Most existing work on evolutionary optimization assumes that there are analytic functions for evaluating the objectives and constraints. In the real world, however, the objective or constraint values ...of many optimization problems can be evaluated solely based on data and solving such optimization problems is often known as data-driven optimization. In this paper, we divide data-driven optimization problems into two categories, i.e., offline and online data-driven optimization, and discuss the main challenges involved therein. An evolutionary algorithm is then presented to optimize the design of a trauma system, which is a typical offline data-driven multiobjective optimization problem, where the objectives and constraints can be evaluated using incidents only. As each single function evaluation involves a large amount of patient data, we develop a multifidelity surrogate-management strategy to reduce the computation time of the evolutionary optimization. The main idea is to adaptively tune the approximation fidelity by clustering the original data into different numbers of clusters and a regression model is constructed to estimate the required minimum fidelity. Experimental results show that the proposed algorithm is able to save up to 90% of computation time without much sacrifice of the solution quality.
Correspondence to Dr Jan O Jansen; Jjansen@uabmc.edu This edition of Trauma Surgery & Acute Care Open contains an article by Mitra et al, which describes a 5-year, retrospective, registry-based ...cohort study of transfusion practices in an Australian trauma center.1 The aim of the study was to evaluate the association of two ‘modifiable risk factors’—the time to blood component transfusion, and the volume of blood components transfused—with hospital mortality. The authors also found that, after adjusting for injury and shock severity, the volume of blood components transfused was associated with hospital mortality. The past two decades have seen several large, prospective, multicenter randomized clinical trials of transfusion strategies in trauma patients, that have improved outcomes, and shaped our practice.5 6 An important lesson from these studies has been that transfusing blood early (as was done in this study), avoiding the use of crystalloids, and balanced resuscitation saves lives.7 The conclusion by Mitra et al that ‘these findings suggest investigation into strategies to achieve earlier control of hemorrhage’, to reduce the need for transfusion—rather than limiting transfusion per se—is the correct one.
OBJECTIVE:To calculate the current and projected financial burden of EGS hospital admissions in a single-payer healthcare system.
SUMMARY OF BACKGROUND DATA:EGS is an important acute care service, ...which demands significant healthcare resources. EGS admissions and associated costs have increased over time, associated with an aging demographic. The National Health Service is the sole provider of emergency care in Scotland.
METHODS:Principal, high and low Scottish population projections were obtained for 2016 until 2041. EGS admission data were projected using an ordinary least squares linear regression model. An exponential function, fitted to historical length of hospital stay (LOS) data, was used to project future LOS. Historical hospital unit cost per bed day was projected using a linear regression model. EGS cost was calculated to 2041 by multiplying annual projections of population, admission rates, LOS, and cost per bed day.
RESULTS:The adult (age >15) Scottish population is projected to increase from 4.5 million to 4.8 million between 2016 and 2041. During this time, EGS admissions are expected to increase from 83,132 to 101,090 per year, cost per bed day from £786 to £1534, and overall EGS cost from £187.3 million to £202.5 million.
CONCLUSIONS:The future financial burden of EGS in Scotland is projected to increase moderately between 2016 and 2041. This is in sharp contrast to previous studies from settings such as the United States. However, if no further reductions in LOS or cost per bed day are made, especially for elderly patients, the cost of EGS will rise dramatically.
Access to health care is an important issue, particularly in remote areas. Since 2010, 106 rural hospital have closed in the United States, potentially limiting geographic access to health care. The ...aim of this study was to evaluate the impact of these hospital closures on the proportion of the population who can reach a secondary care facility, by road, within 15, 30, 45, or 60 min.
Geographical information system analysis, using population data obtained from the 2010 U.S. Census Bureau and hospital data between 2010 and 2019 from the Center for Medicare and Medicaid Services, created 15-, 30-, 45-, and 60-min drive time isochrones (areas from which a central location can be reached within a set time).
Rural hospital closures resulted in 0%-0.97% of the population no longer being able to access a hospital within 15 min. The most marked changes were in the East South Central (0.97%, 178,478 residents) and West South Central (0.54%, 197,660 residents) divisions. Lesser degrees of change were noted for longer drive times. The changes were more marked when the rural population was analyzed exclusively.
Recent closures of rural hospitals in the United States have impacted population access to hospital care, although the extent varies. There are regions, such as the Southern and Southeastern United States, which demonstrate greater and potentially more concerning losses in population coverage, probably because of the greater number of closures. Future work should evaluate clinical implications of hospital closures and loss of population coverage.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Conducting clinical trials in trauma care is challenging. As new treatments become available, we are faced with the dilemma of how to confirm their effectiveness, and strengthen the evidence base. ...Randomized controlled trials are the gold standard, but target groups in trauma care are often small and specialized, making the classical approach to trial design difficult. Bayesian designs represent an innovative means of increasing trial efficiency, and conducting trials with more realistic sample sizes. This article examines the design of such trials, using the UK-REBOA Trial as an example.
