Impact of Residents on Hand Surgery Fellows' Educational Experience: A Cross-Sectional Survey

PURPOSE

To survey current hand surgery fellows on the perceived impact of residents on their fellowship educational experience.

METHODS

Electronic surveys were distributed to 177 hand surgery fellows in the United States. The survey was designed to elucidate details of their fellowship programs, percentage of time working with, and in competition with, residents in differing clinical settings, perception of the impact of residents on their education, and strategies for resolving conflicts with attending physicians and residents.

RESULTS

Of the 177 hand surgery fellows, 72 (40.1%) responded to the survey, of which 61 (84.7%) were orthopedic surgery-trained, 11 (15.3%) were plastic surgery-trained, and 0 (0%) were general surgery-trained. As fellows, 56 (78%) respondents reported working alongside a dedicated resident on their service. The median percentage of time spent working with the residents was 50% or higher for all clinical environments. The median perceived percentage time in competition with residents was 25% in the operating room and 0% for all other clinical environments. Fifty-one (71%) respondents agreed or strongly agreed that residents enhanced their educational experience, and 55 (76%) respondents stated that these interactions will positively or somewhat positively affect their abilities to practice as a future hand surgeon. A plurality of fellows reported that they resolved conflicts cooperatively with residents (n = 34, 47.2%) and that this was their preference (n = 36, 50.0%). The majority of fellows were comfortable with discussing educational conflicts with their attending and/or program director (n = 67, 93.1%).

CONCLUSIONS

Hand surgery fellows frequently work with residents. The operating room is the most frequent site for competition between fellows and residents. Fellows responded positively when asked if residents should be involved in their fellowship. When conflicts do arise, fellows have the skills to manage conflicts with residents collaboratively.

CLINICAL RELEVANCE

This study evaluates the relationship between residents and fellows to improve the postgraduate educational experience.

Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients

INTRODUCTION

Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation.

MATERIALS AND METHODS

We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated.

RESULTS

86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home.

CONCLUSION

DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.

Rectal Contrast CT Scans of Limited Utility in Diagnosing Colonic Injuries in Penetrating Trauma: A Meta-Analysis

OBJECTIVES

Using rectal contrast computed tomography (CT) to identify traumatic colorectal injuries has become commonplace; however, these injuries remain relatively infrequent findings on CTs obtained for penetrating back and flank trauma. We conducted a meta-analysis to ascertain the efficacy of rectal contrast CT in identifying such injuries in victims penetrating injuries.

METHODS

PubMed and Embase were queried for relevant articles between 1974 and 2022. Review articles, case studies, and non-English manuscripts were excluded. Studies without descriptive CT and operative findings were excluded. Positive scans refer to rectal contrast extravasation. Sensitivity and specificity of rectal contrast CT scans were calculated with aggregated CT findings that were cross-referenced with laparotomy findings.

RESULTS

Only 8 manuscripts representing 506 patients quantified colorectal injuries and specified patients with rectal contrast extravasation. Seven patients with true colorectal injuries had no contrast extravasation on CT. There was one true positive scan. Another scan identified contrast extravasation, but laparotomy revealed no colorectal injury. Rectal contrast had sensitivity of 12.5%, specificity 99.8%, positive predictive value (PPV) 50%, negative predictive value (NPV) 99%, and a false negative rate of 88% in identifying colonic injuries.

DISCUSSION

The summation of 8 manuscripts suggest that the addition of rectal contrast in identifying colonic and rectal injuries may be of limited utility given its poor sensitivity and may be unnecessary. In its absence, subtle clues such as hematomas, extraluminal air, IV-dye extravasation, and trajectory may be additional indicators of injury. Further investigations are required to demonstrate a true benefit for the addition of rectal contrast.

Serial rotational thromboelastography (ROTEM) in mechanically ventilated patients with COVID-19 demonstrates hypercoagulopathy despite therapeutic heparinization

Background

Clinical hypercoagulopathy in patients with COVID-19 has been anecdotally described, but there is lack of evidence due to the novelty of this disease. Our study reports the results of rotational thromboelastography (ROTEM) in relation to traditional laboratory coagulation tests and acute phase markers among a cohort of severely ill, mechanically ventilated patients with COVID-19.

Methods

Patients with COVID-19 (N=21) with respiratory failure requiring mechanical ventilation were included in this prospective case series. ROTEM was serially obtained for all patients on three different days during their intensive care unit (ICU) stay and analyzed using repeated measures analysis. Demographic variables, symptoms at the time of presentation, ROTEM values, laboratory values for traditionally measured coagulation profiles, and acute phase reactants were analyzed, in addition to the use of anticoagulation and clinical hypercoagulopathic complications.

Results

The average age of our cohort was 57.9 years old (SD=14.4) and 76.2% were male. The mortality rate was 14.3% (3 of 21). Two patients (12.5%) were identified to have new-onset deep vein thrombosis, two patients (12.5%) were found to have ≥3 episodes of central venous catheter thrombosis, and three patients (18.7%) had confirmed stroke. ROTEM demonstrated elevated EXTEM and INTEM clotting times, including elevated FIBTEM maximum clot firmness (MCF_FIB). All patients treated with therapeutic anticoagulation still demonstrated hypercoagulopathy within the MCF_FIB tests.

Discussion

Repeated measure ROTEMs were able to detect hypercoagulopathy in ICU patients with COVID-19 despite therapeutic anticoagulation with heparin.

Level of evidence

III.

Firearms: the leading cause of years of potential life lost

Objectives

Data from the Centers for Disease Control and Prevention (CDC) show that firearm deaths are increasing in the USA. The aims of this study were to determine the magnitude of potential years of life lost due to firearms and to examine the evolution of firearm deaths on the basis of sex, race, and geographical location within the USA.

Methods

Data was extracted (2009–2018) from the National Vital Statistics Reports from the CDC and the Web-based Injury Statistics Query and Reporting System database. Years of potential life lost was calculated by the CDC standard of subtracting the age at death from the standard year of 80, and then summing the individual years of potential life lost (YPLL) across each cause of death.

Results

The YPLL in 2017 and 2018 was higher for firearms than motor vehicle crashes (MVCs). In 2018, the YPLL for firearms was 1.42 million and 1.34 million for MVC. Males comprised the majority (85.4%) of the 38 929 firearm deaths. White males had the most YPLL due to suicide, with 4.95 million YPLL during the course of the 10-year period; black males had the most YPLL due to homicide with 3.2 million YPLL during the same time period. The largest number of suicides by firearms was in older white males. Firearm-related injury deaths were highest in the South, followed by the West, Midwest, and Northeast, respectively.

