Race and Insurance Status Disparities in Post-discharge Disposition After Hospitalization for Major Trauma

BACKGROUND

Investigations detailing predictive measures of hospital disposition after traumatic injury are scarce. We aim to examine the discharge practices among trauma centers in the US and to identify factors that may influence post-hospital disposition.

METHODS

A retrospective analysis of trauma patients using the American College of Surgeons-Trauma Quality Improvement Program dataset from 2007-2017. Primary study outcome was hospital disposition (including long term care facility [LTC], others). Secondary outcomes included: Intensive Care Unit (ICU)-length of stay (LOS), complications, others).

RESULTS

6 899 538 patients were analyzed. Odds of LTC discharge was significantly higher for Black patients (aOR = 1.30, 95% CI:1.24-1.37), abbreviated injury score (AIS) ≥3 (aOR = 4.22, 95% CI: 4.05-4.39), and higher injury severity score (ISS) (aOR = 9.41, 95% CI:9.03-9.80). Significantly more self-pay patients were discharged home compared to other insurance types (P < .0001). Significantly longer hospital- and ICU-LOS were experienced by those who had an AIS ≥3 (hospital: 4.8 days (±7.1) vs. 7.9 (±10.1); ICU: 4.6 (±6.9) vs. 5.9 (±7.9), P < .0001) and had a high ISS (hospital: 4.5 days (±5.9) vs. 16.8 (±17.9); ICU: 3.6 (±5.0) vs. 10.2 (±11.5), P < .0001).

CONCLUSIONS

Patient race, insurance status, and injury severity were predictive of post-hospitalization care discharge. Self-pay and Black patients were less likely to be discharged to secondary care facilities. These findings have the potential to improve in-hospital patient management and predict discharge secondary care needs, and necessitate the need for future research to investigate the extent of inequalities in access to trauma care.

Hospital Volume of Emergency General Surgery and its Impact on Inpatient Mortality for Geriatric Patients: Analysis From 3994 Hospitals

BACKGROUND

Previous investigations have shown a positive association between hospital volume of operations and clinical outcomes. However, it is unclear whether such relationships also apply to emergency surgery. We sought to examine the association between hospital case volume and inpatient mortality for 7 common emergency general surgery (EGS) operations among geriatric patients.

METHODS

This is a population based retrospective cohort study using the Centers of Medicare and Medicaid Services (CMS) Limited Dataset Files (LDS) from 2011 to 2013. The 7 most common emergency surgeries included (1) partial colectomy, (2) small-bowel resection (SBR), (3) cholecystectomy, (4) appendectomy, (5) lysis of adhesions (LOA), (6) operative management of peptic ulcer disease (PUD), and (7) laparotomy with the primary outcome being inpatient mortality. Risk-adjusted inpatient mortality was plotted against operative volume. Subsequently an operative volume threshold was calculated using a best fit regression method. Based on these estimates, high- and low-volume hospitals were compared to examine significance of outcomes. Significance was defined as P-value < .05.

RESULTS

The final cohort comprised of 414 779 patients from 3994 hospitals. The standardized mortality ratio (SMR) for high-volume centers were lower in 6 out of 8 surgeries examined. Small-bowel resection and partial colectomy operations had a significant decrease in mortality based on a volume threshold.

CONCLUSION

We observed decreased mortality with higher surgical volume for small-bowel resection and partial colectomy operations. Such differences may be related to practice patterns during the perioperative period, as complications related to the perioperative care were significantly lower for high-volume centers.

ACGME 2011 Duty Hours Restrictions and Their Effects on Surgical Residency Training and Patients Outcomes: A Systematic Review

OBJECTIVE

The ACGME instituted the 2011 residency duty-hour restrictions (DHR) to increase resident well-being and patient safety. However, its eventual remodeling came after patient care was deemed unaffected. We aimed to identify the effects of the ACGME 2011-DHR on (1) patient outcomes, (2) surgical resident case volume, and (3) surgical resident quality of life.

DESIGN

Literature search using Google Scholar, PubMed, Cochrane, and Embase for publications between 2010 and 2020, on the 2011-DHR effects on resident and patient outcomes. Studies containing the number of cases performed during training, quality of life, and surgical patients' outcomes were included.

