Development and Initial Performance of the Hospital Mental Health Risk Screen

BACKGROUND

Patients hospitalized after emergency care are at risk for later mental health problems such as depression, anxiety, and posttraumatic stress disorder symptoms. The American College of Surgeons Committee on Trauma standards for verification require Level I and II trauma centers to screen patients at high risk for mental health problems. This study aimed to develop and examine the performance of a novel mental health risk screen for hospitalized patients based on samples that reflect the diversity of the US population.

STUDY DESIGN

We studied patients admitted after emergency care to 3 hospitals that serve ethnically, racially, and socioeconomically diverse populations. We assessed risk factors during hospitalization and mental health symptoms at follow-up. We conducted analyses to identify the most predictive risk factors, selected items to assess each risk, and determined the fewest items needed to predict mental health symptoms at follow-up. Analyses were conducted for the entire sample and within 5 ethnic and racial subgroups.

RESULTS

Among 1,320 patients, 10 items accurately identified 75% of patients who later had elevated levels of mental health symptoms and 71% of those who did not. Screen performance was good to excellent within each of the ethnic and racial groups studied.

CONCLUSIONS

The Hospital Mental Health Risk Screen accurately predicted mental health outcomes overall and within ethnic and racial subgroups. If performance is replicated in a new sample, the screen could be used to screen patients hospitalized after emergency care for mental health risk. Routine screening could increase health and mental health equity and foster preventive care research and implementation.

Association Between Fecal Contamination and Outcomes After Emergent General Surgery Colorectal Resection: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma (EAST) Multicenter Study

Background: The impact of fecal contamination on clinical outcomes in patients undergoing emergent colorectal resection is unclear. We hypothesized that fecal contamination is associated with worse clinical outcomes regardless of operative technique. Patients and Methods: This is a post hoc analysis for an Eastern Association for the Surgery of Trauma-sponsored multicenter study that prospectively enrolled emergency general surgery patients undergoing urgent/emergent colorectal resection. Subjects were categorized according to presence versus absence of intra-operative fecal contamination. Propensity score matching (1:1) by age, weight, Charlson comorbidity index, pre-operative vasopressor use, and method of colonic management (primary anastomosis [ANST] vs. ostomy [STM]) was performed. χ² analysis was then performed to compare the composite outcome (surgical site infection and fascial dehiscence). Results: A total of 428 subjects were included, of whom 147 (34%) had fecal contamination. Propensity score matching (1:1) resulted in a total of 147 pairs. After controlling for operative technique, fecal contamination was still associated with higher odds of the composite outcome (odds ratio [OR], 2.47; 95% confidence interval [CI], 1.45-4.2; p = 0.001). Conclusions: In patients undergoing urgent/emergent colorectal resection, fecal contamination, regardless of operative technique, is associated with worse clinical outcomes. Selection bias is possible, thus randomized controlled trials are needed to confirm or refute a causal relation.

Utilization of trauma nurse screening procedure for triage of the injured patient

PURPOSE

The treatment of trauma patients requires significant hospital resources. Numerous protocols exist to triage the injured patient and determine the level of care they may require. The purpose of this work is to describe an institutional trauma nurse screening procedure and to evaluate its effectiveness in triaging injured patients.

METHODS

This retrospective study was conducted at a large, tertiary trauma center from January to June 2021. Patients were assessed by trauma nurse clinicians (TNC) utilizing a standardized screening process to determine suitability for trauma activation. If the patient did not meet activation criteria, they were sent to the main Emergency Department for evaluation and treatment. Patients could be activated later by the emergency physician. The primary variables of interest were number of activations after initial "rule out," injury severity score (ISS) for patients who were activated, mechanism of injury, and disposition.

RESULTS

A total of 1874 TNC screenings were performed. Of these, 1449 (77%) patients did not meet trauma activation criteria. Only 41 (2.8%) patients initially ruled out were later activated by the emergency physician and admitted for treatment of injuries. The average ISS of all activated patients was 9 ± 6. Thirty-six patients had an ISS ≤ 15, four between 16 and 25, and only one patient had an ISS > 25. Twenty-seven patients were admitted to the ward, five went to step-down units, and five required intensive care unit admission. Four patients required operative intervention for their injuries.