Acute pain is common after injury. This study intended to evaluate the feasibility of quantifying pain experience over an entire admission using “area under the pain curve” and to identify factors ...associated with increased pain.
This retrospective single-center study included all trauma patients admitted from 2013 to 2020. Maximum pain scores were extracted for each day. Pain was defined as area under the curve (AUC) of maximum pain scores/day plotted against time. Injury patterns were analyzed by dichotomizing Abbreviated Injury Scale (AIS) scores (AIS < 3 versus AIS ≥ 3) for each body region. Urinary drug screen results were collected from admission data. A general linear model was used to determine which injury patterns, mechanisms, and age groups were predictive of increased AUC in all patients together and separate by operative and nonoperative groups.
We identified 21,640 patients, of which 70% were male and 83% had suffered blunt injury. Overall injury severity was associated with increased pain experience. Serious head injury, younger age, and older age (compared to 45-49 y) were associated with decreased pain. Spinal injuries, thoraco-abdominal injuries, and combined thoracic and lower extremity injuries were predictive of increased pain. Compared to patients with no positive test for illicit substances or documentation of prehospital narcotic medications, the pain experience was greater for both, those who had been administered a narcotic in the prehospital setting and those who tested positive for illicit substances.
This study extends the concept of total pain experience using AUC methodology. Our results demonstrate associations between increased pain and certain patterns of injury, ages, and presence of drugs on admission. Measuring total pain experience could assist in comparing pain-management strategies. Future research should focus on validating pain experience against quality-of-life measurements.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The provision of emergency general surgery services is a global issue, with important implications for patients and workforce. The aim of this study was to analyze the characteristics of emergency ...general surgical patients in the United Kingdom, with reference to diagnostic case mix, operative workload, comorbidity, discharge destination, and outcomes, to facilitate comparisons and future service development.
This is a cross-sectional population-based study based in the National Health Service in Scotland, one of the home nations of the United Kingdom. All patients aged 16 or older admitted under the care of a general surgeon, as an emergency, to a National Health Service hospital in Scotland, in 2016, were included.
There were 81,446 emergency general surgery admissions by 66,498 patients. Median episode age was 53 years. There were more female patients than male (55% vs 45%, p < 0.0001). The most common diagnoses were nonspecific abdominal pain (20.2%), cholecystitis (7.2%), constipation (3.4%), pancreatitis (3.1%), diverticular disease (3.1%), and appendicitis (3.1%). Only 25% of patients had operations (n = 20,292). The most frequent procedures were appendicectomy (13.1%), endoscopy (11.3%), and drainage of skin lesions (9.7%). Diagnoses and operations differed with age. Overall median length of stay was 1 day. With a 6-month follow-up, patients older than 75 years had a 19.8% mortality rate.
Emergency general surgery in the United Kingdom is a high-volume, diagnostically diverse, and low-operative volume specialty with high short-term mortality rate in elderly patients. Consideration should be given to alternative service delivery models, which make better use of surgeons' skills while also ensuring optimal care for patients who are increasingly elderly and have complex chronic health problems.
Epidemiologic study, level III.
Background
Incisional hernia prevention strategies related to fascial closure technique during laparotomy are well described yet poorly implemented in practice. The factors hindering the surgeon’s ...adoption of evidence-based techniques for fascial closure are poorly understood and characterized.
Methods
Using an exploratory sequential mixed methods design, we first collected 139 responses to a validated quantitative survey based on a Theoretical Domain Framework for adoption of healthcare practices. Mean scores from survey responses were tabulated, and the findings were used to develop an interview guide for subsequent qualitative individual semi-structured phone interviews. Fourteen practicing surgeons were purposively sampled from social media outlets and our institution. The interviews were recorded and transcribed verbatim for coding and thematic analysis using NVivo 12 Plus. Data from the surveys and interviews were integrated using joint displays.
Results
Quantitative and qualitative analyses from surveys and semi-structured interviews revealed various themes related to surgeon decision-making related to fascial closure technique. Surgeons cited limitations of prior studies, applicability of findings, anecdotal experiences, and situation-specific environments that influence their decision-making. Peer influence and lack of training also affected surgeons’ perspectives on integrating small bite technique into practice.
Conclusion
Trial design limitations, peer influence, and patient-specific factors impacted surgeon decision-making in the choice of fascial closure technique. Future clinical trials in diverse patient populations may improve surgeons’ confidence in implementing technique for fascial closure.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Conducting clinical trials in trauma care is challenging. As new treatments become available, we are faced with the dilemma of how to confirm their effectiveness and strengthen the evidence base. ...Randomized controlled trials are the criterion standard, but target groups in trauma care are often small and specialized, making the classic approach to trial design difficult. Bayesian designs represent an innovative means of increasing trial efficiency and conducting trials with more realistic sample sizes. This article examines the design of such trials, using the UK-REBOA Trial as an example.
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