RESULTS

Fifteen studies met inclusion criteria. There was no difference in complication rates for surgical patients post 2011-DHR (p = 0.561). 2011-DHR caused surgical caseload shifts from interns to senior residents reflected by decreased operative cases for interns (p = 0.005) with significantly more total cases performed by chief residents (p = 0.0006). Pre-2011-DHR had more work flexibility that led to higher resident well-being (p = 0.01). Only 25% of residents approved of the 2011-DHR while 87% felt these restrictions would have adverse effects.

CONCLUSION

Current literature supports that the 2011-DHR did not improve patient outcomes, decreased surgical experience for junior residents and shifted clinical responsibilities to senior residents. System wide regulations such as the 2011-DHR may unintentionally create professional and personal life imbalance and introduce stress over resident inability to perform clinical responsibilities. Future systemic interventions to address resident well-being should be made with caution and not solely limited to the number of hours they work in a single week or in a single shift.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Use in Animal Trauma Models

BACKGROUND

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was developed to prevent traumatic exsanguination. We aim to identify the outcomes in animal models with 1) partial versus complete REBOA occlusion and 2) zone 1 versus 2 placements.

METHODS

The PRISMA guidelines were followed. We conducted a search of PubMed, EMBASE and Google Scholar for REBOA studies in animal trauma models using the following search terms: "REBOA trauma", "REBOA outcomes" "REBOA complications". SYRCLE's RoB Tool was utilized for the risk of bias and study quality assessment.

RESULTS

Our search yielded 14 RCTs for inclusion. Eleven studies directly investigated partial REBOA versus total aortic occlusion. Overall, partial REBOA techniques were associated with similar attainment of proximal MAP but with significantly less ischemic burden. Significant mortality benefit with partial occlusion was observed in three studies. Survival time post-occlusion also was improved with zone 3 placement versus zone 1 (100% versus 33%; P < 0.01).

CONCLUSIONS

There appears to be a fine balance between desired proximal arterial pressure and time of occlusion for overall survival and subsequent risk of distal ischemia. Many "partial occlusion" techniques may be superior in attaining such balance over prolonged REBOA inflation where no distal flow is allowed. Tailored zone 3 placement may offer significant mortality and morbidity advantages compared to sustained total occlusion and indiscriminate zone 1 placement strategies. As clear conclusions regarding REBOA are unlikely to be established in animal models, larger randomized investigations utilizing human subjects are needed to describe optimal REBOA technique and applicability in greater detail.

608 Perceived Burnout among Burn Surgeons: Results from a Survey of American Burn Association Members

Introduction

Burnout is a significant and increasingly recognized issue. We aimed to investigate burn surgeons’ (BSurg) perceptions regarding burnout, contributing factors, and implications to better identity possible targeted interventions.

Methods

42-question anonymous online survey was distributed by the ABA to BSurg members. Respondents included BSurgs in university or non-university hospital settings.

Results

Experience of burnout was reported among 89.8% of university and 84.6% of non-university hospital affiliated respondents. After adjusting for confounders, university BSurgs exhibited higher risk of perceived burnout compared to non-university settings (aOR 1.081, 95%CI:0.237,4.937). Women BSurgs were at 5 times higher risk of reporting burnout compared to men (aOR 5.048, 95%CI:0.488,52.255). BSurgs aged 40–44 had twice the risk of reporting burnout as ≥50 (aOR 1.985, 95%CI:0.018,216.308). Practicing for 21–30 years had 12 times higher risk of reporting burnout than practicing &gt;30 (aOR 12.264, 95% CI:0.611,246.041). Those working &lt; 50 hours/week reported burnout more frequently than those who work ≥80 hours/week (aOR 2.469, 95% CI:0.80,76.662).

Conclusions

Overall reports of burnout were high amongst burn surgeon respondents. Those with 21–30 years of clinical practice were at significantly higher risk of reporting burnout despite believing that their colleagues’ burnout was more frequent than their own. Interventions addressing perceived burnout in younger burn surgeons may be limited by lack of participation due to fear of repercussions from administration or peers. Future administration-led burnout initiatives should acknowledge the differences between burn surgeon groups and offer resources unique to the individual physician’s needs for burnout prevention to be successful.