CONCLUSION

These results suggest that nursing screening protocols can be safe, effective tools for triage of trauma patients.

Validation of the American Association for the Surgery of Trauma Emergency General Surgery Grading System for Colorectal Resection: An EAST Multicenter Study

BACKGROUND

The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection.

METHODS

Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality.

RESULTS

There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not.

CONCLUSION

The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.

Challenging Traditional Paradigms in Posttraumatic Pulmonary Thromboembolism

Importance

Pulmonary clots are seen frequently on chest computed tomography performed after trauma, but recent studies suggest that pulmonary thrombosis (PT) and pulmonary embolism (PE) after trauma are independent clinical events.

Objective

To assess whether posttraumatic PT represents a distinct clinical entity associated with the nature of the injury, different from the traditional venous thromboembolic paradigm of deep venous thrombosis (DVT) and PE.

Design, Setting, and Participants

This prospective, observational, multicenter cohort study was conducted by the Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group. The study was conducted at 17 US level I trauma centers during a 2-year period (January 1, 2018, to December 31, 2020). Consecutive patients 18 to 40 years of age admitted for a minimum of 48 hours with at least 1 previously defined trauma-associated venous thromboembolism (VTE) risk factor were followed up until discharge or 30 days.

Exposures

Investigational imaging, prophylactic measures used, and treatment of clots.

Main Outcomes and Measures

The main outcomes of interest were the presence, timing, location, and treatment of any pulmonary clots, as well as the associated injury-related risk factors. Secondary outcomes included DVT. We regarded pulmonary clots with DVT as PE and those without DVT as de novo PT.

Results

A total of 7880 patients (mean [SD] age, 29.1 [6.4] years; 5859 [74.4%] male) were studied, 277 with DVT (3.5%), 40 with PE (0.5%), and 117 with PT (1.5%). Shock on admission was present in only 460 patients (6.2%) who had no DVT, PT, or PE but was documented in 11 (27.5%) of those with PE and 30 (25.6%) in those with PT. Risk factors independently associated with PT but not DVT or PE included shock on admission (systolic blood pressure <90 mm Hg) (odds ratio, 2.74; 95% CI, 1.72-4.39; P < .001) and major chest injury with Abbreviated Injury Score of 3 or higher (odds ratio, 1.72; 95% CI, 1.16-2.56; P = .007). Factors associated with the presence of PT on admission included major chest injury (14 patients [50.0%] with or without major chest injury with an Abbreviated Injury Score >3; P = .04) and major venous injury (23 [82.1%] without major venous injury and 5 [17.9%] with major venous injury; P = .02). No deaths were attributed to PT or PE.

Conclusions and Relevance

To our knowledge, this CLOTT study is the largest prospective investigation in the world that focuses on posttraumatic PT. The study suggests that most pulmonary clots are not embolic but rather result from inflammation, endothelial injury, and the hypercoagulable state caused by the injury itself.

Does routine postoperative contrast radiography improve outcomes for patients with perforated peptic ulcer? A multicenter retrospective cohort study

BACKGROUND

Perforated peptic ulcer is a morbid emergency general surgery condition. Best practices for postoperative care remain undefined. Surgical dogma preaches practices such as peritoneal drain placement, prolonged nil per os, and routine postoperative enteral contrast imaging despite a lack of evidence. We aimed to evaluate the role of postoperative enteral contrast imaging in postoperative perforated peptic ulcer care. Our primary objective was to assess effects of routine postoperative enteral contrast imaging on early detection of clinically significant leaks.

METHODS

We conducted a multicenter retrospective cohort study of patients who underwent repair of perforated peptic ulcer between July 2016 and June 2018. We compared outcomes between those who underwent routine postoperative enteral contrast imaging and those who did not.

RESULTS

Our analysis included 95 patients who underwent primary/omental patch repair. The mean age was 60 years, and 54% were male. Thirteen (14%) had a leak. Eighty percent of patients had a drain placed. Nine patients had leaks diagnosed based on bilious drain output without routine postoperative enteral contrast imaging. Use of routine postoperative enteral contrast imaging varied significantly between institutions (30%-87%). Two late leaks after initial normal postoperative enteral contrast imaging were confirmed by imaging after a clinical change triggered the second study. Two patients had contained leaks identified by routine postoperative enteral contrast imaging but remained clinically well. Duration of hospital stay was longer in those who received routine postoperative enteral contrast imaging (12 vs 6 days, median; P = .000).

