Trauma and Acute Care Surgery

"Safer at Home": The effect of the Covid-19 Lockdown on Epidemiology, Resource Utilization and Outcomes at a Large Urban Trauma Center Background The COVID-19 pandemic has affected the entire global healthcare system. In California, due to a high burden of cases, a lockdown order was announced on March 19th, 2020. This study investigated the impact of the lockdown on the epidemiology and outcomes of trauma admissions at the largest trauma center in Los Angeles. Methods Retrospective study comparing epidemiological and clinical characteristics and outcomes of trauma admissions, during the lockdown period (03/20/2020 to 06/30/2020) to a similar period in the previous year (03/20/2019 to 06/30/2019). Data collection included demographics, mechanism of injury, prehospital transportation, substance use, injury severity, resource utilization, and outcomes. Findings There were 1,202 admissions during the lockdown period in 2020 and 1,143 during the same calendar period in 2019. Following the lockdown, there was a reduction in the automobile versus pedestrian admissions by 42.5%, motorcycle injuries by 38.7%, and bicycle accidents by 28.4%, but no significant effect on the number of motor vehicle accident admissions. There was an increase in ground level falls by 32.5%, especially in the elderly group. The absolute number of gunshot wounds increased by 6.2% and knife injuries by 39.3%. Suicides increased by 38.5%. Positive testing for substance use increased by 20.9%. During the lockdown patients suffered less severe trauma, with ISS<9 (p<0.001), as well as less severe head (p=0.001) and severe chest trauma (p<0.001). Trauma deaths were reduced by 27.9% and the crude overall mortality was significantly lower during the lockdown period (4.1% vs 5.9%, p= 0.046). ICU admission rates, mechanical ventilation, and ICU LOS were all reduced. Conclusions The COVID-19 lockdown in 2020 had a significant effect on the epidemiology, clinical characteristics and critical care resource utilization of trauma admissions in a large academic trauma center. These findings may help in planning and optimization of hospital resources during the pandemic. Level of Evidence Therapeutic, level III study type Retrospective observational Grant support: None Conflicts of interest: None Statement of human rights: The study was approved by the Institutional Review Board of the University of Southern California Address for Correspondance: Demetrios Demetriades MD, PhD, FACS, Professor of Surgery, Department of Surgery, University of Southern California, Los Angeles, demetria@usc.edu This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections. © 2020 Lippincott Williams & Wilkins, Inc.

Advanced age heightens hepatic damage in a murine model of scald burn injury Background: Elderly burn patients exhibit a lower survival rate compared with younger counterparts. The liver is susceptible to damage after burn injury, which predisposes to poor outcomes. Lipid homeostasis and the antioxidant glutathione system play fundamental roles in preserving liver integrity. Herein, we explored changes in these major pathways associated with liver damage in the aging animals after burn injury. Methods: We compared liver enzymes, histology, lipid-peroxidation, and glutathione-metabolism profiles from young and aged female mice after a 15% total-body-surface-area burn. Mice were euthanized at 24hours after injury, and livers and serum were collected. Results: Aged burn animals exhibited elevated (p< 0.05) Aspartate-aminotransferase (AST), Alanine-aminotransferase (ALT) levels, and increased inflammatory cell infiltration, edema, and necrosis compared to their younger counterparts. The percentage of adipophilin-stained area in livers from young sham, young burn, aged sham, and aged burn groups was 10%, 44%, 16%, and 78% (p< 0.05), respectively. Liver malonaldehyde (DMA) levels were 1.4 ± 0.5, 2.06 ± 0.2, 1.81 ± 0.12, and 3.45 ± 0.2 nmol/mg (p< 0.05) in young sham, young burn, aged sham, and aged burn mice, respectively. Oxidized glutathione (GSSG) content increased 50% in the young burn, and 88% in aged burn animals compared with the young sham group (p< 0.05). The reduced glutathione GSH/GSSG ratio was significantly reduced by 54% in aged burn mice compared to young sham animals (p< 0.05). Furthermore, glutathione peroxidase (GPX) gene expression showed a 96% decrease in the aged burn group compared to young sham mice (p< 0.05). Conclusions: Aged burn animals exhibit severe liver damage from heightened lipid peroxidation and inadequate antioxidative response. The increased peroxidation is associated with abundant lipid deposits in hepatic tissue post-burn and a weak antioxidative response due to hepatic GPX downregulation. Further studies will focus on the functional significance of these findings concerning hepatic homeostasis. Level of evidence This is a basic science paper and, therefore, does not require a level of evidence. Study Type Basic Sciences Conflict of interest: None Disclosures of funding: (Supported by K08GM134185 (J.P.I.) and R01AG018859, R01GM115257, R35GM131831, 1 I01 BX004335 (E.J.K.).) Juan-Pablo Idrovo, M.D., Assistant Professor of Surgery and Critical Care., University of Colorado Denver / Anschutz Medical Campus, 12631 E. 17th Ave, Room 6001, Aurora, CO 80045. Office: 303-724-8366, Fax: 303-724-2733. Email: juan.idrovo@cuanschutz.edu © 2020 Lippincott Williams & Wilkins, Inc.

