Standard venous thromboembolism (VTE) prophylaxis with enoxaparin results in inadequate protection in certain patients, with subtherapeutic plasma anti-Xa levels associated with elevated VTE rates. ...We hypothesized that many trauma patients would be subtherapeutic on the standard prophylactic dose of enoxaparin. Our goal was to adjust the enoxaparin dose to achieve target anti-Xa levels to take advantage of the drug based on its pharmacologic properties.
Patients admitted to the trauma service were included if they received at least three doses of prophylactic enoxaparin and underwent at least two screening venous duplex. Peak plasma anti-Xa levels of 0.2 IU/mL or less were considered low, and the dose was increased by 10 mg twice daily until adequate anti-Xa levels were obtained. A strict screening venous duplex protocol was followed. Patients were excluded if they were diagnosed with a deep venous thrombosis before beginning enoxaparin or did not have correctly timed anti-Xa levels.
Sixty-one trauma patients met inclusion criteria. There were three patients diagnosed with VTE (4.9%). Patients had a mean age of 45.9 years and were predominantly male (70.5%). Of the 61 patients, 18 (29.5%) had therapeutic anti-Xa levels on standard enoxaparin 30 mg twice daily. Compared with patients who had therapeutic anti-Xa levels on enoxaparin 30 mg twice daily, the 43 patients (70.5%) who were subtherapeutic were more likely to be male, have greater body weight, and larger body surface area. There were no significant bleeding events in the group that received an enoxaparin dose adjustment.
Most patients had subtherapeutic anti-Xa levels while on enoxaparin 30 mg twice daily, suggesting inadequate VTE prophylaxis. The need for routine use of a higher dose of prophylactic enoxaparin in trauma patients and the effects of routinely dose adjusting enoxaparin on VTE rates should be the study of future prospective, randomized trials.
Therapeutic study, level IV.
Gallbladder disease frequently requires emergency general surgery (EGS). The Affordable Care Act (ACA) mandated health insurance coverage for all with the intent to improve access to care and ...decrease morbidity, mortality, and costs. We hypothesize that after the ACA open-enrollment in 2014 the number of EGS cholecystectomies decreased as access to care improved with a shift in EGS cholecystectomies to teaching institutions.
A retrospective review of the National Inpatient Sample Database from 2012 to quarter 3 of 2015 was performed. Patients age 18-64, with a nonelective admission for gallbladder disease based on ICD-9 codes, were collected. Outcomes measured included cholecystectomy, complications, mortality, and wage index-adjusted costs. The effect of the ACA was determined by comparing preACA to postACA years.
189,023 patients were identified. In the postACA period the payer distribution for admissions decreased for Self-pay (19.3% to 13.6%, P < 0.001), Medicaid increased (26.3% to 34.0%, P < 0.001) and Private insurance was unchanged (48.6% to 48.7%, P = 0.946). PostACA, admissions to teaching hospitals increased across all payer types, EGS cholecystectomies decreased, while complications increased, and mortality was unchanged. Median costs increased significantly for Medicaid and Private insurance while Self-pay was unchanged. Based on adjusted DID analyses for Insured compared to Self-pay patients, EGS cholecystectomies decreased (−2.7% versus −1.21%, P = 0.033) and median cost increased more rapidly (+$625 versus +$166, P = 0.017).
The ACA has changed EGS, shifting the majority of patients to teaching institutions despite insurance type and decreasing the need for EGS cholecystectomy. The trend toward higher complication rate with increased overall cost requires attention.
•The Affordable Care Act (ACA) has increased insurance coverage to previously uninsured individuals.•The ACA has decreased the need for EGS cholecystectomy.•The ACA shifted more EGS cholecystectomies to teaching institutions.•Complications after EGS cholecystectomy increased after implementation of the ACA.
Previous studies have established that posthemorrhagic shock mesenteric lymph (PHSML) contains proinflammatory mediators, while the cellular basis of PHSML is less well characterized in acute models ...of injury. CD103 dendritic cells (DCs) have been identified in the mesenteric lymph (ML) in models of chronic intestinal inflammation, suggesting an important role in the gut response to injury. We have previously demonstrated the ability of vagal nerve stimulation (VNS) to prevent gut barrier failure after trauma/hemorrhagic shock (T/HS); however, the ability of VNS to alter ML DCs is unknown. We hypothesized that the CD103 MHC-II DC population would change in PHSML and that VNS would prevent injury-induced changes in this population in PHSML.
Male Sprague-Dawley rats were randomly assigned to trauma/sham shock or T/HS. T/HS was induced by midline laparotomy and 60 minutes of HS (blood pressure, 35 mm Hg), followed by fluid resuscitation. A separate cohort of animals underwent cervical VNS after the HS phase. Gut tissue was harvested at 2 hours after injury for histologic analysis. ML was collected during the pre-HS, HS, and post-HS phase. For flow cytometric analysis, ML cells were subjected to staining with CD103 and MHC-II antibodies, and this cell population was compared in the pre-HS and post-HS phase from the same animal. The CD4Foxp3 cell (T reg) population in the ML node (MLN) was also tested to determine effects of CD103 DC modulation in the ML.