CONCLUSION

Routine postoperative enteral contrast imaging after perforated peptic ulcer repair likely does not improve the detection of clinically significant leaks and is associated with increased duration of hospital stay.

Empiric antifungals do not decrease the risk for organ space infection in patients with perforated peptic ulcer

Introduction

Infection control in patients with perforated peptic ulcers (PPU) commonly includes empiric antifungals (AF). We investigated the variation in the use of empiric AF and explored the association between their use and the subsequent development of organ space infection (OSI).

Methods

This was a secondary analysis of a multicenter, case–control study of patients treated for PPU at nine institutions between 2011 and 2018. Microbiology and utilization of empiric AF, defined as AF administered within 24 hours from the index surgery, were recorded. Patients who received empiric AF were compared with those who did not. The primary outcome was OSI and secondary outcome was OSI with growth of Candida spp. A logistic regression was used to adjust for differences between the two cohorts.

Results

A total of 554 patients underwent a surgical procedure for PPU and had available timing of AF administration. The median age was 57 years and 61% were male. Laparoscopy was used in 24% and omental patch was the most common procedure performed (78%). Overall, 239 (43%) received empiric AF. There was a large variation in the use of empiric AF among participating centers, ranging from 25% to 68%. The overall incidence of OSI was 14% (77/554) and was similar for patients who did or did not receive empiric AF. The adjusted OR for development of OSI for patients who received empiric AF was 1.04 (95% CI 0.64 to 1.70), adjusted p=0.86. The overall incidence of OSI with growth of Candida spp was 5% and was similar for both groups (adjusted OR 1.29, 95% CI 0.59 to 2.84, adjusted p=0.53).

Conclusion

For patients undergoing surgery for PPU, the use of empiric AF did not yield any significant clinical advantage in preventing OSI, even those due to Candida spp. Use of empiric AF in this setting is unnecessary.

Study type

Original article, case series.

Level of evidence

III.

Surgical Faculty Perception of Service-Based Advanced Practice Provider Impact: A Southwestern Surgical Congress Multicenter Survey

BACKGROUND

A previous single-center survey of trauma and general surgery faculty demonstrated perceived positive impact of trauma and surgical subspecialty service-based advanced practice providers (SB APPs). The aim of this multicenter survey was to further validate these findings.

METHODS

Faculty surgeons on teams that employ SB APPs at 8 academic centers completed an electronic survey querying perception about advanced practice provider (APP) competency and impact.

RESULTS

Respondents agreed that SB APPs decrease workload (88%), length of stay (72%), contribute to continuity (92%), facilitate care coordination (87%), enhance patient satisfaction (88%), and contribute to best practice/safe patient care (83%). Fewer agreed that APPs contribute to resident education (50%) and quality improvement (QI)/research (36%). Although 93% acknowledged variability in the APP level of function, 91% reported trusting their clinical judgment.

CONCLUSION

This study supports the perception that SB APPs have a positive impact on patient care and quality indicators. Areas for potential improvement include APP contribution to resident education and research/QI initiatives.

Statewide Analysis of Peptic Ulcer Disease: As Hospitalizations Decrease, Procedural Volume Remains Steady

Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors’ clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.

Burn Surgeon and Palliative Care Physician Attitudes Regarding Goals of Care Delineation for Burned Geriatric Patients

Palliative care specialists (PCS) and burn surgeons (BS) were surveyed regarding: 1) importance of goals of care (GoC) conversations for burned seniors; 2) confidence in their own specialty's ability to conduct these conversations; and 3) confidence in the ability of the other specialty to do so. A 13-item survey was developed by the steering committee of a multicenter consortium dedicated to palliative care in the injured geriatric patient and beta-tested by BS and PCS unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Burn Association and American Academy for Hospice and Palliative Medicine. Forty-five BS (7.3%) and 244 PCS (5.7%) responded. Palliative physicians rated being more familiar with GoC, were more comfortable having a discussion with laypeople, were more likely to have reported high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to BS. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so. BS favored leading team discussions, whereas palliative specialists preferred jointly led discussions. Both groups agreed that discussions should occur within 72 hours of admission. Both groups believe themselves to conduct GoC discussions for burned seniors better than the other specialty perceived them to do so, which led to disparate views on perceptions for the optimal leadership of these discussions.