Letter to the editor, regarding "Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study" No abstract available

TRAUMA PATIENT TRANSPORT TIMES UNCHANGED DESPITE TRAUMA CENTER PROLIFERATION: A 10 YEAR REVIEW Introduction In certain regions of the U.S. there has been a dramatic proliferation of trauma centers. The goal of our study was to evaluate transport times during this period of trauma center proliferation. Methods Aggregated data summarizing level I trauma center admissions in Arizona between 2009 and 2018 were provided to our institution by the Arizona Department of Health Services. We evaluated patient demographics, transport times and injury severity for both rural and urban injuries. Results Data included statistics summarizing 266,605 level I trauma admissions in the state of Arizona. The number of state-designated trauma centers during this time increased from 14 to 47, with level I centers increasing from 8 to 13. Slight decreases in mean ISS (rural 9.4 vs. 8.4; urban 7.9 vs 7.0) were observed over this period. Median transport time for cases transported from the injury scene directly to a level I center remained stable in urban areas at 0.9 hours in both 2009 and 2018. In rural areas, transport times for these cases were approximately double, but also stable, with median times of 1.8 and 1.9 hours. Transport times for cases requiring inter-facility transfer prior to admission at a level I center increased by 0.3 hours for urban injuries (5.3 hours to 5.6) and 0.9 hours for rural injuries (5.6 to 6.5). Conclusion Despite the 3-fold increase in the number of state-designated trauma centers, transport time has not decreased in urban or rural areas. This finding highlights the need for regulatory oversight regarding the number and geographic placement of state-designated trauma centers. Level of Evidence III The authors declare no conflicts of interest. The study was presented as a Quickshot at the 79th Annual Meeting of AAST & Clinical Congress of Acute Care Surgery held online instead of Waikoloa, Hawaii, September 9-12, 2020. Corresponding Author: Jordan A. Weinberg, MD, Division Chief, Trauma/Acute General Surgery, Trauma Administration, St. Joseph's Hospital and Medical Center, 350 W. Thomas Road, Phoenix, AZ 85013. Tel: (602) 406-3157. Email: JordanWeinberg@Creighton.edu © 2020 Lippincott Williams & Wilkins, Inc.

Transfuse for Hemodynamics Not Hemodilution – Response to Letter to the Editor regarding timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study No abstract available

Fast Track Pathway Provides Safe, Value Based Care on Busy Acute Care Surgery Service Abstract: Background Fast track(FT) pathways have been adopted across a multitude of elective surgeries but have been slow to be adopted into the acute care surgery(ACS) realm. We hypothesized that a FT pathway for acute cholecystitis patients would decrease patient length of stay and resource utilization. Methods All patients at two hospitals, one with a FT pathway and one with a traditional pathway, that underwent an urgent laparoscopic cholecystectomy for acute cholecystitis between May 1, 2019 and October 31, 2019 were queried using CPT codes. Exclusion criteria were conversion to open or partial cholecystectomy. Retrospective chart review was used to gather demographics, operative, hospital course, and outcomes. Time to OR, hospital length of stay, and resource utilization were the primary outcomes. Results There was a total of 479 urgent laparoscopic cholecystectomies performed, four hundred and thirty(89.8%) were performed under the FT pathway. The median[IQR] time to the OR was not different: 14.1 hours[8.3-29.0 hours] for FT and 18.5 hours[11.9-25.9 hours] for traditional(p=0.316). However, the median length of stay was shorter by 15.9 hours in the FT cohort(22.6 hours, [14.2-40.4] vs 38.5 hours,[28.3-56.3];p<0.001). Under the FT pathway, 33.0% of patients were admitted to the hospital and 75.6% were discharged from the PACU, compared to 91.8% and 12.2% on the traditional pathway(both p<0.001). 59.6% of FT patients received a phone call follow up, as opposed to 100% of the traditional patients having clinic follow up(p<0.001). ED bounce back rate, readmission rates, and complication rates were similar(p>0.2 for all). On multivariate analysis, having a fast track pathway was an independent predictor of discharge within 24 hours of surgical consultation(OR 7.65, 95% CI 2.90-20.15, p<0.001). Conclusions Use of a fast track program for patients with acute cholecystitis has a significant positive impact on resource utilization without compromise of clinical outcomes. Level of Evidence Level III, Therapeutic/Care Management Disclosures: All authors have no relevant financial conflicts or personal relationships that could inappropriately influence this work or its conclusions. Sources of funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors Presented at the 79th Annual Meeting of American Association for the Surgery of Trauma, September 8-18th, 2020 as a podium presentation. Address correspondence to: Kali Kuhlenschmidt, MD, University of Texas Southwestern Medical Center, Division of General and Acute Care Surgery, 5323 Harry Hines Blvd., Dallas, Texas 75390-9158. Kali.Kuhlenschmidt@UTSouthwestern.edu. (812) 483-1782 © 2020 Lippincott Williams & Wilkins, Inc.