VNS reduced histologic gut injury and ML flow seen after injury. The CD103 MHC-II DC population in the PHSML was significantly decreased compared with pre-HS and was associated with decreased T reg expression in the MLN. VNS prevented the injury-induced decrease in the CD103 MHC-II+ DC population in the ML and restored the T reg population in the MLN.
These findings suggest that VNS mediates the inflammatory responses in ML DCs and MLN T reg cells by affecting the set point of T/HS responsiveness.
Conflicting evidence exists evaluating associations between cannabis (THC) and post-traumatic DVT.
Retrospective analysis (2014–2023) of patients ≥15yrs from two Level I trauma centers with robust ...VTE surveillance and prophylaxis protocols. Multivariable hierarchical regression assessed the association between THC and DVT risk. THC + patients were direct matched to other drug use categories on VTE risk markers and hospital length of stay.
Of 7365 patients, 3719 were drug-, 575 were THC + only, 2583 were other drug+, and 488 were TCH+/other drug+. DVT rates by exposure group did not differ. TCH + only patients had higher GCS scores, shorter hospital length of stay, and the lowest pelvic fracture and mortality rates. A total of 458 drug-, 453 other drug+, and 232 THC+/other drug + patients were matched to 458, 453, and 232 THC + only patients. There were no differences in DVT event rates in any paired sub-cohort set. Additionally, iteratively adjusted paired models did not show an association between THC and DVT.
THC does not appear to be associated with increased DVT risk in patients with strict trauma chemoprophylaxis. Toxicology testing is useful for identifying substance abuse intervention opportunities, but not for DVT risk stratification in THC + patients.
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•Cannabis use has increased nationwide and conflicting evidence exists surrounding venous thromboembolism (VTE) risk and cannabis use.•DVT rates were comparable in a direct matched analysis of patients based on THC toxicology screen.•THC use does not seem be associated with higher DVT risk in trauma patients with rigorous chemoprophylaxis.
Surgical pancreatic necrosectomy (SPN) is an option for the management of infected pancreatic necrosis. The literature indicates that an escalating, combined endoscopic, interventional radiology and ...minimally invasive surgery "step-up" approach, such as video-assisted retroperitoneal debridement, may reduce the number of required SPNs and ICU complications, such as multiple organ failure. We hypothesized that complications for surgically treated severe necrotizing pancreatitis patients decreased during the period of adoption of the "step-up" approach.
The American college of surgeons national surgery quality improvement program database (ACS-NSQIP) was used to find SPN cases from 2007 to 2019 in ACS-NSQIP submitting hospitals. Mortality and Clavien-Dindo class 4 (CD4) ICU complications were collected. Predictors of outcomes were identified by univariate and multivariate analyses.
There were 2457 SPN cases. SPN cases decreased from 0.09% in 2007 to 0.01% in 2019 of NSQIP operative cases (p < 0.001). Overall mortality was 8.5% and did not decrease with time. CD4 complications decreased from 40 to 27% (p < 0.001). There was a 65% reduction in SPN cases requiring a return to the operating room. Multivariate predictors of complications were emergency general surgery (EGS, p < 0.001), serum albumin (p < 0.0001) and modified frailty index (mFI) (p < 0.0001). Multivariate predictors of mortality were EGS (p < 0.0001), serum albumin (p < 0.0001), and mFI (p < 0.04). The mFI decreased after 2010 (p < 0.001).
SPNs decreased after 2010, with decreasing CD4 complications, decreasing reoperation rates and stable mortality rates, likely indicating broad adoption of a "step-up" approach. Larger, prospective studies to compare indications and outcomes for "step up" versus open SPN are warranted.
Methamphetamine (METH) use causes significant vasoconstriction, which can be severe enough to cause bowel ischemia. Methamphetamines have also been shown to alter the immune response. These effects ...could predispose METH users to poor wound healing, increased infections, and other post-operative complications. We hypothesized that METH users would have longer length of stay and higher rates of complications compared to non–METH users.
The trauma registry for our urban Level 1 trauma center was searched for patients that received an exploratory laparotomy from 2016 to 2019. A total 204 patients met criteria and 52 (25.5%) were METH positive. Length of stay (LOS), ventilator days, abbreviated injury scale (AIS), and wound class were compared using nonparametric statistics. Age and injury severity score (ISS) were compared using a Student's t-test. A Chi Square or Fisher's Exact test was used to compare sex, mechanism of injury, and rates of infectious complications.
Methamphetamine-positive patients had a significantly higher rate of surgical site infections (7.4% versus 0%, P = 0.001). Patients that developed surgical site infection had equivalent rates of smoking and diabetes, as well as equivalent abdominal AIS and wound class compared to those who did not develop surgical site infection. Hospital and ICU LOS, ventilator days, ISS, and mortality were equivalent between METH positive and negative patients. Rates of other infectious complications were the same between groups.
Methamphetamine use is associated with an increased rate of surgical site infection after trauma laparotomy. Other serious complications and mortality were not affected by METH use.
Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic ...prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.