Laparoscopic omental patch for perforated peptic ulcer disease reduces length of stay and complications, compared to open surgery: A SWSC multicenter study

RCTs showed benefits in Lap repair of perforated peptic ulcer (PPU). The SWSC Multi-Center Trials Group sought to evaluate whether Lap omental patch repairs compared to Open improved outcomes in PPU in general practice. Data was collected from 9 SWSC Trial Group centers. Demographics, operative time, 30-day complications, length of stay and mortality were included. 461 PATIENTS: Open in 311(67%) patients, Lap in 132(28%) with 20(5%) patients converted from Lap to Open. Groups were similar at baseline. Significant variability was found between centers in their utilization of Lap (0-67%). Complications at 30 days were lower in Lap (18.5% vs. 27.5%, p < 0.05) as was unplanned re-operation (4.7% vs 14%, p < 0.05). Lap reduced LOS (6 vs 8 days, p < 0.001). Ileus was more in Lap (42% vs 18 p < 0.001) operative time was 14 min higher in Lap(p < 0.01) and admission to OR time was 4 h higher in Lap(<0.05). No significant difference readmission or mortality. Our results suggest Lap should be considered a first-line option in suitable PPU patients requiring omental patch repair in centers that have the capacity and resources 24/7.

Statewide Analysis of Peptic Ulcer Disease: As Hospitalizations Decrease, Procedural Volume Remains Steady

Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors' clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.

Interhospital Transfers with Wide Variability in Emergency General Surgery

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume ( P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume ( P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.

Interhospital Transfers with Wide Variability in Emergency General Surgery

Interhospital transfer of emergency general surgery (EGS) patients is a common occurrence. Modern individual hospital practices for interhospital transfers have unknown variability. A retrospective review of the Maryland Health Services Cost Review Commission database was undertaken from 2013 to 2015. EGS encounters were divided into three groups: encounters not transferred, encounters transferred from a hospital, and encounters transferred to a hospital. In total, 380,405 EGS encounters were identified, including 12,153 (3.2%) encounters transferred to a hospital, 10,163 (2.7%) encounters transferred from a hospital, and 358,089 (94.1%) encounters not transferred. For individual hospitals, percentage of encounters transferred to a hospital ranged from 0 to 30.05 per cent, encounters transferred from a hospital from 0.02 to 14.62 per cent, and encounters not transferred from 69.25 to 99.95 per cent of total encounters at individual hospitals. Percentage of encounters transferred from individual hospitals was inversely correlated with annual EGS hospital volume (P < 0.001, r = -0.59), whereas percentage of encounters transferred to individual hospitals was directly correlated with annual EGS hospital volume (P < 0.001, r = 0.51). Individual hospital practices for interhospital transfer of EGS patients have substantial variability. This is the first study to describe individual hospital interhospital transfer practices for EGS.

Trauma Surgeon and Palliative Care Physician Attitudes Regarding Goals-of-Care Delineation for Injured Geriatric Patients

Background:

The value of defining goals of care (GoC) for geriatric patients is well known to the palliative care community but is a newer concept for many trauma surgeons. Palliative care specialists and trauma surgeons were surveyed to elicit the specialties’ attitudes regarding (1) importance of GoC conversations for injured seniors; (2) confidence in their own specialty’s ability to conduct these conversations; and (3) confidence in the ability of the other specialty to do so.

Methods:

A 13-item survey was developed by the steering committee of a multicenter, palliative care-focused consortium and beta-tested by trauma surgeons and palliative care specialists unaffiliated with the consortium. The finalized instrument was electronically circulated to active physician members of the American Association for the Surgery of Trauma and American Academy for Hospice and Palliative Medicine.

Results:

Respondents included 118 trauma surgeons (8.8%) and 244 palliative care specialists (5.7%). Palliative physicians rated being more familiar with GoC, were more likely to report high-quality training in performing conversations, believed more palliative specialists were needed in intensive care units, and had more interest in conducting conversations relative to trauma surgeons. Both groups believed themselves to perform GoC discussions better than the other specialty perceived them to do so and favored their own specialty leading team discussions.