Efficacy and feasibility of Amniotic membrane for the treatment of burn wounds: a meta-analysis No abstract available

Roadway Features Associated with Elderly Drivers in Motor Vehicle Crashes Background As the number of older US drivers has increased over the past decades, so has the number of injuries, hospitalizations, and deaths from motor vehicle crashes (MVCs) involving elderly drivers. We seek to identify personal, environmental, and roadway features associated with increased crashes involving elderly drivers. We hypothesize that elderly drivers are more likely to be involved in MVCs at intersections with more complex signage and traffic flow. Methods This is a retrospective observational study using 2015-2019 police traffic crash reports and a Department of Public Health database of built-environment variables from a single urban center. Demographics and environmental/road features were compared for vehicle-only MVCs involving elderly (≥ 65 years) and younger drivers. Chi-squared and nonparametric tests were used to analyze 36,168 drivers involved in MVCs. Results There were 2,575 (7.1%) elderly drivers involved in MVCs during the study period. Left turns and all-way stop signs were associated with increased crash risk among elderly drivers compared to younger drivers. Elderly-involved MVCs were less likely to occur at intersections with left-turn restrictions, traffic lights, only one-way streets, and bike lanes compared to MVCs with younger drivers. Elderly drivers were more likely to be involved in MVCs on weekdays, less often intoxicated at the time of the crash, and less frequently involved in fatal MVCs compared to younger drivers. However, elderly drivers were more frequently the at-fault party, especially after age 75. Conclusions Updates to roadway features have potential to decrease injury and death from MVCs involving elderly adults. Left turn restrictions or other innovative safety treatments at all-way stops or where left turns are permitted may mitigate road crashes involving older adults. Education may increase awareness of higher-risk driving tasks such as turning left, and driving alternatives including public transportation/paratransit may offer alternate means to maintain activities of daily living. Level of Evidence Level IV Conflict of Interest: The authors have no disclosures Presentation: Presented at the 79th Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery, September 9-12, 2020 in Waikoloa, Hawaii (Virtual) Disclosures of Funding: None © 2020 Lippincott Williams & Wilkins, Inc.