Resuscitative Endovascular Balloon Occlusion of Aorta: A Systematic Review

BACKGROUND

The data on resuscitative endovascular balloon occlusion of the aorta (REBOA) use continue to grow with its increasing use in trauma centers. The data in her last 5 years have not been systematically reviewed. We aim to assess current literature related to REBOA use and outcomes among civilian trauma populations.

METHODS

A literature search using PubMed, EMBASE, and JAMA Network for studies regarding REBOA usage in civilian trauma from 2016 to 2020 is carried out. This review followed preferred reporting items for systematic reviews and meta-analysis guidelines.

RESULTS

Our search yielded 35 studies for inclusion in our systematic review, involving 4073 patients. The most common indication for REBOA was patient presentation in hemorrhagic shock secondary to traumatic injury. REBOA was associated with significant systolic blood pressure improvement. Of 4 studies comparing REBOA to non-REBOA controls, 2 found significant mortality benefit with REBOA. Significant mortality improvement with REBOA compared to open aortic occlusion was seen in 4 studies. In the few studies investigating zone placement, highest survival rate was seen in patients undergoing zone 3. Overall, reports of complications directly related to overall REBOA use were relatively low.

CONCLUSION

REBOA has been shown to be effective in promoting hemodynamic stability in civilian trauma. Mortality data on REBOA use are conflicting, but most studies investigating REBOA vs. open occlusion methods suggest a significant survival advantage. Recent data on the REBOA technique (zone placement and partial REBOA) are sparse and currently insufficient to determine advantage with any particular variation. Overall, larger prospective civilian trauma studies are needed to better understand the benefits of REBOA in high-mortality civilian trauma populations.

STUDY TYPE

Systematic Review.

LEVEL OF EVIDENCE

III- Therapeutic.

REBOA Use, Practices, Characteristics, and Implementations Across Various US Trauma Centers

BACKGROUND

Hemorrhage accounts for >30% of trauma-related mortalities. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemostasis in the civilian population remains controversial. We aim to investigate REBOA practices through analysis of surgeon and trauma center characteristics, implementation, patient characteristics, and overall opinions.

METHODS

An anonymous 30-question standardized online survey on REBOA use was administered to active trauma surgeon members of the Eastern Association for the Surgery of Trauma.

RESULTS

A total of 345 responses were received, and 130/345 (37.7%) reported REBOA being favorable, 42 (12.2%) reported REBOA unfavorably, and 173 (50.1%) were undecided. The majority of respondents (87.6%) reported REBOA performance in the trauma bay. 170 (49.3%) of respondents reported having deployed REBOA at least once over the past 2 years. 80.0% reported blunt trauma being the most common mechanism of injury in REBOA patients. Resuscitative endovascular balloon occlusion of the aorta deployment in zone 3 of the aorta was significantly higher in patients reported to suffer a pelvic fracture or pelvic hemorrhage, whereas REBOA deployment in zone 1 was significantly higher among patients reported to suffer hepatic, splenic, or other intra-abdominal hemorrhage (P < .05).

CONCLUSION

Among survey respondents, frequency of REBOA use was low along with knowledge of clear indications for use. While current REBOA usage among respondents appeared to model current guidelines, additional research regarding REBOA indications, ideal patient populations, and outcomes is needed in order to improve REBOA perception in trauma surgeons and increase frequency of use.

A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review

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Blunt thoracic aortic injuries are life threatening and require urgent intervention.

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Rare presentation of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery off the aortic arch distal to the takeoff of the left subclavian artery.

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An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR.

Introduction

Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy.

Presentation of case

A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent.

Discussion

BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks.

Conclusion

Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.

Current grading of gall bladder cholecystitis and management guidelines: Is it sufficient?

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These two cases highlight the limitations in current grading systems, particularly in the context of gallbladder size.

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We propose modifications to the PGS to include not only abnormal anatomy but instances of distorted gallbladder anatomy due to inflammation and/or the large to giant size in order to account for the increased risk of complications.

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Both distorted gallbladder anatomy and giant gallbladder size can make laparoscopic cholecystectomy a challenge, and thus warrant contribution to overall clinical grade.

