We present a rare case of traumatic self-enucleation of the bilateral globes resulting in traumatic subarachnoid and intraventricular hemorrhages. This case highlights the critical importance of ...multidisciplinary trauma care, starting with recognition of the potential for less obvious injuries such as contralateral optic nerve injury in unilateral enucleation, intracranial hemorrhage, and cerebrovascular injuries. We highlight the role of a thorough trauma assessment and workup, especially in the context of highly distracting injuries in patients who may also have severe mental illness. The trauma and acute care surgeon, who also serves as the critical care specialist, should be well prepared to facilitate care between multiple subspecialists including neurosurgeons, interventional radiologists, vascular surgeons, and psychiatrists, with a high index of suspicion for occult trauma in seemingly isolated injuries.
Limited data exist regarding the impact of advanced care planning for injured geriatric patients. We hypothesized that patients with advance directives limiting care (ADLC) compared with those ...without ADLC are more likely to undergo withdrawal of life-sustaining support (WLSS).
This is a propensity-matched analysis utilizing American College of Surgeons Trauma Quality Improvement Program patients 65 years or older who presented between 2017 and 2018. Patients with and without ADLC on admission were compared. The primary outcome was WLSS and days prior to WLSS. Additional factors examined included hospital length of stay (LOS), unplanned operations, unplanned intensive care unit admissions, and in-hospital cardiac arrests. Prior to matching, logistic regression model assessed factors associated with WLSS. Patients with and without ADLC were matched 1:1 via a propensity score using patient and injury factors as covariates, and matched pair analysis compared differences in WLSS between patients with and without ADLC.
There were 597,840 patients included: 44,001 patients with an ADLC (7.36%) compared with 553,839 with no ADLC (92.64%). Patients with an ADLC underwent WLSS more often than those with no ADLC (7.68% vs. 2.48%, p < 0.001). In a 1:1 propensity-matched analysis, patients with ADLC were more likely to undergo WLSS (odds ratio OR, 2.38' 95% confidence interval CI, 2.22-2.55), although stronger predictors of WLSS included severity of injury (Injury Severity Score, 25+; OR, 23.84; 95% CI, 21.55-26.36), unplanned intensive care unit admissions (OR, 3.30; 95% CI, 2.89-3.75), and in-hospital cardiac arrests (OR, 4.97; 95% CI, 4.02-6.15).
A small proportion of the geriatric trauma population had ADLC on admission. While ADLC was predictive of WLSS, adverse events were more strongly associated with WLSS. To ensure patient-centered care and reduce futile interventions, surgeons should delineate goals of care early regardless of ADLC.
Therapeutic/Care Management; Level III.
BACKGROUND/OBJECTIVES
Over a million older patients in the United States are admitted yearly for emergency general surgery (EGS) conditions. Seven procedure types dominate: colon, small bowel, ...gallbladder, ulcer disease, adhesiolysis, appendix, and laparotomy operations. A higher comorbidity burden is known to increase mortality in this population, but the impact of specific comorbidity combinations is unknown. Our objectives were to (1) characterize the distribution of procedures, comorbidities, and outcomes for older patients undergoing EGS; and (2) apply a data‐driven approach (association rule mining) to identify comorbidity combinations associated with disproportionately high mortality.
DESIGN, SETTING, AND PARTICIPANTS
Cross‐sectional study of patients 65 years and older who underwent one of the seven procedures previously cited, taken from the 2011 Nationwide Inpatient Sample. A total of 280 885 patient encounters were identified.
MEASUREMENTS
In‐hospital mortality, procedures, and comorbidities based on the Elixhauser Comorbidity Index.
