoperative evaluation, venous thromboembolism prophylaxis, positioning, induction, airway management, monitoring, anesthetic maintenance, ventilator management, and adverse effects of the pneumoperitoneum, rhabdomyolysis, and postoperative care.

National patterns of injury and outcomes of gunshot wounds to the penis: A Trauma Quality Programs retrospective cohort analysis.

AIM: Gunshot wounds (GSW) to the penis represent a rare type of traumatic injury in the civilian United States population. Although small, single-center studies have reported results of care for these types of injured patients, no national analyses have examined this group. METHODS: A cohort of patients with GSW to the penis was identified using the 2017 American College of Surgeons Trauma Quality Programs database, a comprehensive national database of 753 accredited trauma centers. RESULTS: Gunshot wounds to the penis occurred in 722 patients, which represents 1.7% of all GSW patients (n = 41,017). Gunshot wounds from altercations with law enforcement or accidental discharge of a firearm were rare; the vast majority (n = 655, 90.7%) occurred as a result of assault, intentional self-harm, attempted suicide, or attempted homicide. Patients with a major concomitant non-genitourinary injury comprised 119 (16.5%) patients of the cohort. Most patients (n = 499, 69.1%) underwent a genitourinary procedure during their trauma admission. Penile salvage was successful in most cases, with only 13 (1.8%) patients requiring completion penectomy. Most patients (87.8%) required admission with a median length of stay of 49.8 h. Most patients were treated at the initial trauma center without requiring transfer to another center, and complications during admission were rare. CONCLUSIONS: This analysis, the first national examination of care of patients with GSW to the penis, reveals overall favorable outcomes. Admission and surgical intervention were required in most patients, but penectomy was rare and length of stay was generally short. These results will guide resource utilization and quality improvement efforts in this patient cohort.