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While the PGS, Tokyo Guidelines, and AAST grading scales are validated grading scales for acute cholecystitis, additional modifications can further characterize different types of acute cholecystitis to better guide patient management.

Variations in surgical peer-reviewed publications among editorial board members, associate editors and their respective journal: Towards maintaining academic integrity

Background

Physician scientists who are also Editorial Board members or Associate Editors may prefer publishing in their own journal and therefore create an environment for conflicts of interest to arise.

Objectives

To assess the relationship between the number of peer-reviewed publications in surgical journals in which authors serve as Editorial Board Members and Associate Editors and their total number of annual publications.

Materials and methods

A cross-sectional study utilizing PubMed was performed regarding the total annual number of peer-reviewed publications by Editorial Board Members/Associate Editors and the number published in their respective affiliated journals from 2016 to 2019. Significance defined as p < 0.05.

Results

80 Associate Editors and 721 Editorial Board Members (n = 801 total) were analyzed from 10 surgical journals. The mean number of total annual peer-reviewed publications varied from 5.19 to 17.18. The mean number of annual peer-reviewed publications in affiliated journals varied from 0.06 to 2.53. Multiple significant associations were discovered between the total number of annual peer-reviewed publications and number of peer-reviewed publications in affiliated journals for all authors/surgical journals evaluated, except for the International Journal of Surgery (p > 0.05).

Conclusions

We found significant associations between the total number of annual peer-reviewed publications by Editorial Board Members/Associate Editors and number of annual peer-reviewed publications by their affiliated surgical journals. The implementation and enforcement of a standardized double-blind review process and mandatory reporting of any potential conflicts of interest can reduce possible bias and promote a fair and high-quality peer-review process.

Post-Traumatic Stress Disorder in Adult and Pediatric Trauma Populations: A Literature Review

Each year, traumatic injuries affect 2.6 million adults in the United States leading to significant health problems. Although many sequelae stem directly from physical manifestations of one's sustained injuries, mental health may also be affected in the form of post-traumatic stress disorder (PTSD). PTSD can lead to decreased physical recovery, social functioning, and quality of life. Several screening tools such as the Injured Trauma Survivor Screen, PTSD CheckList, Primary Care PTSD, and Clinician-Administered PTSD Scale for DSM-5 have been used for initial PTSD screening of the trauma patient. Early screening is important as it serves as the first step in delivering the appropriate mental health care to those in need. Factors that increase the likelihood of developing PTSD include younger age, nonwhite ethnicity, and lower socioeconomic status. Current data on male or female predominance of PTSD in trauma populations is inconsistent. Cognitive behavioral therapy, hypnosis, and psychoeducation have been used to treat symptoms of PTSD. This review discusses the impact PTSD has on the trauma patient and the need for universal screening in this susceptible population. Ultimately, trauma centers should implement such universal screening protocols as to avoid absence, or undertreatment of PTSD, both of which having longstanding consequences.

Reported burnout among U.S. general surgery residents: A survey of the association of program directors in surgery members

Introduction

The literature remains unclear on the development, consequences, and interventions for burnout in resident populations. We aim to identify the prevalence and nuances of reported burnout in general surgery resident physicians to better understand which factors contribute the greatest risk.

Methods

A 42-question anonymous online survey was distributed by the Association of Program Directors in Surgery (APDS) to general surgery resident physicians. ANOVA, chi-square and multinomial regression analyses were performed with significance defined as p < 0.05. This survey was reported in line with the STOCSS criteria.

Results

81 survey responses were received. Burnout was reported by 89.5% of university-hospital affiliated respondents and 95.2% of community teaching hospital affiliated respondents. After adjustment, community respondents showed a nearly fifteen times greater likelihood of burnout (aOR = 14.735, 95% CI: 0.791,274.482). Females were 2.7 times as likely as males to report burnout (aOR = 2.749, 95% CI: 0.189,39.960) and nearly twice as likely to report contemplating suicide (aOR = 1.819, 95% CI: 0.380,8.715). Burnout rates by hours worked/week revealed that 100% of those working ≥80 h/week report experiencing burnout.