Conclusions:

Both groups believe themselves to conduct GoC discussions for injured seniors better than the other specialty perceived them to do so, which led to disparate views on the optimal leadership of these discussions.

Comparison of individual and composite radiographic markers of frailty in trauma

BACKGROUND

Clinical frailty scores usually involve questionnaires or physical testing. Many trauma patients are not able to participate in these. Radiographic measurement of frailty may be a viable alternative. Individual radiographic markers of frailty have been investigated, such as sarcopenia or osteopenia. The ideal radiographic variable (or variables) to measure frailty in trauma is unknown.

STUDY DESIGN

A retrospective review was performed of restrained drivers ages 40 and greater at a single institution from 2010-2015. Multiple markers of radiographic frailty were measured including: sarcopenia, osteopenia, vascular calcifications, sarcopenic obesity, emphysema, renal volume, cervical spine degeneration, and cerebral atrophy. Frailty was defined as the worst quartile for each radiographic variable, and these values were summed to create a composite marker of frailty. The primary outcome was discharge disposition. We hypothesized that a composite frailty score would be associated with discharge disposition while individual markers would not be associated with discharge disposition.

RESULTS

Overall 489 patients were included in this study. Cerebral atrophy (p = 0.05), renal volume (p = 0.004), sarcopenia (p = 0.05), vascular calcifications (p = 0.02) and sarcopenic obesity (p = 0.01) were associated with discharge disposition. Pearson's correlation coefficients between radiographic frailty markers were all less than 0.4. Youden's Index was 0.26 (p < 0.001) at a composite score of 3. In multivariable analysis, the composite score of 3 or greater was associated with poor discharge disposition (OR 2.39, 95% CI 1.10-5.18, p = 0.03).

CONCLUSIONS

Individual radiographic frailty markers are inadequate markers of frailty, as they may miss patients who are frail. This study also suggests that a composite radiographic frailty score may better predict patient outcome than individual radiographic markers of frailty.

Influence of luminal stenosis in aneurysmal and non-aneurysmal blunt cerebrovascular injury

BACKGROUND

Current blunt cerebrovascular injury (BCVI) grading grossly differentiates injury characteristics such as luminal stenosis (LS) and aneurysmal disease. The effect of increasing degree of LS beyond the current BCVI grading scale on stroke formation is unknown.

STUDY DESIGN

BCVI over a 3-year period were retrospectively reviewed. To investigate influence of LS beyond the BCVI grading scale within aneurysmal and non-aneurysmal BCVI, grade 2 BCVI were subdivided into BCVI with ≥ 25% and ≤ 50% LS and BCVI with > 50% and ≤ 99% LS. Grade 3 BCVI were subdivided into BCVI with pseudoaneurysm (PSA) without LS and BCVI with PSA and LS. We hypothesized increased LS beyond the current BCVI grade distinctions would be associated with higher rates of stroke formation.

RESULTS

312 BCVI were included, of which 140 were carotid BCVI and 172 vertebral BCVI. Sixteen carotid BCVI underwent endovascular intervention (EI) and 19 suffered a stroke. In carotid BCVI stroke rates increased sequentially with BCVI grade except in grade 3. There was a stroke rate of 12% in grade 1 carotid BCVI, 18% in grade 2, 6% in grade 3, and 31% in grade 4. In subgroup analysis for grade 2 carotid BCVI, BCVI with > 50% and ≤ 99% LS had higher rates of stroke (22% vs. 15%, p = 0.44) than BCVI with ≥ 25% and ≤ 50% LS. In subgroup analysis of grade 3 carotid BCVI, BCVI with PSA and LS had higher rates of stroke (9% vs. 4%, p = 0.48) than BCVI with PSA without LS. Higher rates of EI in grade 2 carotid BCVI with > 50% and ≤ 99% LS (22% vs. 5%, p = 0.14) and grade 3 carotid BCVI with PSA and LS (35% vs. 4%, p = 0.01) were noted in subgroup analysis.

CONCLUSION

Higher percentage LS beyond the currently used BCVI grading scale has a non-significantly increased rate of stroke in both aneurysmal and non-aneurysmal BCVI. Grade 3 BCVI with PSA and LS seems to be a high-risk subgroup. Use of EI confounds modern measurement of stroke risk in higher LS BCVI.