The expression of repulsive guidance molecule a (RGMa) after traumatic brain injury: Time-course changes in gene expression in a murine model of controlled cortical impact INTRODUCTION Repulsive guidance molecule a (RGMa) is a key protein that negatively regulates neuronal regeneration as its inhibition enhances axonal growth and promotes functional recovery in animal models of spinal cord injury. However, the role of RGMa in traumatic brain injury (TBI) remains elusive. This study aimed to clarify TBI-responsive RGMa expression in a murine model. METHODS Adult male C57Bl/6J mice were subjected to controlled cortical impact. Brains were extracted 6 hours and 1, 3, 7, 14 and 21 days after injury (n=6 in each group). Changes in the mRNA expression of RGMa and its receptor, neogenin, were evaluated by quantitative polymerase chain reaction in the damaged area of the cortex and contralateral cortex, along with expression measurement of inflammation-related molecules. Neurological deficit was also assessed by the cylinder test. RESULTS Neurological score was consistently lower in the TBI group compared to the sham group throughout the experimental period. mRNA expressions of representative inflammatory cytokine TNF-alpha and chemokine CCR2 were remarkably increased in the injured cortex on day 1 and gradually decreased over time, although remaining at higher values at least until day 14. mRNA expressions of RGMa and neogenin were significantly suppressed in the damaged cortex until day 3. Interestingly, RGMa expression was suppressed most on day 1 and recovered over time. CONCLUSION In the acute phase of TBI, gene expression of inflammatory cytokines significantly increased, and gene expressions of RGMa and neogenin significantly decreased in the inflammatory milieu of the damaged area. Despite the subsequent remission of inflammation, RGMa gene expression recovered to the normal level one week after TBI. Intrinsic regenerative response to acute brain injury might be hampered by the following recovery of RGMa expression, hinting at the possibility of functional RGMa inhibition as a new, effective maneuver against TBI. Corresponding author: Goro Tajima, MD, PhD, Assistant Professor, Nagasaki University Hospital, Emergency and Critical Care Center, 1-7-1 Sakamoto, Nagasaki city 852-8501, Japan, Tel: +81(095) 819-7765, Fax: +81(095) 819-7978 E-mail: gtajima@nagasaki-u.ac.jp This study was presented at the 79th AAST annual meeting, Sept. 8-18, 2020, Virtual AAST Annual Meeting Conflicts of Interest and Source of Funding: All authors declare no conflicts of interest. This work was supported by the Japan Society for the Promotion of Science Grant-in-Aid Scientific Research (B) (No. 18H02903), and a research funding from Mitsubishi Tanabe Pharma Corporation. © 2020 Lippincott Williams & Wilkins, Inc.

Long-Term Outcomes of Psychoactive Drug Use in Trauma Patients: A Multicenter Patient-Reported Outcomes Study Introduction Psychoactive drug use (PDU) is reported in up to 40% of trauma patients and is associated with a higher rate of in-hospital complications. However, little is known about its long-term impact on trauma patients. We aimed to assess the long-term functional, mental and psychosocial outcomes of PDU in trauma patients 6-12 months after injury. Methods Trauma patients with moderate to severe injuries (ISS>9) who had a toxicology screen upon admission to one of three level 1 trauma centers were contacted by phone 6-12 months post-injury. PDU was defined as the presence of a psychoactive, non-prescribed substance on toxicology screen including amphetamine, barbiturate, benzodiazepine, cannabinoid, methamphetamine, methadone, opioid, oxycodone, methylenedioxymethamphetamine (ecstasy), phencyclidine, tricyclic antidepressant and cocaine. The interviews systematically evaluated functional limitations, social functioning, chronic pain, and mental health (PTSD, depression, anxiety). Patients with a score of <47 on the SF-12 social functioning sub-domain were considered to have social dysfunction. Multivariable regression models were built to determine the independent association between PDU and long-term outcomes. Results Of the 1,699 eligible patients, 571 (34%) were included in the analysis, and 173 (30.3%) screened positive for PDU on admission. Patients with PDU were younger (median age: 43[28,55] vs 66[46,78], P< 0.001), had more penetrating injuries (8.7% vs 4.3%, P=0.036), and were less likely to have received a college education (41.3% vs 54.5%, P=0.004). After adjusting for patients' characteristics including the presence of a baseline psychiatric comorbidity, patients with PDU on admission were more likely to suffer from daily chronic pain, mental health disorders, and social dysfunction 6-12 months after injury. There was no difference in the functional limitations between patients with and without PDU. Conclusion On the long term, PDU in trauma patients is strongly and independently associated with worse mental health, more chronic pain and severe impairment in social functioning. A trauma hospitalization presents an opportunity to identify patients at risk and to mitigate the long-term impact of PDU on recovery. Level of evidence Prognostic/epidemiologic, level III. Corresponding Author: Haytham M.A. Kaafarani, MD, MPH, FACS, Associate Professor of Surgery, Harvard Medical School, Division of Trauma, Emergency Surgery & Surgical Critical Care, 165 Cambridge Street, Suite 810, Boston, MA 02114, P: 617-643-2439, F: 617-726-9121 4 E: hkaafarani@mgh.harvard.edu The authors have no financial or non-financial competing interests to disclose. The present study was not funded by any entity. This article was presented at the 79th Annual Meeting of American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery © 2020 Lippincott Williams & Wilkins, Inc.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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