Conclusion

Overall burnout rates reported by surgical residents respondents were high. Community teaching hospital setting, female gender, and increased number of hours worked per week may be associated with higher rates of burnout. Both female and community-affiliated residents were at increased risk of reporting suicidal ideation. Targeted interventions are needed to adequately address program-specific causes for resident burnout and reduce its prevalence in high-risk cohorts.

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Burnout as self-reported by general surgery residents is exceptionally high.

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Risk factors associated with increased reporting of burnout include female gender, community affiliated teaching hospitals, and increased work hours.

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Residents reporting burnout are more likely to consider leaving the medical field altogether, report their burnout affects their ABSITE performance and aspects of daily life.

Successful management of gunshot wound to the chest resulting in multiple intra-abdominal and thoracic injuries in a pediatric trauma patient: A case report and literature review

INTRODUCTION

Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance.

CASE PRESENTATION

A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition.

DISCUSSION

Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible.

CONCLUSION

Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes.

Prophylactic Inferior Vena Cava Filters : Outcomes in Severely Injured Trauma Patients

BACKGROUND

Patients with major trauma and contraindications to anticoagulation are often considered candidates for a prophylactic inferior vena cava filter (IVCF). Prophylactic IVCFs are controversial in trauma and backed by varying levels of evidence. This study aims to analyze outcomes in severely injured patients who receive IVCFs.

METHODS

A retrospective review of trauma patients aged ≥ 16 years with ISS ≥ 15 admitted to our level 1 trauma center from years 2013 through 2018. Patients were divided into 2 groups: prophylactic IVCF versus VTE chemoprophylaxis. The analysis evaluated demographics, stratified by ISS (15-24, 25-34, ≥35), and subgrouped those with AIS-Head ≥3. Adjusted outcome measures included DVT, PE, mortality, and ICU length-of-stay (ICU-LOS).

RESULTS

The study sample included 413 patients with prophylactic IVCFs and 2487 on VTE chemoprophylaxis. IVCF placement was associated with higher severity injuries: ISS 28 versus 25 and lower GCS 10.0 versus 11.8, TBI prevalence 83% versus 68% (P < .001). Patients with IVCFs had increased ICU-LOS (23.2 days vs 12.2 days), DVT (14.8% vs 4.3%), and PE (5.8% vs 1.6%) for patients with ISS <35 (P < .001). ISS ≥35 was not associated with intergroup DVT or PE rate differences (P = .81 and .43). No intergroup mortality differences were observed, including after ISS stratification. Among patients with AIS-Head ≥3, prophylactic IVCF was associated with lower in-hospital mortality (8.4% vs 15.7%, P = .001).

CONCLUSIONS

Prophylactic IVCF placement was associated with higher rates of DVT and nonfatal PE, and prolonged ICU-LOS. Prophylactic IVCF placement was not associated with increased in-hospital mortality for severely injured trauma patients. Among patients with concomitant critical head injuries (AIS-Head ≥3), prophylactic IVCF placement was associated with lower in-hospital mortality than VTE chemoprophylaxis.

A rare case of pre-hospital globe enucleation after a penetrating injury to the orbit during an assault: A case report and literature review

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This is a rare case of traumatic enucleation of the right globe sustained after an assault.

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Traumatic enucleation requires significant retro-ocular force to cause globe separation from the surrounding supportive structures within the orbit.

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Optic nerve avulsion from traumatic enucleation can cause contralateral visual deficits such as temporal hemianopia in the uninjured eye.

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Current open and closed globe injury classification systems are not applicable to traumatic enucleation indicating the need for new system development to guide treatment options.

Introduction

Ocular trauma is a common occurrence in trauma settings but often occurs with little to no effect on the vision of the patient. Traumatic enucleation is a rare but devastating injury.

Case presentation

A 40-year-old male presented to our trauma center after an assault resulting in right globe enucleation. CT confirmed absence of the globe with disruption of the ipsilateral orbital contents and distal optic nerve disruption. The patient was started on intravenous antibiotics and the right orbit was packed. He was taken to the operating room for exploration of the right orbit and placement of an implant. His remaining hospital course was unremarkable.