Conclusion

Firearms are now the leading cause of YPLL in trauma. Firearm deaths have overtaken MVC as the mechanism for the main cause of potential years of life lost since 2017. Suicide in white males accounts for more YPLL than homicides. Deaths related to firearms are potentially preventable causes of death and prevention efforts should be redirected.

Level of evidence

Level III—Descriptive Study.

Learner Preferences and Perceptions of Virtual Hand Surgery Education During the COVID-19 Pandemic

PURPOSE

In response to the COVID-19 pandemic, many postgraduate medical education lectures and conferences have been moved to a virtual platform. Questions remain regarding the effectiveness of virtual education, what types of educational offerings can be transitioned to a virtual format, and what types of curricula should still take place in person.

METHODS

This study surveyed trainees from the United States who participated in a single institution's hand surgery virtual flipped classroom curriculum of 6 week-long modules. Demographics, premodule and postmodule achieved levels of learning based on Bloom's taxonomy, technology usage, and preferences were surveyed.

RESULTS

Of the 65 participants, 41 (63.1%) responded to the survey. Trainees included hand surgery fellows (27/41 [65.9%]), orthopedic surgery residents (11/41[26.8%]), and plastic surgery residents (3/41 [7.3%]). On average, most trainees read, viewed, and participated in more than half of the articles (28/41 [68.3%]), electronic videos (31/41 [75.6%]), and conferences (35/41 [85.4%]) per week. The median level of achieved learning increased from "I can apply" to "I can analyze" for all modules. Self-directed learning was preferred for basic facts and knowledge (26/41 [63.4%]) and faculty-directed learning was preferred to review and practice advanced concepts (34/41 [82.9%]). The participants perceived benefits of the virtual curriculum to include increased scheduling flexibility (8/41[19.5%]), expert opinions (7/41 [17.1%]), and diversity of educational formats (3/41 [7.3%]). The perceived drawbacks included decreased interaction (8/41 [19.5%]), technical difficulties (6/41 [14.6%]), excessive detail (3/41 [7.3%]), and single-institution bias (2/41 [4.9%]).

CONCLUSIONS

The flipped virtual classroom model is an effective and preferred method of instruction for trainees. Trainees achieved a higher level of learning following the completion of each week-long module. Considerations for the implementation of a virtual curriculum include content quality, quantity, and reducing single-institution bias.

CLINICAL RELEVANCE

The implementation of virtual learning can enhance hand surgery education for the modern learner.

Plasma metagenomic sequencing to detect and quantify bacterial DNA in ICU patients suspected of sepsis: A proof-of-principle study

BACKGROUND

Timely recognition of sepsis and identification of pathogens can improve outcomes in critical care patients but microbial cultures have low accuracy and long turnaround times. In this proof-of-principle study, we describe metagenomic sequencing and analysis of nonhuman DNA in plasma. We hypothesized that quantitative analysis of bacterial DNA (bDNA) levels in plasma can enable detection and monitoring of pathogens.

METHODS

We enrolled 30 patients suspected of sepsis in the surgical trauma intensive care unit and collected plasma samples at the time of diagnostic workup for sepsis (baseline), and 7 days and 14 days later. We performed metagenomic sequencing of plasma DNA and used computational classification of sequencing reads to detect and quantify total and pathogen-specific bDNA fraction. To improve assay sensitivity, we developed an enrichment method for bDNA based on size selection for shorter fragment lengths. Differences in bDNA fractions between samples were evaluated using t test and linear mixed-effects model, following log transformation.

RESULTS

We analyzed 72 plasma samples from 30 patients. Twenty-seven samples (37.5%) were collected at the time of infection. Median total bDNA fraction was 1.6 times higher in these samples compared with samples with no infection (0.011% and 0.0068%, respectively, p < 0.001). In 17 patients who had active infection at enrollment and at least one follow-up sample collected, total bDNA fractions were higher at baseline compared with the next sample (p < 0.001). Following enrichment, bDNA fractions increased in paired samples by a mean of 16.9-fold. Of 17 samples collected at the time when bacterial pathogens were identified, we detected pathogen-specific DNA in 13 plasma samples (76.5%).

CONCLUSION

Bacterial DNA levels in plasma are elevated in critically ill patients with active infection. Pathogen-specific DNA is detectable in plasma, particularly after enrichment using selection for shorter fragments. Serial changes in bDNA levels may be informative of treatment response.

LEVEL OF EVIDENCE

Epidemiologic/Prognostic, Level V.

The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial

INTRODUCTION

The traditional treatment of traumatic hemothorax (HTX) has been an insertion of a large-bore 36- to 40-Fr chest tube. Our previous single-center randomized controlled trial (RCT) had shown that 14-Fr percutaneous catheters (PCs) (pigtail) were equally as effective as chest tube. We performed a multicenter RCT, hypothesizing that PCs are as equally effective as chest tubes in the management of patients with traumatic HTX (NCT03546764).

METHODS

We performed a multi-institution prospective RCT comparing 14-Fr PCs with 28- to 32-Fr chest tubes in the management of patients with traumatic HTX from July 2015 to September 2020. We excluded patients who were in extremis and required emergent tube placement and those who refused to participate. The primary outcome was failure rate, defined as a retained HTX requiring a second intervention. Secondary outcomes included daily drainage output, tube days, intensive care unit and hospital length of stay, and insertion perception experience (IPE) score on a scale of 1 to 5 (1, tolerable experience; 5, worst experience). Unpaired Student's t test, χ2, and Wilcoxon rank sum test were used with significance set at p < 0.05.

RESULTS

After exclusion, 119 patients participated in the trial, 56 randomized to PCs and 63 to chest tubes. Baseline characteristics between the two groups were similar. The primary outcome, failure rate, was similar between the two groups (11% PCs vs. 13% chest tubes, p = 0.74). All other secondary outcomes were also similar, except PC patients reported lower IPE scores (median, 1: "I can tolerate it"; interquartile range, 1-2) than chest tube patients (median, 3: "It was a bad experience"; interquartile range, 2-5; p < 0.001).

CONCLUSION

Small caliber 14-Fr PCs are equally as effective as 28- to 32-Fr chest tubes in their ability to drain traumatic HTX with no difference in complications. Patients reported better IPE scores with PCs over chest tubes, suggesting that PCs are better tolerated.