"Second-look" laparotomy: warranted, or contributor to excessive open abdomens?

INTRODUCTION

The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients.

METHODS

This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, clinical variables, complications and mortality were collected. Fisher's exact t test was used for statistical analysis.

RESULTS

During this time frame, 96 patients were managed with OA and 59 patients required a bowel resection. 55 (57%) of those required one bowel resection at the index operation with 4 (4.2%) only requiring one bowel resection at the second operation. In the patients requiring bowel resections, 18 (30%) required a resection at SL. At SL laparotomy, resection was required for questionably viable bowel at the index operation 60% (11), whereas 39% (7) had normal appearing bowel. Indications for resection at SL laparotomy included evolution of existing ischemia, new onset ischemia, staple line revision, and "other". 23 patients (39%) were hemodynamically unstable, contributing to the need for temporary abdominal closure. In the multivariate analysis, preoperative shock was the only predictor of need for further resection. Complications and mortality were similar in both groups.

CONCLUSION

Almost one-fifth of the patients undergoing SL laparotomy for open abdomen required bowel resections, with 6.8% of those having normal appearing bowel at index operation, therefore in select EGS patients, SL laparotomy is a reasonable strategy.

Validation of a Geriatric Trauma Prognosis Calculator: A P.A.L.Li.A.T.E. Consortium Study

BACKGROUND/OBJECTIVES

The P.A.L.Li.A.T.E. (prognostic assessment of life and limitations after trauma in the elderly) consortium has previously created a prognosis calculator for mortality after geriatric injury based on age, injury severity, and transfusion requirement called the geriatric trauma outcome score (GTOS). Here, we sought to create and validate a prognosis calculator called the geriatric trauma outcome score ii (GTOS II) estimating probability of unfavorable discharge.

DESIGN

Retrospective cohort.

SETTING

Four geographically diverse Level 1 trauma centers.

PARTICIPANTS

Trauma admissions aged 65 to 102 years surviving to discharge from 2000 to 2013.

INTERVENTION

None.

MEASUREMENTS

Age, injury severity score (ISS), transfusion at 24 hours post-admission, discharge dichotomized as favorable (home/rehabilitation) or unfavorable (skilled nursing/long term acute care/hospice). Training and testing samples were created using the holdout method. A multiple logistic mixed model (GTOS II) was created to estimate the odds of unfavorable disposition then re-specified using the GTOS II as the sole predictor in a logistic mixed model using the testing sample.

RESULTS

The final dataset was 16,114 subjects (unfavorable discharge status = 15.4%). Training (n = 8,057) and testing (n = 8,057) samples had similar demographics. The formula based on the training sample was (GTOS II = Age + [0.71 × ISS] + 8.79 [if transfused by 24 hours]). Misclassification rate and AUC were 15.63% and 0.67 for the training sample, respectively, and 15.85% and 0.67 for the testing sample.

CONCLUSION

GTOS II estimates the probability of unfavorable discharge in injured elders with moderate accuracy. With the GTOS mortality calculator, it can help in goal setting conversations after geriatric injury.

Acute Care Surgery: Defining the Economic Burden of Emergency General Surgery

BACKGROUND

Trauma centers (TCs) have been shown to provide lifesaving, but more expensive, care when compared with non-TCs (NTC). Limited data exist about the economic impact of emergency general surgery (EGS) patients on health care systems. We hypothesized that the economic burden would be higher for EGS patients managed at TCs vs NTCs.

METHODS

The Maryland Health Services Cost Review Commission database was queried from 2009 to 2013. The American Association for the Surgery of Trauma EGS ICD-9 codes were used to define the top 10 EGS diagnoses. Demographic characteristics, TC designation, severity of illness, and hospital charge data were collected. Differences in total charges between TCs and NTCs were analyzed by Wilcoxon test using SAS 9.3 software (SAS Institute).

RESULTS

A total of 435,623 patients were included. Median age was 61 years (interquartile range 47 to 76 years) and 55.9% were female. Median length of stay was 4 days; 90.3% were admitted via emergency department; and overall mortality was 5.1%. Overall median charges were $11,081 for TC vs $8,264 for NTC (p < 0.0001). Minor, moderate, major, and extreme severities of illness all had higher charges at TC vs NTC with no ICU admissions, respectfully ($5,908 vs $5,243; $7,051 vs $6,003; $10,501 vs $8,777; and $23, 997 vs $18,381; p < 0.001). Care at TCs was nearly twice as expensive if patients were admitted to the ICU, even when stratifying by severity of illness.