Discussion

Documented mechanisms of injury for traumatic enucleation are diverse, but often involve significant retro-ocular force to completely dislodge the globe from the orbit. Optic nerve avulsion may cause associated optic nerve chiasm damage leading to temporal hemianopia in the uninjured contralateral eye. Treatment involves stabilization and preparation for future implant placement.

Conclusion

Traumatic enucleation is extremely rare. Development of a grading system applicable to traumatic enucleation may be helpful in guiding management in this complex patient population.

Timing of Prophylactic Inferior Vena Cava Filter Placement and Trauma Outcomes : Does Early Placement Matter?

BACKGROUND

Prophylactic inferior vena cava filters (IVCFs) are often placed in trauma patients who cannot receive prophylactic anticoagulation. IVCFs are utilized in an effort to reduce the risk of acute pulmonary embolism (PE) and mortality. This study aims to investigate whether time-to-filter placement is associated with differences in trauma outcomes.

METHODS

We conducted a single-center retrospective review of adult trauma patients who underwent prophylactic IVCF placement. Patients were divided into 2 groups based on time-to-filter: 0-48 hours and >48 hours. Outcome measures included post-filter deep vein thrombosis (DVT), post-filter PE, in-hospital mortality, and ICU length of stay (ICU-LOS). Significance was defined as P < .05.

RESULTS

During the 6-year study period, 513 patients underwent prophylactic IVCF placement. Both groups were similar with respect to injury severity score (ISS) (P = .540), percent of patients on home anticoagulation (38% and 39%, P = .845), abbreviated injury scale (AIS) by anatomic region (P = .899), and traumatic brain injury (TBI) prevalence (P = .182). Time-to-filter was not associated with significant differences in DVT, PE, or in-hospital mortality (P > .05 for all). Filter placement in the first 48 hours was associated with shorter ICU-LOS and hospital-LOS.

CONCLUSIONS

Currently, there are no investigations in the trauma literature looking at the impact of time-to-filter on complications related to venous thromboembolism and potential survival benefit. Results of this investigation showed that IVCF placement within the first 48 hours was significantly associated with shorter ICU- and hospital- LOS.

Perceived Burnout Among Burn Surgeons: Results From a Survey of American Burn Association Members

Burnout is a significant and increasingly recognized issue. They aimed to investigate burn surgeons'(BSurg) perceptions regarding burnout, contributing factors, and implications to better identity possible targeted interventions. A 42-question anonymous online survey was distributed by the ABA to BSurg members. Respondents included BSurgs in university or nonuniversity hospital settings. Experience of burnout was reported among 89.8% of university and 84.6% of nonuniversity hospital-affiliated respondents. After adjusting for confounders, university BSurgs exhibited a higher risk of perceived burnout compared with nonuniversity settings (aOR: 1.081, 95% CI: 0.237, 4.937). Women BSurgs were at 5 times higher risk of reporting burnout compared with men (aOR: 5.048, 95% CI: 0.488, 52.255). BSurgs aged 40 to 44 had twice the risk of reporting burnout as ≥50 (aOR: 1.985, 95% CI:0.018, 216.308). Practicing for 21 to 30 years had 12 times higher risk of reporting burnout than practicing >30 (aOR: 12.264, 95% CI: 0.611, 246.041). Those working <50 hr/wk reported burnout more frequently than those who work ≥80 hr/wk (aOR: 2.469, 95% CI: 0.80, 76.662). Overall reports of burnout were high amongst burn surgeon respondents. Those with 21 to 30 years of clinical practice were at significantly higher risk of reporting burnout despite believing that their colleagues' burnout was more frequent than their own. Interventions addressing perceived burnout in younger burn surgeons may be limited by lack of participation due to fear of repercussions from administration or peers. Future administration-led burnout initiatives should acknowledge the differences between burn surgeon groups and offer resources unique to the individual physician's needs for burnout prevention to be successful.