LEVEL OF EVIDENCE

Therapeutic, level II.

Variation in use of damage control laparotomy for trauma by trauma centers in the United States, Canada, and Australasia

Background

It is unknown how frequently damage control (DC) laparotomy is used across trauma centers in different countries. We conducted a cross-sectional survey of trauma centers in the United States, Canada, and Australasia to study variations in use of the procedure and predictors of more frequent use of DC laparotomy.

Methods

A self-administered, electronic, cross-sectional survey of trauma centers in the United States, Canada, and Australasia was conducted. The survey collected information about trauma center and program characteristics. It also asked how often the trauma program director estimated DC laparotomy was performed on injured patients at that center on average over the last year. Multivariable logistic regression was used to identify predictors of a higher reported frequency of use of DC laparotomy.

Results

Of the 366 potentially eligible trauma centers sent the survey, 199 (51.8%) trauma program directors or leaders responded [United States = 156 (78.4%), Canada = 26 (13.1%), and Australasia = 17 (8.5%)]. The reported frequency of use of DC laparotomy was highly variable across trauma centers. DC laparotomy was used more frequently in level-1 than level-2 or -3 trauma centers. Further, high-volume level-1 centers used DC laparotomy significantly more often than lower volume level-1 centers (p = 0.02). Nearly half (48.4%) of high-volume volume level-1 trauma centers reported using the procedure at least once weekly. Significant adjusted predictors of more frequent use of DC laparotomy included country of origin [odds ratio (OR) for the United States vs. Canada = 7.49; 95% confidence interval (CI) 1.39–40.27], level-1 verification status (OR = 6.02; 95% CI 2.01–18.06), and the assessment of a higher number of severely injured (Injury Severity Scale score > 15) patients (OR per-100 patients = 1.62; 95% CI 1.20–2.18) and patients with penetrating injuries (OR per-5% increase = 1.27; 95% CI 1.01–1.58) in the last year.

Conclusions

The reported frequency of use of DC laparotomy was highly variable across trauma centers. Those centers that most need to evaluate the benefit-to-risk ratio of using DC laparotomy in different scenarios may include high-volume, level-1 trauma centers, particularly those that often manage penetrating injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00396-7.

Biomechanical comparison of tenorrhaphy constructs for tendon reconstructions and transfers

With tendon transfers or reconstructions, the tenorrhaphy must be strong enough to withstand early mobilization in the immediate postoperative period to decrease adhesion formation and optimize functional outcomes. The purpose of this study was to compare the strength, bulk, and gliding resistance of four common tendon-to-tendon attachment constructs. A biomechanical study was performed utilizing 80 cadaveric tendons to compare four common tendon tenorrhaphy constructs: the end-weave (EW); Pulvertaft (PT); single-pass, side-to-side (SP-STS); and simple, side-to-side (STS) attachments. The primary outcome measures investigated included tenorrhaphy morphology, gliding resistance, tensile strength, and deformation at failure of the different constructs. A total of 40 tendon pairs, 10 per repair group, were constructed, biomechanically evaluated, and outcomes were compared. There were no significant differences in the cross-sectional area of the native tendon (p = 0.334) or repair site (p = 0.564) and no difference in the added bulk of the repair (p = 0.663) between the repair groups. Gliding resistance was not significantly different between the repair groups (p = 0.110). The SP-STS repair was significantly stronger (p < 0.001), stiffer (p < 0.001), and exhibited less displacement at peak load (p = 0.004), and greater force generation at 1 cm of displacement (p = 0.002) compared to the other constructs. The SP-STS is significantly stronger, without a significant difference in bulk and gliding resistance compared to the PT, EW, STS repairs. SP-STS can be utilized in tendon transfers and reconstructions to safely permit early active mobilization.

Management of Minor Traumatic Brain Injury in an ED Observation Unit

Introduction

Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress.

Methods

This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention.

Results

There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention.

Conclusion

Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.

Fam49b, the source of antigenic peptide for ERAAP surveillance, controls thymocyte development

The aminopeptidase ERAAP, the ER aminopeptidase associated with antigen processing, is essential for trimming of peptides presented by classical and non-classical MHC class I molecules. The function of ERAAP is monitored by semi-invariant CD8+ T cells that recognize the QFL ligand. The QFL ligand consists of a 9-mer peptide encoded by the highly conserved Fam49a/b genes and is presented by non-classical Qa-1bmolecules expressed on surface of ERAAP-deficient cells only. Recently, Fam49b is identified as a novel negative regulator of TCR signaling, that functions by binding to active rac-1 and modulates reorganization of cytoskeleton. However, the function of Fam49b in T cells development has remained unclear. We show that Fam49b-deficient thymocytes receive higher TCR signaling and are defective in T cell development. Our studies reveal that Fam49b plays an important role in regulating thymocytes development and lineage commitment of conventional T cells as well as agonist selected T cells such as CD8αα αβ T cells. [This research was supported by NIH grants R01 AI130210 and R37 AI060040]

Fam49b-deficient lymphocytes modulate whole body energy metabolism

TCR signal strength is determined by the balance of positively regulating, and negatively regulating proteins. Fam49b is identified as new negative regulator of TCR signaling that functions by binding to active rac-1 GTPase. In the absence of Fam49b, thymocytes receive higher TCR signaling and are defective in development of conventional T cell as well as agonist selected T cells such as CD8αα+ αβ T cells. Obesity is characterized by chronic inflammation and immune dysregulation, but the link between obesity and T cells has remains unclear. We show that Fam49b-deficient mice have a high level of energy expenditure and are resistant to high fat diet induced obesity. Furthermore, the higher energy expenditure characteristic was also observed in Fam49b-deficient chimera mice. The study reveals that Fam49b deficient lymphocytes play an important role in whole body energy metabolism. [This research was supported by NIH grants R01 AI130210 and R37 AI060040]

Post-traumatic stress disorder can be predicted in hospitalized blunt trauma patients using a simple screening tool

BACKGROUND

Post-traumatic stress disorder (PTSD) has debilitating psychiatric and medical consequences. The purpose of this study was to identify whether PTSD diagnosis and PTSD symptom scale score (PTSD severity) could be predicted by assessing peritraumatic experiences using a single question or screening tools at different time points in patients hospitalized after admission to the hospital after significant physical trauma, but with stable vitals (level II trauma).