RESULTS
Overall mortality was 5.6%. The most common procedures were gallbladder (33.7%), ulcer surgery (21.5%), and adhesiolysis (21.0%). Mortality increased for all procedures as patients aged. Comorbidities associated with the highest mortality included coagulopathy (adjusted odds ratio aOR = 3.74; 95% confidence interval CI = 3.41–4.11; p < .001), fluid and electrolyte disorders (FED) (aOR = 2.89; 95% CI = 3.66–3.14; p < .001), and liver disease (aOR = 1.89; 95% CI = 1.61–2.22; p < .001). Three‐way comorbidity combinations most highly associated with mortality were coagulopathy, FED, and peripheral vascular disease (aOR = 5.10; 95% CI = 4.17–6.24; p < .001), and coagulopathy, FED, and chronic pulmonary disease (aOR = 4.83; 95% CI = 4.00–5.82; p < .001).
CONCLUSION
For older patients, combinations of comorbidities portend additional risk beyond single comorbidities, and the associated risk burden is driven by the specific constellation of comorbidities present. Future work must continue to examine the effect of co‐occurring diseases to provide personalized and realistic prognostication for older patients undergoing EGS. J Am Geriatr Soc 67:503–510, 2019.
Background
Resident physicians are using the Internet to gather information about graduate medical education programs. The content of fellowship websites has been demonstrated to influence ...applicants’ decisions. The purpose of this study was to evaluate the content of the surgical critical care fellowship (SCCF) program websites.
Methods
A list of Eastern Association for the Surgery of Trauma (EAST) and American Association for the Surgery of Trauma (AAST) SCCF programs was obtained, and compared to the Accreditation Council for Graduate Medical Education (ACGME) list of accredited programs. The accessibility of each website was assessed through Google®. Content areas were assessed for each SCCF website.
Results
At the time of this study, 76 SCCF were listed on the EAST website and an additional 14 were supplied by the AAST database. 125 programs were listed in the ACGME database. Of the 76 SCCF listed by EAST, 44 (58%), 32 (42%), and 7 (9%) of SCCF programs had an EAST listing that was 3, 5, or 10 years or more out of date, respectively. Of the 90 SCCF programs listed on EAST or AAST sites, 36 programs (40%) had an inaccurate PD named on their listing. One hundred and nineteen of the 125 (95%) SCCF programs had websites accessible through Google®. Only 25 (20%) programs had a website containing a program description, faculty list, curriculum, and current/past fellows list.
Conclusions
Many SCCF websites lacked information regarding program specifics. Valuable information for potential applicants was inadequate across SCCF websites.
Anastomotic leaks after esophagectomy are a significant cause of postoperative morbidity and death. Barium esophagram and esophagogastroduodenoscopy are commonly used to survey for leaks; however, ...each has inherent risks and limitations. We sought to evaluate the effectiveness of daily drain amylase levels in detecting anastomotic leaks after esophagectomy.
We retrospectively reviewed 146 consecutive patients who underwent esophagectomy with cervical and intrathoracic anastomosis using gastric conduit. We collected daily drain amylase levels and obtained postoperative barium esophagrams routinely. Receiver operating characteristic analysis was performed to evaluate the ability of drain amylase to detect anastomotic leaks and to determine the sensitivity and specificity at various cutoff values.
There were no in-hospital or outpatient deaths within 30 days of operation in this consecutive series of patients. A leak occurred in 22 of 146 esophagectomy patients (15%) that required postoperative intervention. An additional 13 patients (9%) had a leak requiring only alteration of diet or antibiotics. The sensitivity and specificity for barium esophagram was 36.9% and 95%, respectively. For drain amylase obtained on postoperative day 4, a cutoff of 38 IU/L yielded a sensitivity of 100% and a specificity of 52.0%, and a cutoff of 250 IU/L yielded a sensitivity of 66.7% and a specificity of 95.9% in detecting leaks eventually requiring intervention.
Drain amylase levels recorded on day 4 after esophagectomy are more accurate for the detection of esophageal anastomotic leak than barium esophagram. Drain amylase levels represent a noninvasive test that may facilitate safe, early discharge after esophagectomy.
Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and ...that there might be significant variation in day 1 discharge rates between hospitals.
We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission.
A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges.
Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.