Uncommon Presentation of Severe Empyema of the Gallbladder: Case Report and Literature Review

Patient: Male, 60-year-old

Final Diagnosis: Severe empyema of the gallbladder

Symptoms: Abdominal and/or epigastric pain • fever

Medication: —

Clinical Procedure: —

Specialty: Surgery

Subclavian artery injury secondary to blunt trauma successfully managed by median sternotomy with supraclavicular extension: A case report and literature review

INTRODUCTION

Subclavian artery injury secondary to blunt trauma is rare and only a few cases have been documented in the literature. Subclavian arteries are protected by the clavicles, ribs, and chest wall. Clinical management and surgical approach vary depending on the specific injury. We present the case of a 50 year old male with blunt right subclavian transection.

CASE PRESENTATION

A 50-year-old male presented after being struck by a train. On exam, the patient had open injuries to the right upper chest/extremity. CTA showed a transection of the mid right subclavian artery along with a long traumatic occlusion distal to the defect. The patient was taken to the operating room where median sternotomy with supraclavicular extension was used to expose the transected ends of the subclavian artery and successfully perform a bypass graft. After a long hospital stay, he had a near-full functional recovery.

DISCUSSION

Blunt subclavian injury is rare and carries a high mortality. Adequate intervention requires prompt identification and proper surgical approach for repair. Median sternotomy offers the best approach to visualize the proximal right subclavian artery. Extension with a supraclavicular incision can be necessary for distal control. This approach offered timely intervention, which ultimately saved his life and allowed for return of pre-trauma functional status.

CONCLUSION

Prompt identification of subclavian artery injury is paramount as such injuries carry a high mortality. Median sternotomy with supraclavicular extension is an appropriate open surgical approach to successfully manage proximal right subclavian artery injuries.

USMLE Scores and Clinical Rotation Role in Predicting ABSITE Performance Among Surgery Interns

BACKGROUND

The American Board of Surgery In-training Examination (ABSITE) is an important marker of medical knowledge. It is unclear what factors predict or improve these scores. We evaluated demographics, United States Medical Licensing Examination (USMLE) step 1 and 2 scores, and surgical rotations during the intern year to determine if there were any correlations with the ABSITE performance.

METHODS

This was a multicenter retrospective review during a 6-y period, investigating the correlation and association of demographics, USMLE scores, and types of rotations on the ABSITE percentile score of interns. Demographics included age, gender, race/ethnicity, U.S. versus international/foreign medical graduate for stratified analyses. Descriptive analysis was performed with ANOVA, correlation was evaluated with 95% confidence interval, and significance was defined as P < 0.05.

RESULTS

Complete records obtained on 89 interns from six different general surgery programs over 6 y revealed that there was a significant correlation between USMLE 1 and 2 with the ABSITE. USMLE 2 correlation was the strongest (r = 0.44, 95% confidence interval = [0.25-0.60], P < 0.05). There was a significant difference in ABSITE performance (mean score difference of 17.3 percentile, P = 0.01) of interns who had an intensive care unit rotation before examination. Other surgical rotations were not associated with an ABSITE difference. Demographic factors such as age, gender, race/ethnicity, or medical graduate background status were not associated with ABSITE scores.

CONCLUSIONS

USMLE step 2 scores had a higher correlation with intern ABSITE performance. An intensive care unit rotation before taking the ABSITE was associated with a significant difference in their percentile scores. Demographic factors were not correlated with ABSITE performance.

Giant pelvic abscess with sepsis: Case report and review of current literature

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We present a case of massive pelvic abscess complicated by sepsis and necrotizing fasciitis successfully treated with surgical drainage.

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There was complete resolution of sepsis following open surgical drainage of a massive pelvic abscess complicated by necrotizing fasciitis.

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Larger multi-loculated abscesses or when associated with necrotizing infections may be better approached surgically.

Introduction

Intra-abdominal and pelvic abscesses can develop because of multiple etiologies. Typically, these abscesses are managed via a combination of medical (antibiotics) and surgical (drainage) interventions. This is a unique case report of a giant idiopathic pelvic abscess with necrotizing fasciitis that failed conservative management with antibiotics, requiring urgent surgical intervention and complex closure of the wound.

Case presentation

A 71-year-old female presented to the emergency department in sepsis, complaining of right hip and flank pain of one-month duration. Imaging revealed a giant right flank abscess with necrotizing fasciitis. The abscess extended from the pelvis to the right retroperitoneal space, traversing several soft tissue planes, to the skin. She was treated emergently with open surgical drainage, debridement, and delayed complex closure. The patient significantly improved post-operatively and was subsequently discharged.