METHODS

Patients completed the 'initial question' and the National Stressful Events Survey Acute Stress Disorder Scale (NSESSS) at 3 days to 5 days after trauma (NSESSS-1). The same scale was administered 2 weeks to 4 weeks after trauma (NSESSS-2). The Posttraumatic Stress Disorder Symptoms Scale Interview for DSM-5 (PSSI-5) was administered 2 months after trauma. PTSD diagnosis and PTSD severity were extracted from the PSSI-5. Linear multivariate regression analyses were used to establish whether scores for NSESSS-1 or NSESSS-2 predicted PTSD diagnosis/PTSD severity. Non-linear multivariate regression analyses were performed to better understand the relationship between NSESSS-1/NSESSS-2 and PTSD diagnosis/PTSD severity.

RESULTS

A single question assessing the experience of fear, helplessness, or horror was not an effective tool for determining the diagnosis of PTSD (p=0.114) but can be a predictor of PTSD severity (p=0.039). We demonstrate that administering the NSESSS after either 3 days to 5 days (p=0.008, p<0.001) or 2 weeks to 4 weeks (p=0.039; p<0.001) can predict the diagnosis of PTSD and PTSD severity. Scoring an NSESSS above 14/28 (50%) increases the chance of experiencing a higher PTSD severity substantially and linearly.

DISCUSSION

Our initial question was not an effective predictor of PTSD diagnosis. However, using the NSESSS at both 3 days to 5 days and 2 weeks to 4 weeks after trauma is an effective method for predicting PTSD diagnosis and PTSD severity. Additionally, we show that patients who score higher than 14 on the NSESSS for acute stress symptoms may need closer follow-up.

LEVEL OF EVIDENCE

Level III, prognostic.

Early versus delayed complex abdominal wall reconstruction with biologic mesh following damage-control surgery

BACKGROUND

Damage-control surgery for trauma and intra-abdominal catastrophe is associated with a high rate of morbidities and postoperative complications. This study aimed to compare the outcomes of patients undergoing early complex abdominal wall reconstruction (e-CAWR) in acute settings versus those undergoing delayed complex abdominal wall reconstruction (d-CAWR).

METHOD

This study was a pooled analysis derived from the retrospective and prospective database between the years 2013 and 2019. The outcomes were compared for differences in demographics, presentation, intraoperative variables, Ventral Hernia Working Grade (VHWG), US Centers for Disease Control and Prevention wound class, American Society of Anesthesiologists (ASA) scores, postoperative complications, hospital length of stay, and readmission rates. We performed Student's t test, χ2 test, and Fisher's exact test to compare variables of interest. Multivariable linear regression model was built to evaluate the association of hospital length of stay and all other variables including the timing of complex abdominal wall reconstruction (CAWR). A p value of <0.05 was considered significant.

RESULTS

Of the 236 patients who underwent CAWR with biological mesh, 79 (33.5%) had e-CAWR. There were 45 males (57%) and 34 females (43%) in the e-CAWR group. The ASA scores of IV and V, and VHWG grades III and IV were significantly more frequent in the e-CAWR group compared with the d-CAWR one. Postoperatively, the incidence of surgical site occurrence, Clavien-Dindo complications, comprehensive complication index, unplanned reoperations, and mortality were similar between the two groups. Backward linear regression model showed that the timing of CAWR (β = -11.29, p < 0.0001), ASA (β = 3.98, p = 0.006), VHWG classification (β = 3.62, p = 0.015), drug abuse (β = 13.47, p = 0.009), and two comorbidities of cirrhosis (β = 12.34, p = 0.001) and malignancy (β = 7.91, p = 0.008) were the significant predictors of the hospital length of stay left in the model.

CONCLUSION

Early CAWR led to shorter hospital length of stay compared with d-CAWR in multivariable regression model.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Firearm Deaths are Increasing and Endemic in the USA: It is a Problem of Suicides and Not Homicides

BACKGROUND

To analyze and report on the changes in epidemiology traumatic causes of death in the USA.

METHODS

Data were extracted from the annual National Vital Statistics Reports (2008-2017) from Center for Disease Control and analyzed for trends during the time period given. Generalized additive model was applied to evaluate the significance of trend using R software.

RESULTS

Firearm deaths (39,790) and firearm death rate (12.2/100,000) in 2017 were the highest reported, and this increasing trend was significant (p < 0.001) the last ten years. Deaths from motor vehicle crash (MVC) and firearm homicides did not change significantly during the same time period. Firearm deaths were lower than MVC deaths by 21% (8,197/39,790) in 2008, but after 10 years, the difference was only 1% (458/40,231). Years of life lost from firearms is now higher than MVC. Suicides by firearm in 2017 were the highest reported at 23,854/39,773 (60%). In 2017, suicides by firearm victims were predominantly white 20,328/23,562 (85%), men 20,362/23,562 (86%), and the largest group was between the ages of 55-64.

CONCLUSIONS

Death from firearms in the USA is increasing and endemic. They were the highest ever reported in 2017 by the CDC. While deaths from MVC used to be the main cause of traumatic death in the USA, deaths from firearms now almost equal it. Calculated years of life lost from firearms is now more than from MVC. Most firearm deaths are not from homicides but are from suicides, and they are predominantly in white older males of the baby boomer generation (born 1946-1964).

Randomized Clinical Trial of 14-French (14F) Pigtail Catheters versus 28-32F Chest Tubes in the Management of Patients with Traumatic Hemothorax and Hemopneumothorax

Introduction

Traditional management of traumatic hemothorax/hemopneumothorax (HTX/HPTX) has been insertion of large-bore 32–40 French (Fr) chest tubes (CTs). Retrospective studies have shown 14Fr percutaneous pigtail catheters (PCs) are equally effective as CTs. Our aim was to compare effectiveness between PCs and CTs by performing the first randomized controlled trial (RCT). We hypothesize PCs work equally as well as CTs in management of traumatic HTX/HPTX.

Methods

Prospective RCT comparing 14Fr PCs to 28–32Fr CTs for management of traumatic HTX/HPTX from 07/2015 to 01/2018. We excluded patients requiring emergency tube placement or who refused. Primary outcome was failure rate defined as retained HTX or recurrent PTX requiring additional intervention. Secondary outcomes included initial output (IO), tube days and insertion perception experience (IPE) score on a scale of 1–5 (1 = tolerable experience, 5 = worst experience). Unpaired Student’s t-test, chi-square and Wilcoxon rank-sum test were utilized with significance set at P < 0.05.