CONCLUSIONS

Emergency general surgery patients treated at TCs incurred increased costs compared with NTCs, independent of patient severity. These costs nearly doubled for those admitted to the ICU. As acute care surgery grows as a specialty, additional investigation is required to better understand the reasons for this cost differential.

Feeding the Postoperative Patient on Vasopressor Support: Feeding and Pressor Support

Initiating enteral nutrition in the postoperative patient can be challenging. Postoperative ileus and bowel edema, bowel anastomosis, and intra-abdominal pathology contribute to the reluctance and inability to achieve adequate nutrition in this patient population. The addition of vasopressors confounds the difficulties. Clinical data are sparse but suggest that most postoperative patients requiring vasopressor therapy can be safely initiated and advanced on enteral nutrition. Consideration of the vasopressor agent being utilized and its dose is imperative, as are individual patient characteristics. Temporal changes in the dosage should be closely monitored, as increasing doses may reflect worsening clinical status that can be due to intestinal ischemia. Well-designed prospective trials are clearly necessary to address this controversial topic.

Emergency General Surgery: Defining Burden of Disease in the State of Maryland

Acute care surgery services continue expanding to provide emergency general surgery (EGS) care. The aim of this study is to define the characteristics of the EGS population in Maryland. Retrospective review of the Health Services Cost Review Commission database from 2009 to 2013 was performed. American Association for the Surgery of Trauma-defined EGS ICD-9 codes were used to define the EGS population. Data collected included patient demographics, admission origin [emergency department (ED) versus non-ED], length of stay (LOS), mortality, and disposition. There were 3,157,646 encounters. In all, 817,942 (26%) were EGS encounters, with 76 per cent admitted via an ED. The median age of ED patients that died was 74 years versus 61 years for those that lived ( P < 0.001). Twenty one per cent of ED admitted patients had a LOS > 7 days. Of 78,065 non-ED admitted patients, the median age of those that died was 68 years versus 59 years for those that lived ( P < 0.001). Twenty eight per cent of non-ED admits had LOS > 7 days. In both ED and non-ED patients, there was a bimodal distribution of death, with most patients dying at LOS ≤ 2 or LOS > 7 days. In this study, EGS diagnoses are present in 26 per cent of inpatient encounters in Maryland. The EGS population is elderly with prolonged LOS and a bimodal distribution of death.

Initial screening test for blunt cerebrovascular injury: Validity assessment of whole-body computed tomography

INTRODUCTION

Our whole-body computed tomography protocol (WBCT), used to image patients with polytrauma, consists of a noncontrast head computed tomography (CT) followed by a multidetector computed tomography (40- or 64- slice) that includes an intravenous, contrast-enhanced scan from the face through the pelvis. WBCT is used to screen for blunt cerebrovascular injury (BCVI) during initial CT imaging of the patient with polytrauma and allows for early initiation of therapy with the goal of avoiding stroke. WBCT has not been directly compared with CT angiography (CTA) of the neck as a screening tool for BCVI. We hypothesize that WBCT is a valid modality to diagnose BCVI compared with neck CTA, thus screening patients with polytrauma for BCVI and limiting the need for subsequent CTA.

METHODS

A retrospective review of the trauma registry was conducted for all patients diagnosed with BCVI from June 2009 to June 2013 at our institution. All injuries, identified and graded on initial WBCT, were compared with neck CTA imaging performed within the first 72 hours. Sensitivity was calculated for WBCT by the use of CTA as the reference standard. Proportions of agreement also were calculated between the grades of injury for both imaging modalities.