Discussion

Pelvic abscesses are commonly due to gastrointestinal, genitourinary, post-surgical, or rarely idiopathic causes. US, CT, or MRI are the imaging modalities effective in diagnosing and staging abscess severity. Currently percutaneous, image-guided abscess drainage is the primary management due to it being minimally invasive, having better outcomes and reduced hospital stay. In large, multi-loculated abscess as exhibited by our patient, open surgical drainage and debridement of the infected cavity was not only successful but imperative in effective resolution.

Conclusion

Most pelvic abscesses can be treated with percutaneous drainage but those complicated by necrotizing fasciitis, or multi-loculated collections may be better treated with open drainage.

When "looks" can be deceiving - Internuclear ophthalmoplegia after mild traumatic brain injury: Case report and literature review

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We report a case of WEMINO caused by mild traumatic brain injury, presenting with typical left ocular manifestations.

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CT scan of brain was noncontributory, but MRI managed to delineate the site of injury in the MLF in the left temporo-occipital white matter.

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Although more common in demyelinating diseases, clinicians should be cognizant of this syndrome in mild TBI patients that have ocular exotropia.

Introduction

Walled-eyed monocular internuclear ophthalmoplegia (WEMINO) syndrome is a sub-variant of internuclear ophthalmoplegia (INO) and involves the same clinical findings with the addition of exotropia of the ipsilateral eye. Causes typically include multiple sclerosis (MS) and ischemia (hemorrhagic or embolic) but can be secondary to blunt trauma as seen in our presented case.

Presentation of case

A 27-year-old man presented with new-onset visual changes, diplopia, and strabismus following a motor vehicle collision. Physical exam showed left ocular exotropia and slight hypertropia on forward gaze with deficiency of left convergence and disconjugate eye movements on horizontal gaze with right nystagmus on rightward gaze. Imaging showed hyperintensities in the right middle cerebellar peduncle and left temporal-occipital white matter likely consistent with diffuse axonal injury but otherwise nonspecific. The patient was treated conservatively with left eyepatch and exhibited improvement of exotropia and diplopia at 1 week follow up.

Discussion

Common causes of WEMINO syndrome include MS and ischemia with no prior reports, to our knowledge, being secondary to the blunt trauma seen in our case. Patients with WEMINO present with the typical signs of failure of ipsilateral adductive movement during lateral along with ipsilateral exotropia. Management involves treating the underlying disorder, if possible, with conservative measures with traumatic origins.

Conclusion

Until now, WEMINO syndrome secondary to trauma has not been previously documented. Our patient was effectively treated with conservative measures alone.

Surgical management for an infected urachal cyst in an adult: Case report and literature review

INTRODUCTION

Incomplete urachal obliteration during fetal development gives rise to distinct malformations of the median umbilical ligament. Most anomalies are asymptomatic and resolve during early infancy, but some go unrecognized until adulthood. These rare cases can present with acute abdominal symptomatology secondary to infected urachal remnants.

PRESENTATION OF CASE

A 20-year-old man presented with periumbilical pain. Physical exam showed a warm, erythematous infra-umbilical mass that was tender to palpation. CT revealed an infected urachal cyst. The patient underwent urachal abscess incision and drainage with cyst excision. The patient returned home on postoperative day two. Two-week outpatient follow-up confirmed an uncomplicated recovery.

DISCUSSION

Surgical excision of urachal anomalies in adults is curative and preventive against recurrent infection and malignancy, but preoperative management is currently unstandardized. Current literature recommends a two-stage approach characterized by preoperative antibiotics and cyst incision and drainage followed later by complete surgical excision. Our patient underwent a single therapeutic approach with preoperative antibiotics and definitive operative excision. Our patient had a comparable outcome with no complications and a short hospitalization.

CONCLUSION

Preoperative antibiotics with excision of urachal remnants was effective in our case. Staged approaches are appropriate in complicated cases as a means to reduce post-operative infection rates and hospital stays. Urachal remnant excision is recommended in adults to prevent future malignancy.