Results

Forty-three patients were enrolled. Baseline characteristics between PC patients (N = 20) and CT patients (N = 23) were similar. Failure rates (10% PCs vs. 17% CTs, P = 0.49) between cohorts were similar. IO (median, 650 milliliters[ml]; interquartile range[IR], 375–1087; for PCs vs. 400 ml; IR, 240–700; for CTs, P = 0.06), and tube duration was similar, but PC patients reported lower IPE scores (median, 1, “I can tolerate it”; IR, 1–2) than CT patients (median, 3, “It was a bad experience”; IR, 3–4, P = 0.001).

Conclusion

In patients with traumatic HTX/HPTX, 14Fr PCs were equally as effective as 28–32Fr CTs with no significant difference in failure rates. PC patients, however, reported a better insertion experience.

www.ClinicalTrials.gov Registration ID: NCT02553434

The Impact of FASTPASS: A Collaboration With Emergency Department to Improve Management of Patients With Gallbladder Disease and Acute Appendicitis

BACKGROUND

Efficient Emergency Department (ED) throughput depends on several factors, including collaboration and consultation with surgical services. The acute care surgery service (ACS) collaborated with ED to implement a new process termed "FASTPASS" (FP), which might improve patient-care for those with acute appendicitis and gallbladder disease. The aim of this study was to evaluate the 1-year outcome of FP.

METHODS

FASTPASS is a joint collaboration between ACS and ED. ED physicians were provided with a simple check-list for diagnosing young males (<50-year old) with acute appendicitis (AA) and young males or females (<50-year old) with gallbladder disease (GBD). Once ED deemed patients fit our FP check-list, patients were directly admitted (FASTPASSed) to the observation unit. The ACS then came to evaluate the patients for possible surgical intervention. We performed outcome analysis before and after the institution of the FP. Outcomes of interest were ED length of stay (LOS), time from ED to the operating room (OR) (door-to-knife), hospital LOS (HLOS), and cost.

RESULTS

During our 1-year study period, for those patients who underwent GBD/AA surgery, 56 (26%) GBD and 27 (26%) AA patients met FP criteria. Compared to the non-FP patients during FP period, FP halved ED LOS for GBD (7.4 ± 3.0 versus 3.5 ± 1.7 h, P < 0.001) and AA (6.7 ± 3.3 versus. 1.8 ± 1.6 h, P < 0.001). Similar outcome benefits were observed for door-to-knife time, HLOS, and costs.

CONCLUSIONS

In this study, the FP process improved ED throughput in a single, highly-trained ER leading to an overall improved patient care process. A future study involving multiple EDs and different disease processes may help decrease ED overcrowding and improve healthcare system efficiency.

The Role of Nutritional Access in Malnourished Elderly Undergoing Major Surgery for Acute Abdomen: A Propensity Score-Matched Analysis

BACKGROUND

About 50% of the elderly undergoing emergency abdominal surgery are malnourished. The role of timely surgical nutritional access in this group of patients is unknown.

METHODS

We analyzed the National Inpatient Sample database from 2009 through the first three-quarters of 2015 of patients aged ≥65 years who were malnourished and underwent major abdominal surgery for the acute abdomen within the first 2 days of hospital admission.

RESULTS

Of 3 246 721 patients analyzed, 4311 patients met inclusion criteria. Of these, only 507 (11.8%) patients had surgical nutritional access (gastrostomy or jejunostomy) (group I), while 3804 patients (88.2%) did not (group II). In the propensity score-matched population, there were 482 patients in each group. The patients in group I had lower odds of mortality and postoperative gastrointestinal complications (paralytic ileus, anastomotic dehiscence, and intestinal fistulae) (P-value <.01, respectively).

DISCUSSION

Elderly who receive surgical nutritional access have lower rates of gastrointestinal complications and mortality.

Body Mass Index and Mortality in Blunt Trauma: The Right BMI can be Protective

BACKGROUND

There are limited studies examining the role of BMI on mortality in the trauma population. The aim of this study was to analyze whether the "obesity paradox" exists in non-elderly patients with blunt trauma.

METHODS

A retrospective study was performed on the Trauma Quality Improvement Program (TQIP) database for 2016. All non-elderly patients aged 18-64, with blunt traumatic injuries were identified. A generalized additive model (GAM) was built to assess the association of mortality and BMI adjusted for age, gender, race, and injury severity score (ISS).

RESULTS

28,475 patients (mean age = 42.5, SD = 14.3) were identified. 20,328 (71.4%) were male. Age (p < 0.0001), gender (p < 0.0001), and ISS (p < 0.0001) had significant associations with mortality. After GAM, BMI showed a significant U-shaped association with mortality (EDF = 3.2, p = 0.003). A BMI range of 31.5 ± 0.9 kg/m² was associated with the lowest mortality.

CONCLUSION

High BMI can be a protective factor in mortality within non-elderly patients with blunt trauma. However, underweight or morbid obesity suggest a higher risk of mortality.

Open tracheostomy for COVID-19-positive patients: A method to minimize aerosolization and reduce risk of exposure

Introduction

The COVID-19 virus is highly contagious and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies.

Methods

This is a case series of 18 patients who were COVID-19 positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts.

Results

There were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7, BMI was 32.6, and the pre-tracheostomy ventilator day was 20.4. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation.

Conclusion

This report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals.

Repeat Head Computed Tomography in Anticoagulated Traumatic Brain Injury Patients: Still Warranted

Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neuro-surgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ2 and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older ( P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission ( P < 0.001), were more likely to present with an abnormal neurologic examination ( P = 0.004), and had higher hospital and intensive care unit lengths of stay ( P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.

Prothrombin Complex Concentrate Use in Coagulopathy of Lethal Brain Injuries Increases Organ Donation

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration ( P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10) patients. Of these seven patients, consent for donation was obtained in six patients and resulted in 19 solid organs being procured. The cost of PCC per patient was $1022 ± 544. PCC effectively reveres coagulopathy associated with lethal traumatic brain injury and enabled patients to proceed to organ donation. Although various methodologies exist for the treatment of coagulopathy to facilitate organ donation, PCC provides a rapid and cost-effective therapy for reversal of coagulopathy in patients with lethal traumatic brain injuries.