RESULTS

A total of 319 injured vessels were identified in 227 patients. On initial WBCT 80 (25%) of the injuries were grade I, 75 (24%) grade II, 45 (14%) grade III, 41 (13%) grade IV, and 58 (18%) were classified as indeterminate: 27 vertebral and 31 carotid lesions. Twenty (6%) of the 319 injuries were not detected on WBCT but identified on subsequent CTA (9 grade I, 7 grade II, 4 grade III); 6 vertebral and 14 carotid. For each vessel type and for all vessels combined, WBCT demonstrated sensitivity rates of over 90% to detect BCVI among the population of patients with at least one vessel injured. There was concordant grading of injuries between WBCT and initial diagnostic CTA in 154 (48% of all injuries). Lower grade injures were more discordant than higher grades (55% vs 13%, respectively; P < .001). Grading was upgraded 8% of the time and downgraded 25%.

CONCLUSION

WBCT holds promise as a rapid screening test for BCVI in the patient with polytrauma to identify injuries in the early stage of the trauma evaluation, thus allowing more rapid initiation of treatment. In addition, in those patients with high risk for BCVI but whose WBCT results are negative for BCVI, neck CTA should be considered to more confidently exclude low-grade injuries.

Infectious complications and mortality in an American acute care surgical service

BACKGROUND

Acute care surgery (ACS) services have evolved in an effort to provide 24-h surgical services for a wide array of general surgical emergencies. The formation of ACS services has been shown to improve outcomes and lead to more expeditious care. Despite the advances of ACS, the etiology and timing of patient mortality has yet to be described. We hypothesized that infectious complications occur more frequently in ACS patients that die during their hospitalization.

METHODS

A retrospective review of a local ACS service (non-trauma) registry was conducted. Demographic variables, admission and discharge data, and ICD-9 codes were collected. ICD-9 codes were used to identify patients with sepsis, shock, GI perforation, peritonitis, and other hospital acquired infections (urinary tract, bloodstream, and ventilator-associated pneumonias). Univariate and multivariate logistic regression analysis was performed to model the outcome of death.

RESULTS

1,329 patients were analyzed. 53 % were male with the mean age of 52 years and an average length of stay of 13 days. 106 (8 %) died while in the hospital. Of the patients who died, 34 (32 %) died within 7 days of admission. The majority of mortalities (56 %) occurred after hospital day 14. In ACS patients that died, there were significantly higher rates of sepsis, shock, peritonitis, urinary tract infections, and VAP. After adjustment; age, sepsis on admission, and shock on admission were associated with greater odds of death.

CONCLUSION

ACS patients with sepsis and shock have higher mortality rate than those patients without. The majority of ACS patient deaths occurred after hospital day 14. Further investigation and continued focus on preventing and rapidly treating infectious complications as they arise is warranted.

Loop versus end colostomy reversal: has anything changed?

PURPOSE

Though primary repair of colon injuries is preferred, certain injury patterns require colostomy creation. Colostomy reversal is associated with significant morbidity and healthcare cost. Complication rates may be influenced by technique of diversion (loop vs. end colostomy), though this remains ill-defined. We hypothesized that reversal of loop colostomies is associated with fewer complications than end colostomies.

METHODS

This is a retrospective, multi-institutional study (four, level-1 trauma centers) of patients undergoing colostomy takedown for trauma during the time period 1/2006-12/2012. Data were collected from index trauma admission and subsequent admission for reversal and included demographics and complications of reversal. Student's t test was used to compare continuous variables against loop versus end colostomy. Discrete variables were compared against both groups using Chi-squared tests.

RESULTS

Over the 6-year study period, 218 patients underwent colostomy takedown after trauma with a mean age of 30; 190 (87%) were male, 162 (74%) had penetrating injury as their indication for colostomy, and 98 (45%) experienced at least one complication. Patients in the end colostomy group (n = 160) were more likely to require midline laparotomy (145 vs. 18, p < 0.001), had greater intra-operative blood loss (260.7 vs. 99.4 mL, p < 0.001), had greater hospital length of stay (8.4 vs. 5.5 days, p < 0.001), and had more overall complications (81 vs. 17, p = 0.005) than patients managed with loop colostomy (n = 58).

CONCLUSIONS

Local takedown of a loop colostomy is safe and leads to shorter hospital stays, less intra-operative blood loss, and fewer complications when compared to end colostomy.

Skeletal fluorosis. A report of two cases

Two illustrative cases of patients with skeletal fluorosis and classic radiographic changes are presented. One patient demonstrated a progressive paraparesis, while the other was diagnosed incidentally on routine radiographs. A review of the literature, treatment, and histologic findings are presented.