San Diego County's geographic location lends a unique demographic of migrant patients injured by falls at the United States-Mexico border. To prevent migrant crossings, a 2017 Executive Order ...allocated funds to increase the southern California border wall height from 10 ft to 30 ft, which was completed in December 2019. We hypothesized that the elevated border wall height is associated with increased major trauma, resource utilization, and health care costs.
Retrospective trauma registry review of border wall falls was performed by the two Level I trauma centers that admit border fall patients from the southern California border from January 2016 to June 2022. Patients were assigned to either "pre-2020" or "post-2020" subgroups based upon timing of completion of the heightened border wall. Total number of admissions, operating room utilization, hospital charges, and hospital costs were compared.
Injuries from border wall falls grew 967% from 2016 to 2021 (39 vs. 377 admissions); this percentage is expected to be supplanted in 2022. When comparing the two subgroups, operating room utilization (175 vs. 734 total operations) and median hospital charges per patient ($95,229 vs. $168,795) have risen dramatically over the same time period. Hospital costs increased 636% in the post-2020 subgroup ($11,351,216 versus $72,172,123). The majority (97%) of these patients are uninsured at admission, with costs largely subsidized by federal government entities (57%) or through state Medicaid enrollment postadmission (31%).
The increased height of the United States-Mexico border wall has resulted in record numbers of injured migrant patients, placing novel financial and resource burdens on already stressed trauma systems. To address this public health crisis, legislators and health care providers must conduct collaborative, apolitical discussions regarding the border wall's efficacy as a means of deterrence and its impact on traumatic injury and disability.
Prognostic and Epidemiological; Level IV.
The liver is the most commonly injured organ after blunt abdominal trauma. Nonoperative management is the standard of care in stable individuals. Liver injuries, particularly high-grade injuries, can ...develop pseudoaneurysms (PSAs), which can rupture and cause life-threatening bleeding, even after hospital discharge. There is no consensus on whether patients should receive predischarge contrast computed tomography (CT) screening, or at what time interval after injury, nor which patients are at the highest risk for PSA. The purpose of this study was to identify the rates of PSA in our population and potential risk factors for their formation.
The trauma registry at our Level 1 urban trauma center was queried for patients admitted with liver injuries between 2015 and 2021. Demographic information was collected from the registry. Individual charts were then reviewed for timing of CT scans, CT findings, interventions, and complications. Liver injury grade was assessed using radiology reports or operative findings. The frequency of PSAs was then analyzed using descriptive statistics using Microsoft Excel and SPSS for odds ratio.
A total of 172 patients were admitted with liver injuries during the study period. 130 patients received a CT scan diagnosing liver injury, 42 were diagnosed with liver injury intraoperatively. Of the 130 patients (59.9%) which received follow-up CT scans, six (6.5%) developed PSA, four of which being from penetrating injuries (odds ratio, 6.95).
This study demonstrated a low incidence of PSA consistent with the known literature. We found the majority of the PSA developed following penetrating injury. This may represent a significant indication for follow-up imaging regardless of grade. A larger study will be necessary to identify those most at risk for PSA formation and determine the best PSA screening algorithm.
•Traumatic liver pseudoaneurysms are a rare complication.•Screening with IV contrast CT scans can detect their presence.•Prophylactic angioembolization of pseudoaneurysms can decrease the incidence of life-threatening complications.
The human genome contains a variant form of the α7-nicotinic acetylcholine receptor (α7nAChR) gene that is uniquely human. This CHRFAM7A gene arose during human speciation and recent data suggests ...that its expression alters ligand tropism of the normally homopentameric human α7-AChR ligand-gated cell surface ion channel that is found on the surface of many different cell types. To understand its possible significance in regulating inflammation in humans, we investigated its expression in normal human leukocytes and leukocyte cell lines, compared CHRFAM7A expression to that of the CHRNA7 gene, mapped its promoter and characterized the effects of stable CHRFAM7A overexpression. We report here that CHRFAM7A is highly expressed in human leukocytes but that the levels of both CHRFAM7A and CHRNA7 mRNAs were independent and varied widely. To this end, mapping of the CHRFAM7A promoter in its 5'-untranslated region (UTR) identified a unique 1-kb sequence that independently regulates CHRFAM7A gene expression. Because overexpression of CHRFAM7A in THP1 cells altered the cell phenotype and modified the expression of genes associated with focal adhesion (for example, FAK, P13K, Akt, rho, GEF, Elk1, CycD), leukocyte transepithelial migration (Nox, ITG, MMPs, PKC) and cancer (kit, kitL, ras, cFos cyclinD1, Frizzled and GPCR), we conclude that CHRFAM7A is biologically active. Most surprisingly however, stable CHRFAM7A overexpression in THP1 cells upregulated CHRNA7, which, in turn, led to increased binding of the specific α7nAChR ligand, bungarotoxin, on the THP1 cell surface. Taken together, these data confirm the close association between CHRFAM7A and CHRNA7 expression, establish a biological consequence to CHRFAM7A expression in human leukocytes and support the possibility that this human-specific gene might contribute to, and/or gauge, a human-specific response to inflammation.
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