Blunt Assault: ‘Million Dollar Baby’

Contrasting reports exist in the literature regarding the management of patients with blunt assault to the head, neck, and face and more importantly for clearing the cervical spine. The purpose of our study was to determine the risk of cervical spine injuries after blunt assault to the head, neck, and face and its association with other injuries. We performed a retrospective case review of all blunt assault trauma admissions to the head, neck, and face at our Level I trauma center. We identified all patients who were assaulted with hands and feet and blunt instruments. A total of 3286 patients with blunt assault to the head, neck, and face were identified of whom 11 (0.003%) were found to have a cervical spine fracture or cervical spine subluxation. None of the patients had a cervical spinal cord injury. The 11 patients composed our study population with a mean age of 39 ± 7.8 years, 100 per cent were male, and the mean Injury Severity Score was 12 ± 7.9. Five (45%) patients required surgery for stabilization of the cervical spine. Mortality was reported in only one patient who had a C7 transverse process fracture. Cervical spine injury after blunt assault is rare but does occur and encompasses significant injuries requiring surgical intervention. However, these injuries are the result of direct blows to the cervical spine and we suggest that assaulted patients with no direct trauma to the neck do not require an exhaustive evaluation of the cervical spine.

Curative resection of a duodenal gastrointestinal stromal tumor in the setting of von Willebrand's disease

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the alimentary tract and usually presents with gastrointestinal hemorrhage. The diagnosis of GIST is typically made with upper endoscopy after excluding other causes of bleeding. The surgical management of GIST can be challenging depending upon the location of the tumor. We present a unique case of duodenal GIST in the setting von Willebrand's disease diagnosed after emergent laparotomy for massive gastrointestinal hemorrhage. Key strategies in curing our patient were treating the underlying bleeding disorder, collaborating with radiology and gastroenterology teams, and early exploratory laparotomy for refractory hemorrhage. This case demonstrates the challenges of diagnosing and managing GIST in patients with underlying coagulopathies.

Nationwide Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta in Civilian Trauma

Importance

The need for improved methods of hemorrhage control and resuscitation has resulted in a reappraisal of resuscitative endovascular balloon occlusion of the aorta (REBOA). However, there is a paucity of data regarding the use of REBOA on a multi-institutional level in the United States.

Objective

To evaluate the outcomes in trauma patients after REBOA placement.

Design, Setting, and Participants

A case-control retrospective analysis was performed of the 2015-2016 American College of Surgeons Trauma Quality Improvement Program data set, a national multi-institutional database of trauma patients in the United States. A total of 593 818 adult trauma patients (aged ≥18 years) were analyzed and 420 patients were matched and included in the study; patients who were dead on arrival or were transferred from other facilities were excluded. Trauma patients who underwent REBOA placement in the ED were identified and matched with a similar cohort of patients (the no-REBOA group). Both groups were matched in a 1:2 ratio using propensity score matching for demographics, vital signs, mechanism of injury, injury severity score, head abbreviated injury scale score, each body region abbreviated injury scale score, pelvic fractures, lower extremity vascular injuries and fractures, and number and grades of intra-abdominal solid organ injuries.

Main Outcomes and Measures

Outcome measures were the rates of complications and mortality.

Results

Of 593 818 trauma patients, 420 patients (the REBOA group, 140 patients; 36 women and 104 men; mean [SD] age, 44 [20] years; the no-REBOA group, 280 patients; 77 women and 203 men; mean [SD] age, 43 [19] years) were matched and included in the analysis. Among the REBOA group, median injury severity score was 29 (interquartile range [IQR], 18-38) and 129 patients (92.1%) had a blunt mechanism of injury. There was no significant difference between groups in median 4-hour blood transfusion (REBOA: packed red blood cells, 6 U [IQR, 3-8 U]; platelets, 4 U [IQR, 3-9 U], and plasma, 3 U [IQR, 2-5 U]; and no-REBOA: packed red blood cells, 7 U [IQR, 3-9 U]; platelets, 4 U [IQR, 3-8 U], and plasma, 3 U [IQR, 2-6 U]) or 24-hour blood transfusion (REBOA: packed red blood cells, 9 U [IQR, 5-20 U]; platelets, 7 U [IQR, 3-13 U], and plasma, 9 U [IQR, 6-20 U]; and no-REBOA: packed red blood cells, 10 U [IQR, 4-21 U]; platelets, 8 U [IQR, 3-12 U], and plasma, 10 U [IQR, 7-20 U]), median hospital length of stay (REBOA, 8 days [IQR, 1-20 days]; and no-REBOA, 10 days [IQR, 5-22 days]), or median intensive care unit length of stay (REBOA, 5 days [IQR, 2-14 days]; and no-REBOA, 6 days [IQR, 3-15 days]). The mortality rate was higher in the REBOA group as compared with the no-REBOA group (50 [35.7%] vs 53 [18.9%]; P = .01). Patients who underwent REBOA placement were also more likely to develop acute kidney injury (15 [10.7%] vs 9 [3.2%]; P = .02) and more likely to undergo lower extremity amputation (5 [3.6%] vs 2 [0.7%]; P = .04).

Conclusions and Relevance

Placement of REBOA in severely injured trauma patients was associated with a higher mortality rate compared with a similar cohort of patients with no placement of REBOA. Patients in the REBOA group also had higher rates of acute kidney injury and lower leg amputations. There is a need for a concerted effort to clearly define when and in which patient population REBOA has benefit.

Management of Suspected Tension Pneumothorax in Tactical Combat Casualty Care: TCCC Guidelines Change 17-02