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Resilience, or the ability to adapt to difficult or challenging life experiences, may be an important mediator in trauma recovery. The primary aim of this study was to describe resilience levels for ...trauma patients using the validated Connor-Davidson Resilience Scale.
Adult trauma patients admitted to a Level 1 trauma center (June 2022–August 2022) were surveyed at the time of admission and by phone between 2 weeks and 1 month after the original survey to obtain follow-up scores. We utilized the validated Connor-Davidson Resilience Scale score, a 25-question survey with 5 subfactors (Tenacity, Positive Outlook, Social Support, Problem Solving, and Meaning and Purpose). Each question was scored from 0 to 4 (maximum score 100, representing the highest resilience). Patient factors were collected from the electronic medical record and trauma health registry. Wilcoxon signed-rank test and multivariable linear regression were used to understand associations with Connor-Davidson Resilience Scale scores.
We enrolled 98 patients. The median age was 50 years (interquartile range 32–67), and 74% were male sex. The baseline median Connor-Davidson Resilience Scale score on admission was 88 (interquartile range 81–94). Follow-up surveys (N = 64) showed a median score of 89.5 (80–90.5) (P = non-significant). No demographic variable was significantly associated with increasing baseline Connor-Davidson Resilience Scale score. Increased length of stay (β = 1.03), insurance (β = −7.50), and unknown race (β = 23.69) were correlated with follow-up Connor-Davidson Resilience Scale scores. The subfactor “Meaning and Purpose” decreased at follow-up but was not statistically significant (P = .05).
Validated tools that can accurately distinguish variability in resilience scores are needed for the trauma patient population to understand its relationship with long-term patient health outcomes.
Despite the theoretical understanding that DOACs have a more predictable therapeutic effect that negates the need for frequent monitoring, this difference in the predictability of levels between men ...and women raises questions about whether there is a biological difference in how individuals respond to DOACs.4 The seminal DOAC trials enrolled around 40% female patients; however, these studies were not examined for sex-specific outcomes.5 The absence of these data makes it difficult to generate conclusions about whether testing and reversal protocols should differ for men and women.6 7 Furthermore, the lack of standardized anti-Xa testing, with specifically calibrated levels required for each Xa inhibitor, complicates whether and how widely testing should be adopted. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Thromb Res 2020; 192: 40–51. doi:10.1016/j.thromres.2020.05.008 7 Siegerink B, Govers-Riemslag JWP, Rosendaal FR, Ten Cate H, Algra A. Intrinsic coagulation activation and the risk of arterial thrombosis in young women: results from the risk of arterial thrombosis in relation to oral contraceptives (RATIO) case-control study.
Physicians, medical students, and health care professionals are charged with staying current throughout their training. No studies have examined the scope of trauma surgery-related podcasts and ...videos. Our goal was to characterize and evaluate the growing number of trauma-related podcasts and YouTube channels.
We conducted a search across 3 podcasting platforms (Google Podcasts, Apple Podcasts, and Spotify) and 1 video-sharing site (YouTube) for podcasts published up to November 11, 2022. We queued platforms for "Trauma" and "Trauma Surgery." We included podcasts or video channels in English that focused on trauma surgery or trauma survivorship and recovery. Descriptive analyses were used to determine the characteristics of podcasts and YouTube channels, reported as counts.
We identified 91 podcasts and 103 YouTube channels dedicated to trauma recovery and/or trauma surgery. The longest running podcast was the "TraumaCast," and the oldest YouTube channel was "TraumaPro." The podcast with the most episodes was "Trauma Therapist," and the YouTube channel with the most episodes was the Arizona Trauma Association. Podcasts were aimed at public audiences, whereas YouTube channels focused on providers. A large proportion of content is not created by licensed professionals.
Our study shows that popular trauma-focused podcasts target the general population, not health care professionals. The content creators behind these digital platforms seek to educate the public on the recovery process after traumatic injury. We must better understand the advantages and pitfalls of these ubiquitous resources.
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