This change to the Tactical Combat Casualty Care (TCCC) Guidelines that updates the recommendations for management of suspected tension pneumothorax for combat casualties in the prehospital setting does the following things: (1) Continues the aggressive approach to suspecting and treating tension pneumothorax based on mechanism of injury and respiratory distress that TCCC has advocated for in the past, as opposed to waiting until shock develops as a result of the tension pneumothorax before treating. The new wording does, however, emphasize that shock and cardiac arrest may ensue if the tension pneumothorax is not treated promptly. (2) Adds additional emphasis to the importance of the current TCCC recommendation to perform needle decompression (NDC) on both sides of the chest on a combat casualty with torso trauma who suffers a traumatic cardiac arrest before reaching a medical treatment facility. (3) Adds a 10-gauge, 3.25-in needle/ catheter unit as an alternative to the previously recommended 14-gauge, 3.25-in needle/catheter unit as recommended devices for needle decompression. (4) Designates the location at which NDC should be performed as either the lateral site (fifth intercostal space [ICS] at the anterior axillary line [AAL]) or the anterior site (second ICS at the midclavicular line [MCL]). For the reasons enumerated in the body of the change report, participants on the 14 December 2017 TCCC Working Group teleconference favored including both potential sites for NDC without specifying a preferred site. (5) Adds two key elements to the description of the NDC procedure: insert the needle/ catheter unit at a perpendicular angle to the chest wall all the way to the hub, then hold the needle/catheter unit in place for 5 to 10 seconds before removing the needle in order to allow for full decompression of the pleural space to occur. (6) Defines what constitutes a successful NDC, using specific metrics such as: an observed hiss of air escaping from the chest during the NDC procedure; a decrease in respiratory distress; an increase in hemoglobin oxygen saturation; and/or an improvement in signs of shock that may be present. (7) Recommends that only two needle decompressions be attempted before continuing on to the "Circulation" portion of the TCCC Guidelines. After two NDCs have been performed, the combat medical provider should proceed to the fourth element in the "MARCH" algorithm and evaluate/treat the casualty for shock as outlined in the Circulation section of the TCCC Guidelines. Eastridge's landmark 2012 report documented that noncompressible hemorrhage caused many more combat fatalities than tension pneumothorax.1 Since the manifestations of hemorrhagic shock and shock from tension pneumothorax may be similar, the TCCC Guidelines now recommend proceeding to treatment for hemorrhagic shock (when present) after two NDCs have been performed. (8) Adds a paragraph to the end of the Circulation section of the TCCC Guidelines that calls for consideration of untreated tension pneumothorax as a potential cause for shock that has not responded to fluid resuscitation. This is an important aspect of treating shock in combat casualties that was not presently addressed in the TCCC Guidelines. (9) Adds finger thoracostomy (simple thoracostomy) and chest tubes as additional treatment options to treat suspected tension pneumothorax when further treatment is deemed necessary after two unsuccessful NDC attempts-if the combat medical provider has the skills, experience, and authorizations to perform these advanced interventions and the casualty is in shock. These two more invasive procedures are recommended only when the casualty is in refractory shock, not as the initial treatment.

Improving survival after an emergency resuscitative thoracotomy: a 5-year review of the Trauma Quality Improvement Program

BACKGROUND

Advancement in trauma care has led to the evolution of emergency resuscitative thoracotomy (ERT) for the revival of trauma patients. We now have more precise understanding of selecting suitable patients for achieving optimal outcomes. The aim of our study was to analyze the utilization and survival trends during the past 5 years, as well as factors that influence survival after ERT.

METHODS

A 5-year (2010-2014) analysis of all trauma patients ≥18 years who underwent ERT in the American College of Surgeons Trauma Quality Improvement Program. Outcome measures were utilization rates and survival trends after ERT during the 5-year period. Regression analysis was performed.

RESULTS

2229 patients underwent ERT, mean age was 37±17 years, 81% were male. Overall 56% patients had penetrating mechanism, location of major injury was thorax in 48, and 71% had signs of life (SOL) on arrival. The overall survival rate was 9.6%. From 2010-2014 ERT utilization has decreased from 331/100 000 to 243/100 000 trauma admissions (p=0.002) and the survival rate has improved from 7.9% to 11.3% (p<0.001). On regression, the independent predictors of survival were penetrating mechanism, age<60 years, SOL on arrival, no prehospital CPR and ISS. No patient aged >60 years with a blunt mechanism of injury (MOI) survived, and there were no survivors above the age of 70 years, regardless of injury mechanism.

DISCUSSION

Utilization of ERT has been decreased during the study period along with improved survival rates. The results of our study demonstrate that performing ERT on patients aged >60 years with a blunt MOI or on any patient aged ≥70 years, regardless of MOI, is futile and should be avoided.

LEVEL OF EVIDENCE

Level III, prognostic studies.

A Prospective Study of 7-Year Experience Using Percutaneous 14-French Pigtail Catheters for Traumatic Hemothorax/Hemopneumothorax at a Level-1 Trauma Center: Size Still Does Not Matter

BACKGROUND

The effectiveness of 14-French (14F) pigtail catheters (PCs) compared to 32-40F chest tubes (CTs) in patients with traumatic hemothorax (HTX) and hemopneumothorax (HPTX) is becoming more well known but still lacking. The aim of our study was to analyze our cumulative experience and outcomes with PCs in patients with traumatic HTX/HPTX. We hypothesized that PCs would be as effective as CTs.

METHODS

Using our PC database, we analyzed all trauma patients who required chest drainage for HTX/HPTX from 2008 to 2014. Primary outcomes of interest, comparing PCs to CTs, included initial drainage output in milliliters (mL), tube insertion-related complications, and failure rate. For our statistical analysis, we used the unpaired Student's t test, Chi-square test, and Wilcoxon rank-sum test. We defined statistical significance as P < 0.05.

RESULTS

During the 7-year period, 496 trauma patients required chest drainage for traumatic HTX/HPTX: 307 by CTs and 189 by PCs. PC patients were older (52 ± 21 vs. 42 ± 19, P < 0.001), demonstrated a significantly higher occurrence of blunt trauma (86 vs. 55%, P ≤ 0.001), and had tubes placed in a non-emergent fashion (Day 1 [interquartile range (IQR) 1-3 days] for PC placement vs. Day 0 [IQR 0-1 days] for CT placement, P < 0.001). All primary outcomes of interest were similar, except that the initial drainage output for PCs was higher (425 mL [IQR 200-800 mL] vs. 300 mL [IQR 150-500], P < 0.001). Findings for subgroup analysis among emergent and non-emergent PC placement were also similar to CT placement.

CONCLUSION

PCs had similar outcomes to CTs in terms of failure rate and tube insertion-related complications, and the initial drainage output from PCs was not inferior to that of CTs. The usage of PCs was, however, selective. A future multi-center study is needed to provide additional support and information for PC usage in traumatic HTX/HPTX.

Role of Laparoscopic Surgery in the Current Management of Mirizzi Syndrome

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis caused by extrinsic biliary compression by stones in the gallbladder infundibulum or cystic duct. The purpose of this study was to evaluate the outcomes associated with a laparoscopic approach to this disease process. This is a 10-year, retrospective study conducted at two academic medical centers with established acute care surgery practices. Patients with a diagnosis of MS confirmed intraoperatively were included. Eighty-eight patients with MS were identified with 55 (62.5%) being type 1. Twenty six (29.5%) patients, all type 1, underwent successful laparoscopic cholecystectomy. Of the 62 patients that underwent open cholecystectomy, 27.3 per cent had a laparoscopy converted to open procedure. There was no significant difference in overall complications (19.2 vs 29%) among those undergoing laparoscopic versus open cholecystectomy. Length of stay was lower in patients that had a laparoscopic approach (P = 0.001). Laparoscopic cholecystectomy can safely be attempted in type 1 MS and seems to be associated with fewer overall complications and shorter length of stay compared with an open approach.

Role of Laparoscopic Surgery in the Current Management of Mirizzi Syndrome

Mirizzi syndrome (MS) is an uncommon complication of cholelithiasis caused by extrinsic biliary compression by stones in the gallbladder infundibulum or cystic duct. The purpose of this study was to evaluate the outcomes associated with a laparoscopic approach to this disease process. This is a 10-year, retrospective study conducted at two academic medical centers with established acute care surgery practices. Patients with a diagnosis of MS confirmed intraoperatively were included. Eighty-eight patients with MS were identified with 55 (62.5%) being type 1. Twenty six (29.5%) patients, all type 1, underwent successful laparoscopic cholecystectomy. Of the 62 patients that underwent open cholecystectomy, 27.3 per cent had a laparoscopy converted to open procedure. There was no significant difference in overall complications (19.2 vs 29%) among those undergoing laparoscopic versus open cholecystectomy. Length of stay was lower in patients that had a laparoscopic approach ( P = 0.001). Laparoscopic cholecystectomy can safely be attempted in type 1 MS and seems to be associated with fewer overall complications and shorter length of stay compared with an open approach.

Levetiracetam Prophylaxis for Post-traumatic Brain Injury Seizures is Ineffective: A Propensity Score Analysis

INTRODUCTION

Early seizures after severe traumatic brain injury (TBI) have a reported incidence of up to 15 %. Prophylaxis for early seizures using 1 week of phenytoin is considered standard of care for seizure prevention. However, many centers have substituted the anticonvulsant levetiracetam without good data on the efficacy of this approach. Our hypothesis was that the treatment with levetiracetam is not effective in preventing early post-traumatic seizures.

METHODS

All trauma patients sustaining a TBI from January 2007 to December 2009 at an urban level-one trauma center were retrospectively analyzed. Seizures were identified from a prospectively gathered morbidity database and anticonvulsant use from the pharmacy database. Statistical comparisons were made by Chi square, t tests, and logistic regression modeling. Patients who received levetiracetam prophylaxis were matched 1:1 using propensity score matching with those who did not receive the drug.

RESULTS

5551 trauma patients suffered a TBI during the study period, with an overall seizure rate of 0.7 % (39/5551). Of the total population, 1795 were diagnosed with severe TBI (Head AIS score 3-5). Seizures were 25 times more likely in the severe TBI group than in the non-severe group [2.0 % (36/1795) vs. 0.08 % (3/3756); OR 25.6; 95 % CI 7.8-83.2; p < 0.0001]. Of the patients who had seizures after severe TBI, 25 % (9/36) received pharmacologic prophylaxis with levetiracetam, phenytoin, or fosphenytoin. In a matched cohort by propensity scores, no difference was seen in seizure rates between the levetiracetam group and no-prophylaxis group (1.9 vs. 3.4 %, p = 0.50).

CONCLUSIONS

In this propensity score-matched cohort analysis, levetiracetam prophylaxis was ineffective in preventing seizures as the rate of seizures was similar whether patients did or did not receive the drug. The incidence of post-traumatic seizures in severe TBI patients was only 2.0 % in this study; therefore we question the benefit of routine prophylactic anticonvulsant therapy in patients with TBI.

Non-invasive diagnosis and treatment strategies for traumatic brain injury: an update

PURPOSE OF REVIEW

Traumatic Brain Injury (TBI) remains the leading cause of morbidity and mortality in U.S. Since the last decade, there have been several advances in the understanding and management of TBI that have shown the potential to improve outcomes. The aim of this review is to provide a useful overview of these potential diagnostic and treatment strategies that have yet to be proven, along with an assessment of their impact on outcomes after a TBI.

RECENT FINDINGS

Recent technical advances in the management of a TBI are grounded in a better understanding of the pathophysiology of primary and secondary insult to the brain after a TBI. Hence, clinical trials on humans should proceed in order to evaluate their efficacy and safety.

SUMMARY

Mortality associated with TBI remains high. Nonetheless, new diagnostic and therapeutic techniques have the potential to enhance early detection and prevention of secondary brain insult.

More Helmets Fewer Deaths: Motorcycle Helmet Legislation Impacts Traumatic Brain Injury-Related Mortality in Young Adults

The aim of our study was to assess the impact of helmet legislations on the incidence and the mortality rate of motorcycle collision (MCC)-related traumatic brain injury (TBI) in young adult trauma patients. A 1-year (2011) retrospective analysis was performed of all patients under 21 years old with trauma-related hospitalization using the Nationwide Inpatient Sample database (representing 20% of all in-patient admissions). Patients with MCC were identified using E-codes. States were classified into three groups based on helmet legislations: universal age helmet legislation, <18 years helmet legislation, and <21 years helmet legislation. Outcome measures were the rates of TBI and mortality. Linear regression analysis was used to assess outcomes among the states. A total of 1,165,150 patients with trauma-related hospitalizations across 29 states were reviewed of which, 587 patients with MCC were included. Ten states had universal age legislation; 13 states had age <18 years legislation, and 6 states had age <21 years legislation. There was a lower incidence in the rate of TBI (P = 0.03) in states with universal helmet legislations compared with states with age-restricted helmet legislation. Universal helmet legislations lowered the rate of MCC-related TBI injures by a factor of 2.15 (β coefficient: 2.15; 95% confidence interval: 0.91–10.18; P = 0.04). States with age-restricted helmet legislations have a higher rate of traumatic brain injury and mortality compared with states with universal helmet legislations. Establishing universal helmet legislations across the states may provide a potential preventive strategy against traumatic brain injury.

Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010-2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13-15), and median head Abbreviated Injury Scale score was 3 (2-4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay (P = 0.02) and longer intensive care unit length of stay (P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.

Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010–2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13–15), and median head Abbreviated Injury Scale score was 3 (2–4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay ( P = 0.02) and longer intensive care unit length of stay ( P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH.